U.S. Physical Therapy, Inc.

Good day, everyone, and welcome to the U.S. Physical Therapy Third Quarter 2022 Earnings Conference 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. In order to ask a question during the session, please press the star key followed by the number one on your telephone. Please be advised that today's conference is being recorded. If you require any further assistance, please press star, then zero. I'd now like to turn the call over to Chris Redding, President and CEO. Please go ahead, sir.

Thanks, Ashley. Good morning and welcome, everyone, to our third quarter 2022 U.S. Physical Therapy Earnings Call. Today I'm calling in from Denver, where we have the largest aggregation of private practices for the annual physical therapy private practice meeting. It's a great place for us to see friends and colleagues and work on deal-related opportunities for the future. Additionally, this year, in conjunction with this PPS meeting, we held our annual APTQI board meeting, where we continue to work on behalf of our profession in areas such as fair reimbursement for the amazing life-altering results we produce for our patients. Excuse me one second. We continue to push for the reduction of administrative burden. We're working to ensure that we have an adequate supply of therapists to serve the growing needs of our aging population, replacing unnecessary and excessive pharmaceutical and other more expensive interventions with proven, functionally restoring care. We focus on other legislative and long-term efforts. I'm proud of the work that we're doing within APTQI and our member companies' ongoing support of those efforts, which to date have helped mitigate some of the significant and harmful cuts proposed by CMS these past few years. Joining me on the call this morning include Kerry Hendrickson, our CFO. I'm really happy Kerry's part of our team. He arrived here two years ago as we worked our way through year one of the pandemic. He's doing a great job. Eric Williams, Graham Reeve, our co-COOs are also here with me. They've been working extremely hard along with our regional presidents in conjunction with our partners and our local staff who work every day to provide outstanding care while we work to make ongoing adjustments during what has been a rather continuously involving environment. and this year to include a rather sharp and significant inflation across all cost areas, coupled with some employee scarcity, which I think we're beginning to deal with more effectively at this point. Finally, Rick Binstein, who in addition to being our Executive Vice President and General Counsel, is my right arm in so many important areas and ways, including especially in our acquisition-related work. Well, we've tried hard recently to make sure Rick stays as busy as possible. Rick is also, unfortunately, a Phillies fan, so that's the only real strike against him at this point. Before I continue further, I'll ask our Senior Vice President of Finance and Accounting, Jake Martinez, to please cover a brief disclosure. Jake, if you would.

Thank you, Chris. This presentation contains forward-looking statements which involve certain risks and uncertainties. These forward-looking statements are based on the company's current views and assumptions. The company's actual results may vary materially from those anticipated. Please see the company's filings with the Securities and Exchange Commission for more information.

Thanks. Okay, thanks. Thanks, Jake. I'm going to start this morning with some color and highlights around our third quarter performance, and then Kerry can fill in any gaps if he thoroughly reviews our financial results. This year we have seen the resumption of our long-standing seasonal pattern, which seemed to really be absent in 2021. With the advent of summer and school letting out, we normally slowed just a little bit, and then later we picked up, and that returned as per our normal seasonal pattern this year. June, July with vacations and travel slowed modestly, with July coming in at 28.4 visits per clinic per day, and then started to pick up with a kickoff of fall football and the start of school. Ultimately, we finished the quarter averaging 28.8 visits per clinic per day. In spite of a very active de novo and development year, which can sometimes mute those volumes somewhat, and considering we were impacted about 3,500 visits that last week of September and into early October, into the early October quarter by Hurricane Ian, which devastated parts of Florida and did considerable damage across several southern states along the southeast coast. Overall patient visits increased 2.8% from the prior year quarter. One of the bright spots showing up this quarter from the very good work our payer contracting team has initiated around negotiating some of our payer contracts, which has been a stated focus of ours all year, those efforts are beginning to bear fruit. Our net rate for physical therapy came in at just over $104. which was the $1.08 improvement from our Q3 2021 performance and an $0.83 sequential improvement from Q2 this year. I will point out we're still in very early innings here. We've got a lot more work to do and a lot of contracts to touch before it's over. So earlier this week, each month we have for each of our industrial injury prevention partnerships, a partnership call where we go over detailed performance and opportunity. I was on one of those calls earlier this week with our legacy IAP injury prevention partnership, and they're getting some nice wins with respect to contracted rate renegotiation. These legacy partners are doing a tremendous job Excuse me, guys, I'm struggling with my voice this morning. Hang on one sec. Tremendous job this year in spite of the macro challenges affecting all of us. Injury prevention revenue was at an all-time high for this third quarter at just over $20 million, which was more than 92% improvement compared with our 2021 Q3, and a 27.1 same-store organic growth rate in that business. A gross profit percentage for our IIP services was approximately 22%. Overall, our gross profit for the entirety of our injury prevention business increased 64.6% year-over-year, an excellent continued trajectory for that segment of our business. So shifting gears a bit, our challenges at the moment center around making adjustments to deal with the current inflationary environment. including in our labor costs, and while we are taking steps and making progress toward mitigating some of those challenges, we need more time to completely impact and adjust a number of key areas, including, as we discussed, in our net rate. Total salaries and related costs were 58.6% of revenues versus 56% in the 2021 quarter. I will point out that for us, this includes the labor necessary to build and collect for the clinical work that we perform. Rent, supplies, and contract labor are also higher than historic levels, and there's a percent of revenue about 200 basis points above where we were a year ago at this time. These changes have come fairly acutely this year, starting really to appear for us in mid-Q2, and we continue to work our way through a series of mitigation efforts, which will be ongoing and require additional time to more significantly address the resulting cost and margin impacts felt today. I want to close my remarks by emphasizing two very bright spots for us, and the first of those is our people, starting with our partners and our clinical teams. They've been through a tough few years starting in early 2020 with COVID, where together we were able to navigate that very early difficult time well. COVID continued through 20 into 21, which meant they were spending long days treating patients while masked up all day. The job is very physical and the adjustments necessitated due to COVID made that work even harder. And the reality is, even though you don't hear about it on the news anymore, COVID is still around, and we continue to make adjustments in order to keep our staff and patients safe. Throughout all of this time, our teams across the country and across the company have done an exemplary job adjusting and working to do the utmost for our patients. I just want them to hear how much we all appreciate those efforts and want them to remember they are making a huge difference in the lives and in the function of our patients. The final bright spot I will highlight here has been our development these past two years. We have onboarded some fantastic partners who brought us a lot of joy and enthusiasm to continue this mission we are on. Speaking personally, I felt to make this job one where I roll out of bed every day excited and grateful, in spite of any challenges that we may have, in large part due to the wonderful people that I get to work with every day. I'm supremely pleased with the deals we've announced this year, including the most recent one we announced earlier this week. The people and the talent are amazing, and I'm also excited about what we still have in the works yet to complete. So that concludes my color on the quarter. I'll ask Kerry to provide a more detailed overview of the financials before we open things up for questions. Thank you, Kerry.

Thank you, Chris, and good morning, everyone. As you saw in the release, we reported adjusted EBITDA off of the third quarter of $17 billion and operating results per share of 58 cents. Like all companies, we're dealing with inflationary cost pressures and labor pressures. We expect those factors to continue to impact us in the near term, but our volumes remain strong by historic standards, and our team is focused, as always, on finding ways to become even more efficient so we can produce the best possible results for all of our stakeholders. Looking at our volumes, our physical therapy patient volumes per day per clinic, as Chris noted, were 28.8 in the third quarter. That's the second highest per day volumes in the third quarter in the company's history. By month, our average visits per clinic per day for all clinics were 28.4 in July, 29.0 in August, and 28.9 in September. Chris noted we had some impact from Hurricane Ian. We lost about 3,500 visits at the end of September for that. We would have been at about 29.0 in September as well were it not for those lost visits. We expect October volume to be similar to August and September, which is a good place to be given some of the lingering impact of Hurricane Ian in Florida, Georgia, and South Carolina in the first couple of weeks of October. Our net rate for our physical therapy operations was $104.01 for the third quarter of 2022. That compares to 102.93 that were reported for the third quarter of 21. Our rate has increased each quarter this year, moving from $103 in the first quarter to $103.18 in the second quarter and then to $104.01 in the third quarter. This is despite the pressures on Medicare rates from the reductions that were put in place at the beginning of the year and the phase-out of sequestration relief, which is now complete. As we noted, we've seen some nice commercial rate increases this year because of the hard work of our contracting team, which has resulted in our average commercial rates increasing each quarter in 2022. We still have a lot of work to do on this front, but it's good to see some progress here. Our workers' comp average rate is up 2.5% in the first nine months of 2022 compared to 2021. And our Medicare rates, they dipped in the first and the second quarters of the year, but then they increased in the third quarter due to the adoption of remote therapeutic monitoring, which is new in 2022, and other hard work on the ops team side. Our physical therapy revenues were $117.5 million in the third quarter of 2022, which was an increase of $4.4 million, or 3.9% from the third quarter of 2021. Our physical therapy operating costs were $95.5 million as compared to $86.2 million in the prior year. And our margin in physical therapy was 18.7%. Looking at the revenue at our mature clinics, they were flat year over year with a 1.5% decrease in visits that was offset by a 1.4% increase in rate. Our physical therapy salaries and related costs at our mature clinics increased 5% in the third quarter of 2022 compared to last year. And then contract services and rents were also higher at our mature clinics. Revenues for our industrial engine prevention business were an all-time high, $20.2 million in the third quarter of 2022. That was a $9.7 million increase over the third quarter of 2021, which is 92.1%. Our industrial injury expenses increased $7.9 million to $15.8 million in the third quarter. That gave us a margin of $4.4 million, which was an increase of $1.7 million, or 64.6% over the prior year. And our same-store IIP revenue increased 27.1% in the third quarter of last year versus third quarter of last year. Our gross profit was $26.8 million in the third quarter of 2022, and that compares to $29.8 million in the third quarter of last year, and our gross profit margin was 19.2%. Our corporate office costs remain steady. They were $11.9 million in the third quarter of 2022. That's actually $1 million lower than they were in the third quarter of 21, with the decrease primarily due to lower estimated bonus expense this year. As a percent of revenue, corporate costs were 8.5% of revenues in the third quarter of 2022, and that's down from 10.2% revenue in the third quarter of 21. Couple of unusual things, our other income line includes a $2 million gain from the elimination of a liability for potential content to payment related to a prior acquisition. It also includes a gain of about $785,000 related to the revaluation of our put right liability associated with the potential second phase purchase of the IIP business that we acquired in November of 2021. Both of those items though were excluded from our adjusted EBITDA and operating results. Our interest expense increased from $268,000 in the third quarter of 2021 to $2 million in the third quarter of 2022 due to an increase in our debt, primarily related to acquisitions closed since the third quarter of last year, and also higher interest rates in the third quarter of this year than last year. Our net income attributable to non-controlling interest was $3.3 million in the third quarter of 22. That's less than the $4.1 million we had in the third quarter of last year. As a percent of profits are non-controlling interest for 12.1% in the third quarter of 22, as compared to 13.8% in the third quarter of 21. That reduction in non-controlling interest percentage is due to our proactive purchases of non-controlling interest from existing partners, resulting in a greater percentage of profits being retained by USPH. In 2021, we purchased $30 million of non-controlling interest from our existing partners, and we purchased another $14.1 million in the first nine months of this year. Our balance sheet remains in an excellent position. We have a $150 million term loan with a five-year swap agreement in place that fixes the one-month term SOFA rate on that $150 million at 2.815%. including the applicable margin based on a leverage ratio, the all-in rate on that $150 million of debt is currently 4.665%. In our statement of comprehensive income and our financial statements, you can see that our swap agreement currently has a mark-to-market value of almost $6 million, meaning that the current expectation is it will pay $6 million less in interest expense over the remaining term of our five-year swap agreement than we would have paid without the swap at a variable interest rate. In addition to the term loan, we have a $175 million revolving credit facility that had nothing drawn on it at September 30, and we We had cash in our balance sheet of $37.9 million at September 30. We do now have $5 million on our revolving credit facility after closing on the 14 clinic acquisition that we announced earlier this week. The acquisition was primarily funded with our excess cash, but we did use the revolver to fund the remaining $5 million. Barings on the revolver are at a variable rate, which for November will be right around 5%. Our low leverage coupled with very sufficient capacity remaining on our credit facility provides us tremendous flexibility for the right growth opportunities as we identify them at the right price. As we look forward, our cost mitigation efforts we put in place early in the third quarter are ongoing, but we expect our costs to remain elevated due to the significant inflationary economic environment. With solid volumes and rates, we expect our full-year results to be within our previous guidance ranges for operating results, which was $2.65 to $2.75 per share, and EBITDA also, which was in a range of $73.5 to $75.4 million, but most likely on the low end of those ranges. Just in closing, I'll say we are all working very hard as a team to produce the best possible results for all of our stakeholders, as I noted in my opening comments. And with that, Chris, I'll turn the call back to you.

Yeah, thanks, Kerry. Great job. Operator, let's go ahead and open it up for questions.

Certainly at this time, if you'd like to ask a question, please press star 1 on your touch-tone phone. You may withdraw your question at any time by pressing the pound key. Once again, that is star and 1. And we'll take our first question from Brian Tankolet with Jefferies. Please go ahead. Your line is open.

Good morning, guys. Hey, Brian. Hi, nice to be back. I guess my first question, you know, good rate growth performance this quarter. Chris, is this early signs of progress in terms of trying to negotiate better rates with payers? And how should we be thinking about the remaining opportunity to drive rate growth going forward?

Yes, good question. Yes, I do think it's early progress. The team's worked really hard. Our injury prevention team is having success there, too, although that doesn't show up in our net rate that you just referenced. We've got a lot more work to do, though. We have some contracts that just kicked in in October that aren't in those numbers. But I would encourage you guys not to get too far ahead of this. This is not going to be a linear process that's easy necessarily to predict quarter to quarter. So hang with us. We're continuing to work on it. And as I said, we're early innings on this. So more to do, more to come.

I appreciate that. And then, Chris, obviously good acquisition announced the other day, you know, good size. It looks like it's a good business. But as we think about the environment right now for deals with rates where they are, you know, private equity in theory kind of like a little bit maybe slowing down, what are your conversations like now with some of the targets that I know you cultivate a lot of these relationships over years? So just curious what those discussions are today and how should you be thinking about your opportunity set going forward?

Yeah, you know, the conversations haven't changed much. In fact, we're at the annual private practice meeting. I think the environment, as you referenced, certainly has changed. I think the multiples will change, quite frankly. They need to, and I think they will. And so we'll see what that does over the long run. I mean, these aren't moment-to-moment conversations where, you know, you pick up the phone and say, okay, you know, the world's different. But people, you know, the conversations I've been having, people understand that. The marketplace is changing. There are deals that have been right at the closing point, not our deals, but others that have stopped, stalled, or been taken off the table, presumably because of leverage or bank issues and other things. And so that's going to begin to seep in to this process, and whether that slows deal flow or just adjusts expectations, we'll have to wait and see. We continue to be active, and we continue to know that we'll be able to get things done, and we expect to make some adjustments accordingly.

And then, Chris, last question for me. As I think about the broader healthcare space, right, I mean, there's a lot of discussion about tightness in clinician labor, but I know you guys have done better in that front, but obviously the center of your business is still the therapists and the centers and the PTAs. How are you thinking about, you know, turnover and what are you seeing in terms of your ability to recruit clinicians in this supposedly tight labor market?

Yeah, I think it's feeling to me like the recruiting side. We've made some adjustments. We've invested in some new tools. We've been able to, through the summer with the graduating classes, pick up a number of key people, moving some people from competitors in some cases. It's not easy, but it feels better than it did, you know, maybe five or six months ago. I think it's feeling better for us as well on the injury prevention side. Again, I wouldn't consider it normal. At our APTQI meeting yesterday, one of our members presented an analysis and I don't have it in front of me at the moment. Actually, I may be able to pull it up on my phone. But it indicated that there were 21,000 physical therapists that fell out of the workplace in 20, actually 22,000 that fell out of the workforce in 2021, 300,000 total health care providers out of the workforce, 22,000 PTs, To give you some perspective, the average graduating class that aggregates all of the PT clinics in the country produce 11,000 graduates a year, approximately. So it's two years' worth of new workforce that evaporated at some point last year. And as you remember, last year was a blow and go year for us. We had record earnings last year and record volumes. So we're making adjustments. You know, those adjustments take some time. It's beginning to feel a little bit better. And I think for us, the important thing is that the clinicians, our partners, understand the importance of their work. They're connected, you know, to the difference they make. They're given the support that they need, which we're working hard to do. And We'll work our way through it from there. Awesome. Thanks. Thank you. Welcome back.

And we'll take our next question from Matt LaRue with William Blair. Please go ahead. Your line is open.

Hi, this is actually Madeline Mullen on for Matt LaRue. I know you mentioned last quarter that you were engaging in some cost control efforts, including switching suppliers. And I was wondering if you could sort of quantify the impact that you've seen from that this quarter and what you see going forward into 2023. And then also, I know that contract labor was a big headwind last quarter, and it was an impact on the takedown of your guidance. I was wondering if you could talk about whether you think that the contract labor costs are going to be more transitory or if you see those continuing into 2023.

Well, I definitely see contract labor continuing. We're never without contract labor, and I think this environment, it would be crazy to think that we're going to be without it. I would tell you that the guidance change was not particularly impacted by the amount of contract labor, certainly slightly, but that was a minor part of our guidance adjust, much more significant on the cost of capital side and on the general inflationary side. So we continue to work. Look, we're working our way through this. We're rolling out, as you mentioned, you know, some vendor changes through a GPO rollout that's in its early stages. We continue to make careful adjustments with respect to our staffing. We're rolling out some... improvements in our onboarding for our patients and our front desk areas that will hopefully, as we get further into 2023, will allow us to make some further adjustments in our front office staff. But this is going to be kind of a slow, steady process. This isn't a one-and-done kind of opportunity. It's going to take us a little bit more time.

Great. Thank you. And then just as you think about acquisitions, I know you mentioned that you drew down on your debt to fund the most recent acquisition this week. Is there a leverage ratio that you want to stay below? Are you focusing more on acquisitions you can pay for in cash in order to not draw down on the debt? Just wondering how you're thinking about that.

Yeah, well, I mean, certainly we have covenants and, you know, understandings with our bank, you know, those ratios right now. We get credit for prospective EBITDA that gets annualized in these deals, but, you know, our leverage ratio, including that prospective credit, would be at three times, and we'll stay under that. Sure, we won't. just to be clear that's the that's the covenant just making sure you know that's clear we're currently in about 1.6 times or around that so go ahead i'm sorry chris quit yeah no that's fine i mean the point is we're well within those ranges that keep us comfortable um will we use cash look we always have cash available you know 20 and 25 million dollars to to fund the ongoing needs of our business we'll actually pay down, you know, that credit facility, that $5 million that we borrowed as we're able, and then re-borrow as we need to. And so that'll be a rather fluid process that occurs each and every week, in fact, depending upon cash availability and outflow.

Great. Thank you so much. That's all from me.

Yeah, thank you.

And once again, as a reminder, to ask a question, that is star and one. And we'll go next to Mike Petusky with Barrington Research. Please go ahead. Your line is open.

Hey, Mike. Hey, Mike. Hey. So I guess I wanted to ask, and I understand it's early, but on the GPO rollout, I mean, what kind of buy-in or pushback are you getting from your therapist partners? I mean, are they sort of, you know, sort of getting on board or resistant or somewhere in between. Thanks.

Yeah, this is Graham. So far it's been well received. I mean, we're working through partner by partner, but so far we've had a good adoption on it and we're working to move it out for more people.

Yeah, Mike, I think like anything else, will it be 100% uniform and will the sensitivities around it be 100% one way or the other? No. But I think our partners understand where they are and where we are and where the world is right now. And buying the same stuff and paying more for it just doesn't make a lot of sense. And we have a new opportunity and, you know, it'll be changed, but we're working our way through it.

And, Chris, I guess, given that you're in a meeting, I'm extra curious what the current view is, you know, in the industry, yourself, as far as reimbursement, sort of a more rational reimbursement approach, including specifically for 2023. Any thoughts?

Yeah, so we had our APTQI meeting. Again, that's the vehicle that we use to do our lobbying, our congressional work, all of the important work that we're doing to elevate the fact that You know, physical therapy, there are a few good studies out right now that indicate that not only does physical therapy bend, downwardly bend the cost curve for somebody who completes a full session of physical therapy, but when they complete that full session, they don't disconnect early, makes an even more meaningful difference in the total quality of their life. and in their healthcare span. And so the congressional champions that we're speaking to, they understand that. Many of them have had physical therapy themselves. We're now, you know, collectively of the age where people have things that are beginning to happen. All of us do, our kids do, our parents certainly, and they recognize it. So CMS is not the rational, you know, arbiter now at this point of where rape should be. And we hope and expect that we'll get some relief here at the end of the year with through and with some congressional action. That isn't certain at this point. It won't be certain until it happens. But we're making progress and we expect to be there. Longer term, look, I think we're going to begin to see a shift. in commercial payers. And this is just my view. This is not based on anything else. But I think payers are beginning to see that they can't eliminating physical therapy and they can't cut their way to improving their total cost dynamic because if people don't have access to PT, which is what's going to happen, I mean, we're in the process right now, quite honestly, of looking at contracts that no longer make sense to us to take at a certain reimbursement rate. we've actually begun to drop some of those contracts. And so, you know, with anything, I think as there's consolidation in our PT world, we have larger companies with more resources, better ability to negotiate. You know, some of this low-hanging fruit for these payers are making mints on Medicare Advantage and booking record earnings. It's going to have to flow to providers, and we're certainly going to fight for our fair share. I'm tired of taking low rates, frankly.

This one's more of a housekeeping, but does anybody there have the payer mix for the quarter? Sure, I have it. Yeah, yeah, I've got it. So for commercial insurance, it was 45.7%. Medicare was 34.4%. Medicaid was 4.1%. Workers' comp was 9.5%, and then everything else together was 6.3%. Okay, and just a quick follow-up related to that. Obviously, over time, Medicare and Medicaid has sort of moved up a bit as a percentage. Workers' comp looks like it's moved down over time. I mean, is there any way for you guys to sort of intentionally – to take steps that can sort of shift, you know, towards the, you know, $130, $140 reimbursement versus, you know, whatever it is, $95 or whatever that might be in, you know, government pay. Thanks.

Right. Yeah. A few months ago, I think effective beginning July, We brought back a key exec who had actually been the driving force and the author behind a lot of our comp-based activities a number of years ago, which helped us meaningfully grow our comp rate. Obviously, at the beginning of the pandemic, our comp, and from my perspective, A lot of our competitors' comp business fell, and we've yet to get that back, as you pointed out. But we've added resources in this area, rolling out new programs. We've updated our training. We've updated our web presence and our marketing and our sales efforts. And, you know, we've yet to see meaningful change, but we're beginning to feel like we're moving back in the right direction. We hope to make some progress there. We're obviously early, but we're focused on it.

Okay, can I think of one more quick one? Just on the recent acquisition, the one from earlier this week, the press release was sort of vague. It sort of seemed to say that the 14 facilities maybe were in a single state, but maybe that could get bigger. Can you just talk about what the possibility is? either geographically, if you're willing to talk about that, or from a facility standpoint, how much that particular practice could grow. Thanks.

Yeah, that practice is primarily in one state, although it does technically cover two states. Let me tell you, Mike, these guys are as capable as any group that we've, you know, ever worked with. They open new clinics. which get the profitability in what I think is record time. We have a number of new clinics slated to open with them. And we have some activities that are beyond the two states that they're in currently. Again, primarily one, technically two, that would take them in some other areas. And they have relationships that go beyond those two states. So I think this is a group that can – grow very very significantly over the next few years and then you know beyond that so very excited about it i'm happy to have them part of the team and the family and looking forward to helping them you know recognize their vision are you willing to share the geography or no i'm not right now and it sounds funny but the reason is We have so much in development with them. They want to jump on the market before the word gets out so that people don't shore up their defenses. And so as crazy as it seems, we're going to keep that quiet as long as we can. It's a good market, though.

Yeah, fair enough. It sounds like you're excited. Very good. Congrats. Thanks.

Thanks, Wayne.

Bye.

And once again, as a reminder to ask a question, that is star and one. And there appears to be no further questions at this time. I'll turn the call back over to the speakers for any closing remarks.

Okay, Ashley, thank you. Thanks, everyone. We appreciate your time this morning. I'm going to be tied up a little bit this afternoon with activities that are slated at this private practice conference. I think Carrie is expected to be available, and certainly I'll be available once I get back. So thank you for your time, and have a great day.

Thank you, and this does conclude today's program. Thank you for your participation. You may disconnect at any time.