Cross Country Healthcare Inc
NASDAQ:CCRN
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Cross Country Healthcare Inc
Earnings Call Analysis
Q3-2023 Analysis
Cross Country Healthcare Inc
The company's revenue for the third quarter stood at $442 million, squarely in the guidance range but at its lower end, representing a decline of 18% from the prior quarter and a substantial 30% decrease year over year. This downward trend was primarily attributed to a 'normalization' in the demand for travel and local permanent job placements and a decrease in bill rates. Concurrently, a narrower gross margin of 22% was observed, a sequential dip of 75 basis points, influenced by heightened healthcare insurance costs and workers' compensation burdens, amidst a highly competitive market environment.
To counterbalance the softer revenue and gross margin, the company adeptly reduced its Selling, General and Administrative expenses (SG&A) by 12% sequentially and 13% compared to the previous year to $70 million, largely due to decreased variable compensation post-pandemic performance and ongoing salary overhead management. They also strategically decreased their internal workforce by approximately 20% since the year's start while continuing to target investment in the most promising business areas and their technology team.
The business reported an adjusted EBITDA of $27 million, equating to a margin slightly over 6%. Although this quarter saw a contraction in profitability, management emphasizes their focus on long-term sustainable profit growth, envisioning eventual adjusted EBITDA margins reaching high single digits to low double digits in future periods. Moreover, with a notable reduction in interest expenses by nearly 80% due to lesser borrowings and a substantial cash position, the company is set to see further decreases in interest obligations.
The company's largest segment, Nurse and Allied, faced a 20% sequential dip and a 35% reduction year over year, with its Travel Nurse and Allied unit experiencing a more pronounced downfall. Nonetheless, they foresee potential mid-single-digit declines in rates and volumes. In contrast, the Physician Staffing segment delivered a robust performance with a 92% surge in revenue, indicating a strong foothold in high-rate specialty areas, even excluding the influence of its strategic acquisitions.
With a strong operating cash flow generation of $70 million in the quarter and $236 million year-to-date, the company's financial health remains robust, marked by aggressive share repurchases and a commitment to a $100 million share repurchase plan. The Days Sales Outstanding (DSO) saw an improvement, and continued progress is aimed towards tradition aligning levels below 60 days.
Looking ahead to the fourth quarter, the company anticipates a revenue range between $400 million and $410 million, suggesting a 7-10% sequential decline, primarily because of expected further drops in travel-related revenues. Adjusted EBITDA is forecasted to fall between $19 million and $24 million, which would correspond to a margin of approximately 5% at the midpoint. Adjusted earnings per share are projected to be $0.25 to $0.35, reflecting a persistent strategic vision for durability and profit resilience.
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Good afternoon, everyone. Welcome to the Cross Country Healthcare's Earnings Conference Call for the Third 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 Martin; 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 third quarter of 2023 as well as our outlook for the fourth 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 today, 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 U.S. 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, everyone, for joining us this afternoon. Overall, I was pleased with our continued ability to execute in what remains a challenging market. For the third quarter, consolidated revenue was $442 million, with adjusted EBITDA of $27 million, primarily reflecting a tightening in bill pay spreads within our travel business. I'll touch on some of the market dynamics in a moment, but I want to stress that we continue to manage the business for long-term success and strategically position ourselves for future growth opportunities as we see in the market. As expected, travel revenue was down 22% from the second quarter, driven by both lower rates and fewer travelers on assignments. Average travel bill rates declined approximately 8% sequentially, in line with our estimates for a mid to high single-digit decline in both the third and fourth quarters. Demand for travelers remained fairly stable throughout the third quarter after having rebounded from the lows we experienced in the second quarter. Seasonal needs remain below expectations, but we do still anticipate that will pick up as we progress through the fourth quarter. Regardless, the relative softness in demand will likely impact the number of travelers we have on assignment over the near term. As we have called out previously, bill rates for open orders have largely stabilized, but in many cases, remain too low to attract targets needed to fill them. As a result of the pullback in bill rates this year, amidst elevated compensation expectation for nurses, we are seeing some margin compression due to a tightening in the bill pay spreads. So this appears to be a broader issue across the industry that may persist for the next several quarters. We will strive to remain competitive in order to preserve our market share while protecting our profitability. Our local or per diem business has also felt the impacts from the softness in demand as clients continue to seek to reduce reliance on contingent clinical staff. Turning to our other business lines. Physician Staffing continued its strong performance with reported revenue up more than 90% year-over-year, putting us quickly on pace to hit an annual run rate of $200 million. And on an organic basis, decision staffing was up 21% from the prior year, continuing to outpace the low double-digit growth projected by the staffing industry analysts. Driving this was a combination of higher billable days and an improved mix of higher bill rate specialties. As one of our fastest-growing businesses, we continue to make investments that will fuel organic growth. And though the contribution income for the business remains below our target, we believe the continued ramp in production, combined with targeting higher margin specialties will ultimately lead to improved profitability in 2024. Within Nurse and Allied, our education business returned from summer break and started off the new school year strong, continuing its trend of double-digit year-over-year growth in the third quarter. Our Home Care business also performed well in the third quarter, up mid-single digits both sequentially and over the prior year. On the back of 5 home care MST wins since our last call, this business is poised to reaccelerate entering 2024. Now let me spend a moment on Intellify. Our proprietary vendor management system that we believe is a market-leading platform for clients that provides data analytics and real-time insights. As we previously shared, Intellify not only saves billions of dollars with our MSP accounts, but it opens up a multibillion-dollar opportunity in the vendor neutral space. Since launch, we have not only converted more than half of our MSPs onto Intellify. We have won 5 new vendor-neutral programs, 2 of which that are live today. This showcases our ability to implement programs in rapid succession. Our most recent win is also our largest date with annual spend expected to be in excess of $100 million once fully implemented. On the back of this win, we are continuing to expand the functionality of Intellify by introducing predictive analytics and time and attendance, building on our robust baseline feature set that already includes industry-leading dashboards and reporting, internal resource pools, internal travel programs, MSPs for Nurse and Allied, per diems, locums, nonclinical and RPO. These new add-ons will greatly enhance the value proposition for our clients. Shifting gears. We know that pay transparency has been important to the industry in recent years. Today, I'm excited to announce that we have created a new company called Cross Country DAS, which introduces bill rate transparency by utilizing data analytics to provide health care systems with independent objective, real-time insights. We believe the data analytics tool offered by DAS is the first such solution in the market. This new offering can be embedded within Intellify or licensed on a stand-alone basis. In fact, we recently licensed DAS to a large national health care system, which is utilizing the tool to price check providers on a local, regional and national basis. This client has credited DAS with helping save them billions of dollars from their current staffing providers. Though not yet material in dollars to Cross Country, it is significant in terms of the value we bring to health care systems. This further showcases our ability to develop and deploy innovative technologies to advance health care and help hospitals rationalize their costs. This brings me to our outlook. Given my earlier comments on the current market backdrop, including recent demand trends and industry-wide market pressure, we anticipate that fourth quarter revenue will be between $400 million and $410 million, with adjusted EBITDA coming in at $19 million to $24 million. For the full year, the guidance implies we'll generate between $143 million and $148 million in adjusted EBITDA, representing a margin above 7%. As previously noted, we will continue to balance investments with cost savings to preserve profitability while ensuring we maintain sufficient capacity to fuel long-term growth. Though we are not providing guidance for 2024 at this time, we have seen stability in the broader market and believe we can achieve similar margins for the full year in the high single digits given the expected tailwinds from recent wins, continued growth from higher-margin businesses like education and home care staffing, as well as enhanced productivity driven by our technology investments and leveraging our low-cost center of excellence [indiscernible]. I am confident in our ability to drive long-term sustainable profitable growth, and we remain focused on increasing shareholder value through our deployment capital. As noted in today's press release, our cash generation was solid in the third quarter, allowing us to continue repurchasing our shares as well as paying down all of our debt. We will look to leverage our technology investments and healthy balance sheet to further enhance our platform as well as diversify our offerings as we follow the patient across the continuum of care. In closing, we are confident about our prospects exiting the year, specifically our ability to build upon the early momentum from Intellify, which we believe will be a meaningful driver of long-term revenue growth and margin expansion. I want to thank our devoted employees for their ongoing hard work and contributions. We were recently named to the top most 100 loved workplaces by Newsweek as well as the 2024 best companies to work for by U.S. News and World Report. These recognitions validate our efforts to foster a culture of growth, inclusion and well being. Lastly, thank you to all of our professionals who may Cross Country their employer of choice as well as our shareholders for believing in the company. With that, let me turn the call over to Bill.
Thanks, John, and good afternoon, everyone. As John highlighted, our consolidated revenue for the third quarter of $442 million was within our guidance range, albeit towards the lower end as our local business experienced softer demand for per diem assignments than we anticipated. Compared to the prior year and prior quarter, revenue was down 30% and 18%, respectively, driven in large part by the continued normalization in both travel demand and bill rates. I'll get into more detail on the segments in just a few minutes. Gross profit for the quarter was $97 million, which represented a gross margin of 22%. Gross margin was down 75 basis points sequentially due to the compression of bill pay spreads in both the travel and local businesses as well as an increase in burdens such as health care insurance and workers comp. As John mentioned, the industry remains very competitive, and though pay rates have come down slightly faster than bill rates, the cost of housing remains very high, driving down the overall margin. Moving down the income statement. Selling, general and administrative expense was $70 million, down 12% sequentially and 13% 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 in prior quarters. We continue 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 third quarter into the start of the fourth, we reduced our internal headcount by approximately 20% since the start of the year, while continuing to invest in areas of the business with the highest growth potential as well as in our technology team. Based on the cost actions taken to date as well as lower compensation associated with the sequential decline in revenue, we anticipate total SG&A will decline in the low to mid-single digits for the fourth quarter. And as a percentage of revenue, SG&A was 16%, up from 15% last quarter and 13% in the prior year. With the revenue at the lower end of our expectations and a tighter gross margin, we reported adjusted EBITDA of $27 million, representing an adjusted EBITDA margin of just over 6% for the quarter. As we stated before, we are managing this business towards long-term sustainable profitability, which necessitates certain investments to be made to ensure sufficient capacity to achieve those goals. We believe that as new Intellify programs ramp and we continue to drive productivity improvements across the business that we can achieve our stated goal of high single to low double-digit adjusted EBITDA margins in the coming quarters. Interest expense was $700,000, which was down nearly 80%, both sequentially and from the prior year. The decline was entirely driven by lower average borrowings throughout the quarter. The majority of the interest expense reported for the third quarter was related to the carrying costs for the ABL and the fees on our outstanding letters of credit. Though we ended the quarter with no outstanding debt, we may continue to see amounts drawn and repaid under the ABL during the coming quarter, but we expect interest expense will continue to decline as we're likely to be a net cash position for most of the quarter. The effective interest rate on amounts drawn under ABL was 6.8% as of September 30. Also on the income statement, we reported $4.5 million in depreciation and amortization, which continues to grow as our technology projects are completed and put into use. And we also recorded an additional $2 million in bad debt expense, which was down 25% sequentially. And finally, on the income statement. Income tax expense was $7 million, representing an effective tax rate of 34%, which was a little higher than we expected. Based on the current mix of business, we now anticipate a full year effective tax rate of approximately 31%. Our overall performance resulted in adjusted earnings per share of $0.39, near the midpoint of our guidance. Turning to the segments. Nurse and Allied reported revenue of $397 million, down 20% sequentially and 35% from the prior year. Our largest business, Travel Nurse and Allied, was down 22% sequentially and 39% from the prior year. Fill rates for travel were down 8% sequentially, while billable hours were down 15%. Looking to the fourth quarter, we expect travel to decline sequentially in the high single to low double-digit range, with rates and volumes anticipated to be down in the mid-single digits, respectively. The decline in billable hours is driven by the continued softness in overall travel demand and delayed seasonal needs. With our current capacity, the possibility remains that we could see sequential growth across the quarter as new Intellify programs ramp and seasonal orders are received. Our local or per diem business continues to feel the impact from the softness in demand with revenue down approximately 14% from the prior quarter and 32% from the prior year. The majority of the decline comes from a reduction in billable hours as rates were down about 4% sequentially and over the prior year. Also within the Nurse and Allied segment, both our Education and home care staffing businesses reported year-over-year growth. Our education business, which was impacted by the summer break, is poised to see a strong fourth quarter returning to higher double-digit growth. And finally, Physician Staffing once again delivered robust performance, reporting $46 million in revenue, which was up 92% over the prior year. Excluding the impact from the Mint and Lotus acquisitions completed last year, the business was up 21%. Average revenue per day filled continue to improve as we focus on higher rate specialties and continue to experience softer growth – sorry, stronger growth across the locum specialties relative to lower bill rate specialties within advanced practices. Turning to the balance sheet. We ended the quarter with $14 million in cash and no outstanding debt. With the health of our balance sheet and strong cash flow, 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 $70 million in cash from operations in the third quarter, which represented a 260% conversion on adjusted EBITDA. On a year-to-date basis, we generated $236 million in cash from operations, by far our strongest performance in a 9-month period. Driving this performance was strong collections as the business continues to normalize.DSO was 67 days, down 5 days since the start of the year. Our goal remains to bring DSO below 60 days, which is more in line with our historic performance, and we believe that we can continue to make progress towards that in the coming quarters. As I mentioned, we've done a good job of collecting on our receivables and believe opportunity remains for further improvement. Cash used in investing activity was $3 million, reflecting investments in our technology initiatives. From a financing activity perspective, we paid down $30 million on the ABL and repurchased an additional 617,000 shares. And this brings me to our outlook for the fourth quarter. We're guiding to revenue between $400 million and $410 million, representing a sequential decline of 7% to 10%, driven predominantly by the expected decline in both rates and billable hours for travel. We're guiding to an adjusted EBITDA range of between $19 million and $24 million, representing an adjusted EBITDA margin of approximately 5% at the midpoint of guidance. As John mentioned previously, we're managing the business for longer-term success, not to a single quarter and continue to believe that we can achieve and maintain high single-digit adjusted EBITDA margins. Adjusted earnings per share is expected to be between $0.25 and $0.35 based on an average share count of 34.4 million shares. Also assumed in this guidance is a gross margin of between 21.5% and 22%, interest expense of $500,000, depreciation and amortization of $5 million, stock-based compensation of $2 million and an effective tax rate of 31%. And that concludes our prepared remarks, and we would now like to open the line for questions. Operator?
[Operator Instructions] And our first question is from Brian Tanquilut with Jefferies.
I guess my first question, as I think about the seasonality of demand and what you're seeing in Q4 and maybe weighing that versus just the fundamental demand for core contract nurse staffing. How are you thinking about those dynamics going forward? Maybe just looking at it even past Q4.
Brian, this is John. Good evening to you as well. So what we're looking at the demand in the fourth quarter. I think we'll start back in April when we saw the low of demand hit at the beginning of April this year. Then we saw demand tick up to today about 30% where we sit up from where we were in the low of April. And we're up about 7% from August.Now, we were all anticipating much larger volumes of winter demand that never really materialized. And so the majority of the orders that we have now, up 30% from April are -- the overwhelming majority are non-winter needs or core staff. And so we really feel at this point, demand has stabilized in the market moving forward. And while there may be a little bit of winter orders in these numbers, it's not more than 5% in the numbers that we have right now. And that will continue to be stable in orders moving forward. And again, maybe a little tick down of these winter orders that are in the mix of the orders we currently have.
And then maybe as I think about your margin commentary for, as I think about what you had previously stated goals for kind of sustained double-digit margin levels, obviously not there today. How should we be thinking about the ability to drive that up as we think about 2024? And maybe, Bill, just any comments you can make in terms of how we should be modeling factors to think about as you model 2024.
Yes. Sure, Brian. Good evening to you. So I think when you look at the third quarter's performance, the pay bill spreads were a bit more compressed than we would have anticipated at the start of the quarter. That's a function of a few things. There's a lot of still heavy competition for the candidates, bill rates, though they've stabilized on open orders still seem to be a bit lower than where we'd like to see them in order to generate the margins we'd like.But really, when you look under the hood, it's not that the bill rates have come down, the pay rates are coming down. It's that the housing costs still kind of remain pretty stubbornly high, and it's also a mix of where we're sending our clinicians. So there's a little bit of that going into the pay-bill spreads. The other things that really impacted the quarter, we had a little bit of an uptick in health insurance. A few more people went to the doctor and what was anticipated. So our health costs rose a bit more than we were looking forward to. And then we also had some actuarial adjustments to workers' comp. So those were the 3 big drivers to the kind of the 75 basis point decline we saw sequentially. And so we're not modeling that to bounce back going into Q4. As we move through 2024, I think there is some opportunity that payable spreads could improve. I think the mix of the businesses as locums continues to grow, Home Care continues to grow well, Education, high double-digit growth is expected for the fourth quarter going right back to the trajectory they were on. And then you move beyond that and you say, okay, so what else drives the margins? Well, Intellify, we talked about this numerous times, but obviously, the more we can grow spend under management from the vendor neutral programs. You got the capture on that spend, but then you also have the fees that are attracted to the portion you're not capturing. So we just had our biggest win, $100 million account. We're really excited about that. That account is actively in implementation, hopefully, won't probably go live until, if it does, late Q4 or early Q1 at this point in time, but it's moving forward in the Q. So I think that's another opportunity. And then we still have a handful of accounts that have not converted. And when I say a handful, there's relatively few, but they are some of the larger ones that are on third-party tech that we've just had to kind of delay because we've been kind of busy implementing the other new wins that we've had. So as we talked about, we've always said we would prioritize new wins to migrate to Intellify before we kind of move old programs off. But that's another opportunity as we go into the new year. But realistically, beyond the mix, beyond Intellify, I think you start looking at SG&A. And I can tell you there's a real concerted effort internally for us to look at how do we become more efficient as an organization, how do we improve productivity across the organization. There's a lot of levers we can pull. Again, we've talked about this a little bit as well. We have a nice -- a very good center of excellence in India that we can certainly leverage more than we have. We have a few hundred people there today. The idea here is there's much more we can do with that group. So we're looking at that. I think also then we've got the back-office systems and the middle office systems that we've got that long-term Oracle project that we've been doing. That will be ramping and going live throughout 2024 and into 2025. That will drive some efficiencies as well.Because today, unfortunately, a lot of our middle office is on different platforms. So that means billing, collections, cash apps, payroll are all done through different platforms. So as we kind of migrate to one common platform, we'll have more efficiencies as well. But John, anything you want to throw in there?
Well, yes, I would just add and the investments we're making in the technology with Intellify and experience and as we're creating a very -- and we have an integrated system that allows our clinicians to self-service more and more, that will also create some efficiencies on our recruitment and production side as well.
Our next question is from Kevin Fischbeck with Bank of America.
Maybe just a follow-up on that because it looks to me -- you guys talked a lot about bill pay spreads in the quarter, which are obviously a pressure. But it does look like since the revenue peaked in Q1, you've had 6 straight quarters of sequential declines in revenue, but you've also had 6 straight quarters of sequential increases of SG&A as a percentage of revenue over that time. So it feels like most of the margin compression has actually been on that G&A side.And although you've done a great job taking dollars out. So the dollar number is certainly trending down as a percentage of revenue is not coming down fast enough relative to the revenue drop. So like I mean, how do you think about that going forward? If bill rates or total revenue drop, like, is that where the deleveraging happens? Where is the biggest opportunity if you think about high single-digit margin sustainably? Where does that G&A number have to be to make that all work out? And exactly kind of how do you get there if the revenue run rate is in a $1.7 billion, $1.8 billion range.
Sure. Well, Kevin, this is Bill. A couple of things. First, you're right, the SG&A as a percent of revenue has ticked up. It's more a function of the revenues come down, but it's been a rate issue more than anything else. And so the clinicians, you're still staffing those clinicians, you still have the body count associated with that. So everything from recruitment to account management to the folks that are responsible for onboarding, et cetera. So you wind up having that issue of the declining average revenue per FTE simply because of the bill rate compression that we've seen.But yes, looking ahead, I do think that the SG&A is the number that we are going to have to squeeze on and continue to find the opportunities to drive it down. Barring anything else, if the margin remained at 22%, and you had to put 8%, you could easily see it, that'd be 14%. So we'd be 200 basis points off of that mark right now for where we ultimately want to get to. So that's what we're lining up to really go after as we move into 2024. I will say further on to the last question from Brian. We've taken a lot of cost actions. We've taken out 20% of the headcount since the start of the year, all with a very -- I would say, it has not been a broad sort approach. We've been very targeted and focused on where we reduce, but it's important to understand, we still have investments in there, right? So we're still spending. There's a fair amount of IT expense tied to projects. from a consulting and professional fees perspective that doesn't get capitalized. And so that's running through there. It's probably north of well over $1 million a quarter that's in there just from third-party spend, maybe $1.5 million. That's in the operating expense from projects. And then you've got other areas that we just haven't scaled down because we still believe in them as opportunities for growth. And so home care education, the business we talked about and physician staffing are still invested heavier than -- we're not at full capacity to say it another way.
Okay. Great. That's helpful. I guess, as you talked about the demand, I think you said 5% of the orders were kind of winter orders. Where would that normally be at this point in the year?
It would be somewhere probably 20% or north of 20%, 20%, 30%. But the difference is, Kevin, we'll be getting the orders of the winter needs and then you fill them because what happens is the starts start happening from October all the way through January, February for those winter needs. So the 5% is more of a stagnant 5%.As we also mentioned in the prepared remarks, a lot of the orders we're seeing, about 50% of them, aren't at the bill rates that would commensurate with the pay rates that the nurses are expecting. And so some of what we're seeing is we don't see the quick return on the orders. And what happens is hospitals are waiting until they are beyond demand, beyond what they need to then increase the bill rate to attract the supply. And so what we're seeing is not as many orders. So it's a combination of, yes, 5% and probably it's about 20% or 20% to 25% of those orders or winter orders, but those orders turn fast. They come in and we start booking them in July, August, September, October. We haven't seen that. We're seeing around 5% and they're taking a little longer to book, if that makes sense.
And then I guess as you think about next year, again, you guys aren't giving guidance here, but I guess, like, do you feel like the Q4 number is like is a good base to kind of start a run rate? Or is there still anything kind of in here where you say like, hey, it's still a moving target as far as where demand and bill rates go? Anything else to kind of think about as far as what Q4 looks like and why that may or may not be a good starting point for next year.
Yes, Kevin, it's Bill again. I'll start on this, and I'm sure John will weigh in. If you look at the fourth quarter and I do think it's a good jumping off point as you look to the next year. There's both headwinds and tailwinds. And just to put that in context, when we look at the travel bill rates, and we talked about there's a lot of stability in the open order rates, and there's a lot of stability for the last 4 or 5 months on the rates that we're locking at.From the rates we're locking at to what's implied in the guidance, there's probably another low single-digit sequential decline in bill rates on travel as you go into the first half of 2024. So you had a little bit of a headwind there. Then it really becomes how fast the other programs really start to ramp from the MSP wins and the VMS wins that we've had. But John, anything you want to throw in there?
I think you covered it, Bill. I think there's puts and takes to everything. I think what we're very encouraged by are those 5 Intellify wins we had this year, which are ahead of our schedule. Winning that $100 million deal that we're implementing right now will give us an opportunity to capture 20% to 40% of that in our staffing side. And then in addition, we did win 5 more MSPs for our home health business. And then we also won a Locum's MSP and we had cross sold to our current existing MSPs, 3 locums MSPs.So one of the things also just looking at our overhead, one of the things where we continue to invest in is, as Bill mentioned, technology because we're never done investing in technology. Obviously, with Intellify we're getting a lot of good momentum with Intellify, but also with our data aggregation services or DAS, that is truly the first, what we believe, is the first technology in the industry that has true bill rate transparency that's catching on. So we're investing in technology. And of course, with that comes investing in marketing to get the word out of this great technology that we have that really, we believe, is industry changing. And then investing in sales because it all goes hand in hand. So we continue to invest in those areas, and that will have some -- we believe will have upside for us in 2024. Dan, do you want to add anything to that?
Sure. Kevin, this is Dan. I just think we should also look at our sales funnel is 25% bigger going into this quarter than it was even last quarter. And last quarter was the biggest one we have ever had. So the opportunity that's ahead of us continues to be really, really strong.One of the things that I'm seeing is that customers are being a lot more selective. We give them way more options than historically we have. So not only MSP or VMS, but some customers are looking at self-managed programs where they just take the technology and manage it themselves. So we see lots of opportunity going. Probably the biggest area of interest in the last quarter has been around our IRP technology. That allows us to help them manage their own core staff first using Experience, our mobile app, and then add in those augmented staff that we can provide on a contingent basis. And so we're really starting to add more value into the whole workforce than we ever have. And from my point of view, I think that's what's really going to begin to make a difference in our win rate.
Our next question is from Trevor Romeo with William Blair.
First, just wanted to ask on the supply side. I guess, what are you seeing in terms of willingness for nurses to either move into travel roles or kind of continue traveling? It seems like hospitals have been pretty successful in reducing turnover. Just curious kind of what extent you're seeing maybe travel fatigue with nurses who did travel assignments, but maybe now have less incentive to travel given the decrease in pay rates.
Trevor, this is John. I think really what we're seeing when you look at the macro numbers, I think it's really looking at the macro numbers and looking at if you look at the JOLTS, the BLS JOLTS data of the openings to hires. And that's, I think, at 2.27%, and it was, I think, 2.27. I think you adjusted from down from 2.3% down to 2.27% for August.I think what we're seeing is that hospitals are still having a hard time hiring nurses and there still is a systemic shortage of nurses that is not going away. And I think they have -- even though while openings declined a little bit, hires have declined even more than the openings. So it's hard to hire nurses now. We did have quite a bit of labor disruptions where we're seeing pay increases happen to the core staff. So that may have slowed a little travel down. But as we've said before, really when you look at the contingency labor in health care and the travel nurse in particular, in Travel Allied, we're just a number or percentage of what the base pay rates are. So when hospitals need to attract clinicians, they have to bring out a certain pay rate that will have a compensation package that will attract enough clinicians. So what we're seeing is as -- and we're seeing the clinicians, as we mentioned, about half of our orders are at rates that are truly not fillable for the pay expectations of clinicians. As hospitals start to want to utilize more of these open orders and fill these open orders, I would imagine we're going to see that there's the opportunity for them to have those lower bill rates to increase the billings that are fillable. And so to answer your question, we're not seeing a lot of nurses leave travel nurse right now. I think maybe 6 months ago, 9 months ago as the market was changing, we saw a bunch of travelers go permanent and we saw the market contract. But right now, with the stabilization of the amount of open orders we have, the stabilization of the bill rates also creates a stabilization of pay rates, which are keeping those travel nurses within the industry still. And actually, one other thing I would add to that is one of the things we've seen in our renewal rates, and that's how we track on a clinician who has an assignment with us and then takes another assignment with us. Our renewal rates are -- has been very steady for the last several months, and that percentage is at pretty much historic highs or historically would have been at our high.
Okay. That's helpful. And then on your MSP contracts, how has your capture rate been trending lately, given the step down in orders? Are you seeing opportunities to boost that capture rate to provide some downside protection? And how do you think about kind of balancing that with retaining supply for potential new orders?
Sure. So we're very careful about our capture rate, and we're very calculated and strategic about it. Historically, we averaged somewhere between 65% and 70% capture rate, and we're right in that market. I think we were 66% or 67% in the last couple of quarters -- last couple of months. And part of that is we could close those orders to suppliers, but we don't.One of the unique opportunities that we have is to make sure that we have a strong supplier network and that we truly are a partner network with them that we're partnering with them and giving them opportunities to fill orders. Because at the end of the day, the more supplier supply we can have, it gives us the opportunity to have our suppliers help fill our current MSPs and then have us at Cross Country, have excess supply to go out and win new MSPs.
Our next question is from Tobey Sommer with Truist Securities.
I wanted to make sure I understood your comments about high single-digit EBITDA margin still sort of achievable. What kind of revenue and gross margin do you assume in that comment that would yield that? And is that comment applicable to 24%? Or is that sort of a longer-term vision?
Tobey, it's Bill. So I guess it's -- I wouldn't say it's a longer-term vision, but I mean it's certainly not a 1Q out kind of a number. I think that there's a handful of things. We do want to see organic top line growth. Obviously, a little bit of gross margin improvement would be helpful, whether that's from improved mix or bill pay spreads or Intellify wins, et cetera.So I think there's a little bit of that, but we're not counting on massive on any one of those in a more significant way than the other. I think it's about a multifaceted approach of getting to that answer. I think we've got to do all of the above. We talked about growing margins. We've talked about tightening our SG&A and getting more efficient. So there isn't really one answer that I'm going to point to that's going to say is more important than another. I think we've got to do it all.
Okay. That makes sense. So -- and if we're going to have potentially bill pay spread compression and you're going to balance sort of profitability and defending market share. Then the sort of the outlook for high single-digit margin could be quarters away, not just a single quarter away. Right?
I mean again, it depends on how the business really performs as we move into early '24, right? So if the larger programs like the one we just talked about, the $100 million program, if that ramps, it has the possibility of potential to add $10 million annually in the bottom line, right? And just broad stroke and thinking about the profitability of how that works with a vendor neutral.So that's a couple of million dollars a quarter right there, just from having that kind of a program go live. So you've got that opportunity. I think the opportunity of getting SG&A down further. When I said earlier, we are laser-focused on this right now. We've got a company-wide initiative to look at how do we take our more manual processes and bring them to a place where we automate them or bring them to the lowest cost possible, right? That's what we're looking to do. So I wouldn't say it's far, far into the future. I mean, I'm not going to go out and put a quarter out there as to when it exactly happens. But it's certainly possible in '24 to see us get back to 8%. Maybe not for the full year, but I think certainly within '24.
And Tobey, this is John. I would just add, we're going to manage the gross margin to the EBITDA, which really means that we'll be looking at that SG&A number to make sure that we get to that to high single digits. And that's how we've being managing the business. And what that means is as we're investing in technology in sales and marketing, as we're – and some of the things that we've done, and as Bill mentioned, we reduced workforce by 20% over the last year.But what we've done is we've also kept enough that we believe as the market rebounds in 2024, we want to be in a position to capture the upside. We don't want to go so low that we couldn't capture the upside of that. And of course, we can continue to flex up or down depending on where the market -- what happens to the market over the next 6 months, 9 months as we look into 2024.
Could you comment on sort of the competitive pressures for market share and gross margin and bill pay spread, I guess are all sort of intertwined? What is the dynamic there as others are probably feeling the same thing and feeling like they need to try to take share to cover their own G&A percentage and have enough revenue on top to kind of hit their margin and profit goals?
Tobey, this is John again. I'll start and have Bill add on if he has any more color to add. But there's definitely more pressure on margins as we saw a demand drop, right, from where we were in COVID. But I think also, there's only -- there's a reasonable amount you could drop, right? So you can only drop a reasonable amount and still retain your profitability.And of course, there will always be some one-off competitors out there that won't go very low. But what happens is they aren't usually able to bring enough supply when they go very low. And so we think that there'll still be pressure on margin as we enter in 2024. But I think we've done a relatively good job of managing that while being able to meet our needs, fill our MSP clients and still really hold our margin in Nurse and Allied fairly well compared to what I'm seeing out there in the market.
Tobey, I would just add, we look at advertised pay packages nationwide, market by market, and we benchmark ourselves. And I think we're certainly competitive in every market we're in. I would say that there are competitors out there who are looking to offer what I would say, are excessive pay packages that are driving margins down, but it's not, to John's point, really sustainable, and we're not jumping on that bandwagon.At this point in time, it's kind of like you look at it and say, well, what would it take it to we had to go to that point? And it doesn't seem like they're getting a lot of share. So I don't know how prevalent it really is that they're all doing this industry-wide. Because we can see it's very, very few. They're increasing the pay packages in general, but there's a handful that have gotten a little bit more on the aggressive side that makes it a little bit harder for us as well. So I think it's a highly competitive market when you're looking at the candidate side, as you know. So we're doing what we can to manage our overall gross margin.
Last question for me if I could. In your fourth quarter guidance, does that include any labor disruption revenue? And if so, is it kind of bigger or smaller than what would average be included in the quarter on average over time?
It's not really meaning -- it's not that material, to be honest with you. I mean, we support them when we can, but it's not going to be a material number to our quarter.
Our next question is from Kevin Steinke with Barrington Research.
On the 5 wins for Intellify that you mentioned, should we think of those as competitive takeaways?
Yes. 100%. Those are competitive takeaways, but those are not new space or new green space.
Okay. Great. So I guess the takeaway from that, and you mentioned you're a little ahead of schedule is that the offering continues to resonate well in the marketplace.
Yes, very well. As a matter of fact, Kevin, I was out at the ANCC Magnet Conference in Chicago a couple of weeks ago. And it was interesting, the feedback we had from our current clients who are attending the conference, just coming up and giving testimonials about Intellify and how the technology has truly made a big impact within their organizations and helped them with the reporting, helping them with the insights, the data analytics, to be able to get the reporting on their phone in real time when they need it.And what they're always most impressed about is how our dashboards are actually built right into our VMS that when they're actually putting an order in the dashboard right there, they actually put the order in from the dashboard. And so great feedback. And the other feedback we got were from prospective clients, they were just coming up and looking at our technology and saying, wow, this is nowhere near what I have with my current vendor. And so we're very encouraged by that. And it's almost like we're doubling down on getting the word out there, and that's why we talked about investing so much in sales and marketing because we know our technology. People try to imitate it, but no one can duplicate what we've done with our proprietary algorithms, with how we've coded this technology. It's very different than a lot of what's out there in the market. And as people try to come and compete with us, we already are starting to build the next generation of our technology. That's one of the offerings we've put out, which we talked a little bit about in our prepared remarks was our data aggregation services. As I mentioned earlier, it is truly the first transparent bill rate technology, what we believe in the industry.
Kevin, this is Dan. I think I'd like to add a little bit, too. Just as a reminder, I know we've talked about it on previous calls, but there was a prolonged period of time when health systems were not going out to market for their VMS or their MSP programs. And so we've seen tons of activity, and I don't see that slowing anytime soon as evidenced by the remarks I made about our sales pipeline.Another way for you to think about this is our existing customers are also buying more. And so just quarter-over-quarter, we had a 40% increase in service add-ons to those same customers. And a lot of that is enabled by this technology. So adding locums, as John pointed out earlier or adding interim leadership or RPO or these other things happen so much faster, and it delights the customers in a way because they can see the impact so much faster with all the transparency. And then they start telling their friends. So I think this is -- we have an opportunity with this abundant amount of activity. In my opinion, by the time this is done, we'll win more than we lose.
Our last question is from Bill Sutherland with the Benchmark Company.
I wanted to get a clarification, if I could, on something I think you said, Bill, about the rates, you're looking out on the locked-in rate. And you said that could be a bit of a headwind in next year. I guess I just wanted to clarify that that's kind of what-
Yes. No worries. Good evening to you. So if you think about what I said, we have open order rates, and we have the rate at which we're locking, which I consider like the market clearing rate, the rate at which we can get a clinician to the bedside. And we've seen stability in both. That's the good news, right? Both are no longer continuing that downward trajectory. The open order rate and the lock rate are moving kind of sideways up or down 1% or 2%, nothing that significant.But we're still blending down the overall portfolio. So when you look at -- because we've been locking at this rate for so many months now. The fourth quarter is getting much, much closer. The average bill rate you'll see for the fourth quarter will be very close to what we're locking at. And my point was that it's just a handful of points, 2, 3 percentage points from where we expect the fourth quarter to blend out to be to what that could look like in the first quarter, sans anything else happening on the bill rates. So that's all that really was. It's just about the portfolio averaging down to the current lock rates we're seeing in the market.
And then just to clarify on how you're feeling about just the numbers that you can -- you've got tons of orders. But in terms of fill rate, do you have a sense of what that's going to trend like in the quarter in the next quarter?
I mean, along with bill rate stability, we've seen relative stability in our production as well. So when you look week-over-week, is in terms of what we call net lease book. As we go each week, we go through at a recruiter level, we look to see how much we are adding to the backlog of revenue. And so that's kind of seen some stability as well. I think the key to seeing an uptick, and we've been asked this before, but if bill rates were to increase, would we see a bill rate increase or would we see a volume increase.And I think it's more likely we would see a volume increase. And what I mean is if the average open order rate were to start to rise a little bit, we would be able to fill more of the orders. So that's really what it comes down to it. It doesn't need to be a wild bill rate swing for us to start to fill more. It's just that the open order average rate, if that inches closer to what we're seeing the market close towards, we could start to see volume growth. So Marc, I don't know if you have any color on that?
No. But I think it's interesting to point out that our recruiter productivity has been consistent and at the same level for the better part of 2 quarters now. So even though there's been bill rate pressure and orders that are below market rate, we're seeing the same productivity. That's why it's encouraging in terms of a volume perspective moving forward.
Okay. That's good. So I'm thinking it feels like with all the puts and takes that 4Q, I think someone said is that a good starting point, and we've been thinking about 3Q as a trough and maybe it's not -- to think about 4Q as necessarily that, but it's sort of a baseline? Is that kind of what is the best way to think about it?
Yes, I think so. I think you'll have assumptions to layer into that, like we talked about puts and takes as you move through 2024. But it starts to feel like that's a good starting point as you move into the new year. And for all the reasons we talked about. The fact that orders have remained fairly stable and actually have ticked up over the last couple of quarters, bill rates have leveled off. It feels like we're getting to that point of stabilization in the market, and we will look to grow off of that, of course.
Is there -- on cross-country debt, just curious about the monetization model for that if there is something significant in that way.
You know what? Really what this is doing is there's 2 different types of ways to monetize it. We can sell it directly to a nonclient of ours. And the idea with that is we want to make sure that there is transparency in this industry about bill rates, just like we just we brought transparency and the industry is where transparency – the clinician pay rate over the last 5, 6 years.And so part of that is to show clients that how they could rationalize the costs by understanding what the market rates are. And then they look at -- and what DAS does is it shows them the low, medium and high rate ranges from a local, regional, national level. And then the hospital can make sure that they can choose -- they can obviously select what type of rate they feel to attract -- what's going to attract clients in their area. And so that's one way we can rationalize -- one way we can monetize it by selling it directly. But that also allows us to start having conversations with these nonclients of bars to show them really how we can help them save money. And then #2, we also embed and can embed DAS into Intellify and that is also to be monetized as we embed it into Intellify as it is a separate product from Intellify. It can be embedded into Intellify but we would monetize that when it's embedded in.
Last one for me. The 5 wins you've had in Intellify, what's the aggregate dollars on that in total?
We haven't given out the numbers yet because as we're going through even the one that's greater than $100 million, as we're implementing them, we'll actually get to see the actual dollars and the actual spend through there. So as -- we will give the numbers in future calls. But right now, we're letting these first 5 that, especially because we're implementing 3 right now, come in before we give that total dollar.
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, operator. 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 the next call in February.
Ladies and gentlemen, this does conclude today's conference call. Thank you for your participation. You may now disconnect.