Quest Diagnostics (DGX) Q3 2026 earnings call transcript

I would like to introduce Domini, Chokshi, Vice President and Investor Relations for Quest Diagnostics. Please go ahead. Thank you and good morning. I'm joined by Jim Davis, our Chairman, Chief Executive Officer and President, and Sam Samad, our Chief Financial Officer. During this call, we may make forward-looking statements and will discuss non-GAP measures. We provide a reconciliation of non-GAP measures to comparable GAP measures into tables for earnings press release.

Actual results may differ materially from those projected. Risk and uncertainties that may affect Quest Diagnostics' future results include, but are not limited to, those described in our most recent annual report on Form 10K and subsequently filed quarterly reports on Form 10Q and current reports on Form 8K. For this call, reference to reported EPS referred to reported diluted EPS and references to adjusted EPS referred to adjusted diluted EPS. Growth rates associated with our long-term outlook projections, including consolidated revenue growth, revenue growth from acquisitions, organic revenue growth, and adjusted earnings growth are compound annual growth rates.

Now, here's Jim.

Thanks, Domini, and welcome everyone to this morning's call. I'm excited to discuss our strong performance in the third quarter and how our strategy to connect people and providers to innovative testing and actionable insights is illuminating paths for better health and generating shareholder value. We grew revenues 10% and adjusted earnings per share over 15% in the quarter. On continued strength across our physician, hospital, and consumer channels complemented by productivity gains from automation and AI.

Our robust organic revenue growth demonstrates that our solutions are fulfilling the expanding clinical care needs of an aging population, as well as the increasing number of people focused on prevention and wellness.

With these growth trends and our strong performance, we are again raising our guidance for revenues and earnings per share for the full year.

Now I'll provide more detail on how we executed our strategy across our key customer channels and operations during the quarter. Quest operates at the center of healthcare. We deliver solutions that make testing simpler and smarter for our core clinical customers, physicians and hospitals, as well as for customers in the higher growth areas of consumer health, life sciences, and data analytics.

In the physician channel, we delivered high single digit revenue growth in the third quarter on strong commercial execution and broad demand across our test portfolio. We also continue to grow in geographies where we've expanded our access in recent years through health plan collaborations and outreach acquisitions.

We are excited about our collaborations with personius medical care and opportunities to serve new customers based on our growing kidney diagnostics expertise. In addition, we are taking steps to serve the growing nephrology call point, and we're recently named the primary national lab provider for predialysis chronic kidney disease testing for a kidney care organization.

In the hospital channel, we grew revenues by double digits during the quarter on strong volume from Colab Solutions with Core Well Health in Michigan. Reference testing revenues grew in the mid single digits.

As a preferred strategic partner, Quest provides a range of solutions to help hospitals address continuing financial workforce and other pressures. From reference in Colab arrangements to outreach acquisitions, we improve quality, innovation, and efficiency.

Our role serving half of the nation's hospitals each year continues to fuel a robust pipeline of potential Colab collaborations and outreach acquisitions.

During the quarter, we finalized a definitive agreement to acquire select outreach assets from a longtime Colab customer, a leading health system in the northeastern U. S. We expect to close this transaction later this year. In the consumer health channel, we continue to generate robust growth as we delivered solutions that enable people to own their health. We are excited to announce the ability for iPhone and iPad users to order labs directly from the Apple Health app, which we see as a continuation of our strategy to deliver innovative solutions that will fulfill the growing interest in preventative health and wellness.

Users of the Apple Health app will be able to seamlessly purchase, schedule, and receive test results for over 50 biomarkers, including APOB and LP Little A, all within the app. The panel also includes biometric measurements, such as blood pressure and weight, at the same time blood is drawn at one of our 2,000 patient service centers. The offering will unlock greater health insights based on both biomarker and biometric data, and we look forward to the full launch of this service later this year.

At Quest, we often say that wellness is not the absence of sickness. It's health that is proactive, personal, and connected.

Through QuestHealth. com and our many collaborations, we are making wellness possible for more people. We expect our growth rate across consumer health to exceed 30% for the full year.

Turning now to advanced diagnostics, we continue to focus on delivering innovative tests in five key clinical areas, advanced cardiomotabolic and endocrine, auto-immune, brain health, oncology, and women's and reproductive health. During the quarter, we grew revenues by double digits for key tests across several of these key areas, including an advanced cardiomotabolic, hormone, and Alzheimer's disease.

As we approach Alzheimer's Disease Awareness Month in November, I'd like to share our view of this fast-changing area of dementia care. Many diseases today are highly preventable, thanks largely to diagnostic innovations enabling early diagnosis.

We envision a future where Alzheimer's is also a preventable disease, and primary care physicians guided by blood-based tests diagnosed and even treat the disease at a much earlier stage. We also believe our multi-biomarker approach can improve clinical evaluation of Alzheimer's disease and other dementias. Over the summer, we announced that we will soon add the FDA-cleared Roche-PTAU-217 tests to our portfolio. We launched a new AD to Tech panel with APOE, AMOLoid Beta, and PTAU-217 as these biomarkers provide different but complementary information to improve accuracy.

For instance, PTAU-217 can falsely elevate with some comorbidities, so a physician may need to refer to AMOLoid Beta to confirm a true positive for Alzheimer's. Blood testing for this highly complex disease is in the early phases of development, and we look forward to adding significant new biomarkers to our portfolio to support earlier diagnosis and treatment.

In Women's Health, we recently formed the first industry collaboration with Waters Corporation focused on providing access to on clarity self-collection kit through clinical, health plan, and consumer health channels, including patient service centers in the United States. This new collaboration builds on our experience providing HPV self-collection options for cervical cancer screening with a new convenient at-home option. We expect to introduce the Waters innovation to clinicians, health plans, and consumers of QuestHealth. com next year. I'd like to now turn to Operational Excellence.

We remain on track to deliver 3% in annual cost savings and productivity improvements through our Invigorate program. Automation and AI continue to be major drivers of improvements in quality, productivity, and efficiencies. As one example, specimen aliquotting involves splitting specimens into small portions prior to testing. The process traditionally requires several human touch points, raising the risk of errors that can slow down the whole testing process.

During the quarter, we extended an automated aliquotting solution to three drug monitoring labs to enhance quality and efficiency. Today, 10 of our labs use an automated aliquotting solution, and we plan to extend these capabilities to other labs.

We also recently began to use AI at our Clifton, New Jersey lab to scan water for signs of microbes and other impurities as part of our dialysis water testing services. The solution improves quality as well as efficiency, because it automatically releases specimens with negative findings, so our medical team has more time to concentrate on positive or questionable cases.

Lastly, Project NOVA, our initiative to enhance the experiences of health care providers and patients, recently advanced from the design phase to the solutions build phase, and we are on schedule to begin to deploy epic solutions in our first lab in the fall of 2027.

Our strong third quarter reflects the critical role lab insights play in our nation's health care. Before I turn it over to Sam for details of our performance and guidance, I want to share our perspective on the 2027 preliminary rate setting process under PAMA and steps we are taking to support passage of the results act.

Since PAMA was passed into law in 2014, we have been concerned about the flaws in the data collection process. After six years of PAMA delays by Congress, labs were required for a second time to provide their lab data in 2026. We remain deeply concerned that the data collection process this year was also flawed, and the resulting preliminary rate cuts for 2027 are excessive.

With ACLA, we continue to advocate for the passage of the Bipartisan Bicameral Results Act to permanently reform PAMA to ensure the data used to set rates properly reflects the market. Over 135 co-sponsors in Congress share our concerns about PAMA and our commitment to results. We have been told by our champions on the Hill to expect CBO to score the legislation by mid-November.

Securing a score is an important milestone as the sponsors work toward potentially including the results act in any year end package.

Results is the innovative reform our industry and patients need, and we are calling on Congress to enact this important legislation by years end. Now I'll turn it over to Sam for more details on our performance and guidance before sharing some final thoughts about the quarter. Sam?

Thanks, Jim. As Jim shared, we delivered the strong third quarter with consolidated revenues of $3.1 billion, up 10% versus the prior year.

Revenues for diagnostic information services were up 10.2% compared to the prior year, and 10.1% organically, reflecting continued strong growth in our physician, hospital, and consumer channels. Total volume measured by the number of requisitions increased 14.5% versus the third quarter of 2025, with organic volume up 14.4%. Our core mental health and personius medical care relationships contributed 9.5% to volume in the quarter, excluding these two relationships, volumes grew by 5%. As anticipated, total revenue per requisition was down 4.2% versus the prior year, due to the core well and personius business mix.

Adjusting for that business mix, revenue per requisition was up by 1.7% versus prior year, driven primarily by an increased number of tests per requisition. Unit price reimbursement remained generally flat, consistent with our expectations.

Reported operating income in the third quarter was $479 million, or 15.5% of revenues, compared to $386 million, or 13.7% of revenues last year. On an adjusted basis, operating income was $517 million, or 16.7% of revenues, compared to $458 million, or 16.3% of revenues last year. The 40 basis point improvement versus prior year was driven by organic revenue growth, partially offset by wage increases, and the business mix impacts from core well and personius.

Reported EPS in the quarter was $2.78 compared to $2.16 a year ago. Adjusted EPS was $3 versus $2.60 in the prior year, an increase of 15.4%. This increase was largely driven by strong organic operating performance.

Cash from operations was $1.49 billion a year to date, versus $1.42 billion in the prior year. This year over year increases the result of higher operating income in the current year, partially offset by timing of networking capital, and prior year favorability associated with a one time CARES Act tax credit. Turning now to our updated full year 2026 guidance, with our strong performance and continued momentum across our business, we are raising and narrowing our full year revenue and EPS estimates.

We now expect revenues to be between $12.065 billion and $12.105 billion, reflecting a growth rate of 9.3% to 9.7%. Reported EPS to be in a range of $10.21 to $10.31, and adjusted EPS in a range of $11.25 to $11.35.

Cash from operations to be approximately $1.9 billion, and capital expenditures to be approximately $550 million. Our 2026 full year guidance reflects the following considerations.

The revenue guide does not include any contribution from prospective M&A, other than what we have announced to date. Nova expense expectations remain consistent for the full year at an EPS impact of $0.25, with approximately 70% of these expenses to be incurred in the second half of this year. Operating margin is expected to expand versus prior year. Share count is expected to be slightly below 2025.

Adjusted effective tax rate is expected to be consistent with 2025, and interest expense is now expected to be lower than 2025.

Looking ahead, while we will provide 2027 and longer term guidance at a later time, I want to offer a few comments on the potential impact of PAML. The PAMA impact for 2027 is estimated at approximately 1% of total company revenues, consistent with our previous commentary.

The cumulative impact is expected to be less than 1.3% of total revenues for years 2027 through 2029. We intend to offset some of this anticipated headwind. Consistent with prior years, we will provide 2027 guidance in the context of our fourth quarter and full year earnings results early next year. We also look forward to sharing our long-term outlook along with updates on our growth strategies at our 2027 Investor Day on March 25th at the New York Stock Exchange.

We will provide additional information on this event over the coming weeks. With that, I will now turn it back to Jim.

Thanks, Sam. In summary, during the quarter, we delivered robust revenue and earnings growth on sustained demand from physicians, hospitals, and consumers, complemented by productivity gains from AI and automation. Revenues grew by 10% and adjusted EPS grew by over 15%. Demonstrating continued broad demand for our innovations and insights.

With our strong business performance and growth momentum, we are raising our revenue and EPS guidance for the full year. I want to close by thanking my close colleagues for their commitment and care to delivering diagnostic insights to create a healthier world, one life at a time.

Thank you, Jim. Now we'd be happy to take your questions. Operator?

Yeah. Thanks, Andy. Good morning. Let me just make a few comments on PAMA, the data collection process. And then I'll have Sam talk about offsets and things like that. So CMS yesterday released some very important data. I don't know if you all saw that. We had been pushing CMS since they announced the fee cuts to provide the information. And the volumes by the segment. So how much of the data came from independence?

How much came from hospital outreach? And how much came from PLLs? Recall in the last survey that over 90% of the data came from independent labs. And independent labs surely do not have 90% share of this market. On the new, what they released yesterday is that the independence represented 76.5% of the volume report. Again, it is way over estimating the share that independent labs have. Hospital outreach, which has a significant amount of share, hospitals owning outreach share, was less than 10% of the data reported.

So if you don't have information, strong volumes being reported by the hospital segment, again, it's going to shift the volume weighted median way to the left. So with this information, it emboldens us even further to push fast and furious for the Results Act. Now, what we're doing, our Trade Association, Quest and all the members are working, continuing to work hard to pass the Results Act.

We are eagerly anticipating a score by the CBO. We think that will come at some point in mid to late November. And once that score comes out, the primary committees, House Ways and Means, House Energy and Commerce, Senate Finance, they'll convene. And we're going to urge these committees to include the Results Act in some end of your passage, some end of your package. So we're going to continue to push hard for the Results Act. Again, we're emboldened even more because now we realize that again, the data collection process is way over estimated the share position of the independent labs.

Sam, let me give it to you to talk a little bit about our budgeting process and offsets.

Yeah, I think thank you and for the question. I think you asked about PAMA offsets. First of all, as we've mentioned on the call, the impact from PAMA, we expect to be next year, roughly 1% of revenues. That's largely consistent with our expectations prior to the data collection and the outcome of the data collection. As we have indicated repeatedly, I think in the past, we intend to offset a portion of this impact.

When we announce our Q4 results, provide guidance, we will give you a lot more clarity on what that means. Assuming that the PAMA impact is real and is materialized or is about to materialize because PAMA has essentially the prices have come down if that in fact were to happen. In terms of just qualitatively on 2027 impacts, I mean, first of all, as I said, roughly 1% of impact from PAMA, we intend to offset a portion of it. If we're going to look at many aspects of our, I would say, infrastructure support functions and look at potential efficiencies that we can generate beyond the efficiencies that we have been generating across our business.

We will not impact things that drive growth. We will not impact our front line. We will not impact our lab operations in any way or our ability to serve patients because utilization has been very strong. And we continue to be very pleased with the utilization that we're seeing. So, again, in terms of 2027, without giving you numbers, I would say the core law and personius impact, which we expect this year to be roughly 3% in terms of additional revenue growth, that obviously will not be a factor next year in terms of growth because we will lap these partnerships in October of this year. We've got the 1% impact from PAMA that, you know, if it were to happen, that would be a negative impact on revenue growth.

Utilization, we expect it to continue at the same levels that we're seeing. There's no reason to expect any moderation of the utilization that we're seeing. From a margin perspective, and we do expect to see some continued improvement on the margin from those two partnerships, core law and personius, as we enter 2027, as we said before, you know, those came with lower margins because of integration and investments, integration expenses and investments. But we expect improvement on those margins in 2027.

We will be making additional investments in NOVA as expected because we intend to launch, at least launch Epic in our first lab at the end of 2027. So we do intend to make some investments in NOVA that are beyond the investments that we've made in 2026. So there will be some additional expenses year over year regarding NOVA.

And from a pricing perspective, XPAMA, we expect to maintain this flatish outlook in terms of pricing across our third party payer partners.

Yeah. Good morning. And thanks, Michael. So let me start in Samkin's interject here. So the 5% you referenced here is our volume growth in the quarter X, for Senius and X Corwell. So it was 5% revenue growth, 6.6%, 5% volume growth, and 6.6% revenue growth. Now, as we look across the channels that we always talk about, our physician channel, our hospital channel, both reference in CoLab and our consumer channel, we are seeing strong growth across all three. In the physician channel, in the quarter, revenue grew above mid-single digits. So strong revenue growth, strong volume growth.

In our hospital reference business, again, this is reference, not CoLab, not Corwell. Our volumes were doubled digit in the quarter, revenue slightly less than that, but strong growth through our hospital segment. And as I noted in the commentary, our consumer channel all in, both Quest Health Direct plus our partnerships continue to generate growth north of 30% this year. So I would tell you, it's across all channels in our business, and we feel good about this going into next year.

Yeah, thanks, Erin. Look, we're really excited about the Apple Health Partnership. It is in what I would call data testing mode at this point. And we expect to go live. They expect to go live at some point later this year before the start of next year. I gave a lot of detail in the script. It's a $119 rack. The types of biomarkers we're going to do, like we do for other what we call employer health stuff. We do check the patient's weight and blood pressure in our PSCs. That is routine for other types of wellness work that we do.

And it's a seamless experience that one can use through the Apple Health app. I can't really provide a forecast because we'll have to wait and see after the launch how quick the update is.

But it's a great partnership. Look, the ability to combine biometrics with biomarkers, we strongly believe will unlock additional insights into what is going on inside the human body. Those insights then can lead to actionable actions for the patient consumer to take in order to prove their biomarkers, which ultimately leads to an improvement in their human health. So excited about it. Again, expect full launch later in the year, and we'll know more in terms of the uptake and we'll probably comment on that in January.

You asked Aaron as well, this is Sam, about pricing across consumers. So let me focus more on margins across consumer margins. Across our consumer business are actually a creative to our overall operating margins. So that's an important note, because as you see, this channel is growing about 30%, and it's really driving also a creative margins. The reason margins are a creative to our overall business, number one, no denials, no patient concessions.

So we benefit from that tailwind. In addition to the fact that these are much more dense recs, so we see sometimes 10 tests per rec and maybe even north of that in certain cases. So you see dense tests, dense recs that help our overall test per rec and also more creative margins. So that's the part that I wanted to make sure it's clear.

Yeah, I think Tykel, to be fair, it's a combination of the leverage you get off of volume. You know, this is a rather high fixed cost business. So an incremental rec drops down at a very, very nice contribution margin. But our invigorate program, you know, we've always targeted for our invigorate to offset wage inflation at 3%, probably north at 3% this year, somewhere between 3% and 4%. That's at least $120 million of pressure on us every single year.

I don't know that we mentioned field cost in the script, but we've given an estimate of $10 million for the year. It's actually going to be closer to $14 million based on prices going up again here in the third quarter, and we don't see them coming down at this point in the fourth quarter. So we're all setting that.

So our invigorate program continues to deliver. You know, you push through the organic volume, you deliver on the invigorate, and that's what leads us to 40 basis points of margin improvement in the quarter.

All right. So let me address the APA and SAML and give some comments on the additional AK. So in the quarter, we saw a reduction of about 11% in terms of rec volume from ACA exchange members. So requisition volume down 8%, but our test per rec on those requisitions was up 8%. So the net impact from a pure test standpoint was down 3%. When we then look at the types of tests that are being ordered on that requisition, it suggests a higher acuity patient. So these are higher revenue tests. So the net impact overall was maybe 10 basis points of revenue loss on the exchange. So it's next to nothing. So we're not really feeling an impact from it, like some of the health systems hospitals are reporting.

In terms of the additional AK filing, Sam, you can comment on it.

Yeah, thank you for the question. Yesterday, we learned of unauthorized access to a test ordering system used by certain clients who don't use an EMR. As we stated in the 8K that we filed this morning, this incident has not materially disrupted our business operations or our ability to serve physicians and patients. So the investigation is it's in its early stages. We're not in a position right now to provide any more information or take additional questions on the details at this time. But we will provide updates as appropriate as we go forward.

Thanks, Jim.

Okay, so again, on the data itself, 76 and a half percent of the data collected by CMS here in 2026, which was from the January to July period of 2025. Came from independent labs, which we know is significantly higher than the share that independent labs have. Only 9%, less than 10% came from hospitals, and we know that the share of the outreach market by hospitals, primarily from the physicians they own, is significantly higher than 9%. That obviously affects the volume weighted median calculation and in a very adverse way.

So again, with respect to the results act, it requires a CBO score. We expect that CBO score to come.

We're being told in the mid to late November timeframe. And then we go hard at work through the committees. Now, I can't give you a probability of results act getting included or the potential for another delay. What has seemed to become traditional at the end of the year is some type of healthcare package. There's always extenders that look to be extended.

And so our goal is to be included in that end of year package. Now, could there be a delay in the race? Hey, that's always a possibility.

And obviously, if we don't see results getting done, if the committees can't get together and get agreement on the new approach, then we'll push for a delay. Having said that, the House Ways and Means, I'm sorry, House Energy and Commerce had a hearing on the results act earlier this summer. It was a positive hearing. So we believe it has momentum. We've stated that over 135 congressional people have signed on to support it.

And so when Congress is back in session post the election, we're going to be hard at work. We're hard at work right now. We're visiting with staff members of both the Senate and the finance side that still remain in Washington, D. C. Now, in terms of the offset, look, we'd love to give you an upper and we're not being coy at all.

You know, we've said 100, 1% of 20, you know, 2026 revenue, totally in dollars. Can't give you guidance yet, but expect, you know, expect it to be another five, six hundred billion next year. So take 1% of that number. And that is the impact. Now, that's from Medicare. That's from Medicaid plans that are absolutely tied to the Medicare. It's not managed Medicaid, it's straight Medicaid plans.

And then there's a very, very small number of health plans that over the last five years, we didn't get off of a tie to that schedule. But over the last five years, the vast majority of our health plans, we've taken out any language that would tie their fee schedule. To a, to a Medicare fee schedule. So we roughly feel it's in that 1% range. Now, is 100% of that going to drop to the bottom line? Absolutely not. Okay. We're in the midst of our budgeting process. As Sam said, the things we're not going to touch are, you know, the variable cost structure of the company, which we produce invigorated savings on every year. We can't touch the bottom.

We can't touch logistics. We're not going to touch the, there's always going to be more efficiencies in the lab. But given the incredibly strong volume growth that we have right now, we have to keep the frontline physician staff in order to handle the volume. The best way to offset this is to grow our way out of it. Now, we're left with a billion dollars of other costs in the company outside of the work required to, to provide patient results. And as Sam indicated, we're in the middle of our budgeting process right now. We go through every program in the company and, you know, some will delay. Some we're going to keep because they're important to growth in 27, 28 and 29.

So there will be some portion that we offset. Again, we're not trying to be coy. We're working through our budgeting process and we will give you, you know, the firm update on our January. So key takeaway. Lisa says don't don't assume the full impact in your model. There will be an offset. We can't tell you what the offset is because we're working through our plans right now.

Yeah, look, I think we've always set a range of $100 to $120 million, not knowing the results of the latest data collection process, which again, we believe to be flawed. There were 1500 codes that are going to get some type of reduction.

And, you know, 775 of those Luke. You know, are going to face the maximum 15% cut. So it wasn't an exact science that we knew until the data came out. But there's again, 775 that get a 15% cut 1200 in total will get cut of the 1550. And so there's less than 15% codes on another, you know, roughly four to 500.

So that's how we sharpen the pencils. Now, did we expect it to be 15% on 775? No, we didn't. We didn't expect the data process to come out this way. And obviously based on the data, I gave you that 76 and a half percent of the data came from independent labs. We thought it would be a better process, but it wasn't. And we can't change that now. All we can do is push for the results.

I will give you one prediction, though, today. And that is the Brewers in six games. So thanks for the question.

Yeah. So thank you for the question. I mean, DSOs, first of all, let's talk about a couple of things which drive DSOs that maybe are part of your question and maybe to alleviate some of your concerns there.

We look at two key things that are drivers of our business and our ability to collect from our patients, from our customers. And those are bad debt and what we call patient price concessions. Bad debt is usually what we attribute to our inability to collect from certain client bill customers, mostly hospitals. And patient price concessions are the inability to collect from patients on whether it's their co-pay or if they're uninsured patients, that we haven't collected from at the time they come to our PSC, for instance, then there might be a bill that they owe them that we might not be able to collect from them.

Now, for those two bad debt and patient price concessions, we have not seen any meaningful increase on both of these. Patient price concessions are flat versus the same period last year. Bad debt is mostly in line with what we have seen traditionally. So there's no issues with regards to those two. DSOs are up about three days since your end. A lot of that is mixed, mixed driven by some of our client bill business, which usually has longer terms on it. That doesn't mean it's higher exposure, it just means we have longer terms and we collect on those longer terms accordingly.

There's also a nuance here with regards to less collection days in Q3 and so far this year in terms of less banking days than we had last year. So that also drives DSOs higher. In terms of what we expect, again, no meaningful impact because we are still seeing no meaningful, negative impact on patient price concessions or bad debt. Those are still in line with what we saw, what we see historically.

Yeah, thank you, Elizabeth. So let me start with the NOVA piece and Jim can talk about the PAMA impact. And I think you're referring to some of the health plan contracts with regards to NOVA.

So let me just make sure everybody is on the same page. We expect this year that it's going to be 25 cent impact. We expect that 70% of that impact is going to be in the second half, 30% of the first half. Our expectations between Q3 and Q4 is that there's a slight ramp in Q4 versus Q3. So if you think about that 70% in the second half, it's more tilted towards Q4 in terms of investment, which is fairly in line with the activity on the NOVA project overall. As we progress through this project, we are incurring more expensive around the sources that are involved in all the efforts that go into it as we now go from design to build stage.

Jim, did you want to refer to the PAMA or address it? Yeah, so again, on the PAMA impact, $120 million, which includes Medicare and straight Medicaid state fee schedules that are tied to Medicare. Look, we have probably over 700, maybe even closer to 1,000 contracts with various health plan organizations. I know we're used to the big five or six and all the blues plans, but there's a lot of various health plans out there. A very, very small minority of those contracts had some tie to the Medicare fee schedule.

Over the last five years or since the last, the first hit on PAMA, our organization worked incredibly hard to make sure in all of our contracts that language was completely taken out. And for the most part, it was. But I would call that additional, we look at our health plan book of business. Every year, we're getting some price increases. We've been saying on the calls that we've been flat, just slightly up.

So whatever that impact is, we'll be worked in the construct of the entire health plan set of contract negotiations. As you know, we routinely negotiate a third at 25%, a third to a fourth of all health plan contracts every year in our business. And so any addition beyond that 1% impact is worked within the contract of those negotiations.

Yeah. Thanks Kevin. Again, 5% in Q2 was 4.1% for the year. It's running 0.3%. You did know to shift in rep for rec increase from Q2 to Q3 and Q2 roughly 2.9% in this quarter 1.7%. Nothing. Here's what's driving it. As I mentioned on one of the questions. Our growth from the hospital reference business was up significantly. It was double digit volume growth in the quarter.

What we saw in the quarter, what was driving a bunch of that growth was a lot of single test recs from some very large health systems that were leveraging our LP little a business or leveraging our Alzheimer's business. And that, and so hospital reference work in general has a very low test correct. It's like 1.6 tests per rec.

We saw that number drop slightly because, again, a lot of organizations started to leverage our capacity for some very important test. The other thing we saw in the quarter, we haven't talked much about it, but was the cyclospora spur that the volume that came our way during the third quarter. Those were a lot of single test requisitions. The revenue on that test is pretty low 15, 16 bucks or somewhere in that range.

And so that's why we saw a shift down in the growth rate of our rep for rec. Again, it's still growing. It's growing at a very nice clip. It just slowed from Q2 to Q3. But again, nice volume increase sequentially Q2 to Q3 from 4, 1 to 5%.

So, Kevin, let me add a couple of points as well. I think to address the other parts of your question. I mean, first of all, just to close out on the rep for rec comment from Jim, within that 1.7% excluding poor law and personias within that growth of rep for rec, there is no negative price impact.

Okay, so that I just want to make sure that's clear prices relatively flat, which is in line with what we've been seeing in past quarters. With regards to volume, it is a clean volume quarter. The 5% has no unusual items with it within it. It doesn't have any weather or mostly no weather impact. We've had a pretty, I would say, good weather quarter here in Q3. So, there is no negative weather impact.

With regards to Hicks in the quarter, we did have a 10 basis point impact from Hicks. And Jim mentioned that earlier. Expectation for Q4 is that we've sized it as a 10 to 20 basis point impact from Hicks in Q4. But again, pretty modest impact, because what we're seeing is higher acuity patients staying, test for rec increasing with the patients that are remaining on the exchanges.

Yeah, thanks, Jack. And hope you're doing well.

This is Sam. So, you know, from a sequential standpoint. Yeah, so we were essentially up and I'm referring to operating margins here. We were up 20 basis points versus Q two of 26. So the past quarter.

You know, a couple of things. As we think about that, I mean, we did have the improvement in the margins on call well and for seniors helping us as we go from Q two to Q three. As we said, sequentially throughout the year, we're going to continue to improve the margin rate of those partnerships. So it's in line with that.

You know, some SG&A leverage that we saw in Q three, some benefits on SG&A that we talked about in our prepared remarks. But really nothing that's that substantial. But there's also a benefit related to supplemental deferred compensation, which is entirely driven by market performance. It's a market valuation of those investments in our supplemental deferred compensation plans. We saw a hit from that in Q two. We saw really no impact material impact from that in Q three. So that's a and I'll remind everybody that's a neutral EPS impact. Okay. It just impacts operating margin. But it did help Q three operating margins versus Q two. So those are the main things there, Jack. Nothing that's materially impactful in terms of business performance, except for the call well and for seniors, the sequential improvement in margins that we are pleased to develop.

Yeah, thank you for the question. We're not going to provide a breakdown right now in terms of how that breaks down between 28 and 29. Again, these are estimates. We're still going through the data and really analyzing it and getting, you know, more precise on these estimates, especially for 28 and 29. But I think what we've said captures, you know, on a, I would say it captures mostly the impact that we expect in those two years, which is a 30 basis point cumulative impact of revenues and a roughly 1% impact of revenues in 2027.

Yeah, thanks. And good question. I think as everybody know, we took on the laboratory testing associated with dialysis testing for end stage renal disease patients that go through for Cenius help.

And what it's done, and your question is really good, is it's opened up the door to a set of new relationships with a lot of nephrologists across the country, some of whom we were serving, but many of whom we were not serving. So in fact, we have fielded a specialized sales force to call on nephrologists and offer a broad set of, you know, cardio metabolic testing associated with either early stage kidney disease, mid stage or late stage kidney disease.

So that's why we were excited about the opportunity to begin with. And this just represents a whole new opportunity. It wasn't a segment of physicians that we routinely called on if they were part of a specialty group. Sure, we called on them. But it's getting a lot more focused by a specialized channel that we have in Quest Diagnostics.

And it should result in opportunities as we go into 2027.

And I think that was our last question. Jim, any closing remarks? Yeah, first again, thanks for joining our call today. We certainly appreciate all your questions and continued support. And we wish you a good day ahead.