Cross Country Healthcare Inc
NASDAQ:CCRN
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Cross Country Healthcare Inc
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Good afternoon, everyone. Welcome to Cross Country Healthcare’s Earnings Conference Call for the Second Quarter 2023. Please be advised that this call is being recorded and a replay of this webcast will be available on the company’s website. Details for accessing the audio replay can be found in the company’s earnings release issued this afternoon. At the conclusion of the prepared remarks, I will open the lines for questions.
I would now like to turn the call over to Josh Vogel, Cross Country Healthcare’s Vice President of Investor Relations. Thank you and please go ahead, sir.
Thank you and good afternoon, everyone. I’m joined today by our President and Chief Executive Officer, John Martins as well as Bill Burns, our Chief Financial Officer; Dan White, Chief Commercial Officer; and Marc Krug, Group President of Delivery. Today’s call will include a discussion of our financial results for the second quarter of 2023 as well as our outlook for the third quarter. A copy of our earnings press release is available on our website at crosscountry.com.
Please note that certain statements made on this call may constitute forward-looking statements. These statements reflect the company’s beliefs based upon information currently available to it. As noted in our press release, forward-looking statements can vary materially from actual results and are subject to known and unknown risks, uncertainties and other factors, including those contained in the company’s 2022 annual report on Form 10-K and quarterly reports on Form 10-Q, as well as in other filings with the SEC. The company does not intend to update guidance or any of its forward-looking statements prior to the next earnings release.
Additionally, we reference non-GAAP financial measures such as adjusted EBITDA or adjusted earnings per share. Such non-GAAP financial measures are provided as additional information and should not be considered substitutes for or superior to those calculated in accordance with US GAAP. More information related to these non-GAAP financial measures is contained in our press release. Also during this call, we may refer to pro forma when normalized numbers pertain to our most recent acquisitions as though the results were included or excluded from the periods presented.
With that, I will now turn the call over to our Chief Executive Officer, John Martins.
Thanks, Josh and thank you to everyone for joining us this afternoon. For the second quarter, consolidated revenue of $541 million, an adjusted EBITDA of $44 million were above for the year at the high end of our guidance ranges.
Our results reflected strong execution in an environment where clients remained focused on controlling our labor costs. This is evident to me that our ongoing investments in technology are driving efficiency and productivity gains, enabling our dedicated employees and healthcare professionals deliver best-in-class services.
Bill will get into more detail on the numbers, but I wanted to spend a few moments, discussing our second quarter performance. I’ll start with our largest business, travel. Revenue was down approximately 16% in the first quarter, driven by a mix of lower rates and billable hours. As expected, average bill rates declined approximately 7% sequentially and are expected to decline by the mid to high single-digits in both the third and fourth quarters. This would place travel rates on track to settle in roughly 35% above pre-COVID levels as we enter 2024, in line with our prior expectations.
As we reported last quarter, demand dropped in April and has been slowly rebounding. In particular, we saw notable pickups in MedSurg, EOR, labor and delivery and pediatrics, and in allied, we saw strength in imaging and lab specialties. So demand has rebounded, the corresponding growth in the number of travelers in the third quarter has been slower than anticipated.
As there appears to be a gap in open order rates relative to the compensation that nurses are seeking. Accordingly, we still expect revenue for the third quarter to be withdrawn. Though a little softer than we previously envisioned. For the fourth quarter, we continue to expect sequential volume growth in the business. In part, due to the improving outlook for orders, as well as a likely seasonal needs, we expect to see ramping in coming months.
Heading to our other businesses, I’d like to highlight physician staffing revenue which was up 32% year-over-year organically and 12% sequentially in the second quarter, driven by an increase in the number of days filled across most specialties and revenue per day filled.
When we include our most recent acquisitions of Mint and Lotus, which continue to operate above expectations, our physician business was up 105% year-over-year and now is on an annual revenue run rate of more than a $180 million. Education also performed very well in the second quarter, up 42% year-over-year. This division is now closed to an annual revenue run rate of $100 million.
Now, let me spend a moment on our technology initiatives. As you know, we have been successfully redesigning our entire technology landscape using a data-centric model that provides analytics and insights in real time, with Intellify, our proprietary vendor management system at the center of our ecosystem.
Since introducing Intellify at our Investor Day event last year, we have successfully migrated nearly half of our managed service program onto this platform with plans to convert the balance over the coming months. As a reminder, this will save us millions of dollars annually in tech fees paid to third-parties.
However, the wheel driver for long-term revenue growth and margin expansion in my opinion, is the multibillion dollar opportunity Intellify opens within the vendor neutral states. We’re meeting with perspective clients, conversations go beyond just contingent labor by offering a comprehensive, technology-enabled platform that empowers the user with intuitive data and analytics as well as labor level of efficiency and transparency.
We believe Intellify to be highly differentiated in the industry and the feedback we received thus far from clients, prospects and our subcontract partners has been extremely positive. For example, one of our partners recently noted that the data Intellify introduces helps staffing agencies track their efficiency within the marketplace which is very useful tool.
As I mentioned on the last call, we find our first vendor neutral contract in March which went live on May 1st. Today, I’m thrilled to announce that we are actively implementing Intellify talent solutions at another new customer. We have the very robust pipeline with clients interested within this technology evident in the numerous live demos we’ve done so far. And we look forward to updating you on our new business opportunities on future calls.
And equally exciting technology initiative underway, it’s on the candidate-facing side. In mid-May we released the latest version of our Xperience app, which allows travel nurse and allied professionals to utilize a self-service model, easily searching and applying for jobs with convenient functionality and pay transparency. Since the launch, there have been thousands of downloads with KPIs showing positive daily active user, retention and job view trends.
This app is a crucial piece of Cross Country’s ongoing digital transformation. As we pivot to a tech-enabled platform, our mobile-first ecosystem will assist in optimizing candidate and client experiences rationalizing business operations and streamlining our delivery models. The full year we continue to target an investment of nearly $30 million on technology related initiatives that we believe will further improve our go-to-market strategy as well as our efficiency.
This brings me to our outlook. Given the market backdrop and the seasonality in parts of our business like education, we anticipate that the third quarter revenue will be between $440 million and $450 million. Beyond the third quarter, our expectations for continued improvement in travel demand as well as potential growth in many of our businesses like education, physician staffing and homecare, point to a full year revenue that will be above $2.05 billion and an adjusted EBITDA margin of approximately 8%.
I remain confident in our ability to drive long-term sustainable, profitable growth and we are focused on increasing shareholder value through our deployment of capital. As you see in today’s press release, our cash generation was very strong in the second quarter, allowing us to fully repay remaining $74 million on our term loan in June. We will also recall, that we announced the restoration of our $100 million share repurchase plan in May.
With the term loan now gone, and give we believe our shares are undervalued. Share repurchases remain an attractive use of capital. We will also look to leverage our technology investments and robust balance sheet to further diversify our platform. By following the patient across the continual of care, as well as like entering new markets like we did with interim leadership to the hire of acquisition late in 2022.
In closing, we are confident about our prospects and ability to build upon the early momentum from Intellify, which we believe is a game changer for Cross Country and the industry. All of our success would not be achievable without our dedicated employees and I want to thank each of them for their hard work and contributions. We have such an incredible team.
We recently won 2023 Top Workplace Healthcare Industry Award from Energage, and I’m also humbled to highlight our recent award of Winner of Newsweek magazine’s most loved workplace certification, which recognizes organizations where employees are the happiest and most satisfied. Our workplace culture is second to none in my opinion.
And this award is reflective of that as the surveys employees on various elements such as respect, collaboration, support and a sense of belonging inside the company. Lastly, I want to thank all of our professionals who make Cross Country their employer of choice as well as our shareholders who believe in the company.
With that, let me turn the call over to Bill.
Thanks, John and good afternoon, everyone. As John highlighted, consolidated revenue for the second quarter of $541 million was above the high end of our guidance range, fueled by over performance across both physician staffing and education. Compared to the prior year and prior quarter, revenue was down 28% and 13% respectively, driven in large part by the expected normalization in travel bill rates and to a lesser extent, the decline in number of professionals on assignment. I’ll get into more details on the segments in just a few minutes.
Gross profit for the quarter was $123 million, which represented a gross margin of 22.8%. And gross margin was up 40 basis points sequentially due primarily to the impact in the annual payroll tax reset at the start of the year.
Moving down the income statement, selling, general and administrative expense was $79 million, down 6% sequentially and 8% over the prior year. The majority of the decrease relates to lower variable compensation following the historic performance throughout the pandemic as well as the reductions in salary and benefit costs we mentioned last quarter.
Our goal remains to proactively balance investments with current market conditions to maintain our profitability, while ensuring we have sufficient capacity for future growth. Including actions taken throughout the second quarter and into the start of the third quarter, we’ve reduced our internal headcount by more than 10% since the start of the year, while continuing to invest in areas of business with highest growth potential as well as in our technology initiatives.
Based on the cost actions taken to-date as well as lower compensation associated with the sequential decline in revenue, we anticipate our SG&A will decline in the mid to high single digits for the third quarter. As a percent of revenue, SG&A was 14.6%, up from 13.5% last quarter have the decline in revenue, outpaced the reductions in SG&A.
The better than expected top line performance coupled with tight cost management drove another quarter of strong earnings with adjusted EBITDA of $44 million, representing an adjusted EBITDA margin of 8.2% consistent with our goal to maintain margins in the high single to low double digit range.
Interest expense was $3.1 million, which was down 15% sequentially and 18% from the prior year. The decline was entirely driven by lower average borrowings during the quarter, partly offset by higher interest rates. Our effective interest rate for the quarter was 12%, reflecting the reduction in borrowing under our ABL.
At the end of the quarter, we prepaid the remaining balance on subordinated term loan and therefore expect to see interest expense materially lower for the third quarter. And as a result of the prepayment of our term loan, we incurred $1.7 million on the extinguishment for the write-off of the debt issuance costs.
Also on the income statement, we recorded $900,000 in restructuring costs, primarily related to the severance associated with the reduction in headcount I mentioned a moment ago. And finally, on the income statement, income tax expense was $9 million, representing an effective tax rate of 29.6% in line with expectations both fully year effective tax rate of between 29% and 30%. Outperformance resulted in an adjusted earnings per share of $0.69, above the high end of guidance, driven by the overall strong performance and lowered interest expense.
Turning to the segments, nurse and allied reported revenue of $495 million, down 15% sequentially and 32% from the prior year. Our largest business, Travel Nurse and Allied was down 16% sequentially and down 36% from the prior year. Bill rates for travel were down 7% sequentially, in line with expectations while billable hours were down almost 10%, following the softness we experienced in orders through the first half of the year.
The decline relative to the prior year was fairly evenly split between lower bill rates and fewer billable hours. Looking to the third quarter, we continue to expect bill rates to decline in the mid to high single-digits. While billable hours are expected to decline in the low double-digits. Let me spend a moment on that.
As we called out, demand softened considerably coming into the start of the year, before troughing the second quarter and while total orders are gradually improving, average bill rates continue to soften, which is creating a gap to pay expectations by clinicians.
As a result, we’re not yet seeing an improvement in the weekly production, with a slightly softer third quarter than we anticipated a few months ago when we start of this rebounding. That said, we remain optimistic by the seasonal needs pick up, we will start to see our travel on assignment grow once again. It’s worth noting that we continue to have more than double the number of travelers as we get prior to the pandemic.
Our local or per diem business continues to feel the impact from a softness in demand with revenue down approximately 9% from the prior quarter, predominantly due to a decline in billable hours. Also within the Nurse and Allied segment, our Education business continued its trend of robust growth, growing more than 40% over the prior year.
Home care staffing services performed within our expectations, though down 2% over the prior year, predominantly due to lower needs from a single client. Both of these businesses remain on track to achieve an annual run rate of approximately $100 million each.
Finally, Physician Staffing once again exceeded their expectations, delivering $45 million in revenue, which was up 12% sequentially and more than double the prior year, thanks to the impact of our acquisition completed late last year.
Turning to the balance sheet. We ended the quarter with $673,000 in cash and $31 million in outstanding debt under our ABL facility. Given our continued strong performance and positive cash flow, our total leverage felt to less than 0.2 times. With the health of our balance sheet, an incredibly low leverage, we remain well positioned to make further investments in technology and acquisitions as well as to continue repurchasing shares under our $100 million share repurchase plan.
From a cash flow perspective, we generated $119 million in cash from operations, our second highest quarter on record that’s compared with $80 million last year and $46 million last quarter. The $166 million in cash generates from operations on a year-to-date basis represented a 172% conversion on the $97 million in year-to-date adjusted EBITDA.
Fueling this performance was strong collections that drove further reduction in DSO, which now stands at 63 days. Our goal remains to bring DSO below 60 days which is more in line with our historical performance and we believe that we can continue make progress towards that in the second half of the year.
Cash used in investing activities was $4 million, reflecting our continued ramp in technology investments. And from a financing activity perspective, we paid down a $110 million in debt, and repurchased almost 200,000 shares under our 10b5-1 trading plans during the blackout windows. Having retired our expense to subordinated debt and paying down a considerable portion of the ABL, we anticipate being opportunistic in making additional share repurchases when possible in the third quarter.
This brings me to our outlook for the third quarter. We are guiding to revenue of between $440 million and $450 million, representing a sequential decline of 17% to 19%, driven predominantly by the softness in travel bill rates and volumes as well as the impact for summer vacation on our education business. We are expecting adjusted EBITDA to be between $27 million and $32 million, representing an adjusted EBITDA margin of approximately 6% to 7%.
As John has mentioned previously, we’re managing this business to the longer-term success and not to a single quarter. We continue to believe this business can achieve and maintain high single to low down digit adjusted EBITDA margins, adjusted earnings per share is expected to be between $0.35 and $0.45 based on an average share count of 35.5 million shares. Also assumed in our guidance is the gross margin of between 22.5% and 23%, interest expense of $1.5 million, depreciation and amortization of $4.5 million, stock-based compensation of $2.5 million and an effective tax rate of 30%.
And that concludes our prepared remarks. And we’d now like to open the lines for questions. Operator?
Thank you. We will now begin the question-and-answer session. [Operator Instructions] Our first question comes from Brian Tanquilut with Jefferies. Your line is open.
Hi, this is [Knorr] [ph] in for Brian. Congrats on the quarter. I guess I just want to take a step back and get your opinion on where you think your relationship with MSPs will be moving forward? Would love to get some clarity on that front. Thanks.
Sure. Hey, Knorr this is John. MSPs are still a vital part of Cross Country’s strategy. But what we’ve seen since probably last summer, that the sentiment has changed in the marketplace, where hospitals are moving towards than to neutral space. And that in and of itself, that has been cyclical where throughout the year it changes which is a flavor of the day going back from predominantly been to neutral to predominantly MSP and we’re in market right now where it’s moving towards that vendor neutral VMS. And Cross Country, we feel very – we’re very excited about our prospects in the vendor neutral space right now and be able to compete in that vendor neutral space.
When we launched Intellify at our Investor Day in September, that was showing – it was originally we invested in Intellify, it was to be a replacement for the third-party VMSs we had from [inaudible]. But as we saw the sentiment of the market changed to the VMS vendor neutral space, we were able to quickly pivot Intellify into a vendor neutral platform.
And we then in January, officially launched our Intellify Talent Solutions business though a vendor neutral business, we hired Eric Christenson, who has been a pioneer in the vendor neutral space, to come onboard and within as we mentioned in my prepared remarks, in the first quarter, we won our first vendor neutral deal and by May, we had implemented that deal and we’re implementing our second deal in vendor neutral.
So, we’re very excited about the prospects of that with the vendor neutral business an Intellify brings to the market, because from what we’re hearing from our prospects, our clients that are on it, and our vendor partners is, it is a totally differentiated model than the other vendor management programs out there in – on the market. So we’re really excited about that aspect, but we also at Cross Country, are still working and have the full sales team selling MSPs, but it’s really making sure that we delivered the client what is the model that they want and to be most effective for them.
Knorr, this is Dan. I’m going to add just a little bit as John said. You know, our pipeline remains really strong and I would say, just thinking about the mix between the vendor neutral and MSP, there’s probably close to 60%, 65% that are more in this neutral sort of desired stay and maybe 35-ish, 40% in the MSP category.
Right, thank you.
Thank you. Next we will hear from Trevor Romeo with William Blair. You may proceed.
Hi, good afternoon. Thanks a lot for taking the questions. First, I kind of just wanted to ask about your confidence in demand trend visibility. Just kind of given the step-down in revenue you’re guiding to the Q3 and the reduction to the minimum full year guide. So just a couple of questions on that front. I guess one, have you built any extra conservatism into the guide kind of given the environment? And then specifically, could we dive a bit more into the comment about you know the gap in order rates and the compensation nurses are seeking? Could you may flesh that out a bit more?
Yeah, Trevor this is Bill. Thanks for the question. I guess I’d start with your first question, which is, you know, do we build in conservatism? I mean, I think we try our darn just to give you the numbers we have that most confidence that we can continue to exceed. You know it wasn’t – it was not something we took lightly to reduce the min guide to $2.05 billion from the $2.01 billion.
But in the context with the market and this kind of gets into the second part of the question, where demand has rebounded. The net week booked or how we look at you know our production – our weekly production hasn’t bounced up as high as we’d like and then so, we’re just seeing a little bit of a softness in that third quarter going into the fourth quarter. We still anticipate the third quarter is the trough.
Now, that min guide that we have, if you squeeze out the numbers to what it got implied for the fourth quarter, you would say, it doesn’t show a big bounce off of the third quarter, in fact, it’s you know virtually flat if you took the midpoint of the guidance range. I would not read into that. I still think that the fourth quarter at this point is an upward trend off of the third quarter.
That said, you know, there’s still some headwinds in the marketplace. We still have bill rate pressures, if there’s one little silver lining although demand has trended up since the trough and kind of in mid-April. We’ve not seen a continued deterioration in the open order bill rates. So those bill rates have been remained pretty stable over the last you know call it, three plus months. We’re still winding those through our entire book of business and that’s what really gives us the rate pressure going into Q3 and Q4.
And I would add – Trevor, this is John Martins, that what we’re seeing in – for the second part of your question, is that the nurse pay expectation there’s a disparity between what the bill rates for the hospitals are right now. And it will come to an equilibrium we believe in the upcoming months.
And part of that will be as we start seeing the few orders coming in and demand potentially spiking higher. We’ll see you know the bill rate and pay rate equal to where it will be where both sides will come together you know that’s only the adequate bill rate and the appropriate pay rates. And that’s when we’ll start seeing really the volumes to start picking up in the back half of the year.
Okay. Thanks, John and that was a helpful color. I guess as my follow-up just kind of on the levels of contingent on contract labor at the hospitals right now, I think some of the public you know facility operators report in the last week, sounds like some are kind of comfortable with the levels that they have now that might be expecting further moderation. Just kind of wondering if you could give us your view of kind of broadly how your clients are you know thinking about the level of contingent staff they have now and where they are in that normalization process?
Yeah. I think majority of the clients right now feel that they’ve gotten to the appropriate levels where bill rates are trending down, especially the bill rates that we’re opening up are trending more down towards that 30% to 35% above COVID levels.
And in terms of volumes, I think that – we’re still hearing that there is still the need on the floor for more nurses. And so I think as we get to that right bill rate, the hospitals are more willing now to see that has a strategic key to bring in travelers to help them grow their revenue and volumes.
Okay, thank you. That was helpful. Appreciate it.
Our next question will come from Tobey Sommer with Truist Securities. Your line is open.
Thanks. I wanted to ask you about the seasonal orders that typically come in over the winter perhaps for a slightly higher rate. What’s your anticipation of how that’ll play out and do you have any visibility into that at this point or is that still forthcoming?
So this is John, Tobey. So it’s still forthcoming. What we’re seeing right now, we’re seeing our clients looking toward to bringing on 26-week contracts that will get them through the early part of the flu season and get them through the New Year.
And so we’re seeing a trickle of some of the flu or winter needs and that we’re seeing – but we’re seeing more of the 26-week needs. And the sentiment we’re getting from our clients, are that there is still leading and that will be a little bit more just in time, if you will, rather than preparing and planning out further as we’ve seen previous pre-COVID of looking and really trying to get ahead of winter needs.
And just to be clear. As we head into 2024, is it – is annualizing that kind of especially how our higher fourth quarter number and sustaining in 8% EBITDA margin. Is that how we think about or is that an influx at this point?
Hey, Tobey it’s Bill. Yeah I think that’s a good run rate to assume going into 2024. I think you know there is potential of course for some continued bill rate pressure, but you know not expecting we’ve been pretty close on how we’ve modeled out the bill rate so far. So that plays out that way. I think that’s a good jump off point. If there’s a little headwind then it really comes down to the ability for volumes to offset or the other lines of business that have been you know having pretty robust growth like local tenants and education and so forth.
And could you talk about MSP churn something we’ve heard about in the industry a lot of people are deciding to move to vendor neutral even many staffing led MSPs kind of looking and seeming like vendor neutral at this stage. Love to get your perspective and what do you think we’re kind of more than half the way through the post-pandemic churn that is likely or there’s still a lot to come?
Sure. This is John, Tobey. I think there is, we’re probably not halfway through the churn going through out there in the market. The sentiment has turned over the last year towards the vendor neutral – moving towards the vendor neutral platform.
And we’ve been pretty transparent that we had a higher churn that we’ve historically seen as well and those losses have come to for the most, to the vendor neutral players. And that’s one of the reasons as I mentioned earlier why it is important for us to launch Intellify to be able to play in that space and having our first two wins of the year and implementing both of those is key for us to gain market share in that space.
And, it’s very difficult. I’ll tell you back right after the great recession 2008-09 we saw them moved to vendor neutral at that point as well and then once the affordable care act came into play in 2014-15 we saw MSPs become the flavor of the day for about five year period actually probably due to pandemic rose, probably a 50:50 split between MSP and VMS and now it’s moving towards that VMS.
And to your point, yes, even strategically led MSPs are now looking a lot like vendor neutral. Now here’s what I tell you why that’s not bad for us and even in some of the churn that we’ve had ourselves, we’d have developed such great long-term relationships and because how we’ve acted ethically with our clients and how we perform for our clients over the years, when we do lose a client of churn to VMS, in most cases, we actually become a preferred vendor and/or even Tier 0 which means we actually still received the orders first.
And the other thing that we’ve seen when we do go and have this churn on these clients, is that, many times we’re only a portion of a large health systems MSP, and there’ll be another MSP vendor in there, and when they consolidate under one platform, will then be able to be Tier 0 in the whole system.
We had one last year that we had lost and now we actually have more travelers on assignment. In that former MSP, because we have to access now to the whole system. So, yeah to answer your question, yeah we’re definitely seeing it more towards go to vendor neutral, we think we position Cross Country very well with the Intellify rollout.
We believe our technology Intellify with our internal resource pool or a technology or apps that all support clients’ to white label this technology from the shelves to create and utilize Intellify for their own internal travel pools as well positions us well to capture market churn to vendor neutral space. Dan, you got something?
Yeah. Tobey, I just wanted to add a little bit more color to this idea of churn. It’s really important to remember that these contracts where they’re vendor neutral or not, are typically three years. And when you taken to consideration that no one was doing anything through the pandemic, it’s just makes sense, right, that a lot of this activity is happening because it’s just sort of supply chain hygiene, if you will, right, to get back on track with that activity. So, we expect there to be a lot of activity. We see you know lots of RFPs and a lots of activities coming from all kinds of sources.
And this is John again, Tobey. I would just add the other thing is, this is probably the biggest pipeline we’ve had between vendor neutral and MSP that Cross Country has ever seen. So there is a lot of churn in the market. And it seems like healthcare systems are all reevaluating what they’re going to do and which bottom they’re moving forward with.
And thanks for all that – that context. Just as a follow-up. Are you winning or losing share amid all of those – all that pipeline and activity in the marketplace?
You know, right now, I think we probably lost a little bit of share, but you know you have a couple of factors, right. So you have bill rates coming down, volumes coming down. We’re still you know well over $1 billion of spend in their management in our MSPs and now we’re adding onto vendor neutral.
So as I think we will get to little bit I think you know this is a long-term gain for us and as we’re just getting into the vendor neutral space, I think we’ll quickly make that up.
And, Tobey it’s Bill. You know I mean I think you asked the state question where we’re in the process. I’d say, it’s still early innings for Intellify, we – John called out the 50% converted on the MSP program so we got that much of a spend already live. We’ve obviously got a roadmap to convert more by the end of third quarter I think that number will be north of 75% and we’ve got one vendor neutral live, one being implemented. So it’s early innings for Intellify, but it’s making great strides.
Thank you.
[Operator Instructions] Our next question comes from Bill Sutherland with The Benchmark Company. Your line is open.
Thank you. Nice work, guys on the quarter. Bill, can you go through the 4Q seasonality, just remind us. I know education rebounds strongly. What else do you see usually?
I mean I could say that the businesses that usually see some seasonality in the fourth quarter, locum tenens and this is historical, not what we expect to play out, because there’s such tailwinds there. But historically locum would see a small low single digit sequential decline going in the fourth quarter, we’re not anticipating that. I would actually say we’ll probably see sequential growth going into the fourth quarter in that business.
Education, you mentioned, they come off of a, you know their lowest point of the year. In fact, there’ll be down about 25% sequentially but, the growth going into the fourth quarter because of the new school year that could be 30%, 35% sequential growth. So they usually bounce up even higher than they were in the quarter before that, so I think we’ll see really good growth there.
The travel business, we don’t tend to see a lot of seasonality in the fourth quarter for us, believe it or not, that’s actually a little bit of a slower start to the first quarter. And then in our local business, I’d say, the holidays tend to impact us a little bit more as you go through you know the Thanksgiving and the yearend holidays, Christmas, New Year, et cetera. So, those are the general impacts that we’re seeing through the fourth quarter.
They tend to be muted out. I mean, so you have education come back, you have a little bit of headwinds on the local side and I think you know in this case, locum tenens will be a tailwind. So I don’t want to anticipate a big seasonal change in the other businesses, that’s going to drive the revenue numbers.
Okay. Hey, John is your physician staffing business all locums now or do you still have recruiting replacements?
It’s 99%. I think it is very little. It’s a 99.5% probably very high, Bill can give you that number. It’s majority of it, is locums and you know look that’s one of the areas that we’re excited along with education and home care, where we’re growing those businesses and it’s a very good market for locums, Bill.
And as Bill Burns mentioned, that business is up 32% year-over-year organically. A 105% with our acquisitions of Mint and Lotus, we’re going to make that business, so it’ll be a $180 million business and it’s interesting when you sort of looking at the diversification of Cross Country. And as we start to grow certainly into locums, become a much more major player of the locum space, our education business is a business that we acquired in 2015 and it’s done well certainly for us, but on higher revenue, we grew it year-over-year 42% and that’s a business that will be a $100 million business as well.
Our home care business we required a little over two years ago, that is a business that will be over a $100 million businesses. So, and just sort of looking at Cross Country, and how we’ve really executed in such a different level over the past four years, it’s really been an amazing turnaround of what’s happened. You know as we look at what nurse and allied business - travel nurse and allied business and yes we’ve had these COVID tailwinds but we believe we’d executed at market or above market during the whole pandemic and still to currently today.
And as the market is the market in travel nursing right now and it’s obviously it’s the bill rates have come down and volumes have come down and we anticipate those to take a while towards the year. Cross Country continues to execute very high level and if we look at our nursing – I’m sorry our locums, our education and our home care business those were all executing at a high level. So we’re very excited about the prospects. Dan?
Hey, Bill I just figured I would add some color since you were asking a little bit about sort of term placement, if you will. I think it’s important to note that in addition to whatever new sales we’re making, we’ve had really great success, cross selling into the accounts that we already have. So, you know we’ve had 18 different services added into our client base.
Six of those are in that RPO search kind of business, but as John mentioned, you know interim leadership, locums are all really doing nicely in our base accounts. And that I figured out also at we got our first home care you know pace program go live also on Intellify. So, it’s really you know getting, hitting across all of the businesses, locums, our pay centers, et cetera are all now on that same tech platform.
Dan, is that – does that Intellify for a pace centers back your second vendor neutral?
No, that is not a new customer. That is implemented and an existing pace customer.
And this is John, Bill. That is actually MSO or an MSP it’s certainly going to be MSP that one.
Okay. Allied is, I don’t think I kind of mentioned, I’m just kind of curious kind of how that’s doing and sights with insight nurse and allied?
Yeah I mean the travel and allied side of the business is actually faring quite well when you look at that relative to travel our ends I’d say that the rate reductions haven’t been as steep, the volume declines haven’t been as steep. It’s on track I would say you know to be north of a $400 million and well north of that it depends well how the year – trajectory plays out. But it’s a good size of the travel business.
This is Marc, just to add a little more. Imaging continues to see robust demand, cath lab, X-ray, MRI, we term it the path of the surgery you know pre-posed continues to see very heavy demand. Anything related to cardiovascular services also very high demand on the allied space.
And then just going to wrap up with just revisiting this revisiting this situation here with the nurses and their pay expectation. So you’re just figuring that as the [RECs] [ph] go unfilled, hospitals get frustrated, they start to put out the – you know put to give you the pay rates that you can actually fill the REC. And that’s kind of just the natural progression you’re expecting?
I think, it’s more of a combination. I think, nurses and rightfully throughout with the pandemic, right, going into the burning building as we needed them. Their pay had increased during these crisis needs quite high. And now the expectations as these bill rates are coming down, as the pay rates are going down.
So I think there’s a natural – people will agree on that, we will hit where bill rates will still settle in where we think they will, 30% to 35% above pre-COVID levels. And the nurses will understand that, that’s where the market is now of the pay rate. And we think that will happen as demand continues to increase.
So maybe hospitals will bring some of their – and I would say you know about half of our orders that we have on open demand, half of them are probably below the market of where we need to fill and half of them are probably at the market where we need to fill. So those ones that are below the market, yeah, we do anticipate some of those rates will come up. But we also anticipate that the nurses pay expectation on the higher end of the market will come down more to where the market rates are. If that makes sense?
Yeah. And so what happens with the spread, John, in that case?
The spread should have very little impact to us on the gross margin spread, because the nurses pay will come down as in line with the gross – with the pay – with the bill, I’m sorry. But with that said, in a tighter market, you know you could see a little bit more pressure on margins. But up to this point, we have not seen a tremendous amount of pressure on margins. So Bill, I know if you want to –
Yeah. Bill, I would just add that for the second quarter, we saw bill pay housing spreads. It’s important to include that as well, because that was part of what was holding down the gross margin on a year-over-year is up over 40 basis points. So we’re seeing that the bill pay spread is holding up as bill rates are coming down, but it is slowing down some of the production you know for folks making a decision to take an assignment. So you’ve got those two pieces need to settle into that equilibrium John mentioned.
Okay. Thanks again.
Our next question will come from Kevin Fischbeck with Bank of America. Your line is open.
Okay. I just want to maybe go back to another question about the visibility that you have. I guess this is the second time you cut guidance this year. And when you think about kind of where that shortfall has materialized versus your initial expectations, you know where has that been? And I guess, do you feel like that you have better visibility today on that driver? Or is that still kind of an influx moving target that’s hard to fully come down?
Hey, Kevin, it’s Bill. Look, I think the expectation was a few months ago that we would see that curve bending on the number of travelers on assignment starting to regrow earlier in the third quarter. We’ve seen it level off, and we’re seeing some modest improvement throughout the quarter, but not to the degree we wanted. So, that’s really what it is. It’s coming back to saying, the third quarter seems to be – still be the trough.
The outlook improving, we have bill rates that have stabilized in the market, improving – still improving demand in the backdrop. So it points to that fourth quarter. And as you get the seasonal needs that we expect, you know it’s something we’ve seen every year. So it is expected to come through. That will give that actually a little bit of uplift that we’re expecting to make the fourth quarter the turning point on the volume side.
And I guess maybe that earlier point, I think that, John made about the – that some of these orders, the 26-week orders are people are waiting on it, and that you expect them to be more just in time. I mean, is there a reason why people would be waiting on it? Or does that increase the risk that you won’t see that seasonal increase that you would normally be expecting?
So Kevin, it’s two parts. Two parts is, we’re seeing the 26-week orders come in now as hospitals want to lock in the clinicians longer. But for the flu season. But what we’re seeing is, historically, pre-COVID, we would see these flu or winter orders start coming in, in July and certainly by now entering August, we’d start seeing come in a much more higher volume.
That’s not happening now and the sentiment we’re hearing from our clients is that, they’re just waiting because these orders, while we receive them now, the clinicians will start in the fourth quarter and then into the first quarter. They’re just waiting a little closer to see where their needs are going to be and how they want to manage that contingent labor.
The other thing we’re also hearing is that, there is – for the RSV, which hit hard last year, there is now a vaccine that is going to come out on the market and we can get approved. It depends what age group that will be approved for when the pediatric hospitals find out what age group that will be approved for, that will also depend on how many clinicians will be, because if it’s approved for an infant, they’ll need less contingency labor, if it’s only improved for a 5-year old or older, they will need more. So there’s a couple of factors why they’re waiting.
Okay, thanks.
Thank you. Our last question will come from A.J. Rice with Credit Suisse. You may proceed.
Hi everybody. Thanks and I missed at the beginning a little bit, so I’m sorry if I duplicate this. But it sounds like you were down about 9% in travelers on assignment in Q2 from Q1, if I got that right. But it sounds like you’re saying orders were there. It’s just that the people became unwilling to fill those orders, because they had higher expectation on pricing. Is that right? Or is this more a go-forward phenomenon that you’re mainly trying to call out today?
It’s not a perfect correlation to be clear. So I think orders had fell so sharply that the decline in TOA was going to happen. We had signaled that last quarter. The rebound in orders is there. But as we said, we’re just not seeing the weekly production ramp as quickly following the order trends. So it’s a timing issue of building back the travelers on assignment rather than whether there’s enough orders.
There’s – the orders are there, I think, to be able to put the travelers back on assignment, but it’s a little bit of what John had talked about, about the pay expectations relative to the open orders that are there today. So we have every expectation that we’re going to see the TOA grow as we move through the quarter and as we get into the start of the fourth quarter.
Okay. I mean there’s a couple of things and maybe these are dumb questions, but I’m going to ask. We hear this anecdotal stuff of people that are travelers and they’re making so much money for 9 months, if they take the summer off. Is any of this a phenomenon in your mind that travelers haven’t engaged for the summer and when they come back in the fall, then you’ll see more plentiful supply to fill some of these orders?
It’s Marc. I mean, we see a little of that. I think that’s a little overblown. Most of our travelers will do two or three assignments and take time off. It’s not just – it’s very seasonal. But I think the notion that they made all this money and they’re taking the time off is actually not true.
Okay. Okay. Another thing we are hearing from the hospital side is that they’re accelerating their hiring of permanent labor. As you run through the people that you’ve been recruiting for travel assignments, are you finding that a percentage of them are just choosing to go back in this environment and back to their traditional permanent assignment? Is that part of what’s going on?
That’s not a large part. Of course, there’s always a portion of nurses who came into the marketplace during the pandemic, who were not travelers who now are going back to their permanent jobs. But there’s – I would say there’s more nurses that we’ve gained into the Travel Nurse pool because of the pandemic than we’ve lost going back. And so yes, so there’s a small portion that had gone back, but most travel nurses still want to stay in the market and remain to have that flexible workforce and be part of that gig economy.
A.J, this is Dan. I would add though, so while it has – I’m not disagreeing with anything that’s just been said. I would also mention that our RPO customers and our existing client base absolutely are ramping up their own internal TA functions and getting better at this. And that’s an area, so you might be mixing the two and you don’t necessarily have to.
Well, this is John again, A.J. Yeah, hospitals have done a tremendous job of reducing the contingency spend and bringing on permanent nurses. But with that said, there is still such a systemic issue in the shortage of clinicians, nurses, in particular, that this is an issue that’s not going to be solved by bringing in some of these nurses. The hospitals that have – are bringing down their contingency labor spend, there’s still, in most cases, still double of where they were pre-COVID. So there’s still a lot of need for contingency labor.
And frankly, especially as Dan was saying, in the RPO business, there’s still a lot of need for more nurses to go back permanently into the perm jobs. So I think this is why we’re very excited and very bullish upon our industry. While travel nursing has normalized, moving back to normalization during coded, and now we’re seeing where the bill rates will in the next couple of quarters will come in plateau and we’ll leave 30% to 35% above pre-COVID levels.
And we’re seeing demand start to tick up, and we’ll get that equilibrium for the pay and the build balance, and we’ll start to see those sequential growth throughout the back -- during the back half of the year. What excites us and why we’re bullish is because the systemic issues aren’t going away. Whether it’s the BLS data or the report, the surveys are coming out, there’s just not a solution that will solve this problem in the near future.
Okay. Let me just ask one other one. On the comment about seeing more hospitals be willing to consider vendor-neutral alternatives to MSPs and so forth, and you’re getting called in to bid on that. I wonder, did you have perfect view before, before you had Intellify? Because it seems like to me, Intellify has made you competitive there, and really up-ed your game on the vendor-neutral side. So I’m wondering, are you just seeing more of what may have, in some ways, already been out there? Or is it really indeed a big shift in the way people are thinking about whether they want to try vendor-neutral or not?
This is John, A.J. And we have more visibility now to all the programs that hospitals are wanting that we had before because prior to having Intellify, we didn’t have a vendor-neutral offering. And so, when our sales teams, and we have multiple sales teams going in from a vendor-neutral perspective and from a MSP perspective, when we didn’t have the vendor-neutral sales team, when we were calling in with the MSP, if a client didn’t want an MSP, we were essentially shut down. Now that we have 2 different offerings, we’re able to go and have visibility on to which of the clients that are focusing on having a vendor-neutral VMS, and we’re getting a seat at that table.
Dan, do you want to add anything to that?
Sure. So A.J., you might also think about it this way. Many customers who went into the pandemic with a vendor-neutral solution are now coming to us saying, “Gosh, I wish I had more support and more services”. And whether that’s a traditional staffing-led MSP or just some additional set of services, they’re coming to us with, “I wanted something different than what I had going in”.
So I think a lot of this is just customers, number one, having to go-to-market; and number two, seeing alternatives out there that they might not have had before. I’ll use the example of an internal resource pool that – the technology for that really wasn’t that available prior to the pandemic, and a lot of us have built some pretty sophisticated tools now that allow them to do that.
So coupling on those and internal travel agency capability, and just a lot more sophistication. It’s very hard for me to just tell you that, “Oh, this one is purely vendor-neutral, and this other one is purely a traditional MSP”. It’s just not like that anymore. We have a much more sophisticated and needy in the proper-sense client.
Okay. Great. No, that’s helpful.
Thank you. Ladies and gentlemen, this does conclude the Q&A period. I’ll now turn it back over to John Martins for closing remarks.
Thank you, Sheila. In closing, I’d like to thank everyone for participating in today’s call, and we look forward to updating you on the progress of the company on our next call.
Ladies and gentlemen, this does conclude today’s conference call. Thank you for your participation. You may now disconnect.