Acadia Healthcare Company Inc

NASDAQ:ACHC

Earnings Call Analysis

Acadia Healthcare Reports Robust Growth

Acadia experienced a solid year in 2023, seeing revenue rise by 12.2%, adjusted EBITDA by 13.1%, and adjusted EPS by 14.3% over the previous year. Same facility revenue jumped by 10.3% in Q4 2023, while overcoming labor cost challenges, as wage inflation dropped from 8% to below 5%. They added 302 beds in 2023, keeping pace with their expansion goals, and continued to develop their service lines, opening new facilities such as the 101-bed Montrose Behavioral Health Hospital in Chicago. They opened two new Comprehensive Treatment Centers (CTCs) for opioid use disorder, aiming to open up to 14 more in 2024. Acadia announced a partnership with Ascension Seton to expand its Creek Hospital in Austin by 106 beds and acquired Turning Point Centers, completing its service line presence in Salt Lake City. They also added 13 outpatient programs in Q4, totaling 39 for the year, enhancing the continuum of care. Looking ahead, Acadia plans to add about 1,200 beds in 2024, escalating expansion efforts.

Acadia Focuses on Quality and Technology for Patient Safety and Care

Acadia has emphasized its commitment to quality patient care and safety as foundational elements of its operational model, planning to open up to 14 new Comprehensive Treatment Centers (CTCs) in 2024. The company has recently enhanced its technology infrastructure, integrating electronic medical records and patient monitoring technology across 53 facilities to improve clinical outcomes and foster value-based care partnerships with payers.

Strong Financial Growth in the Fourth Quarter of 2023

Acadia reported a revenue increase of 10% in Q4 of 2023, reaching $742.8 million, with same-facility revenue growth of 10.3%. The revenue rise was attributed to a 7.1% increase in revenue per patient day and a 2.9% increase in patient days. Adjusted EBITDA raised by 11.9% to $169.6 million, and adjusted income per diluted share to Acadia stockholders increased by 13.3% to $0.85. Acadia also settled three lawsuits in New Mexico for $400 million in January 2024.

Forecast for 2024: Revenue and Earnings Growth

For 2024, Acadia provided guidance of revenue in the range of $3.18 billion to $3.25 billion, with adjusted EBITDA between $730 million to $770 million, and adjusted earnings per diluted share projected to be $3.40 to $3.70. The company anticipates adding approximately 1,200 beds, excluding acquisitions.

Balancing Startup Costs and Corporate Overhead

Acadia expects startup costs in 2024 to be similar to those in 2023, ranging from around $20 million to $25 million for the full year. These projections coincide with the company's anticipation of a stable corporate cost structure and positive returns from prior investments in various sectors including IT and quality initiatives.

Interest in New Behavioral Health Initiatives

The company expressed a keen interest in participating in new behavioral pilot programs introduced by CMMI, focusing on integrating behavioral health with primary care under a value-based care framework. Acadia is actively monitoring additional program details from CMS and is poised to take part and leverage its capabilities once the programs' specifics are released.

Understanding Volume Growth: Demand and Staffing

An analyst inquiry highlighted the importance of volume growth to Acadia, which can be attributed to underlying demand increases and the industry's improved staffing conditions. Acadia has yet to provide a precise breakdown of these growth factors.

Earnings Call Transcript 2023-Q4

[Operator]

Good day, and welcome to the Acadia Healthcare Fourth Quarter and Full Year 2023 Earnings Conference Call. [Operator Instructions] Please note, today's event is being recorded.

I'd now like to turn the conference over to Gretchen Hommrich. Please go ahead.

[Gretchen Hommrich, executive]

Good morning, and welcome to Acadia's Fourth Quarter 2023 Conference Call. I'm Gretchen Hommrich, Vice President of Investor Relations for Acadia. Here with me today are Chris Hunter, Acadia's Chief Executive Officer; and Heather Dixon, our Chief Financial Officer.

I'll first provide you with our safe harbor before turning the call over to Chris. 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 2024 and beyond.

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.

At this time, I would like to turn the conference call over to our Chief Executive Officer, Chris Hunter, for opening remarks.

[Christopher Hunter, executive]

Thank you, Gretchen, and good morning, everyone. Thank you for being with us for Acadia's Fourth Quarter 2023 Conference Call.

Our strong fourth quarter capped off another outstanding year of solid financial and operational performance for Acadia. Our team has continued to execute on our strategy with positive results across our 4 lines of business. For the full year 2023, we reported robust annual revenue growth of 12.2%, adjusted EBITDA growth of 13.1% and adjusted EPS growth of 14.3% as compared to 2022, excluding income from the provider relief fund recognized in both periods.

Moving to our fourth quarter results. Our same facility revenue increased 10.3% compared with the fourth quarter of last year, with the increase driven by both rate improvements and patient day growth. We were also pleased to see consistent improvement in our labor trends throughout 2023.

Our wage inflation decreased from a peak of 8% in the fourth quarter of 2022 to below 5% in the fourth quarter of 2023, which is an improvement of over 300 basis points. In addition to improvements in the external labor market, our initiatives to drive higher employee engagement and more operational consistency in our facilities have enhanced our ability to attract and retain employees in a competitive market.

We have focused on more extensive clinical training for new staff and more intentional sharing of best practices while at the same time, investing in technology tools that support Acadia employees and clinicians across our 253 facilities. We've also had an emphasis on benefits and progressive career development opportunities for employees at all levels of our facilities. Efforts to improve retention and hiring are evident in our ability to support annual patient day growth of over 5% to ensure we provide high-quality patient care. Our team has done an outstanding job in meeting the higher patient demand and effectively managing operations.

During the fourth quarter, we continued to extend our market reach and add capacity through each one of our 5 defined growth pathways as follows: in support of our first pathway facility expansions, we added 98 beds during the fourth quarter for a total of 302 beds that additions to existing facilities in 2023. We are pleased that this was in line with our stated goal to add approximately 300 beds.

For our second pathway, we remained focused on developing wholly owned de novo facilities in underserved markets for behavioral health care services. During the fourth quarter, we opened the newly renovated 101-bed adult hospital, Montrose Behavioral Health Hospital in Chicago, Illinois. We have also completed construction on our 80-bed inpatient hospital, Coachella Valley Behavioral Health, located in Indio, California, which we expect to open later this year.

Our CTC service line offers comprehensive care for patients who are affected by opioid use disorder or OUD. We opened 2 new CTC locations in the fourth quarter, bringing our total to 6 CTC opened in 2023, in line with our goal for the year, and we remain focused on accelerating our CTC expansion by opening up to 14 CTCs in 2024.

The opioid epidemic continues to intensify with approximately 9 million Americans misusing opioids in the past year in new, more potent drugs continuing to emerge. In fact, some experts believe that we have now entered the fourth wave of the opioid epidemic as drug users have now evolved from prescription drugs in the first wave to heroin and then to fentanyl in the second and third waves and now to polysubstances that include fentanyl mixed with substances such as cocaine and methamphetamine.

According to a recent report, nearly 93% of fentanyl positive urine samples contained additional substances. Methamphetamine, a highly addictive drug was found in 60% of fentanyl positive tests last year, which is an 875% increase since 2015. As we continue to expand this important area of our business, we remain focused on driving strong clinical outcomes, improving access and delivering an exceptional patient experience spanning our traditional opioid treatment programs or OTPs to mobile vans and telehealth solutions.

But regardless of how patients come to Acadia for OUD treatment, quality is always a top priority and we were proud to have recently received a quality score of over 99% across 13 measures by the Commission on Accreditation of Rehabilitation Facilities or CARF.

For our third growth pathway, we are working to expand our reach through our joint ventures. Notably, Acadia is considered an attractive partner of choice for establishing relationships with premier health systems across the country. As the leading pure-play behavioral health provider, we bring the clinical expertise and experience and a proven ability to expand behavioral health care in more communities. Today, Acadia has 21 joint venture partnerships for 22 hospitals with 11 hospitals already in operation and 11 additional hospitals expected to open over the next few years.

In early January 2024, Acadia announced a joint venture partnership with Ascension Seton, one of the nation's leading integrated health care systems. The joint venture will focus on expanding Acadia's current operations across Creek Hospital in Austin, Texas, by constructing a 106-bed expansion of our existing acute behavioral hospital.

This is the company's second joint venture partnership with Ascension and follows the opening in 2020 of Ascension Saint Thomas, a behavioral health facility in Nashville. Our new partnership with Ascension is a testament to the strength of our relationship and reflects our solid track record of clinical, operational and financial outcomes with our joint venture partners.

The new partnership will expand access to behavioral health care in Austin and its surrounding communities. The joint venture hospital will be in close proximity to Ascension Seton hospitals and will be one of the training sites for students, residents and fellows from the Dell Medical School at the University of Texas at Austin.

Together with our JV partners, we have a shared commitment to providing access to high-quality compassionate behavioral health care and supporting the critical need in our local communities. Joint ventures will continue to play an important role in Acadia's future growth, and we remain excited about the opportunities to work with other leading providers in attractive geographies.

For our fourth pathway, we continue to look for acquisitions that support our growth objectives and meet the criteria of our capital allocation strategy. Last week, we closed on our previously announced acquisition of Turning Point Centers, a 76-bed specialty provider of substance use disorder and primary mental health treatment services that supports the Salt Lake City, Utah, metropolitan market. This acquisition completes the continuum of care in that market and represents the first market where Acadia has all 4 service lines present.

Our fifth and final growth pathway, extending the continuum of care is important to our clinical strategy. One of the key focus areas of this pathway is expanding our partial hospitalization programs or PHP in intensive outpatient programs, IOP, that can provide 4 to 6 hours of care per day. The majority of our acute and specialty patients can clinically benefit from these programs as they offer a step-down level of care after discharge from a high acuity stay, but also enable patients to step up again in acuity as their needs change. This not only improves clinical outcomes but also enhances the overall patient experience.

We added 13 outpatient programs during the fourth quarter, bringing Acadia's total to 39 outpatient programs added during calendar 2023. We are also working to increase the opportunity for our patients to utilize PHP, IOP services as only a portion of our clinically eligible patients stepped down to PHP, IOP care post discharge today.

As we stated at our Investor Day in December of 2022, we expected an acceleration of our bed additions in 2024, and we are pleased to deliver on that goal this year by adding approximately 1,200 beds. This will include approximately 400 bed additions to existing facilities, which is a step up from our historical average of 300 bed additions to existing facilities. We continued to make progress on our new facilities that will open in Florida, California, Michigan, Texas, Colorado, Arizona and Wisconsin in 2024.

Additionally, we plan to open up to 14 new CTC locations in 2024. As we continue to extend our market reach, patient safety and quality patient care remain our top priorities for delivering the best possible outcome for our patients. Quality is foundational to every aspect of the work we do at Acadia and drives operational effectiveness.

Our quality initiatives are focused on providing industry-leading care to the patients we serve daily, supporting our Acadia teammates through leadership development and thorough competency-based training, building proactive tools for identifying risks and opportunities and utilizing technology, including a quality data platform and predictive analytics to monitor our progress.

We have made significant technology investments in 2023 to further strengthen our core capabilities enable us to deliver stronger clinical outcomes. Our recent investments in electronic medical records have helped support our clinical staff with improved retention, employee satisfaction and workflow efficiencies. Our optimized EMR, which has been implemented using the insight from several of our medical nursing and clinical leaders ensures we translate the best of behavioral science into practice at every bed side.

In addition, we have now implemented patient monitoring technology in 53 facilities promoting higher touch care for fewer incidents and enhance patient safety. These investments in our core infrastructure, combined with the EMR and patient care technology, provide access to better data to measure outcomes and provide a framework for value-based care. The ability to measure and demonstrate these outcomes is important for collaborating with payers.

We are proud of our impressive growth and progress over the past year and look forward to the significant opportunities ahead for Acadia to extend our market reach to serve even more patients in 2024. Our strategic priorities will focus on accelerating facility growth, expanding services across the care continuum, strengthening our capabilities and strategically leveraging technology to enhance patient care and improve clinical outcomes, all with the focus on delivering the highest quality patient care.

We are well positioned to meet our objectives with our financial strength, scale and committed employees and clinicians who work hard every day to address the nation's critical need for safe, quality treatment for mental health and substance use issues.

At this time, I will now turn the call over to Heather to discuss our financial results for the quarter and 2024 guidance.

[Heather Dixon, executive]

Thanks, Chris, and good morning, everyone. Our fourth quarter financial performance reflects strong and consistent growth in our business in 2023. We achieved solid top line growth with $742.8 million in revenue for the quarter, up 10% over the fourth quarter of last year. Our same-facility revenue grew 10.3% compared with the fourth quarter of 2022, which included an increase in revenue per patient day of 7.1% and patient days growth of 2.9%.

The company recorded income related to the Provider Relief Fund established by the CARES Act of $2 million during the fourth quarter of 2023 and $5.2 million during the fourth quarter of 2022.

Excluding income from the PRF for both periods as well as the unfavorable adjustment to PLGL of $5.9 million or [ $0.05 ] per diluted share that was recorded in the fourth quarter of '22, adjusted EBITDA for the fourth quarter of '23 increased 11.9% over the prior year to $169.6 million, and adjusted income attributable to Acadia stockholders per diluted share was $0.85, up 13.3% from the prior year.

Consistent with previous periods, adjustment to income for the fourth quarter of 2023 include transaction, legal and other costs, loss on impairment, gain on sale of property and the related income tax effects of all items. Maintaining a strong financial position and disciplined capital allocation are top priorities for Acadia. As of December 31, 2023, we had $100.1 million in cash and cash equivalents and $516.5 million available under our $600 million revolving credit facility with a net leverage ratio of approximately 1.9x.

As previously announced on January 19, 2024, we entered into an amended credit agreement with our lenders to increase our Term Loan A by $350 million. Also in January '24, we paid $400 million to settle 3 lawsuits in New Mexico previously disclosed.

Moving on to our outlook for 2024. As noted in our press release, we established our 2024 guidance, which includes revenue in the range of $3.18 billion to $3.25 billion, adjusted EBITDA in the range of $730 million to $770 million, adjusted earnings per diluted share in the range of $3.40 to $3.70, and total bed additions, excluding acquisitions of approximately 1,200 beds.

We also established financial guidance for the first quarter of 2024 as follows: revenue in a range of $775 million to $785 million, adjusted EBITDA in a range of $170 million to $175 million, and adjusted earnings per diluted share in a range of $0.78 to $0.83.

This guidance reflects our expectation that same-facility revenue growth will be driven by mid-single-digit growth for both revenue per day and patient days for the full year. Please note that our guidance includes onetime payments from a state of approximately $10 million or $0.09 per diluted share for the year, of which, approximately $7 million or $0.06 per diluted share was received in the first quarter of 2024.

Also, as a reminder, the company's guidance does not include the impact of any future acquisitions, divestitures, transaction, legal and other costs or nonrecurring legal settlements expense.

With that, operator, we are ready to open the call for questions.

[Operator]

[Operator Instructions]

Today's first question comes from Whit Mayo with Leerink Partners.

[Benjamin Mayo, analyst]

Heather, just on the guidance, can you maybe frame for us what you're assuming inside that for start-up losses? And then also on corporate overhead this year, I don't think you're going to be investing as much as last year? And then if you could share any more details on the $10 million state payment. I presume that's just a state supplemental DPP like payment or something?

[Heather Dixon, executive]

I'll go maybe in reverse order. The $10 million state payment, you're correct. That is a onetime that split over 2 payments, DPP payments. In terms of corporate costs, we have seen -- in 2023, we did see those costs increase from the prior year, but we've seen that stabilize in Q4 of 2023. And we are starting to see our selective investments pay off, for example, investments we've made in quality, IT, managed care, marketing, many areas. We're starting to see those benefits to the business as a whole, specifically in the positive labor trends that we just talked about and also our continued ability to meet that growing demand and deliver quality care.

Turning to 2024, we expect to continue to see operating leverage as we move throughout the year. And our expectation is that the corporate costs will stay relatively consistent and continue to moderate specifically as a percentage of revenue as we see sort of the continued leverage throughout the year.

In terms of start-up costs, we expect the start-up costs will run in a similar range to 2023, probably around $20 million to $25 million for the full year and around $5 million to $6 million per quarter. They're not significantly higher really because of the back ending of the opening of the bed. So you'll see that probably increase a little bit per quarter. But that's what we're expecting for start-up costs.

[Benjamin Mayo, analyst]

Great. And my second question, Chris, just CMMI is launching a new behavioral pilot focused on what appears to be the integration of behavioral with primary care with some value-based care to it. I know it's early, but just any preliminary thoughts on your desire to participate in this program. We're seeing a lot more of these 1115 waiver plans approved from states as well. So just curious if you have any thoughts on both of those?

[Christopher Hunter, executive]

Yes. Thanks, Whit. I mean I'd say to start, I mean, just overall, we're really glad to see the announcement. I mean we're tracking it closely. But I think we're still largely in waiting mode here for a number of the key areas of additional detail from CMS. So a number of those details that would include the care model, the funding model, geographic participation, et cetera.

But overall, just the key details of the program are yet to be released. And we're eagerly awaiting those specifics. It is something that we would like to participate in, and we think that we have some really compelling capabilities and just eagerly, we'll continue to track and await those ongoing details that are to come.

[Operator]

And our next question today comes from A.J. Rice, UBS.

[Albert Rice, analyst]

Obviously, volumes have been an important part of the story. I guess there's 2 ways that you can be seeing volume growth, one from just continued growth in demand -- underlying demand, but also I know the industry has faced some constraints on staffing, and that seems to be easy now. I wonder if you could just give us a little flavor for what true underlying demand is trending? And how much some of the growth is happening just because you're getting more access to staffing to be able to take patients?

[Heather Dixon, executive]

So I would say you're right, A.J., there's a mix of both. We're seeing the demand for our services continue to be very strong. That's certainly not slowing down. We're also benefiting from capacity additions that we've made over the last couple of years. So we have the ability to meet the demand, whether it's through capacity additions or fully owned de novos or JVs.

And then we're starting to see our ability to optimize how we accept what's in coming and really make sure that we have patients accessing the facilities in the right way. You're right. We're also seeing improvement in the labor trends. That's certainly contributing to our ability to serve the patients. We're seeing that all of the investments that we've made and our ability to really begin to see stabilization and labor contribute to our ability to serve those beds.

[Christopher Hunter, executive]

And A.J., this is Chris. I just add a couple of quick things on that. I just think overall, some of the recruiting practices that we put in place have also helped us to meet this volume that we're continuing to see. And now we expect that to remain the case throughout '24. Just a few initiatives that I might point out that I think are helping us attract talent in, but also retain talent. I mean, first of all, these investments that we continue to make in technology to improve patient care and employee safety have been extremely helpful as we've done employee engagement surveys as well.

I think the intentional onboarding and training for our clinical staff has also helped us significantly to that front, we've seen some real variation historically.

And then I just think relentless focus on employee engagement in every facility, tracking it and measuring it and holding our operators accountable has also led to some real improvements on that front that have enabled us to meet the demand that you're referencing. So...

[Albert Rice, analyst]

No, that's helpful. And maybe just a follow-on to that is I know you're commenting on the strength and the rate updates and so forth. I think in the 10-K, you typically provide some payer mix data, has that been across the board? And is it resulting in any shift? The growth you're seeing does it tend to be more Medicaid, commercial, even Medicare? Can you comment on any trend in payer mix you're seeing?

[Heather Dixon, executive]

Yes, sure. A.J., I can give you a quick update on the payer mix. What you will see, whenever you see the 10-K, you're right, you'll see it this afternoon. You'll see a slight uptick in Medicaid as a mix percentage, it went from 54.3% to 56.8% as part of the mix. There's a couple of things I would say, driving that part of it is volume growth, where we've opened new facilities or new beds at expanded facilities. There is certainly more bed additions related to Medicaid, and that's driving some of the increase in the payer mix.

And then we just continue to have strong demand there as we build referral resources and really talk about the relationships that we have there to make sure we can meet the demand. We continue to have really good support from our Medicaid payers historically. And on average, I would say our Medicaid rates have performed a little bit better than what we've seen in the historical trends, and that's certainly a part of the growth.

And then we have some incremental funding that comes through from the Medicaid facilities as they see sort of the need to really bolster the behavioral programs that they have. Medicare, we saw a little bit more normalized seasonality. Typically, that sort of declined a little bit in Q4, and that's kind of what's leading to the increase or part of it in Medicaid. And then certainly, our commercial business book is part of the seasonal decline from a specialty perspective in Q4.

[Operator]

And our next question today comes from Brian Tanquilut with Jefferies.

[Brian Tanquilut, analyst]

Chris, maybe as I think about your comments about how we're in Phase IV of the opioid epidemic, or what sort of investment do you need to make or should we expect you to make in order to take further advantage of, I should say, the opportunities emerging from the continuation of this opioid crisis?

[Christopher Hunter, executive]

Yes. Thanks for the question, Brian. I mean, I think we've continued to invest, not only in pulling together a really strong team for our CTC business, but also just optimizing the facilities that we have. I think we've done an excellent job, and our team has done an excellent job this past year of significantly reducing the variations that we've seen in wait times as an example. We've made investments in advance of redetermination to make sure that we were ready.

We had kiosks in place at each of these facilities that continue to be very beneficial for patients when they check in. They want to get in and out of our CTC clinics inside of 5 minutes. And the technology that we put in place with these kiosks enable them to do that. So I think that's been very beneficial as well.

But I think overall, our ability to coordinate across the company in advance of redetermining is one of the reasons that we've been able to navigate through that, particularly well this past year. And there are investments that we will make that I think are modest with respect to just ensuring that we have the right team, particularly to be able to handle many of these RFPs that we anticipate given the magnitude of the $50-plus million in opioid settlement dollars. So that's one area that I would call out.

There are also some things that we've considered from a technology standpoint, dispensing units for dispensing methadone, which is obviously DEA regulated and very precise dosing is critical. And so we've looked at some technology there as well. But none of these are significant investments that I would call out, and I would just call it continued optimization of the really strong operational job that this team has continued to deliver.

[Brian Tanquilut, analyst]

That makes a lot of sense. And then maybe as I think about the fact that you're adding 1,200 beds this year, and I think you've got another 10,000 -- 1,000 or so next year. And then the Austin announcement, could we expect an uptick in sort of patient day growth going forward?

[Heather Dixon, executive]

I'll take that one. The patient day growth we've seen has been strong for the last quarter. We also are thinking about how it's going to trend for the fourth -- sorry, for the 4 quarters for next year. For '23, we saw an uptick for the full year to 5 -- just over 5%, 5.1%. And that's up from what we had seen in the previous years that we're sort of hovering around the 3% to 4% range, plus or minus.

We do expect to see a continuation at that higher level for the patient days growth for the full year for 2024 in the mid-single digits. So maybe a direct answer to your question is yes, we do expect to see that sort of continue with that higher range, but pretty consistent with where we came in.

[Christopher Hunter, executive]

Yes. And one other thing I would just add, Brian, is that when we did the Investor Day, one of our goals was to lay out the significant ramp in bed growth that we anticipated from 570 beds in 2022 to 670 in 2023 and then really stepping up to what we had guided as 1,150 both this year and next year. And so we continue to feel very confident in our ability to deliver on that.

Obviously, we have -- I said in my opening remarks, a number of JV projects that we expect to come online this year, 3 in particular, the Ascension Seton facility in Austin, which is our second with Ascension. Henry Ford in Detroit, which is a particularly large facility, 192 beds there. And then we'll be opening a facility just outside of Denver with Intermountain, a 144-bed facility there later this year as well.

And then there's a number of de novos that we have very strong visibility into from one that we're getting ready to open in Tampa, the Agave Ridge facility in Mesa, and then there's another facility in Madison, Wisconsin, with over 100 beds that we'll open later this year as well.

We also have really strong visibility into our bed additions. And then our CTC de novos as well that I mentioned will ramp from 6 to 14 incremental this year as well. So all that in totality just continues to give us strong visibility into what we had previously laid out of 1,150, and we've guided to roughly 1,200 beds that we'll bring online this year.

[Operator]

And our next question comes from Kevin Fischbeck with Bank of America.

[Kevin Fischbeck, analyst]

It sounds like you're making a lot of progress on labor. I guess, can you just tell us what labor expense growth you're expecting in the guidance for 2024?

[Heather Dixon, executive]

Yes, sure. No problem. So yes, we are pleased. We have seen some progress. If you think about base wage inflation, as we mentioned in sort of the first part of the call, we did see the continued decline, and we saw an improvement down below 5% base wage inflation for Q4 '23. We would expect for that managed level of wage inflation to continue during 2024.

We're really pleased with the investments we've made. We still have some pockets of challenges, but we've made investments in specific geographies, as you know, over the past year, and we've focused on the employee engagement initiatives that Chris has talked about.

So we expect that, that base wage inflation will reflect that more normalized rate, and we'll continue to see the trends that we saw as we exited 2023. Just as a reminder, Q1, we had sort of -- or Q4 last year, we had a high watermark, and we've come down over 300 basis points to just below 5%.

[Kevin Fischbeck, analyst]

Okay. So this is kind of where you think the run rate is there's not like a step down from here to 3% or 4% in the near term?

[Heather Dixon, executive]

I wouldn't say in the near term that we would be expecting that. We'll see a little bit of just a normal quarterly cadence as we have merit increases, and we have some of the payroll tax resets that come in Q1. But apart from that, I would think this would be sort of the new normal rate for 2024.

[Kevin Fischbeck, analyst]

And then it sounds like the Medicaid volume was relatively strong in Q4, but I just want to make sure any disruption at all from redeterminations?

[Christopher Hunter, executive]

Kevin, this is Chris. I'll take that. I mean, overall, I would say no. During the fourth quarter, we just continued to be pleased in the continuation of the same trends that we were seeing in the third quarter and really throughout the year. So we just don't see a significant impact on either patient volume or patient mix going forward.

I think the impact continues to be very consistent and manageable. I think we're -- we ended the year and said that we estimated that about 70% of our patients had completed redeterminations. And we, I think, continue to anticipate the process will run its course, and we'll largely complete our patient population by midway through the year by the end of the second quarter.

And I just think that the experience that we're seeing is that our ability to secure alternate forms of coverage for our patients remains really strong. I mean, the vast majority of those patients that have lost coverage are resolving favorably within 30 days of a coverage notification, which is really consistent with what we saw in the third quarter. So just overall, we continue to be cautiously optimistic and think we're just going to continue to see a continuation of the trends from Q3.

[Operator]

And our next question comes from Scott Fidel with Stephens.

[Scott Fidel, analyst]

Just wanted to drill in a bit more on the rate increases that you've talked about in the mid-single digits. And just interested in terms of between the commercial and the Medicaid books. Would you say that both are generally trending in that mid-single-digit range or is there any variance? And then on the Medicaid side, I'm curious around what you're budgeting or assuming for FY '25 Medicaid rates as the cycle starts to kick in, in the back half of the year?

[Heather Dixon, executive]

Let me take the first half of that. So in terms of the rate, what I would say is across the different payers and markets, of course, we have variation. It just depends on what the market is and sort of what the bed need is in those markets and a variety of factors. What we're expecting for the year is that mid-single-digit growth. And that, I would say, you always have some above, some below, but it's pretty consistent across the business lines, and it's pretty consistent across the payer lines. So nothing that I would think that we need to point out and sort of call out as a significant deviation from that. It's relatively consistent.

As we think about the full year and specifically to your question for the back half, as usual, we don't have a lot of visibility into the second half of the year. We do have visibility into the first half and the strong rate growth that we're projecting, which is the mid-single-digit level. We have a significant portion of our contracts that are renewed in the second half of the year, and as we have seen those come through and sort of the conversations that we're having, we feel really good about the visibility we have for the first half of the year.

But we'll continue to watch and continue to have those conversations with payers and see how those go for the second half of the year before I'm able to really give you any specific information about, say, Medicaid or any other payers for the second half of the year.

[Scott Fidel, analyst]

Okay. Got it. And then just on my follow-up question. Just interested at from this current vantage point when thinking about the quarterly cadence of both EBITDA and operating cash flows, if there's any sort of unique items relative to 2024 that you'd want to call out? Or do you think that it's going to be largely a sort of normal seasonality to EBITDA and cash flows this year?

[Heather Dixon, executive]

Yes. I mean I think the quarterly cadence will be relatively consistent with what we normally see from year-to-year. Obviously, calling out that a couple of years ago, we had some abnormalities. We do think Q1 will have the normal seasonality as we sort of begin the ramp from the holiday period from 2023, probably a little bit slower growth in volume from the first quarter as part of the normal cadence.

And then you'll see, as I mentioned, that Q1 impact as we reset sort of payroll taxes at the beginning of the year from a cost perspective.

Q2 and Q3 usually look pretty similar. And then Q4, as you know, has a little bit of normal seasonality that comes through relating to the holidays and sort of the inpatient days. So that's what I would expect. I think Q4, probably we have that impact of normal seasonality, Q1 normal seasonality and then Q2 and Q3 look pretty similar.

[Operator]

And our next question comes from Sarah James at Cantor Fitzgerald.

[Sarah James, analyst]

I was hoping we could dive a little bit deeper into the technology advancements you're making. So when you talk about clinical efficiency and remote monitoring. How do you think about that changing the daily workflow or the efficiency of your clinical workers? Can they see more patients? Or how do you think about it? And then when you say remote monitoring, what type of devices are you talking about? Are you talking about like tablet and video camera-based remote nurses? Or are you talking more like RPM devices?

[Christopher Hunter, executive]

Sarah, this is Chris. I'll take that. For the remote monitoring, we're effectively talking about not video but being able to track monitoring of the patients that are generally wearing a bracelet and we have a tablet where one of our staff is able to check on them at the appropriate time. As you know, for those that are danger to themselves or others, particularly our acute patients, we may have to do bed checks from a 5-minute duration to a 15-minute duration, and this really enables us to monitor that and to follow through and execute on those requirements. So that's been incredibly helpful as we've rolled that out to 53 facilities and as we also continue to roll out or EMR.

We continue to see just really strong overall outcomes across the board. I would start with quality. We've seen really strong improvements in a number of just very important metrics, the metabolic screening, discharge planning, national quality metrics that will continue to be really important to payers going forward. And I think we continue to perform well ahead of the benchmark on restraint and seclusion, national quality measures as well, which is really important as these events are where both staff and patient injuries most frequently occur.

So we're clearly seeing benefits just from a patient safety and compliance standpoint as well. We've seen upticks, as I said earlier, on employee satisfaction because clearly, clinicians in this day and age are trained on an EMR. They're not trained in paper. And so that is very dissatisfying when they come into our industry broadly, and there has not been historically the level of investment, as you know, relative to the Med-Surg facilities that we see in behavioral health across the board, not just Acadia. So I think our ability to make that happen has been very effective.

And then I think just overall, the efficiency to your question, everything from utilization review to improve documentation quality from standardized charts, reducing paper storage cost, all of these things together all tie in to enabling us to serve our patients in a more quality-oriented and efficient manner and also keep our patients safe and our staff safe.

[Operator]

And our next question comes from Peter Chickering with Deutsche Bank.

[Pito Chickering, analyst]

Some quick ones here. What percent of revenues were CTC in the quarter, and if I think about growth of around 20%, is that in the ballpark? And also can you break out the growth from patients versus pricing that would be amazing?

[Heather Dixon, executive]

Yes. So what you'll see -- Peter, it's Heather. You'll see later this afternoon sort of the revenue growth by business line, and CTC was just right at 20% -- just right under 20%. So pretty consistent with what we've seen in the previous quarters. For Q4, is that the breakout you're asking for, for Q4 volume versus rates? Or were you asking for -- or asking for 2024?

[Pito Chickering, analyst]

Either would be lovely.

[Heather Dixon, executive]

Okay. Great. So for 2023 Q4, we saw the growth in patient days of 2.9% on a same-facility basis. And then the revenue per patient day was 7.1% for 2023, Q4. And then for the full year 2024, we're expecting mid-single digits for both.

[Pito Chickering, analyst]

Got it. And then so looking out at the fourth quarter with CTC at 20% implies the rest of the business is growing around 9%. So over sort of 2x the growth coming from CTC. I guess any color on what percent of your 12% EBITDA growth in the quarter came from CTC?

[Heather Dixon, executive]

No. I would just say that we continue to see EBITDA margins across those different business lines, relatively consistent. As you look at those from quarter-to-quarter and then across the business lines -- the only thing I would point out is our closures during 2023, we had a few closures and of those, there were 3 that were in the specialty business. So you'll see a little bit of differentiation there as you look at the revenue contribution by business line. But apart from that, pretty consistent.

[Operator]

This concludes today's question-and-answer session. I would like to turn the conference back over to Chris Hunter for closing remarks.

[Christopher Hunter, executive]

Thank you. Before we end the call, I just want to again thank our committed facility leaders, our clinicians and our over 23,000 dedicated employees across the country who have continued to just work tirelessly to meet the needs of patients in a safe and effective manner. We have a really strong foundation and a proven strategy for driving growth in delivering greater value to both the patients we serve and our shareholders.

Thank you all for being with us this morning, and thank you for your interest in Acadia. If you have any additional questions today, please don't hesitate to contact us directly. Have a great day.

[Operator]

Thank you. This concludes today's conference call. We thank you all for attending today's presentation. You may now disconnect your lines, and have a wonderful day.