Addus Homecare Corp

NASDAQ:ADUS

Earnings Call Transcript 2018-Q4

[Operator]

Good day ladies and gentlemen, and welcome to the Addus HomeCare Corporation Fourth Quarter 2018 Earnings Conference Call. At this time all participants are in a listen-only mode. Later we will conduct a question-and-answer session and instructions will follow at that time. [Operator Instructions]. As a reminder this call is being recorded. I would now like to introduce your host for today's conference Dru Anderson. Maám, you may begin.

[Dru Anderson, Corporate Communications]

Thank you Heather. Good morning and welcome to the Addus HomeCare Corporation fourth quarter 2018 earnings conference call. 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 2019 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 fourth quarter 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 President and Chief Executive Officer, Mr. Dirk Allison. Please go ahead, sir.

[Dirk Allison, President and CEO]

Thank you, Dru. Good morning, everyone, and thank you for joining us for our fourth quarter conference call. With me today is Brian Poff, our Chief Financial Officer. I will begin with some general comments, and then Brian will discuss the fourth quarter results that we issued yesterday afternoon. Following our comments we would be happy to respond to any questions.

As we announced yesterday, our solid operating performance continued in the fourth quarter of 2018. Revenue for the fourth quarter was $139.8 million compared to $112 million for the same period in 2017, an increase of 24.8%, driven by a combination of 2.4% organic growth and our acquisitions.

Adjusted earnings per diluted share for the fourth quarter of 2018 increased to $0.55 as compared to $0.45 for the same period in 2017, an increase of 22.2%. Our adjusted EBITDA for the fourth quarter of 2018 increased 17% to $12.3 million from $10.6 million, and we had an adjusted EBITDA margin of 8.8%, even with the continuing lack of a minimum wage price increase offset in Illinois. As Brian will detail our cash position continues to be strong reflecting the efforts of our reimbursement team.

Our fourth quarter same store growth was below our ongoing target of 3% to 5%. This lower same store growth was primarily the result of three items, first, the lack of an Illinois minimum wage related rate increase which we discussed last quarter. Second lower referrals in New Mexico due to the transition of MCO's who managed that state's Medicaid program. And three, lower referrals in Illinois related to the ramp up period for a major new coordinated care unit which is an outsourced personal care referral company used by the state. Importantly we have seen referrals return to a more normal status in the first quarter of 2019 for both New Mexico and Illinois.

We remain confident in our target same store growth rate of 3% to 5% although we may be on the lower end of that range until we are able to obtain the Illinois minimum wage rate increase. As we mentioned on our last call the lack of an offset to the Chicago and South Cook [ph] minimum wage increase negatively affected our margins with fourth quarter margins impacted by approximately 70 basis points. Our team is diligently working with Illinois state leaders to pass a rate increase. At this time there is a bill before the Illinois' legislature which would increase our reimbursement rate as we have requested. While we have no assurances that this bill will pass and become law, we continue to believe that state leadership understands the importance of passing this reimbursement increase to offset the mandated minimum wage increase the industry experienced July 1, 2018.

Let me update you on our 2018 acquisitions, the transition of our Arcadia acquisition has gone well and is complete. Both teams worked hard during this period of time and we were able to complete this process on time and within budget as we had expected. We have closed the former headquarters of Arcadia and have moved all back office functions to Addus' corporate and support center locations. Cost to effect this closing were booked in our fourth quarter as acquisition cost. We have realized full synergies as we head into our first quarter of 2019.

During the fourth quarter of 2018 we were also able to complete the transition of Ambercare our home health and hospice segment. While synergies were not as material as those for Arcadia we were able to achieve our targets for transition during the quarter. Severance and reorganization costs were recorded in our fourth quarter. During the fourth quarter we also completed our conversion of all home health and hospice sites to home care home base again on budget as we had planned. Our team is excited to be on this new platform which should help our operational efficiencies in these two service lines.

Our home health segment represents $10.3 million in annualized revenues. There has been a lot of recent public discussion around PDGM and how it effects home health companies. Addus is certainly aligned with our other home health industry participants concerning this issue. However, I want you to understand that our exposure to PDGM is extremely small and based on our review will have no material effect on our financial results.

As we previously announced Addus has signed a definitive agreement to acquire the assets VIP Health Care Services, a New York City based provider of personal care services. We're very excited that the team at VIP will be joining the Addus family. This acquisition is an important step to further our strategy of developing strong operations in the States where we operate. Together with our South Shore operation on Long Island we believe VIP will give us the coverage to outperform market services to our MCO partners in both Long Island and the five boroughs. Over the past few weeks our team along with the VIP senior leadership have been involved with transition discussions which we believe will help us as we complete this acquisition. We are awaiting state approval for the transaction and anticipate a close for this acquisition during the second quarter of 2019.

In addition to VIP our development team continues to work with other potential acquisition targets. Currently we are under a letter of intent with two potential acquisitions; one, which strengthens a state in which we currently operate while the other allows us to enter one of our targeted new states. Of course there can be no assurance that we can complete either or both of these transaction or as to the timing of the transaction. We are excited about our ability to close additional acquisitions during 2019. Our pipeline remains strong allowing us to focus on opportunities in the strategic markets that we have previously discussed.

On our last earnings call I mentioned that CMS had announced that personal care services can be added by Medicare Advantage Plans to their care offerings beginning in 2019. While we feel that 2020 and 2021 will be a time frame when the majority of Medicare Advantage providers consider this service, we are now beginning our service to some of these providers. We have contracts with two large Medicare Advantage plans to provide personal care services to their members during 2019. Recently we started to receive our first patients under these contracts. We are excited about working with these partners to gather the appropriate data which will allow Addus to help Medicare Advantage providers as they continue to expand their offering around personal care. I believe that this is a positive step towards expanding the availability of our home care services under a value based payment system and continues to indicate the increasing awareness by the federal government of the value of personal care services in improving the quality and lowering the cost of health care.

Before I turn this call over to Brian for a more detailed review of fourth quarter performance, let me thank all the employees of Addus. We should all realize that our company provides very important and much needed services to our patients at a low cost. Our services enable these patients to stay in their homes instead of progressing to much more expensive health care which occur in a less intimate setting. The good work that Addus does is only possible due to the commitment and hard work of each of our employees. With that let me turn the call over to Brian.

[Brian Poff, EVP and CFO]

Thank you Dirk and good morning to everyone. Our financial results for the fourth quarter of 2018 demonstrated solid execution of our strategy as we continued to expand on the growing demand for home care services with an increasing level of profitable growth both organically and from acquisitions. We believe we are well positioned to continue this trajectory in 2019. We expect the impact of our growth from acquisitions to be strengthened by the anticipated completion of the VIP healthcare services transaction in the second quarter of 2019. We also continued to evaluate and work towards other acquisition opportunities from an ongoing pipeline of potential transactions.

As Dirk mentioned total net service revenues for the fourth quarter increased 24.8% to 139.8 million from 112 million for the fourth quarter of 2017. Personal care revenues accounted for 93% of revenue for the fourth quarter and increased by 15.9% over last year. This growth reflected a 13.2% increase in billable hours per business day and just under 1% increase in revenue per billable hours.

The remaining growth in revenue was attributable to our hospice and home health services with no contribution from these segments in the prior year period. For 2018 these service lines added approximately 10 million in revenue for the fourth quarter and 25.7 million for the year after the acquisition of Ambercare in May. Gross margin was 27.1% for the fourth quarter compared with 27.5% for the fourth quarter last year. However with the adoption of ASU 2014-09 lowering our gross margin for the most recent quarter by a 150 basis points our comparable gross margin percentage to the prior year quarter was 28.6%.

While we continue to be impacted by Chicago minimum wage increase we saw improved margins in our skilled business during the quarter as we continue to focus on driving operational cost efficiencies. G&A expenses 20.7% of revenue for the quarter compared with 17.6% for the fourth quarter last year. Approximately 90 basis points of the increase for the fourth quarter of 2018 was due to growth in M&A expenses, stock based compensation, restructuring charges, and severance and other costs compared to the fourth quarter of 2017. An additional 40 basis points is related to the impact of the adoption of the accounting standards update. The remainder of the increase is primarily attributable to the G&A costs associated with our recent acquisitions.

The company's adjusted EBITDA increased 17% to 12.3 million for the fourth quarter of 2018 compared to 10.6 million in the fourth quarter 2017. Adjusted EBITDA margin was 8.8% compared with 9.4% for the fourth quarter of 2017. Adjusted net income per diluted share grew 22.2% to $0.55 for the fourth quarter from $0.45 for the fourth quarter of 2017. The adjusted per share results for the fourth quarter of 2018 exclude the following; M&A transaction expenses of $0.11, restructuring charges of $0.02, and non-cash stock based compensation of $0.07. As previously reported our adjusted per share results for the fourth quarter of 2017 exclude write down deferred tax asset of $0.12 related to the Tax Reform Act, gain on sale of a joint venture divestiture of $0.01, M&A transaction expenses of $0.04, non-cash stock based compensation of $0.04.

Our tax rate for the fourth quarter of 2018 was 20.8% fairly consistent with our expectations. For 2019 we continue to expect our tax rate to be in the low 20% range. Our fourth quarter net cash from operations totaled 8.5 million. At December 31, 2018 we had 70.4 million in cash on hand and under our new credit facility announced last quarter we continue to have capacity to support our acquisition strategy with only 20 million in bank debt.

DSO has declined to 70 days at the end of the fourth quarter of 2018 compared with 71 days at the end of the third quarter. DSOs for the Illinois Department on Aging was 55 days at the end of the fourth quarter compared with 66 days at the end of the third quarter. This decline was partially offset by an increase in DSOs in our managed care business primarily related to the client transitions in New York and New Mexico between MCOs. We expect our receivables in these markets to return to normal levels after the completion of the MCO transitions.

This concludes our prepared comments this morning and thank you for being with us. I will now ask the operator to please open the lines for your questions.

[Operator]

Thank you. [Operator Instructions]. Your first question comes from Brian Tanquilut with Jefferies. Your line is open.

[Brian Tanquilut, Jefferies, Inc.]

Hey, good morning guys. Congrats on a good 2018. So my first question for you guys, Dirk as I think about labor obviously one of the key concerns or topics of discussion for investors, how are you thinking about labor pressures and how that affects you guys whether it's translating from higher wage rates that you have to pay or whether it's Amazon or to Chipotle [ph] or whoever putting pressure on hiring? And then if you don’t mind just give us a profile on who the clinician is and how that helps you differentiate from the other employers that I mentioned? Thank you.

[Dirk Allison, President and CEO]

Thanks Brian, let me start with that see if I can answer the question. We certainly as all health care service providers have some level of pressure due to the economy as it is today. Probably our largest pressure has been the increase in minimum wage in some of our states but at the same time, you know that we have a number of employees that are under union contracts in various states. And so once we negotiate a contract with those unions at whatever rate it is at that point everybody that comes to work for us that rate is already established and we do not have to negotiate or pay higher rates to get those individuals. That's in the markets where the industry has been largely unionized about the state and the unions.

In addition to that about 35% of our labor workforce are family members taking care of additional family members. So it's really less a function of labor wage rates with them as opposed to our being able to actually hire them and get them trained and put them in the house to take care of their. So once we get them on board there's not a lot of shift between companies, certainly not just because there may be a small increase in hourly rate somewhere else. It's hard to transfer those patients. So, again I think it's fair to say we do face some pressure from the economy and competitors that you mentioned but our union contracts as well as our makeup of our labor force with our family caregivers shield us to that to a degree.

[Brian Tanquilut, Jefferies, Inc.]

And Dirk just a follow-up to that, so in the states where you get increasing minimum wage given the dynamics you just described with the unions, I mean how does that normally translate? I know Illinois seems to be an issue right now but this seems temporary but generally speaking or in other states what are you seeing in terms of the pricing movement between minimum wage changes and the rate that the states are reimbursing?

[Brian Poff, EVP and CFO]

Brian generally what you see in most of the minimum wage increases are in states where the unions are fairly strong and that's not totally exclusive but it's the vast majority. And what we've seen -- we tend to see in those markets is first the unions negotiate with the state and get the minimum wage increased. And then as an after effect of that then we start working with the unions to then go back to the states and try to get a bill passed that will cover the minimum wage increase that are coming up.

So in certain markets you may have stepped increases over a period of three to four years, each year you have to negotiate with the state legislature to get those increases. Very few states have put into effect a white race is going to cover your wage increase, it is going to cover you for multiple years. They tend to do that on a year-by-year basis. So it is, we negotiate for the increase a little bit generally after the minimum wage has already been passed into law but I will tell you in the States where we are affected by minimum wage the most, the union states, the union are partners with us, the union itself they do partner with us working hand in hand with the leaders of the state to make sure that that price increase or that rate increase to us is given. Because the alternative is if a state fails to increase rates enough to offset these minimum wage increase then over a period of time companies are going to quit servicing that individual at home and that person is going to end up in a higher institutionalized setting, a higher cost setting.

So the state leadership understands that while it costs money it's also -- it's good for the population and overall good for the cause. So we've had good experience in the last three to four years of maintaining these increases to offset minimum wage with the exception as you know there is a delay right now with Illinois which is not unusual.

[Brian Tanquilut, Jefferies, Inc.]

No, got it. I appreciate it. Last question from me Dirk, you have talked about Medicare Advantage briefly in your prepared remarks. So I figured you're in the middle of other discussions with other payers right now -- if you don’t mind just walking us through what those discussions are like, what they're looking for, and how they're thinking about structuring contracts and how to pay you whether we are hearing pay for performance type of arrangement, if you don’t mind just give us some color on where you think that will go as we head into 2020? Thank you.

[Dirk Allison, President and CEO]

Well, you know certainly we believe Medicare Advantage is a nice potential upside for a company like ourselves over the next three to five years. I think we've been very consistent saying that. As far as negotiation we have relationships with most of the large Medicare Advantage players, some of which offer other services like Medicaid, managed Medicaid in various states. So while it may not be the same department or part of the company that we negotiate with, we do in a lot of cases already have inroads from a reputation standpoint.

The negotiation with the Medicare Advantage obviously at this point in time is a little different than for Medicaid. In the Medicaid side most in MCO's are rate taker from the state at least at first until the state eventually gives them the ability to start tightening their network and maybe looking at how they reimburse the various participants or providers in that market. Medicare Advantage is different, this is a benefit that the -- providers are offering to their membership. I believe long-term the Medicare Advantage providers are going to want us to go to more of a per member per month type reimbursement, a risk based approach.

I think the problem we have now and they do is it's very early in the process. We've got to gather data to allow us to do that and we've got to decide and the Medicare Advantage providers have to decide what kind of service are they going to buy. Are they going to do a Medicaid type personal care service where as long as you can do a couple of aspects of your activities, daily living they are going to give you coverage for multiple months or is it going to be more of an acute offering at first so that it's much more limited in scope as to what they're offering as far as personal care.

So I'm not trying to evade the subject on the negotiation, it's just different with every Medicare Advantage company based on what they're looking to offer to their members and I think over a period of time the real upside for a company like Addus is when the Medicare Advantage shifts from thinking that personal care is a benefit to sell the plan to their members and start thinking in terms of personal care is a way to reduce the medical loss ratio that they experience for their members. So we're hoping to see that occur over the next couple of years.

[Brian Tanquilut, Jefferies, Inc.]

Alright, thanks guys.

[Operator]

Thank you. Your next question comes from Frank Morgan with RBC Capital Markets. Your line is open.

[Frank Morgan, RBC Capital Markets]

Good morning, appreciate some of that initial color about the acquisition backlog but just curious if you could give us a little more color on the actual service lines that you're seeing most of the likely activity and are you seeing any new entrants in terms of competition for deals and any changes in valuations and given this MA opportunity?

[Dirk Allison, President and CEO]

Yeah, Frank the two deals that we mentioned under the letter of intent are majority personal care services. They may have a slight segment, a small segment of the other two offerings that we have but by and large their personal care service is in important markets for us. The rates that we're having to pay have not changed, very steady at that six times -- maybe six to seven times EBITDA and so we're very -- that's been very consistent for us as related to the majority of the personal care services.

As far as competition honestly at this point in time especially related around the personal care acquisitions we've not seen an increase and competition has been very steady. Now that's different if we were out looking at just a hospice acquisition, as you know that market has been pretty hot and very frothy as far as the rate you have to pay to get those companies. And there's been a lot of PE firms out there looking for those. So, if we were in a hospice I would have a different answer but because these are vastly the majority of this personal care it's not that competitive.

[Frank Morgan, RBC Capital Markets]

Got you and with your -- you called 50 million in revenue with this pending VIP deal, when we get to the end of the year what do you think would be a good year for acquisitions, I mean what kind of number would it take to say in terms of just acquired revenue or transact whatever basis you want to look at it really under sort of a best case scenario what kind of growth you think you might be able to log?

[Dirk Allison, President and CEO]

Well understanding I'm not giving you guidance by saying this but just trying to answer your question as honestly as I can, I think it would probably change depending on who is giving you the answer. I would tell you I personally would like to see us bring in at least 100 million of revenue during 2019. I think if you were talking to our conservative CFO he would tell you more like 75 million or so. So, we'll go with 100 million, how about that.

[Frank Morgan, RBC Capital Markets]

Yeah, I like that, nice round number. Just one last one and I will get back in the queue. On the home care home base conversion any -- I know this is a small part of your business right now but any disruption in a sense have you noticed as a result of that, and I will hop off thanks?

[Dirk Allison, President and CEO]

Well I think anytime we went through two things related to Ambercare's hospice services and home health care too. The thing by the way did a great job during this transition of really hanging in there working hard but I think we faced two factors that probably did reduce our ADC in the hospice side a bit, small bit and that was one the home care home base conversion you never go through something that major a material without a little bit of a slowdown just due to the fact that the people that operate the company every day are really tied up in getting that conversion. And the second thing for us was we had a plan when we acquired Ambercare that we were going to look at the sales force, the sales team and that we were going to make changes to get into a place we wanted to be. And so during the third and fourth quarter of this year we have had a lot of changes in our hospice sales force that have now in the first quarter really started to pay benefits. So, I would say home care home base was a slight disruption but other things also added to that.

[Operator]

Thank you. Your next question comes from Matthew Gillmor with Robert Baird. Your line is open.

[Matthew Gillmor, Robert W. Baird]

Thanks for the question. Maybe asking about the organic growth trend, I want to follow up on some of the temporary items that you mentioned that impacted referrals in New Mexico and Illinois. I think I understand the dynamics in New Mexico with the new MCOs but could you provide a little bit more details on the issue with Illinois, I think you mentioned a change in vendor for coordinated care, so just sort of wondering what that is? And then if you could also sort of size the impact on some of these temporary items, it sounded like you'd maybe be closer to 3% without the items but just wanted to confirm if that was correct?

[Dirk Allison, President and CEO]

Yes, we think we would been above 3% had these items not occurred. Let me explain to you the CCUs in Illinois. The way Illinois operates is that they outsource their referral system for personal care to companies that are called coordinated care units. These companies actually go out and do assessments of potential patients looking at what activities of daily living they are deficient and cannot do for themselves and then based on what they find they develop a plan of care and then they'll contact a company like Addus and they'll give us that plan of care and we'll pick up the patient. What happened during the fourth quarter, one of our large CCU's sold and was acquired by an out of state company and it took a period of time for that new company to ramp up and get back to where they were handling as many referrals as we had seen the company handle prior to the sale. That now has occurred. In the first quarter we don't have a lot of experience well I guess we're halfway through the quarter so we have seen an increase in our referrals both in New Mexico and Illinois back towards more normal level.

So we're comfortable that our 3% to 5% is still a good number. We believe on an annual basis that won't be a problem. The first half of the year honestly could be towards the lower part of that just because as we mentioned a large part of our business is in Illinois and any rate increase that we're working on the potential effect to date we've been talking to state about is July 1st. So we would go through the first two quarters without an increase.

[Matthew Gillmor, Robert W. Baird]

Got it, thanks and then as a follow up to the acquisition pipeline discussion you had with Frank I guess I just wanted to confirm that these two discussions you are having, these two LOIs that those are I guess relatively advanced and I guess the reason I ask as I assume you are under LOI pretty frequently and maybe you can correct me if I'm wrong? And then would you characterize those deals as being sort of on the larger side of what you've done the last couple years or on the smaller side, just to sort of size them up?

[Dirk Allison, President and CEO]

We don't always have to sign a lot of letter of intent. We try to do enough work beforehand, that's not to say we don't sign that and potentially we don’t close the deal. That does happen, I want to be very clear about that. But in these two instances while we can't guarantee we will get close. We are fairly long, fairly far along on our process of working through the final stages of due diligence and trying to get to that final definitive document. As far as the size you know when you look at the size going all the way back to options in 2017 we've acquired things from about 18 million to 20 million in revenue. Upwards of 50 million in revenue. We have acquired some even smaller 5 plus million. I would say these are in that mid type range. Not the biggest we've done but certainly not the smallest either.

[Matthew Gillmor, Robert W. Baird]

Got it and then last question, you talked about the Medicare Advantage contracts that you are live with in 2019, I guess I just wanted to confirm that those are in states where you already provide services? And then as you're talking with Medicare Advantage plans is that a state by state discussion or are they looking for more national type partners?

[Dirk Allison, President and CEO]

Well they are in states in which we operate but you realize we operate in 24 states and we have probably 8 to 10 states that are fairly large and cover a majority of the state, especially as we continue to increase that with these acquisitions. So it's nice for us, our team has done a great job of going in and working with the Medicare Advantage providers specifically around maybe a particular state that they're big in and we're big in. But we're also always looking for opportunities to add our services elsewhere where we may be able to partner with them, that's a strong word because it's not an official partnership. But certainly it's a relationship where if we can continue to grow in markets where they have a large population of Medicare Advantage we would believe we would get our fair share of those patients going forward.

[Matthew Gillmor, Robert W. Baird]

Got it, thank you.

[Operator]

Thank you. [Operator Instructions]. Your next question comes from Dana Hambly with Stephens. Your line is open.

[Dana Hambly, Stephens, Inc.]

Hey, thanks for taking the questions. Dirk, just to clarify the two Medicare Advantage contracts you just started are those multi-state or are those limited to a single state right now?

[Dirk Allison, President and CEO]

Those are multi state.

[Dana Hambly, Stephens, Inc.]

Those are multi, okay. And just sort of a process, is it similar with the Medicare Advantage to what you're doing with Medicaid right now in so much as you're approved for X number of billable hours and then it's your job to go deliver that or is it different with M&A?

[Dirk Allison, President and CEO]

Today it is that way. I do want to say Dana I think long-term is a really opportunity for a company like ours with our size because if we can ever get to the data and go to more of a per member per month pricing model I think that will help us not only have the opportunity for possibly increase margins a bit but also be an offering that I think more Medicare Advantage providers would like to see in the future.

[Dana Hambly, Stephens, Inc.]

Okay, and is the current structure kind of similar to what you're seeing in maybe some of your larger Medicaid states right now with regarding the number of billable hours?

[Dirk Allison, President and CEO]

I don't think the Medicare Advantage itself you can model after our Medicaid business. You know in our Medicaid business we stay for about 26 months with a patient and we provide right at 60 hours of average care per month. You are going to see a much shorter duration of care maybe 30 days and you're going to see potentially less hours. So from a revenue standpoint today, again realize most the Medicare Advantage providers today are looking at this as a benefit to sell the plan. I don't think they've really yet said by offering more services in this particular area we can reduce our overall medical loss ratio through less nursing room visits, maybe less hospital days. I think that will come and as that comes you may see the way the service levels between Medicaid and Medicare get more similar. But today they are truly a different service level.

[Dana Hambly, Stephens, Inc.]

Okay, alright, that's helpful. Is there any concern on the switch to the new CCU in Illinois to this out of state entity that their criteria will change on billable hours?

[Dirk Allison, President and CEO]

No, we're not concerned at all. We know them very well. We've worked with them. I just think it was a matter of anytime you take over a company and change management and you've got to bring your systems in. It takes you a bit to get up and going and I think they've actually done a good job doing that. It just took them a little bit of time during the fourth quarter.

[Dana Hambly, Stephens, Inc.]

Okay, and then lastly the New York narrow networks I believe they narrowed last year. As I recall I think that's supposed to narrow again this year. Just correct me if I'm wrong there but also could you just what's the general criteria for remaining within one of these narrow networks and have you seen any other states thinking about this?

[Dirk Allison, President and CEO]

Well I think the criterion, again I think each MCO can make their own decisions. I think it would have to do with the coverage, what kind of coverage can you give them if they're limited to a certain number of providers they want providers that can cover their entire membership population. So a company like Addus that has let's take Long Island as an example, we probably can service more locations on Long Island than any of our competitors which gives us a real advantage when the MCO's are looking to reduce the network. Now if we weren't providing the proper service levels, if we had issues with our patients complaining to the MCOs about us not showing up, us not doing the right service level, us not following the plan of care then I don't care how much geographic coverage you provide I think you would be in trouble. So you start with providing the proper appropriate service and then hopefully our size and geographic coverage allows us to stay in these networks. As far as other states that we operate in we are not aware today of any states that are looking to at this point in time limit the size of their provider network. Again realize and I think you do Dana that is an advantage to a company like ours that has the coverage size and hopefully the expertise in the service area. So we would see in other states what we're seeing in Long Island today and that is really nice growth and a lot of that growth coming with caregivers that is very important as we have this -- the difficulty of finding caregivers today.

[Dana Hambly, Stephens, Inc.]

Alright, thanks guys.

[Operator]

Thank you and I'm showing no further questions at this time. I'd like to turn the call back over to Mr. Dirk Allison, President and Chief Executive Officer for closing remarks.

[Dirk Allison, President and CEO]

Thank you operator. I want to thank everyone today for their interest in Addus and for participating on our earnings call. We hope you have a great week, thank you.

[Operator]

Ladies and gentlemen, thank you for participating in today's conference. This does conclude the program and you all may disconnect. Everyone have a wonderful day.