HCA HEALTHCARE, INC.

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HCA HEALTHCARE, INC. MANAGEMENT'S DISCUSSION AND ANALYSIS OF FINANCIAL CONDITION AND RESULTS OF OPERATIONS (form 10-Q)

05/03/2022 | 04:36pm EDT

Forward-Looking Statements

This quarterly report on Form 10-Q 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 and 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) developments related to COVID-19, including, without limitation, the length and severity of its impact and the spread of virus strains with new epidemiological characteristics; the volume of canceled or rescheduled procedures and the volume of COVID-19 patients cared for across our health systems; measures we are taking to respond to COVID-19; the impact and terms of government and administrative regulation and stimulus and relief measures (including the Families First Coronavirus Response Act, the Coronavirus Aid, Relief, and Economic Security ("CARES") Act, the Paycheck Protection Program and Health Care Enhancement Act, the Consolidated Appropriations Act, 2021, the American Rescue Plan Act of 2021 ("ARPA") and other enacted and potential future legislation) and whether various stimulus and relief programs continue or new similar programs are enacted in the future; changes in revenues due to declining patient volumes, changes in payer mix and deteriorating macroeconomic conditions (including increases in uninsured and underinsured patients); potential increased expenses related to labor, supply chain or other expenditures; workforce disruptions, including the impact of any current or future vaccine mandates; supply shortages and disruptions; and the timing, availability and adoption of effective medical treatments and vaccines (including boosters), (2) the impact of our substantial indebtedness and the ability to refinance such indebtedness on acceptable terms, as well as risks associated with disruptions in the financial markets and the business of financial institutions as the result of COVID-19, which could impact us from a financial perspective, (3) the impact of current and future federal and state health reform initiatives and possible changes to other federal, state or local laws and regulations affecting the health care industry, including but not limited to, the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively, the "Affordable Care Act"), and the effects of additional changes to the Affordable Care Act, its implementation, or interpretation (including through executive orders and court challenges), and proposals to expand coverage of federally-funded insurance programs as an alternative to private insurance or establish a single-payer system (such reforms often referred to as "Medicare for All"), and also including any such laws or governmental regulations which are adopted in response to COVID-19, (4) the effects related to the implementation of sequestration spending reductions required under the Budget Control Act of 2011, related legislation extending these reductions and those required under the Pay-As-You-Go Act of 2010 ("PAYGO Act") as a result of the federal budget deficit impact of the ARPA, 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, (5) increases in the amount and risk of collectability of uninsured accounts and deductibles and copayment amounts for insured accounts, (6) the ability to achieve operating and financial targets, and attain expected levels of patient volumes and control the costs of providing services, (7) 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, (8) increases in wages and the ability to attract and retain qualified management and personnel, including affiliated physicians, nurses and medical and technical support personnel, (9) the highly competitive nature of the health care business, (10) 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, (11) the efforts of health insurers, health care providers, large employer groups and others to contain health care costs, (12) the outcome of our continuing efforts to monitor, maintain and comply with appropriate laws, regulations, policies and procedures, (13) the availability and terms of capital to fund the expansion of our business and improvements to our existing facilities, (14) changes in accounting practices, (15) changes in general economic conditions nationally and regionally in our markets, including inflation and economic and business conditions (and the impact thereof on the economy, financial markets and banking industry) resulting from COVID-19, (16) the emergence of and effects related to pandemics, epidemics and infectious diseases, (17) future divestitures which may result in charges and possible impairments of long-lived assets, (18) changes in business strategy or development plans, (19) delays in receiving payments for services provided, (20) the outcome of pending and any future tax audits, disputes and litigation associated with our tax positions, (21) potential adverse impact of known and unknown government investigations, litigation and other claims that may be made against us, (22) the impact of potential cybersecurity incidents or security breaches, (23) our ongoing ability to demonstrate meaningful use of certified electronic health record ("EHR") technology and the impact of interoperability requirements, (24) the impact of natural disasters, such as hurricanes and floods, physical risks from climate change or similar events beyond our control, (25) 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 (26) other risk factors described in our annual report on Form 10-K for the year ended December 31, 2021 and our other filings with the Securities and Exchange Commission. 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, which forward-looking statements reflect management's views only as of the date of this report. We undertake no obligation to revise or update any forward-looking statements, whether as a result of new information, future events or otherwise.


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                ITEM 2. MANAGEMENT'S DISCUSSION AND ANALYSIS OF
           FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)


COVID-19

On March 11, 2020, the World Health Organization designated COVID-19 as a global pandemic. We believe the extent of COVID-19's impact on our operating results and financial condition has been and will continue to be driven by many factors, most of which are beyond our control and ability to forecast. Because of these uncertainties, we cannot estimate how long or to what extent COVID-19 will impact our operations.

First Quarter 2022 Operations Summary

Revenues increased to $14.945 billion in the first quarter of 2022 from $13.977 billion in the first quarter of 2021. Net income attributable to HCA Healthcare, Inc. totaled $1.273 billion, or $4.14 per diluted share, for the quarter ended March 31, 2022, compared to $1.423 billion, or $4.14 per diluted share, for the quarter ended March 31, 2021. First quarter results for 2022 include gains on sales of facilities of $10 million, or $0.02 per diluted share. In March 2022, the state of Texas received approval from the Centers for Medicare & Medicaid Services ("CMS") to implement a proposed directed payment program effective for the current program year that began September 1, 2021. During the first quarter of 2022, revenues include $244 million and other operating expenses include $90 million from provider tax assessments related to this program for the period September through December 2021. All "per diluted share" disclosures are based upon amounts net of the applicable income taxes. Shares used for diluted earnings per share were 307.374 million shares for the quarter ended March 31, 2022 and 343.321 million shares for the quarter ended March 31, 2021. During 2021 and the first quarter of 2022, we repurchased 37.812 million shares and 8.375 million shares, respectively, of our common stock.

Revenues increased 6.9% on a consolidated basis and 7.8% on a same facility basis for the quarter ended March 31, 2022, compared to the quarter ended March 31, 2021. The increase in consolidated revenues can be primarily attributed to the combined impact of a 3.6% increase in revenue per equivalent admission and a 3.2% increase in equivalent admissions. The same facility revenues increase primarily resulted from the combined impact of a 2.7% increase in same facility revenue per equivalent admission and a 5.0% increase in same facility equivalent admissions. The consolidated and same facility increases in revenue per equivalent admission were negatively impacted by declines in acuity of COVID-19 patients.

During the quarter ended March 31, 2022, consolidated admissions increased 0.1% and same facility admissions increased 2.1% compared to the quarter ended March 31, 2021. Surgeries increased 4.3% on a consolidated basis and 4.6% on a same facility basis during the quarter ended March 31, 2022, compared to the quarter ended March 31, 2021. Emergency department visits increased 11.7% on a consolidated basis and 14.6% on a same facility basis during the quarter ended March 31, 2022, compared to the quarter ended March 31, 2021. Consolidated and same facility uninsured admissions declined 4.9% and 3.0%, respectively, for the quarter ended March 31, 2022, compared to the quarter ended March 31, 2021.

Cash flows from operating activities declined $643 million, from $1.988 billion for the first quarter of 2021 to $1.345 billion for the first quarter of 2022. The decline in cash provided by operating activities was primarily related to the combined impact of negative changes in working capital items of $492 million, primarily related to a payment of $344 million for deferred payroll taxes from 2020, and a $121 million decline in net income, excluding gains on sales of facilities.


Results of Operations

Revenue/Volume Trends

Our revenues generally relate to contracts with patients in which our performance obligations are to provide health care services to the patients. Revenues are recorded during the period our obligations to provide health care services are satisfied. Our performance obligations for inpatient services are generally satisfied over periods that average approximately five days, and revenues are recognized based on charges incurred in relation to total expected charges. Our performance obligations for outpatient services are generally satisfied over a period of less than one day. The contractual relationships with patients, in most cases, also involve a third-party payer (Medicare, Medicaid, managed care health plans and commercial insurance companies, including plans offered through the health insurance exchanges) and the transaction prices for the services provided are dependent upon the terms provided by (Medicare and Medicaid) or negotiated with (managed care health plans and commercial insurance companies) the third-party payers. The payment arrangements with third-party payers for the services we provide to the related patients typically specify payments at amounts less than our standard charges. Medicare generally pays for inpatient and outpatient services at prospectively determined rates based on clinical, diagnostic and other factors. Services provided to patients having Medicaid coverage are generally paid at prospectively determined rates per discharge, per identified service or per covered member. Agreements with commercial insurance carriers, managed care and preferred provider organizations generally provide for payments based upon predetermined rates per diagnosis, per diem rates or discounted fee-for-service rates. 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.


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                ITEM 2. MANAGEMENT'S DISCUSSION AND ANALYSIS OF
           FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)


Results of Operations (continued)

Revenue/Volume Trends (continued)

Revenues increased 6.9% from $13.977 billion in the first quarter of 2021 to $14.945 billion in the first quarter of 2022. Managed Medicaid revenues for the quarter ended March 31, 2022 include $244 million, for the period from September through December 2021, related to the March 2022 CMS approval of a Texas directed payment program for the current program year that began September 1, 2021. Our revenues are based upon the estimated amounts we expect to be entitled to receive from patients and third-party payers. Estimates of contractual adjustments under managed care and commercial insurance plans are based upon the payment terms specified in the related contractual agreements. Revenues related to uninsured patients and uninsured copayment and deductible amounts for patients who have health care coverage may have discounts applied (uninsured discounts and contractual discounts). We also record estimated implicit price concessions (based primarily on historical collection experience) related to uninsured accounts to record self-pay revenues at the estimated amounts we expect to collect. Patients treated at our hospitals for non-elective care, who have income at or below 400% of the federal poverty level, are eligible for charity care. Because we do not pursue collection of amounts determined to qualify as charity care, they are not reported in revenues. Our revenues by primary third-party payer classification and other (including uninsured patients) for the quarters ended March 31, 2022 and 2021 are summarized in the following table (dollars in millions):


                                              2022        Ratio        2021        Ratio
Medicare                                    $  2,726        18.2 %   $  2,559        18.3 %
Managed Medicare                               2,324        15.6        2,053        14.7
Medicaid                                         579         3.9          527         3.8
Managed Medicaid                               1,110         7.4          725         5.2
Managed care and insurers                      7,152        47.9        6,885        49.1
International (managed care and insurers)        356         2.4          333         2.4
Other                                            698         4.6          895         6.5
Revenues                                    $ 14,945       100.0 %   $ 13,977       100.0 %



Consolidated and same facility revenue per equivalent admission increased 3.6% and 2.7%, respectively, in the first quarter of 2022, compared to the first quarter of 2021. Consolidated and same facility equivalent admissions increased 3.2% and 5.0%, respectively, in the first quarter of 2022, compared to the first quarter of 2021. Consolidated and same facility outpatient surgeries increased 7.0% and 6.8%, respectively, in the first quarter of 2022, compared to the first quarter of 2021. Consolidated and same facility inpatient surgeries declined 0.6% and increased 0.8%, respectively, in the first quarter of 2022, compared to the first quarter of 2021. Consolidated and same facility emergency department visits increased 11.7% and 14.6%, respectively, in the first quarter of 2022, compared to the first quarter of 2021.

To quantify the total impact of the 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 quarters ended March 31, 2022 and 2021 follows (dollars in millions):



                                                                  2022         2021

Patient care costs (salaries and benefits, supplies, other operating expense and depreciation

  and amortization)                                             $ 12,744     $ 11,643

Cost-to-charges ratio (patient care costs as percentage of gross patient charges)

                                              11.3 %       11.4 %
Total uncompensated care                                        $  7,005     $  6,821
Multiply by the cost-to-charges ratio                               11.3 %       11.4 %
Estimated cost of total uncompensated care                      $    792     $    778




Same facility uninsured admissions declined by 1,030 admissions, or 3.0%, in the first quarter of 2022 compared to the first quarter of 2021. Same facility uninsured admissions in 2021, compared to 2020, declined 6.3% in the fourth quarter, increased 1.2% in the third quarter, increased 6.6% in the second quarter of 2021, and declined 15.7% in the first quarter. The fluctuations in quarterly same facility admissions were primarily due to reimbursements received, as provided for under the Families First Coronavirus Response Act and subsequent legislation, for uninsured patients diagnosed with COVID-19 and the resulting classification of those patients as insured admissions, as well as general fluctuations in patient volumes resulting from COVID-19's impact on our operations. The government program to reimburse for testing and treatment of uninsured COVID-19 patients stopped accepting claims in March 2022.



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                ITEM 2. 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 quarters ended March 31, 2022 and 2021 are set forth in the following table.


                            2022      2021
Medicare                       23 %      24 %
Managed Medicare               23        22
Medicaid                        5         5
Managed Medicaid               13        12
Managed care and insurers      30        30
Uninsured                       6         7
                              100 %     100 %



The approximate percentages of our inpatient revenues related to Medicare, managed Medicare, Medicaid, managed Medicaid, managed care and insurers for the quarters ended March 31, 2022 and 2021 are set forth in the following table.

                            2022      2021
Medicare                       24 %      24 %
Managed Medicare               18        17
Medicaid                        6         5
Managed Medicaid                9         6
Managed care and insurers      43        48
                              100 %     100 %



At March 31, 2022, we had 91 hospitals in the states of Texas and Florida. During the quarter ended March 31, 2022, 58% of our admissions and 50% of our revenues were generated by these hospitals. Uninsured admissions in Texas and Florida represented 75% of our uninsured admissions during the quarter ended March 31, 2022.

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. The Texas Healthcare Transformation and Quality Improvement Program ("Texas Waiver Program") currently operates pursuant to a Medicaid waiver. During April 2022, CMS withdrew its previous letter that challenged the approval and extension of the Texas Waiver Program, and the program is now approved and extended through September 2030. Our Texas Medicaid revenues included Texas Waiver Program supplemental revenues of $103 million and $138 million during the first quarters of 2022 and 2021, respectively. In March 2022, the state of Texas received approval from CMS to implement a proposed directed payment program effective for the current program year that began September 1, 2021. During the first quarter of 2022, revenues include $385 million related to this program for the period September 2021 through March 2022. We receive supplemental payments in several other states. We are aware these supplemental payment programs are currently being reviewed by certain state agencies and some states have made requests to CMS to replace their existing supplemental payment programs. It is possible these reviews and 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.

Key Performance Indicators

We present certain metrics and statistical information that management uses when assessing our results of operations. We believe this information is useful to investors as it provides insight to how management evaluates operational performance and trends between reporting periods. Information on how these metrics and statistical information are defined is provided in the following tables summarizing operating results and operating data.


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                ITEM 2. MANAGEMENT'S DISCUSSION AND ANALYSIS OF
           FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)



Results of Operations (continued)

Operating Results Summary

The following is a comparative summary of results of operations for the quarters ended March 31, 2022 and 2021 (dollars in millions):

                                                      2022                       2021
                                               Amount        Ratio        Amount       Ratio
Revenues                                      $ 14,945        100.0      $ 13,977       100.0

Salaries and benefits                            6,939         46.4         6,301        45.1
Supplies                                         2,321         15.5         2,224        15.9
Other operating expenses                         2,752         18.5         2,421        17.4
Equity in earnings of affiliates                   (11 )       (0.1 )         (21 )      (0.2 )
Depreciation and amortization                      732          5.0           697         5.0
Interest expense                                   408          2.7           384         2.7
Gains on sales of facilities                       (10 )       (0.1 )          (2 )         -
                                                13,131         87.9        12,004        85.9
Income before income taxes                       1,814         12.1         1,973        14.1
Provision for income taxes                         349          2.3           393         2.8
Net income                                       1,465          9.8         1,580        11.3
Net income attributable to noncontrolling
interests                                          192          1.3           157         1.1
Net income attributable to HCA Healthcare,
Inc.                                          $  1,273          8.5      $  1,423        10.2
% changes from prior year:
Revenues                                           6.9 %                      8.7 %
Income before income taxes                        (8.1 )                    143.6
Net income attributable to HCA Healthcare,
Inc.                                             (10.6 )                    145.0
Admissions(a)                                      0.1                       (4.1 )
Equivalent admissions(b)                           3.2                       (6.4 )
Revenue per equivalent admission                   3.6                       16.1
Same facility % changes from prior year(c):
Revenues                                           7.8                        9.0
Admissions(a)                                      2.1                       (4.2 )
Equivalent admissions(b)                           5.0                       (6.5 )
Revenue per equivalent admission                   2.7                       16.6




(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 revenues and gross outpatient revenues and then dividing the resulting
amount by gross inpatient revenues. The equivalent admissions computation
"equates" outpatient revenues 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 which were either acquired or divested during the current and prior
period.


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                ITEM 2. MANAGEMENT'S DISCUSSION AND ANALYSIS OF
           FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)


Results of Operations (continued)

Quarters Ended March 31, 2022 and 2021

Revenues increased to $14.945 billion in the first quarter of 2022 from $13.977 billion in the first quarter of 2021. Net income attributable to HCA Healthcare, Inc. totaled $1.273 billion, or $4.14 per diluted share, for the quarter ended March 31, 2022, compared to $1.423 billion, or $4.14 per diluted share, for the quarter ended March 31, 2021. First quarter results for 2022 include gains on sales of facilities of $10 million, or $0.02 per diluted share. In March 2022, the state of Texas received approval from CMS to implement a proposed directed payment program effective for the current program year that began September 1, 2021. During the first quarter of 2022, revenues include $244 million and other operating expenses include $90 million from provider tax assessments related to this program for the period September through December 2021. All "per diluted share" disclosures are based upon amounts net of the applicable income taxes. Shares used for diluted earnings per share were 307.374 million shares for the quarter ended March 31, 2022 and 343.321 million shares for the quarter ended March 31, 2021. During 2021 and the first quarter of 2022, we repurchased 37.812 million shares and 8.375 million shares, respectively, of our common stock.

Revenues increased 6.9% on a consolidated basis and 7.8% on a same facility basis for the quarter ended March 31, 2022, compared to the quarter ended March 31, 2021. The increase in consolidated revenues can be primarily attributed to the combined impact of a 3.6% increase in revenue per equivalent admission and a 3.2% increase in equivalent admissions. The same facility revenues increase primarily resulted from the combined impact of a 2.7% increase in same facility revenue per equivalent admission and a 5.0% increase in same facility equivalent admissions. The consolidated and same facility increases in revenue per equivalent admission were negatively impacted by declines in acuity of COVID-19 patients.

Salaries and benefits, as a percentage of revenues, were 46.4% in the first quarter of 2022 and 45.1% in the first quarter of 2021. Salaries and benefits per equivalent admission increased 6.7% in the first quarter of 2022 compared to the first quarter of 2021. Same facility salaries and benefits per full time equivalent increased 7.7% for the first quarter of 2022 compared to the first quarter of 2021 as we continue to utilize certain contract, overtime and other premium rate labor costs to support our clinical staff and patients. We intend to reduce our utilization of and rates paid for premium rate labor, but the pace and amount of any expected future declines may be affected by labor market conditions and other factors.

Supplies, as a percentage of revenues, were 15.5% in the first quarter of 2022 and 15.9% in the first quarter of 2021. Supply costs per equivalent admission increased 1.1% in the first quarter of 2022 compared to the first quarter of 2021. Supply costs per equivalent admission increased 5.9% for medical devices and 2.5% for general medical and surgical items and declined 10.7% for pharmacy supplies in the first quarter of 2022 compared to the first quarter of 2021. The decline in pharmacy supplies is primarily related to certain COVID-19 therapies used in the surge of COVID-19 cases during the first quarter of 2021.

Other operating expenses, as a percentage of revenues, were 18.5% in the first quarter of 2022 and 17.4% in the first quarter of 2021. Other operating expenses is primarily comprised of contract services, professional fees, repairs and maintenance, rents and leases, utilities, insurance (including professional liability insurance) and nonincome taxes. We have seen inflation have a negative impact on certain of these expenses and expect inflationary pressures will continue to impact operating expenses in the future. Provisions for losses related to professional liability risks were $143 million and $134 million for the first quarters of 2022 and 2021, respectively. For the quarter ended March 31, 2022, other operating expenses included $90 million of Texas provider tax assessments for September through December 2021 related to CMS' March 2022 approval of a Texas directed payment program (effective for the current program year that began September 1, 2021).

Equity in earnings of affiliates was $11 million and $21 million in the first quarters of 2022 and 2021, respectively.

Depreciation and amortization increased $35 million, from $697 million in the first quarter of 2021 to $732 million in the first quarter of 2022. The increase in depreciation relates primarily to capital expenditures at our existing facilities.

Interest expense was $408 million in the first quarter of 2022 and $384 million in the first quarter of 2021. Our average debt balance was $35.798 billion for the first quarter of 2022 compared to $31.019 billion for the first quarter of 2021. The average effective interest rate for our long-term debt was 4.6% and 5.0%, respectively, for the quarters ended March 31, 2022 and 2021.

During the first quarters of 2022 and 2021, we recorded gains on sales of facilities of $10 million and $2 million, respectively.



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                ITEM 2. MANAGEMENT'S DISCUSSION AND ANALYSIS OF
           FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)


Results of Operations (continued)

Quarters Ended March 31, 2022 and 2021 (continued)

The effective tax rates were 21.5% and 21.7% for the first quarters of 2022 and 2021, respectively. The effective tax rate computations exclude net income attributable to noncontrolling interests as it relates to consolidated partnerships. Our provisions for income taxes for the first quarters of 2022 and 2021 included tax benefits of $64 million and $74 million, respectively, related to employee equity award settlements. Excluding the effect of these adjustments, the effective tax rate for the first quarters of 2022 and 2021 would have been 25.5% and 25.7%, respectively.

Net income attributable to noncontrolling interests increased from $157 million for the first quarter of 2021 to $192 million for the first quarter of 2022. The increase in net income attributable to noncontrolling interests related primarily to the operations of two of our Texas markets and our surgery centers.

Liquidity and Capital Resources

Cash provided by operating activities totaled $1.345 billion in the first quarter of 2022 compared to $1.988 billion in the first quarter of 2021. The $643 million decline in cash provided by operating activities, in the first quarter of 2022 compared to the first quarter of 2021, related primarily to the combined impact of negative changes in working capital items of $492 million, primarily related to a payment of $344 million for deferred payroll taxes from 2020, and a $121 million decline in net income, excluding gains on sales of facilities. The combination of interest payments and net income tax payments in the first quarter of 2022 totaled $411 million, compared to the net combination of interest payments and income tax refunds in the first quarter of 2021 of $362 million. Working capital totaled $4.488 billion at March 31, 2022 and $3.960 billion at December 31, 2021.

Cash used in investing activities was $845 million in the first quarter of 2022 compared to $649 million in the first quarter of 2021. Excluding acquisitions, capital expenditures were $861 million in the first quarter of 2022 and $654 million in the first quarter of 2021. Planned capital expenditures are expected to approximate $4.2 billion in 2022. At March 31, 2022, there were projects under construction which had estimated additional costs to complete and equip over the next five years of approximately $4.5 billion. We expect to finance capital expenditures with internally generated and borrowed funds.

Cash provided by financing activities totaled $425 million in the first quarter of 2022, compared to cash used in financing activities of $2.104 billion in the first quarter of 2021. During the first quarter of 2022, net cash flows provided by financing activities included a net increase of $3.120 billion in our indebtedness, payment of dividends of $177 million, repurchase of common stock of $2.101 billion and distributions to noncontrolling interests of $171 million. During the first quarter of 2021, net cash flows used in financing activities included a net increase of $33 million in our indebtedness, payment of dividends of $169 million, repurchase of common stock of $1.527 billion and distributions to noncontrolling interests of $234 million.

We are a highly leveraged company with significant debt service requirements. Our debt totaled $37.696 billion at March 31, 2022. Our interest expense was $408 million for the first quarter of 2022 and $384 million for the first quarter of 2021.

In addition to cash flows from operations, available sources of capital include amounts available under our senior secured credit facilities ($6.435 billion and $5.075 billion available as of March 31, 2022 and April 30, 2022, respectively) and anticipated access to public and private debt markets.

Investments of our insurance subsidiaries, held to maintain statutory equity levels and to provide liquidity to pay claims, totaled $513 million and $541 million at March 31, 2022 and December 31, 2021, respectively. An insurance subsidiary maintained net reserves for professional liability risks of $134 million and $154 million at March 31, 2022 and December 31, 2021, respectively. Our facilities are insured by our insurance subsidiary for losses up to $75 million per occurrence; however, this coverage is generally subject, in most cases, to a $15 million per occurrence self-insured retention. Additionally, the insurance subsidiary has entered into reinsurance contracts providing reimbursement for a certain portion of losses in excess of self-insured retentions. Net reserves for the self-insured professional liability risks retained were $1.809 billion and $1.813 billion at March 31, 2022 and December 31, 2021, respectively. Claims payments, net of reinsurance recoveries, during the next 12 months are expected to approximate $482 million. We estimate that approximately $439 million of the expected net claim payments during the next 12 months will relate to claims subject to the self-insured retention.



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                ITEM 2. MANAGEMENT'S DISCUSSION AND ANALYSIS OF
           FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)


Liquidity and Capital Resources (continued)

During March 2022, we issued $6.000 billion aggregate principal amount of senior secured notes comprised of (i) $1.000 billion aggregate principal amount of 3 1/8% senior secured notes due 2027, (ii) $500 million aggregate principal amount of 3 3/8% senior secured notes due 2029, (iii) $2.000 billion aggregate principal amount of 3 5/8% senior secured notes due 2032, (iv) $500 million aggregate principal amount of 4 3/8% senior secured notes due 2042 and (v) $2.000 billion aggregate principal amount of 4 5/8% senior secured notes due 2052. During March 2022, we used a portion of the net proceeds to pay down our revolving credit facilities. During April 2022, we redeemed all $1.250 billion outstanding aggregate principal amount of our 4.75% senior secured notes due 2023 and provided a notice of our election to redeem all $1.250 billion outstanding aggregate principal amount of our 5.875% senior notes due 2023.

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 12 months.

Summarized Financial Information

HCA Inc., a direct wholly-owned subsidiary of HCA Healthcare, Inc., is the primary obligor under a substantial portion of our indebtedness, including our senior secured credit facilities, senior secured notes and senior unsecured notes. The senior secured notes and senior unsecured notes issued by HCA Inc. are fully and unconditionally guaranteed on an unsecured basis by HCA Healthcare, Inc. The senior secured credit facilities and senior secured notes are fully and unconditionally guaranteed on a senior secured basis by substantially all existing and future, direct and indirect, 100% owned material domestic subsidiaries that are "Unrestricted Subsidiaries" under our Indenture dated December 16, 1993 (except for certain special purpose subsidiaries that only guarantee and pledge their assets under our senior secured asset-based revolving credit facility). For a list of subsidiary guarantors, see Exhibit 22 to this quarterly report on Form 10-Q.

The subsidiary guarantees rank senior in right of payment to all subordinated indebtedness of each subsidiary guarantor, equally in right of payment with all senior indebtedness of the subsidiary guarantors and are structurally subordinated in right of payment to all indebtedness and other liabilities of any nonguarantor subsidiaries of the subsidiary guarantors (other than indebtedness and liabilities owed to one of the subsidiary guarantors). The subsidiary guarantees are secured by first-priority liens on the subsidiary guarantors' assets, subject to certain exceptions, that secure our senior secured cash flow credit facility on a first-priority basis. The subsidiary guarantees are secured by second-priority liens on the subsidiary guarantors' assets that secure our senior secured asset-based revolving credit facility on a first-priority basis and our senior secured cash flow credit facility on a second-priority basis.

The subsidiary guarantees may be automatically and unconditionally released and discharged upon certain customary events, including in the event such guarantee is released under our senior secured credit facilities. The indentures governing the senior secured notes include a "savings clause" intended to limit each subsidiary guarantor's obligations as necessary to prevent the guarantee from constituting a fraudulent conveyance under applicable law, which could reduce a subsidiary guarantor's liability on its guarantee to zero. For further information regarding the guarantees, refer to the applicable indentures that are filed as exhibits to this quarterly report on Form 10-Q and our annual report on Form 10-K for the year ended December 31, 2021.



                                       24

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                ITEM 2. MANAGEMENT'S DISCUSSION AND ANALYSIS OF
           FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)


Liquidity and Capital Resources (continued)

Summarized Financial Information (continued)

Summarized financial information is presented on a combined basis and transactions between the combining entities have been eliminated. Financial information for nonguarantor entities has been excluded. The summarized operating results information for the quarter ended March 31, 2022 and year ended December 31, 2021 and the summarized balance sheet information at March 31, 2022 and December 31, 2021, for HCA Healthcare, Inc., HCA Inc. and the subsidiary guarantors (the Parent, Subsidiary Issuer and Subsidiary Guarantors) follow (dollars in millions):




Quarter Ended March 31, 2022 and Year Ended
December 31, 2021:
                                                          Quarter                 Year
                                                       March 31, 2022       December 31, 2021
Revenues                                              $          8,728     $            34,889
Income before income taxes                                       1,155                   6,061
Net income                                                         920                   4,666
Net income attributable to Parent, Subsidiary
Issuer and Subsidiary Guarantors                                   896                   4,564

At March 31, 2022 and December 31, 2021:

                                                       March 31, 2022       December 31, 2021
Current assets                                        $          9,415     $             8,268
Property and equipment, net                                     16,040                  15,559
Goodwill and other intangible assets                             5,695                   5,694
Total noncurrent assets                                         22,719                  22,370
Total assets                                                    32,134                  30,638
Current liabilities                                              6,807                   5,697
Long-term debt, net                                             35,769                  33,904
Intercompany balances                                            3,668                   3,423
Income taxes and other liabilities                                 744                   1,053
Total noncurrent liabilities                                    40,722                  38,912
Stockholders' deficit attributable to Parent,
Subsidiary Issuer and Subsidiary
  Guarantors                                                   (15,551 )               (14,124 )
Noncontrolling interests                                           156                     153


The first-priority liens securing the subsidiary guarantees discussed above include liens on (i) substantially all of the capital stock of substantially all wholly owned first-tier subsidiaries of HCA Inc. or of the subsidiary guarantors (but limited to 65% of the stock of any such wholly owned first-tier subsidiary that is a foreign subsidiary), subject to certain limited exceptions, and (ii) substantially all indebtedness owing to HCA Inc. or to the subsidiary guarantors, including any and all intercompany indebtedness owed by HCA Healthcare, Inc. or any subsidiary thereof to HCA Inc., or any subsidiary guarantor. For a list of affiliates whose securities are pledged as collateral for the senior secured notes, see Exhibit 22 to this quarterly report on Form 10-Q.

Under the first lien intercreditor agreement, the administrative agent for the lenders under the cash flow credit facility, subject to the occurrence of certain events, has the exclusive right to direct foreclosures and take other actions with respect to these liens, and the trustee for the senior secured notes has no right to take any such actions. In certain circumstances, including upon certain events of default under the senior secured credit facilities and the senior secured notes, the collateral agent in respect of the cash flow credit facility and the senior secured notes could proceed against the collateral granted to it to secure such indebtedness, including the aforementioned pledged capital stock and pledged indebtedness, and require such collateral to be delivered to the collateral agent to the extent not already in its possession for purposes of perfecting the lien on such assets. For further information regarding the collateral, including events or circumstances that may require delivery of the collateral, refer to the applicable indentures, the first lien intercreditor agreement, the cash flow credit agreement and the pledge agreement that are filed as exhibits to this quarterly report on Form 10-Q and our annual report on Form 10-K for the year ended December 31, 2021.



                                       25

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                ITEM 2. MANAGEMENT'S DISCUSSION AND ANALYSIS OF
           FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)


Liquidity and Capital Resources (continued)

Summarized Financial Information (continued)

There is no trading market for any of HCA Healthcare, Inc.'s affiliates whose securities are pledged as collateral for the senior secured notes.

Rule 13-02 of Regulation S-X requires the presentation of summarized financial information of the combined affiliates whose securities are pledged as collateral for the senior secured notes unless such information is not material. The rule provides that such information is not material if the assets, liabilities and results of operations of the combined affiliates whose securities are pledged as collateral are not materially different than the corresponding amounts presented in the consolidated financial statements of the Registrant. Healthtrust, Inc. - The Hospital Company ("Healthtrust") is the first-tier subsidiary of HCA Inc., and the common stock of Healthtrust is pledged as collateral for the senior secured notes. Due to the corporate structure relationship of HCA Healthcare, Inc. and Healthtrust, all of HCA Healthcare, Inc.'s operating subsidiaries, including all other affiliates whose securities are pledged as collateral for the senior secured notes, are also subsidiaries of Healthtrust. The corporate structure relationship, combined with the application of push-down accounting in Healthtrust's consolidated financial statements related to HCA Healthcare Inc.'s debt and financial instruments, mean that the assets, liabilities and results of operations of Healthtrust (and, therefore, of the combined affiliates whose securities are pledged as collateral for the senior secured notes) are not materially different than the corresponding amounts presented in the financial statements of HCA Healthcare, Inc. As a result, summarized financial information of affiliates whose securities are pledged as collateral for the senior secured notes is not required to be presented under Rule 13-02.

Market Risk

We are exposed to market risk related to changes in market values of securities. The investment securities held by our insurance subsidiaries were recorded at $513 million at March 31, 2022. These investments are carried at fair value, with changes in unrealized gains and losses that are not credit-related being recorded as adjustments to other comprehensive income. At March 31, 2022, we had net unrealized losses of $10 million on the insurance subsidiaries' investments.

We are exposed to market risk related to market illiquidity. Investment securities held by our insurance subsidiaries could be impaired by the inability to access the capital markets. Should the 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 $1.440 billion of long-term debt at March 31, 2022 was subject to variable rates of interest, while the remaining balance of long-term debt of $36.256 billion at March 31, 2022 was subject to fixed rates of interest. Both the general level of interest rates and 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% or (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 4.6% and 5.0% for the quarters ended March 31, 2022 and 2021, respectively.




                                       26

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                ITEM 2. MANAGEMENT'S DISCUSSION AND ANALYSIS OF
           FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)


Liquidity and Capital Resources (continued)

Market Risk (continued)

The estimated fair value of our total long-term debt was $39.038 billion at March 31, 2022. 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 $14 million. To mitigate the impact of fluctuations in interest rates, we generally target a portion 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.

Tax Examinations

At March 31, 2022, the Internal Revenue Service was conducting examinations of the Company's 2016, 2017 and 2018 federal income tax returns and the 2019 return for one affiliated partnership. We are also subject to examination by state and foreign taxing authorities. Management believes HCA Healthcare, Inc. and its predecessors, subsidiaries and affiliates properly reported taxable income and paid taxes in accordance with applicable laws and agreements established with 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.


                                       27

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                ITEM 2. MANAGEMENT'S DISCUSSION AND ANALYSIS OF
           FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)

                                 Operating Data

                                                            2022            2021
Number of hospitals in operation at:
March 31                                                         182             186
June 30                                                                          187
September 30                                                                     183
December 31                                                                      182
Number of freestanding outpatient surgical centers in
operation at:
March 31                                                         124             121
June 30                                                                          122
September 30                                                                     123
December 31                                                                      125
Licensed hospital beds at(a):
March 31                                                      48,892          49,561
June 30                                                                       49,693
September 30                                                                  48,950
December 31                                                                   48,803
Weighted average beds in service(b):
Quarter:
First                                                         41,818          42,363
Second                                                                        42,464
Third                                                                         42,088
Fourth                                                                        41,685
Year                                                                          42,148
Average daily census(c):
Quarter:
First                                                         29,797          29,678
Second                                                                        28,901
Third                                                                         31,144
Fourth                                                                        29,273
Year                                                                          29,752
Admissions(d):
Quarter:
First                                                        506,956         506,380
Second                                                                       532,041
Third                                                                        536,848
Fourth                                                                       514,706
Year                                                                       2,089,975
Equivalent admissions(e):
Quarter:
First                                                        859,290         832,489
Second                                                                       916,212
Third                                                                        905,627
Fourth                                                                       881,910
Year                                                                       3,536,238
Average length of stay (days)(f):
Quarter:
First                                                            5.3             5.3
Second                                                                           4.9
Third                                                                            5.3
Fourth                                                                           5.2
Year                                                                             5.2








                                       28

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                ITEM 2. MANAGEMENT'S DISCUSSION AND ANALYSIS OF
           FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)


                                                        2022            2021
Emergency room visits(g):
Quarter:
First                                                  2,056,389       1,841,778
Second                                                                 2,128,428
Third                                                                  2,338,180
Fourth                                                                 2,166,959
Year                                                                   8,475,345
Outpatient surgeries(h):
Quarter:
First                                                    247,421         231,228
Second                                                                   262,107
Third                                                                    249,192
Fourth                                                                   265,709
Year                                                                   1,008,236
Inpatient surgeries(i):
Quarter:
First                                                    126,880         127,590
Second                                                                   136,460
Third                                                                    126,436
Fourth                                                                   131,583
Year                                                                     522,069
Days revenues in accounts receivable(j):
Quarter:
First                                                         51              48
Second                                                                        48
Third                                                                         51
Fourth                                                                        49
Outpatient revenues as a % of patient revenues(k):
Quarter:
First                                                         37 %            36 %
Second                                                                        38 %
Third                                                                         34 %
Fourth                                                                        38 %
Year                                                                          37 %




(a)
Licensed beds are those beds for which a facility has been granted approval to
operate from the applicable state licensing agency.
(b)
Represents the average number of beds in service, weighted based on periods
owned.
(c)
Represents the average number of patients in our hospital beds each day.
(d)
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.
(e)
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 revenues and gross outpatient revenues and then dividing the resulting
amount by gross inpatient revenues. The equivalent admissions computation
"equates" outpatient revenues to the volume measure (admissions) used to measure
inpatient volume resulting in a general measure of combined inpatient and
outpatient volume.
(f)
Represents the average number of days admitted patients stay in our hospitals.
(g)
Represents the number of patients treated in our emergency rooms.
(h)
Represents the number of surgeries performed on patients who were not admitted
to our hospitals. Pain management and endoscopy procedures are not included in
outpatient surgeries.
(i)
Represents the number of surgeries performed on patients who have been admitted
to our hospitals. Pain management and endoscopy procedures are not included in
inpatient surgeries.
(j)
Revenues per day is calculated by dividing revenues for the quarter by the days
in the quarter. Days revenues in accounts receivable is then calculated as
accounts receivable at the end of the quarter divided by revenues per day.
(k)
Represents the percentage of patient revenues related to patients who are not
admitted to our hospitals.



                                       29

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