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Operator
Good day, and thank you for standing by. Welcome to the AEMN Healthcare Third 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 be advised that today's conference is being recorded. I would now like to hand the conference over to your first speaker today, Randy Reese, Senior Director of Investor Relations and Strategy.
Randy Reese
Please go ahead. Good afternoon, everyone.
spk01
Welcome to AMN Healthcare's third quarter 2023 earnings call. A replay of this webcast will be available at ir.amnhealthcare.com at 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. of various factors and 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, President and Chief Executive Officer, and Jeff Knutson, Chief Financial Officer. I will now turn the call over to Carrie.
Carrie Grace
Thank you, Randy, and welcome, everyone. As the healthcare sector tries to find post-pandemic normal for demand and cost, managing labor costs while building a sustainable workforce has been a major theme in healthcare for 2023. Amidst extraordinary staffing challenges during the pandemic, healthcare employers struggle to keep up with hiring needs and use contingent labor to bridge the gap. Healthcare organizations have made significant progress in hiring permanent workers, and this has been felt across the staffing industry in the form of lower demand for travelers. We anticipated a market reset was coming, but it has been deeper and more sustained than we and the rest of the industry expected. At the same time, as clients think about building a more sustainable workforce, our broad and deep set of technology-enabled talent solutions has positioned us well to support clients as they redesigned their own workforce mix and day-to-day operations. Third quarter revenue was in line with our expectations. Consistent with what the market is experiencing, third quarter revenue was 14% lower than Q2 and down 25% year-over-year. We expect the rate of sequential decline in revenue to be a mid-single digit percentage for Q4, a slower decline than the prior two quarters. This outlook calls for a stable to slightly higher number of nurse and allied travelers on assignment offset by lower bill rate and hours and seasonal declines in other businesses. While staffing demand varies from client to client, most clients are asking for help with more than temporary staffing. To that end, we have made solid progress on our four key priorities that we discussed at the beginning of the year to extend our leadership in total talent solutions. First, we have reinforced our position as the preferred partner to help healthcare organizations optimize their workforce strategy. We began the year with a strong push to reestablish more proactive relationships with clients after three years of crisis management. To serve all clients' current and future needs, AMN has established an accelerated cadence of rolling out enhancements and innovations in our technology platform that will continue through the end of this year and beyond. After focusing on serving our MSP clients in a time of crisis, we are back to serving the broader market with the entirety of our solution set. We are doing things that will greatly help us and our clients over the long term. True innovation. Our connection with clients is accelerating in several ways. At the front end, we are making it easier to do business with AMN. This means empowering our client-facing team members with greater integration across our 20 solutions. We have strengthened our ability to deliver multifaceted, tech-enabled workforce solutions that simplify labor management and provide a variety of options for making the labor force more flexible and cost-effective. clients will be able to access our full set of solutions through our better integrated sales and service organization. This effort to simplify our client relationships includes a stepped up branding initiative that aims to drive greater recognition of the breadth and depth of our presence in the marketplace for healthcare workforce solutions. Recently, we announced that StaffCare and Merit Hawkins have been consolidated under the AMN Physician Solutions brand. As we continue to integrate into the AMN brand across our businesses, we expect to produce many benefits for our healthcare professionals and current and prospective clients. Second, we have made strategic moves to ensure AMN is the preferred employer for healthcare professionals and team members. We have delivered greater workplace flexibility aligned pay and benefits with market benchmarks, launched new career planning and mentoring support, and reinforced our industry leadership in diversity, equality, equity, and inclusion. Our team members are gaining empowerment from improved ease of processes, faster, more responsive team communications, and the integration of AMN Passport, our industry-leading mobile app, into our workflows. Passport continues its strong growth of registrants and average daily users. This growth is driven by the increasing value we are building into Passport for healthcare professionals. Our roadmap for Passport is to broaden its reach across the spectrum of healthcare occupations and job types. We are excited about the power that Passport is bringing to healthcare professionals and see it gaining momentum every day. Passport is only part of the promising results we have produced in improving the credentialing process and candidate experience. Third, we have strengthened our portfolio of talent solutions in many ways with our strong commitment to technology enablement with our one AMN initiative. We are more digitally connected. AMN already has launched powerful integrations and strong implementation and support capabilities that are essential to integrating our solutions into bigger tech stacks and into total workforce solutions. Over the next few quarters, our transformative efforts will make the value proposition across our solutions come to life. A major milestone in our digital acceleration is the go-live this month of ShiftWise Flex, the latest generation of our market-leading vendor management system that is trusted by many of the nation's largest health systems. The newly re-engineered platform manages a full range of program management options, as well as clinical and non-clinical labor sourcing options, from agency staffing and independent contractors to float pool and direct hire. ShiftWise selects and powers users with intuitive dashboards, real-time data-driven labor market insights, powerful supplier support, and passport integration for AI-powered talent matching, credentialing, and candidate self-service. ShiftWise Flex is here at the right time as health systems seek faster and more powerful and transparent ways to develop sustainable workforce agility that delivers great outcomes for patients and their caregivers. And fourth, We have continued to generate strong cash flows and put capital to work. Our capital expenditures this year are on track to reach a record high $100 million, focused primarily on innovations that we expect to bring attractive long-term returns. Last week, we announced plans to acquire MSDR, which will bolster our locum tenens growth strategy and presence in attractive physician specialties. Accelerating our organic locums growth with an acquisition has been a priority for us, and the expertise and track record of MSDR are strong complements to and growth accelerators for our existing locums business. Our strong balance sheet and cash flows enable us to make acquisitions that improve the value we bring to all stakeholders. Across the AMN organization, we are excited to have reached the stage of our progression. I have been honored to lead this extraordinary group of people from identifying needed changes to developing a growth map, accelerating our pace of innovation, and delivering results while simultaneously managing through a significant post-pandemic workforce reset. We have turned the sales engine back on for all market segments and have been rewarded with some early traction and wins. We are positioning AMN to win across all market segments as the market recovers. We are confident that the long-term investment thesis for AMN is attractive. The healthcare workforce faces structural constraints serving demand growth for care driven by an aging population. We are convinced that our tech-enabled services model will win, and AMN is well positioned with valuable clients who need our depth and breadth of solutions. While the overall market continues to be challenging, our pace of positive change is accelerating, and AMN is doing the right things to embrace all levels of our very large market opportunity. Now, I'll turn the call over to Jeff, who will review our latest financial results and outlook.
Randy
Thank you, Carrie, and good afternoon, everyone. Third quarter revenue of $853 million was near the high end of our guidance range, driven by outperformance in our nurse and allied segment. Consolidated revenue was down 25% from the third quarter of 2022. Sequentially, revenue was lower by 14% as the operating environment remained challenging with clients maintaining lower demand levels and lower bill rates within nurse and allied and BMS, as well as lower volumes across physician and leadership solutions. Gross margin for the quarter was 33.9%, slightly exceeding our guidance range. Compared with the prior year period, gross margin was up 10 basis points. Sequentially, gross margin increased 60 basis points, primarily due to the release of a workers' compensation reserve. Consolidated SG&A expenses were $163 million, or 19.1% of revenue, compared with $215 million or 18.9% of revenue in the prior year period and $202 million or 20.4% of revenue in the previous quarter. Third quarter SG&A expenses were reduced by several favorable items that amounted to a benefit of $5 million. The decrease in SG&A expenses year over year was primarily due to lower employee expenses stemming from the current demand environment and lower bad debt reserve. Sequentially, lower employee expenses driven by lower business volumes and a decrease in non-recurring expenses led to the significant decrease in SG&A expenses. Adjusted SG&A, which excludes certain non-recurring expenses and stock-based compensation expense, was $157 million in the third quarter, or 18.4% of revenue, compared with $204 million or 17.9% of revenue in the prior year period and $170 million or 17.1% of revenue in the prior quarter. The increase in adjusted SG&A as a percentage of revenue both year-over-year and sequentially was primarily due to lower revenue. In the third quarter, nurse and allied revenue was $573 million, down 31% from the year-ago period. Segment revenue was down 17%, driven by the continued trend of lower volume, hours, and bill rates. Average bill rate was down 10% year-over-year and down 7% sequentially. Year-over-year, volume was down 19%, and average hours worked were down 4%. Sequentially, volume was down 12%, and average hours were down 1%. Travel nurse revenue for the third quarter was $384 million, a decrease of 34% from the prior year period and 20% from the prior quarter. Allied revenue during the quarter was $168 million, down 12% year-over-year and 8% sequentially. Nurse and allied gross margin during the third quarter was 27.5%, which increased 50 basis points from the prior year period and 80 basis points sequentially. A benefit of 40 basis points came from the release of a workers' compensation reserve. Segment operating margin of 14.5% increased 60 basis points year-over-year due to higher gross margin and lower bad debt expense, partially offset by lower SG&A leverage. Sequentially, operating margin decreased 40 basis points as the improvement in gross margin was more than offset by lower SG&A leverage. For our physician and leadership solution segment, third quarter revenue of $160 million was down 9% year-over-year and sequentially. The decrease in revenue year-over-year was primarily due to lower performance within interim and search, while sequentially, the revenue fall was driven by lower volumes across all three businesses in the segment. Locum Tenens revenue in the quarter was $113 million, a 6% increase from the prior year period. Sequentially, LOCUM's revenue was down 8%, driven by lower volume, primarily in non-CRNA positions. Interim leadership revenue of $31 million decreased 35% from the prior year period and 15% from the prior quarter. Search revenue of $16 million was down 25% from the prior year and down 10% sequentially. Interim and search revenue were down year over year, mainly due to lower demand, as cost management remains a prominent factor for healthcare systems. Gross margin for physician leadership solutions was 33.4%, down 60 basis points year over year, mainly due to an unfavorable revenue mix shift, partially offset by improved gross margin within locum tenants. Sequentially, gross margin was down 170 basis points, primarily due to lower gross margin in locum tenants. Segment operating margin was 13.5%, which decreased 10 basis points year-over-year. Sequentially, operating margin decreased 150 basis points, primarily due to lower gross margin. Technology and workforce solutions revenue for the third quarter was $120 million, down 11% year-over-year and 4% sequentially. Language services revenue of $66 million increased 20% year-over-year and 4% sequentially. VMS revenue for the quarter was $38 million, a decrease of 37% year-over-year and 18% sequentially. Segment gross margin was 65%, down from 75.6% in the prior year period, primarily due to an unfavorable revenue makeshift and lower gross margin in language services. Sequentially, gross margin fell 170 basis points as margin improvement within language services was more than offset by the revenue mix shift. Segment operating margin in the third quarter was 42.1% compared with 52.7% in the prior year and 44.1% in the prior quarter. The decrease in operating margin was driven by lower gross margin compared with the prior periods. Third quarter consolidated adjusted EBITDA was $134 million, a decrease of 27% year-over-year and 17% sequentially. Adjusted EBITDA margin of 15.7% was down 30 basis points year-over-year and 60 basis points sequentially. The favorable items that impacted SG&A expenses and the workers' comp reserve release increased adjusted EBITDA margin by 90 basis points. Third quarter net income was $53 million, down 43% year-over-year and down 13% sequentially. Third quarter GAAP diluted earnings per share was $1.39. Adjusted earnings per share for the quarter was $1.97 compared to $2.57 in the prior year period and $2.38 in the prior quarter. Day sales outstanding was 61 days eight days higher than the prior quarter, and two days higher than the prior year, primarily due to expected billing delays with the implementation of a new back office system in the quarter. Operating cash flow for the third quarter was $172 million, and capital expenditures were $30 million. As of September 30th, we had cash in equivalents of $29 million, long-term debt of $945 million, including a $95 million draw on a revolving line of credit and a net leverage ratio of 1.4 times to 1. Moving to fourth quarter 2023 guidance, we project consolidated revenue to be in a range of $790 million to $810 million, down 28 to 30% from the prior year period. Guidance does not include the pending acquisition of MSDR, which we expect to close later this quarter. Gross margin is projected to be between 32.3 and 32.8%. Reported SG&A expenses are projected to be 21 to 21.5% of revenue. Operating margin is expected to be 5.9 to 6.5%. And adjusted EBITDA margin is expected to be 12.5 to 13%. Sequentially, Adjusted EBITDA margin is expected to be lower due to lower gross margin from a revenue mix shift toward lower margin businesses and less leverage over SG&A with lower revenue. Additional fourth quarter guidance details can be found in today's earnings release. Now, operator, please open the call for questions.
Operator
Thank you. At this time, we will conduct the question and answer session. As a reminder, to ask a question, you will need to press star one one on your telephone and wait for your name to be announced. To withdraw your question, please press star one one again.
Jeff
Please stand by while we compile the Q&A roster. First question comes from the line of Trevor Romeo of William Blair.
Operator
Please go ahead.
Trevor
Hi, good evening. Thanks so much for taking the questions. First one just on the travel nurse and allied business. I think we're all just trying to find out where the bottom is for the market. I think you talked about fourth quarter reflecting a tapering of that downtrend. I guess as you see it here, do you think the Q4 run rate will be the trough? And are there any data points you can point to that kind of give you confidence in that stabilization?
Carrie Grace
Hey, Trevor. Thanks for the question. And I know we talked a bit about this in some of the opening comments. Let me frame out a bit of what we're seeing from clients in the market, and then I'll let Jeff fill in a little bit with some of the questions about what we see in Q4 and potentially going into the early part of next year. We're at a point with clients where it really is client by client where they are. I think there's a number of public company CEO comments over the past week that have supported the tremendous progress. that the healthcare systems have made in replacing their permanent workforce throughout the course of this year. And we certainly have been partnering with our clients on that, but seen that. And so if you look at the travel piece, we have clients who really have progressed to the point that they're now talking about, how do I support future volumes? And we have clients who still have some work to do in getting their contingent labor back to more normalized levels. Broadly speaking, we think that the industry will be back to, by the end of this year, what we would consider more normalized levels. I think that's reflected in some of the guidance that we gave about traveler volumes in Q4. Bill rates are slightly different. So what I would say is we've seen tremendous progress getting back to what we would consider more normal rates as we exit this year, but we still have some clients who are working on what their overall levels are. Jeff.
Randy
Yeah, Trevor, I would just add, you know, when we think about the fourth quarter, I would say on balance, you know, the winner needs orders played out as we thought they would. There was a slight headwind from some later start dates and lower bill rates than we had expected. And then within the client dynamics, you know, that Carrie spoke about, I would say that most of our clients we did see sequential increases in Q4 over Q3 and their utilization, but there were several large clients that were continuing to reduce utilization with the progress they've made on hiring and retention. So as we just look at you know, the pace, where they're pacing relative to those that behaved as we thought they would, there could be room for them to improve further in the first quarter and reduce their utilization, which, you know, could lead to nurse and allied, you know, being flat to slightly down in Q1 over Q4. From a bill rate standpoint, you know, in Q2 and Q3, we saw sequential declines in the bill rate of about 7%. The expectation is that bill rates will be down 4% in Q4 over Q3, and that that could continue to move, you know, low single digits moving into next year downward.
Trevor
Okay, thank you, Jeff and Kerry. That was helpful. And then for my follow-up, I wanted to touch on the MSDR deal a bit more. You know, could you maybe tell us any more about how that business has grown historically beyond just, you know, this year, I think, looks like about 50% growth based on your press release, and what kind of growth you'd expect from MSDR going forward, and maybe how much opportunity you'd have for both revenue and cost synergies in that deal.
Carrie Grace
Yes, let me give you a little bit of how we think about MSDR, particularly in the context of our broader AMM business. I know we have talked for some time about locums being one of our M&A priorities, and so we love the market. We love the growth opportunity that we see both in terms of just our clients very focused on revenue growth, but also just some of the workforce structural changes that you see within the physician space, making more of them interested in a locums type of role. For MSVR in particular, and I'll let Jeff talk a little bit about what we've seen in terms of some of the numbers, and certainly they've had you know, very strong historical growth. What's very compelling to us beyond their profile across a number of specialties that we are not as strong in is that we have really, we think, two significant synergy opportunities. The first one is while they have a consolidated back-end platform, they still have some opportunities between their two organizations for front-end synergies. that we're going to be focused on in 2024. And the second part, Trevor, is if you look at our locums business today, we are more constrained by supply than demand. So what's very attractive, both for MSDR and for AMN, is to be able to put the strength of their supply, particularly around a number of very key specialties, into our already existing demands.
Jeff
All right. Thank you very much.
Jeff
All right. Thank you. And one moment for our next question. The next question comes from the line of Kevin Fishbeck of Bank of America. Please go ahead.
Kevin Fishbeck
Great. Thanks. You know, I guess clearly the market's going through some pretty significant changes right now, and it's hard to kind of see, you know, where share is moving, but I guess from your perspective, do you feel like you guys are gaining share or losing share over the past couple of quarters into Q4?
Carrie Grace
Yeah. Kevin, let me kind of take it in two parts that I've talked about both of these in the past couple quarters because I think that these are the two elements that we look at relative to the overall share piece. So the first one is We talked a lot about the industry had this pent-up RFP cycle for clients coming out of three years of crisis management. That's not AMN phenomena that was happening across the industry. So if I look at where we are in that RFP cycle for clients, we're at the tail end. So we still have a couple of clients both this quarter and into next quarter that that we would consider kind of the tail end of that, you know, bigger COVID RFP cycle. If you look at our RFPs going into next year, it is a significantly smaller number of clients that would be going into RFP. So that's been the first piece that we've been very focused on, particularly coming out of COVID and ensuring that we were aligned and realigned with our clients coming out of really, you know, a generational crisis. The second piece is on sales, which is incredibly important around just not just retaining your clients, but growing. I talked last quarter about how we have turned on sales after it was really effectively shut off during COVID and the growth that we saw in our pipeline, which was quite significant, 300%, if we looked at kind of year over year. Quarter to quarter, we have seen our pipeline continue to expand. That expansion is across MSP, VMS, and all of our other solutions. At the same time that we have been continuing to build the sales pipeline, we've seen the pipeline progress. So if I look at the indicators of where our share position is going, they are positive.
Kevin Fishbeck
Okay, could you just, I guess those two statements felt a little bit incongruous to me. If you're saying you're largely through the RFP, but your sales pipeline is high. So what's the difference between the sales pipeline and then the RFP? Was that an AMN comment versus an industry comment?
Carrie Grace
Yeah, I'm sorry, Kevin. So if we look at growth, one is, are you keeping all of your clients through this post-COVID RFP cycle? Thing one. Thing two is, are you continuing to grow on top of that? So we are doing both simultaneously. How are we ensuring that we get through this RP cycle, have a solid base with clients, and then how do we continue to grow off of that, both with new clients and names, as well as expanding existing client relationships?
Kevin Fishbeck
Okay. And then can you talk a little bit about the types of services that are being increasingly asked for? Are we seeing a shift back to MSPs, or are we still looking at VMSs are partial solutions. What are we looking at in this new sales cycle?
Carrie Grace
We're seeing both. So we are seeing a healthy increase in our MSP pipeline. We are also seeing a healthy increase in our VMS pipeline. So the answer is if you look at the growth that we've had, and I'd say particularly over the past two to three quarters in our sales pipeline, it's coming from both MSP and VMS solutions.
Kevin Fishbeck
Would you say that's – how does that compare to your current business mix? Is it more shifted to one versus the other?
Carrie Grace
You know, it's a good question. I don't know that there's a bias one way or the other. I think that we have become more client-centric in how we approach a new client. And so we've probably had a slight bias towards MSP in the past. And if you look at our approach now, we really look at and say we want to participate fully in all of those markets. So as clients embrace MSP models, we want to be their first choice. As clients embrace vendor neutral or other types of hybrid models, we also want to be their first choice.
Jeff
Okay, great. Thanks. Thank you. One moment for our next question.
Operator
Next question comes from the line of Toby Sommer of Truist Securities. Please go ahead.
spk05
Hey, good afternoon. This is Jasper Vivon for Toby. Just curious what you're seeing from a bill pay spread perspective. Do you see spreads continuing to narrow into the first quarter of 24, or are you starting to see that spread compression stabilize a bit on some of your newer orders? Thanks.
Randy
Yeah, Jasper, this is Jeff. I would say, you know, if you exclude the workers' comp benefit that we received in the third quarter, you know, the midpoint of our gross margin guidance is down about 100 basis points sequentially in Q4 over Q3. That's pretty equally driven, I would say, by a change in business mix shifting to lower margin business biz across Certainly PLS and TWS, but we are seeing compression in the bill pay spread just given the lower demand environment on nurse and allied, and that's a driver of the Q4 over Q3 change. And as we move into next year and certainly the early part of the first two quarters of next year, we wouldn't anticipate that to change from a bill pay spread dynamic standpoint.
Jeff
Okay, got it.
spk05
Yeah, apologies if I missed this, but was there any strike planning or labor disruption work contemplated in the 4Q revenue guide? Like, I know there's been some union action that notable clients the past couple months, but not sure if that's translated to anything from a revenue perspective.
Randy
Yeah, there's about $2 million of labor disruption revenue embedded in the Q4 guide, and that number was right around a million in our Q3 actuals, a little less than that, so pretty immaterial in both periods.
Jeff
Okay, great. Thanks for taking the questions. Thank you. One moment for our next question. Next question comes from the line of Brian Tenequilla of Jefferies.
Operator
Please go ahead.
Brian
Hey, good afternoon. Kerry, I'll just follow up to Kevin's questions earlier. As I think about, you know, we cover the hospitals, right, and they're all still saying that they're still trying to reduce their use and spend on contract labor. And I know in your prepared remarks you talked about kind of like a flattening or the stabilization of broader demand. How should we be thinking about that? And what gives you the confidence that you're not losing a share in this environment?
Carrie Grace
You know, I guess what we have anecdotally heard from others is that what we've been experiencing is similar to what others are experiencing in our industry. Obviously, we work very closely with a number of suppliers broadly across a number of different clinical roles. And so as we work with our clients around how they think about rebuilding a sustainable workforce, to your point, Brian, there was a significant focus around how do you bring down contingent labor, both in terms of the size, but also if you looked at the marginal cost of that labor relative to permanent hires, there was a historically high difference between that. So the focus, I think, was both on numbers, but it was also because you were at a point where you had a dislocation in terms of the marginal cost. If you look at what has happened subsequently, you've seen the marginal cost, partially because the marginal cost of a permanent hire has gone up, the labor inflation, but also the cost of contingent labor has gone down. that as systems look at how they're going to really manage and be able to staff a cost-effective full mix, it has become much more cost-effective for them to bring in contingent labor for the flex. Now, is that true for every client? No. There are some clients that are still at relatively high contingent labor costs. There are other clients, and some have been public about this even more recently, who They're at a point where they look at it and say, hey, I need to actually build back volume, and I can do this in a more cost-effective way. So there's not a one-size-fits-all answer for a client. We have clients who are in different places. We have seen, to Jeff's earlier comment, a number of our clients start to actually go back up, but we still have some very large clients who have targets that they would want to bring it down a little bit from where they are now.
Brian
Okay, that makes sense. Maybe, Jeff, as I think about your fourth quarter guidance, right, so midpoints, $800 million of revenue, you gave the EBITDA margin there, so just a little over $100 million of EBITDA for Q4. Is that the right jumping-off point to use? I mean, you annualize that and then put a growth rate on top of that, and then what are the other moving parts that we need to be thinking about? As we think about 24, I know you called out some of the, what do you call it, discretionary bonuses that were not in the back half of So just trying to get any help that you can share with us as we try to model 24.
Randy
Yeah, Brian. So I'll list out a couple of tailwinds and headwinds off of that Q4 exit rate. So, you know, certainly on the tailwind side, we would expect continued growth in language services moving into next year. That business was up 20% year over year in Q3. We'll obviously have the tailwind in locums from the MSBR acquisition, which we spoke about earlier. And then we still have the opportunity to capitalize on a pretty large sales pipeline. I would say just given ramp and other things, any new client wins would probably impact the second half of 24 much more so than the first half. And then we still do have the opportunity to improve our internal capture within Nurse and Allied. We're still a couple hundred basis points below pre-pandemic norms on that side. From a headwind standpoint, you know, we talked about where certain clients are and that there could be further reductions in Q1 over Q4 levels. And then within nurse and ally, we will have an impact on our international nurse business next year from visa retrogression. That will, again, disproportionately impact the back half of next year, but there will start to be impact in Q1 and Q2. We would anticipate that business to be down about $70 million on the top line year over year next year. And that will also pose a 30 to 40 basis point headwind to nurse and allied gross margins just from a mixed standpoint. And then additionally, just given the performance This year, we do have very low levels of incentive comp in the Q4 run rate, and that'll be about $5 to $6 million of additional SG&A moving into next year per quarter. That's not in Q4.
Jeff
Jeff, if I add all that, I mean, are you still expecting growth in U.S. next year? Excuse me.
Randy
Yeah, I mean, I think with just, I mean, with the MSDR acquisition alone, yes, there would be growth. But, you know, off of the Q4 run rate, you know, in nurse and allied, you know, again, if it's flattish to slightly down in Q1, then we would expect, you know, Q2 and Q3 to be seasonally lower off that Q1 base, you know, next year. Okay, got it.
Jeff
Thank you.
Jeff
All right. Thank you. One moment for our next question.
Operator
Next question comes from the line of Jeff Siller of BMO Capital Markets. Please go ahead.
Jeff Siller
Hey, thank you. Ryan on for Jeff. Just looking at some of the industry data, the NCLEX pass rates up this year, some of the visa stuff you just mentioned, and then the burnout, how do you kind of triangulate those different factors for the outlook on supply governance next year?
Carrie Grace
Yeah, a couple things on supply. I'm going to split out nurse and allied with locums. So if we look at nurse and allied supplies, so we look at just applications that we get, we are up significantly from pre-COVID levels. So depending on kind of what area, I think 30 to 50% above. And so we still see very healthy supply. You know, part of the burnout challenge, it actually, these types of roles become attractive to clinicians who still want to stay and participate in patient care, but want more control over how they do that. From a locum standpoint, we have, we've had strong demand. You know, you can take that year over year. You can take it since pre-COVID. And so we are looking for more supply. And I would say that's true of the entire industry. So as much as we've talked about the nursing shortage and the nursing burnout, the physician numbers are actually marginally worse. And so that supply we think is going to be one that is MSDR is going to allow supply for us in that space. But it's something that we think is going to make the locum's business attractive, particularly as we can keep more physicians in, maybe in roles that they can have more control over.
Jeff Siller
Got it. And then just on the physician bill rates, I know you put out a report recently about higher salaries for doctors. Would you expect the trajectory of the bill rate increase over the next you know, a couple years or so to mirror what we saw in NERSC, or it would be a little bit more gradual on the way up and down?
Randy
We would expect, if we just look at our RDF trends in locums this year, that that would probably moderate going into 2024 than where we were at this year in terms of year-over-year increases.
Randy Reese
Okay, thank you for your question.
Operator
As a reminder, to ask a question, you will need to press star one one on your telephone and wait for your name to be announced.
Jeff
One moment for our next question. Next question comes from the line of Andre Childress of Baird. Please go ahead.
Randy Reese
Okay, I see Andre online. If you could, make sure you're unmuted. Maybe we'll come back to Andre.
Operator
Okay. Andre, if you could rejoin using the call me feature, we may be able to address your question. Seeing no questions, additional questions at this time, I'll go ahead and hand the call back over to Carrie Grace, President, Chief Executive Officer. Please go ahead.
Carrie Grace
So thank you on behalf of our entire AMN team who have the privilege of working with our clients and clinicians every day to positively impact healthcare. We thank all of you for your interest in AMN.
Jeff
All right, thank you for your participation in today's conference. This does conclude the program. You may now disconnect.
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