Acadia Healthcare Company Inc

NASDAQ:ACHC

Earnings Call Transcript 2020-Q4

[Operator]

Please standby, we are about to begin. As a reminder, this call is being recorded. Please proceed.

[Gretchen Hommrich, Director, IR]

Good morning, and welcome to Acadia's Fourth Quarter 2020 Conference Call. I'm Gretchen Hommrich, Director of Investor Relations for Acadia. I'll first provide you with our safe harbor, before turning the call over to the 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 quarterly and annual financial performance for 2021 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.

You are hereby cautioned 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 fourth 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 for opening remarks, I would like to turn the conference call over to Chief Executive Officer, Debbie Osteen.

[Debra Osteen, CEO]

Good morning, and thank you for being with us today for our fourth 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 about our financial and operating results for the fourth quarter end year, and guidance for 2021.Following David's comments, I will provide additional details on our strategy going forward. We will then open the line for your questions.

We are very pleased with our solid financial and operating performance for the fourth quarter, capping off what was an extraordinary and challenging year for our Company and the nation since the onset of the Covid-19 pandemic.

Before we get into the results, I want to thank all of the Acadia's dedicated employees, and clinicians for their continued support and heroic work to provide the highest quality care to our patients and their families, in a safe and accessible manner.

As the global COVID-19 pandemic continues to affect communities across the nation, we recognized our critical role as a leading provider of behavioral healthcare services. The ongoing uncertainties and economic and societal concerns, as well as the added fear and isolation caused by the pandemic have resulted in heightened demand for our services, especially for those already struggling with mental health and substance use issues.

As always, our primary mission is to support our patients and the communities we serve. We are fortunate to have an experienced team across our operations, and a proven business model that supports our ability to meet this strong demand, and execute our strategy in this dynamic environment.

We're pleased to complete the sale of our U.K. operations to Waterland Private Equity in January. This transaction represents a significant milestone for Acadia, as it enables us to focus singularly on our U.S. operations and we now have complete financial flexibility to pursue our strategic agenda. We are committed to our efforts to extend Acadia's market reach and enhance our service offerings in the U.S., which will in turn maximize long-term value for our stockholders.

Our U.S. operations delivered favorable results, with improvement across all key metrics for the fourth quarter of 2020, driven by higher demand and operational improvements. U.S. same-facility revenue increased 7.6%, including a 3.6% increase in patient days and a 3.8% increase in revenue per patient day, reflecting robust demand for our services.

Throughout 2020, we continued to see measurable improvement in our cost management efforts that we implemented in 2019 and 2020, driving operation efficiencies. And in fact we achieved our goal of $20 million in annual run rate savings by the end of 2020.

We continue to employ disciplined cost management across our business to maintain our strong capital position. We remain committed to making strategic investments in our future growth in the U.S. by expanding our market reach to bed expansions and additional growth opportunities.

Despite challenges from COVID, we added a total of 460 beds, which includes 220 beds through the opening of two new joint venture facilities, as well as opening six CTCs in the U.S. We have extended our strong track record of partnering with health systems and hospitals across the country through joint ventures.

In December, we opened Ascension St. Thomas Behavioral Health, a new 76-bed inpatient facility, through our joint venture with Ascension St. Thomas in Nashville, Tennessee. With the proceeds from our divestiture at the UK operations, we now have a balance sheet that will allow us to pursue additional investments to grow. We believe ample opportunities exist, which I will discuss in more detail at the end of this call.

Now I will turn the call over to David Duckworth to discuss our financial results in more detail.

[David Duckworth, CFO]

Thanks, Debbie, and good morning.

First of all, I'd like to point out that our U.K. business was reclassified to discontinued operations in our fourth quarter of financial statements. References to continuing operations represent our U.S. only business, while references to combined results include the UK business.

Revenue from our continuing operations for the fourth quarter was $541.3 million, compared to $501.2 million for the fourth quarter of 2019, a growth rate of 8%. Including discontinued operations, the results for the fourth quarter of 2020 reflect total consolidated revenue of $843.3 million. As Debbie noted, we reached an agreement to sell the UK business at the end of 2020, and completed the transaction on January 19th. The sale of the UK business resulted in a loss of $867.3 million, which is included in the loss from discontinued operations.

Results for the fourth quarter of 2020 include other income of $32.8 million related to the Provider Relief Fund established by the CARES Act. The Company's lost revenues and additional expenses incurred in the 12 months ended December 31, 2020 as a result of the COVID-19 pandemic exceeded the grant income recognized in 2020.

Combined adjusted income attributable to Acadia stockholders per diluted share was $1.13 for the fourth quarter of 2020. Adjustments to income include transaction-related expenses, debt extinguishment costs, loss on impairment, loss on sale, and the income tax effect of adjustments-to-income.

Acadia's combined adjusted EBITDA for the fourth quarter of 2020 was $207.5 million excluding income recognized from the CARES Act, combined adjusted EBITDA was $174.6 million compared to $144.4 million for the fourth quarter of 2019.

I would now like to provide an update on the UK sale proceeds, and debt transactions. As of December 31, 2020, the Company had $378.7 million in cash and cash equivalents, which excludes cash held by our UK operations. Cash flows from continuing operations were $503 million for 2020. In early January 2021, the Company voluntarily paid down $105 million of Term B loans.

From the U.K. sale on January 19th, the company received gross proceeds of $1.525 billion before deducting the settlement of foreign currency hedging liabilities of $85 million. Cash retained by the buyer of approximately $75 million and transaction cost of approximately $16 million. These deductions resulted in net proceeds of approximately $1.350 billion.

The company initially used the sales proceeds to repay all of its outstanding Term A and Term B loans of $1.80 billion and added cash to the balance sheet. On January 29, 2021, the company sent conditional notices of full redemption for our $650 million of 5.625% Senior Notes due 2023 and our $390 million of 6.5% Senior Notes due 2024.

The redemption of this combined $1.40 billion of additional debt along with breakage costs of only $6 million and estimated transaction costs of $9 million is expected to be completed in early March and to be funded with cash from the balance sheet of $430 million and proceeds from a new senior secured credit facility of $625 million.

The company expects to enter a new term loan and revolving line of credit facility as part of a five-year senior secured credit facility. Upon completion of all of these transactions, Acadia's debt structure is expected to include a $1.25 billion of our senior secured credit facility, $450 million of 5.5% Senior Notes due in 2028 and $475 million of 5% Senior Notes due in 2029. These actions should result in the company's net leverage ratio being below 3 times and we expect to maintain our leverage going forward in the range of 3 times to 4 times.

Turning to our financial guidance, as noted in our press release, we are providing guidance for the year in the first quarter as follows. First, for the full year 2021, revenue in a range of $2.230 billion to $2.280 billion, adjusted EBITDA in a range of $490 million to $520 million. Adjusted earnings per diluted share in a range of $2.20 to $2.45, interest expense of approximately $80 million to $85 million, of which $11 million of interest expense is expected to be eliminated after the first quarter.

Our tax rate of approximately 26.5%, stock compensation of approximately $28 million, depreciation and amortization expense in a range of $105 million to $110 million, operating cash flows in a range of $250 million to $285 million and total capital expenditures in a range of $285 million to $325 million, which includes approximately $45 million for maintenance capital expenditures.

And for the first quarter of 2021, our guidance includes revenue in a range of $540 million to $550 million, adjusted EBITDA in a range of $110 million to $115 million and adjusted earnings per diluted share in a range of $0.40 to $0.45.

As a reminder, this guidance does not include discontinued operations or the impact of any future acquisitions, divestitures or transaction related expenses. Acadia is in a strong financial position for 2021 and beyond as a result of the sale of the UK business, our cost management initiatives and our disciplined capital allocation.

Our first quarter and full-year guidance represents management's confidence in the business underpinned by the positive revenue and cost trends we are seeing in our US operations. We will continue to make strategic investments in the business, while aligning our cost to meet the ongoing needs of our patients.

We are confident in the essential nature of the services we provide, coupled with robust demand will lead to growth through 2021 and beyond.

I will now turn it back to Debbie for additional details on our strategy going forward.

[Debra Osteen, CEO]

I'd now like to spend a few minutes, giving you our view of the business for the next five years. As we look to the years ahead, we believe Acadia is well positioned to address the needs of those seeking treatment for mental health and substance use issues. And we expect the demand for our services will continue to increase.

Without question, 2020 was a very difficult year for many people and even more pronounced for those already struggling with mental health and substance use issues. Based on a recent report by McKenzie, approximately 35 million Americans are expected to experience behavioral health conditions post pandemic. Prior to the pandemic, there were approximately 20 million adults with the substance use disorders.

Research collected since the onset of the COVID-19 pandemic last spring has pointed to an increase in substance use related to stress, job loss, isolation and as a means to cope with other issues like anxiety and depression.

Studies also demonstrate that COVID-19 is affecting the mental health of children and adolescents and that depression and anxiety are prevalent. Elevated levels of mental health and substance use disorders are expected to remain long after the COVID-19 pandemic ends. Therefore, we believe that there will be continued growth in demand for our services.

We are also seeing higher demand as societal acceptance of behavioral health increases and coverage options for those seeking treatment expand and improve. We operate in a growing and fragmented industry. Our four diversified service lines offer exceptional high levels of care for our patients. Our expansive network of treatment facilities and options enabled greater access to care, allowing us to serve the diverse needs of patients while maintaining a keen focus on the individual's needs.

I'd like to give a brief overview of our service lines. Acadia's acute business is our largest service line at 47% of U.S. revenues. This segment provides the highest level of care for patients who are a threat to themselves or others. We are very diversified within this service line. With 44 inpatient acute psychiatric facilities across 20 states and Puerto Rico and we see opportunities to further grow our share of this highly fragmented market.

Turning to our second largest service line, our specialty business is focused on inpatient residential programs that treat patients who are suffering from either substance use or eating disorders. This area of treatment is highly specialized and Acadia is further differentiated by our strong marketing platform and National clinical referral network.

Within this service line, we are positioned as an in-network provider for over 90% of our services. We also have a favorable payer mix which includes 63% commercial revenue. Specialty contributes 21% of our total U.S. revenue.

Next is our CTC, or Comprehensive Treatment Centers, which is an outpatient business, which combines behavioral therapy and medication to treat substance use disorders. In addition to the many challenges presented by COVID-19, there are reports that the pandemic is also causing a resurgence in opioid use in the wake of widespread unemployment and isolation. With the 131 clinics, we are the largest provider of medication assisted treatment in the U.S. and our robust platform helps eliminate barriers to treatment.

We continue to see opportunities to help individuals deal with their opioid misuse. And as previously mentioned, we plan to open 11 new locations in 2021. Additionally, we continue to see positive legislative support for our services and favorable reimbursement trends, including expanded funding of Medicare and Medicaid last year.

Our CTC business contributes approximately 17% of our U.S. revenue. Lastly, our RTC business also known as residential treatment centers, is our fourth service line in the U.S., representing approximately 14% of our U.S. revenue. This service line provides longer term residential treatment for children and adolescents with behavioral health disorders in a non-hospital setting.

Acadia's RTC business is differentiated by our unique, specialized programs, led by strong facility management teams, and our relationships with state referring agencies. This business demonstrates consistent returns, and we will continue to look to grow the bed additions in our existing facilities.

As we continue to deal with the challenges from the COVID-19 pandemic and other societal and economic disruptions, we are focused on our strategic priorities that will ensure our business is positioned to deliver the highest quality of care for those who need treatment, both now and into the future.

With our singular focus now on our U.S. operations, and increased financial flexibility, we intend to make strategic investments in four distinct growth pathways. Bed expansions, de novo facilities, partnering with health systems and through strategic M&A. Together these growth pathways will provide additional opportunities for Acadia to reach more patients in new and existing markets.

We expect that our multiple pathways will provide a 10% EBITDA growth rate over the next five years. I will now spend some time discussing in more detail these four strategic growth levers that will support sustained, long-term growth across our service lines.

First, we believe facility expansions provide us with the best return for our investments. To address the growing demand in our existing markets, we add beds to existing Acadia facilities, which allows us to leverage the facilities to existing cost structure, and improved margins, and profitability.

As I mentioned, we added 240 beds to existing facilities in 2020, and plan to add approximately 300 beds this year to meet the ongoing demand in our current markets. After 2021, we believe that our existing facilities will have ongoing expansion opportunities, and expect to add 300 to 350 beds to existing facilities, which is included in our assumptions of our 10% EBITDA growth target.

Our second pathway to growth is partnering with health systems across the country through joint venture agreements to build new facilities. This provides the access to attractive markets that might otherwise be inaccessible through acquisitions. We also benefit from the partner hospitals established market presence and favorable reputation in the community.

And importantly, joint ventures enabled us to integrate physical and mental health services to develop quality programs. Through our partnership with Covenant Health, we expect to open a new 90-bed inpatient facility in Knoxville later this year.

We also announced a joint venture partnership with Henry Ford Health System for 192-bed inpatient facility, which will service the Detroit metro area when it opens in late 2022. With a solid pipeline of approximately 30 projects in different stages, we expect 2022 to be the strongest year for joint ventures with our partners today, with four to five facilities expected to open.

Our third pathway is opening wholly-owned de novos. There are many markets throughout the country that are still under served with a shortage of available beds for behavioral health treatment. We believe there are as many as 100 markets in the U.S. with a significant need for inpatient psychiatric beds. This year we expect to open one acute inpatient 80-bed facility in Cincinnati, Ohio.

For years 2023 to 2025, we expect to open three to four new inpatient facilities including JVs and wholly-owned de novos. We also believe there is still tremendous unmet need for medication assisted treatment in the 32 states, we currently operate in. Additionally, five states remain of interest for de novo targets. We plan to open 11 CTC locations throughout the U.S. in 2021 and 6 to 10 CTC locations per year for years 2022 to 2025.

The fourth pathway to growth is through M&A. We recently announced that we signed a definitive agreement to acquire Vallejo Behavioral, 61-bed acute facility located in Vallejo, California from Adventist Health.

Tuck-in acquisitions have been an important part of Acadia's growth strategy. And we believe this facility will be a good addition to our portfolio. The fragmented behavioral healthcare industry provides ample opportunity for future acquisitions, and we are well positioned to capitalize on these opportunities, with our flexible balance sheet and disciplined capital allocation framework.

Future M&A would be incremental to our 10% EBITDA growth target. Our growth for each of these pathways is supported by our marketing platform, which has been and continues to be a strength for the Company.

We have a strong, diversified referral base across all service lines and regions. We strive to eliminate barriers to treatment, to prop response times from initial outreach to admissions. Our marketing team has been and will continue to play an essential role by supporting our facilities and working to reach the many patients that need our services.

Another focus for us moving forward will be within the area of telehealth. During the second quarter of 2020 with the implementation of stay-at-home orders, we quickly expanded our telehealth capabilities to better reach and support our patients. We see telehealth as an opportunity to expand the continuum of care for our patients both now and into the future. At the same time, we will be reinforcing our quality proposition.

We believe increasing the utilization of our telehealth platforms will help broaden community outreach, assist with physician coverage, support increased opportunities for group therapy, and encourage more timely assessments. We will continue to evaluate opportunities to grow in this area of our business within three major buckets.

Support for existing services, expansion of existing services, and growth into new services, Acadia is setting the standard for excellence in the treatment of behavioral health and substance use concerns. We are intently focused on fostering high levels of quality and safety for all of our patients every day.

Our strong financial position will support our strategic focus on our US operations and growth initiatives. Across our operations, we will leverage our experienced clinical teams to deliver the highest quality of patient care. While also extending our market reach and advancing our market leadership as a leading behavioral healthcare provider.

This concludes our prepared remarks this morning. I will now ask Cody to open the floor for your questions.

[Operator]

[Operator Instructions] We'll take our first question from Ralph Jacobi from Citi.

[Ralph Jacobi, Citi]

Thank you very much and very helpful framework. Just wanted to clarify on the 10% growth you said to facility expansion, I think was included, M&A was not included. What about the partnership and de novos? Are those included in the 10%?

[David Duckworth, CFO]

Yes, Ralph. The facility expansions, joint ventures and de novos are included in the 10% and as we commented, M&A would be incremental to that threshold.

[Ralph Jacobi, Citi]

And then you just de-levered the balance sheet. You talked about the target sort of the - I guess the three to four times range. I guess, how quickly should we think of the speed and ramp-up of these projects and in regard to that leverage ratio?

[David Duckworth, CFO]

Well, these projects that we highlighted are really funded with cash from operations. They are included in our projection of capital expenditures, which we do believe will continue to accelerate as we finalize some of those projects. And so there is an earnings ramp associated with new facilities, not with the bed expansions at existing facilities, but with those new facilities. So we plan to fund those with cash that we generate in the business. And really see the de-leveraging benefit of that as we look out over the next several years.

[Ralph Jacobi, Citi]

Okay, that's helpful. And then just my follow up here. Can you talk a little bit more about the guidance? The underlying assumptions may be on the same store metrics, the volume, pricing and then implied margins at the midpoint of guidance is about 22%. Maybe how you view the opportunities to move that higher or whether it's more about sort of driving top line to your point, sort of breaking out all of the opportunities that you have going forward. Any color around trajectory there would be helpful. Thanks.

[David Duckworth, CFO]

Yes, sure. We do believe that revenue growth will continue at the 6% to 8% range. Our second quarter obviously will have a comp that compares to what was a challenging quarter in 2020. So it is expected to be above that range. But in addition to that 6% revenue growth, we do see margin improvement in the business.

Our 2021 guidance assumes about a 27% margin for our U.S. same facility group. And then as you mentioned, the implied guidance for the company in total which would include our corporate office as well as any new facilities and start-up losses that are not part of that same facility group puts our consolidated margin in the range of 22% to 23%.

The revenue growth is 6% to 8%. It continues to break down very similar to the trends we've seen in the past with about 2% to 3% pricing growth within that, as well as 4% to 5% volume growth. We do believe going forward, as we look past 2021 with the volume growth, the efficiencies and the ongoing cost management focus that we have, we should continue to see margin improvement as we grow the business and the expectation there is around 50 basis points of annual margin improvement.

[Operator]

Your next from Pito Chickering with Deutsche Bank. Please go ahead.

[Pito Chickering, Deutsche Bank]

Good morning, guys, thanks for taking my questions. Just dwelling a little bit on the same store patient days are up 3.6% comprised of admissions up 70 basis points and like the stay up 2.9%. Can you give us some more color on the emissions? What you seeing from each referral channel, for example, you said that acute is nearly 40% of your business? How is demand in the ER of referral channel trended?

And also length of stay, any color on what's happening in terms of like the stay growing. Is this a read through for trends in 2021 and beyond in a post-COVID environment?

[Debra Osteen, CEO]

Good morning, Pito. I've just mentioned a little bit along the service lines and what we saw in the fourth quarter, our acute continue to see very strong volumes and it's really driven by our referral network which includes the ERs and we did not see much disruption there and in fact that stayed very consistent with what we've seen from June forward.

Our specialty service line, we did see sequential decline there from quarter three. and that was really due to the resurgence in COVID. There was some reluctance to travel and we saw certain markets that were - we consider to be more hotspots, California, Arizona. We managed through that very well, but - and we have actually started to see recovery on that in January and it's even stronger in February. So I think that was a temporary, and that's again based on the fact that we pull from a broad area, a geographic area across the country.

RTC was very stable and it's really been stable throughout the pandemic. We actually not only saw stability there, but we saw improvement in our census in RTC. And then the last area that I'll mention is our CTC and that continues to be strong. It's outperformed the prior year, and we mentioned that we're adding clinics this year. We feel like this is an area for strong growth, but it certainly in the fourth quarter was extremely strong, and we were very pleased that we were able to offer services and there was really no disruption there.

Linked to stay I think it has been, even though it is up slightly. I think as we look at it, we don't see one common factor there. I think that it's within our expected range if we look at it by service line, I think that while I say there is no one common factor. I do think that in the acute area, it is up from what we have seen over the years and I think part of that could be to some increase in acuity, but as I said, it's still within the range that we see and have seen over many years.

[Pito Chickering, Deutsche Bank]

And then for a follow-up question telehealth is typically used more in the outpatient setting. Can you give us some color on what you mean by growing into new services? Is there a chance that you can leverage your physicians, nurses to expand outside of the inpatient or residential service market? Thanks so much.

[Debra Osteen, CEO]

Sure. We feel like we have a strong platform here. And as I mentioned in my remarks, we did expand the capabilities of our facilities very quickly, really within about two weeks, which I have to give credit to our IT department, working in collaboration with our facilities.

But we also think there may be opportunity to expand telehealth and as you mentioned, using our physician network and our capabilities that we have clinically, not only for patient follow-up that might occur as patients are discharged, but then also we're looking at additional markets that we might not be in right now, as well as partnerships that we might have with other tele-health providers or perhaps even trying to expand our capabilities here within Acadia.

[Pito Chickering, Deutsche Bank]

So I mean, just to be sort of very clear, on the telehealth, you're talking about possibly expanding outside of your core business lines into the demand you're seeing within the behavioral telehealth market?

[David Duckworth, CFO]

Yes Pito. We do believe that could be an opportunity. We have already seen an expansion and just a better continuum of care in our existing markets that does expand our reach and we believe that trend could continue.

[Pito Chickering, Deutsche Bank]

Great, thanks so much guys.

[Debra Osteen, CEO]

I will just add, Pito before you go, our - what we have used telehealth for is really - even through our assessments and using it as a way to extend the therapy because we do pull from some wide geographic areas. So when we talk about extending beyond our current offerings, we believe that we may have opportunity to extend our connection to patients that are in other parts of the country, and also - we also pull from rural markets where sometimes they go back and they don't have a continuum, and they don't have resources. So we want to be available to them and we see telehealth as a way to do that.

[Operator]

We will take our next question from Whit Mayo with UBS.

[Whit Mayo, UBS]

Just quickly on the 10%. Does that include start-up cost and should we think that same store EBITDA is more like a high-single digit number. And then the de novos and the new hospitals will contribute above and beyond the 10% number? I just trying to make sure I sort of decompose the building blocks to get to 10%?

[David Duckworth, CFO]

Yes. Whit, it's a good question. That does include us covering our start-up costs. In every year, we have some normal level of start-up, given that we are typically opening multiple facilities every year. We of course could see a year especially in 2022, where we have more facilities opening. But the 10% does have us covering that investment in that start-up period.

Of course, keeping in mind that we could see some years where we have more facilities coming online. But it's inclusive of that number.

[Whit Mayo, UBS]

Also what are you budgeting for startup cost in 2021?

[David Duckworth, CFO]

In 2021, we believe it will be in the range of $6 million to $8 million. We do have three facilities in various phases of the process right now. That compares to more like $4 million to $5 million in 2020 for the facilities that were at a similar phase in the process. So some slight growth in that investment in 2021.

[Whit Mayo, UBS]

Okay. And maybe two quick ones. I'm just curious. Debbie maybe to get an update on some of the underperforming hospitals that you had in late 2019? How are those performing versus budget and plan and then back to your comments around sort of like policy and legislation, when I've seen like California ACT 5. Is there anything that is kind of like bubbled up to the surface that you are paying a particularly close amount of attention to? Thanks.

[Debra Osteen, CEO]

Sure. With respect to the five facilities, I think in 2020, we were able to execute our plans around them for improvement, and despite COVID, they actually performed very well. And I was pleased and they were all unique as we had talked about a couple of years ago. But I think that they have all exceeded the budget expectations.

And then they are strong performers and we did see a couple more specialties as we had talked about and we saw some disruption from COVID, not anything that was controllable by the facility, but overall we see a lot of opportunity for each of those, there meeting our expectations, but we expect them to continue to improve this year, and they are very solid strong facilities for the company.

As far as legislation, and I think I've been watching the - as we have a new President, just his views on healthcare and particularly mental health, and I think that I've been pleased to see that he is supportive of enforcing mental health parity and I think that while there's been some work and attention given to that, I think that's opportunity frankly for the industry. I do think that there are still managed care companies that have not embraced parity, and should be held accountable.

And so I think he has said very publicly that he wants to focus on that. He is also a supporter of telehealth for rural communities and I see that as a positive because telehealth is not going to replace our inpatient business, but it can be as I talked earlier, a real continuum for us that allows people that can't drive or have too far of a distance to come to services.

And then I think just from the state point of view, we've seen strong support for mental health across the board, and I think a lot of that is based on the attention that mental health is getting, and you've been putting some of those numbers out. And there is very strong demand and I think the states have really collaborated with us and been very supportive in what we're trying to do at our place, and really the industry and meeting the needs.

So I'm encouraged that I think we have a president that is supportive of what we do, and also had talked about funding for opioid and extending that. So we're watching that very carefully and we're making sure our voice is heard, but I'm pleased that he understands the importance of mental health.

[Operator]

We'll hear next from Kevin Fischbeck with Bank of America.

[Kevin Fischbeck, Bank of America]

I just want to confirm the five-year growth targets of 10% EBITDA. What EBITDA number is that? Is that of the 2021 guidance or is that off of the 2020 pro forma number?

[David Duckworth, CFO]

That's off of the 2021 guidance. And it's a similar growth rate, if we think about 2021 compared to 2020. So it's a trend that we see in 2021 and continuing over that five-year period.

[Kevin Fischbeck, Bank of America]

Okay. And just to confirm that you think it should be relatively stable. You talked a few times about like 2022 is going to be a big year for JVs and we're going to be adding more beds in the out years. But that it should be more of that kind of consistent ratable over that time period?

[David Duckworth, CFO]

That's how we see it, Kevin. We do see just the ongoing bed expansions being very stable. Within that the number of new facilities being very stable. And so we do think that is a really as we look at each year, that's a number that we think we can achieve. And I think the new facilities, of course, even if we are investing in a greater number of those, and there is potentially a greater investment in that and a cost in that that could drive incrementally greater returns once you get one to two years into those new facilities,.

But it's a very stable rate of growth that we are projecting.

[Kevin Fischbeck, Bank of America]

Yes.

[Debra Osteen, CEO]

And Kevin, we see potential for M&A over and above that, which I talked about earlier. We think that there is a good pipeline, and we believe that that will be additional growth opportunity, which obviously we have not included in the 10%, but we think that there is real potential now that we do have our balance sheet in much better condition. We look at tuck-ins and other opportunities out in the market and we think that there is a good pipeline for that.

[Kevin Fischbeck, Bank of America]

Then my question. It is very helpful if you kind of reset the U.S. business and the exposure to different service lines. As you think about exiting this the growth strategy five years from now, are those percentages going to be pretty much the same or would you expect the business to be shifting in one direction over another? Thanks.

[David Duckworth, CFO]

We provided the detail around the service lines within our U.S. business, and we do certainly see the acute service line growing through the joint ventures and other growth pathways that are focused maybe more on acute, but the growth should occur throughout all of our service lines.

So I think any shift would be very gradual. We could see acute continue to grow as a mix of our U.S. business, but we believe all the service lines really provide a good platform for continuing growth. So I don't think we see a significant shift in the composition of the business five years from now.

[Operator]

We will hear next from A.J. Rice with Credit Suisse.

[A.J. Rice, Credit Suisse]

Yes, thanks for laying out those different business segments. That was very helpful. It does sound like acute will grow given where some of the strategic initiatives are with M&A and JV and so forth faster than the rest of those business lines. I guess the question is if part of the target is to get a 50 basis point improvement in margin sort of annually, how much of that is driven by margin differentials across the business lines and the business shifting toward higher margin business, which I would assume acute is relative to some of those other businesses? But if you could confirm that.

[David Duckworth, CFO]

No, we don't see that being a contributing factor to the margin improvement. It really is more the growth, the efficiencies that we believe we should continue to see from volume growth at existing facilities, leveraging the cost structure that we already have. That is the key driver of margin growth. We don't view the service mix being a factor in that margin improvement.

[A.J. Rice, Credit Suisse]

Is there a big differential in margin across the business lines?

[David Duckworth, CFO]

We see across our U.S. service lines strong margins and would really characterize all service lines being around the U.S., same facility level, which is approximately 27%. It can be different across the country and the different programs that we operate. But in general, our service lines are similar to our overall U.S. same facility margins.

[Debra Osteen, CEO]

And A.J. I'll just add.

[A.J. Rice, Credit Suisse]

Okay.

[Debra Osteen, CEO]

I think in the specialty area, we have a lot of diversity. And so depending on payer mix, you might see some variance of margin there because you have some or larger and very specialized and there is a lot of diversity there. So with acute, it's a little bit more straightforward and certainly with CTC as well. But I think within specialty, we have a very strong payor mix there as well as referral base.

[A.J. Rice, Credit Suisse]

Okay. And then maybe the other question, just to ask, would be around labor. Obviously, that's been a constraint in this sector from time to time on growth and some of the other sectors like acute or talking about some pressures they're having in finding adequate labor and some burnout an existing staff and so forth. Can you just sort of give us an update on how you see that, what's happening with your turnover rate? What's happening with your ability to recruit and some of the initiatives, maybe in that regard?

[Debra Osteen, CEO]

Well, A.J, we've had a very strong focus on recruitment and retention and I think that we did see occasions in the fourth quarter because of COVID and because we saw a lot more staff being impacted and we certainly saw more patients coming in that. I think the team did a fantastic job of just making sure they got services.

But I will say that there are occasions where we've utilized agency and over time, just to ensure that we have appropriate staff, but as I look at the company and really look across the service lines, we haven't seen significant disruption or change in the availability. We were very fortunate. Our turnover rate is fairly stable. We always work to bring it down, but it's stable and I think that again - I just go back to the operators in the field just did a great job of making sure we had the staff there within the patients needed to seek treatment.

[Operator]

We'll hear next from Brian Tanquilut with Jefferies.

[Brian Tanquilut, Jefferies]

Good morning guys and congratulations. I guess, Debbie just to follow up on your comments on M&A earlier. What is your appetite for larger deals at this point? Or should we be thinking about this more as a tuck-in strategy? And then I guess given the lack of deal flow in this space. I mean is it safe to assume that valuations are much lower than what we saw, say, three years to four years ago?

[Debra Osteen, CEO]

I'll take the first part of that question and let David talk about valuations. But I think M&A has historically been a priority here. I think, we're very well-informed about platforms that are out there and larger platforms. We're not going to comment on any specific transaction, but I'll just say we're open to what makes sense for us. We do look at valuation in multiples, but we also look at the strategic part of that as well as synergy. So I think that we - as we approach this year, we have an open mind for M&A, but we also have a disciplined approach to it in a framework, that's going to keep us very disciplined.

And I think that it looks from just the pipeline that there are opportunities not only for the tuck-ins, but perhaps going forward some of the larger M&A that might come to market. You want me to mention that?

[David Duckworth, CFO]

And really Brian nothing to add around valuation compared to the last several years. I think Debbie's point is the right one. We will remain disciplined. We think many different types of M&A opportunities will be attractive. And we will look at those and just evaluate it under our framework. But we do not have a specific view right now on where valuation should be.

[Brian Tanquilut, Jefferies]

And then I guess as I look at the CTC side of the business or just the whole addiction treatment complex, right. Obviously, the states are trying to negotiate a big settlement with the drug supply chain and they're saying that they're going to use the funds to pay for addiction treatment at the community level. So have you had conversations with your state clients yet on what that could mean for Acadia or just the industry as a whole once that settlement happens, presumably sometime this year?

[Debra Osteen, CEO]

We stay in very close touch with our states and I think the CEOs and leadership out in the field, really do a good job of making sure that they're talking with state and officials and those that are, I think involved in making decisions around funding. I do - we talked about this, I guess maybe year before last and it didn't work out. It does look like this it's going to happen now with the settlement.

And I think that we believe that we're in a good position to receive some of those funds, but we can't really predict how the states right now will lay that out. There are other proactive preventative services that I think they would seek to have. But we also believe we provide a key part of that continuum. So I think we are in close contact. We're watching that and we're hopeful that it will allow us to treat more individuals with the funding that may or may not become available.

[Operator]

Your next from John Ransom with Raymond James.

[John Ransom, Raymond James]

Good morning, thanks for the update and all the detail on your U.S. business. Just a couple for me. On the CTC side, given this - there is no public comp out there stand-alone. I don't think that businesses fully understood. But are there any sizable private equity-backed portfolio companies that you could see yourself being interested in or is this going to be in your opinion probably just a de novo type of this?

[Debra Osteen, CEO]

Well, as I mentioned to Brian, we don't comment on specifics, but there are platforms for CTC. And we certainly know them and I think that they have some different geographies than we might have. So those platforms might provide an opportunity for us to move into other states that we're not in or states that we feel would be good to go in with an acquisition rather than a de novo.

I do think the team is - does a very thorough job of really looking at what makes the most sense for states. And really, they've got some good criteria and metrics that they view, but we would not - will allow M&A in the CTC area. We just now see a very strong pipeline frankly for our de novos and we have plans and they are concrete, very defined by state. But on the other hand, we would always be open to opportunity if it presented.

[John Ransom, Raymond James]

Okay. On your labor, you know off here as how many of them vaccinated. And are you seeing - is there a subset that just not willing to take the vaccine at this point as we've seen in other sectors of healthcare?

[Debra Osteen, CEO]

We have tried to be very open with our staff and provide communication and education about the vaccine. I think that right now, I think about 15% of our staff have received the vaccine. I think that it varies by facility and by state, but they're also states as we know from hearing the news are in varying stages of actually getting the vaccine out to those that need it.

But we're going to continue to educate about I think the importance of the vaccine, but we've not mandated it here. We don't plan to do that, but we do think it's important for just the country, and we would always encourage our staff to receive it. But we're not at this point mandating it.

[John Ransom, Raymond James]

And then lastly for me, if you - if we think about the de novo losses that you're going to absorb it in your 10% EBITDA target, could you maybe you provide some sizing of that just from a dollar perspective at least kind of 2020, '21 and you've got it maybe in '22?

[David Duckworth, CFO]

Yes. We mentioned John, for this year, we have three facilities that are starting up and that's around $6 million to $8 million number for us. So that first year where our facility is going through the opening process and the licensing survey process hints to be around a $2 million loss. I think the team that we have has done a great job in finding ways to manage that, and the survey process and our work with the survey team is essential to that. So I think in general, it's around $2 million of facility. The timing of opening is a factor, and

[John Ransom, Raymond James]

Right.

[David Duckworth, CFO]

But I think we could see some improvement in that number. But in general, it's about $2 million per facility and should stay sort of in that $5 million to $10 million range

[John Ransom, Raymond James]

And how long does it generally take you to get to your average occupancy? When you open up a new either wholly-owned or JV. Is there a difference in the JV and the wholly-owned in terms of the - I would assume the JVs ramp quicker because you're probably transfer over some existing patients from the acute care hospitals? But just how long does it take on those two cases to get the full occupancy?

[David Duckworth, CFO]

Yes, we do have a goal for a new facility of getting to breakeven from an earnings perspective by the end of the first year. Getting all the way to the average occupancy for the company of a mature facility can be two years to three years, and the joint ventures that we've opened...

[John Ransom, Raymond James]

Right.

[David Duckworth, CFO]

Have demonstrated a faster ramp in the occupancy compared to a de novo. So intend to be a little bit faster in getting to that occupancy, but it's a two to three-year ramp to get all the way to the company average.

[John Ransom, Raymond James]

And I'm sorry if you mentioned this, but do I remember correctly that you own generally 80% of the JVs? Is that right? I mean...

[David Duckworth, CFO]

It depends on the transaction. Yes. Sorry, John...

[John Ransom, Raymond James]

Yes.

[David Duckworth, CFO]

It depends on the transaction. The contributions from both parties that is a general target that we have, and where we see a lot of our joint ventures. But we're very flexible in working through what's right for a specific transaction and it can vary some around that level.

[Operator]

Thank you. And that concludes today's question-and-answer session. I would now like to turn the conference back over to Debbie Osteen for any additional or closing remarks.

[Debra Osteen, CEO]

Well, thank you again for being with us today and for your interest in Acadia Healthcare. I'm so grateful to our field and corporate leaders for their resiliency, and their commitments to keeping our key growth and operational initiatives moving forward, while at the same time responding to this unprecedented crisis. If you have additional questions today, please do not hesitate to contact us directly, and have a good day.

[Operator]

Thank you. That does conclude today's conference. Thank you all for your participation.