HCA Healthcare, Inc. - Quarter Report: 2023 September (Form 10-Q)

10-Q

UNITED STATES

SECURITIES AND EXCHANGE COMMISSION

Washington, D.C. 20549

Form 10-Q

(Mark One)

☒ QUARTERLY REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934

For the quarterly period ended September 30, 2023

☐ TRANSITION REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934

For the transition period from to

Commission file number 1-11239

HCA Healthcare, Inc.

(Exact name of registrant as specified in its charter)



Delaware	27-3865930
(State or other jurisdiction of incorporation or organization)	(I.R.S. Employer Identification No.)

One Park Plaza Nashville, Tennessee	37203
(Address of principal executive offices)	(Zip Code)

(615) 344-9551

(Registrant’s telephone number, including area code)

Not Applicable

(Former name, former address and former fiscal year, if changed since last report)

Securities registered pursuant to Section 12(b) of the Act:



Title of each class	Trading Symbol(s)	Name of each exchange on which registered
Voting common stock, $.01 par value	HCA	New York Stock Exchange

Indicate by check mark whether the registrant (1) has filed all reports required to be filed by Section 13 or 15(d) of the Securities Exchange Act of 1934 during the preceding 12 months (or for such shorter period that the registrant was required to file such reports), and (2) has been subject to such filing requirements for the past 90 days. Yes ☒ No ☐

Indicate by check mark whether the registrant has submitted electronically every Interactive Data File required to be submitted pursuant to Rule 405 of Regulation S-T (§ 232.405 of this chapter) during the preceding 12 months (or for such shorter period that the registrant was required to submit such files). Yes ☒ No ☐

Indicate by check mark whether the registrant is a large accelerated filer, an accelerated filer, a non-accelerated filer, smaller reporting company or an emerging growth company. See the definitions of “large accelerated filer,” “accelerated filer,” “smaller reporting company” and “emerging growth company” in Rule 12b-2 of the Exchange Act.



Large accelerated filer	☒	Accelerated filer	☐

Non-accelerated filer	☐	Smaller reporting company	☐

Emerging growth company	☐

If an emerging growth company, indicate by check mark if the registrant has elected not to use the extended transition period for complying with any new or revised financial accounting standards provided pursuant to Section 13(a) of the Exchange Act. ☐

Indicate by check mark whether the registrant is a shell company (as defined in Rule 12b-2 of the Exchange Act). Yes ☐ No ☒

Indicate the number of shares outstanding of each of the issuer’s classes of common stock as of the latest practicable date.


Class of Common Stock	Outstanding at October 23, 2023
Voting common stock, $.01 par value	267,660,800 shares

HCA HEALTHCARE, INC.

Form 10-Q

September 30, 2023



		Page of Form 10-Q
Part I.	Financial Information

Item 1.	Financial Statements (Unaudited):

	Condensed Consolidated Income Statements — for the quarters and nine months ended September 30, 2023 and 2022	3

	Condensed Consolidated Comprehensive Income Statements — for the quarters and nine months ended September 30, 2023 and 2022	4

	Condensed Consolidated Balance Sheets — September 30, 2023 and December 31, 2022	5

	Condensed Consolidated Statements of Stockholders’ Equity (Deficit) — for the quarters and nine months ended September 30, 2023 and 2022	6

	Condensed Consolidated Statements of Cash Flows — for the nine months ended September 30, 2023 and 2022	7

	Notes to Condensed Consolidated Financial Statements	8

Item 2.	Management’s Discussion and Analysis of Financial Condition and Results of Operations	16

Item 3.	Quantitative and Qualitative Disclosures About Market Risk	28

Item 4.	Controls and Procedures	28

Part II.	Other Information

Item 1.	Legal Proceedings	28

Item 1A.	Risk Factors	28

Item 2.	Unregistered Sales of Equity Securities and Use of Proceeds	28

Item 5.	OOther Information	29

Item 6.	Exhibits	29

Signatures		30

HCA HEALTHCARE, INC.

CONDENSED CONSOLIDATED INCOME STATEMENTS

FOR THE QUARTERS AND NINE MONTHS ENDED SEPTEMBER 30, 2023 AND 2022

Unaudited

(Dollars in millions, except per share amounts)


	Quarter						Nine Months
	2023			2022			2023		2022
Revenues	$	16,213		$	14,971		$	47,665	$	44,736

Salaries and benefits		7,556			6,899			21,917		20,630
Supplies		2,417			2,320			7,318		6,942
Other operating expenses		3,379			2,860			9,316		8,305
Equity in (earnings) losses of affiliates		(19	)		(10	)		6		(29	)
Depreciation and amortization		769			749			2,288		2,219
Interest expense		483			446			1,447		1,288
Losses (gains) on sales of facilities		(2	)		3			12		25
Losses on retirement of debt		—			—			—		78
		14,583			13,267			42,304		39,458
Income before income taxes		1,630			1,704			5,361		5,278
Provision for income taxes		355			360			1,131		1,090
Net income		1,275			1,344			4,230		4,188
Net income attributable to noncontrolling interests		196			210			595		626
Net income attributable to HCA Healthcare, Inc.	$	1,079		$	1,134		$	3,635	$	3,562
Per share data:
Basic earnings	$	3.98		$	3.97		$	13.26	$	12.13
Diluted earnings	$	3.91		$	3.91		$	13.07	$	11.97
Shares used in earnings per share calculations (in millions):
Basic		271.173			285.958			274.171		293.583
Diluted		275.424			289.852			278.173		297.702

The accompanying notes are an integral part of the condensed consolidated financial statements.

HCA HEALTHCARE, INC.

CONDENSED CONSOLIDATED COMPREHENSIVE INCOME STATEMENTS

FOR THE QUARTERS AND NINE MONTHS ENDED SEPTEMBER 30, 2023 AND 2022

Unaudited

(Dollars in millions)


	Quarter						Nine Months
	2023			2022			2023			2022
Net income	$	1,275		$	1,344		$	4,230		$	4,188
Other comprehensive loss before taxes:
Foreign currency translation		(35	)		(76	)		3			(181	)

Unrealized losses on available-for-sale securities		(7	)		(16	)		(5	)		(58	)
Losses included in other operating expenses		—			—			—			1
		(7	)		(16	)		(5	)		(57	)

Defined benefit plans		—			—			—			—
Pension costs included in salaries and benefits		1			2			1			7
		1			2			1			7

Change in fair value of derivative financial instruments		—			1			—			6
Interest costs included in interest expense		—			—			—			4
		—			1			—			10
Other comprehensive loss before taxes		(41	)		(89	)		(1	)		(221	)
Income tax benefits related to other comprehensive loss items		(6	)		(12	)		—			(33	)
Other comprehensive loss		(35	)		(77	)		(1	)		(188	)
Comprehensive income		1,240			1,267			4,229			4,000
Comprehensive income attributable to noncontrolling interests		196			210			595			626
Comprehensive income attributable to HCA Healthcare, Inc.	$	1,044		$	1,057		$	3,634		$	3,374

The accompanying notes are an integral part of the condensed consolidated financial statements.

HCA HEALTHCARE, INC.

CONDENSED CONSOLIDATED BALANCE SHEETS

Unaudited

(Dollars in millions)


	September 30, 2023			December 31, 2022
ASSETS
Current assets:
Cash and cash equivalents	$	891		$	908
Accounts receivable		9,182			8,891
Inventories		2,030			2,068
Other		2,191			1,776
		14,294			13,643

Property and equipment, at cost		57,772			54,757
Accumulated depreciation		(30,655	)		(29,182	)
		27,117			25,575

Investments of insurance subsidiaries		382			381
Investments in and advances to affiliates		739			823
Goodwill and other intangible assets		9,778			9,653
Right-of-use operating lease assets		2,079			2,065
Other		200			298
	$	54,589		$	52,438
LIABILITIES AND STOCKHOLDERS’ EQUITY (DEFICIT)
Current liabilities:
Accounts payable	$	4,139		$	4,239
Accrued salaries		1,912			1,712
Other accrued expenses		3,803			3,581
Long-term debt due within one year		2,553			370
		12,407			9,902

Long-term debt, less debt issuance costs and discounts of $341 and $301		36,793			37,714
Professional liability risks		1,590			1,528
Right-of-use operating lease obligations		1,776			1,752
Income taxes and other liabilities		1,666			1,615

Stockholders’ equity (deficit):
Common stock $0.01 par; authorized 1,800,000,000 shares; outstanding 268,967,300 shares — 2023 and 277,378,300 shares — 2022		3			3
Accumulated other comprehensive loss		(491	)		(490	)
Retained deficit		(1,989	)		(2,280	)
Stockholders’ deficit attributable to HCA Healthcare, Inc.		(2,477	)		(2,767	)
Noncontrolling interests		2,834			2,694
		357			(73	)
	$	54,589		$	52,438

The accompanying notes are an integral part of the condensed consolidated financial statements.

HCA HEALTHCARE, INC.

CONDENSED CONSOLIDATED STATEMENTS OF STOCKHOLDERS’ EQUITY (DEFICIT)

FOR THE QUARTERS AND NINE MONTHS ENDED SEPTEMBER 30, 2023 AND 2022

Unaudited

(Dollars in millions)


	Equity (Deficit) Attributable to HCA Healthcare, Inc.
						Capital			Accumulated						Equity
	Common Stock					in Excess			Other						Attributable to
	Shares			Par		of Par			Comprehensive			Retained			Noncontrolling
	(in millions)			Value		Value			Loss			Deficit			Interests			Total
Balances, December 31, 2021		305.477		$	3	$	—		$	(404	)	$	(532	)	$	2,422		$	1,489
Comprehensive income (loss)										(43	)		1,273			192			1,422
Repurchase of common stock		(8.375	)										(2,101	)					(2,101	)
Share-based benefit plans		1.879											(57	)					(57	)
Cash dividends declared ($0.56 per share)													(171	)					(171	)
Distributions																(171	)		(171	)
Other													(1	)		4			3
Balances, March 31, 2022		298.981			3		—			(447	)		(1,589	)		2,447			414
Comprehensive income (loss)										(68	)		1,155			224			1,311
Repurchase of common stock		(12.230	)				(111	)					(2,571	)					(2,682	)
Share-based benefit plans		0.253					118												118
Cash dividends declared ($0.56 per share)													(163	)					(163	)
Distributions																(162	)		(162	)
Other							(7	)								29			22
Balances, June 30, 2022		287.004			3		—			(515	)		(3,168	)		2,538			(1,142	)
Comprehensive income (loss)										(77	)		1,134			210			1,267
Repurchase of common stock		(3.361	)				(113	)					(585	)					(698	)
Share-based benefit plans		0.261					116												116
Cash dividends declared ($0.56 per share)													(162	)					(162	)
Distributions																(217	)		(217	)
Other							(3	)								61			58
Balances, September 30, 2022		283.904			3		—			(592	)		(2,781	)		2,592			(778	)
Comprehensive income										102			2,081			565			2,748
Repurchase of common stock		(6.781	)				(40	)					(1,479	)					(1,519	)
Share-based benefit plans		0.255					48					57							105
Cash dividends declared ($0.56 per share)													(159	)					(159	)
Distributions																(475	)		(475	)
Other							(8	)					1			12			5
Balances, December 31, 2022		277.378			3		—			(490	)		(2,280	)		2,694			(73	)
Comprehensive income										20			1,363			180			1,563
Repurchase of common stock		(3.340	)										(849	)					(849	)
Share-based benefit plans		1.902											(87	)					(87	)
Cash dividends declared ($0.60 per share)													(168	)					(168	)
Distributions																(187	)		(187	)
Other													(7	)		40			33
Balances, March 31, 2023		275.940			3		—			(470	)		(2,028	)		2,727			232
Comprehensive income										14			1,193			219			1,426
Repurchase of common stock		(3.311	)										(924	)					(924	)
Share-based benefit plans		0.303											72						72
Cash dividends declared ($0.60 per share)													(165	)					(165	)
Distributions																(155	)		(155	)
Other													2			(27	)		(25	)
Balances, June 30, 2023		272.932			3		—			(456	)		(1,850	)		2,764			461
Comprehensive income (loss)										(35	)		1,079			196			1,240
Repurchase of common stock		(4.167	)				(86	)					(1,065	)					(1,151	)
Share-based benefit plans		0.202					86						15						101
Cash dividends declared ($0.60 per share)													(164	)					(164	)
Distributions																(155	)		(155	)
Other													(4	)		29			25
Balances, September 30, 2023		268.967		$	3	$	—		$	(491	)	$	(1,989	)	$	2,834		$	357

The accompanying notes are an integral part of the condensed consolidated financial statements.

HCA HEALTHCARE, INC.

CONDENSED CONSOLIDATED STATEMENTS OF CASH FLOWS

FOR THE NINE MONTHS ENDED SEPTEMBER 30, 2023 AND 2022

Unaudited

(Dollars in millions)


	2023			2022
Cash flows from operating activities:
Net income	$	4,230		$	4,188
Adjustments to reconcile net income to net cash provided by operating activities:
Increase (decrease) in cash from operating assets and liabilities:
Accounts receivable		(168	)		(487	)
Inventories and other assets		(274	)		53
Accounts payable and accrued expenses		211			(644	)
Depreciation and amortization		2,288			2,219
Income taxes		61			159
Losses on sales of facilities		12			25
Losses on retirement of debt		—			78
Amortization of debt issuance costs and discounts		26			22
Share-based compensation		205			258
Other		166			124
Net cash provided by operating activities		6,757			5,995
Cash flows from investing activities:
Purchase of property and equipment		(3,585	)		(3,072	)
Acquisition of hospitals and health care entities		(281	)		(176	)
Sales of hospitals and health care entities		183			652
Change in investments		(30	)		10
Other		(7	)		(10	)
Net cash used in investing activities		(3,720	)		(2,596	)
Cash flows from financing activities:
Issuance of long-term debt		3,220			5,976
Net change in revolving credit facilities		(1,420	)		(230	)
Repayment of long-term debt		(691	)		(2,774	)
Distributions to noncontrolling interests		(497	)		(550	)
Payment of debt issuance costs		(31	)		(53	)
Payment of dividends		(501	)		(497	)
Repurchase of common stock		(2,901	)		(5,481	)
Other		(234	)		(209	)
Net cash used in financing activities		(3,055	)		(3,818	)
Effect of exchange rate changes on cash and cash equivalents		1			(33	)
Change in cash and cash equivalents		(17	)		(452	)
Cash and cash equivalents at beginning of period		908			1,451
Cash and cash equivalents at end of period	$	891		$	999
Interest payments	$	1,460		$	1,329
Income tax payments, net	$	1,070		$	931

The accompanying notes are an integral part of the condensed consolidated financial statements.

HCA HEALTHCARE, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS

NOTE 1 — BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES

Reporting Entity

HCA Healthcare, Inc. is a holding company whose affiliates own and operate hospitals and related health care entities. The term “affiliates” includes direct and indirect subsidiaries of HCA Healthcare, Inc. and partnerships and joint ventures in which such subsidiaries are partners. At September 30, 2023, these affiliates owned and operated 183 hospitals, 126 freestanding surgery centers, 22 freestanding endoscopy centers and provided extensive outpatient and ancillary services. HCA Healthcare, Inc.’s facilities are located in 20 states and England. The terms “Company,” “HCA,” “we,” “our” or “us,” as used herein and unless otherwise stated or indicated by context, refer to HCA Healthcare, Inc. and its affiliates. The terms “facilities” or “hospitals” refer to entities owned and operated by affiliates of HCA and the term “employees” refers to employees of affiliates of HCA.

Basis of Presentation

The accompanying unaudited condensed consolidated financial statements have been prepared in accordance with generally accepted accounting principles for interim financial information and with the instructions to Form 10-Q and Article 10 of Regulation S-X. Accordingly, they do not include all the information and footnotes required by generally accepted accounting principles for complete consolidated financial statements. In the opinion of management, all adjustments considered necessary for a fair presentation have been included and are of a normal and recurring nature.

The majority of our expenses are “costs of revenues” items. Costs that could be classified as general and administrative would include our corporate office costs, which were $80 million and $74 million for the quarters ended September 30, 2023 and 2022, respectively, and $227 million and $228 million for the nine months ended September 30, 2023 and 2022, respectively. Operating results for the quarter and nine months ended September 30, 2023 are not necessarily indicative of the results that may be expected for the year ending December 31, 2023. For further information, refer to the consolidated financial statements and footnotes thereto included in our annual report on Form 10-K for the year ended December 31, 2022.

Revenues

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

HCA HEALTHCARE, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS (Continued)

NOTE 1 — BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES (continued)

Revenues (continued)

Our revenues are based upon the estimated amounts we expect to be entitled to receive from patients and third-party payers. Estimates of contractual adjustments under managed care and commercial insurance plans are based upon the payment terms specified in the related contractual agreements. Revenues related to uninsured patients and uninsured copayment and deductible amounts for patients who have health care coverage may have discounts applied (uninsured and other discounts). We also record estimated implicit price concessions (based primarily on historical collection experience) related to uninsured accounts to record these revenues at the estimated amounts we expect to collect. Patients treated at our hospitals for non-elective care, who have income at or below 400% of the federal poverty level, are eligible for charity care. Because we do not pursue collection of amounts determined to qualify as charity care, they are not reported in revenues. Our revenues by primary third-party payer classification and other (including uninsured patients) for the quarters and nine months ended September 30, 2023 and 2022 are summarized in the following table (dollars in millions):


	Quarter
	2023		Ratio			2022		Ratio
Medicare	$	2,560		15.8	%	$	2,569		17.2	%
Managed Medicare		2,535		15.6			2,229		14.9
Medicaid		1,001		6.2			797		5.3
Managed Medicaid		1,039		6.4			939		6.3
Managed care and insurers		7,687		47.4			7,184		47.9
International (managed care and insurers)		375		2.3			311		2.1
Other		1,016		6.3			942		6.3
Revenues	$	16,213		100.0	%	$	14,971		100.0	%

	Nine Months
	2023		Ratio			2022		Ratio
Medicare	$	7,865		16.5	%	$	7,790		17.4	%
Managed Medicare		7,635		16.0			6,813		15.2
Medicaid		2,478		5.2			1,987		4.4
Managed Medicaid		2,846		6.0			3,003		6.7
Managed care and insurers		23,140		48.5			21,480		48.1
International (managed care and insurers)		1,127		2.4			992		2.2
Other		2,574		5.4			2,671		6.0
Revenues	$	47,665		100.0	%	$	44,736		100.0	%

To quantify the total impact of the trends related to uninsured patient accounts, we believe it is beneficial to view total uncompensated care, which is comprised of charity care, uninsured discounts and implicit price concessions. A summary of the estimated cost of total uncompensated care for the quarters and nine months ended September 30, 2023 and 2022 follows (dollars in millions):


	Quarter						Nine Months
	2023			2022			2023			2022
Patient care costs (salaries and benefits, supplies, other operating expenses and depreciation and amortization)	$	14,121		$	12,828		$	40,839		$	38,096
Cost-to-charges ratio (patient care costs as percentage of gross patient charges)		10.9	%		11.2	%		10.6	%		11.2	%
Total uncompensated care	$	9,042		$	8,050		$	25,516		$	23,512
Multiply by the cost-to-charges ratio		10.9	%		11.2	%		10.6	%		11.2	%
Estimated cost of total uncompensated care	$	975		$	901		$	2,705		$	2,633

HCA HEALTHCARE, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS (Continued)

NOTE 1 — BASIS OF PRESENTATION AND SIGNIFICANT ACCOUNTING POLICIES (continued)

Revenues (continued)

The total uncompensated care amounts include charity care of $3.531 billion and $3.206 billion, respectively, and the related estimated costs of charity care were $382 million and $359 million, respectively, for the quarters ended September 30, 2023 and 2022. The total uncompensated care amounts include charity care of $10.684 billion and $10.281 billion, respectively, and the related estimated costs of charity care were $1.133 billion and $1.151 billion, respectively, for the nine months ended September 30, 2023 and 2022.

Reclassifications

Certain prior year amounts have been reclassified to conform to the current year presentation.

NOTE 2 — ACQUISITIONS AND DISPOSITIONS

During the nine months ended September 30, 2023, we paid $83 million to acquire a hospital facility in Texas. During the nine months ended September 30, 2023 and 2022, we paid $198 million and $176 million, respectively, to acquire nonhospital health care entities. Purchase price amounts have been allocated to the related assets acquired and liabilities assumed based upon their respective fair values.

During the nine months ended September 30, 2023, we received proceeds of $162 million for the sale of two hospital facilities in Louisiana. During the nine months ended September 30, 2023 and 2022, we received proceeds of $21 million and $38 million, respectively, related to sales of real estate and other health care entity investments. We recognized pretax losses of $12 million and $25 million, respectively, for these transactions. We also received net proceeds of $614 million on September 30, 2022 related to the sale of a controlling interest in a subsidiary of our group purchasing organization, which was effective October 1, 2022.

NOTE 3 — INCOME TAXES

Our provisions for income taxes for the quarters ended September 30, 2023 and 2022 were $355 million and $360 million, respectively, and the effective tax rates were 24.8% and 24.1%, respectively. Our provisions for income taxes for the nine months ended September 30, 2023 and 2022 were $1.131 billion and $1.090 billion, respectively, and the effective tax rates were 23.7% and 23.4%, respectively. Our provisions for income taxes included tax benefits related to settlements of employee equity awards of $89 million and $70 million for the nine months ended September 30, 2023 and 2022, respectively.

Our gross unrecognized tax benefits were $653 million, excluding accrued interest of $168 million, as of September 30, 2023 ($639 million and $129 million, respectively, as of December 31, 2022). Unrecognized tax benefits of $326 million ($278 million as of December 31, 2022) would affect the effective rate, if recognized.

At September 30, 2023, the Internal Revenue Service was conducting examinations of the Company’s 2016, 2017 and 2018 federal income tax returns and the 2019 returns of certain affiliates. We are also subject to examination by state, local and foreign taxing authorities. Depending on the resolution of any tax disputes, the completion of examinations by taxing authorities, or the expiration of statutes of limitation for specific taxing jurisdictions, we believe it is reasonably possible that our liability for unrecognized tax benefits may significantly increase or decrease within the next 12 months. However, we are currently unable to estimate the range of any possible change.

NOTE 4 — EARNINGS PER SHARE

We compute basic earnings per share using the weighted average number of common shares outstanding. We compute diluted earnings per share using the weighted average number of common shares outstanding, plus the dilutive effect of outstanding equity awards, computed using the treasury stock method.

HCA HEALTHCARE, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS (Continued)

NOTE 4 — EARNINGS PER SHARE (continued)

The following table sets forth the computation of basic and diluted earnings per share for the quarters and nine months ended September 30, 2023 and 2022 (dollars and shares in millions, except per share amounts):


	Quarter				Nine Months
	2023		2022		2023		2022
Net income attributable to HCA Healthcare, Inc.	$	1,079	$	1,134	$	3,635	$	3,562

Weighted average common shares outstanding		271.173		285.958		274.171		293.583
Effect of dilutive incremental shares		4.251		3.894		4.002		4.119
Shares used for diluted earnings per share		275.424		289.852		278.173		297.702
Earnings per share:
Basic earnings	$	3.98	$	3.97	$	13.26	$	12.13
Diluted earnings	$	3.91	$	3.91	$	13.07	$	11.97

NOTE 5 — INVESTMENTS OF INSURANCE SUBSIDIARIES

A summary of our insurance subsidiaries’ investments at September 30, 2023 and December 31, 2022 follows (dollars in millions):


	September 30, 2023
			Unrealized Amounts
	Amortized Cost		Gains		Losses			Fair Value
Debt securities	$	404	$	—	$	(43	)	$	361
Money market funds and other		124		—		—			124
	$	528	$	—	$	(43	)		485
Amounts classified as current assets									(103	)
Investment carrying value								$	382


	December 31, 2022
			Unrealized Amounts
	Amortized Cost		Gains		Losses			Fair Value
Debt securities	$	415	$	—	$	(38	)	$	377
Money market funds and other		96		—		—			96
	$	511	$	—	$	(38	)		473
Amounts classified as current assets									(92	)
Investment carrying value								$	381

At September 30, 2023 and December 31, 2022, the investments in debt securities of our insurance subsidiaries were classified as “available-for-sale.” Changes in unrealized gains and losses that are not credit-related are recorded as adjustments to other comprehensive income (loss).

HCA HEALTHCARE, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS (Continued)

NOTE 5 — INVESTMENTS OF INSURANCE SUBSIDIARIES (continued)

Scheduled maturities of investments in debt securities at September 30, 2023 were as follows (dollars in millions):


	Amortized Cost		Fair Value
Due in one year or less	$	13	$	13
Due after one year through five years		148		139
Due after five years through ten years		165		140
Due after ten years		78		69
	$	404	$	361

The average expected maturity of the investments in debt securities at September 30, 2023 was 5.2 years, compared to the average scheduled maturity of 8.7 years. Expected and scheduled maturities may differ because the issuers of certain securities have the right to call, prepay or otherwise redeem such obligations prior to their scheduled maturity date.

NOTE 6 — ASSETS AND LIABILITIES MEASURED AT FAIR VALUE

Accounting Standards Codification 820, Fair Value Measurements and Disclosures (“ASC 820”), emphasizes fair value is a market-based measurement, and fair value measurements should be determined based on the assumptions market participants would use in pricing assets or liabilities. ASC 820 utilizes a fair value hierarchy that distinguishes between market participant assumptions based on market data obtained from sources independent of the reporting entity (observable inputs classified within Levels 1 and 2 of the hierarchy) and the reporting entity’s own assumptions about market participant assumptions (unobservable inputs classified within Level 3 of the hierarchy).

Level 1 inputs utilize quoted prices (unadjusted) in active markets for identical assets or liabilities. Level 2 inputs are inputs other than quoted prices included in Level 1 that are observable for the asset or liability, either directly or indirectly. Level 2 inputs may include quoted prices for similar assets and liabilities in active markets, as well as inputs observable for the asset or liability (other than quoted prices), such as interest rates, foreign exchange rates, and yield curves observable at commonly quoted intervals. Level 3 inputs are unobservable inputs for the asset or liability, which are typically based on an entity’s own assumptions, as there is little, if any, related market activity.

The investments of our insurance subsidiaries are generally classified within Level 1 or Level 2 of the fair value hierarchy because they are valued using quoted market prices, broker or dealer quotations, or alternative pricing sources with reasonable levels of price transparency.

The following tables summarize our assets measured at fair value on a recurring basis as of September 30, 2023 and December 31, 2022, aggregated by the level in the fair value hierarchy within which those measurements fall (dollars in millions):


	September 30, 2023
				Fair Value Measurements Using
	Fair Value			Quoted Prices in Active Markets for Identical Assets (Level 1)			Significant Other Observable Inputs (Level 2)		Significant Unobservable Inputs (Level 3)
Investments of insurance subsidiaries:
Debt securities	$	361		$	—		$	361	$	—
Money market funds and other		124			124			—		—
Investments of insurance subsidiaries		485			124			361		—
Less amounts classified as current assets		(103	)		(103	)		—		—
	$	382		$	21		$	361	$	—

HCA HEALTHCARE, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS (Continued)

NOTE 6 — ASSETS AND LIABILITIES MEASURED AT FAIR VALUE (continued)


	December 31, 2022
				Fair Value Measurements Using
	Fair Value			Quoted Prices in Active Markets for Identical Assets (Level 1)			Significant Other Observable Inputs (Level 2)		Significant Unobservable Inputs (Level 3)
Investments of insurance subsidiaries:
Debt securities	$	377		$	—		$	377	$	—
Money market funds and other		96			96			—		—
Investments of insurance subsidiaries		473			96			377		—
Less amounts classified as current assets		(92	)		(92	)		—		—
	$	381		$	4		$	377	$	—

The estimated fair value of our long-term debt was $36.120 billion and $35.555 billion at September 30, 2023 and December 31, 2022, respectively, compared to carrying amounts, excluding debt issuance costs and discounts, aggregating $39.687 billion and $38.385 billion, respectively. The estimates of fair value are generally based on Level 2 inputs, including quoted market prices or quoted market prices for similar issues of long-term debt with the same maturities.

NOTE 7 — LONG-TERM DEBT

A summary of long-term debt at September 30, 2023 and December 31, 2022, including related interest rates at September 30, 2023, follows (dollars in millions):


	September 30, 2023			December 31, 2022
Senior secured asset-based revolving credit facility (effective interest rate of 6.7%)	$	1,480		$	2,900
Senior secured revolving credit facility		—			—
Senior secured term loan facilities (effective interest rate of 6.8%)		1,331			1,880
Other senior secured debt (effective interest rate of 4.0%)		974			953
Senior secured debt		3,785			5,733
Senior unsecured notes (effective interest rate of 5.0%)		35,902			32,652
Debt issuance costs and discounts		(341	)		(301	)
Total debt (average life of 9.6 years, rates averaging 5.1%)		39,346			38,084
Less amounts due within one year		2,553			370
	$	36,793		$	37,714

During January 2023, the availability under our senior secured revolving credit facility was increased by $1.500 billion to total $3.500 billion, the senior secured term loan B facility was fully retired and certain administrative updates were made to our credit agreements.

During May 2023, we issued $3.250 billion aggregate principal amount of senior notes comprised of (i) $1.000 billion aggregate principal amount of 5.200% senior notes due 2028, (ii) $1.250 billion aggregate principal amount of 5.500% senior notes due 2033 and (iii) $1.000 billion aggregate principal amount of 5.900% senior notes due 2053. We used the net proceeds to repay borrowings under our asset-based revolving credit facility.

HCA HEALTHCARE, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS (Continued)

NOTE 8 — CONTINGENCIES

We operate in a highly regulated and litigious industry. As a result, various lawsuits, claims and legal and regulatory proceedings have been and can be expected to be instituted or asserted against us. We are also subject to claims and suits arising in the ordinary course of business, including claims for personal injuries or wrongful restriction of, or interference with, physicians’ staff privileges. In certain of these actions the claimants may seek punitive damages against us which may not be covered by insurance. We are also subject to claims by various taxing authorities for additional taxes and related interest and penalties. The resolution of any such lawsuits, claims or legal and regulatory proceedings could have a material, adverse effect on our results of operations, financial position or liquidity.

Health care companies are routinely subject to investigations by various governmental agencies. Under the federal False Claims Act (“FCA”), private parties have the right to bring qui tam, or “whistleblower,” suits against companies that submit false claims for payments to, or improperly retain overpayments from, the government. Some states have adopted similar state whistleblower and false claims provisions. Certain of our individual facilities have received, and from time to time, other facilities may receive, government inquiries from, and may be subject to investigation by, federal and state agencies. Depending on whether the underlying conduct in these or future inquiries or investigations could be considered systemic, their resolution could have a material, adverse effect on our results of operations, financial position or liquidity.

Texas operates a state Medicaid program pursuant to a waiver from the Centers for Medicare & Medicaid Services under Section 1115 of the Social Security Act (the “Program”). The Program includes uncompensated-care pools; payments from these pools are intended to defray the uncompensated costs of services provided by our and other hospitals to Medicaid eligible or uninsured individuals. Separately, we and other hospitals provide charity care services in several communities in the state. In 2018, the Civil Division of the U.S. Department of Justice and the U.S. Attorney’s Office for the Southern District of Texas requested information about whether the Program, as operated in Harris County, complied with the laws and regulations applicable to provider related donations, and the Company cooperated with that request. On May 21, 2019, a qui tam lawsuit asserting violations of the FCA and the Texas Medicaid Fraud Prevention Act related to the Program, as operated in Harris County, was unsealed by the U.S. District Court for the Southern District of Texas. Both the federal and state governments declined to intervene in the qui tam lawsuit. The Company believes that our participation is and has been consistent with the requirements of the Program and is vigorously defending against the lawsuit being pursued by the relator. We cannot predict what effect, if any, the qui tam lawsuit could have on the Company.

NOTE 9 — SHARE REPURCHASE TRANSACTIONS AND ACCUMULATED OTHER COMPREHENSIVE LOSS

During January 2023 and 2022, our Board of Directors authorized share repurchase programs for up to $3 billion and $8 billion, respectively, of our outstanding common stock. During the nine months ended September 30, 2023, we repurchased 10.818 million shares of our common stock at an average price of $268.18 per share through market purchases pursuant to the January 2022 authorization (which was completed during the second quarter of 2023) and the January 2023 authorization. At September 30, 2023, we had $1.685 billion of repurchase authorization available under the January 2023 authorization.

The components of accumulated other comprehensive loss are as follows (dollars in millions):


	Unrealized Losses on Available- for-Sale Securities			Foreign Currency Translation Adjustments			Defined Benefit Plans			Total
Balances at December 31, 2022	$	(30	)	$	(373	)	$	(87	)	$	(490	)
Unrealized losses on available-for-sale securities, net of $1 income tax benefit		(4	)								(4	)
Foreign currency translation adjustments, net of $1 of income taxes				2							2
Expense reclassified into operations from other comprehensive loss								1			1
Balances at September 30, 2023	$	(34	)	$	(371	)	$	(86	)	$	(491	)

HCA HEALTHCARE, INC.

NOTES TO CONDENSED CONSOLIDATED FINANCIAL STATEMENTS (Continued)

NOTE 10 — SEGMENT AND GEOGRAPHIC INFORMATION

Effective January 1, 2023, we reorganized our operations from two geographically organized groups into three geographically organized groups: the National, American and Atlantic Groups. The National Group includes 57 hospitals located in Alaska, California, Idaho, Indiana, Kentucky, Nevada, New Hampshire, North Carolina, Tennessee, Utah and Virginia, the American Group includes 57 hospitals located in Colorado, central Kansas, Louisiana and Texas, and the Atlantic Group includes 62 hospitals located in Florida, Georgia, northern Kansas, Missouri and South Carolina. The seven hospitals we operate in England remain in the Corporate and other group. Prior periods presented have been restated according to the new organizational structure.

Adjusted segment EBITDA is defined as income before depreciation and amortization, interest expense, gains and losses on sales of facilities, losses on retirement of debt, income taxes and net income attributable to noncontrolling interests. We use adjusted segment EBITDA as an analytical indicator for purposes of allocating resources to geographic areas and assessing their performance. Adjusted segment EBITDA is commonly used as an analytical indicator within the health care industry and also serves as a measure of leverage capacity and debt service ability. Adjusted segment EBITDA should not be considered as a measure of financial performance under generally accepted accounting principles, and the items excluded from adjusted segment EBITDA are significant components in understanding and assessing financial performance. Because adjusted segment EBITDA is not a measurement determined in accordance with generally accepted accounting principles and is thus susceptible to varying calculations, adjusted segment EBITDA, as presented, may not be comparable to other similarly titled measures of other companies. The geographic distributions of our revenues, equity in earnings of affiliates, adjusted segment EBITDA and depreciation and amortization for the quarters and nine months ended September 30, 2023 and 2022 are summarized in the following table (dollars in millions):


	Quarter						Nine Months
	2023			2022			2023			2022
Revenues:
National Group	$	4,352		$	4,092		$	13,340		$	12,382
Atlantic Group		5,470			4,951			15,617			14,337
American Group		5,491			5,117			16,226			15,528
Corporate and other		900			811			2,482			2,489
	$	16,213		$	14,971		$	47,665		$	44,736
Equity in (earnings) losses of affiliates:
National Group	$	—		$	—		$	(2	)	$	(1	)
Atlantic Group		—			(1	)		(2	)		(2	)
American Group		(13	)		(13	)		(35	)		(31	)
Corporate and other		(6	)		4			45			5
	$	(19	)	$	(10	)	$	6		$	(29	)
Adjusted segment EBITDA:
National Group	$	799		$	780		$	2,826		$	2,602
Atlantic Group		1,158			1,014			3,219			2,833
American Group		1,210			1,178			3,662			3,832
Corporate and other		(287	)		(70	)		(599	)		(379	)
	$	2,880		$	2,902		$	9,108		$	8,888
Depreciation and amortization:
National Group	$	206		$	207		$	621		$	598
Atlantic Group		249			231			735			686
American Group		244			236			719			701
Corporate and other		70			75			213			234
	$	769		$	749		$	2,288		$	2,219

Adjusted segment EBITDA	$	2,880		$	2,902		$	9,108		$	8,888
Depreciation and amortization		769			749			2,288			2,219
Interest expense		483			446			1,447			1,288
Losses (gains) on sales of facilities		(2	)		3			12			25
Losses on retirement of debt		—			—			—			78
Income before income taxes	$	1,630		$	1,704		$	5,361		$	5,278

ITEM 2. MANAGEMENT’S DISCUSSION AND ANALYSIS OF

FINANCIAL CONDITION AND RESULTS OF OPERATIONS

Forward-Looking Statements

This quarterly report on Form 10-Q includes certain disclosures which contain “forward-looking statements” within the meaning of the federal securities laws, which involve risks and uncertainties. Forward-looking statements include statements regarding expected capital expenditures, expected net claim payments, expected inflationary pressures, expected labor costs and all other statements that do not relate solely to historical or current facts, and can be identified by the use of words like “may,” “believe,” “will,” “expect,” “project,” “estimate,” “anticipate,” “plan,” “initiative” or “continue.” These forward-looking statements are based on our current plans and expectations and are subject to a number of known and unknown uncertainties and risks, many of which are beyond our control, which could significantly affect current plans and expectations and our future financial position and results of operations. These factors include, but are not limited to, (1) changes in or related to general economic conditions nationally and regionally in our markets, including inflation and economic and business conditions (and the impact thereof on the economy, financial markets and banking industry); changes in revenues due to declining patient volumes; changes in payer mix (including increases in uninsured and underinsured patients); potential increased expenses related to labor, supply chain or other expenditures; workforce disruptions; supply shortages and disruptions; and the impact of potential federal government shutdowns, (2) the impact of our substantial indebtedness and the ability to refinance such indebtedness on acceptable terms, (3) the impact of current and future federal and state health reform initiatives and possible changes to other federal, state or local laws and regulations affecting the health care industry, including, but not limited to, the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (collectively, the “Affordable Care Act”), additional changes to the Affordable Care Act, its implementation, or interpretation (including through executive orders and court challenges), and proposals to expand coverage of federally-funded insurance programs as an alternative to private insurance or establish a single-payer system (such reforms often referred to as “Medicare for All”), (4) the effects related to the implementation of sequestration spending reductions required under the Budget Control Act of 2011, related legislation extending these reductions and those required under the Pay-As-You-Go Act of 2010 as a result of the federal budget deficit impact of the American Rescue Plan Act of 2021, and the potential for future deficit reduction legislation that may alter these spending reductions, which include cuts to Medicare payments, or create additional spending reductions, (5) increases in the amount and risk of collectability of uninsured accounts and deductibles and copayment amounts for insured accounts, (6) the ability to achieve operating and financial targets, attain expected levels of patient volumes and revenues, and control the costs of providing services, (7) possible changes in Medicare, Medicaid and other state programs, including Medicaid supplemental payment programs or Medicaid waiver programs, that may impact reimbursements to health care providers and insurers and the size of the uninsured or underinsured population, (8) personnel-related capacity constraints, increases in wages and the ability to attract, utilize and retain qualified management and other personnel, including affiliated physicians, nurses and medical and technical support personnel, (9) the highly competitive nature of the health care business, (10) changes in service mix, revenue mix and surgical volumes, including potential declines in the population covered under third-party payer agreements, the ability to enter into and renew third-party payer provider agreements on acceptable terms and the impact of consumer-driven health plans and physician utilization trends and practices, (11) the efforts of health insurers, health care providers, large employer groups and others to contain health care costs, (12) the outcome of our continuing efforts to monitor, maintain and comply with appropriate laws, regulations, policies and procedures, (13) the availability and terms of capital to fund the expansion of our business and improvements to our existing facilities, (14) changes in accounting practices, (15) developments related to COVID-19, including, without limitation, the length and severity of COVID-19-related impacts and the spread of virus strains with new epidemiological characteristics; the volume of canceled or rescheduled procedures and the volume and acuity of COVID-19 patients cared for across our health systems; and measures we are taking to respond to COVID-19, (16) the emergence of and effects related to pandemics, epidemics and infectious diseases, (17) future divestitures which may result in charges and possible impairments of long-lived assets, (18) changes in business strategy or development plans, (19) delays in receiving payments for services provided, (20) the outcome of pending and any future tax audits, disputes and litigation associated with our tax positions, (21) the impact of known and unknown government investigations, litigation and other claims that may be made against us, (22) the impact of actual and potential cybersecurity incidents or security breaches, including the data security incident disclosed in July 2023, (23) our ongoing ability to demonstrate meaningful use of certified electronic health record technology and the impact of interoperability requirements, (24) the impact of natural disasters, such as hurricanes and floods, physical risks from climate change or similar events beyond our control, (25) changes in U.S. federal, state, or foreign tax laws including interpretive guidance that may be issued by taxing authorities or other standard setting bodies, (26) the results of our efforts to use technology and resilience initiatives to drive efficiencies, better outcomes and an enhanced patient experience, and (27) other risk factors described in our annual report on Form 10-K for the year ended December 31, 2022 and our other filings with the Securities and Exchange Commission. As a consequence, current plans, anticipated actions and future financial position and results of operations may differ from those expressed in any forward-looking statements made by or on behalf of HCA. You are cautioned not to unduly rely on such forward-looking statements when evaluating the information presented in this report, which forward-looking statements reflect management’s views only as of the date of this report. We undertake no obligation to revise or update any forward-looking statements, whether as a result of new information, future events or otherwise.

ITEM 2. MANAGEMENT’S DISCUSSION AND ANALYSIS OF

FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)

Third Quarter 2023 Operations Summary

Revenues increased to $16.213 billion in the third quarter of 2023 from $14.971 billion in the third quarter of 2022. Net income attributable to HCA Healthcare, Inc. totaled $1.079 billion, or $3.91 per diluted share, for the quarter ended September 30, 2023, compared to $1.134 billion, or $3.91 per diluted share, for the quarter ended September 30, 2022. Third quarter results for 2023 include a $105 million loss before income taxes related to a hospital-based physician staffing joint venture where a controlling interest was acquired during the second quarter of 2023. This loss was primarily related to revenues that fell below expectations. All “per diluted share” disclosures are based upon amounts net of the applicable income taxes. Shares used for diluted earnings per share were 275.424 million shares for the quarter ended September 30, 2023 and 289.852 million shares for the quarter ended September 30, 2022. During 2022 and the first nine months of 2023, we repurchased 30.747 million shares and 10.818 million shares, respectively, of our common stock.

Revenues increased 8.3% on a consolidated basis and 7.9% on a same facility basis for the quarter ended September 30, 2023, compared to the quarter ended September 30, 2022. The increase in consolidated revenues can be primarily attributed to the combined impact of a 3.6% increase in revenue per equivalent admission and a 4.5% increase in equivalent admissions. The same facility revenues increase primarily resulted from the combined impact of a 3.6% increase in same facility revenue per equivalent admission and a 4.1% increase in same facility equivalent admissions. Florida and the Centers for Medicare & Medicaid Services ("CMS") approved a Medicaid hospital directed payment program (the program fiscal year is from October 1 through September 30). We recorded revenues of $397 million during the quarter and nine months ended September 30, 2023 related to the program year ended September 30, 2023 and revenues of $266 million during the quarter and nine months ended September 30, 2022 related to the program year ended September 30, 2022.

During the quarter ended September 30, 2023, consolidated admissions increased 2.8% and same facility admissions increased 3.4% compared to the quarter ended September 30, 2022. Surgeries increased 0.9% on a consolidated basis and 1.1% on a same facility basis during the quarter ended September 30, 2023, compared to the quarter ended September 30, 2022. Emergency department visits increased 2.8% on a consolidated basis and 3.5% on a same facility basis during the quarter ended September 30, 2023, compared to the quarter ended September 30, 2022. Consolidated and same facility uninsured admissions increased 3.2% and 3.3%, respectively, for the quarter ended September 30, 2023, compared to the quarter ended September 30, 2022.

Cash flows from operating activities declined $541 million, from $3.020 billion for the third quarter of 2022 to $2.479 billion for the third quarter of 2023. The decline in cash provided by operating activities was primarily related to negative changes in working capital items of $480 million.

Results of Operations

Revenue/Volume Trends

ITEM 2. MANAGEMENT’S DISCUSSION AND ANALYSIS OF

FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)

Results of Operations (continued)

Revenue/Volume Trends (continued)

Revenues increased 8.3% from $14.971 billion in the third quarter of 2022 to $16.213 billion in the third quarter of 2023. Our revenues are based upon the estimated amounts we expect to be entitled to receive from patients and third-party payers. Estimates of contractual adjustments under managed care and commercial insurance plans are based upon the payment terms specified in the related contractual agreements. Revenues related to uninsured patients and uninsured copayment and deductible amounts for patients who have health care coverage may have discounts applied (uninsured and other discounts). We also record estimated implicit price concessions (based primarily on historical collection experience) related to uninsured accounts to record self-pay revenues at the estimated amounts we expect to collect. Patients treated at our hospitals for non-elective care, who have income at or below 400% of the federal poverty level, are eligible for charity care. Because we do not pursue collection of amounts determined to qualify as charity care, they are not reported in revenues. Our revenues by primary third-party payer classification and other (including uninsured patients) for the quarters and nine months ended September 30, 2023 and 2022 are summarized in the following table (dollars in millions):


	Quarter
	2023		Ratio			2022		Ratio
Medicare	$	2,560		15.8	%	$	2,569		17.2	%
Managed Medicare		2,535		15.6			2,229		14.9
Medicaid		1,001		6.2			797		5.3
Managed Medicaid		1,039		6.4			939		6.3
Managed care and insurers		7,687		47.4			7,184		47.9
International (managed care and insurers)		375		2.3			311		2.1
Other		1,016		6.3			942		6.3
Revenues	$	16,213		100.0	%	$	14,971		100.0	%

	Nine Months
	2023		Ratio			2022		Ratio
Medicare	$	7,865		16.5	%	$	7,790		17.4	%
Managed Medicare		7,635		16.0			6,813		15.2
Medicaid		2,478		5.2			1,987		4.4
Managed Medicaid		2,846		6.0			3,003		6.7
Managed care and insurers		23,140		48.5			21,480		48.1
International (managed care and insurers)		1,127		2.4			992		2.2
Other		2,574		5.4			2,671		6.0
Revenues	$	47,665		100.0	%	$	44,736		100.0	%

Consolidated and same facility revenue per equivalent admission each increased 3.6% in the third quarter of 2023, compared to the third quarter of 2022. Consolidated and same facility equivalent admissions increased 4.5% and 4.1%, respectively, in the third quarter of 2023, compared to the third quarter of 2022. Consolidated and same facility outpatient surgeries increased 1.0% and 0.9%, respectively, in the third quarter of 2023, compared to the third quarter of 2022. Consolidated and same facility inpatient surgeries increased 0.8% and 1.6%, respectively, in the third quarter of 2023, compared to the third quarter of 2022. Consolidated and same facility emergency department visits increased 2.8% and 3.5%, respectively, in the third quarter of 2023, compared to the third quarter of 2022.

ITEM 2. MANAGEMENT’S DISCUSSION AND ANALYSIS OF

FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)

Results of Operations (continued)

Revenue/Volume Trends (continued)


	Quarter						Nine Months
	2023			2022			2023			2022
Patient care costs (salaries and benefits, supplies, other operating expenses and depreciation and amortization)	$	14,121		$	12,828		$	40,839		$	38,096
Cost-to-charges ratio (patient care costs as percentage of gross patient charges)		10.9	%		11.2	%		10.6	%		11.2	%
Total uncompensated care	$	9,042		$	8,050		$	25,516		$	23,512
Multiply by the cost-to-charges ratio		10.9	%		11.2	%		10.6	%		11.2	%
Estimated cost of total uncompensated care	$	975		$	901		$	2,705		$	2,633

Same facility uninsured admissions in 2023, compared to 2022, increased 3.3% in the third quarter, declined 6.6% in the second quarter and declined 1.1% in the first quarter. Same facility uninsured admissions declined in 2022, compared to 2021, 5.5% in the fourth quarter, 4.5% in the third quarter, 5.1% in the second quarter and 3.0% in the first quarter.

The approximate percentages of our admissions related to Medicare, managed Medicare, Medicaid, managed Medicaid, managed care and insurers and the uninsured for the quarters and nine months ended September 30, 2023 and 2022 are set forth in the following table.


	Quarter						Nine Months
	2023			2022			2023			2022
Medicare		20	%		22	%		21	%		22	%
Managed Medicare		25			23			25			23
Medicaid		4			4			4			4
Managed Medicaid		13			14			13			14
Managed care and insurers		31			30			30			30
Uninsured		7			7			7			7
		100	%		100	%		100	%		100	%

The approximate percentages of our inpatient revenues related to Medicare, managed Medicare, Medicaid, managed Medicaid, managed care and insurers for the quarters and nine months ended September 30, 2023 and 2022 are set forth in the following table.


	Quarter						Nine Months
	2023			2022			2023			2022
Medicare		21	%		23	%		22	%		23	%
Managed Medicare		17			16			18			17
Medicaid		10			8			8			7
Managed Medicaid		7			7			7			8
Managed care and insurers		45			46			45			45
		100	%		100	%		100	%		100	%

At September 30, 2023, we had 93 hospitals in the states of Texas and Florida. During the quarter ended September 30, 2023, 58% of our admissions and 51% of our revenues were generated by these hospitals. Uninsured admissions in Texas and Florida represented 72% of our uninsured admissions during the quarter ended September 30, 2023.

ITEM 2. MANAGEMENT’S DISCUSSION AND ANALYSIS OF

FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)

Results of Operations (continued)

Revenue/Volume Trends (continued)

We receive a significant portion of our revenues from government health programs, principally Medicare and Medicaid, which are highly regulated and subject to frequent and substantial changes. Some state Medicaid programs use, or have applied to use, waivers granted by CMS to implement Medicaid expansion, impose different eligibility or enrollment restrictions, or otherwise implement programs that vary from federal standards. We receive supplemental payments in several states. We are aware these supplemental payment programs are currently being reviewed by certain government agencies and some states have made requests to CMS to replace their existing supplemental payment programs. It is possible these reviews and requests will result in the restructuring of such supplemental payment programs and could result in the payment programs being reduced or eliminated. Because deliberations about these programs are ongoing, we are unable to estimate the financial impact the program structure modifications, if any, may have on our results of operations.

Key Performance Indicators

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

Operating Results Summary

The following is a comparative summary of results of operations for the quarters and nine months ended September 30, 2023 and 2022 (dollars in millions):


	Quarter
	2023						2022
	Amount			Ratio			Amount			Ratio
Revenues	$	16,213			100.0		$	14,971			100.0

Salaries and benefits		7,556			46.6			6,899			46.1
Supplies		2,417			14.9			2,320			15.5
Other operating expenses		3,379			20.8			2,860			19.1
Equity in earnings of affiliates		(19	)		(0.1	)		(10	)		(0.1	)
Depreciation and amortization		769			4.7			749			5.0
Interest expense		483			3.0			446			3.0
Losses (gains) on sales of facilities		(2	)		—			3			—
		14,583			89.9			13,267			88.6
Income before income taxes		1,630			10.1			1,704			11.4
Provision for income taxes		355			2.2			360			2.4
Net income		1,275			7.9			1,344			9.0
Net income attributable to noncontrolling interests		196			1.2			210			1.4
Net income attributable to HCA Healthcare, Inc.	$	1,079			6.7		$	1,134			7.6
% changes from prior year:
Revenues		8.3	%					(2.0	)%
Income before income taxes		(4.4	)					(46.0	)
Net income attributable to HCA Healthcare, Inc.		(4.9	)					(50.0	)
Admissions(a)		2.8						(2.6	)
Equivalent admissions(b)		4.5						1.3
Revenue per equivalent admission		3.6						(3.2	)
Same facility % changes from prior year(c):
Revenues		7.9						(1.3	)
Admissions(a)		3.4						(1.5	)
Equivalent admissions(b)		4.1						2.3
Revenue per equivalent admission		3.6						(3.5	)

ITEM 2. MANAGEMENT’S DISCUSSION AND ANALYSIS OF

FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)

Results of Operations (continued)

Operating Results Summary (continued)


	Nine Months
	2023					2022
	Amount			Ratio		Amount			Ratio
Revenues	$	47,665			100.0	$	44,736			100.0

Salaries and benefits		21,917			46.0		20,630			46.1
Supplies		7,318			15.4		6,942			15.5
Other operating expenses		9,316			19.5		8,305			18.6
Equity in losses (earnings) of affiliates		6			—		(29	)		(0.1	)
Depreciation and amortization		2,288			4.9		2,219			4.9
Interest expense		1,447			3.0		1,288			2.9
Losses on sales of facilities		12			—		25			0.1
Losses on retirement of debt		—			—		78			0.2
		42,304			88.8		39,458			88.2
Income before income taxes		5,361			11.2		5,278			11.8
Provision for income taxes		1,131			2.3		1,090			2.4
Net income		4,230			8.9		4,188			9.4
Net income attributable to noncontrolling interests		595			1.3		626			1.4
Net income attributable to HCA Healthcare, Inc.	$	3,635			7.6	$	3,562			8.0
% changes from prior year:
Revenues		6.5	%				2.4	%
Income before income taxes		1.6					(27.2	)
Net income attributable to HCA Healthcare, Inc.		2.0					(30.7	)
Admissions(a)		2.7					(1.9	)
Equivalent admissions(b)		5.0					0.9
Revenue per equivalent admission		1.4					1.4
Same facility % changes from prior year(c):
Revenues		6.4					3.4
Admissions(a)		3.3					(0.2	)
Equivalent admissions(b)		5.1					2.5
Revenue per equivalent admission		1.2					0.8

(a)

Represents the total number of patients admitted to our hospitals and is used by management and certain investors as a general measure of inpatient volume.

(b)

Equivalent admissions are used by management and certain investors as a general measure of combined inpatient and outpatient volume. Equivalent admissions are computed by multiplying admissions (inpatient volume) by the sum of gross inpatient revenues and gross outpatient revenues and then dividing the resulting amount by gross inpatient revenues. The equivalent admissions computation “equates” outpatient revenues to the volume measure (admissions) used to measure inpatient volume, resulting in a general measure of combined inpatient and outpatient volume.

(c)

Same facility information excludes the operations of hospitals and their related facilities which were either acquired or divested during the current and prior period.

ITEM 2. MANAGEMENT’S DISCUSSION AND ANALYSIS OF

FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)

Results of Operations (continued)

Quarters Ended September 30, 2023 and 2022

Revenues increased to $16.213 billion in the third quarter of 2023 from $14.971 billion in the third quarter of 2022. Net income attributable to HCA Healthcare, Inc. totaled $1.079 billion, or $3.91 per diluted share, for the quarter ended September 30, 2023, compared to $1.134 billion, or $3.91 per diluted share, for the quarter ended September 30, 2022. All “per diluted share” disclosures are based upon amounts net of the applicable income taxes. Shares used for diluted earnings per share were 275.424 million shares for the quarter ended September 30, 2023 and 289.852 million shares for the quarter ended September 30, 2022. During 2022 and the first nine months of 2023, we repurchased 30.747 million shares and 10.818 million shares, respectively, of our common stock.

Salaries and benefits, as a percentage of revenues, were 46.6% in the third quarter of 2023 and 46.1% in the third quarter of 2022. Salaries and benefits per equivalent admission increased 4.8% in the third quarter of 2023, compared to the third quarter of 2022. Same facility salaries and benefits per full time equivalent increased 3.1% for the third quarter of 2023, compared to the third quarter of 2022. We continue to utilize certain contract, overtime and other premium rate labor costs to support our clinical staff and patients. These costs have declined compared to the prior year period for each quarter during 2023; however, any future declines may be affected by labor market conditions and other factors.

Supplies, as a percentage of revenues, were 14.9% in the third quarter of 2023 and 15.5% in the third quarter of 2022. Supply costs per equivalent admission declined 0.4% in the third quarter of 2023, compared to the third quarter of 2022. Supply costs per equivalent admission increased 2.2% for medical devices and declined 5.3% for pharmacy supplies and 1.3% for general medical and surgical items in the third quarter of 2023, compared to the third quarter of 2022.

Other operating expenses, as a percentage of revenues, were 20.8% in the third quarter of 2023 and 19.1% in the third quarter of 2022. Other operating expenses is primarily comprised of contract services, professional fees, repairs and maintenance, rents and leases, utilities, insurance (including professional liability insurance), directed payment programs and nonincome taxes. The 1.7% increase in other operating expenses as a percentage of revenues for the third quarter of 2023, compared to the third quarter of 2022, was primarily related to increased costs for directed payment programs in certain states, as well as increased insurance costs and professional fees. We have seen inflation have a negative impact on certain of these expenses and expect inflationary pressures will continue to impact operating expenses in the future. Provisions for losses related to professional liability risks were $145 million and $89 million for the third quarters of 2023 and 2022, respectively. During the third quarter of 2022, we recorded a reduction of $55 million, or $0.15 per diluted share, to our provision for professional liability risks related to the receipt of updated actuarial information.

Equity in earnings of affiliates was $19 million and $10 million in the third quarters of 2023 and 2022, respectively.

Depreciation and amortization increased $20 million, from $749 million in the third quarter of 2022 to $769 million in the third quarter of 2023. The increase in depreciation relates primarily to capital expenditures at our existing facilities.

Interest expense was $483 million in the third quarter of 2023 and $446 million in the third quarter of 2022. Our average debt balance was $38.881 billion for the third quarter of 2023, compared to $38.196 billion for the third quarter of 2022. The average effective interest rate for our debt was 4.9% and 4.6%, respectively, for the quarters ended September 30, 2023 and 2022.

During the third quarters of 2023 and 2022, we recorded gains on sales of facilities of $2 million and losses on sales of facilities of $3 million, respectively.

The effective tax rates were 24.8% and 24.1% for the third quarters of 2023 and 2022, respectively. The effective tax rate computations exclude net income attributable to noncontrolling interests as it relates to consolidated partnerships.

ITEM 2. MANAGEMENT’S DISCUSSION AND ANALYSIS OF

FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)

Results of Operations (continued)

Quarters Ended September 30, 2023 and 2022 (continued)

Net income attributable to noncontrolling interests declined from $210 million for the third quarter of 2022 to $196 million for the third quarter of 2023. The decline in net income attributable to noncontrolling interests related primarily to the operations of a physician staffing joint venture and our group purchasing organization.

Nine Months Ended September 30, 2023 and 2022

Revenues increased to $47.665 billion in the first nine months of 2023 from $44.736 billion in the first nine months of 2022. Net income attributable to HCA Healthcare, Inc. totaled $3.635 billion, or $13.07 per diluted share, for the nine months ended September 30, 2023, compared to $3.562 billion, or $11.97 per diluted share, for the nine months ended September 30, 2022. Results for the first nine months of 2023 and 2022 include losses on sales of facilities of $12 million, or $0.07 per diluted share, and $25 million, or $0.09 per diluted share, respectively. Results for the first nine months of 2022 also include losses on retirement of debt of $78 million, or $0.20 per diluted share. Our provision for income taxes for the first nine months of 2023 and 2022 included tax benefits of $89 million, or $0.32 per diluted share, and $70 million, or $0.24 per diluted share, respectively, related to employee equity award settlements. All “per diluted share” disclosures are based upon amounts net of the applicable income taxes. Shares used for diluted earnings per share were 278.173 million shares for the nine months ended September 30, 2023 and 297.702 million shares for the nine months ended September 30, 2022.

Revenues increased 6.5% on a consolidated basis and 6.4% on a same facility basis for the nine months ended September 30, 2023, compared to the nine months ended September 30, 2022. The increase in consolidated revenues can be primarily attributed to the combined impact of a 1.4% increase in revenue per equivalent admission and a 5.0% increase in equivalent admissions. The increase in same facility revenues can be primarily attributed to the combined impact of a 1.2% increase in revenue per equivalent admission and a 5.1% increase in equivalent admissions.

Salaries and benefits, as a percentage of revenues, were 46.0% in the first nine months of 2023 and 46.1% in the first nine months of 2022. Salaries and benefits per equivalent admission increased 1.2% in the first nine months of 2023, compared to the first nine months of 2022. Same facility salaries and benefits per full time equivalent increased 1.9% for the first nine months of 2023, compared to the first nine months of 2022. We continue to utilize certain contract, overtime and other premium rate labor costs to support our clinical staff and patients. These costs have declined compared to the prior year period; however, any future declines may be affected by labor market conditions and other factors.

Supplies, as a percentage of revenues, were 15.4% in the first nine months of 2023 and 15.5% in the first nine months of 2022. Supply costs per equivalent admission increased 0.4% in the first nine months of 2023, compared to the first nine months of 2022. Supply costs per equivalent admission increased 3.1% for medical devices and 0.3% for general medical and surgical items and declined 7.3% for pharmacy supplies in the first nine months of 2023, compared to the first nine months of 2022. The decline in pharmacy supplies is primarily related to certain COVID-19 therapies during the first nine months of 2022.

Other operating expenses, as a percentage of revenues, were 19.5% in the first nine months of 2023 and 18.6% in the first nine months of 2022. Other operating expenses is primarily comprised of contract services, professional fees, repairs and maintenance, rents and leases, utilities, insurance (including professional liability insurance), directed payment programs and nonincome taxes. The 0.9% increase in other operating expenses as a percentage of revenues for the first nine months of 2023, compared to the first nine months of 2022, was primarily related to increased costs for directed payment programs in certain states, as well as increased professional fees. We have seen inflation have a negative impact on certain of these expenses and expect inflationary pressures will continue to impact operating expenses in the future. Provisions for losses related to professional liability risks were $433 million and $374 million for the first nine months of 2023 and 2022, respectively.

Equity in losses of affiliates was $6 million and equity in earnings of affiliates was $29 million in the first nine months of 2023 and 2022, respectively.

Depreciation and amortization increased $69 million, from $2.219 billion in the first nine months of 2022 to $2.288 billion in the first nine months of 2023. The increase in depreciation relates primarily to capital expenditures at our existing facilities.

ITEM 2. MANAGEMENT’S DISCUSSION AND ANALYSIS OF

FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)

Results of Operations (continued)

Nine Months Ended September 30, 2023 and 2022 (continued)

Interest expense was $1.447 billion in the first nine months of 2023 and $1.288 billion in the first nine months of 2022. Our average debt balance was $38.695 billion for the first nine months of 2023 compared to $37.243 billion for the first nine months of 2022. The average effective interest rate for our debt was 5.0% and 4.6%, respectively, for the nine months ended September 30, 2023 and 2022.

During the first nine months of 2023 and 2022, we recorded losses on sales of facilities of $12 million and $25 million, respectively.

During March 2022, we issued $6.000 billion aggregate principal amount of senior notes and used a portion of the net proceeds to pay down our revolving credit facilities. During April 2022, we redeemed all $1.250 billion outstanding aggregate principal amount of our 4.75% senior notes due 2023. During May 2022, we redeemed all $1.250 billion outstanding aggregate principal amount of our 5.875% senior notes due 2023. The aggregate pretax loss on retirement of debt for these two redemptions was $78 million.

The effective tax rates were 23.7% and 23.4% for the first nine months of 2023 and 2022, respectively. The effective tax rate computations exclude net income attributable to noncontrolling interests as it relates to consolidated partnerships. Our provisions for income taxes for the first nine months of 2023 and 2022 included tax benefits of $89 million and $70 million, respectively, related to employee equity award settlements.

Net income attributable to noncontrolling interests declined from $626 million for the first nine months of 2022 to $595 million for the first nine months 2023. The decline in net income attributable to noncontrolling interests related primarily to the operations of two of our Texas markets and our group purchasing organization, partially offset by an increase from our surgery centers.

Liquidity and Capital Resources

Cash provided by operating activities totaled $6.757 billion for the first nine months of 2023 compared to $5.995 billion for the first nine months of 2022. The $762 million increase in cash provided by operating activities, for the first nine months of 2023 compared to the first nine months of 2022, related primarily to positive changes in working capital items of $847 million. The combination of interest payments and net income tax payments in the first nine months of 2023 and 2022 totaled $2.530 billion and $2.260 billion, respectively. Working capital totaled $1.887 billion at September 30, 2023 and $3.741 billion at December 31, 2022 (decline due primarily to the $2.183 billion increase in long-term debt due within one year).

Cash used in investing activities was $3.720 billion in the first nine months of 2023 compared to $2.596 billion in the first nine months of 2022. Excluding acquisitions, capital expenditures were $3.585 billion in the first nine months of 2023 and $3.072 billion in the first nine months of 2022. Planned capital expenditures are expected to approximate $4.7 billion in 2023. At September 30, 2023, there were projects under construction which had estimated additional costs to complete and equip over the next five years of approximately $4.5 billion. We expect to finance capital expenditures with internally generated and borrowed funds.

Cash used in financing activities totaled $3.055 billion in the first nine months of 2023, compared to $3.818 billion in the first nine months of 2022. During the first nine months of 2023, net cash flows used in financing activities included a net increase of $1.109 billion in our indebtedness, payment of dividends of $501 million, repurchase of common stock of $2.901 billion and distributions to noncontrolling interests of $497 million. During the first nine months of 2022, net cash flows used in financing activities included a net increase of $2.972 billion in our indebtedness, payment of dividends of $497 million, repurchase of common stock of $5.481 billion and distributions to noncontrolling interests of $550 million.

We are a highly leveraged company with significant debt service requirements. Our debt totaled $39.346 billion at September 30, 2023. Our interest expense was $1.447 billion for the first nine months of 2023 and $1.288 billion for the first nine months of 2022.

In addition to cash flows from operations, available sources of capital include amounts available under our senior secured credit facilities ($6.455 billion and $6.615 billion available as of September 30, 2023 and October 23, 2023, respectively) and anticipated access to public and private debt markets.

ITEM 2. MANAGEMENT’S DISCUSSION AND ANALYSIS OF

FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)

Liquidity and Capital Resources (continued)

Investments of our insurance subsidiaries, held to maintain statutory equity levels and to provide liquidity to pay claims, totaled $485 million and $473 million at September 30, 2023 and December 31, 2022, respectively. An insurance subsidiary maintained net reserves for professional liability risks of $131 million and $147 million at September 30, 2023 and December 31, 2022, respectively. Our facilities are insured by our insurance subsidiary for losses up to $80 million per occurrence; however, this coverage is generally subject, in most cases, to a $15 million per occurrence self-insured retention. Additionally, the insurance subsidiary has entered into reinsurance contracts providing reimbursement for a certain portion of losses in excess of self-insured retentions. Net reserves for the self-insured professional liability risks retained were $1.934 billion and $1.836 billion at September 30, 2023 and December 31, 2022, respectively. Claims payments, net of reinsurance recoveries, during the next 12 months are expected to approximate $527 million. We estimate that approximately $490 million of the expected net claim payments during the next 12 months will relate to claims subject to the self-insured retention.

Management believes that cash flows from operations, amounts available under our senior secured credit facilities and our anticipated access to public and private debt markets will be sufficient to meet expected liquidity needs for the foreseeable future.

Market Risk

We are exposed to market risk related to changes in market values of securities. The investment securities held by our insurance subsidiaries were recorded at $485 million at September 30, 2023. These investments are carried at fair value, with changes in unrealized gains and losses that are not credit-related being recorded as adjustments to other comprehensive income. At September 30, 2023, we had net unrealized losses of $43 million on the insurance subsidiaries’ investments.

We are exposed to market risk related to market illiquidity. Investment securities held by our insurance subsidiaries could be impaired by the inability to access the capital markets. Should the insurance subsidiaries require significant amounts of cash in excess of normal cash requirements to pay claims and other expenses on short notice, we may have difficulty selling these investments in a timely manner or be forced to sell them at a price less than what we might otherwise have been able to in a normal market environment. We may be required to recognize credit-related impairments on our investment securities in future periods should issuers default on interest payments or should the fair market valuations of the securities deteriorate due to ratings downgrades or other issue-specific factors.

We are also exposed to market risk related to changes in interest rates. Debt of $2.811 billion at September 30, 2023 was subject to variable rates of interest, while the remaining debt balance of $36.535 billion at September 30, 2023 was subject to fixed rates of interest. Both the general level of interest rates and our leverage affect our variable interest rates. Our variable debt is comprised primarily of amounts outstanding under the senior secured credit facilities. The average effective interest rate for our debt was 5.0% and 4.6% for the nine months ended September 30, 2023 and 2022, respectively.

The estimated fair value of our long-term debt was $36.120 billion at September 30, 2023. The estimates of fair value are based upon the quoted market prices for the same or similar issues of long-term debt with the same maturities. Based on a hypothetical 1% increase in interest rates, the potential annualized reduction to future pretax earnings would be approximately $28 million. To mitigate the impact of fluctuations in interest rates, we generally target a majority of our debt portfolio to be maintained at fixed rates.

We are exposed to currency translation risk related to our foreign operations. We currently do not consider the market risk related to foreign currency translation to be material to our consolidated financial statements or our liquidity.

Tax Examinations

At September 30, 2023, the Internal Revenue Service was conducting examinations of the Company’s 2016, 2017 and 2018 federal income tax returns and the 2019 returns of certain affiliates. We are also subject to examination by state, local and foreign taxing authorities. Management believes HCA Healthcare, Inc. and its predecessors, subsidiaries and affiliates properly reported taxable income and paid taxes in accordance with applicable laws and agreements established with taxing authorities and final resolution of any disputes will not have a material, adverse effect on our results of operations or financial position. However, if payments due upon final resolution of any issues exceed our recorded estimates, such resolutions could have a material, adverse effect on our results of operations or financial position.

ITEM 2. MANAGEMENT’S DISCUSSION AND ANALYSIS OF

FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)


Operating Data

	2023		2022
Number of hospitals in operation at:
March 31		180		182
June 30		182		182
September 30		183		182
December 31				182
Number of freestanding outpatient surgical centers in operation at:
March 31		126		124
June 30		126		126
September 30		126		125
December 31				126
Licensed hospital beds at(a):
March 31		48,891		48,892
June 30		49,063		48,979
September 30		49,279		49,179
December 31				49,281
Weighted average beds in service(b):
Quarter:
First		41,684		41,818
Second		41,802		41,930
Third		41,927		42,056
Fourth				42,119
Year				41,982
Average daily census(c):
Quarter:
First		29,310		29,797
Second		28,116		28,256
Third		28,396		28,287
Fourth				28,790
Year				28,778
Admissions(d):
Quarter:
First		525,235		506,956
Second		522,996		515,113
Third		537,943		523,092
Fourth				530,298
Year				2,075,459
Equivalent admissions(e):
Quarter:
First		916,535		859,290
Second		938,834		902,757
Third		958,504		917,262
Fourth				931,990
Year				3,611,299
Average length of stay (days)(f):
Quarter:
First		5.0		5.3
Second		4.9		5.0
Third		4.9		5.0
Fourth				5.0
Year				5.1

ITEM 2. MANAGEMENT’S DISCUSSION AND ANALYSIS OF

FINANCIAL CONDITION AND RESULTS OF OPERATIONS (Continued)



	2023			2022
Emergency room visits(g):
Quarter:
First		2,252,669			2,056,389
Second		2,294,205			2,223,999
Third		2,343,514			2,278,782
Fourth					2,412,781
Year					8,971,951
Outpatient surgeries(h):
Quarter:
First		255,971			247,421
Second		263,601			258,182
Third		254,557			252,026
Fourth					265,610
Year					1,023,239
Inpatient surgeries(i):
Quarter:
First		130,460			126,880
Second		132,447			130,961
Third		133,521			132,470
Fourth					131,840
Year					522,151
Days revenues in accounts receivable(j):
Quarter:
First		50			51
Second		50			53
Third		52			53
Fourth					53
Outpatient revenues as a % of patient revenues(k):
Quarter:
First		38	%		37	%
Second		40	%		39	%
Third		37	%		37	%
Fourth					38	%
Year					38	%

(a)

Licensed beds are those beds for which a facility has been granted approval to operate from the applicable state licensing agency.

(b)

Represents the average number of beds in service, weighted based on periods owned.

(c)

Represents the average number of patients in our hospital beds each day.

(d)

Represents the total number of patients admitted to our hospitals and is used by management and certain investors as a general measure of inpatient volume.

(e)

Equivalent admissions are used by management and certain investors as a general measure of combined inpatient and outpatient volume. Equivalent admissions are computed by multiplying admissions (inpatient volume) by the sum of gross inpatient revenues and gross outpatient revenues and then dividing the resulting amount by gross inpatient revenues. The equivalent admissions computation “equates” outpatient revenues to the volume measure (admissions) used to measure inpatient volume resulting in a general measure of combined inpatient and outpatient volume.

(f)

Represents the average number of days admitted patients stay in our hospitals.

(g)

Represents the number of patients treated in our emergency rooms.

(h)

Represents the number of surgeries performed on patients who were not admitted to our hospitals. Pain management and endoscopy procedures are not included in outpatient surgeries.

(i)

Represents the number of surgeries performed on patients who have been admitted to our hospitals. Pain management and endoscopy procedures are not included in inpatient surgeries.

(j)

Revenues per day is calculated by dividing revenues for the quarter by the days in the quarter. Days revenues in accounts receivable is then calculated as accounts receivable at the end of the quarter divided by revenues per day.

(k)

Represents the percentage of patient revenues related to patients who are not admitted to our hospitals.

ITEM 3. QUANTITATIVE AND QUALITATIVE DISCLOSURES ABOUT MARKET RISK

The information called for by this item is provided under the caption “Market Risk” under Item 2, “Management’s Discussion and Analysis of Financial Condition and Results of Operations.”

ITEM 4. CONTROLS AND PROCEDURES

Evaluation of Disclosure Controls and Procedures

HCA’s management, with the participation of HCA’s chief executive officer and chief financial officer, has evaluated the effectiveness of HCA’s disclosure controls and procedures as of September 30, 2023. Based on that evaluation, HCA’s chief executive officer and chief financial officer concluded that HCA’s disclosure controls and procedures were effective as of September 30, 2023.

Changes in Internal Control Over Financial Reporting

During the period covered by this report, there have been no changes in our internal control over financial reporting that have materially affected or are reasonably likely to materially affect our internal control over financial reporting.

PART II. OTHER INFORMATION

ITEM 1. LEGAL PROCEEDINGS

The information set forth in “Note 8 – Contingencies” in the notes to condensed consolidated financial statements is incorporated herein by reference.

ITEM 1A. RISK FACTORS

Reference is made to the factors set forth under the caption “Forward-Looking Statements” in Part I, Item 2 of this quarterly report on Form 10-Q and other risk factors described in our annual report on Form 10-K for the year ended December 31, 2022, which are incorporated herein by reference. There have not been any material changes to the risk factors previously disclosed in our annual report on Form 10-K for the year ended December 31, 2022.

ITEM 2. UNREGISTERED SALES OF EQUITY SECURITIES AND USE OF PROCEEDS

During January 2023, our Board of Directors authorized a share repurchase program for up to $3 billion of our outstanding common stock. During the quarter ended September 30, 2023, we repurchased 4,166,799 shares of our common stock at an average price of $273.59 per share through market purchases pursuant to the authorization. At September 30, 2023, we had $1.685 billion of repurchase authorization available under the authorization.

The following table provides certain information with respect to our repurchases of common stock from July 1, 2023 through September 30, 2023 (dollars in billions, except per share amounts).


Period	Total Number of Shares Purchased		Average Price Paid per Share		Total Number of Shares Purchased as Part of Publicly Announced Plans or Programs		Approximate Dollar Value of Shares That May Yet Be Purchased Under Publicly Announced Plans or Programs
July 2023		956,594	$	292.72		956,594	$	2.545
August 2023		1,692,795	$	271.74		1,692,795	$	2.085
September 2023		1,517,410	$	263.61		1,517,410	$	1.685
Total for third quarter 2023		4,166,799	$	273.59		4,166,799

On October 23, 2023, our Board of Directors declared a quarterly dividend of $0.60 per share on our common stock, payable on December 28, 2023 to stockholders of record at the close of business on December 14, 2023. Future declarations of quarterly dividends and the establishment of future record and payment dates are subject to the final determination of our Board of Directors. Our ability to declare future dividends may also from time to time be limited by the terms of our debt agreements.

ITEM 5. OTHER INFORMATION

(c) During the three months ended September 30, 2023, no director or officer (as defined in Rule 16a-1(f) of the Exchange Act) of the Company adopted or terminated a “Rule 10b5-1 trading arrangement” or “non-Rule 10b5-1 trading arrangement,” as each term is defined in Item 408(a) of Regulation S-K.

ITEM 6. EXHIBITS

(a) List of Exhibits:


22	—	List of Subsidiary Guarantors and Pledged Securities.

31.1	—	Certification of Chief Executive Officer Pursuant to Section 302 of the Sarbanes-Oxley Act of 2002.

31.2	—	Certification of Chief Financial Officer Pursuant to Section 302 of the Sarbanes-Oxley Act of 2002.

32	—	Certification Pursuant to 18 U.S.C. Section 1350, as Adopted Pursuant to Section 906 of the Sarbanes-Oxley Act of 2002.

101	—	The following financial information from our quarterly report on Form 10-Q for the quarter ended September 30, 2023 filed with the SEC on October 26, 2023, formatted in Inline Extensible Business Reporting Language: (i) the condensed consolidated balance sheets at September 30, 2023 and December 31, 2022, (ii) the condensed consolidated income statements for the quarters and nine months ended September 30, 2023 and 2022, (iii) the condensed consolidated comprehensive income statements for the quarters and nine months ended September 30, 2023 and 2022, (iv) the condensed consolidated statements of stockholders’ equity (deficit) for the quarters and nine months ended September 30, 2023 and 2022, (v) the condensed consolidated statements of cash flows for the nine months ended September 30, 2023 and 2022 and (vi) the notes to condensed consolidated financial statements. The instance document does not appear in the Interactive Data File because its XBRL tags are embedded within the Inline XBRL document.

104	—	The cover page from the Company’s Quarterly Report on Form 10-Q for the quarter ended September 30, 2023, formatted in Inline XBRL (included in Exhibit 101).

SIGNATURES

Pursuant to the requirements of the Securities Exchange Act of 1934, the registrant has duly caused this report to be signed on its behalf by the undersigned thereunto duly authorized.



HCA Healthcare, Inc.

By:	/S/ WILLIAM B. RUTHERFORD
	William B. Rutherford
	Executive Vice President and Chief Financial Officer

Date: October 26, 2023