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Acadia Healthcare Company Inc
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Please standby. We're about to begin. As a reminder, this call is being recorded. Please proceed.
Good morning and welcome to Acadia's First Quarter 2020 Conference Call. I'm Gretchen Hommrich, Director of Investor Relations for Acadia. I'll provide you with our Safe Harbor before turning the call over to our Chief Executive Officer, Debbie Osteen.
To the extent any non-GAAP financial measure is discussed in today's call, you will also find a reconciliation of that measure to the most directly comparable financial measure calculated according to GAAP on our website by viewing yesterday's news release under the Investors link.
This conference call may contain forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995, including statements, among others, regarding Acadia's expected operational and financial performance for 2020 and beyond.
For this purpose, any statements made during this call that are not statements of historical fact may be deemed to be forward-looking statements. Without limiting the foregoing, the words believes, anticipates, plans, expects, and similar expressions are intended to identify forward-looking statements.
We caution you that these statements may be affected by the important factors, among others, set forth in Acadia's filings with the Securities and Exchange Commission and in the company's first quarter news release, and consequently, actual operations and results may differ materially from the results discussed in the forward-looking statements. The company undertakes no obligation to update publicly any forward-looking statements whether as a result of new information, future events or otherwise.
At this time, I would like to turn the conference call over to Debbie Osteen for opening remarks.
Good morning and thank you for being with us today for our first quarter 2020 conference call. I'm here today with Chief Financial Officer, David Duckworth, and other members of our executive management team. David and I will provide some remarks on our response to the COVID-19 pandemic and on our financial and operating results for the first quarter. We will also discuss what we are seeing so far in the second quarter. We will then open the call for your questions.
Before we discuss our results, I believe it is important to reinforce in times like these that our top priorities now and always are the health and safety of our patients, employees and visitors. We have put into action the following initiatives to protect them, while continuing to provide quality care to our patients.
First, in February, we implemented the recommended precautionary measures in response to COVID-19 including recommendations and requirements issued by the CDC and state and local health authorities.
Second, we instituted social distancing practices and protective measures throughout our facilities, which includes restricting and in many cases suspending visitor access, closing common areas, limiting group therapy and screening patients and staff who enter our facilities based on criteria established by the CDC.
Third, we enhanced our supply chain management to ensure we have key PPE and supplies for the continued safety of our employees. This included conducting and updating a weekly inventory across the company for PPE and establishing a web based process to request PPE for better visibility of our needs and distribution. I want to thank our procurement team who has been an integral part of this process.
Fourth, over the course of the last two months, we have significantly increased communications with physicians, facility staff, division leadership, and our corporate employee, including daily updates, calls and webinars which resources and guidance for the facilities, and we established a task force of key leaders that meets daily to address concerns, develop action plans and monitor responses throughout our facilities.
Moving to our results for the first quarter, they were in line with our expectations. During the quarter, we achieved revenue growth of 2.9% compared to the same period of 2019, reflecting our continued focus on growth initiatives both through service expansion at our existing facilities and opening new facilities.
Through the first two months of the quarter, we were very pleased with our same facility patient day trends for both the U.S. and U.K. operations. For our U.S. operations, same facility patient days increased more than 4% through the first two months of the year compared to the prior year. The COVID-19 pandemic affected our business starting in late March and caused same facility patient day volumes to decline 3% in the last two weeks of the month relative to the same period last year. In the U.K., same facility patient days were flat through the first two months in 2020 and then declined 3% in the last two weeks of March as compared to the same period last year.
The impact of COVID-19 vary by geography and business lines with facilities and hotspot areas across our network, more affected than others. The diversity of our service model, breadth of our network and actions taken to shift our marketing efforts has offset some of the impact of the pandemic and continues to serve as well during this crisis.
Some of the factors that affected our business lines starting in late March were first, slowdown and referrals from traditional sources, such as emergency rooms and medical professionals. In many of our markets, our acute facilities receive referrals from emergency rooms. As ER visits declined, there was a corresponding effect on our admissions.
Second, the stay at home orders implemented by many cities and states. We saw a very direct correlation to our admissions as states encouraged individuals to remain home. While not intended, we believe our potential patients did not seek the care they needed. As states begin to modify these orders, we anticipate that our potential patients will again seek needed mental health assistance.
Third, the various effects of travel restrictions on our facilities who draw patients nationally for treatment, particularly in our specialty service line. We have some facilities that admit patients from a wide geographic area and a portion of these patients travel to reach our services.
We believe these factors are temporary and the demand for our services remained strong across the portfolio, and we expect to see continued improvement as restrictions are lifted. However, we do not have visibility on win volumes from our referral sources will return to prior levels.
In the month of April, our volumes declined 7% compared to last year, reflecting some deterioration in the first two weeks, with signs of stabilization and improvement during the last two weeks.
Shifting to the U.K. operations beginning in late March, our U.K. operations also faced temporary disrupts from the impact of the stay at home orders on the referral and commissioning process. While the volume impact in the U.K. has been limited due to the longer length of stay for many of our service lines, certain services with a shorter length of stay have been impacted.
In April, we have seen stability in our census ending the month at a 5% decline compared to the prior year. From our discussions with the NHS, we believe there may be a surge in individuals requiring mental health and addiction treatment, and we have developed a comprehensive plan to meet this need across our service lines.
Due to the pandemic, there has only been a slight delay in the construction of our retool beds and we are still on target to reopen those beds by the end of the year. As we move forward, these beds will be important to help address the demand and following the pandemic.
With the health of our experienced senior leadership team, strong local leadership and staff in our facilities, we have implemented the following actions to help mitigate some of the impact from the COVID-19 pandemic. These include increased utilization of technologies to support stay at home orders and better serve market demand, including telehealth options for patients and virtual visitations for families and guardians.
I would like to thank the administration and state agencies for relaxing and modifying regulations for telehealth. They worked rapidly to allow practitioners to work across state lines as we strive to accommodate our patients.
We shifted the approach for our sales and marketing platform to better reach patients who need our help during this pandemic, and with our referral sources, many of whom have been working from home through telehealth for care continuity.
We launched a national behavioral health crisis hotline designed to offer urgent assistance to any individuals in need of mental health or addiction treatment. The centralized 24x7 crisis line offers immediate, no charge, clinically approved assessments to support underserved communities and connect patients with the treatment they need. And we collaborated with other large public healthcare providers across the country in an effort to absorb patients coming from medical hospitals as they converted their resources to fight COVID-19.
In addition, as volume started to decline in the latter part of March and throughout April, our operations team was very proactive in implementing necessary changes to mitigate the financial impact, including aligning corporate and facility level staffing costs with patient volumes and the implementing a hiring freeze for non-clinical staff, canceling all non-essential business travel, reducing discretionary expenditures and temporarily reducing marketing spending, negotiating with our vendors and lessors for discounts and/or revise payment terms, and closely managing our working capital as our facilities continue to bill and collect for services rendered.
We continue to make prudent investments to serve our patients' needs, ensure the safety and wellbeing of everyone at our facilities and prepare for the mental and emotional impacts that this pandemic could produce in the months ahead. During the quarter, we added 78 beds to existing facilities in the U.S. Moving forward in 2020, we plan to reduce our capital expenditures and have modified the number of beds that we will add during the year.
We also remained committed to our partnership strategy. In recent discussions with our partners and prospects during this crisis, they acknowledged that while COVID-19 requires considerable resources and executive attention from their health system. Their leaders also believe this crisis will end, and it is critical that they keep working on future plans. We expect to open three de novo facilities later in 2020, including two facilities with joint venture partners positioning us for the growth that we see across the portfolio.
I would like to update you on our sales process for our U.K. business. As we announced in March, the Board decided to temporarily suspend the sale process of our U.K. business until market conditions recover. We believe interest from potential buyers remained strong and our objective will be to restart the process at the appropriate time to maximize value for our stockholders.
Lastly, before I turn the call over to David, I'd like to recognize and thank every one of our employees across our network. Their strength and dedication to providing care to our patients during these challenging times has been nothing short of amazing. We continue to draw strength from each other and our patients as they continue on their path to recovery. This pandemic has undoubtedly created mental and emotional issues that will need to be treated in the months and potentially years ahead, and Acadia is ready to answer that call.
Now, I will turn the call over to David Duckworth to discuss our financial results and guidance in more detail.
Thanks Debbie, and good morning. Revenue for the first quarter was $782.8 million, an increase of 2.9% compared with $760.6 million for the first quarter of 2019. The company's consolidated adjusted EBITDA for the first quarter of 2020 was $132.8 million compared to $136 million in the first quarter last year.
Net income attributable to Acadia stockholders for the first quarter of 2020 was $33.5 million or $0.38 per diluted share compared with a net income of $29.5 million or $0.34 per diluted share for the first quarter of 2019. Adjusted income attributable to Acadia stockholders per diluted share was $0.42 for the first quarter of 2020, which excludes transaction related expenses of $3.5 million and the income tax effect of adjustments to income of $0.3 million.
Turning to our financial guidance. The impact of COVID-19 on our operations and financial results during 2020 will depend on among other things, the length of time and severity of the pandemic, the lifting of stay at home orders and state restrictions, the timing and phasing of the economic reopening and the willingness of patients to travel.
As we announced in our press release due to these factors and the general uncertainty related to the COVID-19 pandemic, we're withdrawing the 2020 financial guidance that we previously issued with our fourth quarter announcement in February.
We continue to be confident in the company's long-term growth opportunities based on the increasing need for mental health and addiction treatment services. We have ample liquidity and capital to invest in and grow our business. As of March 31, 2020, we had $81 million in cash and cash equivalents, plus availability on our $500 million revolving credit facility.
Subsequent to the end of the quarter, Acadia borrowed a $100 million under its revolving line of credit in early April to enhance its overall cash position. Acadia's balance sheet remains strong and the company remains well-positioned to meet the long-term demand.
As part of our ongoing review of the business and efforts to enhance our financial, we conducted a thorough evaluation of all capital expenditure projects planned for 2020. To further enhance our cash position, we decided to decrease our expansion capital expenditures by $35 million from the previous range of $240 million to $260 million to a revise range of $205 million to $225 million.
We are completing the projects that are close to completion, many of which have beds coming online in the near-term at new and existing facilities. The $35 million reduction represents termination or delays in certain early stage projects based on project returns and other considerations. We have a high level of discretion to make further adjustments to our 2020 plan.
Also to provide for greater near-term financial flexibility in light of the impact from the ongoing pandemic, we have amended our credit agreement to increase the maximum consolidated leverage ratio from 5.75 times to 6.5 times for June 30 and September 30, 2020 and from 5.5 times to 6.25 times for December 31, 2020.
Additionally, the company is closely monitoring the impact of legislative actions including the passing into law of the CARES Act in late March. Several of the notable benefits of the recent legislation include, first, reimbursement to hospitals and other healthcare providers of public health and social services emergency fund of $100 billion has been established to prevent -- prepare for and respond to COVID-19 by reimbursing eligible healthcare providers for expenses or lost revenues, and additional 75 billion was approved in April, 2020.
Acadia received approximately $20 million in April relating to the initial allocation of these funds. We are currently reviewing the terms and conditions associated with these payments and completing the attestation process.
Second, the Medicare Advanced Payments program. Medicare has offered advanced payments equal to our Medicare revenue for a three-month period. We applied for and received approximately $45 million of advanced payments in April, 2020, which we expect to repay over a three-month period from August to November of this year. Third, a temporary suspension of Medicare sequestration, the lifting of the 2% reduction from May 1, 2020 to December 31, 2020 results in an expected earnings and cash benefit of approximately $3 million in 2020.
Fourth, a delay in the payment of employer payroll taxes. The employer portion of social security payroll taxes for the period from March 27, 2020 to December 31, 2020 can now be deferred and paid in two equal installments at the end of 2021 and 2022, resulting in a cash benefit of approximately $39 million for 2020.
And finally, the increase in the interest deductibility limitation applicable to our U.S. income taxes. As part of The Tax Cuts and Jobs Act of 2017, our interest deduction was limited to 30% of the adjusted taxable income. Within the CARES Act, this interest expense deduction threshold was increased to 50% of adjusted taxable income for the 2019 and 2020 tax years, making our interest expense fully deductible for these years. This change provides a cash flow benefit in the form of refunds or lower tax payments of $16 million for the 2019 portion and between $15 million and $20 million for the 2020 portion.
In total, we expect to receive approximately $100 million of incremental cash during the second quarter of 2020. We will continue to monitor further developments and allocation of funds.
That concludes my prepared remarks this morning. I'll turn it back over to Debbie for some final comments.
Thanks David. We believe the demand for mental health and substance use treatment is not discretionary or elective. We believe this crisis will have wide ranging consequences for many individuals. Behavioral healthcare providers will be in necessity to support our societies on the road to recovery.
We believe the global conversation has focused correctly on the importance of physical isolation to stop the spread of COVID-19, but across the world this may be a negative experience for those with mental health issues prior to the pandemic or as a result of the isolation and inability to seek treatment. With our experienced management team, diversification of services and scale across 40 states, Puerto Rico and the U.K., we believe Acadia will play a vital and leading role in the industry.
This concludes our prepared remarks this morning. I will now ask Jennifer to open the floor for your questions.
Thank you. [Operator Instructions]
And we'll go first to Kevin Fischbeck with Bank of America.
Great. Thanks. I was wondering if you could talk a little bit about how you think about growth during a recession. Maybe you can just walk us through payer mix shift, maybe give us a sense of kind of the commercial rates versus Medicare versus Medicaid? How you think about volumes during recession and then any kind of cost offsets you might have on labor or other areas? Thanks.
Yeah, Kevin, I'll start with that. We do think that the business is resilient and performs well during a recession. And the demand we expect will continue, and as we've mentioned, could potentially increase as we go through the next several months and years.
On your question about the payer mix, I think we have a very strong and stable, payer mix is diversified across the different payers and even within the different service lines that we have is a very strong and diversified payer mix. We do have -- 50% of our revenue in the U.S. is Medicaid and a very balanced mix of Medicare and commercial making up the other two main categories that we have with a very low mix around 7% of self pay revenue. So, we do treat patients that have insurance coverage through a government or a commercial plan.
In terms of how we think about the differences between the different rates across those different payer categories, it does depend on the service line and depend on the market. But for the most part, we do not see a significant difference across those different payer categories. We do think about commercial as being about 10% on average above our Medicare rates and Medicaid rates, while it depends on the market, maybe about 10% below Medicare rates. So, a pretty, pretty tight range from commercial to Medicaid rates.
I'll just add Kevin, that I think, many people so far have been able to keep their health insurance benefits if they've been furloughed. We're going to watch that very carefully. But I do know that in past economic downturns, the mental health business in particular has been resilient, as David mentioned. And we think, we're well-positioned to take care of the patients with our services and the diversification of those services. We will watch this carefully, but we do believe there's going to be a real demand surge in both the U.S. and the U.K., and we feel like we're very well prepared to handle that.
Okay. Great. And let me -- just last question. As far as the slowdown in the bed openings that you're doing right now, how do you think that's going to impact growth into next year? Do you think that that will have a meaningful headwind to your long-term growth target?
Kevin, we really don't. We entered the year with a very strong number of bed additions in the U.S. and talked about approximately 600 new beds. And the revisions that we've made in our CapEx plan, I think, allow us to continue to bring on a strong number of beds this year. The revised range is between 500 and 600, so we do not see a material change in the bed additions that we're bringing online, which supports the growth rate that we expect next year and the following years.
Great. Thank you.
I'll also mention, Kevin, that in the U.K. the retool beds that we have been in process with, those beds have had just a slight delay, but we are definitely on track to bring them back by the end of the year. So, the growth that we project in the U.K. is certainly still on track and we feel good about where we'll end up at the year's end.
Okay. Thank you
We will go next to A.J. Rice with Credit Suisse.
Hello, everybody. Good to hear everyone's safe. I know this maybe isn't a fair question, but it's somewhat striking. We don't have a lot of comparables, but your number one peer talked about in their psychiatric or behavioral health business, they were down 25% in the last two weeks of March in admissions and you're calling out about a 3% decline. I don't know if you have any sense of -- is that mix driven you think, geographically driven? I guess that level of disparity, we're used to some level of disparity, but that level seems to stand out. Any thoughts about that?
I mean, A.J., I think that we're a little unclear on the comparison with the other company and their metrics. But we really feel like we have differences between our two companies. We have a lot of diversification of our service line and really our markets as well. We have a very diverse and broad referral base, and I think that has served us well during this crisis. But I also think that we acted very quickly to address the decline in volumes with selecting staffing. We immediately shifted our sales and marketing approach.
I can't speak for how others have done that, but I do know that we did work with a sense of urgency. We expanded the telehealth very quickly. We shifted our focus with consumers and also our referral sources. So, I think that as we look across our service lines, we certainly have had impact, but I think that we took action to try and minimize that impact during all of this crisis.
I mean, across those service lines, was there any meaningful service lines that were down in that order of magnitude or were they all similarly off as the aggregate number suggests?
The four main service lines for our U.S. business, of course, include acute being the largest, our specialty business, and then our CTC and residential businesses. The CTC and residential volumes have been very stable throughout. We've -- of course, the residential, those patients are with us for a longer period of time. And CTC, we have kept those patient and treatment and just really been focused on continuing the treatment and the medication that they need.
And then as you compare our acute and specialty, I think it's been a similar decline between the two as we think about how the different service lines make up the 7% decline that we mentioned for April. So we -- we've not seen a significant difference from that level either within the acute or the specialty businesses.
Okay. Maybe my other question would be, you had two items that were in progress before we hit this COVID situation, one being the changeover of your sourcing, your GPO in February and the other being the five facilities that were under pressure in the second half of last year. Can you provide us an update on have those played out as you expected? Is there any challenges or positive surprises on any of that?
Well, I think, we were very pleased, A.J., with the progress that we were making in the first quarter with the facilities that we discussed last year. And I think that certainly the action steps that we put in place, we were seeing results. Several of the facilities in the group are specialty and they do draw from a national referral networks. So, they have been impacted by the stay at home orders. But we do believe that we have implemented the right actions. And I think that we were pleased with where we were before the COVID-19 started impacting volumes at the end of March.
I'll say about the initiatives that we put in place around procurement. We're very thankful that we did that in the fall and built our team. And we -- our initiatives are on track. We have made a transition to a new GPO. Certainly, the focus during -- into March and into April has been on making sure that we have proper PPE, but they have not taken their eyes off of the other initiatives. And those are moving forward and we feel like we're on track to end up where we expected to be at the end of the year.
Okay. Thanks a lot.
Thank you.
We will go next to Ralph Giacobbe with Citi.
Thanks. Good morning. I wanted to ask a little about -- you had noted the demand surge you expect. I guess, just a little bit more on the visibility on that. Is that just your expectation that is going to come, or is there some sort of your backlog that's just not allowing you to sort of see that demand?
And then related to that, how are you finding the labor backdrop at this point? Obviously, a different skill set, but perhaps for the first time in a long time hospitals sort of furloughing staff, do you see that as sort of a viable opportunity to add staff for you?
Well, I'll answer the first part of the question. And I think that we know that there has been a surge in the hotline. SAMHSA reported a 900% increase. And in past recessions and crisis, it really has been linked to suicide and really stress and anxiety. So, while we can't predict how that might happen over the next course of the -- this year and into next year, it's -- I think as Gallup polled, which was done late March, they found that 60% of the adults that they polled were reported experiencing daily feelings of stress. And so, I think even the polling company said that was unprecedented. We expect that there has been paid -- there have been patients that have stayed at home, because of the stay at home orders. I think unlike other situations, there has been a factor of fear and I think other specialties have seen it as well where patients were afraid to seek care, because they didn't want to exposure to Covid-19. So, I think our instincts are and our belief is that there will be demand and it could be greater than what we normally see.
And on the labor question, the business in the U.S. and the U.K. I think have performed very well through a strong employment market. And we've been able to staff our facilities with all the resources that we need to support the volumes as we enter potentially a lower unemployment market. It's probably too early to say what impact that could have, but it could be a -- an additional positive for us as we think about recruiting and having all the resources we need to support the business.
Okay. That's helpful. And if I could -- just one more. I know obviously you pulled guidance, but any broad commentary around the consideration between pricing and volume maybe in the second quarter. As patient days come down, would you expect revenue per patient day to increase just based on the argument of higher acuity or would that not be the case? And maybe if you can just give us a sense of what was revenue in April in the U.S. compared to the volume down 7%. Thanks.
It's too early to provide any specific numbers there. I do think -- of course, we provided the volume decline that we have seen for the full month of April. As we think about revenue per day, it will be impacted by service mix. And there are certain parts of the business where the way we're paid and this is within our CTC business, we're working with our payers, because in some states and with some payers, we get paid when the patient is physically at our facility and is able to receive counseling and some other services. So, our payers have been very supportive, but we do need to work through just finalizing how our payment will work with the CTC business. So, we are dealing with some revenue per day initiatives like that, but it's too early to provide any specific ranges there for the quarter.
Okay. Thank you.
We will go next to Brian Tanquilut with Jefferies.
Guys, I hope everyone's safe from COVID and from the start the other day around here. I guess, my first question for Debbie, as I think about the marketing pullback that you've talked about, how are you thinking about how that would impact demand or volumes once we get past COVID? Or are you re-ramping the marketing efforts at this point? Or what are the plans in terms of just taking out your strategy?
Well, I think we're really monitoring it on a daily and weekly basis. And as we see a need to change our current strategy, which has been to reduce some of the expenditure, we are prepared to do that. We have some very good metrics here and we're able to track that very, very closely with data. And so, as we see the demand start to return, we will change our strategy to really meet that. I think that that certainly we've focused more locally and regionally with the spend at this point, but as we see travel start to come back, we will make adjustments to our spend and our strategy as we need to.
I appreciate that. And I guess my follow-up, Debbie, as I think about the U.K. suspension of the sale process, then what are the discussions with the -- with your advisors on that one? I mean, is that -- obviously this is a temporary decision, right? But how are you thinking about what factors would drive you to get back to market? Or is there anything operationally that you need to see with assets before you say we're ready to restart the process?
Well, our advisors in the U.K. have maintained regular dialogue with the potential buyers and they've had discussions with them. Their interest levels in Priory remained strong. I think that what we're looking for is more visibility on the progression and the recovery from COVID-19. It certainly has had a big impact in the U.K., much like the U.S. But I think primarily we want to see a normalization of the debt market conditions in the U.K. We want to see this -- financing a transaction of the size of Priory can happen.
I do think that buyers are interested in meeting with our management team. They've had some interaction, but they want to go to the facilities. And so, we're waiting for the opportunity to allow that to happen. And right now, as I know you can understand our management team is really focused on getting through this, but at some point as we move through the crisis, buyers want to be visiting facilities and we'll provide that opportunity. But I do believe their interest level is very strong in the asset.
I appreciate that. Thank you.
We will go next to Pito Chickering with Deutsche Bank.
Good morning, guys. Thanks for taking my questions. Drilling into the U.K. market a minute. Can you talk about what disruptions you saw within the U.K.? How was different than in the U.S. and what the NHS telling you about how they view discharges over the next say, 30, 60, 90 days.
Yeah, Pito, I think one of the key differences other than just the volume impact being more limited in the U.K. market is on the labor side. We have been managing with a higher level of staff absences in the U.K. There was a -- just a slightly different approach in that market to encourage even healthcare workers to self isolate if they met certain criteria. And we saw that accelerate some in early April, but have really already seen that peak and a lot of the workers that self isolated in early April have returned to the business. But that will have an impact on our labor costs for April. There's a continuing pay for those employees, as well as just back filling those positions.
But the team there has done a great job managing that, have also had a lot of flexibility around how we staff the facilities. So, really pleased to work through that. We think fairly quickly and be able to run the facilities that we have there with the right level of staffing.
We've also been told our team there that there may be reimbursement for some of those salary costs that are a direct result of COVID-19. They have not given detail around that, but we do believe that some of those expenses will be offset. We just don't know what that number will look like at this point.
Great. Thanks. And then states like Georgia that have already begun easing the restrictions. Like, I realize it's very early in their process, but what have you seen specifically in Georgia? What bounce backs have you seen relative to other states? And sort of what lines of business are coming back faster? Thanks so much.
Well, it's very early on, and many states are in partial phases of return. We have seen an increase in our admissions at our facilities in Georgia, and we've had specifically seen increases in the ER visits. Again, I don't know what that will mean long-term, but we have seen a relationship between the state opening and then calls and add admissions. We don't know that that will hold true for all our states, but it certainly has in the early states that have come on.
We will go next to Matthew Gillmor from Baird. Sir, your line is open. You may be on mute.
Hey, good morning. Sorry about that. I wanted to ask about the shift and referral sources. It sounds like you all are able to shift your resources as ER volumes declined at acute hospitals. Can you give us a sense for how those patients are now sort of getting treatment at your facilities? And do you think that's a durable shift or something that'll revert back once COVID normalizes?
I think, Matthew, what we've seen is that those higher acuity patients have continued to go to the ER and it's not so much that there's been a complete shift. But there have been -- markets that have been more impacted and -- but those higher acuity patients, I think, are still going to the emergency room or finding another way to get to our facility. And we mentioned the broad referral base that we have. There's -- many other ways that those patients can get to our facilities. And it's really -- it's been isolated to markets that are more impacted. But I think the volume there has continued. But overall for the company given, especially some of the markets that have seen a greater impact, it has just been at a lower rate.
Got it. Fair enough. And can you -- could you provide some commentary on FMAP rate increases that some states are getting, and do you have any visibility as to how or if that'll trickle down into provider rates?
No. Indirectly, I think, it's a benefit for providers. We don't have any visibility into that as of right now.
Got it. Thanks very much.
Thank you.
We will go next to Whit Mayo with UBS.
Hey, thanks. Good morning. I know this is a hard question, but as you guys revisit your two or three-year plan, what do you think has changed in the last month that might influence that number up or down as you think about 2020, 2021, I mean, you're going to presumably have a little bit more volume mix as a consideration. There's just a lot of crosscurrents as I play this out in my head. So, just any thoughts as you think about kind of the out year, would be helpful at this point?
I think we don't really see any major changes to -- certainly our industry, but to our strategies. I think, there may be future opportunities that we might look at. I think telehealth and the reimbursement changes that have been made and some of the other rule changes may give us opportunity to actually grow that area. We've already put in place a pretty robust platform for that. So that may continue. It was part of our strategy before, but I think we might see that accelerate now that reimbursement is matching some of that.
I think we feel like our long-term growth opportunities based on demand really will not change. I think, we're confident in what we have in our service lines and some of the plans we have around it. Our partnership strategy, we've actually seen an increase in some of the discussions, which was a little surprising, to be honest, to me that they were continuing to remain engaged and -- but I do think that -- we think there might be opportunities there that certainly would need to meet our capital criteria, but we think that it makes sense to keep investing in our CTCs, the JVs and de novos as appropriate. And we'll watch carefully for any opportunities that might present as just a result of what's happened here in the first part of the year.
No, that's helpful. And maybe just the follow on to the -- your comment on the CTC business. I mean, we've heard patients are getting longer supplies of drugs given social distancing requirements, et cetera. Just curious how you've responded and you mentioned that some of the payers have adjusted to the new realities of this. Can you elaborate a little bit more on those conversations? Is this a concern for you, or do you feel pretty comfortable that they're all being fairly responsible about this?
I think with that the states have been very cognizant of the fact that we had to change our model. I do think that the way we have done this treatment in the past, which is with medication and therapy that we'll see a return after some of the stay at home orders are lifted to our previous model. But I think that so far our -- the CTC staff have just done an outstanding job of really handing out appropriate care in a new context, which is the medications that are being done on 15 and 30 days, but also still trying to maintain contact with those patients either through phone. They -- some of them have been able to use telehealth to really connect and make sure that our patients in that area are still safe and receiving the right inappropriate treatment.
We have had -- many states that have recognized that we've had to make these changes. They've been very cooperative. We have a few states that we're still, as David mentioned earlier, talking with about how to ensure that we are reimbursed for this change. And I think, we're optimistic that they will find a way to make this happen. But at this point the CTC group management facility level, they acted very, very quickly to put these changes in place really almost overnight. And I think that we have -- we've seen that. I think our patients have actually increased slightly in that area. And I think that we'll see and continue to see our volumes remain in that business area.
Okay. Thanks a lot.
We will go next to Gary Taylor with JPMorgan.
Hey, good morning. Most of my questions answered. Just had a few. We heard a few anecdotal comments from med surg hospitals with behavioral units over the course of the quarter about deferring some of those patients to try to create some additional on campus capacity in case they had to house COVID-19 patients. Were you seeing any of that? Was any of that measurable as part of this pretty solid and defensive top line you had this quarter?
I think we did see in some markets there were instances where the med surg system needed to free up beds. I think, we actually had an agreement with a large med surge company here in Nashville to accommodate if they needed their beds freed. That didn't end up happening, but we were prepared for it and they were prepared for it. We, I think, saw this really being more market specific and we actually probably saw this more in markets where the COVID-19 was more impactful, but I wouldn't call it material in our business or our volumes, but we certainly set up the structure if there was a need for our services and our bed.
Thanks. And then my last question would just be -- any comments about NHS? Anything that they have said? I guess, we think about how they do their budgeting, their global budgeting, the regional budgeting. And I'm just wondering if because of pandemic, it's possible any budget dollars could get shifted towards medical versus behavioral. Is there any insight into that at all?
No, I think, Gary, the NHS has been very focused on mental health services and having the capacity to meet what they view as a continuing and an increasing demand. And they have shown their support to providers through block contracts and other arrangements to make sure that those beds would be available. There was also -- as you guys know, every April is our rate increase for the NHS. And we did receive word that we are in the middle of our 2% to 3% range and NHS took the initiative to provide that clarity for providers for support and it's usually a process that we go through throughout the second quarter with our many other payers and local commissioning groups, they are in the U.K. But I think the NHS is focused on having the mental health beds available and providing the right reimbursement to providers.
Okay. Thank you.
Next to John Ransom with Raymond James.
Hey, good morning. Thanks for letting me at the end. David, just doing the math on your new covenant, this would imply something like $500 million of EBITDA. Is there something that we're missing in that math?
No. I think we view -- we -- our goal was to set the right covenant to give us the maximum amount of flexibility as we go through these uncertain times. So, yeah, we do view ourselves as having some, room as we don't yet know the potential impact, but your math is right.
Okay. The second question is, if we think about -- let's just assume for a minute, seven points of revenue declined to go along with seven points of volume decline. Is that a dollar for dollar reduction of EBITDA, or should there be some offsets?
John, there's a lot of moving pieces, of course, as we think about the volume decline and how it impacts our cost structure. We do have a highly flexible and variable cost structure. So we -- the team's doing a great job and already had a lot of tools in place that have been implemented over the last several months, just to really allow us to adjust the cost structure quickly as we saw the volume declines. But it depends on so many factors, including just where we see the volume declines, how significant it is at any one facility. But we do think we have a variable cost structure that allows us to make adjustments. But it's too early to do the math on just how we see that playing out over the next several months.
And look, I'm sorry if I missed this, I was having problems with your call this morning for some reasons. But if I think of this business on a continuum of sensitivity to recession, I would assume the opioid business and the residential business being probably up in a downtick, the adult acute business, just mix shift to government. And then what would be -- sensitive would be, I would assume the residential addiction business, just fewer corporate cases coming out of that line of businesses. Is that the right way to think about your business?
I think we agree that the business is resilient in those other service lines. I think even the substance abuse with the demand there we think will continue. And we do not view that as a discretionary service. We think -- after the temporary factors abate that we will pick back up on the volumes there and think that's also another resilient service line for us.
Right. Okay. Thanks a lot.
We will go next to Ryan Daniels with William Blair.
Hey guys. This is Nick Spiekhout in for Ryan. Similarly, most of my questions have been answered at this point. But I guess, with the beginning of April or towards the end of April, have you been seeing kind of like an uptick in referrals again? And if so, which I guess, referral channels have been the quickest to come back and kind of which ones have been the most resilient over the past couple of weeks?
Yes, we have seen improvement. It's at the end of April and that includes seeing an uptick in our referral volumes. I would say we do have that broad base of referrals, most of those referrals have been very resilient and it depends on the market. We look at the data for each of our facilities every day. But ERs are the ones that in certain markets did decline the most and have come back the most in late April.
There are some other referral sources. The adolescent business with a lot of schools around the country being closed, there's been less adolescent referrals and the team has done a nice job. They're just shifting certain services in some facilities to be more adult focused. And so, there have been referrals like that that have gone down and it may stay down for awhile. But it's a very diversified referral base and has come back nicely here at the end of April.
Thanks. And then, I guess, kind of going on that, so, there's a word that school districts may not even come back in discussion in the fall. I was wondering if you had any sort of plans of potentially dealing with that lack of referrals from that area, or I guess anything on that front.
Yeah, I think, obviously, we think the demand there for that population will continue, and our marketing strategy is focused on all the different ways we can access those patients.
I do think also that if the schools remain close, I don't think that eliminates the need for the services. It's certainly been an important referral source for us. But if that should change, I think there'll be other ways that parents and others will find their way to services and to our services in particular. So, I think that we're prepared to shift if we need to. But I think at this point, we've had the stay at home orders, which I think has been a factor in adolescents seeking care that they are going to school. But I think that there still will be -- some of the behaviors will not be eliminated just because they're not in school. So, we'll watch that carefully and make sure we're staying in contact with where they may seek help. And that would be professionals and pediatricians and others where parents might access if they have a need with an adolescent or a child.
Great. Thanks guys.
Thank you.
Thank you.
We will go next to Scott Fidel with Stephens.
Hey, great. Thank you. Gerard on for Scott. I thought maybe I would just dig in a little bit to, you guys talk about three major items impacting the volumes in the U.S., the slowdown in the referrals, stay at home orders and the various travel restrictions. Just wanted to see if you guys can put maybe an order of magnitude kind of on those three items and how those have volumes through April so far?
No. I think, we -- there's not a way to directly manage that. I think, our goal is to give an idea and some color as to the different factors that we think have had this temporary impact on our referrals. But it's hard to quantify each one of those factors. The stay at home orders are very widespread and have affected the referral sources. And so that's probably the biggest factor that we're dealing with because it does have an indirect impact into the referral volumes. But there's not a way to quantify each one.
Great. Thanks. And then I guess, just maybe a quick -- just a quick additional question just on the de novo pipeline. Do you think you could coming out of this pandemic potentially see and sort of acceleration and acute hospitals wanting to partner on behavioral facilities?
I think, this certainly could be that dynamic. I think that as I mentioned a little earlier, we have seen them stay engaged. And we plan to make some announcements very soon about agreements that we've reached with large systems. So, I think there could be opportunity there. It's hard to know how their strategies might change, but it kind of makes sense that they might look to work together in the future, which would be a positive out of this. But we'll be open to that and we're certainly believed that there still are underserved markets that make sense for de novo bills. And we'll watch that.
We're watching our construction costs very closely as well as what we're paying for land and other things. So, there may be opportunity to actually see some cost savings. I'm not going to predict that, but we clearly are watching it and trying to build as efficiently as we can, but also at the same time, I think there could be opportunity in the future.
Great. Thanks.
Thank you.
And at this time, there are no further questions.
Thanks again for being with us today and for your interest in Acadia Healthcare. I'm so grateful and proud of the continued commitment and professionalism of all of our employees as they come to work every day to care for our patients.
If you have additional questions today, please do not hesitate to contact us directly and have a good day.
This does conclude today's conference. We thank you for your participation.