Quest Diagnostics Incorporated (DGX) Earnings Call Transcript
November 10, 2020
Earnings Call Speaker Segments
Hi. Good afternoon, everybody. This is Erin Wright. I cover life sciences tools, diagnostics at Crédit Suisse. We're obviously happy to have Quest Diagnostics with us today at our 2020 Crédit Suisse Healthcare Conference. We're obviously in a virtual format this year. So it's a little bit different. If you do have questions for us and for the company, please feel free to e-mail me at erin.wright@crédit-suisse.com. And with that, I don't want to waste any more time, I do want to introduce Chairman, President and CEO of Quest Diagnostics, Steve Rusckowski. We also have Shawn Bevec on the line as well, who heads up the IR effort at Quest. And with that, I think we have a fireside chat format today, so we'll get started with some Q&A.
I think the first thing that is on everyone's mind is sort of the news yesterday in terms of a vaccine and how we should think about Quest and your positioning in a post kind of vaccine world. And I think that there's a lot of components to that question, but I wanted to give you kind of a general question to kind of get started here.
Yes. So thanks, Erin. Thanks for having us. And the news has just come from yesterday so we're digesting what it means and what it could mean for next year. And as we are always thinking about '21, we were thinking about '21, including the eventuality of a vaccine. So it doesn't surprise us that we now have the first that will be available and we now have clarity about when that will be. So when we think about look '21, we think about 2 components. One is the obvious one, what's going to happen with COVID testing. And if you think about '21 compared to '20, we'll have a full year of COVID testing in '21, which we did not have for '20. You remember, we essentially brought up our first test on March 9 and, for all intents and purposes, we didn't get up to nearly the volumes where we're at today until we get into the June time frame. So we'll have an easy comparison, if you will, in terms of volumes for COVID testing. So independent of vaccine, we expect to have a material amount of COVID testing in '21 because the vaccine will only be so available. There will be a large portion of the year, particularly as we come out of this year into the winter months of '21, that we'll still have considerable demand. And then as we get into the spring and the vaccines become available and hopefully, that starts to reduce the prevalence of the virus and as we get into the summer, we'll probably see some decline in the back half of the year. But at this point, that's pretty speculative. The second part of this is that we do believe that some of the vaccines will drive more serology testing, antibody testing. We think there will be a broader role. We need to -- we are working actively with those potential vaccine company candidates on what that will mean. But that's still unclear at this point, but we do believe there's got to be a role for more antibody serology testing in '21. So that's the first part, COVID. The second is what's going on with the base business. As we all realize, the second quarter was a little watermark for health care. We saw we're down by 50%, 60% in the month of May. Fortunately, we start to see a rapid recovery in June. We were hopeful going into the third quarter. And actually, in the third quarter, the recovery continued. And what we said on our earnings call was that we were down by about high single digits at the beginning of the quarter to mid-single digits through the end of the quarter from 2019 levels. And we're tracking that carefully given the third wave we're into right now. But in regards to base business, again, think about the comparison. Despite the recovery in the second half of the year, we still had a very deep drop in the second quarter. So we'll be down for the full year double digits in base business despite the recovery of the back half. And then when you compare that to what we'll see in '21, we'll have an easy compare for '21 as well. So we're tracking utilization. We're tracking all the trends. We're hopeful that we're not going to see those shelter-in-place lockdowns and that will affect health care in the winter months. But again, there's some uncertainty around that. So let me stop there and see where you'd like to go with each of those topics, Erin.
Yes, there's a lot to ask there. I think let's walk through a little bit of the fourth quarter dynamics, where I guess you feel somewhat comfortable to provide some guidance. It's still obviously broad. There's a lot of variables to keep in mind. But can you provide some of the upside, downside risks to the ranges that you gave for -- or what's implied for the fourth quarter in terms of base business growth as well as COVID-related testing?
Yes. Shawn, why don't you bring us through the assumptions related to our guidance?
Sure. A lot of the assumptions that we shared on the earnings call were really centered around sort of the midpoint of guidance. And basically, what we said is that we would expect that the base business trends would kind of continue throughout the fourth quarter. So no real improvement, but no deterioration either. And recall, we said that our base business exiting September was down sort of mid- to high single digits, some modest improvement into October. And then on the COVID testing side, we said that we expected about 90,000 tests a day on the molecular side, which is where we sort of ended up in the -- ended in the third quarter, and roughly 10,000 tests per day on the serology side. And then given the CMS announcement around the new molecular reimbursement, we had clarity at least that we would have that $100 reimbursement rate through the end of the year. And then as you know, there is a change, and it's tied to turnaround times. And then finally, we did acknowledge that we are tracking better than that, than that sort of midpoint scenario. But to really get you to the lower end or the upper end, it's really going to depend on the level of COVID molecular testing and/or what happens with the base business.
Okay. That makes sense. And then, in terms of your -- or what you're seeing in the market in areas where we have seen a spike in COVID cases, have you seen the response different? I mean, I assume you have, to some extent, relative to what we saw, for instance, back in March. And how is that impacting your thinking in terms of base business growth?
Yes. A couple of things. One is COVID testing on base. Two things. One is if you recall on the -- in the summer months, we had a spike in July. And we actually then saw some slowing of COVID testing in August and September. And we disclose every week what's happening with our volumes. And what you see is a gradual build, and we are prepared, from a capacity perspective, to be able to satisfy the demand that we see coming in. The demand is now building. So we have seen that in the last couple of 3 weeks as this third wave is hitting the country. The second part of it is we're watching that base business, and we were cautious and not sure what would happen with people using their physician or going into the hospital. But so far, we feel that the assumptions that Shawn just went through are valid, that it feels like things are stable for now. We still have 6 or 7 weeks left in the year. But so far, it's feeling like we're not seeing the abrupt change in health care delivery and people not going through doc's office or hospitals only seeing COVID patients. So so far, health care is delivering as we came out of the third quarter.
Okay. And then on COVID testing capacity, it sounds like you're where you need to be from a capacity standpoint. Is that safe to say? And then also, kind of where are you at in terms of capacity utilization?
Yes. No, we're not where we need to be. We continue to build the capacity. We're building it as fast as we could. This has been a march we've announced since March 9 when we ran out the first tests. What we said this week is we're at about 215,000 tests per day, call it, 1.5 million per week and that we need more capacity for a few reasons. One is the demand. It feels like it will continue to grow through the early months now of the winter and then into next year. There will be new demand sources presenting themselves in '21. There will be return to field or court with sports teams. There's going to be renewed interest in returning to campus, whether that's colleges or universities as well as K-12. A lot of the return to office hasn't really started yet. There was hope that we would be going back in offices in the fall. Many have pushed that out to beginning of next year. Some are thinking about the summer. There's all sorts of other nonclinical COVID venues that we believe they're going to drive some demand. So we're going to continue to drive demand. The second part of this is when we have more demand, it's also going to put pressure on turnaround times. So we want to make sure that we improve our turnaround times going forward. Having a little more capacity than demand allows you flexibility to move around that -- move around that demand to the right location to get the best turnaround times you can. And so we continue to believe that adding capacity will help us with that. And the third is where we've deployed pooling, it's dependent upon having prevalence rates within geographies that the mathematics works, the advantage of pooling. And when you get over about a 10% prevalence rate, it no longer holds up. And so that puts pressure on our capacity as well. We assumed in that capacity level is the assumption around some baseline level of prevalence throughout the country. And as we see in some states around the country, we're seeing prevalence rates going up to double digits, which creates a problem for the advantages of pooling. So we will continue to build it going forward because we need it for time. We need it for the demand that we see in the future. And also, some of these hotspots, if you will, can put pressure on pooling concepts.
Okay. And how do you anticipate repurposing some of this capacity longer term?
Well, first of all, it's allowed us to kind of look at our fleet of systems. And one of our platform providers is Hologic, and we're now working on the current platform, which is a good change for us. And we have plenty of uses for that platform going through forward. Not an issue. And the same is true with Thermo Fisher, with Roche. We're constantly looking at our laboratory locations. We're constantly looking at ways we can consolidate. We announced last year that we're consolidating our immunoassay testing, moving away from multiple platforms to one common platform provided to us by Siemens. And we're moving quickly through the deployment of that. And actually, part of that will allow us to consolidate one of our major facilities in New Jersey. We're building a brand-new facility, which would be the largest and most sophisticated facility in Clifton, New Jersey. And we're hopeful to open that up in the early to late spring of '21. So what we've done around the pandemic has accelerated. Some of our replatforming and so it's actually a positive consequence of what we've had to deal with from the pandemic.
Okay. That makes sense. And then you spoke to turnaround times. Do you anticipate there would be any issues in reaching that $100 price that a reimbursement rate that CMS has laid out there with the turnaround times that they're suggesting?
Yes. So right now, so there's 2 tests for this premium, if you will, that CMS has put in place on Jan 1. One is that your overall testing, both commercially and for Medicare and Medicaid, the majority will be greater -- better than 2 days. Right now, we're running better than that. So we meet that test. And as I've mentioned, as we build more capacity, it will help us with our ability to keep it at that level. The second is for the specific test for Medicaid -- excuse me, Medicare. It has to be 2 days or less. And right now, the majority of our testing is. So we're looking at improving that. So right now, as we sit, the majority of our testing -- excuse me, all of our testing would not hit the 2 days, but we're working on improving that. So we'll see where we are in the January time frame. And Shawn, right now, have we disclosed the percentage of our COVID testing that's Medicare billed?
No, we have not.
Okay. But Medicare is a portion of our COVID testing but a minor portion.
Would it be proportional to the base business in terms of size?
Medicare?
Yes.
Close.
Yes. It doesn't seem unreasonable.
Okay. But the commercial reimbursement rates would be comparable or follow suit, right?
It could. They're not tied to it contractually. We negotiated prices, obviously, looking at the Medicare rate. But they're not tied to that change on Jan 1 from CMS.
Okay. And so if we did see like a vaccine, does -- where -- does pricing then drop to where we sell kind of previously? Or how should we think about that dynamic?
Hard to tell. I mean, hard to tell. First of all, it feels like the demand will continue to build. We're not going to have the vaccine immediately. We all know that, right? We don't know what the availability is really, how quickly the supply chain will be able to respond, and then also, the execution of getting the vaccine to the right population. So that would take your -- the fraction of the U.S. population in the first half of '21. And then I mentioned this to be more demand for us all those areas of life that we haven't opened up yet that are going to need to have testing. I even you mentioned the airlines and entertainment. You think about the airlines trying to get back in the air. And we're working with some of the major airlines and cruise lines and all the different venues that have virtually closed. Testing will be demanded to bring those up. But I don't say they're nonclinical. And then we're talking about, as a country, more testing. And the question is, where do we need it? And how do we get it? And how much more do we need? We do have variation around the number of -- the prevalence of testing by state and some of these states that are that are lighting up right now, we might have to deploy more testing there. So I don't see demand lighting up, particularly in the first half, because of what I just mentioned. And then maybe in the back half of the year, if the vaccine is more broadly deployed and if the virus slows down as we saw it last summer and we start to see the decline the effects of the pandemic, we'll start to see demand come down. But for the full year, as I said in my introductory comments, if you compare it to '20, we're going to have a material amount of testing for COVID in '21.
Okay. And how are you thinking about the opportunity and traction for a multiplex test, RSV, flu, COVID combined? Is that something you anticipate meaningful traction for? And is that near term and then coinciding, obviously, with the flu season and also reimbursement thereon?
Yes. Yes. So we're happy we brought it out. There's no question when people present themselves the symptoms of the flu, you want to rule out COVID. We also are mindful that we -- and hopeful that there'll be a mild flu season for a lot of reasons. But we're starting to see some of that come through. But so far, it looks like we are off to a slow start with the flu season, which is bittersweet, obviously. And then as far as reimbursement, we haven't settled the reimbursement rate. And there's a range depending upon the add up to COVID plus the flu plus the respiratory panel, what it should be. But Shawn, you've indicated a reasonable price to consider for those that want to have some indication on what it could be?
Yes. There are some CPT codes out there for multiplex respiratory panels, and the reimbursement rate starts at roughly $140, $142 for just a few analytes. And it goes all the way up to as much as $400-plus when you have upwards of 15, 20 analytes. So we think at a minimum, the $140 rate would be a reasonable assumption as sort of a floor. But again, a reimbursement rate has not been established yet for those COVID multiplex panels.
Okay. That makes sense. And then PAMA, I did want to get an update there. Obviously, you've got some relief with the CARES Act. But at the same time, I mean, longer term, there's a question around have you earned some goodwill in sort of the market and from a government perspective in terms of your COVID response here and how does -- do you think that changes the conversation around PAMA going forward?
Yes. Yes. So the pandemic and our response to it and our visibility as the industry can't hurt us with the PAMA discussion. We're spending a fair amount of time speaking with senators and congresswomen and men that are actively engaged in the health committees and broadly throughout the United States on the importance of the lab industry. And fortunately, for us, the pandemic has made very clear the importance of the lab industry. And clearly, we're the poster child of what you need to have to fight a pandemic, and we need to keep strong as a country. So we're in a better place as an industry than we were before the pandemic. And with that said, we continue the multiple-pronged approach that we've had to make sure the next turn we have of updating the clinical and fee schedule is done in the right way. So as you mentioned, we do have the LAB Act. The LAB Act buys us some time. There will be no cut in '21, and that will give us time to get it right. And we're working with MedPAC on a recommendation to CMS at a better approach to gather the data to reflect the intention of congresses, which is to get our fee schedule adjusted to reflect the market. So that's happening. Second is we continue to have our lawsuit, and we were hopeful that we'd get a response from our lawsuit in '20. We're running out of time, but we're still hopeful we'll get a decision in the court on whether they agreed that it was done in the wrong way and CMS needs to reconsider how they implement the act. And then finally is we continue to push on just working, in general, with CMS on better ways of collecting the data. So we believe we're in a better place now that we've had the pandemic than we were before, and we'd like to get some certainty around PAMA going forward in '21. So that's where it stands.
Okay. That's fair. And then thinking about building cash flow here and opportunities from a market consolidation standpoint, do you think that there is going to be stepped-up opportunity on that front, either -- whether it's associated with COVID or PAMA or otherwise? But how should we think about your opportunity from an acquisition standpoint as well as partnerships, too?
Yes. So fortunately, we're operating at a better level from a cash perspective this year than we contemplated going into the year. And that will be hopefully true in '21. Our capital performance strategy hasn't changed. Even though we suspended our share repurchases in '20, we continued this year with providing a dividend. We continued this year with buying strategically aligned accretive acquisitions. And we continue to invest in the business, both from a capital -- capital budget perspective. I mentioned the big facility we're building in New Jersey. But also now, given some of the opportunities we see for growth to accelerate growth in '21 and '22, we're actually looking at making additional investments with some of the some of the extra cash that we see now, might get more where we are with the pandemic. And so as we come out of '20, we'll reevaluate where we are with share repurchases. We will stay with our strategy of giving the majority of our free cash flow back to our shareholders. And that has been through the dividend and also with a reasonable level of share repurchases to at least offset the effects of our equity programs on our own shares. And that will give us enough capacity to invest in the business as we've done in the past. But also, we do think there's going to be opportunities for further consolidation. We are seeing a higher level of interest now than several months ago, with hospital systems reevaluating or evaluating their laboratory strategy. And despite the pandemic, you've seen here in a couple of deals that we've done, in Memorial Hermann in Texas and also Mid-Atlantic (sic) [ Mid America ] Clinical Laboratory in Indiana are 2 examples where those systems were evaluated or evaluating what they need to do from their lab strategy and decided to partner with Quest Diagnostics. And we see a growing level of interest, as I thought we would, because there's been a lot of pressure on integrated delivery systems with the pandemic. And I think that's just going to help with our strategy to consolidate. And now we have the cash and balance sheet to take advantage of those if they present themselves, so we can make some money for our shareholders.
And has anything changed in terms of your long-term targets in the way of acquisition contributions to top line growth over the next several years in light of some of these dynamics?
No. We said 2 years ago at our Investor Day, we felt that given what we see happening in the marketplace with PAMA, what's happening with commercial payers, what's happening with consumer payment of health care that it would be a catalyst for further consolidation and therefore, we should see about 2% growth per year through acquisitions. We believe that's still a reasonable goal for us to have, and we'll see how this develops and see if there's more as we go forward. But right now, that 2% seems like a reasonable goal for us.
I know one of the things that you brought up in the past is that having those conversations with hospital administrators just takes time, and it's an evolving relationship. And so is that truly expedited in this sort of environment? I think you kind of mentioned that a little bit. But is that just going to be more of a focus rather than the outright M&A of smaller regional labs?
Yes. They usually go hand in hand. Typically, when we have one of these conversations, it is this 3-legged stool, where we talk to them about their most sophisticated testing they send out and they rely on us as more of their primary provider for that. And then second is given our methodologies and know-how and purchasing power, can we help them save some money with their acute care laboratory? And then when we do that, it raises the question, do they really want to be in what's referred to as the outreach laboratory business and should they consider monetizing? So in the case of Memorial Hermann this year, they decided to monetize their laboratory outreach, rely on us for their possible inpatient and efficiency gains there and as part of that, bring more of the sophisticated testing in our way as well. So it provides a better overall relationship. And I would argue that it's not just a productivity opportunity. It's an effectiveness proposition as well that is what -- the conversations lead itself to as if we have better diagnostics and better comprehensive workups, then we're going to get better clinical outcomes. And Quest Diagnostics, can you help us with our clinical practice, either on the physician side of the house or the acute care side. And so that's where it becomes much more strategic. Many delivery systems are looking at that triple aim, where great clinical outcome, great experience and great productivity. And we can help them with that overall goal as well.
And then I think a bigger question or a bigger picture question that we're getting a lot lately is sort of what structural changes for the lab business in a post-COVID world, in a vaccine sort of environment, like what -- how should we be thinking differently, if at all, about sort of the long-term underlying growth trends, volume trends across your business? Is it -- do you see better traction from a consumer-driven effort, for instance? Or are there other initiatives that you can expedite in light of this that makes sense in terms of your longer-term strategic vision over the next 3 to 5 years?
Well, 2 things. One is I do believe this will lead to more consolidation where we hit on that. And then second is what we are seeing is the disruption that's being caused by telemedicine. And when you think about a world where more of those doc visits are done with a virtual -- in a virtual setting, then those virtual settings, whether it's a telemedicine provider that has both the platform or -- and the health care provision or a platform provider, they're not going to have hundreds of laboratories in their network. So they're going to have a more finite set. They're clearly going to rely on the best-known and best-providing and best-performing laboratories. And therefore, that should serve us well going forward. And we were very well positioned before the pandemic, and we're actively working to make sure we have a better position. And in that world, we do see a growing direct-to-consumer opportunity. We brought up that business a couple of years ago. It's doing very nicely on the base business, but also with COVID now with serology first. And now with COVID, we're seeing that continue to grow. So there is going to be a growing need for consumers to have their basic laboratory testing done as well as some of the specialized testing like COVID done direct with Quest Diagnostics and not go through their physician where they can, within those states that allow it. Or if they do need a physician's order and an oversight, then we can provide that electronically.
Okay. That makes sense. And can you give us -- I guess, digging into that a little bit more, can you give us an update on like Safeway, Walmart and your other consumer-direct kind of [ relations ]?
Yes. So those retail relationships continue to build. We believe it's really important to have a great experience. And the more we can put our patient service centers into those retail settings, the better we are. We continue to build our presence with Walmart. Safeway continues to go well. And we had very strong working relationships in the past with CVS, but more so during the pandemic. We're very present in many of their drive-throughs as they expanded in health care as well. So those continue to build. And in those locations, yes, they will provide us with patient service centers so we can do draws, but we're also intending that those are -- will be great settings for us to do basic health care services. And when you think about the pandemic, one of the unfortunate consequences of it is many people aren't getting their basic health care services. So they haven't checked their blood pressure. The haven't checked their meds. They haven't had their retinal exams for diabetes. So there's more and more gaps in care that have happened, and we're going to have to catch up. And so I think there's going to be more and more opportunity for us to use those convenient locations where consumers and patients go to and tag on to what the opportunity for them to have some of their basic health care taken care of by a partnership like we have with Walmart and others.
What does that take from an investment standpoint to broader expand some of those services, whether it be at your patient service centers or in connection with the Walmart or other retail facilities? What -- can your local phlebotomists do your basic vital testing?
In many cases, they can. We have the expansion of their license to do some of the basic biometrics. We offer today before the pandemic a wellness product that we sell to employers. The product is called Blueprint for Wellness. And in that wellness product, some of the most basic biometrics are done by our patient service centers, and that would include blood pressure, weight, waist circumference. And that could include some other diagnostics as well as we go forward. So it does require some more training, outfitting those facilities with the devices and the space, but we do have that physical space and that capability as a platform to expand what kind of services we can provide there. With health care workers that are much less expansive than the traditional health care workers that might do this in a doc's office or at a hospital.
And you could potentially incorporate telemedicine offerings there, too, I would assume?
Exactly. Exactly. If you need a consult with the doc, we can do it virtually. And there's no reason why we couldn't set that up in the 2,000 patient service centers that we have. .
And then it doesn't get brought up as much lately just because of all the COVID noise, but I did want to bring up kind of commercial payer relationships, the PLN, UnitedHealth network. I mean, how is that panning out relative to your expectations, if you can even understand or decipher in this sort of environment?
Yes. So we got back in the network in '19 with UnitedHealthcare and with Horizon. What we said is we now have the best access we've had for over a decade. It affords us not a 1-year opportunity, but a multiyear opportunity. We continue to work picking up share, if you will, with UnitedHealthcare. That relationship continues to be very strong. I was actually just out in Minneapolis a couple of weeks ago, so continue to work it. You also probably have seen that we changed our relationship with Anthem in a better way. Some of it modeling after some of the work we're doing with United. So that gathers presence. And I would just say, just in general, our working relationships with the national health care insurance companies as well as the regionals has really gotten very strong. And I would say, never been better, but we're always getting better. Okay? So the biggest opportunity we have is to continue to have those strong value propositions with them, continuing to work on the network design, benefit design incentives,to get more and more of the share of laboratory services with a company like Quest Diagnostics, which, in our mind, has the value proposition which is really second to none, great quality, great service at very competitive pricing. So therefore, they really need just a small handful of laboratories to serve their membership, and we want to help them with that.
And have you really seen this drive volume as yet?
Yes. We're picking up share. We picked up share in '19. We indicated in the first quarter, as we entered '20 in the January and February time frame, we saw a continuation of that share gain. And so we were optimistic. Then unfortunately, there are so much smaller noise in the second quarter with the slowdown overall in health care. But we're still tracking the overall share of wallet and market share. We feel like we continue to make progress. And we continue to work all those active strategies with the payers to achieve what we're trying to achieve. So we're not done yet but making good progress.
And any other exclusive contracts that you have out there that could come up for renewal that we should be aware of?
Not that I can recall. Shawn, anything we haven't mentioned or should mention?
The 2 largest contracts left where there's a national exclusive relationship with one of the national labs would be Florida Blue and then IBC outside of Philly. So we're the exclusive with Florida Blue. Our nearest competitor has the IBC contract. Those are multiyear contracts. So we'll have to see as those come up for renewal.
Okay. So nothing has changed on that front.
Just -- the last point on that would be that both of those health plans have roughly 3 million lives each. So just to give you a sense of the size.
Okay. Great. And then one last one. Serology testing, I guess it hasn't like meaningfully ramped up yet, but maybe that's to come. Can you just remind us on sort of the profit profile, pricing dynamics across the serology testing opportunity?
Yes. So we do think there's an opportunity in front of us. We do believe that the vaccine and some understanding what portion of the population should get the vaccine, whether the vaccine works or not, we think we can add value with some of our testing, particularly the serology test that's on the market and expansions of it. So that's there. We have plenty of capacity. We're readily underutilizing the capacity. We have close to 200,000 tests per day capacity, and we're using about 10,000 to 15,000 per day. So plenty of capacity. And it's highly leveraged based upon the rest of Quest. It's a blood test so leverage that, draw or leverage that visit, and we could greatly expand its utilization. So the reimbursement for it hasn't changed. We're at $42. And we think that's the right level it should be at, given what we provide to the marketplace, and we have get received any indication that will change. So that's all in front of us.
Okay. All right. Well, thank you so much for the time. I really appreciate it.
Okay. Thanks, Erin. Appreciate it.
And hope you have a great day of meetings.
Yes, you, too.
Thanks, Erin.
Bye-bye.
Thank you.
Bye.
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