Enhabit Q3 2023 Earnings Call Transcript

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November 8, 2023

There are 8 speakers on the call.

Operator

Good morning, everyone, and welcome to Inhabit Home Health and Hospice's Third Quarter 2023 Earnings Conference Call. Today's conference call is being recorded. If you have any objections, you may disconnect at this time. I will now turn the call over to Jordan Lloyd, Inhabit Home Health and Hospice Director of Investor Relations.

Speaker 1

Thank you, operator, and good morning, everyone. Thank you for joining Inhabit Home Health and Hospice Third Quarter 2023 Earnings Conference Call. With me on the call today participants are Bart Jacobsmeyer, President and Chief Executive Officer and Krissy Carlisle, Chief Financial Officer. Before we begin, if you do not already have a copy, the 3rd quarter earnings release, supplemental information and related Form 8 ks filed with the SEC are available on our website at investors. Ehab.com.

Speaker 1

On Page 2 of the supplemental information, you'll find the Safe Harbor statements, which are also set forth on the last page of the earnings release. During the call, we'll make forward looking statements, which are subject to risks and uncertainties, participants, many of which are beyond our control. Certain risks and uncertainties that could cause actual results to differ materially from our projections, estimates and expectations are discussed in the SEC's filing under the Form 10 ks and subsequent quarterly reports on Form 10 Q, each of which will be available on the company's website once filed. We encourage you to read them. You're cautioned not to place undue reliance on the estimates, projections, guidance and other forward looking information presented, which are based on current estimates of future events and speak only as of today.

Speaker 1

We do not undertake a duty to update these forward looking statements. Our supplemental information and discussion on this call will include certain non GAAP financial measures. For such measures, reconciliation to the most directly comparable GAAP measure is available at the end of the supplemental information and earnings release. I would like to remind everyone that we will adhere to one question and one follow-up to allow everyone to ask a question. If you have additional questions, please feel free to rejoin the queue.

Speaker 1

With that, I'll turn the call over to Barb.

Speaker 2

Thank you, Jordan. Good morning and thanks for joining us. Participants. Let me open by thanking our 11,000 employees. This is an incredibly dynamic operating environment and I'm so proud of our staff remaining focused on providing a better way to care for our patients, their families and each other.

Speaker 2

We are excited to be listed as number 42 in the U. S. News Best Healthcare Companies to Work For. U. S.

Speaker 2

News ranked the top 3 79 publicly traded companies spanning 20 industries, analyzing publicly available employee sentiment and other data that demonstrates how a company supports the everyday experience of its workers. Recognitions like this are important and reflect our commitment to our team and their commitment to our patients. I want to remind everyone that The purpose of today's call is to discuss our financial and operational results and outlook. As previously announced, we commenced a strategic review process. Our Board is conducting a thorough process with the assistance of our advisors participants and discussions with interested parties are ongoing.

Speaker 2

We will not be commenting beyond that and so we ask that to keep your questions focused on our business and our results. We have a lot of important updates to discuss with you today, including the final home health rule, continued improvements in labor recruitment, retention and cost and progress with payer innovation. Participants. Let's begin our updates with the final home health rule. CMS finalized a permanent adjustment cut that will result in a negative 2.6% impact, offset by a positive market basket update of 3.3%.

Speaker 2

Participants. After productivity adjustments and fixed dollar loss ratio adjustments, the result is a positive 0.8% versus the proposed negative 2.2%. The continued march of these cuts where the home health community does not know what to expect from Medicare year after year is not helpful in creating a stable home health landscape. In fact, it is detrimental to larger policy goals of providing equitable, high quality healthcare to seniors in their homes. Participants.

Speaker 2

While this final rule means we will be receiving less of a cut than under what was proposed, it does not restore home health reimbursement to where it should be. We know for a fact that CMS' market basket projections have missed actual market basket increase figures participants by more and more each of the past few years. Between 2021 2022, participants' final market basket projections missed the actual market basket increase by a combined 5.2%, but no corrective action has been taken. We anticipate this year's update ultimately will also fall short of the actual market basket cost increase. Participants.

Speaker 2

Importantly, the advocacy efforts that we and the entire home health community are presently undertaking with Congress, the administration and in the courts will not stop merely because Medicare decided to cut home health marginally less than what was proposed. Participants. While the cut amounts are concerning at any level, the bigger issue is the fact that the permanent cuts and the ongoing threat of future temporary cut clawbacks create a damaging overhang on the industry and adversely affect the availability of home health care services. While our payment update does not cover our inflationary costs, we are working diligently to remain competitive for our highly skilled workforce. We will continue to manage our resources as efficiently as possible to meet the needs of our patients and the needs of our partners in the care continuum.

Speaker 2

Turning now to an update on staffing. We are very pleased with the continued success of our recruitment and retention of clinical staff. Recall that during the Q2 of this year, we had 200 net new full time nursing hires. During the Q3, we added another 100 and 66 net new home health full time nurses and we continue to hire for additional growth. Participants.

Speaker 2

With this success, we have eliminated all hospice nursing contract labor and are on track to have substantially all home health nursing contract labor eliminated by the end of the year. Our home health team continues to do a great job managing productivity and optimization of our clinical staff. Our cost per visit increased 1.1% year over year as improved nursing productivity and optimization participants to offset the impact of merit and market increases for clinical staff. For Hospice, the implementation of the case management model An industry standard provides Inhabit with a platform for growth, driving positive recruitment and retention and addressing capacity constraints. This platform will allow us to grow and control our average daily cost per day.

Speaker 2

While cost per day increased year over year, it has now been stable over the past three quarters. With our hospice locations now fully staffed, we hired 3 new business development leaders with a combined 50 years of experience working with other hospice companies in the industry. We are pleased to be able to turn our focus to growth versus managing capacity challenges and are optimistic as we head into 2024. Participants. And now let's talk about our continued success with payer innovation.

Speaker 2

The strongest value proposition in our negotiations with payers continues to be our low 30 day hospital readmission rate, which is 20% better than the national average. Our payer innovation team has continued to succeed in demonstrating this value proposition to Medicare Advantage Payers. We had another strong quarter negotiating 11 new contracts, 10 of the 11 are episodic agreements. Participants. Since the inception of the Payer Innovation team last summer, we have successfully negotiated 48 new agreements.

Speaker 2

2 thirds of these are at episodic rates. Our Home Health business development and branch operation teams have been successful in moving volume to our payer innovation agreements. During the Q3, we admitted over 6 1,000 patients within our new contracts. That's 72% sequential growth in admissions under these agreements. Participants.

Speaker 2

Remember that in quarter 2, our new 2023 national agreement was effective for only 2 months. In the Q2 of this year, 10% of our non episodic visits were in the new payer innovation contracts. In the Q3, this grew to 22% of our non episodic visits. We continue to estimate that every 5% of visits That shift from previous non episodic payer contracts to new non episodic payer innovation contracts represents an approximate $2,000,000 increase to revenue and adjusted EBITDA annually. We are confident in our ability to make continued improvement in Medicare Advantage pricing and in the shift of our Medicare Advantage admissions to these improved payers.

Speaker 2

Some payers are now recognizing the variation of quality results within the industry and are willing to pay for access participants to high quality providers like Inhabit. Our success in staffing and nursing productivity participants in implementing the Hospice case management model, in our ongoing payer innovation contracting and in building on the quality of our services are examples of our continuing investment for the future to meet the growing needs of home health and hospice services. I will now turn it over to Krissy to further discuss this quarter's results, guidance and the 2024 outlook.

Speaker 3

Participants. Thanks, Barb. Consolidated net revenue was $258,300,000 for the 3rd quarter, down $7,400,000 or 2.8% year over year. Adjusted EBITDA was $23,200,000 down 8 point to be in the range of $5,000,000 or 26.8 percent year over year. We estimate the continued shift to more non episodic payers in home health decreased revenue and adjusted EBITDA approximately $8,000,000 year over year.

Speaker 3

In our Home Health segment, participants. Total admissions increased 1.6% year over year as continued strong growth in non episodic admissions Our nonepisodic visits grew to approximately 31% of our total home health visits in the quarter. This represents an approximate 800 basis point increase year over year participants and is consistent with the percent we reported in Q2 of 2023. While we are making significant progress demonstrating our value proposition to payers as we negotiate new agreements with improved rates and are successfully shifting Medicare Advantage volume into our payer innovation agreements. Care fee for service volume.

Speaker 3

We estimate the impact of this payer mix shift was approximately $8,000,000 net of the impact from improved pricing and payer innovation contracts on revenue and adjusted EBITDA during the 3rd quarter. Participants. In our hospice segment, admissions decreased 3.4% year over year, while average daily census decreased 2.8% year over year. Sequentially, admissions increased 1.6% over the 2nd quarter. Our monthly average daily census trended up each month of Q3 and this positive trend continued in October.

Speaker 3

This is the first positive trending we've experienced since November of last year. And as a reminder, the Hospice final rule for fiscal year 2024 went into effect on October 1, 2023 participants and is expected to increase our reimbursement rates by 2.9%. Over the past two quarters, you've heard us talk about the diversification of our referral sources and the expansion of the number of admissions coming from facilities. These patients tend to be admitted to hospice care later in their journey. This diversification of referral sources is lowering our hospice cap exposure.

Speaker 3

With the Hospice Medicare fiscal year ending on September 30, we're pleased to report that we had only one location with approximately $20,000 of cap exposure. This is a significant improvement from 2022, During which we have 4 locations with a combined cap exposure of approximately $1,000,000 participants. Our home office, general and administrative expenses increased to 10.2% of consolidated revenue, primarily due to merit increases, participants in talent acquisition and employee development and a declining revenue base. We have now anniversaried our stand alone company costs. These costs totaled $5,800,000 in the Q3 of this year compared to $5,500,000 in the prior year period.

Speaker 3

By the end of June this year, we transitioned all services from Encompass Health except for certain technology services. All that remains as of today is the transition of our PeopleSoft Financials and HR systems, and we expect to complete that transition of those services by the end of Q1 2024. Let's transition now to the balance sheet. Information on our debt and liquidity metrics is included on Page 15 of the supplemental slides. Participants.

Speaker 3

We regularly assess our financial performance and evaluate that performance against our obligations, including those in our credit agreement. As we continue to work with our advisors as part of our strategic review and with uncertainty in the debt markets, participants Prior to the close of the Q3, we proactively reached out to our bank group and received a waiver for the Q3 2023 covenant period. Participants. This waiver was obtained out of an abundance of caution. We ended Q3 with a leverage ratio of 5 point one four times versus a covenant of 5.25 times.

Speaker 3

As you can see from our financial performance in Q3 leverage position, the waiver we proactively obtained was ultimately not needed. Over the last few weeks, we continue to work with our bank group to amend our credit agreement to provide additional cushion to the financial covenants. As part of this amendment and as shown on Page 16 of the supplemental slides, we secured financial covenant relief for the 6 quarters ending Q1

Speaker 4

in 2025.

Speaker 3

The levels we requested and received, like the waiver, were done out of an abundance of caution As we continue to operate in an industry with shifting dynamics and payer sources and reimbursement. It's notable participants that the financial information provided to the bank group for the amendment process was before participants the issuance of the final home health rule. The amendment to our credit agreement includes a permanent reduction in our revolver commitment to to $220,000,000 As of today, we have $180,000,000 drawn on the revolver, leaving us with $40,000,000 of availability. As a reminder, we have drawn on the revolver only once since our separation from Encompass. Participants.

Speaker 3

That draw was made in the Q4 of 2022 when we had 3 acquisitions and a $15,000,000 deferred payroll tax associated with COVID relief efforts. That represented over $50,000,000 of stacked payments and we only drew $20,000,000 on the revolver. Since that time, we've repaid $10,000,000 of that draw participants. With cash on hand of approximately $30,000,000 and the $40,000,000 of availability under our revolver, we believe we have adequate liquidity to to support our operations, including our de novo strategy. Let's turn now to guidance.

Speaker 3

Participants. Our greatest challenge in forecasting relates to the shift of Medicare eligibles into Medicare Advantage and forecasting not only the mix of traditional Medicare admissions versus Medicare Advantage admissions, but also forecasting the shift of Medicare Advantage into our payer innovation contracts. Participants. While our progress with our payer innovation agreements has been strong, it has not been enough to overcome the negative impact of the continued erosion of Medicare fee for service volumes. As a result, we revised our full year 2023 adjusted EBITDA guidance to a range of $93,000,000 to $98,000,000 In regards to free cash flow, we generated approximately $48,000,000 during the 1st 9 months of 2023.

Speaker 3

Free cash flow in the 4th quarter is dependent on the timing of working capital needs, participants, specifically accounts receivable. Based on our revised guidance, we expect to generate between $50,000,000 $67,000,000 of adjusted free cash flow in 2023, which equates to a free cash flow conversion rate of approximately 54% to 68%. Participants. Before opening it up for Q and A, I want to touch briefly on our outlook for 2024. Participants.

Speaker 3

It's too early to provide specifics, but these are the factors we are considering as we think about next year. Let's start with our Home Health segment and pricing. Based on our preliminary analysis of the final rule, we expect our Medicare pricing to increase approximately 1.2% in 2024 and we expect our Medicare Advantage pricing to improve based on the success of our payer innovation team, including a full year of impact from the national agreement that became effective May 1, 2023. In regards to volumes, we expect the success we've had with our payer innovation team and our recruitment and retention of clinical staff to drive volume growth in 2024. Participants.

Speaker 3

With our traditional Medicare mix of home health revenues now in line with our peers, we expect the continued decline in our traditional Medicare volumes to slow to a more industry like rate in 2024. And the new episodic payer On the cost side of the equation, we believe a 3% wage increase will be sufficient to maintain our success with recruitment and retention. We are also closely monitoring the results of the MetaLogic's Pulse rollout that was completed in Q3 to determine what impact it may have on our 2024 visits per episode. For our Hospice segment, for pricing, we expect our reimbursement rate will increase approximately 2.9% for the 1st 3 quarters of the year based on the final rule. Participants.

Speaker 3

For volumes, we are clinically staffed to grow and are working with our talent acquisition team to further build our business development team for growth. Participants. Participants. In regards to cost, we expect our cost per day will not increase in 2024 as we expect volumes to increase without the need to hire a significant number of additional staff, resulting in operating leverage against the fixed costs associated with our case management staffing model. Based on these factors, we believe the company is well positioned for revenue and adjusted EBITDA growth in 2024.

Speaker 3

With that, I'll ask the operator to open the lines for Q and A.

Operator

Our first question will come from the line of Brian Tanquilut with Jefferies. Please go ahead.

Speaker 5

Hi, good morning. Christy, thanks for all the color that you shared with us. So maybe just to kind of like dig a little deeper into some of these comments. As I think about cost per visit, What do you think operationally you guys will need to do between now and into next year participants to drive EBITDA growth, especially as we think about the CVV line.

Speaker 3

Well, I think again it gets down to productivity and optimization, Brian. Participants. We really focus on the density and scale of our markets, and we've demonstrated our ability to participants that 3% wage increase even in 2023. And again, we expect to continue to do that in 2024 again as our volumes continue to grow.

Speaker 2

And Brian, I'll add to that. I think the other thing to keep in mind is that we did use more contract labor this year, mainly because we had success with hiring. Participants. So as we kind of talked about before, we tended to use contract labor more when we knew that there was an end in sight in employees coming out of orientation. So being able to now get rid of that by the end of the year will also create an opportunity for us on that cost per visit in 2024.

Speaker 5

Participants. That's really helpful. And then maybe I just think about the top line, right, in your comments on fee for service volumes and the participants. How do you think number 1, how should we think about the remaining opportunity to drive new contracts into the system. And then within the existing contracts, obviously, there's a ramp there.

Speaker 5

How should we be thinking about participants the runway left on that ramp and what the right sort of mature level would be for some of these wins that you've had over the last year.

Speaker 2

To give numbers consolidated when we look at so many of the regional contracts that cover multiple states. What I would say is that participants. The branch directors and the business development folks in each individual market have now the tools in place to be able to prioritize that. We also have gotten continued feedback from our sales team in the field on what other payer agreements would be helpful to be on to be seen as a more full service provider. So in addition to our success, we still have another 40 contracts in our pipeline that are being worked today.

Speaker 2

So again, it's about really the execution at that local level on driving the volume not only into the new payer innovation, but to utilize that longer list of payers that we can take to also continue to earn that fee for service business.

Speaker 5

Awesome. Thank you.

Operator

Your next question comes from the line of Joanna Gajuk with Bank of America. Please go ahead. Participants.

Speaker 6

Hi, good morning. Thanks so much for taking the questions. So I guess, a follow-up to the comments around the Medicare rate update, Right. So, you said 1.2% and the wage is growing 3%. So you're saying essentially you assume the volume growth will help you offset or that 3% cost inflation rate and In the end, combined entity export EBITDA to growth, is there a way how to think about it?

Speaker 2

Well, certainly, I think as we look to giving guidance in 2024, we'll certainly have more details around them. But I would say it's volume growth, its continued focus on productivity and optimization. It's getting rid of all the contract labor and then it's also the visits per episode that we've we rolled out Medallogix Pulse to all of the locations by the end of the Q3. So there will be kind of a combination of the offsets that we'll have a lot more color on as we prepare for 2024 guidance.

Speaker 6

No, obviously understood. Yes, there's going to be a more detailed guidance, but I figured I'd just ask that. And then participants. My other question and I guess a follow-up to some comments around pricing in segments. In the slides, you talk about revenue reserves, I guess benefiting the pricing in segments.

Speaker 6

So what was this, I guess benefit I guess in the quarter in 1,000,000 of dollars and how should we think about this impacting Q4 if at all?

Speaker 3

Yes. So Joanna, remember that in the spring of this year, we disclosed a material weakness in regards to our accounts receivable reserves and revenue reserves and took a $12,000,000 adjustment in the Q4 of 2022 based off of that analysis. Participants. We noted at the time that as we continue down the path of remediating that material weakness and redesigning our controls around that process participants that if and when we got to a point that we believe the $12,000,000 was overly conservative participants that we would inform the community and take that back into revenue. And that's what we did in the Q3.

Speaker 3

We've redesigned the controls at this point, and they're still in the process of being tested. But again, based off of this redesign, we determined that we were able to take back $1,500,000 on a consolidated basis of that reserve. Participants. And so that was the net impact to the company in the Q3 of this year. It's too early to say what would happen in the 4th quarter, it's something that we're continuing to look at again as we test the operating effectiveness of the redesigned controls.

Speaker 3

But again, the Q3 impact was a $1,500,000 good guy.

Speaker 6

Participants. It sounds like you do not assume a similar benefit in Q4, correct?

Speaker 3

I think it would be premature to assume such.

Speaker 6

Great. Thank you. I'll hop back in.

Operator

Your next question will come from the line of Wood Mayo with Leerink Partners. Please go ahead.

Speaker 7

Participants. Hey, thanks. Good morning. Just looking at the 10 new MA contracts that you guys signed in the 3rd quarter, Does this cover where you have 1% of your current admissions, 50% of your admissions? I'm just trying to visualize the coverage aspect of these new contracts to And figure out how impactful this really could be.

Speaker 7

Thanks.

Speaker 2

I participants. I don't know that I know it by admissions. That's why we're looking at as we look at our visits, what percentage of our visits from our prior ones can we move in. As I think we've talked about in the past, the initial goal is not necessarily to focus on those for additional growth, but to be able to move from some of those really poor paying non episodic agreements into these new agreements. So at this stage, that's been the focus and that's why the plan is to continue to update everyone on where we are with that percent of non that are in these new payer innovation contracts.

Speaker 7

That's helpful. I appreciate it. And then maybe my follow-up question, and I know, Chrissy, you're in the middle of the planning process or beginning the process. But how do you think of the right corporate overhead bring that down with some of the transition cost from the former parent company or something, I don't know, but just any thoughts there would be helpful.

Speaker 3

Yes. Whit, you're absolutely right. It's a little too early for me to give specifics on that. I think the best that I would tell you right now is again we're really closely monitoring all of our corporate costs and you've heard about some of the actions that we've taken in the latter part of this year in regards to items like virtual clinical orientation, even not the home office, but looking at some of the back office It's important to note that you can look at kind of the $5,800,000 of stand alone company costs that were in the 3rd quarter. That may increase slightly participants in the Q4 and Q1 of next year, again, as we kind of continue to roll off of The final big piece, the PeopleSoft piece being the biggest piece of IT from Encompass.

Speaker 3

But it may be what I'm looking at right now is are we running towards the lower end of that original $26,000,000 to $28,000,000 estimate of standalone cost And even possibly running under it on a go forward basis. So I think that's what I'm very interested in at this point.

Speaker 7

Okay. Thank you.

Operator

Participants. Your next question will come from the line of Jamie Purce with Goldman Sachs. Please go ahead.

Speaker 4

Participants. Hey, thank you. Good morning. I wanted to get a little bit more color on just what you think is going on with the Medicare fee for service business that's been down 11%. I know you guys have been asked about this in the past and have said the markets are Down 4 ish percent.

Speaker 4

So is there a reason that you think at this point you can diagnose why you're underperforming the market? And then Relatedly, I mean, just what gives you confidence in the comments for 2024 that you'll be more in line with market growth and see for service?

Speaker 2

Yes. So I think probably the biggest thing to look at is where our peers have been as it relates to a percent of their Home Health revenues being fee for service Medicare and our peers have been pretty consistently in that 60% to 65% range over the last few years. As we noted, we were at 65% this quarter, and so we are nearing more that normal range of our peers versus our historic 75 plus percent. So that's what gives us confidence that we're really more to peer average now, so that what we experience in the future will be more like what our peers are experiencing as folks move into MA from traditional fee for service Medicare.

Speaker 4

Okay. And then I also wanted to follow-up on the comments next year around Medicare Advantage pricing growth. I don't think you gave a number there, just said you thought it improved with the mix shift towards the payer innovation contracts. But participants. I guess, one, what's included in those comments with respect to the United contract?

Speaker 4

Any color on where you are in that negotiation process and how we should think about the potential rate update for that contract next year. And then Any more precision you can provide on MA pricing next year would be great. Thank you.

Speaker 3

Yes, Jamie. It's It's too early and I don't know that we would provide precise pricing, especially on a specific contract, participants because that's kind of forbidden via the agreements themselves. We like the trends that we're seeing. Again, as we continue to shift for guidance and determine what we are willing to say and what we can say within the confines of our agreements. Again, from a per visit pricing, participants.

Speaker 3

Our agreements are kind of coming in at that 25% to 30% discount compared to the historic 35% to 40% discount. So we like what we're seeing there and are confident in our ability based on what we've seen thus far in 2023 and our ability to shift into the higher paying contracts.

Speaker 4

Participants. Okay, thanks. And if I could squeeze one last one in, just following up on an earlier question. What's been your contract labor expense for 'twenty three? And participants.

Speaker 4

Would it be right to assume most of that goes away next year? Thanks for the question.

Speaker 6

I have the we can certainly get

Speaker 2

you the side, I have the utilization side of it. So when you look at and this is quarter 3 information right now. But so for example, in quarter 3, 1 point 3 percent of our home health visits were performed by contract nurses. That was compared to 2.2% last quarter. Hospice visits, there was only 1% of hospice visits performed by contract nurses and that was more in that beginning part of the quarter, but we've eliminated all hospice contract labor by the end of the quarter.

Speaker 2

Last year this time 6% of our hospice participants were done by contract labor just to give a comparison for hospice.

Speaker 3

And Jamie, the only thing that I would add to that is when you look at our hospice cost per day, participants. You see that the year over year increase was about 8.5%. In the prior two quarters, it was in the double digit increase. Well, again, with the elimination of contract labor by the end of the 3rd quarter for that segment, that was a reduction in our cost per day of about that increase, I should say, of about 260 basis points. So you see the magnitude it can have.

Speaker 4

Participants. Okay, great. Thank you.

Operator

And I'll now turn the call over to Jordan for closing remarks.

Speaker 1

Participants. Thank you, Regina. If anyone has any additional questions, please feel free to call me at 469-860-6061.

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