Acadia Healthcare Company, Inc. (ACHC) Earnings Call Transcript & Summary

We've got day 2 of the 44th Annual Raymond James Conference here in the happiest place on Earth. We've got a hybrid format. So the team of Acadia, namely Chris and David are going to go through some slides. And then the important part of the presentation is where I get to talk and ask questions. So I'm especially looking forward to that. So take it away, team.

Okay. Great. Thank you all for being here bright and early on this first slot. So before we get started, we're just going to ask everyone to briefly review our safe harbor statement here, and we'll get right into it. So I would start by just saying, at a time of unprecedented demand and need in the U.S. for behavioral health services we're just really pleased at Acadia to be in this position where we're the single largest stand-alone behavioral health company in the country, 250 facilities across the nation, 75,000 patients that we have the privilege of serving daily. And we're confident that we have built a strong foundation during a time of record demand for our services, particularly coming out of the COVID pandemic. We believe that we really are at an inflection point as an industry, and we feel like we can be the company that meets the needs of the industry and really takes a leadership role in moving the entire industry forward. So is the single largest pure-play behavioral health provider in the country with both national scale and regional density, as you can see on this map on the left. You can see these are our 250 facilities, and we have program services facilities spanning the full care continuum in locations across 39 states and Puerto Rico. So 4 complementary service lines, you can see the green dots represent our acute facilities. We have 52 acute facilities where we're treating high acuity patients in inpatient facilities. And then you can see in the orange dots, we have 37 specialty facilities where we primarily treat substance use and eating disorder patients. And then the 151 blue dots that you can see these represent our comprehensive treatment center or CTC facilities where we're treating OUD patients in outpatient settings. And then finally, the 10 purple dots are our 10 residential treatment center programs where we treat children and adolescents with behavioral health disorders. . We wanted to just do one quick slide that frames the industry. And you can see, I mean, no surprise, we're operating in a very large and growing market. estimated to be a total of $185 billion for all of behavioral health, which we break out here between mental health and substance use. So the mental health market is $65 billion, and the white box represents really the complex mental health treatment, the higher acuity cases. This is where we have strategically decided to position the company. And then between the complex mental health market, which is the white box and the substance use market, which is the light blue box on the right, that's $110 billion of the $185 billion. So 60% of the market is really the area where we are focused at Acadia. Our estimated growth rates here for the industry from 2018 to '21 is 7% for mental health, 8% for substance use, which we're estimating to continue to climb based on all the growth drivers that you see on the right. I mean clearly, unmet need for complex care, 30 million-plus Americans that are receiving no treatment today. The destigmatization of mental health, the bipartisan support that we're continuing to see for behavioral health across the congressional landscape. And then just the fact that we have a low industry maturity overall, still significant fragmentation in this industry and really limited integration with physical health and also very light investment historically across the industry in IT. So the last slide I wanted to cover here just quickly before handing things over to David is just a quick overview of our strategy, and we went into this in more depth on December 7 at our first ever Investor Day that we had in New York. But our strategic vision, just at a high level is to become the indispensable behavioral health provider for higher acuity and complex needs patients. And to achieve that, we have 3 major priorities. Our first priority is to accelerate our pace of growth for new facilities. So we have a very high confidence in our ability to increase our pace of new market entry, and we're going to be doing so through multiple paths. Secondly, expanding our care continuum, particularly for patients with opioid use disorder and other substance abuse disorder conditions. We're going to expand both our inpatient and outpatient services across markets, and we'll continue to expand the ways that our patients seek treatment. And then third, further strengthening our capabilities. I mentioned technology before, including our selective technology investments that will continue to differentiate us and improve the way that we deliver care to our patients. And this is really going to be reflected as an increase, as we discussed at our Investor Day in our historical level of spend in IT across the board. So just to dig a little bit deeper in these IT investments that are going to cover various areas. We really think that these -- well, first of all, they're going to mainly focus on a few areas. The first is continuing to scale electronic medical records across our acute and specialty sites of care. And then also continuing to scale tech-enabled monitoring to ensure that patient safety and compliance, particularly in our acute and specialty facilities continues to remain high. And then also key corporate office leadership just to drive the maturation and innovation that we believe our industry needs and also in functional areas like HR recruiting, marketing, strategy, technology and transformation. So we really believe that these investments are going to set us up and really help us create substantial value in multiple ways over time through several areas, a few that I would just tick off are: first, to better support our medical teams with respect to patient safety and compliance. These investments in remote monitoring are a great example of that. Secondly, enhanced overall patient experience. Third would be improvement in employee satisfaction, which we really think will have a significant impact on recruiting and retention over time as we continue to advance technology, and we're already seeing that. Improved payer engagement. So with more robust data and analytics investments, that's going to position us to support the move to value-based care, which is happening a little bit slower in behavioral health than it is in other aspects of health care and to position us to move at the appropriate speed that the market moves. And then finally, we believe that these disciplined investments will help us drive revenue and margin improvement opportunities for the company over time. So with that, I'm going to turn things over to David and let him go through some of the additional slides.

All right. Thank you, Chris. Good morning. I'm going to spend just 2 additional slides talking about how the growth strategy that Chris just talked through translates to earnings growth for the company. We did spend time at our Investor Day in December really having our leaders of our different growth initiatives across joint ventures where we are really seeing an accelerating opportunity to partner in select markets, across de novos and across our facility expansions. Our leaders were at Investor Day talking about our accelerating outlook around with the demand environment and the other tailwinds that we have, what the capacity additions will mean for the company in terms of our earnings growth? And we did lay out a target in early 2021. We had just sold the U.K. business, which we had for a number of years, and we're excited to be a U.S.-only company, again and laid out a target of 10% EBITDA growth, organic EBITDA growth without M&A for the company. And we've been pleased the last 2 years to deliver on that 10%. The -- our 2023 outlook also reflects a 10% EBITDA growth. And that's being driven by adding across all of our growth pathways, 600 to 700 beds per year, including our existing facilities, joint ventures and de novos, but not including any M&A opportunities that would be incremental to that. We see that accelerating as we project ahead the joint ventures that we've already signed and announced that are in the design and construction process. As those come online, we believe that 600 to 700 beds will accelerate to more than 1,000 beds a year, and we did not bring all of our slides from Investor Day. But hopefully, if you're interested in seeing more about that, refer back to those materials because we lay it out by growth pathway. But what that acceleration will do is drive a higher growth rate for the company. We've sized it for now going from the 10% to 12%. As we think ahead to those beds coming online, going through their start-up process and ultimately contributing to EBITDA growth for the company. And I would say additionally, we are funding the investments that we're making that Chris talked about, technology, corporate office capabilities, that is embedded in that 10% to 12%. So we're excited to be able to not only pay for that, but also see all of those investments further contribute to strengthening the company and really driving further opportunities for more efficiencies and deliver on the outlook that we have. And then I wanted to spend the last slide just talking through our 2023 guidance. We did report -- it was almost to the hour a week ago, we reported our fourth quarter results and shared more about our 2023 outlook. And we are excited about what lies ahead for this year. We did narrow and tighten our guidance slightly compared to some initial guidance that we provided in December. But our guidance reflects a lot of confidence and visibility we have in the year, starting with our organic volume growth, which has been growing for the company in a range of 2% to 4% a year, but is accelerating to 4% to 6% for 2023. And we talked last week about how it's early in the year, but we are already seeing record senses for the company and seeing from a year-over-year growth perspective, seeing our volume growth at the high end of that range, so at 6%. That's being driven by -- we had a number of facilities bring on new beds and programs in the second half of 2022. And even early in 2023, we've had a number of facilities opened the programs that they've been working hard over the last few years to open. The growth strategy that's reflected in our 2023 outlook, we're going to open 2 de novos this year. Excited about -- those are just markets that, in our view, are underbedded where we have been working hard to bring new bids and programs to a market that needs new facilities. And we have one of those in California, and one of those in the Chicago market that we're excited to bring on. And 2 of our JVs will open this year as well. The revenue per patient day has been positive for the company, growing at mid- to high single digits just as we engage with payers, not only on the value of the services we provide, but also just inflation and demand and the history of rate increases for our industry. So we do believe that will continue to be a positive. And like a lot of companies, we've been managing over the last few years through a challenging labor market at times in certain geographies and the business and our operators have managed to do that very well. We did see wage inflation in the second half of 2022 at the 7% to 8% level, and we believe that will continue through the first part of 2023, mainly because we have moved ahead with measures to stay proactive and stay making the investments in our people and in our business that we think will deliver our outlook going forward, and that includes merit increases for our employees in the first half of the year. Otherwise, our view is that the labor market is improving. We're seeing signs of that within our own data and certainly seeing signs of that as we look to external data. And so I believe with a stable labor market this year, a number of other positives around our revenue and our revenue per day, I believe we're set up for another 10% a year for 2023. And that concludes the slides. We'll move to the moment John has been waiting for.

You're kind of cutting into my time there.

Oh, sorry about that.

So one broad thematic issue that we hear is as we exit the COVID world and go back into whatever new world this is, what's going to stick and what's going to kind of fade away. So behavioral health, I think some of the online ad or all focus models have not done so well. We certainly are seeing elevated demand. But as you sit here, what do you think change permanently? And what do you think was sort of a temporary COVID effect as you think about your planning and the industry dynamics?

Particularly around telehealth?

Well, just in general, industry in general. And just how informs your decision making? Like how does the COVID changes do or do not affect how you think about the future?

Yes. I mean I would start and say several things. I mean I would say, first of all, I think everyone expected with the early surge in telehealth for that to play a role, and it clearly has. I mean we have half of our CTC patients right now are in sort of -- some sort of treatment through a tele encounter. And so I think that there is even more prevalence there. We see it in our residential treatment centers, in particular, where parents want to stay in touch with their children that are in our facilities even more regularly and telehealth is a great way to do that. I think there are also real opportunities for us to continue to expand our virtual capabilities beyond what we have, like our flagship specialty facilities, Sierra Tucson in Arizona, Timberline Knolls in Illinois, where we have great really cutting-edge eating disorder programs, I think there's a way for us to use virtual capabilities to expand those programs to our other locations. But I think just on the telehealth side, we are dealing, as we went through earlier, we've made a strategic decision to focus on the higher acuity patients, which I think in many ways have less applicability at least in the near term around telehealth. We see one of the things that our psychiatrists would say is that physically being in a room with a patient, particularly if they have a substance use disorder and being able to see, do they have track marks on their arm and being able to really understand, are they seeing weight gain or weight loss. These are being able to do an examination in person just continues to be critical I think originally, at the early part of the pandemic, people felt like maybe psychiatry would accelerate in other ways. But I still think for the sicker patients that we work with there's still opportunity, but we need a hybrid approach there as well. And so we're using more virtual services than we ever have. I think the other thing that I would just say is that this continues to be a very fragmented market. I think the effects of the pandemic and rising interest rates, it's a very tough operating environment for moms and pops and single facilities. And so I think that really advantages us, particularly with the strong balance sheet. I think it sets us up to be an acquirer of choice, and we're spending a lot of time on the M&A front. So I think we believe that we'll continue to see consolidation in this market as well. David, I don't know if there's anything you would add.

I don't think so. As I think about COVID, it was maybe more of a challenge for the behavioral industry, including us because the procedures we had to go through around keeping our patients and employees safe without the premium funding for treating those patients as some companies receive. So it's been a positive that that's been more stable. Our teams at the local level did a fantastic job navigating that over the last few years and putting protocols in place to continue treating patients that needed our treatment. But hopefully, that's something that we've now worked through the worst of it, and there's been a lot of demand, as we looked at earlier, a lot of tailwinds around stigma declining and the demand is as strong as it's ever been coming off the pandemic, and we think we're positioned well.

So going from the high level of conceptual to ride into analyst 101. That's about where I operated at the freshmen level. Labor margin on a consolidated basis, there's a lot of noise in that. We hosted a call, as you know, afterwards, where you talked about some of the dynamics, but maybe just level set people on same-store labor margin in the fourth quarter and just some of the dynamics that may be made that stat look a little worse than it appeared -- it looked better -- it looked worse than it actually was.

Yes, we did. We reported a number of metrics around labor, and that includes base wage inflation, which was 8% for our fourth quarter. And you can certainly see, as you look at our salaries as a percentage of revenue, that it reflects that higher wage inflation. I think as we manage the business and as we report the results for the business. We have our same facility group which reflects all of our facilities that we've had opened for a year or more, which is most of the company at this point, but not including new facilities and not including our corporate office. And we have been able, even with wage inflation being higher than it was historically and being higher in the second part of the year than the first part of the year, with our volume growth and with our revenue per day growth, which reflects reimbursement increases from our payers, our same facility margins have been growing and have been performing very well, and we expect that to continue. But we are sort of taking that growth and reinvesting it in corporate office capabilities, which we talked about on the slides and in opening more facilities. And those facilities go through a period of time where they're hiring their staff, but not seeing the volume that they will grow to over their first few years of operations. And so that did have an impact on some of our labor metrics and -- but we believe, like we said earlier, we're positioned very well. Our outlook for the year reflects that while wage inflation remains higher, we are covering that with our stronger volume and with our continuing revenue per day growth, but also making some really important investments for the company that will drive continued growth, continued strengthening of the company long term.

So just one more on labor. Turnover is something that a lot of your peers are looking to reduce. Can you help us with where your turnover peaked, where it is now and where it is versus the pre-pandemic or baseline?

Yes. We mentioned earlier, we have seen some positive internal metrics that would suggest an improving labor environment. For us, it does vary, we're in 39 states in Puerto Rico, have a lot of different employees that we hire. Each of our service lines has a slightly different mix of clinical employees. So we look at turnover and other metrics across geographies and across all of those job categories. And we have seen for the last several months an improving turnover, a decline in our turnover. And we talked about it in a slightly different way last week as improvement in our net new hires. So it's an early trend. I guess we're hesitant to say that it's definitively a peak that we saw in August of 2022, which is where we last saw a turnover at the higher historical level. But turnover for the company has been stable. But it also is something that we think we can improve over time. And we're happy to see that improvement, but I think there's more to come.

Yes, I would just add a few things on that. I mean I do think that there's opportunity for us to improve turnover. I mean I think we are the ultimate purpose-driven company. So many people join Acadia because they've seen in their own family or their community challenges around eating disorders, schizophrenia, bipolar disorder, alcohol and drug dependency. Everyone has a story that they've seen that draws into the company. We need to do a better job of telling our story, both externally as well as internally. We talked about the lack of technology investment across the industry. We're no different. We have not historically done town halls across all of our facilities to the extent that we are now. We're really dialing up the communication. And we're being much more intentional about career paths within the company as well, which is one of the things that we hear when we go out and visit many of our facilities. And so we've been very intentional about putting strategies in place that will improve our turnover and enable us to retain more people and also recruit more people in, over time.

Another theme that we're hearing from investors is the worry about the downside effects of the ending of the PHE. And so in your case, that -- let's focus on Medicaid. So the states lose their FMAP additional funding back half of the year. That's when you said 75% of your Medicaid rates are set second half of the year. And we're going to -- estimates vary a bit, but something like 15 million or so people are going to migrate out of Medicaid into either exchanges or commercial or nowhere. And you have been getting extraordinary rate increases relative to history. But you also said that you didn't think you're getting a lot of the FMAP money. So just kind of talk through how you're thinking about second half expectations with some of the changes coming in Medicaid.

Sure. Maybe I'll start, and David can add a few things.

This might have been the longest question.

That was a long question. So let's talk about redetermination here to start. I mean clearly, we have Medicaid in all lines of business, and it's something that we're taking very seriously. And I think it puts patients at risk if they were to clearly lose coverage. Very few, the research and all data would show very few patients actually understand that they may be at risk of losing coverage this year on the Medicaid side. So we have a real opportunity to further strengthen the relationship that we have across lines of business and educate them. So we're doing a number of things. We have several strategies that cut across all lines of business. This really started with our CTC business, where they proactively were even late last year, putting QR codes out, people that were coming in and getting a dose of methadone had a chance to scan this QR code, learn more, have a conversation with our staff directly about their own coverage eligibility. We have, since that time, taken that across the country, across the company, we're putting kiosks in place to force these conversations. And we're also putting a hot line in place that we have recently decided to invest in just to make it a one-stop location for a patient of Acadia, doesn't matter what line of business to reach out to us directly to help guide them through the process. So we're doing everything we can proactively to educate our patients and to help guide them through this process. And why don't you kind of take it from there with any other commentary?

Yes, on Medicaid rate increases, John mentioned that a number of our states see that contract renewal and rate renewal happen in the second part of the year. Our team at the facility level and our operations leaders alongside a corporate managed care team that we have that does a fantastic job engaging with our payers and our government relations team that helps with the state relationships and legislatively anything that we can do in that state. States are focused on mental health. And we come alongside those states and really help them meet the need and how that need is growing and changing in their markets. And we expect that to continue to be reflected in our rate increases along with inflation. We're very mindful of state budgets and methodology around mental health, which has been a fairly simple reimbursement model for a number of years. But we think there's room and reason to continue rate increases to be more consistent from a Medicaid perspective. It has not always been the most consistent payer overall even though one state to another is very different, but we believe we're positioned well in the second half of the year, and the team is already hard at work on that.

And you're seeing last question, we're almost on time. Any difference in what you see from Medicaid managed care versus straight Medicaid from a rate standpoint?

It tends to be very similar recently. Of course, most states now have a significant portion of their lives are part of a managed Medicaid plan for acute business that's 80%, 90% of those Medicaid members are in a managed Medicaid plan. So there does not seem to be a significant difference right now in that methodology. .

Great. With that, we'll head to breakout. Thank you.

Thank you.

All right. Thanks.