The companies on the Global 500 employ 70.2 million people, and their revenue represents more than one-third of the world’s GDP.

Fortune Global 500

With a combined revenue of $21 trillion and $2.1 trillion in profits, the 2026 Fortune 500 is the definitive list of America's largest companies.

Fortune 500

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The corporations on our annual list of the world's 500 largest companies combined to generate $41.7 trillion in revenue over the past year.

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The 300 companies on this year’s list brought in over $12.6 trillion in revenue for the latest 12 months, with the median revenue figure at $22 billion.

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The corporations on our annual list posted aggregate revenues of $41 trillion for the second year in a row.

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The Fortune 500, in its 70th year in 2024, ranks the biggest U.S. companies by revenue.

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The corporations on our annual list of the world’s largest companies delivered a record $41 trillion in aggregate revenues.

The Fortune 500, in its 69th year in 2023, ranks the biggest U.S. companies by revenue.

The U.S.’s largest health care facility operator reported a decrease in profit and revenue growth in 2022 versus the year prior, partly due to the phasing out of government assistance that accompanied the pandemic. 
<ul> 
 	<li>HCA Healthcare, which operates in 20 states in the U.S., has in aggregate removed hospitals from its portfolio and added outpatient surgery centers since 2020, reflecting a broader shift to outpatient care among hospital conglomerates.</li> 
 	<li>The health care giant has struggled with staffing issues, like many in the industry, employing higher-cost temporary staffing during the pandemic’s onset. A survey conducted by union researchers found that HCA staffed its hospitals at 30% below the national average in 2020. Responding to the survey, HCA said that its staffing was “safe, appropriate," and “in line” with its industry.</li> 
 	<li>The company has repeatedly fought with the Federal Trade Commission over its acquisition of more hospitals, first in Utah in June 2022, and then in Louisiana in April 2023.</li> 
</ul>

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Aggregate sales hit $37.8 trillion last year—an increase of 19%, the highest annual growth rate in the list’s history.

This year’s Fortune 500 marks the 68th running of the list.

F500 2022-HCA Healthcare

Tennessee-based national health care facility operator HCA Healthcare retains its 2021 position after a year that saw profits rise to nearly $59 billion from $51.5 billion. The company was called into action multiple times throughout 2021 as COVID-19 waves swept the country and sent hospital visits ticking upward. HCA has faced criticism in some areas of the country from consumer advocates who contend that it has boosted profits at its hospitals during the pandemic by reducing staffing and services; HCA says that such changes haven’t affected the quality of care. In the first months of 2022, HCA has received 2.1% more same-facility admissions relative to 2021 and 14.6% more emergency room visits.

After a year in which humanity leaned more heavily than ever on tech giants, see which companies topped Fortune's ranking of corporate reputation.

Total revenue for the world’s biggest companies fell 4.8% to $31.7 trillion this year—the first decline in half a decade.

G500-2021-207-HCA Healthcare

<span data-sheets-value="{&quot;1&quot;:2,&quot;2&quot;:&quot;As with many other hospital companies, Nashville-based HCA Healthcare faced considerable financial pressure related to the pandemic, suspending its quarterly dividend last spring. Admissions to its hospitals dropped 4.7% for the year owing to fewer procedures and less emergency-room traffic. COVID-19 cases in 2020 made up about 8% of its hospitals’ overall admissions. But HCA finished the year strong: It brought in annual revenue of $51.5 billion, a hair above the previous year’s tally, as revenue per hospitalized patient increased 10.5%. Net income attributable to the company rose 7.1% to nearly $3.8 billion, compared with $3.5 billion in 2019.\n\n\n&quot;}" data-sheets-userformat="{&quot;2&quot;:12673,&quot;3&quot;:{&quot;1&quot;:0},&quot;10&quot;:2,&quot;11&quot;:4,&quot;15&quot;:&quot;Calibri&quot;,&quot;16&quot;:11}">As with many other hospital companies, Nashville, Tenn.-based HCA Healthcare faced considerable financial pressure related to the pandemic, suspending its quarterly dividend last spring. Admissions to its hospitals dropped 4.7% for the year owing to fewer procedures and less emergency-room traffic. COVID-19 cases in 2020 made up about 8% of its hospitals’ overall admissions. But HCA finished the year strong: It brought in annual revenue of $51.5 billion, a hair above the previous year’s tally, as revenue per hospitalized patient increased 10.5%. Net income attributable to the company rose 7.1% to nearly $3.8 billion, compared with $3.5 billion in 2019.

This year’s Fortune 500 marks the 67th running of the list.

F500-2021-62-HCA Healthcare

<span data-sheets-value="{&quot;1&quot;:2,&quot;2&quot;:&quot;As with many other hospital companies, Nashville-based HCA Healthcare faced considerable financial pressure related to the pandemic, suspending its quarterly dividend last spring. Admissions to its hospitals dropped 4.7% for the year owing to fewer procedures and less emergency-room traffic. COVID-19 cases in 2020 made up about 8% of its hospitals’ overall admissions. But HCA finished the year strong: It brought in annual revenue of $51.5 billion, a hair above the previous year’s tally, as revenue per hospitalized patient increased 10.5%. Net income attributable to the company rose 7.1% to nearly $3.8 billion, compared with $3.5 billion in 2019.\n\n\n&quot;}" data-sheets-userformat="{&quot;2&quot;:12673,&quot;3&quot;:{&quot;1&quot;:0},&quot;10&quot;:2,&quot;11&quot;:4,&quot;15&quot;:&quot;Calibri&quot;,&quot;16&quot;:11}">As with many other hospital companies, Nashville-based HCA Healthcare faced considerable financial pressure related to the pandemic, suspending its quarterly dividend last spring. Admissions to its hospitals dropped 4.7% for the year owing to fewer procedures and less emergency-room traffic. COVID-19 cases in 2020 made up about 8% of its hospitals’ overall admissions. But HCA finished the year strong: It brought in annual revenue of $51.5 billion, a hair above the previous year’s tally, as revenue per hospitalized patient increased 10.5%. Net income attributable to the company rose 7.1% to nearly $3.8 billion, compared with $3.5 billion in 2019.

For an astounding 13th straight year, Apple claims the top spot in Fortune’s annual ranking of corporate reputation, based on a survey of almost 3,800 executives, directors, and analysts.

This year's Fortune Global 500 generated $33.3 trillion in revenues and $2.1 trillion in profits.

G500-2020-219-HCA-Healthcare

HCA Healthcare, a Nashville-based hospital operator, continued its steady growth in 2019 with annual revenue of $51.3 billion, an increase of nearly $5 billion from the previous year, even as net income dipped 5%. HCA's facility admissions have increased over the past year, and it now operates 184 hospitals, up from 179 the year before. Its hospitals treated 35 million patients in 2019, a new record. And the company's goal of expanding clinical capacity has been boosted by multimillion-dollar capital investments. Like many hospital operators, HCA is facing considerable financial pressure related to the coronavirus pandemic; this spring, it suspended its quarterly dividend.

This year's Fortune 500 marks the 66th running of the list.

F500-2020-065-HCA-Healthcare

HCA Healthcare, a Nashville-based hospital operator, continued its steady growth in 2019 with annual revenue of $51.3 billion, an increase of nearly $5 billion from the previous year, even as net income dipped 5%. HCA's facility admissions have increased over the past year, and it now operates 184 hospitals, up from 179 the year prior. Its hospitals treated 35 million patients in 2019, a new record. And the company's goal of expanding clinical capacity has been boosted by multimillion-dollar capital investments. Like many hospital operators, HCA is facing considerable financial pressure related to the coronavirus pandemic; this spring, it suspended its quarterly dividend.

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This year's Fortune 500 marks the 64th running of the list.

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This year's Fortune 500 marks the 61st running of the list. Wal-Mart claims the top spot again. See who made the list.

Global business is back. After limping through a worldwide financial crisis and economic slowdown, the 500 largest companies ranked by revenues shattered all sorts of performance records in 2013: They racked up combined revenues of $31.1 trillion, up 2.5% from 2012, and profits soared 27% to nearly $2 trillion. China’s 95 companies (up from 89 last year) posted $5.8 trillion in revenues. The U.S. has four fewer companies on the list than last year but remains (for now) the country leader, with 128 corporations on the list—including No. 1 Wal-Mart Stores—reporting $8.6 trillion in revenues. 

Wal-Mart stayed on top as its sales crept closer to half-a-trillion dollars. Apple moved into the top five. And UnitedHealth Group continued its steady climb. 

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HCA Healthcare owns many of the largest chains of hospitals, clinics, surgery centers, medical labs, and freestanding emergency rooms in the U.S., in addition to operating locations in the U.K. The company was founded in 1968 as one of the first U.S. hospital conglomerates. Since then, along with its industry rivals, it has undergone tremendous growth, partly through acquisitions of smaller health care chains.

Q2 2026

Q1 2026

Q4 2025

Q3 2025

Q2 2025

Q1 2025

Q4 2024

HCA Healthcare (HCA): Company Profile, Stock Price, News, Rankings

legacy

HCA Healthcare

hca healthcare

Ladies and gentlemen, welcome to HCA Healthcare Fourth Quarter 2025 Earnings Conference Call. Today's call is being recorded. At this time, for opening remarks and introductions, I would like to turn the call over to Vice President of Investor Relations, Mr. Frank Morgan. Please go ahead, sir.

Good morning, and welcome to everyone on today's call. With me this morning is our CEO, Sam Hazen, and CFO, Mike Marks. Sam and Mike will provide some prepared remarks, and then we'll take questions. Before I turn the call over to Sam, let me remind everyone that should today's call contain any forward-looking statements, they're based on management's current expectations. Numerous risks, uncertainties, and other factors may cause actual results to differ materially from those that might be expressed today. More information on forward-looking statements and these factors are listed in today's press release and in our various SEC filings. On this morning's call, we may reference measures such as Adjusted EBITDA, which is a non-GAAP financial measure. A table providing supplemental information on Adjusted EBITDA and reconciling net income attributable to HCA Healthcare, Inc., is included in today's release.

This morning's call is being recorded, and a replay of the call will be available later today. With that, I'll now turn the call over to Sam.

Good morning, and thank you for joining the call. We closed out the year with strong results that were mostly consistent with the previous quarters in 2025. We delivered our 19th straight quarter of volume growth, reflecting continued solid demand across our markets. The benefit of network investments and improved results in capacity management, quality patient outcomes, and stakeholder engagement. Revenue increased 6.7% compared to the prior year quarter, and with disciplined expense management, margins improved both sequentially and year over year. For the quarter, net income attributable to HCA Healthcare increased almost 31%. Diluted earnings per share as adjusted, increased 29%, and adjusted EBITDA increased around 11% versus the prior year period. Reflecting on 2025, this was another successful year for HCA Healthcare.

Throughout the year, our teams executed at a high level, we gained ground with our strategic agenda, and we stayed focused on the fundamentals. Additionally, we invested significantly in network expansion, workforce development, and clinical capabilities. These investments helped deliver positive outcomes across the HCA Healthcare system. As a result, our networks had approximately 47 million patient encounters during the year, representing a record level of patient care activity for the company. I want to thank my colleagues for their outstanding work, their dedication to our patients, and their unyielding commitment to our mission. Now, let me transition to the policy environment. We continue to monitor several policy matters, including the expired enhanced premium tax credits, the ongoing developments related to Medicaid supplemental payment programs, and the Rural Health Transformation Program. These matters continue to evolve. As we learn more, we will provide updates at the appropriate times.

That said, we believe our core business remains strong, with forecasted volumes in our long-term 2%-3% growth range. This past year, we strengthened the company's Resiliency Program in three important areas, and this gives us confidence that we can navigate effectively through these policy dynamics. The first was organizational. In this area, we added new capabilities that were aligned around the company's operating imperatives. Next, we strengthened the management systems to enhance execution. And lastly, we ramped up leadership development. The second area relates to competitive positioning. We increased hospital capacity, clinical service offerings, and outpatient facilities across our networks to create greater patient access and address the needs of our communities. The third was financial. Here, we advanced our cost management agenda and improved our balance sheet with strong cash flow and disciplined capital allocation.

These results allowed us to invest significantly in our networks, our people, and our AI and tech agenda. In closing, we are well positioned to move forward as we begin 2026. We continue to believe the HCA Way of combining high-quality, local provider networks with the distinct capabilities, talent, and scale of a national healthcare system, creates sustained value for our stakeholders and allows us to deliver more effectively on our mission. With that, I will turn over the call to Mike for more details on the quarter and our outlook for 2026.

Thank you, Sam, and good morning, everyone. We were pleased with the results of the fourth quarter of 2025, which reflected strong operational performance combined with disciplined capital allocation. Let me note some same-facility volume comparisons to fourth quarter of 2025 versus fourth quarter of 2024. Admissions increased 2.4%, and equivalent admissions increased 2.5%, in line with our expectations of 2%-3% growth. Inpatient surgeries were flat, and outpatient surgical volume was down slightly. ER visits increased 50 basis points. Overall, respiratory volumes had no material impact on year-over-year volume. Regarding payer mix report, same facility total commercial equivalent admissions increased 1.1% over the prior year, with exchanges growing 2.5% and commercial, excluding exchanges, increasing approximately 1%. Medicare increased 3.5%, and Medicaid increased 2.2%.

Same-facility net revenue per equivalent admission increased 2.9% versus prior year quarter. The 80 basis point improvement in Adjusted EBITDA margin in the quarter was driven primarily by solid revenue growth, good results in labor management, and improvements in other operating expenses. Adjusted EBITDA grew approximately 11% compared to the prior year quarter, primarily due to strong operating performance and an approximate $150 million increase in our hurricane markets. As we've said in the past, Medicaid supplemental payment programs are complex, vary on timing, and do not fully cover our cost to treat Medicaid patients. Due to a retro payment from Virginia in the fourth quarter, the net impact of supplemental payments was approximately flat versus prior year quarter. Now, let me discuss full year results for 2025, which reflected good demand growth in our markets.

On the same facility basis, we posted growth in revenue of 6.6%, equivalent admissions of 2.4%, and net revenue per equivalent admission of 4.1% versus prior year. Consolidated Adjusted EBITDA increased 12.1% over prior year, and we delivered a 90 basis point improvement in Adjusted EBITDA margins. The net benefit from supplemental payments increased by $420 million. Hurricane-impacted markets contributed approximately $125 million in Adjusted EBITDA growth. Diluted earnings per share, as adjusted, increased 28.5%. Moving to capital allocation. Capital expenditures totaled $1.5 billion in the quarter and $4.9 billion for the year. Additionally, we purchased $2.6 billion of our outstanding shares during the quarter and $10 billion in the year.

We paid $162 million in dividends for the quarter and $679 million for the year. Cash flow from operations was $2.4 billion in the quarter and $12.6 billion for the year. This represents a 20% increase in operating cash flow in 2025 over full year 2024. Our debt to Adjusted EBITDA leverage remained at the low end of our targeted range. Given our strong balance sheet, we are well-positioned for the future. So with that, let me speak to our 2026 guidance. We expect revenues to range between $76.5 billion and $80 billion. We expect Adjusted EBITDA to range between $15.55 billion and $16.45 billion.

We expect net income attributable to HCA Healthcare to range between $6.5 billion and $7 billion. We expect diluted earnings per share to range between $29.10 and $31.50. Further, we continued to see opportunities to deploy capital and drive organic growth in our markets through investing in high acuity programs, increasing our network through new access points, and building new inpatient capacity. As a result of these opportunities, we have increased our capital spending range from $5 billion to $5.5 billion. Our 2026 guidance includes the following assumptions: growth in equivalent admissions between 2% and 3%. An adverse impact on adjusted EBITDA between $600 million and $900 million related to the health insurance exchanges.

This includes impact from administrative reforms enacted in 2025, the One Big Beautiful Bill Act, and the expiration of the enhanced premium tax credits. We expect an offset to this exchange headwind of approximately $400 million through resiliency initiatives designed to generate efficiencies throughout the organization. We anticipate decline in supplemental payment programs net benefit between $250 million and $450 million. The expected decline in net benefit is driven primarily by Tennessee's program reverting back to four quarters of net benefit versus six quarters in 2025, a pause on one specific program in Texas, and a one-time retro payment from Virginia. This guidance does not include any potential impact in 2026 from additional approvals of grandfathered applications. We do not anticipate any significant growth to adjusted EBITDA from our hurricane-impacted markets over prior year.

We expect full year margins to be slightly above 20%, consistent with 2025, and cash flow from operations to range between $12 billion and $13 billion. Lastly, we plan to continue investing in our technology and digital innovation strategies, which we expect will deliver long-term value and help position the company for the future. Considering these factors, our overall 2026 Adjusted EBITDA guidance reflects strength and momentum in operations, increased investment in strategic initiatives, consistent business fundamentals, and a disciplined approach to capital allocation. Given what we see today, including the demand in our markets, our Resiliency Program, and our digital transformation initiatives, we remain comfortable that we will perform within our long-term plan over time. As noted in our release this morning, our board of directors have authorized a new $10 billion share repurchase program.

We currently anticipate completing a majority of the existing authorization in 2026, subject to market conditions and other factors. In addition, our board declared an increase in our quarterly dividend from $0.72 to $0.78 per share. In conclusion, 2025 marked another year of solid operational performance for HCA, and we believe that we are well-positioned for continued progress and success in 2026. With that, I will turn the call over to Frank for questions.

Thank you, Mike. As a reminder, please limit yourself to one question, so we might get as many as possible in the opportunity to ask a question. Toby, you may now give instructions to those who would like to ask questions.

Thank you. We will now begin the question and answer session. If you'd like to ask a question, please press Star, then the number one on your telephone keypad to raise your hand and enter the queue. If you would like to withdraw your question at any time, simply press Star one again. Your first question comes from the line of AJ Rice with UBS. Your line is open.

Hi, everybody. Thanks for the comments and the detailed commentary on the guidance. I wondered maybe, because the focus is on the top line, of course, in your comments. Can you talk about the expense items, SWB, supplies, other, other operating expenses, professional fees, et cetera? What are your underlying assumptions there that are embedded in the guidance? Is there margin improvement opportunities on any of those lines in 2026?

Good morning, AJ. When I look at the margin, and I noted this in my comments, but, you know, the midpoint of our revenue and Adjusted EBITDA guidance range suggests expectations for pretty stable margins in 2026 versus 2025. As we noted on our third quarter call, we continue to expect mostly stable trends in our operating costs, consistent with the last past couple of years. I might note that we do see and expect continued physician cost pressures, and believe that those could even be maybe in the high single digits of growth in 2026 versus 2025. So those would be kind of some comments on the cost side of our guidance.

Okay, and the contract labor and, and just general labor, that's steady year-to-year is the underlying assumption?

It is. I mean, the only thing I might mention is that contract labor as a percent of SWB, you know, we came in at about 4.2%, for the fourth quarter, and that's, that feels like, you know, kind of our run right now as we come into 2026. But other than that, I mean, the resiliency plan is reflected in our guidance, as I noted in my comments. And, you know, largely, the resiliency plan is there to help us offset as much of the adverse impact of the exchange headwinds as possible. And you see that in our guidance as well, and I think it reflects, you know, really strong cost and operating leverage as we head into 2026.

Your next question comes from the line of Ann Hynes with Mizuho. Your line is open.

Great, thank you. So it sounds like the net, negative headwind from ACA subsidies is in the $200 million-$500 million range. Can you just go into, more of the resiliency programs, provide some more detail on what's, making up that $400 million, and obviously, the confidence and executing, throughout the year, just from a timing perspective, and when you expect to lose potential volume?

Sure. I'll start with resiliency, and I'll pick up the second part again of your question related to the exchanges. But, you know, as we've talked about over the last really year plus, we have been implementing steps to try to mitigate the impact of this health insurance exchange headwind. We've been working to both enhance and accelerate our financial resiliency program. I would make a couple of contextual notes related to our program. The first is that our program has four key areas of focus: revenue integrity, variable and fixed cost efficiencies, and capacity management. We are leveraging three primary capabilities in driving our financial resiliency program. First, internal and external benchmarking and advanced analytics. Second, digital transformation with AI and automation, and third, expanding and leveraging our shared service platforms.

Our 2026 plan includes significant efforts in corporate, in our large shared service platforms, and in our hospital operations. We have plan elements to drive better capacity management, including managing throughput and length of stay in our inpatient settings, in our emergency rooms, and our operating rooms. On the cost side, we have robust plans to drive labor efficiency, supply cost actions, and operating costs, covering both variable and fixed costs. We're proud of our teams, and I, I think they have done a wonderful job embracing resiliency as a strategic imperative, and, we have confidence that, we'll be able to execute on this $400 million of incremental cost savings in 2026 versus 2025.

A little bit more on your question related to HIX, and let me just say this, you know, our estimated range, as I noted in my comments, of $600 million-$900 million adverse impact to EBITDA, includes the potential impacts from administrative reforms that were passed as part of the One Big Beautiful Bill Act and enacted through rulemaking, as well as the expiration of the EPTCs. And so, as a reminder, our health exchange volumes represent approximately 8% of admissions and 10% of revenue in 2025. And the estimate impact centers around some key variables that are included in our calculations. First, you know, how many people lose exchange coverage? And what form of coverage, if any, do those lives migrate to?

For those retaining coverage, is there a change in metal tier or utilization? As you can imagine, assumptions around the variables are informed through our own data and experience, as well as incorporating external studies and analysis. These variables are difficult to predict and require significant judgments. Our model contemplates a 15%-20% decline in our HIX volumes for 2026. We assume this volume will migrate to either employer-sponsored insurance or to uninsured. Of the decline in our HIX volumes, we assume approximately 15%-20% will move to employer-sponsored coverage, which carries a benefit, with the remaining migrating to uninsured, which includes a decline in utilization from those individuals no longer having coverage. From a timing perspective, we are, you know, watching the enrollment figures carefully.

As you know, they were released recently by CMS, but these recently released enrollment data include a couple of key areas that will dictate the timing of the impact. The first one is whether people can pay and sustain their premiums, given the significant increase they are facing from EPTC expiration. The second one is if there will be a metal tier shift from Silver to Bronze, and the impact on utilization and collectibility of our patient new balances. We're watching these trends carefully as we go through the opening days, weeks, and months of 2026, and we will keep you informed as they play out during 2026 on our quarterly calls.

Your next question comes from the line of Pito Chickering with Deutsche Bank. Your line is open.

Hey, thanks, and good morning, guys. Thanks for taking my questions. A 2026 guidance question here, just are there any one-timers we should be adjusting out for 2025? But if you take the baseline of 25 and pull out, I think, $450 million-$900 million from HIX and supplemental payments, offset by the resiliency programs, I just wanna make sure that I'm calculating the core growth of what HCA is doing at sort of 3%-12%, with 7% at the midpoint, versus just your long-term guidance of 4%-6%. So you're still guiding core above your long-term guidance?

Let me say, I think from a range perspective, that I would just reiterate two or three of the moving parts for clarity. You know, we've noted the range of potential adverse impact from the exchanges of $600 million-$900 million. We've noted that we believe that the supplemental payments could have a $250 million-$450 million decline in net benefit, and that decline in net benefit does not include any potential new approvals or grandfathered applications by CMS. Lastly, resiliency, you know, we are confident that we'll be able to execute on our plans for 2026, given the $400 million target.

I think in taking those kind of swing factors into account, Pito, we do agree, and we're pleased with the strength and the performance of the company, and the momentum of the company as we go into 2026.

Any chance you can size up the potential, if all the approvals come through, how much they could add to 2026 unit times?

Yeah, we're not sizing the potential approvals until we get a sense of the actual approval from CMS, and what changes, if any, they make through their review and approval processes. So not quite sizing that yet.

Your next question comes on a line of Justin Lake with Wolfe Research. Your line is open.

Hi, thanks. This is Anna on for Justin. Just wanted to ask, the $400 million of resiliency benefit in 2026 is impressive. Can you talk about how much of that comes from ramping AI initiatives, and how we should think about further resiliency opportunities beyond 2026, as some of the Medicaid cuts begin in the out years? Thanks.

Yeah, we've mentioned this before, but I think the way to think about the Resiliency Program is that it's a multi-year program. The $400 million came from our assessment of implementation status of the long list of opportunities that we're working on. Based on that assessment of our implementation status, it gave us confidence to include $400 million of savings in 2026 versus 2025 in our overall guidance. As we move forward, we continue to work on our resiliency plan. It's a program, and I mentioned on the previous question, you know, components that we're working on.

But, we're really pleased with the depth and breadth of our Resiliency Program and believe that it gives us, you know, good support here as we move through the back half of the decade.

Your next question comes from the line of Whit Mayo with Leerink Partners. Your line is open.

Hey, thanks. You guys have been working on some digital efforts with payers recently, I think at least some of the large national ones around data and disputes.

... Can you maybe talk about that and how it's manifesting into, you know, revenue cycle, yield collections or pricing, or maybe just reduce payer friction? Thanks.

Sure, Hey Whit, thank you. We have, over the last year, have launched a series of engagements with many of our major payers. And, these engagements kind of focus on digital integration. So think about, you know, electronic data exchange, think about, the kinds of activities that, HCA and our payers can partner on to produce administrative, simplification. And I think, they also include, dispute resolution, in trying to find better ways, to resolve disputes between the parties. We're pleased with these engagements, and I think it gives us strength, in our overall relationships with payers.

And, you know, frankly, we continue to work with our payers to find ways, to make things better for their members and our patients, and to, to digitize the whole workflow, between, ourselves and, our payer partners. So I think overall, these engagements have produced good, progress, with the relationship between us and our payers. And, and so, we're excited as we head into 2026 to continue to work and, with these, with our payers on these initiatives.

And Mike, speak to the working capital improvements this year, which are, you know, part and parcel to some of that, not entirely all of it, but I think that is reflected in the cash flow production that the company had, and then our working capital improved this year.

For sure. And we had a nice reduction in net days in AR, especially in the fourth quarter. That really reflects, you know, the benefits of sharing data and exchanging data with payers digitally, and certainly is a part of what's driving those enhancements. So I think the efforts here are clearly on administrative simplification. I do think they have impacts in our revenue cycle, both in terms of getting claims paid more timely, but also through potential mitigation of denials and disputes, which is beneficial for both us and our payers.

And Mike, let me add to the, just the whole resiliency agenda. You know, this is not an episodic event for us. It just happens to be a maturation of what, in my estimation, is cultural within HCA, and that is being cost effective and finding ways to leverage scale, utilize best practices. Now, we have tools, as Mike alluded to, that are in front of us as opportunities to create even more consistency, efficiencies, and transparency in the company's overall costs. And that's why the program is lining up in a well-timed manner with some of the enhanced premium tax credit challenges. But we see this program continuing to mature, and as we get more capable at using these tools, it's gonna help us find even more opportunities.

This is not a one-time event, it's a cultural dynamic in our company around being cost effective, being high quality, and finding ways to improve from a process standpoint and a leverage standpoint with our overall scale.

Your next question comes from the line of Brian Tanquilut with Jefferies. Your line is open.

Hey, good morning, guys, and congrats on the quarterly guidance. Mike, as I think about just the rural benefit from One Big Beautiful Bill, I'm curious if you have any updated thoughts, maybe they finalized some of the rules there, and then just any call outs in Q1 to think about, other than sort of the tough comp that we should be contemplating. Thanks.

On the Rural Health Transformation Program, you know, under the One Big Beautiful Bill Act, you know, all 50 states have allocated their program funding, but these are largely state-driven programs, and most of the details have not yet been released. We do not yet know the timing, the structure, or the size of any state-level awards, or how much of the funding will be distributed within each state. So our approach, Brian, has been to really stay actively engaged with our state and federal partners regarding both the program design and then our response to program design, to ensure that once the applications are open, that we will participate in a way that's meaningful.

At this stage, we do view the Rural Health Transformation Fund as a potential opportunity, but it's not something that we have reflected in our guidance, given the remaining uncertainty. When I think about the quarter, you know, we had a strong quarter. You know, we noted that there's maybe one part of that that was a little different than we anticipated, when we gave our third quarter update, and that's the state supplemental payments. You may recall that on our third quarter update, we thought we would finish the full year at a $300 million net benefit, state supplemental payment programs for the quarter, for the year of 2025, because we were anticipating a year-over-year decline in fourth quarter, given some known headwinds, from the prior year.

We ended up getting a retro payment from Virginia in the fourth quarter, which kind of pushed us flat in the quarter and led us up to a $420 million net benefit for the full year. So that's about the that's the only thing I can think of, Brian, that would be a little different than we anticipated when we gave our update for guidance in our third quarter call. I mean, volumes came in largely where we anticipated. Our rates were stable, a stable operating environment with rates, and our expense management, I thought, was really good in the quarter. So overall, we deem our fourth quarter performance as being strong.

Mike, let me, let me add to the rural, discussion, just one minute here. Roughly 15% of our hospitals, we believe, are rural hospitals of some sort, and so that's a large footprint that we have that's complementary to the networks across the company. So we have a number of assets in rural communities. Secondly, we have a number of programs where our health systems, from one community to the other, provide services in rural communities, whether it's telemedicine, transport systems, satellite clinic with our physicians, urgent care, whatever, and so that's another vehicle. The third piece for us is workforce. Our graduate medical education programs, even our, our nursing rotations with our Galen College of Nursing programs, create opportunities for us to, we believe, participate in the programs.

But as Mike said, we're having to work through roughly 20 different programs in our company to understand how those funds are going to be applied. So we do think we have elements of the company that are in rural America in a way that deserves funding through these programs.

Your next question comes from the line of Ben Hendrix with RBC Capital Markets. Your line is open.

Great, thank you very much. I was wondering if you could provide some thoughts on the potential for a transition to a health savings account construct for the enhanced subsidies. Assuming those funds go directly to customer HSAs, is there any, any initial thoughts you have on how that would impact your current assessment of the, EPTC expiry headwinds? And then, how should we think about the impact on uncompensated care, assuming patients have access to the funds, but may, may not be purchasing insurance?

So, hey, Ben, good morning. You know, as you think about President Trump's healthcare plan announcement last week, I think the plan, as we understand it, was really aimed at improving affordability. The themes seem to be including insurance plan account, bringing pharmaceutical prices and increasing price transparency. And to your point, potentially changing the way that instead of exchanges with tax credits, maybe a little bit more related to cash coming into healthcare savings accounts. It's a little early to get a sense for what aspects of that plan will come to fruition. We're monitoring it, as you can imagine, closely, as Congress picks those up and decides how they will react.

So at this point, it's a little early to try to size potential impacts related to those kinds of potential changes. We're just gonna have to see how they flow through Congress, and we'll update when we know more.

Your next question comes from the line of Matthew Gillmor with KeyBanc. Your line is open.

Hey, thanks for the question. I want to follow up on the exchange discussion for 2026. Can you give us a sense for how the exchange reforms and the subsidy expirations will impact the volume outlook? I, I'm curious if there's a drag that's being absorbed within the 2%-3% volume outlook from the exchange expiration. And can you also give us a sense for how you're thinking about the decline in utilization from folks that have moved to uninsured within your outlook? Thanks.

Sure. So if you just think about the, the modeling, and again, I, I think it's important to, to always start with context. You know, this modeling, these, these judgments are significant, and they're early. So, you know, part of our work as we go through the next days, weeks, and months, will be to test these assumptions against our actual experience. And so we're gonna know more, Matthew, at the end of first quarter, into second quarter, and we will keep you updated as we learn more. But yes, I do think that the overall volume of the company, although it's within that range of 2%-3%, has an impact here on exchanges. And if you think about the walk-through of the math, and, and so I'll just go back through it because I, I, I think it, it's instructive.

You know, we contemplate a 15%-20% decline in our HIX volumes in 2026, and that this volume will migrate to either employer-sponsored insurance or to uninsured. Of the decline in our volume, we assume approximately 15%-20% of those people will end up with employer-sponsored insurance coverage, which does carry a benefit, but the remaining will go to uninsured. For the ones that go to uninsured, we do anticipate a decline in utilization from those individuals no longer having coverage. We believe that that decline is somewhere in the 30% range, compared to their utilization of healthcare services when they had healthcare insurance through the exchanges.

The only other thing I might mention with the exchange population is, we find that they tend to utilize the emergency room in a way that's heavier than our traditional managed care or commercial population. So clearly, you know, that's the folks that become uninsured, even with this slight decline of utilization, that population as well, almost entirely uses the emergency room. So those will be some additional comments on the impact on volume.

Your next question comes from the line of Andrew Mok with Barclays. Your line is open.

... Hi, good morning. Outpatient surgery has declined year-over-year on a negative comp and moderated from the previous quarter. Can you elaborate on what you saw there, and if there are any payer categories you would call out, you know, driving some of that volume pressure? Thanks.

Hey, Andrew. Absolutely. You know, if I pull up out of just outpatient surgery, let me just talk about outpatient in general first, and then we'll touch surgery. But overall, on the outpatient side, you know, we were pleased with our outpatient revenue growth, which actually grew at a rate higher than our inpatient revenue growth. As a reminder, we kinda characterize our outpatient revenue into four categories: emergency services, outpatient surgery, which includes both hospital-based and ASCs, our ambulatory platforms, which include physician clinics and urgent care clinics, and other hospital-based outpatient services, including cardiology, diagnostics, and the like. All four categories experienced solid revenue growth over prior year in the quarter. A couple of notes on outpatient surgery specifically.

Our same facility cases were down about 50 basis points in fourth quarter over prior year, with hospitals being about flat and ASCs down about 1.5%. Payer mix, though, continued to be solid, with declines to prior year, primarily driven by Medicaid. In addition to the payer mix environment, we saw a decline in lower intensity cases like ENT. So as a result, we had good growth in net revenue and earnings in our outpatient surgery business overall, inclusive of both the hospitals and the ambulatory surgery center platform.

And Mike, let me just add to just the whole outpatient discussion. We continued to invest, you know, significantly in outpatient facility development. Just this past year, we added roughly 100 business units to our outpatient footprint across the company, and we find ourselves heading into 2026 and 2027 with significant capital in the pipeline that's geared toward, yes, some inpatient capacity and inpatient capabilities, but also quite a bit of outpatient development. Moreover, I would suggest that we have a better pipeline for acquisition opportunities inside of our outpatient footprint than we've seen in a few years, again, allowing us to complement the existing networks that we have.

And so when we look at overall revenue production of the company, I think, Mike, in the fourth quarter, our outpatient revenue as a percent of total was actually up on a year-over-year basis. Some of that is due to the components that Mike laid out, but it's also due to the fact that we're adding units at a greater pace than we are, obviously, our inpatient hospitals. And so the combination of that, we think, is important to our overall network resiliency, and by that we mean creating an environment where patients have easier access into the HCA Healthcare system.

Our payers actually have better price points for their members, such that they can get into the system with urgent care or a physician clinic or an ambulatory surgery center in a manner that is most productive for them as a patient, but also, for their insurance company. So we're pretty excited about the overall construct that's evolving for our company. I think today we have about 2,700 outpatient facilities or so. That continues to grow, and we see that, pushing toward our targets of, you know, 18-20 outpatient facilities per hospital as we finish out this decade. And that, again, will come through capital development and greenfield projects, but also acquisitions that make sense for us strategically.

Your next question comes from the line of Sarah James with Cantor Fitzgerald. Your line is open.

Hey, everyone, it's Gabby on for Sarah. I just wanted to double-click on the payer mix, and if you can share any color on how it played out compared to your internal expectations, specifically Medicaid impacting positively for the first time in 2025, and if that's something you expect to persist. Thank you.

Yeah, good question. So when I think about fourth quarter volume and the composition, and I mentioned this in the fall, you know, I think on the exchange side, we had a 2.5% growth. We were actually down a smidge sequentially from third quarter to fourth quarter. I think that really reflects a couple of things. One, and this also impacted Medicaid, is just the timing of the Medicaid redetermination process in the prior year. So we think we have fully sunsetted that timeline in prior year, and so you saw, you know, less exchange growth, and you also saw a bit more Medicaid volume growth.

Medicaid at 2.2% growth over prior year, you know, seems to be now back to kind of a normal growth rate, more consistent with our overall volume growth rate for Medicaid. The healthcare exchanges, you know, clearly we did not see a pull forward of demand as people were anticipating premium increases. But, you know, the 2.5% growth, we do believe, reflects that timing of the Medicaid redetermination process in prior year. Otherwise, I think, you know, we were generally pleased with our payer mix in the quarter and our overall volume growth. I mean, Medicare up 3.5%, and total equivalent admissions up 2.5%, I think, you know, really reflects a solid demand for the company as we finish the year.

Your next question comes from the line of Ryan Langston with TD Cowen. Your line is open.

Good morning. I guess with the balance sheet in a pretty good place and maybe fair to expect smaller hospitals and health systems seeing more detrimental impact from subsidy expiration and impacts from the One BBB.

... I guess now that the subsidies are expired, can you give us a sense on your M&A opportunities, if that pipeline is bigger, smaller, size of the assets, and then maybe kind of touch on capital budget priorities for 2026? Thanks.

So as I just mentioned, this is Sam. We have seen some acceleration in the outpatient space. In our pipeline through acquisitions is a little greater than it's been in past years. And we continue to execute on those appropriately, assuming we can get to a reasonable deal, and we've been able to accomplish that in certain circumstances. So, from that standpoint, that's been what we've seen mostly in the market, is in-market type transactions that are complementary to the network and again, create a better patient offering for us overall. With respect to hospitals and tax-exempt hospitals specifically, you know, we just haven't seen it yet, that there is a significant opportunity for the company that makes sense from a financial standpoint.

We continue to be well-positioned, as you just mentioned, with our balance sheet being in a great position. The capabilities of the company as a scaled player allows us to assimilate individual hospitals or hospital systems synergistically, but we haven't seen it. And so we obviously are open to those type of transactions, if and when they present themselves. We're fortunate, as we've mentioned in the past, that we do have great markets within HCA's portfolio overall, and the opportunities to invest in those markets organically is compelling. And we've been able to do that, again, in our outpatient space, but also with our hospitals. Our hospitals are running 73%-74% occupancy. We have many strategic positioned hospitals that need capital.

I think our capital is at an all-time high for approved projects that will come online in 2026, 2027, maybe early 2028. It's almost $7 billion of capital that's in the pipeline. Mike alluded to the fact that we're lifting our capital spending because of those circumstances, to somewhere between $5-$5.5 billion, and we will continue to evaluate that. So we're finding ways to invest productively, as well as use our assets productively with acquisitions, where appropriate, investing in our networks, and then looking for out-in-market opportunities, if in fact, they do present themselves in an appropriate way.

Your next question comes from the line of Scott Fidel with Goldman Sachs. Your line is open.

Hi, thanks. Good morning. Curious if you could talk a bit about your expectations for growth in terms of specialties and procedures in 2026. Maybe talk about some of the areas where you're expecting outsized procedure growth around some of the categories that, you know, we, we've certainly seen the company investing in, and then also just underlying growth due to, you know, different trends that we're seeing in the market. Thanks.

So, this is Sam. You know, we've said this in the past, and, you know, we have geography that's diversified in the sense that no one division in HCA generates more than 10% of the profits of the company. We also have similar diversification, if you will, in services, in that no specific service line generates any more than 15% of the revenue of the company. So given that, we haven't seen anything that's disproportionate, vis-a-vis, one other service line. I will tell you that we've seen reasonable demand for cardiac services. Some of that's technology-driven in electrophysiology. We continue to believe that that pattern will persist into 2026.

Obviously, within our emergency room, we continue to believe that our emergency room services are a very important component to community health and at the same time to our networks. And so we're investing in our emergency rooms, both from a patient care standpoint, an operational throughput standpoint, as well as a supply standpoint, to make sure we have sufficient resources in that particular area. And then within surgeries, I mean, we do have specific efforts afoot, but they're more generic, if you will. They're not necessarily specialty-oriented. I will tell you that our case mix continues to grow, and that growth is driven, we believe, by the acuity of the patients in many instances in our medical space.

So we see a lot of patients who have intense medical needs, creating more acute care requirements, whether it's intensive care or deeper med-surg capabilities, and that's part of what is going on in the communities that we serve as well. That's a bit of an overview. I don't have any other specifics for 2026 around different categories of growth that we expect, but we can try to get that to you if that's something that would be helpful.

Your next question comes from the line of Raj Kumar with Stephens. Your line is open.

... Maybe just in line, the kind of recent winter storm, maybe any operational disruptions to call out, and maybe kind of any considerations for the 1Q relative to annual guidance that we should be kind of thinking about related to any potential impacts there?

Well, it looks like Armageddon out here in Nashville right now. So, to say that we're aware of what the impacts are gonna be at this point, we're not. I mean, we've had snowstorms before. We had a massive storm in Texas a few years ago, and we were able to navigate through that. My sense is, as we close out January, we'll have some sense of the impact of the storm here in Nashville, as well as a few other markets for the company. But I don't think it's as significant in most other markets as we maybe are experiencing here. Having said that, we have plenty of opportunity, I think, to recover some of the challenges that, you know, are typical for these type of storms.

Your next question comes from the line of Steve Baxter with Wells Fargo. Your line is open.

Yeah, hi, thank you. Could you expand a little bit on the pause Texas Medicaid supplemental payments? It was mentioned during the guidance call. I guess, what exactly is happening there, and what needs to happen for that payment to come back online in 2026? And how much, I guess, would be your year-over-year impact? Is that driving? Thank you.

So, the pause program is called ATLIS. Stands for Aligning Technology by Linking Interoperable Systems. There was a commissioner that issued a termination notice on that program on their way out as they were leaving office. The new executive commissioner that is now in place has agreed to review that program, effectively putting it on pause versus terminating it. We don't know yet the timeline for this review, but we are encouraged that the department is willing to review the program and consider a potential reinstatement. From a sizing standpoint, you know, when I think about the overall guidance for 2026, and we've highlighted a $250 million-$450 million decline in net benefit from state supplemental payments. This Texas pause is about a third of that decline.

The other two that we noted that are the other two-thirds of that decline, one would be the retro payment from Virginia that we received in fourth quarter of 2025. And then the second is the Tennessee program, where we had 6 quarters of benefit in 2025 and only 4 quarters of benefit in 2026. So that's each of those three items are about a third of that decline of $250-$450.

Your next question comes from the line of Josh Raskin with Nephron Research. Your line is open.

Thanks. Good morning. I know this came up a little bit, but can you speak to your technology agenda and where you think the greatest opportunities are for HCA? And specifically interested in areas where you think AI can help already, looking at both the administrative costs, but also as well as the revenue enhancement opportunities.

HCA Healthcare (HCA) Q4 2025 Earnings Call Transcript

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