Q3 2023 ATI Physical Therapy Inc Earnings Call

Participants

Joanne Fong; SVP, Treasurer & Head of IR; ATI Physical Therapy, Inc.

Sharon Vitti; CEO; ATI Physical Therapy, Inc.

Eimile Tansey; Chief People Officer; ATI Physical Therapy, Inc.

Joe Jordan; CFO; ATI Physical Therapy, Inc.

Brian Tanquilut; Analyst; Jefferies Financial Group Inc.

Presentation

Operator

Good afternoon, and welcome to ATI Physical Therapy's third quarter 2023 earnings conference call and webcast. All participants have been placed in the listen-only mode. After today's presentation, there will be an opportunity to ask questions. (Operator Instructions) Please note this event is being recorded.
On the call today is Sharon Vitti, Chief Executive Officer; Eimile Tansey, Chief People Officer; Joseph Jordan, Chief Financial Officer; and Joanne Fong, Senior Vice President, Treasurer, and Head of Investor Relations.
I'll now turn the call over to Ms. Fong.

Joanne Fong

Thank you, Lisa. Good afternoon, everyone. Thank you for joining us today. To cover, we'd like to remind you that certain financial statements made during this call will be forward-looking statements which are subject to various risks and uncertainties and reflect our current expectations based on beliefs, assumptions, and information currently available to us.
Although we believe that such expectations are reasonable, we undertake no obligation to revise any statements to reflect changes that occur after this call. Descriptions of some of the factors that cause actual results to differ materially from these forward-looking statements can be found in the Risk Factors section in the company's filings with the Securities and Exchange Commission.
In addition, please note that the company will be discussing certain non-GAAP financial measures that we believe are important and evaluate performance. Details on relationship between these non-GAAP measures to the most comparable GAAP measures and reconciliation of historical non-GAAP financial measures can be found in the earnings press release that's posted on ATI's website and filed with the SEC.
And with that, I'd like to turn the call over to Sharon.

Sharon Vitti

Thank you, Joanne. Welcome everyone to the ATI Q3 2023 earnings call. I wanted to let folks know that in addition to the EL team members Joanne mentioned, we also have Chris Cox, our COO, on the call; Scott Gregerson, our Chief Growth Officer, on the call; Gus Oakes, our Chief Information Officer; and Erik Kantz, our Chief Legal Officer. And they'll be available to participate in the Q&A.
So earlier today, we reported our third quarter 2023 results, and we delivered strong people, operating, and financial gains in the quarter. We have seen continued advancement in many areas within the ATI organization driven by our strong teamwork across the national platform and the continued passion around our mission to expand access to care and help people live their healthiest life.
So I'm going to go through some highlights of the third quarter and I'll start with growth. The demand for ATI services remained strong and was escalated in Q3. Our providers are committed to ensuring all new patients get started with their care at ATI as soon as possible as we know that is the best for the patients and their clinical outcomes.
So as our referrals convert to visit, it creates a vibrant and busy atmosphere that is palpable to our patients and our providers. In particular, in the quarter, our sales team outperformed expectations in generating physician referrals to our clinics. Q3 visits per day were the highest since the start of COVID. In September 2023, our referrals per day were greater than 3,000, which is an all-time high for us. Our visits per day per clinic was also the highest since the start of COVID.
Contributing to that favorable performance was the meaningful progress we've made in the quarter optimizing our clinical footprint -- clinic footprint. We closed 14 underperforming clinics in the quarter, bringing the year-to-date total of closures to 36. We also selectively opened three de novo clinics in the quarter, bringing the year-to-date total of openings to 13.
Lastly, we've completed a strategic review of the market and our business capabilities. Under Scott Gregerson's leadership, we've identified several opportunities for growth beyond clinic footprint expansion. We look forward to discussing the areas of growth that position ATI to lead in the musculoskeletal sector as we make progress in the quarters ahead.
(technical difficulty) some key area for us, our people are what differentiate us from the competition. Eimile Tansey, who you'll hear from later, has done an outstanding job since joining the company just over a year ago. While her accomplishments are numerous, I want to call out two key areas.
Under Eimile's leadership, she's reorganized the talent acquisition team and positioned them as strategic business partners to our field leaders. She has also reestablished ATI's culture as people focused and is extending our refreshed ATI brands to the candidate pools.
As our people teams and programs gain traction, our base of clinical FTEs is growing and increasing our ability to provide more patients with access to high-quality care. Growing clinician headcount is an important unlock for our business. In the third quarter, the clinician headcount increased by an astounding 134 people, an all-time high growth number. This was achieved through a combination of targeted hiring and strong retentions. Eimile will go into details on our approach to provider acquisition and retention later in the call.
From an operations lens, we're continuously working to improve operations to positively impact the patient experience -- the patient journey -- clinician experience and our financials. In this quarter, the team notably drove rate per visit improvement and clinician productivity to favorably impact Q3 results.
So as we dig into rate, our rate per visit in Q3 was $109.90. That increased by more than $5 from the second quarter. Primary drivers include increases in contracted rates and operational improvements in revenue cycle management, both driving stronger revenue per visit in current and prior periods. While the improvement related to prior periods is onetime, the enhancements in revenue cycle management and contract rates should carry forward into 2024.
Speaking of rates, the Medicare fee schedule final rules were just published. We're disappointed in the continuing Medicare fee schedule rate cuts for physical therapy. It makes no sense given the value and effectiveness of high-quality PT to our country's physical health.
There is a bright spot on the CMS front for ATI. This is the fourth year that ATI has received an exceptional provider rating from the MIPS program, which is a Merit-Based Incentive Payment System, which is one of the CMS quality payment programs.
The exceptional provider rating earned by our clinical team for high quality performance will again qualify the provider for a bonus percentage on top of the Medicare reimbursement rate and will be helpful to our 2024 financials once finalized.
Onto provider productivity, our providers continue to perform at a high level sequential quarter over quarter. While Q3 showed up with a modest 0.2 visits per day per clinical FTE decline from Q2 to Q3, each established provider on average had slightly higher visits per day quarter over quarter on those days when in the clinic, basically accounting for higher vacation days taken during the summer months and the ramp time for all our new providers.
Financials show consistent progress. In 2023, revenue increased every quarter from the prior sequential quarter. Q3 2023 marked ATI's highest revenue since the impact started, since the pandemic started in early 2020. Joe will provide detailed financial walk-through of Q3 results later in the call.
We have incredible teams at ATI that are making a difference in the lives of our patients in our communities every day. Today starts our ATI Employee Appreciation Week. I want to thank our talented and dedicated clinicians and leaders that emotionally invest and are passionate about enriching the lives of our colleagues, patients, and communities. You are what fuels ATI and makes us special.
With that, I'll turn the call over to Eimile for a discussion of our people and performance during the quarter.

Eimile Tansey

Thanks, Sharon. I'd like to share what we're seeing in the current labor market and review the traction we've gained from our initiatives to hire and retain skilled providers and our programs to develop future leaders in the industry. The current labor market remains challenging, and we anticipate the headwinds we are facing to continue for some time.
While each local market has its unique nuances, the national imbalance between the supply of physical therapists and the demand for PT services will take several years to reach equilibrium. However, we've made good progress year to date with growing the clinical team, and I'm confident that we can continue to grow by working on the things we can control, specifically staying on top of the market trends, listening to our employees, and cultivating our culture.
Last year, I discussed that I would be focused on increasing clinical candidates at the top of the funnel and on developing programs that would further advance ATI as an outstanding place for providers to start, build, and accelerate their careers.
This year, we are beginning to witness returns from these programs as we continue to forge a culture characterized by high level provider experience, clinical excellence, and outstanding customer service. This is reflected in the results of this year's employee engagement survey, where we received positive feedback, most notably around rewarding roles, respectful direct leaders, and an inclusive culture. We also identified areas of opportunity and are motivated to take the valuable feedback to continue improving our employees' experience and make ATI the employer of choice.
As a result of the work we are doing around our people strategy, we have seen significant growth in our provider base. In the third quarter, as Sharon mentioned, clinician headcount grew 5% sequentially quarter over quarter. Furthermore, our retention metric has remained at pre-COVID levels now for two consecutive quarters. These improvements are evidence that we are doing the right things for our providers and our patients, enabling us to achieve our mission and expanding patient access to high-quality care.
I wanted to thank the entire HR team for all the hard work this year to get us to where we are now. We have many opportunities in front of us and have a focus on making sure we implement improvements and refinements that allow our providers to operate at the top of their license.
I'm proud of ATI's outstanding brand, an amazing culture, and the progress we have made this year to further augment that culture. ATI is defined by our people, and I'm excited to continue the work we are doing to ensure ATI remains a great place to learn and grow.
Now, I'd like to turn it over to Joe for a financial review.

Joe Jordan

Thank you, Eimile, and thank you to everyone for joining the call. I will cover our third quarter financial results, and I'll start out with net revenue, which was $177 million for the quarter. That's a 13% increase over the prior year, which reported net revenue of $157 million. And if we break that down a little bit further, net patient revenue was $162 million, which increased 14% year over year. And other revenue was $15 million, which is a 5% increase over the prior year.
As Sharon mentioned earlier, visits per day per clinic were up during the quarter at 25.9, and that's an increase of 0.2 versus the second quarter of 2023. And if we compare to the third quarter of the prior year, we increased our visits per day per clinic by 2.7. Now, these improvements in the visits per day per clinic metric reflect our continued efforts to fully utilize our clinics and ultimately, to optimize profit through leveraging our fixed costs.
Our rate per visit during the quarter, as Sharon said, was $109.90, which sequentially increased from $104.74 in the second quarter of 2023, which is about 4.9%, and from $103.46 or 6.2% from the third quarter of the prior year.
And then focus on the sequential increase, the primary drivers were improvement in contracted rates, both new and existing contracts, and process improvements within the revenue cycle management function, which drove higher rate realization. A portion of which is related to prior claims, but as Sharon talked about earlier, portion that will continue into the fourth quarter and really beyond into next year.
Salaries and related costs in the third quarter of 2023 was $97 million, which is a 7.5% increase over $90 million in the third quarter of the prior year. And the primary driver there is more clinicians and increased support staff supporting the higher revenue, and then a little bit of wage inflation and higher incentive payments as well.
Our PT salaries and related cost per visit during the quarter were $57.47, which sequentially increased from $54.81 in the second quarter of 2023, about 4.8%, and from $56.20 or 2.3% from the third quarter of the prior year. The quarter over quarter increase was primarily due to lower labor productivity with visits per day per clinical FTE declining by 0.2. But that's driven by seasonality when you move from Q2 to Q3, as well as onboarding new providers, and Eimile talked about all the new providers that were added in the third quarter.
When looking at year over year, the increase was primarily due to increased support staff and higher compensation per clinical FTE, which is partially offset by higher labor productivity when looking year over year of 0.6.
Rent, clinic supplies, contract labor and other was $53 million or a 2.5% increase year over year from $51 million in Q3 of the prior year, and it's driven by increased spend on contract labor and outside services. And on a per clinic basis, these costs were approximately $57,000, which increased from $54,000 in both the second quarter of 2023 as well as the third quarter of 2022.
Our provision for doubtful accounts for the quarter was $3 million, which is 2.1% of net patient revenue, compared to the third quarter prior year of $3 million and 2% of net patient revenue.
And then SG&A during the quarter was approximately $25 million, which is essentially flat with the prior year. Our operating loss excluding impairment charges was $1 million, which improved year over year from $13 million loss in the prior year, reflecting the higher revenue generated in the current year.
Interest expense during the quarter was $15 million compared to $12 million in the third quarter of 2022 with the increase primarily driven by a higher interest rate environment and a lower hedge benefit. Income tax expense for the quarter was $100,000, compared to an income tax benefit of $7 million in the third quarter of the prior year. And net loss was $15 million, compared to $117 million in the third quarter of the prior year, which included $107 million in goodwill impairment charges in the prior year.
Adjusted EBITDA during the third quarter was $9 million, and that's a 5.3% margin. It increased over the prior year when we had an adjusted EBITDA loss in the third quarter of $400,000. The year-over-year increase in adjusted EBITDA was primarily driven by higher revenue and the associated earnings that come along with that higher revenue.
We're pleased with the progress that we made during the third quarter due to the hard work of our dedicated team. And with the momentum that we carried into the third quarter and through the third quarter and really even into the beginning of the fourth quarter, we remain confident with our adjusted EBITDA guidance and project to hit the high end of the guidance for revenue, which, as a reminder, was $680 million to $695 million, and the high end of the guidance of adjusted EBITDA, which was $30 million to $36 million range.
Our cash flow use year to date was $63 million with $18 million used to fund operations, $15 million used to fund investing activities, and $31 million used to fund financing activities. (technical difficulty) [An important to note] as part of the financing activities was $25 million in repayments on the revolving line of credit.
And then as of September 30, 2023, our liquidity is approximately $40 million, and that $40 million consists of cash and cash equivalents of $20 million and available revolver capacity of $20 million. In addition to the $40 million of liquidity, we do have access to $25 million in a delayed draw term loan subject to certain restrictions.
That wraps up the financial update. And now, I'd like to turn the call back over to Sharon for closing remarks.

Sharon Vitti

Thanks, Joe. Thanks, Eimile, and Joanne, and everyone participating. We have momentum and are poised to lead in the musculoskeletal landscape. We've clearly demonstrated momentum year to date in 2023. We have the right team in place to deliver results and generate value for our patients, employees, communities, and shareholders.
We have a positive trajectory that should deliver significant growth in 2024. I remain excited for the opportunities ahead and look forward to sharing more about our growth expectations on our year-end call.

Question and Answer Session

Operator

Thank you again for joining. We'll now open the line for Q&A. (Operator Instructions) Brian Tanquilut, Jefferies.

Brian Tanquilut

Congrats on the quarter. I guess, Sharon, my first question is, as we think about year-to-date openings and closings, just as we net that out, looking into 2024, how should investors be thinking about the footprint and how that affects the revenue base for next year?

Sharon Vitti

Thanks, Brian. So a few, things, I did mention -- I think there are two ways to look at it. So one is, there's the expansion of the footprint, and it's a little too early for us to say what we're going to do in 2024 around the expansion of footprint only because there's a lot of moving pieces. So I would say, that's one piece.
But I'd say the other is, we are looking at other opportunities to grow top line beyond the expansion of footprint. So as I see this, it's a combination of the two that is going to get us the top line. And I think we've got to look at this as a multiyear journey.
'24 is almost upon us and we will -- we have some de novos in the pipeline and we're looking at should we increase that number. But I would say, the other piece is around growth and working with different new channels for referrals, et cetera. It's also going to be impactful in our '24, '25 growth of top line.

Joe Jordan

And then Brian, it's Joe. Maybe just to add to that, as Sharon said, we'll talk more about 2024 when we do our year end. But even if we're closing a handful of clinics to optimize our fleet, we're still looking at adding clinicians.
And so I think, on an overall basis, we expect momentum that we carried through the third quarter and expect to carry into the fourth quarter will continue into 2025, where, on an overall basis, we're looking to drive improvements in revenue, not a decline in revenue even if there is a minor negative impact to the fleet, which, we'll talk more about that as we get into the guidance for next year.

Sharon Vitti

I mean we need both.

Brian Tanquilut

Okay. That's helpful.

Sharon Vitti

Yeah, we need both, Brian, but I do think we have opportunities right in front of us that we're harvesting right now that don't require the heavy lift of a footprint expansion.

Brian Tanquilut

No, that makes a lot of sense. Joe, revenue per visit, just -- I know there's a one-timer there, but how should we be thinking about the growth rate given the contracts that you guys are signing right now on that rev per visit KPI going forward?

Joe Jordan

Yeah. And really -- absolutely. And really, like I said and like Sharon said, Brian, there's two components. It's new and existing contracts and getting some improvements in rates with those contracts. But some of the improvements in RCM that we've seen go back to prior claims. But certainly, a lot of the changes also impacted the current Q3 claims, and we'd expect those impacts to carry forward into future quarters.
So we're pleased with not only the payer contracting rate improvements that we've seen, but also the improvements in RCM which will allow us to realize higher revenue rates moving forward.
As far as breaking out the onetime piece versus the recurring, I'd say, roughly 30% to 40% of what we saw in Q3 relative to Q2, that improvement carries forward. So that puts us somewhere in the, call it, mid-106s. Obviously, when you're bifurcating, now, one-time versus recurring, it's not going to be 100% precise, but I think that's a good spot to anchor to.
But probably important to note that we'll continue to focus on driving improvements in RCM, we'll continue to focus on driving improvements in payer contracting, and so the goal would be not to stop at those mid-106s to see where we can get to beyond that.

Brian Tanquilut

All right. Last question for me, Joe. As I think about interest expense, $15.5 million here, is that sort of the right baseline we should be thinking about that? And then maybe just looking at the cash flow as well, obviously, there's cash burn during the quarter. So splitting those together, how should we be thinking about cash generation and then what your interest coverage looks like going forward?

Joe Jordan

Yes, the cash -- and just, I'm going to break out interest expense from cash interest because I'm guessing you care a little bit more about cash interest piece of that. The cash interest, probably somewhere around $14 million a quarter in cash interest based on the debt structure, assuming the current interest rate environment and other recent improvements in the interest rate environment which could drive it down because our interest does have a variable component to it.
But I think $14 million is a good place to earmark it. And so to your point, that's $56 million of cash interest. So we will be a user of cash in 2023, although we think Q4 will be generating single digit millions of cash in 2024. We'll come out and talk more about that, obviously, when we're in 2024. But you could do the math on the cash interest plus some amount of CapEx and realize that to be cash flow positive. It's probably somewhere in the $70 million-plus of adjusted EBITDA range.
And we like the momentum that we've been able to gain throughout 2023 and through Q3. And as I mentioned, we think we'll continue to gain momentum in 2024. I don't foresee being cash flow positive in 2024 yet, but it's an important step towards cash flow positive. And with the $40 million of liquidity and the availability that we have on the delayed draw term loan, I think we feel that it gives us the runway to continue to grow into our capital structure.

Operator

(Operator Instructions) All right. And there are no further questions at this time, I'd like to turn the call back over to Sharon Vitti for any additional or closing remarks.

Sharon Vitti

This ends the Q&A portion of our call. Thank you to our investors, analysts, and all the ATI team members for joining the ATI Q3 quarterly earnings call, and we will look forward to seeing you in the New Year. Thank you.

Operator

Thank you. And that does conclude today's presentation. Thank you for your participation. You may now disconnect.