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What changed in Universal Health Services's 10-K — 2022 vs 2023

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Paragraph-level year-over-year comparison of Universal Health Services's 2022 and 2023 10-K annual filings, covering the Business, Risk Factors, Legal Proceedings, Cybersecurity, MD&A and Market Risk sections. Every new, removed and edited paragraph is highlighted side-by-side so you can see exactly what management changed in the 2023 report.

+576 added−601 removedSource: 10-K (2024-02-27) vs 10-K (2023-02-27)

Top changes in Universal Health Services's 2023 10-K

576 paragraphs added · 601 removed · 405 edited across 8 sections

Item 1. Business

Business — how the company describes what it does

17 edited+0 added−1 removed97 unchanged
Biggest changeIn addition to any liabilities that a hospital may incur under EMTALA, an injured patient, the patient’s family or a medical facility that suffers a financial loss as a direct result of another hospital’s violation of the law can bring a civil suit against the hospital unrelated to the rights granted under that statute.
Biggest changeIn addition to any liabilities that a hospital may incur under EMTALA, an injured patient, the patient’s family or a medical facility that suffers a financial loss as a direct result of another hospital’s violation of the law can bring a civil suit against the hospital unrelated to the rights granted under that statute. 6 The federal government broadly interprets EMTALA to cover situations in which patients do not actually present to a hospital’s emergency room, but present for emergency examination or treatment to the hospital’s campus, generally, or to a hospital-based clinic that treats emergency medical conditions or are transported in a hospital-owned ambulance, subject to certain exceptions.
Other factors that affect utilization include general and local economic conditions, market penetration of managed care programs, the degree of outpatient use, the availability of 2 reimbursement programs such as Medicare and Medicaid, and demographic changes such as the growth in local populations. Utilization across the industry also is being affected by improvements in clinical practice, medical technology and pharmacology.
Other factors that affect utilization include 2 general and local economic conditions, market penetration of managed care programs, the degree of outpatient use, the availability of reimbursement programs such as Medicare and Medicaid, and demographic changes such as the growth in local populations. Utilization across the industry also is being affected by improvements in clinical practice, medical technology and pharmacology.
The adoption of new or expanded conversion legislation and the increased review of not-for-profit hospital conversions may limit our ability to grow through acquisitions of not-for-profit hospitals. 3 Utilization Review: Federal regulations require that admissions and utilization of facilities by Medicare and Medicaid patients must be reviewed in order to ensure efficient utilization of facilities and services.
The adoption of new or expanded conversion legislation and the increased review of not-for-profit hospital conversions may limit our ability to grow through acquisitions of not-for-profit hospitals. Utilization Review: Federal regulations require that admissions and utilization of facilities by Medicare and Medicaid patients must be reviewed in order to ensure efficient utilization of facilities and services.
HIPAA Administrative Simplification and Privacy Requirements: The administrative simplification provisions of HIPAA, as amended by the Health Information Technology for Economic and Clinical Health Act (“HITECH”), require the use of uniform electronic data transmission standards for health care claims and payment transactions submitted or received electronically. These provisions are intended to encourage electronic commerce in the health care industry.
HIPAA Administrative Simplification and Privacy Requirements: The administrative simplification provisions of HIPAA, as amended by the Health Information Technology for Economic and Clinical Health Act (“HITECH”), require the use of uniform 5 electronic data transmission standards for health care claims and payment transactions submitted or received electronically. These provisions are intended to encourage electronic commerce in the health care industry.
EMTALA does not generally apply to patients admitted for inpatient services; however, CMS has sought industry comments on the potential applicability of EMTALA to hospital inpatients and the responsibilities of hospitals with specialized capabilities, respectively. CMS 6 has not yet issued regulations or guidance in response to that request for comments.
EMTALA does not generally apply to patients admitted for inpatient services; however, CMS has sought industry comments on the potential applicability of EMTALA to hospital inpatients and the responsibilities of hospitals with specialized capabilities, respectively. CMS has not yet issued regulations or guidance in response to that request for comments.
HIPAA also established federal rules protecting the privacy and security of personal health information. The privacy and security regulations address the use and disclosure of 5 individual health care information and the rights of patients to understand and control how such information is used and disclosed. Violations of HIPAA can result in both criminal and civil fines and penalties.
HIPAA also established federal rules protecting the privacy and security of personal health information. The privacy and security regulations address the use and disclosure of individual health care information and the rights of patients to understand and control how such information is used and disclosed. Violations of HIPAA can result in both criminal and civil fines and penalties.
Although the level of government involvement varies from state to state, the trend is to provide for increased governmental review and, in some cases, approval of a transaction in which a not-for-profit entity sells a health care facility to a for-profit entity.
Although the level of government involvement varies from state to state, the trend is to provide for increased governmental review and, in some cases, approval of a transaction in which a not-for-profit entity sells a health care facility 3 to a for-profit entity.
In accordance with Section 303A.12(a) of the New York Stock Exchange Listed Company Manual, we submitted our CEO’s certification to the New York Stock Exchange in 2022.
In accordance with Section 303A.12(a) of the New York Stock Exchange Listed Company Manual, we submitted our CEO’s certification to the New York Stock Exchange in 2023.
Certificates of Need: Many of the states in which we operate hospitals have enacted certificates of need (“CON”) laws as a condition prior to hospital capital expenditures, construction, expansion, modernization or initiation of major new services.
Certificates of Need: Certain of the states in which we operate hospitals have certificates of need (“CON”) laws as a condition prior to hospital capital expenditures, construction, expansion, modernization or initiation of major new services.
Civil money penalties may include fines of up to $112,131 per violation and damages of up to three times the total amount of the remuneration and/or exclusion from participation in Medicare and Medicaid.
Civil money penalties may include fines of up to $120,816 per violation and damages of up to three times the total amount of the remuneration and/or exclusion from participation in Medicare and Medicaid.
Our behavioral health care facilities located in the U.K. generated net revenues of approximately $685 million in 2022 and $688 million in 2021. Total assets at our U.K. behavioral health care facilities were approximately $1.235 billion as of December 31, 2022 and $1.351 billion as of December 31, 2021.
Our behavioral health care facilities located in the U.K. generated net revenues of approximately $761 million in 2023 and $685 million in 2022. Total assets at our U.K. behavioral health care facilities were approximately $1.327 billion as of December 31, 2023 and $1.235 billion as of December 31, 2022.
As of February 27, 2023, we owned and/or operated 359 inpatient facilities and 39 outpatient and other facilities including the following located in 39 states, Washington, D.C., the United Kingdom and Puerto Rico: Acute care facilities located in the U.S.: • 28 inpatient acute care hospitals; • 21 free-standing emergency departments, and; • 7 outpatient centers & 1 surgical hospital.
As of February 27, 2024, we owned and/or operated 360 inpatient facilities and 48 outpatient and other facilities, including the following, located in 39 states, Washington, D.C., the United Kingdom and Puerto Rico: Acute care facilities located in the U.S.: • 27 inpatient acute care hospitals; • 27 free-standing emergency departments, and; • 10 outpatient centers & 1 surgical hospital.
Net revenues from our acute care hospitals, outpatient facilities and commercial health insurer accounted for 57% of our consolidated net revenues during 2022 and 56% during 2021. Net revenues from our behavioral health care facilities and commercial health insurer accounted for 43% of our consolidated net revenues during 2022 and 44% during 2021.
Net revenues from our acute care hospitals, outpatient facilities and commercial health insurer accounted for 57% of our consolidated net revenues during each of 2023 and 2022. Net revenues from our behavioral health care facilities and commercial health insurer accounted for 43% of our consolidated net revenues during each of 2023 and 2022.
However, such conduct and business arrangements may lead to increased scrutiny by government enforcement authorities. 4 Although we believe that our arrangements with physicians and other referral sources have been structured to comply with current law and available interpretations, there can be no assurance that all arrangements comply with an available safe harbor or that regulatory authorities enforcing these laws will determine these financial arrangements do not violate the anti-kickback statute or other applicable laws.
Although we believe that our arrangements with physicians and other referral sources have been structured to comply with current law and available interpretations, there can be no assurance that all arrangements comply with an available safe harbor or that regulatory authorities enforcing these laws will determine these financial arrangements do not violate the anti-kickback statute or other applicable laws.
Behavioral health care facilities (331 inpatient facilities and 10 outpatient facilities): Located in the U.S.: • 185 inpatient behavioral health care facilities, and; • 8 outpatient behavioral health care facilities. Located in the U.K.: • 143 inpatient behavioral health care facilities, and; • 2 outpatient behavioral health care facilities. Located in Puerto Rico: • 3 inpatient behavioral health care facilities.
Behavioral health care facilities (333 inpatient facilities and 10 outpatient facilities): Located in the U.S.: • 186 inpatient behavioral health care facilities, and; • 8 outpatient behavioral health care facilities. Located in the U.K.: • 144 inpatient behavioral health care facilities, and; • 2 outpatient behavioral health care facilities. Located in Puerto Rico: • 3 inpatient behavioral health care facilities.
These types of referrals are known as “self-referrals.” Sanctions for violating the Stark Law include civil penalties up to $27,750 for each violation, and up to $185,009 for sham arrangements.
These types of referrals are known as “self-referrals.” Sanctions for violating the Stark Law include civil penalties up to $29,899 for each violation, and up to $199,338 for sham arrangements.
The fact that conduct or a business arrangement does not fall within a safe harbor or exception does not automatically render the conduct or business arrangement illegal under the anti-kickback statute.
The fact that 4 conduct or a business arrangement does not fall within a safe harbor or exception does not automatically render the conduct or business arrangement illegal under the anti-kickback statute. However, such conduct and business arrangements may lead to increased scrutiny by government enforcement authorities.
Removed
The federal government broadly interprets EMTALA to cover situations in which patients do not actually present to a hospital’s emergency room, but present for emergency examination or treatment to the hospital’s campus, generally, or to a hospital-based clinic that treats emergency medical conditions or are transported in a hospital-owned ambulance, subject to certain exceptions.

Item 1A. Risk Factors

Risk Factors — what could go wrong, per management

239 edited+105 added−141 removed172 unchanged
Biggest changeNet cash used in financing activities Net cash used in financing activities was $318 million during 2022 and $1.069 billion during 2021. 2022: The $318 million of net cash used in financing activities during 2022 consisted of the following: • generated $705 million of proceeds from new borrowings consisting primarily of $700 million of proceeds generated from the new tranche A term loan facility which commenced in June, 2022; • spent $833 million to repurchase shares of our Class B Common Stock in connection with: (i) open market purchases pursuant to our stock repurchase program ($811 million), and; (ii) income tax withholding obligations related to stock-based compensation programs ($22 million); • spent $89 million on net repayment of debt as follows: (i) $51 million related to our tranche A term loan facility; (ii) $32 million related to our revolving credit facility, and; (iii) $6 million related to other debt facilities; • spent $58 million to pay quarterly cash dividends of $.20 per share; • spent $49 million in connection with the purchase of ownership interests from minority members, net of sales, consisting primarily of our purchase of George Washington University's 20% ownership in the George Washington University Hospital (we now own 100% of the hospital); • generated $14 million from the issuance of shares of our Class B Common Stock pursuant to the terms of employee stock purchase plans; • spent $5 million to pay profit distributions related to noncontrolling interests in majority owned businesses, and; • spent $3 million to pay financing costs. 2021: The $1.069 billion of net cash used in financing activities during 2021 consisted of the following: • spent $3.038 billion on net repayment of debt as follows: (i) $1.911 billion related to our tranche A term loan facility; (ii) $490 million related to our terminated tranche B term loan facility; (iii) $410 million related to the early redemption of our previously outstanding $400 million, 5.00% senior secured notes which were scheduled to mature in June, 2026; (iv) $225 million related to our accounts receivable securitization program, and; (v) $2 million related to other debt facilities; • generated $3.255 billion of proceeds related to new borrowings as follows: (i) $1.7 billion related to our tranche A term loan facility; (ii) $699 million (net of discount) related to the August, 2021 issuance of $700 million, 1.65% senior secured notes due in September, 2026; (iii) $499 million (net of discount) related to the August, 2021 issuance of $500 million, 2.65% senior secured notes due in January, 2032; (iv) $343 million pursuant to our revolving credit facility, and; (v) $14 million of proceeds received related to other debt facilities; • spent $1.221 billion to repurchase shares of our Class B Common Stock in connection with: (i) open market purchases pursuant to our stock repurchase program ($1.201 billion), and; (ii) income tax withholding obligations related to stock-based compensation programs ($20 million); • spent $66 million to pay quarterly cash dividends of $.20 per share; • spent $19 million to pay financing costs incurred in connection with various financing transactions; • generated $13 million from the issuance of shares of our Class B Common Stock pursuant to the terms of employee stock purchase plans; • received $13 million in capital contributions from minority members in majority owned businesses, and; • spent $7 million to pay profit distributions related to noncontrolling interests in majority owned businesses. 2023 Expected Capital Expenditures: During 2023, we expect to spend approximately $725 million to $875 million on capital expenditures which includes expenditures for capital equipment, construction of new facilities, and renovations and expansions at existing hospitals.
Biggest changeNet cash used in financing activities Net cash used in financing activities was $494 million during 2023 and $318 million during 2022. 2023: The $494 million of net cash used in financing activities during 2023 consisted of the following: • generated $185 million of proceeds from additional borrowings pursuant to our revolving credit facility; • spent $547 million to repurchase shares of our Class B Common Stock in connection with: (i) open market purchases pursuant to our stock repurchase program ($524 million), and; (ii) income tax withholding obligations related to stock-based compensation programs ($23 million); • spent $85 million on net repayment of debt as follows: (i) $79 million related to our tranche A term loan facility, and; (ii) $6 million related to other debt facilities; • spent $55 million to pay quarterly cash dividends of $.20 per share; • generated $14 million from the issuance of shares of our Class B Common Stock pursuant to the terms of employee stock purchase plans; • spent $7 million to pay profit distributions related to noncontrolling interests in majority owned businesses, and; • received $3 million for the purchase of minority ownership interests in majority owned businesses. 2022: The $318 million of net cash used in financing activities during 2022 consisted of the following: • generated $705 million of proceeds from new borrowings consisting primarily of $700 million of proceeds generated from the new tranche A term loan facility which commenced in June, 2022; • spent $833 million to repurchase shares of our Class B Common Stock in connection with: (i) open market purchases pursuant to our stock repurchase program ($811 million), and; (ii) income tax withholding obligations related to stock-based compensation programs ($22 million); • spent $89 million on net repayment of debt as follows: (i) $51 million related to our tranche A term loan facility; (ii) $32 million related to our revolving credit facility, and; (iii) $6 million related to other debt facilities; • spent $58 million to pay quarterly cash dividends of $.20 per share; • spent $49 million in connection with the purchase of ownership interests from minority members, net of sales, consisting primarily of our purchase of George Washington University's 20% ownership in the George Washington University Hospital (we now own 100% of the hospital); • generated $14 million from the issuance of shares of our Class B Common Stock pursuant to the terms of employee stock purchase plans; • spent $5 million to pay profit distributions related to noncontrolling interests in majority owned businesses, and; • spent $3 million to pay financing costs. 2024 Expected Capital Expenditures: During 2024, we expect to spend approximately $850 million to $1.000 billion on capital expenditures which includes expenditures for capital equipment, construction of new facilities, and renovations and expansions at existing hospitals.
Critical Accounting Policies and Estimates The preparation of financial statements in conformity with accounting principles generally accepted in the United States requires us to make estimates and assumptions that affect the amounts reported in our consolidated financial statements and accompanying notes. A summary of our significant accounting policies is outlined in Note 1 to the financial statements.
Critical Accounting Policies and Estimates The preparation of financial statements in conformity with accounting principles generally accepted in the United States requires us to make estimates and assumptions that affect the amounts reported in our consolidated financial statements and accompanying notes. A summary of our significant accounting policies is outlined in Note 1 to the Consolidated Financial Statements .
Our Same Facility results also neutralize (if applicable) the effect of items that are non-operational in nature including items such as, but not limited to, gains/losses on sales of assets and businesses, impacts of settlements, legal judgments and lawsuits, impairments of long-lived and intangible assets and other amounts that may be reflected in the current or prior year financial statements that relate to prior periods.
Our Same Facility results also neutralize (if applicable) the effect of items that are non-operational in nature including items such as, but not limited to, gains/losses on sales of assets and businesses, impacts of settlements, legal judgments and lawsuits, impairments of long-lived and intangible assets and other amounts that may be reflected in the current or prior year financial statements that relate to prior periods.
In light of this decision, the government issued a final rule on August 19, 2022 eliminating the rebuttable presumption in favor of the qualifying payment amount (“QPA”) by the IDR entity and providing additional factors the IDR entity should consider when choosing between two competing offers.
In light of this decision, the government issued a final rule on August 19, 2022 eliminating the rebuttable presumption in favor of the qualifying payment amount (“QPA”) by the IDR entity and providing additional factors the IDR entity should consider when choosing between two competing offers.
Revolving credit and tranche A term loan borrowings under the Credit Agreement bear interest at our election at either (1) the ABR rate which is defined as the rate per annum equal to the greatest of (a) the lender’s prime rate, (b) the weighted average of the federal funds rate, plus 0.5% and (c) one month SOFR rate plus 1%, in each case, plus an applicable margin based upon our consolidated leverage ratio at the end of each quarter ranging from 0.25% to 0.625%, or (2) the one, three or six month SOFR rate plus 0.1% (at our election), plus an applicable margin based upon our consolidated leverage ratio at the end of each quarter ranging from 1.25% to 1.625%.
Revolving credit and tranche A term loan borrowings under the Credit Agreement bear interest at our election at either (1) the ABR rate which is defined as the rate per annum equal to the greatest of (a) the lender’s prime rate, (b) the weighted average of the federal funds rate, plus 0.5% and (c) one month term SOFR rate plus 1%, in each case, plus an applicable margin based upon our consolidated leverage ratio at the end of each quarter ranging from 0.25% to 0.625%, or (2) the one, three or six month term SOFR rate plus 0.1% (at our election), plus an applicable margin based upon our consolidated leverage ratio at the end of each quarter ranging from 1.25% to 1.625 %.
Interest on the 2026 Notes is payable on March 1st and September 1st until the maturity date of September 1, 2026. Interest on the 2030 Notes payable on April 15th and October 15th, until the maturity date of October 15, 2030.
Interest on the 2026 Notes is payable on March 1st and September 1st until the maturity date of September 1, 2026. Interest on the 2030 Notes is payable on April 15th and October 15th, until the maturity date of October 15, 2030.
However, the liens on the collateral securing The Notes and the Guarantees will be released if: (i) The Notes have investment grade ratings; (ii) no default has occurred and is continuing, and; (iii) the liens on the collateral securing all first lien obligations (including the Credit Agreement and The Notes) and any junior lien obligations are released or the collateral under the Credit Agreement, any other first lien obligations and any junior lien obligations is released or no longer required to be pledged.
However, the liens on the collateral securing The Notes and the Guarantees will be released if: (i) The Notes have investment grade ratings; (ii) no default has occurred and is continuing, and; (iii) the liens on the collateral securing all first lien obligations (including the Credit Agreement and The Notes) and any junior lien obligations are released or the collateral under the Credit Agreement, any other first lien obligations and any junior lien obligations is released or no longer required to be pledged.
The liens on any collateral securing The Notes and the Guarantees will also be released if the liens on that collateral securing the Credit Agreement, other first lien obligations and any junior lien obligations are released.
The liens on any collateral securing The Notes and the Guarantees will also be released if the liens on that collateral securing the Credit Agreement, other first lien obligations and any junior lien obligations are released.
On August 24, 2021, we completed the following via private offerings to qualified institutional buyers under Rule 144A and to non-U.S. persons outside the United States in reliance on Regulation S under the Securities Act of 1933, as amended: o Issued $700 million of aggregate principal amount of 1.65% senior secured notes due on September 1, 2026, and; o Issued $500 million of aggregate principal amount of 2.65% senior secured notes due on January 15, 2032.
On August 24, 2021, we completed the following via private offerings to qualified institutional buyers under Rule 144A and to non-U.S. persons outside the United States in reliance on Regulation S under the Securities Act of 1933, as amended: • Issued $700 million of aggregate principal amount of 1.65% senior secured notes due on September 1, 2026, and; • Issued $500 million of aggregate principal amount of 2.65% senior secured notes due on January 15, 2032.
Please see Self-Insured/Other Insurance Risks above for additional disclosure related to our professional and general liability claims and reserves. During 2020, we entered into a various agreements with the District of Columbia (the “District”) related to the development, leasing and operation of an acute care hospital and certain other facilities/structures on land owned by the District (“District Facilities”).
Please see Self-Insured/Other Insurance Risks above for additional disclosure related to our professional and general liability claims and reserves. During 2020, we entered into various agreements with the District of Columbia (the “District”) related to the development, leasing and operation of an acute care hospital and certain other facilities/structures on land owned by the District (“District Facilities”).
Fair values are determined based on estimated future cash flows using appropriate discount rates. Please see additional disclosure below in Provision for Asset Impairment . Goodwill and Intangible Assets: Goodwill and indefinite-lived intangible assets are reviewed for impairment at the reporting unit level on an annual basis or more often if indicators of impairment arise.
Fair values are determined based on estimated future cash flows using appropriate discount rates. Please see additional disclosure below in Provision for Asset Impairments . Goodwill and Intangible Assets: Goodwill and indefinite-lived intangible assets are reviewed for impairment at the reporting unit level on an annual basis or more often if indicators of impairment arise.
These leases contain various renewal options, as disclosed in Note 9 to the Consolidated Financial 73 Statements-Relationship with Universal Health Realty Income Trust and Other Related Party Transactions . We also lease two free-standing emergency departments and space in certain medical office buildings which are owned by the Trust.
These leases contain various renewal options, as disclosed in Note 9 to the Consolidated Financial Statements-Relationship with Universal Health Realty Income Trust and Other Related Party Transactions . We also lease two free-standing emergency departments and space in certain medical office buildings which are owned by the Trust.
We can provide no assurance that further reductions to Medicaid revenues, particularly in the above-mentioned states, will not have a material adverse effect on our future results of operations. In January, 2020, CMS announced a new opportunity to support states with greater flexibility to improve the health of their Medicaid populations.
We can provide no assurance that further reductions to Medicaid revenues, particularly in the above-mentioned states, will not have a material adverse effect on our future results of operations. 57 In January, 2020, CMS announced a new opportunity to support states with greater flexibility to improve the health of their Medicaid populations.
See Note 8 to the Consolidated Financial Statements-Commitments and Contingencies for additional disclosure related to our self-insured general and professional liability and workers’ compensation liability. 45 Long-Lived Assets: We review our long-lived assets for impairment whenever events or circumstances indicate that the carrying value of these assets may not be recoverable.
See Note 8 to the Consolidated Financial Statements-Commitments and Contingencies for additional disclosure related to our self-insured general and professional liability and workers’ compensation liability. Long-Lived Assets: We review our long-lived assets for impairment whenever events or circumstances indicate that the carrying value of these assets may not be recoverable.
To obtain a complete understanding of our financial performance, the Same Facility results should be examined in connection with our net income as determined in accordance with U.S. GAAP and as presented in the condensed consolidated financial statements and notes thereto as contained in this Annual Report on Form 10-K.
To obtain a complete understanding of our financial performance, the Same Facility results should be examined in connection with our net income as determined in accordance with U.S. GAAP and as presented in the consolidated financial statements and notes thereto as contained in this Annual Report on Form 10-K.
Private insurance carriers typically make direct payments to hospitals or, in some cases, reimburse their policy holders, based upon the particular hospital’s established charges and the particular coverage provided in the insurance policy. Private insurance reimbursement varies among payers and states and is generally based on contracts negotiated between the hospital and the payer.
Private insurance carriers typically make direct payments to hospitals or, in some cases, reimburse their policy holders, based upon the 63 particular hospital’s established charges and the particular coverage provided in the insurance policy. Private insurance reimbursement varies among payers and states and is generally based on contracts negotiated between the hospital and the payer.
The ACO program allows providers (including hospitals), physicians and other designated professionals and suppliers to voluntarily work together to invest in infrastructure and redesign delivery processes to achieve high quality and efficient delivery of services. The program is intended to produce savings as a result of 63 improved quality and operational efficiency.
The ACO program allows providers (including hospitals), physicians and other designated professionals and suppliers to voluntarily work together to invest in infrastructure and redesign delivery processes to achieve high quality and efficient delivery of services. The program is intended to produce savings as a result of improved quality and operational efficiency.
Charges and reimbursement rates for inpatient routine services vary depending on the type of services provided (e.g., medical/surgical, intensive care or behavioral health) and the geographic location of the hospital. Inpatient occupancy levels fluctuate 52 for various reasons, many of which are beyond our control.
Charges and reimbursement rates for inpatient routine services vary depending on the type of services provided (e.g., medical/surgical, intensive care or behavioral health) and the geographic location of the hospital. Inpatient occupancy levels fluctuate for various reasons, many of which are beyond our control.
Our Same Facility basis results reflected on the tables below also exclude from net revenues and other operating expenses, provider tax assessments incurred in each period as discussed below Sources of Revenue-Various State Medicaid Supplemental Payment Programs.
Our Same Facility basis results reflected on the tables below also exclude from net revenues and other operating expenses, provider tax assessments incurred in each period as discussed below Sources of Revenue-Summary of Various State Medicaid Supplemental Payment Programs.
Our Same Facility basis results reflected on the table below also excludes from net revenues and other operating expenses, provider tax assessments incurred in each period as discussed below Sources of Revenue-Various State Medicaid Supplemental Payment Programs.
Our Same Facility basis results reflected on the table below also excludes from net revenues and other operating expenses, provider tax assessments incurred in each period as discussed below Sources of Revenue-Summary of Various State Medicaid Supplemental Payment Programs.
Patients are generally not responsible for any difference between customary hospital charges and amounts reimbursed for such services under Medicare, Medicaid, some private insurance plans, and managed care plans, but are responsible for services not covered by such plans, exclusions, deductibles or co-insurance features of their coverage.
Patients are generally not responsible for any difference between customary hospital charges and amounts reimbursed for such services under Medicare, Medicaid, some private insurance plans, and managed care plans, but are responsible for services not 53 covered by such plans, exclusions, deductibles or co-insurance features of their coverage.
The CAA addresses surprise medical bills stemming from emergency services, out-of-network ancillary providers at in-network facilities, and air ambulance carriers. The legislation prohibits surprise billing when out-of-network emergency services or out-of-network services at an in-network facility are provided, unless informed consent is 41 received.
The CAA addresses surprise medical bills stemming from emergency services, out-of-network ancillary providers at in-network facilities, and air ambulance carriers. The legislation prohibits surprise billing when out-of-network emergency services or out-of-network services at an in-network facility are provided, unless informed consent is received.
Including DSH payments, an increase to the Medicare Outlier threshold and certain other adjustments, we estimate our overall increase from the final IPPS 2023 rule (covering the period of October 1, 2022 through September 30, 2023) will approximate 4.4%.
Including DSH payments, an increase to the Medicare Outlier threshold and certain other adjustments, we estimate our overall increase from the final IPPS 2023 rule (covering the period of October 1, 2022 through September 30, 2023) will 55 approximate 4.4%.
Investments in and the equity in earnings of 72 non-guarantor subsidiaries, which would otherwise be consolidated in accordance with GAAP, are excluded from the below summarized financial information pursuant to SEC Regulation S-X Rule 13-01.
Investments in and the equity in earnings of non-guarantor subsidiaries, which would otherwise be consolidated in accordance with GAAP, are excluded from the below summarized financial information pursuant to SEC Regulation S-X Rule 13-01.
The Legislation permits existing physician investments in a hospital to continue under a “grandfather” clause if the arrangement satisfies certain requirements and restrictions, but physicians are prohibited from increasing the aggregate percentage of their ownership in the hospital.
The Legislation permits existing physician investments in a hospital to continue under a “grandfather” clause if the arrangement satisfies certain requirements and restrictions, but physicians are prohibited from 54 increasing the aggregate percentage of their ownership in the hospital.
We have certain lease termination rights in connection with the District Facilities beginning on the tenth anniversary of the lease commencement date for various and decreasing amounts as provided for in the agreements.
We have certain lease termination rights in connection with the District Facilities beginning on the tenth anniversary of the lease commencement date for various and 74 decreasing amounts as provided for in the agreements.
Our patient registration process includes an interview of the patient or the patient’s responsible party at the time of 44 registration. At that time, an insurance eligibility determination is made and an insurance plan code is assigned.
Our patient registration process includes an interview of the patient or the patient’s responsible party at the time of registration. At that time, an insurance eligibility determination is made and an insurance plan code is assigned.
See below in Sources of Revenue and Health Care Reform for additional disclosure; • under the Legislation, hospitals are required to make public a list of their standard charges, and effective January 1, 2019, CMS has required that this disclosure be in machine-readable format and include charges for all hospital items and services and average charges for diagnosis-related groups.
See below in Sources of Revenues and Health Care Reform for additional disclosure; • under the Legislation, hospitals are required to make public a list of their standard charges, and effective January 1, 2019, CMS has required that this disclosure be in machine-readable format and include charges for all hospital items and services and average charges for diagnosis-related groups.
This projected impact from the IPPS 2023 final rule includes an increase of approximately 0.5% to partially restore cuts made as a result of the American Taxpayer Relief Act of 2012 (“ATRA”), as required by the 21st Century Cures Act, but excludes the impact of the sequestration reductions related to the 2011 Act, Bipartisan Budget Act of 2015, and Bipartisan Budget Act of 2018, as discussed below.
This projected impact from the IPPS 2023 final rule includes an increase of approximately 0.5% to partially restore cuts made as a result of the American Taxpayer Relief Act of 2012 (“ATRA”), as required by the 21st Century Cures Act, but excludes the impact of the sequestration reductions related to the 2011 Act, Bipartisan Budget Act of 2015, and Bipartisan Budget Act of 2018.
Although our ability to pass on increased costs associated with providing healthcare to Medicare and Medicaid patients is limited due to various federal, state and local laws which, in certain circumstances, limit our ability to increase prices, we have been 46 negotiating increased rates from commercial insurers to defray our increased cost of providing patient care.
Although our ability to pass on increased costs associated with providing healthcare to Medicare and Medicaid patients is limited due to various federal, state and local laws which, in certain circumstances, limit our ability to increase prices, we have been requesting and negotiating increased rates from commercial insurers to defray our increased cost of providing patient care.
We are experiencing inflationary pressures, primarily in personnel costs, and we anticipate impacts on other cost areas within the next twelve months.
We are experiencing inflationary pressures, primarily in personnel costs, and we anticipate continuing impacts on other cost areas within the next twelve months.
Supreme Court rejected the latest such case on June 17, 2021, when the Court held in California v. Texas that the plaintiffs lacked standing to challenge the Legislation’s requirement to obtain minimum essential health insurance coverage, or the individual mandate. The Court dismissed the case without specifically ruling on the constitutionality of the Legislation.
The U.S. Supreme Court rejected the latest such case on June 17, 2021, when the Court held in California v. Texas that the plaintiffs lacked standing to challenge the Legislation’s requirement to obtain minimum essential health insurance coverage, or the individual mandate. The Court dismissed the case without specifically ruling on the constitutionality of the Legislation.
Although the patient’s ultimate eligibility determination may result in adjustments to net revenues, these adjustments did not have a material impact on our results of operations in 2022 or 2021 since our facilities make estimates at each financial reporting period to adjust revenue based on historical collections.
Although the patient’s ultimate eligibility determination may result in adjustments to net revenues, these adjustments did not have a material impact on our results of operations in 2023 or 2022 since our facilities make estimates at each financial reporting period to adjust revenue based on historical collections.
Becerra , CMS is applying the default rate, generally average sales price plus 6 percent, to 340B acquired drugs and biologicals for 2023. CMS stated they will address the remedy for 340B drug payments from 2018-2022 in future rulemaking prior to the CY 2024 OPPS/ASC proposed rule.
Becerra , CMS is applying the default rate, generally average sales price plus 6%, to 56 340B acquired drugs and biologicals for 2023. CMS stated they will address the remedy for 340B drug payments from 2018-2022 in future rulemaking prior to the CY 2024 OPPS/ASC proposed rule.
Our judgments regarding the existence of impairment indicators are based on market conditions and operational performance of each reporting unit. We have designated October 1 st as our annual impairment assessment date for our goodwill and indefinite-lived intangible assets. We performed an impairment assessment as of October 1, 2022 which indicated no impairment of goodwill.
Our judgments regarding the existence of impairment indicators are based on market conditions and operational performance of each reporting unit. We have designated October 1 st as our annual impairment assessment date for our goodwill and indefinite-lived intangible assets. We performed an impairment assessment as of October 1, 2023 which indicated no impairment of goodwill.
(e) Reflects our future minimum operating lease payment obligations related to our operating lease agreements outstanding as of December 31, 2022 as discussed in Note 7 to the Consolidated Financial Statements . Some of the lease agreements provide us with the option to renew the lease and our future lease obligations would change if we exercised these renewal options.
(e) Reflects our future minimum operating lease payment obligations related to our operating lease agreements outstanding as of December 31, 2023 as discussed in Note 7 to the Consolidated Financial Statements . Some of the lease agreements provide us with the option to renew the lease and our future lease obligations would change if we exercised these renewal options.
This revenue was earned pursuant to contract terms with various Medicaid managed care plans which requires the annual payout of QIF funds when a managed care service delivery area’s actual claims-based UHRIP payments are less than targeted UHRIP payments for a specific rate year.
This revenue was earned pursuant to contract terms with various Medicaid managed care plans which requires the annual payout of QIF funds when a managed care service delivery area’s actual claims-based CHIRP payments are less than targeted CHIRP payments for a specific rate year.
We receive annual Medicaid revenues of approximately $100 million, or greater, from each of Texas, California, Nevada, Illinois, Pennsylvania, Washington, D.C., Florida, Kentucky and Massachusetts. We also receive Medicaid disproportionate share hospital payments in certain states including Texas and South Carolina.
We receive annual Medicaid revenues of approximately $100 million, or greater, from each of Texas, California, Nevada, Illinois, Pennsylvania, Washington, D.C., Kentucky, Florida, Massachusetts and Virginia. We also receive Medicaid disproportionate share hospital ("DSH") payments in certain states including Texas and South Carolina.
We exclude the $372 million for professional and general liability claims from the contractual obligations table because there are no significant contractual obligations associated with these liabilities and because of the uncertainty of the dollar amounts to be ultimately paid as well as the timing of such payments.
We exclude the $431 million for professional and general liability claims from the contractual obligations table because there are no significant contractual obligations associated with these liabilities and because of the uncertainty of the dollar amounts to be ultimately paid as well as the timing of such payments.
Notes originally issued under Rule 144A or Regulation S that were not exchanged in the exchange offer remain outstanding and may not be offered or sold in the United States absent registration under the Securities Act or an applicable exemption from registration requirements thereunder.
Notes originally issued under Rule 144A or Regulation S that were not exchanged remain outstanding and may not be offered or sold in the United States absent registration under the Securities Act or an applicable exemption from registration requirements thereunder.
Such Provider Taxes are subject to various federal regulations that limit the scope and amount of the taxes that can be levied by states in order to secure federal matching funds as part of their respective state Medicaid programs.
Such Provider Taxes are subject to various federal regulations that limit the scope and amount of the taxes that can be levied by states in order to secure federal matching funds as part of their respective state Medicaid supplemental payment programs.
As part of the FFY 2022 IPPS final rule and FFY 2023 final rule, as discussed above, and as a result of the on-going COVID-19 pandemic, CMS has implemented a budget neutral payment policy to fully offset the 2% VBP withhold during each of FFY 2022 and FFY 2023.
As part of the FFY 2022 IPPS final rule and FFY 2023 final rule, as discussed above, and as a result of the COVID-19 pandemic, CMS has implemented a budget neutral payment policy to fully offset the 2% VBP withhold during each of FFY 2022 and FFY 2023.
(b) Assumes that all debt outstanding as of December 31, 2022, including borrowings under our Credit Agreement, remain outstanding until the final maturity of the debt agreements at the same interest rates (some of which are floating) which were in effect as of December 31, 2022.
(b) Assumes that all debt outstanding as of December 31, 2023, including borrowings under our Credit Agreement, remain outstanding until the final maturity of the debt agreements at the same interest rates (some of which are floating) which were in effect as of December 31, 2023.
Adjustments related to the final settlement of these retrospectively determined amounts did not materially impact our results in 2022, 2021 or 2020. If it were to occur, each 1% adjustment to our estimated net Medicare revenues that are subject to retrospective review and settlement as of December 31, 2022, would change our after-tax net income by approximately $1 million.
Adjustments related to the final settlement of these retrospectively determined amounts did not materially impact our results in 2023, 2022 or 2021. If it were to occur, each 1% adjustment to our estimated net Medicare revenues that are subject to retrospective review and settlement as of December 31, 2023, would change our after-tax net income by approximately $2 million.
As of December 31, 2022, the applicable margins were 0.50% for ABR-based loans and 1.50% for SOFR-based loans under the revolving credit and term loan A facilities. The revolving credit facility includes a $125 million sub-limit for letters of credit.
As of December 31, 2023, the applicable margins were 0.50% for ABR-based loans and 1.50% for SOFR-based loans under the revolving credit and term loan A facilities. The revolving credit facility includes a $125 million sub-limit for letters of credit.
As of December 31, 2022, we had combined aggregate principal of $2.0 billion from the following senior secured notes: o $700 million aggregate principal amount of 1.65% senior secured notes due in September, 2026 (“2026 Notes”) which were issued on August 24, 2021. o $800 million aggregate principal amount of 2.65% senior secured notes due in October, 2030 (“2030 Notes”) which were issued on September 21, 2020. o $500 million of aggregate principal amount of 2.65% senior secured notes due in January, 2032 (“2032 Notes”) which were issued on August 24, 2021.
As of December 31, 2023, we had combined aggregate principal of $2.0 billion from the following senior secured notes: • $700 million aggregate principal amount of 1.65% senior secured notes due in September, 2026 (“2026 Notes”) which were issued on August 24, 2021. • $800 million aggregate principal amount of 2.65% senior secured notes due in October, 2030 (“2030 Notes”) which were issued on September 21, 2020. • $500 million of aggregate principal amount of 2.65% senior secured notes due in January, 2032 (“2032 Notes”) which were issued on August 24, 2021.
See Note 10 to the Consolidated Financial Statements-Revenue Recognition , for additional disclosure related to our revenues including a disaggregation of our consolidated net revenues by major source for each of the periods presented herein.
For additional disclosure related to our revenues including a disaggregation of our consolidated net revenues by major source for each of the periods presented herein, please see Note 10 to the Consolidated Financial Statements-Revenue .
(c.) In September, 2020, we completed the offering of $800 million aggregate principal amount of 2.65% Senior Notes due in 2030. (d.) In August, 2021, we completed the offering of $700 million aggregate principal amount of 1.65% Senior Notes due in 2026.
(b.) In September, 2020, we completed the offering of $800 million aggregate principal amount of 2.65% Senior Notes due in 2030. (c.) In August, 2021, we completed the offering of $700 million aggregate principal amount of 1.65% Senior Notes due in 2026.
HHS is to determine the amount of Medicaid DSH payment cuts imposed on each state based on a defined methodology. As Medicaid DSH payments to states will be cut, consequently, payments to Medicaid-participating providers, including our hospitals in Texas and South Carolina, will be reduced in the coming years.
HHS is to determine the amount of Medicaid DSH payment cuts imposed on each state based on a defined methodology. As Medicaid DSH payments to states will be cut, consequently, payments to Medicaid-participating providers, including our hospitals in Texas, will be reduced in the coming years.
Additional funds may be obtained through: (i) borrowings under our existing revolving credit facility, which had $886 million of available borrowing capacity as of December 31, 2022, or through refinancing the existing Credit Agreement; (ii) the issuance of other short-term and/or long-term debt, and/or; (iii) the issuance of equity.
Additional funds may be obtained through: (i) borrowings under our existing revolving credit facility, which had $701 million of available borrowing capacity as of December 31, 2023, or through refinancing the existing Credit Agreement; (ii) the issuance of other short-term and/or long-term debt, and/or; (iii) the issuance of equity.
Supplemental Guarantor Financial Information As of December 31, 2022, we had combined aggregate principal of $2.0 billion from The Notes: • $700 million aggregate principal amount of the 2026 Notes; • $800 million aggregate principal amount of the 2030 Notes, and; • $500 million of aggregate principal amount of the 2032 Notes.
Supplemental Guarantor Financial Information As of December 31, 2023, we had combined aggregate principal of $2.0 billion from The Notes: • $700 million aggregate principal amount of the 2026 Notes; 71 • $800 million aggregate principal amount of the 2030 Notes, and; • $500 million of aggregate principal amount of the 2032 Notes.
Increase to self-insured professional and general liability reserves: Our estimated liability for self-insured professional and general liability claims is based on a number of factors including, among other things, the number of asserted claims and reported incidents, estimates of losses for these claims based on recent and historical settlement amounts, estimates of incurred but not reported claims based on historical experience, and estimates of amounts recoverable under our commercial insurance policies.
Adjustments to self-insured professional and general liability and workers' compensation liability reserves: Professional and general liability: Our estimated liability for self-insured professional and general liability claims is based on a number of factors including, among other things, the number of asserted claims and reported incidents, estimates of losses for these claims based on recent and 48 historical settlement amounts, estimates of incurred but not reported claims based on historical experience, and estimates of amounts recoverable under our commercial insurance policies.
All Acute Care Hospital Services The following table summarizes the results of operations for all our acute care operations during 2022 and 2021.
All Acute Care Hospital Services The following table summarizes the results of operations for all our acute care operations during 2023 and 2022.
On August 1, 2022, CMS approved the CHIRP program, with a pool of $5.2 billion, for the rate period effective September 1, 2022 to August 31, 2023.
On August 1, 2022, CMS approved the CHIRP program, with a pool of $5.2 billion, for the rate period effective September 1, 2022 to August 31, 2023. On July 31, 2023, CMS approved the CHIRP program, with a pool of $6.5 billion, for the rate period of September 1, 2023 to August 31, 2024.
Days sales outstanding (“DSO”): Our DSO are calculated by dividing our net revenue by the number of days in the year. The result is divided into the accounts receivable balance at the end of the year. Our DSO were 55 days at December 31, 2022 and 50 days at December 31, 2021.
Days sales outstanding (“DSO”): Our DSO are calculated by dividing our net revenue by the number of days in the year. The result is divided into the accounts receivable balance at the end of the year. Our DSO were 57 days at December 31, 2023 and 55 days at December 31, 2022.
Obligations under operating leases for real property, real property master leases and equipment amount to $922 million as of December 31, 2022. The real property master leases are leases for buildings on or near hospital property for which we guarantee a certain level of rental income.
Obligations under operating leases for real property, real property master leases and equipment amount to $915 million as of December 31, 2023. The real property master leases are leases for buildings on or near hospital property for which we guarantee a certain level of rental income.
(d) Consists of: (i) $54 million related to long-term contracts with third-parties consisting primarily of certain revenue cycle data processing services for our acute care facilities; (ii) $224 million related to the future expected costs to be paid to a third-party vendor in connection with the ongoing operation of an electronic health records application and purchase and implementation of a revenue cycle and other applications for our facilities; (iii) $16 million for other software applications, and; (iv) $75 million in healthcare infrastructure in Washington D.C. in connection with various agreements with the District of Columbia, as discussed below.
(d) Consists of: (i) $65 million related to long-term contracts with third-parties consisting primarily of certain revenue cycle data processing services for our acute care facilities; (ii) $188 million related to the future expected costs to be paid to a third-party vendor in connection with the ongoing operation of an electronic health records application and purchase and implementation of a revenue cycle and other applications for our facilities; (iii) $4 million for other software applications, and; (iv) $70 million in healthcare infrastructure in Washington D.C. in connection with various agreements with the District of Columbia, as discussed below.
The Consolidated Appropriations Act of 2023 (“CAA of 2023”), signed into law on December 29, 2022, provides for the transitional reduction of the 6.2% enhanced FMAP during 2023 to 5.0% during the second quarter, 2.5% during the third quarter and 1.5% during the fourth quarter of 2023. • Effective April 1, 2023, the CAA of 2023 allows states to initiate Medicaid renewals, post-enrollment verifications, and redeterminations over a 12-month period for all individuals who are enrolled in such plan (or waiver) as of April 1, 2023.
The CAA of 2023, signed into law on December 29, 2022, provided for the transitional reduction of the 6.2% enhanced FMAP during 2023 to 5.0% during the second quarter, 2.5% during the third quarter and 1.5% during the fourth quarter of 2023. • Effective April 1, 2023, the CAA of 2023 allows states to initiate Medicaid renewals, post-enrollment verifications, and redeterminations over a 12-month period for all individuals who are enrolled in such plan (or waiver) as of April 1, 2023.
When other statutorily required adjustments and hospital patient service mix are considered, we estimate that our overall Medicare OPPS update for 2021 will aggregate to a net increase of 3.3% which includes a 9.2% increase to behavioral health division partial hospitalization rates.
When other statutorily required adjustments and hospital patient service mix are considered, we estimate that our overall Medicare OPPS update for 2022 will aggregate to a net increase of 2.4% which includes a 3.0% increase to behavioral health division partial hospitalization rates.
We consider these to be “level 2” in the fair value hierarchy as outlined in the authoritative guidance for disclosures in connection with debt instruments. 71 Our total debt as a percentage of total capitalization was approximately 45% at December 31, 2022 and 41% at December 31, 2021.
We consider these to be “level 2” in the fair value hierarchy as outlined in the authoritative guidance for disclosures in connection with debt instruments. Our total debt as a percentage of total capitalization was approximately 44% at December 31, 2023 and 45% at December 31, 2022.
Failure to renew these programs beyond their scheduled termination dates, failure of the public hospitals to provide the necessary IGTs for the states’ share of the DSH programs, failure of our hospitals that currently receive supplemental Medicaid revenues to 61 qualify for future funds under these programs, or reductions in reimbursements, could have a material adverse effect on our future results of operations.
Failure to renew these programs beyond their scheduled termination dates, failure of the public hospitals to provide the necessary IGTs for the states’ share of the DSH programs, failure of our hospitals that currently receive supplemental Medicaid revenues to qualify for future funds under these programs, or reductions in reimbursements, could cause our estimates to differ by material amounts which could have a material adverse effect on our future results of operations.
In addition, we lease the real property of certain other facilities from non-related parties as indicated in Item 2. Properties, as included herein.
In addition, we lease the real property of certain other facilities from non-related parties as indicated in Item 2.
The increase was primarily due to: (i) a net $45 million increase in aggregate interest expense on our revolving credit, demand notes, senior notes, term loan facilities and accounts receivable securitization program, resulting from an increase in our aggregate average cost of borrowings pursuant to these facilities (2.8% during 2022 as compared to 2.1% during 2021), as well as an increase in the aggregate average outstanding borrowings ($4.40 billion during 2022 as compared to $3.72 billion during 2021), partially offset by; (ii) a net $2 million decrease in other combined interest expenses, including a $4 million increase in capitalized interest on major projects.
The increase was primarily due to: (i) a net $102 million increase in aggregate interest expense on our revolving credit, demand notes, senior notes, term loan facilities and accounts receivable securitization program, resulting from an increase in our aggregate average cost of borrowings pursuant to these facilities (4.8% during 2023 as compared to 2.8% during 2022), as well as an increase in the aggregate average outstanding borrowings ($4.63 billion during 2023 as compared to $4.40 billion during 2022), partially offset by; (ii) a net $22 million decrease in other combined interest expenses, including a $16 million increase in capitalized interest on major projects.
Recent Accounting Pronouncements: For a summary of recent accounting pronouncements, please see Note 1 to the Consolidated Financial Statements-Accounting Standards as included in this Report on Form 10-K for the year ended December 31, 2022.
Recent Accounting Pronouncements: For a summary of recent accounting pronouncements, please see Note 1 to the Consolidated Financial Statements-Business and Summary of Significant Accounting Standards as included in this Report on Form 10-K for the year ended December 31, 2023.
This program remains subject to CMS approval. Texas Delivery System Reform Incentive Payments: In addition, the Texas Medicaid Section 1115 Waiver included a DSRIP pool to incentivize hospitals and other providers to transform their service delivery practices to improve quality, health status, patient experience, coordination, and cost-effectiveness.
DSRIP In addition, the Texas Medicaid Section 1115 Waiver included a Delivery System Reform Incentive Payments ("DSRIP") pool to incentivize hospitals and other providers to transform their service delivery practices to improve quality, health status, patient experience, coordination, and cost-effectiveness.
In connection with this program, included in our financial results was approximately $36 million during 2022 and $23 million during 2021 (recorded during fourth quarters of each year). We estimate that our reimbursements pursuant to this DPP will approximate $34 million during the year ended December 31, 2023.
In connection with this program, included in our financial results was approximately $43 million during 2023 and $36 million during 2022 (recorded during fourth quarters of each year). We estimate that our reimbursements pursuant to this DPP will approximate $41 million during the year ended December 31, 2024.
The American Hospital Association and American Medical Association have announced their intent to join this case as amici supporting the Texas Medical Association; • possible unfavorable changes in the levels and terms of reimbursement for our charges by third party payers or government based payers, including Medicare or Medicaid in the United States, and government based payers in the United Kingdom; • our ability to enter into managed care provider agreements on acceptable terms and the ability of our competitors to do the same; • the outcome of known and unknown litigation, government investigations, false claims act allegations, and liabilities and other claims asserted against us and other matters as disclosed in Note 8 to the Consolidated Financial Statements - Commitments and Contingencies and the effects of adverse publicity relating to such matters ; • competition from other healthcare providers (including physician owned facilities) in certain markets; • technological and pharmaceutical improvements that increase the cost of providing, or reduce the demand for healthcare; • our ability to attract and retain qualified personnel, nurses, physicians and other healthcare professionals and the impact on our labor expenses resulting from a shortage of nurses and other healthcare professionals; • demographic changes; • there is a heightened risk of future cybersecurity threats, including ransomware attacks targeting healthcare providers.
Court of Appeals for the Fifth Circuit; • possible unfavorable changes in the levels and terms of reimbursement for our charges by third party payers or government based payers, including Medicare or Medicaid in the United States, and government based payers in the United Kingdom; • our ability to enter into managed care provider agreements on acceptable terms and the ability of our competitors to do the same; • the outcome of known and unknown litigation, government investigations, false claims act allegations, and liabilities and other claims asserted against us and other matters as disclosed in Note 8 to the Consolidated Financial Statements - Commitments and Contingencies and the effects of adverse publicity relating to such matters ; • competition from other healthcare providers (including physician owned facilities) in certain markets; • technological and pharmaceutical improvements that increase the cost of providing, or reduce the demand for healthcare; • our ability to attract and retain qualified personnel, nurses, physicians and other healthcare professionals and the impact on our labor and related expenses resulting from a shortage of nurses, physicians and other healthcare professionals; • demographic changes; • there is a heightened risk of future cybersecurity threats, including ransomware attacks targeting healthcare providers.
The Credit Agreement is secured by certain assets of the Company and our material subsidiaries (which generally excludes asset classes such as substantially all of the patient-related accounts receivable of our acute care hospitals, and certain real estate assets and assets held in joint-ventures with third parties) and is guaranteed by our material subsidiaries.
The Credit Agreement is secured by certain assets of the Company and our material subsidiaries (which generally excludes asset classes such as substantially all of the patient-related accounts receivable of our acute care hospitals, if sold to a receivables facility pursuant to the Credit Agreement, and certain real estate assets and assets held in joint-ventures with third parties) and is guaranteed by our material subsidiaries.
Oklahoma Transition to Managed Care and Implementation of a Medicaid Managed Care DPP In May, 2022, Oklahoma enacted legislation (SB 1337 and SB 1396) that directs the Oklahoma Health Care Authority (“OHCA”) to: (i) transition its Medicaid program from a fee for service payment model to a managed care payment model by no later than October 1, 2023, and: (ii) concurrently implement a Medicaid managed care DPP using a managed care gap of ninety percent (90%) average commercial rates.
In May, 2022, Oklahoma enacted legislation that directs the Oklahoma Health Care Authority ("OHCA") to: (i) transition its Medicaid program from a fee for service payment model to a managed care payment model by no later than October 1, 2023, and: (ii) concurrently implement a Medicaid managed care DPP using a managed care gap of 90% of average commercial rates.
The average effective interest rate, including amortization of deferred financing costs, original issue discount and designated interest rate swap expense/income, on borrowings outstanding under our revolving credit, demand notes, senior notes, term loan A and 66 B facilities and accounts receivable securitization program, which amounted to approximately $4.40 billion during 2022 and $3.72 billion during 2021, were 2.9% during 2022 and 2.2% during 2021.
The average effective interest rate, including amortization of deferred financing costs, original issue discount and designated interest rate swap expense/income, on borrowings outstanding under our revolving credit, demand notes, senior notes, term loan A facility and accounts receivable securitization program, which amounted to approximately $4.63 billion during 2023 and $4.40 billion during 2022, were 4.9% during 2023 and 2.9% during 2022.
The Joint Committee was unable to reach an agreement by the November 23, 2011 deadline and, as a result, across-the-board cuts to discretionary, national defense and Medicare spending were implemented on March 1, 2013 resulting in Medicare payment reductions of up to 2% per fiscal year.
The Joint Committee was unable to reach an agreement by the November 23, 2011 deadline and, as a result, across-the-board cuts to discretionary, national defense and Medicare spending were implemented on March 1, 2013 resulting in Medicare payment reductions of up to 2% per fiscal year. Subsequent legislation has extended this sequestration through 2032.
(g) Consists of accrued and unpaid estimated claims expense incurred in connection with our commercial health insurers and self-insured employee benefit plans. As of December 31, 2022, the total net accrual for our professional and general liability claims was $372 million, of which $74 million is included in other current liabilities and $298 million is included in other non-current liabilities.
(g) Consists of accrued and unpaid estimated claims expense incurred in connection with our commercial health insurers and self-insured employee benefit plans. As of December 31, 2023, the total net accrual for our professional and general liability claims was $431 million, of which $70 million is included in other current liabilities and $361 million is included in other non-current liabilities.
State Directed Payment Program ("SDP") On February 7, 2023, the Division of Health Care Financing and Policy (“DHCFP”) held a public workshop that outlined a new provider fee on private hospitals located in Nevada that would effectively capture new Medicaid federal share for certain categories of services eligible for the new payment programs.
Nevada State Directed Payment Program ("SDP"): As previously reported, in February, 2023, the Nevada Division of Health Care Financing and Policy (“DHCFP”) outlined a new provider fee on private hospitals located in Nevada that would effectively capture new Medicaid federal share for certain categories of services eligible for the new payment program.
(f) Consists of $146 million of estimated future payments related to our non-contributory, defined benefit pension plan (estimated through 2080), as disclosed in Note 8 to the Consolidated Financial Statements , and $23 million of estimated future payments related to other retirement plan liabilities ($19 million of liabilities recorded in other non-current liabilities as of December 31, 2022 in connection with these retirement plans).
(f) Consists of $139 million of estimated future payments related to our non-contributory, defined benefit pension plan (estimated through 2080), as disclosed in Note 8 to the Consolidated Financial Statements , and $26 million of estimated future payments related to other retirement plan liabilities ($22 million of liabilities recorded in other non-current liabilities as of December 31, 2023 in connection with these retirement plans).
In connection with this transaction, our Consolidated Balance Sheets at December 31, 2022 and December 31, 2021 reflect financial liabilities, which are included in debt, of approximately $81 million and $82 million, respectively. At December 31, 2022, the carrying value and fair value of our debt were approximately $4.8 billion and $4.4 billion, respectively.
In connection with this transaction, our consolidated balance sheets at December 31, 2023 and December 31, 2022 reflect financial liabilities, which are included in debt, of approximately $77 million and $81 million, respectively. At December 31, 2023, the carrying value and fair value of our debt were approximately $4.9 billion and $4.6 billion, respectively.
Contractual Obligations and Off-Balance Sheet Arrangements As of December 31, 2022 we were party to certain off balance sheet arrangements consisting of standby letters of credit and surety bonds which totaled $169 million consisting of: (i) $159 million related to our self-insurance programs, and; (ii) $10 million of other debt and public utility guarantees.
Contractual Obligations and Off-Balance Sheet Arrangements As of December 31, 2023 we were party to certain off balance sheet arrangements consisting of standby letters of credit and surety bonds which totaled $189 million consisting of: (i) $170 million related to our self-insurance programs, and; (ii) $19 million of other debt and public utility guarantees.
We routinely hedge our exposures to foreign currencies with certain financial institutions in an effort to minimize the impact of certain currency exchange rate fluctuations, but these hedges may be inadequate to protect us from currency exchange rate fluctuations.
We have international subsidiaries that operate in the United Kingdom. We routinely hedge our exposures to foreign currencies with certain financial institutions in an effort to minimize the impact of certain currency exchange rate fluctuations, but these hedges may be inadequate to protect us from currency exchange rate fluctuations.
In some areas, the labor scarcity is putting a strain on our resources and staff, which has required us to utilize higher‑cost temporary labor and pay premiums above standard compensation for essential workers.
In some areas, the labor scarcity has strained our resources and staff, which has required us to utilize higher‑cost temporary labor and pay premiums above standard compensation for essential workers.
In November, 2022, CMS issued its OPPS final rule for 2023. The hospital market basket increase is 4.1% and the productivity adjustment reduction is -0.3% for a net market basket increase of 3.8%. The final rule provides that in light of the Supreme Court decision in American Hospital Association v.
The hospital market basket increase is 4.1% and the productivity adjustment reduction is -0.3% for a net market basket increase of 3.8%. The final rule provides that in light of the Supreme Court decision in American Hospital Association v.
The declaration empowered the HHS Secretary to waive certain Medicare, Medicaid and Children’s Health Insurance Program (“CHIP”) program requirements and Medicare conditions of participation under Section 1135 of the Social Security Act.
The declaration empowered the HHS Secretary to waive certain Medicare, Medicaid and CHIP program requirements and Medicare conditions of participation under Section 1135 of the Social Security Act.

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Item 2. Properties

Properties — owned and leased real estate

12 edited+0 added−1 removed5 unchanged
Biggest changeClairsville, Ohio 100 Owned Fremont Hospital Fremont, California 148 Owned Friends Hospital (15) Philadelphia, Pennsylvania 219 Owned Fuller Hospital Attleboro, Massachusetts 109 Owned Garfield Park Behavioral Hospital Chicago, Illinois 88 Owned Glen Oaks Hospital Greenville, Texas 54 Owned Granite Hills Hospital West Allis, Wisconsin 120 Leased Gulf Coast Treatment Center Fort Walton Beach, Florida 28 Owned 28 United States: Name of Facility Location Number of Beds Real Property Ownership Interest Gulfport Behavioral Health System Gulfport, Mississippi 109 Owned Hampton Behavioral Health Center Westhampton, New Jersey 120 Owned Harbour Point Behavioral Health Center Portsmouth, Virginia 186 Owned Hartgrove Behavioral Health System Chicago, Illinois 160 Owned Havenwyck Hospital Auburn Hills, Michigan 243 Owned Heartland Behavioral Health Services Nevada, Missouri 151 Owned Hermitage Hall Nashville, Tennessee 111 Owned Heritage Oaks Hospital Sacramento, California 125 Owned Heritage Oaks Patient Enrichment Center Sacramento, California 16 Owned Hickory Trail Hospital DeSoto, Texas 86 Owned Highlands Behavioral Health System Highlands Ranch, Colorado 86 Owned Hill Crest Behavioral Health Services Birmingham, Alabama 221 Owned Holly Hill Hospital Raleigh, North Carolina 296 Owned The Horsham Clinic Ambler, Pennsylvania 206 Owned HRI Hospital Brookline, Massachusetts 62 Owned The Hughes Center Danville, Virginia 64 Owned Inland Northwest Behavioral Health (9) Spokane, Washington 100 Owned Intermountain Hospital Boise, Idaho 155 Owned Kempsville Center of Behavioral Health Norfolk, Virginia 106 Owned KeyStone Center Wallingford, Pennsylvania 153 Owned Kingwood Pines Hospital Kingwood, Texas 116 Owned La Amistad Behavioral Health Services Maitland, Florida 85 Owned Lakeside Behavioral Health System Memphis, Tennessee 373 Owned Lancaster Behavioral Health Hospital (8) Lancaster, Pennsylvania 126 Owned Laurel Heights Hospital Atlanta, Georgia 124 Owned Laurel Oaks Behavioral Health Center Dothan, Alabama 118 Owned Laurel Ridge Treatment Center San Antonio, Texas 330 Owned Liberty Point Behavioral Healthcare Stauton, Virginia 58 Owned Lighthouse Behavioral Health Hospital Conway, South Carolina 105 Owned Lighthouse Care Center of Augusta Augusta, Georgia 82 Owned Lincoln Prairie Behavioral Health Center Springfield, Illinois 97 Owned Lincoln Trail Behavioral Health System Radcliff, Kentucky 140 Owned Mayhill Hospital Denton, Texas 59 Leased McDowell Center for Children Dyersburg, Tennessee 32 Owned The Meadows Psychiatric Center Centre Hall, Pennsylvania 119 Owned Meridell Achievement Center Austin, Texas 134 Owned Mesilla Valley Hospital Las Cruces, New Mexico 120 Owned Michael’s House Palm Springs, California 110 Owned Michiana Behavioral Health Plymouth, Indiana 83 Owned Midwest Center for Youth and Families Kouts, Indiana 74 Owned Millwood Hospital Arlington, Texas 134 Leased Mountain Youth Academy Mountain City, Tennessee 90 Owned Natchez Trace Youth Academy Waverly, Tennessee 115 Owned Newport News Behavioral Health Center Newport News, Virginia 132 Owned North Spring Behavioral Healthcare Leesburg, Virginia 127 Leased North Star Hospital Anchorage, Alaska 74 Owned North Star Bragaw Anchorage, Alaska 30 Owned Oak Plains Academy Ashland City, Tennessee 98 Owned Okaloosa Youth Academy Crestview, Florida 75 Leased Old Vineyard Behavioral Health Services Winston-Salem, North Carolina 164 Owned Palmer Residential Treatment Center Palmer, Alaska 30 Owned Palmetto Lowcountry Behavioral Health North Charleston, South Carolina 108 Owned Palmetto Summerville Behavioral Health Summerville, South Carolina 64 Leased Palm Point Behavioral Health Titusville, FL 74 Owned Palm Shores Behavioral Health Center Bradenton, Florida 65 Owned Palo Verde Behavioral Health Tucson, Arizona 84 Leased 29 United States: Name of Facility Location Number of Beds Real Property Ownership Interest Parkwood Behavioral Health System Olive Branch, Mississippi 148 Owned The Pavilion Behavioral Health System Champaign, Illinois 122 Owned Peachford Hospital Atlanta, Georgia 246 Owned Pembroke Hospital Pembroke, Massachusetts 120 Owned Pinnacle Pointe Behavioral Healthcare System Little Rock, Arkansas 127 Owned Poplar Springs Hospital Petersburg, Virginia 208 Owned Prairie St John’s Fargo, North Dakota 158 Owned PRIDE Institute Eden Prairie, Minnesota 42 Owned Provo Canyon Behavioral Hospital Orem, Utah 80 Owned Provo Canyon School Provo, Utah 274 Owned Psychiatric Institute of Washington Washington, D.C. 130 Owned Quail Run Behavioral Health Phoenix, Arizona 116 Owned The Recovery Center Wichita Falls, Texas 34 Leased The Ridge Behavioral Health System Lexington, Kentucky 110 Owned Rivendell Behavioral Health Hospital Bowling Green, Kentucky 125 Owned Rivendell Behavioral Health Services of Arkansas Benton, Arkansas 80 Owned River Crest Hospital San Angelo, Texas 80 Owned Riveredge Hospital Forest Park, Illinois 210 Owned River Oaks Hospital Harahan , Louisiana 126 Owned River Park Hospital Huntington, West Virginia 187 Owned River Point Behavioral Health Jacksonville, Florida 84 Owned Rockford Center Newark, Delaware 148 Owned Rolling Hills Hospital Franklin, Tennessee 130 Owned Roxbury Treatment Center Shippensburg, Pennsylvania 112 Owned Salt Lake Behavioral Health Salt Lake City, Utah 118 Leased San Marcos Treatment Center San Marcos, Texas 265 Owned SandyPines Residential Treatment Center Jupiter , Florida 149 Owned Sierra Vista Hospital Sacramento, California 171 Owned Saint Simons by the Sea Saint Simons Island , Georgia 101 Owned Skywood Recovery Augusta, Michigan 100 Owned Southeast Behavioral Health (17) Cape Girardeau, Missouri 102 Owned Spring Mountain Sahara Las Vegas, Nevada 30 Owned Spring Mountain Treatment Center Las Vegas, Nevada 110 Owned Springwoods Behavioral Health Fayetteville, Arkansas 80 Owned Stonington Institute North Stonington, Connecticut 64 Owned Streamwood Behavioral Healthcare System Streamwood, Illinois 178 Owned Summit Oaks Hospital Summit, New Jersey 126 Owned SummitRidge Hospital Lawrenceville, Georgia 96 Owned Suncoast Behavioral Health Center Bradenton, Florida 60 Owned Texas NeuroRehab Center Austin, Texas 137 Owned Three Rivers Behavioral Health West Columbia, South Carolina 129 Owned Three Rivers Midlands West Columbia, South Carolina 64 Owned Turning Point Care Center Moultrie, Georgia 79 Owned University Behavioral Center Orlando, Florida 112 Owned University Behavioral Health of Denton Denton, Texas 104 Owned Valle Vista Health System Greenwood, Indiana 140 Owned Valley Hospital Phoenix, Arizona 122 Owned Via Linda BHS (14) Scottsdale, Arizona 120 Leased The Vines Hospital Ocala, Florida 98 Owned Virginia Beach Psychiatric Center Virginia Beach, Virginia 100 Owned Wekiva Springs Center Jacksonville, Florida 120 Owned Wellstone Regional Hospital Jeffersonville, Indiana 100 Owned West Oaks Hospital Houston, Texas 176 Owned Willow Springs Center Reno, Nevada 116 Owned Windmoor Healthcare of Clearwater Clearwater, Florida 144 Owned Windsor Laurelwood Center for Behavioral Medicine Willoughby, Ohio 160 Leased 30 United States: Name of Facility Location Number of Beds Real Property Ownership Interest Wyoming Behavioral Institute Casper, Wyoming 129 Owned United Kingdom: Name of Facility Location Number of Beds Real Property Ownership Interest Acer Clinic Chesterfield, UK 14 Owned Acer Clinic 2 Chesterfield, UK 14 Owned Adele Cottage Rainworth, UK 2 Owned Albert Ward Darlington, UK 26 Owned Amberwood Lodge Dorset, UK 9 Owned Ashbrook Birmingham, UK 16 Owned Ashfield House Huddersfield, UK 6 Owned Beacon Lower Bradford, UK 8 Owned Beacon Upper Bradford, UK 8 Owned Beckly Halifax, UK 12 Owned Beeches Retford, UK 12 Owned Birches Newark, UK 6 Owned Broughton House Lincolnshire, UK 34 Owned Broughton Lodge Macclesfield, UK 20 Owned CAS Brunel Bristol, UK 32 Owned Chaseways Sawbridgeworth, UK 6 Owned Cherry Tree House Mansfield Woodhouse, UK 6 Owned Conifers Derby, UK 7 Owned Cygnet Alders Clinic Gloucester, UK 20 Owned Cygnet Appletree Meadowfield, UK 26 Owned Cygnet Aspen House Doncaster, UK 20 Owned Cygnet Aspen Lodge Doncaster, UK 16 Owned Cygnet Bostall House Abbey Wood, UK 6 Owned Cygnet Cedars Birmingham, UK 24 Owned Cygnet Cedar Vale East Bridgeford, UK 14 Owned Cygnet Churchill London, UK 57 Owned Cygnet Delfryn House Flintshire, UK 28 Owned Cygnet Delfryn Lodge Flintshire, UK 24 Owned Cygnet Elms Birmingham, UK 10 Owned Cygnet Fountains Blackburn, UK 32 Owned Cygnet Grange Sutton-in-Ashfield, UK 8 Owned Cygnet Heathers West Bromwich, UK 20 Owned Cygnet Hospital—Beckton London, UK 62 Owned Cygnet Hospital—Bierley Bradford, UK 63 Owned Cygnet Hospital—Blackheath London, UK 32 Leased Cygnet Hospital Bury Bury, UK 167 Owned Cygnet Hospital Clifton Nottingham, UK 25 Owned Cygnet Hospital—Derby Derby, UK 50 Owned Cygnet Hospital—Ealing Ealing, UK 26 Owned Cygnet Hospital—Godden Green Sevenoaks, UK 39 Owned Cygnet Hospital—Harrogate Middlesex, UK 36 Owned Cygnet Hospital—Harrow Harrow, UK 61 Owned Cygnet Hospital Hexham Northumberland, UK 27 Owned Cygnet Hospital—Kewstoke Weston-super-Mare, UK 72 Owned Cygnet Hospital Sheffield Sheffield, UK 57 Owned Cygnet Hospital—Stevenage Stevenage, UK 88 Owned Cygnet Hospital—Taunton Taunton, UK 57 Owned Cygnet Hospital Woking Woking, UK 60 Owned 31 United Kingdom: Name of Facility Location Number of Beds Real Property Ownership Interest Cygnet Hospital—Wyke Bradford, UK 52 Owned Cygnet Joyce Parker Hospital Coventry, UK 56 Owned Cygnet Lodge Sutton-in-Ashfield, UK 8 Owned Cygnet Lodge—Brighouse Brighouse, UK 25 Owned Cygnet Lodge – Kenton Middlesex, UK 15 Owned Cygnet Lodge—Lewisham London, UK 17 Owned Cygnet Lodge – Salford Manchester, UK 24 Owned Cygnet Lodge – Woking Woking, UK 31 Owned Cygnet Manor Shirebrook, UK 20 Owned Cygnet Newham House Middlesbrough, UK 20 Owned Cygnet Nield House Crewe, UK 30 Owned Cygnet Oaks Barnsley, UK 35 Owned Cygnet Pindar House Barnsley, UK 22 Owned Cygnet Raglan House West Midlands, UK 25 Owned Cygnet Sedgley House Wolverhampton, UK 20 Owned Cygnet Sedgley Lodge Wolverhampton, UK 14 Owned Cygnet Sherwood House Mansfield, UK 30 Owned Cygnet Sherwood Lodge Mansfield, UK 17 Owned Cygnet St.
Biggest changeClairsville, Ohio 100 Owned Fremont Hospital Fremont, California 148 Owned Friends Hospital (13) Philadelphia, Pennsylvania 219 Owned Fuller Hospital Attleboro, Massachusetts 109 Owned Garfield Park Behavioral Hospital Chicago, Illinois 88 Owned Glen Oaks Hospital Greenville, Texas 54 Owned Granite Hills Hospital West Allis, Wisconsin 120 Leased Gulf Coast Treatment Center Fort Walton Beach, Florida 28 Owned Gulfport Behavioral Health System Gulfport, Mississippi 109 Owned Hampton Behavioral Health Center Westhampton, New Jersey 120 Owned Harbour Point Behavioral Health Center Portsmouth, Virginia 186 Owned Hartgrove Behavioral Health System Chicago, Illinois 160 Owned Havenwyck Hospital Auburn Hills, Michigan 243 Owned Heartland Behavioral Health Services Nevada, Missouri 121 Owned Heritage Oaks Hospital Sacramento, California 125 Owned Heritage Oaks Patient Enrichment Center Sacramento, California 16 Owned Hermitage Hall Nashville, Tennessee 111 Owned Hickory Trail Hospital DeSoto, Texas 86 Owned Highlands Behavioral Health System Littleton, Colorado 86 Owned Hill Crest Behavioral Health Services Birmingham, Alabama 221 Owned Holly Hill Hospital Raleigh, North Carolina 296 Owned The Horsham Clinic Ambler, Pennsylvania 206 Owned HRI Hospital Brookline, Massachusetts 66 Owned The Hughes Center Danville, Virginia 96 Owned Inland Northwest Behavioral Health (9) Spokane, Washington 100 Owned Intermountain Hospital Boise, Idaho 155 Owned Kempsville Center of Behavioral Health Norfolk, Virginia 106 Owned KeyStone Center Wallingford, Pennsylvania 153 Owned Kingwood Pines Hospital Kingwood, Texas 116 Owned La Amistad Behavioral Health Services Maitland, Florida 85 Owned Lakeside Behavioral Health System Memphis, Tennessee 373 Owned Lancaster Behavioral Health Hospital (8) Lancaster, Pennsylvania 126 Owned Laurel Heights Hospital Atlanta, Georgia 124 Owned Laurel Oaks Behavioral Health Center Dothan, Alabama 118 Owned Laurel Ridge Treatment Center San Antonio, Texas 330 Owned Liberty Point Behavioral Healthcare Stauton, Virginia 58 Owned Lighthouse Behavioral Health Hospital Conway, South Carolina 105 Owned Lighthouse Care Center of Augusta Augusta, Georgia 82 Owned Lincoln Prairie Behavioral Health Center Springfield, Illinois 97 Owned Lincoln Trail Behavioral Health System Radcliff, Kentucky 140 Owned Mayhill Hospital Denton, Texas 59 Leased McDowell Center for Children Dyersburg, Tennessee 32 Owned The Meadows Psychiatric Center Centre Hall, Pennsylvania 119 Owned Meridell Achievement Center Austin, Texas 134 Owned Mesilla Valley Hospital Las Cruces, New Mexico 120 Owned Michael’s House Palm Springs, California 110 Owned Michiana Behavioral Health Plymouth, Indiana 83 Owned Midwest Center for Youth and Families Kouts, Indiana 74 Owned Millwood Hospital Arlington, Texas 134 Leased Mountain Youth Academy Mountain City, Tennessee 90 Owned Natchez Trace Youth Academy Waverly, Tennessee 115 Owned Newport News Behavioral Health Center Newport News, Virginia 132 Owned 31 United States: Name of Facility Location Number of Beds Real Property Ownership Interest North Spring Behavioral Healthcare Leesburg, Virginia 127 Leased North Star Bragaw Anchorage, Alaska 30 Owned North Star DeBarr Residential Treatment Center Anchorage, Alaska 30 Owned North Star Hospital Anchorage, Alaska 74 Owned North Star Palmer Residential Treatment Center Palmer, Alaska 30 Owned Oak Plains Academy Ashland City, Tennessee 20 Owned Okaloosa Youth Academy Crestview, Florida 72 Leased Old Vineyard Behavioral Health Services Winston-Salem, North Carolina 164 Owned Palmetto Lowcountry Behavioral Health North Charleston, South Carolina 108 Owned Palmetto Summerville Behavioral Health Summerville, South Carolina 64 Leased Palm Point Behavioral Health Titusville, FL 74 Owned Palm Shores Behavioral Health Center Bradenton, Florida 65 Owned Palo Verde Behavioral Health Tucson, Arizona 84 Leased Parkwood Behavioral Health System Olive Branch, Mississippi 148 Owned The Pavilion Behavioral Health System Champaign, Illinois 122 Owned Peachford Hospital Atlanta, Georgia 246 Owned Pembroke Hospital Pembroke, Massachusetts 120 Owned Pinnacle Pointe Behavioral Healthcare System Little Rock, Arkansas 127 Owned Poplar Springs Hospital Petersburg, Virginia 208 Owned Prairie St John’s Fargo, North Dakota 132 Owned PRIDE Institute Eden Prairie, Minnesota 42 Owned Provo Canyon School Provo, Utah 250 Owned Psychiatric Institute of Washington Washington, D.C. 130 Owned Quail Run Behavioral Health Phoenix, Arizona 116 Owned The Recovery Center Wichita Falls, Texas 34 Leased The Ridge Behavioral Health System Lexington, Kentucky 110 Owned Rivendell Behavioral Health Hospital Bowling Green, Kentucky 125 Owned Rivendell Behavioral Health Services of Arkansas Benton, Arkansas 80 Owned River Crest Hospital San Angelo, Texas 80 Owned River Oaks Hospital Harahan, Louisiana 126 Owned River Park Hospital Huntington, West Virginia 187 Owned River Point Behavioral Health Jacksonville, Florida 84 Owned River Vista Behavioral Health Madera, California 128 Owned Riveredge Hospital Forest Park, Illinois 210 Owned Rockford Center Newark, Delaware 148 Owned Rolling Hills Hospital Franklin, Tennessee 130 Owned Roxbury Treatment Center Shippensburg, Pennsylvania 112 Owned Saint Simons By-The-Sea Saint Simons Island, Georgia 101 Owned Salt Lake Behavioral Health Salt Lake City, Utah 118 Leased San Marcos Treatment Center San Marcos, Texas 265 Owned SandyPines Residential Treatment Center Jupiter, Florida 149 Owned Sierra Vista Hospital Sacramento, California 171 Owned Skywood Recovery Augusta, Michigan 100 Owned Southeast Behavioral Health (15) Cape Girardeau, Missouri 102 Owned Spring Mountain Sahara Las Vegas, Nevada 30 Owned Spring Mountain Treatment Center Las Vegas, Nevada 110 Owned Springwoods Behavioral Health Fayetteville, Arkansas 80 Owned Stonington Institute North Stonington, Connecticut 64 Owned Streamwood Behavioral Healthcare System Streamwood, Illinois 178 Owned Summit Oaks Hospital Summit, New Jersey 126 Owned SummitRidge Hospital Lawrenceville, Georgia 106 Owned Suncoast Behavioral Health Center Bradenton, Florida 60 Owned Texas NeuroRehab Center Austin, Texas 137 Owned Three Rivers Behavioral Health West Columbia, South Carolina 129 Owned Three Rivers Midlands West Columbia, South Carolina 64 Owned 32 United States: Name of Facility Location Number of Beds Real Property Ownership Interest Turning Point Care Center Moultrie, Georgia 79 Owned University Behavioral Center Orlando, Florida 112 Owned University Behavioral Health of Denton Denton, Texas 104 Owned Valle Vista Health System Greenwood, Indiana 140 Owned Valley Hospital Phoenix, Arizona 122 Owned Via Linda Behavioral Hospital (12) Scottsdale, Arizona 120 Leased The Vines Hospital Ocala, Florida 98 Owned Virginia Beach Psychiatric Center Virginia Beach, Virginia 100 Owned Wekiva Springs Center Jacksonville, Florida 120 Owned Wellstone Regional Hospital Jeffersonville, Indiana 100 Owned West Oaks Hospital Houston, Texas 176 Owned Willow Springs Center Reno, Nevada 116 Owned Windmoor Healthcare of Clearwater Clearwater, Florida 144 Owned Windsor Laurelwood Center for Behavioral Medicine Willoughby, Ohio 160 Leased Wyoming Behavioral Institute Casper, Wyoming 129 Owned United Kingdom: Name of Facility Location Number of Beds Real Property Ownership Interest Adarna House Bradford, UK 9 Owned Adele Cottages Rainworth, UK 4 Owned Amberwood Lodge Dorset, UK 9 Owned Ashbrook Birmingham, UK 16 Owned Ashfield House Huddersfield, UK 6 Owned Beacon House Lower Bradford, UK 8 Owned Beacon House Upper Bradford, UK 8 Owned Beckly Halifax, UK 12 Owned Beeches Retford, UK 12 Owned Birches Newark, UK 6 Owned Broughton House Lincolnshire, UK 34 Owned Broughton Lodge Macclesfield, UK 20 Owned Chaseways Sawbridgeworth, UK 6 Owned Cherry Tree House Mansfield Woodhouse, UK 6 Owned Conifers Derby, UK 7 Owned Cygnet Acer Chesterfield, UK 14 Owned Cygnet Acer 2 Chesterfield, UK 14 Owned Cygnet Alders Clinic Gloucester, UK 20 Owned Cygnet Appletree Meadowfield, UK 26 Owned Cygnet Aspen Clinic Doncaster, UK 16 Owned Cygnet Aspen House Doncaster, UK 20 Owned Cygnet Bostall House Abbey Wood, UK 6 Owned Cygnet Brunel Bristol, UK 32 Owned Cygnet Cedars Birmingham, UK 24 Owned Cygnet Cedar Vale East Bridgeford, UK 16 Owned Cygnet Churchill London, UK 57 Owned Cygnet Delfryn House Flintshire, UK 28 Owned Cygnet Delfryn Lodge Flintshire, UK 24 Owned Cygnet Elms Birmingham, UK 10 Owned Cygnet Fountains Blackburn, UK 34 Owned Cygnet Grange Sutton-in-Ashfield, UK 8 Owned Cygnet Heathers West Bromwich, UK 20 Owned Cygnet Hospital—Beckton London, UK 62 Owned 33 United Kingdom: Name of Facility Location Number of Beds Real Property Ownership Interest Cygnet Hospital—Bierley Bradford, UK 63 Owned Cygnet Hospital—Blackheath London, UK 32 Leased Cygnet Hospital—Bury Bury, UK 187 Owned Cygnet Hospital—Clifton Nottingham, UK 25 Owned Cygnet Hospital—Derby Derby, UK 50 Owned Cygnet Hospital—Ealing Ealing, UK 26 Owned Cygnet Hospital—Godden Green Sevenoaks, UK 39 Owned Cygnet Hospital—Harrogate Middlesex, UK 36 Owned Cygnet Hospital—Harrow Harrow, UK 60 Owned Cygnet Hospital—Hexham Northumberland, UK 27 Owned Cygnet Hospital—Kewstoke Weston-super-Mare, UK 72 Owned Cygnet Hospital—Maidstone Maidstone, UK 65 Owned Cygnet Hospital—Sheffield Sheffield, UK 57 Owned Cygnet Hospital—Sherwood Mansfield, UK 44 Owned Cygnet Hospital—Stevenage Stevenage, UK 88 Owned Cygnet Hospital—Taunton Taunton, UK 57 Owned Cygnet Hospital—Woking Woking, UK 62 Owned Cygnet Hospital—Wyke Bradford, UK 52 Owned Cygnet Hospital Colchester - Highwoods Colchester, UK 20 Owned Cygnet Hospital Colchester - Larch Court Essex, UK 4 Owned Cygnet Hospital Colchester - Oak Court Essex, UK 12 Owned Cygnet Hospital Colchester - Ramsey Colchester, UK 21 Owned Cygnet Joyce Parker Hospital Coventry, UK 57 Owned Cygnet Lodge Sutton-in-Ashfield, UK 8 Owned Cygnet Lodge—Brighouse Brighouse, UK 25 Owned Cygnet Lodge—Kenton Middlesex, UK 15 Owned Cygnet Lodge—Lewisham London, UK 17 Owned Cygnet Lodge—Salford Manchester, UK 24 Owned Cygnet Lodge—Woking Woking, UK 31 Owned Cygnet Manor Shirebrook, UK 20 Owned Cygnet Newham House Middlesbrough, UK 20 Owned Cygnet Nield House Crewe, UK 30 Owned Cygnet Oaks Barnsley, UK 35 Owned Cygnet Pindar House Barnsley, UK 22 Owned Cygnet Raglan House West Midlands, UK 25 Owned Cygnet Sedgley House Wolverhampton, UK 20 Owned Cygnet Sedgley Lodge Wolverhampton, UK 14 Owned Cygnet Sherwood House Mansfield, UK 30 Owned Cygnet Sherwood Lodge Mansfield, UK 17 Owned Cygnet St.
The remaining 20% ownership interest is held by an unaffiliated third party. (10) We hold a 51% ownership interest in this facility. The remaining 49% ownership interest is held by unaffiliated third parties. (11) We manage and hold a 52% ownership interest in this facility.
The remaining 20% ownership interest is held by an unaffiliated third party. (10) We hold a 51% ownership interest in this facility. The remaining 49% ownership interest is held by unaffiliated third parties. (11) We manage and hold a 52% ownership interest in this facility. The remaining 48% ownership interest is held by an unaffiliated third party.
Facilities The following tables set forth the name, location, type of facility and, for acute care hospitals and behavioral health care facilities, the number of licensed beds: Acute Care Hospitals Name of Facility Location Number of Beds Real Property Ownership Interest Aiken Regional Medical Centers (1) Aiken, South Carolina 211 Leased Aurora Pavilion Behavioral Health Services (1) Aiken, South Carolina 62 Leased ER at Sweetwater North Augusta, South Carolina — Owned Centennial Hills Hospital Medical Center Las Vegas, Nevada 339 Owned ER at Valley Vista North Las Vegas, Nevada — Owned Corona Regional Medical Center Corona, California 238 Owned Desert Springs Hospital Medical Center Las Vegas, Nevada 282 Owned Desert View Hospital Pahrump, Nevada 25 Owned Doctors Hospital of Laredo (6) Laredo, Texas 183 Owned Doctors Hospital Emergency Room Saunders Laredo, Texas — Owned Doctors Hospital Emergency Room South Laredo, Texas — Leased Fort Duncan Regional Medical Center Eagle Pass, Texas 101 Owned The George Washington University Hospital (19) Washington, D.C. 395 Leased Henderson Hospital Henderson, Nevada 303 Owned ER at Green Valley Ranch Henderson, Nevada — Owned Lakewood Ranch Medical Center Lakewood Ranch, Florida 120 Owned ER at Fruitville Sarasota, Florida — Owned Manatee Memorial Hospital Bradenton, Florida 295 Owned ER at Sun City Wimauma, Florida −− Northern Nevada Medical Center Sparks, Nevada 219 Owned 26 Name of Facility Location Number of Beds Real Property Ownership Interest ER at McCarran NW Reno, Nevada — Owned Northern Nevada Sierra Medical Center Reno, Nevada 158 Owned Northwest Texas Healthcare System Amarillo, Texas 405 Owned Northwest Texas Healthcare System Behavioral Health Amarillo, Texas 90 Owned Northwest Emergency at Town Square Amarillo, Texas — Owned Northwest Emergency on Georgia Amarillo, Texas — Owned Palmdale Regional Medical Center Palmdale, California 184 Owned South Texas Health System (2) Edinburg Regional Medical Center/Children’s Hospital (2) Edinburg, Texas 251 Owned South Texas Health System Behavioral (2) McAllen, Texas 134 Owned South Texas Health System Heart (2) McAllen, Texas 60 Owned South Texas Health System McAllen (1) (2) McAllen, Texas 431 Leased South Texas Health System ER Alamo (2) Alamo, Texas — Owned South Texas Health System ER McColl (2) Edinburg, Texas — Owned South Texas Health System ER Mission (1) (2) Mission, Texas — Leased South Texas Health System ER Monte Cristo (2) Edinburg, Texas — Owned South Texas Health System ER Ware Road (2) McAllen, Texas — Owned South Texas Health System ER Weslaco (1) (2) Weslaco, Texas — Leased Southwest Healthcare System Inland Valley Medical Center Campus Wildomar, California 120 Owned Rancho Springs Medical Center Campus Murrieta, California 120 Owned Spring Valley Hospital Medical Center Las Vegas, Nevada 364 Owned ER at Blue Diamond Las Vegas, Nevada — Owned Valley Health Specialty Hospital Las Vegas, Nevada 66 Owned St.
Facilities The following tables set forth the name, location, type of facility and, for acute care hospitals and behavioral health care facilities, the number of licensed beds: Acute Care Hospitals Name of Facility Location Number of Beds Real Property Ownership Interest Aiken Regional Medical Centers (1) Aiken, South Carolina 211 Leased Aurora Pavilion Behavioral Health Services (1) Aiken, South Carolina 62 Leased ER at Sweetwater North Augusta, South Carolina — Owned Centennial Hills Hospital Medical Center Las Vegas, Nevada 339 Owned ER at Valley Vista North Las Vegas, Nevada — Owned ER at West Craig Las Vegas, Nevada — Owned Corona Regional Medical Center Corona, California 259 Owned Desert View Hospital Pahrump, Nevada 25 Owned Doctors Hospital of Laredo (6) Laredo, Texas 183 Owned Doctors Hospital Emergency Room Saunders Laredo, Texas — Owned Doctors Hospital Emergency Room South Laredo, Texas — Leased Fort Duncan Regional Medical Center Eagle Pass, Texas 101 Owned The George Washington University Hospital (17) Washington, D.C. 395 Leased Henderson Hospital Henderson, Nevada 303 Owned ER at Green Valley Ranch Henderson, Nevada — Owned 28 Name of Facility Location Number of Beds Real Property Ownership Interest Lakewood Ranch Medical Center Lakewood Ranch, Florida 120 Owned ER at Fruitville Sarasota, Florida — Owned Manatee Memorial Hospital Bradenton, Florida 295 Owned ER at Sun City Center Wimauma, Florida −− Owned Manatee ER at Bayshore Gardens Bradenton, Florida −− Owned Northern Nevada Medical Center Sparks, Nevada 124 Owned ER at Damonte Ranch Reno, Nevada — Owned ER at McCarran NW Reno, Nevada — Owned Northern Nevada Sierra Medical Center Reno, Nevada 158 Owned ER at Spanish Springs Sparks, Nevada — Owned Northwest Texas Healthcare System Amarillo, Texas 405 Owned Northwest Texas Healthcare System Behavioral Health Amarillo, Texas 90 Owned Northwest Emergency at Town Square Amarillo, Texas — Owned Northwest Emergency on Georgia Amarillo, Texas — Owned Palmdale Regional Medical Center Palmdale, California 184 Owned South Texas Health System (2) South Texas Health System Edinburg/South Texas Health System Children’s (2) Edinburg, Texas 294 Owned South Texas Health System Behavioral (2) McAllen, Texas 134 Owned South Texas Health System Heart (2) McAllen, Texas 60 Owned South Texas Health System McAllen (1) (2) McAllen, Texas 431 Leased South Texas Health System ER Alamo (2) Alamo, Texas — Owned South Texas Health System ER McColl (2) Edinburg, Texas — Owned South Texas Health System ER Mission (1) (2) Mission, Texas — Leased South Texas Health System ER Monte Cristo (2) Edinburg, Texas — Owned South Texas Health System ER Ware Road (2) McAllen, Texas — Owned South Texas Health System ER Weslaco (1) (2) Weslaco, Texas — Leased Southwest Healthcare System Southwest Healthcare Inland Valley Hospital Wildomar, California 120 Owned Southwest Healthcare Rancho Springs Hospital Murrieta, California 120 Owned Spring Valley Hospital Medical Center Las Vegas, Nevada 364 Owned ER at Blue Diamond Las Vegas, Nevada — Owned Valley Health Specialty Hospital Las Vegas, Nevada 66 Owned St.
Mary’s Regional Medical Center Enid, Oklahoma 229 Owned Summerlin Hospital Medical Center Las Vegas, Nevada 485 Owned Temecula Valley Hospital Temecula, California 140 Owned Texoma Medical Center Denison, Texas 354 Owned TMC Behavioral Health Center Denison, Texas 60 Owned ER at Anna Anna, Texas — Owned ER at Sherman Sherman, Texas — Owned Valley Hospital Medical Center Las Vegas, Nevada 328 Owned Elite Medical Center (ER) Las Vegas, Nevada — Owned Wellington Regional Medical Center (1) Wellington, Florida 235 Leased ER at Westlake Westlake, Florida — Leased Inpatient Behavioral Health Care Facilities United States: Name of Facility Location Number of Beds Real Property Ownership Interest Alabama Clinical Schools Birmingham, Alabama 80 Owned Alliance Health Center Meridian, Mississippi 214 Owned Anchor Hospital Atlanta, Georgia 122 Owned Arbour Hospital Jamaica Plain, Massachusetts 136 Owned Arrowhead Behavioral Health (16) Maumee, Ohio 48 Owned Austin Oaks Hospitals Austin, Texas 80 Owned Beaumont Behavioral Health (18) Dearborn, Michigan 87 Leased Behavioral Hospital of Bellaire Houston, Texas 124 Leased Belmont Pines Hospital Youngstown, Ohio 121 Owned Benchmark Behavioral Health Systems Woods Cross, Utah 94 Owned BHC Alhambra Hospital Rosemead, California 115 Owned Black Bear Lodge Sautee Nacoochee, Georgia 115 Owned Bloomington Meadows Hospital Bloomington, Indiana 78 Owned 27 United States: Name of Facility Location Number of Beds Real Property Ownership Interest Brentwood Behavioral Healthcare Flowood, Mississippi 121 Owned Brentwood Hospital Shreveport, Louisiana 260 Owned The Bridgeway North Little Rock, Arkansas 127 Owned The Brook Hospital—Dupont Louisville, Kentucky 88 Owned The Brook Hospital—KMI Louisville, Kentucky 110 Owned Brooke Glen Behavioral Hospital Fort Washington, Pennsylvania 146 Owned Brynn Marr Hospital Jacksonville, North Carolina 102 Owned Calvary Center Phoenix, Arizona 68 Owned Canyon Creek Behavioral Health Temple, Texas 102 Leased Canyon Ridge Hospital Chino, California 157 Owned The Carolina Center for Behavioral Health Greer, South Carolina 156 Owned Cedar Creek Hospital St.
Mary’s Regional Medical Center Enid, Oklahoma 229 Owned Summerlin Hospital Medical Center Las Vegas, Nevada 490 Owned Temecula Valley Hospital Temecula, California 140 Owned Texoma Medical Center Denison, Texas 354 Owned TMC Behavioral Health Center Denison, Texas 60 Owned ER at Anna Anna, Texas — Owned ER at Sherman Sherman, Texas — Owned Valley Hospital Medical Center Las Vegas, Nevada 306 Owned Elite Medical Center (ER) Las Vegas, Nevada 0 Owned ER at Desert Springs Las Vegas, Nevada — Owned ER at North Las Vegas North Las Vegas, Nevada — Owned Wellington Regional Medical Center (1) Wellington, Florida 235 Leased ER at Westlake Westlake, Florida — Leased Inpatient Behavioral Health Care Facilities United States: Name of Facility Location Number of Beds Real Property Ownership Interest Alabama Clinical Schools Birmingham, Alabama 80 Owned Alliance Health Center Meridian, Mississippi 214 Owned Anchor Hospital Atlanta, Georgia 122 Owned 29 United States: Name of Facility Location Number of Beds Real Property Ownership Interest Arbour Hospital Jamaica Plain, Massachusetts 138 Owned Arrowhead Behavioral Health (14) Maumee, Ohio 48 Owned Aspen Grove Behavioral Hospital Orem, Utah 80 Owned Austin Oaks Hospital Austin, Texas 80 Owned Beaumont Behavioral Health (16) Dearborn, Michigan 137 Leased Behavioral Hospital of Bellaire Houston, Texas 124 Leased Belmont Pines Hospital Youngstown, Ohio 127 Owned Benchmark Behavioral Health Systems Woods Cross, Utah 94 Owned BHC Alhambra Hospital Rosemead, California 115 Owned Black Bear Lodge Sautee Nacoochee, Georgia 115 Owned Bloomington Meadows Hospital Bloomington, Indiana 78 Owned Brentwood Behavioral Healthcare Flowood, Mississippi 121 Owned Brentwood Hospital Shreveport, Louisiana 260 Owned The Bridgeway North Little Rock, Arkansas 127 Owned The Brook Hospital—Dupont Louisville, Kentucky 88 Owned The Brook Hospital—KMI Louisville, Kentucky 110 Owned Brooke Glen Behavioral Hospital Fort Washington, Pennsylvania 146 Owned Brynn Marr Hospital Jacksonville, North Carolina 102 Owned Calvary Healing Center Phoenix, Arizona 68 Owned Canyon Creek Behavioral Health (1) Temple, Texas 102 Leased Canyon Ridge Hospital Chino, California 157 Owned The Carolina Center for Behavioral Health Greer, South Carolina 156 Owned Cedar Creek Hospital St.
Johns, Michigan 54 Owned Cedar Grove Residential Treatment Center Murfreesboro, Tennessee 45 Owned Cedar Hills Hospital (7) Portland, Oregon 98 Owned Cedar Ridge Behavioral Hospital Oklahoma City, Oklahoma 60 Owned Cedar Ridge Residential Treatment Center Oklahoma City, Oklahoma 56 Owned Cedar Ridge Bethany Bethany, Oklahoma 56 Owned Cedar Springs Hospital Colorado Springs, Colorado 110 Owned Centennial Peaks Hospital Louisville, Colorado 104 Owned Center for Change Orem, Utah 58 Owned Central Florida Behavioral Hospital Orlando, Florida 174 Owned Chris Kyle Patriots Hospital Anchorage, Alaska 36 Owned Clarion Psychiatric Center Clarion, Pennsylvania 112 Owned Clive Behavioral Health (11) Clive, Iowa 100 Leased Coastal Behavioral Health Savannah, Georgia 50 Owned Coastal Harbor Treatment Center Savannah, Georgia 141 Owned Columbus Behavioral Center for Children and Adolescents Columbus, Indiana 57 Owned Compass Intervention Center Memphis, Tennessee 108 Owned Copper Hills Youth Center West Jordan, Utah 197 Owned Coral Shores Behavioral Health Stuart, Florida 80 Owned Cumberland Hall Hospital Hopkinsville, Kentucky 97 Owned Cumberland Hospital for Children and Adolescents New Kent, Virginia 108 Owned Cypress Creek Hospital Houston, Texas 128 Owned DeBarr Residential Treatment Center Anchorage, Alaska 30 Owned Del Amo Behavioral Health System Torrance, California 166 Owned Diamond Grove Center Louisville, Mississippi 55 Owned Dover Behavioral Health System Dover, Delaware 104 Owned El Paso Behavioral Health System El Paso, Texas 166 Owned Emerald Coast Behavioral Hospital Panama City, Florida 86 Owned Fairmount Behavioral Health System Philadelphia, Pennsylvania 239 Owned Fairfax Fairfax Behavioral Health Kirkland, Washington 157 Owned Fairfax Behavioral Health—Everett Everett, Washington 30 Leased Fairfax Behavioral Health—Monroe Monroe, Washington 34 Leased Forest View Hospital Grand Rapids, Michigan 108 Owned Fort Lauderdale Behavioral Health Center Fort Lauderdale, Florida 182 Owned Foundations Behavioral Health Doylestown, Pennsylvania 122 Leased Foundations for Living Mansfield, Ohio 84 Owned Fox Run Center St.
Johns, Michigan 54 Owned Cedar Grove Residential Treatment Center Murfreesboro, Tennessee 45 Owned Cedar Hills Hospital (7) Portland, Oregon 98 Owned Cedar Ridge Behavioral Hospital Oklahoma City, Oklahoma 60 Owned Cedar Ridge Residential Treatment Center Oklahoma City, Oklahoma 56 Owned Cedar Ridge Behavioral Hospital at Bethany Bethany, Oklahoma 56 Owned Cedar Springs Hospital Colorado Springs, Colorado 110 Owned Centennial Peaks Hospital Louisville, Colorado 104 Owned Center for Change Orem, Utah 58 Owned Central Florida Behavioral Hospital Orlando, Florida 174 Owned Chris Kyle Patriots Hospital Anchorage, Alaska 36 Owned Clarion Psychiatric Center Clarion, Pennsylvania 112 Owned Clive Behavioral Health (1) (11) Clive, Iowa 100 Leased Coastal Behavioral Health Savannah, Georgia 50 Owned Coastal Harbor Treatment Center Savannah, Georgia 145 Owned Columbus Behavioral Center for Children and Adolescents Columbus, Indiana 57 Owned Compass Intervention Center Memphis, Tennessee 148 Owned Copper Hills Youth Center West Jordan, Utah 197 Owned Coral Shores Behavioral Health Stuart, Florida 80 Owned Cumberland Hall Hospital Hopkinsville, Kentucky 97 Owned Cumberland Hospital for Children and Adolescents New Kent, Virginia 108 Owned Cypress Creek Hospital Houston, Texas 128 Owned Del Amo Behavioral Health System Torrance, California 166 Owned Diamond Grove Center Louisville, Mississippi 57 Owned Dover Behavioral Health System Dover, Delaware 104 Owned El Paso Behavioral Health System El Paso, Texas 166 Owned Emerald Coast Behavioral Hospital Panama City, Florida 86 Owned Fairfax Fairfax Behavioral Health Kirkland, Washington 157 Owned Fairfax Behavioral Health—Everett Everett, Washington 30 Leased Fairfax Behavioral Health—Monroe Monroe, Washington 34 Leased Fairmount Behavioral Health System Philadelphia, Pennsylvania 239 Owned Forest View Hospital Grand Rapids, Michigan 108 Owned 30 United States: Name of Facility Location Number of Beds Real Property Ownership Interest Fort Lauderdale Behavioral Health Center Fort Lauderdale, Florida 182 Owned Foundations Behavioral Health Doylestown, Pennsylvania 122 Leased Foundations for Living Mansfield, Ohio 84 Owned Fox Run Center St.
Williams Darlington, UK 12 Owned Cygnet Storthfield House Derbyshire, UK 22 Owned Cygnet Victoria House Darlington, UK 6 Owned Cygnet Views Matlock, UK 10 Owned Cygnet Wallace Hospital Dundee, UK 10 Owned Cygnet Wast Hills Birmingham, UK 26 Owned Cygnet Woodside Bradford, UK 9 Owned Dene Brook Rotherham, UK 13 Owned Devon Lodge Southampton, UK 12 Owned Dove Valley Mews Barnsley, UK 10 Owned Ducks Halt Essex, UK 5 Owned Eleni House Essex, UK 8 Owned Ellen Mhor Dundee, UK 12 Owned Elston House Newark, UK 8 Owned Fairways Ipswich, UK 8 Owned Farm Lodge Rainham, UK 5 Owned The Fields Sheffield, UK 54 Owned Highwoods Colchester, UK 20 Owned Gables Essex, UK 7 Owned Gledcliffe Road Huddersfield, UK 6 Owned Gledholt Huddersfield, UK 9 Owned Gledholt Mews Huddersfield, UK 21 Owned Glyn House Stoke on Trent, UK 5 Owned Hawkstone Keighley, UK 10 Owned Hollyhurst Darlington, UK 19 Owned Hope House Hartlepool, UK 11 Owned Kirkside House Leeds, UK 7 Owned Kirkside Lodge Leeds, UK 8 Owned Langdale Coach House Huddersfield, UK 3 Owned Langdale House Huddersfield, UK 8 Owned Larch Court Essex, UK 4 Owned Limes Houses Mansfield, UK 6 Owned Lindsay House Dundee, UK 2 Owned Longfield House Bradford, UK 9 Owned Lowry House Hyde, UK 12 Owned Maidstone Maidstone, UK 65 Owned 32 United Kingdom: Name of Facility Location Number of Beds Real Property Ownership Interest Marion House Derby, UK 5 Owned Meadows Mews Tipton, UK 10 Owned Morgan House Stoke on Trent, UK 5 Owned Newbus Grange Neasham, UK 17 Owned Nightingale Dorset, UK 10 Owned Norcott House Liversedge, UK 11 Owned Norcott Lodge Liversedge, UK 9 Owned Oak Court Essex, UK 12 Owned Oakhurst Lodge Hampshire, UK 8 Owned Oaklands Northumberland, UK 19 Owned Old Leigh House Essex, UK 7 Leased The Orchards Essex, UK 5 Owned Outwood Leeds, UK 10 Owned Oxley Lodge Huddersfield, UK 4 Owned Oxley Woodhouse Huddersfield, UK 13 Owned Pines Mansfield Woodhouse, UK 7 Owned Ramsey Colchester, UK 21 Owned Ranaich House Dunblane, UK 14 Owned Redlands Darlington, UK 5 Owned Rhyd Alyn Flintshire, UK 6 Owned Shear Meadow Hemel Hempstead, UK 4 Owned Sherwood Lodge Step Down Mansfield, UK 9 Owned The Squirrels Hampshire, UK 9 Owned 4, 5, 7 The Sycamores South Normanton, UK 6 Owned 15 The Sycamores South Normanton, UK 4 Owned Tabley House Nursing Home Knutsford, UK 51 Leased Thistle House Dundee, UK 10 Owned Thornfield Grange Bishop Auckland, UK 9 Owned Thornfield House Bradford, UK 7 Owned Thors Park Essex, UK 14 Owned Toller Road Leicestershire, UK 8 Owned Trinity House Galloway, UK 13 Owned Tupwood Gate Nursing Home Caterham, UK 33 Owned 1Vincent Court Lancashire, UK 5 Owned Walkern Lodge Stevenage, UK 4 Owned Willow House Birmingham, UK 8 Owned 12 Woodcross Street Wolverhampton, UK 8 Owned Woodrow House Stockport, UK 9 Owned Yew Trees Essex, UK 10 Owned Puerto Rico: Name of Facility Location Number of Beds Real Property Ownership Interest First Hospital Panamericano—Cidra Cidra, Puerto Rico 165 Owned First Hospital Panamericano—San Juan San Juan, Puerto Rico 45 Leased First Hospital Panamericano—Ponce Ponce, Puerto Rico 30 Leased 33 Outpatient Behavioral Health Care Facilities United States: Name of Facility Location Real Property Ownership Interest Arbour Counseling Services Rockland, Massachusetts Owned The Canyon at Santa Monica Santa Monica, California Leased Foundations San Francisco San Francisco, California Leased Michael’s House Outpatient Palm Springs, California Leased The Pointe Outpatient Behavioral Health Services Little Rock, Arkansas Leased Saint Louis Behavioral Medicine Institute St.
Williams Darlington, UK 12 Owned Cygnet Storthfield House Derbyshire, UK 22 Owned Cygnet Victoria House Darlington, UK 26 Owned Cygnet Views Matlock, UK 10 Owned Cygnet Wallace Hospital Dundee, UK 10 Owned Cygnet Wast Hills Birmingham, UK 26 Owned Dene Brook Rotherham, UK 13 Owned Devon Lodge Southampton, UK 12 Owned Dove Valley Mews Barnsley, UK 10 Owned Ducks Halt Essex, UK 5 Owned Eleni House Essex, UK 8 Owned Ellen Mhor Dundee, UK 12 Owned Elston House Newark, UK 8 Owned Fairways Ipswich, UK 8 Owned 34 United Kingdom: Name of Facility Location Number of Beds Real Property Ownership Interest The Fields Sheffield, UK 54 Owned Gables Essex, UK 7 Owned Gledcliffe Road Huddersfield, UK 6 Owned Gledholt Huddersfield, UK 9 Owned Gledholt Mews Huddersfield, UK 21 Owned Glyn House Stoke on Trent, UK 5 Owned Hansa Lodge Rainham, UK 5 Owned Hawkstone Keighley, UK 10 Owned Hollyhurst Darlington, UK 19 Owned Hope House Hartlepool, UK 11 Owned Kirkside House Leeds, UK 7 Owned Kirkside Lodge Leeds, UK 8 Owned Langdale Coach House Huddersfield, UK 3 Owned Langdale House Huddersfield, UK 8 Owned Lindsay House Dundee, UK 2 Owned Longfield House Bradford, UK 9 Owned Lowry House Hyde, UK 12 Owned Malborn & Teroan Mansfield, UK 6 Owned Marion House Derby, UK 5 Owned Meadows Mews Tipton, UK 10 Owned Morgan House Stoke on Trent, UK 5 Owned Nightingale Dorset, UK 10 Owned Norcott House Liversedge, UK 11 Owned Norcott Lodge Liversedge, UK 9 Owned Oakhurst Lodge Hampshire, UK 8 Owned Oaklands Northumberland, UK 19 Owned Old Leigh House Essex, UK 7 Leased The Orchards Essex, UK 5 Owned Outwood Leeds, UK 10 Owned Oxley Lodge Huddersfield, UK 4 Owned Oxley Woodhouse Huddersfield, UK 13 Owned Pines Mansfield Woodhouse, UK 7 Owned Ranaich House Dunblane, UK 14 Owned Redlands Darlington, UK 5 Owned Rhyd Alyn Flintshire, UK 6 Owned River View Darlington, UK 4 Owned Shear Meadow Hemel Hempstead, UK 4 Owned Sherwood Lodge Step Down Mansfield, UK 9 Owned The Squirrels Hampshire, UK 9 Owned 4, 5, 7 The Sycamores South Normanton, UK 6 Owned 15 The Sycamores South Normanton, UK 4 Owned Tabley House Nursing Home Knutsford, UK 51 Leased Thistle House Dundee, UK 10 Owned Thornfield Grange Bishop Auckland, UK 9 Owned Thornfield House Bradford, UK 7 Owned Thors Park Essex, UK 14 Owned Toller Road Leicestershire, UK 8 Owned Trinity House Galloway, UK 13 Owned Trinity Lodge Lockerbie, UK 6 Owned Tupwood Gate Nursing Home Caterham, UK 33 Owned Ty Alarch Merthyr Tydfil 6 Owned 1Vincent Court Lancashire, UK 5 Owned Walkern Lodge Stevenage, UK 4 Owned Willow House Birmingham, UK 8 Owned Woodcross & Turls Hill Wolverhampton, UK 8 Owned 35 United Kingdom: Name of Facility Location Number of Beds Real Property Ownership Interest Woodrow House Stockport, UK 9 Owned Puerto Rico: Name of Facility Location Number of Beds Real Property Ownership Interest First Hospital Panamericano—Cidra Cidra, Puerto Rico 165 Owned First Hospital Panamericano—Ponce Ponce, Puerto Rico 30 Owned First Hospital Panamericano—San Juan San Juan, Puerto Rico 45 Owned Outpatient Behavioral Health Care Facilities United States: Name of Facility Location Real Property Ownership Interest Arbour Counseling Services Rockland, Massachusetts Owned The Canyon at Santa Monica Los Angeles, California Leased Foundations San Francisco San Francisco, California Leased Michael’s House Outpatient Palm Springs, California Leased The Pointe Outpatient Behavioral Health Services Little Rock, Arkansas Leased Saint Louis Behavioral Medicine Institute St.
The remaining 25% ownership interest is held by an unaffiliated third party. (14) We manage and hold a 51% ownership interest in this facility. The remaining 49% ownership interest is held by an unaffiliated third party. (15) We manage and hold a 80% ownership interest in this facility. The remaining 20% ownership interest is held by an unaffiliated third party.
(12) We manage and hold a 51% ownership interest in this facility. The remaining 49% ownership interest is held by an unaffiliated third party. (13) We manage and hold a 80% ownership interest in this facility. The remaining 20% ownership interest is held by an unaffiliated third party. (14) We manage and hold a 70% ownership interest in this facility.
(16) We manage and hold a 70% ownership interest in this facility. The remaining 30% ownership interest is held by an unaffiliated third party. (17) We manage and hold a 75% ownership interest in this facility. The remaining 25% ownership interest is held by an unaffiliated third party. (18) We manage and hold a 74% ownership interest in this facility.
The remaining 30% ownership interest is held by an unaffiliated third party. (15) We manage and hold a 75% ownership interest in this facility. The remaining 25% ownership interest is held by an unaffiliated third party. (16) We manage and hold a 74% ownership interest in this facility. The remaining 26% ownership interest is held by an unaffiliated third party.
Louis, Missouri Owned Skywood Outpatient Royal Oak, Michigan Leased Talbott Recovery Atlanta, Georgia Owned United Kingdom: Name of Facility Location Real Property Ownership Interest Long Eaton Day Services Nottingham, UK Owned Sheffield Day Services Sheffield, UK Owned Outpatient Centers and Surgical Hospital Name of Facility Location Real Property Ownership Interest Aiken Surgery Center Aiken, South Carolina Owned Cancer Care Institute of Carolina Aiken, South Carolina Owned Cornerstone Regional Hospital (3) Edinburg, Texas Leased Manatee Diagnostic Center Bradenton, Florida Leased Palms Westside Clinic ASC (5) Royal Palm Beach, Florida Leased Quail Surgical and Pain Management Center (10) Reno, Nevada Leased Riverside Medical Clinic Surgery Center Riverside, California Leased Temecula Valley Day Surgery (4) Murrieta, California Leased (1) Real property leased from Universal Health Realty Income Trust.
Louis, Missouri Owned Skywood Outpatient Bingham Farms, Michigan Leased Talbott Recovery Atlanta, Georgia Owned United Kingdom: Name of Facility Location Real Property Ownership Interest Long Eaton Day Services Nottingham, UK Owned Sheffield Day Services Sheffield, UK Owned Outpatient Centers and Surgical Hospital Name of Facility Location Real Property Ownership Interest Cancer Care Institute of Carolina Aiken, South Carolina Owned Cedar Hill Urgent Care Washington, DC Leased Cornerstone Regional Hospital (3) Edinburg, Texas Leased Las Vegas Institute for Advanced Surgery Las Vegas, NV Leased Manatee Diagnostic Center Bradenton, Florida Leased Palms Westside Clinic ASC (5) Royal Palm Beach, Florida Leased Personalized Radiation Oncology (18) Reno, Nevada Leased Quail Surgical and Pain Management Center (10) Reno, Nevada Leased Riverside Medical Clinic Surgery Center Riverside, California Leased The Surgery Center of Aiken Aiken, South Carolina Owned Temecula Valley Day Surgery (4) Murrieta, California Leased 36 (1) Real property leased from Universal Health Realty Income Trust.
Legal Proceedings The information regarding our legal proceedings is contained in Note 8 to the Consolidated Financial Statements - Commitments and Contingencies , as included this Form 10-K, is incorporated herein by reference.
The aggregate lease payments on facilities leased by us were $107 million in 2023, $104 million in 2022 and $93 million in 2021. ITEM 3. Legal Proceedings The information regarding our legal proceedings is contained in Note 8 to the Consolidated Financial Statements - Commitments and Contingencies , as included this Form 10-K, is incorporated herein by reference.
We believe that the leases on the facilities, medical office buildings and other real estate leased or owned by us do not impose any material limitation on our operations. The aggregate lease payments on facilities leased by us were $104 million in 2022, $93 million in 2021 and $82 million in 2020. ITEM 3.
We own or lease medical office buildings adjoining some of our hospitals. We believe that the leases on the facilities, medical office buildings and other real estate leased or owned by us do not impose any material limitation on our operations.
The remaining 26% ownership interest is held by an unaffiliated third party. (19) The land of this facility is leased pursuant to the terms of a lease that is scheduled to expire in August, 2082. The lease contains one, twenty-five year renewal option. We own or lease medical office buildings adjoining some of our hospitals.
(17) The land of this facility is leased pursuant to the terms of a lease that is scheduled to expire in August, 2082. The lease contains one, twenty-five year renewal option. (18) We own a noncontrolling ownership interest of 30% in the entity that operates this facility that is managed by a third-party.
Removed
The remaining 48% ownership interest is held by an unaffiliated third party. 34 (12) We manage and hold a 74.1% ownership interest in this facility. The remaining 25.9% ownership interest is held by an unaffiliated third party. (13) We manage and hold a 75% ownership interest in this facility.

Item 3. Legal Proceedings

Legal Proceedings — active lawsuits and investigations

76 edited+39 added−42 removed114 unchanged
Biggest changeProviders will report healthcare related expenses attributable to COVID-19 that have not been reimbursed by another source, which may include general and administrative or healthcare related operating expenses. Funds may also be applied to lost revenues, represented as a negative change in year-over-year net patient care operating income. All such fund payments must be expended by June 30, 2021.
Biggest changeWe received accelerated payments under this program during 2020, and returned early all of those funds during the first quarter of 2021. We, and other providers, will report healthcare related 18 expenses attributable to COVID-19 that have not been reimbursed by another source, which may include general and administrative or healthcare related operating expenses.
On December 31, 2021, we entered into an asset purchase and sale agreement with the Trust, which was amended during the first quarter of 2022, pursuant to the terms of which: • a wholly-owned subsidiary of ours purchased from the Trust, the real estate assets of the Inland Valley Campus of Southwest Healthcare System located in Wildomar, California, at its fair market value of $79.6 million. • two wholly-owned subsidiaries of ours transferred to the Trust, the real estate assets of the following properties: o Aiken Regional Medical Center (“Aiken”), located in Aiken, South Carolina (which includes a 211-bed acute care hospital and a 62-bed behavioral health facility), at its fair-market value of approximately $57.7 million, and; o Canyon Creek Behavioral Health (“Canyon Creek”), located in Temple, Texas, at its fair-market value of approximately $26.0 million. • in connection with this transaction, since the fair-market value of Aiken and Canyon Creek, which totaled approximately $83.7 million in the aggregate, exceeded the $79.6 million fair-market value of the Inland Valley Campus of Southwest Healthcare System, we received approximately $4.1 million in cash from the Trust.
On December 31, 2021, we entered into an asset purchase and sale agreement with the Trust, which was amended during the first quarter of 2022, pursuant to the terms of which: • a wholly-owned subsidiary of ours purchased from the Trust, the real estate assets of the Inland Valley Campus of Southwest Healthcare System located in Wildomar, California, at its fair market value of $79.6 million. • two wholly-owned subsidiaries of ours transferred to the Trust, the real estate assets of the following properties: o Aiken Regional Medical Center (“Aiken”), located in Aiken, South Carolina (which includes a 211-bed acute care hospital and a 62-bed behavioral health facility), at its fair-market value of approximately $57.7 million, and; o Canyon Creek Behavioral Health (“Canyon Creek”), a 102-bed facility located in Temple, Texas, at its fair-market value of approximately $26.0 million. • in connection with this transaction, since the fair-market value of Aiken and Canyon Creek, which totaled approximately $83.7 million in the aggregate, exceeded the $79.6 million fair-market value of the Inland Valley Campus of Southwest Healthcare System, we received approximately $4.1 million in cash from the Trust.
In some markets, certain of our competitors may have greater financial resources, be better equipped and offer a broader range of services than we offer. The number of inpatient facilities, as well as outpatient surgical and diagnostic centers, many of which are fully or partially owned by physicians, in the geographic areas in which we operate has increased significantly.
In some markets, certain of our competitors may have greater financial resources, be better equipped and offer a broader range of services than we offer. The number of inpatient facilities, as well as outpatient surgical and diagnostic centers, many of which are 15 fully or partially owned by physicians, in the geographic areas in which we operate has increased significantly.
See Note 9 to the Consolidated Financial Statements- Relationship with Universal Health Realty Income Trust and Other Related Party Transactions for additional disclosure regarding the Company’s group purchasing organization agreement with Premier, Inc. Marc D. Miller is the son of Alan B. Miller, our Executive Chairman of the Board. Mr. Alan B.
See Note 9 to the Consolidated Financial Statements- Relationship with Universal Health Realty Income Trust and Other Related Party Transactions for additional disclosure regarding the Company’s group purchasing organization agreement with Premier, Inc. Marc D. Miller is the son of Alan B. Miller, our Executive Chairman of the Board. 13 Mr. Alan B.
If any of our hospitals achieve poor 13 results on the quality measures or patient satisfaction surveys (or results that are lower than our competitors) or if our standard charges are higher than our competitors, our patient volume could decline because patients may elect to use competing hospitals or other health care providers that have better metrics and pricing.
If any of our hospitals achieve poor results on the quality measures or patient satisfaction surveys (or results that are lower than our competitors) or if our standard charges are higher than our competitors, our patient volume could decline because patients may elect to use competing hospitals or other health care providers that have better metrics and pricing.
If our facilities do not stay current with 14 technological advances in the health care industry, patients may seek treatment from other providers and/or physicians may refer their patients to alternate sources, which could adversely affect our results of operations and harm our business.
If our facilities do not stay current with technological advances in the health care industry, patients may seek treatment from other providers and/or physicians may refer their patients to alternate sources, which could adversely affect our results of operations and harm our business.
In those states that do not have CON laws or which set relatively high levels of expenditures before they become reviewable by state authorities, competition in the form of new services, facilities and capital spending is more prevalent.
In those states 10 that do not have CON laws or which set relatively high levels of expenditures before they become reviewable by state authorities, competition in the form of new services, facilities and capital spending is more prevalent.
The base rents are paid monthly and the bonus rents, which as of January 1, 2022 are applicable only to McAllen Medical Center, are computed and paid on a quarterly basis, based upon a computation that compares current quarter revenue to a corresponding quarter in the base year.
The base rents are paid monthly and the bonus rents, which effective as of January 1, 2022 are applicable only to McAllen Medical Center, are computed and paid on a quarterly basis, based upon a computation that compares current quarter revenue to a corresponding quarter in the base year.
We derive a significant portion of our revenue from third-party payers, including the Medicare and Medicaid programs. Changes in these government programs in recent years have resulted in limitations on reimbursement and, in some cases, reduced levels of reimbursement for healthcare services.
We derive a significant portion of our revenue from third-party payers, including the Medicare and Medicaid programs. Changes in these government programs in recent years have resulted in limitations on reimbursement and, in some cases, reduced 14 levels of reimbursement for healthcare services.
We receive annual Medicaid revenues of approximately $100 million, or greater, from each of Texas, California, Nevada, Illinois, Pennsylvania, Washington, D.C., Florida, Kentucky and Massachusetts. We also receive Medicaid disproportionate share hospital payments from certain states including, most significantly, Texas.
We receive annual Medicaid revenues of approximately $100 million, or greater, from each of Texas, California, Nevada, Illinois, Pennsylvania, Washington, D.C., Florida, Kentucky, Massachusetts and Virginia. We also receive Medicaid disproportionate share hospital payments from certain states including, most significantly, Texas.
The CARES Act also makes other forms of financial assistance available to healthcare providers, including through Medicare and Medicaid payment adjustments and an expansion of the Medicare Accelerated and Advance Payment Program, which makes available accelerated payments of Medicare funds in order to increase cash flow to providers.
The CARES Act also makes other forms of financial assistance available to healthcare providers, including through Medicare and Medicaid payment adjustments and an expansion of the Medicare Accelerated and Advance Payment Program, which made available accelerated payments of Medicare funds in order to increase cash flow to providers.
Subject to the terms of the master lease, Aiken and Canyon Creek have the right to renew their leases, at the then current fair 10 market rent (as defined in the master lease), for seven, five-year optional renewal terms.
Subject to the terms of the master lease, Aiken and Canyon Creek have the right to renew their leases, at the then current fair market rent (as defined in the master lease), for seven, five-year optional renewal terms.
This transaction generated a gain of approximately $68.4 million for the Trust, our share of which (approximately $4.0 million) is included in our consolidated statement of income for the year ended December 31, 2021.
This transaction generated a gain of 11 approximately $68.4 million for the Trust, our share of which (approximately $4.0 million) is included in our consolidated statement of income for the year ended December 31, 2021.
The joint venture has three, 10-year renewal options at computed lease rates as stipulated in the 11 lease (2041 through 2070) and two additional, 10-year renewal options at fair market values lease rates (2071 through 2090).
The joint venture has three, 10-year renewal options at computed lease rates as stipulated in the lease (2041 through 2070) and two additional, 10-year renewal options at fair market values lease rates (2071 through 2090).
We intend to selectively seek opportunities to expand our base of operations by adhering to our disciplined program of rational growth, but may not be successful in accomplishing acquisitions on favorable terms. Relationship with Universal Health Realty Income Trust At December 31, 2022, we held approximately 5.7% of the outstanding shares of Universal Health Realty Income Trust (the “Trust”).
We intend to selectively seek opportunities to expand our base of operations by adhering to our disciplined program of rational growth, but may not be successful in accomplishing acquisitions on favorable terms. Relationship with Universal Health Realty Income Trust At December 31, 2023, we held approximately 5.7% of the outstanding shares of Universal Health Realty Income Trust (the “Trust”).
Employee Assistance We continue to support the overall health and financial well-being of our employees across the extensive programs and benefit plans that we offer. In 2022, we continued to expand the UHS Resource Guide which provides details on access to the benefits, resources and support tools available to employees throughout our organization.
Employee Assistance We continue to support the overall health and financial well-being of our employees across the extensive programs and benefit plans that we offer. In 2023, we continued to expand the UHS Resource Guide which provides details on access to the benefits, resources and support tools available to employees throughout our organization.
The real property of this facility, which was completed and opened in late, 2020, is also leased from the Trust (annual rental of approximately $2.6 million and $2.5 million during 2022 and 2021, respectively) pursuant to the lease terms as provided in the table below.
The real property of this facility, which was completed and opened in late 2020, is also leased from the Trust (annual rental of approximately $2.7 million, $2.6 million and $2.5 million during 2023, 2022 and 2021, respectively) pursuant to the lease terms as provided in the table below.
In addition, certain of our subsidiaries are tenants in several medical office buildings (“MOBs”) and two free-standing emergency departments owned by the Trust or by limited liability companies in which the Trust holds 95% to 100% of the ownership interest.
In addition, certain of our subsidiaries are tenants in various medical office buildings (“MOBs”) and two free-standing emergency departments owned by the Trust or by limited liability companies in which the Trust holds 95% to 100% of the ownership interest.
Within our acute care division, approximately 370 physicians are employed by physician practice management subsidiaries of ours either directly or through contracts with affiliated group practices structured as 501A corporations.
Within our acute care division, approximately 380 physicians are employed by physician practice management subsidiaries of ours either directly or through contracts with affiliated group practices structured as 501A corporations.
Labor Relations Approximately 825 of our employees at four of our hospitals are unionized. At Valley Hospital Medical Center, housekeeping and dietary employees are represented by the Culinary Workers Union, Local 226, and engineers are represented by the International Union of Operating Engineers.
Labor Relations Approximately 535 of our employees at four of our hospitals are unionized. At Valley Hospital Medical Center, housekeeping and dietary employees are represented by the Culinary Workers Union, Local 226, and engineers are represented by the International Union of Operating Engineers.
The advisory agreement was renewed by the Trust for 2023 at the same rate in place for 2022, 2021 and 2020, providing for an advisory computation at 0.70% of the Trust’s average invested real estate assets.
The advisory agreement was renewed by the Trust for 2024 at the same rate in place for 2023, 2022 and 2021, providing for an advisory computation at 0.70% of the Trust’s average invested real estate assets.
We earned an advisory fee from the Trust, which is included in net revenues in the accompanying consolidated statements of income, of approximately $5.1 million during 2022, $4.4 million during 2021 and $4.1 million during 2020. In addition, certain of our officers and directors are also officers and/or directors of the Trust.
We earned an advisory fee from the Trust, which is included in net revenues in the accompanying consolidated statements of income, of approximately $5.3 million during 2023, approximately $5.1 million during 2022 and $4.4 million during 2021. In addition, certain of our officers and directors are also officers and/or directors of the Trust.
Members of the medical staffs of our hospitals also serve on the medical staffs of hospitals not owned by us and may terminate their affiliation with our hospitals at any time. In addition, within our behavioral health division, approximately 490 psychiatrists are employed by subsidiaries of ours either directly or through contracts with affiliated group practices structured as 501A corporations.
Members of the medical staffs of our hospitals also serve on the medical staffs of hospitals not owned by us and may terminate their affiliation with our hospitals at any time. In addition, within our behavioral health division, approximately 500 physicians are employed by subsidiaries of ours either directly or through contracts with affiliated group practices structured as 501A corporations.
Total aggregate rent expense under the operating leases on three hospital facilities with the Trust (McAllen Medical Center, Wellington Regional Medical Center and Inland Valley Campus of Southwest Healthcare System) was $17.7 million and $17.1 million during 2021 and 2020, respectively.
Total aggregate rent expense under the operating leases on three hospital facilities with the Trust (McAllen Medical Center, Wellington Regional Medical Center and Inland Valley Campus of Southwest Healthcare System) was $17.7 million during 2021.
On a combined basis, after deducting an allocation for corporate overhead expense, these facilities generated 14% in 2022 and 24% in 2021, of our income from operations after net income attributable to noncontrolling interest. Excluding the impact of the $57.6 million provision for asset impairment recorded during 2022, as discussed in Item 7.
On a combined basis, after deducting an allocation for corporate overhead expense, these facilities generated 16% in 2023 and 14% in 2022, of our income from operations after net income attributable to noncontrolling interest. Excluding the impact of the $57.6 million provision for asset impairment recorded during 2022, as discussed in Item 7.
We are unable at this time to predict how this trend will affect our results of operations, but it could negatively impact our revenues if we are unable to meet quality standards established by both governmental and private payers. 15 Controls designed to reduce inpatient services and increasing rates of “denials” may reduce our revenues.
We are unable at this time to predict how this trend will affect our results of operations, but it could negatively impact our revenues if we are unable to meet or maintain high quality standards established by both governmental and private payers. Controls designed to reduce inpatient services and increasing rates of “denials” may reduce our revenues.
Certain hospitals that are located in the areas served by our facilities are specialty or large hospitals that provide medical, surgical and behavioral health services, facilities and equipment that are not available at our hospitals. The increase in outpatient treatment and diagnostic facilities, outpatient surgical centers and freestanding ambulatory surgical also increases competition for us.
Certain hospitals that are located in the areas served by our facilities are specialty or large hospitals that provide medical, surgical and behavioral health services, facilities and equipment that are not available at our hospitals. The increase in outpatient treatment and diagnostic facilities, including outpatient surgical centers and addiction treatment centers, also increases competition for us.
In addition, in some markets like California, there are requirements to maintain specified nurse-staffing levels which could adversely affect our net revenues to the extent we cannot meet those levels.
In addition, in some markets such as California, there are requirements to maintain specified nurse-staffing levels which could adversely affect our net revenues to the extent we cannot meet those levels.
It may become difficult for us to attract and retain an adequate number of physicians to practice in certain of the non-urban communities in which our hospitals are located.
It may become difficult for us to attract and retain an adequate number of physicians to practice in certain communities in which our hospitals are located.
In addition, we have rights of first refusal to: (i) purchase the respective leased facilities during and for 180 days after the lease terms at the same price, terms and conditions of any third-party offer, or; (ii) renew the lease on the respective leased facility at the end of, and for 180 days after, the lease term at the same terms and conditions pursuant to any third-party offer.
In addition, we have rights of first refusal to: (i) purchase the respective leased facilities during and for a specified period after the lease terms at the same price, terms and conditions of any third-party offer, or; (ii) renew the lease on the respective leased facility at the end of, and for a specified period after, the lease term at the same terms and conditions pursuant to any third-party offer.
The market value of our investment in the Trust was $37.6 million at December 31, 2022 and $46.8 million at December 31, 2021, based on the closing price of the Trust’s stock on the respective dates. The Trust commenced operations in 1986 by purchasing certain hospital properties from us and immediately leasing the properties back to our respective subsidiaries.
The market value of our investment in the Trust was $34.1 million at December 31, 2023 and $37.6 million at December 31, 2022, based on the closing price of the Trust’s stock on the respective dates. The Trust commenced operations in 1986 by purchasing certain hospital properties from us and immediately leasing the properties back to our respective subsidiaries.
Effective January 1, 2022, the annual fair market value lease rate for this hospital is $6.3 million (there is no longer a bonus rental component of the lease payment). On each January 1 st through 2026, the annual rent will increase by 2.50% on a cumulative and compounded basis.
Effective January 1, 2024, the annual lease rate for this hospital is $6.6 million (there is no longer a bonus rental component of the lease payment). On each January 1 st through 2026, the annual rent will increase by 2.50% on a cumulative and compounded basis.
Our pre-tax share of income from the Trust was $1.2 million during 2022, $6.2 million during 2021 and $1.1 million during 2020 , which are included in other income, net, on the accompanying consolidated statements of income for each year. We received dividends from the Trust amounting to $2.2 million during each of 2022, 2021 and 2020.
Our pre-tax share of income from the Trust was $874,000 during 2023, $1.2 million during 2022 and $6.2 million during 2021, which are included in other income (expense), net, on the accompanying consolidated statements of income for each year. We received dividends from the Trust amounting to $2.3 million during 2023 and $2.2 million during each of 2022 and 2021.
As an EEO Employer, we support and are fully committed to recruitment, selection, placement, promotion and compensation of all individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.
As an EEO Employer we support, and are fully committed, to recruitment, selection, placement, promotion and compensation of all individuals without regard to race, color, religion, age (40 and over or as otherwise defined by applicable law), sex (including pregnancy, gender identity, and sexual orientation), genetic information (including family medical history), national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.
The carrying value of our investment in the Trust was $8.4 million and $9.4 million at December 31, 2022 and 2021, respectively, and is included in other assets in the accompanying consolidated balance sheets.
The carrying value of our investment in the Trust was $7.0 million and $8.4 million at December 31, 2023 and 2022, respectively, and is included in other assets in the accompanying consolidated balance sheets.
The loss of the services of one or more of our senior executives or of a significant portion of our local hospital management personnel could significantly undermine our management expertise and our ability to provide efficient, quality healthcare services at our facilities, which could harm our business. Effective January 1, 2021, Mr. Alan B.
The loss of the services of one or more of our senior executives or of a significant portion of our local hospital management personnel could significantly undermine our management expertise and our ability to provide efficient, quality healthcare services at our facilities, which could harm our business.
California: We own 5 inpatient acute care hospitals, 2 acute outpatient centers, 8 inpatient behavioral healthcare facilities and 3 behavioral healthcare outpatient facilities as listed in Item 2. Properties . On a combined basis, these facilities contributed 11% of our consolidated net revenues during each of 2022 and 2021.
California: We own 5 inpatient acute care hospitals, 2 acute outpatient centers, 9 inpatient behavioral healthcare facilities and 3 behavioral healthcare outpatient facilities as listed in Item 2. Properties . On a combined basis, these facilities contributed 11% our consolidated net revenues during both 2023 and 2022, respectively.
Nevada: We own 10 inpatient acute care hospitals, 5 free-standing emergency departments, 1 acute outpatient center and 3 inpatient behavioral healthcare facilities as listed in Item 2. Properties . On a combined basis, these facilities contributed 17% and 18% of our consolidated net revenues during 2022 and 2021, respectively.
Nevada: We own 9 inpatient acute care hospitals, 9 free-standing emergency departments, 3 acute outpatient centers and 3 inpatient behavioral healthcare facilities as listed in Item 2. Properties . On a combined basis, these facilities contributed 16% and 17% of our consolidated net revenues during 2023 and 2022, respectively.
Such exemptions and support are not available to us. In some markets, certain of our competitors may have greater financial resources, be better equipped and offer a broader range of services than us.
Such exemptions and support are not available to us. While our facilities tend to be located in fast growing, concentrated geographies, in some markets, certain of our competitors may have greater financial resources, be better equipped and offer a broader range of services than us.
Our Consolidated Balance Sheet as of December 31, 2022 and 2021 reflects a financial liability of $80.9 million and $82.4 million, respectively, which is included in debt, for the fair value of real estate assets that we exchanged as part of the transaction.
Our consolidated balance sheets as of December 31, 2023 and 2022 reflect a financial liability of $77.5 million and $80.9 million, respectively, which is included in debt, for the fair value of real estate assets that we exchanged as part of the transaction.
Subsequent legislation enacted by Congress eliminated the 2% reduction through 2021 but extended these reductions through 2030 in exchange. The payment reduction suspension was extended through March 31, 2022, with a 1% payment reduction from then until June 30, 2022 and the full 2% payment reduction thereafter. The most recent legislation extended these reductions through 2032. Please see
The payment reduction suspension was extended through March 31, 2022, with a 1% payment reduction from then until June 30, 2022 and the full 2% payment reduction thereafter. The most recent legislation extended these reductions through 2032. Please see
On a combined basis, after deducting an allocation for corporate overhead expense, these facilities generated 27% in 2022 and 13% in 2021, of our income from operations after net income attributable to noncontrolling interest.
On a combined basis, these facilities contributed 17% of our consolidated net revenues during both 2023 and 2022, respectively. On a combined basis, after deducting an allocation for corporate overhead expense, these facilities generated 26% in 2023 and 27% in 2022, of our income from operations after net income attributable to noncontrolling interest.
Miller (85) Executive Chairman of the Board Steve G. Filton (65) Executive Vice President, Chief Financial Officer and Secretary Matthew J. Peterson (53) Executive Vice President, President of Behavioral Health Division Edward H. Sim (51) Executive Vice President, President of Acute Care Division Mr. Marc D. Miller was appointed Chief Executive Officer and President effective January 1, 2021.
Filton (66) Executive Vice President, Chief Financial Officer and Secretary Matthew J. Peterson (54) Executive Vice President, President of Behavioral Health Division Edward H. Sim (52) Executive Vice President, President of Acute Care Division Mr. Marc D. Miller was appointed Chief Executive Officer and President effective January 1, 2021.
We compete with other health care providers in recruiting and retaining qualified hospital management, nurses and other medical personnel. Our acute care and behavioral health care facilities are experiencing the effects of a nationwide staffing shortage, which has caused and may continue to cause an increase in salaries, wages and benefits expense in excess of the inflation rate.
Our acute care and behavioral health care facilities are experiencing the effects of a nationwide staffing shortage, which has caused and may continue to cause an increase in salaries, wages and benefits expense in excess of the inflation rate.
Our failure to either recruit and retain qualified hospital management, nurses and other medical support personnel or control our labor costs could harm our results of operations. Increased labor union activity is another factor that could adversely affect our labor costs.
If our general labor and related expenses increase, we may not be able to raise our rates correspondingly. Our failure to either recruit and retain qualified hospital management, nurses and other medical support personnel or control our labor costs could harm our results of operations. Increased labor union activity is another factor that could adversely affect our labor costs.
In addition, in some markets like California, there are requirements to maintain specified nurse-staffing levels. To the extent we cannot meet those levels, we may be required to limit the healthcare services provided in these markets which would have a corresponding adverse effect on our net operating revenues. Many states in which we operate hospitals have CON laws.
To the extent we cannot meet appropriate staffing levels, we may be required to limit the healthcare services provided in these markets which would have a corresponding adverse effect on our net operating revenues. Certain states in which we operate hospitals have CON laws.
In connection with this MOB, which is expected to be completed and opened during the first quarter of 2023, a ground lease and a master flex lease was executed between a wholly-owned subsidiary of ours and the Trust, pursuant to the terms of which our subsidiary will master lease approximately 68% of the rentable square feet of the MOB at an initial minimum rent of $1.3 million annually.
In connection with this MOB, a ground lease and a master flex lease was executed between a wholly-owned subsidiary of ours and the Trust, pursuant to the terms of which our subsidiary will master lease approximately 68% of the rentable square feet of the MOB at an initial minimum rent of $1.3 million annually plus a pro-rata share of the common area maintenance expenses.
The table below provides certain details for each of the hospitals leased from the Trust as of January 1, 2023: Hospital Name Annual Minimum Rent End of Lease Term Renewal Term (years) McAllen Medical Center $ 5,485,000 December, 2026 5 (a) Wellington Regional Medical Center $ 6,477,000 December, 2026 5 (b) Aiken Regional Medical Center/Aurora Pavilion Behavioral Health Services $ 3,982,000 December, 2033 35 (c) Canyon Creek Behavioral Health $ 1,800,000 December, 2033 35 (c) Clive Behavioral Health Hospital $ 2,701,000 December, 2040 50 (d) (a) We have one 5-year renewal option at existing lease rates (through 2031).
Additionally, the joint venture has rights of first offer to purchase the facility prior to any third-party sale. 12 The table below provides certain details for each of the hospitals leased from the Trust as of January 1, 2024: Hospital Name Annual Minimum Rent End of Lease Term Renewal Term (years) McAllen Medical Center $ 5,485,000 December, 2026 5 (a) Wellington Regional Medical Center $ 6,639,000 December, 2026 5 (b) Aiken Regional Medical Center/Aurora Pavilion Behavioral Health Services $ 4,072,000 December, 2033 35 (c) Canyon Creek Behavioral Health $ 1,841,000 December, 2033 35 (c) Clive Behavioral Health $ 2,775,000 December, 2040 50 (d) (a) We have one 5-year renewal option at existing lease rates (through 2031).
At Brooke Glen Behavioral Hospital, unionized employees are represented by the Teamsters, and registered nurses are represented by the Northwestern Nurses Association/Pennsylvania Association of Staff Nurses and Allied Professionals.
At HRI Hospital in Boston, registered nurses, licensed practical nurses, certain technicians and some clerical employees are represented by the SEIU. At Brooke Glen Behavioral Hospital, unionized employees are represented by the Teamsters, and registered nurses are represented by the Northwestern Nurses Association/Pennsylvania Association of Staff Nurses and Allied Professionals.
Certified facilitators foster the Service Excellence culture and deliver training at their facilities. During 2022, we strengthened our recruitment efforts, improved the overall hiring and onboarding experience, expanded the training resources employees need to do their jobs effectively and safely, facilitated more teamwork and collaboration, addressed burnout, expanded mentorship and increased employee engagement.
During 2023, we strengthened our recruitment efforts, improved the overall hiring and onboarding experience (89% very satisfied/satisfied with overall recruitment process), expanded the training resources employees need to do their jobs effectively and safely, facilitated more teamwork and collaboration, addressed burnout, expanded mentorship and increased employee engagement.
If these states increase mandatory nurse-staffing ratios or additional states in which we operate adopt mandatory nurse-staffing ratios, such changes could significantly affect labor costs and have an adverse impact on revenues if we are required to limit admissions in order to meet the required ratios.
If these states increase mandatory nurse-staffing ratios or additional states in which we operate adopt mandatory nurse-staffing ratios, such changes could significantly affect labor costs and have an adverse impact on revenues if we are required to limit admissions in order to meet the required ratios. 16 We cannot predict the degree to which we will be affected by the future availability or cost of attracting and retaining talented medical support staff.
See “Regulation and Other Factors.” 9 Our ability to negotiate favorable service contracts with purchasers of group health care services also affects our competitive position and significantly affects the revenues and operating results of our hospitals. Managed care plans attempt to direct and control the use of hospital services and to demand that we accept lower rates of payment.
See “Regulation and Other Factors.” Our ability to negotiate favorable service contracts with purchasers of group health care services also affects our competitive position and significantly affects the revenues and operating results of our hospitals.
The master flex lease could be reduced during the term if certain conditions are met. Executive Officers of the Registrant The executive officers, whose terms will expire at such time as their successors are elected, are as follows: Name and Age Present Position with the Company Marc D. Miller (52) Chief Executive Officer, President and Director Alan B.
Executive Officers of the Registrant The executive officers, whose terms will expire at such time as their successors are elected, are as follows: Name and Age Present Position with the Company Marc D. Miller (53) Chief Executive Officer, President and Director Alan B. Miller (86) Executive Chairman of the Board Steve G.
We strive to retain and attract qualified doctors by maintaining high ethical and professional standards and providing adequate support personnel, technologically advanced equipment and facilities that meet the needs of those physicians. In addition, we depend on the efforts, abilities, and experience of our medical support personnel, including our nurses, pharmacists and lab technicians and other health care professionals.
We strive to retain and attract qualified doctors by maintaining high ethical and professional standards and providing adequate support personnel, technologically advanced equipment and facilities that meet the needs of those physicians.
A key element of our growth strategy is expansion through the acquisition of additional hospitals in select markets. The competition to acquire hospitals is significant. We compete for acquisitions with other for-profit health care companies, private equity and venture capital firms, as well as not-for-profit entities. Some of our competitors have greater resources than we do.
We compete for acquisitions with other for-profit health care companies, private equity and venture capital firms, as well as not-for-profit entities. Some of our competitors have greater resources than we do.
If we do not continually enhance our hospitals with the most recent technological advances in diagnostic and surgical equipment, our ability to maintain and expand our markets will be adversely affected.
Increases in these physician related expenses could continue to have an unfavorable material impact on our results of operations for the foreseeable future. If we do not continually enhance our hospitals with the most recent technological advances in diagnostic and surgical equipment, our ability to maintain and expand our markets will be adversely affected.
These include formal instructor-led, in-person or virtual training, informal mentoring or networking opportunities or self-administered online courses. 8 Training programs are designed to assist with personal and skill development, career advancement and succession planning. In addition to mandatory training that focus on keeping employees mindful and informed of key policies and skill sets, many are voluntary.
Employee Development In keeping with our culture of continuous improvement, training opportunities are available for all employees, regardless of level or status. These include formal instructor-led, in-person or virtual training, informal mentoring or networking opportunities or self-administered online courses. Training programs are designed to assist with personal and skill development, career advancement and succession planning.
Generally, hospitals compete for service contracts with group health care service purchasers on the basis of price, market reputation, geographic location, quality and range of services, quality of the medical staff and convenience. The importance of obtaining contracts with managed care organizations varies from market to market depending on the market strength of such organizations.
In return, hospitals secure commitments for a larger number of potential patients. Generally, hospitals compete for service contracts with group health care service purchasers on the basis of price, market reputation, geographic location, quality and range of services, quality of the medical staff and convenience.
There is a high degree of uncertainty regarding the implementation and impact of the Coronavirus Aid, Relief, and Economic Security Act (the “CARES Act”) and the Paycheck Protection Program and Health Care Enhancement Act (“PPPHCE Act”).
Compliance with the Coronavirus Aid, Relief, and Economic Security Act (the “CARES Act”) and the Paycheck Protection Program and Health Care Enhancement Act (“PPPHCE Act”).
The COVID-19 pandemic has led to a constrained supply environment which could result in higher cost to procure, and potential unavailability of, critical personal protection equipment, pharmaceuticals and medical supplies. Should a supply disruption result in the inability to obtain especially high margin drugs and compound components necessary for patient care, our consolidated financial statements could be negatively impacted.
Should a supply disruption result in the inability to obtain especially high margin drugs and compound components necessary for patient care, our consolidated financial statements could be negatively impacted.
Generally, the top ten attending physicians within each of our facilities represent a large share of our inpatient revenues and admissions. The loss of one or more of these physicians, even if temporary, could cause a material reduction in our revenues, which could take significant time to replace given the difficulty and cost associated with recruiting and retaining physicians.
The loss of one or more of these physicians, even if temporary, could cause a material reduction in our revenues, which could take significant time to replace given the difficulty and cost associated with recruiting and retaining physicians. Continued increase in hospital based physician expenses will materially affect our costs and results of operations.
We cannot predict whether the loss of any such favorable conditions available to providers during the declared PHE will ultimately have a negative financial impact on us.
States were also permitted to begin Medicaid eligibility redeterminations on March 31, 2023, which is anticipated to result in a large decrease in Medicaid enrollment. We cannot predict whether the loss of any such favorable conditions available to providers during the declared PHE will ultimately have a negative financial impact on us.
Any of the events described below could have a material adverse effect on our business, financial condition and results of operations.
Any of the events described below could have a material adverse effect on our business, financial condition and results of operations. Additional risks and uncertainties that we are not aware of, or that we currently deem to be immaterial, could also impact our business and results of operations.
We have continuous training on workplace safety and launched a “We Care” program guide to ensure our hospitals support employees in a detailed way in the event of an employee injury. Employee Development In keeping with our culture of continuous improvement, training opportunities are available for all employees, regardless of level or status.
We continue to promote the employee assistance program which has provided a superior level of service to all our employees and members of their households. 8 W e have continuous training on workplace safety and launched a “We Care” program guide to ensure our hospitals support employees in a detailed way in the event of an employee injury.
In January, 2022, the Trust commenced construction on a new 86,000 rentable square feet multi-tenant MOB that is located on the campus of Northern Nevada Sierra Medical Center in Reno, Nevada. Northern Nevada Sierra Medical Center, a 158-bed newly constructed acute care hospital owned and operated by a wholly-owned subsidiary of ours, was completed and opened in the April, 2022.
Northern Nevada Sierra Medical Center, a 170-bed newly constructed acute care hospital owned and operated by a wholly-owned subsidiary of ours, was completed and opened in April, 2022.
The length and extent of the disruptions caused by the COVID‑19 pandemic are currently unknown; however, we expect such disruptions to continue for the foreseeable future. This staffing shortage may require us to further enhance wages and benefits to recruit and retain nurses and other clinical staff and support personnel or require us to hire expensive temporary personnel.
This staffing shortage may require us to further enhance wages and benefits to recruit and retain nurses and other clinical staff and support personnel or require us to hire expensive temporary personnel.
All training is tailored to include potential Americans with Disabilities Act accommodations. Across the company, we offer educational and work opportunities, including internships, externships and clinical field placement opportunities. We also offer financial assistance programs, such as tuition reimbursement, to support employees participating in degree or certification programs.
In addition to mandatory training that focus on keeping employees mindful and informed of key policies and skill sets, many are voluntary. All training is tailored to include potential Americans with Disabilities Act accommodations. Across the company, we offer educational and work opportunities, including internships, externships and clinical field placement opportunities.
Equal Employment Opportunity We are committed to the principle of Equal Employment Opportunity ("EEO") for all employees and applicants.
We also offer financial assistance programs, such as educational reimbursement, to support employees participating in degree, certification and continuing education programs. Equal Employment Opportunity We are committed to the principle of Equal Employment Opportunity ("EEO") for all employees and applicants.
Risks Related to the Regulatory Environment Reductions or changes in Medicare and Medicaid funding could have a material adverse effect on our future results of operations. The Budget Control Act of 2011 (the “Budget Control Act”) mandated significant reductions in federal spending for fiscal years 2012-2021, including a reduction of 2% on all Medicare payments during this period.
The Budget Control Act of 2011 (the “Budget Control Act”) mandated significant reductions in federal spending for fiscal years 2012-2021, including a reduction of 2% on all Medicare payments during this period. Subsequent legislation enacted by Congress eliminated the 2% reduction through 2021 but extended these reductions through 2030 in exchange.
Texas: We own 7 inpatient acute care hospitals, 12 free-standing emergency departments and 21 inpatient behavioral healthcare facilities as listed in Item 2. Properties . On a combined basis, these facilities contributed 17% and 16% of our consolidated net revenues during 2022 and 2021, respectively.
Risks Related to Business Operations A significant portion of our revenue is produced by facilities located in Texas, Nevada and California. Texas: We own 7 inpatient acute care hospitals, 12 free-standing emergency departments and 21 inpatient behavioral healthcare facilities as listed in Item 2. Properties .
The impact of the COVID-19 pandemic, which began during the second half of March, 2020, has had a material effect on our operations and financial results since that time. The length and extent of the disruptions caused by the COVID‑19 pandemic are currently unknown; however, we expect such disruptions to continue into the future.
Risks Related to the COVID-19 Pandemic COVID-19 and other pandemics, epidemics, or public health threats may adversely affect our business, results of operations and financial condition. 17 The impact of the COVID-19 pandemic, which began during the second half of March, 2020, has had a material effect on our operations and financial results since that time.
In addition, employers and traditional health insurers are increasingly interested in containing costs through negotiations with hospitals for managed care programs and discounts from established charges. In return, hospitals secure commitments for a larger number of potential patients.
Managed care plans, including managed Medicare and Medicaid plans, attempt to direct and control the use of hospital services and to demand that we accept lower rates of payment. In addition, employers and traditional health insurers are increasingly interested in containing costs through negotiations with hospitals for managed care programs and discounts from established charges.
We are also subject to a highly regulated business environment, and failure to comply with the various laws and regulations applicable to us could lead to substantial penalties and other adverse effects on our business. 7 Human Capital Management Employees and Medical Staff As of December 31, 2022, we had approximately 93,800 total employees consisting of: (i) approximately 82,300 employees located in the U.S., of which approximately 59,700 were employed full-time, and; (ii) approximately 11,500 employees located in the U.K.
We are 7 also subject to a highly regulated business environment, and failure to comply with the various laws and regulations applicable to us could lead to substantial penalties and other adverse effects on our business.
On a combined basis, after deducting an allocation for corporate overhead expense, these facilities generated 15% in 2022 and 14% in 2021, of our income from operations after net income attributable to noncontrolling interest. Our revenues and results of operations are significantly affected by payments received from the government and other third party payers.
On a combined basis, after deducting an allocation for corporate overhead expense, these facilities generated 12% in 2023 and 15% in 2022, of our income from operations after net income attributable to noncontrolling interest. This geographic concentration makes us particularly sensitive to regulatory, economic, public health, environmental and competitive conditions in those states.
There can be no assurance that we will be able to raise additional funds on terms acceptable to us, if at all.
There can be no assurance that we will be able to raise additional funds on terms acceptable to us, if at all. The federal government had previously declared COVID-19 a national emergency, that declaration expired on May 11, 2023 at which time the favorable payment provisions available to us during the declared national emergency ended.
In 2022, the UHS Foundation continued to support employees and their families who suffered losses due to natural disasters across the country, including fires in Boulder, Colorado, Hurricane Ida, Hurricane Ian, and the storms that impacted Kentucky. Competition The health care industry is highly competitive.
In 2023, the UHS Foundation continued to support employees and their families who suffered losses due to natural disasters across the country, including tornados in Arkansas and Hurricane Ian. Environmental We have implemented environmentally sustainable practices and we comply with applicable legal and regulatory environmental standards to protect our patients, visitors, staff and local communities.
Removed
At Desert Springs Hospital, which is scheduled to discontinue all inpatient operations by March of 2023, engineers are represented by the International Union of Operating Engineers and registered nurses are represented by the Service Employees International Union (“SEIU”). At HRI Hospital in Boston, registered nurses, licensed practical nurses, certain technicians and some clerical employees are represented by the SEIU.
Added
Human Capital Management Employees and Medical Staff As of December 31, 2023, we had approximately 96,700 total employees consisting of: (i) approximately 84,450 employees located in the U.S., of which approximately 61,100 were employed full-time, and; (ii) approximately 12,250 employees located in the U.K.
Removed
Leading into 2022, we launched a new empl oyee assistance program which has provided a superior level of service to all our employees and members of their households. They also provided support on site at any of our hospitals.
Added
At Fairmount Behavioral Health, registered nurses and certain other professional job classifications are represented by District 1199C, National Union of Hospital and Health Care Employees, AFSCME, AFL-CIO, as are Licensed Practical Nurses who are currently organized in a separate bargaining unit.

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Item 4. Mine Safety Disclosures

Mine Safety Disclosures — required of mining issuers

13 edited+1 added−1 removed2 unchanged
Biggest changeIn February, 2022, our Board of Directors authorized a $1.4 billion increase to the program. As of December 31, 2022, we had an aggregate available repurchase authorization of $947.37 million. Pursuant to this program, shares of our Class B Common Stock may be repurchased, from time to time as conditions allow, on the open market or in negotiated private transactions.
Biggest changePursuant to this program, shares of our Class B Common Stock may be repurchased, from time to time as conditions allow, on the open market or in negotiated private transactions. There is no expiration date for our stock repurchase programs.
Dividend equivalents are accrued on unvested restricted stock units and are paid upon vesting of the restricted stock unit. Our Credit Agreement contains covenants that include limitations on, among other things, dividends and stock repurchases (see below in Capital Resources-Credit Facilities and Outstanding Debt Securities ). 36 Equity Compensation Refer to Item 12.
Dividend equivalents are accrued on unvested restricted stock units and are paid upon vesting of the restricted stock unit. Our Credit Agreement contains covenants that include limitations on, among other things, dividends and stock repurchases (see below in Capital Resources-Credit Facilities and Outstanding Debt Securities ). 38 Equity Compensation Refer to Item 12.
There is no other plan or program that has expired during this time period. Also, there is no other plan or program that we have determined to terminate prior to expiration, or under which we do not intend to make further purchases. Dividends During the year ended December 31, 2022 we paid dividends of $0.80 per share.
There is no other plan or program that has expired during this time period. Also, there is no other plan or program that we have determined to terminate prior to expiration, or under which we do not intend to make further purchases. Dividends During the year ended December 31, 2023 we paid dividends of $0.80 per share.
ITEM 4. Mine Saf ety Disclosures Not applicable. 35 PART II ITEM 5 . Market for Registrant’s Common Equity, Related Stockholder Matters and Issuer Purchases of Equity Securities Our Class B Common Stock is traded on the New York Stock Exchange under the symbol UHS.
ITEM 4. Mine Saf ety Disclosures Not applicable. 37 PART II ITEM 5 . Market for Registrant’s Common Equity, Related Stockholder Matters and Issuer Purchases of Equity Securities Our Class B Common Stock is traded on the New York Stock Exchange under the symbol UHS.
The graph assumes an investment of $100 made in our common stock and each Index as of January 1, 2018 and has been weighted based on market capitalization. Note that our common stock price performance shown below should not be viewed as being indicative of future performance.
The graph assumes an investment of $100 made in our common stock and each Index as of January 1, 2019 and has been weighted based on market capitalization. Note that our common stock price performance shown below should not be viewed as being indicative of future performance.
Stock Price Performance Graph The following graph compares the cumulative total stockholder return on our common stock with the cumulative total return on the stock included in the Standard & Poor’s 500 Index and a Peer Group Index during the five-year period ended December 31, 2022.
Stock Price Performance Graph The following graph compares the cumulative total stockholder return on our common stock with the cumulative total return on the stock included in the Standard & Poor’s 500 Index and a Peer Group Index during the five-year period ended December 31, 2023.
Also includes 745, 286 and 550 restricted shares that were forfeited and canceled by former employees pursuant to the terms of our restricted stock purchase plan during October, November and December, 2022, respectively. (2) The only publicly announced program pursuant to which the shares were repurchased was the share repurchase program described above.
Also includes 40, 46 and 543 restricted shares that were forfeited and canceled by former employees pursuant to the terms of our restricted stock purchase plan during October, November and December, 2023, respectively. (2) The only publicly announced program pursuant to which the shares were repurchased was the share repurchase program described above.
In addition, during the three-month period ended December 31, 2022, 17,727 shares were repurchased in connection with income tax withholding obligations resulting from stock-based compensation programs. For the year ended December 31, 2022, we have repurchased approximately 6.67 million shares at an aggregate cost of approximately $810.86 million (approximately $121.63 per share).
In addition, during the three-month period ended December 31, 2023, 32,019 shares were repurchased in connection with income tax withholding obligations resulting from stock-based compensation programs. For the year ended December 31, 2023, we have repurchased approximately 3.86 million shares at an aggregate cost of approximately $524.48 million (approximately $136.05 per share).
Companies in the peer group, which consist of companies in the S&P 500 Index or S&P MidCap 400 Index are as follows: Acadia Healthcare Company, Inc., Community Health Systems, Inc., HCA Healthcare, Inc., LifePoint Health, Inc. (included until November, 2018, when it was acquired by Apollo Management) and Tenet Healthcare Corporation.
Companies in the peer group, which consist of companies in the S&P 500 Index or S&P MidCap 400 Index are as follows: Acadia Healthcare Company, Inc., Community Health Systems, Inc., HCA Healthcare, Inc., and Tenet Healthcare Corporation.
The number of stockholders of record as of January 31, 2023, were as follows: Class A Common 17 Class B Common 729 Class C Common 1 Class D Common 85 Stock Repurchase Programs As of December 31, 2021, we had an aggregate available purchase authorization of $358.2 million.
The number of stockholders of record as of January 31, 2024, were as follows: Class A Common 17 Class B Common 656 Class C Common 1 Class D Common 81 Stock Repurchase Programs As of January 1, 2023, we had an aggregate available repurchase authorization of $947.37 million under our stock repurchase program.
There is no expiration date for our stock repurchase programs. As reflected below, during the fourth quarter of 2022, we have repurchased approximately 812,141 shares at an aggregate cost of approximately $107.23 million (approximately $132.03 per share) pursuant to the terms of our stock repurchase program.
As reflected below, during the fourth quarter of 2023, we have repurchased approximately 1.13 million shares at an aggregate cost of approximately $157.32 million (approximately $139.28 per share) pursuant to the terms of our stock repurchase program.
In addition, for the year ended December 31, 2022, 153,305 shares were repurchased in connection with income tax withholding obligations resulting from stock-based compensation programs.
In addition, for the year ended December 31, 2023, 164,649 shares were repurchased in connection with income tax withholding obligations resulting from stock-based compensation programs. As of December 31, 2023, we had an aggregate available repurchase authorization of $422.88 million pursuant to our stock repurchase program.
During the period of October 1, 2022 through December 31, 2022, we repurchased the following shares: Additional Dollars Authorized For Repurchase (in thousands) Total number of shares purchased (1) Total number of shares cancelled Average price paid per share for forfeited restricted shares Total Number of shares purchased as part of publicly announced programs (2) Average price paid per share for shares purchased as part of publicly announced program Aggregate purchase price paid (in thousands) Maximum number of dollars that may yet be purchased under the program (in thousands) October, 2022 — 1,730 745 $ 0.01 — $ — $ — $ 1,054,597 November, 2022 — 191,955 286 $ 0.01 182,141 $ 129.64 $ 23,612 $ 1,030,985 December, 2022 — 637,764 550 $ 0.01 630,000 $ 132.73 $ 83,617 $ 947,368 Total October through December $ - 831,449 1,581 $ 0.01 812,141 $ 132.03 $ 107,229 (1) Includes shares that were repurchased in connection with income tax withholding obligations resulting from the exercise of stock options and the vesting of restricted stock grants.
During the period of October 1, 2023 through December 31, 2023, we repurchased the following shares: Additional Dollars Authorized For Repurchase (in thousands) Total number of shares purchased (1) Total number of shares cancelled Average price paid per share for forfeited restricted shares Total Number of shares purchased as part of publicly announced programs (2) Average price paid per share for shares purchased as part of publicly announced program Aggregate purchase price paid (in thousands) Maximum number of dollars that may yet be purchased under the program (in thousands) October, 2023 — 388 40 $ 0.01 — $ — $ — $ 580,204 November, 2023 — 681,009 46 $ 0.01 679,495 $ 131.47 $ 89,334 $ 490,870 December, 2023 — 480,746 543 $ 0.01 450,000 $ 151.08 $ 67,987 $ 422,883 Total October through December $ — 1,162,143 629 $ 0.01 1,129,495 $ 139.28 $ 157,321 (1) Includes shares that were repurchased in connection with income tax withholding obligations resulting from the exercise of stock options and the vesting of restricted stock grants.
Removed
Company Name / Index 2017 Base 2018 2019 2020 2021 2022 Universal Health Services, Inc. $ 100.00 $ 103.16 $ 127.53 $ 122.42 $ 116.10 $ 126.98 S&P 500 Index $ 100.00 $ 95.62 $ 125.72 $ 148.85 $ 191.58 $ 156.88 Peer Group $ 100.00 $ 135.63 $ 168.65 $ 192.34 $ 304.63 $ 281.64
Added
Company Name / Index 2018 Base 2019 2020 2021 2022 2023 Universal Health Services, Inc. $ 100.00 $ 123.62 $ 118.67 $ 112.54 $ 123.09 $ 133.96 S&P 500 Index $ 100.00 $ 131.49 $ 155.68 $ 200.37 $ 164.08 $ 207.21 Peer Group $ 100.00 $ 124.34 $ 141.81 $ 224.60 $ 207.65 $ 237.61

Item 6. [Reserved]

Selected Financial Data — reserved (removed by SEC in 2021)

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Biggest changeNet revenues from our acute care hospitals, outpatient facilities and commercial health insurer accounted for 57% of our consolidated net revenues during 2022 and 56% during 2021. Net revenues from our behavioral health care facilities and commercial health insurer accounted for 43% of our consolidated net revenues during 2022 and 44% during 2021.
Biggest changeNet revenues from our acute care hospitals, outpatient facilities and commercial health insurer accounted for 57% of our consolidated net revenues during each of 2023 and 2022. Net revenues from our behavioral health care facilities and commercial health insurer accounted for 43% of our consolidated net revenues during each of 2023 and 2022.
Forward-looking statements include, among other things, the information concerning our possible future results of operations, business and growth 38 strategies, financing plans, expectations that regulatory developments or other matters will or will not have a material adverse effect on our business or financial condition, our competitive position and the effects of competition, the projected growth of the industry in which we operate, and the benefits and synergies to be obtained from our completed and any future acquisitions, and statements of our goals and objectives, and other similar expressions concerning matters that are not historical facts.
Forward-looking statements include, among other things, the information concerning our possible future results of operations, business and growth 40 strategies, financing plans, expectations that regulatory developments or other matters will or will not have a material adverse effect on our business or financial condition, our competitive position and the effects of competition, the projected growth of the industry in which we operate, and the benefits and synergies to be obtained from our completed and any future acquisitions, and statements of our goals and objectives, and other similar expressions concerning matters that are not historical facts.
Forward-Looking Statements and Risk Factors You should carefully review the information contained in this Annual Report, and should particularly consider any risk factors that we set forth in this Annual Report on Form 10-K for the year ended December 31, 2022, and in other reports or documents that we file from time to time with the Securities and Exchange Commission (the “SEC”).
Forward-Looking Statements and Risk Factors You should carefully review the information contained in this Annual Report, and should particularly consider any risk factors that we set forth in this Annual Report on Form 10-K for the year ended December 31, 2023, and in other reports or documents that we file from time to time with the Securities and Exchange Commission (the “SEC”).
This section generally discusses our results of operations for the year ended December 31, 2022, as compared to the year ended December 31, 2021. For discussion of our result of operations and changes in our financial condition for the year ended December 31, 2021 as compared to the year ended December 31, 2020, please refer to Part II, Item 7.
This section generally discusses our results of operations for the year ended December 31, 2023, as compared to the year ended December 31, 2022. For discussion of our result of operations and changes in our financial condition for the year ended December 31, 2022 as compared to the year ended December 31, 2021, please refer to Part II, Item 7.
ITEM 6. [RESERVED] 37 ITEM 7. Management’s Discussion and Analysis of Financial Condition and Results of Operations The following Management’s Discussion and Analysis of Financial Condition and Results of Operations (“MD&A”) is intended to promote an understanding of our operating results and financial condition.
ITEM 6. [RESERVED] 39 ITEM 7. Management’s Discussion and Analysis of Financial Condition and Results of Operations The following Management’s Discussion and Analysis of Financial Condition and Results of Operations (“MD&A”) is intended to promote an understanding of our operating results and financial condition.
Management’s Discussion and Analysis of Financial Condition and Results of Operations in our Annual Report on Form 10-K for the year ended December 31, 2021, as filed with the Securities and Exchange Commission on February 24, 2022. Overview Our principal business is owning and operating, through our subsidiaries, acute care hospitals and outpatient facilities and behavioral health care facilities.
Management’s Discussion and Analysis of Financial Condition and Results of Operations in our Annual Report on Form 10-K for the year ended December 31, 2022, as filed with the Securities and Exchange Commission on February 27, 2023. Overview Our principal business is owning and operating, through our subsidiaries, acute care hospitals and outpatient facilities and behavioral health care facilities.
Our behavioral health care facilities located in the U.K. generated net revenues of approximately $685 million in 2022 and $688 million in 2021. Total assets at our U.K. behavioral health care facilities were approximately $1.235 billion as of December 31, 2022 and $1.351 billion as of December 31, 2021.
Our behavioral health care facilities located in the U.K. generated net revenues of approximately $761 million in 2023 and $685 million in 2022. Total assets at our U.K. behavioral health care facilities were approximately $1.327 billion as of December 31, 2023 and $1.235 billion as of December 31, 2022.
As of February 27, 2023, we owned and/or operated 359 inpatient facilities and 39 outpatient and other facilities including the following located in 39 states, Washington, D.C., the United Kingdom and Puerto Rico: Acute care facilities located in the U.S.: • 28 inpatient acute care hospitals; • 21 free-standing emergency departments, and; • 7 outpatient centers & 1 surgical hospital.
As of February 27, 2024, we owned and/or operated 360 inpatient facilities and 48 outpatient and other facilities, including the following, located in 39 states, Washington, D.C., the United Kingdom and Puerto Rico: Acute care facilities located in the U.S.: • 27 inpatient acute care hospitals; • 27 free-standing emergency departments, and; • 10 outpatient centers & 1 surgical hospital.
Behavioral health care facilities (331 inpatient facilities and 10 outpatient facilities): Located in the U.S.: • 185 inpatient behavioral health care facilities, and; • 8 outpatient behavioral health care facilities. Located in the U.K.: • 143 inpatient behavioral health care facilities, and; • 2 outpatient behavioral health care facilities. Located in Puerto Rico: • 3 inpatient behavioral health care facilities.
Behavioral health care facilities (333 inpatient facilities and 10 outpatient facilities): Located in the U.S.: • 186 inpatient behavioral health care facilities, and; • 8 outpatient behavioral health care facilities. Located in the U.K.: • 144 inpatient behavioral health care facilities, and; • 2 outpatient behavioral health care facilities. Located in Puerto Rico: • 3 inpatient behavioral health care facilities.

Item 7. Management's Discussion & Analysis

Management's Discussion & Analysis (MD&A) — revenue / margin commentary

35 edited+26 added−10 removed108 unchanged
Biggest changeBecause Legislation provisions are effective at various times over the next several years, we anticipate that many of the provisions in the Legislation may be subject to further revision. Initiatives to repeal the Legislation, in whole or in part, to delay elements of implementation or funding, and to offer amendments or supplements to modify its provisions have been persistent.
Biggest changeInitiatives to repeal the Legislation, in whole or in part, to delay elements of implementation or funding, and to offer amendments or supplements to modify its provisions have been persistent. The ultimate outcomes of legislative attempts to repeal or amend the Legislation and legal challenges to the Legislation are unknown.
On November 27, 2019, CMS published a final rule on “Price Transparency Requirements for Hospitals to Make Standard Charges Public.” This rule took effect on January 1, 2021 and requires all hospitals to also make public their payer-specific negotiated rates, minimum negotiated rates, maximum negotiated rates and cash for all items and services, including individual items and services and service packages, that could be provided by a hospital to a patient.
On November 27, 2019, CMS published a final rule on “Price Transparency Requirements for Hospitals to Make Standard Charges Public.” This rule took effect on January 1, 2021 and requires all hospitals to also make public 20 their payer-specific negotiated rates, minimum negotiated rates, maximum negotiated rates and cash for all items and services, including individual items and services and service packages, that could be provided by a hospital to a patient.
While attempts to repeal the entirety of the Legislation have not been successful to date, a key provision of the Legislation was repealed as part of the Tax Cuts and Jobs Act and on December 14, 2018, a Texas Federal District Court Judge declared the Legislation unconstitutional, reasoning that the individual mandate tax penalty was essential to and not severable from the remainder 19 of the Legislation.
While attempts to repeal the entirety of the Legislation have not been successful to date, a key provision of the Legislation was repealed as part of the Tax Cuts and Jobs Act and on December 14, 2018, a Texas Federal District Court Judge declared the Legislation unconstitutional, reasoning that the individual mandate tax penalty was essential to and not severable from the remainder of the Legislation.
Among these laws are the federal False Claims Act, the Health Insurance Portability and Accountability Act of 1996, (“HIPAA”), the federal anti-kickback statute and the provision of the Social Security Act commonly known as the “Stark Law.” These laws, and particularly the anti-kickback statute and the Stark Law, impact the relationships that we may have with physicians and other referral sources.
Among these laws are the federal False Claims Act, the Health Insurance Portability and Accountability Act of 1996, (“HIPAA”), the federal anti-kickback statute and the provision of the Social Security Act commonly known as the “Stark Law.” These laws, and particularly the anti-kickback statute and the Stark Law, impact the relationships that we may have with physicians and 21 other referral sources.
To the extent that significant changes in the climate occur in areas where our facilities are located, we may experience increased frequency of severe 23 weather conditions or natural disasters or other changes to weather patterns, all of which may result in physical damage to or a decrease in demand for properties affected by these conditions.
To the extent that significant changes in the climate occur in areas where our facilities are located, we may experience increased frequency of severe weather conditions or natural disasters or other changes to weather patterns, all of which may result in physical damage to or a decrease in demand for properties affected by these conditions.
The Legislation provides that a healthcare provider that retains an overpayment in excess of 60 days is subject to the federal civil False Claims Act, although certain final regulations implementing this statutory requirement remain pending. The Legislation also expands the Recovery Audit Contractor program to Medicaid.
The Legislation provides that a healthcare provider that retains an overpayment in excess of 60 days is subject to the 19 federal civil False Claims Act, although certain final regulations implementing this statutory requirement remain pending. The Legislation also expands the Recovery Audit Contractor program to Medicaid.
Additionally, such facilities are subject to periodic inspection by government authorities to assure their continued compliance with these various standards. 22 All of our hospitals are deemed certified, meaning that they are accredited, properly licensed under the relevant state laws and regulations and certified under the Medicare program.
Additionally, such facilities are subject to periodic inspection by government authorities to assure their continued compliance with these various standards. All of our hospitals are deemed certified, meaning that they are accredited, properly licensed under the relevant state laws and regulations and certified under the Medicare program.
If we fail to comply with those standards, we may be subject to sanctions and penalties that could harm our business and results of operations. We are subject to pending legal actions, purported stockholder class actions, governmental investigations and regulatory actions.
If we fail to comply with those standards, we may be subject to sanctions and penalties that could harm our business and results of operations. 22 We are subject to pending legal actions, purported stockholder class actions, governmental investigations and regulatory actions.
Given the location of our facilities, we are particularly susceptible to revenue loss, cost increase, or damage caused by severe weather conditions or natural disasters such as hurricanes, wildfires, earthquakes, or tornadoes.
Given the location of our facilities, 24 we are particularly susceptible to revenue loss, cost increase, or damage caused by severe weather conditions or natural disasters such as hurricanes, wildfires, earthquakes, or tornadoes.
Each share of Class A Common Stock entitles the holder thereof to one vote; each share of Class B Common Stock entitles the holder thereof to one-tenth of a vote; each share of Class C Common Stock entitles the holder thereof to 100 votes (provided the holder of Class C Common Stock holds a number of shares of Class A Common Stock equal to ten times the number of shares of 25 Class C Common Stock that holder holds); and each share of Class D Common Stock entitles the holder thereof to ten votes (provided the holder of Class D Common Stock holds a number of shares of Class B Common Stock equal to ten times the number of shares of Class D Common Stock that holder holds).
Each share of Class A Common Stock entitles the holder thereof to one vote; each share of Class B Common Stock entitles the holder thereof to one-tenth of a vote; each share of Class C Common Stock entitles the holder thereof to 100 votes (provided the holder of Class C Common Stock holds a number of shares of Class A Common Stock equal to ten times the number of shares of Class C Common Stock that holder holds); and each share of Class D Common Stock entitles the holder thereof to ten votes (provided the holder of Class D Common Stock holds a number of shares of Class B Common Stock equal to ten times the number of shares of Class D Common Stock that holder holds).
However, if any of our systems are damaged, fail to function properly or otherwise become unavailable, we may incur substantial costs to repair or replace them, and may experience loss or corruption of critical data such as protected health information or other data subject to privacy laws and proprietary business information and interruptions or disruptions and delays in our ability to perform critical functions, which could materially and adversely affect our businesses and results of operations and could result in significant penalties or fines, litigation, loss of customers, significant damage to our reputation and business, and other losses.
However, if any of our or our third-party service providers’ systems are damaged, fail to function properly or otherwise become unavailable, we may incur substantial costs to repair or replace them, and may experience loss or corruption of critical data such as protected health information or other data subject to privacy laws and proprietary business information and interruptions or disruptions and delays in our ability to perform critical functions, which could materially and adversely affect our businesses and results of operations and could result in significant penalties or fines, litigation, loss of customers, significant damage to our reputation and business, and other losses.
State efforts to regulate the construction or expansion of health care facilities could impair our ability to expand. Many of the states in which we operate hospitals have enacted Certificates of Need, or (“CON”), laws as a condition prior to hospital capital expenditures, construction, expansion, modernization or initiation of major new services.
State efforts to regulate the construction or expansion of health care facilities could impair our ability to expand. Certain states in which we operate hospitals have certificates of need (“CON”) laws as a condition prior to hospital capital expenditures, construction, expansion, modernization or initiation of major new services.
Risks Related to Information Technology A cyber security incident could cause a violation of HIPAA, breach of member privacy, or other negative impacts. We rely extensively on our information technology (“IT”) systems to manage clinical and financial data, communicate with our patients, payers, vendors and other third parties and summarize and analyze operating results.
Risks Related to Information Technology 23 A cyber security incident could cause a violation of HIPAA, breach of patient or other persons privacy, or other negative impacts. We rely extensively on our information technology (“IT”) systems to manage clinical and financial data, communicate with our patients, payers, vendors and other third parties and summarize and analyze operating results.
Our IT systems are subject to damage or interruption from power outages, facility damage, computer and telecommunications failures, computer viruses, security breaches including credit card or personally identifiable information breaches, vandalism, theft, natural disasters, catastrophic events, human error and potential cyber threats, including malicious codes, worms, phishing attacks, denial of service attacks, ransomware and other sophisticated cyber-attacks, and our disaster recovery planning cannot account for all eventualities.
Our IT systems, and the networks and information systems of third parties that we rely on, are subject to damage or interruption from power outages, facility damage, computer and telecommunications failures, computer viruses, security breaches including credit card or personally identifiable information breaches, vandalism, theft, natural disasters, catastrophic events, human error and potential cyber threats, including malicious codes, worms, phishing attacks, denial of service attacks, ransomware and other sophisticated cyber-attacks, and our disaster recovery planning cannot account for all eventualities.
As we continue to invest in modern technologies, emergency rooms and operating room expansions, the construction of medical office buildings for physician expansion and reconfiguring the flow of patient care, we spend large amounts of money generated from our operating cash flow or borrowed funds.
The cost of construction materials and labor has significantly increased. As we continue to invest in modern technologies, emergency rooms and operating room expansions, the construction of medical office buildings for physician expansion and reconfiguring the flow of patient care, we spend large amounts of money generated from our operating cash flow or borrowed funds.
At December 31, 2022, 23.6 million shares of Class B Common Stock were reserved for issuance upon conversion of shares of Class A, C and D Common Stock outstanding, for issuance upon exercise of options to purchase Class B Common Stock and for issuance of stock under other incentive plans.
At December 31, 2023, 20.5 million shares of Class B Common Stock were reserved for issuance upon conversion of shares of Class A, C and D Common Stock outstanding, for issuance upon exercise of options to purchase Class B Common Stock and for issuance of stock under other incentive plans.
In addition, as of December 31, 2022, we had approximately $3.9 billion of goodwill recorded on our consolidated balance sheet.
In addition, as of December 31, 2023, we had approximately $3.9 billion of goodwill recorded on our consolidated balance sheets.
Settlements of lawsuits involving Medicare and Medicaid issues routinely require both monetary payments and corporate integrity agreements, each of which could have a material adverse effect on our business, financial condition, results of operations and/or cash flows. The failure of certain employers, or the closure of certain facilities, could have a disproportionate impact on our hospitals.
Settlements of lawsuits involving Medicare and Medicaid issues routinely require both monetary payments and corporate integrity agreements, each of which could have a material adverse effect on our business, financial condition, results of operations and/or cash flows.
Failure to comply with these requirements may result in daily monetary penalties. As part of the CAA, Congress passed legislation aimed at preventing or limiting patient balance billing in certain circumstances. The CAA addresses surprise medical bills stemming from emergency services, out-of-network ancillary providers at in-network facilities, and air ambulance carriers.
As part of the CAA, Congress passed legislation aimed at preventing or limiting patient balance billing in certain circumstances. The CAA addresses surprise medical bills stemming from emergency services, out-of-network ancillary providers at in-network facilities, and air ambulance carriers.
The Foreign Corrupt Practices Act regulates U.S. companies in their dealings with foreign officials, prohibiting bribes and similar practices, and requires that they maintain records that fairly and accurately reflect transactions and appropriate internal accounting controls.
The Foreign Corrupt Practices Act regulates U.S. companies in their dealings with foreign officials, prohibiting bribes and similar practices, and requires that they maintain records that fairly and accurately reflect transactions and appropriate internal accounting controls. In addition, the United Kingdom Bribery Act has wide jurisdiction over certain activities that affect the United Kingdom.
As of March 24, 2022, the shares of Class B and Class D Common Stock (excluding shares issuable upon exercise of options) constituted 90.3% of the outstanding shares of our Common Stock, had the right to elect two members of the Board of Directors and constituted 10.5% of our general voting power as of that date.
And as of that date, the shares of Class B and Class D Common Stock (excluding shares issuable upon exercise of options) constituted 89.7% of the outstanding shares of our Common Stock, had the right to elect two members of the Board of Directors and constituted 9.6% of our general voting power as of that date.
Constitution and that the coverage of certain HIV prevention medication violates the Religious Freedom Restoration Act. We are unable to predict the outcome of this litigation or its potential impact at this time.
Constitution and that the coverage of certain HIV prevention medication violates the Religious Freedom Restoration Act. The government has appealed the decision to the U.S. Circuit Court of Appeals for the Fifth Circuit. We are unable to predict the outcome of this litigation or its potential impact at this time.
In addition, the United Kingdom Bribery Act has wide jurisdiction over certain activities that affect the United Kingdom. 21 Our operations in the United Kingdom are also subject to a high level of regulation relating to registration and licensing requirements employee regulation, clinical standards, environmental rules as well as other areas.
Our operations in the United Kingdom are also subject to a high level of regulation relating to registration and licensing requirements employee regulation, clinical standards, environmental rules as well as other areas.
As of March 24, 2022, the shares of Class A and Class C Common Stock constituted 9.7% of the aggregate outstanding shares of our Common Stock, had the right to elect five members of the Board of Directors and constituted 89.5% of our general voting power as of that date.
As of March 22, 2023, the shares of Class A and Class C Common Stock constituted 10.3% of the aggregate outstanding shares of our Common Stock, had the right to elect five members of the Board of Directors and constituted 90.4% of our general voting 26 power as of that date.
Although we evaluate the financial feasibility of such projects by determining whether the projected cash flow return on investment exceeds our cost of capital, such returns may not be achieved if the cost of construction continues to rise significantly or the expected patient volumes are not attained. 24 The deterioration of credit and capital markets may adversely affect our access to sources of funding and we cannot be certain of the availability and terms of capital to fund the growth of our business when needed.
Although we evaluate the financial feasibility of such projects by determining whether the projected cash flow return on investment exceeds our cost of capital, such returns may not be achieved if the cost of construction continues to rise significantly or the expected patient volumes are not attained.
While we may elect to enter into hedging arrangements to protect our business against certain currency fluctuations, these hedging arrangements do not provide comprehensive protection, and our results of operations could be adversely affected by foreign exchange fluctuations. Brexit could lead to legal and regulatory uncertainty as the United Kingdom determines which European Union laws to replace or replicate.
While we may elect to enter into hedging arrangements to protect our business against certain currency fluctuations, these hedging arrangements do not provide comprehensive protection, and our results of operations could be adversely affected by foreign exchange fluctuations.
The occurrence of these events could adversely affect our revenue and results of operations, thereby harming our business. If any of our existing health care facilities lose their accreditation or any of our new facilities fail to receive accreditation, such facilities could become ineligible to receive reimbursement under Medicare or Medicaid.
If any of our existing health care facilities lose their accreditation or any of our new facilities fail to receive accreditation, such facilities could become ineligible to receive reimbursement under Medicare or Medicaid.
The exit of the United Kingdom from the European Union could also create future economic uncertainty, both in the United Kingdom and globally, and could cause disruptions to and create uncertainty surrounding our business. Any of these effects of Brexit, and others we cannot anticipate, could harm our business, financial condition or results of operations.
The exit of the United Kingdom from the European Union could also create future economic uncertainty, both in the United Kingdom and globally, and could cause disruptions to and create uncertainty surrounding our business.
We continue to see rising costs in construction materials and labor. Such increased costs could have an adverse effect on the cash flow return on investment relating to our capital projects. The cost of construction materials and labor has significantly increased.
Any of these effects of Brexit, and others we cannot anticipate, could harm our business, financial condition or results of operations. 25 We continue to see rising costs in construction materials and labor. Such increased costs could have an adverse effect on the cash flow return on investment relating to our capital projects.
The ultimate outcomes of legislative attempts to repeal or amend the Legislation and legal challenges to the Legislation are unknown. Legislation has already been enacted that has eliminated the penalty for failing to maintain health coverage that was part of the original Legislation.
Legislation has already been enacted that has eliminated the penalty for failing to maintain health coverage that was part of the original Legislation.
Failure of our acute care hospitals to continue to meet the applicable meaningful use criteria would have an adverse effect on our future net revenues and results of operations. 20 If we fail to comply with extensive laws and government regulations, we could suffer civil or criminal penalties or be required to make significant changes to our operations that could reduce our revenue and profitability.
If we fail to comply with extensive laws and government regulations, we could suffer civil or criminal penalties or be required to make significant changes to our operations that could reduce our revenue and profitability.
It has been projected that the Legislation will result in a net reduction in Medicare and Medicaid payments to hospitals totaling $155 billion over 10 years. The Legislation revises reimbursement under the Medicare and Medicaid programs to emphasize the efficient delivery of high quality care and contains a number of incentives and penalties under these programs to achieve these goals.
The Legislation revises reimbursement under the Medicare and Medicaid programs to emphasize the efficient delivery of high quality care and contains a number of incentives and penalties under these programs to achieve these goals. The Legislation implements a value-based purchasing program, which will reward the delivery of efficient care.
During 2022, in conjunction with our stock repurchase program, we repurchased approximately 6.7 million shares at an aggregate cost of approximately $811 million. As of December 31, 2022, we had an aggregate available repurchase authorization of approximately $947 million pursuant to this program, including a $1.4 billion increase authorized by our Board of Directors in February, 2022.
During 2023, in conjunction with our stock repurchase program, we have repurchased approximately 3.9 million shares at an aggregate cost of approximately $525 million. As of December 31, 2023, we had an aggregate available repurchase authorization of approximately $423 million.
The Legislation implements a value-based purchasing program, which will reward the delivery of efficient care. Conversely, certain facilities will receive reduced reimbursement for failing to meet quality parameters; such hospitals will include those with excessive readmission or hospital-acquired condition rates.
Conversely, certain facilities will receive reduced reimbursement for failing to meet quality parameters; such hospitals will include those with excessive readmission or hospital-acquired condition rates. It remains unclear what portions of that legislation may remain, or what any replacement or alternative programs may be created by future legislation. A 2012 U.S.
We are required to treat patients with emergency medical conditions regardless of ability to pay.
The government's appeal of the district court's order is pending in the U.S. Court of Appeals for the Fifth Circuit. We are required to treat patients with emergency medical conditions regardless of ability to pay.
Removed
It remains unclear what portions of that legislation may remain, or what any replacement or alternative programs may be created by future legislation. 18 A 2012 U.S.
Added
On April 26, 2023, CMS announced updated enforcement processes that requires a shortened timeline for coming into compliance when a violation has been identified and the automatic imposition of a civil monetary penalties in certain circumstances of noncompliance. Failure to comply with these requirements may result in daily monetary penalties.
Removed
On July 13, 2021, HHS, the Department of Labor and the Department of the Treasury issued an interim final rule, which begins to implement this legislation. The rule would limit our ability to receive payment for services at usually higher out-of-network rates in certain circumstances and prohibit out-of-network payments in other circumstances.
Added
HHS, the Department of Labor and the Department of the Treasury have issued interim final rules that begin to implement the legislation.
Removed
The economies in the communities in which our hospitals operate are often dependent on a small number of large employers. Those employers often provide income and health insurance for a disproportionately large number of community residents who may depend on our hospitals and other health care facilities for their care.
Added
The rules have limited the ability of our hospital-based physicians to receive payments for services at usually higher out-of-network rates in certain circumstances, and, as a result, have caused us to increase subsidies to these physicians or to replace their services at a higher cost level.
Removed
The failure of one or more large employer or the closure or substantial reduction in the number of individuals employed at facilities located in or near the communities where our hospitals operate, could cause affected employees to move elsewhere to seek employment or lose insurance coverage that was otherwise available to them.
Added
On February 28, 2022, a district judge in the Eastern District of Texas invalidated portions of the rule governing aspects of the Independent Dispute Resolution (“IDR”) process.
Removed
Legal uncertainty or a worsening of the economic conditions in the United Kingdom could materially affect our business and future results of operations. On June 23, 2016, the United Kingdom affirmatively voted in a non-binding referendum in favor of the exit of the United Kingdom from the European Union (“Brexit”) and it was approved by vote of the British legislature.
Added
In light of this decision, the government issued a final rule on August 19, 2022 eliminating the rebuttable presumption in favor of the qualifying payment amount (“QPA”) by the IDR entity and providing additional factors the IDR entity should consider when choosing between two competing offers.
Removed
On March 29, 2017, the United Kingdom triggered Article 50 of the Lisbon Treaty, formally starting negotiations regarding its exit from the European Union. On January 31, 2020, the United Kingdom formally exited the European Union.
Added
On September 22, 2022, the Texas Medical Association filed a lawsuit challenging the IDR process provided in the updated final rule and alleging that the final rule unlawfully elevates the QPA above other factors the IDR entity must consider. On February 6, 2023, a federal judge vacated parts of the rule, including provisions related to considerations of the QPA.
Removed
On December 24, 2020, the United Kingdom and the European Union reached a post-Brexit trade and cooperation agreement that created new business and security requirements and preserved the United Kingdom’s tariff- and quota-free access to the European Union member states.
Added
Failure of our acute care hospitals to continue to meet the applicable meaningful use criteria would have an adverse effect on our future net revenues and results of operations.
Removed
The trade and cooperation agreement was provisionally applied as of January 1, 2021 and entered into force on May 1, 2021, following ratification by the European Union. Changes to the trading relationship between the United Kingdom and the European Union may result in increased cost of goods imported into the United Kingdom.
Added
Aspects of United Kingdom data protection law, including the UK Data Protection Act and legislation commonly referred to as the UK GDPR, remain unclear following the United Kingdom’s exit from the European Union, including with respect to data transfers between the United Kingdom and other jurisdictions.
Removed
Brexit could also lead to increased legal and regulatory complexity as national laws and regulations in the United Kingdom start to diverge from European Union laws and regulations.
Added
We cannot fully predict how the Data Protection Act, the UK GDPR, and other United Kingdom data protection laws or regulations may develop in the medium to longer term nor the effects of divergent laws and guidance regarding data transfers.
Removed
For instance, rules for data transfers outside of the United Kingdom and European Economic Area have changed significantly with Brexit and a recent Court of European Justice decision, and are subject to further revision and updated regulatory guidance, making necessary compliance measures challenging to ascertain and implement with respect to our United Kingdom operations.
Added
Our systems, in turn, interface with and rely on third-party systems that we do not control, including medical devices and other processes supporting the interoperability of healthcare infrastructures.
Added
Third parties to whom we outsource certain of our functions, or with whom our systems interface and who may, in some instances, store our sensitive and confidential data, are also subject to the risks outlined above and may not have or use controls effective to protect such information.
Added
An attack, breach or other system disruption affecting any of these third parties could similarly harm our business. On February 22, 2024, UnitedHealth Group Incorporated (“UnitedHealth”) indicated in a Form 8-K filing, that a suspected nation-state associated cyber security threat actor had gained access to some of its Change Healthcare information technology systems.
Added
In the Form 8-K filing, UnitedHealth indicated that it cannot estimate the duration or extent of the disruption.
Added
To the best of our knowledge this did not directly have any impact on our information technology systems; however, as a result of the disruption to the Change Healthcare systems, certain of our patient billing and collections processes have been disrupted which may cause delays in a portion of our patient bills being received by commercial payers thereby delaying the related cash remittances to us.
Added
In addition, in connection with our acute care segment commercial health insurer, certain functions, including certain administrative functions, interface directly and/or indirectly with Change Healthcare systems. Such functions include, but are not limited to, eligibility and enrollment, patient access, claims management and payments, and billings and collections.
Added
As of the filing date of this report on Form 10-K, the Change Healthcare systems remain inoperable. As we continue to assess the potential impact of this event, we have not determined that this incident is reasonably likely to materially impact our cash flows, financial condition or results of operations.
Added
In the event of a material breach or cyber-attack, the associated expenses and losses may exceed our current insurance coverage for such events. In addition, some adverse consequences are not insurable, such as reputational harm and third-party business interruption.
Added
Further, consumer confidence in the integrity, availability and confidentiality of information systems and information, including patient personal information and critical operations data, in the healthcare industry generally could be impacted to the extent there are successful cyberattacks at other healthcare services companies, which could have a material adverse effect on our business, financial position or results of operations.
Added
Continuing Inflationary Pressures continue to increase our operating costs and we may not be able to pass on increases in costs commensurate with these increases in costs. We are experiencing inflationary pressures, primarily in personnel costs, and we anticipate continuing impacts on other cost areas within the next twelve months.
Added
The extent of any future impacts from inflation on our business and our results of operations will be dependent upon how long the elevated inflation levels persist and the extent to which the rate of inflation further increases, if at all, neither of which we are able to predict.
Added
If elevated levels of inflation were to persist or if the rate of inflation were to accelerate, our expenses could increase faster than anticipated and we may utilize our capital resources sooner than expected.
Added
Further, given the complexities of the reimbursement landscape in which we operate, our ability to pass on increased costs associated with providing healthcare to Medicare and Medicaid patients is limited due to various federal, state and local laws, which in certain circumstances, limit our ability to increase prices, commercial payers may be unwilling or unable to increase reimbursement rates commensurate with the inflationary impacts on our costs.
Added
The United Kingdom’s exit from the European Union will continue to have uncertain effects and could adversely impact our business, results of operations and financial condition. On January 31, 2020, the United Kingdom formally exited the European Union, which exit, commonly referred to as “Brexit”, may cause disruptions to, and uncertainty surrounding, our business in the United Kingdom and elsewhere.
Added
The ultimate effects of the Brexit are still difficult to predict as there remain ongoing significant legal and regulatory uncertainty as the United Kingdom determines which European Union laws to replace or replicate and the resulting divergence between the national laws and regulations in the United Kingdom and the European Union laws and regulations.
Added
Changes related to Brexit could subject us to heightened risks in that region, including disruptions to trade and free movement of goods, services and people that may lead to increased costs of goods imported into the United Kingdom, disruptions to our employees in the United Kingdom and the workforce of our business partners, increased foreign exchange volatility with respect to the British pound and additional legal, political and economic uncertainty.
Added
The deterioration of credit and capital markets may adversely affect our access to sources of funding and we cannot be certain of the availability and terms of capital to fund the growth of our business when needed.

Item 7A. Quantitative and Qualitative Disclosures About Market Risk

Market Risk — interest-rate, FX, commodity exposure

4 edited+0 added−0 removed10 unchanged
Biggest changeMaturity Date, Fiscal Year Ending December 31 (dollar amounts in thousands) 2023 2024 2025 2026 2027 Thereafter Total Long-term debt: Fixed rate: Debt $ 6,447 $ 7,008 $ 6,255 $ 701,345 $ 7,136 $ 1,437,502 $ 2,165,693 Average interest rates 2.4 % 2.4 % 2.4 % 2.4 % 2.8 % 3.2 % 2.6 % Variable rate: Debt $ 75,000 $ 120,000 120,000 2,327,287 0 0 $ 2,642,287 Average interest rates 5.9 % 5.9 % 5.9 % 5.9 % 0.0 % 0.0 % 5.9 % Interest rate swaps: Notional amount Average interest rates As calculated based upon our variable rate debt outstanding as of December 31, 2022 that is subject to interest rate fluctuations, each 1% change in interest rates would impact our pre-tax income by approximately $26 million.
Biggest changeMaturity Date, Fiscal Year Ending December 31 (dollar amounts in thousands) 2024 2025 2026 2027 2028 Thereafter Total Long-term debt: Fixed rate: Debt $ 6,686 $ 6,345 $ 702,847 $ 7,191 $ 7,751 $ 1,431,774 $ 2,162,594 Average interest rates 2.4 % 2.4 % 2.4 % 2.8 % 2.8 % 3.2 % 2.7 % Variable rate: Debt $ 120,000 $ 120,000 2,509,875 0 0 0 $ 2,749,875 Average interest rates 7.0 % 7.0 % 7.0 % 0.0 % 0.0 % 0.0 % 7.0 % Interest rate swaps: Notional amount Average interest rates As calculated based upon our variable rate debt outstanding as of December 31, 2023 that is subject to interest rate fluctuations, each 1% change in interest rates would impact our pre-tax income by approximately $27 million.
We consider those inputs to be “level 2” in the fair value hierarchy as outlined in the authoritative guidance for disclosures in connection with derivative instruments and hedging activities. 75 The table below presents information about our long-term financial instruments that are sensitive to changes in interest rates as of December 31, 2022.
We consider those inputs to be “level 2” in the fair value hierarchy as outlined in the authoritative guidance for disclosures in connection with derivative instruments and hedging activities. 75 The table below presents information about our long-term financial instruments that are sensitive to changes in interest rates as of December 31, 2023.
When applicable, we measure our interest rate swaps at fair value on a recurring basis. The fair value of our interest rate swaps is based on quotes from our counterparties.
The fair value of our interest rate swaps is based on quotes from our counterparties.
Although we do not anticipate nonperformance by our counterparties to interest rate swap agreements, the counterparties expose us to credit risk in the event of nonperformance. We do not hold or issue derivative financial instruments for trading purposes. During the years ended December 31, 2022, 2021 and 2020, we had no cash flow hedges outstanding.
Although we do not anticipate nonperformance by our counterparties to interest rate swap agreements, the counterparties expose us to credit risk in the event of nonperformance. We do not hold or issue derivative financial instruments for trading purposes. When applicable, we measure our interest rate swaps at fair value on a recurring basis.

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