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spk30: Good day, and welcome to the Addis Homecare's first quarter 2024 earnings conference call. All participants will be in a listen-only mode. Should you need assistance, please signal a conference specialist by pressing the star key followed by zero. After today's presentation, there will be an opportunity to ask questions. To ask a question, you may press star and one on a touch-tone phone. To withdraw your question, please press star then 2. Please note this event is being recorded. I would now like to turn the conference over to Drew Anderson. Please go ahead.
spk29: Thank you. Good morning and welcome to the Addis Home Care Corporation first quarter 2024 earnings conference call. Today's call is being recorded. To the extent any non-GAAP financial measure is discussed in today's call, you will also find a reconciliation of that measure to the most directly comparable financial measure calculated according to GAAP by going to the company's website and reviewing yesterday's news release. This conference call may also contain forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995, including statements, among others, regarding ADIS expected quarterly and annual financial performance for 2024 or beyond. For this purpose, any statements made during this call that are not statements of historical fact may be deemed to be forward-looking statements. Without limiting the foregoing, discussions of forecasts, estimates, targets, plans, beliefs, expectations, and the like are intended to identify forward-looking statements. You are hereby cautioned that these statements may be affected by important factors, among others, set forth in ADIS filings with the Securities and Exchange Commission and in its first quarter 2024 news release. Consequently, actual operations and results may differ materially from the results discussed in the forward-looking statement. The company undertakes no obligation to update any forward-looking statement, whether as a result of new information, future events, or otherwise. I would now like to turn the call over to the company's chairman and chief executive officer, Mr. Dirk Allison. Please go ahead, Dirk.
spk06: Thank you, Drew. Good morning and welcome to our 2024 first quarter earnings call. With me today are Brian Poff, our chief financial officer, and Brad Bickham, our president, chief operating officer. As we do on each of our quarterly calls, I will begin with a few overall comments and then Brian will discuss the first quarter results in more detail. Following our comments, the three of us would be happy to respond to any questions. Yesterday, we announced our results for the first quarter of 2024. These results highlight the continued strong financial performance by Addis. This performance is made possible by the hard work and dedication of all our employees as they continue to provide quality care to our clients and patients by helping to fulfill our mission of taking care of individuals in their homes. As I have said many times in the past, I'm very thankful for all that the employees do for our company. As we announced yesterday, our total revenue for the first quarter of 2024 was $280.7 million, an increase of 11.6% as compared to $251.6 million for the first quarter of 2023. This revenue growth resulted in adjusted earnings per share of $1.21 as compared to adjusted earnings per share for the first quarter of 2023 of 97 cents, an increase of 24.7%. Our adjusted EBITDA of $32.4 million was an increase of 24.6% over the first quarter of 2023. During the first quarter of 2024, we continued to experience strong cash flows, allowing us to reduce our debt balance to $101.4 million. At quarter end, our cash balance was approximately $77 million, which together with our availability under our existing credit facility, continue to give us the financial flexibility to be opportunistic as we see potential acquisitions come to market. It remains our primary focus to use our financial capacity to acquire strategic operations that align with our overall growth strategy of adding clinical services where we have strong personal care presence, enhancing our existing personal care markets, and adding new personal care markets where we can enter at scale. We also believe this acquisition strategy will continue to strengthen our ability to participate in value-based contracts with our payers and to adapt to potential reimbursement changes. I want to provide some thoughts related to the final Medicaid access rule that was issued on April 22. As we anticipated, the proposed 80% compensation requirement was retained in this rule despite an overwhelming number of comments submitted detailing the challenges this would present. Of course, we and other providers are disappointed with the results, even though we support the overall policy aims of providing higher wages and increasing access to home and community-based services. However, several significant positive changes were made in the final rule, and I would like to touch on a few of these. First, the implementation period was extended by 50% from four years to six years. Realistically, we believe this substantially increases the likelihood that the rule will not be implemented in its current form or possibly at all for a variety of reasons, including as a result of legal or congressional action or potential administrative changes in either of the next two presidential election cycles. As important, this extended implementation timeframe give states and providers a better opportunity to plan and adjust to the specific requirements of any rule that may ultimately be implemented. Second, a number of technical adjustments were made between the original draft and final rule, which both clarify and improve the definition of allowable costs for providers like ADDIS. For example, certain costs such as training, mileage, and PPE will be deducted from total payments before calculating for calculating compliance with the 80% requirement. Similarly, refunded or recouped payments will be excluded. Also, the categories of items constituent compensation have been clarified to include PTO, retirement, insurance, including workman's compensation, and tuition payments not previously addressed. The rule also clarified and expanded certain tasks that now count as direct care work and expands the definition of direct care workers to add clinical supervisors. All of these changes combine to lessen the potential impact of the rule on our margins. While these items were addressed in the final rule, there was still not a complete specific set of definitions, although additional commentary was included in an effort to protect against the possibility of setting a definition that could be construed as too narrow. We believe this gives states a certain level of flexibility in working with providers in deciding on other potential costs that should be considered in the calculation. Stepping back to the bigger picture, there are other points worth making on the rule and its impact. We continue to believe the rule disproportionately impacts small providers and encourages scale, which will lead to further consolidation opportunities. The rule allows states to develop separate minimum compliance levels for small providers and to provide hardship exemptions, but two important factors should be noted. First, the exemption and the hardship exception both require states to create additional reporting requirements, and these requirements can only be waived by CMS at its option to the extent applicable to less than 10% of providers. Even more crucially, The rule requires states to develop a plan subject to CMS approval to reduce in a reasonable period of time the number of providers that qualify for these exemptions or exceptions. At best, we believe these are temporary Band-Aids, not long-term solutions for small providers. Second, and I want to emphasize this point, small providers relying on these provisions will be able to pay less to workers. but they will be at a competitive disadvantage for labor with large providers like Addis who will likely be required to pay a higher rate. We believe these exceptions will provide us more access to labor, which, as we know regularly, is the primary limiting factor on revenue growth. So I'll repeat what I said last quarter. We believe that personal care providers must have scale in each state where they operate to be successful under the rule as finalized. This will not only allow the larger providers to spread their costs over a bigger revenue base, but also will provide more opportunity for meaningful advocacy with the states in which they operate, while also promoting a favorable hiring and retention dynamic. Before I leave this topic, I also want to note that we expect both Congress and individual states to review their options and take actions they believe are appropriate in reaction to the rule. Individual members of Congress already have issued calls to withdraw the rule or have introduced legislation to block finalization of certain aspects of the rule and more may follow. Some states may institute litigation to block the rule, the outcome of which is unknown. States may also look at opportunities to increase funding in an effort to meet the aims of the rule, causing less impact to providers and clients. So in summary, six years is a very long time. We expect many more curves in the road before then, but we are confident in our strategic approach to both manage and thrive in this dynamic landscape. We are currently in the process of looking at personal care opportunities that would give us a larger presence in our current state. We are also looking for opportunities where we can enter new states in a material way. Personal care is a valuable service to our elderly and disabled population, and we are optimistic that states will evolve their programs to remain viable regardless of the rule. During the first quarter, we continued to experience good results related to our ability to hire caregivers especially in our personal care segment. During the first quarter of 2024, our personal care hiring was equal to what we saw in the first quarter of last year at 84 hires per business day. Sequentially, our hires per day were up 5% over the fourth quarter of last year, despite some weather difficulties in January. In addition to our strong hiring numbers, we continue to see consistent momentum in the Starts for Business Day over the past few quarters. As for our clinical segments, hiring has continued to improve over what we experienced in the early part of 2023. As we have over the past couple of years, we continue to utilize the funding we received from the American Rescue Plan Act, or ARPA. To date, we have received approximately $38 million of which we have over 13 million remaining to be utilized. We continue receiving these funds in the first quarter of this year, and as we have previously shared, these funds have been helpful with our caregiver recruitment and retention efforts to support the delivery of personal care services. In addition to utilizing the ARPA funds for direct recruitment and retention of caregivers, we continue to utilize the funds to improve our caregivers' experience through the implementation of enhanced caregiver training and continued development of a caregiver application that we believe will improve our retention and overall service delivery. In our personal care segment, our services continue to receive favorable reimbursement support from many of the states in which we operate. Although some of the federal financial support to states have been reduced, we feel confident that personal care services continue to show real value to state Medicaid programs as well as our managed care partners through a reduction in overall cost of care. As for our clinical segments, effective October 1, 2023, Medicare hospice reimbursement was increased by approximately 3.1%. On January 1 of this year, home health Medicare reimbursement was increased by approximately 0.8%. Although this year's home health rate increase was below what is required to cover ongoing operating cost increases, we believe that traditional Medicare home health reimbursement pressures are likely to moderate over the next few years. Now let me discuss our same-store revenue growth for the first quarter of 2024. For our personal care segment, our same-store revenue growth was 9.3% when compared to the first quarter of 2023. During the first quarter of 2024, we saw personal care same-store hours for business day remain flat as compared to the same period in 2023 as we experienced difficult winter weather in a couple of our key markets early in the first quarter of this year. We did see a sequential improvement in hours each month in the quarter as we moved past these early weather challenges. We continue to see our investments in hiring and scheduling optimization initiatives take hold and contribute to our hours growth. Turning to our clinical operation, our hospice same store revenue increased 5.8% when compared to the first quarter in 2023. While our same store ADC was down 0.9% when compared to the same quarter last year and flat sequentially, we did see a nice improvement in our same store ADC during February and March. This ADC growth has continued into April. As of the end of the first quarter of 2024, our hospice medium length of stay, exclusive of our journey care and recently acquired Tennessee quality care operation, was 27 days as compared to 25 days for the fourth quarter of 2023. For comparison purposes, we have historically excluded our journey care operation as it has a higher proportion of shorter length of stay patients due to our inpatient units in the Chicago area. We are encouraged by the steady sequential improvement in both ADC and admission volume in our hospice segment early this year and anticipate those favorable trends continuing in 2024. Our home health segment, same store volume, decreased 3.1% over the same quarter in 2023, but did increase 1.7% on a sequential basis. As most home health providers have experienced, we continue to be affected by the movement of Medicare beneficiaries from Medicare Pay-per-Service to Medicare Advantage, but we feel we may be seeing a leveling off of this shift in the market we currently serve. We are continuing to work with our Medicare Advantage payers to obtain higher per visit rates as we work in parallel to transition to episodic or case rates. We are also continuing to focus on process improvements to increase our efficiency around staffing, referral conversion rates, and collections. While home health is our smallest segment and only 5% of our revenue, we feel it complements both our personal care services, particularly where we participate in value-based contracting models, and our hospice services by allowing us to provide the full continuum of home-based clinical care. Acquisitions will continue to be an important part of our growth strategy at Addis. Even with the various challenges we have seen, we are committed to using our capital to make sure we meet the strategic goals we have publicly discussed. With the Medicaid access rule finalized, we are focused on opportunities that will help us obtain the needed skill in our current personal care markets to operate more efficiently. We are also open to entering select new states with personal care services. If we can do so through transactions which will give us the scale we feel is important to be successful under the new Medicaid access rule. As for our clinical segment, we are focused on home health opportunities which operate in certain of our personal care states where we have the opportunity to continue our growth in value-based care and to complement our existing hospice operation. As far as our value-based care efforts, I noted last quarter that we continue to gather data which demonstrates material reductions in both emergency room visits as well as percentage of patients readmitted to the hospital at various post-discharge intervals. We continue to believe our success is due to our ability to provide both non-clinical personal care services to identify changes in condition and clinical resources as needed for specific skilled patient care interventions. We are now utilizing this information as part of our conversation with various Medicare Advantage and commercial payers to demonstrate how ADDIS can be an integral part of providing quality, cost-effective care to plan members that can reduce the overall medical loss ratio by simultaneously improving overall quality of care. During the first quarter of 2024, we began to use our new value-based care management system. We are excited about this technology as it will allow us to increase both the scale and efficiency of our value-based program, which we believe is important to further develop these types of relationships with our large payers. Before I close my remarks, I want to once again say how proud I am of our team for the care they are providing to our elderly, and disabled consumers and patients. There is no question that the majority of clients and patients want to receive care at home, which remains one of the safest and most cost-effective places to receive this care. We believe the heightened awareness of the value of home-based care is favorable for our industry and will continue to be a growth opportunity for our company. We understand and appreciate that our operations and growth are dependent on both our dedicated caregivers and other employees who work so incredibly hard providing outstanding care and support to our clients, patients, and their families. With that, let me turn the call over to Brian.
spk21: Thank you, Dirk, and good morning to everyone. Addis had a strong start to 2024, continuing our momentum with an impressive financial and operating performance for the first quarter. Our results included solid year-over-year organic growth of 9.3% in personal care services, well above our long-term expected range of 3% to 5%, but in line with our expectations. This growth reflects steady volumes as well as continued favorable rate support for personal care services in some of our larger markets. We were pleased to see consistent positive year-over-year trends in our hospice business in the first quarter, inclusive of our Tennessee quality care acquisition. Our hospice same-store revenue growth of 5.8% was our third consecutive quarter of sequential increase, and the highest percentage increase we have seen since prior to the COVID pandemic. We continue to see favorable admission trends as we have experienced three consecutive quarters of sequential same-store admission growth. Same-store revenue for our home health services, which is 6% of our business, was down 15.1% from the same period a year ago as we continue to intentionally limit admissions from payers with less favorable reimbursement rates. We remain focused on maintaining a consistent margin profile in our home health business as it complements our personal care and hospice services. Acquisitions remain an important part of our growth strategy with our primary focus on markets where we can leverage our strong personal care presence and add clinical services or enhance and expand our personal care services in strategic geographies. With our size and scale and the support of a strong balance sheet, we are well positioned to execute our strategy and we are optimistic we will see attractive acquisition opportunities in 2024. As Dirk noted, total net service revenues for the first quarter were $280.7 million. The revenue breakdown is as follows. Personal care revenues were $208 million, or 74.1% of revenues. Hospice care revenues were $55.9 million, or 19.9% of revenues. Home health revenues were $16.9 million, or 6% of revenue. Our first quarter results include the operations of our most recent acquisition, Tennessee Quality Care, a provider of home health, hospice, and private duty nursing services, which we acquired on August 1, 2023. Other financial results for the first quarter of 2024 include the following. Our gross margin percentage was 31.4%, compared with 31.2% for the first quarter of 2023. As expected, gross margin was affected in the first quarter of our annual merit increases and the annual reset of payroll taxes, as well as compression from certain collective bargaining negotiations. In the absence of any additional mixed changes from M&A, we anticipate our gross margin percentage to remain materially stable over the next few quarters and consistent with our historical annual patterns. G&A expense was 21.8% of revenue compared with 22.4% of revenue for the first quarter a year ago and a decline sequentially from 22% in the fourth quarter of 2023. Adjusted G&A expense for the first quarter of 2024 is 19.9%, a decrease from 20.8% in the comparable prior year quarter and down sequentially from 20.6% in the fourth quarter of 2023 primarily as a result of lower legal expenses and the normal timing of certain accruals. The company's adjusted EBITDA increased 24.6% to $32.4 million compared with $26 million a year ago. Adjusted EBITDA margin was 11.6% compared with 10.4% for the first quarter of 2023, reflecting continued leverage on our increasing revenues. With a solid start to 2024, we continue to expect our adjusted EBITDA margin percentage for the full year to remain above 11%, consistent with 2023. Adjusted net income per diluted share was $1.21 compared with 97 cents for the first quarter of 2023. The adjusted per share results for the first quarter of 2024 exclude the following. Acquisition expenses of 12 cents and non-cash stock-based compensation expense of $0.12. The adjusted per share results for the first quarter of 2023 exclude the following, acquisition expenses of $0.06 and non-cash stock-based compensation expense of $0.13. Our tax rate for the first quarter of 2024 was 25.7% in line with our expectations. For calendar 2024, we continue to anticipate our tax rate will be in the mid-20% range. DSOs were 34.6 days at the end of the first quarter of 2024, compared with 39.1 days at the end of the fourth quarter of 2023, primarily as a result of continued consistent cash collection from the majority of our payers, as well as some ordinary course timing differences from certain payers. Our DSOs for the Illinois Department of Aging for the first quarter were 30.2 days compared with 49.5 days at the end of the fourth quarter of 2023. Our net cash flow from operations continues to be very strong, coming in at $38.7 million for the first quarter. We received approximately $10.2 million in ARPA funding during the quarter, partially offset by $2.4 million in ARPA funds utilized. net of the ARPA activity, our cash flow from operations in the first quarter would have been $30.9 million. While we continue to see strong cash flows, we benefited from approximately $8.4 million in net working capital changes in the first quarter, which was primarily related to favorable timing on receivable payments. We would anticipate these timing differences to normalize over the course of the full year and continue to expect our cash flow to represent approximately 80% of unadjusted EBITDA. As of March 31, 2024, the company had cash of $76.7 million, with capacity and availability under our revolver of $486.9 million and $377.5 million, respectively. With our strong cash flow, we have continued to pay down debt, and reduced our revolver balance by an additional $25 million in the first quarter. Importantly, we have the financial flexibility to continue to pursue our strategic growth initiatives, including acquisitions. As mentioned, we will continue to selectively pursue acquisitions in 2024 that are consistent with our goal of bolstering our personal care services and adding complementary clinical services. At the same time, we will continue to diligently manage our net leverage ratio which is currently well under one time net of cash on hand. This concludes our prepared comments this morning. We'd like to thank you for being with us. I'll now ask the operator to please open the line for your questions.
spk30: We will now begin the question and answer session. To ask a question, you may press star then one on your touchstone phone. If you are using a speakerphone, please pick up your handset before pressing the keys. If at any time your question has been addressed and you would like to withdraw your question, please press star, then two. At this time, we will pause momentarily to assemble our roster. The first question today comes from Brian Tanquillet with Jefferies. Please go ahead.
spk33: Hey, good morning, guys. I guess my first question for Derek or Brian Brian, as I think about your comments on acquisitions, and obviously the rule is out now, how are you thinking about the kinds of assets that you'd be interested in? Would you be focused more on the personal care side, or is it still an interest in the home nursing side, and then maybe sizing? I hear it loud and clear you want scale and density, so I'm curious how you're approaching the acquisition strategy here.
spk21: Yeah, Brian, I think our focus remains largely on continuing to bolster our personal care services in markets that we currently operate in. I think with the 80-20 rule, the access rule, I guess the more formal term for it, out now, it's clear to us that size and scale is going to be important. I think we've always kind of had that approach generally anyway, but this further reinforces that in our mind. So I think acquisitions and personal care that continue to build scale in markets we operate in today are important. We also would look at selective, you know, additional markets that we could enter at scale would also be, we think, good opportunities for us. And then, you know, where we can continue to add clinical services, where we have strong personal care to help with some of the things we're doing on value-based is also still important to us. So I think those are kind of our focus areas, but I'll let Dirk add a little color if you'd like.
spk06: I think that's great. I think the real key with the Medicaid access rule that we've seen is we do believe, to emphasize what Brian said, We believe size is important, and so we'll be looking to add backfill in markets in which we currently operate, but at the same time, we're looking for new markets in states where we aren't today, again, with the qualification that we could enter with size.
spk33: I understand. And then maybe, Brian, just any comments or color you can share with us in terms of how we should be thinking about the sequential change process? trajectory in earnings or revenues for Q2 and into Q3 as well?
spk21: Yeah, I think from Dirk's comments, I think particularly in personal care and hospice, we had a little bit of probably volume softness early in the quarter. Hospice coming off of the holiday season, a little bit of weather impacted our personal care services early, but we actually saw a nice growth through the quarter and into April and into Q2. So I think you know, we would expect that trajectory to continue. So I think we feel good where we are coming out of the quarter on the volume side. And just thinking about it from a margin perspective, obviously we have a reset in Q1 traditionally with payroll taxes and our annual merit increases. Keep in mind, most of those, you know, go into place, you know, March 1. So not a full quarter impact. A little bit will go into Q2. for the first full quarter there, but we also get a leisurely little relief on the payroll tax side, Q1 into Q2. So, you know, we would expect, you know, margins to remain relatively stable, you know, Q2 into Q3, and then Q4 is annually always the best margin quarter for us as we get our hospice rate increase with no kind of offsetting costs for those three months. Awesome. Thank you, guys.
spk30: The next question comes from Scott Fidel with Stevens. Please go ahead.
spk25: Hi. Thanks. Good morning. I had a couple of follow-up questions just on the 80-20 rule I wanted to ask you. The first would be if you've been able yet to come up with sort of what the overall adjustment would be that you think you can make on gross margin when considering the ad backs and some of these other exclusions in terms of how that would compare, you know, when thinking about, I guess, a sort of 80-20 rule adjusted gross margin for personal care compared to your gap margin in personal care?
spk06: Yeah, you know, I think obviously, as we stated, the changes that came out in the final rule around some of the expenses and revenue definition were very positive. will be helpful as we go forward. Let me make sure you understand this. We still believe that the 80-20 rule is difficult for smaller providers, but for a company our size, we feel very confident, especially when you consider the fact that this is a six-year implementation, that between market share growth, which we anticipate will occur in all of our markets due to this rule, along with our ability to invest in technology and do some of the things we're looking at on the cost side, we believe we'll be able to handle any impact that the 80-20 would have on our margin over that period of time.
spk25: Okay, and then one other on the rule. As we've been doing some checks on this, we've been getting some feedback that would seem to suggest that revenues that are based on value-based care contracting may have different treatment in the rule and may, you know, could be sort of largely sort of not affected by the rule. You know, just, and Brian, just interested in sort of how you guys are ascertaining that piece in terms of the value-based care. And then also, if that's the case, whether there would be more opportunity, you think, to shift more of your revenues to value-based care contracts, you know, whether it be with payers or even with sort of how the states are structuring their contracts.
spk14: Hey, Scott, this is Brad. That's our understanding as well, that value-based care revenue is excluded. I think there is certainly an opportunity, and it's something that we've been doing before the rule was implemented, is... working on those value-based arrangements, looking at being able to scale those. From a payer appetite standpoint, there's a lot of appetite out there for these types of arrangements. So that is certainly an opportunity that we'll be looking at, not just because of the rule, but just because I think it just makes good business sense overall.
spk06: And also, Scott, to follow up what Brad said, it's one of the reasons we're looking in markets, not only where we operate today, but potentially in new markets as where there might be real opportunity to work with providers in a value-based care approach. So that's another part of our overall acquisition strategy.
spk25: Well, it certainly seems to validate some of the investments that you've been making on the BBC side in personal care. And Dirk, just on that sort of other part on, you know, thoughts on, you know, sort of the potential for states to start maybe moving over, you know, to sort of structuring these more as you know, value-based or some level of risk sharing in them. Obviously, in other business lines across both Medicare and Medicaid, we have a tremendous amount of that going on. So just curious if that will be a sort of key area of focus for Addis, you know, in terms of, I guess, communicating some of that opportunity maybe. And it just modernizes the contracting anyway, you know, around personal care too.
spk06: Yeah, you know, it's something we started Three or four years ago, we really were on the front end of seeing that payers wanted to start looking at a different way of having these contracts. Some of the states were moving towards that direction. So we made the investment. We talked about that this is the first full quarter with our new technology, our software system. One of the limiting factors we had before on our ability to grow value-based care contracting was the fact that a lot of it was still done manually. while we were looking for the system. Now that that's in, we believe we will have additional opportunities to grow that business, and it will continue to be a focus of Addis, along with the other things that we're doing, but certainly value-based care is one of the main reasons why we're trying to get size and coverage in a state.
spk25: Okay, and then just one quick follow-up just on that sort of size and scale point you're making. Currently, Addis is in 21 states for personal care. Obviously, you've got a few states like Illinois that drive a lot of the revenue. You definitely have some of the smaller states as well. Maybe give us an update just on your thinking around, are there some of those 21 states where you think you may need to exit because of the rule? If you have an estimate on what the revenue is, contribution would be from those states that may no longer be sustainable under the new rules. And that's it for me. Thanks.
spk06: Yeah, I think the difficulty, Scott, in determining whether or not a state is viable today is we don't know over the next six years what's going to happen with the payment rate of that state, the various rules required. We do know that most states in which we operate, and I'd say to all the states we operate, the program is very viable to that state. to the Medicaid program. So today, there are some smaller states we're in that we'll be looking at and we'll be monitoring to see how they change. But I would say as of the date, there's no state that we've identified that cannot be successful in this particular, with this particular rule.
spk28: Okay, thank you.
spk30: The next question comes from Andrew Mock with Barclays. Please go ahead.
spk26: Hi. Good morning. I just wanted to follow up on the 80-20 rule. First, despite some of the changes in the final rule that you're more constructive on, it still sounds like there's still a fair amount of uncertainty hanging over the industry and even the likelihood that this gets finalized in six years or so. So, one, are you able to share with us a preliminary estimate of the unmitigated impact of the rule as it impacts your P&L today? Thanks.
spk06: No, we can't because, again, with so much still out there, we're still looking for clarification of definitions. We're talking to states about what they're going to do as it relates to the rule. It would be unfair to try to give a number because, again, with a six-year time frame, there is so much that will change, not just with Addis but with the states themselves. So what we're approaching it from is truly standing back, Andrew, and saying, With our size and coverage in our markets, we're going to be fine. And the way for us to work with this rule is to continue to do the things that we've been doing, grow our markets in those states, look at our technology, and try to get more efficient with our cost basis. And one thing that I think people are truly probably missing, the fact is market share growth. As small providers are not able to work under this rule, and we believe strongly that is a problem as exists today, that as you bring margin from that market share move, you will mitigate the issue related to your margin with this rule.
spk26: Got it. Okay. And then it sounds like one of the big definitional swing factors of the role of the clinical supervision. Do you have a sense for how much clinical supervision costs are sitting in your GNA line today that would potentially be reclassed to direct care for the purposes of the pass-through adjustment? Thanks.
spk06: Well, I think the difficulty there is what's the definition of clinical? I think some of the folks in the, there's different thoughts in the industry as about what might qualify in that particular line. And so, We don't know today. We don't have enough information from the rule to tell you exactly what that percentage would be. We can tell you it will be positive. So I think that's certainly one of the nice changes in the rule is that clinical supervision salaries have got put into the definition, which will be helpful as we continue to mitigate any issues.
spk27: Great. Thank you.
spk30: The next question comes from Jared Haas with William Blair. Please go ahead.
spk10: Hey, guys. Good morning. Thanks for taking the question. I'll maybe ask one just sticking with value-based care opportunities and appreciate the comments around having the technology system in place to sort of help that scale. I was hoping, are you able to kind of level set for us just today kind of what the penetration is within your book of business in terms of value-based contracts, either on a sort of percentage of revenue basis or maybe the number of partners that you have in a value-based contract? And then having the technology system in place, do you have a sense as to maybe how quickly that could scale over the next handful of years?
spk14: Yeah, we've, you know, on the value-based, you know, as Dirk pointed out, you know, this is the first quarter where we've had our new IT software in place that allows us to really start scaling this program. We currently have seven value-based contracts in effect. And we certainly could add more. There certainly is not a lack of interest in doing it. And we're talking with several of those payers about actually expanding those programs. We cover currently a little over 6,000 clients that are in value-based arrangements. Now, from a revenue standpoint, still immaterial. Certainly, I think this is an opportunity to grow. As I mentioned, we have several payers that we're currently in that are very pleased with how these arrangements are working and are looking for us to actually expand those significantly.
spk10: That's great, I appreciate that. And then maybe I'll just ask a follow-up on the home health segment. And it sounded like from the prepared remarks, there's some process improvements you guys are implementing. I think you mentioned around staffing and referral conversion rates. So we'd love to just hear a little bit about maybe what some of those workflows look like from an improvement perspective. And then also sticking with kind of the referral dynamic, If you take a step back and think about all the sort of structural pressures facing Medicare Advantage plans on their rates and MLRs and some of the issues that they're working through, have you guys noticed any changes just in terms of post-acute care referral trends with those plans? Are they getting a bit more restrictive in terms of prioritizing quality with the post-acute care providers that they're referring to? Anything really changed on that front?
spk14: Yeah, I'll first start with the home health process improvement question. You know, if you think about our home health operations, it's certainly our smallest segment is the one where, you know, we've done a handful of acquisitions, none of which I would necessarily characterize as kind of a platform acquisition. And so when you think about, you know, kind of integrating and looking at process within that segment of our business, you know, there's certainly a lot of opportunities to really get more consistency in how we do things. And so we're looking at, you know, one, looking at centralizing intake, looking at centralizing scheduling. And when you say centralizing, it's really kind of focusing at, you know, these are your tasks, you know, whether you're in the office, you know, in a central office or in a office out in the field, this is what you do to really kind of increase that, the efficiency of that workflow. And particularly on the intake side, you know, we think there's certainly opportunities to accept more cases and improve those conversion rates. So looking forward to that project getting completed. I think we're looking at kind of Q3, Q4 to really get that wrapped up, but very optimistic on where we stand with home health. And when you look at on the referral process, we really haven't seen significant changes or any changes related to Medicare Advantage focusing on just a handful of providers, if you will. You know, we still get a lot of referrals from payers on the Medicare Advantage side that, you know, we're not going to accept just because rates aren't there or we're going to prioritize where we have episodic rates.
spk09: Okay. That's great. I appreciate all the color. Thanks.
spk30: The next question comes from Ryan Lansman with Cowan. Please go ahead.
spk08: Hi, good morning. Just following maybe on Brian's earlier question, in terms of kind of the scale you would need to get into a new market, I guess if you did move into a new geography, especially in the CCS side, how do we think about that in terms of necessary size, whether it be revenues or maybe comparable to maybe recent deals like TQC or other size parameters, just so we can get a sense on maybe the minimum size that you believe you need to move into a new GI?
spk06: Well, to go into a new market, we would really like to see either immediately or a clearly defined timeline to get to the top one or two market share providers in that particular state. We believe you need to be very large. We believe you need to have the ability to have a voice with the state. So if you see us entering into any new state, I think you can assume. And again, remember, states are different. So it's hard for us to give you a revenue because what might be a number one market share in one state certainly might not be in another. But in those various states that we're looking at, we would like to be number one or number two going into the market.
spk08: Got it. And then just one more for me, maybe more of a philosophical question. Obviously, in the New York state budget, there were some changes to the CD program that's coming in the 25 budget, I know that it's kind of low single-digit operating income exposure, but it's still a pretty decent-sized state, I think the third largest in terms of revenues. I guess do those changes and kind of maybe just some of the tone that the governor took maybe, does that change your longer-term strategy in the state going forward, or is it kind of just steady state from here? Yeah.
spk06: Well, realize that CDPAP's about 4% of our overall revenue. It's a very small part. I know you say that's material, but for us, it's very small. It's a very, very low single-digit margin of that, you know, from an EBITDA standpoint, and that's not even from a bottom-line standpoint. So, you know, for us, as we look at New York, they've tried changes before. I think three or four years ago, they were going to minimize the number of folks in CDPAP. That never got implemented. I think for them to go to 1FI by the beginning of April of next year is going to be really a tough task. So for us, we're going to continue to operate and do the best we can in that market. But just understand that it is one of the markets where it's very difficult for us. And from a strategy standpoint, it's not a market that we can do the things we're trying to do, which is three levels of care, and value-based care. So from that standpoint, it takes a back seat as far as acquisitions and other items and investments.
spk08: Got it. Let me squeeze one quick one in. Hospice revenue per day up, I think, 3.7%. That's pretty strong, certainly above the latest fee-for-service Medicare rate. Anything to call out there maybe in terms of acuity changes or geographic distribution, anything else there?
spk21: No, Ryan, I think, you know, we obviously have a little bit of a mixed shift pretty consistently, so there's a little bit of contribution there. But I think overall in hospice, we saw a little better implicit price concession, just some of our revenue adjustment in the quarter than what we maybe saw the same quarter last year. I think that was beneficial this quarter to a certain extent.
spk07: Got it. Thank you.
spk30: As a reminder, if you would like to ask a question, please press star, then 1 to be joined into the question queue. The next question comes from Joanna Gajuk with Bank of America. Please go ahead.
spk31: Good morning. Thank you for taking the question. So just first a follow-up here on the margins and I guess some of the cost items. So gross margin in the quarter was essentially in line with your prior quarters, with your prior comment on the Q4 call and But even that was better because GNA was really there at the source of uptake here. So excluding stock comp and acquisition expense, right, you mentioned GNA was, you know, close to 20%. You know, it sounds like there's some timing, but how should we think about the next couple of quarters? The quarter sounds like maybe that's a low point. From here, we should expect some increase in that ratio.
spk21: Yeah, Joanne, I think being at just under 20% on adjusted G&A for the quarter, I think, as I mentioned earlier, our merit increases and some of those costs typically come in on March 1, so you haven't seen a full quarter impact. And the majority of those are through our corporate staff, our branch staff, that's our G&A line, not a direct cost. So I think you'll see a little bit of that go into the first full quarter in Q2. I think overall, as a percentage revenue, we would expect adjusted G&A to kind of still be in that you know, 20-ish percent. It might be a little tick up from what we saw in Q1, but fairly close and consistent.
spk31: Okay, that makes sense. And the other one, in terms of volume, so you said maybe some weather impact in personal care, right, about Southwest Q kind of exit the quarter, right? kind of back to where you thought you would be, is that the way to think about it, that kind of this was a temporary, maybe you recouped some of those last visits and kind of, you know, your talks, updated talks for the whole year when it comes to personal care volumes?
spk14: Yeah, I mean, if you look on the PCS side, a weather event, you know, if you have a snow or an ice storm, particularly in kind of some of the downstate Illinois markets or out in some of the more rural markets, you know, a lot of times caregivers can't make those visits. We attempt to try to reschedule those, you know, but that's challenging. And you can only reschedule that, you know, within, you know, depending if it's a weekly auth or a monthly auth determines when you can reschedule or have an opportunity to. So, you know, it's unfortunate. I'm always rooting for bad weather on the weekends in those markets because I'm an operator. You know, unfortunately, we had some that is kind of early in the week. You know, Mondays are worse than it would be if it's on a Friday. So, again, kind of a temporary blip. But if you look at just where we, you know, progressed throughout the quarter on PCS, January was, you know, was impacted by the weather events. But we saw a nice pickup in February and actually exited pretty strong in March. and expect those trends to continue. And if you look at our hiring numbers as well, kind of mirror that. January was a little soft because of, frankly, the weather impact there. We actually had a nice hiring in February and, frankly, followed that up with what really was record hiring in March. And our April hiring numbers were solid as well.
spk31: Great. Good to hear that. And if I may just follow up on the discussion around the 80-20 trend. provision in the access reg. So in that reg specifically, you know, CMS actually did say something along the lines of, you know, they expect the states to look at the rates, right, to see if they are actually sufficient. I mean, there's a lot of requirements now um different requirements for states to um disclose that information and keep updating those so do you expect states to actually be forced to wait space to ensure their you know they're essentially not provided to deliver the care of congress obviously if they don't um ensure the access you know they will end up uh paying uh higher or sending more money for some of these um seniors or people with disabilities that end up in nursing homes, right? So how do you think about this, forcing some states to improve rates?
spk14: Yeah, Joanna, I'll start, and then Dirk may add some color to it. You know, that's one of the aspects of the rule that, you know, I think we, like others in the industry, are in favor of. I think having more transparency around how rates are calculated and formulated by states is very important. I do think there will be some pressure on states to raise rates because, as you point out, the alternative is actually putting individuals in a much more costly institutional setting. So I certainly think there's opportunities over the next six years to really work with states in where those rates need to be in order to be able to maintain the programs at their current status and, frankly, to try to grow the personal care programs in those states.
spk31: Right, exactly. And then the last one is, so you mentioned, you know, there's obviously some clarifications in the record, some definitions and denominators and things like that, but it sounds like there's still some additional clarity that you might be expecting. So is this something you expect to come out from the states? Because that was another element of this regulation, right? Clearly CMS gave a lot of authority or flexibility to the states to... you know, when it comes to that 80-20 provision. Is that how you read it? Like, there's going to be more information coming out from the states, and that's when you could kind of be more clear when it comes to, like, what exactly is happening. But obviously, since this is in six years, you might not hear about it for a while. But I guess I want to say in the regular, it also talks about that the states have to – or I guess prove that they are ready for it in four years or something like that. So that doesn't mean that we kind of like, you know, four years from now we hear more details or you think it's going to be sooner than that. Thank you.
spk14: Yeah, I think, you know, Fran, unfortunately the way states tend to work is they wait more to the back end. So I don't expect to have any near-term clarification on some of those elements in the rules. And as you point out, there were a lot of provisions, that were left open for the states to determine and have some flexibility with. And CMS said that they would provide, I think, technical assistance to help the states go through that process. But, you know, this is something that I think states will, you know, the reality is they'll probably take a little bit of a wait-and-see approach, you know, even though some of the significant provisions for them actually kick in in four years. But I don't anticipate getting anything in the near term. I think we'll be kind of closer to the back end. of that four-year period.
spk31: Yeah, I know. This is how usually these governments work when it comes to deadlines. They were at the very last minute. And if I may just speak to the very last one, sorry, because there was also discussion around some of these specific, you know, elements called out in this regulation. And, you know, I would check to buy some larger companies estimated, you know, adjusting for the supervisory costs. This could be, you know, like 500 basis points for them. So I know you're not willing to give specifics, but would it be in this range or much smaller than that? Thank you.
spk06: You know, I think it depends on how companies are defining clinical supervision. To get to the number you specified takes a great deal of breadth in the definition for those of us that operate in the industry. So I'm not sure that We would, you know, we're agreeable with that number at this point in time until we get more clarification. However, I think what we said earlier applies. The fact that they included, CMS included clinical supervisory salaries in the definition was very helpful, and it will give us some relief towards the 80-20. Great.
spk30: Thank you for that. Thanks for taking the questions. This concludes our question and answer session. I would like to turn the conference back over to Dirk Allison for any closing remarks.
spk06: Thank you, operator. I want to thank everybody for their interest today in Addis and for being part of our call. Hope you have a great week. Thank you.
spk30: The conference is now concluded. Thank you for attending today's presentation. You may now disconnect. Thank you.
spk12: Thank you. Thank you. Thank you. Thank you. music music Thank you.
spk30: Good day and welcome to the Addis Homecare's first quarter 2024 earnings conference call. All participants will be in a listen-only mode. Should you need assistance, please signal a conference specialist by pressing the star key followed by zero. After today's presentation, there will be an opportunity to ask questions. To ask a question, you may press star and one on a touch-tone phone. To withdraw your question, please press star then 2. Please note this event is being recorded. I would now like to turn the conference over to Drew Anderson. Please go ahead.
spk29: Thank you. Good morning and welcome to the Addis Home Care Corporation first quarter 2024 earnings conference call. Today's call is being recorded. To the extent any non-GAAP financial measure is discussed in today's call, you will also find a reconciliation of that measure to the most directly comparable financial measure calculated according to GAAP by going to the company's website and reviewing yesterday's news release. This conference call may also contain forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995, including statements, among others, regarding ADIS expected quarterly and annual financial performance for 2024 or beyond. For this purpose, any statements made during this call that are not statements of historical fact may be deemed to be forward-looking statements. Without limiting the foregoing, discussions of forecasts, estimates, targets, plans, beliefs, expectations, and the like are intended to identify forward-looking statements. You are hereby cautioned that these statements may be affected by important factors, among others, set forth in ADIS filings with the Securities and Exchange Commission and in its first quarter 2024 news release. Consequently, actual operations and results may differ materially from the results discussed in the forward-looking statement. The company undertakes no obligation to update any forward-looking statement, whether as a result of new information, future events, or otherwise. I would now like to turn the call over to the company's chairman and chief executive officer, Mr. Dirk Allison. Please go ahead, Dirk.
spk06: Thank you, Drew. Good morning and welcome to our 2024 first quarter earnings call. With me today are Brian Poff, our chief financial officer, and Brad Bickham, our president, chief operating officer. As we do on each of our quarterly calls, I will begin with a few overall comments and then Brian will discuss the first quarter results in more detail. Following our comments, the three of us would be happy to respond to any questions. Yesterday, we announced our results for the first quarter of 2024. These results highlight the continued strong financial performance by Addis. This performance is made possible by the hard work and dedication of all our employees as they continue to provide quality care to our clients and patients by helping to fulfill our mission of taking care of individuals in their homes. As I have said many times in the past, I'm very thankful for all that the employees do for our company. As we announced yesterday, our total revenue for the first quarter of 2024 was $280.7 million, an increase of 11.6% as compared to $251.6 million for the first quarter of 2023. This revenue growth resulted in adjusted earnings per share of $1.21 as compared to adjusted earnings per share for the first quarter of 2023 of $0.97, an increase of 24.7%. Our adjusted EBITDA of $32.4 million was an increase of 24.6% over the first quarter of 2023. During the first quarter of 2024, we continued to experience strong cash flows, allowing us to reduce our debt balance to $101.4 million. At quarter end, our cash balance was approximately $77 million, which together with our availability under our existing credit facility, continue to give us the financial flexibility to be opportunistic as we see potential acquisitions come to market. It remains our primary focus to use our financial capacity to acquire strategic operations that align with our overall growth strategy of adding clinical services where we have strong personal care presence, enhancing our existing personal care markets, and adding new personal care markets where we can enter at scale. We also believe this acquisition strategy will continue to strengthen our ability to participate in value-based contracts with our payers and to adapt to potential reimbursement changes. I want to provide some thoughts related to the final Medicaid access rule that was issued on April 22. As we anticipated, the proposed 80% compensation requirement was retained in this rule despite an overwhelming number of comments submitted detailing the challenges this would present. Of course, we and other providers are disappointed with the result, even though we support the overall policy aims of providing higher wages and increasing access to home and community-based services. However, several significant positive changes were made in the final rule, and I would like to touch on a few of these. First, the implementation period was extended by 50% from four years to six years. Realistically, we believe this substantially increases the likelihood that the rule will not be implemented in its current form or possibly at all for a variety of reasons, including as a result of legal or congressional action or potential administrative changes in either of the next two presidential election cycles. As important, this extended implementation timeframe give states and providers a better opportunity to plan and adjust to the specific requirements of any rule that may ultimately be implemented. Second, a number of technical adjustments were made between the original draft and final rule, which both clarify and improve the definition of allowable costs for providers like ADDIS. For example, certain costs such as training, mileage, and PPE will be deducted from total payments before calculating for calculating compliance with the 80% requirement. Similarly, refunded or recouped payments will be excluded. Also, the categories of items constituent compensation have been clarified to include PTO, retirement, insurance, including workman's compensation, and tuition payments not previously addressed. The rule also clarified and expanded certain tasks that now count as direct care work and expands the definition of direct care workers to add clinical supervisors. All of these changes combine to lessen the potential impact of the rule on our margins. While these items were addressed in the final rule, there was still not a complete specific set of definitions, although additional commentary was included in an effort to protect against the possibility of setting a definition that could be construed as too narrow. We believe this gives states a certain level of flexibility in working with providers in deciding on other potential costs that should be considered in the calculation. Stepping back to the bigger picture, there are other points worth making on the rule and its impact. We continue to believe the rule disproportionately impacts small providers and encourages scale, which will lead to further consolidation opportunities. The rule allows states to develop separate minimum compliance levels for small providers and to provide hardship exemptions, but two important factors should be noted. First, the exemption and the hardship exception both require states to create additional reporting requirements, and these requirements can only be waived by CMS at its option to the extent applicable to less than 10% of providers. Even more crucially, the rule requires states to develop a plan subject to CMS approval to reduce in a reasonable period of time the number of providers that qualify for these exemptions or exceptions. At best, we believe these are temporary Band-Aids, not long-term solutions for small providers. Second, and I want to emphasize this point, small providers relying on these provisions will be able to pay less to workers. but they will be at a competitive disadvantage for labor with large providers like Addis who will likely be required to pay a higher rate. We believe these exceptions will provide us more access to labor, which, as we know regularly, is the primary limiting factor on revenue growth. So I'll repeat what I said last quarter. We believe that personal care providers must have scale in each state where they operate to be successful under the rule as finalized. This will not only allow the larger providers to spread their costs over a bigger revenue base, but also will provide more opportunity for meaningful advocacy with the states in which they operate, while also promoting a favorable hiring and retention dynamic. Before I leave this topic, I also want to note that we expect both Congress and individual states to review their options and take actions they believe are appropriate in reaction to the rule. Individual members of Congress already have issued calls to withdraw the rule or have introduced legislation to block finalization of certain aspects of the rule and more may follow. Some states may institute litigation to block the rule, the outcome of which is unknown. States may also look at opportunities to increase funding in an effort to meet the aims of the rule, causing less impact to providers and clients. So in summary, six years is a very long time. We expect many more curves in the road before then, but we are confident in our strategic approach to both manage and thrive in this dynamic landscape. We are currently in the process of looking at personal care opportunities that would give us a larger presence in our current state. We are also looking for opportunities where we can enter new states in a material way. Personal care is a valuable service to our elderly and disabled population, and we are optimistic that states will evolve their programs to remain viable regardless of the rule. During the first quarter, we continued to experience good results related to our ability to hire caregivers especially in our personal care segment. During the first quarter of 2024, our personal care hiring was equal to what we saw in the first quarter of last year at 84 hires per business day. Sequentially, our hires per day were up 5% over the fourth quarter of last year, despite some weather difficulties in January. In addition to our strong hiring numbers, we continue to see consistent momentum in the Starts for Business Day over the past few quarters. As for our clinical segments, hiring has continued to improve over what we experienced in the early part of 2023. As we have over the past couple of years, we continue to utilize the funding we received from the American Rescue Plan Act, or ARPA. To date, we have received approximately $38 million of which we have over 13 million remaining to be utilized. We continue receiving these funds in the first quarter of this year, and as we have previously shared, these funds have been helpful with our caregiver recruitment and retention efforts to support the delivery of personal care services. In addition to utilizing the ARPA funds for direct recruitment and retention of caregivers, we continue to utilize the funds to improve our caregivers' experience through the implementation of enhanced caregiver training and continued development of a caregiver application that we believe will improve our retention and overall service delivery. In our personal care segment, our services continue to receive favorable reimbursement support from many of the states in which we operate. Although some of the federal financial support to states have been reduced, we feel confident that personal care services continue to show real value to state Medicaid programs as well as our managed care partners through a reduction in overall cost of care. As for our clinical segments, effective October 1, 2023, Medicare hospice reimbursement was increased by approximately 3.1%. On January 1 of this year, home health Medicare reimbursement was increased by approximately 0.8%. Although this year's home health rate increase was below what is required to cover ongoing operating cost increases, we believe that traditional Medicare home health reimbursement pressures are likely to moderate over the next few years. Now let me discuss our same-store revenue growth for the first quarter of 2024. For our personal care segment, our same-store revenue growth was 9.3% when compared to the first quarter of 2023. During the first quarter of 2024, we saw personal care same-store hours for business day remain flat as compared to the same period in 2023 as we experienced difficult winter weather in a couple of our key markets early in the first quarter of this year. We did see a sequential improvement in hours each month in the quarter as we moved past these early weather challenges. We continue to see our investments in hiring and scheduling optimization initiatives take hold and contribute to our hours growth. Turning to our clinical operation, our hospice same store revenue increased 5.8% when compared to the first quarter in 2023. While our same store ADC was down 0.9% when compared to the same quarter last year and flat sequentially, we did see a nice improvement in our same store ADC during February and March. This ADC growth has continued into April. As of the end of the first quarter of 2024, our hospice medium length of stay, exclusive of our journey care and recently acquired Tennessee quality care operation, was 27 days as compared to 25 days for the fourth quarter of 2023. For comparison purposes, we have historically excluded our journey care operation as it has a higher proportion of shorter length of stay patients due to our inpatient units in the Chicago area. We are encouraged by the steady sequential improvement in both ADC and admission volume in our hospice segment early this year and anticipate those favorable trends continuing in 2024. Our home health segment, same store volume, decreased 3.1% over the same quarter in 2023, but did increase 1.7% on a sequential basis. As most home health providers have experienced, we continue to be affected by the movement of Medicare beneficiaries from Medicare fee-for-service to Medicare Advantage, but we feel we may be seeing a leveling off of this shift in the market we currently serve. We are continuing to work with our Medicare Advantage payers to obtain higher per visit rates as we work in parallel to transition to episodic or case rates. We are also continuing to focus on process improvements to increase our efficiency around staffing, referral conversion rates, and collections. While home health is our smallest segment and only 5% of our revenue, we feel it complements both our personal care services, particularly where we participate in value-based contracting models, and our hospice services by allowing us to provide the full continuum of home-based clinical care. Acquisitions will continue to be an important part of our growth strategy at Addis. Even with the various challenges we have seen, we are committed to using our capital to make sure we meet the strategic goals we have publicly discussed. With the Medicaid access rule finalized, we are focused on opportunities that will help us obtain the needed skill in our current personal care markets to operate more efficiently. We are also open to entering select new states with personal care services. If we can do so through transactions which will give us the scale we feel is important to be successful under the new Medicaid access rule. As for our clinical segment, we are focused on home health opportunities which operate in certain of our personal care states where we have the opportunity to continue our growth in value-based care and to complement our existing hospice operations. As far as our value-based care efforts, I noted last quarter that we continue to gather data which demonstrates material reductions in both emergency room visits as well as percentage of patients readmitted to the hospital at various post-discharge intervals. We continue to believe our success is due to our ability to provide both non-clinical personal care services to identify changes in condition and clinical resources as needed for specific skilled patient care interventions. We are now utilizing this information as part of our conversation with various Medicare Advantage and commercial payers to demonstrate how ADDIS can be a critical part of providing quality, cost-effective care to plan members that can reduce the overall medical loss ratio by simultaneously improving overall quality of care. During the first quarter of 2024, we began to use our new value-based care management system. We are excited about this technology as it will allow us to increase both the scale and efficiency of our value-based program, which we believe is important to further develop these types of relationships with our large payers. Before I close my remarks, I want to once again say how proud I am of our team for the care they are providing to our elderly, and disabled consumers and patients. There is no question that the majority of clients and patients want to receive care at home, which remains one of the safest and most cost effective places to receive this care. We believe the heightened awareness of the value of home-based care is favorable for our industry and will continue to be a growth opportunity for our company. We understand and appreciate that our operations and growth are dependent on both our dedicated caregivers and other employees who work so incredibly hard providing outstanding care and support to our clients, patients, and their families. With that, let me turn the call over to Brian.
spk21: Thank you, Dirk, and good morning, everyone. Addis had a strong start to 2024, continuing our momentum with an impressive financial and operating performance for the first quarter. Our results included solid year-over-year organic growth of 9.3% in personal care services, well above our long-term expected range of 3% to 5%, but in line with our expectations. This growth reflects steady volumes as well as continued favorable rate support for personal care services in some of our larger markets. We were pleased to see consistent, positive year-over-year trends in our hospice business in the first quarter, inclusive of our Tennessee quality care acquisition. Our hospice same-store revenue growth of 5.8% was our third consecutive quarter of sequential increase and the highest percentage increase we have seen since prior to the COVID pandemic. We continue to see favorable admission trends as we have experienced three consecutive quarters of sequential same-store admission growth. Same-store revenue for our home health services, which is 6% of our business, was down 15.1% from the same period a year ago, as we continue to intentionally limit admissions from payers with less favorable reimbursement rates. We remain focused on maintaining a consistent margin profile in our home health business, as it complements our personal care and hospice services. Acquisitions remain an important part of our growth strategy, with our primary focus on markets where we can leverage our strong personal care presence and add clinical services, or enhance and expand our personal care services in strategic geographies. With our size and scale and the support of a strong balance sheet, we are well positioned to execute our strategy, and we are optimistic we will see attractive acquisition opportunities in 2024. As Dirk noted, total net service revenues for the first quarter were $280.7 million. The revenue breakdown is as follows. Personal care revenues were $208 million, or 74.1% of revenue. Hospice care revenues were $55.9 million, or 19.9% of revenue. Home health revenues were $16.9 million, or 6% of revenue. Our first quarter results include the operations of our most recent acquisition, Tennessee Quality Care, a provider of home health, hospice, and private duty nursing services, which we acquired on August 1, 2023. Other financial results for the first quarter of 2024 include the following. Our gross margin percentage was 31.4%, compared with 31.2% for the first quarter of 2023. As expected, gross margin was affected in the first quarter by our annual merit increases and the annual reset of payroll taxes, as well as compression from certain collective bargaining negotiations. In the absence of any additional mixed changes from M&A, we anticipate our gross margin percentage to remain materially stable over the next few quarters, and consistent with our historical annual pattern. G&A expense was 21.8% of revenue compared with 22.4% of revenue for the first quarter a year ago and a decline sequentially from 22% in the fourth quarter of 2023. Adjusted G&A expense for the first quarter of 2024 is 19.9%, a decrease from 20.8% in the comparable prior year quarter and down sequentially from 20.6% in the fourth quarter of 2023, primarily as a result of lower legal expenses and the normal timing of certain accruals. The company's adjusted EBITDA increased 24.6% to $32.4 million compared with $26 million a year ago. Adjusted EBITDA margin was 11.6% compared with 10.4% for the first quarter of 2023, reflecting continued leverage on our increasing revenues. With a solid start to 2024, we continue to expect our adjusted EBITDA margin percentage for the full year to remain above 11%, consistent with 2023. Adjusted net income per diluted share was $1.21 compared with $0.97 for the first quarter of 2023. The adjusted per share results for the first quarter of 2024 exclude the following. acquisition expenses of $0.12, and non-cash stock-based compensation expense of $0.12. The adjusted per share results for the first quarter of 2023 exclude the following, acquisition expenses of $0.06 and non-cash stock-based compensation expense of $0.13. Our tax rate for the first quarter of 2024 was 25.7% in line with our expectations. For calendar 2024, we continue to anticipate our tax rate will be in the mid-20% range. DSOs were 34.6 days at the end of the first quarter of 2024, compared with 39.1 days at the end of the fourth quarter of 2023, primarily as a result of continued consistent cash collection from the majority of our payers, as well as some ordinary course timing differences from certain payers. Our DSOs for the Illinois Department of Aging for the first quarter were 30.2 days compared with 49.5 days at the end of the fourth quarter of 2023. Our net cash flow from operations continues to be very strong, coming in at $38.7 million for the first quarter. We received approximately $10.2 million in ARPA funding during the quarter, partially offset by $2.4 million in ARPA funds utilized. net of the ARPA activity, our cash flow from operations in the first quarter would have been $30.9 million. While we continue to see strong cash flows, we benefited from approximately $8.4 million in net working capital changes in the first quarter, which was primarily related to favorable timing on receivable payments. We would anticipate these timing differences to normalize over the course of the full year and continue to expect our cash flow to represent approximately 80% of unadjusted EBITDA. As of March 31, 2024, the company had cash of $76.7 million, with capacity and availability under our revolver of $486.9 million and $377.5 million, respectively. With our strong cash flow, we have continued to pay down debt, and reduced our revolver balance by an additional $25 million in the first quarter. Importantly, we have the financial flexibility to continue to pursue our strategic growth initiatives, including acquisitions. As mentioned, we will continue to selectively pursue acquisitions in 2024 that are consistent with our goal of bolstering our personal care services and adding complementary clinical services. At the same time, we will continue to diligently manage our net leverage ratio which is currently well under one-time net of cash on hand. This concludes our prepared comments this morning. We'd like to thank you for being with us. I'll now ask the operator to please open the line for your questions.
spk30: We will now begin the question and answer session. To ask a question, you may press star, then 1 on your touchtone phone. If you are using a speakerphone, please pick up your handset before pressing the keys. If at any time your question has been addressed and you would like to withdraw your question, please press star, then two. At this time, we will pause momentarily to assemble our roster. The first question today comes from Brian Tanquillet with Jefferies. Please go ahead.
spk33: Hey, good morning, guys. I guess my first question for Derek or Brian Brian, as I think about your comments on acquisitions, and obviously the rule is out now, how are you thinking about the kinds of assets that you'd be interested in? Would you be focused more on the personal care side, or is it still an interest in the home nursing side? And then maybe sizing. I hear it loud and clear you want scale and density, so I'm curious how you're approaching the acquisition strategy here.
spk21: Yeah, Brian, I think our focus remains largely on continuing to bolster our personal care services in markets that we currently operate in. I think with the 80-20 rule, the access rule, I guess the more formal term for it, out now, it's clear to us that size and scale is going to be important. I think we've always kind of had that approach generally anyway, but this further reinforces that in our mind. So I think acquisitions and personal care that continue to build scale in markets we operate in today are important. We also would look at selective, you know, additional markets that we could enter at scale would also be, we think, good opportunities for us. And then, you know, where we can continue to add clinical services, where we have strong personal care to help with some of the things we're doing on value-based is also still important to us. So I think those are kind of our focus areas, but I'll let Dirk add a little color if you'd like.
spk06: I think that's great. I think the real key with the Medicaid access rule that we've seen is we do believe, to emphasize what Brian said, We believe size is important, and so we'll be looking to add backfill in markets in which we currently operate, but at the same time, we're looking for new markets in states where we aren't today, again, with the qualification that we could enter with size.
spk33: I understand. And then maybe, Brian, just any comments or color you can share with us in terms of how we should be thinking about the sequential change process? trajectory in earnings or revenues for Q2 and into Q3 as well?
spk21: Yeah, I think from Dirk's comments, I think particularly in personal care and hospice, we had a little bit of probably volume softness early in the quarter. Hospice coming off of the holiday season, a little bit of weather impacted our personal care services early, but we actually saw a nice growth through the quarter and into April and into Q2. So I think you know, we would expect that trajectory to continue. So I think we feel good where we are coming out of the quarter on the volume side. And just thinking about it from a margin perspective, obviously we have a reset in Q1 traditionally with payroll taxes and our annual merit increases. Keep in mind, most of those, you know, go into place, you know, March 1. So not a full quarter impact. A little bit will go into Q2. for the first full quarter there, but we also get a leisurely little relief on the payroll tax side Q1 and Q2. So, you know, we would expect, you know, margins to remain relatively stable, you know, Q2 into Q3, and then Q4 is annually always the best margin quarter for us as we get our hospice rate increase with no kind of offsetting costs for those three months. Awesome. Thank you, guys.
spk30: The next question comes from Scott Fidel with Stevens. Please go ahead.
spk25: Hi. Thanks. Good morning. I had a couple of follow-up questions just on the 80-20 rule I wanted to ask you. The first would be if you've been able yet to come up with sort of what the overall adjustment would be that you think you can make on gross margin when considering the add-backs and some of these other exclusions in terms of how that would compare, you know, when thinking about, I guess, a sort of 80-20 rule adjusted gross margin for personal care compared to your gap margin in personal care?
spk06: Yeah, you know, I think obviously, as we stated, the changes that came out in the final rule around some of the expenses and revenue definition were very positive. will be helpful as we go forward. Let me make sure you understand this. We still believe that the 80-20 rule is difficult for smaller providers, but for a company our size, we feel very confident, especially when you consider the fact that this is a six-year implementation, that between market share growth, which we anticipate will occur in all of our markets due to this rule, along with our ability to invest in technology and do some of the things we're looking at on the cost side, we believe we'll be able to handle any impact that the 80-20 would have on our margin over that period of time.
spk25: Okay, and then one other on the rule. As we've been doing some checks on this, we've been getting some feedback that would seem to suggest that revenues that are based on value-based care contracting may have different treatment in the rule and may, you know, could be sort of largely sort of not affected by the rule. You know, just, and Brian, just interested in sort of how you guys are ascertaining that piece in terms of the value-based care. And then also, if that's the case, whether there would be more opportunity, you think, to shift more of your revenues to value-based care contracts, you know, whether it be with payers or even with sort of how the states are structuring their contracts.
spk14: Hey, Scott, this is Brad. That's our understanding as well, that value-based care revenue is excluded. I think there is certainly an opportunity, and it's something that we've been doing before the rule was implemented, is... working on those value-based arrangements, looking at being able to scale those. From a payer appetite standpoint, there's a lot of appetite out there for these types of arrangements. So that is certainly an opportunity that we'll be looking at, not just because of the rules, but just because I think it just makes good business sense overall.
spk06: And also, Scott, to follow up what Brad said, it's one of the reasons we're looking in markets, not only where we operate today, but potentially in new markets as where there might be real opportunity to work with providers in a value-based care approach. So that's another part of our overall acquisition strategy.
spk25: Well, it certainly seems to validate some of the investments that you've been making on the BBC side in personal care. And Dirk, just on that sort of other part on, you know, thoughts on, you know, sort of the potential for states to start maybe moving over, you know, to sort of structuring these more as you know, value-based or some level of risk sharing in them. Obviously, in other business lines across both Medicare and Medicaid, we have a tremendous amount of that going on. So just curious if that will be a sort of key area of focus for Addis, you know, in terms of, I guess, communicating some of that opportunity maybe. And it just modernizes the contracting anyway, you know, around personal care too.
spk06: Yeah, you know, it's something we started recently. Several years ago, we really were on the front end of seeing that payers wanted to start looking at a different way of having these contracts. Some of the states were moving towards that direction. So we made the investment. We talked about that this is the first full quarter with our new technology, our software system. One of the limiting factors we had before on our ability to grow value-based care contracting was the fact that a lot of it was still done manually. while we were looking for the system. Now that that's in, we believe we will have additional opportunities to grow that business, and it will continue to be a focus of Addis, along with the other things that we're doing, but certainly value-based care is one of the main reasons why we're trying to get size and coverage in a state.
spk25: Okay, and then just one quick follow-up just on that sort of size and scale point you're making. Currently, Addis is in 21 states for personal care. Obviously, you've got a few states like Illinois that drive a lot of the revenue. You definitely have some of the smaller states as well. Maybe give us an update just on your thinking around, are there some of those 21 states where you think you may need to exit because of the rule? If you have an estimate on what the revenue is, contribution would be from those states that may no longer be sustainable under the new rules. And that's it for me. Thanks.
spk06: Yeah, I think the difficulty, Scott, in determining whether or not a state is viable today is we don't know over the next six years what's going to happen with the payment rate of that state, the various rules required. We do know that most states in which we operate, and I'd say to all the states we operate, the program is very viable to the state. to the Medicaid program. So today, there are some smaller states we're in that we'll be looking at and we'll be monitoring to see how they change. But I would say as of the date, there's no state that we've identified that cannot be successful in this particular, with this particular rule.
spk28: Okay, thank you.
spk30: The next question comes from Andrew Mock with Barclays. Please go ahead.
spk26: Hi. Good morning. I just wanted to follow up on the 80-20 rule. First, despite some of the changes in the final rule that you're more constructive on, it still sounds like there's still a fair amount of uncertainty hanging over the industry and even the likelihood that this gets finalized in six years or so. So, one, are you able to share with us a preliminary estimate of the unmitigated impact of the rule as it impacts your P&L today? Thanks.
spk06: No, we can't because, again, with so much still out there, we're still looking for clarification of definitions. We're talking to states about what they're going to do as it relates to the rule. It would be unfair to try to give a number because, again, with a six-year time frame, there is so much that will change, not just with Addis but with the states themselves. So what we're approaching it from is truly standing back, Andrew, and saying, With our size and coverage in our markets, we're going to be fine. And the way for us to work with this rule is to continue to do the things that we've been doing, grow our markets in those states, look at our technology, and try to get more efficient with our cost basis. And one thing that I think people are truly probably missing, the fact is market share growth. As small providers are not able to work under this rule, and we believe strongly that is a problem as exists today, that as you bring margin from that market share move, you will mitigate the issue related to your margin with this rule.
spk26: Got it. Okay. And then it sounds like one of the big definitional swing factors of the role of the clinical supervision. Do you have a sense for how much clinical supervision costs are sitting in your GNA line today that would potentially be reclassed to direct care for the purposes of the pass-through adjustment? Thanks.
spk06: Well, I think the difficulty there is what's the definition of clinical? I think some of the folks in the... There's different thoughts in the industry as about what might qualify in that particular line. And so... We don't know today. We don't have enough information from the rule to tell you exactly what that percentage would be. We can tell you it will be positive. So I think that's certainly one of the nice changes in the rule is that clinical supervision salaries have got put into the definition, which will be helpful as we continue to mitigate any issues.
spk27: Great. Thank you.
spk30: The next question comes from Jared Haas with William Blair. Please go ahead.
spk10: Hey, guys. Good morning. Thanks for taking the question. I'll maybe ask one just sticking with value-based care opportunities and appreciate the comments around having the technology system in place to sort of help that scale. I was hoping, are you able to kind of level set for us just today kind of what the penetration is within your book of business in terms of value-based contracts, either on a sort of percentage of revenue basis or maybe the number of partners that you have in a value-based contract? And then having the technology system in place, do you have a sense as to maybe how quickly that could scale over the next handful of years?
spk14: Yeah, we've, you know, on the value-based, you know, as Bert pointed out, you know, this is the first quarter where we've had our new IT software in place that allows us to really start scaling this program. We currently have seven value-based contracts in effect. And we certainly could add more. There certainly is not a lack of interest in doing it. And we're talking with several of those payers about actually expanding those programs. We cover currently a little over 6,000 clients that are in value-based arrangements. Now, from a revenue standpoint, still immaterial. Certainly, I think this is an opportunity to grow. As I mentioned, we have several payers that we're currently in that are very pleased with how these arrangements are working and are looking for us to actually expand those significantly.
spk10: That's great. I appreciate that. And then maybe I'll just ask a follow-up on the home health segment. And, you know, it sounded like from the prepared remarks, there's some process improvements you guys are implementing. I think you mentioned around staffing and referral conversion rates. So we'd love to just hear a little bit about maybe what some of those workflows look like from an improvement perspective. And then also sticking with kind of the referral dynamic, If you take a step back and think about all the sort of structural pressures facing Medicare Advantage plans on their rates and MLRs and some of the issues that they're working through, have you guys noticed any changes just in terms of post-acute care referral trends with those plans? Are they getting a bit more restrictive in terms of prioritizing quality with the post-acute care providers that they're referring to? Anything really changed on that front?
spk14: Yeah, I'll first start with the home health process improvement question. You know, if you think about our home health operations, it's certainly our smallest segment is the one where, you know, we've done a handful of acquisitions, none of which I would necessarily characterize as kind of a platform acquisition. And so when you think about, you know, kind of integrating and looking at process within that segment of our business, you know, there's certainly a lot of opportunities to really get more consistency in how we do things. And so we're looking at, you know, one, looking at centralizing intake, looking at centralizing scheduling. And when you say centralizing, it's really kind of focusing at, you know, these are your tasks, you know, whether you're in the office, you know, in a central office or in a office out in the field, this is what you do to really kind of increase that, the efficiency of that workflow. And particularly on the intake side, you know, we think there's certainly opportunities to accept more cases and improve those conversion rates. So looking forward to that project getting completed. I think we're looking at kind of Q3, Q4 to really get that wrapped up, but very optimistic on where we stand with home health. And when you look at on the referral process, we really haven't seen significant changes or any changes related to, you know, Medicare Advantage focusing on just a handful of providers, if you will. You know, we still get a lot of referrals from payers on the Medicare Advantage side that, you know, we're not going to accept just because rates aren't there or we're going to prioritize where we have episodic rates.
spk09: Okay. That's great. I appreciate all the color. Thanks.
spk30: The next question comes from Ryan Lanson with Cowan. Please go ahead.
spk08: Hi, good morning. Just following maybe on Brian's earlier question, in terms of kind of the scale you would need to get into a new market, I guess if you did move into a new geography, especially in the TCS side, how do we think about that in terms of necessary size, whether it be revenues or maybe comparable to maybe recent deals like TQC or other size parameters, just so we can get a sense on maybe the minimum size that you believe you need to move into a new GI?
spk06: Well, to go into a new market, we would really like to see either immediately or a clearly defined timeline to get to the top one or two market share providers in that particular state. We believe you need to be very large. We believe you need to have the ability to have a voice with the state. So if you see us entering into any new state, I think you can assume. And again, remember, states are different. So it's hard for us to give you a revenue because what might be a number one market share in one state certainly might not be in another. But in those various states that we're looking at, we would like to be number one or number two going into the market.
spk08: Got it. And then just one more for me, maybe more of a philosophical question. Obviously, in the New York state budget, there were some changes to the CD program that's coming in the 25 budget. I know that it's kind of low single-digit operating income exposure, but it's still a pretty decent-sized state, I think the third largest in terms of revenues. I guess do those changes and kind of maybe just some of the tone that the governor took maybe, does that change your longer-term strategy in the state going forward, or is it kind of just steady state from here? Yeah.
spk06: Well, realize that CDPAP's about 4% of our overall revenue. It's a very small part. I know you say that's material, but for us, it's very small. It's a very, very low single-digit margin at that, you know, from an EBITDA standpoint, and that's not even from a bottom-line standpoint. So, you know, for us, as we look at New York, they've tried changes before. I think three or four years ago, they were going to minimize the number of folks in CDPAP. That never got implemented. I think for them to go to 1FI by the beginning of April of next year is going to be really a tough task. So for us, we're going to continue to operate and do the best we can in that market. But just understand that it is one of the markets where it's very difficult for us. And from a strategy standpoint, it's not a market that we can do the things we're trying to do, which is three levels of care, and value-based care. So from that standpoint, it takes a backseat as far as acquisitions and other items and investments.
spk08: Got it. Let me squeeze one quick one in. Hospice revenue per day up, I think, 3.7%. That's pretty strong, certainly above the latest fee-for-service Medicare rate. Anything to call out there maybe in terms of acuity changes or geographic distribution, anything else there?
spk21: No, Ryan, I think, you know, we obviously have a little bit of a mixed shift pretty consistently, so there's a little bit of contribution there, but I think overall in hospice, we saw a little better implicit price concession to some of our revenue adjustment in the quarter than what we maybe saw the same quarter last year, and I think that was beneficial this quarter to a certain extent.
spk07: Got it. Thank you.
spk30: As a reminder, if you would like to ask a question, please press star, then 1 to be joined into the question queue. The next question comes from Joanna Gajuk with Bank of America. Please go ahead.
spk31: Good morning. Thank you for taking the question. So just first a follow-up here on the margins and I guess some of the cost items. So gross margin in the quarter was essentially in line with your prior quarters, with your prior comments on the Q4 call and But even that was very good. GNA was really there at the source of uptake here. So excluding stock comp and acquisition expense, right? You mentioned GNA was, you know, very close to 20%. You know, it sounds like there's some timing. But how should we think about the next couple of quarters? The quarter sounds like maybe that's a low point. From here, we should expect some increase in that ratio.
spk21: Yeah, Joanne, I think being at just under 20% on adjusted G&A for the quarter, you know, I think, as I mentioned earlier, our merit increases and some of those costs typically come in on March 1. So you haven't seen a full quarter impact. And majority of those are through our corporate staff, our branch staff, that's our G&A line, not a direct cost. So I think you'll see a little bit of that, you know, go into the first full quarter in Q2. I think overall, as a percentage revenue, we would expect, you know, adjusted G&A to kind of still be in that you know, 20-ish percent. It might be a little tick up from what we saw in Q1, but fairly close and consistent.
spk31: Okay, that makes sense. And the other one, in terms of volume, so you said maybe some weather impact in personal care, right, about Southwest Q, kind of exit the quarter, right? kind of back to where you thought you would be, is that the way to think about it, that kind of this was a temporary, maybe you recouped some of those last visits and kind of, you know, your talks, updated talks for the whole year when it comes to personal care volumes?
spk14: Yeah, I mean, if you look on the PCS side, a weather event, you know, if you have a snow or an ice storm, particularly in kind of some of the downstate Illinois markets or out in some of the more rural markets, you know, a lot of times caregivers can't make those visits. We attempt to try to reschedule those, you know, but that's challenging. And you can only reschedule that, you know, within, you know, depending if it's a weekly auth or a monthly auth determines when you can reschedule or have an opportunity to. So, you know, it's unfortunate. I'm always rooting for bad weather on the weekends in those markets because I'm an operator. You know, unfortunately, we had some that is kind of early in the week. You know, Mondays are worse than it would be if it's on a Friday. So, again, kind of a temporary blip. But if you look at just where we, you know, progressed throughout the quarter on PCS, January was, you know, was impacted by the weather events. But we saw a nice pickup in February and actually exited pretty strong in March. and expect those trends to continue. And if you look at our hiring numbers as well, kind of mirror that. January was a little soft because of, frankly, the weather impact there. We actually had a nice hiring in February and, frankly, followed that up with what really was record hiring in March. And our April hiring numbers were solid as well.
spk31: Great. Good to hear that. And if I may just follow up on the discussion around the 80-20 trend. provision in the access reg. So in the reg specifically, you know, CMS actually did say something along the lines of, you know, they expect the states to look at the rates, right, to see if they are actually sufficient. I mean, there's a lot of requirements now um different requirements for states to um disclose that information and keep updating those so do you expect states to actually be forced to wait space to ensure their you know they're essentially not provided to deliver the curriculum because obviously if they don't um ensure the access you know they will end up uh paying uh higher or sending more money for some of these um seniors or people with disability that end up in nursing homes, right? So how do you think about this, forcing some states to improve rates?
spk14: Yeah, Joanna, I'll start, and then Dirk may add some color to it. You know, that's one of the aspects of the rule that, you know, I think we, like others in the industry, are in favor of. I think having more transparency around how rates are calculated and formulated by states is very important. I do think there will be some pressure on states to raise rates because, as you point out, the alternative is actually putting individuals in a much more costly institutional setting. So I certainly think there's opportunities over the next six years to really work with states in where those rates need to be in order to be able to maintain the programs at their current status and, frankly, to try to grow the personal care programs in those states.
spk31: Right, exactly. And then the last one is, so you mentioned, you know, there's obviously some clarifications in the record around this and definitions and denominators and things like that, but it sounds like there's still some additional clarity that you might be expecting. So is this something you expect to come out from the states? Because that was another element of this regulation, right? Clearly CMS gave a lot of authority or flexibility to the states to... you know, when it comes to that 80-20 provision. Is that how you read it? Like, there's going to be more information coming out from the states, and that's when you could kind of be more clear when it comes to, like, what exactly is happening. But obviously, since this has been six years, you might not hear about it for a while. But I guess I want to say in the regular, it also talks about that the states have to – say or I guess prove that they are ready for it in four years or something like that. So that doesn't mean that we kind of like, you know, four years from now we hear more details or you think it's going to be sooner than that. Thank you.
spk14: Yeah, I think, you know, Fran, unfortunately the way states tend to work is they wait more to the back end. So I don't expect to have any near-term clarification on some of those elements in the rules. And as you point out, there were a lot of provisions that were left open for the states to determine and have some flexibility with. And CMS said that they would provide, I think, technical assistance to help the states go through that process. But, you know, this is something that I think states will, you know, the reality is they'll probably take a little bit of a wait-and-see approach, you know, even though some of the significant provisions for them actually kick in in four years. But I don't anticipate getting anything in the near term. I think we'll be kind of closer to the back end. of that four-year period.
spk31: Yeah, I know. This is how usually these governments work when it comes to deadlines. They were at the very last minute. And if I may just speak to the very last one, sorry, because there was also discussion around some of these specific, you know, elements called out in this regulation. And, you know, I would check to buy some larger companies estimated, you know, adjusting for the supervisory costs. This could be, you know, like 500 basis points for them. So I know you're not willing to give specifics, but would it be in this range or much smaller than that? Thank you.
spk06: You know, I think it depends on how companies are defining clinical supervision. To get to the number you specified takes a great deal of breadth in the definition for those of us that operate in the industry. So I'm not sure that We would, you know, we're agreeable with that number at this point in time until we get more clarification. However, I think what we said earlier applies. The fact that they included, CMS included clinical supervisory salaries in the definition was very helpful, and it will give us some relief towards the 80-20. Great.
spk31: Thank you for that.
spk30: Thanks for taking the questions. This concludes our question and answer session. I would like to turn the conference back over to Dirk Allison for any closing remarks.
spk06: Thank you, operator. I want to thank everybody for their interest today in Addis and for being part of our call. Hope you have a great week. Thank you.
spk30: The conference is now concluded. Thank you for attending today's presentation. You may now disconnect.
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