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MarketScreener Homepage  >  Equities  >  Nyse  >  HCA Healthcare, Inc.    HCA

HCA HEALTHCARE, INC.

(HCA)
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HCA Hospital America : HEALTRE, INC. Management's Discussion and Analysis of Financial Condition and Results of Operations (form 10-K)

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02/20/2020 | 04:24pm EDT
The selected financial data and the accompanying consolidated financial
statements present certain information with respect to the financial position,
results of operations and cash flows of HCA Healthcare, Inc. which should be
read in conjunction with the following discussion and analysis. The terms "HCA,"
"Company," "we," "our," or "us," as used herein, refer to HCA Healthcare, Inc.
and its affiliates. The term "affiliates" means direct and indirect subsidiaries
of HCA Healthcare, Inc. and partnerships and joint ventures in which such
subsidiaries are partners.
Forward-Looking Statements
This annual report on Form
10-K
includes certain disclosures which contain "forward-looking statements" within
the meaning of the federal securities laws, which involve risks and
uncertainties. Forward-looking statements include statements regarding expected
share-based compensation expense, expected capital expenditures, expected
dividends, expected net claim payments and all other statements that do not
relate solely to historical or current facts, and can be identified by the use
of words like "may," "believe," "will," "expect," "project," "estimate,"
"anticipate," "plan," "initiative" or "continue." These forward-looking
statements are based on our current plans and expectations and are subject to a
number of known and unknown uncertainties and risks, many of which are beyond
our control, which could significantly affect current plans and expectations and
our future financial position and results of operations. These factors include,
but are not limited to, (1) the impact of our substantial indebtedness and the
ability to refinance such indebtedness on acceptable terms, (2) the impact of
the Patient Protection and Affordable Care Act, as amended by the Health Care
and Education Reconciliation Act of 2010 (collectively, the "Affordable Care
Act"), including the effects of court challenges to, any repeal of, or changes
to, the Affordable Care Act or additional changes to its implementation, the
possible enactment of additional federal or state health care reforms and
possible changes to other federal, state or local laws or regulations affecting
the health care industry, including single-payer proposals (often referred to as
"Medicare for All"), (3) the effects related to the continued implementation of
the sequestration spending reductions required under the Budget Control Act of
2011, and related legislation extending these reductions, and the potential for
future deficit reduction legislation that may alter these spending reductions,
which include cuts to Medicare payments, or create additional spending
reductions, (4) increases in the amount and risk of collectability of uninsured
accounts and deductibles and copayment amounts for insured accounts, (5) the
ability to achieve operating and financial targets, and attain expected levels
of patient volumes and control the costs of providing services, (6) possible
changes in Medicare, Medicaid and other state programs, including Medicaid
supplemental payment programs or Medicaid waiver programs, that may impact
reimbursements to health care providers and insurers and the size of the
uninsured or underinsured population, (7) the highly competitive nature of the
health care business, (8) changes in service mix, revenue mix and surgical
volumes, including potential declines in the population covered under
third-party payer agreements, the ability to enter into and renew third-party
payer provider agreements on acceptable terms and the impact of consumer-driven
health plans and physician utilization trends and practices, (9) the efforts of
health insurers, health care providers, large employer groups and others to
contain health care costs, (10) the outcome of our continuing efforts to
monitor, maintain and comply with appropriate laws, regulations, policies and
procedures, (11) increases in wages and the ability to attract and retain
qualified management and personnel, including affiliated physicians, nurses and
medical and technical support personnel, (12) the availability and terms of
capital to fund the expansion of our business and improvements to our existing
facilities, (13) changes in accounting practices, (14) changes in general
economic conditions nationally and regionally in our markets, (15) the emergence
of and effects related to pandemics, epidemics and infectious diseases,
(16) future divestitures which may result in charges and possible impairments of
long-lived assets, (17) changes in business strategy or development plans,
(18) delays in receiving payments for services provided, (19) the outcome of
pending and any future tax audits, disputes and litigation associated
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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Forward-Looking Statements (continued)
with our tax positions, (20) potential adverse impact of known and unknown
government investigations, litigation and other claims that may be made against
us, (21) the impact of potential cybersecurity incidents or security breaches,
(22) our ongoing ability to demonstrate meaningful use of certified electronic
health record ("EHR") technology and the impact of interoperability
requirements, (23) the impact of natural disasters, such as hurricanes and
floods, or similar events beyond our control, (24) changes in U.S. federal,
state, or foreign tax laws including interpretive guidance that may be issued by
taxing authorities or other standard setting bodies, and (25) other risk factors
described in this annual report on Form
10-K.
As a consequence, current plans, anticipated actions and future financial
position and results of operations may differ from those expressed in any
forward-looking statements made by or on behalf of HCA. You are cautioned not to
unduly rely on such forward-looking statements when evaluating the information
presented in this report.
2019 Operations Summary
Net income attributable to HCA Healthcare, Inc. totaled $3.505 billion, or
$10.07 per diluted share, for 2019, compared to $3.787 billion, or $10.66 per
diluted share, for 2018. The 2019 results include gains on sales of facilities
of $18 million, or $0.04 per diluted share, and losses on retirement of debt of
$211 million, or $0.47 per diluted share. The 2018 results include gains on
sales of facilities of $428 million, or $0.91 per diluted share, and losses on
retirement of debt of $9 million, or $0.02 per diluted share. The 2019 results
also include revenues of $86 million, or $0.19 per diluted share, related to the
resolution of transaction price differences regarding certain
out-of-network
services performed in prior periods. The 2018 results also include a reduction
in our provision for income taxes of $67 million, or $0.19 per share, for the
remeasurement of certain of our deferred tax assets and liabilities for which we
were unable to record reasonable estimates in 2017. During 2019 and 2018, we
recorded reductions to the provision for professional liability risks of
$50 million, or $0.11 per diluted share, and $70 million, or $0.15 per diluted
share, respectively. During 2018, we recorded additional expenses and losses of
revenues estimated at approximately $31 million, or $0.07 per diluted share,
associated with the impact of hurricane Michael on our Florida facilities. This
amount is prior to any insurance recoveries. During 2018, we recorded a benefit
of $49 million, or $0.11 per diluted share, from an insurance recovery related
to hurricane Harvey business interruption losses incurred during 2017, and we
recorded a reduction to the provision for income taxes of $28 million, or $0.08
per diluted share, for tax credits related to certain 2017 hurricane-related
expenses. Our provisions for income taxes for 2019 and 2018 included tax
benefits of $65 million, or $0.19 per diluted share, and $124 million, or $0.35
per diluted share, respectively, related to employee equity award settlements.
All "per diluted share" disclosures are based upon amounts net of the applicable
income taxes. Shares used for diluted earnings per share were 348.226 million
shares and 355.303 million shares for the years ended December 31, 2019 and
2018, respectively. During 2019 and 2018, we repurchased 7.949 million and
14.070 million shares, respectively, of our common stock.
Revenues increased to $51.336 billion for 2019 from $46.677 billion for 2018.
Revenues increased 10.0% and 5.9%, respectively, on a consolidated basis and on
a same facility basis for 2019, compared to 2018. The consolidated revenues
increase can be primarily attributed to the combined impact of a 3.2% increase
in revenue per equivalent admission and a 6.6% increase in equivalent
admissions. The same facility revenues increase resulted primarily from a 2.3%
increase in same facility revenue per equivalent admission and a 3.5% increase
in same facility equivalent admissions.
During 2019, consolidated admissions increased 5.2% and same facility admissions
increased 2.8%, compared to 2018. Inpatient surgical volumes increased 3.4% on a
consolidated basis and increased 1.1% on a same facility basis during 2019,
compared to 2018. Outpatient surgical volumes increased 4.0% on a
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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
2019 Operations Summary (continued)
consolidated basis and increased 1.6% on a same facility basis during 2019,
compared to 2018. Emergency room visits increased 4.5% on a consolidated basis
and increased 2.8% on a same facility basis during 2019, compared to 2018.
The estimated cost of total uncompensated care increased $415 million for 2019,
compared to 2018. Consolidated and same facility uninsured admissions increased
5.8% and 3.7%, respectively, and consolidated and same facility uninsured
emergency room visits increased 5.8% and 3.9%, respectively, for 2019, compared
to 2018.
Interest expense totaled $1.824 billion for 2019, compared to $1.755 billion for
2018. The $69 million increase in interest expense for 2019 was due to the
increase in the average debt balance.
Cash flows from operating activities increased $841 million, from $6.761 billion
for 2018 to $7.602 billion for 2019. The increase in cash flows from operating
activities was primarily related to the increase in net income, excluding gains
on sales of facilities and losses on retirement of debt, of $222 million and
increases related to income taxes of $322 million and depreciation and
amortization of $318 million.
Business Strategy
We are committed to providing the communities we serve with high quality,
cost-effective health care while growing our business and creating long-term
value for our stockholders. To achieve these objectives, we align our efforts
around the following growth agenda:
Grow Our Presence in Existing Markets.
We believe we are well positioned in a number of large and growing markets that
will allow us the opportunity to generate long-term, attractive growth through
the expansion of our presence in these markets. We plan to continue recruiting
and strategically collaborating with the physician community and developing
comprehensive service lines such as cardiology, neurology, oncology, orthopedics
and women's services. Additional components of our growth strategy include
providing access and convenience through developing various outpatient
facilities, including, but not limited to surgery centers, urgent care clinics,
freestanding emergency care facilities and imaging centers.
Achieve Industry-Leading Performance in Clinical and Satisfaction Measures.
Achieving high levels of patient safety, patient satisfaction and clinical
quality are central goals of our business. To achieve these goals, we have
implemented a number of initiatives including infection reduction initiatives,
hospitalist programs, advanced health information technology and evidence-based
medicine programs. We routinely analyze operational practices from our
best-performing hospitals to identify ways to implement organization-wide
performance improvements and reduce clinical variation. We believe these
initiatives will continue to improve patient care, help us achieve cost
efficiencies and favorably position us in an environment where our constituents
are increasingly focused on quality, efficacy and efficiency.
Recruit and Employ Physicians to Meet the Needs for High Quality Health
Services.
We depend on the quality and dedication of the health care providers and other
team members who serve at our facilities. We believe a critical component of our
growth strategy is our ability to successfully recruit and strategically
collaborate with physicians and other professionals to provide high quality
care. We attract and retain physicians by providing high quality, convenient
facilities with advanced technology, by expanding our specialty services and by
building our outpatient operations. We believe our continued investment in the
employment, recruitment and retention of physicians will improve the quality of
care at our facilities.
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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Business Strategy (continued)
Continue to Leverage Our Scale and Market Positions to Grow the Company.
We believe there is significant opportunity to continue to grow our company by
fully leveraging the scale and scope of our organization. We continue to invest
in initiatives such as care navigators, clinical data exchange and centralized
patient transfer operations, which will enable us to improve coordination of
care and patient retention across our markets. We believe our centrally managed
business processes and ability to leverage cost-saving practices across our
extensive network will enable us to continue to manage costs effectively. We
continue to invest in our Parallon subsidiary group to leverage key components
of our support infrastructure, including revenue cycle management, health care
group purchasing, supply chain management and staffing functions.
Pursue a Disciplined Development Strategy.
We continue to believe there are significant growth opportunities in our
markets. We will continue to provide financial and operational resources to
analyze and develop our
in-market
opportunities. To complement our
in-market
growth agenda, we intend to focus on selectively developing and acquiring new
hospitals, outpatient facilities and other health care service providers. We
believe the challenges faced by the hospital industry may continue to spur
consolidation and we believe our size, scale, national presence and access to
capital will position us well to participate in any such consolidation.
Critical Accounting Policies and Estimates
The preparation of our consolidated financial statements requires management to
make estimates and assumptions that affect the reported amounts of assets and
liabilities, the disclosure of contingent liabilities and the reported amounts
of revenues and expenses. Our estimates are based on historical experience and
various other assumptions we believe are reasonable under the circumstances. We
evaluate our estimates on an ongoing basis and make changes to the estimates and
related disclosures as experience develops or new information becomes known.
Actual results may differ from these estimates.
We believe the following critical accounting policies affect our more
significant judgments and estimates used in the preparation of our consolidated
financial statements.
Revenues
Revenues are recorded during the period the health care services are provided,
based upon the estimated amounts due from payers. Estimates of contractual
allowances under managed care health plans are based upon the payment terms
specified in the related contractual agreements. Laws and regulations governing
the Medicare and Medicaid programs are complex and subject to interpretation.
The estimated reimbursement amounts are made on a payer-specific basis and are
recorded based on the best information available regarding management's
interpretation of the applicable laws, regulations and contract terms.
Management continually reviews the contractual estimation process to consider
and incorporate updates to laws and regulations and the frequent changes in
managed care contractual terms resulting from contract renegotiations and
renewals. We have invested significant resources to refine and improve our
billing systems and the information system data used to make contractual
allowance estimates. We have developed standardized calculation processes and
related employee training programs to improve the utility of our patient
accounting systems.
The Emergency Medical Treatment and Labor Act ("EMTALA") requires any hospital
participating in the Medicare program to conduct an appropriate medical
screening examination of every person who presents to the hospital's emergency
room for treatment and, if the individual is suffering from an emergency medical
condition,
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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Critical Accounting Policies and Estimates (continued)
Revenues (continued)
to either stabilize the condition or make an appropriate transfer of the
individual to a facility able to handle the condition. The obligation to screen
and stabilize emergency medical conditions exists regardless of an individual's
ability to pay for treatment. Federal and state laws and regulations, including
but not limited to EMTALA, require, and our commitment to providing quality
patient care encourages, the provision of services to patients who are
financially unable to pay for the health care services they receive.
Prior to November 2017, patients treated at hospitals for
non-elective
care, who have income at or below 200% of the federal poverty level, were
eligible for charity care. During November 2017, we expanded our charity policy
to include patients who have income above 200%, but at or below 400%, of the
federal poverty level and we limit the patient responsibility amounts for these
patients to a percentage of their annual household income, computed on a sliding
scale based upon their annual income and the applicable percentage of the
federal poverty level. The federal poverty level is established by the federal
government and is based on income and family size. Because we do not pursue
collection of amounts determined to qualify as charity care, they are not
reported in revenues. We provide discounts to uninsured patients who do not
qualify for Medicaid or charity care. We may attempt to provide assistance to
uninsured patients to help determine whether they may qualify for Medicaid,
other federal or state assistance, or charity care. If an uninsured patient does
not qualify for these programs, the uninsured discount is applied.
Due to the complexities involved in the classification and documentation of
health care services authorized and provided, the estimation of revenues earned
and the related reimbursement are often subject to interpretations that could
result in payments that are different from our estimates. Adjustments to
estimated Medicare and Medicaid reimbursement amounts and disproportionate-share
funds, which resulted in net increases to revenues, related primarily to cost
reports filed during the respective year were $51 million, $29 million and
$41 million in 2019, 2018 and 2017, respectively. The adjustments to estimated
reimbursement amounts, which resulted in net increases to revenues, related
primarily to cost reports filed during previous years were $13 million,
$51 million and $56 million in 2019, 2018 and 2017, respectively. We expect
adjustments during the next 12 months related to Medicare and Medicaid cost
report filings and settlements will result in increases to revenues generally
similar to the amounts recorded during these years.
The collection of outstanding receivables for Medicare, Medicaid, managed care
payers, other third-party payers and patients is our primary source of cash and
is critical to our operating performance. The primary collection risks relate to
uninsured patient accounts, including patient accounts for which the primary
insurance carrier has paid the amounts covered by the applicable agreement, but
patient responsibility amounts (deductibles and copayments) remain outstanding.
Implicit price concessions relate primarily to amounts due directly from
patients. Estimated implicit price concessions are recorded for all uninsured
accounts, regardless of the age of those accounts. Accounts are written off when
all reasonable collection efforts have been performed.
The estimates for implicit price concessions are based upon management's
assessment of historical writeoffs and expected net collections, business and
economic conditions, trends in federal, state and private employer health care
coverage and other collection indicators. Management relies on the results of
detailed reviews of historical writeoffs and collections at facilities that
represent a majority of our revenues and accounts receivable (the "hindsight
analysis") as a primary source of information in estimating the collectability
of our accounts receivable. We perform the hindsight analysis quarterly,
utilizing rolling twelve-months accounts receivable collection and writeoff
data. We believe our quarterly updates to the estimated implicit price
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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Critical Accounting Policies and Estimates (continued)
Revenues (continued)
concession amounts at each of our hospital facilities provide reasonable
estimates of our revenues and valuations of our accounts receivable. These
routine, quarterly changes in estimates have not resulted in material
adjustments to the valuations of our accounts receivable or
period-to-period
comparisons of our results of operations. At December 31, 2019 and December 31,
2018, estimated implicit price concessions of $6.953 billion and $6.280 billion,
respectively, had been recorded to adjust our revenues and accounts receivable
to the estimated amounts we expect to collect.
To quantify the total impact of and trends related to uninsured patient
accounts, we believe it is beneficial to view total uncompensated care, which is
comprised of charity care, uninsured discounts and implicit price concessions. A
summary of the estimated cost of total uncompensated care for the years ended
December 31, follows (dollars in millions):

                                                            2019          2018          2017
Patient care costs (salaries and benefits, supplies,
other operating expenses and depreciation and
amortization)                                             $ 44,118      $ 

40,035 $ 37,557

Cost-to-charges

ratio (patient care costs as percentage of gross
patient charges)                                              12.0 %        12.4 %        12.9 %

Total uncompensated care                                  $ 31,105$ 26,757$ 23,420
Multiply by the
cost-to-charges
ratio                                                         12.0 %        12.4 %        12.9 %

Estimated cost of total uncompensated care                $  3,733      $  

3,318 $ 3,021




Days revenues in accounts receivable were 50 days, 51 days and 52 days at
December 31, 2019, 2018 and 2017, respectively. Management expects a
continuation of the challenges related to the collection of the patient due
accounts. Adverse changes in the percentage of our patients having adequate
health care coverage, increases in patient responsibility amounts under certain
health care coverages, general economic conditions, patient accounting service
center operations, payer mix, or trends in federal, state, and private employer
health care coverage could affect the collection of accounts receivable, cash
flows and results of operations.
Professional Liability Claims
We, along with virtually all health care providers, operate in an environment
with professional liability risks. Our facilities are insured by our 100% owned
insurance subsidiary for losses up to $50 million per occurrence, subject, in
most cases, to a $15 million per occurrence self-insured retention. The
insurance subsidiary has obtained reinsurance for professional liability risks
generally above a retention level of $25 million per occurrence. We purchase
excess insurance on a claims-made basis for losses in excess of $50 million per
occurrence. Provisions for losses related to professional liability risks were
$497 million, $447 million and $466 million for the years ended December 31,
2019, 2018 and 2017, respectively. During 2019 and 2018, we recorded reductions
to the provision for professional liability risks of $50 million and
$70 million, respectively, due to the receipt of updated actuarial information.
Reserves for professional liability risks represent the estimated ultimate cost
of all reported and unreported losses incurred through the respective
consolidated balance sheet dates. The estimated ultimate cost includes
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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Critical Accounting Policies and Estimates (continued)
Professional Liability Claims (continued)
estimates of direct expenses and fees paid to outside counsel and experts, but
does not include the general overhead costs of our insurance subsidiary or
corporate office. Individual case reserves are established based upon the
particular circumstances of each reported claim and represent our estimates of
the future costs that will be paid on reported claims. Case reserves are reduced
as claim payments are made and are adjusted upward or downward as our estimates
regarding the amounts of future losses are revised. Once the case reserves for
known claims are determined, information is stratified by loss layers and
retentions, accident years, reported years, and geographic location of our
hospitals. Several actuarial methods are employed to utilize this data to
produce estimates of ultimate losses and reserves for incurred but not reported
claims, including: paid and incurred extrapolation methods utilizing paid and
incurred loss development to estimate ultimate losses; frequency and severity
methods utilizing paid and incurred claims development to estimate ultimate
average frequency (number of claims) and ultimate average severity (cost per
claim); and Bornhuetter-Ferguson methods which add expected development to
actual paid or incurred experience to estimate ultimate losses. These methods
use our company-specific historical claims data and other information.
Company-specific claim reporting and payment data collected over an approximate
20-year
period is used in our reserve estimation process. This company-specific data
includes information regarding our business, including historical paid losses
and loss adjustment expenses, historical and current case loss reserves, actual
and projected hospital statistical data, professional liability retentions for
each policy year, geographic information and other data.
Reserves and provisions for professional liability risks are based upon
actuarially determined estimates. The estimated reserve ranges, net of amounts
receivable under reinsurance contracts, were $1.589 billion to $1.903 billion at
December 31, 2019 and $1.514 billion to $1.814 billion at December 31, 2018. Our
estimated reserves for professional liability claims may change significantly if
future claims differ from expected trends. We perform sensitivity analyses which
model the volatility of key actuarial assumptions and monitor our reserves for
adequacy relative to all our assumptions in the aggregate. Based on our
analysis, we believe the estimated professional liability reserve ranges
represent the reasonably likely outcomes for ultimate losses. We consider the
number and severity of claims to be the most significant assumptions in
estimating reserves for professional liabilities. A 2.5% change in the expected
frequency trend could be reasonably likely and would increase the reserve
estimate by $32 million or reduce the reserve estimate by $31 million. A 2.5%
change in the expected claim severity trend could be reasonably likely and would
increase the reserve estimate by $117 million or reduce the reserve estimate by
$107 million. We believe adequate reserves have been recorded for our
professional liability claims; however, due to the complexity of the claims, the
extended period of time to resolve the claims and the wide range of potential
outcomes, our ultimate liability for professional liability claims could change
by more than the estimated sensitivity amounts and could change materially from
our current estimates.
The reserves for professional liability risks cover approximately 2,300 and
2,200 individual claims at December 31, 2019 and 2018, respectively, and
estimates for unreported potential claims. The time period required to resolve
these claims can vary depending upon the jurisdiction and whether the claim is
settled or litigated. The average time period between the occurrence and final
resolution for our professional liability claims is approximately four years,
although the facts and circumstances of each individual claim can result in an
occurrence-to-resolution
timeframe that varies from this average. The estimation of the timing of
payments beyond a year can vary significantly.
Reserves for professional liability risks were $1.827 billion and $1.741 billion
at December 31, 2019 and 2018, respectively. The current portion of these
reserves, $457 million and $466 million at December 31, 2019
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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Critical Accounting Policies and Estimates (continued)
Professional Liability Claims (continued)
and 2018, respectively, is included in "other accrued expenses." Obligations
covered by reinsurance and excess insurance contracts are included in the
reserves for professional liability risks, as we remain liable to the extent
reinsurers and excess insurance carriers do not meet their obligations. Reserves
for professional liability risks (net of $46 million and $50 million receivable
under reinsurance and excess insurance contracts at December 31, 2019 and 2018,
respectively) were $1.781 billion and $1.692 billion at December 31, 2019 and
2018, respectively. The estimated total net reserves for professional liability
risks at December 31, 2019 and 2018 are comprised of $695 million and
$703 million, respectively, of case reserves for known claims and $1.086 billion
and $989 million, respectively, of reserves for incurred but not reported
claims.
Changes in our professional liability reserves, net of reinsurance recoverable,
for the years ended December 31, are summarized in the following table (dollars
in millions):

                                                           2019          2018          2017
Net reserves for professional liability claims,
January 1                                                 $ 1,692$ 1,603$ 1,494
Provision for current year claims                             499           486           467
Favorable development related to prior years' claims           (2 )         (39 )          (1 )

Total provision                                               497           447           466

Payments for current year claims                                8             3             7
Payments for prior years' claims                              400           355           350

Total claim payments                                          408           358           357

Net reserves for professional liability claims,
December 31                                               $ 1,781$ 1,692$ 1,603



Income Taxes
We calculate our provision for income taxes using the asset and liability
method, under which deferred tax assets and liabilities are recognized by
identifying the temporary differences that arise from the recognition of items
in different periods for tax and accounting purposes. Deferred tax assets
generally represent the tax effects of amounts expensed in our income statement
for which tax deductions will be claimed in future periods. Interest and
penalties payable to taxing authorities are included as a component of our
provision for income taxes. We have elected to treat taxes incurred on global
intangible
low-taxed
income as a period expense.
Although we believe we have properly reported taxable income and paid taxes in
accordance with applicable laws, federal, state or foreign taxing authorities
may challenge our tax positions upon audit. Significant judgment is required in
determining and assessing the impact of uncertain tax positions. We report a
liability for unrecognized tax benefits from uncertain tax positions taken or
expected to be taken in our income tax returns. During each reporting period, we
assess the facts and circumstances related to uncertain tax positions. If the
realization of unrecognized tax benefits is deemed probable based upon new facts
and circumstances, the estimated liability and the provision for income taxes
are reduced in the current period. Final audit results may vary from our
estimates.
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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Results of Operations
Revenue/Volume Trends
Our revenues depend upon inpatient occupancy levels, the ancillary services and
therapy programs ordered by physicians and provided to patients, the volume of
outpatient procedures and the charge and negotiated payment rates for such
services. Gross charges typically do not reflect what our facilities are
actually paid. Our facilities have entered into agreements with third-party
payers, including government programs and managed care health plans, under which
the facilities are paid based upon the cost of providing services, predetermined
rates per diagnosis, fixed per diem rates or discounts from gross charges. We do
not pursue collection of amounts related to patients who meet our guidelines to
qualify for charity care; therefore, they are not reported in revenues. We
provide discounts to uninsured patients who do not qualify for Medicaid or
charity care.
Revenues increased 10.0% to $51.336 billion for 2019 from $46.677 billion for
2018 and increased 7.0% for 2018 from $43.614 billion for 2017. The increase in
revenues in 2019 can be primarily attributed to the combined impact of a 3.2%
increase in revenue per equivalent admission and a 6.6% increase in equivalent
admissions compared to the prior year. The increase in revenues in 2018 can be
primarily attributed to the combined impact of a 2.8% increase in revenue per
equivalent admission and a 4.1% increase in equivalent admissions compared to
the prior year.
Same facility revenues increased 5.9% for the year ended December 31, 2019
compared to the year ended December 31, 2018 and increased 6.5% for the year
ended December 31, 2018 compared to the year ended December 31, 2017. The 5.9%
increase for 2019 can be primarily attributed to the combined impact of a 2.3%
increase in same facility revenue per equivalent admission and a 3.5% increase
in same facility equivalent admissions. The 6.5% increase for 2018 can be
primarily attributed to the combined impact of a 3.9% increase in same facility
revenue per equivalent admission and a 2.5% increase in same facility equivalent
admissions.
Consolidated admissions increased 5.2% during 2019 compared to 2018 and
increased 3.5% during 2018 compared to 2017. Consolidated surgeries increased
3.7% during 2019 compared to 2018 and increased 2.6% during 2018 compared to
2017. Consolidated emergency room visits increased 4.5% during 2019 compared to
2018 and increased 1.6% during 2018 compared to 2017.
Same facility admissions increased 2.8% during 2019 compared to 2018 and
increased 2.5% during 2018 compared to 2017. Same facility surgeries each
increased 1.4% during 2019 compared to 2018 and during 2018 compared to 2017.
Same facility emergency room visits increased 2.8% during 2019 compared to 2018
and increased 0.1% during 2018 compared to 2017.
Same facility uninsured emergency room visits increased 3.9% and same facility
uninsured admissions increased 3.7% during 2019 compared to 2018. Same facility
uninsured emergency room visits increased 3.8% and same facility uninsured
admissions increased 8.5% during 2018 compared to 2017.
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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Results of Operations (continued)
Revenue/Volume Trends (continued)
The approximate percentages of our admissions related to Medicare, managed
Medicare, Medicaid, managed Medicaid, managed care and insurers and the
uninsured for the years ended December 31, 2019, 2018 and 2017 are set forth
below.

                                Years Ended December 31,
                              2019           2018       2017
Medicare                          29 %           30 %      30 %
Managed Medicare                  18             17        16
Medicaid                           5              5         6
Managed Medicaid                  12             12        12
Managed care and insurers         28             28        28
Uninsured                          8              8         8

                                 100 %          100 %     100 %


The approximate percentages of our inpatient revenues related to Medicare, managed Medicare, Medicaid, managed Medicaid, and managed care and insurers for the years ended December 31, 2019, 2018 and 2017 are set forth below.

                                Years Ended December 31,
                              2019           2018       2017
Medicare                          28 %           28 %      28 %
Managed Medicare                  15             14        13
Medicaid                           5              4         5
Managed Medicaid                   5              6         5
Managed care and insurers         47             48        49

                                 100 %          100 %     100 %



At December 31, 2019, we owned and operated 45 hospitals and 33 surgery centers
in the state of Florida. Our Florida facilities' revenues totaled
$11.494 billion, $10.892 billion and $10.168 billion for the years ended
December 31, 2019, 2018 and 2017, respectively. At December 31, 2019, we owned
and operated 46 hospitals and 29 surgery centers in the state of Texas. Our
Texas facilities' revenues totaled $13.101 billion, $12.023 billion and
$10.634 billion for the years ended December 31, 2019, 2018 and 2017,
respectively. During 2019, 2018 and 2017, 56%, 57% and 56% of our admissions and
48%, 49% and 48%, respectively, of our revenues were generated by our Florida
and Texas facilities. Uninsured admissions in Florida and Texas represented 72%,
70% and 70% of our uninsured admissions during 2019, 2018 and 2017,
respectively.
We receive a significant portion of our revenues from government health
programs, principally Medicare and Medicaid, which are highly regulated and
subject to frequent and substantial changes. In December 2017, the Centers for
Medicare & Medicaid Services ("CMS") announced that it will phase out federal
matching funds for Designated State Health Programs under waivers granted under
Section 1115 of the Social Security Act. Texas currently operates its Healthcare
Transformation and Quality Improvement Program pursuant to a Medicaid waiver. In
December 2017, CMS approved an extension of this waiver through September 30,
2022, but
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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Results of Operations (continued)
Revenue/Volume Trends (continued)
indicated that it will phase out some of the federal funding. Our Texas Medicaid
revenues included Medicaid supplemental waiver payments of $416 million,
$450 million and $351 million during 2019, 2018 and 2017, respectively.
In addition, we receive supplemental payments in several other states. We are
aware these supplemental payment programs are currently being reviewed by CMS
and certain state agencies, and that some states have made waiver requests to
CMS to replace their existing supplemental payment programs. It is possible
these reviews and waiver requests will result in the restructuring of such
supplemental payment programs and could result in the payment programs being
reduced or eliminated. Because deliberations about these programs are ongoing,
we are unable to estimate the financial impact the program structure
modifications, if any, may have on our results of operations.
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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Results of Operations (continued)
Operating Results Summary
The following are comparative summaries of operating results for the years ended
December 31, 2019, 2018 and 2017 (dollars in millions):

                                                 2019                     2018                     2017
                                          Amount       Ratio       Amount       Ratio       Amount       Ratio
Revenues                                 $ 51,336       100.0     $ 46,677       100.0     $ 43,614       100.0

Salaries and benefits                      23,560        45.9       21,425        45.9       20,059        46.0
Supplies                                    8,481        16.5        7,724        16.5        7,316        16.8
Other operating expenses                    9,481        18.5        8,608        18.5        8,051        18.4
Equity in earnings of affiliates              (43 )      (0.1 )        (29 )      (0.1 )        (45 )      (0.1 )
Depreciation and amortization               2,596         5.0        2,278         4.9        2,131         4.9
Interest expense                            1,824         3.6        1,755         3.8        1,690         3.9
Gain on sales of facilities                   (18 )         -         (428 )      (0.9 )         (8 )         -
Losses on retirement of debt                  211         0.4            9           -           39         0.1

                                           46,092        89.8       41,342        88.6       39,233        90.0

Income before income taxes                  5,244        10.2        5,335        11.4        4,381        10.0
Provision for income taxes                  1,099         2.1          946  

2.0 1,638 3.7


Net income                                  4,145         8.1        4,389         9.4        2,743         6.3
Net income attributable to
noncontrolling interests                      640         1.3          602  

1.3 527 1.2


Net income attributable to HCA
Healthcare, Inc.                         $  3,505         6.8     $  3,787         8.1     $  2,216         5.1

% changes from prior year:
Revenues                                     10.0 %                    7.0 %                    5.1 %
Income before income taxes                   (1.7 )                   21.8                     (8.9 )
Net income attributable to HCA
Healthcare, Inc.                             (7.4 )                   70.9                    (23.3 )
Admissions(a)                                 5.2                      3.5                      2.4
Equivalent admissions(b)                      6.6                      4.1                      3.0
Revenue per equivalent admission              3.2                      2.8                      2.1
Same facility % changes from prior
year(c):
Revenues                                      5.9                      6.5                      3.8
Admissions(a)                                 2.8                      2.5                      1.1
Equivalent admissions(b)                      3.5                      2.5                      1.5
Revenue per equivalent admission              2.3                      3.9                      2.2



(a) Represents the total number of patients admitted to our hospitals and is used

by management and certain investors as a general measure of inpatient volume.

(b) Equivalent admissions are used by management and certain investors as a

general measure of combined inpatient and outpatient volume. Equivalent

admissions are computed by multiplying admissions (inpatient volume) by the

sum of gross inpatient revenue and gross outpatient revenue and then dividing

the resulting amount by gross inpatient revenue. The equivalent admissions

computation "equates" outpatient revenue to the volume measure (admissions)

used to measure inpatient volume, resulting in a general measure of combined

inpatient and outpatient volume.

(c) Same facility information excludes the operations of hospitals and their

    related facilities that were either acquired, divested or removed from
    service during the current and prior year.



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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Results of Operations (continued)
Years Ended December 31, 2019 and 2018
Net income attributable to HCA Healthcare, Inc. totaled $3.505 billion, or
$10.07 per diluted share, for 2019, compared to $3.787 billion, or $10.66 per
diluted share, for 2018. The 2019 results include gains on sales of facilities
of $18 million, or $0.04 per diluted share, and losses on retirement of debt of
$211 million, or $0.47 per diluted share. The 2018 results include gains on
sales of facilities of $428 million, or $0.91 per diluted share, and losses on
retirement of debt of $9 million, or $0.02 per diluted share. The 2019 results
include revenues of $86 million, or $0.19 per diluted share, related to the
resolution of transaction price differences regarding certain
out-of-network
services performed in prior periods. The 2018 results include a reduction in our
provision for income taxes of $67 million, or $0.19 per diluted share, for the
remeasurement of certain of our deferred tax assets and liabilities for which we
were unable to record reasonable estimates in 2017. During 2019 and 2018, we
recorded reductions to the provision for professional liability risks of
$50 million, or $0.11 per diluted share, and $70 million, or $0.15 per diluted
share, respectively. During 2018, we recorded additional expenses and losses of
revenues estimated at approximately $31 million, or $0.07 per diluted share,
associated with the impact of hurricane Michael on our Florida facilities. This
amount is prior to any insurance recoveries. During 2018, we recorded a benefit
of $49 million, or $0.11 per diluted share, from an insurance recovery related
to hurricane Harvey business interruption losses incurred during 2017, and we
recorded a reduction to the provision for income taxes of $28 million, or $0.08
per diluted share, for tax credits related to certain 2017 hurricane-related
expenses. Our provisions for income taxes for 2019 and 2018 included tax
benefits of $65 million, or $0.19 per diluted share, and $124 million, or $0.35
per diluted share, respectively, related to employee equity award settlements.
All "per diluted share" disclosures are based upon amounts net of the applicable
income taxes. Shares used for diluted earnings per share were 348.226 million
shares and 355.303 million shares for the years ended December 31, 2019 and
2018, respectively. During 2019 and 2018, we repurchased 7.949 million and
14.070 million shares, respectively, of our common stock.
During 2019, consolidated admissions increased 5.2% and same facility admissions
increased 2.8% compared to 2018. Consolidated inpatient surgeries increased 3.4%
and same facility inpatient surgeries increased 1.1% during 2019 compared to
2018. Consolidated outpatient surgeries increased 4.0%, and same facility
outpatient surgeries increased 1.6% during 2019 compared to 2018. Emergency room
visits increased 4.5% on a consolidated basis and increased 2.8% on a same
facility basis during 2019 compared to 2018.
Revenues increased 10.0% to $51.336 billion for 2019 from $46.677 billion for
2018. The increase in revenues was primarily due to the combined impact of a
3.2% increase in revenue per equivalent admission and a 6.6% increase in
equivalent admissions compared to 2018. Same facility revenues increased 5.9%
due primarily to the combined impact of a 2.3% increase in same facility revenue
per equivalent admission and a 3.5% increase in same facility equivalent
admissions compared to 2018.
Salaries and benefits, as a percentage of revenues, were 45.9% each in 2019 and
2018. Salaries and benefits per equivalent admission increased 3.1% in 2019
compared to 2018. Same facility labor rate increases averaged 2.7% for 2019
compared to 2018. Share-based compensation expense was $347 million in 2019 and
$268 million in 2018.
Supplies, as a percentage of revenues, were 16.5% each in 2019 and 2018. Supply
costs per equivalent admission increased 3.0% in 2019 compared to 2018. Supply
costs per equivalent admission increased 2.8% for medical devices, 8.6% for
pharmacy supplies and 1.0% for general medical and surgical items in 2019
compared to 2018. Same facility supply costs per equivalent admission increased
1.6% for medical devices and 2.2% for general medical and surgical items and
declined 2.1% for pharmacy supplies in 2019 compared to 2018.
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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Results of Operations (continued)
Years Ended December 31, 2019 and 2018 (continued)
Other operating expenses, as a percentage of revenues, were 18.5% each in 2019
and 2018. Other operating expenses are primarily comprised of contract services,
professional fees, repairs and maintenance, rents and leases, utilities,
insurance (including professional liability insurance) and nonincome taxes.
Provisions for losses related to professional liability risks were $497 million
and $447 million for 2019 and 2018, respectively.
Equity in earnings of affiliates was $43 million for 2019 and $29 million for
2018.
Depreciation and amortization, as a percentage of revenues, was 5.0% in 2019 and
4.9% in 2018. Depreciation expense was $2.579 billion for 2019 and
$2.262 billion for 2018, and the $317 million increase was due to both
acquisitions and increased capital expenditures in 2019 (same facility
depreciation amortization increased $154 million).
Interest expense increased to $1.824 billion for 2019 from $1.755 billion for
2018. The increase in interest expense was due to an increase in the average
debt balance. Our average debt balance was $34.288 billion for 2019 compared to
$33.065 billion for 2018. The average interest rate for our long-term debt was
5.3% for both 2019 and 2018.
Gains on sales of facilities were $18 million and $428 million, respectively,
for 2019 and 2018. The gains on sales of facilities for 2019 related primarily
to sales of real estate and other investments. The gains on sales of facilities
for 2018 related primarily to the sale of the two hospital facilities in our
Oklahoma market.
During June 2019, we issued $5.000 billion aggregate principal amount of senior
secured notes comprised of $2.000 billion aggregate principal amount of 4 1/8%
notes due 2029, $1.000 billion aggregate principal amount of 5 1/8% notes due
2039 and $2.000 billion aggregate principal amount of 5 1/4% notes due 2049.
During July 2019, we redeemed all $600 million outstanding aggregate principal
amount of 4.25% senior secured notes due 2019, all $3.000 billion outstanding
aggregate principal amount of 6.50% senior secured notes due 2020 and all
$1.350 billion outstanding aggregate principal amount of 5.875% senior secured
notes due 2022. The pretax loss on retirement of debt for these redemptions was
$211 million. During 2018, we issued $2.000 billion aggregate principal amount
of senior notes comprised of $1.000 billion aggregate principal amount of 5.375%
notes due 2026 and $1.000 billion aggregate principal amount of 5.625% notes due
2028. We used the net proceeds for general corporate purposes, including funding
the purchase of a hospital, and the redemption of all $1.500 billion aggregate
principal amount of our existing 3.750% senior secured notes maturing in March
2019. The pretax loss on retirement of debt was $9 million.
The effective tax rates were 23.9% and 20.0% for 2019 and 2018, respectively.
The effective tax rate computations exclude net income attributable to
noncontrolling interests as it relates to consolidated partnerships. Our
provision for income taxes for 2018 included $28 million of benefits for tax
credits related to certain 2017 hurricane-related expenses and $67 million of
benefits related to the remeasurement of our deferred tax assets and liabilities
due to the enactment of the Tax Act. Our provisions for income taxes for 2019
and 2018 also included tax benefits of $65 million and $124 million,
respectively, related to employee equity award settlements. Excluding the effect
of these adjustments, the effective tax rates for 2019 and 2018 would have been
25.3% and 24.6%, respectively.
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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Results of Operations (continued)
Years Ended December 31, 2019 and 2018 (continued)
Net income attributable to noncontrolling interests increased from $602 million
for 2018 to $640 million for 2019. The increase in net income attributable to
noncontrolling interests related primarily to a joint venture in one of our
Texas markets and the operations of our surgery center partnerships.
For results of operations comparisons relating to years ending December 31, 2018
and 2017, refer to our annual report on Form
10-K,
Item 7. Management's Discussion and Analysis of Financial Condition and Results
of Operations for the year ended December 31, 2018, filed with the Securities
and Exchange Commission on February 21, 2019.
Liquidity and Capital Resources
Our primary cash requirements are paying our operating expenses, servicing our
debt, capital expenditures on our existing properties, acquisitions of hospitals
and other health care entities, repurchases of our common stock, distributions
to stockholders and distributions to noncontrolling interests. Our primary cash
sources are cash flows from operating activities, issuances of debt and equity
securities and dispositions of hospitals and other health care entities.
Cash provided by operating activities totaled $7.602 billion in 2019 compared to
$6.761 billion in 2018 and $5.426 billion in 2017. The $841 million increase in
cash provided by operating activities for 2019, compared to 2018, was primarily
related to the increase in net income, excluding gains on sales of facilities
and losses on retirement of debt, of $222 million and increases related to
income taxes of $322 million and depreciation and amortization of $318 million.
The $1.335 billion increase in cash provided by operating activities for 2018,
compared to 2017, was primarily related to the increase in net income, excluding
gains on sales of facilities, of $1.309 billion. Working capital totaled
$3.439 billion at December 31, 2019 and $2.644 billion at December 31, 2018. The
increase in working capital of $795 million is primarily related to a decline in
long-term debt due within one year of $643 million. Cash payments for interest
and income taxes increased $147 million for 2019 compared to 2018 and declined
$289 million for 2018 compared to 2017.
Cash used in investing activities was $5.720 billion, $3.901 billion and
$4.279 billion in 2019, 2018 and 2017, respectively. Excluding acquisitions,
capital expenditures were $4.158 billion in 2019, $3.573 billion in 2018 and
$3.015 billion in 2017. We expended $1.682 billion, $1.253 billion and
$1.212 billion for acquisitions of hospitals and health care entities during
2019, 2018 and 2017, respectively. Planned capital expenditures are expected to
approximate $4.0 billion to $4.2 billion in 2020. At December 31, 2019, there
were projects under construction which had an estimated additional cost to
complete and equip over the next five years of approximately $3.0 billion. We
expect to finance capital expenditures with internally generated and borrowed
funds. Cash received from sales of hospitals and health care entities declined
$747 million for 2019 compared to 2018 primarily related to the receipt during
2018 of $758 million from the sale of the two hospitals in our Oklahoma market.
Cash used in financing activities totaled $1.771 billion in 2019, $3.075 billion
in 2018 and $1.061 billion in 2017. During 2019, we had a net increase of
$567 million in our indebtedness, paid dividends of $550 million and paid
$1.031 billion for repurchases of common stock. During 2018, we had a net
decline of $344 million in our indebtedness, paid dividends of $487 million and
paid $1.530 billion for repurchases of common stock. During 2017, we had a net
increase of $1.509 billion in our indebtedness and paid $2.051 billion for
repurchases
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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Liquidity and Capital Resources (continued)
of common stock. During 2019, 2018 and 2017, we made distributions to
noncontrolling interests of $542 million, $441 million and $448 million,
respectively.
We, or our affiliates, may in the future repurchase portions of our debt or
equity securities, subject to certain limitations, from time to time in either
the open market or through privately negotiated transactions, in accordance with
applicable SEC and other legal requirements. The timing, prices, and sizes of
purchases depend upon prevailing trading prices, general economic and market
conditions, and other factors, including applicable securities laws. During
January 2020 and 2019, our Board of Directors authorized share repurchase
programs for up to $4 billion ($2 billion for each authorization) of our
outstanding common stock, and at December 31, 2019, there was $1.241 billion of
share repurchase authorization that remained available under the January 2019
authorization. Funds for the repurchase of debt or equity securities have, and
are expected to, come primarily from cash generated from operations and borrowed
funds. On January 27, 2020, our Board of Directors declared a quarterly dividend
of $0.43 per share on our common stock payable on March 31, 2020 to stockholders
of record at the close of business on March 2, 2020. During 2019, our Board of
Directors declared four quarterly dividends of $0.40 per share, or $1.60 per
share in the aggregate, on our common stock. The timing and amount of future
cash dividends will vary based on a number of factors, including future capital
requirements for strategic transactions, share repurchases and investing in our
existing markets, the availability of financing on acceptable terms, debt
service requirements, changes to applicable tax laws or corporate laws, changes
to our business model and periodic determinations by our Board of Directors that
cash dividends are in the best interest of stockholders and are in compliance
with all applicable laws and agreements of the Company.
In addition to cash flows from operations, available sources of capital include
amounts available under our senior secured credit facilities ($3.237 billion as
of December 31, 2019 and $3.187 billion as of January 31, 2020) and anticipated
access to public and private debt and equity markets.
Investments of our insurance subsidiaries, held to maintain statutory equity
levels and to provide liquidity to pay claims, totaled $462 million and
$409 million at December 31, 2019 and 2018, respectively. The insurance
subsidiary maintained net reserves for professional liability risks of
$175 million and $183 million at December 31, 2019 and 2018, respectively. Our
facilities are insured by our 100% owned insurance subsidiary for losses up to
$50 million per occurrence; however, this coverage is subject, in most cases, to
a $15 million per occurrence self-insured retention. Net reserves for the
self-insured professional liability risks retained were $1.606 billion and
$1.509 billion at December 31, 2019 and 2018, respectively. Claims payments, net
of reinsurance recoveries, during the next 12 months are expected to approximate
$448 million. We estimate that approximately $394 million of the expected net
claim payments during the next 12 months will relate to claims subject to the
self-insured retention.
Financing Activities
We are a highly leveraged company with significant debt service requirements.
Our debt totaled $33.722 billion and $32.821 billion at December 31, 2019 and
2018, respectively. Our interest expense was $1.824 billion for 2019 and
$1.755 billion for 2018.
During August 2018, we issued $2.000 billion aggregate principal amount of
senior unsecured notes comprised of $1.000 billion aggregate principal amount of
5.375% notes due 2026 and $1.000 billion aggregate principal amount of 5.625%
notes due 2028. We used the net proceeds for general corporate purposes,
including
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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Liquidity and Capital Resources (continued)
Financing Activities (continued)
funding the purchase of a hospital, and the redemption of all $1.500 billion
aggregate principal amount of our existing 3.750% senior secured notes maturing
in March 2019.
During January 2019, we issued $1.500 billion aggregate principal amount of
senior unsecured notes comprised of $1.000 billion aggregate principal amount of
5.875% notes due 2029 and $500 million aggregate principal amount of 5.625%
notes due 2028. We used the net proceeds to fund the purchase of a
seven-hospital health system located in western North Carolina.
During June 2019, we issued $5.000 billion aggregate principal amount of senior
secured notes comprised of $2.000 billion aggregate principal amount of 4 1/8%
notes due 2029, $1.000 billion aggregate principal amount of 5 1/8% notes due
2039 and $2.000 billion aggregate principal amount of 5 1/4% notes due 2049.
During July 2019, we redeemed all $600 million outstanding aggregate principal
amount of 4.25% senior secured notes due 2019, all $3.000 billion outstanding
aggregate principal amount of 6.50% senior secured notes due 2020 and all
$1.350 billion outstanding aggregate principal amount of 5.875% senior secured
notes due 2022.
Management believes that cash flows from operations, amounts available under our
senior secured credit facilities and our anticipated access to public and
private debt markets will be sufficient to meet expected liquidity needs during
the next twelve months.
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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Contractual Obligations and
Off-Balance
Sheet Arrangements
As of December 31, 2019, maturities of contractual obligations and other
commercial commitments are presented in the table below (dollars in millions):

                                                              Payments Due by Period
                                                                    2-3           4-5
Contractual Obligations(a)             Total        Current         Years        Years        After 5 Years
Long-term debt including interest,
excluding the senior secured
credit facilities(b)                  $ 42,756$  1,667$  6,061$ 7,227$        27,801
Loans outstanding under the senior
secured credit facilities,
including interest(b)                    7,132           266         3,031        1,284                2,551
Professional liability risks(c)          1,827           457           774          399                  197
Right-of-use operating lease
obligations                              2,530           411           635          410                1,074
Other obligations(d)                        25            22             2            1                    -

Total contractual obligations $ 54,270$ 2,823$ 10,503

    $ 9,321$        31,623




                                                                     Commitment Expiration by Period
Other Commercial Commitments Not Recorded on the                                 2-3         4-5
Consolidated Balance Sheet                          Total         Current       Years       Years       After 5 Years
Surety bonds(e)                                    $     60$     59$     1     $     -     $             -
Letters of credit(e)                                     33             18          15           -                   -
Physician commitments(f)                                 37             30           7           -                   -

Total commercial commitments                       $    130$    107$    23     $     -     $             -



(a) We have not included obligations related to unrecognized tax benefits of

$550 million at December 31, 2019, as we cannot reasonably estimate the

timing or amounts of cash payments, if any, at this time.

(b) Estimates of interest payments assume that interest rates and borrowing

spreads at December 31, 2019, remain constant during the period presented.

(c) The estimation of the timing of payments for professional liability risks

beyond a year can vary significantly. The time period required to resolve

these claims can vary depending upon the jurisdiction and whether the claim

is settled or litigated.

(d) Amounts include physician commitments that are recorded in our consolidated

balance sheet. Amounts also include future other obligations that are not

recorded in our consolidated balance sheet.

(e) Amounts relate primarily to instances in which we have agreed to indemnify

various commercial insurers and lenders who have provided surety bonds and

letters of credit to cover damages for legal cases which were awarded to

plaintiffs by the courts, Medicaid provider bonds, educational administrative

bonds and utility and construction deposits.

(f) In consideration for physicians relocating to the communities in which our

hospitals are located and agreeing to engage in private practice for the

benefit of the respective communities, we make advances to physicians to

assist in establishing the physicians' practices. The actual amount of these

commitments to be advanced often depends upon the financial results of the

physicians' private practice during the recruitment agreement payment period.

    The physician commitments reflected were based on our maximum exposure on
    effective agreements at December 31, 2019.


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                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Market Risk
We are exposed to market risk related to changes in market values of securities.
The investments in our 100% owned insurance subsidiaries were $462 million at
December 31, 2019. These investments are carried at fair value, with changes in
unrealized gains and losses being recorded as adjustments to other comprehensive
income. At December 31, 2019, we had a net unrealized gain of $18 million on the
insurance subsidiaries' investment securities.
We are exposed to market risk related to market illiquidity. Investments in debt
and equity securities of our 100% owned insurance subsidiaries could be impaired
by the inability to access the capital markets. Should the 100% owned insurance
subsidiaries require significant amounts of cash in excess of normal cash
requirements to pay claims and other expenses on short notice, we may have
difficulty selling these investments in a timely manner or be forced to sell
them at a price less than what we might otherwise have been able to in a normal
market environment. We may be required to recognize credit-related impairments
on our investment securities in future periods should issuers default on
interest payments or should the fair market valuations of the securities
deteriorate due to ratings downgrades or other issue-specific factors.
We are also exposed to market risk related to changes in interest rates, and we
periodically enter into interest rate swap agreements to manage our exposure to
these fluctuations. Our interest rate swap agreements involve the exchange of
fixed and variable rate interest payments between two parties, based on common
notional principal amounts and maturity dates. The notional amounts of the swap
agreements represent balances used to calculate the exchange of cash flows and
are not our assets or liabilities. Our credit risk related to these agreements
is considered low because the swap agreements are with creditworthy financial
institutions. The interest payments under these agreements are settled on a net
basis. These derivatives have been recognized in the financial statements at
their respective fair values. Changes in the fair value of these derivatives,
which are designated as cash flow hedges, are included in other comprehensive
income.
With respect to our interest-bearing liabilities, approximately $3.706 billion
of long-term debt at December 31, 2019 was subject to variable rates of
interest, while the remaining balance in long-term debt of $30.016 billion at
December 31, 2019 was subject to fixed rates of interest. Both the general level
of interest rates and, for the senior secured credit facilities, our leverage
affect our variable interest rates. Our variable debt is comprised primarily of
amounts outstanding under the senior secured credit facilities. Borrowings under
the senior secured credit facilities bear interest at a rate equal to an
applicable margin plus, at our option, either (a) a base rate determined by
reference to the higher of (1) the federal funds rate plus 0.50% and (2) the
prime rate of Bank of America or (b) a LIBOR rate for the currency of such
borrowing for the relevant interest period. The applicable margin for borrowings
under the senior secured credit facilities may fluctuate according to a leverage
ratio. The average effective interest rate for our long-term debt was 5.3% for
both 2019 and 2018, respectively.
The estimated fair value of our total long-term debt was $37.026 billion at
December 31, 2019. The estimates of fair value are based upon the quoted market
prices for the same or similar issues of long-term debt with the same
maturities. Based on a hypothetical 1% increase in interest rates, the potential
annualized reduction to future pretax earnings would be approximately
$37 million. To mitigate the impact of fluctuations in interest rates, we
generally target a majority of our debt portfolio to be maintained at fixed
rates.
We are exposed to currency translation risk related to our foreign operations.
We currently do not consider the market risk related to foreign currency
translation to be material to our consolidated financial statements or our
liquidity.
                                       71

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Table of Contents

                              HCA HEALTHCARE, INC.
          MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION
                     AND RESULTS OF OPERATIONS (Continued)
Market Risk (continued)
Financial Instruments
Derivative financial instruments are employed to manage risks, including
interest rate exposures, and are not used for trading or speculative purposes.
We recognize derivative instruments, such as interest rate swap agreements, in
the consolidated balance sheets at fair value. Changes in the fair value of
derivatives are recognized periodically either in earnings or in stockholders'
equity, as a component of other comprehensive income, depending on whether the
derivative financial instrument qualifies for hedge accounting, and if so,
whether it qualifies as a fair value hedge or a cash flow hedge. Gains and
losses on derivatives designated as cash flow hedges, to the extent they are
effective, are recorded in other comprehensive income, and subsequently
reclassified to earnings to offset the impact of the hedged items when they
occur.
The net interest paid or received on interest rate swaps is recognized as
interest expense. Gains and losses resulting from the early termination of
interest rate swap agreements are deferred and amortized as adjustments to
expense over the remaining period of the debt originally covered by the
terminated swap.
Effects of Inflation and Changing Prices
Various federal, state and local laws have been enacted that, in certain cases,
limit our ability to increase prices. Revenues for general, acute care hospital
services rendered to Medicare patients are established under the federal
government's prospective payment system. Total
fee-for-service
Medicare revenues were 21.0%, 21.1% and 21.3% of our revenues for 2019, 2018 and
2017, respectively.
Management believes hospital industry operating margins have been, and may
continue to be, under significant pressure because of changes in payer and
service mix and growth in operating expenses in excess of the increase in
prospective payments under the Medicare program. In addition, as a result of
increasing regulatory and competitive pressures, our ability to maintain
operating margins through price increases to
non-Medicare
patients is limited.
Tax Examinations
The Internal Revenue Service began an examination of the Company's 2016 and 2017
federal income tax returns during 2019. We are also subject to examination by
state and foreign taxing authorities. Management believes HCA Healthcare, Inc.,
its predecessors, subsidiaries and affiliates properly reported taxable income
and paid taxes in accordance with applicable laws and agreements established
with the IRS, state and foreign taxing authorities, and final resolution of any
disputes will not have a material, adverse effect on our results of operations
or financial position. However, if payments due upon final resolution of any
issues exceed our recorded estimates, such resolutions could have a material,
adverse effect on our results of operations or financial position.
                                       72
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  Table of Contents
Item 7A. Quantitative and Qualitative Disclosures about Market Risk
Information with respect to this Item is provided under the caption "Market
Risk" under Item 7, "Management's Discussion and Analysis of Financial Condition
and Results of Operations."
Item 8. Financial Statements and Supplementary Data
Information with respect to this Item is contained in our consolidated financial
statements indicated in the Index to Consolidated Financial Statements on Page
F-1
of this annual report on Form
10-K.
Item 9. Changes in and Disagreements with Accountants on Accounting and Financial
        Disclosure











None.

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