Aveanna Healthcare Holdings Inc.

Good morning and welcome to the Aviana Healthcare Holdings fourth quarter 2023 earnings conference call. Today's call is being recorded and we have allocated one hour for prepared remarks and Q&A. At this time, I'd like to turn the call over to Debbie Stewart, Aviana's Chief Accounting Officer. Thank you. You may begin.

Good morning and welcome to Aviana's fourth quarter 2023 earnings call. I am Debbie Stewart, the company's Chief Accounting Officer. With me today is Jeff Shainer, our Chief Executive Officer, and Matt Buchhalter, our Chief Financial Officer. During this call, we will make forward-looking statements. Risk factors that may impact those statements and could cause actual future results to differ materially from currently projected results are described in this morning's press release and the reports we file with the SEC. The company does not undertake any duty to update such forward-looking statements. Additionally, during today's call, we will discuss certain non-GAAP measures, which we believe can be useful in evaluating our performance. The presentation of this additional information should not be considered in isolation or as a substitute for results prepared in accordance with GAAP. A reconciliation of these measures can be found in this morning's press release, which is posted on our website, aviana.com. and in our most recent annual report on Form 10-K, which will be filed with the SEC this afternoon. With that, I will turn the call over to Aviana's Chief Executive Officer, Jeff Shainer. Jeff?

Thank you, Debbie. Good morning, and thank you for joining us today. We appreciate each of you investing your time this morning to better understand our Q4 and full year 2023 results and how we are moving Aviana forward in 2024 and beyond. My initial comments will briefly highlight our fourth quarter and full year 2023 results, along with the steps we are taking to address the labor markets and our ongoing efforts with government and preferred payers to create additional capacity. I will then provide insight on how we are thinking about year two of our strategic transformation and overall outlook for 2024 prior to turning the call over to Matt to provide further details into the quarter and our 2024 outlook, starting with some highlights for the fourth quarter and full year 2023. Revenue for the fourth quarter was approximately $479 million, representing a 6.1% increase over the prior year period. Fourth quarter adjusted EBITDA was $38.7 million, representing a 30.4% increase over the prior year period, primarily due to the improved payer rate environment as well as cost reduction efforts taking hold. Finally, full year 2023 revenue and adjusted EBITDA was approximately $1.895 billion and $139.2 million, representing a 6% and 7.6% respective increase over the prior year. As we have previously discussed, the labor environment represented the primary challenge that we needed to address in 2023 to see Aviana resume the growth trajectory that we believed our company could achieve. It is important to note that our industry does not have a demand problem. The demand for home and community-based care continues to be strong, with both state and federal governments and managed care organizations asking for solutions that can create more capacity. I am proud of our focus and execution in 2023 as we aligned our objectives with those of our preferred payers and government partners. By focusing our clinical capacity on our preferred payers, we achieved year-over-year growth in revenue and adjusted EBITDA. We also experienced improvement in our caregiver hiring and retention trends by aligning our efforts to those payers willing to engage with us on enhanced reimbursement rates and value-based agreements. While we continue to operate in a challenging labor and inflationary environment, our preferred payer strategy allows us to return to a more normalized growth rate in our business segments. Since our third quarter earnings call, I am pleased with the continued progress we have made on several of our rate improvement initiatives with both government and preferred payers, as well as the continued signs of improvement in the caregiver labor market. Specifically, as it relates to our private duty services business, our goal for 2023 was to execute a legislative strategy that would increase rates by double digit percentages across our various states with particular emphasis on California, Texas, and Oklahoma, which represented approximately 25 percent of our total PDS revenue. At year-end 2023, we had successfully obtained double-digit PDS rate increases in eight key states, including Oklahoma. We have also achieved rate wins in an additional 11 states that were either in line or slightly better than our expectations. These combined 19 states represent approximately 55% of our PDS footprint, and we expect to see positive progress into 2024 as we focus on the remaining states. As a point of reference, the majority of the rate increases were effective in the second half of 2023, which will result in a full-year benefit in 2024. While we are pleased that our PDS legislative messaging has been well received by state legislatures, we still have much work to do. As an example of the work ahead, our PDN rate request was not included in the California governor's proposed budget. We believe that we made significant strides with the governor, Medi-Cal department leadership, and California legislature demonstrating the importance of PDN rate increases and how they support an overall lower healthcare cost, improve patient satisfaction, and quality outcomes. However, it is clear that we need to further accelerate our preferred payer strategy and government affairs efforts to continue to advocate for children with complex medical conditions. This strategy allows us to become a solution for overcrowded children's hospitals and distraught parents who want their children to be cared for in the comfort of their home. We have a proven track record of expanding our preferred payer programs and will enhance our efforts in California similar to our approach in other states. As we look at our preferred payer initiatives in other states, our goal for 2023 was to double our PDS preferred payers from 7 to 14. In the fourth quarter, we added two additional preferred payer agreements, achieving our goal of 14. Our PDS preferred payer volumes remain consistent at 17 percent of total PDS volumes, We are optimistic that we will continue to execute this strategic initiative into 2024. While we are taking a national approach to our PDS preferred payer strategy, we are placing particular focus in 2024 on the state of California and continuing our positive traction in the state of Texas. Using Texas as a point of reference as of year end, We are approaching 60% of our Texas PDN volumes with a preferred payer and still believe we have an opportunity to further improve this trend to approximately 70% in 2024. We plan to execute a similar playbook in California over the next 18 to 24 months and are optimistic we can achieve positive results. Moving to our preferred payer progress in home health. Our goal for 2023 was to improve our episodic payer mix by 10% from approximately 60% to above 70% by year-end 2023. We signed a total of eight episodic agreements in 2023 and improved our episodic mix from approximately 60% at the end of 2022 to 74% in Q4. We continue to remain focused on aligning our home health caregiver capacity with those payers willing to reimburse us on an episodic basis and focus on improved clinical and financial outcomes. We are encouraged by our 2023 rate increases, preferred payer agreements, and subsequent recruiting results. Our business is demonstrating signs of recovery as we achieve our rate goals previously discussed. Home and community-based care will continue to grow, and Aviana is a comprehensive platform with a diverse payer base, providing a cost-effective, high-quality alternative to higher-cost care settings. And most importantly, we provide this care in the most desirable setting, the comfort of the patient's home. Before I turn the call over to Matt, let me comment on our strategic plan and our initial outlook for 2024. As we enter year two of our strategic transformation, we remain highly focused on those initiatives that created positive momentum in 2023. We will continue to focus our efforts on four primary strategies. First, enhancing partnerships with government and preferred payers to create additional caregiver capacity. Second, identifying cost efficiencies and synergies that allow us to leverage our growth Third, managing our capital structure and collecting our cash while producing positive free cash flow. And fourth, engaging our leaders and employees in delivering our Aviana mission. While executing the above key strategies, we still believe it is important to set expectations that acknowledge the environment that we are operating in and the time it will take to fully transform our company to sustain growth. Accordingly, We currently expect full-year 2024 revenue to be in a range of $1.96 to $1.98 billion and adjusted EBITDA to be in a range of $146 to $150 million. We believe our outlook provides a prudent view considering the challenges we face with the evolving labor market and hopefully it proves to be conservative as we execute throughout the year. In closing, I am very proud of our Aviana team. We offer a cost-effective patient-preferred and clinically sophisticated solution for our patients and families. Furthermore, we are the right solution for our payers, referral sources, and government partners. By partnering with preferred payers, we can and will move rate and wage metrics in meaningful ways that support our growth. This strategy allows us to hire, retain, and engage more caregivers in providing the mission of Aviana every day. With that, let me turn the call over to Matt to provide further details on the quarter and our 2024 outlook. Matt?

Thanks, Jeff, and good morning. I'll first talk about our fourth quarter financial results and liquidity before providing additional details on our initial outlook for 2024. Starting with the top line, we saw revenues rise 6.1% over the prior year period to $479 million. We experienced revenue growth in two of our operating divisions, led by our private duty services and medical solution segments, which grew by 6.1% and 17.5% compared to the prior year quarter. Consolidated gross margin was $148.4 million, or 31%, representing a 15.3 percent increase over the prior year period. Consolidated adjusted EBITDA was $38.7 million, a 30.4 percent increase as compared to the prior year, reflecting the improved payer rating environment as well as cost reduction efforts taking hold. Now taking a deeper look at each of our segments, starting with private duty services, revenue for the quarter, was approximately $383 million, a 6.1 percent increase, and was driven by approximately 10.1 million hours of care, a volume increase of 5.1 percent over the prior year. While volumes have improved over the prior year, we continue to be constrained in our top-line growth due to the shortage of available caregivers, although we are continuing to see signs of improvement in the labor markets. Q4 revenue per hour of $38.04 was up 38 cents, or 1%, as compared to the prior year quarter. We remain optimistic about our ability to attract caregivers and address market demands for our services when we obtain acceptable reimbursement rates. Turning to our cost of labor and gross margin metrics, we achieved $103.6 million of gross margin, or 27%. a 12.7 percent increase from the prior year quarter. Our cost of revenue rate of $27.76 was sequentially flat from Q3. While we continue to experience wage pressures in the labor markets, we did improve our Q4 spread per hour to $10.28, representing a 7.6 percent increase over the prior year. Moving on to our home health and hospice segment, Revenue for the quarter was approximately $54 million, a 1.1% decrease over the prior year. Revenue was driven by 9,200 total admissions, with approximately 74% being episodic and 11,300 total episodes of care, up sequentially from Q3. Medicare revenue per episode for the quarter was $3,064, up 1.8% as compared to the prior year. We continue to focus on rightsizing our approach to growth in the near term by focusing on preferred payers that reimburse us on an episodic basis. This episodic focus has accelerated our margin expansion and improved our clinical outcomes. With episodic emissions over 70 percent, we have achieved our goals of rightsizing our margin profile and enhancing our clinical offerings. As we enter 2024, We believe our admission growth will normalize in the 3% to 5% range. We're committed to a disciplined approach to growth while shifting our capacity to those payers who value our clinical resources. We're pleased with our gross margin of 50.9% in Q4, demonstrating our continued focus on cost initiatives to achieve our targeted margin profile. We believe this is the right long-term growth strategy and we hold a strong belief in this business and its lasting value proposition. Our home health and hospice platform is dedicated to creating value through effective operational management and the delivery of exceptional patient care. Now, to our medical solution segment results for Q4. During the quarter, we produced revenue of $41.3 million, a 17.5% increase over the prior year. Revenue was driven by approximately 90,000 unique patients served, an 8.4% increase over the prior year period, and revenue per UPS of $458.80. Gross margins were 42% for the quarter, up 2.3% over the prior year period, and in line with our targeted margin profile for medical solutions. We continue to implement initiatives to be more effective and efficient in our operations to leverage overhead as we continue to grow. While other intral providers have decided to exit the market, we see this as an opportunity to expand our national intral presence and to further our payer partnerships. In summary, we continue to fight through a difficult labor environment while keeping our patients' care at the center of everything we do. It is clear to us that shifting caregiver capacity to those preferred payers who value our partnership is the path forward at Aviano. As Jeff stated, our primary challenge continues to be reimbursement rates. With the positive momentum we experienced in 2023, we're optimistic that such trends will continue into 2024. As we continue to make progress with the rate environment, we'll pass through wage improvements and other benefits to our caregivers and the ongoing effort to better improve volumes. Now, moving to our balance sheet and liquidity. At the end of the fourth quarter, we have liquidity in excess of $232 million, representing cash on hand of approximately $43.9 million, $20 million of availability under our securitization facility, and approximately $168 million of availability on our revolver, which was undrawn as of the end of the quarter. we had $32 million in outstanding letters of credit at the end of Q4. I'm proud of the progress we've made in enhancing our overall liquidity throughout the year. On the debt services front, we had approximately $1.47 billion of variable rate debt at the end of Q4. Of this amount, $520 million is hedged with fixed rate swaps, and $880 million is subject to an interest rate cap which limits further exposure to increases in SOFR above 3 percent. Accordingly, substantially all of our variable rate debt is hedged. Our interest rate swaps extend through June 2026, and our interest rate caps extend through February 2027. One last item I will mention related to our debt is that we have no material term loan maturities until July 2028. Looking at cash flow, Cash provided by operating activities was positive $22.7 million for the quarter, and free cash flow was positive approximately $12.5 million. While Q4 benefited from some timing-related items, which we expect to be moderate headwinds into Q1 cash flows, we continue to believe we will be a positive operating cash flow company in 2024. We also expect to see continued cash flow benefits as our top line and cost management initiatives come to fruition. Before I hand the call over to the operator for Q&A, let me take a moment to address our initial outlook for 2024. As Jeff mentioned, we currently expect full-year revenue to be in the range of $1.96 to $1.98 billion and adjusted EBITDA range of $146 to $150 million. As we think about seasonality, we expect our revenue to grow as rate increases are implemented throughout the year and our volumes grow. Accordingly, we expect approximately 20 percent of our full-year adjusted EBITDA guidance to be recognized in the first quarter and approximately 44 percent of our full-year guided adjusted EBITDA to be recognized in the first half of 2024. As most of our annual rate increases typically become effective in the second half of the year, we expect our adjusted EBITDA to ramp as we use those increases to attract and retain more caregivers and drive volumes. Our EBITDA will also ramp as we realize the benefits of our continued cost savings initiatives. In closing, I'm proud of all of our Aviana team members and their hard work in achieving our 2023 results. I look forward to the continued execution of our 2024 strategic plan and updating you further at the end of Q1. With that, let me turn the call over to the operator.

Thank you. At this time, we'll be conducting a question and answer session. If you'd like to ask a question, please press star 1 on your telephone keypad. A confirmation tone will indicate your line is in the question queue. You may press star 2 if you'd like to remove your question from the queue. For participants using speaker equipment, it may be necessary to pick up your handset before pressing the star keys. To allow for as many questions as possible, we ask that you each keep to one question and one follow-up. Thank you. Our first question comes from the line of Brian Tanklet with Jefferies. Please proceed with your question.

Good morning. You have Taji Phillips on for Brian. Thank you for taking my question. So maybe to start, the midpoint of your guidance implies that margins will be roughly 7.5% for 2024. Maybe can you talk to the building blocks that are or key assumptions that are built into your margins for 2024 and what would need to happen to see the business outperform your implied guidance? And then lastly, if you can provide as much detail, break down the margin expectations across all three segments.

Hey, Taja, good morning. Thanks for your question. Taja, I think as I'll start and I'll turn it over to Matt, but I think as we think of our 2024 guidance, you know, we have very good visibility into rate coming out of 2023. So, I think first in that story is we've got solid momentum. from our 19 rate increases. I think five or six of those rate increases were effective, one one of 24, so we've got nice momentum rolling into the year. We know our home health and hospice final rules, so really good visibility into this year. Obviously, we're now working on a legislative plan for 2024, which most of those come due mid to late year, so our heads are down on the year. In Matt's prepared remarks, he talked about 20% of the implied guide we think will be in Q1. We would remind everyone Q1, from a seasonal standpoint, is our low point. We've got a lot of payroll tax headwinds in Q1 coming out of the holidays. But we're off, you know, sitting here in early March. We're off to a really nice start to the year. We're very pleased on where we are today. So I think you'd see it from our standpoint building throughout the year, Q1 being our low point. But please have leverage to pull. I think big picture, you know, we remain prudent. I'll use the word prudent in our guidance. that we continue to execute against our strategic plan to rebuild the company. Our ultimate goal, Taji, is still to get back to 10% adjusted EBITDA. And, you know, we're still a year or so from that point. But we know the plan. They're executing as a plan to get us back to that 10% target. And I think you'll see it build throughout the year. And I think the most important part is, as we said in our comments around our four strategic initiatives for this year, We know exactly what to do. We know how to do it. And it's just about us executing. And I think as we showed in 2023 that this team knows how to execute against our business plan. So with that, Matt, let me turn to you on more guidance.

Yeah, I think that's really well said, Jeff. I think you nailed it. You know, 2024 guidance, I think, is a prudent concept and consistent with how we, you know, have been performing and leading the broader markets. On margin expansion there, Taji, I don't think you really think anything on gross margin to be different than what you've come to expect with our current business platforms. That'll be consistently in line. Potential for outperform associated with it could be continued overachieving of our preferred payers and overachieving of our state rate increases. Once again, that doesn't necessarily increase your gross margin profile. because what we're doing is taking those dollars and reinvesting them back into our caregivers and back into our workforce to really drive those volumes. Now, with those volumes driving, we're leveraging overhead with it, and we're continuing to have cost-savings initiatives throughout the organization. We did a really nice job of it in 2023. We're continuing to do it in 2024. We'll nip and tuck where we can, but we're also going to invest in the right areas that will demonstrate better clinical outcomes and, you know, really overachieve for our preferred payer initiatives through value-based care too. So in line with where we expect, see that build and EBITDA build throughout the year. And I think that's the way you should think about it. Well said.

Yes, just one more question for me, Jeff. Last question, when we're thinking about the labor environment, I really appreciate the commentary and your prepared remarks, but how should we be thinking about wage inflation in 2024?

Yeah, I think Matt just said it really well, Taj. We still focus, our focus is on rate, which then drives incremental rate. So I think as you think about our margin profile, Matt said it well, and I will point out in our home health and hospice business, you saw 50.9% gross margins for Q4. It's taken us about two years to get that back to the 50%. That was our target. I'm really proud of the home health and hospice team for how hard they worked to get it there. But I think as we think of margins, gross margins, and Matt said it well, they'll be consistent in 2024 as we saw it, you know, kind of Q3, Q4 run rate. Every rate increase we earn, whether it's a preferred payer or a government, state or federal agency, we're going to pass that rate or a large portion of that rate through to the caregivers. That is our value proposition to our preferred payers. It's our value proposition to our government partners. So I think you'll think of gross margins being consistent in the course of the year. And as Matt said, well, we're really trying to drive the growth levers, both in PDS, home health and hospice, and AMS. So we're real excited to get the top line and also bottom line growth in 24 where we expected it. Thanks, Taji.

Thank you. Thank you.

Thank you. Our next question comes from the line of Ben Hendricks with RBC Capital Markets. Please proceed with your question.

Hey, great. Thanks, guys.

Just appreciate all the commentary about the preferred payer progress in Texas and expectations to go to 70% this year. I was wondering if you could remind us kind of where we are in California and where that could go in the near term in terms of preferred payer relationships on the PDN side. And then separately, kind of in areas where we're not yet seeing that double-digit rate increase in budgets, How do we think about how much of the PDN preferred payer penetration can make up for that shortfall? Thanks.

Morning, Beth. Thanks so much. Great question. I think California, we've been heads down. I'll start big, broad picture in California and then drill into your question on kind of how we think about California. We've been at the government affairs legislative process in California now for over two years now. I think it's no surprise to anyone that California is staring down somewhere between 50 and 80 billion. I know it's a pretty broad area deficit this coming year. So, you know, big, big, big issues and opportunities in California for them to tackle their budget. We've made meaningful progress, significant progress with both the governor, current governor, his staff, leadership staff, the head of HHS, which is Medi-Cal, Dr. Golley, as well as the legislature. I think as we think of this moving forward, we think of accelerating our preferred payer strategy to your question, Ben, in California. Unlike Pennsylvania or Texas that is predominantly 90 plus percent Medicaid MCO for our business, California still the majority, more than 50% of the PDM population in California still is on Medi-Cal, still is a we are paid by Medi-Cal, they are overseen by Medi-Cal families. What we have seen, though, in the last two years as California wage and hyperinflation have played through is that families have found their ways to either what's called a whole child model program, which is specific to California, as well as some of the commercial plans in California and some of the Medicaid MCO plans that are established in California. So we are seeing families find their ways, and I think it's nothing more specific than they just realized to get their children coverage, both acute care coverage and home, they need to get to a MCO plan or a whole child model plan. We are seeing a shift in our population in 23 and as we enter 24. Now, it is still less than 50% of the population, so we're pleased that we get to accelerate our preferred payer strategy in California. We are not going to give up on our legislative strategy. We're going to continue to double down our legislative strategy because at the end of the day, $44.12 is what we're reimbursed in California for Medi-Cal. That's not enough. It's not competitive to higher wages on the Medi-Cal program. So we're going to continue to do both. Then you asked for a specific metric. We have not shared that publicly yet, and I think over the course of 2024, we'll reevaluate that. But we're excited that we have two levers to pull in California, not just a government affairs strategy, but we're going to use our Texas strategy, our Pennsylvania strategy, Mayo State's, and accelerated in California. And I will say, out of the 14 preferred payers we have today, I think it's two or three of them today are based in California. So a couple of our preferred payers today are already in the state of California, and they pay us well above the Medicaid PDN rate. So hopefully that's helpful, Ben.

Yeah, thank you very much.

Anything else, Ben?

I think that's it for me for now. Thank you.

Awesome. Thanks, Beth.

Thank you. Our next question comes from the line of Raj Kumar with Stevens, Inc. Please proceed with your question.

Hey, this is Raj on for Scott Piedel. A quick question on just, you know, when we think about 23 and all the momentum game across the three business lines, you know, where do you see the most upside in 2024 among the three business lines?

Raj, good morning and thanks. Great question. You know, I think all three of our business lines have the ability to grow materially and produce great, great results. As Matt mentioned, we've really been focused the last 18 months on, you know, cost efficiencies, cost synergies. So we've got our corporate overhead to a place where we think we are, you know, in a really nice place to oversee a business but to do it at good leverage. I think the business that you will hear us be probably most proud of is the, is the rebound of our home health and hospice business. You know, I think everyone saw a year and a half ago, we were, we were in a difficult spot in our home health and hospice business. And, uh, you know, we were still, still finishing the integration of four companies, still transitioning to home care, home base, getting our arms around clinical outcomes and financial outcomes where we sit today, entering 2024. We are just focused on growing the business and producing great clinical outcomes, and both, not either, but both. And really proud of Shane and Mary and the entire team who lead our home health and hospice team. They have absolutely turned that business around for us, have got us in a great place as we enter 2024. We have great momentum in our PDS business. We have great momentum in our AMS business in 23, but turning around our home health and hospice business was one of our top five priorities in the company and just incredibly proud of that team and the discipline that we have instilled to not try to be a solution for everyone in home health and hospice. but to be a solution for those payers that are willing to reimburse us on an episodic basis. And I think you heard Matt talk about, you know, north of 70% is where we want to be. We ended the year at 74% episodic. That's exactly where we want to be in that business. And so really proud of that team as we run into 2024. Raj.

Great. And as my follow-up, just kind of thinking about just cash flow and, you know, with the framing of, you know, being a free cash flow, operating cash flow positive, how would you kind of frame the working capital dynamics in 2024 and, you know, the ability to further expand upon the EBITDA conversion rate to operating cash flow?

Yeah, great question. And kind of combining the idea of cash flow and liquidity here, all in one, you know, I think we'll experience, I know we'll experience moderate headwinds in Q1. You know, we addressed that in the script as well. But then we also have just normal seasonality that occurs for us in Q1 in the business itself with just EBITDA with headwinds of state taxes, just a little bit of re-engagement with the workforce right out of the holidays as well. And then just our third priority liability season, TPL season, which just extends DSO out a few days in Q1. That kind of rebounds back into Q2 and Q3 as that cash starts coming in. And so you'll see a dip in Q1 a little bit as it starts to then add it back in Q2 and Q3. We look forward to increasing our overall liquidity in 2024. It's a great opportunity for us to do so. What we'll do with that, we'll see how that kind of plays out. We are interested in the idea of small M&A tuck-ins, where appropriate, when appropriate in the market. We continue to look at deals when they come up, but that's probably more in the back half of this year or into 2025. Right now, we're going to focus on operating our business effectively, efficiently, converting that EBITDA into cash, and growing our overall liquidity position.

That's well said, Matt. And the only other thing I'll add is, There's been a tremendous amount of conversation nationally over the last 22 days on Change Healthcare and UnitedHealthcare. I couldn't be more proud of Matt, our team, our billing leadership team. Although Albiana doesn't bill claims directly through Change Healthcare directly, some of our vendor partners do. And our team has done an amazing job of getting bills out the doors, ensuring that Aviana continues to be paid for the great work that we have done. And, you know, it's been a lot of hours and it's been a lot of overtime and it's been a lot of work and workarounds. You know, it's a relatively low impact to Aviana, specifically the change issue, but our team has worked incredibly hard the last three weeks to ensure that our liquidity, our cash flow is solid, and I'm proud to say that it is. And so kudos to our RCM billing teams who've really just worked to make that a reality for Aviana. Thank you, Raj.

Thank you for all the call there.

Thank you. Our next question comes from the line of Pito Chickering with Deutsche Bank. Please proceed with your question.

Hi there. You've got Kieran Ryan on for Pito. Thanks for taking the questions. Apologies if you touched on a few of these things. Just wanted to confirm a couple points. First off, on the margin expansion for 2024, guidance implies 20 basis points. Is it fair to say from your commentary that we should expect that to come through the SG&A line with maybe some potential for outperformance on gross margin? But, you know, as far as what's guided, that's most likely to come in SG&A, correct?

Yeah, I think, more than Kieran, yes. I think the answer is that, yes, we have set up our infrastructure to allow us to be able to grow and leverage our growth. And I think if you, I think if you take the Q3, Q4 performance of the company and transform that into 2024, it probably gives you a better idea of where our gross margins would be, specifically because of the comments around home health and hospice and their improvement. But, yes, Kieran, I think our feedback would be that, you know, there's moderate, minimal to moderate improvement in opportunity and gross margin. where we think we'll be able to overperform in the year is really growth, our ultimate revenue growth rate, volume growth rates, rate improvements that we win within the course of the year, and driving that through the adjusted EBIT online. Matt, anything you'd add to that?

I think you nailed it. You know, gross margins kind of flat on our H2 results from 2023, kind of reengaging that through 2024. Obviously, a little bit of seasonality in here in the front half of the year, specifically Q1, which is some, you know, state tax and implications that occur. But then from there, just good old-fashioned leveraging overhead, nipping and tucking where appropriate, taking some costs out where appropriate. But I think that's where you'll see that 20 basis point margin expansion on the bottom line.

Got it. Thank you. And then lastly, just as we think about where revenues and PDS grow in 2024, wherever that shakes out, say somewhere in the 4% to 5% range maybe, how should we think about the contribution from volumes first rate, 24. Thank you.

Yeah, historically, you know, we would have told you that, you know, rate would have been 1%, you know, for an entire year out there. I think you can look at 2023 and see that, you know, we grew 3.8% on the rate and 3.5% on the volume to be just north of 7. I think you kind of nailed it in that 4% to 5% range is a good range for us. We had a very successful year with 19 state rate increases. eight of them being double digits, you know, as well as our preferred payers being 17% of our total PDS volume. You know, we're going to continue that engagement into 2024, but I think I would take it and draw it right down the middle and say half of it will be rate, half of it will be volume. There's a chance to outperform, of course, you know, if we're able to lean in and pull in additional preferred payers through it, but splitting it, you know, kind of 50-50 is where I would model it out.

Thanks a lot. Thanks, Keir.

Thank you. Ladies and gentlemen, there are no other questions at this time. I'll turn the floor back to Mr. Shainer for any final comments.

Thank you, Melissa, and thank you, everyone, for your interest in our Aviana story. We look forward to updating you on our continued progress at the end if you want. Thank you, and have a great day.

Thank you. This concludes today's conference. You may disconnect your lines at this time. Thank you for your participation. you Thank you. Thank you. Thank you. Good morning and welcome to the Aviana Healthcare Holdings fourth quarter 2023 earnings conference call. Today's call is being recorded and we have allocated one hour for prepared remarks and Q&A. At this time, I'd like to turn the call over to Debbie Stewart, Aviana's chief accounting officer. Thank you. You may begin.

Good morning and welcome to Aviana's fourth quarter 2023 earnings call. I am Debbie Stewart, the company's chief accounting officer. With me today is Jeff Shainer, our Chief Executive Officer, and Matt Buchhalter, our Chief Financial Officer. During this call, we will make forward-looking statements. Risk factors that may impact those statements and could cause actual future results to differ materially from currently projected results are described in this morning's press release and the reports we file with the SEC. The company does not undertake any duty to update such forward-looking statements. Additionally, during today's call, we will discuss certain non-GAAP measures, which we believe can be useful in evaluating our performance. The presentation of this additional information should not be considered in isolation or as a substitute for results prepared in accordance with GAAP. A reconciliation of these measures can be found in this morning's press release, which is posted on our website, aviana.com. and in our most recent annual report on Form 10-K, which will be filed with the SEC this afternoon. With that, I will turn the call over to Aviana's Chief Executive Officer, Jeff Shainer. Jeff?

Thank you, Debbie. Good morning, and thank you for joining us today. We appreciate each of you investing your time this morning to better understand our Q4 and full year 2023 results and how we are moving Aviana forward in 2024 and beyond. My initial comments will briefly highlight our fourth quarter and full year 2023 results, along with the steps we are taking to address the labor markets and our ongoing efforts with government and preferred payers to create additional capacity. I will then provide insight on how we are thinking about year two of our strategic transformation and overall outlook for 2024 prior to turning the call over to Matt to provide further details into the quarter and our 2024 outlook, starting with some highlights for the fourth quarter and full year 2023. Revenue for the fourth quarter was approximately $479 million, representing a 6.1% increase over the prior year period. Fourth quarter adjusted EBITDA was $38.7 million, representing a 30.4% increase over the prior year period, primarily due to the improved payer rate environment as well as cost reduction efforts taking hold. Finally, full-year 2023 revenue and adjusted EBITDA was approximately $1.895 billion and $139.2 million, representing a 6% and 7.6% respective increase over the prior year. As we have previously discussed, the labor environment represented the primary challenge that we needed to address in 2023 to see Aviana resume the growth trajectory that we believed our company could achieve. It is important to note that our industry does not have a demand problem. The demand for home and community-based care continues to be strong, with both state and federal governments and managed care organizations asking for solutions that can create more capacity. I am proud of our focus and execution in 2023 as we aligned our objectives with those of our preferred payers and government partners. By focusing our clinical capacity on our preferred payers, we achieved year-over-year growth in revenue and adjusted EBITDA. We also experienced improvement in our caregiver hiring and retention trends by aligning our efforts to those payers willing to engage with us on enhanced reimbursement rates and value-based agreements. While we continue to operate in a challenging labor and inflationary environment, our preferred payer strategy allows us to return to a more normalized growth rate in our business segments. Since our third quarter earnings call, I am pleased with the continued progress we have made on several of our rate improvement initiatives with both government and preferred payers, as well as the continued signs of improvement in the caregiver labor market. Specifically, as it relates to our private duty services business, our goal for 2023 was to execute a legislative strategy that would increase rates by double digit percentages across our various states with particular emphasis on California, Texas, and Oklahoma, which represented approximately 25 percent of our total PDS revenue. At year-end 2023, we had successfully obtained double-digit PDS rate increases in eight key states, including Oklahoma. We have also achieved rate wins in an additional 11 states that were either in line or slightly better than our expectations. These combined 19 states represent approximately 55% of our PDS footprint, and we expect to see positive progress into 2024 as we focus on the remaining states. As a point of reference, the majority of the rate increases were effective in the second half of 2023, which will result in a full-year benefit in 2024. While we are pleased that our PDS legislative messaging has been well received by state legislatures, we still have much work to do. As an example of the work ahead, our PDN rate request was not included in the California governor's proposed budget. We believe that we made significant strides with the governor, Medi-Cal department leadership, and California legislature demonstrating the importance of PDN rate increases and how they support an overall lower healthcare cost, improve patient satisfaction, and quality outcomes. However, it is clear that we need to further accelerate our preferred payer strategy and government affairs efforts to continue to advocate for children with complex medical conditions. This strategy allows us to become a solution for overcrowded children's hospitals and distraught parents who want their children to be cared for in the comfort of their home. We have a proven track record of expanding our preferred payer programs and will enhance our efforts in California similar to our approach in other states. As we look at our preferred payer initiatives in other states, our goal for 2023 was to double our PDS preferred payers from 7 to 14. In the fourth quarter, we added two additional preferred payer agreements, achieving our goal of 14. Our PDS preferred payer volumes remain consistent at 17 percent of total PDS volumes, We are optimistic that we will continue to execute this strategic initiative into 2024. While we are taking a national approach to our PDS preferred payer strategy, we are placing particular focus in 2024 on the state of California and continuing our positive traction in the state of Texas. Using Texas as a point of reference as of year end, We are approaching 60% of our Texas PDN volumes with a preferred payer and still believe we have an opportunity to further improve this trend to approximately 70% in 2024. We plan to execute a similar playbook in California over the next 18 to 24 months and are optimistic we can achieve positive results. Moving to our preferred payer progress in home health. Our goal for 2023 was to improve our episodic payer mix by 10% from approximately 60% to above 70% by year end 2023. We signed a total of eight episodic agreements in 2023 and improved our episodic mix from approximately 60% at the end of 2022 to 74% in Q4. We continue to remain focused on aligning our home health caregiver capacity with those payers willing to reimburse us on an episodic basis and focus on improved clinical and financial outcomes. We are encouraged by our 2023 rate increases, preferred payer agreements, and subsequent recruiting results. Our business is demonstrating signs of recovery as we achieve our rate goals previously discussed. Home and community-based care will continue to grow, and Aviana is a comprehensive platform with a diverse payer base providing a cost-effective, high-quality alternative to higher-cost care settings. And most importantly, we provide this care in the most desirable setting, the comfort of the patient's home. Before I turn the call over to Matt, let me comment on our strategic plan and our initial outlook for 2024. As we enter year two of our strategic transformation, we remain highly focused on those initiatives that created positive momentum in 2023. We will continue to focus our efforts on four primary strategies. First, enhancing partnerships with government and preferred payers to create additional caregiver capacity. Second, identifying cost efficiencies and synergies that allow us to leverage our growth Third, managing our capital structure and collecting our cash while producing positive free cash flow. And fourth, engaging our leaders and employees in delivering our Aviana mission. While executing the above key strategies, we still believe it is important to set expectations that acknowledge the environment that we are operating in and the time it will take to fully transform our company to sustain growth. Accordingly, We currently expect full-year 2024 revenue to be in a range of $1.96 to $1.98 billion and adjusted EBITDA to be in a range of $146 to $150 million. We believe our outlook provides a prudent view considering the challenges we face with the evolving labor market and hopefully it proves to be conservative as we execute throughout the year. In closing, I am very proud of our Aviana team. We offer a cost-effective patient preferred and clinically sophisticated solution for our patients and families. Furthermore, we are the right solution for our payers, referral sources, and government partners. By partnering with preferred payers, we can and will move rate and wage metrics in meaningful ways that support our growth. This strategy allows us to hire, retain, and engage more caregivers in providing the mission of Aviana every day. With that, let me turn the call over to Matt to provide further details on the quarter and our 2024 outlook. Matt?

Thanks, Jeff, and good morning. I'll first talk about our fourth quarter financial results and liquidity before providing additional details on our initial outlook for 2024. Starting with the top line, we saw revenues rise 6.1% over the prior year period to $479 million. We experienced revenue growth in two of our operating divisions, led by our private duty services and medical solution segments, which grew by 6.1% and 17.5% compared to the prior year quarter. Consolidated gross margin was $148.4 million, or 31%, representing a 15.3 percent increase over the prior year period. Consolidated adjusted EBITDA was $38.7 million, a 30.4 percent increase as compared to the prior year, reflecting the improved payer rating environment as well as cost reduction efforts taking hold. Now taking a deeper look into each of our segments, starting with private duty services, revenue for the quarter, was approximately $383 million, a 6.1 percent increase, and was driven by approximately 10.1 million hours of care, a volume increase of 5.1 percent over the prior year. While volumes have improved over the prior year, we continue to be constrained in our top-line growth due to the shortage of available caregivers, although we are continuing to see signs of improvement in the labor markets. Q4 revenue per hour of $38.04 was up 38 cents, or 1%, as compared to the prior year quarter. We remain optimistic about our ability to attract caregivers and address market demands for our services when we obtain acceptable reimbursement rates. Turning to our cost of labor and gross margin metrics, we achieved $103.6 million of gross margin, or 27%. a 12.7 percent increase from the prior year quarter. Our cost of revenue rate of $27.76 was sequentially flat from Q3. While we continue to experience wage pressures in the labor markets, we did improve our Q4 spread per hour to $10.28, representing a 7.6 percent increase over the prior year. Moving on to our home health and hospice segment, Revenue for the quarter was approximately $54 million, a 1.1% decrease over the prior year. Revenue was driven by 9,200 total admissions, with approximately 74% being episodic, and 11,300 total episodes of care, up sequentially from Q3. Medicare revenue per episode for the quarter was $3,064, up 1.8% as compared to the prior year. We continue to focus on rightsizing our approach to growth in the near term by focusing on preferred payers that reimburse us on an episodic basis. This episodic focus has accelerated our margin expansion and improved our clinical outcomes. With episodic emissions over 70 percent, we have achieved our goals of rightsizing our margin profile and enhancing our clinical offerings. As we enter 2024, We believe our emission growth will normalize in the 3% to 5% range. We're committed to a disciplined approach to growth while shifting our capacity to those payers who value our clinical resources. We're pleased with our gross margin of 50.9% in Q4, demonstrating our continued focus on cost initiatives to achieve our targeted margin profile. We believe this is the right long-term growth strategy and we hold a strong belief in this business and its lasting value proposition. Our home health and hospice platform is dedicated to creating value through effective operational management and the delivery of exceptional patient care. Now, to our medical solution segment results for Q4. During the quarter, we produced revenue of $41.3 million, a 17.5% increase over the prior year. Revenue was driven by approximately 90,000 unique patients served, an 8.4% increase over the prior year period, and revenue per UPS of $458.80. Gross margins were 42% for the quarter, up 2.3% over the prior year period, and in line with our targeted margin profile for medical solutions. We continue to implement initiatives to be more effective and efficient in our operations to leverage overhead as we continue to grow. While other internal providers have decided to exit the market, we see this as an opportunity to expand our national internal presence and to further our payer partnerships. In summary, we continue to fight through a difficult labor environment while keeping our patients' care at the center of everything we do. It is clear to us that shifting caregiver capacity to those preferred payers who value our partnership is the path forward at Aviano. As Jeff stated, our primary challenge continues to be reimbursement rates. With the positive momentum we experienced in 2023, we're optimistic that such trends will continue into 2024. As we continue to make progress with the rate environment, we'll pass through wage improvements and other benefits to our caregivers and the ongoing effort to better improve volumes. Now, moving to our balance sheet and liquidity. At the end of the fourth quarter, we have liquidity in excess of $232 million, representing cash on hand of approximately $43.9 million, $20 million of availability under our securitization facility, and approximately $168 million of availability on our revolver, which was undrawn as of the end of the quarter. we had $32 million in outstanding letters of credit at the end of Q4. I'm proud of the progress we've made in enhancing our overall liquidity throughout the year. On the debt services front, we had approximately $1.47 billion of variable rate debt at the end of Q4. Of this amount, $520 million is hedged with fixed rate swaps, and $880 million is subject to an interest rate cap which limits further exposure to increases in SOFR above 3 percent. Accordingly, substantially all of our variable rate debt is hedged. Our interest rate swaps extend through June 2026, and our interest rate caps extend through February 2027. One last item I will mention related to our debt is that we have no material term loan maturities until July 2028. Looking at cash flow, Cash provided by operating activities was positive $22.7 million for the quarter, and free cash flow was positive approximately $12.5 million. While Q4 benefited from some timing-related items, which we expect to be moderate headwinds into Q1 cash flows, we continue to believe we will be a positive operating cash flow company in 2024. We also expect to see continued cash flow benefits as our top line and cost management initiatives come to fruition. Before I hand the call over to the operator for Q&A, let me take a moment to address our initial outlook for 2024. As Jeff mentioned, we currently expect full-year revenue to be in the range of 1.96 to 1.98 billion and adjusted EBITDA range of 146 to 150 million. As we think about seasonality, we expect our revenue to grow as rate increases are implemented throughout the year and our volumes grow. we expect approximately 20 percent of our full-year adjusted EBITDA guidance to be recognized in the first quarter and approximately 44 percent of our full-year guided adjusted EBITDA to be recognized in the first half of 2024. As most of our annual rate increases typically become effective in the second half of the year, we expect our adjusted EBITDA to ramp as we use those increases to attract and retain more caregivers and drive volumes. Our EBITDA will also ramp as we realize the benefits of our continued cost savings initiatives. In closing, I'm proud of all of our Aviana team members and their hard work in achieving our 2023 results. I look forward to the continued execution of our 2024 strategic plan and updating you further at the end of Q1. With that, let me turn the call over to the operator.

Thank you. At this time, we'll be conducting a question and answer session. If you'd like to ask a question, please press star 1 on your telephone keypad. A confirmation tone will indicate your line is in the question queue. You may press star 2 if you'd like to remove your question from the queue. For participants using speaker equipment, it may be necessary to pick up your handset before pressing the star keys. To allow for as many questions as possible, we ask that you each keep to one question and one follow-up. Thank you. Our first question comes from the line of Brian Tankulak, with Jefferies. Please proceed with your question.

Good morning. You have Taji Phillips on for Brian. Thank you for taking my question. So maybe to start, the midpoint of your guidance implies that margins will be roughly 7.5% for 2024. Maybe can you talk to the building blocks that are or key assumptions that are built into your margins for 2024 and what would need to happen to see the business outperform your implied guidance? And then lastly, if you can provide as much detail, break down the margin expectations across all three segments.

Hey, Taja, good morning. Thanks for your question. You know, Taja, I think as I'll start and I'll turn it over to Matt, but I think as we think of our 2024 guidance, you know, we have very good visibility into rate coming out of 2023. So I think first in that story is we've got solid momentum from our 19 rate increases. I think five or six of those rate increases were effective, one one of 24, so we've got nice momentum rolling into the year. We know our home health and hospice final rules, so really good visibility into this year. Obviously, we're now working on a legislative plan for 2024, which most of those come due mid to late year, so our heads are down on the year. In Matt's prepared remarks, he talked about 20% of the implied guide we think will be in Q1. We would remind everyone Q1, from a seasonal standpoint, is our low point. We've got a lot of payroll tax headwinds in Q1 coming out of the holidays, But we're off, you know, sitting here in early March. We're off to a really nice start to the year. We're very pleased on where we are today. So I think you'd see it from our standpoint building throughout the year, Q1 being our low point. But please have leverage to pull. I think big picture, you know, we remain prudent. I'll use the word prudent in our guidance today. that we continue to execute against our strategic plan to rebuild the company. Our ultimate goal, Taji, is still to get back to 10% adjusted EBITDA. And, you know, we're still a year or so from that point. But we know the plan. They're executing as a plan to get us back to that 10% target. And I think you'll see it build throughout the year. And I think the most important part is, as we said in our comments around our four strategic initiatives for this year, We know exactly what to do. We know how to do it. And it's just about us executing. And I think as we showed in 2023 that this team knows how to execute against our business plan. So with that, Matt, let me turn to you on more guidance.

Yeah, I think that's really well said, Jeff. I think you nailed it. You know, 2024 guidance, I think, is a prudent concept and consistent with how we, you know, have been performing and leading the broader markets. On margin expansion there, Taji, I don't think you really think anything on gross margin to be different than what you've come to expect with our current business platforms. That will be consistently in line. Potential for outperform associated with it could be continued overachieving of our preferred payers and overachieving of our state rate increases. Once again, that doesn't necessarily increase your gross margin profile. because what we're doing is taking those dollars and reinvesting them back into our caregivers and back into our workforce to really drive those volumes. With those volumes driving, we're leveraging overhead with it, and we're continuing to have cost-savings initiatives throughout the organization. We did a really nice job of it in 2023. We're continuing to do it in 2024. We'll nip and tuck where we can, but we're also going to invest in the right areas that will demonstrate better clinical outcomes and really overachieve for our preferred payer initiatives through value-based care too. So in line with where we expect, see that build and EBITDA build throughout the year. And I think that's the way you should think about it. Well said.

Yes, just one more question for me, Jeff. Last question, when we're thinking about the labor environment, I really appreciate the commentary and your prepared remarks, but how should we be thinking about wage inflation in 2024?

Yeah, I think Matt just said it really well, Taj. We still focus, our focus is on rate, which then drives incremental rate. So I think as you think about our margin profile, Matt said it well, and I will point out in our home health and hospice business, you saw 50.9% gross margins for Q4. It's taken us about two years to get that back to the 50%. That was our target. I'm really proud of the home health and hospice team for how hard they worked to get it there. But I think as we think of margins, gross margins, and Matt said it well, they'll be consistent in 2024 as we saw it, you know, kind of Q3, Q4 run rate. Every rate increase we earn, whether it's a preferred payer or a government, state or federal agency, we're going to pass that rate or a large portion of that rate through to the caregivers. That is our value proposition to our preferred payers. It's our value proposition to our government partners. So I think you'll think of gross margins being consistent in the course of the year. And as Matt said, well, we're really trying to drive the growth levers, both in PDS, home health and hospice, and AMS. So we're real excited to get the top line and also bottom line growth in 24 where we expected it. Thanks, Taji.

Thank you. Thank you.

Thank you. Our next question comes from the line of Ben Hendricks with RBC Capital Markets. Please proceed with your question.

Hey, great. Thanks, guys.

Just appreciate all the commentary about the preferred payer progress in Texas and expectations to go to 70% this year. I was wondering if you could remind us kind of where we are in California and where that could go in the near term in terms of preferred payer relationships on the PDN side. And then separately, kind of in areas where we're not yet seeing that double-digit rate increase in budgets, How do we think about how much of the PDN preferred payer penetration can make up for that shortfall?

Thanks. Thanks so much. Great question. I think California, we've been heads down. I'll start big, broad picture in California and then drill into your question on kind of how we think about California. We've been at the government affairs legislative process in California now for over two years. I think it's no surprise to anyone that California is staring down somewhere between 50 and 80 billion. I know it's a pretty broad area deficit this coming year. So, you know, big, big, big issues and opportunities in California for them to tackle their budget. We've made meaningful progress, significant progress with both the governor, current governor, his staff, leadership staff, the head of HHS, which is Medi-Cal, Dr. Golley, as well as the legislature. I think as we think of this moving forward, we think of accelerating our preferred payer strategy to your question, Ben, in California. Unlike Pennsylvania or Texas that is predominantly 90 plus percent Medicaid MCO for our business, California still the majority, more than 50% of the PDM population in California still is on Medi-Cal, still is a we are paid by Medi-Cal, they are overseen by Medi-Cal families. What we have seen though in the last two years as California wage and hyperinflation have played through is that families have found their ways to either what's called a whole child model program, which is a specific California, as well as some of the commercial plans in California and some of the Medicaid MCO plans that are established in California. So we are seeing families find their ways, and I think it's nothing more specific than they just realized to get their children coverage, both acute care coverage and home, they need to get to a MCO plan or a whole child model plan. We are seeing a shift in our population in 23 and as we enter 24. Now, it is still less than 50% of the population, so we're pleased that we get to accelerate our preferred payer strategy in California. We are not going to give up on our legislative strategy. We're going to continue to double down our legislative strategy because at the end of the day, $44.12 is what we're reimbursed in California for Medi-Cal. That's not enough. It's not competitive to higher wages on the Medi-Cal program. So we're going to continue to do both. Then you asked for a specific metric. We have not shared that publicly yet, and I think over the course of 2024 we'll reevaluate that. But we're excited that we have two levers to pull in California, not just a government affairs strategy, but we're going to use our Texas strategy, our Pennsylvania strategy, Mayo State's, and accelerated in California. And I will say, out of the 14 preferred payers we have today, I think it's two or three of them today are based in California. So a couple of our preferred payers today are already in the state of California, and they pay us well above the Medicaid PDN rate. So hopefully that's helpful, Ben.

Yeah, thank you very much.

Anything else, Ben?

I think that's it for me for now. Thank you.

Awesome. Thanks, man.

Thank you. Our next question comes from the line of Raj Kumar with Stevens Inc. Please proceed with your question.

Hey, this is Raj on for Scott Piedel. A quick question on just, you know, when we think about 23 and all the momentum game across the three business lines, you know, where do you see the most upside in 2024 among the three business lines?

Good morning and thank you. Great question. You know, I think all three of our business lines have the ability to grow materially and produce great, great results. As Matt mentioned, we've really been focused the last 18 months on cost efficiencies, cost synergies. So we've got our corporate overhead to a place where we think we are in a really nice place to oversee a business but to do it at good leverage. I think the business that you will hear us be probably most proud of is the, is the rebound of our home health and hospice business. You know, I think everyone saw a year and a half ago, we were, we were in a difficult spot in our home health and hospice business. And, uh, you know, we were still, still finishing the integration of four companies, still transitioning to home care, home base, getting our arms around clinical outcomes and financial outcomes where we sit today entering 2024, uh, We are just focused on growing the business and producing great clinical outcomes, and both, not either, but both. And really proud of Shane and Mary and the entire team who lead our home health and hospice team. They have absolutely turned that business around for us, have got us in a great place as we enter 2024. We have great momentum in our PDS business. We have great momentum in our AMS business in 23, but turning around our home health and hospice business was one of our top five priorities in the company and just incredibly proud of that team and the discipline that we have instilled to not try to be a solution for everyone in home health and hospice. but to be a solution for those payers that are willing to reimburse us on an episodic basis. And I think you heard Matt talk about, you know, north of 70% is where we want to be. We ended the year at 74% episodic. That's exactly where we want to be in that business. And so really proud of that team as we run into 2024. Rush.

Great. And as my follow-up, just kind of thinking about just cash flow and, you know, with the framing of, you know, being a free cash flow, operating cash flow positive, how would you kind of frame the working capital dynamics in 2024 and, you know, the ability to further expand upon the EBITDA conversion rate to operating cash flow?

Yeah, great question. And kind of combining the idea of cash flow and liquidity here, all in one, you know, I think we'll experience, I know we'll experience moderate headwinds in Q1. You know, we addressed that in the script as well. But then we also have just normal seasonality that occurs for us in Q1 in the business itself with just EBITDA with headwinds of state taxes, just a little bit of re-engagement with the workforce right out of the holidays as well. And then just our third priority liability season, TPL season, which just extends DSO out a few days in Q1. That kind of rebounds back into Q2 and Q3 as that cash starts coming in. And so you'll see a dip in Q1 a little bit as it starts to then add it back in Q2 and Q3. We look forward to increasing our overall liquidity in 2024. It's a great opportunity for us to do so. What we'll do with that, we'll see how that kind of plays out. We are interested in the idea of small M&A tuck-ins, where appropriate, when appropriate in the market. We continue to look at deals when they come up, but that's probably more in the back half of this year or into 2025. Right now, we're going to focus on operating our business effectively, efficiently, converting that EBITDA into cash, and growing our overall liquidity position.

That's well said, Matt. And the last thing I'll add is, There's been a tremendous amount of conversation nationally over the last 22 days on Change Healthcare and UnitedHealthcare. I couldn't be more proud of Matt, our team, our billing leadership team. Although Aviana doesn't bill claims directly through Change Healthcare directly, some of our vendor partners do, and our team has done an amazing job of getting bills out the doors, ensuring that Aviana continues to be paid for the great work that we have done. And, you know, it's been a lot of hours and it's been a lot of overtime and it's been a lot of work and workarounds. But, you know, it's a relatively low impact to Aviana, specifically the change issue. But our team has worked incredibly hard the last three weeks to ensure that our liquidity, our cash flow is solid. And I'm proud to say that it is. And so kudos to our RCM billing teams who've really just worked to make that a reality for Aviana. Thank you, Raj.

Thank you for all the call there.

Thank you. Our next question comes from the line of Pito Chickering with Deutsche Bank. Please proceed with your question.

Hi there. You've got Kieran Ryan on for Pito. Thanks for taking the questions. Apologies if you touched on a few of these things. Just wanted to confirm a couple points. First off, on the margin expansion for 2024, guidance implies 20 basis points. Is it fair to say from your commentary that we should expect that to come through the SG&A line with maybe some potential throughout performance on gross margin? But, you know, as far as what's guided, that's most likely to come in SG&A, correct?

Yeah, I think, more than Kieran, yes. I think the answer is that, yes, we have set up our infrastructure to allow us to be able to grow and leverage our growth. And I think if you I think if you take the Q3, Q4 performance of the company and transform that into 2024, it probably gives you a better idea of where our gross margins would be, specifically because of the comments around home health and hospice and their improvement. But, yes, Kieran, I think our feedback would be that, you know, there's moderate, minimal to moderate improvement in opportunity and gross margin. where we think we'll be able to overperform in the year is really growth, our ultimate revenue growth rate, volume growth rates, rate improvements that we win within the course of the year, and driving that through the adjusted EBITDA line. Matt, I think you nailed it.

You know, gross margins kind of flat on our H2 results from 2023, kind of reengaging that through 2024. Obviously, a little bit of seasonality in here in the front half of the year, specifically Q1, which is some, you know, state tax and implications that occur. But then from there, just good old-fashioned leveraging overhead, nipping and tucking where appropriate, you know, taking some costs out where appropriate. But I think that's where you'll see that, you know, 20 basis point margin expansion on the bottom line.

Got it. Thank you. And then lastly, just as we think about where revenues and PDS grow in 2024, wherever that shakes out, say somewhere in like the 4% to 5% range maybe, how should we think about the contribution from volumes versus rate 24? Thank you.

Yeah, historically, you know, we would have told you that, you know, rate would have been 1%, you know, for an entire year out there. I think you can look at 2023 and see that, you know, we grew 3.8% on the rate and 3.5% on the volume to be just north of 7. I think you kind of nailed it in that 4% to 5% range is a good range for us. We had a very successful year with 19 state rate increases. eight of them being double digits, you know, as well as our preferred payers being 17% of our total PDS volume. You know, we're going to continue that engagement into 2024, but I think I would take it and draw it right down the middle and say half of it will be rate, half of it will be volume. There's a chance to outperform, of course, you know, if we're able to lean in and pull in additional preferred payers through it, but splitting it, you know, kind of 50-50 is where I would model it out.

Thanks a lot. Thanks, Keir.

Thank you. Ladies and gentlemen, there are no other questions at this time. I'll turn the floor back to Mr. Shainer for any final comments.

Thank you, Melissa, and thank you everyone for your interest in our Aviana story. We look forward to updating you on our continued progress at the end if you want. Thank you and have a great day.

Thank you. This concludes today's conference. You may disconnect your lines at this time. Thank you for your participation.