ATI Physical Therapy, Inc.

Good afternoon, everyone, and welcome to ATI Physical Therapy's third quarter 2024 earnings conference call and webcast. All participants will be in a listen-only mode. After today's presentation, there will be an opportunity to ask questions. To ask a question during this time, simply press star followed by the number one on your telephone keypad. If you would like to withdraw your question, you can press star one again. And please note that this event is being recorded. On the call today is Sharon Vitti, Chief Executive Officer, Emily Tansey, Chief People Officer, and Joseph Jordan, Chief Financial Officer. I will now turn the call over to Mr. Jordan.

Good afternoon, everyone, and thank you for joining us today. Before we begin, I'd like to remind everyone that certain statements made during this call will be forward-looking and subject to various risks and uncertainties. The statements reflect our current expectations based on our beliefs, assumptions, and information currently available to us. And while we believe these expectations are reasonable, we undertake no obligation to revise any statements to reflect changes that occur after this call. Descriptions of some of the factors that could cause actual results to differ materially from these forward-looking statements can be found in the risk factors section of the company's filings with the FCC. In addition, please note that we'll be discussing certain non-GAAP financial measures that we believe are important to evaluating our performance. Details on the relationship between those non-GAAP financial measures to the most comparable GAAP measures, as well as a reconciliation between the two, can be found in the earnings press release that is posted on ATI's website and filed with the FCC. With that, I'll turn the call over to Sharon to kick us off.

Thank you, Jo. Good afternoon, everyone. I appreciate you taking time to join us today. So I will present today along with Jo Jordan and Emily Tansy, and we also have Chris Cox, Eric Kamp, and Scott Bergersen on the call today. Earlier today, we reported our third quarter 2024 results and provided financial guidance for the fourth quarter. I'm super excited to share that ATI delivered another strong quarter. Let me start by providing an overview of our key performance highlights and ongoing initiatives before handing it over to Jo to cover our financials in more detail and to discuss our expectations on the remainder of the year. To begin, we saw revenue and adjustability grow year over year. We continue to see positive momentum across the business and are pleased to, once again, achieve both our revenue and adjustability to the guidance for the third quarter. This demonstrates the continued strength of our business and the growing demand for ATI services. The trust we have built with referring physicians and patients remains a key driver of our performance. Our patient referrals per day in the quarter grew more than 5% year over year. Our clinic saw over 1,400 more patient visits per day compared to Q3 of last year. And this uptick in patient volume is truly a testament to the strength of our clinical teams and the value we're able to provide to the communities we serve, providing access to high quality patient care. One of the key highlights of this quarter was the continued expansion of our clinical teams, supported by our ongoing people strategies and culture refresh. Emily Tansley, our chief people officer, will share more on this later. So our attention remains fixed on continuous operational improvements. With robust demand and more stability around our workforce, we continue to build on our insights and fine tune our operations. Clinician productivity improved by more than .1 when compared to Q3 of last year. This is driven by operational enhancements such as better resource allocation and streamlined clinic workflows. We improved access for patients without sacrificing quality of care. Our clinics are busier year over year, seeing over two more visits per day per clinic compared to Q3 of last year. And while some clinics still have excess capacity, we strive to match demand with supply and to leverage our clinical real estate and fixed costs. In the quarter, we continued to execute on our strategic real estate plan to refine our geographic footprint aligned with patient population needs. We closed eight clinics and divested one as part of that plan. Our strategies have clearly delivered results in the third quarter. I'm pleased about how our teams have maintained our standard of care throughout this growth. Our Google star rating remains an impressive 4.9 out of 5, which speaks to the high level of patient satisfaction we consistently achieve. Patient experience is important and at the heart of our purpose. This rating is a direct reflection of our commitment to deliver exceptional care at every visit to every patient. I'm very proud of the incredible people we have at ATI who are committed to enhancing the lives of our patients every day. They are the foundation of what we've achieved. I'm honored to be a part of this outstanding organization that continues to lead in the musculoskeletal care space and is driven by our shared purpose of making every life an active life. With that, I'll turn the call over to Emily.

Thanks Sharon. I'd like to take a moment to discuss the current labor market and highlight the progress we've made with our initiatives to attract and retain skilled providers, enabling us to expand access to high quality care. While the labor market remains challenging and we expect these headwinds to persist for foreseeable future, we are navigating them with determination. Every local market has its own unique characteristics. On a macro level, the mismatch between the supply of physical therapists and the growing demand for PT services will take time to balance out. By these challenges, we continue to make progress. In the third quarter, we grew our clinician head count by 3% year over year. An annualized clinician attrition held steady at 21%, which we believe is in line with the industry. I am confident that we will continue to grow by focusing on what we can control, such as staying attuned to the market trends, listening to our employees, and nurturing our culture. A culture that stands for excellence in care delivery, a strong provider experience, and exceptional customer service. These values were reflected in our recent employee engagement survey. Where we received overwhelmingly positive feedback, particularly in areas such as rewarding work, supportive leadership, and fostering an inclusive environment. We also identified opportunities for improvement and we're eager to use this feedback to enhance the employee experience further and solidify API as the employer of choice. These achievements show that we are doing the right things for both our providers and our patients, helping us fulfill our purpose to make every life an active life. I want to extend my gratitude to the entire HR team for their hard work and dedication. We have many exciting opportunities ahead of us and we remain focused on improvements that allow our clinicians to operate at the top of their license. I'm incredibly proud of ATI's strong brand, our vibrant culture, and the progress we've made this year in strengthening that culture. ATI is truly defined by its people and I'm excited to continue building on the work we've done to ensure ATI remains a place where people can learn, grow, and thrive. Now I'd like to turn the call over to Joe to discuss our financial performance in the quarter.

Thank you, Emily. As Emily mentioned, I'll talk about our third quarter 2024 financial performance and I'll also talk about Q4 guidance. Starting out with third quarter results, our net revenue in the quarter was $190 million, which is a .1% increase year over year from $177 million. If we dive down deeper, our net patient revenue was $175 million, which is a .7% increase year over year, while the revenue was $15 million, essentially flat, over the prior year. Visits per day per clinic, which Sharon talked about a little bit earlier, was 28.3 during the quarter, which increased 2.4 visits year over year from 25.9 in Q3 of the prior year. That does reflect our continued efforts to improve utilization of clinic capacity. Our rate per visit during the quarter was $109.83, which is essentially flat year over year from 109.90 in the third quarter of 2023. Salaries and related costs in the third quarter were $106 million, which is an .7% increase year over year from $97 million in the prior year. That's primarily due to more clinical and support staff, some wage inflation, and having one more paid day in Q3 of 2024 when compared to the prior year. PT salaries and related costs per visit during the quarter were $58.29, which increased .4% year over year from $57.47, with the increase driven primarily by wage inflation. And partially offset by the higher labor productivity that Sharon touched on earlier, which moved from 9.3 in Q3 of last year to 9.4 in Q3 of this year. Rent, clinic supplies, contract, labor, and other in the third quarter was $54 million, which is a .4% increase year over year from $53 million. And on a per clinic basis, these costs were approximately $61,000, increasing .7% year over year from $57,000 in the third quarter of the prior year, which is due to increased contractor usage and higher spend on outside services. Our provision for doubtful accounts during the quarter was approximately $5 million, which is .8% of PT revenue compared to .1% of PT revenue last year. SG&A during the quarter was approximately $24 million, decreasing $1 million from $25 million in the prior year due to lower corporate insurance costs and lower spend on third-party services. Non-cash long-lived impairment charges were $0.1 million during the quarter. And operating income during the quarter was $1 million, which increased from a loss of $1 million in the prior year and reflects higher revenue earned and the flow through to earnings. Notable -the-line items during the quarter included losses resulting from an increase in fair value of second-lean pick notes, contingent common shares, and warrants totaling $19 million. These instruments are marked markets of fair value each quarter, with evaluation analysis done as of quarter end. Interest expense during the quarter was $15 million, which decreased .7% year over year and is primarily due to lower interest rates, partially offset by a higher principal outstanding balance. Income tax benefit for the quarter was $0.1 million compared to income tax expense in the prior year of .1. Net loss during the quarter was $33 million, compared to $15 million in the third quarter of 2023. And adjusted EBITDA during the quarter was $12 million, which is a .4% margin. And that increased from $9 million, or .3% margin, the prior year, with the -over-year increase in adjusted EBITDA primarily driven by higher revenue and then the associated earnings that flow through to the bottom line. Cash used -to-date was approximately $13 million, compared to $63 million in the prior year. Breaking that down further, operating cash used was $31 million, compared to $18 million in the prior year. The -over-year increase was primarily driven by higher accounts receivable on higher revenue and a higher payout of accrued annual incentive payments. Cash used in investing activities was $9 million, compared to $15 million last year, with the decrease primarily due to fewer new clinic openings. And financing cash generated was $27 million in the current year, compared to financing cash used of $31 million last year. The increase in 2025 is primarily driven by the $25 million delayed draw term loan, which was fully drawn in January, and higher net revolver borrowings. As of September 30, 2024, available liquidity was approximately $23 million, which consisted of cash and cash equivalents. And with that, I'll turn to 2024 Q4 guidance. Our outlook for Q4 includes anticipated revenue to be in the range of $182 to $192 million, and adjusted EBITDA to be in the range of $9 to $14 million. This guidance reflects the dynamics that we're seeing in the market and the strategies and tactics that we're employing to navigate and grow clinical FTE, and in turn, revenue and advance the overall clinic operations. With that, I'll turn the call back over to Sharon for closing remarks.

Thank you, Joe and Emily. Appreciate all your remarks. As we look toward the final quarter of 2024 and beyond, we remain focused on continuing to grow the business through the expansion of clinical workforce and the execution of our people and operational strategies. I want to take a moment to thank our entire team, the clinicians, support teams, and leadership. Your dedication and hard work have made these results possible. We're confident in our ability to build on this momentum and to drive long-term value for our patients, employees, and shareholders alike. I'll now hand it back to the operator to open the call for Q&A.

Great, thank you. And at this time, as a reminder to ask a question, please press star followed by the number one on your telephone keypad. Again, if you do have a question at this time, please press star one on your telephone keypad. And we'll pause for just a moment to compile the Q&A roster. Thank you. Your first question comes from the line of Brian Tenkilt from Jeffreys. Your line is open.

Hi, this is Nora Roble and for Brian. Thanks for taking my questions. Looking at the salaries and related cost line, curious if you can provide some insight into what you're seeing in terms of wage inflation? Are you guys seeing any signs of moderation or is there some persistence you're seeing in those elevated costs? And then relatedly, how much of the flight margin compression implied in the midpoint of your Q4 guidance boils down to elevated wage inflation? Thank you.

Thanks for the question, Nora. Yeah, Joe, you can jump in. I wish we were seeing a break in wage inflation and we're not. Joe can provide the numbers, but it's a headwind that continues for us on and over many of the other PT providers. Joe, do you want to add some numbers to that?

Yeah, absolutely. Maybe a little bit of color. What we've seen year over year is low to mid single-digit wage inflation. Continue to see pressure from a contractor to full-time clinician perspective, meaning we're still leveraging contractors and you can see that in our KPI tables in the back of the press release. We are seeing throughout the year wage inflation remaining relatively stable. We certainly see year over year increases, but don't expect to see a big lift in wages in Q4 relative to Q3. Part of the driver of Q4 guidance is having one less business day when you look year over year. So one less business day, same amount of paid days. That's less of a flow through to adjust the dividend.

Great. As a follow-up, looking at patient revenue per visit coming in roughly flat in the quarter, curious if you can provide an update on the reimbursement landscape on the commercial side of the business and any expectations for remediation of the recently announced Medicare rule?

Another good set of questions. So I think on the commercial side, they have a great team that goes out, has great relationships with the commercial payers. I'd say we are seeing certainly some progress from some of the commercial payers and then that's probably balanced out by some of the guidance. So I think the team is doing a fantastic job and I would say we will continue to work with payers and try to either one, look at our rates and move those in the right direction or two, come up with creative ways that we can work with payers around valuing the impact of PT as it relates to musculoskeletal care and cost of care. I would say on the Medicare side, we are hopeful and have been working with some of the larger organizations like an APTA, a PTQI to certainly educate CMS and MedTac and also to try to one, in the short term, have them revisit the upcoming cut for our scheduled decrease in payment for 2025. In subsequent years, we've had good luck with that and so we are working hard to push that and see if we can have a favorable response for 2025. And then I'd say at the ATI level, we are fortunate to have again very good scores in our MIPS and our MIPS performance with CMS and so that helps to soften the blow. It doesn't, it certainly doesn't compensate for it fully but that's an offset that helps us as we move into 2025 and see where CMS lands on their rate cuts. Joe, do you want to add anything to that?

The only thing I'd add is just a reminder when you're with a Medicare rate cut, so to have a flat rate year over year on the quarter still involves some improvements elsewhere throughout the organization. We were seeing commercial rate increases and the other thing I'd say is if you go back to Q3 of last year, it was our peak rate. We had talked about last year some one-time items but I would think of the 109 that we had this year more compared to even our Q4 rate of high 108. So I would say stepping back despite some Medicare cuts, slight improvement in rate if you were looking at it relative to like Q4 of last year.

Okay, thank you. Absolutely.

And once again, if you do have a question, please press star one on your telephone keypad. Again, if you do have a question, please press star one at this time. Okay, and with no further questions, I'd like to turn the call back over to Sharon Vede.

All right, thanks everyone for your participation in our third quarter earnings call today. We look forward to connecting with you in the new year and wishing everyone a happy holiday season. Thank you.

Thank you. Once again, this concludes today's conference call and you may now disconnect. Have a great day.