Select Medical Holdings Corp

NYSE:SEM

Earnings Call Transcript 2024-Q3

[Operator]

Good morning, and thank you for joining us today for the Select Medical Holdings Corporation's Earnings Conference Call to discuss the third quarter 2024 results and the company's business outlook.

Speaking today are the company's Executive Chairman and Co-Founder, Robert Ortenzio; and the company's Senior Executive Vice President of Strategic Finance and Operations, Martin Jackson. Management will give you an overview of the quarter and then open the call up for questions.

Before we get started, we would like to remind you that this conference call may contain forward-looking statements regarding future events or the future financial performance of the company, including, without limitation, statements regarding operating results, growth opportunities and the other statements that refer to the Select Medical's plans, expectations, strategies, intentions and beliefs.

These forward-looking statements are based on the information available to the management of Select Medical today, and the company assumes no obligation to update these statements as circumstances change.

At this time, I would like to turn the call over to Mr. Robert Ortenzio. Please go ahead.

[Robert Ortenzio, executive]

Thank you, operator. Good morning, everyone. Welcome to Select Medical's earnings call for the third quarter 2024. As most of you are aware, this quarter, we successfully completed Concentra's initial public offering. Concentra issued 23,250,000 shares and now trades under the symbol CON on the New York Stock Exchange. Select Medical now owns 81.74% of Concentra stock. We expect to distribute its remaining interest in Concentra to our shareholders by the end of the year, contingent upon receiving the waiver of the IPO lockup, which is based on market conditions.

As noted on last quarter's earnings call, Concentra entered into financing arrangements, which included a new senior credit facility consisting of an $850 million 7-year term loan, a $400 million 5-year revolving facility, which was undrawn at closing, and $650 million of 6.875% senior notes due 2032. The majority of the net proceeds of Concentra's IPO and related debt transactions were used by Select to pay down debt.

Concentra will be holding their Q3 conference call later this morning at 10:30 Eastern Time, where they will provide more detailed information regarding their performance for the third quarter.

On the development front, in September, Select Medical opened a 48-bed inpatient rehab hospital in Jacksonville, Florida, with our partner, UF Health. The joint venture hospital is branded UF Health Rehabilitation Hospital North and resides in the new tower of UF Health North.

We're also pleased to announce a few new inpatient rehab projects including an acquisition of a 50-bed hospital in Oklahoma City that is scheduled to close in December. The hospital will be a joint venture with our current partner, SSM. Early next year, we also plan on opening a 54-bed rehab hospital in Temple, Texas. Contingent upon regulatory approval, we plan on opening a new 68-bed facility in Jersey City, which is Hudson County, New Jersey, branded as Kessler in late 2026.

We have a number of development projects in line for 2025 and 2026 in the inpatient rehab division. We're on track to open our second hospital with UPMC in Central Pennsylvania, in Q2 of 2025 and our fourth inpatient rehab with Cleveland Clinic in Fairhill, Ohio, in Q3 of 2025. In Q1 of 2026, we are slated to open our fourth rehabilitation hospital as part of our joint venture with Banner in Tucson, Arizona, and a new freestanding 63-bed rehab hospital in Ozark, Missouri, with Cox Health Systems. In Q4 2026, our new 60-bed rehab hospital in Southern New Jersey, Bacharach Institute for Rehab in partnership with AtlantiCare is scheduled to open.

Between the specific projects I just mentioned as well as some other smaller expansions and new distinct part rehab units and existing hospitals, we plan to add 569 additional beds through our operations for the remainder of 2024 through 2026. The additional beds will consist of 543 inpatient rehab beds, which include 112 nonconsolidating beds and 26 long-term acute care hospital beds. There are also a number of other opportunities under consideration, which would further increase our Select Specialty Hospital footprint.

This quarter, our outpatient rehab division added 9 clinics via 8 de novos and One Clinic acquisition. This offset the closure of 4 terminated management agreements, 3 underperforming clinics and the forwarding of 2 clinics into existing operations upon lease expiration. The pipeline for future growth includes 6 executed leases for de novo clinics scheduled to open later this year as well as 12 for 2025. We also plan to acquire 2 clinics later this year.

Overall, we had a strong third quarter of 2024 with all 4 divisions exceeding prior year Q3 results in both revenue and adjusted EBITDA. The hospital divisions continued to exceed expectations with the inpatient rehab division returning double-digit growth in both revenue and adjusted EBITDA for the third consecutive quarter this year.

Overall, our consolidated adjusted EBITDA grew 6% from $193.8 million to $205.5 million with an adjusted EBITDA margin of 11.7% compared to 11.6% in prior year Q3. Revenue grew by 6% compared to Q3 of the prior year.

Our critical illness recovery hospital division continues to perform well with a 3% increase in revenue and a 9% increase in adjusted EBITDA compared to the same quarter prior year. Critical illness incurred $2.5 million in start-up losses related to new hospitals this quarter compared to $5 million in the same quarter prior year. Current quarter start-up losses primarily relate to the opening of Rush Specialty Hospital in Chicago in April. Our occupancy and average daily census both increased by 1% from same quarter last year, occupancy from 65%, up from 64%.

Our rate per patient day increased 2%. Our adjusted EBITDA margin was 8.7% for the quarter compared to 8.2% in the prior year Q3. Critical illness experienced a slight reduction, [ 0.3% ] in their salary ranges and benefit to revenue ratio compared to prior Q3 with a 58% margin. We have seen nursing agency rates stabilize while utilization continues to decrease from prior year. We also continue to see decreases in nursing orientation hours, 13% reduction from prior year Q3 and sign on and incentive bonus dollars, an 18% reduction from prior year Q3.

Our inpatient rehab hospital division had a very strong quarter with a 14% increase in revenue and a 12% increase in adjusted EBITDA compared to Q3 prior year. Inpatient rehab incurred $3.7 million of start-up losses this quarter, primarily related to the opening of the UF Health Jacksonville in late September and our Rush Specialty hospital rehab unit in April. We did not incur any start-up losses within the rehab division in prior Q3.

Average daily census increased 4% and our rate per patient day increased 6%. Our occupancy of 82% was 2% lower than prior year 84%, which is a result of our new hospitals. The adjusted EBITDA margin for inpatient rehab was 21.3% for Q3, which was lower than prior year margin of 21.7%, again, due to new hospital start-up losses. Our same-store adjusted EBITDA margin was 23.4% for the quarter.

Concentra experienced increases of 3% in both net revenue and adjusted EBITDA over prior year same quarter. The increase in revenue was driven primarily by a 4% increase in rate, which was attributable to workers' comp state fee schedule increases, consistent with the first half of the year, Concentra workers' comp volume remained strong with an increase of 2% from prior year Q3. This volume was offset by a 4% decrease in employer base visits, which are reimbursed at lower rates. The demand for employer-based visits have normalized as the labor force has stabilized compared to the COVID years where we experienced significant churn in labor force.

Concentra's adjusted EBITDA margin was 20.7% for the quarter compared to 20.9% same quarter prior year. Our outpatient rehab division experienced an increase of 7% in revenue with patient volumes increasing by 6% and our net revenue per visit increasing from $100 prior year Q3 to $101, Q3 of this year. Our volumes continues to maintain an upward trend and net revenue per visit has increased with continued improvement in commercial and managed care rates, offset by the decrease in our Medicare rates.

The outpatient division's adjusted EBITDA increased by 7%, compared to prior year, and the adjusted EBITDA margin increased from 9% to 9.1%. The outpatient team continues to focus on improving patient access, productivity and staffing. EPS was $0.43 per share for the third quarter compared to $0.38 per share in the same quarter prior year. Adjusted EPS was $0.50 per share compared to adjusted EPS of $0.46 per share Q3 of the prior year.

In regards to our allocation and deployment of capital, our Board of Directors declared a cash dividend of $0.125 payable on November 26, 2024, to stockholders of record as of the close of business on November 13, 2024. This past quarter, we did not repurchase shares under our Board-authorized share repurchase program. We will continue to evaluate stock repurchases, reduction of debt and development opportunities.

In closing, I'd like to acknowledge the passing this past week of my father, my co-founder and our Chairman Emeritus, Rocco Ortenzio. Rocco was a visionary and force in the health care industry for over 6 decades. The last 28 years at Select Medical, where he was instrumental in guiding our company's success. You will be deeply missed, but his legacy of leadership will carry forward.

That concludes my remarks, and I'll now turn it over to Marty Jackson for some additional financial details before we open the call up for questions.

[Martin Jackson, executive]

Thanks, Bob, and good morning, everyone. I will begin by providing additional details on the progress we continue to make regarding our labor cost within the critical illness recovery hospital division.

Overall, our SWB, as a percentage of revenue ratio was 58.1% this quarter, which is a decrease from 58.4% in Q3 of prior year.

In the third quarter of this year, we again saw decreases in agency costs and utilization from the prior year of Q3. Compared to Q3 of '23, RN agency costs decreased by 4%, and utilization decreased from 15.4% to 14.7%. Agency utilization also dropped 6% from the sequential quarter Q2, which was 15.7%. The agency rate for RNs remained consistent with prior year at $78 an hour.

Nursing sign-on and incentive bonus dollars decreased by 18% from Q3 of prior year, from $7.8 million to $6.4 million. Finally, we saw a decrease of 13% in our orientation hours. We're very pleased with the continued progress we have made in regards to these labor costs. On July 26, Concentra entered into financing arrangements as Bob had mentioned on their $850 million, 7-year term loan, $400 million 5-year revolver, which is undrawn and $650 million [ 6.78%] senior notes, which is due 2032.

Using these proceeds from the Concentra IPO and debt transactions, Select made voluntary prepayments $1.6 billion on our term loan and $300 million repayment on our revolving credit facility. At the end of July, we also decreased our revolving credit facility by $220 million from $770 million to $550 million. And as of September 30, we had almost $500 million of availability on our revolver.

The net decrease in our consolidated debt balance in Q3 was $498 million. At the end of the quarter, we had consolidated debt balances outstanding of $3.1 billion, $191.5 million of cash on the balance sheet. Our consolidated leverage at the end of the quarter was 3.38x compared to 4.13x last quarter. Total Select debt at the end of the quarter included $1.2 billion, the 6.25% senior notes, $373 million in term loans and $10 million on our revolver. And we also had $448 million of other miscellaneous debt.

Select ended the quarter with net leverage for our credit agreement of 3.06x. Total Concentra debt at the end of the quarter includes $850 million term loan, $650 million of the senior and [ 7/8 ] senior notes, $7.6 million of other miscellaneous debt. Concentra ended the quarter with net leverage of 3.7x.

Effective with September 30, 2024, reporting, Concentra has been designated an unrestricted subsidiary under the Select credit agreement, and Concentra activity is no longer included in the Select credit agreement computations. Interest expense was $55.4 million in the third quarter. This compares to $50.3 million in the same quarter prior year. The increase in interest expense was principally due to the accelerated recognition of the gain on our interest rate hedge $13.7 million in the second quarter due to the expected prepayment of our term loan, which occurred in Q3. This increase was mitigated by the net debt reduction and lower interest rates on Concentra debt.

For the third quarter, operating activities provided $181 million in cash flow. Our days sales outstanding, or DSO, was 55 days as of September 30, '24. This compares to 52 days, September 30, '23. 56 days, on June 30 of '24 and 58 days as of March 31, 2024. We continue to see improvement in our DSO every quarter as the claims processing backlog that resulted from the change health care cyber incident resolves itself. We expect to continue to see improvement in Q4.

Investing activities used $45.1 million of cash in the third quarter. This is primarily due to almost $51 million in purchases of property, equipment and other assets, offset by sales of assets. Financing activities used $55.6 million of cash in the third quarter. We had $511.2 million in proceeds from the Concentra's IPO, almost $837 million in net proceeds from Concentra term loan and $637 million net closures from the issuance of Concentra senior notes.

These proceeds were used to offset primarily by $1.6 billion payment on Select term loan, $335 million in net payments on our revolver, $15.2 million in dividends on our common stock and $9.4 million in net payments on other debt.

As stated previously, we did not repurchase any shares under our board authorized repurchase program this quarter. Last year, the Board approved a 2-year extension of the share repurchase program, which remains in effect until December 31, 2025, unless further extended or earlier terminated by the Board.

We are updating our business outlook for '24. We now expect revenue to be in the range of $6.95 billion to $7.15 billion, adjusted EBITDA to be in the range of $865 million to $885 million. Fully diluted earnings per share to be in the range of $2.01 to $2.12 and adjusted earnings per share to be in the range of $2.09 to $2.20. Capital expenditures are expected to be in the range of $200 million to $250 million for this year.

That concludes our prepared remarks. And at this time, we would like to turn it back to the operator to open up the call for questions.

[Operator]

[Operator Instructions]. Our first question will be coming from Ben Hendrix of RBC Capital Markets.

[Benjamin Hendrix, analyst]

First, to Bob, our deepest condolences for Rocco's passing. Our thoughts are certainly with you there. And just a second question, I guess, for Marty, I just wanted to get some more comments on LTAC occupancy trends. I think we may have misconstrued some seasonal occupancy trends as staffing related. It doesn't sound like that's the case. Maybe you could provide just some more detail on kind of what you're seeing from an occupancy standpoint, in that segment versus your targets? And if there's any outlier threshold influence there.

[Martin Jackson, executive]

Yes. Ben, the occupancy rate for this past quarter, I mean, we were actually pretty pleased with it. It was higher than prior year same quarter. And it really is seasonality of the third quarter. So it really didn't have anything to do with staffing issues. It's really just a function of the quarter.

[Benjamin Hendrix, analyst]

And anything that you can comment on observations on outlier thresholds impacting the segment at all?

[Martin Jackson, executive]

Our operators have done a very good job managing through the high-cost outlier. So we really haven't seen too much of an impact there.

[Operator]

Our next question will be coming from Justin Bowers of Deutsche Bank.

[Justin Bowers, analyst]

Bob, condolences to you and your family. When I look at pro forma net leverage post spin, I arrive around a number of about 3x, maybe a little lower than that. The company is going to generate a substantial amount of free cash flow, even after all the development projects that you laid out.

Any thoughts or preferences on capital deployment, given what we know now? And is there sort of an optimal leverage range for the company? Or would you sort of even take that down to 2 or that level?

[Robert Ortenzio, executive]

Thanks, Justin, and thanks for your comments for my dad. Yes, I mean I think that -- I hate to say that the answer has kind of always been similar from Marty on capital deployment. We do kind of pride ourselves on our history of being opportunistic on our deployment. We are fortunate to have lots of opportunities in the development area, as you saw from my comments on some deals that we have, and there's others behind that.

So I would describe our development pipeline is quite robust right now. And then there is obviously the opportunity to deleverage through free cash flow or have stock buybacks and all options are on the table as they -- as we'd like to always have them. I will say that we have worked hard to drive our leverage down to 3x. And we've gotten some uplift from the rating agencies as you've seen. We're pleased with that, and we would like very much and it's a priority to maintain that. So I think a 3x leverage is very good for us, very positive allows us to keep all of our options open.

And I think as we go forward as a smaller company without Concentra, we want to maintain that flexibility. So I would say that's a long answer to say 3x is really where we want to be, and we want to try to maintain that. And then we want to be opportunistic in terms of where we allocate our free cash flow.

[Justin Bowers, analyst]

Understood. And then 2 just quick clarifications. On on LTAC development, it sounds like there's -- at least through 2026, there's one program that you have or project that you have line of sight on. Is that right, with 26 additional beds?

[Robert Ortenzio, executive]

Well, there are other opportunities. We've only listed one. I mean we find as that business is evolving with the threshold levels, making that business even tougher. Our operators are navigating. We have a very big platform. We are finding that a lot of our new LTAC development projects are bleeding into our partnerships, our existing ones and our new ones as we continue to perform very well with our partners on inpatient and outpatient rehab.

LTAC has become a part of that model, which we like. We will also do some de novos. But it is not a place where we won't spend capital. But as we look across our business segments and on the hospitals, bigger opportunities for capital deployment on rehab, and then also some on outpatient, although that's relatively modest. On the LTAC side, we would like to grow, but we are not looking to have really large capital deployment in that area. So it's another way of saying is we like the hospital within a hospital model, which is less capital intensive. So we will look for those opportunities.

So the LTACs will continue to be a growth segment for us. And -- but with our platform, we can be a little bit more judicious on our capital and find opportunities where we can grow in the LTAC space without a lot of capital and then continue to allocate that primarily right now because of the opportunities on the inpatient rehab side.

[Justin Bowers, analyst]

Got it. And then one just quick one. On the IRF rates, I think in the 2Q call, you talked about 2% for the federal funds base rate. And then the final rule said basically like 3% net market basket net of productivity. Can you just square those 2 for us, at least on the Medicare side? Is the right way to think about sort of like the base rate is 3%?

[Martin Jackson, executive]

Yes, Justin, this is Marty. Yes, we think it is in that 3% range.

[Operator]

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

[William Sutherland, analyst]

My condolences as well on Rocco's passing, a great guy. I had one question on LTAC. Noticing on fewer hospital listed as of the last quarter, was there a removal or something from the portfolio?

[Martin Jackson, executive]

Hold on just for a second, Bill. I think we saw a reduction from a year ago.

[William Sutherland, analyst]

Maybe I was wrong. I thought you were 107, you -- okay, maybe I was wrong, but the second quarter is -- it was already at 106.

[Martin Jackson, executive]

Yes, we're looking right now, Bill. I think we did close. Yes, you're right. We did close one in Ohio.

[William Sutherland, analyst]

Okay. Just underperforming or...

[Martin Jackson, executive]

Yes, it was a consolidation, Bill.

[William Sutherland, analyst]

Okay. All right. Marty, while I've got you, what are you thinking about as far as additional progress you can make on SWB as a percent of revenue? Is there more wood to chop?

[Martin Jackson, executive]

Yes. We think that there is, Bill. Where we -- the numbers that we provide for our targets are really annual. We think, we'll probably end this year in that 57% range. As you know, we started off very well in the first quarter in that 54%, 55% range. And so next year, we think we can see that come down.

And there's really 2 points that are going to drive that. One is the commercial contracts we continue to have some success on the negotiation of our commercial contracts. If we can obtain what we've done in the past year, being that mid-range single-digit increases, that will certainly help that number come down.

The second one is volume increases. Volume increases has a big impact on the ability to drive that number down. And the hope is that -- given the CMS mandate, that Medicare Advantage follow traditional Medicare patient criteria that we'll see improvements in the preauthorization admission approval rates of Medicare Advantage. So if that occurs that SWB as a percentage of revenue will continue to drop.

[William Sutherland, analyst]

Got it. And then looking at outpatient rehab and the progress you're making steadily here, kind of what are the keys for the next sort of step up? I know that -- it's a business that you run in the mid-teens margin area in the past. I'm not sure what's on your -- what's on the planner for progress forward from here?

[Martin Jackson, executive]

Yes. Bill, one of the major movers for us is our clinical efficiency. Clinical efficiency being the number of patients that therapists can see in a day. And we've really kind of focused over the past year in doing -- using technology to help us do that.

We've got a very significant release that's occurring on the end of the year, and we think that, that will be a game changer. That will be a big help for us. So we anticipate, we'll see some nice improvement in the margins come next year.

[William Sutherland, analyst]

Was that an internally developed system or -- I'm just curious?

[Martin Jackson, executive]

Yes. Yes, it was.

[Operator]

Our next question comes from Joanna Gajuk of Bank of America.

[Christian Malachy Porter, analyst]

This is Christian Porter on for Joanna. I also wanted to add my condolences. Our question was about outpatient rehab. So margins came in much better than our estimate. And we just wanted to know if you could talk about your efforts to improve efficiency One of your peers saw higher contract labor costs in Q2, and we were wondering if you were seeing any of that and just trends around volume, staffing and pricing?

[Martin Jackson, executive]

Yes. I mean, there's a couple of questions that you put there. I think what we saw was -- the first one I'll focus on is really taking a look at supplemental staffing, the agency staffing. We've seen that decline sequentially. And so that certainly helped the margin. And then I think we talked with the prior caller with Bill on what we're doing on the technology side through our systems to help enhance our clinical efficiency. So both of those, we think, will -- one has helped them just recently, we think the technology will certainly help in the future.

[Operator]

And I would now like to turn the call back to management for closing remarks.

[Robert Ortenzio, executive]

Thank you, operator. No closing remarks. We appreciate everybody who was on, your questions and your condolences to Rocco. So thank you. We look forward to updating you next quarter.

[Operator]

And this concludes today's conference. Thank you for your participation. You may now disconnect.