US Physical Therapy Inc
NYSE:USPH
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US Physical Therapy Inc
Earnings Call Analysis
Q2-2024 Analysis
US Physical Therapy Inc
In the second quarter of 2024, U.S. Physical Therapy (USPT) reported robust growth, with total visits per clinic per day hitting record levels, averaging 30.6%, 31.2% in April, and 29.8% in July. The total visits exceeded budget expectations by around 6,600 and were 108,000 higher than in the same period last year. Revenue from Physical Therapy surged to $143.5 million, reflecting an 8.5% increase year-over-year, driven largely by the opening of 25 additional clinics and an uptick in visits from mature locations.
USPT's efforts in renegotiating contracts, particularly in workers' compensation, are beginning to materialize. The net rate rose to $105.05 per visit—a 3% increase from the previous year, despite a 1.8% Medicare reduction. The focus on enhancing reimbursement rates has led to a notable shift in the contribution of workers' compensation to revenue, growing from 9.6% to 10.1%. This category is crucial as it represents the highest earnings segment.
The company recorded an adjusted EBITDA of $22.1 million with a margin of 16.4%, down from $23.6 million and 17.7% respectively the previous year. While operating results slightly dipped, from $0.76 per share to $0.73, the overall financial health remains sound, with a promising trajectory for the upcoming months driven by effective management of operational costs.
Despite strong demands, USPT faces challenges related to labor costs. Operating costs rose by 10.3% primarily due to increased salaries, contract labor, and the expansion of clinics. The per visit cost increased to $84.46, up from $80.61, a trend driven by competitive pressures for staffing. Management is addressing these challenges by bolstering recruiting efforts and adjusting staffing ratios to maintain service quality without overspending on labor.
USPT reaffirmed its EBITDA guidance for 2024, expecting it to fall within the range of $80 million to $85 million. This update considers the challenging employment climate and anticipated salary adjustments. The management expects to see continuous growth in patient volumes and progress on net rates, indicating a strategic focus on sustainable growth in a recovering labor market.
Injury prevention services showed impressive growth, with net revenues up 23.2%. The IIP margin improved to 21.4%, indicating successful integration of recent acquisitions. USPT's proactive approach in this sector reflects its commitment to diversifying services and leveraging operational synergies to enhance profitability.
USPT is focused on not only tackling the immediate labor challenges but also reinforcing its long-term strategies to ensure sustainable growth. They are investing in technology and automation to enhance operational efficiency, which could help to alleviate some labor pressures. The company maintains a solid balance sheet, with $142.5 million in debt at a favorable fixed rate, along with substantial cash reserves for future investments.
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Good day, and thank you for standing by. Welcome to the U.S. Physical Therapy Second Quarter 2024 Earnings Conference Call. [Operator Instructions] Please be advised that today's conference is being recorded. [Operator Instructions]
I'd now like to turn the call over to Chris Reading, President and CEO. Please go ahead, sir.
Thanks, Jamie. Good morning, and welcome, everyone, to our second quarter 2024 U.S. Physical Therapy Earnings Call. With me on the line this morning, I've got Carey Hendrickson, our Chief Financial Officer; Eric Williams, our President and COO East; Graham Reeve, our Chief Operating Officer West; Rick Binstein, our Executive Vice President and General Counsel. Before we make some prepared remarks relating to our quarter and year, I'll ask Jake Martinez to cover a brief disclosure.
Thank you, Chris. This presentation includes forward-looking statements, which involve certain risks and uncertainties. These forward-looking statements are based on the company's current views and assumptions. The company's actual results may vary materially from those anticipated. Please see the company's filings with the Securities and Exchange Commission for more information. This presentation also contains certain non-GAAP measures as defined in Regulation G. The related reconciliations can be found in the company's earnings release and the company presentation on our website. Chris?
Thanks, Jake. So let's get started. My discussion this morning will cover variety of highlights. We've definitely made some progress in some key areas. We will also touch on one of the primary challenges as well. Let's start with the fact that this was a very solid quarter from a volume perspective, the best visit per clinic per day, quarter in our history. April was a high month at 31.2% marking in a high also for the year, followed by May, nicely over 30%, June, just under 30% at 29.8%. And all of this follows our normal seasonal progression with school finishing and summer vacations kicking off a bit before things get back to normal, as they have begun to do with school starting up here in Texas this week in many places.
Speaking in a minute through our expectations, our total visits ahead of where we budgeted them to be the midpoint this year, better by approximately 6,600 visits and ahead of last year same period by over 108,000 visits. Our partnerships are doing great job addressing demand and doing [indiscernible] and what continues to be around the tight labor market. More on that in a minute. The kudos are due to our contracting team. We're starting to see their hard work over the past 18 months really beginning to bear fruit. Net rate for the quarter progressed nicely and finished at $105.05 per visit, up a little bit more than $3 per visit over the same quarter in 2023.
As you might remember, last year, we renegotiated a large volume of commercial more comp-related contracts, while those adjustments took a little time to phase and [ show up ], we're doing so now and really nice progression that we are seeing and expect to continue as the year goes forward. We have also seen a work comp volume move up. And while the aggregate percentage has changed a little, it really shows up when you see the number in rate of year-over-year change in work comp visits, which I'll have Eric cover as we open it up for discussion after these prepared remarks.
The combination of rate for commercial plans and our faster-than-average work comp growth is resulting in a very nice uptick in our net rate so far for the year. And actually, we expect that to continue as we go forward. In the injury prevention side of things, we had a very good quarter. Revenues grew by more than 23%. We also saw a nice margin improvement of about 70 basis points to 21.4% with an increased profitability of more than 27%. And I was just out in Denver spent a few days with our Briotix partners. They're working to integrate our recent Atlas acquisition, 9 opportunities going very well. The integration of our teams is progressing nicely with what I think will be some enhancements that will be beneficial to us in the long run once this combination is fully complete. Both of our injury prevention partnerships East and West are doing well in gaining new customers and have a better than expected -- better than budget trajectory in the year so far where we have more work, and frankly, we are behind where we expected to be at this point. And really, our primary point of struggle is around our PT-related costs for labor. Carey will cover the pre visit and percent of revenue cost in detail, but the sum of it all is that the people we have hired this last year and likely in the period, slightly preceding that or at a higher rate, given inflation and employee scarcity than we've experienced in the past.
Therapists overall are about 4% more on average before incentives, front office personnel are about 5% more. Additionally, in a handful of markets, we have greater-than-expected use of contracted [ travel-based ] labor, that obviously has hurt us and impacting our performance in our margin despite the strong gains in net rate that we've made. It's a little bit of a two-edged sword and that we have good demand in and across most of our partnerships addressing that immediate demand in the current environment has necessitated that we bring on more contract labor than we initially envisioned.
Our ops teams are very aware of where we are and where we would like to be, working hard to ensure that we have the staffing balance appropriately for the season, and we have sufficient resources to meet the demand, but remain highly efficient at the same time. Additionally, we've made numerous investments in the areas of recruiting that we expect to bear fruit and some longer-term initiatives with respect to [indiscernible] relationships, partnerships and affiliations. These are all things you should expect us to be doing over the coming months and quarters as we look to readjust to the market practice that are currently influencing our outlook for the remainder of the year.
Let me say this. Well, I know our cost issue is an unfavorable development we have to overcome. When you look at our key focus areas over time, we're in a very good history of overcoming obstacles. We have a dedicated and capable group of partners, great ops team, all of whom are working at this time and remainder over the coming period.
One final note. We are busy and remain committed on the development side of things, a few of our deals have pushed out a little bit due to factors that we don't control on the seller side of the equation. But rest assured, we are working hard, and we expect a strong finish through the year for our development efforts with some exciting markets and partners who we are interested to make part of our family as we look ahead.
That concludes my overview and prepared remarks, Carey, as he always does so well will cover the detail behind these teams. Go ahead, Carey.
Great. Thank you, Chris, and good morning, everyone. We saw some really good things inside of our numbers for the second quarter, things that we expect to continue to benefit us through the remainder of the year and beyond. Chris mentioned some of them in his remarks that they're particularly notable and we're repeating a few of them. Our hard work on rate negotiations and our focus on increasing workers' comp as a percentage of our overall business continued to take root in the second quarter resulting in a substantial year-over-year increase in our net rate.
Also, our average visits per day in the second quarter, a record high for the company. And our IIP business grew to mid-teens rate in the second quarter even before adding acquisition that we made on April 30. Our salaries and contract labor were higher than we would have liked in the quarter, but the business itself is strong as we continue to see meaningful growth in these key indicators. We reported adjusted EBITDA for the second quarter of 2024 of $22.1 million compared to $23.6 million in the prior year. Our adjusted EBITDA margin was 16.4% in the second quarter of this year compared to 17.7% in the second quarter of the prior year.
Traditionally, most calculate our EBITDA margin without the benefit of knowing what our adjusted revenue per minority interest is, which makes it appear that our margin is lower than it actually is. This adjusted EBIT margin that I just quoted to 16.4% in the second quarter is calculated on an apples-to-apples basis with both revenue and EBITDA adjusted for minority interest.
Our operating results were $11 million in the second quarter of 2024, which is an increase of $600,000 over the second quarter of 2023. On a per share basis, operating results were slightly lower than '24 than '23. It was $0.73 this quarter, it was $0.76 in the same quarter of last year. That small decrease is related to the increase in shares that were associated with the secondary offering that we completed in May last year.
Our average visits per clinic per day in the first quarter was 30.6%, which is the highest volume for a quarter in the company's history. Chris noted what the progression was throughout the month. The lower number in June, as he mentioned, is our typical seasonal pattern as both patients and our clinicians take vacations and the schedule just changes a little bit in the summer there for families. In July, our average visits per day was 29.8%, which is consistent with July of last year and it is in sync with our seasonal expectations.
Our net rate was $105.05 in the second quarter of 2024, which was $3.02 per visit or 3% higher than the second quarter of last year, even with another 1.8% Medicare reduction by CMS that was in effect in the second quarter of 2024. This was the highest quarterly net rate we've had since 2020, while enduring 4 Medicare rate reductions by CMS since that time. Excluding Medicare, our rate was up $4.80 per visit or 4.5% over the second quarter of last year. The increase was largely related to our strategic priority of increasing reimbursement rates through contract negotiations with commercial and other payers and our focus on growing our workers' comp business.
We're also focused on maximizing our cash collections through improvements in our revenue cycle management. Each of our major category of payers increased year-over-year. Workers' comp, which is one of our highest rate categories, increased from 9.6% of our revenue mix in the second quarter of 2023 to 10.1% in the second quarter of 2024. These rate-enhancing initiatives will remain high priorities throughout 2024 and beyond. Physical Therapy revenues were $143.5 million in the second quarter of 2024 which was an increase of $11.2 million or 8.5% in the second quarter of 2023. This increase was driven by having 25 more clinics on average in the second quarter of 2024 than in the second quarter of last year as well as an increase in our visits in Mature Clinics and, of course, the increase in our net rate.
Physical Therapy operating costs were $114.7 million, which was an increase of 10.3% over the second quarter of last year due in part again to having 25 more clinics on average in the second quarter of last year as well as the increases in salaries and wages and contract labor costs that we've mentioned. On a per visit basis, our total operating costs were $84.46 in the second quarter, which compares to $80.61 in the second quarter of 2023. Our salaries and related cost per visit were $59.66 in the second quarter of 2024 compared to $57.59 in the second quarter of '23. And our Physical Therapy margin was 20.1% in the second quarter of '24. As Chris noted, our IIP team produced excellent growth in the first quarter IIP net revenues were up $4.5 million or 23.2% over the second quarter of '23, with IIP income up $1.1 million or 27.4%. Excluding the acquisition that we closed on March 31, 2024, our net revenues were still up 13.5%, with our gross profit up 15.7%. Our IIP margin increased from 20.7% in the second quarter of '23 to 21.4% in the second quarter of '24.
Our corporate office costs were $14.2 million, which is 8.5% of revenue, right in line with expectations in the second quarter of 2024. That compared to $12.1 million or 8% of revenue in the second quarter of '23. The second quarter of '23 included a downward revision in our bonus accrual causing it to look a little bit better as a percent of revenue than in the second quarter of this year. Our corporate costs in the second quarter of this year were actually lower than our budget by about $400,000.
Quickly turning to our balance sheet. It continues to be an excellent position. We have $142.5 million of debt on our term loan with a swap agreement in place that places the rate on our debt at 4.7% which you know is a very favorable rate in today's market and well below the current Fed funds rate even. In the first half of 2024 alone, the swap agreement saved us $1.8 million in interest expense with cumulative savings of $5.1 million since the third quarter of 2022 in interest expense.
In addition to the term loan, we also have a $175 million revolving credit facility that had nothing drawn on it during the second quarter. So that's all available capacity and we have approximately $90 million of excess cash over and above what we need for working capital, ready for deployment [ into ] growth initiatives. We deployed $40 million of cash and acquisitions so far this year and expect to deploy more before the end of the year.
As we noted in our release, we're updating our EBITDA guidance for full year 2024, returning to our original range of $80 million to $85 million. The change in guidance reflects our updated expectations for salaries and related costs and contract labor through the remainder of the year related to the continuing challenging employment environment particularly for our clinicians and our front office staff. We expect our patient volumes to continue to be strong during 2024, and we expect to make additional progress on net rate throughout the year.
With those details, Chris, I'll turn it back to you. We'll take questions.
Okay, Carey. Great job. Thank you. Jamie, let's go ahead and open it up for questions.
[Operator Instructions] We'll go first to Brian Tanquilut with Jefferies.
Chris, may I start with you. So the labor challenges that we're seeing here, right? I mean, I guess, 2 questions. It doesn't seem like it's impacting your ability to drive volume growth. So -- is this just a matter of basically a reset in the baseline for what your therapists are making? And then maybe the second part of the question would just be, how are you thinking about the strategies and initiatives to drive and improve that labor situation?
Yes, good question. So first part is the perspective that it hasn't impacted our volume because the volume has been pretty good. I think it has impacted our volume in a negative way. I mean, it's -- we're -- we've beefed up our recruiting teams, we're doing better, but we still have markets where if somebody does leave us and turnover has been good, if somebody does leave us, they relocate the family to another state or another place, it takes a while to fill that spot and we do feel it. And so I think if the labor market eases, I think reciprocally will have a further uplift on volume, but demand is good. Look, the operations team, it's a tough balance, particularly as we have gone into and through now vacation season with our staff working hard to deal with the volume that they have and the necessity to bring in some other or ancillary staff to fill those gaps to keep volume up. Ops team is very aware of it. Eric and Graham and our regional presidents. And it's tough, but we've got to just keep everything very dialed in. I mean a greater number of techs hired in the period than I kind of expected. So they're digging into that a bit. That may just be a seasonal thing, and we're coming out of that season now [ that ] schools back in? And then just on the demand side, any time that there's pressure around hiring the tendency is to pay more to just block it down. And so we need to do a better longer-term job on widening the funnel. And so we're making some adjustments and some investments in the part of our business that really interfaces most closely with the PT schools around the country and offering, I think, a wider complement of things that we can do for those programs to help them and reciprocally help us as well. And so it's a little bit longer-term program and project, but all those things are in the works right now.
Okay. That makes sense. And then maybe just my follow-up question would just be on the turnover. Are you seeing any change there? And -- or is that something that's just stable? And then what we're seeing is just like a replacement cycle that's consistent with the historical trends?
Yes. I think turnover has been -- actually been pretty steady, steady, meaning it's been good for the last 1.5 years, 2 years. We -- I think the group has done a good job on that where we've seen pressure is, this year, we had the -- we gave probably larger than average raises just because people were pressed and the market is tight and it's very competitive. And then newer people coming in, we now are paying a bit more than we were a couple of years ago. And so I think it's that combination. Where I think we're going to have to retest and I don't know that it will be on the clinician side of the market but on our hourly wage area in our front desk and looking maybe for some more efficiencies there or retesting the numbers that we've been paying this last year to see if we can [ balance ] inflation has abated a bit to see if we can get those back down a little. And so all those factors along with making sure and our cash flow has been fantastic. Our collections have been really good. And our executive who handles that area is doing a great job and just making sure as efficient as we need to be and can be on the backside of our operations as well.
And so that in combination with the fact that I expect that we'll still see some more rate growth. And I'm really pleased with all of the reports and how that is lining up and Carey and I both expect to see that to continue to progress over the coming period. And so it's going to have to be that combination of operational focus seeing what we can do in terms of rate at the front desk and some efficiencies in some other areas. And hopefully, we can get it down a bit.
We'll hear next from Larry Solow with CJS Securities.
Finally, a question on the volumes, maybe a little bit of a follow-up to Brian's question just on the [indiscernible] constraints. So volumes are as you pointed out at record levels and a seasonally strong quarter. Just curious if we look year-to-date, we're pretty much flat, right, on a same-store basis. I know Q1 was -- maybe a little [ unclear ] because there was some weather but still growing 2% to 3% volume in the last 10 years. So is there -- as we get above this 30 per visit per day. And I've asked the question before, are there constraints? I mean, clearly, it sounds like -- I guess staffing is one of them. Just -- and you did mention that volumes are sort of in line with your expectations. So you kind of bake in a little bit of a slower volume year -- his year? Or just any color around that would be great.
Yes. I don't think [ 30 ] is the threshold for anything. I mean a lot of our workforce or part-time regular committed part time, but part time moms that are working part time with kids still at home, all the things. So we do have the ability to flex staffing [ assuming ] that staffing is available and people are available. And I think that's been the biggest limiting factor so far this year. And you're right. We're were flat on the year after having a lighter than expected first quarter.
Second quarter came in about where we expected. It was a little bit lighter in June, and I think we had modeled particularly after a strong April. But volume generally speaking, demand for new patients is there. We just have to be able to assess it from a staff perspective. And so I don't think this is a scaling for us. We certainly don't have a scaling from a facility standpoint and you look at physical [indiscernible] and things like that. And it's all about creating incremental staffing so that we can continue to grow.
And on pricing, you've done a great job, obviously, made some good strides. It feels to me like, hopefully, you continue to negotiate and renegotiate right, because Physical Therapy, as we know, is a cost saver, right? And with these inflationary pressures, but you should be able to go back and some industries are getting so much more price, right? So I feel like [indiscernible] and just on the Medicare side, any update there? I think they came out with of their proposals, maybe this is the last year of proposed cuts, any thoughts longer term maybe going to a CPI-based index pricing on the government side or anything there [indiscernible].
That's what we're supposed -- what's supposed to happen now in the interim period, this comment period following the July release, we're pressing hard. I mean having 5 years worth of cuts in a row in succession. It's just -- it's making operational adjustments very, very difficult. And I think we've squeezed and maneuver and managed not perfectly buying stretch, but I think pretty well. And yes, I don't know that I can name another industry that's had maybe home health and some stretches, this kind of punishment unnecessarily. It all frankly comes from a mistake that MedPAC made when this all began, or they didn't realize that Physical Therapy was part of the code set that they were impacting. They thought they were impacting interventional pain management specialists, PM&R doctors and orthopedic surgeons, the guys at the top of the [ food ] chain. And it's unfortunate, but we're in it. We're almost out the other side. I can't imagine that this is going to continue without some reversal. And we're spending a lot more time in D.C. with the lobby group, our industry group, APTQI, with the APTA with the Congressmen and women and hopefully, once this election cycle is through and we get some daylight on the other side and people can focus on governing we can make some progress.
Got it. And the proposed cut, I guess, for '25, I believe, is just on the similar to the initial proposal for '24 is under 3%. Is that right?
Yes, I think correct.
3.5%.
Correct.
And [indiscernible] Your comment -- I just had a quick question, a random one. Just go ahead, what was your thought there?
I was just saying, in the meantime, we're working -- we can't control what Medicare does, what CMS does, unfortunately. But in the meantime, we're trying to control what we can control, and that's putting a lot of effort towards contract and rate negotiations and for commercial, for workers' comp progressing, we're seeing really good progress there. And you'll remember when we did these negotiations. Many of them, we built in 3-year step increases. So they continue to produce fruit each year to have continual step increases in our rates. So that's good, and that's going to benefit us going forward. It's already benefited us. We're seeing really starting to see the impact of it now. And I'm pleased with our team has done a really good job on that as well as the increase in workers' comp that the number of visits in particular and as a percent of our mix, it's a really good thing because that's one of our highest rate categories. So we're working hard to move that rate even with the pressure from CMS.
Great. I was just going to ask you to start [indiscernible] with the Hurricane Beryl, I know it caused a little bit of lateness in your results and some shutdowns around in the Huston area. I know you guys have a decent amount of facilities down there. Was there any volume impact we should expect in Q3?
We lost about 2,600 visits as a result of that. But I noted in my comments that our average visits per day in July was 29.8, so it's still right in line with what June was and right in line with our expectations and right about the same place it was last year in July '23.
We'll go next to Joanna Gajuk with Bank of America.
So I guess on the labor very topical [ Q ]. But my question is, Chris, to your point, you've been hiring these workers for a year or maybe even longer at this higher rate. So my question is like why is such a surprise on labor during this quarter? I mean you've been talking about like staffing improving and turnover below the industry, which I guess that still holds. But I guess, why were you so surprised with this quarter? Why, I guess it didn't transpire in Q1?
It's -- go ahead, Carey.
I was just going to say one of the things that play into, I think was, we expected to be able to transition from contract labor to permanent employees in some of these markets that we're really challenged with. And so that would have helped us, but we had higher contract labor and that was part of the equation that -- Chris, go ahead.
No, I think part of it was we had a really strong April really, really strong April. And spring quarter is usually a very strong volume quarter for us. And I think the combination of during the quarter with a lot of demand resulted maybe in us having slight increments here and there of staff beyond where we needed as the quarter progressed. We're still feeling peeling this onion a bit. As Carey said, we have a handful of markets that kind of stand out as markets where at least, I believe that we shouldn't have as much contract labor as we do. We should be able to find long-term employees that are committed and part of our staff. We have good teams there. But for whatever reason, we're struggling in those same [ form of ] markets. And so Eric and Graham and the rest of the team, meeting with partners working on that. We're trying to look at some of the underlying factors. But as Carey mentioned, we didn't expect to be carrying as much of contract labor as we have. Then honestly, I thought as inflation begin to subside a bit, we can get our offered hourly rates down. I don't know that we've seen that transpire yet, but we're going to have to test it because I think particularly at our front desk were too high. And we're going to have to see what we can do there. And so a combination of factors I wish it was perfect, of course and we'll have to make some adjustments.
When it comes to --- go ahead.
The only other comment I would add to that is while our turnover rate is low and we are backfilling clinical and nonclinical positions at a higher rate. But there's also an impact on the existing staff within the business. I mean when you start bringing in newer people, potentially less experienced, it does have an impact in terms of doing market adjustments to hang on to existing staff. So it's something that we're battling right now. I -- there's no question. I think there's a couple of things that we're in the process of doing that. It will have an impact for us.
We're certainly going -- to Chris' point, where we saw labor adds in the business, taking a hard look at ensuring that the productivity we have within that clinic is consistent with our staffing ratios for clinical and nonclinical staff, so the people that added staff, do we get the volume to leverage those additional expenses. I will say that looking a little bit deeper on this and to Chris's point, we still are peeling the onion a little bit in '23 de novos that we had in place didn't lever costs as effectively as they should. So we're in the process of evaluating those businesses to see what we can do in terms of changing their trajectory. We did expect them to contribute a little bit more than we did from a net income perspective. So that's a place we're going to have to revisit. There's no doubt that the additional resources that we're putting in here will help us, particularly in recruiting are going to help us. I think we've added roughly a 40% increase in recruiting staff to help us in those problem markets where we've over-relied on contract labor. So I think those additional resources will help there. And my hope is the additional resources will also decrease fill times to bring PTs on board where we do have turnover because to Chris' point, there is a volume impact associated with turnover that's reflected in these first 2 quarters a number of [indiscernible]. So it's an area that we're just going to continue to have to focus and invest in and going forward over the balance of the year.
So this is great. And if I may, it sounds like there -- I guess, the handful of markets that stand out. So -- and I guess the question there is like does something changed competitively? Are you seeing like more competition from other therapy providers, physical therapy? Or is it nursing homes? Or is there anybody else that, I guess, changes behavior that made it kind of more competitive?
Let me take that, I think. We're seeing young people come out of score right now. Now that some years ago, everybody moved to mandatory doctor program, seeing younger people come out of school with higher and higher levels of debt. I mean -- those of us who have kids in college, we know that the progression for just general college little and graduate level programs has increased every year. And so what we're also seeing which differs from years and years ago, is we're seeing people with debt levels that are so high that while -- when I came out of school, I knew the only thing I wanted to do was orthopedic outpatient physical therapy. And while some of these kids would like to be in the settings that we offer because they're fantastic settings, they have to go where the money is the highest. And so in some cases, that may be in a hospital. I mean a physician-owned practice. It may mean home health nights and weekends. And so while the competitive market hasn't necessarily seismically shifted, what has shifted is the amount of debt that these kids have and necessity to make choices that are purely based on how many dollars they can put in the bank at a given time. And we haven't been a profession that's been driven that way. But we're seeing more and more people that are faced with those realities. And we've got -- as an industry, we've got to adjust.
If I may, last one on this topic, and I guess my last question. So you also mentioned that you look to obviously try to manage down the cost but you also mentioned from efficiency. So can you maybe elaborate a bit maybe Eric can chime in, in terms of like what exactly you can do to kind of improve the efficiencies, which would result in labor.
Well, that's definitely volume. I mean volume is our best way to lever our cost but the point that I was referencing earlier is going back and taking a look at where we had a head count adds, particularly in the tech and front office space, which is where a lot of our head count adds did take place and making sure that those clinics with those additional heads are really at the threshold that we would expect from a visit perspective to support that kind of staffing. So that's a clinic-by-clinic analysis that's going to result in -- if we're overstaffed, shuffling people around and putting them in the right place or taking labor out in event that they don't have the volume to support it.
Our next question will come from the line of Jared Haase with William Blair.
Carey, maybe for you, just want to make sure I understood kind of the -- going back to the original guidance range for adjusted EBITDA for the year. Some of the assumptions in the second half of the year. I just want to understand kind of the puts and takes there. Is that largely reflecting swing factors in the labor environment in the second half of the year or anything else that you'd call out in terms of assumptions for the guidance? And are you assuming further increases in labor costs for here? Or is that largely kind of based on current trends?
The guidance -- it includes -- it's based on current trends and our labor. And that really is -- there's really no impact on the revenue side. We're doing what we thought we'd do from our previous guidance and forecast on that side. It's just on the cost side, we had to bump it up a little bit to kind of reflect what we've seen so far this year.
Carey, if I may, I want to add one thing. When we originally did guidance, we had a pretty good sized deal that we had close to done, and we had baked in and unfortunately, as [ lies ] happens sometimes, one of the owners went and probably is still going through a difficult divorce that put the kibosh on that opportunity and so that in combination with some of the other factors that we've discussed at length here. But that was a pretty good chunk of both revenue and EBITDA that was -- we expected to be in the door by the end of June that we had to adjust that.
Understood. That makes sense, and that's helpful. And then I guess just as a follow-up, maybe taking a step back, this is a bit more of a strategic question. But I'm curious how you think about the balance between growth and profitability going forward. Obviously, you're seeing strong demand and very nice volume trends that, of course, is leading to some of the incremental contract labor utilization to help support that. Do you start to consider at all kind of pivoting the strategy a bit, maybe capture a little less volume growth, but you have a little bit more stability on the expense side?
Yes, it's tough. I mean, it's a fair question. It's a good question. We're in the service business to take care of people. And so when somebody is at your door and they've had surgery and they want to be seeing we -- just as caregivers at heart -- we have a hard time saying no to that. And so generally speaking we -- most of our facilities, probably with a few exceptions. We don't have waiting unless they don't have a lot of patients that they turn away. It's not to say that we shouldn't look at our mix of patients and how we prioritize based on acuity and maybe even based on in some cases, payer dynamics, who gets to the front of the line. And we're having to look at all those things, quite honestly, to make sure that all the next 10 patients come in are patients that are just barely above our cost to deliver care. We've got to be focused. That's why the focus on more comp has been so important. And I guess on that, just to create some perspective, I'd like Eric to talk a little bit about the growth in that comp area because I do think it relates to your question in how we prioritize what we do and when we make step adjustments and other things. Eric, do you want to touch on that?
Yes, sure. I'm happy to talk about that. I know it's been a focus of our quarterly calls here for a little while. There was a lot of work that was done to really properly position the organization to grow work comp. Carey referenced it, work comp went from 9.6% of revenues Q2 last year, at 10.1% this year. And while that may seem relatively slow or light when compared to what work comp percentages look like in the past, we're making substantial strides in terms of visit growth. Our visit growth in Q2 on work comp was 12.6%. And we're running about 9.3% year-to-date. So this category is growing really, really well. I think it's directly tied to the efforts we've had in terms of substantially increasing network participation. And we have another 9 work contracts that are going to be coming online here in Q3 and Q4 that I think will further drive growth in the work comp category. And it's absolutely our highest paying segment of the business and growing well. So it's gone great, and I think it will continue to grow going forward here as we move through the year.
[Operator Instructions] We'll go next to Michael Petusky with Barrington Research.
So I guess I wanted to circle back in things that you can do. And I know that you guys have done some initiatives in terms of automation, particularly with front desk. And I'm just wondering, have you guys sort of maxed out what you're going to do there -- can do there? Or is there more that can be done to sort of maybe alleviate some of the pressures you're feeling around labor in that part of your business?
I don't think we're max at the front desk, Eric, I don't know if you or Graham want to touch on that, but we're still fortunately and unfortunately, we think we still have opportunity there, and we're early [ in innings ] yet, I think, on some of that automation change.
Yes. Chris, I think that's a very fair description of where we're at. I think there's still opportunity here. We haven't taken advantage of all of the functionality that is available to us. And that really goes back to some of the integration issues that we're having with our EMR vendor that we're working through as it relates to the ability to turn on some of that functionality. So it's going slower but it's not going to be the magic pill. I think it's going to help some, but it's not going to have this major, major impact in terms of decreasing front office staff. I think at our larger facilities, it creates efficiencies for us but we're continuing to look at other opportunities besides automation in terms of how we can leverage administrative costs within our business. And more to come on that as we go down that path, and we'll share it with you guys as that vision unfold.
And one other initiative that was talked about maybe 12, 18 months ago that I haven't heard a lot about since is GPO and I mean, is that something that's still at all a meaningful focus? Or is that also sort of very marginal in terms of impact?
Go ahead, Graham.
Well, we're still working through it. It's been challenging in some areas. We're looking at different options for how we can do different savings mechanisms. We do have it stood up. It's rolled out to probably about 45% to 50% of our clinics. We've seen some savings, but it hasn't moved the middle as much as we were thinking it might. So we're looking at some different options on how we might be able to get some more movement on that sort of spend.
Okay. And then I guess just to sort of wrap up of this idea. I mean is there an issue, Chris, do you feel like in terms of getting partner buying in on some of these initiatives that really is needed, where you want to let these guys, they're entrepreneurial guys, you want to let them run their business, but at some level, maybe they're not taking advantage of all that you guys could help them with in terms of optimizing. I'm just curious if maybe a recalibration of how this works would be helpful.
Yes. No, I actually don't think that's -- and that's not to say that any initiative that we don't have people who are excited and early adopters and other people who are going to come on with a little different perspective. I think our partners have done a great job, and we've built a lot of trust over the years. It varies by category and by specific activity, whatever it is we're doing. For instance, right now, and we've been working on this for a while, and it really has been, as Eric mentioned, the systems issue but remote therapeutic monitoring, which is an opportunity that CMS provides to us to interface with patients as they perform their home program and maintain a level of consistency. We think that's really important, and we thought it was important a year ago, but we couldn't get the vendors and systems to talk efficiently. And while we had partners who were interested in it, it was too clunky and it was difficult. And we've finally gotten the vendor interface worked out, taking a lot longer than we had hoped. That's the nature of thing sometimes as you bring different companies together and you try to get things to work and try to push as hard as you can. And if it's too inefficient, it doesn't get adopted as readily. So there was a period of time, for instance, on that initiative and rollout where we decided to press pause because it wasn't worth beating the drum on and getting people frustrated. So we have to focus on other things. And that's the nature of operations. I mean you live on relationships and your focus where you think you can get the greatest return. And if you're working on 100 things, you're probably not getting a lot done and you have to focus on the key things that are going to make a difference. And so I think our partners do a good job. I think they understand they're certainly not fighting. But these are day-to-day, minute-to-minute, kind of issues that just require a lot of attention and precision. And in some places, we've got to dial in a little better. In other places, we're going to have to just figure out, but the reality is it's going to be a little bit more expensive, and we're going to have to come up with some other revenue opportunities to offset it. And that's just the nature of the business right now.
Let me just sneak one last one in, and then I'll get off. In terms of sort of the labor headwinds and just -- on the other side, the CMS cuts over the last several years? I mean, is it -- is there -- do you think there's an opportunity for APTA, other sort of leaders in terms of this industry to sort of go and say, look, at this point, like something is going to, we're at a place where something is going to give and access to service and all the rest of it is going to impacted like this just feels like it has gotten to a point where it's almost enough is enough. And I'm just curious if you guys have been talking about sort of a way to go to the power to be and say, look, we need some help here. Everybody else gets price increases relative to inflationary pressures and we continue to face these headwinds. But we still face the headwinds in pricing and then headwinds in paying clinical and just final office staff.
Yes. Mike, it's -- the world is complicated, but this particular issue isn't complicated. We know that we save on the medical side of things. You know that we save significant costs. We know that patients who go through a course of physical therapy, it's going to last some the entirety of their health care year, 18 months following the course of PT. For a Medicare age patient, they're going to spend less, particularly being more active, more socially engaged lower -- more activity, and lower [indiscernible] all of that. It's going to last [indiscernible] APTQI, which is for about all of the big companies, for the most part, are part of along with APTA, we're in -- this is now a law. And we don't run into many lawmakers who think that we should have these cuts or the necessary or they make sense to them. But I think it's been a bit of a disfunctional [ ways to delay if ] -- I think we all -- we've all noticed that. And so unwinding needs, which have a secondary budget impact relative to the neutrality has been called -- been mitigated, but they haven't [ done in a while ]. I hope we can possibly at least maybe the cut for '25 as we have in the more recent period, and then we should move into the system, which allows us to have cost of living based rate changes. I mean if you look at the cumulation, I don't know exactly.
I have to look at it what it's been, but it's close to 10% that we've absorbed in this year on an accumulated basis, but in this year, if you look at where we are compared to where we were in 2019, it's tens of millions of dollars to fall straight to the bottom line or specifically get removed straight from the bottom line. And it's been a weird thing and I'm not whining, it is what it is. We've got to deal with it. But if you've given me a neutral to 1% to 2% increase every year, what we could do with that would be amazing. And I think we're about to turn the page, and it's been a long time coming and we're kind of tired of dealing this loss cycle that we've been in. But I think we're nearing. And we will continue to press our DC constituency hard what the way the world is, it's just hard to get necessarily the aggregated attention you need to make dramatic change, but we're not giving up.
And our final question in queue will be a follow-up from Larry Solow with CJS Securities.
Just a question on the workers' comp, I guess, more from a high level. This used to be like a mid-teens percent of your business, right? Pre-COVID obviously, the world has a little bit or remote work and all accelerated, but I feel like your target audience can't really be remote in terms of a working field. So I'm just curious what -- structurally, is there anything different that has caused a dramatic decline in workers' comp volume over the years, I guess, since COVID?
Larry, I wish I had a perfect answer for that. I mean, all of our companies that are [ more ] of post-COVID saw a drop in -- a pretty significant drop in work comp percentage. I can't tell you that I know why that makes sense or why it would happen, but it has happened. And now all we can do is to focus on what we do, and that focus has been to retain particularly a front office to make sure that communication and [ follow-up ] across. In the comp world, multiple constituencies who have interest in the case. It's the payer, it's a case manager maybe the company, the doctor, of course,always, but it's just that continuous retraining and we focused on that. And as Eric said, we've gotten access to a broader network. And to be honest, through COVID we were dealing with other things at the time. And it's been a long over that period, which was a couple of years, give or take, on best turnover, you lose people and you lose some traction. So I'm trying to get back. I'm not going to promise that we're going to get back to 14%. But as Eric said, we are growing our comp visits at a rate that's a pretty nice rate. So we'll see where it ends up.
Okay. I just may squeeze one last one on a more positive note. Carey said, the industrial prevention business, obviously grew nicely. I think it's at low double digits on an organic basis. What's the driver there? And does that business -- is that contra indicator of employment [indiscernible] because obviously, although I know the improved market is tight, things are maybe getting -- unemployment is coming up a little bit so things are maybe not loosening a little bit or getting worse, I guess, maybe better for you guys in a sense. But what's going on in this business that's driving that growth?
Yes. Yes. Yes. So simply, it works, it works really well. We now have more programs and services and kind of program lines than ever before. When we started, we had one primary and a couple very peripheral, and now we have 15 and 20 different individualized programs. As a result of some of the acquisitions that we've done those have all integrated well and some of the growth that we've had, both in the team and our service offering. So one, it works, it saves money. We're seeing companies where we get a foot in the door, be willing to expand from just their most problematic sites across the country so that there is a really nice organic intra-customer growth opportunity we're seeing, as you might guess, as risk managers and heads of HR move within an industry within an industry area to different companies and they've had good luck with us, good success before. It's not luck, good success. They're bringing us in and a lot of companies are dealing with the musculoskeletal issue that is a significant problem for them. And it's awards getting out for this -- these type programs, they work. And so it's a combination of things. But I'm really proud of our teams. We've added and grown and strengthen these teams over time. And they're doing a good job right now and I expect the momentum that we have will continue.
In terms of the question about how it relates to where the economy is, I would say some of these programs are cyclical in that, the economy is blowing and going, they're busier and some are countercyclical. So in other words, maybe when labor gets really tight, our post-offer testing which is meant to screen out people who might get injured down the line are likely to be injured. We have companies and some segments that we can't find anybody. We can't screen anybody out and so as labor gets tighter, some of those programs slowed down, but that's always in the mix. Now we have enough diversity across our programs where if we see a slowdown. And one, we're seeing a pickup in another and it doesn't show up as much. So it's just pretty steady overall.
Ladies and gentlemen, at this time, as there are no further questions, I'd like to turn the floor back over to Chris Reading for any additional or closing comments.
Okay, Jamie. Thank you. Listen, I know this is a long call. I want to thank everybody for your questions and your attention. I know we have some follow-up call scheduled. So please reach out to Carey or I, and we're happy to spend time with you. and just know that we're working hard on these opportunities. So have a great day. Thanks again. Bye.
Once again, ladies and gentlemen, that will conclude the U.S. Physical Therapy Second Quarter 2024 Earnings Call. Thank you for your participation. You may disconnect at this time.