Addus Homecare Corp
NASDAQ:ADUS
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Addus Homecare Corp
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Good day, and welcome to the Addus HomeCare First Quarter 2024 Earnings Conference Call. [Operator Instructions] Please note, this event is being recorded. I would now like to turn the conference over to Dru Anderson. Please go ahead.
Thank you. Good morning, and welcome to the Addus HomeCare Corporation First Quarter 2024 Earnings Conference Call. Today's call is being recorded.
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 by going to the company's website and reviewing yesterday's news release.
This conference call may also contain forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995, including statements, among others, regarding Addus' expected quarterly and annual financial performance for 2024 or 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, discussions of forecasts, estimates, targets, plans, beliefs, expectations and the like are intended to identify forward-looking statements. You are hereby cautioned that these statements may be affected by important factors, among others, set forth in Addus' filings with the Securities and Exchange Commission and in its first quarter 2024 news release.
Consequently, actual operations and results may differ materially from the results discussed in the forward-looking statements. The company undertakes no obligation to update any forward-looking statements, whether as a result of new information, future events or otherwise.
I would now like to turn the call over to the company's Chairman and Chief Executive Officer, Mr. Dirk Allison. Please go ahead, sir.
Thank you, Dru. Good morning, and welcome to our 2024 first quarter earnings call. With me today are Brian Poff, our Chief Financial Officer; and Brad Bickham, our President and Chief Operating Officer. As we do on each of our quarterly calls, I will begin with a few overall comments, and then Brian will discuss the first quarter results in more detail. Following our comments, the 3 of us would be happy to respond to any questions.
Yesterday, we announced our results for the first quarter of 2024. These results highlight the continued strong financial performance by Addus. This performance is made possible by the hard work and dedication of all our employees as they continue to provide quality care to our clients and patients by helping to fulfill our mission of taking care of individuals in their homes. As I have said many times in the past, I'm very thankful for all the employees -- for all that the employees do for our company.
As we announced yesterday, our total revenue for the first quarter of 2024 was $280.7 million, an increase of 11.6% as compared to $251.6 million for the first quarter of 2023. This revenue growth resulted in adjusted earnings per share of $1.21 as compared to adjusted earnings per share for the first quarter of 2023 of $0.97, an increase of 24.7%.
Our adjusted EBITDA of $32.4 million was an increase of 24.6% over the first quarter of 2023. During the first quarter 2024, we continued to experience strong cash flows, allowing us to reduce our debt balance to $101.4 million. At quarter end, our cash balance was approximately $77 million, which, together with our availability under our existing credit facility, continue to give us the financial flexibility to be opportunistic as we see potential acquisitions come to market.
It remains our primary focus to use our financial capacity to acquire strategic operations that align with our overall growth strategy of adding clinical services where we have strong personal care presence, enhancing our existing personal care market and adding new personal care markets where we can enter at scale. We also believe this acquisition strategy will be -- will continue to strengthen our ability to participate in value-based contracts with our payers and to adapt to potential reimbursement changes.
I want to provide some thoughts related to the final Medicaid access rule that was issued on April 22. As we anticipated, the proposed 80% compensation requirement was retained in this rule despite an overwhelming number of comments submitted detailing the changes -- challenges this would present.
Of course, we and other providers are disappointed with the results even though we support the overall policy aims of providing higher wages and increasing access to home and community-based services. However, several significant positive changes were made in the final rule, and I would like to touch on a few of these.
First, the implementation period was extended by 50% from 4 years to 6 years. Realistically, we believe this substantially increases the likelihood that the rule will not be implemented in its current form or possibly at all for a variety of reasons, including as a result of legal or congressional action or potential administrative changes in either of the next 2 presidential election cycles. As important, this extended implementation time frame gives states and providers a better opportunity to plan and adjust to the specific requirements of any rule that may ultimately be implemented.
Second, a number of technical adjustments were made between the original draft and final rule, which both clarify and improve the definition of allowable costs for providers like Addus. For example, certain costs such as training, mileage and PPE will be deducted from total payments before calculating compliance with the 80% requirement.
Similarly, refunded or recouped payments will be excluded. Also, the categories of items [ constituent ] compensation have been clarified to include PTO, retirement, insurance, including workman's compensation and tuition payments not previously addressed. The rule also clarified and expanded certain tasks that now count as direct care work and expands the definition of direct care workers to add clinical supervisors.
All of these changes combined to lessen the potential impact of the rule on our margins. While these items were addressed in the final rule, there were still not a complete specific set of definitions, although additional commentary was included in an effort to protect against the possibility of setting a definition that could be construed as too narrow. We believe this gives states a certain level of flexibility in working with providers in deciding on other potential costs that should be considered in the calculation.
Stepping back to the bigger picture, there are other points worth making on the rule and its impact. We continue to believe the rule disproportionately impacts small providers and encourages scale, which will lead to further consolidation opportunities.
The rule allows states to develop separate minimum compliance levels for small providers and to provide hardship exemptions, but 2 important factors should be noted. First, the exemption and the hardship exception both require states to create additional reporting requirements, and these requirements can only be weighed by CMS at its option to the extent applicable to less than 10% of provider.
Even more crucially, the rule requires states to develop a plan subject to CMS approval to reduce in a reasonable period of time the number of providers to qualify for these exemptions or exceptions. At best, we believe these are temporary Band-Aids, not long-term solutions for small providers.
Second, and I want to emphasize this point, small providers relying on these provisions will be able to pay less to workers, but they will be at a competitive disadvantage for labor with large providers like Addus, who will likely be required to pay a higher rate. We believe these exceptions will provide us more access to labor, which, as we note regularly, is the primary limiting factor on revenue growth.
So I'll repeat what I said last quarter. We believe that personal care providers must have scale in each state where they operate to be successful under the rule as finalized. This will not only allow the larger providers to spread their costs over a bigger revenue base but also will provide more opportunity for meaningful advocacy with states in which they operate while also promoting a favorable hiring and retention dynamic.
Before I leave this topic, I also want to note that we expect both Congress and individual states to review their options and take actions they believe are appropriate in reaction to the rule. Individual members of Congress already have issued calls to withdraw the rule or have introduced legislation to block finalization of certain aspects of the rule, and more may follow.
Some states may institute litigation to block the rule, the outcome of which is unknown. States may also look at opportunities to increase funding in an effort to meet the aims of the rule, causing less impact to providers and clients.
So in summary, 6 years is a very long time. We expect many more curves in the road before then, but we are confident in our strategic approach to both manage and thrive in this dynamic landscape. We are currently in the process of looking at personal care opportunities that would give us a larger presence in our current state. We are also looking for opportunities where we can enter new states in a material way.
Personal care is a valuable service to our elderly and disabled population. And we are optimistic that states will evolve their programs to remain viable regardless of the rule.
During the first quarter, we continued to experience good results related to our ability to hire caregivers, especially in our personal care segment. During the first quarter of 2024, our personal care hiring was equal to what we saw in the first quarter of last year at 84 hires per business day. Sequentially, our hires per day were up 5% over the fourth quarter of last year despite some weather difficulties in January. In addition to our strong hiring numbers, we continue to see consistent momentum in the starts per business day over the past few quarters.
As for our clinical segments, hiring has continued to improve from what we experienced in the early part of 2023. As we have over the past couple of years, we continue to utilize the funding we received from the American Rescue Plan Act or ARPA. To date, we have received approximately $38 million, of which we have over $13 million remaining to be utilized.
We continue receiving these funds in the first quarter of this year. And as we have previously shared, these funds have been helpful with our caregiver recruitment and retention efforts to support the delivery of personal care services.
In addition to utilizing the ARPA funds for direct recruitment and retention of caregivers, we continue to utilize the funds to improve our caregivers' experience through the implementation of enhanced caregiver training and continued development of a caregiver application that we believe will improve our retention and overall service delivery.
In our personal care segment, our services continue to receive favorable reimbursement support from many of the states in which we operate. Although some of the federal financial support to states have been reduced, we feel confident that personal care services continue to show real value to state Medicaid programs as well as our managed care partners through a reduction in overall cost of care.
As for our clinical segments, effective October 1, 2023, Medicare hospice reimbursement was increased by approximately 3.1%. On January 1 of this year, home health Medicare reimbursement was increased by approximately 0.8%. Although this year's home health rate increase was below what is required to cover ongoing operating cost increases, we believe that traditional Medicare home health reimbursement pressures are likely to moderate over the next few years.
Now let me discuss our same-store revenue growth for the first quarter of 2024. For our personal care segment, our same-store revenue growth was 9.3% when compared to the first quarter of 2023. During the first quarter of 2024, we saw personal care same-store hours per business day remain flat as compared to the same period in 2023 as we experienced difficult weather -- winter weather in a couple of our key markets early in the first quarter of this year.
We did see a sequential improvement in hours each month in the quarter as we moved past these early weather challenges. We continued to see our investments in hiring and scheduling optimization initiatives take hold and contribute to our hours growth.
Turning to our clinical operation. Our hospice same-store revenue increased 5.8% when compared to the first quarter in 2023. While our same-store ADC was down 0.9% when compared to the same quarter last year and flat sequentially, we did see a nice improvement in our same-store ADC during February and March. This ADC growth has continued into April.
As of the end of the first quarter of 2024, our hospice medium length of stay, exclusive of our JourneyCare and recently acquired Tennessee Quality Care operation, was 27 days as compared to 25 days for the fourth quarter of 2023. For comparison purposes, we have historically excluded our JourneyCare operation as it has a higher proportion of shorter length of stay patients due to our inpatient units in the Chicago area. We are encouraged by the steady sequential improvement in both ADC and admission volume in our hospice segment early this year and anticipate those favorable trends continuing in 2024.
Our home health segment same-store volume decreased 3.1% over the same quarter in 2023 but did increase 1.7% on a sequential basis. As most home health providers have experienced, we continue to be affected by the movement of Medicare beneficiaries from Medicare fee-for-service to Medicare Advantage, but we feel we may be seeing a leveling off of this shift to the market we currently serve.
We are continuing to work with our Medicare Advantage payers to obtain higher per visit rate as we work in parallel to transition to episodic or case rate. We are also continuing to focus on process improvements to increase our efficiency around staffing, referral conversion rates and collections.
While home health is our smallest segment and only 5% of our revenue, we feel it complements both our personal care services, particularly where we participate in value-based contracting models and our hospice services by allowing us to provide the full continuum of home-based clinical care.
Acquisitions will continue to be an important part of our growth strategy at Addus. Even with the various challenges we have seen, we are committed to using our capital to make sure we meet the strategic goals we have publicly discussed.
With the Medicaid access rule finalized, we are focused on opportunities that will help us obtain the needed scale in our current personal care markets to operate more efficiently. We are also open to entering select new states with personal care services. If we can do so through transactions, which will give us the scale, we feel it's important to be successful under the new Medicaid access rule.
As for our clinical segment, we are focused on home health opportunities which operate in certain of our personal care states, where we have the opportunity to continue our growth in value-based care and to complement our existing hospice operation. As far as our value-based care efforts, I noted last quarter that we continue to gather data, which demonstrates material reductions in both emergency room visits as well as the percentage of patients readmitted to the hospital at various post-discharge interval.
We continue to believe our success is due to our ability to provide both nonclinical personal care services, to identify changes in condition and clinical resources as needed for specific skilled patient care interventions. We are now utilizing this information as part of our conversation with various Medicare Advantage and commercial payers to demonstrate how Addus can be an integral part of providing quality cost-effective care to plan members that can reduce the overall medical loss ratio by simultaneously improving overall quality of care.
During the first quarter of 2024, we began to use our new value-based care management system. We are excited about this technology as it will allow us to increase both the scale and efficiency of our value-based program, which we believe is important to further develop these types of relationships with our large payers.
Before I close my remarks, I want to once again say how proud I am of our team for the care they are providing to our elderly and disabled consumers and patients. There is no question that the majority of clients and patients want to receive care at home, which remains one of the safest and most cost-effective places to receive this care.
We believe the heightened awareness of the value of home-based care is favorable for our industry and will continue to be a growth opportunity for our company. We understand and appreciate that our operations and growth are dependent on both our dedicated caregivers and the other employees who work so incredibly hard providing outstanding care and support to our clients, patients and their families.
With that, let me turn the call over to Brian.
Thank you, Dirk, and good morning, everyone. Addus had a strong start to 2024, continuing our momentum with an impressive financial and operating performance for the first quarter.
Our results included solid year-over-year organic growth of 9.3% in personal care services, well above our long-term expected range of 3% to 5% but in line with our expectations. This growth reflects steady volumes as well as continued favorable rate support for personal care services in some of our larger markets.
We were pleased to see consistent positive year-over-year trends in our hospice business in the first quarter, inclusive of our Tennessee Quality Care acquisition. Our hospice same-store revenue growth of 5.8% was our third consecutive quarter of sequential increase and the highest percentage increase we have seen since prior to the COVID pandemic. We continue to see favorable admission trends as we have experienced 3 consecutive quarters of sequential same-store admission growth.
Same-store revenue for our home health services, which was 6% of our business, was down 15.1% from the same period a year ago as we continue to intentionally limit admissions from payers with less favorable reimbursement rates. We remain focused on maintaining a consistent margin profile in our home health business as it complements our personal care and hospice services.
Acquisitions remain an important part of our growth strategy with our primary focus on markets where we can leverage our strong personal care presence and add clinical services or enhance and expand our personal care services in strategic geographies. With our size and scale and the support of a strong balance sheet, we are well positioned to execute our strategy. And we are optimistic we will see attractive acquisition opportunities in 2024.
As Dirk noted, total net service revenues for the first quarter were $280.7 million. The revenue breakdown is as follows. Personal care revenues were $208 million or 74.1% of revenue. Hospice care revenues were $55.9 million or 19.9% of revenue. Home health revenues were $16.9 million or 6% of revenue.
Our first quarter results include the operations of our most recent acquisition, Tennessee Quality Care, a provider of home health, hospice and private duty nursing services, which we acquired on August 1, 2023.
Other financial results for the first quarter of 2024 include the following. Our gross margin percentage was 31.4% compared with 31.2% for the first quarter of 2023. As expected, gross margin was affected in the first quarter by our annual merit increases and the annual reset of payroll taxes as well as compression from certain collective bargaining negotiations. In the absence of any additional mix changes from M&A, we anticipate our gross margin percentage to remain materially stable over the next few quarters and consistent with our historical annual pattern.
G&A expense was 21.8% of revenue compared with 22.4% of revenue for the first quarter a year ago and a decline sequentially from 22% in the fourth quarter of 2023. Adjusted G&A expense for the first quarter of 2024 was 19.9%, a decrease from 20.8% in the comparable prior year quarter and down sequentially from 20.6% in the fourth quarter of 2023, primarily as a result of lower legal expenses and the normal timing of certain accruals.
The company's adjusted EBITDA increased 24.6% to $32.4 million compared with $26 million a year ago. Adjusted EBITDA margin was 11.6% compared with 10.4% for the first quarter of 2023, reflecting continued leverage on our increasing revenues. With a solid start to 2024, we continue to expect our adjusted EBITDA margin percentage for the full year to remain above 11%, consistent with 2023.
Adjusted net income per diluted share was $1.21 compared with $0.97 for the first quarter of 2023. The adjusted per share results for the first quarter of 2024 exclude the following: acquisition expenses of $0.12 and noncash stock-based compensation expense of $0.12.
The adjusted per share results for the first quarter of 2023 exclude the following: acquisition expenses of $0.06 and noncash stock-based compensation expense of $0.13. Our tax rate for the first quarter of 2024 was 25.7%, in line with our expectations. For calendar 2024, we continue to anticipate our tax rate will be in the mid-20% range.
DSOs were 34.6 days at the end of the first quarter of 2024 compared with 39.1 days at the end of the fourth quarter of 2023, primarily as a result of continued consistent cash collection from the majority of our payers as well as some ordinary course timing differences from certain payers. Our DSOs for the Illinois Department of Aging for the first quarter were 30.2 days compared with 49.5 days at the end of the fourth quarter of 2023.
Our net cash flow from operations continues to be very strong, coming in at $38.7 million for the first quarter. We received approximately $10.2 million in ARPA funding during the quarter, partially offset by $2.4 million in ARPA funds utilized. Net of the ARPA activity, our cash flow from operations in the first quarter would have been $30.9 million.
While we continue to see strong cash flows, we benefited from approximately $8.4 million in net working capital changes in the first quarter, which was primarily related to favorable timing on receivable payments. We would anticipate these timing differences to normalize over the course of the full year and continue to expect our cash flow to represent approximately 80% of unadjusted EBITDA.
As of March 31, 2024, the company had cash of $76.7 million with capacity and availability under our revolver of $486.9 million and $377.5 million, respectively. With our strong cash flow, we have continued to pay down debt and reduced our revolver balance by an additional $25 million in the first quarter.
Importantly, we have the financial flexibility to continue to pursue our strategic growth initiatives, including acquisitions. As mentioned, we will continue to selectively pursue acquisitions in 2024 that are consistent with our goal of bolstering our personal care services and adding complementary clinical service. At the same time, we will continue to diligently manage our net leverage ratio, which is currently well under 1x net of cash on hand.
This concludes our prepared comments this morning, and we'd like to thank you for being with us. I'll now ask the operator to please open the line for your questions.
[Operator Instructions] The first question today comes from Brian Tanquilut with Jefferies.
I guess my first question for Dirk or Brian, as I think about your comments on acquisitions and obviously, the rule is out now, how are you thinking about the kinds of assets that you'd be interested in? Would you be focused more on the personal care side? Or is it still an interest in the home nursing side? And then maybe sizing, I hear it loud and clear you want scale and density, just how you're approaching the acquisition strategy here.
Yes, Brian. I think our focus remains largely on continuing to bolster our personal care services in markets that we currently operate in. I think with the 80-20 rule, the access rule, I guess, is a more formal term for it, [ it's ] out now. It's clear to us that size and scale is going to be important.
I think we always kind of had that approach generally anyway, but this further reinforces that in our mind. So I think acquisitions in personal care that continue to build scale in markets we operate in today are important.
We also would look at selective additional markets if we could enter at scale would also be, we think, good opportunities for us. And then where we can continue to add clinical services where we have strong personal care to help with some of the things we're doing on value-based is also still important to us. So I think those are kind of our focus areas, but I'll let Dirk add a little color if he'd like.
Yes. I think that's great. I think the real key with the Medicaid access rule that we've seen is we do believe, to emphasize what Brian said, we believe size is important. And so we'll be looking to add backfill in markets in which we currently operate. But at the same time, we're looking for new markets in states where we aren't today, again, with the qualification that we could enter with size.
Understand. And then maybe, Brian, just any comment or color you can share with us in terms of how we should be thinking about the sequential change in trajectory in earnings or revenues for Q2 and into Q3 as well?
Yes. I think from Dirk's comments, I think particularly in personal care and hospice, we had a little bit of probably volume softness early in the quarter. Hospice was coming off of the holiday season. A little bit of weather impacted our personal care services early, but we actually saw nice growth through the quarter and into April and into Q2. So I think we would expect that trajectory to continue.
So I think we feel good where we are coming out of the quarter on the volume side. And just thinking about it from a margin perspective. Obviously, we have a reset in Q1 traditionally with payroll taxes and our annual merit increases.
Keep in mind, most of those go into place March 1. So not a full quarter impact. A little bit will go into Q2 for the first full quarter there, but we also get at least a little relief on the payroll tax hike Q1 and into Q2.
So we would expect margins to remain relatively stable Q2 into Q3. And then Q4 is annually always the best margin quarter for us as we get our hospice rate increase with [ no kind ] of offsetting costs for those 3 months.
The next question comes from Scott Fidel with Stephens.
I had a couple of follow-up questions just on the 80-20 rule I wanted to ask you. The first would be if you've been able yet to come up with sort of what the overall adjustment would be that you think you can make on gross margin when considering the add-backs and some of these other exclusions in terms of how that would compare when thinking about, I guess, the sort of 80-20 rule adjusted gross margin for personal care compared to your GAAP margin in personal care.
Yes. I think, obviously, as we stated, the changes that came out in the final rule around some of the expenses and revenue definition were very positive, will be helpful as we go forward. We still -- let me make sure you understand this. We still believe that the 80-20 rule is difficult for smaller providers.
But for a company our size, we feel very confident, especially when you consider the fact that this is a 6-year implementation, that between market share growth, which we anticipate will occur in all of our markets due to this rule along with our ability to invest in technology and do some of the things we're looking at on the cost side, we believe we'll be able to handle any impact that the 80-20 would have on our margin over that period of time.
Okay. And then one other on the rule. As we've been doing some checks on this, we've been getting some feedback that would seem to suggest that revenues that are based on value-based care contracting may have different treatments in the rule and may -- could be sort of largely sort of not affected by the rule.
Dirk, just -- and Brian, just interested in sort of how you guys are ascertaining that piece in terms of the value-based care. And then also, if that's the case, whether there will be more opportunity you think to shift more of your revenues to value-based care contracts, whether it be with payers or even with sort of how the states are structuring their contracts.
Scott, this is Brad. That's our understanding as well that the value-based care revenue is excluded. I think there is certainly an opportunity, and it's something that we've been doing before the rule was implemented is working on those value-based arrangements, looking at being able to scale those.
From a payer appetite standpoint, there's a lot of appetite out there for these types of arrangements. So that is certainly an opportunity that we'll be looking at, not just because of the rules, but just because I think it just makes good business sense overall.
And also, Scott, to follow up what Brad said, it's one of the reasons we're looking in markets not only where we operate today, but potentially in new markets where there might be real opportunity to work with providers in a value-based care approach. So that's another part of our overall acquisition strategy.
Well, certainly it seems to validate some of the investments that you've been making on the BBC side in personal care. And Dirk, just on that sort of other part on -- thoughts on sort of the potential for states to start maybe moving over to sort of structuring these more as value-based or some level of risk sharing in them.
Obviously, in other business lines across both Medicare and Medicaid, we have a tremendous amount of that going on. So just curious if that will be a sort of a key area of focus for Addus in terms of, I guess, communicating some of that opportunity maybe -- and just modernizes the contracting anyway around personal care, too.
Yes. It's something we started 3 or 4 years ago. We really were on the front end of seeing the payers wanted to start looking at a different way of having these contracts, so some of the states were moving towards that direction.
So we made the investment. We talked about that this is the first full quarter with our new technology, our software system. One of the limiting factors we had before on our ability to grow value-based care contracting was the fact that a lot of it was still done manually, while we were looking for the system. Now that that's [ done ] we believe we will have additional opportunities to grow that business. And it will continue to be a focus of Addus, along with the other things that we're doing, but certainly, value-based care is one of the main reasons why we're trying to get size and coverage in a state.
Okay. And then just one quick follow-up just on that sort of size and scale point you're making. So currently, Addus is in 21 states for personal care. Obviously, you've got a few states like Illinois that drive a lot of the revenue. So you definitely have some of the smaller states as well.
And is there -- maybe give us update just on your thinking around are there some of those 21 states where you think you may need to exit because of the rule? And if you have a sort of estimate on, I guess, what the revenue contribution would be from those states that may no longer be sustainable under the new rules? And that's it for me.
Yes. I think the difficulty, Scott, in determining whether or not a state is viable today is we don't know over the next 6 years what's going to happen with the payment rate of that state, the various rules required. We do know that most states in which we operate -- and I'd say to all the states we operate, the program is very valuable to that -- to the state, to the Medicaid program.
So today, there are some smaller states we're in that we'll be looking at, and we'll be monitoring to see how they change. But I would say, as of to date, there's no state that we've identified that cannot be successful in this particular -- with this particular rule.
The next question comes from Andrew Mok with Barclays.
Just wanted to follow up on the 80-20 rule. First, despite some of the changes in the final rule that you're more constructive on, it still sounds like there's still a fair amount of uncertainty hanging over the industry and even the likelihood that this gets finalized in 6 years or so. So one, are you able to share with us a preliminary estimate of the unmitigated impact of the rule as it impacts your P&L today?
No, we can't because again, with so much still out there, we're still looking for clarification of definitions. We're talking to states about what they're going to do as it relates to the rule. It would be unfair to try to give a number because, again, with a 6-year time frame, there is so much that will change, not just with Addus but with the states themselves.
So what we're approaching it from is truly standing back, Andrew, and saying, with our size and coverage in our markets, we're going to be fine. And the way to be -- for us to work with this rule is to continue to do the things that we've been doing, grow our markets in those states, look at our technology and try to get more efficient with our cost basis.
And one thing that I think people are truly probably missing the fact is market share growth. As small providers are not able to work under this rule, and we believe strongly that is a problem as exists today, that as you bring margin from that market share move, you will mitigate the issue related to your margin with this rule.
Got it. Okay. And then it sounds like one of the big definitional swing factors of the rule is the clinical supervision. Do you have a sense for how much clinical supervision costs are sitting in your G&A line today that would potentially be reclassed to direct care for the purposes of the pass-through adjustment?
Well, I think the difficulty there is what's the definition of clinical. I think some of the folks in -- there's different thoughts in the industry as about what may qualify in that particular line. And so we don't know today. We don't have enough information from the rule to tell you exactly what that percentage would be.
We can tell you it will be positive. So I think that's certainly one of the nice changes in the rule is that clinical supervision salaries have got put into the definition, which will be helpful as we continue to mitigate any issues.
The next question comes from Jared Haase with William Blair.
I'll maybe ask one, just sticking with value-based care opportunities. And appreciate the comments around having the technology system in place to sort of help that scale. I was hoping -- are you able to kind of level set for us just today kind of what the penetration is within your book of business in terms of value-based contracts, either on a sort of percentage of revenue basis or maybe the number of partners that you have in a value-based contract? And then having the technology system in place, do you have a sense as to maybe how quickly that could scale over the next handful of years?
Yes. We've -- on the value base, as Dirk pointed out, this is the first quarter where we've had our new IT software in place that allows us to really start scaling this program. We currently have 7 value-based contracts in effect. And we certainly could add more.
There's not -- there certainly is not a lack of interest in doing it. And we're talking with several of those payers about actually expanding those programs. We cover currently a little over 6,000 clients that are in value-based arrangements.
Now from a revenue standpoint, it's still immaterial. But there is a -- certainly, I think this is an opportunity to grow. As I mentioned, we have several payers that we're currently in that are very pleased with how these arrangements are working and are looking for us to actually expand those significantly.
That's great. Appreciate that. And then maybe I'll just ask a follow-up on the home health segment. And it sounded like from the prepared remarks, there is some process improvements you guys are implementing, I think you mentioned around staffing and referral conversion rates. So would love to just hear a little bit about what some of those workflows look like from an improvement perspective.
And then also sticking with kind of the referral dynamic. As I take a step back and think about all the sort of structural pressures facing Medicare Advantage plans on their rates and MLRs and some of the issues that they're working through, have you guys noticed any changes just in terms of post-acute care referral trends with those plans? Are they getting a bit more restrictive in terms of prioritizing quality with the post-acute care providers that they're referring to, anything really changed on that front?
Yes. First, I'll start with the home health process improvement question. If you think about our home health operations, certainly our smallest segment is the one where we've done a handful of acquisitions, none of which I would necessarily characterize as kind of a platform acquisition.
And so when you think about kind of integrating and looking at process within that segment of our business, there's certainly a lot of opportunities to really get more consistency in how we do things. And so we're looking at -- one, looking at the centralizing intake, looking at centralizing scheduling. And when you say centralizing, it's really kind of focusing at these are your tasks. Whether you're in the office, in a central office or in an office out in the field, this is what you do to really kind of increase that -- the efficiency of that workflow.
And particularly on the intake side, we think there's certainly opportunities to accept more cases and improve those conversion rates. So looking forward to that project getting completed. I think we're looking at kind of Q3, Q4 to really get that wrapped up, but very optimistic on where we stand with home health.
And when you look at it on the referral process, we really haven't seen significant changes or any changes related to Medicare Advantage focusing on just a handful of providers, if you will. We still get a lot of referrals from payers on the Medicare Advantage side that we're not going to accept just because rates aren't there. We're going to prioritize where we have episodic rate.
The next question comes from Ryan Langston with Cowen.
Just following up maybe on Brian's earlier question in terms of kind of the scale you would need to get into a new market. I guess if you did move into a new geography, especially in the [ EDF ] side, how do we think about that in terms of necessary size, whether it be revenues or maybe comparable to maybe recent deals like TQC or other size parameters, just so we can get a sense on maybe the minimum scale that you believe you need to move into a new [ FI ].
Well, to go into a new market, we would really like to see either immediately or a clearly defined timeline to get to the top 1 or 2 market share providers in that particular state. We believe you need to be very large. We believe you need to have the ability to have a voice with the state.
So if you see us entering into any new states, I think you can assume -- and again, remember, states are different. So it's hard for me to give you -- us to give a revenue because what might be a #1 market share in one state certainly might not be in another. But in those various states that we're looking at, we would like to be #1 or #2 going into the market.
Got it. And then just one more for me, maybe more of a philosophical question. Obviously, in the New York state budget, there were some changes to the CDPAP program that's coming in the '25 budget. I know that it's kind of low single-digit operating income exposure, but it's still a pretty decent sized state, I think the third largest in terms of revenues.
I guess do those changes and kind of maybe some of the tone that the governor took, maybe does that change your longer-term strategy in the state going forward? Or is it kind of just steady state from here?
Well, realize that CDPAP's about 4% of our overall revenue. It's a very small part. I know you say that's material, but it's -- for us, it's very small. It's a very, very low single-digit margin if that from an EBITDA standpoint, and that's not even from a bottom line standpoint.
So for us, as we look at New York, it's -- they've tried changes before. I think 3 or 4 years ago, they were going to minimize the number of folks in CDPAP that never got implemented.
I think for them to go to one FI by the end of -- by the beginning of April of next year is going to be really a tough task. So for us, we're going to continue to operate and do the best we can in that market.
But just to understand it, it is one of the markets where it's very difficult for us. And it's not -- from a strategy standpoint, it's not a market that we can do the things we're trying to do, which is 3 levels of care and value-based care. So from that standpoint, it takes a backseat as far as acquisitions and other items and investments.
Got it. And just squeeze one quick one in. Hospice revenue per day, up, I think, 3.7%. That's pretty strong, certainly above the latest fee-for-service, Medicare rate. Anything to call out there maybe in terms of acuity changes or geographic distribution, anything else there?
No, Ryan. I think we had, obviously, have a little bit of mix shift pretty consistently. So there's a little bit of contribution there. But I think overall in hospice, we saw a little better implicit price concession, just some of our revenue adjustment in the quarter what we maybe saw the same quarter last year. I think that was beneficial this quarter to a certain extent.
[Operator Instructions] The next question comes from Joanna Gajuk with Bank of America.
So just first, a follow-up here on the margins and I guess some of the cost items. So gross margin in the quarter was essentially in line with your prior quarters, with your prior comments on the Q4 call and -- but EBITDA was better. Because G&A was rather at the sort of the [ low point ]. So excluding stock comp and acquisition expense, Brian, you mentioned G&A was very close to 20%. It's not that there's some timing. But how should we think about the next couple of quarters? It sort of sounds like maybe that's a low point from here we should expect some increase in that ratio?
Yes, Joanna, I think being just under 20% on adjusted G&A for the quarter -- I think, as I mentioned earlier, our merit increases and some of those costs typically come in on March 1. So you haven't seen a full quarter impact. And majority of those are through our corporate staff, our branched assets, our G&A line, not a direct cost.
So I think you'll see a little bit of that go into the first full quarter in Q2. I think overall, as a percentage of revenue, we would expect adjusted G&A to kind of still be in that 20-ish percent. It might be a little tick up from what you saw in Q1, but fairly close and consistent.
Okay. That makes sense. And the other one on volumes. So you said maybe some weather impact in personal care [ weighed ] but it sounds like you kind of exit the quarter kind of back to where you thought you would be. Is that the way to think about it, that kind of that was temporary? Maybe you recouped some of the -- recouped some of those lost visits and kind of your thoughts for the whole year when it comes to personal care volumes?
Yes. I mean if you look at the PCS side, a weather event, if you have a snow or an ice storm, particularly in kind of some of the downstate Illinois markets or in some of the more rural markets, a lot of times, caregivers can't make those visits. We attempt to try to reschedule those, but that's challenging.
And you can only reschedule that within -- depending if it's a weekly [ off ] or monthly [ off ] determines when you can reschedule or have an opportunity to. So it's unfortunate. I'm always rooting for bad weather on the weekends in those markets because I'm an operator.
Unfortunately, we had some that [ hit us ] kind of early in the week. Mondays are worse than it would be if it's on a Friday. So again, kind of a temporary blip. But if you look at just where we progressed throughout the quarter on PCS, January was impacted by the weather events. But we saw a nice pickup in February and actually exited pretty strong in March and expect those trends to continue.
And if you look at our hiring numbers as well, kind of mirror that. January was a little soft because of, frankly, the weather impacts there. We actually had a nice hiring in February and frankly, followed that up with what really was record hiring in March, and our April hiring numbers have been solid as well.
Great. Good to hear that. And if I may just follow up on the discussion around the 80-20 provision in the access, so in direct specifically, CMS actually did say something along the lines of they expect the states to look at the rates, wait to see if they're actually sufficient. I mean, there's a lot of requirement now, different requirements for state to disclose that information and keep updating those.
So do you expect states to actually be forced to raise rates to ensure there's -- they're essentially now providers to deliver the care? Obviously, if they don't ensure the access, they will end up paying higher or sending more money for some of these senior people with disabilities to end up in nursing homes, right? So how do you think about this forcing some states [ to a preapproved ] rate?
Yes. Joanna, I'll start, and then Dirk may add some color to it. From a -- that's one of the aspects of the rule that I think we, like others in the industry, are in favor of. I think having more transparency around how rates are calculated and formulated by states is very important.
I do think there will be some pressure on states to raise rates because as you point out, the alternative is actually putting individuals in a more costly institutional setting. So I certainly think there's opportunities over the next 6 years to really work with states and where those rates need to be in order to be able to maintain the programs at their current status and frankly, and to try to grow the personal care programs in those states.
Right. Exactly. And then the last one is so you mentioned there's obviously some clarifications in direct around -- there's some definitions and denominators and things like that, but there -- it sounds like there's still some additional clarity that you might be expecting. So is this something you expect to come off of the states because that was another element of this regulation, right?
Clearly, CMS gave a lot of authority for flexibility to the states to -- when it comes to that 80-20 provision. Is that how really -- like there's going to be more information coming out from the states, and that's when you could kind of be more clear when it comes to what exactly is happening?
But obviously, since this is in 6 years, you might not hear about it for a while. But I guess I want to say in direct also talks about that the state has to say or, I guess, prove that they are ready for employers or something like that. So would mean that we kind of like 4 years from now, we will hear more details? Or do you think it's going to be sooner than that?
Yes. I think, frankly, unfortunately, the way states tend to work is they wait more to the back end. So I don't expect to have any near-term clarification on some of those elements in the rules. And as you pointed out there, there were a lot of provisions that were left open for the states to determine to have some flexibility with.
And CMS said that they would provide, I think, technical assistance to help the states go through that process. But this is something that I think states will -- it's just the reality is they'll probably take a little bit of a wait-and-see approach even though some of the significant provisions for them actually kick in, in 4 years. But I don't anticipate getting anything in the near term. I think we'll be kind of closer to the back end of that 4-year period.
Yes. This is how usually these governments work when it comes to deadlines, they wait just kind of last minute. If I may just squeeze in the very last one, sorry, because there was also a discussion around some of the specific elements from -- called out in this regulation. And [ I would check ] by some larger companies estimated -- adjusting for the supervisory costs could be like 500 basis points for them. So I know you're not willing to give specifics, but would it be in this range or much smaller than that?
I think it depends on how companies are defining clinical supervision. To get to the number you specified takes a great deal of breadth in the definition for those of us that operate in the industry. So I'm not sure that we would -- we're agreeable with that number at this point in time until we get more clarification. However, I think what we said earlier applies, the fact that they included -- CMS included clinical supervisory salary and the definition was very helpful, and it will give us some relief towards the 80-20.
This concludes our question-and-answer session. I would like to turn the conference back over to Dirk Allison for any closing remarks.
Thank you, operator. I want to thank everybody for their interest today in Addus and for being part of our call. Hope you have a great week. Thank you.
The conference has now concluded. Thank you for attending today's presentation. You may now disconnect.