Full Press Release Details
HCA HEALTHCARE, INC.
INDEX TO CONSOLIDATED FINANCIAL STATEMENTS
| Page | ||||
| Report of Independent Registered Public Accounting Firm | F-2 | |||
| Consolidated Financial Statements: | ||||
| Consolidated Income Statements for the years ended December 31, 2022, 2021 and 2020 | F-5 | |||
| Consolidated Comprehensive Income Statements for the years ended December 31, 2022, 2021 and 2020 | F-6 | |||
| Consolidated Balance Sheets, December 31, 2022 and 2021 | F-7 | |||
| Consolidated Statements of Stockholders' Equity (Deficit) for the years ended December 31, 2022, 2021 and 2020 | F-8 | |||
| Consolidated Statements of Cash Flows for the years ended December 31, 2022, 2021 and 2020 | F-9 | |||
| Notes to Consolidated Financial Statements | F-10 |
Report of Independent Registered Public Accounting Firm
The Board of Directors and Stockholders
HCA Healthcare, Inc.
Opinion on the Financial Statements
We have audited the accompanying consolidated balance sheets of HCA Healthcare, Inc. (the Company) as of December 31, 2022 and 2021, the related consolidated statements of income, comprehensive income, stockholders' equity (deficit) and cash flows for each of the three years in the period ended December 31, 2022, and the related notes (collectively referred to as the "consolidated financial statements"). In our opinion, the consolidated financial statements present fairly, in all material respects, the financial position of the Company at December 31, 2022 and 2021, and the results of its operations and its cash flows for each of the three years in the period ended December 31, 2022, in conformity with U.S. generally accepted accounting principles.
We also have audited, in accordance with the standards of the Public Company Accounting Oversight Board (United States) (PCAOB), the Company's internal control over financial reporting as of December 31, 2022, based on criteria established in Internal Control-Integrated Framework issued by the Committee of Sponsoring Organizations of the Treadway Commission (2013 framework), and our report dated February 17, 2023 expressed an unqualified opinion thereon.
These financial statements are the responsibility of the Company's management. Our responsibility is to express an opinion on the Company's financial statements based on our audits. We are a public accounting firm registered with the PCAOB and are required to be independent with respect to the Company in accordance with the U.S. federal securities laws and the applicable rules and regulations of the Securities and Exchange Commission and the PCAOB.
We conducted our audits in accordance with the standards of the PCAOB. Those standards require that we plan and perform the audit to obtain reasonable assurance about whether the financial statements are free of material misstatement, whether due to error or fraud. Our audits included performing procedures to assess the risks of material misstatement of the financial statements, whether due to error or fraud, and performing procedures that respond to those risks. Such procedures included examining, on a test basis, evidence regarding the amounts and disclosures in the financial statements. Our audits also included evaluating the accounting principles used and significant estimates made by management, as well as evaluating the overall presentation of the financial statements. We believe that our audits provide a reasonable basis for our opinion.
Critical Audit Matters
The critical audit matters communicated below are matters arising from the current period audit of the financial statements that were communicated or required to be communicated to the audit committee and that: (1) relate to accounts or disclosures that are material to the financial statements and (2) involved our especially challenging, subjective or complex judgments. The communication of critical audit matters does not alter in any way our opinion on the consolidated financial statements, taken as a whole, and we are not, by communicating the critical audit matters below, providing separate opinions on the critical audit matters or on the accounts or disclosures to which they relate.
| Revenue Recognition | ||
| Description of the Matter | For the year ended December 31, 2022, the Company's revenues were $60.233 billion. As discussed in Note 1 to the consolidated financial statements, revenues are based upon the estimated amounts the Company expects to be entitled to receive from patients and third-party payers. Estimates of contractual allowances under managed care and commercial insurance plans are based upon the payment terms specified in the related contractual agreements. Management continually reviews the contractual allowances 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. Revenues related to uninsured patients and uninsured copayment and deductible amounts for patients who have health care coverage may have discounts applied (uninsured discounts and contractual discounts). The Company also records estimated implicit price concessions (based primarily on historical collection experience) related to uninsured accounts to record these revenues and accounts receivable at the estimated amounts the Company expects to collect. The primary collection risks relate to uninsured patient accounts, including amounts owed from patients after insurance has paid the amounts covered by the applicable agreement. Implicit price concessions relate primarily to amounts due directly from patients and are based upon management's assessment of historical write-offs and expected net collections, business and economic conditions, trends in federal, state and private employer health care coverage and other collection indicators. Auditing management's estimates of contractual allowances and implicit price concessions was complex and judgmental due to the significant data inputs and subjective assumptions utilized in determining related amounts. | |
| How We Addressed the Matter in Our Audit | We tested internal controls that address the risks of material misstatement related to the measurement and valuation of revenues, including estimation of contractual allowances and implicit price concessions. For example, we tested management's internal controls over the key data inputs to the contractual allowance and implicit price concession models, significant assumptions underlying management's models, and management's internal controls over retrospective reviews of historical reserve accuracy. To test the estimated contractual allowances and implicit price concessions, we performed audit procedures that included, among others, assessing methodologies and evaluating the significant assumptions discussed above and testing the completeness and accuracy of the underlying data used by the Company in its estimates. We compared the significant assumptions used by management to current industry and economic trends and considered changes, if any, to the Company's business and other relevant factors. We also assessed the historical accuracy of management's estimates as a source of potential corroborative or contrary evidence. | |
| Professional Liability Claims | ||
| Description of the Matter | At December 31, 2022, the Company's reserves for professional liability risks were $2.043 billion and the Company's related provision for losses for the year ended December 31, 2022 was $517 million. As discussed in Note 1 to the consolidated financial statements, reserves for professional liability risks represent the estimated ultimate net cost of all reported and unreported losses incurred and unpaid through the consolidated balance sheet date. Management estimates professional liability reserves and provisions for losses using individual case-basis valuations and actuarial analyses. Trends in the average frequency (number of claims) and ultimate average severity (cost per claim) of claims are significant assumptions in estimating the reserves. | |
| Auditing management's professional liability claims reserves was complex and judgmental due to the significant estimations required in determining the reserves, particularly the actuarial methodology and assumptions related to the severity and frequency of claims. |
/s/ Ernst & Young LLP
We have served as the Company's auditor since 1994.
Nashville, Tennessee
February 17, 2023, except for Note 13, as to which the date is May 26, 2023
HCA HEALTHCARE, INC.
CONSOLIDATED INCOME STATEMENTS
FOR THE YEARS ENDED DECEMBER 31, 2022, 2021 AND 2020
(Dollars in millions, except per share amounts)
| 2022 | 2021 | 2020 | ||||||||||
| Revenues | $ | 60,233 | $ | 58,752 | $ | 51,533 | ||||||
| Salaries and benefits | 27,685 | 26,779 | 23,874 | |||||||||
| Supplies | 9,371 | 9,481 | 8,369 | |||||||||
| Other operating expenses | 11,155 | 9,961 | 9,307 | |||||||||
| Equity in earnings of affiliates | ( 45 | ) | ( 113 | ) | ( 54 | ) | ||||||
| Depreciation and amortization | 2,969 | 2,853 | 2,721 | |||||||||
| Interest expense | 1,741 | 1,566 | 1,584 | |||||||||
| Losses (gains) on sales of facilities | ( 1,301 | ) | ( 1,620 | ) | 7 | |||||||
| Losses on retirement of debt | 78 | 12 | 295 | |||||||||
| 51,653 | 48,919 | 46,103 | ||||||||||
| Income before income taxes | 8,580 | 9,833 | 5,430 | |||||||||
| Provision for income taxes | 1,746 | 2,112 | 1,043 | |||||||||
| Net income | 6,834 | 7,721 | 4,387 | |||||||||
| Net income attributable to noncontrolling interests | 1,191 | 765 | 633 | |||||||||
| Net income attributable to HCA Healthcare, Inc. | $ | 5,643 | $ | 6,956 | $ | 3,754 | ||||||
| Per share data: | ||||||||||||
| Basic earnings per share | $ | 19.43 | $ | 21.52 | $ | 11.10 | ||||||
| Diluted earnings per share | $ | 19.15 | $ | 21.16 | $ | 10.93 | ||||||
| Shares used in earnings per share calculations (in millions): | ||||||||||||
| Basic | 290.348 | 323.315 | 338.274 | |||||||||
| Diluted | 294.666 | 328.752 | 343.605 |
The accompanying notes are an integral part of the consolidated financial statements.
HCA HEALTHCARE, INC.
CONSOLIDATED COMPREHENSIVE INCOME STATEMENTS
FOR THE YEARS ENDED DECEMBER 31, 2022, 2021 AND 2020
(Dollars in millions)
| 2022 | 2021 | 2020 | ||||||||||
| Net income | $ | 6,834 | $ | 7,721 | $ | 4,387 | ||||||
| Other comprehensive income (loss) before taxes: | ||||||||||||
| Foreign currency translation | ( 111 | ) | ( 9 | ) | 18 | |||||||
| Unrealized gains (losses) on available-for-sale securities | ( 55 | ) | ( 16 | ) | 14 | |||||||
| Losses included in other operating expenses | 1 | - | - | |||||||||
| ( 54 | ) | ( 16 | ) | 14 | ||||||||
| Defined benefit plans | 49 | 87 | ( 71 | ) | ||||||||
| Pension costs included in salaries and benefits | 9 | 28 | 28 | |||||||||
| 58 | 115 | ( 43 | ) | |||||||||
| Change in fair value of derivative financial instruments | 6 | 1 | ( 66 | ) | ||||||||
| Interest costs included in interest expense | 2 | 37 | 24 | |||||||||
| 8 | 38 | ( 42 | ) | |||||||||
| Other comprehensive income (loss) before taxes | ( 99 | ) | 128 | ( 53 | ) | |||||||
| Income taxes (benefits) related to other comprehensive income items | ( 13 | ) | 30 | ( 11 | ) | |||||||
| Other comprehensive income (loss) | ( 86 | ) | 98 | ( 42 | ) | |||||||
| Comprehensive income | 6,748 | 7,819 | 4,345 | |||||||||
| Comprehensive income attributable to noncontrolling interests | 1,191 | 765 | 633 | |||||||||
| Comprehensive income attributable to HCA Healthcare, Inc. | $ | 5,557 | $ | 7,054 | $ | 3,712 |
The accompanying notes are an integral part of the consolidated financial statements.
HCA HEALTHCARE, INC.
CONSOLIDATED BALANCE SHEETS
DECEMBER 31, 2022 AND 2021
(Dollars in millions)
| 2022 | 2021 | |||||||
| ASSETS | ||||||||
| Current assets: | ||||||||
| Cash and cash equivalents | $ | 908 | $ | 1,451 | ||||
| Accounts receivable | 8,891 | 8,095 | ||||||
| Inventories | 2,068 | 1,986 | ||||||
| Other | 1,776 | 2,010 | ||||||
| 13,643 | 13,542 | |||||||
| Property and equipment, at cost: | ||||||||
| Land | 2,799 | 2,496 | ||||||
| Buildings | 20,221 | 19,211 | ||||||
| Equipment | 29,981 | 28,256 | ||||||
| Construction in progress | 1,756 | 1,387 | ||||||
| 54,757 | 51,350 | |||||||
| Accumulated depreciation | ( 29,182 | ) | ( 27,287 | ) | ||||
| 25,575 | 24,063 | |||||||
| Investments of insurance subsidiaries | 381 | 438 | ||||||
| Investments in and advances to affiliates | 823 | 448 | ||||||
| Goodwill and other intangible assets | 9,653 | 9,540 | ||||||
| Right-of-use operating lease assets | 2,065 | 2,113 | ||||||
| Other | 298 | 598 | ||||||
| $ | 52,438 | $ | 50,742 | |||||
| LIABILITIES AND STOCKHOLDERS' EQUITY (DEFICIT) | ||||||||
| Current liabilities: | ||||||||
| Accounts payable | $ | 4,239 | $ | 4,111 | ||||
| Accrued salaries | 1,712 | 1,912 | ||||||
| Other accrued expenses | 3,581 | 3,322 | ||||||
| Long-term debt due within one year | 370 | 237 | ||||||
| 9,902 | 9,582 | |||||||
| Long-term debt, less debt issuance costs and discounts of $ 301 and $ 248 | 37,714 | 34,342 | ||||||
| Professional liability risks | 1,528 | 1,514 | ||||||
| Right-of-use operating lease obligations | 1,752 | 1,755 | ||||||
| Income taxes and other liabilities | 1,615 | 2,060 | ||||||
| Stockholders' equity (deficit): | ||||||||
| Common stock $ 0.01 par; authorized 1,800,000,000 shares; outstanding 277,378,300 shares - 2022 and 305,476,800 shares - 2021 | 3 | 3 | ||||||
| Accumulated other comprehensive loss | ( 490 | ) | ( 404 | ) | ||||
| Retained deficit | ( 2,280 | ) | ( 532 | ) | ||||
| Stockholders' deficit attributable to HCA Healthcare, Inc. | ( 2,767 | ) | ( 933 | ) | ||||
| Noncontrolling interests | 2,694 | 2,422 | ||||||
| ( 73 | ) | 1,489 | ||||||
| $ | 52,438 | $ | 50,742 |
The accompanying notes are an integral part of the consolidated financial statements.
HCA HEALTHCARE, INC.
CONSOLIDATED STATEMENTS OF STOCKHOLDERS' EQUITY (DEFICIT)
FOR THE YEARS ENDED DECEMBER 31, 2022, 2021 AND 2020
(Dollars in millions, except per share amounts)
| Equity (Deficit) Attributable to HCA Healthcare, Inc. | Total | |||||||||||||||||||||||||||
| Common Stock | Capital in Excess of Par Value | Accumulated Other Comprehensive Loss | Retained Earnings (Deficit) | Equity Attributable to Noncontrolling Interests | ||||||||||||||||||||||||
| Shares (in millions) | Par Value | |||||||||||||||||||||||||||
| Balances, December 31, 2019 | 338.446 | $ | 3 | $ | - | $ | ( 460 | ) | $ | ( 2,351 | ) | $ | 2,243 | $ | ( 565 | ) | ||||||||||||
| Comprehensive income (loss) | ( 42 | ) | 3,754 | 633 | 4,345 | |||||||||||||||||||||||
| Repurchase of common stock | ( 3.287 | ) | ( 441 | ) | ( 441 | ) | ||||||||||||||||||||||
| Share-based benefit plans | 4.267 | 300 | ( 35 | ) | 265 | |||||||||||||||||||||||
| Cash dividends declared ($ 0.43 per share) | ( 150 | ) | ( 150 | ) | ||||||||||||||||||||||||
| Distributions | ( 626 | ) | ( 626 | ) | ||||||||||||||||||||||||
| Other | ( 6 | ) | 70 | 64 | ||||||||||||||||||||||||
| Balances, December 31, 2020 | 339.426 | 3 | 294 | ( 502 | ) | 777 | 2,320 | 2,892 | ||||||||||||||||||||
| Comprehensive income | 98 | 6,956 | 765 | 7,819 | ||||||||||||||||||||||||
| Repurchase of common stock | ( 37.812 | ) | ( 578 | ) | ( 7,637 | ) | ( 8,215 | ) | ||||||||||||||||||||
| Share-based benefit plans | 3.863 | 280 | 280 | |||||||||||||||||||||||||
| Cash dividends declared ($ 1.92 per share) | ( 628 | ) | ( 628 | ) | ||||||||||||||||||||||||
| Distributions | ( 749 | ) | ( 749 | ) | ||||||||||||||||||||||||
| Other | 4 | 86 | 90 | |||||||||||||||||||||||||
| Balances, December 31, 2021 | 305.477 | 3 | - | ( 404 | ) | ( 532 | ) | 2,422 | 1,489 | |||||||||||||||||||
| Comprehensive income (loss) | ( 86 | ) | 5,643 | 1,191 | 6,748 | |||||||||||||||||||||||
| Repurchase of common stock | ( 30.747 | ) | ( 264 | ) | ( 6,736 | ) | ( 7,000 | ) | ||||||||||||||||||||
| Share-based benefit plans | 2.648 | 282 | 282 | |||||||||||||||||||||||||
| Cash dividends declared ($ 2.24 per share) | ( 655 | ) | ( 655 | ) | ||||||||||||||||||||||||
| Distributions | ( 1,025 | ) | ( 1,025 | ) | ||||||||||||||||||||||||
| Other | ( 18 | ) | 106 | 88 | ||||||||||||||||||||||||
| Balances, December 31, 2022 | 277.378 | $ | 3 | $ | - | $ | ( 490 | ) | $ | ( 2,280 | ) | $ | 2,694 | $ | ( 73 | ) |
The accompanying notes are an integral part of the consolidated financial statements.
HCA HEALTHCARE, INC.
CONSOLIDATED STATEMENTS OF CASH FLOWS
FOR THE YEARS ENDED DECEMBER 31, 2022, 2021 AND 2020
(Dollars in millions)
| 2022 | 2021 | 2020 | ||||||||||
| Cash flows from operating activities: | ||||||||||||
| Net income | $ | 6,834 | $ | 7,721 | $ | 4,387 | ||||||
| Adjustments to reconcile net income to net cash provided by operating activities: | ||||||||||||
| Increase (decrease) in cash from operating assets and liabilities: | ||||||||||||
| Accounts receivable | ( 797 | ) | ( 962 | ) | 327 | |||||||
| Inventories and other assets | ( 59 | ) | ( 540 | ) | ( 304 | ) | ||||||
| Accounts payable and accrued expenses | ( 296 | ) | 999 | 1,255 | ||||||||
| Depreciation and amortization | 2,969 | 2,853 | 2,721 | |||||||||
| Income taxes | 571 | ( 70 | ) | 41 | ||||||||
| Losses (gains) on sales of facilities | ( 1,301 | ) | ( 1,620 | ) | 7 | |||||||
| Losses on retirement of debt | 78 | 12 | 295 | |||||||||
| Amortization of debt issuance costs | 29 | 27 | 30 | |||||||||
| Share-based compensation | 341 | 440 | 362 | |||||||||
| Other | 153 | 99 | 111 | |||||||||
| Net cash provided by operating activities | 8,522 | 8,959 | 9,232 | |||||||||
| Cash flows from investing activities: | ||||||||||||
| Purchase of property and equipment | ( 4,395 | ) | ( 3,577 | ) | ( 2,835 | ) | ||||||
| Acquisition of hospitals and health care entities | ( 224 | ) | ( 1,105 | ) | ( 568 | ) | ||||||
| Sales of hospitals and health care entities | 1,237 | 2,160 | 68 | |||||||||
| Change in investments | 14 | ( 117 | ) | ( 20 | ) | |||||||
| Other | ( 21 | ) | ( 4 | ) | ( 38 | ) | ||||||
| Net cash used in investing activities | ( 3,389 | ) | ( 2,643 | ) | ( 3,393 | ) | ||||||
| Cash flows from financing activities: | ||||||||||||
| Issuances of long-term debt | 5,997 | 4,344 | 2,700 | |||||||||
| Net change in revolving credit facilities | 120 | 2,780 | ( 2,480 | ) | ||||||||
| Repayment of long-term debt | ( 2,830 | ) | ( 3,869 | ) | ( 3,437 | ) | ||||||
| Distributions to noncontrolling interests | ( 1,025 | ) | ( 749 | ) | ( 626 | ) | ||||||
| Payment of debt issuance costs | ( 53 | ) | ( 38 | ) | ( 35 | ) | ||||||
| Payment of dividends | ( 653 | ) | ( 624 | ) | ( 153 | ) | ||||||
| Repurchase of common stock | ( 7,000 | ) | ( 8,215 | ) | ( 441 | ) | ||||||
| Other | ( 212 | ) | ( 284 | ) | ( 205 | ) | ||||||
| Net cash used in financing activities | ( 5,656 | ) | ( 6,655 | ) | ( 4,677 | ) | ||||||
| Effect of exchange rate changes on cash and cash equivalents | ( 20 | ) | ( 3 | ) | 10 | |||||||
| Change in cash and cash equivalents | ( 543 | ) | ( 342 | ) | 1,172 | |||||||
| Cash and cash equivalents at beginning of period | 1,451 | 1,793 | 621 | |||||||||
| Cash and cash equivalents at end of period | $ | 908 | $ | 1,451 | $ | 1,793 | ||||||
| Interest payments | $ | 1,662 | $ | 1,502 | $ | 1,607 | ||||||
| Income tax payments, net | $ | 1,175 | $ | 2,182 | $ | 1,002 |
The accompanying notes are an integral part of the consolidated financial statements.
HCA HEALTHCARE, INC.
NOTES TO CONSOLIDATED FINANCIAL STATEMENTS
NOTE 1 - ACCOUNTING POLICIES
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 December 31, 2022 these affiliates owned and operated 182 hospitals, 126 freestanding surgery centers, 21 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 preparation of financial statements in conformity with generally accepted accounting principles requires management to make estimates and assumptions that affect the amounts reported in the consolidated financial statements and accompanying notes. Actual results could differ from those estimates.
The consolidated financial statements include all subsidiaries and entities controlled by HCA. We generally define "control" as ownership of a majority of the voting interest of an entity. The consolidated financial statements include entities in which we absorb a majority of the entity's expected losses, receive a majority of the entity's expected residual returns, or both, as a result of ownership, contractual or other financial interests in the entity. The accounts of acquired entities are included in our consolidated financial statements for periods subsequent to our acquisition of controlling interests. Significant intercompany transactions have been eliminated. Investments in entities we do not control, but in which we have a substantial ownership interest and can exercise significant influence, are accounted for using the equity method.
The majority of our expenses are "cost of revenue" items. Costs that could be classified as general and administrative include our corporate office costs, which were $378 million, $400 million and $416 million for the years ended December 31, 2022, 2021 and 2020, respectively.
We believe the extent of COVID-19's
impact on our operating results and financial condition has been and could continue to be driven by many factors, most of which are beyond our control and ability to forecast. Because of these uncertainties, we cannot estimate how long or to what extent COVID-19
will impact our operations.
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 CONSOLIDATED FINANCIAL STATEMENTS (Continued)
NOTE 1 - 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 discounts and contractual 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. Our revenues by primary third-party payer classification and other (including uninsured patients) for the years ended December 31, are summarized in the following table (dollars in millions):
| Years Ended December 31, | ||||||||||||||||||||||||
| 2022 | Ratio | 2021 | Ratio | 2020 | Ratio | |||||||||||||||||||
| Medicare | $ | 10,447 | 17.3 | % | $ | 10,447 | 17.8 | % | $ | 10,420 | 20.2 | % | ||||||||||||
| Managed Medicare | 9,201 | 15.3 | 8,424 | 14.3 | 6,997 | 13.6 | ||||||||||||||||||
| Medicaid | 2,636 | 4.4 | 2,290 | 3.9 | 1,965 | 3.8 | ||||||||||||||||||
| Managed Medicaid | 3,998 | 6.6 | 3,124 | 5.3 | 2,621 | 5.1 | ||||||||||||||||||
| Managed care and other insurers | 29,120 | 48.3 | 30,295 | 51.6 | 26,535 | 51.5 | ||||||||||||||||||
| International (managed care and other insurers) | 1,317 | 2.2 | 1,336 | 2.3 | 1,120 | 2.2 | ||||||||||||||||||
| Other | 3,514 | 5.9 | 2,836 | 4.8 | 1,875 | 3.6 | ||||||||||||||||||
| Revenues | $ | 60,233 | 100.0 | % | $ | 58,752 | 100.0 | % | $ | 51,533 | 100.0 | % |
Laws and regulations governing the Medicare and Medicaid programs are complex and subject to interpretation. Estimated reimbursement amounts are adjusted in subsequent periods as cost reports are prepared and filed and as final settlements are determined (in relation to certain government programs, primarily Medicare, this is generally referred to as the "cost report" filing and settlement process). The adjustments to estimated Medicare and Medicaid reimbursement and disproportionate-share amounts, related primarily to cost reports filed during the respective year, resulted in net increases to revenues of $56 million, $53 million and $70 million in 2022, 2021 and 2020, respectively. The adjustments to estimated reimbursement amounts related primarily to cost reports filed during previous years resulted in a net increase to revenues of $42 million in 2022, a net increase to revenues of $19 million in 2021 and a net reduction to revenues of $5 million in 2020.
The Emergency Medical Treatment and Labor Act ("EMTALA") requires any hospital participating in the Medicare program to conduct an appropriate medical screening examination of every person who presents to the hospital's emergency room for treatment and, if the individual is suffering from an emergency medical condition, to either stabilize the condition or make an appropriate transfer of the individual to a facility able to handle the condition. The obligation to screen and stabilize emergency medical conditions exists regardless of an individual's ability to pay for treatment. Federal and state laws and regulations require, and our commitment to providing quality patient care encourages, us to provide services to patients who are financially unable to pay for the health care services they receive.
Patients treated at hospitals for non-elective
care, who have income at or below 400% of the federal poverty level, are eligible for charity care, and we limit the patient responsibility amounts for these patients to a percentage of their annual household income, computed on a sliding scale based upon their annual income and the applicable percentage of the federal poverty level. Patients treated at hospitals for non-elective
care, who have income above 400% of the federal poverty level, are eligible for certain other discounts which limit the patient responsibility amounts for these patients to a percentage of their annual household income, computed on a sliding scale based upon their annual income and the applicable percentage of the federal poverty level. We apply additional discounts to limit patient responsibility for certain emergency services. The federal poverty level is established by the federal government and is based on income and family size. Because we do not pursue collection of amounts determined to qualify as charity care, they are not reported in revenues. We provide discounts to uninsured patients who do not qualify for Medicaid or charity care. We may attempt to provide assistance to uninsured patients to help determine whether they may qualify for Medicaid, other federal or state assistance, or charity care. If an uninsured patient does not qualify for these programs, the uninsured discount is applied.
HCA HEALTHCARE, INC.
NOTES TO CONSOLIDATED FINANCIAL STATEMENTS (Continued)
NOTE 1 - ACCOUNTING POLICIES (continued)
Revenues (continued)
The collection of outstanding receivables from Medicare, Medicaid, managed care payers, other third-party payers and patients is our primary source of cash and is critical to our operating performance. The primary collection risks relate to uninsured patient accounts, including patient accounts for which the primary insurance carrier has paid the amounts covered by the applicable agreement, but patient responsibility amounts (deductibles and copayments) remain outstanding. Implicit price concessions relate primarily to amounts due directly from patients. Estimated implicit price concessions are recorded for all uninsured accounts, regardless of the age of those accounts. Accounts are written off when all reasonable collection efforts have been performed.
The estimates for implicit price concessions are based upon management's assessment of historical writeoffs and expected net collections, business and economic conditions, trends in federal, state and private employer health care coverage and other collection indicators. Management relies on the results of detailed reviews of historical writeoffs and collections at facilities that represent a majority of our revenues and accounts receivable (the "hindsight analysis") as a primary source of information in estimating the collectability of our accounts receivable. We perform the hindsight analysis quarterly, utilizing rolling twelve-months accounts receivable collection and writeoff data. We believe our quarterly updates to the estimated implicit price concession amounts at each of our hospital facilities provide reasonable estimates of our revenues and valuations of our accounts receivable. These routine, quarterly changes in estimates have not resulted in material adjustments to the valuations of our accounts receivable or period-to-period
comparisons of our revenues. At December 31, 2022 and 2021, estimated implicit price concessions of $6.780 billion and $6.784 billion, respectively, had been recorded to adjust our revenues and accounts receivable to the estimated amounts we expect to collect.
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 years ended December 31, follows (dollars in millions):
| 2022 | 2021 | 2020 | ||||||||||
| Patient care costs (salaries and benefits, supplies, other operating expenses and depreciation and amortization) | $ | 51,180 | $ | 49,074 | $ | 44,271 | ||||||
| Cost-to-charges ratio (patient care costs as percentage of gross patient charges) | 11.0 | % | 11.3 | % | 12.0 | % | ||||||
| Total uncompensated care | $ | 31,734 | $ | 29,642 | $ | 29,029 | ||||||
| Multiply by the cost-to-charges ratio | 11.0 | % | 11.3 | % | 12.0 | % | ||||||
| Estimated cost of total uncompensated care | $ | 3,491 | $ | 3,350 | $ | 3,483 |
The total uncompensated care amounts include charity care of $13.615 billion, $13.644 billion and $13.763 billion for the years ended December 31, 2022, 2021 and 2020, respectively. The estimated cost of charity care was $1.498 billion, $1.542 billion and $1.652 billion for the years ended December 31, 2022, 2021 and 2020, respectively.
Cash and Cash Equivalents
Cash and cash equivalents include highly liquid investments with a maturity of three months or less when purchased. Our insurance subsidiaries' cash equivalent investments in excess of the amounts required to pay estimated professional liability claims during the next twelve months are not included in cash and cash equivalents as these funds are not available for general corporate purposes. Carrying values of cash and cash equivalents approximate fair value due to the short-term nature of these instruments.
Our cash management system provides for daily investment of available balances and the funding of outstanding checks when presented for payment. Outstanding, but unpresented, checks totaling $656 million and $536 million at December 31, 2022 and 2021, respectively, have been included in "accounts payable" in the consolidated balance sheets. Upon presentation for payment, these checks are funded through available cash balances or our credit facility.
HCA HEALTHCARE, INC.
NOTES TO CONSOLIDATED FINANCIAL STATEMENTS (Continued)
NOTE 1 - ACCOUNTING POLICIES (continued)
We receive payments for services rendered from federal and state agencies (under the Medicare and Medicaid programs), managed care health plans, commercial insurance companies, employers and patients. We recognize that revenues and receivables from government agencies are significant to our operations, but do not believe there are significant credit risks associated with these government agencies. We do not believe there are any other significant concentrations of revenues from any particular payer that would subject us to any significant credit risks in the collection of our accounts receivable. Days revenues in accounts receivable were 53 days, 49 days and 45 days at December 31, 2022, 2021 and 2020, respectively. Changes in general economic conditions, patient accounting service center operations, payer mix, payer claim processing, or federal or state governmental health care coverage could affect our collection of accounts receivable, cash flows and results of operations.
Inventories are stated at the lower of cost (first-in,
Property and Equipment
Depreciation expense, computed using the straight-line method, was $2.941 billion in 2022, $2.826 billion in 2021 and $2.693 billion in 2020. Buildings and improvements are depreciated over estimated useful lives ranging generally from 10 to 40 years. Estimated useful lives of equipment vary generally from four to 10 years.
When events, circumstances or operating results indicate the carrying values of certain property and equipment expected to be held and used might be impaired, we prepare projections of the undiscounted future cash flows expected to result from the use of the assets and their eventual disposition. If the projections indicate the recorded amounts are not expected to be recoverable, such amounts are reduced to estimated fair value. Fair value may be estimated based upon internal evaluations that include quantitative analyses of revenues and cash flows, reviews of recent sales of similar assets and independent appraisals.
Property and equipment to be disposed of are reported at the lower of their carrying amounts or fair value less costs to sell or close. The estimates of fair value are usually based upon recent sales of similar assets and market responses based upon discussions with and offers received from potential buyers.
Investments of Insurance Subsidiaries
At December 31, 2022 and 2021, the investment securities held by our insurance subsidiaries were classified as
"available-for-sale"
as defined in Accounting Standards Codification ("ASC") No. 320, Investments - Debt Securities
and are recorded at fair value. The investment securities are held for the purpose of providing a funding source to pay liability claims covered by the insurance subsidiaries. We perform quarterly assessments of individual investment securities to determine whether declines in fair value are due to credit-related or noncredit-related factors. Our investment securities evaluation process involves subjective judgments, often involves estimating the outcome of future events, and requires a significant level of professional judgment in determining whether a credit-related impairment has occurred. We evaluate, among other things, the financial position and near term prospects of the issuer, conditions in the issuer's industry, liquidity of the investment, changes in the amount or timing of expected future cash flows from the investment, and recent downgrades of the issuer by a rating agency, to determine if, and when, a decline in the fair value of an investment below amortized cost is considered to be a credit-related impairment. The extent to which the fair value of the investment is less than amortized cost and our ability and intent to retain the investment, to allow for any anticipated recovery of the investment's fair value, are important components of our investment securities evaluation process.
HCA HEALTHCARE, INC.