Bill Rutherford: Yes. Ann, this is Bill. Let me first clarify our 2% to 3% emission our aggregated revenue per equivalent emission, and then obviously there’s categories underneath it. I would tell you regarding Medicaid redetermination still early. We believe there’s some modest benefit that we’ve seen as patients have migrated from Medicaid into Hicks [ph] and other employer sponsor. I don’t believe that’s material yet. We’ll see how that continues to trend throughout 2024. And I would say we don’t have a material fact – material amount factored into our guidance on that. On the two-midnight rule, as we said earlier, it is really early in that progression. It should be positive for us if it’s implemented as expected.
I think it will be positive for patients over time as well, and we’ll just have to see how that plays out. But we don’t have, I’d say, a material adjustment factored into our 2024 numbers for that as well. Our range of guidance, I think accommodates for various outcomes on both of those programs, and we’ll see how that plays out as we go through the first part of the year.
Operator: Great. Thank you. [Operator Instructions] And our next question comes from Whit Mayo with Leerink Partners. Whit, please go ahead.
Whit Mayo: Thanks, and congrats to Bill. I think this might be the second time you’ve retired, so I hope it sticks. But my question really, Sam is I’m curious on any new expense initiatives that you guys have elevated internally as a new strategic focus, anything maybe more creative or imaginative that you’re bringing forth this year to challenge the organization? Thanks.
Sam Hazen: Well, at our Investor Day, Mike Marks presented our financial resiliency program, and it’s got different components to it. There’s more sophisticated integration of our revenue cycle that includes our case management initiative, which I will highlight here. Our case management initiative is to make sure that our patients get into the right setting in the right timeline and free up capacity where appropriate, and so forth. This past year, we had early stage success with that. Our length of stay was down and our case mix was modestly up. So when you put the two together, it’s a good start for us with respect to our case management initiative. That is important on multiple fronts. It allows us to allocate our nurse staffing more effectively to more acute patients and so forth.
We will continue to invest in that initiative as we bring on more technology, more structure to our teams, and better process and benchmarking. The second thing I would highlight is with respect to what we’re calling our internal benchmarking initiative, we have incredible opportunities to compare more deeply into our organization, whether it’s on the variable cost side, with respect to what we allocate and distribute to our facilities or on fixed costs. And both of those categories are getting a lot more benchmarking under Mike’s leadership and we’re finding opportunities to rethink how we organize our cost structure, how we leverage process improvement, how we use technology and automation in those areas to improve processes and variable costs.
So I’m excited about the prospects there. As I mentioned in my commentary, we had a very successful transition from the third quarter to the fourth quarter with respect to what we call clearance, operating leverage. And our operating leverage from the third quarter to the fourth quarter was the best I’d seen in my experiences with the company. And I think part of that, not all of that, is due to some of these initiatives and the transparency we have around our efforts to improve efficiencies, improve clinical outcomes for our patients and so forth. So those are two things I would highlight. Obviously, our technology agenda and our care transformation is a longer run effort with respect to improved outcomes across different dimensions of our business.
And we’ve had some modest success there in the short run, but we’re really banking on those programs giving us long-term value. So those are just a couple of highlights. Whit, I will tell you, our teams, culturally, are disciplined, and as I mentioned, that discipline creates opportunities for us to find better ways to do things for all of our stakeholders. And that mindset is something that we carry forward from one year to the next, and we’ll carry that on into 2024, on into 2025 and so forth. And we think it’s an essential ingredient for a health system success. And I’m pretty proud of our teams and how they embrace that and how they execute on the initiatives to make that happen.
Operator: Thanks, Whit. And our next question comes from the line of Kevin Fischbeck with Bank of America. Kevin, please go ahead.
Kevin Fischbeck: Great, thanks. And I’ll just add my thanks to Bill for your help over the years. I guess, wanted to know, I get a little more color from you guys about the volume expectation for 2024, because you guys know we talk about two to three. It looks like you’re looking for faster growth in 2024. So I just wanted to better understand where that extra growth is coming from. So any color around the service lines or procedures that you think still have room to grow above average. And if there’s anything that you expect from a payer mix perspective in 2024, is there one type of payer where you think there’s a big opportunity for volumes to snap back? Thanks.
Bill Rutherford: Yes. Kevin, let me start and then Sam can add in. So we’re going off our experience, we’ve seen throughout 2023. And as we said earlier in the comments, we thought there was very strong demand for services in our markets. We think our capital programs and our program initiatives are paying off. Our adjusted emissions this year were 4.8%. You’re right. Our guidance next year calls us for three to four expectation on adjusted emissions. That may be a little higher than our two to three historical, but I think we’re reading continued strong demand. We saw really strong enrollment in the health insurance exchanges across our states, and that continues to be a favorable development for us. We believe we continue to see strong economic indicators and employments and our access to contract and lives remain well. So I think all of those factors go into play with our expectations for 2024 and is based on kind of our current experience.
Kevin Fischbeck: Great.
Operator: Thank you. And our next question comes from the line of Stephen Baxter with Wells Fargo. Stephen, please go ahead.
Stephen Baxter: Yes, hi. Thanks. And congrats to Bill as well. I was hoping you could talk a little bit about surgical growth in the quarter, whether there’s any notable puts or takes there by service line or inpatient versus outpatient. And then I guess the overall growth slowed down a little bit as we got to the back half of the year. I guess, how are you thinking about surgical growth in 2024 and especially coming up against maybe some of the tougher comparisons that you’ll have in the first half of the year? Thank you.
Bill Rutherford: So overall, the fourth quarter surgery was a little slower than the year-to-date, and we were talking about that earlier this morning, we did have a more difficult December calendar, even though, we had the same surgical days in total. The way they were allocated created some challenges in our outpatient settings. And we saw outpatient activity not as strong as in the previous two months of the quarter, but at a structural level, there’s nothing to suggest that our surgical volume trends are going to change. For the year, we had really solid volume growth in surgeries, and we continue to invest heavily in our programs, both on the outpatient side and supporting our inpatient activity with more acute and complex program offerings.
