Encompass Health Corp

NYSE:EHC

Earnings Call Transcript 2024-Q1

[Operator]

Good morning, everyone, and welcome to Encompass Health's First Quarter 2024 Earnings Conference Call.

[Operator Instructions]

Today's conference call is being recorded. If you have any objections, you may disconnect at this time. I will now turn the call over to Mark Miller, Encompass Health's Chief Investor Relations Officer.

[Mark Miller, executive]

Thank you, operator, and good morning, everyone. Thank you for joining Encompass Health's First Quarter 2024 Earnings Call. Before we begin, if you do not already have a copy, the first quarter earnings release supplemental information and related Form 8-K filed with the SEC are available on our website at encompasshealth.com.

On Page 2 of the supplemental information, you will find the safe harbor statements, which are also set forth in greater detail on the last page of the earnings release. During the call, we will make forward-looking statements which are subject to risks and uncertainties, many of which are beyond our control. Certain risks and uncertainties, like those relating to regulatory developments as well as volume, bad debt and labor cost trends that could cause actual results to differ materially from our projections, estimates and expectations are discussed in the company's SEC filings including the earnings release and related Form 8-K, the Form 10-K for the year ended December 31, 2023, and the Form 10-Q for the quarter ended March 31, 2024, when filed. We encourage you to read them.

You are cautioned not to place undue reliance on the estimates, projections, guidance and other forward-looking information presented, which are based on current estimates of future events and speak only as of today. We do not undertake a duty to update these forward-looking statements.

Our supplemental information and discussion on this call will include certain non-GAAP financial measures. For such measures, reconciliation to the most directly comparable GAAP measure is available at the end of the supplemental information at the end of the earnings release and as part of the Form 8-K filed yesterday with the SEC, all of which are available on our website.

I would like to remind everyone that we will adhere to the one question and one follow-up question rule to allow everyone to submit a question. If you have additional questions, please feel free to put yourself back in the queue.

With that, I'll turn the call over to Mark Tarr, Encompass Health's President and Chief Executive Officer.

[Mark Tarr, executive]

Thank you, Mark, and good morning, everyone. The broad-based momentum of our business continued in the first quarter evidenced by 13.4% revenue growth and adjusted EBITDA increase of 19.2%, owing largely to our Q1 results, we are increasing our 2024 guidance.

Doug will cover the details of the quarter and increased guidance in his comments. Demand for [ Earth ] services remains strong, and we are continuing to invest in capacity additions to meet the needs of patients requiring inpatient rehabilitation services. During Q1, we added 51 beds to existing hospitals. Over the balance of the year, we plan to open 6 de novo hospitals with a total of 280 beds as well as a 40-bed freestanding hospital to be licensed as a satellite location of an existing hospital.

Consistent with our historical practice, the satellite will be accounted for as a bed addition. We anticipate adding another 93 beds to existing hospitals in 2024, inclusive of the aforementioned satellite. We continue to build and maintain an active pipeline of de novo projects, both wholly owned and joint ventures with acute care hospitals. Since the beginning of this year, we've announced 3 additional de novo projects, bringing our pipeline to 14 hospitals under development with opening dates beyond 2024.

We -- we remain keenly focused on further enhancing the quality of our patient care and resulting outcomes through the deployment of clinical technologies and protocols. We have previously highlighted the installation of in-house dialysis capabilities at many of our hospitals. We now offer this service in 88 of our hospitals and we'll continue the rollout to additional locations in 2024.

As another example of an ongoing clinical project, our quality of life improvement project incorporates an individualized approach to inpatient care in which our therapists focus on a specific patient's interest, lifestyle, home improvement and community mobility needs. The goal of this program is to improve the patient's inpatient experience and readiness for discharge to their community. On March 27 of this year, CMS released the 2025 IRF proposed rule. This included a proposed net market basket update of 2.8% and which we estimate would result in an approximately 3% increase for our IRFs beginning October 1, 2024, based on our current patient mix.

The IRFs final rule is expected to be released in late July or early August. Review Choice Demonstration, or RCD, began in August 2023 in Alabama. Recall that under RCD Cycle 1, which lasted 6 months, every Medicare claim was reviewed for documentation and medical necessity. The affirmation rate target set by CMS under cycle 1 was 80%. All 7 of our Alabama hospitals ended Cycle 1 above the target affirmation rate. For Cycle 2 in Alabama, which runs from May 1 through October 31, we had the choice of continuing with 100% pre-claim review or a random spot check pre-claim review of 5% of claims. Based on our Cycle 1 claim experience, we elected to continue with 100% pre-claim review for Cycle 2. The target affirmation rate for Cycle 2 is 85%.

On March 1, CMS announced it is expanding IRF RCD to Pennsylvania for hospitals billing to the Medicare administrative contractor, Novitas. Our 9 hospitals in Pennsylvania will not be subject to RCD at this time as they build to a different Medicare administrative contractor. During Q1, many providers across the U.S. health care spectrum experienced significant disruptions due to the cyber-attack on Change Healthcare. We have historically used change for the vast majority of our claims processing across our payer base. Our teams and our centralized business office and information technology quickly rallied to successfully implement workarounds using alternative third-party vendors and enhancing our own claims processing capabilities.

As a result of these efforts, we experienced minimal impact to our Q1 cash flow from the change outage. We resumed claims processing would change in early April and continue to maintain the alternative channels we recently developed. Across our 160 inpatient rehabilitation hospitals, we are daily providing high-quality, cost-effective care to medically complex patients. Our dedicated clinical teams work collaboratively with physicians to administer this care, producing leading scores in patient satisfaction and quality outcomes.

This value proposition increasingly resonates with patients, caregivers, referral sources and payers. The demand for inpatient rehabilitation services remains considerably underserved, and continues to grow as the U.S. population ages. We intend to continue to expand our capacity and capabilities to meet this need.

Now I'll turn it over to Doug.

[Douglas Coltharp, executive]

Thank you, Mark, and good morning, everyone. As Mark stated, we are very pleased with our Q1 results. Revenue growth for the quarter of 13.4% was primarily driven by volume as total discharges grew 10%, inclusive of 6.7% same-store growth. Q1 revenue growth did benefit from both leap year and the timing of the Easter holiday. Our Q1 revenue also included a $6.9 million increase in provider tax receipts, primarily attributable to prior periods. Q1 adjusted EBITDA increased 19.2% to $273 million, driven by revenue growth, stable premium labor trends and prudent expense management. Other operating expenses as a percent of revenue decreased 80 basis points, benefiting from the favorable impact of on-site dialysis implementation and efficiencies in our recruiting efforts.

Q1 adjusted EBITDA included approximately $5 million related to the aforementioned provider tax receipts. Q1 net preopening and ramp-up costs were $1.8 million as compared to $4.2 million in Q1 last year. Given the timing of our new hospital openings and the balance between joint venture and wholly owned de novos, our net preopening and ramp-up costs will be concentrated in the final 3 quarters of the year.

We anticipate $15 million to $18 million of de novo net preopening and ramp-up costs for 2024 as compared to $6.6 million in 2023. We continue to generate significant levels of free cash flow. Adjusted free cash flow for the quarter increased 5.6% to $167.6 million due to higher adjusted EBITDA, partially offset by an increase in working capital which was unrelated to the Change Healthcare outage and higher cash tax payments.

Primarily based on the strength of our adjusted EBITDA growth, our net leverage again declined falling to 2.5x from 2.7x at year-end 2023. We ended the first quarter with no amounts drawn on our $1 billion revolving credit facility and more than $130 million of cash on hand. As Mark alluded to, based primarily on our Q1 results, we are raising our 2024 guidance as follows: net operating revenue of $5.25 billion to $5.325 billion, adjusted EBITDA of $1.03 billion to $1.065 billion and adjusted earnings per share of $3.86 to $4.11. The -- the key considerations underlying our guidance can be found on Page 12 of the supplemental slides. And with that, operator, we'll now open the lines for questions.

[Operator]

[Operator Instructions]

And we'll take our first question today from Kevin Fischbeck with Bank of America.

[Kevin Fischbeck, analyst]

I guess we have a little bit more color on the volume in the quarter. Do you have any details about the strength you mentioned that the leap year help -- there's been a lot of kind of focus on how maybe March slowed down. Any comments about volume intra the quarter and how things are maybe trending so far in April?

[Douglas Coltharp, executive]

The volume remained pretty constant throughout the quarter. And so in the month of February, you had the extra day because of leap year, which certainly helped volume in that month -- and then March, discharge volumes certainly benefited from the fact that the Easter holiday fell on the last day of the quarter, which also happened to be a Sunday. But really, we saw good momentum on volume through the entire quarter.

[Mark Tarr, executive]

Kevin, not only was it consistent throughout the quarter, but if you look at it geographically across our 8 regions, it was very consistent across all of our regions, and we're very pleased with the progress that we've continued to make on overall volume growth.

[Kevin Fischbeck, analyst]

Great. And then I guess...

[Douglas Coltharp, executive]

When we look at the total discharge volume growth, we had a 12% increase in Medicare fee-for-service and north of an 11% increase in Medicare Advantage.

[Kevin Fischbeck, analyst]

Okay. Great. And then I guess, maybe just to talk about that for a second. A lot of focus on Medicare Advantage rates and -- can you talk a little bit about how the contracting there for you is going?

And then are you expecting any pressure or flow through from the negative rate adjustments they're getting for next year? Is there any concern about how that might flow down through to your contracting or their utilization management?

[Douglas Coltharp, executive]

So we're right at about 90% of our Medicare contracted revenues being on an episodic basis versus on a per diem basis. And the payment differential for the quarter was just over 3%. So good progress there. Most of those contracts that are on an episodic basis, the annual increases are tied directly to the Medicare fee-for-service rule. So at this point in time, we're really not expecting any adverse consequences from what's going on with regard to the Medicare Advantage rule.

[Operator]

Our next question will come from A.J. Rice with UBS.

[Albert Rice, analyst]

I know the SWB per FTE was about 4% to 5% in the quarter. And I think that's your target for this year. I wonder, when you look at it underlying permanent wage trends, premium labor sign-on bonuses, ship bonuses. Is there any place where you're running higher than the pre-pandemic where there's still opportunities in your mind potentially to improve on that year-to-year rate?

[Douglas Coltharp, executive]

Yes. So total SWB for the quarter was actually up 3.8%, so slightly below the low end of the range that we have out there for the year. And the biggest reason for that is that we would expect a higher growth rate on benefits for the last 3 quarters of the year just based on the positive accrual adjustments we had in the last 3 quarters of 2023.

The -- both categories of premium labor continue to be elevated above where they were pre-pandemic, although they've settled down quite a bit. If we look at what transpired in the quarter in terms of sign-on and ship bonuses, the total there was $14.3 million. That's about a $2 million improvement over where we were in Q1 of last year, and it's up just modestly about $1.2 million from the run rate we experienced in Q4.

That's not unanticipated, just given our normal seasonal trends and also the volume increase that we had in the quarter. Looking at kind of the same pattern for contract labor dollars, we were at $19.3 million in Q1 . Again, that compares favorably to $20.7 million in Q1 of last year, up sequentially from Q4, which was $17.7 million. We again would attribute that predominantly the seasonal patterns and to the volume trend. The contract labor FTEs as a percentage of total FTEs for the quarter was at 1.6%, and that's in the range that we've been -- we were running at the second half of last year, right around 1.5%. Again, pre-pandemic, we would have been just below 1%.

And -- so we do think that there's some continued opportunity, but it really does feel like at least for the foreseeable future, A.J., we've kind of settled into this range. I will note, we continue to make good progress through our recruiting efforts on the quarter. Net new RN hires for the quarter were $148 million, and that's a pretty significant increase over the less than 50 that we had in Q1 of last year.

[Mark Tarr, executive]

And final comment on labor, A.J., is not only on the recruitment side, but retention continues to be a big focus. And our turnover particularly around the nursing continues to trend downward as well as therapy. So we're seeing a lot of positive aspects within the broader umbrella of labor itself.

[Douglas Coltharp, executive]

Yes. And just to put a finer point on Mark's comments there, annualized Q1 nursing turnover was at 20.2% and therapist turnover 6.6%. So those are very positive numbers.

[Mark Tarr, executive]

And both of those would be lower than pre-pandemic.

[Albert Rice, analyst]

Yes, it's a very low number on the therapies, interesting.

[Operator]

Our next question comes from Andrew Mok with Barclays.

[Andrew Mok, analyst]

I was hoping you could give us a little bit more detail on de novo openings this year, just overall cadence and timing. There were no openings in Q1. So how should we think about the 6 de novos for the balance of the year?

[Douglas Coltharp, executive]

Yes. Certainly, as we alluded to at the beginning of the year, you're going to have a different pattern this year than you did last year.

Last year, we benefited in terms of the annual net preopening and ramp-up costs by the fact that we had earlier openings, we had those that were predominantly JVs, 5 of the ones that we opened last year were and you had a couple of hospitals in hospitals, which tend to ramp up faster.

We're skewed now with our openings into the final 3 quarters of this year. which is leading to kind of the year-over-year change and particularly over the balance of 3 quarters. If you look over the final 3 quarters of last year, our net preopening and ramp-up costs were negative $2.4 million. If you subtract out from the $15 million to $18 million range we have for 2024, the $1.8 million we experienced in Q1, you're left with an anticipated $13.2 million to $16.2 million impact in Q2 through Q4, and -- the midpoint of that range is $14.7 million. So that would represent a little over $12 million delta on a year-over-year basis.

[Andrew Mok, analyst]

Got it. That's helpful. But if we just take a step back and think about the 6 de novo, should we think 2 per quarter for the remaining 3 quarters? Or is there even more of a back-end skew to that?

[Douglas Coltharp, executive]

I think we've got 2 opening in Q2 and then the balance are in Q3, 1 short, 1 will likely extend into Q4.

[Andrew Mok, analyst]

Okay. That's helpful. And then occupancy in the quarter ticked up to about 76.7%, which I think was a notable sequential and year-over-year increase. I know you have elevated bed additions coming online this year, but can you give us a sense for what full capacity looks like or maybe where your top decile hospitals sit on an occupancy basis?

[Douglas Coltharp, executive]

Yes. So occupancy during the quarter was definitely favorably impacted by normal seasonality as well as the volume increase we saw and the fact that there were no counterweights in terms of the de novos opening in the quarter. Again, as we move forward, we would hope to see the overall occupancy rate continue to move up modestly over time. And really, the primary reason there, in addition to the fact the demand environment remains very positive, is that we are increasingly seeing a higher percentage of our overall beds in private rooms, which eliminates the capacity constraints that can be caused by gender compatibility and other issues requiring patient isolation.

And again, the increase in private beds is coming from really 2 initiatives. The first being that virtually all of our capacity additions, be they be bed additions to existing hospitals or de novos, are comprised of all private rooms. And then the second is when we are doing major remodels and renovations where we are able we are taking the opportunity to convert semi-private rooms to private rooms.

In terms of targeting a specific theoretical occupancy peak, it's hard to do that because we still have such a mixed bag within our overall physical plan. But generally speaking, in a facility that is all semiprivate, you start to hit capacity constraints north of 80%. When you're in a facility that is all private room, you can run into the mid- to high 90s.

[Operator]

Our next question will come from Ann Hynes with Mizuho Securities.

[Ann Hynes, analyst]

So I just want to talk about guidance. You beat consensus estimates on the adjusted EBITDA side by close to 10%. So even by Encompass' conservative history, just the 1% guidance rate seems conservative to me.

So maybe can you tell us what the quarter actually was versus your internal expectations? And is there anything we should consider as we go out throughout the rest of 2024, why you wouldn't be able to see this type of strong growth going forward?

[Douglas Coltharp, executive]

Yes. Ann, I think you've really hit on the key point, which is, as a reminder, we issue annual guidance. We don't provide quarterly guidance. And I know that creates a challenge for you and your peers because you need to provide quarterly estimates that are out there.

When we were thinking about our own expectations for Q1 performance, we were specifically looking at the momentum that we had coming in from Q4, the normal seasonality. But then we acknowledge the fact that you had an extra day in the quarter due to leap year and that there would be some timing benefit that would be attributable to the Easter holiday falling on a Sunday, which is the last day of the quarter. That's kind of a rare phenomenon.

In the quarter, we also got the unanticipated benefit from the provider tax income. So yes, the quarter was still ahead of our expectations, which is the primary reason that we are revising our guidance upward, but there should not be an assumption made that our expectation internally was consistent with the consensus estimate.

As we look at the back end of the year, I think the primary considerations are one, that I've already reviewed, which is a year-over-year change in the impact from de novo preopening and ramp-up costs.

And then really, it's a pretty straightforward story where you fall in the range that we provided or whether we're able to ultimately revised that range upward through the course of the year is going to be predominantly a function of 2 things.

One is, does volume continue. We've -- we're up against challenging comps, but feel very good about the underlying demand out there. And then what is ultimately the dynamic that exists over the final 3 quarters of the year between the pricing, which is relatively locked in and the rate of labor inflation that we experienced.

[Ann Hynes, analyst]

Great. And I guess my follow-up question really has to do with that rate. I mean, I know you're getting a 3% increase from CMS, but it kind of seems lopsided given the labor environment over the past couple of years.

Is there a delay in the way the calculation works that maybe over the next couple of years, you should see an acceleration of rates, given what's happening in the -- just in the labor environment?

[Douglas Coltharp, executive]

So if you look at the rule making for all of the post-acute sectors, the only sector that has a forecast error adjustment, which means it's looking backwards to say, did we miss a rate of underlying inflation in the providers' cost structure that needs to be factored in the go-forward rate is SNFs. And that dates back to some legislation from the early 2000s, they went to have a good lobbying effort. I can't really tell you anything more about that.

For IRFs, there's no catch-up. And so every year, the market basket update is based on forward looking. It's the anticipated rate of inflation in the next year, not what you experienced in the previous year. So you would hope at some point, those become relatively consistent, but there isn't a catch-up mechanism built into the IRF making -- into the IRF rule making cycle.

[Mark Tarr, executive]

And Ann, 1 of the other areas on that. You never really know when there's going to be some other adjustment around productivity or something that's unforeseen that CMS would apply that would pull the net rate increase downwards. So that's what makes a bit of challenge.

[Operator]

Our next question will come from Scott Fidel with Stephens.

[Scott Fidel, analyst]

First question, just curious on your thinking right now around potential capital return, particularly as it relates to buyback when thinking about the strength and the performance of the business, leverage now being at the low end of the target, the cash on hand, et cetera. Just curious on your sort of thinking about potentially ramping up buyback activity.

[Douglas Coltharp, executive]

Yes, certainly on the table, it's going to be a topic of continuing Board discussion for all of the reasons that you cited.

Even with the cyber-attack on Change Healthcare, our cash flow remained very strong in the quarter because we were able to implement those workarounds and because of the strength of the business and the flow-through from the adjusted EBITDA.

All of the points that you noted are very important ones, which the net leverage is all the way down to 2.5x. There's $130 million of cash on balance sheet. We're generating enough internal cash flow to fund all of our discretionary CapEx plus the dividend. So it certainly opens up other options for capital deployment, and that's very much on the agenda for our Board now.

[Scott Fidel, analyst]

Okay. And then a follow-up question. Just would be interested in your thinking on the final SNF staffing rule. I know it's somewhat second degree removed.

But just really in sort of 2 areas in particular. One, as you've talked about the opportunity over the long term for capturing more volumes from SNFs in terms of SNF conversion, whether that final staffing rule would have any influence over that?

And then just also whether any thoughts on this type of sort of staffing mandate at the federal level, if you've heard anything about that moving into other post-acute sectors? Obviously, IRFs would be top of mind for you in terms of any slippery slope type dynamic relating to the final SNF staffing role.

[Mark Tarr, executive]

Yes. So this is Mark. And certainly, I don't know all the details of the SNF. But just in general, we feel like we have done a really nice job with our quality outcomes and making that value proposition that helps separate us from other providers in the marketplace, whether it's other IRFs or skilled nursing facilities.

Clearly, the SNFs have been challenged the past several years through COVID and otherwise. So they have a lot of ground to make up, so to speak. But we're very focused on what we're doing right now around our programming and our quality, and I don't see the SNF rule having any impact on the market share that we've been able to take.

[Douglas Coltharp, executive]

And it really shouldn't be applicable to IRFs in the future because our staffing is really already dictated by the mandated requirements of care.

The complement of therapists that we have in our facilities is driven by the therapy rules. Again, that's the 3 hours of therapy per day, 5 days a week. It's got to be multi-disciplined therapy, and the preponderance has to be administered in individual versus a group or a concurrent setting.

And then we also have very stringent nursing requirements that are mandated. So this was something that was lacking in the SNF industry, which is why I think you're seeing this come down. It is not something that is applicable because there needs to be adjustment in the IRF segment.

[Mark Tarr, executive]

And keep in mind, we're already taking a pretty acute level rehab patients that's medically complex. And as part of that, we adjust our nursing staffing to make sure that we can do a great job in taking care of those patients and not have those patients go back to the acute care hospital.

So there are a lot of either rules of thumb or formal rules that are currently in place around what it takes the staff for hospitals to meet the type of patients we're taking in.

[Operator]

Our next question will come from John Ransom with Raymond James.

[John Ransom, analyst]

I'm just kind of curious role of -- there's a lot of talk of years about the conveners and the navigators. I'm just wondering, you're in the fight for these patient referrals, if you really notice any sort of change or things kind of settled down and the 3 legs of post-acute kind of have their share.

It looks fairly stable when you look at the numbers across the 3 modalities. But how do you think about -- when you talk to these discharge planners, these Navigators, how are they thinking about things the same or differently than maybe 5 years ago?

[Mark Tarr, executive]

John, I think it has settled down a bit. When we've seen these Navigators come into various marketplaces, there might be a short-term impact on referrals or their approval for a patient to be discharged to an IRF, but that is usually somewhat short-lived.

They see the issues, quality and otherwise, that come in place in the market when they try to dictate where the patient goes according to just the cost of care. And so that pops up in the marketplace then seems to go away within 30 to 45 days. So I think it's settled down overall compared to where it was 3, 4 years ago.

[Operator]

Our next question will come from Pito Chickering with Deutsche Bank.

[Pito Chickering, analyst]

Next quarter. So digging into the OpEx leverage you guys got this quarter, you talked about sort of dialysis and recruiting as large drivers there. What have been the returns on doing dialysis yourselves? And with that also at 88 hospitals? Is it safe to model additional OpEx leverage going forward from that lever?

[Douglas Coltharp, executive]

Yes. So the straight math on the dialysis conversion is when we use an outside contractor on average, it costs us about $600. When we do it internally, it cost us about $300. The reimbursement is the same because that's basically coded into the requirements of the patient when they're admitted to our facility. So that incremental $300 per treatment is a flow-through.

And then you get the other benefits that are very difficult to quantify, such as the fact that the patients therapy isn't being disrupted and you're not having to incur transportation costs to go outside the facility if that's an alternative.

The -- in terms of continuing leverage from that in OOE, we would expect to see that. Now bear in mind, some of that is a straight reduction in cost. Some of it is also a geography issue. When we contract with a third party that $600, 100% of it runs through OOE as a contract services expense.

When we do it internally, that cost gets spread out into other line items, the largest of which is SWB. And then we would expect that based on some of the efficiencies we're seeing both in terms of advertising costs that are out there and some of the different modalities and approaches that we have developed within our recruiting efforts that even as we continue robust recruiting efforts to make sure that we keep pace with our clinical requirements with new hires, that we'll continue to see some efficiencies in recruiting as well.

[Pito Chickering, analyst]

Okay. And then so a quick question on that one. I guess, how many dialysis patients do you guys have?

And then sort of second part here is on provider tax revenues haven't really been a big driver for you guys historically. You obviously saw $6.9 million in the fourth or -- in the first quarter, I guess, how should we think about that going forward?

[Mark Tarr, executive]

Yes. So Pito, somewhere between around 3% to 5% of our total patients are on dialysis care, either internally or where we have a vendor come into our hospital.

So we do think that's going to be a continued focus and look to a larger percentage of the population has issues that we'll put them on some sort of dialysis care. So we think it's a growing need for our hospitals.

[Douglas Coltharp, executive]

Provider taxes, Pito, are notoriously hard to predict in terms of timing and magnitude -- and in most quarters, where we get that kind of provider tax revenue, we've got the offsetting -- largely offsetting expense. So from an EBITDA perspective, it doesn't cause much fluctuation. We haven't baked any net benefit from provider taxes into our guidance for the balance of the year.

[Operator]

Our next question will come from Ben Hendrix with RBC Capital Markets.

[Benjamin Hendrix, analyst]

I think most of my questions have been answered, but I did want to follow up on your comments about the review choice demonstration. And specifically, your decision to continue with 100% pre-claim review in Alabama.

I know you've had periods of elevated denial activity with fiscal intermediaries in the past. It seems like the sampling election would help you sidestep some of that risk. I just wanted to get your thought process there and kind of how relations with intermediaries are going?

[Mark Tarr, executive]

Yes. So the relations have gone well thus far around that, particularly majority of our hospitals under Palmetto.

We decided -- actually, the team decided to continue on with 100% review. It felt like we put in a good discipline with better hospitals around documentation and capturing everything we needed to in the chart and to stray from that just seem like it wasn't the right thing to do, given the process that we already had put in place. So the hospitals actually help make that decision to stay at 100%.

[Douglas Coltharp, executive]

The benefit of the 100% pre-claim review, there's really kind of twofold. One is it allows for a much more iterative process with the MAX, so that we can find out if they're viewing anything regarding a patient's appropriateness in our hospitals as either if they're either viewing it erroneously or if there's -- if they're perceiving they require a change in our documentation, and we can make that adjustment.

The other thing is you get a larger sample size. So one of the risks that's associated with that 5% pre-claim review is they look at one particular patient and they disqualify that patient that based on a circumstance and then apply that through extrapolation to a broader base. Whereas if we've got the 100% pre-claim review they're out there, we can line that patient that they may be contesting up with many others that have been approved elsewhere in their organization and say, you tell us what's different.

So we just think because the infrastructure is already in place and procedures already in place, that this is the right way for us to proceed through cycle 2.

[Benjamin Hendrix, analyst]

And just is the added cost of the 100% material?

[Douglas Coltharp, executive]

No, it's already in place.

[Operator]

[Operator Instructions]

We'll now hear from Brian Tanquilut with Jefferies.

[Brian Tanquilut, analyst]

Congrats on the quarter. I actually just have other questions. Maybe, Doug, can you share with us the -- what it looked like in terms of the growth rates in different diagnoses of patients coming in?

I guess where I'm coming from is, as we think about broader utilization strength, just curious if it's specific to stroke? Or are we seeing more from like elective procedures such as drug replacements?

[Douglas Coltharp, executive]

The story is really pretty consistent with what we saw in the back half of last year. So good growth in neurological and stroke in the quarter. Neurological was up just north of 10%. Stroke was up almost 12%. We did see a pretty significant increase in brain injury. That was up 11.1%. And -- Other ortho was up almost 16%. But again, remember, that's off of a smaller base.

So we are seeing a broadening in terms of some more rapid growth in some of the smaller categories that have gotten deferred for a period of time during COVID, but the strength in our higher acuity categories continues to be there as well.

[Mark Tarr, executive]

Brian, there's electric procedures. We just don't see a lot of them matter of fact, I mean, for just joint replacement, it's a little bit less than 3% of our total patient mix. So it's not really had a large impact on us.

[Douglas Coltharp, executive]

One of our smallest categories, but knee and hip replacement was up 20% during the quarter.

[Operator]

Our final question will come from Jared Haase with William Blair.

[Jared Haase, analyst]

Maybe I'll just ask one around the Change Healthcare disruption. And specifically, I know you mentioned kind of some of the work you did to implement workarounds and maybe enhance or build out some of your internal capabilities.

I'd just be curious, any particular areas of interest that you called out where you made investments or sort of built out those workflows.

And then I guess the other question is just should we think about any leverage benefit from that just in terms of you internalizing a little bit more of the sort of RCM capabilities?

[Douglas Coltharp, executive]

Yes. So you think about how we and how most providers utilize change, it was for 2 things. One is what is called claims scrubbing, which is just to make sure that as you or setting a claim to any particular payer, whether it's CMS through one of the intermediaries or to one of the Medicare Advantage or managed care players that for getting the documentation in the form that is most readily acceptable and desired by that particular payer.

The second thing is that for us and for others Change really served as the electronic intermediary in terms of submitting the claims and getting those processed. The primary thing that we did internally was establish our own electronic interface with CMS and now extending that to other payers as well.

Whether or not there's going to be any kind of leverage that ultimately comes from that, I think it's going to depend on a go-forward basis between the balance that we have in restoring claims processing through change, these other third-party vendors that we identified and put in place during the process and how much we choose to do internally.

It's still somewhat of a dynamic situation. We will refrain from going back to a situation where we have an overdependence on any one single vendor.

[Mark Tarr, executive]

Sure. I do want to call out our teams and our centralized billing office down in Tampa as well as our IT staff because they worked extremely hard to minimize the impact on this and figure out work around to come in at night from the weekends to make sure that we were being taken care of from a company standpoint. So I did want to point that out.

[Jared Haase, analyst]

Yes, that's great to hear.

[Mark Tarr, executive]

All right. Thank you.

[Operator]

That will conclude the question-and-answer session. I will now turn the call over to Mark Miller for any additional or closing remarks.

[Mark Miller, executive]

Thank you, operator. If anyone has additional questions, please call me at [phone]. Thank you again for joining today's call.

[Operator]

This does conclude today's conference. Thank you for your participation. You may now disconnect.