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

[ Good morning ], everybody. John Ransom. Welcome to our 47th IIC. I've been told I have to say that every time. So you'll get used to hearing that. In a very well-timed sequence of events, we have the returning CEO of ACHC, who made a lot of news last week. You can pull up the chart and see how the stock traded. This is Debbie's second time to have to come back to clean up a mess that she didn't make. So she knows how to do it. And so what we're going to do this morning is a brief presentation. I've got some questions, and hopefully, we'll leave some time at the end for some audience questions. So take it away. We have Todd Young with us as well, CFO.

I'm sorry, I didn't get...

An afterthought, I'm just -- I'm so excited to see, Debbie. All right.

Okay. Well, good morning. I'm Debbie Osteen, as John said. And I'm going to start by giving just a brief overview of the company for those that aren't familiar with Acadia. Acadia is a unique company in that we are #1 as far as pure play for behavioral health, but we have a diversification in our services that some of our competitors don't. We have $3.3 billion in revenue for the full year of 2025. We treat 84,000 patients a day. When I left, we were treating 70,000. So we're treating more patients and obviously, those that need our services. We have 277 facilities, and that's across 40 states. And as you can see, it's made up of acute, which is a shorter-term behavioral health facility, specialty, which is primarily substance use and eating disorder. And then we have residential treatment centers, which is longer-term care for children and adolescents. And we have 178 CTC locations. And these are outpatient clinics that are providing Medicaid or medication-assisted treatment. As you look at our revenue by service line, you see that acute is our largest service line, 17% is specialty, equal to CTC, which is also 17%. And then RTC is our smallest revenue by service line. The revenue by payers in the middle. If you are looking at Medicaid, which I know we've all been talking about, 57% of our payers are Medicaid. But this includes all our service lines, and it really varies by service and by state, how Medicaid pays us and how they interact with us. We have a revenue chart up by geography. And I think you can see that we don't have any one state that represents more than 15%. I'll just say, and I'm sure John will be asking questions later, but my goal in returning to Acadia is to build a strong company. with a focus on excellence in patient care. To me, that's the foundation of everything we do and also create shareholder value. And so as I think about the 4 areas that I'm most focused on, the first is patient care. And we have outcome measures that we've implemented, and this has been done over several years, and we want to build on those successes. We are publishing those outcomes, and we're proud of them. They are very positive. They're available on our website. The second area of patient care is safety and quality. Our goal and my goal with the team is to drive continued improvement there. I will say we do lead the industry with our survey results, which is Joint Commission and patient safety, and we've invested a lot over the last few years in patient safety, technology about -- around keeping patients safe, which I think have been well spent. That's behind us. And now we are operating using this technology, but also a focus on the people, which I'll talk about at the end. The second area is volume. We have added 2,500 new beds over the last 3 years. And it's my goal and my focus to see those beds ramp and to see volume improve. We also have new beds coming on this year, 400 to 600 beds will be coming on. And my goal there is to see them ramp faster than the beds in 2025 and to make sure that we're providing access. Some of these are joint venture partnerships that will be added in '26, and we have 1 de novo. The third area is operational excellence. And I think about payer relationships when I think about operations, making sure we're reimbursed appropriately with our payers. And I think my philosophy, and I believe the team agrees with this, is we have to be constructive. We've got to be collaborative. And it's not really a uniform issue. There's not one payer. We have multiple payers in each state. So you're going to see a lot of variety there. But I think the bottom line with our payers is we want to be a partner with them. To do so, we have to demonstrate that we bring value and that we have outcomes. The second area under the operational excellence is really capital discipline as well as expense management. And I think -- as I think about capital, each project should stand on its own merits. It should meet the market need, but we're going to be very careful and very cautious about how we spend capital in 2026 and 2027. The last area, which is probably the most important other than patient care, and that is having the right workforce and talent. And we need to recruit, we need to retain and we need to train highly qualified staff. And I will say that our retention rates are going up, which is positive. So our turnover is going down. But that's an area that we're all keenly focused on is making sure that we have the right staff out in the facilities to treat patients. And the second area of that is talent, which is ensuring that we have the right people in the right position. I'm currently evaluating that. I think that what's needed to support our team might have changed over the last few years. So as we think about the beds we brought on, ramping those beds, my lens is around value to the field and what corporate support is needed there. And I want to ensure that we have alignment so that we're working together and that it's not a corporate and a top-down approach. We want to work with the facilities, and we want to make sure we're meeting their needs. And another part of that is looking at where the scope is for leadership, how we are across the various states, which is 40 that we're in, what kind of supervision are we providing, but also support to the facilities and to the leaders there. My main focus this year is really on execution. And I think that we have made a lot of investment, not just in technology, but all of our bed adds. And as I think about that, I want to make sure we have a framework to realize that value. And I think we can. And I think that part of what my job is, is to make sure that we have the right people and the right talent and that they're focused in the right way, eliminating obstacles for action. And I will let Todd talk about '25 as well as '26 and what we've laid out as far as our expectations.

Thank you, Debbie. Thanks, everyone, for coming out today. As you mentioned, Todd Young, I've been the CFO of Acadia since the end of October. Last week, we released our earnings for Q4 as well as provided guidance for 2026. We encourage you to read the press release and the accompanying slides for just greater background on Acadia. As you can see, we did deliver revenue and adjusted EBITDA in Q4, in line with the expectations we had laid out. And in 2025, as Debbie mentioned, we finished 1,089 beds. It's been a clear focus of the company over the last few years is building out new facilities to take care of more patients across the country. Now it's critical that we ramp those beds from a greater occupancy standpoint to leverage the fixed cost investments we've made. As we think about Q4, pleased, we had 3.1% same-store volume growth, which was an acceleration over Q3. As we look forward, you can see revenue for 2026 at $3.37 billion to $3.45 billion, with adjusted EBITDA in the $575 million to $610 million range. Our same facility growth, 0% to 1%, obviously, lower than Q4. But at the end of the year, the New York Medicaid made the determination that their patients would not be allowed to be seen in facilities outside of the state of New York. We have a large number of specialty facilities in Pennsylvania that had patients from New York. Unfortunately, those patients now have to travel farther somewhere in New York to find beds to be treated. The result of that is about a 350 basis point headwind to same-store growth for us in 2026. From a patient day, you can see that 2% to 3% coming through on patient day growth. And then finally, on free cash flow. As you mentioned, the last few years at Acadia have been marked by significant investment in new facilities. And with that slowing as we're finalizing new facilities in 2026, we're dramatically reducing CapEx. So over a $300 million reduction in growth CapEx from '25 to '26 and expect that to decline more in '27 as we finish the facilities. That is allowing us to project cash flow being positive in 2026, which should help our leverage as we move forward. As we think about the opportunity in front of us, 2,500 beds added over the last 3 years with another 400 to 600 beds to be added in 2026. We do believe that this creates a $200 million EBITDA opportunity embedded in our facilities as we ramp and drive the occupancy higher. This is the key driver of growth in 2026 and will be the key driver for us over the next few years. Operational execution is critical to delivering on this opportunity, and that's what the team is very much focused on as we finalize the new facilities that are well on their way from a construction standpoint, but most importantly, drive greater occupancy amongst the capital we've put in the ground. And that's the prepared remarks, and I will turn it back over to John.

So Debbie, second time you've done this, as I mentioned, what's different today, both kind of micro and macro versus the first time around other than the fact that you will have a sprinting start because you've been inside the company versus last time you had invest some time to get there. But now coming back in with a better data set in your head, what's different about this time versus last time?

Well, I think from a macro point of view, there's really not a lot of difference. I think that there's still very strong demand for our services, and there's still not enough resources to treat the patients that need it. So as I think about that, and I know that there's been a lot of discussion. We obviously had questions about payer pressures. I've been in the business a long time. And I think that it's not a uniform issue. I think it's -- in certain states, we've seen more pressure than others. But I do believe it's our job to make sure we're able to speak with payers, be knowledgeable about what our rates are, what we expect and also to demonstrate our outcomes to them. So I think the team, obviously, I've seen some familiar faces that I brought on during my tenure, but also new individuals. And as I mentioned in my remarks, I'm looking at that with the lens of what we need now. And I believe that the company has added a lot of beds, which I think is positive, but now we have to focus on making those beds work and improving the performance of the company.

Under the prior regime, we understood that a new -- a de novo would be 4 to 5 years to get to target margin. And we calculated -- this would never confirm, but we calculated at that point in time, maybe at low double-digit EBITDA on that investment. So if you spend $20 million, you might get $3 million, $2 million, $3 million. So it wasn't a very robust return. What do you say of the investments that you've had? I know you've talked about a $200 million swing in EBITDA, but what's a reasonable expectation for the returns, especially -- I don't think anybody calls with the bed adds, but the de novos, what kind of return should we be? And in what time frame are you -- do you think is reasonable to expect?

We're not providing specifics on the return expectations other than looking forward here on how do we fill the beds and drive as much value out of them as we can. The decisions have already been made on the construction costs and to add these beds in. I can't change that now. Whether or not those are the right decisions, I'll leave others to make that decision. But fundamentally, we believe these can be very profitable facilities and that we will fill them up and drive positive returns from here. And that's what we're focused on, as Debbie said, it's about executing on these new facilities and filling them up.

Yes, that was just -- and do you think 4 to 5 years, is that -- can you get it done faster, do you think? Or is that still how long do you think...

With de novos?

Yes.

I think so.

That's still the right number?

I think we can get it done faster.

Okay. Yes. That's fine. And what is the difference? We used to have at least 2:1 of a bet add versus a de novo, but what do you think the return difference is now given the construction cost reality?

Well, I'll say before I give the mic to Todd, I think that our expansion beds have always had the strongest return. And part of that is because we have existing overhead in place, and we're leveraging that. We obviously had a bed need. And when a facility gets to be about 75% to 80% occupied, then we're turning away patients. So it makes sense to add in our existing facilities. I think that, that is the highest return, John, for when we're construction costs are up in not just de novos and our JV bills, but also expansion beds, but it's still -- if you're turning away business and you can find a way to accommodate and the reimbursement is there and strong, then that makes the most sense.

Is 2: 1 -- is it better than 2:1? Or is that still the right way to think about it?

Right now, we're not focused on building new beds, so I haven't really spent a lot of time there, John, just given what has happened. But certainly, the expansion is certainly significantly better from a return perspective than the de novo builds.

So talking to investors about your stock over the years. I think the biggest concern today is med mal and legal so when you look at med mal, I know the commitment to quality is part of it, but how should we think about the leading indicators of that? And do you still think we're kind of in the thick of increasing accruals? Or do you think the tide might crest at some point?

Certainly, I'll speak to the expense side of the equation and I'll let Debbie speak on the quality and the investment side. We had $115 million of expense on med mal in 2025. We've guided to $100 million to $110 million of expense in 2026. The reason it's coming down year-over-year is in Q4, we made a significant increase in the accrual for cases that were already on our books. We feel like we've gotten that accrual to the appropriate place. And so now this is more just the go forward. We've certainly seen an increasing cost for insurance with higher self-retention. 3 years ago, cases over $3 million we had insurance on, that's now moved up to $15 million. So that certainly changed sort of the risk profile of these cases. But we're monitoring this differently. We're making sure that the actuarial assumptions and our facts I'm looking at that monthly to see, okay, claims coming in, settlements, how are they tracking versus the expectations so that we have less of these Q4 surprises for investors than it's happened in the last 2 years.

Yes. And they are tracking according to the expectations. I think that when we think about quality and safety and I think about malpractice, we have to really focus on avoiding incidents. And it sounds like that's a simple thing. But I think we do have good tools in place. And we've been in partnership, and I won't call it, it's -- we are working with them and they have developed some outcome measures as well as benchmarking and real-time visibility around incidents. So I mentioned this for those that listen to the call, I guess it's been last week or maybe 2 weeks that the time is going fast. 3 months Yes. We can look real time at each facility now, and we can look at each day and each time, and we can look at 50 measures that tell us what's happening at the facility. So that allows the leaders that are in the local , the CEO of the facility as well as those in supervision and quality. We have a large quality team to say, what do these indicators look like, what are our incidents doing because that's where they start. Our claims result from incidents that we want to avoid. And so we put in this technology around safety to allow tracking rounding for patients. Some of these are basic things. But then also, we'll continue to invest in training of the people that are interfacing with the patients. That's key. They have to do their job. And if they don't, then they need to go somewhere else. But we want to make sure they're trained. And when they come on what they -- to know what's expected of them and that they have to keep the patient safe, then treatment can start, and that's really around active treatment, John. You've heard that for years. I mean, we can't -- we're not a med/surg hospital. We have people that are in a treatment mu, and we need to make sure we're providing excellence there with not just the people, but also the programs that we're doing.

Well, you let me -- this is a perfect segue planned. The Yes, I've been in health care a long time, and I hear quality and what the difference -- the disconnect for me is payers don't really pay for quality. So in your industry, where are we between, I would say, the most progressive payer in terms of trying to lock in incentive payments for outcomes versus the most indifferent? And are we -- is quality something that you just have to have and it doesn't get anything extra, it's the right thing to do, but are we getting to a point where having a differentiated quality makes a difference either in referrals you get. And when I go back to, there's really no great industry database, right, that you can benchmark against. So how do you -- can you turn this into -- long-winded way of saying, can you turn it into dollars? Or is it just the right thing to do table stakes, med mal, but it's not really going to drive any extra sort of incentive reimbursement?

Well, I think that it's difficult, and I know that there's been a struggle to come up with what metrics should be monitored and measured, especially for behavioral health. It's been easier in the med/surg area. But I do think that -- and I would call them enlightened payers.

I said progressive. Okay. That's fine. Neither do I actually, but that's fine. I said progressive, you said enlightened. I like your word better.

Okay, I like enlightened.

I like your word better.

Because really, they're managing risk. And if we can show that they can put a patient in our facility, obviously paying us what we think is appropriate, and we can show them that, that patient is improving then that's a win for them, too, because we do track readmissions and other metrics. That's one metric. But now that we can show outcomes, so the patient came in, they were at this level. And when they left, we can document where they're at. And I think some payers that are managing these populations, they want to see their risk reduced. So I won't say that, that's the only thing they're looking at, certainly, but it is a factor. And now we can demonstrate it better than we were able to before.

Do you guys see follow-up work as well, like 3, 6, 9 months after someone's discharged?

It depends on the program. Some of our specialty facilities do follow up and make sure -- and it's a touch point with the patient. We've also had a focus on putting in partial and outpatients so that there's a continuum we can measure who is getting care after they're in the hospital. And I think that's made a difference also.

So your alumnus announced last week that 10% of their revenue in behavioral is now outpatient, and that's a big focus. How would you characterize your mix and focus on step-down in outpatient?

Well, we've been working on outpatient since I was my last tenure. I think that there's not a replacement for the secure setting with our patients. So I think that we are keeping patients safe. They have -- if they are homicidal or suicidal, they need safety. But I think there is a continuum that needs to be in place. And so patients where they are stabilized and they are in a secure setting, then I believe that they should step down to the lower level of care. We have an emphasis on that. I'll be honest, I was a little surprised at the 10%.

That's low, lower than that.

No, I think it's high. just based on the other services that my former company is providing. But it's a goal of ours to make sure that the patient is in that right setting. So there are markets where the reimbursement is better than others. And so you have to have a lens on that as well, whether you'll be paid for those services. But I think it's needed to have a way for the patient to progress.

So we got 5 minutes. A couple more for me. The I'll call it the methadone business. I think that makes more sense than the acronym. That's a differentiator between you and UHS. It's a big portion of your revenue. It's growing -- was growing 25%, now it's growing 5%. Some people have concerns about that business because of the cost and some of the alternate treatment options. I know Acadia in the past has defended it is the gold standard. And then there's also the dropping, thankfully, number of overdose tests. So just putting all that into a package. How do you view that business today versus, again, maybe 5 years ago when you left?

Yes. I don't really view it differently than when I left. I think the fact that we don't have as many people dying from opioid Narcan has been very effective in preventing some of those deaths. But there's still a large population out there in the U.S. and other countries as well that are not seeking treatment and do not avail themselves of methadone. And you said part of my answer, which it is the gold standard. But as I think about the business, I think about the low capital needed to grow it. I also think about the low labor intensity. So we're not using the higher RNs. There is are in coverage, but it's not at the level. So I think we feel that it has growth potential. There still is demand. I will also say that if there's value that we can bring to shareholders in another way, we would be open to that. But right now, we like the business. I think it's part of the continuum, and it's certainly directed towards a growing population.

Currently, you're spending $100 million on legal, understandable. But how should -- without providing specific guidance, I know you can't do that, but should we think about that at least as the high watermark and then it will come down? Or is that just, again, an annuity expense that we should think about going forward?

We do believe it will come down from here, John. I mean we've had a significant government investigation that we've been conducting in partnership with the DOJ. It's gone well. The team has done a good job of getting that finished up. It's now really in the government's hands. But the significant step down in Q4 to $12 million in fees versus Q3, we view as more in line with going forward and that there will always be some cash running through that line, but certainly, we would like to think the $100 million will be the high watermark.

Okay. Any questions from the studio audience? I always feel like a game show host standing here with my microphone asking that. But any questions anybody has? Yes, sir. I'll repeat it. Go ahead, [ John ].

So what's the unifying characteristic of the states where you can -- you have the [indiscernible] presence.

I'm not sure I understand.

Like in states where you have high concentration, is there a...

And states with high concentration is there a unifying characteristic as to why you're there versus the other 30 or 35 states? And are you going more towards those? Or is the growth diversifying? Which states that have those characteristics that you [indiscernible]?

I mean I think that as we think about the states, some of this is a result of the activity that was done when the company first started. And so you had acquisitions that were concentrated in certain states. So in Pennsylvania, a lot of that is substance use treatment. In other states, it will vary. In California, you have a mix of specialty and acute. So it's going to differ by state. And as we target a state or make decisions about bed additions or building new hospitals, we look at the -- there's a lot of data out there now about bed need. Also reimbursement has to be factored in, is staffing available. So there are other things that we think about when we choose a state. And it's going to -- as you think about CTC, they're really -- it's a clinic. So it's a lot easier to go in a state and add a clinic than it might be in a CON state where you have to pass a high bar, and that's mainly in the acute area.

All right. I think we'll wrap up. Thank you. Breakout downstairs.