AMN Healthcare Services Inc

NYSE:AMN

Earnings Call Analysis

AMN Healthcare's Quarterly Progress Amid Market Challenges

AMN Healthcare reported second-quarter revenue of $741 million, a 25% yearly drop, but stabilized performance and promising demand trends. Net income was $16 million, with $100 million in operating cash flow, and adjusted EBITDA margin exceeded guidance. Despite pressure on placement volume, the third-quarter outlook suggests EBITDA margins will outpace expectations, though revenue could fall 4% short. The Technology and Workforce Solutions segment remains robust, contributing 40% of total operating income. Management anticipates diversified high-margin services will bolster future profitability despite ongoing market volatility.

Struggles Amidst Demand

In the latest earnings report, AMN Healthcare revealed a challenging quarter with a consolidated revenue of $741 million, reflecting a steep decline of 25% year-over-year and a 10% decrease from the prior quarter. This drop is primarily due to decreased volumes in the Nurse and Allied segment, as well as in the Locum Tenens and DMS businesses. The company is grappling with a persistent market pressure, despite consistent demand for healthcare services, suggesting that the sector's recovery is still uneven.

Profitability Under Pressure

Despite the revenue slump, AMN managed to generate a net income of $16 million, which is a stark 73% decrease year-over-year. The adjusted EBITDA stood at $94 million, accounting for a 42% decline compared to the same period last year. However, the adjusted EBITDA margin exceeded guidance expectations, which hints at some operational efficiencies being realized despite falling revenues.

Operating Margins and Cost Management

The consolidated gross margin for the quarter was 31%, dipping 230 basis points from last year, largely due to reduced performance across key segments. AMN has initiated rigorous cost management strategies, resulting in a reduction of SG&A expenses to $149 million, down from $202 million a year earlier. The adjusted SG&A reflected an 18.5% ratio of revenue, indicating the company’s focus on maintaining profitability amidst declining revenues.

Segment Breakdown – Nurse and Allied Solutions

The Nurse and Allied Solutions segment reported revenues of $442 million, a sharp 36% decline from last year, driven by lower volumes and bill rates. Average bill rates decreased 12% year-over-year, bringing challenges in gross margins, which fell to 23.8%. AMN anticipates a drop in revenue for this segment by approximately 32% to 34% in Q3 year-over-year, reflecting ongoing utilization reductions from larger clients amidst a tightening labor market.

Physician and Leadership Solutions Performance

In contrast, the Physician and Leadership Solutions segment exhibited positive growth with revenue reaching $186 million, up 6% year-over-year, thanks to the MSDR acquisition. However, this was somewhat offset by a sequential drop of 1%. Looking ahead, the company projects revenue growth of 12% to 14% in this segment for Q3, indicating a more resilient trend compared to Nurse and Allied solutions.

Technological Solutions Driving Growth

The Technology and Workforce Solutions segment saw revenues decline 11% to $112 million. However, language services within this segment grew robustly by 18%. AMN aims to enhance its service offerings with technology-enabled tools like ShiftWise Flex, which is projected to boost capabilities and attract new clients. The continued alignment with market demands suggests a long-term strategic advantage as healthcare becomes increasingly tech-oriented.

Future Guidance and Expectations

For the upcoming quarter, AMN expects consolidated revenue to range between $660 million and $680 million, marking a reduction of 20% to 23% year-over-year. The guidance for gross margin is forecasted between $30.7 million and $31.2 million, and adjusted EBITDA is expected between 10.6% and 11.1%. The company anticipates flattish SG&A expenses, depicting a cautious approach in navigating the ongoing uncertainties in healthcare staffing demands.

Managing Debt and Cash Flow

AMN's commitment to strengthening its balance sheet is reflected in its debt management strategy; the company has paid down $115 million in debt year-to-date, including $80 million in Q2 alone. With long-term debt at $1.2 billion and a net leverage ratio of 2.6x, debt repayment remains a priority. Future cash flow will also be directed toward further debt reduction to return the leverage ratio below 2.5, before considering new acquisitions or share buybacks.

Cautious Optimism

Despite the evident struggles, AMN remains optimistic about recovery patterns in the healthcare sector. The uptick in customer orders, especially a nearly 20% increase in Nurse and Allied orders since Q2, points toward stabilizing demand. However, the company acknowledges the evolving dynamics of labor supply and demand, indicating that while opportunities are present, the landscape remains competitive and fluid.

Earnings Call Transcript 2024-Q2

[Operator]

Good day, and thank you for standing by. Welcome to the AMN Healthcare Second Quarter 2024 Earnings Conference Call. [Operator Instructions] Please be advised that today's conference is being recorded. I would now like to turn the call over to Randy Reece, Senior Director of Investor Relations. Please go ahead.

[Randle Reece, executive]

Good afternoon, everyone. Welcome to AMN Healthcare's Second Quarter 2024 Earnings Call. A replay of this webcast will be available at ir.amnhealthcare.com at the conclusion of this call. Remarks we make during this call about future expectations, projections, trends, plans, events or circumstances constitute forward-looking statements. These statements reflect the company's current beliefs, based upon information currently available to it. Our actual results may differ materially from those indicated by these forward-looking statements because of various factors and cautionary statements, including those identified in our most recently filed forms 10-K and 10-Q, our earnings release and subsequent filings with the SEC. The company does not intend to update guidance or any forward-looking statements provided today prior to its next earnings release.

This call contains certain non-GAAP financial information. Information regarding and reconciliations of these non-GAAP measures to the most directly comparable GAAP measures are included in our earnings release and on our financial reports page at ir.amnhealthcare.com.

On the call today are Cary Grace, President and Chief Executive Officer; and Jeff Knudson, Chief Financial Officer. I will now turn the call over to Cary.

[Caroline Grace, executive]

Thank you for joining us for a review of our latest financial results and updated outlook. Against some continued challenging market conditions, we made progress on stabilizing our performance. Demand for health care was impressive this quarter, and the market for skilled caregivers show signs of improvement.

Patient demand and labor supply are crucial drivers of long-term growth in our businesses. Our consolidated revenue for the second quarter was $741 million, which enabled us to produce $16 million in net income, $100 million operating cash flow and adjusted EBITDA of $94 million. The adjusted EBITDA margin for the quarter surpassed the high end of guidance. Excluding some discrete items that favorably impacted SG&A, adjusted EBITDA margin would have been above the high end of our guidance range.

While we continue to see some pressure on placement volume and revenue from larger clients, we expect our third quarter adjusted EBITDA margin to be higher than sell-side analyst expectations. Our third quarter outlook at the midpoint implies that adjusted EBITDA and adjusted EPS would be in line with expectations, though our revenue outlook is approximately 4% below consensus.

AMN continues to improve how well we are aligned with all segments of the market for Total Talent Solutions in health care. These efforts are vitally important to our long-term success. Coming off 2023, when we were in a net loss position with MSP contracts, year-to-date, we are net neutral with wins and losses with last year's RFPs behind us, and we are better situated with our clients today.

The diversification of our business portfolio, including several high-margin technology-enabled revenue streams, has enabled AMN to maintain profit margins at attractive levels. At the same time, we are delivering to our staffing customers pricing and value that are in line with our industry peers.

Across our staffing markets, we are working towards capturing our share of large opportunities in VMS, vendor-neutral, third-party and direct staffing where we again made progress this quarter. With our technology investments and rollout, brand consolidation and reorganization of the way we go to market and deliver, AMN effectively has been replatforming most of the company.

ShiftWise Flex is now managing more than half of our ShiftWise vendor-neutral spend under management. We also began deploying ShiftWise Flex for our master vendor MSP clients earlier this quarter. We have a competitive platform that opens opportunities for us in current and new markets. This was demonstrated recently when ShiftWise Flex was awarded a multiyear public sector contract, beating out a competitive list of health care and technology industry rivals.

We have seen a healthy increase in the VMS pipeline, both in terms of spend under management and the number of deals. Our Market Insights tool is now being used by some of our largest clients and will be part of our ShiftWise Flex platform. This powerful tool provides clients with market intelligence, to help inform them on market trends and how to set bill rates to attract health care professionals by specialty, geographic area and by times of the year.

We are rolling out Innovative Workforce Solutions, leveraging our clinician app, AMN Passport, including internal flute pool, internal agency and shift level management. We have deployed these solutions to help some MSP clients and have an active implementation pipeline. We expect that our internal progress will improve our ability to serve clients, win new business and gain market share.

Meanwhile, the AMN team continues to deliver on our clients' current needs to help them build a high-quality, sustainable workforce. Let's review our second quarter performance in detail.

In the second quarter, Nurse and Allied Solutions recorded revenue of $442 million, in line with our expectations. Across our Travel Nurse and Allied businesses, volume, bill rates and average hours were consistent with our assumptions entering the quarter. Gross margin for the segment was lower than the first quarter primarily because of a favorable workers' comp adjustment in the prior quarter. We offset the gross margin movement by reducing expenses and controlling costs.

Our third quarter outlook for Nurse and Allied revenue is down approximately 32% to 34% year-over-year, better than the first half comparisons, but still lower quarter-over-quarter. Demand, as measured by open orders, has been on an upward trend since April. Total Nurse and Allied orders grew nearly 20% since the beginning of the second quarter, with the strongest growth in Travel Nurse.

Though this increase was less than past normal seasonality, it was much improved over last year. At the same time, we continue to see large clients reduce utilization of contingent labor amid strong permanent hiring and reduced employee attrition. Labor market data showed that permanent job growth for hospitals in the first half of 2024 was the strongest since 1982.

Taking into account all these factors, we see scenarios in which Nurse and Allied revenue, excluding international, could range from being modestly down to modestly higher in Q4 from Q3. Visibility for Nurse and Allied beyond the current quarter has been challenging since the beginning of 2023. We expect to receive winter needs orders later in Q3, which will give us more visibility into Q4 trends.

Our Physician and Leadership Solutions segment had second quarter revenue of $186 million, up 6% year-over-year and about 4% lower than we had expected. The organic locum tenens business was up 1% quarter-over-quarter, although down 11% year-over-year. We saw extensions fall off in the quarter as clients were focused on cost management and were slower to make hiring decisions. These factors impacted our organic locums business as well as MSDR.

Demand in locums is healthy and coupled with our technology investments to improve our speed to fill as well as MSDRs capabilities, we are excited about our growth potential in this important market. Results for interim leadership in search were flat versus the first quarter, though demand remains inconsistent.

Segment gross margin in the quarter was lower than the first quarter due to a lower bill pay spread in local tenants. This was offset largely by prudent expense management. For the third quarter, we expect Physician and Leadership Solutions revenue to be up 12% to 14% year-over-year.

In the Technology and Workforce Solutions segment, second quarter revenue was $112 million, lower by 11% year-over-year and in line with our expectations. Language Services posted 18% revenue growth, driven by strong utilization of video interpretation. All other solutions in this segment were consistent with our outlook.

The TWS segment contributed $47 million of operating income, more than 40% of total segment operating income this quarter. The TWS segment profit margin also improved substantially this quarter. Our long-term strategy is to continue increasing the segment share of our revenue and earnings due to its alignment with clients' desires for more tech-enabled solutions and its attractive growth and margin profile.

For the third quarter, we project Technology and Workforce Solutions revenue to be down 10% to 12% from the prior year. We have carefully managed long-term strategy and near-term spending in an improving environment still having its cross-currents. This has made it especially important for AMN to ensure that our perspective of the changing health care sector is as clear and current as possible.

We were delighted to add Jim Hinton to our Board of Directors. Jim has invaluable experience as former CEO of outstanding health systems, Baylor Scott & White and Presbyterian Health Services, New Mexico in addition to serving as a past forward share of the American Hospital Association. We also recently launched our first executive advisory board to help guide the company's mission of providing innovative total talent solutions for health care.

Our Executive Advisory Board will ensure that AMN is closely aligned with the current and future needs of health care organizations as they deal with rising demand and increasingly complex labor supply. At the helm of our Executive Advisory Board is Mike Butler, who is President of Providence and led the health system through extraordinary growth.

Before I turn the call over to Jeff for a financial review. I want to recognize the wonderful AMN team and our health care professionals for their impressive efforts serving our communities and all our stakeholders. Your mission and your excellence are what enables AMN's ability to have such a positive impact in serving the health care needs of our communities.

Now Jeff will continue with a review of our quarterly results and outlook.

[Jeffrey Knudson, executive]

Thank you, Cary, and good afternoon, everyone. Second quarter consolidated revenue was $741 million, down 25% from the second quarter of 2023 and down 10% sequentially, in line with expectations. The sequential decrease was primarily due to lower volume in the Nurse and Allied segment and the Locum Tenens and DMS businesses. Consolidated gross margin for the second quarter was 31%, and also in line with expectations.

Year-over-year, gross margin decreased 230 basis points, driven mainly by lower margins across all 3 segments, partly offset by a favorable segment mix. Sequentially, gross margin decreased 40 basis points primarily due to lower Nurse and Allied segment and Locum's gross margin, partially offset by a favorable revenue mix shift.

Consolidated SG&A expenses were $149 million or 20.1% of revenue compared with $202 million or 20.4% of revenue in the prior year period. and $175 million or 21.3% of revenue in the previous quarter. The decrease in SG&A expenses year-over-year was primarily due to lower employee and professional service expenses as we remain steadfast in reducing costs to massive revenues. Lower employee expenses and favorable actuarial adjustments for professional liability insurance drove the decrease sequentially.

Adjusted SG&A, which excludes acquisition, integration and other costs, legal settlement accrual changes and stock-based compensation expense was $137 million in the second quarter or 18.5% of revenue compared with $170 million or 17.1% of revenue in the prior year period and $162 million or 19.7% of revenue in the previous quarter. Discrete items that we do not expect to recur in the third quarter included an actuarial adjustment for professional liability insurance and a change in the accrual for incentive compensation. These items reduced SG&A by $7 million in the quarter.

Nurse and Allied revenue was $442 million in the second quarter, down 36% from the second quarter of 2023. Sequentially, segment revenue was down 15% driven by lower volume and lower rates in Travel Nurse and Allied. Average bill rate was down 12% year-over-year and 3% sequentially. The influenced by a mix shift toward Allied. Year-over-year, volume decreased 24% and average hours worked were 1% lower. Sequentially, volume was down 11%, and while average hours worked were flat.

Travel Nurse revenue in the second quarter was $277 million, a decrease of 42% from the prior year period and 17% from the prior quarter. Allied revenue in the quarter was $151 million, down 17% year-over-year and 11% sequentially. Nurse and Allied gross margin in the second quarter was 23.8%, a decrease of 290 basis points year-over-year, primarily due to increases in housing travel and allowance expenses and the deleveraging impact of lower bill rates.

Sequentially, gross margin decreased 130 basis points, mainly due to our workers' comp accrual adjustments that benefited the first quarter margin, along with higher housing costs. Segment operating margin of 10.4% decreased 450 basis points year-over-year, but increased 10 basis points sequentially. The slight increase from the first quarter was driven primarily by favorable insurance actuarial adjustments and lower employee expenses offsetting the lower gross margin.

Moving to the Physician and Leadership Solutions segment. Second quarter revenue of $186 million increased 6% year-over-year due to the MSDR acquisition. Sequentially, revenue was down 1% and driven by lower locum tenens revenue and lower volume in the search business as expected. Locum Tenens revenue in the quarter was $143 million, up 17% year-over-year with the growth coming from the MSDR acquisition.

In our leadership revenue of $30 million decreased 17% from the prior year period and was flat sequentially. Search revenue of $13 million was down 27% year-over-year and down 1% sequentially as volumes remain low. Gross margin for the Physician Leadership Solutions segment was 30.5%, down 460 basis points year-over-year and 110 basis points sequentially.

The year-over-year decline was primarily attributable to lower bill pay spread within locum tenants partially offset by improved gross margin in the interim business. Segment operating margin was 11.6%, which decreased 340 basis points year-over-year, primarily due to lower gross margin. Sequentially, operating margin decreased 20 basis points.

Technology and Workforce Solutions revenue for the second quarter was $112 million, down 11% year-over-year as the revenue decrease in the VMS business more than offset the Language Services revenue growth. Sequentially, revenue was flat.

Language Services revenue for the quarter was $75 million, an increase of 18% year-over-year and 5% sequentially. VMS revenue for the quarter was $28 million a decrease of 41% year-over-year and 5% sequentially. Segment gross margin was 60.2%, down from 66.7% in the prior year period primarily due to lower revenue within the VMS and outsourced solutions businesses.

Segment operating margin in the second quarter was 42.1%, a decrease of 200 basis points from the prior year period, driven by the decrease in gross margin, partially offset by a reduction of SG&A expenses. Segment operating margin increased 280 basis points from the prior quarter, mainly due to lower employee expenses.

Second quarter consolidated adjusted EBITDA was $94 million, a decrease of 42% year-over-year and 4% sequentially. Adjusted EBITDA margin for the quarter of 12.7% and was above the high end of the guidance range, mainly due to favorable insurance actuarial adjustments and lower employee expenses.

Year-over-year, adjusted EBITDA margin was down 360 basis points, primarily due to deleveraging on lower revenue, while we reduced SG&A expenses to follow the revenue declines. Sequentially, adjusted EBITDA margin was up 80 basis points, driven by the Technology and Workforce Solutions segment and a favorable mix shift.

Second quarter net income was $16.2 million, down 73% year-over-year and 6% sequentially. Second quarter GAAP diluted earnings per share was $0.42. Adjusted earnings per share for the quarter was $0.98 compared with $2.38 in the prior year period and $0.97 in the prior quarter.

Days sales outstanding for the quarter was 63, 1 day lower than the prior quarter and 10 days higher than a year ago, which was our low mark for DSO in 2023. Since the start of 2024, we have reduced DSO by 7 days and expect to end the year below 60 days.

Operating cash flow for the second quarter was $100 million, and capital expenditures were $27 million. We expect CapEx for the year to total $70 million to $75 million. As of June 30, we had cash and equivalents of $48 million, long-term debt of $1.2 billion, including a $345 million draw on our revolving line of credit and a net leverage ratio of 2.6x:1. During the quarter, we paid off $80 million of revolver debt, bringing the year-to-date pay down to $115 million.

Moving to third quarter 2024 guidance. we project consolidated revenue to be in a range of $660 million to $680 million, down 20% to 23% from the prior year period. Gross margin is projected to be between $30.7 million and 31.2%. Reported SG&A expenses are projected to be 22% to 22.5% of revenue.

Operating margin is expected to be 2.1% to 2.9% and adjusted EBITDA margin is expected to be 10.6% to 11.1%. Average diluted shares outstanding are projected to be approximately 38.3 million. Additional third quarter guidance details can be found in today's earnings release.

And now, operator, please open the call for questions.

[Operator]

[Operator Instructions] Our first question for today will be coming from Trevor Romeo of William Blair.

[Trevor Romeo, analyst]

I think, one, it would just be great if you could provide any details you have on the bill rate and volume assumptions for Nurse and Allied that are embedded in the Q3 guide? And then thinking to Q4, I think Cary talked about a range of potential outcomes relative to Q3. I think Jeff, I kind of always appreciate the look you tend to give on these calls for 2 quarters ahead. So any thoughts on how you'd see Q4 shaping up for bill rates and volumes just based on what you could see at this point would be really helpful.

[Jeffrey Knudson, executive]

Yes. Thanks, Trevor. So as it relates to the Q3 guide, we have bill rates down low single digits sequentially from Q2 and volumes down low double digits in Nurse and Allied from Q2 levels. When we think about the fourth quarter, Cary mentioned the range of scenarios, excluding international.

So with the impact of Visa retrogression on the international business, we would expect that business in the fourth quarter to be down $6 million to $8 million sequentially from Q3. So that's about a 200 basis point drag on the growth within the segment.

And so when we look at bill rates and volumes quarter-over-quarter, again, winter orders will be a big swing factor for us within the quarter where not only those volumes come in, but the start dates within the quarter and then also where the bill rates land. So we would see bill rates within those range of outcomes being anywhere from flattish to maybe down slightly in the fourth quarter, and then volumes ranging from a low single-digit increase to low single digit down quarter-over-quarter.

[Caroline Grace, executive]

And Trevor, we've gotten some indications from clients to accept those orders, but we wouldn't see them until later in the quarter.

[Operator]

And our next question will be coming from Brian Tanquilut of Jefferies.

[Brian Tanquilut, analyst]

Maybe I'll follow-up to Trevor's question. So if we're seeing orders up 20%, Jeff, like you just said, plus low single to minus low single in Q4. Maybe help us bridge that? Like how does the order number translate to different volume expectation? And then also, how are you thinking about typical seasonality? Because you're seeing plus 20% orders here in I think normally seasonal patterns are even more pronounced than that. So just curious what you're thinking or what you're seeing.

[Jeffrey Knudson, executive]

Yes. Brian, on the seasonality, we went back and looked at the couple of years leading up to 2019. And normally, we would have seen demand increase somewhere in the 25% to 30% range versus what we've seen here this year, up 20% and off a lower trough quite honestly.

So yes, the demand trends are improved, but it was off a lower base in not quite back to where we were pre-pandemic. I think when we just think about the volumes within Nurse and Allied, one thing I would say is as we look at the monthly sequence within the third quarter, the traveler count is stable July through September, albeit with a lower starting point in July than we were at the end of Q2.

So that's a much improved trend from where we were in the second quarter, where June was the low point within the quarter. And so with that demand, I would just say when we're -- it gets back to what Cary said about some of our MSP clients, we're still seeing reductions in utilization. And we're seeing extension rates at the low end of what would be historically normal from a continuation standpoint, about 500 basis points off the average, but it's within the norm, but at the low end of that range.

[Brian Tanquilut, analyst]

Okay. That makes sense. And then maybe just as I think about G&A, any discrete items or one-timers on the G&A line that you would call out? And maybe just how you think we should be modeling SG&A going forward?

[Jeffrey Knudson, executive]

Yes. So within the second quarter, we had about $7 million of discrete items that added 100 basis points to adjusted EBITDA margin. So ex those, we would have been at 11.7%, which was 20 basis points above the high end of the guide. About $4 million of that $7 million related to an actuarial adjustment on professional liability insurance, which we true up twice a year in Q2 and Q4.

The remaining $3 million was related to some variable and incentive compensation accruals. We wouldn't expect those to recur in the third quarter, but despite that, we would see adjusted SG&A dollars pretty flattish in the back half to Q3 levels as reported on adjusted SG&A.

[Operator]

And our next question will be coming from the line of Jeff Silber of BMO Capital Markets.

[Jeffrey Silber, analyst]

I wanted to dig into some of the demand trends that you've been talking about. I know it's tough to gauge, but do you think most of your hospital clients are comfortable with the mix of permanent to temporary staff? Do we think that's going to go lower? What it will take it to get moving in the right direction? .

[Caroline Grace, executive]

So Jeff, maybe I'll talk a little bit about what we're seeing from a macro standpoint. So across the board for most of our clients, we're seeing higher patient utilization Against that, what we've been seeing over the past 4 to 5 quarters is very strong permanent hiring. They've also seen higher retention rates. Now those retention rates are coming off of unusually low retention rates during COVID. And we've also seen a lot of effort to hire lower-paid workers to support some of the clinical roles.

But even with all these efforts, and they've been very strong, especially around the permanent hiring, you're still seeing open roles 2.1:1 from a higher standpoint. And so we're seeing still pressure as you increase patient utilization against the workforce that's available. And if you look at the contingent premium, we're now in the back half of the year, getting back, and we're in normal ranges of 15% to 20%.

And so those sets of dynamics, I think, are making it more interesting from a demand standpoint. What we're seeing from clients is even if they have a target of where they want their contingent spend to be. They may have underestimated some of the efforts of permanent hiring or not factored in some of the retention efforts. So we're seeing those factors play in, I'd say, particularly over the past quarter or 2 and where they're coming out.

[Jeffrey Silber, analyst]

All right. That's helpful. If I could ask a similar question about your own workforce. Are you at the point where you think you've rightsized enough that your workforce can handle the current demand environment? And how quickly can you turn if things start to move in the right direction? .

[Caroline Grace, executive]

Yes. We feel good about where we are. We've been very conscientious about rightsizing as we saw demand shake out in different parts of our business. But we are positioning ourselves, both in terms of our workforce and our capabilities to be able to meet rising demand conditions.

[Operator]

And our next question today will be coming from the line of A.J. Rice of UBS.

[Albert Rice, analyst]

Maybe just following on Jeff's comment about -- and I guess, Cary, too, to some degree, of fourth quarter. With what you're envisioning with revenue, how does that translate into -- do you think we're at a stable point with gross margin from Q3 to Q4?

How about SG&A? Is that sort of flatten out. Is there any reason that would step up or down. I think I'm not looking for necessarily specific estimate, but directionally, where we're at is we think we're bottoming out here generally?

[Jeffrey Knudson, executive]

Yes. I would say, A.J., on the gross margins, both from a nurse and Allied standpoint and also from a consolidated standpoint, I think something in the high 30s, 30.8, 30.9, to the low 31 is a reasonable estimate for which is essentially the midpoint of the guide for Q3 and where we were in Q2 that, that's reasonable to think about the fourth quarter that same way. And then from an adjusted SG&A standpoint, dollars being relatively flattish over Q2 levels would also be the right way to think about the fourth quarter.

[William Sutherland, analyst]

Okay. That's helpful. Just thinking about use of cash flow from here. I guess by our calculation, you ended the quarter at 2.6x debt-to-EBITDA, I think you'll be at 3% or above as you exit the year, is paying down debt a priority. Where are you comfortable on that leverage ratio as you go forward?

[Jeffrey Knudson, executive]

Yes. Debt paydown has been a priority as we've gone through the first half of this year, we've paid off $115 million year-to-date, and that includes $80 million in the second quarter alone, A.J. So we'll continue to prioritize debt paydown with excess free cash flow for the remainder of this year and probably into the early part of '25 as well.

[Albert Rice, analyst]

And how -- I guess I'm trying to get at what is the -- what leverage ratio would you sort of be back to a balance between potentially acquisitions, buybacks and leverage? Where would you guys feel comfortable that it's sort of at a good point?

[Jeffrey Knudson, executive]

We'd want to see it back below 2.5 before we would deprioritize debt paydown. .

[Operator]

Our next question will be coming from the line of Mark Marcon of Baird.

[Mark Marcon, analyst]

Really found the comments on the volumes helpful. I was wondering, can you talk a little bit about what you're seeing just in terms of the pay rates that some of the traveling nurses are looking for.

You did mention that the premiums are coming down to 15% to 20% above perm for contingent. And so is that sufficient to fill demand? That's the first question.

[Caroline Grace, executive]

Yes. I think historically, if you look at that premium, that has typically been sufficient to fulfill demand. Obviously, you're going to have differences in geography and specialties. I think, Mark, when you look at one of the things that we look at from a macro standpoint is the premium is off of an increasing permanent wage.

And so I think that's going to be one of the dynamic factors that you look at, where, over the past 1.5 years, we really had the contingent wages at a very high premium coming down. But now as you've gotten into these normalized ranges, it's off of a base that is increasing.

[Mark Marcon, analyst]

Great. So it sounds, Cary, like the fill rates are in line with what your expectations would be? And filling the orders is not an issue. It's still just demand from the clients. Is that correct? .

[Caroline Grace, executive]

Yes, I'd say largely that -- I mean if you have specialties that are hard to fill, they're going to be hard to fill. But if you have orders that are priced at market, you see high fill rates. So it really is about the demand coming back.

[Mark Marcon, analyst]

Okay. Great. And then can you just talk a little bit -- I mean, obviously, everybody in the entire space is facing the same sort of demand characteristics. It sounds like the bill rates are holding up relatively well. Can you just talk a little bit about competition and what you're seeing on that front? And how confident are you in terms of the prognostication that you gave with regards to how you would expect the bill rates to flow through the balance of this year? .

[Caroline Grace, executive]

Yes. Let me talk a little bit about competition and then Jeff can talk a little bit about the transparency we have on bill rates. We have been in a competitive environment. We continue to be in a competitive environment. So I don't see that changing in the short and intermediate term.

And so we've seen pressure as everyone in the industry has over the past year. So that's reflected in both what you have seen from a performance standpoint, but also our forecast.

[Jeffrey Knudson, executive]

Yes, Mark. And then I would just say, on the bill rates for the third quarter, when we look at the bill rates that we have in July for our travelers on assignment and where we're booking future TOA, that supports that low single digit down into the third quarter.

And then obviously, seasonally, we'll get some influence on the bill rate from those winter needs orders. And that, we believe, in the flattish scenario would offset any pressure on bill rates in the nonwinter needs orders.

[Mark Marcon, analyst]

Great. And then on a positive note, you're seeing really nice traction with ShiftWise. You mentioned getting up to 50%. Where do you think that can get to? And what would be the implications of that? .

[Caroline Grace, executive]

Yes. So let me give context for what the 50% is. So we are very happy with how we are doing on ShiftWise Flex. And so our #1 goal is to replatform our ShiftWise clients into ShiftWise Flex. So that 50% number is we are over halfway in terms of client spend under management, putting them on to ShiftWise Flex.

We also started with our first MSP clients. And we expect, as we end this year to have the majority of our VMS clients completed, and we would expect to have made significant progress with our MSP clients. So first priority for us is replatforming existing clients. The second piece, Mark, is building our pipeline, which we saw very healthy progress against when we look at it from a quarter-over-quarter basis.

[Mark Marcon, analyst]

Great. What are the financial implications of that? .

[Caroline Grace, executive]

So if you think about the financial implications, the first one on re-platforming should not be accretive from a revenue standpoint. They're existing clients. We think that there's opportunities, especially because ShiftWise Flex has enhanced capabilities from a technology standpoint for that to be a platform that we can do more with some of those existing clients.

If you look at our pipeline, that pipeline revenue impact really wouldn't have any impact until 2025 as you started to work down the pipeline and then onboard wins from that pipeline. So it won't have an impact this year. You should expect it to have more of an impact as you get into the back half of 2025.

[Operator]

Our next question will be coming from the line of Kevin Fischbeck of Bank of America.

[Kevin Fischbeck, analyst]

Great. I guess you're the second company to say that the orders are up about 20% since the beginning of Q2, but still talking about stable to a little bit below Q2 average revenue. And then Q4, it sounds like still also kind of stable-ish despite the orders going up.

So does that mean something around, I guess, you mentioned that orders are able to be filled if they're at market. Does that mean that these orders that are coming in are not at market? Or why isn't there a better correlation between the 20% and the revenue numbers over the next quarters?

[Caroline Grace, executive]

Yes. I'd say 2 things. One is, you always have some mix of orders that are going to be at market rates or below. And so what you tend to see is for orders that come in that aren't at market, they have very low fill rates and they tend to age. So that's going to be true as you see increased demand, you're going to have some of those orders that are not going to be at market. And you tend to see them age.

In terms of when you look at what we're seeing overall from the demand increases and open orders that we've seen since the beginning of April and a little bit of what Jeff had talked about earlier. We're also seeing for some large clients where they have reduced utilization. We've seen this a lot in our extension rate. And so that's the piece, Kevin, where we're seeing promising signs around the demand, but we still have some stabilization that we are seeing with some of our clients.

[Kevin Fischbeck, analyst]

Okay. And then I guess the winter orders, I guess, I think, historically, you'd have a little bit of color at this point. It sounds like it's kind of been pushed back a little bit as far as when those orders come in. Is that -- is there an implication for that? I guess, in the past, if they come in a little bit later, does that mean that the orders are going to be lower? Or does that not necessarily follow through?

[Jeffrey Knudson, executive]

Yes. I think, Kevin, like from a timing standpoint, we're expecting it to look like last year. I don't know that coming in later signals anything in terms of volume. But what we did see last year versus pre-pandemic was a shift where more of those Q4 starts were in the mid- to late November time frame, which was a couple of weeks later than normal, what we had seen in 2019 and prior.

[Kevin Fischbeck, analyst]

And is that a new normal? Does that mean that hospitals are just waiting a little bit longer to use temp staffing, and that's just the way it's going to be? But the view is that if they need it, they need it and they'll eventually [indiscernible]

[Jeffrey Knudson, executive]

Yes, it could look I don't know if it's a new normal. It could look like last year, but we also then did see some of the benefit into that into the first quarter. I would say the total duration of those orders was probably on par with what we had seen in 2019. They started later, but then maybe went a little longer into the first quarter. .

[Caroline Grace, executive]

Kevin, the other part that I'd say, and again, I don't know that we can call this a new normal, but we're seeing some of these delays just across the board. It's not just with winter orders. So I don't know that I would read anything into that.

[Kevin Fischbeck, analyst]

Okay. And then, I guess, last question on the SG&A side. You spiked out the $7 million. Is there anything else there? Because I guess in the press release commentary about lower compensation costs and with lower demand. Is that something that we should be on the lookout for? If demand does improve? Will there be pressure on G&A next year? Or is this a good base to be thinking about G&A as a percentage of revenue going forward?

[Jeffrey Knudson, executive]

I think probably the biggest thing for next year from a base standpoint is similar to last year as we would have a reset on incentive and variable compensation, just again, given the year that we've had in 2024 and then you would have your normal merit and other inflationary-type adjustments that would hit in '25 that aren't in that base right now.

[Kevin Fischbeck, analyst]

Is there a way to size that?

[Jeffrey Knudson, executive]

On the incentive and variable side, you can think about that probably in the $3 million to $4 million per quarter range. .

[Operator]

And our next question will be coming from the line of Tobey Sommer of Truist Securities.

[Tobey Sommer, analyst]

I was wondering if you could talk about how you feel you're doing with all the internal idiosyncratic changes you could make to address the marketplace as demand is falling now for a protracted period of time. You consolidated some brands. You're trying to cross-sell more services, is my understanding. How do you feel like you're prosecuting the changes you can control? .

[Caroline Grace, executive]

Yes. So if you think about some of the core pieces, Tobey, that we talked about, that we are changing our model to ensure that we are aligning ourselves to a bigger market TAM, the first is our go-to-market strategy. So we had been, for a number of years, focused on a very important but a minority part of the market in MSP. So we have aligned ourselves to all segments of the market, and we're seeing progress on that.

So if you look at Q1 to Q2, we saw healthy increases in the physicians filled in third-party and direct relationships. So we had a number of initiatives that were aimed against that, including operational automation. We made significant progress in our speed to fill. So there were operational and technology enhancements behind being able to achieve some of those increases.

From a brand standpoint, we are completed with the brand integration. And so we've consolidated the staffing brands. We're keeping B.E. Smith, which serves a very different audience, separate, and you will see a reinvigoration of that range. So we're seeing strong outcomes in our overall brand testing. We're seeing over 250,000 clinicians who are now on our Passport app.

So we're seeing progress on our go-to-market strategy to align ourselves against the entirety of the market. On our digitization of the company, again, and I know I talked about a number of these initiatives in my opening comments. But we've been very focused on how we align and innovate with our clients to help them build sustainable workforces.

So a lot of that is what we've done with ShiftWise Flex and the data and analytics and the market data as well as AI-enabled workforce planning and scheduling. Our scheduling platform was rated #1 in class for the second year in a row. So we've done a lot of work around ensuring that we have a tech-enabled set of services to help clients with where they want to go.

And I'd say the same thing for clinicians with the enhancements that we've done on Passport and connecting our clinician as to really important client technology so that we can connect clinicians to clients.

[Tobey Sommer, analyst]

And at this juncture, how do you think it's influencing market share, in your wallet share, however you choose to think about it? .

[Caroline Grace, executive]

Yes. So from a market share standpoint, what we experienced going focused on MSP clients during a significant period of growth during COVID, that was not favorable to us. If we look at this year versus last year in terms of net wins and losses, we came out of last year where we were in a net loss position.

We are and expect to be net neutral on clients from this year. And so that is progress. Obviously, we want to translate and get to a position where we're getting into net worth.

[Tobey Sommer, analyst]

And what are the signs tell you with respect to your international business and visa retrogression? Are there any updates that you've either seen that indicate when you could see a turn or dates out in the future that you're anticipating some sort of an update?

[Caroline Grace, executive]

There was a bullet in release today, and I would say, it was largely neutral. What we're looking for is the October bulletin, which typically comes out in late September. That will set the Visas for next year. And so we should have a better idea, as that bullet in comes out, about what we would expect in terms of leases for the future.

Our strategy on the international side is we are very intentionally keeping our pipeline very up-to-date. So as those Visa numbers get clarified and get awarded that we have all of our commissions in place and ready to go.

[Operator]

Our next question will be coming from the line of Bill Sutherland of Benchmark Company.

[William Sutherland, analyst]

I was just wondering at this point, I think we've checked all the questions here. Jeff, on in Locum the MSDR acquisition. Did you call out the impact in 2Q? And what's in the 3Q guidance?

[Jeffrey Knudson, executive]

Yes. It was $34 million of revenue in the second quarter, Bill, and we would expect that to be maybe down modestly sequentially into Q3.

[William Sutherland, analyst]

Is that seasonality?

[Jeffrey Knudson, executive]

No. I think that gets to what Cary was talking about earlier with what we're seeing probably more broadly in Locums, where we're seeing delays in client decision-making and just in lower extensions and probably more of a focus on the cost of Locums. Demand is still healthy, but it is down from the beginning of the year, and it's certainly down year-over-year.

[William Sutherland, analyst]

And what I was sort of taking away from earlier comments is that the bill pay spread in travelers is getting kind of back to something that is normal. But what's weighing on the spread gross margin is lodging and other costs related to the travelers expenses. Is that what you guys are seeing?

[Jeffrey Knudson, executive]

Yes. That's accurate. When we think about Nurse and Allied gross margins in the second quarter, all other elements of the bill pay spread actually improved slightly over Q1 levels. And the downdraft came from the housing and the per diems as well as we had a favorable workers' comp adjustment in the first quarter that didn't repeat in Q2 within Nurse and Allied.

[William Sutherland, analyst]

Okay. And then just zooming out a little bit, kind of curious about the marketplace's impact on your -- just competitively. And in the past, they haven't -- I don't think, made a big difference in how you do. But curious what it looks like today. .

[Caroline Grace, executive]

What marketplaces, Bill?

[William Sutherland, analyst]

The marketplaces that are designed to be very automated as far as government positions. .

[Caroline Grace, executive]

Got it. I think what we've seen particularly over -- in the past 6 quarters, is that -- when you look at the supply-demand equation, it's actually been -- the premium has been on who has access to the demand. And so the marketplaces tend to be a conduit for supply, but they're not always connected in it directly to the demand side as you would see vendor-neutral, direct or MSP relationships. So they obviously are out there, but we haven't seen them be as much of a factor in this lower demand environment.

[Operator]

Thank you. This does conclude today's Q&A session. I would like to go ahead and turn the call back over to Cary for closing remarks. Please go ahead. .

[Caroline Grace, executive]

Thank you all for your continued interest in AMN. We look forward to continuing to update you on our important mission of empowering the future of care.

[Operator]

Thank you. This concludes today's meeting. You may all disconnect.