Q4医院季度调查：有利的成本趋势和资本预算

1、Global Research24 January 2019UBS Quarterly Hospital Survey: 4Q18UBS Evidence Lab inside: Favorable Cost Trends and Capital Budgets; Ortho/OP are Key PrioritiesIntroducing the UBS Quarterly Hospital SurveyUBS Evidence Lab surveyed 75 hospital executives with oversight across 665 acute care hospitals

2、 which represents over 10% of the U.S. market. This quarterly cross-sector note provides unique and differentiated insight across 90% of industrys cost structure, expectations for capital budgets, outsourcing trends and key areas of strategic focus.Exceedingly low cost growth in 4Q18 and expected to

3、 remain low in 2019 Controllable cost inflation remains at historically low levels with 2019 cost growth expected to trend 0%-2% y/y vs our 2%-3.5% assumption. Moderating costs enhances our confidence around our 2019 hospital forecasts, notably HCA and UHS. Contract labor, premium pay and profession

4、al fees are anticipated to decelerate. Strong interest in ortho/outpatient capabilities strikes us as a positive for THC (USPI) and SGRY. We also see growing interest in psych JVs as a positive for ACHC and UHS.Spending environment stable; relief for CAPX namesHospital capital budgets are expected t

5、o increase by 2.6% on average in the Wave 2 survey, similar to Wave 1s average increase of 2.7%. This is in-line with medtech company commentary in the most recent quarter pointing to a stable hospital capital and purchasing environment. We view the survey as a positive read for capex levered names

6、like Buy rated VAR, BAX, and HRC, Neutral rated ISRG and BDX, and to a lesser extent, names with limited capex exposure, like Buy rated MDT and Neutral rated SYK. For investors concerned about capital spending rolling given macro uncertainties, we think this survey should give investors comfort to i

7、nvest in capital exposed names.Modest tailwind to Labs from PAMA, Value-Based Care ramp positive for PINC Survey results support our thesis that government price cuts will serve as a modest tailwind in 2019/2020 from capturing market share from hospitals looking to partner or sell their lab business

8、 to 3rd parties like DGX and LH. 23% of respondents indicated they expect to outsource more business versus 20% who will look to increase outreach programs. The data also suggests that hospitals expect to see a meaningful increase in net patient revenues tied to value-based/risk-based care over the

9、next several years (doubling by 2025 to 42%/29% of net patient revenues), potentially driving demand for IT solutions from HCIT vendors like Buy-rated Premier (PINC).Healthcare ProvidersAmericasEquitiesWhit MayoAnalyst HYPERLINK mailto:whit.mayo whit.mayo+1-212-713 3842Matthew Taylor, CFAAnalyst HYP

10、ERLINK mailto:matthew-c.taylor matthew-c.taylor+1-212-713 6257Kevin CaliendoAnalyst HYPERLINK mailto:kevin.caliendo kevin.caliendo+1-212-713 3630Nathan Leiphardt, CFAAnalyst HYPERLINK mailto:nathan.leiphardt nathan.leiphardt+1-212-713 3837Jack Wang Associate Analyst HYPERLINK mailto:jack1.wang jack1

11、.wang+1-212-713 2603Yi Cheng, CFAAssociate Analyst HYPERLINK mailto:yi-a.cheng yi-a.cheng+1-212-713 3264Young Li Analyst HYPERLINK mailto:young.li young.li+1-212-713 2078Adam Noble Associate Analyst HYPERLINK mailto:adam.noble adam.noble+1-212-713-9495Brett Gasaway Associate Analyst HYPERLINK mailto

12、:brett.gasaway brett.gasaway+1-212-713 4820 HYPERLINK /investmentresearch /investmentresearchThis report has been prepared by UBS Securities LLC. ANALYST CERTIFICATION AND REQUIRED DISCLOSURES BEGIN ON PAGE 43. UBS does and seeks to do business with companies covered in its research reports. As a re

13、sult, investors should be aware that the firm may have a conflict of interest that could affect the objectivity of this report. Investors should consider this report as only a single factor in making their investment decision.Table of Contents HYPERLINK l _bookmark0 Executive Summary In Pictures3 HY

14、PERLINK l _bookmark1 Survey Overview5 HYPERLINK l _bookmark2 Insight into 4Q18 Cost Trends and the Outlook for 20196 HYPERLINK l _bookmark3 Cost Trends and Expectations by Line Item8 HYPERLINK l _bookmark4 Review and Comparison of Historical Cost Trends14 HYPERLINK l _bookmark5 Capital Budgets Expec

15、ted to Grow Modestly15 HYPERLINK l _bookmark6 Capital Budget Increases by Service Line17 HYPERLINK l _bookmark7 Capital Investment Priorities by Service Line19 HYPERLINK l _bookmark8 Capital Equipment Invesment Priorities20 HYPERLINK l _bookmark9 Most Profitable Service Lines21 HYPERLINK l _bookmark

16、10 Strategic Priorities24 HYPERLINK l _bookmark11 Outpatient24 HYPERLINK l _bookmark12 Post-Acute25 HYPERLINK l _bookmark13 Behavioral Health27 HYPERLINK l _bookmark14 Physician Services Outsourcing28 HYPERLINK l _bookmark15 Lab Services30 HYPERLINK l _bookmark16 Lab Outreach Breakdown by Hospital S

17、ize and Geography30 HYPERLINK l _bookmark17 Mixed hospital opportunity for the labs, though skewed to the upside31 HYPERLINK l _bookmark18 Slight lead for LH in Reference Lab work, though DGX partner of choice HYPERLINK l _bookmark18 for full Outsourcing34 HYPERLINK l _bookmark19 Value-Based Reimbur

18、sement36 HYPERLINK l _bookmark20 Impact on Provider Strategies36 HYPERLINK l _bookmark21 Value and Risk-Based Current and Future Penetration36 HYPERLINK l _bookmark22 GPOs40 HYPERLINK l _bookmark23 GPO Breakdown by Market Share and Hospital Size40 HYPERLINK l _bookmark24 UBS Evidence Lab Supports In

19、creased Service Uptake40EXECUTIVE SUMMARY IN PICTURESSource for exhibits above: UBS Evidence Lab and UBS ResearchAverage growth per adjusted admission for all six of the operating cost line items surveyed has trended from a low of +0.0% (malpractice) to a high of +2.0% (professional fees).While most

20、 cost trends are expected to accelerate on average, increases remain very modest. Further, expectations for 2019 cost growth have also moderated when compared to the prior survey.Hospital capital budgets are skewed to growth with 63% calling for some level of increase, more than the 56% from Wave 1.

21、 12% called for some level of decrease, same as Wave 1.Drilling down further, about 25% noted their budgets are going up more than usual, with only 12% saying they are going down more than usual and 63% considering their budget change normal.EXECUTIVE SUMMARY IN PICTURESView on JVs for the developme

22、nt of a freestanding psychiatric hospital42%3%50%40%30%20%10%0%52%23%9%14%20%5%60%50%40%30%20%10%0%3Q18 Survey4Q18 SurveyNot evaluating, but would consider in the future14%34%Currently evaluating a partnershipNone of the aboveIncrease lab outreach and use of reference labsOutsource entire lab practi

23、ceIncrease use of reference labsIncrease lab outreach14% of hospitals indicated they were actively evaluating a joint venture partnership for the development of a freestanding psychiatric hospital vs. just 3% in the prior survey. This supports the idea that ACHC/UHS could each sign 4-6 new JVs each

24、year for the next several years.Share gains from greater hospital outsourcing are expected to be offset by increased hospital outreach, as 23% expect to shift more business to 3rd party labs vs. 20% suggesting they will look to increase lab outreach operations50%40%30%20%10%0%47%39%30%27%17% 17%20%3

25、%Increase use of reference labs Outsource entire lab practiceResults indicated a slightly higher preference for LH in Reference Lab work than DGX (39% vs. 30%) though meaningful preference in DGX when it comes to complete lab practice Outsourcing (47% vs. 17%).Quest DiagnosticsLab CorpOtherNone50%40

26、%30%20%10%0%41.8%32.4%25.0%19.3%15.0%20172018E2019E2020E2025E% net patient revenue tied to valueHospitals expect to grow their participation in value-based payment models, with 430bps of growth in 2018 as a % of Net Patient Revenue and 116% penetration growth by 2025 reaching 42% of Net Patient Reve

27、nue.Source for exhibits above: UBS Evidence Lab and UBS ResearchUBS Evidence Lab Surveyed 75 CEOs and CFOs with Oversight over 665 HospitalsUBS Evidence Lab surveyed 75 hospital executives with oversight across 665 acute care hospitals which represents over 10% of the US market. This quarterly cross

28、- sector note provides unique and differentiated insight across 90% of industrys cost structure, expectations for capital budgets, outsourcing trends and key areas of strategic focus.Respondents for this survey (Wave 2 / 4Q18) were located across the United States (Midwest: 25%, South: 31%, West: 23

29、%, and Northeast 20%) while the types of communities served by the hospitals were also quite varied: 44% urban/suburban, 37% rural/small town and 19% indicated multiple types of communities served. Respondents to the survey predominantly represented non-profit hospitals (81%).Figure 1: Respondents W

30、ere Geographically DispersedFigure 2: Number of Beds in Hospital(s) Overseen40%40%8%12%0%20%40%60%80%100%Midwest: 25%Northeast: 20%West: 23%South: 31%Less than 5050 to 100100 to 300300 or moreSource: UBS Evidence Lab and UBS ResearchSource: UBS Evidence Lab and UBS ResearchFigure 3: The Majority of

31、Respondents Were Non-ProfitFigure 4: Type of Area Served by Hospital(s)19%81%For profit Not for profitRural19%29%17%8%27%Small Town Suburban Urban MultipleSource: UBS Evidence Lab and UBS ResearchSource: UBS Evidence Lab and UBS ResearchUBS Evidence Lab Survey Indicates Hospitals Expect to Maintain

32、Strong Operating Cost ControlsThe bottom line:We forecast SS controllable cost growth in the 2-3.5% range vs the recent 1-1.5% range, though this remains below both historical averages and top line growth. The survey points to little meaningful inflation entering the cost structure for the foreseeab

33、le future.Our analysis of the UBS Evidence Lab survey indicates operating costs trends have remained in the +0-2% range. Assuming the midpoint of each possible answer range provided to respondents (i.e. 1.5% for 1-2%) and limit of11%, we found that the average growth per adjusted admission for all s

34、ix of the operating cost line items surveyed has trended from a low of +0.0% (malpractice) to a high of +2.0% (professional fees). We note that these are exceptionally low rates of cost inflation and indicate that hospitals have largely been able to maintain their strong control of operating cost in

35、flation exhibited in recent quarters. Taken in aggregate, the growth in these operating costs is also below our expected rates of top-line growth for all five of the hospitals under coverage, indicating likely margin expansion should they perform in line with these trends.mean1SD+1SDmedian-Figure 5:

36、 Hospitals are experiencing cost/AA growth of 0-2% on averageChange in costs/AA in the last three monthsof 2018 as compared to the same period in 2017?lowhigh-12% -9%-6%-3%0%3%6%9%12%Wages/Payroll Contract Labor/Premium PayBenefits Cost Supply Costs Professional FeesProf. Liability (Malpractice)Of t

37、he operating costs items included in the survey, on average, respondents indicated professional fees were experiencing the highest rate of growth (+2.0% y/y).Source: UBS Evidence Lab and UBS Research. Assumes the midpoint of each possible range (i.e. 1.5% for 1-2%) and assumes 11% for responses of 1

38、0+%Figure 6: Operating cost trends largely improved in 4Q18 vs. the 3Q18 surveyMean cost per AA increase/decrease (y/y) 3Q184Q18 Wages/Payroll Contract Labor/Premium PayBenefits Cost Supply Costs Professional FeesProf. Liability (Malpractice)0.9%1.2%1.6%1.8%1.9%-0.1%1.5%0.6%1.3%0.8%2.0%0.0%Source: U

39、BS Evidence Lab and UBS Research. Assumes the midpoint of each possible range (i.e. 1.5% for 1-2%) and assumes 11% for responses of 10+%Cost growth is expected to remain near historically low levels, albeit slightly higher than recent trends. The survey also asked hospital executives about their exp

40、ectations regarding operating cost trends in the upcoming year. Per our analysis, we again found costs per adjusted admission are expected to remaintightly controlled with growth expectations ranging from -0.3% to +2.1% on average for each of the line items. Most importantly, despite the continued t

41、ight labor market and commentary regarding the difficulty in recruiting nurses, the average expected growth in wages per adjusted admission was just +2.1%.mean1SD+1SDmedian-Figure 7: Controllable costs are anticipated to remain modest for the foreseeable futureHow do you anticipate next years cost p

42、eradjusted admission will change versus this year?lowhigh-12% -9%-6%-3%0%3%6%9%12%Wages/Payroll Contract Labor/Premium PayBenefits Cost Supply Costs Professional FeesProf. Liability (Malpractice)Source: UBS Evidence Lab and UBS Research. Assumes the midpoint of each possible range (i.e. 1.5% for 1-2

43、%) and assumes 11% for responses of 10+%Figure 8: Compared to the prior survey, the cost outlook for 2019 has improvedAnticipated 2019 cost per AA increase/decrease (y/y) 3Q18 survey4Q18 survey Wages/Payroll Contract Labor/Premium PayBenefits Cost Supply Costs Professional FeesProf. Liability (Malpr

44、actice)2.0%0.3%2.0%2.4%1.4%0.4%2.1%-0.3%1.8%1.6%1.4%0.6%Source: UBS Evidence Lab and UBS Research. Assumes the midpoint of each possible range (i.e. 1.5% for 1-2%) and assumes 11% for responses of 10+%While most cost trends are expected to accelerate on average, increases remain very modest. When co

45、mparing the average cost/AA increase for each of the line items in the last three months to hospitals expectations for the following year, we find that wages/payroll, benefits costs, supply costs, and professional liability costs are all expected to increase at a faster rate. However, we note that t

46、he average increase expected for each of these trends is still nicely below historical trends and would be viewed positively by operators and investors should they develop as expected. Further, the survey respondents actually expect contract labor and premium pay costs as well as professional fees c

47、osts to moderate relative to recent trends. We posit that a portion of the increase in wages and payroll could merely be reflective of a planned lower reliance on contract labor as indicated by the trends moving in opposite directions.Figure 9: Costs trends are expected to accelerate quite modestly

48、overallMean cost per AA increase/decrease 4Q182019 Salaries, wages, and benefits are the largest component of hospital costs (45% of revenues)Wages/Payroll Contract Labor/Premium PayBenefits Cost Supply Costs Professional FeesProf. Liability (Malpractice)1.5%0.6%1.3%0.8%2.0%0.0%2.1%-0.3%1.8%1.6%1.4%

49、0.6%Source: UBS Evidence Lab and UBS Research. Assumes the midpoint of each possible range (i.e. 1.5% for 1-2%) and assumes 11% for responses of 10+%Cost Trends and Expectations by Line ItemUBS Evidence Lab survey data suggests wage growth remains well controlled. On average, respondents to the hosp

50、ital survey indicated their wages/AA had grown by +1.5% y/y in 4Q18 and an impressive 79% of the hospitals (81% last quarter) indicated their wages/AA had either declined or grown by less than 3.0% y/y. When queried on their expectations for growth in wages/AA next year, hospitals indicated that the

51、y expect the metric to grow at a+2.1% pace on average. While this would represent an acceleration, 2% growth is still a very manageable cost trend and we highlight that only one respondent (5% of respondents last quarter) indicated they are anticipating what we would consider to be a high rate of wa

52、ge inflation (4+%).Figure 10: Wages/AA grew by +1.5% y/y on average in 4Q18Figure 11: Hospitals, on average, expect wage/AA to accelerate to +2.1% y/y next yearChanges in wages/AA in the last 3 months of 2018 as compared to the same period in 2017?Down 10+%Down 9.1-10.0%How do you anticipate 2019s w

53、ages/AA will change versus 2018?1%1%3%1%5%23%40%24%1%Down 10+%Down 9.1-10.0%Down 8.1-9.0%1%Down 7.1-8.0%1%Down 6.1-7.0%Down 5.1-6.0%1%Down 4.1-5.0%1%Down 3.1-4.0%Down 2.1-3.0%1%Down 1.1-2.0%3%Down 0.1-1.0%7%Flat/No change7%Up 0.1-1.0%9%Up 1.1-2.0%Up 2.1-3.0%Up 3.1-4.0%9%Up 4.1-5.0%9%Up 5.1-6.0%1%Up

54、6.1-7.0%Up 7.1-8.0%Up 8.1-9.0%Up 9.1-10.0%Up 10+%1%20%27%Down 8.1-9.0%Down 7.1-8.0%Down 6.1-7.0%Down 5.1-6.0%Down 4.1-5.0%Down 3.1-4.0%Down 2.1-3.0%Down 1.1-2.0%Down 0.1-1.0%Flat/No change Up 0.1-1.0%Up 1.1-2.0%Up 2.1-3.0%Up 3.1-4.0%Up 4.1-5.0%Up 5.1-6.0%Up 6.1-7.0%Up 7.1-8.0%Up 8.1-9.0%Up 9.1-10.0%

55、Up 10+%0%5%10%15%20%25%30%0%10%20%30%40%50%Source: UBS Evidence Lab and UBS ResearchSource: UBS Evidence Lab and UBS ResearchUBS Evidence Lab survey data indicates benefits are expected to grow in line with wages. When compared to the increase in wage costs that survey respondents had experienced ov

56、er the past three months, benefits costs had grown at a slightly slower rate of +1.3% on average. There was also a similar percentage of respondents (76%) indicating well controlled benefits cost growth of less than 3.0% y/y. Again largely mirroring expectations for wage growth, hospitals anticipate

57、 +1.8% benefit cost/AA growth next year, a slight acceleration from trends over the past three months. Here we do observe a larger skew of responses towards high expected benefit cost trends next year with 15% of respondents indicating they anticipate benefit cost/AA growth of greater than 4.0% next

58、 year.Figure 12: Benefits costs/AA grew by +1.3% y/y on average in 4Q18Figure 13: Hospitals, on average, expect benefits costs/AA to accelerate to +1.8% y/y next yearChanges in benefits cost/AA in the last 3 months of 2018 as compared to the same period in 2017?How do you anticipate 2019s benefits c

59、ost/AA will change versus 2018?Down 10+%1%Down 9.1-10.0%Down 8.1-9.0%Down 7.1-8.0%Down 6.1-7.0%Down 5.1-6.0%Down 4.1-5.0%1%Down 3.1-4.0%4%Down 2.1-3.0%5%Down 1.1-2.0%7%Down 0.1-1.0%5%Flat/No changeUp 0.1-1.0%8%Up 1.1-2.0%9%Up 2.1-3.0%Up 3.1-4.0%7%Up 4.1-5.0%5%Up 5.1-6.0%7%Up 6.1-7.0%3%Up 7.1-8.0%Up

60、8.1-9.0%Up 9.1-10.0%1%Up 10+%1%17%17%Down 10+%Down 9.1-10.0%Down 8.1-9.0%Down 7.1-8.0%Down 6.1-7.0%Down 5.1-6.0%1%Down 4.1-5.0%Down 3.1-4.0%Down 2.1-3.0%1%Down 1.1-2.0%3%Down 0.1-1.0%3%Flat/No change Up 0.1-1.0%Up 1.1-2.0%Up 2.1-3.0%Up 3.1-4.0%Up 4.1-5.0%7%Up 5.1-6.0%5%Up 6.1-7.0%Up 7.1-8.0%1%Up 8.1