Q3 2020 Amedisys Inc Earnings Call
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Greetings and welcome to the Amedisys Inc. third quarter 2020 earnings conference call.
This time all participants are in listen only mode. A question and answer session will follow the formal presentation.
I would like to ask a question you May proceed star one on your telephone keypad.
If anyone should require operator assistance during the conference. Please press star zero on your telephone keypad. As a reminder, this conference is being recorded it is now my pleasure to introduce your host Mr. Nicholas Scotto Senior Vice President of Finance.
You Sir you may now begin.
Thank you operator, and welcome to the Amedisys Investor Conference call to discuss the results of the third quarter ended September Thirtyth 2020, a.
A copy of our press release supplemental slides and related form 8-K filing with the FCC are available on the Investor Relations page of our website.
Speaking on today's call from NSS won't be Paul can answer a chairman CEO and President and Scott can Chief Financial Officer also joining US is Chris Gerard Chief operating officer, and Dave Kemmerly, Chief legal and Government Affairs Officer before.
Before we get started with our call I would like to remind everyone that statements made on this conference call. Today may constitute forward looking statements and are protected under the safe Harbor of the private Securities Litigation Reform Act. These forward looking statements are based on information available to Amedisys today.
Company assumes no obligation to update information provided on this call to reflect subsequent events other than as required under applicable securities laws.
These forward looking statements may involve a number of risks and uncertainties, which may cause the company's results or outcomes to differ materially from such statements. These risks and uncertainties include factors detailed in our EPS is he filings, including our forms 10-K, 10-Q and 8-K.
In addition, as required by SEC regulation G., a reconciliation of any non-GAAP measure mentioned during our call today to the most comparable GAAP measure will be available in our forms 10-K, 10-Q and 8-K.
Thank you and now I will turn the call over to Amedisys CEO Paul to syrup.
Thanks, Nick and welcome to the Amedisys third quarter 2014 earnings call.
I'm extremely proud of our performance this quarter as we have once again generated prodigious clinical operational and financial results best thing, both our internal and external expectations and it's a multiyear whats environment with the ongoing cobot pandemic still risk.
Surging and the once in 20 year payment system overhaul P. D. G M.
We delivered on our four strategic pillars, all while we and the country continue to deal with this crippling pandemic in our industry with the transition to PDGF.
Our performance throughout this quarter once again shows the resiliency and persistence of our caregiving company, our clinical team and all of your support from who will stop at nothing to provide the high quality of care to our patients. Our performance is a direct result.
All the work you any.
Increasingly hard circumstances, and I want to send a heartfelt. Thank you to each and every one of you.
This quarter, we will briefly spend time, reviewing our progress against our four strategic pillars digging into our underlying business performance updating our outlook for 2020.
Diving into COVID-19, varying impact on Threeq Q results as well as exploring or even stronger outlook for 2021 and beyond.
During this call Scott and I will cover the following our performance in Q3, which bested our internal modeling and street expectations and highlights how important essential and resilient home health hospice and personal care are to the health care delivery system.
We'll talk about co Goodnight team, which has now sadly settled more into a business as usual we are carefully monitoring these concerning surges and our warning how to execute successfully in this unusual environment and working to turn headwinds into tailwinds.
The reimbursement outlook for both home health and hospice, which will set up 2021 to be our best Medicare reimbursement year in recent history.
Most kogut, including our updated view of 2020 guidance, what we're doing to position ourselves for a strong 2021 and beyond and why the future value proposition of all our business segments looks even more promising.
With that let's dive right into our progress against the four strategic pillars, which are the drivers of our company and its success.
Always starting with quality, we achieved a quality of patient care Star Q PC score of 4.33, and we had 95% of our care centers at four stars or above and 65% of our care centers at 4.5 stars.
Or above.
Our ship score is 4.5 stars, which is important as there will be no more Q PC updates until January 2022 ship will be our interim standard.
Our hospice business once again significantly outperformed the hospice items that national average.
Paul measurement categories and puts us at the top quality wise of the National players next.
Next is Rob.
In home Health, we grew total AD Miss by 5% and total volume by 6%.
Showing just how strong and quickly the business has recovered from the initial impact of COVID-19, we expect these trends to strengthen throughout Q4, setting us up for strong growth in 2021.
In hospice, we delivered strong total AD units at an impressive 9% HBC and hospice was flat as facilities, especially sniffs experienced co. Good related occupancy declines and we faced some challenges related to access restrictions imposed by these facilities.
Workover it is researching.
Some other interesting data points on hospice in the time appropriate include.
Our business mix has shifted during cobot.
Facility based census went from 43% in Q3, 19% to 35% in Q3 20 with a corresponding average length of stay increased from 82 to 106 days. Conversely, non facility business is up from about 50.
7% in Q3, 19% to 64% in Q3 20, our average length of stay in our home base census drops nearly 10 days as a result of patients on census, with co. Good 19, bringing down the average these COVID-19 patients were typically onset.
Census for an average of 14 days.
In order to combat these trends, we have leveraged our additional 73 BD feet on the street towards two strategies, one focus on continuing to steal market share in facilities and two.
Expand our referral base through new non facility based accounts and in all cases, continuing to educate all referral sources on identifying the need for hospice earlier.
Finally, keep in mind that AIDC growth lags ADMET growth by about a quarter. So 9% ADMET growth in Q3 will be reflected in AIDC growth in Q4, and we expect to see attractive AIDC growth into Q4 and beyond into.
2021.
Employer of choice, we drove total voluntary turnover to 19.3% for the quarter and 18.5 year to date with an early exit rate of 11.3% down from 13.2% in Q3 2019 or.
Early exits we define as employees that leave within their first 90 days has been a focus of ours. This year.
We know how valuable our employees are and how hard it can be deployed and secure the best talent.
Once we have them. There is no reason why they should leave us and this will continue to be a high priority going forward. We think we can and should do better on both fronts and expect to show improving results.
Next operational efficiency.
We continue to make great progress in deploying pdgm cost levers in the third quarter, we achieved an LTM RN ratio.
46.7%.
From 40.6% in Q3, 19, and a P.T.J.P.T. ratio.
49.6% up from 43.7% in Q3 19 as you can see we are well on our way to our ratio goal of 50 50 by the end of this year, which has it will continue to provide significant positive impact from margin and will improve our cash.
There as well.
We also continue to make progress on our Izing, our planning and visits realizing nearly 2.5 visits per episode reduction during the quarter, while delivering equal or greater quality and learning to employ a high frequency low cost tools like tele health.
Into our care delivery models.
Overall, our productivity has been improving at a quarter over quarter and sequential rate of approximately 5%.
As we continue to refine our scheduling practices and documentation, becoming even more efficient in how we take care of our patients.
Our performance this quarter has allowed us to increase our EBITDA guidance range from $245 million to $255 million to $269 million to $272 million raising the midpoint of our EBITDA range by 20.5 million.
In dollars Scott will cover the details in his remarks, none of these results would be possible without our over 21000 employees unwavering commitment to providing outstanding care to our patients in their homes.
I want to thank everyone of you for helping to deliver shuts are strong clinical operational and financial results. It all begins with our culture of care, giving which forced the pacing first as we've said great care equals great economics now onto the right.
Tori front and as we reported last quarter. We are very pleased with how the rate environment for 2021 is shaping up.
In July CMS finalized the fiscal year Twentytwenty, one hospice rule.
Which was comprised of a 2.4% payment rate update.
This correlates directly to our specific cost this payment rate increase of about 2.4%.
Given our organic and inorganic growth.
In hospice.
Positive rate updates are increasingly impactful and meaningful to our business and position us well for top and bottom line growth in 2021.
Similarly in late June.
Matt issued the calendar 2021 home health product perspective payment system rate update where CMS proposed to increase payments by 2.6% beginning in January. In addition to this positive payment update CMS also proposed to make permanent the tele health flexibility.
That has been previously granted to home health agencies during the current public health emergency.
Just last week two bills were introduced into Congress, one in the house and one in the Senate that similarly seek to provide telehealth flexibility and importantly payment for telehealth visits during the current and future public health emergencies, we applaud CMS and our congressional champions for their purpose.
Results to extend tele health Flexibilities and payment for those visits during this crisis and beyond we.
We look forward to working with them on this important policy initiative for the home health industry and our patients.
We expect the home health rule to be finalized in the coming days and to be consistent with our comments here.
Rural traditionally comes out around four on Halloween we.
We don't expect to be scared this year, a treat not it's Rick.
These two payment updates will be significant tailwinds for our company as we entered 2021, producing an approximate incremental $40 million in 2021.
The 2021 rate updates for both home health and hospice or just a small piece of why we continue to be increasingly excited about what the next few years appear to have in store for our company.
I want to spend a little time talking about the tremendous opportunity we see in front of us that could propel us to significant future growth and innovation for 2021 and beyond last.
Last week, we completed our annual strategic planning process, our market and regulatory analysis projects. The next five years based on what we see demographically and Regulatorily as well as the industry dynamics to be very strong tailwinds, which should drive outsized growth for a medal.
Yes, and the industries, we play it.
For example, demographics are in our favor thanks to the baby Boomers now between 56 and 76 keeping in mind, our average patient age is 78.
80, meaning we will be experiencing a surge of potential patients in the coming years as baby boomers age into the at home care Sweet spot it more.
More people are turning 65 years old and aging into Medicare faster than they have ever before over 10000 a day.
The burgeoning 75, plus population coupled with ever increasing unsustainable health care costs.
Yes in a very advantageous position as an aging in place company delivering the highest quality care at the lowest cost to seniors.
Also besides demographics psychographics are in our favor nine out of 10 of these baby boomers want to age and die at home ads.
Add to that economics at home care is what people want it's the cheapest type of care and it's the most suitable for the types of long lengths chronic illnesses that we will be treating in the future.
Moving to regulatory CMS implemented massive and comprehensive home health payment reform in 2020, so the rate outlook over the next five years is projected to be stable and positive in both home health and hospice. When you put all the market forces together add what we have.
Quality scale and capital things look very promising and that's why we're so excited.
Besides demographics psychographics economics, and regulatory there was a new accelerator Togut 19.
It is not new news the COVID-19 severely impacted patients in institutional settings, such as skilled nursing facilities and assisted living facilities. A significant portion of COVID-19 deaths have occurred in institutional settings cobot has accelerated the desire to be cared for in the home.
Which is now stronger and more urgent today than it ever has been.
And we are innovating to meet this demand working to be able to increase our capacity to care for more traditional patients as well as moving up the acuity scale focusing on new sicker patients that had no other options but institutions.
By developing a snip at home product for those who want to avoid a sniff stay we are showing we can give patients a home alternative we have made good progress in this product development, which focuses on a package of services.
In conjunction with traditional home health aimed at keeping higher acuity patients at home and out of institutions.
Nip at home represents an interesting new growth Avenue for the company and will be an opportunity for growth even beyond the pandemic.
The time to work with referral sources on taking their higher acuity patients is now and we're capitalizing on it.
Finally, given our scale acquisition and integration capabilities strong cash flows and balance sheet flexibility when the current temporary co goods subsidies holding the home health market together are lifted the true impact of PGGM will finally be felt within our industry, we will be ready to continue.
Our organic and inorganic expansion in home health and are well positioned to capture more and more market share of a still highly fragmented market.
As a result of our 2019 planning and 2020 execution, we are thriving and PDGF and have worked incredibly hard and proactively to turn headwinds into tailwinds, we have navigated and our understanding how to operate during coated.
We are active on building new territories via de Novos and innovating around our core as mentioned.
The growth algorithms, we have developed for Amedisys and 2021 and beyond are truly exciting and I believe we have positioned ourselves optimally to fully capture any opportunities that come our way.
Finally as noted in our August 10th 8-K for tax and estate planning purposes, I exercise 500000 of my vested stock options and retained a 100% of the underlying shares after tax and option costs as I just laid out.
And as Scott will expand upon.
We have many years of Tailwinds ahead of us and I am excited to retain approximately 1.3% ownership of the company. During my almost six years at Amedisys I have not sold a share this.
This transaction resulted in a very positive tax benefit and subsequent EPS impact, which Scott will deal with in his prepared remarks. We believe this method was the best course of action for the company and our shareholders with that I'll turn the call over to Scott, who will run us through our Q3 per.
Hormones and full year 2020 guidance Scott.
Thanks, Paul I'm very pleased to report another impressive quarter results, which was highlighted by a return to growth falling COVID-19 disruption in Q2 and meaningful expansion in our margins.
For the third quarter on a GAAP basis, we delivered net income of 2016 cents per diluted share an increase of $1.13 cents on $544 million in revenue, an increase of 49 million or 10% compared to 2019.
Our GAAP results include our recognition of Capex funds, which is included as other operating income in our statement of operations.
As a reminder, we it doesn't apply our care that fund only to direct costs associated with Coke 19.
The majority of these costs are included in cost of service and consist of the following pp. He of nearly 2 million testing costs of $1.5 million in quarantine pay of approximately $1 million.
Our results were impacted by income or expense items adjusting our GAAP results that we have characterized as non core temporary or onetime in nature slide 15 of our supplemental slides provides detail regarding these items in the income statement line items each adjustment impact.
You'll note that our adjustments include the recognition of care that tons and direct costs associated with co. The 19.
For the quarter on an adjusted basis, our results were as follows.
Revenue increased $49 million or 10% to $544 million EBITDA increased 19 million, a 33% to 76 million EBITDA.
EBITDA as a percentage of revenue increased 240 basis points and EPS increased one dollar nine cents to $2.24 per share.
During the quarter EPS benefited 72 cents from a $24 million tax benefit as a result of executive stock option exercises once.
Once again keep in mind, our adjusted results do not include any of the care that funds our code 19 direct cost.
Additional items impacting our Q3 2020 performance are as follows the suspension of sequestration added nine may into our revenue and gross margin for the quarter.
Continued improvements and clinically into the utilization and the shift in clinical staffing mix drove a substantial portion of our 440 basis point improvement in gross margin.
Don't cancel essence drove lower revenue adjustments health and workers' compensation increased 6.4 million driven by the shift of cost from Q2 to Q3 due to COVID-19 as well as inclusion of Aseracare, which closed in June and rages was split into effect August 1st.
Sequentially EBITDA increased $9 million, driven by $59 million, an increase in revenue and gross margin expansion.
Now turning to our third quarter adjusted segment performance keep in mind segment level EBITDA pre corporate allocation.
In home Health revenue was 326 million up $15 million or 5% compared to prior year driven by our strong recovery in total admissions and total volume.
The same store basis total admissions were up 5% and total volume was up 6%.
Revenue per episode was up $50 or 1.8%, which was driven by the suspension of sequestration and reduction in lupus loss billing period, and an increase in case mix.
Visiting commission cost per visit increased 5% over prior year.
The increase was driven by planned wage increases effective August 1st and.
Increased health insurance expense as a result of the 19 puts it caused a more significant sequential increase than normal seasonality.
Contract to utilization and the impact of lower visit volume on fixed costs.
Our gross margin improvement of 600 basis points was driven by our significant progress on clinical staffing mix and utilization.
Eight point 80 basis point impact from sequestration or lead and the viral nature of our business model, which benefited from higher volumes.
Segment, EBITDA was $70 million up $22 million with an EBITDA margin of 21.3%, representing a 620 basis point improvement.
Other items impacting the third quarter results of our home Health segment include and then Craig crease in DNA of approximately 3 million, mainly driven by planned wage increases.
The addition of resources to support growth higher health and workers' compensation cost increases and incentive comp accruals and investments related pdgm, partially offset by lower travel and training center.
EBITDA was up 16 million sequentially, driven by $36 million increase in revenue highlighted by a 15% sequential increase in total admissions.
I want to provide a little more color on our PDG in performance and observations.
As a reminder, in entering the year the medicines right impact as a result of pdgm with the negative 2.8%.
During the quarter our revenue per episode was positively impacted by the sequestration suspension.
Excluding the impact of sequestration, our revenue prep, so was down only 0.2% from prior year, which is a material improvement as we were down 3.7% and 2.3% in Q1 and Q2, respectively.
As a result of our continued focus on Operationalizing Pdgm, we've made significant progress on overcoming the rate impact.
Clinical staffing we ended the quarter with a 46.7% LP in utilization.
From 40.6% in the third quarter of 2019.
The 49.6% PPA utilization up from 43.7% in the third quarter of 2019.
This continued progress keeps us on track towards that 50% LPN and pita utilization by the end of 2020 K.
Keep in mind that every 1% shifting utilization equates to approximately $450000 of cost savings.
On utilization we ended the second quarter at 14.4 visits per episode, which was down nearly 2.5 visits year over year and one visit sequentially.
As of the end of August 100% of our care centers are utilizing the Metalized CAD product as a reminder, the care product is analytics created patient specific care plan to drive the most optimal outcome.
Our visit metrics only include in person visits on by definition, we have deployed the use of telehealth visits in response to our patients needs during the COVID-19 pandemic.
During Q3, we averaged approximately point for telehealth visits per episode, which was down from 0.6 in Q2.
We have also rolled out the metalogix touch product, which is an hour, which is an outbound calling product is identifying set on our patients at higher risk of readmission.
So these additional parts will touch points are not counted in our business perhaps.
They are another key tool used to provide the highest quality clinical care and helps ensure the best outcomes for our patients.
I want to commend our entire home health leadership and operations the speed at which you have covered volumes and the efficiency and what you did say it was a big driver of our performance this quarter.
Graduates is underperformance and thank you for your efforts.
Turning now to our hospice segment.
Revenue was $200 million of $37 million over prior year, an increase of 23%, which includes the addition of two acquisitions closed during 2020 as Don on January 1st.
Aseracare on June 1st.
Net revenue per day was up 2% to $155.57 driven by sequestration suspension.
Already was up slightly over prior year as the segment continues its recovery from the impact of COVID-19, our facility based census has been most significantly impacted however, we continue to see gains in our non facility volumes as evidenced by a 9% growth in same store admissions compared to a 1% decline in Q2.
Dissipate Q4, AIDC growth the census growth generally lagged admissions.
Hospice cost per day increased 47 cents. Thanks.
The increase was driven by raises in health insurance offset by a significant decline a visit performed by variable cost employees and lower transportation costs as we've experienced limitations and access to our facility based patients which has resulted in a 40% decline in visits or ADCC.
DNA as percentage of revenue was up 200 basis points or $12 million over prior year.
The increase is driven by acquisitions with that or approximately $9 million for the segment.
Excluding acquisition activity DNA is up approximately $3 million due to the addition of resources to support census growth planned wage increases and higher health insurance cost far.
Partially offset by reductions in travel and training EBITDA was 49 million up approximately $7 million an increase of 17%.
Our personal care segment generated approximately 18 million in revenue in the third quarter and maintain EBITDA margin over prior year, COVID-19 continue to impact billable hours and client service in Q3 on a year over year basis. However, we have seen positive sequential trends in our personal care segment, including an increase in high of approximately 40.
6%.
Growth in clients, a 2% and growth and hours of 5%.
Turning to our total general and administrative expenses.
On an adjusted basis total DNA was 176 million or 32.3% of total revenue, which.
Which is up 200 basis points over prior year, which includes 11 may and additional costs related to our acquisition 9 million a hospice segment.
Two main incorporate additionally.
Additionally, incentive comp accruals taxes on stock option exercises raises and help ensure health and workers' comp accounted for approximately $11 million.
Sequentially total DNA was up $24 million and 17 million excluding this their care acquisition the.
The drivers of the sequential DNA growth are expected increases relate to planned wage increases and higher health as well as higher incentive comp accruals driven by our strong Q3 performance.
Expenses DNA to moderate to more normalized percentage of revenue and 2021 through growth in top line in both our legacy and acquisition businesses.
Hi, impressive cash flow generation continued in the third quarter as we produced $83 million in cash flow from operations.
Increase in cash flow was driven by a two day reduction in Dsos of 40 days from the end of the second quarter.
$18 million and payroll tax the perils under the care that than.
$10 million related to an increase in our estimated usage of care that funding, which will be used to offset increased costs related COVID-19 expects to be incurred through June thirtyth 2021 in accordance with the updated guidance issued by HIV test in September.
With our cash flow performance in the third quarter, we expect to generate approximately 300 to 310 made in cash flow from operations for the full year 2020.
This makes the third straight year generating cash flow from operations in excess of 200 million, which allows us to significantly pay down our outstanding revolver, Our fund additional acquisition activity.
Finally, as Paul mentioned in his opening remarks, we are increasing our guidance ranges for 2020.
Our new guidance ranges represent our best view of the business at this time and are as follows.
Revenue of $2.067 billion to $2.072 billion.
Adjusted EBITDA of $269 million to $272 million.
And adjusted EPS of $6 in two cents to $6 an eight cents.
Im very pleased that our ability to increase our guidance ranges given the challenges of implementing pdgm comply.
Completing the stair care acquisition and continue to operationalize.
Our other acquisitions, all while dealing with a COVID-19 pandemic.
As a reminder, our 2020 performance has been impacted by Cove 19, and we expect some of these items normalize in 2021. These items include positive impact from the suspension of sequestration lease expires December 31st.
The impact of missed visits on visit utilization, which impacted revenue and visits per episode.
The hospice margin benefit from lower home health aide visits due to facility access limitations.
And a decrease travel and training costs.
Based on our terrific Q3 performance, we are very pleased with that trajectory as we entered Q4 and we are very confident and excited about our growth prospects for 2021 well.
While we will see normalization our run rates to the items mentioned, we head into 2021 with some meaningful tailwinds, a 2.4% reman reimbursement increase in hospice and propose home health increase of 2.6% cuts.
Continued operational improvement in our core hospice acquisitions.
Significant opportunity for admission growth aided by BD staff expansion and 20, 20% 19 disruption.
And significant improvements in our gross margin driven by changes to visit utilization and staffing mix in the second half of 2020.
This will conclude our prepared remarks operator, please open the line for questions.
Ladies and gentlemen, the floor is now open for questions.
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First question is coming from Brian Tanquilut of Jefferies. Please go ahead.
Hey, good morning, guys, congrats on a very strong quarter.
I guess related to one question Paul I'll just ask.
As we think about growth. So you clearly show showed acceleration in the second.
Third quarter from Q2, despite could be in the background. So how should we think about the remaining growth acceleration opportunities and what do you think will be driving that both from a macro and company specific perspective.
I guess to add to that where do you think volume growth to go from that 6% organic number that you saw in Q3. Thank you.
Thanks, Brian Yes, we feel good about where we are obviously in terms of growth I think the key for us.
He is on the hospice side, our admin growth is very good and strong what we've said when you have a flatter UGC, it's going to pass through and so we should start to see a good AIDC increase which is what we've been focused on so we can tee up particularly good.
Particularly well for next year, so we feel good about it and home health, but the growth has just been fantastic.
Chris is with me to any any any comments on that yes, probably hey, Brian I'll, just kind of go through home health and hospice as well it's on the home health side, Yes, we are.
Happy with how we came out of Q3.
We also progressed nicely through the quarter, so that gives us some some encouraging signs for for the balance of the year.
We see that really it's an opportunity for us continue taking share, which we feel like we're doing both with facility business as well as with our physicians groups. We had 17 over 1700 unique new referral sources in Q3 that had not refer patients to us in the previous year.
Our team has really jelling nicely and we've got a bunch of reps that are really starting to get into that kind of that.
Maturing stage, if you will to where they are starting to see some some some additional growth on top of the ramp up from from new hires so feel really good about the home health side Hospice you know what we like is that you see that we had the 9% EBIT growth in Q3.
But flat on a DC in so.
If you look at the previous three quarters, we had 1% admit growth, 1% EMEA growth in zero percent and are linked to say it's been relatively flat. So there is not a surprise that were flat and HTC in Q3, but a couple of few data points is one is we had the non percent ended growth that we should see excellent.
Ration at 80 C. in in Q4 and beyond on top of that we also had over 800 uniquely where our new referral sources, referring to us in the quarter that had not in the previous.
Previous a year and then also we had a really good progression throughout the quarter on AD mid growth on hospice, so thats encouraging for us.
For for future kind of 80 seat growth and continued rapid growth in the last piece I'd say is we've really invested in new reps on the hospice side, we have 73, new reps in Q3 this year versus last years, 20% increase in the number of reps. So as they get really counterproductive and get onboard that's going to open up opportunities for additional growth.
Hi, Thanks, I'll jump back in queue.
Thanks, Brian.
Thank you. Our next question is coming from Matt rule of William Blair. Please go ahead.
Hey, good morning.
I wanted to ask a little bit more specifically about that.
The fourth quarter and Scott obviously.
Relatively.
Tight range. There. So does that maybe just reflect the visibility that you guys have and to the cost profile and to pdgm, perhaps even into the hospice senses.
Maybe just help us understand what it assumes about.
Volume growth dynamics, and just kind of where the upside downside stress test is around.
Fourth quarter.
Yes. Thanks.
We feel good and then kind of as Chris has talked about Dr. We're seeing going in I mean, its certainly a nice progression for us then.
In those rates, we're assuming kind of a similar growth type movement that we see here, we do think admits around.
Around hospice will accelerate as we move forward just.
The timing growing ADCC little slower as we've talked about the lag, but we do see that accelerating.
You're going to see the normal increases in costs as we move into that around.
What we see around health insurance.
Going up I mean, you have some of those movements, we do have a rate good gab, but yeah, we feel like the visibility that especially on the cost side really felt good with the revenue levers coming through this quarter on the rate side that really offset that year over year impact of sequestration I mean of excuse me a pdgm. So yes, I mean, we feel that it's certainly in our sights less fear.
Couple of kind of the ability to handle through could handle coded.
So most of the most of the costs are baked Dan we're looking at a nice October from a volume perspective so.
We feel good that's why we tightened the range.
And as I think I would add I mean, we increased it.
In the mid range of 20.5 million. So it's a big jump so we feel good about that.
Yes.
Indeed, and Paul just quickly on on SNF at home the product to developing.
Maybe just give a sense for what the payment mechanism might be.
Given that there might be an additional baskin services associated with it and are you would you be targeting beset payors what referral sources.
It would be interesting element of that and I'll jump off. Thank you yeah. Thanks, Matt Yeah. The snip at home basically we've always been anxious to show since we've been producing very good quality and as you've shown in your research quality equals growth. We believe that there is an opportunity, particularly as the market is demanding.
Unless people want to go into service, particularly the people with less acuity and has become less attractive for the snus to take these that theres an opportunity to take the lower acuity patients in sniffs and take care of them at home.
Okay for service really Doesnt have the payment mechanisms to do this so that people were talking with now are largely risk space entities. So in risk.
Brisk pace, taking in M&A also bundles also a COO, so thats where weve been.
Focusing on it if there is not.
What we're trying to do is to.
Have traditional home health and then use some of our personal care networks around that and and then we're working with some talk groups that.
I would.
Referring to that so we we have to piece it together, it's a different model we want to show what works, we anticipate if we do it in a capitated environment and then we can take it to CMS and see if.
Because the benefits would be much lower in cost. If we can then take it to CMS and see if we can get some some changes in the fee for service world, but starting without any proof is a is a hiding.
CMS.
Thanks, Bob.
Thank you. Our next question is coming from AJ Rice of Credit Suisse. Please go ahead Andrew.
Hi, everybody.
Maybe I'll just add.
For modeling question about.
The acquisition landscape, what you're seeing out there.
Both in home health and hospice, how how is pricing change that I know.
Heres active and some of that funding and pushed off some of the deals you thought you might see in the back half into the first half of next year is that still your thinking as to when we'll see some of that rollout.
Yes, the last deals we saw and then I'll have Scott talk about it as it comes out of.
This comes under him, but we've seen at hospice pricing has been very high.
So we've seen and frankly, we've done in the last 18 months, we've done four deals really happy with the deals and the pricing we got post synergies as well as just the ability to incorporate them into our legacy system. So thats what were focused on the hospice. We're always looking we have some reach.
The whole hospices that were out there looking nice sized regional hospices that were out there looking at we think now obviously with the how home health is performing though it's a real opportunity to go out and look for home health assets home health.
Particularly in some of the areas, where we think.
So that we can start to fill and also and I'll have Scott cover. This we've been doing an incredibly good job on de Novos and are still putting out between 10 and 15 de novos a year, so I'll turn that over to Scott.
Yes.
Yes, I agree with your comments around the pipeline excited about it and you'll certainly heavy lean on.
On the home health side and.
If you look at our cash flow position Weve got tremendous opportunity in the 2021 to really take some.
Take some inorganic growth into into the portfolio excited about that to know those as Paul said, it's been a big win for US. We continue to move forward on those we did do a little bit of a pause this year, but when we hit go bid, but those are running really well.
We're doing branches, that's really a nice view for us.
Probably.
Kind of getting those opened anywhere from eight to 12 months by an average cost is to license of about 400000.
We've built a nice rhythm there and I'll, let you would it.
We expect to see us as we talked about 2021, when we give guidance I want to invest some dollars and an increase in that pipeline de novos and to answer your question specifically ha.
We are seeing hospice decently run hospices with no that are relatively clean over 15 times. So it's gotten a little crazy, particularly when it is a PE platform with which they can use to lever. They can justify their pricing that way are always they tell us there hasn't been many home health deals that have been clean so.
So they've always had these other assets around them.
The Q, what we expect is FC quest duration.
No is added back on and when the loans become due.
For the receivables and for payroll is that's when we expect to shake out to occur if the government pushes us out further it's probably got a hold us back on on what we anticipate is a large consolidation opportunity with pdgm in fall, particularly as the reps going to be eliminated in January.
What we're what we've seen a rough rough is trading.
Maybe 12 times 13 times, something like that but post synergies. It's below 10 for us. So thats why were looking and that's that's where we think the markets kind of being in a lot of our competitors now frankly have seen what we've been doing in hospice center now deciding to go after net after hospice, so I think thats going to push the hospice pricing up even more.
Thank you. Our next question is coming from Joanna could you of Bank of America. Please go ahead.
Good morning, Thank you for taking my question here.
Yes.
Hi, how are you.
One other topic here can you talk about your Medicare advantage book of business on the home health side can you update.
Update us on the progress towards your goal of you know.
Increasing debt risk sharing percentage of your contracts, so and with that.
What are you seeing in terms of average pricing have you seen improvement.
Just looking on the average book of business.
Thank you I'm going to punt to Chris on that but in general we're really happy with where we're at we've got a great team.
Doing this just made a lot of progress. So we feel we know this is the future and so were very aggressive in.
Terms of our ability to go out.
Learn as much as we can in risk bearing environments, but Chris what you talked about when we got yes, hi, Joanna. So you know it's still it's a it's a kind of a slow and and grilling product process progress or process that we're going through in terms of just getting plans and give us opportunity to earn additional rate based on quality metrics.
The plans are very open to that they are doing that we have now over 20.
20% of our actual contracts out there have some sort of upside based on quality metrics.
We did some recent analysis is over 30% of our actual it may add minutes have some upside opportunity. Many of those are still new enough arrangements that were not able to really report out the actual gains from that but we should be able to do that in upcoming quarters.
Again. The makeup is typically still you know a per visit rate that may be a little bit better than what we've experienced in the past with upside you know in a in a percent range based on those quality metrics ideally, we want to really kind of close the gap between our Medicare fee for service and our Medicare advantage.
The challenge is that we run into is still very fragmented industry out there even though the plans are interested in quality a lot of times are also just as interested in who is going to take the lowest rate and until there is some consolidation in the industry and some of those.
Those willing to take you know an unfavorable rates are off the table, it's probably still going to be an uphill battle for us, but we're still we're moving it forward our rights are inching up.
But we still got quite a ways to go yet we're also seeing Joanna we're seeing some opportunities with.
With bundles in hospitals, so we're getting having more conversations they are larger and larger areas, where they do have specific regional concentration, which plays well when we have that coverage also Chris and his team have done a fantastic job on driving down our re admissions rate. So what's our rate is like.
11, or something so our 30 day rate is 11 in our inner asias rate, So 14 and a half. So it's really good. So we're continuing to drive that down continuing to show differentials there and that's what a lot of the payers are interested in and and in certain marketplaces for Smes.
Marketplaces were able with the cooperation particularly of hospitals to drive that into single digit. So we feel very good about it and that's what a lot of the payers are very interested in.
Thank you. Our next question is coming from Matthew Gilmore of Baird. Please go ahead.
Hey, thanks.
Question, though back at you I heard you didn't like the music.
You know Paul I, just I think its I think its fortunate that that you are good at your job you don't have.
Yep.
Okay, No DJ future to jump on me I'll, let you pick next time.
Yes.
Okay.
Okay, well, let me try to follow up on some of the 2021 comment I know you are not in a position to give guidance, but just hoping you could help us sort of think through up a framework. If if we did the math right I think you're sort of at a $75 million quarterly run rate for the back half.
Of this year is that kind of a good jumping off point as we are then thinking about organic growth into 2021 and sort of what are the puts and takes I know obviously the sequester as soon as one of the things.
How would you frame it up personally, but I haven't run rate, but you got the yeah, Yeah guidance Thats. The I think you met your right Thats a good starting point I mean, there's some noise in there, but 75 I would I would say is good and if you look at our guidance in the guidance you kind of put for fourth quarter in a similar range of that 75 number I think there's probably four.
Things off the bat I'd consider moving into that one is rate we've talked to that before and you think of what we expect and rate increases for next year net of sequestration, that's probably about a 20 million dollar good Guy I would talk to the only CCH and aseracare as they expand we had said before just alone or CCH, we get a 14 to six.
18 million dollar expansion and expected to close somewhere around 34 to 36 mean for this year, obviously with over 19 that'll be impact as far as in EPS.
So that number I think still sequentially, you're probably between those two somewhere around that $20 million range and then the other items to think too or I do think some hospice visits they are going to come back as far as I talked about that in the prepared comments.
We're seeing a reduction in visits in facilities, specifically, which is probably about a 110 basis point good guy.
In the hospice margins, so I see that coming back and then travel and training will come back around we've seen that for the quarter down around $4 million year over year. So some of that will normalize for us and then we think our growth.
Gross prospects are very strong you see us moving into what was there in Q3, we think that continues to move forward and certainly some low marks in Q2 were going to have an ability to grow that pretty significantly. The other thing that we'll be looking at and Paul mentioned earlier was de novo's, we're going to want to continue to expand that that certainly is going to be a an EBITDA drag.
But we think those and data we're seeing on our Denovos make us pretty bullish on doing that and then we're going to make some investments in the organization.
This high rate of growth.
We continue to look at that but those are the big items to look at but just off the bat or between rate and CCH given you roughly $40 million as you move forward and then the other items will work to finalize as we get closer to close out the year and can look at our plans for next year.
Yep. Thanks.
Thanks, and also Matt My radio station, we're going to put that into.
Thank you. Our next question is coming from Andrew Marc of Barclays. Please go ahead, Andrew Hi.
Hi, Good morning wanted to follow up on your Sniffed at home service and their desire to expand capacity to take market share how far along are you in that process and has capacity been a constraint to volume growth from snip diversion, so far into the pandemic. Thanks.
Now, let's talk about jump ball and then Scott why don't you talk about seven Oliver either way, Chris Yeah. I'll start this is Chris on the on the SNF diversion, which we kind of distinguish that from kind of the futuristic sniff at home, which is more kind of down the road.
It is it is real it's happening right now there are some pockets of various out to our our growth rates.
Or even a little bit ahead of our internal expectations in Q3 and accelerating into Q4. So we have run into some areas to where we do have some staffing constraints, but what weve shown that we can do in the past and we continue to do today is when we see those areas, we react pretty quickly we've been able.
To utilize contract clinicians where necessary.
As well as kind of treat housing business, if necessary as well so that we can make sure. We take care of the patients were not turning away any business related to capacity.
The one the one thing I'll put out there, though is about 2% of our clinical staff.
At any given point in time over the last few months has been on corn team Lee related to COVID-19. So if we run into any kind of spike there than that would also kind of create some additional constraints but.
Our staffing our clinical capacity right now is not inhibiting our growth.
And then on the.
Yes, yes, now piece I'd tell you that we're getting pretty close weve got to finalize the contract which.
We're working pretty hard to get that done over the next few weeks it will be a pilot. So what that may look like in the first iteration of it that ultimately change the fully push it out much farther we are excited about it I think it.
Gives us the ability to move up to.
Up to scale here from a.
From a acuity level, which is what we want to do as far as our strategy in the home.
I think we're going to build it in a way that gives us some certain upside.
If we do the great job that we think we will so we're excited about it I need to get across the finish line, but we'll be talking more about as that pilot tennis begins the rollout and ultimately when we see are able to measure our success yes.
Yes, so we feel good about a jump ball business, we're winning more than we used to.
And then getting clearly some interesting again it risk bearing payers.
Deciding that they want to push more from the lower acuity levels in the SNF into the home. So we're feeling good about it.
Thank you. Our next question is coming from Matthew Borsch of BMO capital markets. Please go ahead.
Okay. Now you got your third not to you on the call.
[music].
So.
Yes.
I wanted to.
Ask about what you're seeing in terms of competition or potential competition in home health from.
Our large.
Large hospital systems large physician groups, possibly.
Hi, integrated plans like Optum.
How much of that is on your radar screen now in hand should it be.
Yes, I think obviously, we look at competition home health is still very much a local or regional play.
And so it varies sometimes we see some of the folks you talked to in the <unk>.
Some of the bigger national players.
In general, though it's a mom and pop business. So we see a lot of players there again, we believe with our quality scores.
And the correlations that come out of that from a growth perspective.
As long as we focus on quality good service good transition, we're tending to win pretty disproportionately worse, we're gaining share out there. So we feel very good about that we don't see much disruptors out there outside.
Outside of the traditional space and there is a lot of news and noise on it in the venture and PE worlds, but we haven't seen a lot of or virtually any disruption from some of these new models that are out there I know Chris No I agree I think that you know for these large systems, if they want to enter into the space. It's not a simple thing to do.
Yes.
And you know and it's in for them to be able to do it in a way that actually is either kind of.
Ill kind of harms us anywhere takes to take share away from us. We're just not seeing at navigating kind of their own existing Tata payer world and systems a lot of times doesn't line up well with with home health, which is more of a traditional Medicare fee for service business. So.
We see it in pockets, but it really is an area that a lot of times our flexibility our service.
Reach geographic service fees and things like that actually helps us gain business from these hospitals that have their own systems. What we are seeing though due to covert is we're seeing hospitals start to put together a preferred provider relationships, which means instead of 15 home health agencies that are calling in what they'll do is they'll.
Generally go by quality and then the limited and so we are out there. So it's a it's a same pie.
Fewer players so we find that attractive.
And then also frankly, what we're also seeing is a lot of people if they tend to have procedures done outside of hospitals and ambulatory environments. We've seen some good growth. There. So we're out there looking at some of the ambulatory world as well.
Ill get institutions in this environment Weve.
We've just seen a lot of real.
Consumer reluctance to.
To want to want to walk into an institution. So we're trying to be good partners on one side and yet we're also trying to folks that follow the business on the other side.
Thank you. Our next question is coming from Justin Bowers update to bank. Please go ahead.
[music].
Hey, Paul I'm actually surprised it took a long isn't good for someone to comment on the 10 Bucks three although I would have thought it would have been one of the elder statements.
Uh huh.
So just on just taking a step back Paul.
Paul It sounds like you guys have gone under a bit of a strategic process I am done.
And.
If I think about some of the comments you made about the Tailwinds earlier, how are you guys thinking about kind of the long term growth algorithm.
On the enterprise is there any way that we can.
Hi level like maybe put some numbers around now yes.
Yes, I mean, we just.
Superstar Mick here did a wonderful job, but we just finished up with the board and what we do after we do strategic planning as we take it out to our leaders and about 100 of them and we are we make sure they buy into it and then we then we turn it into a work plan and deliver against the work plan.
I think that if you just apply that and we'll we'll start to push this out but if you look at if you look at the natural growth rates in home health and hospice and personal care.
Less than anything and health care, if you look at the margins our home health and hospice tremendous margins are.
If you look at kind of so just with the regular winded our back from an industry perspective. You also look ahead and regulatory you are looking at very good updates good consistent updates, which we haven't seen in home health in the past 10 years now the PDG Ams.
Settling and we have we can start to implement against that so we feel very good if we just sit in place and stay in our core businesses. I think we have the best business mix of anybody out there.
Very good waiting in home health and hospice and then moving on personal care largely into networking. So I think we were I think we feel very good about it if we go above the industry, which is what we expect on thats kind of clearly accelerate even more so we expect to be two three points above the industry.
From a growth perspective, if we do to our cash flow if you add.
300 million to 50 300 million.
Year in M&A, and you add that which we can easily do stay still very low leveraged are you add that in and then you are going to accelerate even more growth and then you add in some of our innovative products, that's going to be even more growth. So we'll be bringing this out but it's not all this together.
Again, if we just sit and slow down the river its still pretty nice it's a nice it's a nice ride for the next four or five years.
Yes.
Scott you want to add anything I don't know if I covered that.
No I think you had a lot of five points and I think certainly we are bullish about where we are as a company.
The opportunity in front of us.
His tremendous and I think.
The fact that we've come through kind of a 19 stores, we have continued to accelerate margins which was.
Really if you think about our ability to do acquisitions and as we start looking at pricing on on home health assets look in our own internal margins going help us be very competitive there is no prospects are great.
We always have some work to do but really feel wonderful moving into 2021.
Thank you. Our next question is coming from Bill Sutherland of the Benchmark Company. Please go ahead, Hey, Bill.
Hey, guys.
So I've been hearing that the actual pdgm up coatings, apparently running behind what CMS set an estimated originally.
So.
Given it's supposed to be budget neutral is there potential down the road for some positive offsets. This if this really is I mean are you.
Seeing no.
First of all thank you I love that question.
Thank you.
Yes, and after 2022.
And so if you look at the Dobson Davanzo more important which came out from the partnership.
So that there was a gap in spending or an anticipated capital spending of about 21.5%.
If this continues.
Then I think has a 2022 all turn to Dave Kemmerly here, Yes, Bill. Good question, it's important to note and remember that the bipartisan budget Act of 2018 mandated that the transition to a new payment model in this case pdgm in 2020 be budget neutral and even provide a mechanism for a true up if you will in turn.
22.
Most of the data from the early part 2020 holds throughout the year.
The remainder of this year and then into 2021, there will be a rate give back or increase in the payment rate update for 2022. So when you see that fall rule.
In November of 2021, there should be a rate update for 2022, if behavioral assumptions.
Our playing out like you are now and it was flawed. We set was flawed going in is playing out even prior to cope with that data that Paul referenced from Dobson Davanzo that study is looked at data from January February March maybe in early April clearly.
Clearly showed that it.
Wasn't budget neutral, yes, so while we aren't going to wait by the mailbox for checks from CMS, what we will anticipate is.
We will go to Congress and we will push this.
If there is continued under spending because of the mandate and we have some good friends. There. So we anticipate the industry will do this and then my guess is we'll try to make it up on rates. So I view. This as a very positive I also if you look at the fragmented nature of the industry. What you see is a lot.
A lot of people are still paper based a lot of people are still having problem with the rules.
And it's just as we said increase since the amount of administrative yes, everyone has to deal with so and.
And we think they guessed wrong on the on the cuts so we think.
We think at some point they are going to have to make it up.
So it's a good sign in my opinion.
Thanks Bill.
Thank you. Our next question is coming from John Ransom of Raymond James. Please go ahead John Ransom.
Hi, So just for the record Paul what kind of music deal cycle, I'm, just I need to get dominate.
I'd like Steve Earle here in town, so anytime he's playing or Neil young which shows Mike Prime outdated, so, but I can't know unless we played out here so.
At least you didn't say, some new jazz or broke Ontario.
It allows elevator is again there we go.
Like New York.
I guess it just strikes me that all of us in the Chattering community you know killed a lot of trees over the past 12 months obsessing over.
The GM for you guys adjusted EBITDA being basically not flat so.
Just maybe help understand a little bit all the doom and gloom versus the reality what levers you pulled.
Maybe that loop that maybe with coating, but just a little more behind the covers of how you turn what everybody thought was dogs living with cats, and the jot Pillsbury Lowboy walking around gross stuff not is this just kind of turned into a net flat or what not a lot of data processing that ended up not being a big deal. Yes, I think I think for us and I got to give Chris.
Not that I would like to do this but I got to give Chris Gerard water credit.
Hey.
He had he at us drilling on this here.
Ian here, he Gianni who runs runs home health had literally setup trial and pilots that we're acting like Pdgm was terrible at last fall. So the amount of prep work that was done the amount on our coating folks did a fantastic job they were prepping Melissa ball or there is just.
Fantastic job. So we were really working hard on this and we are working scare too, but we were very planned Paul and so I think the result has been extraordinary I don't know, Chris maybe you see swanning that I've probably done.
No. It was it was really it was preparation it was really us disaggregating all the components identifying the the revenue levers in the cost levers and picking the path to those I mean, we we utilized metal largest care, which has helped us tremendously in our upside management side.
We really drill down into our 2019 data to see how those would play out in 2020 under PDGF and we really quickly identified opportunities around los billing periods and coating opportunities.
As well and then you know just really you know just kind of the spread that through the organization and creating kind of our own our own kind of scorecards that we manage managed off of allowed us to really identify quickly where we were seizing the opportunity, where we had where we add more opportunities twosies and just to execute.
In on it so.
It sounds like it was easy it was not easy at all and it still is a challenge for us and we still have work to do but I think it's just a good old preparation breaking it down.
Indicating well you know all the way upstream and downstream and then you know again execution.
Yes, just like we don't.
Behind all this beauty John there's a lot of work so.
Thank you our next housing joke.
Yes. Please go ahead.
Hey, guys. Thanks.
Thanks, I got pulled off for a little bit. So it's like if you guys covered this just told me that got back in the queue, but can I get an update on Assad on Aseracare.
Really just how they are tracking versus plan any modifications to the integration plan given the pandemic changes anything changing your your view on the slope the integration plan and maybe just some comments on the team turnover would.
Would be helpful. Thanks.
Turnover on the on the newly acquired company, Yes, Yes, anything anything yes turnover that's beyond normal that you would short to call out were positively or negatively.
I'd say in general the integration has gone extremely well we've learned a lot from our from our early days when we acquired to Infinity and then tenets assets.
So we have a really strong team Mike north.
As for has we've only brought in from Humana, along time ago, who is in charge of integrations. Their work with me. There has been doing that and then Kris Novak has done a great job I think the idea is that on the technical integrations have gone extraordinarily well largely because we've been doing that the.
Also the synergy Pullouts have gone on track and on time.
And so we've been tracking that we have a pretty strong discipline and execution on that.
The cultural pieces are always what you try to figure out when you get in so we've been really good about retaining folks are there has been more cultural changes.
With CCH, which was more.
Decentralized than with Aseracare for example.
Honda, but in general we feel really strong about it Scott Scott. This comes under Scott can and Chris So I don't know if I missed anything.
No I think we're pleased with that.
Certainly you can't ignore the COVID-19 impact from a plan perspective on where we thought we would be the will be will be handled that schedule on CCH, but we're seeing some nice improvement. So some good growth numbers from admissions that are really getting us back in line with where we need to be so we're pleased with that but you've got to kind of a distraction as I said I don't know if you are on it.
We talked about we've talked about a $14 million to $16 million incremental improvement coming out of a DCH. We know we're going to be a little low.
Little below where we thought we would exit but still think the incremental build will be strong going into next year Sarrica has a great asset.
That was really performing probably slightly ahead of expectations financially.
And as we did this.
This cloud of Covidien to become known to US and we continue to operate more we were comfortable where we're heading from a plan perspective, let me just kudos to the team they did an integration.
Basically when we were.
In light of Downs had to train remotely couldnt get get to see some of these folks. So it is a tribute to our team as well as the sarrica team on that asset as well as all of our other operations folks do this time, but feel good about them Tonight. It's a nice group of assets that you pull all four of these together and blend demand with our legacy.
Yes.
We feel great about where this.
Does that that hasn't 2021.
Thanks.
Thank you. Our next question is coming from Frank Morgan of RBC Capital markets. Please go ahead Greg.
Good morning.
Most of my question have been answered, but I guess you know give.
Given your view of the industry breadth backdrop over the next several years and the opportunities around.
Potential acquisitions, I guess, what is your comfort with with leverage.
And when you think about doing deals the size of deals and.
What type of leverage.
Mr. rich would you be willing to assume given given the backdrop.
Then the second question was just.
Just about lupus in the quarter up I'm guessing that by wasn't a big issue, but any any specific data on that that'd be great. Thanks.
Yeah ill start Scott Scott doesn't want us lever up so I'll, let him take this one.
Scott will let us let Rob and then just as a great sign I mean, so we're going to do.
This call with the obvious I mean cash from ops is going to be greater than 300 million. This year.
Had some really good some things that helped us out but just leave.
To be over 200 main I think at least three straight years is strong for US you can see through Aseracare will continue to pay down our revolver pretty aggressively I mean that a variety of close to paid off by the end of the year, we'll probably leave that term loan out there, but from a pure leverage perspective, it's the right deal the right assets, we would go up to three eggs.
You know anything above that we would probably maybe potentially use our stock of those right something transformative. The we would we would let this thing levered lever up considering whats available and are under our revolver right now with.
Our availability it in from cash generation you are looking at really close to $500 million right. There from the ability to fund deals so.
A lot of great opportunities out in front of us and.
As our base operations continue to get better it makes us more bullish and I believe that we can integrate well operate well then pay down the debt.
And Frank this is Chris from a loop of perspective Q3 number was 8.6%.
It was down from 9.2% in Q2, so feel really good about our ability to manage.
Okay.
Thank you at this time I'd like to turn the floor back over to management for any additional or closing comments Gregg.
Great. Thank you very much Donna and thank you for the suggestion of Johnny cash next time as intro music.
We'll take a look at it I do love, Johnny cash as well, but I want to thank everyone, who joined us on our call today I'd also like to thank again, all of our employees in the field and those who support them and for helping to deliver such a strong quarter. Please keep doing what you're doing taking care of the people who need us the most we.
Hope everyone has a wonderful day, we hope you stay safe and we hope you vote on Tuesday, and we look forward to updating you on our ever evolving progress and purposeful work on our next quarterly earnings call until then take care.
Ladies and gentlemen, thank you for your participation. This concludes todays event you may disconnect. Your lines at this time and have a wonderful day.
[music].