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Operator
Good day, and thank you for standing by. Welcome to AMN Healthcare second quarter 2023 earnings call. At this time, all participants are in a listen-only mode. After the speaker's presentation, there will be a question and answer session. To ask a question during the session, you will need to press star 1 1 on your telephone. You will then hear an automated message advising your hand is raised. To withdraw your question, please press star 1 1 again. Please note, we will be taking one question from each person with one follow-up question and at which point you will need to re-enter the queue. Finally, please be advised that today's conference is being recorded. I would now like to hand the conference over to your speaker today, Randy Rees, Senior Director of Investor Relations.
Randy Rees
Good afternoon, everyone.
spk09
Welcome to AMN Healthcare's second quarter 2023 earnings call. A replay of this webcast will be available at ir.amnhealthcare.com following the conclusion of this call. Various remarks we make during this call about future expectations, projections, trends, plans, events, or circumstances constitute forward-looking statements. These statements reflect the company's current beliefs based upon information currently available to it. Our actual results may differ materially from those indicated by these forward-looking statements because of various factors in cautionary statements, including those identified in our most recently filed forms 10-K and 10-Q, our earnings release, and subsequent filings with the SEC. The company does not intend to update guidance or any forward-looking statements provided today prior to its next earnings release. This call contains certain non-GAAP financial information. Information regarding and reconciliations of these non-GAAP measures to the most directly comparable GAAP measures are included in our earnings release and on our financial reports page at ir.amnhealthcare.com. On the call today are Carrie Grace, Chief Executive Officer, Jeff Knudson, Chief Financial Officer, Landry Fiedig, Group President and COO of Nursing and Allied Solutions, and James Taylor, President and COO of Physician and Leadership Solutions. I will now turn the call over to Carrie.
Carrie Grace
Thank you, Randy, and welcome, everyone. Let me begin by expressing my gratitude for the remarkable efforts of our healthcare professionals and team members. You empower our mission to improve access and quality of healthcare throughout the country. As we have successfully done in the past, AMN is balancing the demands of short-term business conditions against the pursuit of long-term value for our stakeholders. Healthcare organizations need more powerful strategies and tools to deal with complex labor needs that are growing faster than the supply of workers. We believe strongly in these market dynamics and are investing to address the current and future healthcare environment. To meet these needs, we have ramped internal investments in technology and bringing all of our solutions together. Our industry-leading mobile app, AMN Passport, has surpassed 200,000 users and now engages most of our healthcare professionals on assignment. Our language services platform now has API integration with leading electronic medical record systems, enabling faster and easier connections with our medically qualified interpreters. And the early reception to ShiftWise 2.0, our market-leading VMS platform, has been very favorable. In the near term, we are managing through a demand environment that in our nurse and allied solution segment has remained slow as the healthcare sector has moved toward a new normal for total labor costs. Overall demand for travel nurse staffing is low as clients try to regain a sustainable balance of permanent and contingent staff. This year has been harder to predict as clients have focused on accelerating short-term cost management as well as looking at long-term ways to rebuild their workforce. Our outlook for third quarter revenue in Nurse and Allied is approximately 65 million lower than consensus. As we progress through the second quarter, demand for contingent labor from our large MSP clients was lower than we had assumed. They increased the pace of permanent hiring, and we proactively partnered with them on temp to perm conversions and their overall cost management goals. We are continuing to position our organization to serve our clients in the way they want, whether it is supporting a self-managed operation, vendor-neutral MSP, staffing-led MSP, or the many other solutions we have to offer clients. We have improved our internal fill rates on MSPs throughout this year. In addition, we have invested in our VMS technologies to make them more adaptable to individual client needs if they choose to exercise more internal control over their program. Current and prospective clients continue to be open to new solutions that will help them rebuild and manage their workforce. We have ramped sales and marketing efforts to take advantage of this opportunity not just for staffing-led MSP, but also in pursuit of direct and vendor-neutral MSP. We feel good about the sales pipeline we have developed as we finish the year and how it will impact 2024 and thereafter. For our physician solutions, locum tenens, and permanent placement, client needs remain strong, and we are working to bolster the sustainability of our growth trajectory. Locum Tenens had record high revenue in the second quarter, growing 15% year-over-year while also producing strong profitability. Demand in our interim leadership and permanent placement businesses has been affected by clients' cost control efforts, so perm demand seems to have stabilized. We are pleased that the PLS segment was able to make impressive year-over-year progress on gross and operating margins despite flat revenue and a mixed headwind. Our technology and workforce solution segment saw revenue decline from Q1 to Q2 as VMS tracked the softer staffing market. As expected, profit margins in that segment are lower with a revenue mix shift toward language solutions. That business grew revenue 19% year-over-year, and the segment as a whole continued to have a favorable impact on our consolidated profit margins. As we have noted, clients have reacted to the post-pandemic environment by stepping up permanent hiring and seeking change in how they manage labor flexibility. Overall, we see an environment in which labor supplies will still be challenged to deal with growth in healthcare utilization, as well as improving the overall well-being and engagement of healthcare professionals. We think our broad and deep set of solutions and technology platforms position us well to serve the needs of clients and clinicians now and for the long term. AMN is managing through this environment, realigning talent and adjusting costs appropriately to protect margins, while also sustaining important strategic investment initiatives. In recent weeks, our nurse and allied solutions segment successfully completed a major upgrade of its back office technology platform, to better serve our internal growth objectives and our healthcare professionals. The success and scale of this technology transition set new standards for how we manage change at AMN. In many aspects, we accelerated our pace of technology enablement, and this process will continue into 2024 with lasting benefits for our solutions, clients, healthcare professionals, and team members. Our long track record in technology-enabled solutions, such as VMS, workforce analytics, and broad-based staffing strengthens our positioning with clients who want more comprehensive solutions. Now, I'll turn over the call to Jeff for the details about our results and outlook, after which I will return with some final comments.
Randy
Thank you, Carrie, and good afternoon, everyone. Second quarter revenue of $991 million was near the high end of our guidance range, driven by our performance in locum tenants. Consolidated revenue was down 31% from the second quarter of 2022. Sequentially, as anticipated, revenue was down 12% as client's expense management continued to drive demand levels lower and the expected step-down of bill rates within Nurse and Allied and VMS. Gross margin for the quarter was 33.3%, just below our guidance range. Compared with the prior year period, Gross margin was up 100 basis points, primarily due to a favorable revenue mix shift and margin improvements within the nurse and allied segment, partially offset by margin contraction within technology and workforce solutions. Sequentially, gross margin increased 50 basis points. Consolidated SG&A expenses were $202 million, including a non-recurring legal settlement or 20.4% of revenue compared with $244 million or 17.1% of revenue in the prior year period and $206 million or 18.3% of revenue in the previous quarter. The decrease in S&A expenses year-over-year was primarily driven by lower employee expenses consistent with the current demand environment. Lower business volumes led to lower employee expenses, along with lower bad debt reserve and professional liability insurance expenses. Adjusted SG&A, which excludes certain non-recurring expenses and stock-based compensation expense, was $170 million in the second quarter, or 17.1% of revenue, compared with $229 million, or 16% of revenue, in the prior year period. The increase in adjusted SC&A margin as a percentage of revenue year over year was mainly driven by lower revenue. In the second quarter, nurse and allied revenue was $689 million, down 37% from the near record revenue in the prior year period. Sequentially, segment revenue was down 16%, driven by lower volume and bill rates. Average bill rate was down 19% year over year and down 6% sequentially. Year over year, volume was down 17% and average hours worked were down 3%. Sequentially, volume was down 10% and average hours were down 2%. Travel nurse revenue during the second quarter was $477 million, a decrease of 39% from the prior year period and 19% from the prior quarter. Allied revenue during the quarter was $182 million, down 12% year-over-year and 7% sequentially. Nurse and allied gross margin during the second quarter was 26.7%, which increased 100 basis points from the prior year period and grew 80 basis points sequentially. The year-over-year increase in gross margin was primarily due to normalization of the bill pay spread. Segment operating margin of 14.9% increased 30 basis points year-over-year due to higher gross margin partially offset by lower SG&A leverage. Sequentially, operating margin increased 110 basis points driven by lower bad debt reserve and professional liability expense. Continuing with the physician leadership solution segment, second quarter revenue of $176 million was flat year over year and up 6% sequentially. Locum tenens revenue in the quarter was $122 million, a 15% increase from the prior year and up 14% sequentially. Interim leadership revenue of $36 million decreased 24% from the prior year period and was down 10% from the prior quarter. Search revenue of $18 million dropped 19% from the prior year and was down 5% sequentially. Interim and search revenue were down year over year, primarily due to lower demand as healthcare systems continue to focus on cost containment measures. Gross margin for the physician and leadership solution segment was 35.1%, up 90 basis points year over year, and down 10 basis points sequentially. The margin increase year-over-year was primarily due to improved gross margin for locum tenants, partially offset by the revenue mix within the segment. Segment operating margin was 15%, which increased an impressive 360 basis points year-over-year due to lower SD&A expenses and gross margin improvement. Sequentially, operating margin decreased 10 basis points. Technology and Workforce Solutions revenue during the second quarter was $126 million, down 16% year-over-year and 7% sequentially. Language Services generated revenue of $64 million, an increase of 19% year-over-year and 3% quarter-over-quarter. VMS revenue for the quarter was $47 million, a decrease of 38% year-over-year and 14% sequentially. Segment gross margin was 66.7%, down from 78.3%, and 71.4% in the prior year and prior quarter, respectively. The sharp decrease in gross margin year over year and sequentially was primarily due to a revenue mix shift away from high margin VMS and a lower gross margin in language services. Segment operating margin in the second quarter was 44.1%, compared with 55.2% in the prior year, driven by lower gross margin. Sequentially, segment operating margin decreased 520 basis points. Second quarter consolidated adjusted EBITDA was 162 million, a decrease of 30% year-over-year and 10% sequentially. Adjusted EBITDA margin of 16.3% was flat year-over-year and up 40 basis points sequentially. Second quarter net income was $61 million, down 51% year-over-year and down 28% sequentially. Second quarter GAAP diluted earnings per share was $1.55 in the quarter. Adjusted earnings per share for the quarter was $2.38 compared to $3.31 in the prior year period and $2.49 in the prior quarter. Days sales outstanding was 53 days, two days lower than the prior quarter and three days higher than the prior year when collections were very strong. Operating cash flow for the second quarter was $198 million and capital expenditures were $26 million. As of June 30th, we had cash and equivalents of $7 million long-term debt of $1.04 billion, including a $190 million draw on a revolving line of credit, and a net leverage ratio of 1.5 times to 1. As you may recall, we announced a $200 million accelerated share repurchase program on our previous earnings call, which began in the second quarter. During the quarter, we repurchased 2.4 million shares of stock for a total of $250 million. In total, year to date as of June 30th, we have bought back 4.1 million shares of stock for a total of $425 million. As of today, $227 million was outstanding on the repurchase program authorized by our board of directors. Moving to the third quarter 2023 guidance, we project consolidated revenue to be in a range of $840 million to $860 million. down 24% to 26% from the prior year period. Gross margin is projected to be between 33.3 and 33.8%. Reported SG&A expenses are projected to be 19.8 to 20.3% of revenue. Operating margin is expected to be 8.8 to 9.4%, and adjusted EBITDA margin is expected to be 14.3 to 14.8%. Average diluted shares outstanding are projected to be approximately $38.6 million. Additional third quarter guidance details can be found in today's earnings release. As Kerry mentioned, utilization from our top clients is lower than we anticipated, which is reflected in our third quarter guidance. Order trends have been stable for three months and clients have indicated they will place winter needs orders within the next few weeks. As such, We expect nurse and allied revenue in the fourth quarter to grow modestly over the third quarter level. The physician and leadership solutions and technology and workforce solution segments should see seasonal revenue declines in the mid single digits. As we have noted, clients have reacted to the post-pandemic environment by stepping up permanent hiring and seeking change in how they manage labor flexibility. The result has been a surge of new opportunities along with greater client turnover within the industry. The near-term impact is visible in continued soft demand from our MSP clients and a lesser impact from turnover. These client transitions went largely as expected in recent months and were not the drivers of change in our 2023 expectations. And now, I'd like to hand the call back to Carrie.
Carrie Grace
Thank you, Jeff. This quarter, we say farewell to two of the people who helped build AMN and the concept of total talent solutions in healthcare. Denise Jackson, our corporate secretary and chief legal officer, is retiring after 23 years of making a profound impact on the AMN family. Denise was instrumental in bringing AMN from its IPO to becoming an industry leader in corporate governance. Her fierce conviction, determination, and relentless dedication ensure that our culture embodies diversity, equity, equality, and inclusion. Denise provided well for her succession. She has mentored Whitney Laughlin, her successor, for 17 years, and we are excited to see how Whitney builds on Denise's legacy. Thank you, Denise, and congratulations to Whitney. Landry Seating joined AMN in 2008 as part of an acquisition. We always want acquisitions to bring in leadership talent, and Landry is a brilliant example of how that should work. He was instrumental in the growth of our travel nurse and allied businesses. He became the leader of our nurse and allied solutions segment in March 2020, right at the beginning of the pandemic. Landry kept his team together during the pandemic with his unique blend of business acumen, insightful leadership, and a personal charm that no one who met him will forget. Landry is leaving the staffing industry for another opportunity that is very special to him. We are grateful for his efforts to prepare his successor. Robin Johnson is superbly prepared to take over leadership of Nurse and Allied at this critical time in our evolution. I'm excited about the depth of leadership talent we have built and will continue to build at AMN to bring the best to our clients and healthcare professionals in a changing industry ecosystem. Now, operator, please open the call for questions.
Operator
Thank you. We will now conduct the question and answer session. To ask a question, please press star 11 on your telephone and wait for your name to be announced. To withdraw your question, please press star 11 again. Please remember to limit to one question with one follow-up question. If you have additional questions, we ask that you please re-queue.
Randy Rees
Please stand by while we compile the Q&A roster.
Operator
Our first question comes from AJ Rice of Credit Suisse Financial Services.
AJ Rice
AJ Rice Hi, everybody. Just technical to make sure I understand the Q3. It sounds like you're looking for nurse and allied revenues to be down about 20% if I've got that right from Q2 to Q3. I know in Q2, the volumes were down about 10% and the bill rate were down about 8% in the same category. Can you give us a sense of where you think that split falls out in Q3 between what you're seeing in volume decline versus what you're seeing in bill rate decline?
Randy
Yeah, AJ, the volume decline in nurse and Allen in Q3 would be down low double digits sequentially, and then the bill rate, we had originally expected bill rates to be down, you know, mid single digits in Q3 over Q2, and it's slightly stronger than that, maybe down 7 to 8% Q3 over Q2 on the bill rate side.
AJ Rice
Okay. And then just stepping back with a broader question, I think your principal public peer at least yesterday described what they were seeing in the market heading into the third quarter is an inability at the current bill rates to find staff to fill positions. It sounds like you're putting more of the emphasis on the the demand side that maybe at least I interpreted that they were. I don't know if there's any way to comment on that. You're saying, though, that your order trend has been steady for three months, I guess, would somewhat suggest that the orders are there, I guess. But anyway, do you have any takeaway? open-ended question, but to sort of characterize it from a demand versus supply challenge to market.
Carrie Grace
Hey, AJ, let me give a general comment, and then I'll turn it over to Landry to fill in some detail. I think overall we're seeing the same thing across the market, and there's probably a nuance just in terms of, you know, our businesses and the mix of some of our businesses. But what we talked about last quarter in Nurse and Allied is that we had started to see some modest growth off an early April trial. We continued to see that growth into June, and we expected it to continue into Q3. What we saw is that after the increases that we saw going into June, it really flattened out. And so the change for us was a change in utilization with our largest clients. So it wasn't a supply challenge. It really was a utilization lower than expected from some of our largest clients. And if we go forward into what we have seen and some of the patterning that Jeff mentioned in his opening comments, we have gotten some early indications from clients about winter needs. And based on those indications, we would expect that we would see, you know, a little bit back to some normal seasonal patterning of some growth from Q3 to Q4. I don't know if you want to... Yeah.
Jeff
Hey, AJ Flandre. So, on that pay front, so pay, of course, is just one factor that these clinicians are considering. Whenever they're looking at our jobs accepting our jobs, I think we might have said in the past really location is the number one preference That's the most important There's other things work-life balance flexibility of the job Facilities reputation working conditions. So there's a lot of different factors And we do see certain customers right now there that are posting orders that we would consider below market rate and we do see that those go unfilled for the most part, but that's That dynamic, that's not new. I mean, we've seen that over many years where you have a portion of the needs that go unfilled. A lot of our kind of more strategic and larger clients, they're posting orders at what we would consider market rate. Those customers are experiencing high fill rates. They're getting their jobs filled. So really the reason for some of the softer volumes that we're seeing going into Q3, it's more of a demand story for us, just not being quite as robust as what we'd like to see. And then I guess the last thing that I've mentioned is just applications. Our new application stats are still really, really strong. There's still a lot of interest in travel. They still remain much higher than what we ever saw pre-pandemic.
Randy Rees
Okay, thanks a lot. Okay, one moment for our next question.
Operator
Our next question is from Jeff Silver of BMO Capital Markets.
Jeff Silver
Thanks so much. Given the environment, I'm just curious what your company's been doing with internal headcount. Has there been any changes and should we expect future changes?
Carrie Grace
Yeah, thanks for the question. As you know, one thing that AMN has done extremely well Over its history is be able to flex up and flex down in different environments And so as we saw lower demand Really as you entered, you know less last year and entered this year We have managed our internal resources and headcount accordingly so if you look from the beginning of the year until what we would expect in the third quarter and we will be down around 9% from a headcount standpoint. And we do that. We have programs that we put in place around managing that through normal attrition, performance management. One thing I would note is from a producer standpoint, we have intentionally kept our producers because we expect demand to increase as we get into the fourth quarter and into next year, and we want to be ready for that.
Randy
And Jeff, I would just add, you know, at the midpoint of the Q3 guide, you know, although with revenue coming down as we've moved through the year, adjusted SG&A as a percent of sales has increased, but the absolute dollars have come down sequentially every quarter since the first quarter, and we would expect that trend to continue into the fourth quarter. Okay, that is very helpful.
Jeff Silver
My next question may be long. I apologize about it, but I want to talk about labor disruption. So, our first aspect, I don't know if it had any impact on the second quarter, if you're expecting any impact in the third quarter, but more importantly, and this may be more anecdotal than anything else, I lived In central New Jersey, you know, one of our large hospitals, Robert Wood Johnson, I haven't seen the news today, but the nurses were expected to go on strike tomorrow. And one of the issues was that they wanted hospitals to reduce their contract labor spend. You know, obviously it's self-serving, but I don't remember seeing that kind of pressure from the nurses themselves. Is this something that's happening elsewhere? And does that, you know, produce another headwind for your business?
Randy
Yeah, I would say, Jeff, I mean, for us, we had about $5 million in labor disruption revenue in the second quarter, and there's nothing that we're servicing our clients on from a labor disruption front in the third quarter, so there's zero in revenue embedded in the Q3 guide.
Carrie Grace
And, Jeff, I would say overall we haven't heard that as a theme from clients.
Jeff Silver
Okay, maybe one off here. Thank you so much.
Randy Rees
Okay, one moment for our next question. Our next question is from Trevor Romeo of William Blair.
William Blair
Hi, good afternoon. Thanks so much for taking the questions. One, you know, I kind of appreciate the commentary on winter order indications kind of giving you confidence in Q4 growing sequentially for nurse and allied solutions. I guess as you look kind of forward based on what you're seeing and hearing now, does it feel like there's potential for further softness in either bill rates or volumes, you know, next year after the winter? Or does it kind of feel like Q3 of this year will truly be the trough for the travel business in this demand kind of cycle and hospitals are comfortable with where they stand, you know, kind of in terms of contract labor.
Carrie Grace
Yeah, let me give you some macro comments and then I'll let Landry and Jeff chime in a little bit on what we could expect to see from a bill rate. And I think we've talked a bit about what we expect to see from a demand standpoint. If you look at the macro thesis that we've talked about for some time, That remains intact. And so, you know, on the one side, we expect to continue to see an increase in overall healthcare demand, utilization, aging demographics, a number of factors going into that. And you will continue to have supply constraints against that. And so, we expect for there to continue to be demand across the board. for the services we provide, everything from workforce planning into how we operationalize their workforce strategies, of which contingent staffing is a piece of that. If you look at, on average, what you have seen, and I think this has been reinforced in the commentary from some of the public company hospital systems, they've got, you know, on average you're getting back into a range of normal on contingent labor. The caveat that I would put to that is clients are at different paces of change in getting there. So while we have clients that have gotten down into what they would consider some of their target rates, we have other clients that still are at high levels for a variety of reasons. And so when we think about what that looks like, this year really has been one of how do we get back into more of a normal, sustainable workforce framework But we expect that we will continue to see, you know, the supply, demand, and balance creating a need for our broad-based services as we go forward.
Randy
Yeah, and Trevor, on the bill rate side, you know, our expectations for the fourth quarter is that bill rates would be down low single digits off of Q3 levels. you know, that would put the 2023 exit rate, you know, call it somewhere in the 32, 33% above pre-pandemic levels or a 7% CAGR from 2019. And, you know, that's very much in line with where, from a CAGR standpoint, where annualized nurse wage inflation is running since 2019. So that, you know, gives us confidence that that's, the starting point for bill rates as we think about 24. Yep.
William Blair
Understood. Thanks for that color. And then, you know, I just kind of wanted to touch on the locums business, which I think you highlighted as a revenue record or a record revenue quarter in the second quarter. Just wondering, you know, are you seeing broad-based increases in demand across the locums book or any particular specialties, you know, driving the strength? And then given the strength in Q2 for locums, I guess, how do you reconcile that with the Q3 guide of PLS segment kind of being down 3% to 5%?
Carrie Grace
As I turn that over to James to give some color, I want to just underscore and congratulate our entire locums team for the quarter. It was extraordinary. James, you want to talk a little bit about what you're seeing?
James
Sure. Thank you, Carrie. And like Carrie, I would like to thank the Locums team as well, and specifically under Jeff Decker's leadership. The team has leaned in and really lives the values of who we are as an organization. They do outstanding work. If you think about the Locums business, our Locums market is very strong from a demand perspective, but we're still at 1%. 0.5 times the pre-COVID levels, and that demand is really driven. It's up quarter over quarter and year over year, and from the specific specialties of CRNA, advanced practice, primary care, and surgery, and it continues to surge and continues to move forward. I think I will state is that when you think about our results, our results for Q2, we have record high in revenue of 14.3% sequentially up, 15% over year over year up in revenue, And other favorable metrics that we have from a demand, from fill rate, from book spread, POA, and revenues day fill. All of those metrics were up both quarter over quarter and year over year. Team focusing upon our clients and helping our clients to meet their demand. Because when we meet their demand and put positions in place, those are revenue generating positions that help our clients to be able to meet their financial numbers. And we do that through leveraging our MSP and thinking about total talent solution. So the locums team keeps leveraging our MSP and leveraging our total talent solutions. I think that we're well positioned. Market is very high in demand and the team is delivering against that demand.
Randy
And on the guide, Trevor, I would just add the expectation for locums in Q3 would be pretty flattish sequentially over Q2 and that should still be up. you know, low teens on a year-over-year basis. And then where you are facing some headwinds within interim and search, demand trends remain soft there as hospital systems continue with their cost containment measures. And we would expect both of those businesses to be down, you know, approximately 10% quarter-over-quarter in Q3.
Randy Rees
Got it. Okay. Thank you. That was helpful. Appreciate all the color. Okay, one moment for our next question. Next question is from Brian Tenquilla of Jefferies.
Brian Tenquilla
Hey, good afternoon, guys. I guess my first question would just be, you know, any color you can share with us about, you know, just the competitive environment. I mean, there's a lot of chatter about MSPs moving around and I know, Carrie, you talked about vendor-neutral agreements and wins in that area as well. So just maybe any color you can share on what that environment looks like today.
Carrie Grace
Yeah. Let me start with something I mentioned in the last call that we have seen continue. As you really look at what we're seeing with clients overall, coming out of the pandemic, For three years, they were heads down, focused on dealing with a surge in demand and challenges in their workforce. And so we have seen them come out of the pandemic with a huge need around, how do I find solutions that are going to help me with transparency, cost containment, and building a sustainable workforce? And so we've seen that continue. as an overall theme and a bigger openness across the board for clients to try solutions that are gonna help them achieve that. I know there's been conversations around MSP, VMS, obviously we are major players in both of them. We look at it as what clients need and we wrap our solutions around them. We haven't seen one model change, one competitor change, about what clients are coming from or going to. I think the overall theme we're seeing is clients are looking for a way that they can sustainably build a workforce to serve their needs. And so if you go back and look at what we're seeing overall from a competitive market, it's a competitive market. So it was competitive during the pandemic. And as you've gone into this period of lower demand, that competition has intensified. We think we are well positioned as clients look for a variety of solutions because of the breadth of what we provide to be in a very good position to help clients regardless of whether they want an MSP relationship, a vendor-neutral relationship, or any of the other solutions that we provide. One other thing I should mention, Brian, is If we look year over year at our MSP pipeline, our pipeline is 300% higher than this time last year.
Brian Tenquilla
Got it. Okay, that's awesome. I guess my follow-up, kind of related as well, I mean, as AJ mentioned earlier, I mean, one of your competitors is talking about challenges with recruitment and whatnot, but they called out the tightening of spread between bill rate and take rate. And as I look at your margins, and there's an ally for the quarter, obviously not showing any deterioration. So maybe just curious what your outlook is for margins going forward, you know, gross margins in nurse and allied, given those commentaries.
Randy
We would expect nurse and allied gross margins in the fourth quarter. That's typically seasonally low for us. Brian, just because of the hours worked and, you know, the Q3 levels should be, you know, pretty comparable to where we were in Q2.
Randy Rees
Got it. Thank you. Thank you. One moment for our next question. Next question is from Kevin Fishbeck of Bank of America. Great. Thanks.
Kevin Fishbeck
I wanted to ask about what you guys believe your visibility is into the Q4 trends, because I guess this is Now two quarters where both you and your public competitor have taken down guidance, you know, for the year. And so it seems like the market's in flux and it's kind of hard to hit what seems to be a moving target. You know, because I think last quarter you both sounded like confident that things were firming. I guess, is there a reason to believe that the data points you're getting today are better or more informed data points than what you saw at this point last year or whether things are still in flux and visibility is still kind of below average?
Randy
Yeah, Kevin, you know, I would say, you know, for us, we would really say the behavior among our top clients was very different than what we had seen historically. You know, we've talked many times about how we thought this year would return to some level of normal seasonal patterns, and we did assume a partial recovery, and then we saw utilization decrease. you know, decline into the third quarter. You know, as it relates to Q4, we do believe that the stability that we've seen in the demand trends over the past three months, as well as the indications that we've received from our clients on their winter order needs, is what gives us that visibility into Q4 and that nurse and allied revenue will increase sequentially over Q3, and that Q3 will be the trough within nurse and allied
Kevin Fishbeck
Okay. I guess maybe your comment is a little bit different than theirs, but I guess the competitor was kind of saying that there were a lot of orders that were coming in below kind of market rates and just not being filled. I don't want to call them phantom orders, but kind of orders that, you know, potentially the hospital never fully expected to be filled. I just want to make sure that I had read that these orders, in your view, are kind of orders that make sense, you know, at or near market rates. that you're seeing firming and it's not, there's no mix in kind of how those, you know, those orders are looking and whether you've got real confidence that they're actually fillable orders.
Jeff
Hey, Kevin, it's Landry. So I don't disagree with the other public competitor that, you know, if some of those orders had higher pay rates that they would go at a higher fill rate. So I don't disagree with that. The thing is that that's always been a component in the marketplace. And what we see on those orders that are going unbilled is not disproportionate to what we would have seen before. So that's why we believe, you know, the mix of those orders and based on what the bill rates are and what the market is demanding and what clinicians are demanding, that we need some more demand. And, you know, like Carrie and Jeff both mentioned, it's leveled out. And we've seen the list of winter needs from our clients, from some of our top clients. It's not official, but those lists show us that the demand that will be coming in for winter needs, which means Q4 and into Q1, is at or above what we saw last year.
Kevin Fishbeck
Okay. And then maybe just the last question, I guess. Historically, as we thought about how this year was trending and then we thought about 2024, you guys seem to be guiding to, like, the Q4 numbers probably take that, annualize it, and that's a good base to think about for next year. If I hear what you're saying about nursing allies being up and the other two divisions being down, that Q4 revenue overall might be flat-ish to maybe slightly up, which would put you in a 3-5 type base for annualized. Is that the right way to think about the jumping off point into next year, or is there something wrong with that?
Randy
It's directionally correct, Kevin. I would say you could think about the back half. You know, run rates certainly on the top line would smooth out some of that seasonality, particularly within PLS and TWS, as well as on the margin side.
Kevin Fishbeck
Okay, so the back half of this year guidance annualized, and then from there, you know, you think growth, you know, in bill rates and... and billable hours make sense?
Randy
Rates will depend on inflation, but we would probably envision them being pretty flattish next year off of those Q4 levels. I think Kerry spoke about the depth of the MSP pipeline. Obviously, we have tailwinds. within locums as well as language services as well. And then, you know, the marketplace client churn could potentially, you know, be a headwind as well.
Randy Rees
Okay. Perfect. Thank you. Okay. One moment for our next question. Our next question comes from Toby Sommer of Truist Securities.
organically
Thanks. With another three months at the firm, Carrie, maybe could you share a bit more with us about how you may shape the business in the portfolio as the business, you know, looks to be stabilizing towards your end?
Carrie Grace
Yeah. Thank you. And I think, you know, hopefully you have gotten this sense both in terms of what we've done from a leadership standpoint, as well as areas of emphasis that we have underscored over the past couple quarters. We look at our portfolio as being very well positioned in a period of extraordinary change with our clients and in the overall healthcare workforce ecosystem. Areas of focus for us, number one, particularly during this period of inflection, will be on our customers. And by customers, it will be both on the client side and on the clinician side. On the client side, we will continue to drive towards a total talent solution set for them, starting with how we help them in overall workforce planning, which is of incredibly high interest, and be able to operationalize that plan through our broad set of solutions. All of that, both in terms of how we interface with them and also what we do on our own platform, will have increasing degrees of integration on the technology side. On the clinician side, and we mentioned this in the opening comments about Passport, we continue to want to support our producers in their relationships with their clinicians in making it easy 24-7 for our clinicians to have access to a wider range of capabilities through Passport. Obviously, that has gone very well. We have over 200,000 clinicians on that app. Second big area of focus is all the efforts around 1AMN, how we continue to strongly grow both organically and through M&A, but have a platform that's going to benefit from the growth that we have, both organic and inorganic. It has brand components, how we operate our company more effectively, client centricity about how we approach the clients and truly wrap our entire set of solutions around them. Third big component is technology, which I think you've heard me talk about over the past two quarters, and you should expect that to continue. We are accelerating all things tech and digital. And then the last two pieces are M&A. We have grown very successfully in the past as part of our overall strategy through M&A. We expect the M&A market and opportunities to continue to accelerate as we leave the year and get into next year. And we would expect to participate in that. And then finally, all of that will be underpinned by our foundation and our culture around DEI, inclusion, attracting, and retaining the best talent.
organically
I appreciate that. I was wondering, how do you explain the rapid growth and stratus when at a sort of foundational level it doesn't look like the non-native English-speaking population growth has been as robust? What are the factors contributing to that rapid growth in recent years as well as so far this year?
Carrie Grace
Yeah, it's a good question. There's a couple of things. If you look at the overall, you know, profit pool, For that, we are growing faster. And I think there's a couple of factors. One in terms of, you know, how our clients are utilizing that service. There are some clients who are actually doing it in-house beforehand. So I think there's one is it's not necessarily that, you know, we are taking share away and there's, you know, a bigger influx of customers. a population that their primary language is not English. It's that they've been served in different ways and probably not as efficiently within the health systems in the past. And so I think this is part of a strategy of how you ensure that you are operating your workforce as effectively as possible. Second piece is we started to introduce that solution set into our MSPs. And so a very big part of AMN's value proposition is how do we put our entire solution set into our MSP relationships. Just during the course of this year, we've made progress from having an average of eight of our solutions into our top clients to having nine. And our language services are a big part of that. Final piece that I'll mention, Toby, is we have a video solution. And what we have seen is that that solution has a value proposition that is attractive to clients. And so we think that has also been a part of our outside growth relative to the market.
Randy Rees
Thank you. Okay. Thank you. One moment for our next question. Next question is from Bill Sutherland of the Benchmark Company.
Kevin Fishbeck
Oh, thanks. Hey, everybody. I've been thinking about the locum space, which has been very, very strong for you and others. What do you think would be the limiting factors on growth there? And what's a reasonable kind of, you know, looking over the horizon a little bit as far as the sustainability of the growth?
James
So, first of all, I appreciate your question. And the locum's marketplace from a demand standpoint, as you heard me mention earlier, is the demand is still at 1.5 times of pre-COVID levels. I believe that that will continue to remain where it is. When you think about the demand coming in from the consumer needing care, you think about the aging population in six out of 10 with a chronic disease. And by 2034, you have people that are more over 65 and you're going to have under 17. And then also wait times to actually get into the healthcare systems or those wait times are actually going up. So I think the demand will remain pretty constant and the limiting factor will be the supply and the number of positions that we have within the marketplace to be able to deliver against that. Hence where we come in and I think play a significant role in delivering total talent solution and really thinking through how do we help our clients to one, have revenue generating events that help them to be able to manage their bottom line, but also to provide care for the patients that are needing that. So, at this point, I think we have to think through how do we solve for that could be a very perfect storm, more people needing care with less positions to be able to deliver against that. And I think we play a very significant role in helping with that.
Kevin Fishbeck
And when you think about resuming M&A, Are you thinking more about adding to your toolkit, you know, solutions, or are you thinking more about bench increases to, for instance, in areas strong like locums?
Carrie Grace
You know, I would say what we look at is both. And so you should expect us to look at solutions that are going to mirror what we're seeing and anticipate to see in terms of future client needs. Tech-enabled solutions, language services, and what we did there is probably a great example of what we would continue to look for in the future. And then when we look at areas like what James was just talking about and where we think we have an opportunity to accelerate demand, we will always look at those areas as well. Jeff, what would you add about M&A overall?
Randy
I think the pipeline right now, I would say... is we're starting to see more tech-enabled assets. That market's been pretty slow the last 18 months, so we're seeing activity pick up there, as well as within, you know, James's area on the POS side. Not as much in the pipeline on the travel nurse or allied side.
Randy Rees
Okay.
Randy
Thanks, everybody.
Randy Rees
All right. Thank you. One moment for a final question here. This question is from Andre Childress of Baird.
William Blair
Hey, this is Andre on for Mark Marcon. Thank you for taking our questions. So I'll just have one quick follow up on the last comment you made with the tech enabled assets. Can you first talk about some of the multiple evaluations you're seeing on some of those, you know, companies that are for sale and then also Additionally, on capital allocation, can you talk about maybe your appetite for further share repurchases and how you view your leverage ratio? Thanks.
Carrie Grace
Andre, let me take the first part of that, and then I'll let Jeff talk about repurchases. What we are hearing is that on some of the tech-enabled solutions, there is an expectation as we get through the year that there's a bit of an understanding that some of those assets have been revalued since what we might have seen. While we haven't seen a number of those assets trade over the past, you know, couple quarters, we would expect that there would be some, you know, expectations that those valuations would look more like what you've seen, you know, the broader market trade at. So, our expectation is we not only see more, but we'd see, you know, valuation levels that could make it interesting. On the repurchase side, Jeff, I'll let you talk about that.
Randy
Yeah, I would just say, Andre, obviously, you know, the balance sheet, you know, affords us a tremendous amount of flexibility right now, levered out 1.5 times. You know, we did enter into the $200 million ASR this quarter. That could, on an outside date, be completed as late as November or as early at the counterparty's discretion sometime in the third quarter. Again, that brought our in-year share repurchases to $425 million. We think that's pretty close to the right number for calendar 23. And then moving into 24 and beyond, obviously M&A would be our first priority for capital deployment. And then absent anything compelling on the M&A front, we will look to return capital to shareholders and repurchase shares.
Randy Rees
Great. Thank you for all the color.
Operator
Okay. Thank you for your question. Seeing no further questions at this time, I would now like to turn the conference back to Carrie Grace for closing comments.
Carrie Grace
I appreciate that. I always thank our amazing AMN team members and clinicians, and I just want to leave by calling out four. A special thank you to Landry and Denise. in what they did to build AMN into the incredible company it is today, and a huge congratulations to Robin and Whitney on their new roles. As always, we appreciate your interest in AMN. Thank you all.
Randy Rees
Okay, this concludes today's conference call. Thank you for participating.
Operator
You may now disconnect.
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