Acadia Healthcare Company - Earnings Call - Q1 2025

Executive Summary

• Q1 2025 revenue was $770.5M and adjusted EPS $0.40, landing at the high end of EBITDA guidance ($134.2M) while reaffirming full-year 2025 ranges; same-facility patient days grew 2.2% YoY despite a 1.1% leap-year headwind.
• Versus S&P Global consensus, revenue modestly beat ($770.5M vs $769.8M*) and adjusted EPS beat ($0.40 vs $0.36*); adjusted EBITDA was within/above consensus depending on definition (Street EBITDA $132.1M* vs reported adjusted EBITDA $134.2M; Street “EBITDA actual” shows $125.5M*, reflecting definitional differences). Values retrieved from S&P Global.
• Management highlighted start-up losses and underperforming facilities as planned headwinds (approx. $5M EBITDA impact from a Q1 facility closure; $20M FY headwind from certain facilities; $50–$55M FY start-up losses), but maintained bed expansion targets of 800–1,000 additions for 2025 and affirmed guidance.
• Liquidity remained strong (cash $91.2M; $901.6M availability under a $1B revolver), plus execution of the $300M buyback program (1.6M shares, $47.3M) and new $550M 7.375% senior notes to term-out revolver—key capital allocation signals.
• Catalysts to watch: timing and magnitude of supplemental Medicaid payments (TN-directed payments), ramp of new facilities (start-up losses abate), and resolution of regulatory/legal scrutiny; all cited by management as potential swing factors for cadence and investor sentiment.

What Went Well and What Went Wrong

What Went Well

• Adjusted EBITDA at the high end: $134.2M on revenue of $770.5M; management said results landed “in line” with ranges and EBITDA at high-end for Q1.
• Volume resilience despite headwinds: same-facility patient days +2.2% YoY with leap-year drag (≈110 bps); admissions +2.1% YoY; total facility patient days +0.8%.
• Clear strategic execution: 378 newly licensed beds added (90 at existing, 288 new), plus seven new CTCs; two new facilities opened (North Port, FL and JV with Henry Ford Health in West Bloomfield, MI).
• Quote: “This year is setting up to be the largest bed expansion year in Acadia’s history…” — CEO Chris Hunter.

What Went Wrong

• Margin mix and start-up drag: adjusted EBITDA margin ~17.4%; start-up losses were higher YoY and sequentially given the step-up in newly constructed facilities (Q1 start-up losses ≈$16M, better than plan but still elevated).
• Same-facility adjusted EBITDA down YoY (-9.0%); total facility adjusted EBITDA down 18.3% YoY amid transaction/legal costs, legal settlements, and a closed facility impact.
• Specialty revenue softness: management cited multiple facility closures driving ~5% decline in specialty revenue; underperforming facilities continued to weigh on volumes (~90 bps impact in Q1).

Transcript

Operator (participant)

After today's presentation, there will be an opportunity to ask questions. To ask a question, you may press star, then ons on your telephone keypad. To withdraw your question, please press Star, then two. On today's call, we ask that you please limit yourself to one question and one follow-up during Q&A. Also, please be aware that today's call is being recorded. I would now like to turn the call over to Brian Farley, General Counsel. Please go ahead.

Brian Farley (General Counsel)

Thank you, and good morning. Yesterday, after the market closed, we issued a press release announcing our first quarter 2025 financial results. This press release can be found in the Investor Relations section of the acadiahealthcare.com website. Here with me today to discuss the results are Chris Hunter, Chief Executive Officer, and Heather Dixon, Chief Financial Officer. To the extent any Non-GAAP financial measure is discussed in today's call, you will find in the press release that is posted on our website a reconciliation of that measure to the most directly comparable financial measure calculated according to GAAP. This conference call may contain forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995, including statements, among others, regarding Acadia's expected quarterly and annual financial performance for 2025 and beyond.

These statements may be affected by the important factors, among others, set forth in Acadia's filings with the Securities and Exchange Commission and in the company's first quarter news release, and consequently, actual operations and results may differ materially from the results discussed in the forward-looking statements. At this time, I would like to turn the conference call over to Chris.

Chris Hunter (CEO)

Thank you, Brian, and good morning, everyone. Thank you for being with us for Acadia's first quarter 2025 conference call. We are pleased with our start to 2025, with both first quarter revenue and EBITDA landing in line with our expectations while we made continued progress against our strategic growth initiatives. First quarter revenue of $770.5 million came in just above the midpoint of our outlook range of $765 million-$775 million, while adjusted EBITDA of $134.2 million was near the high end of our outlook range of $130 million-$135 million. We also reaffirmed our previously issued full-year financial guidance ranges for both revenue and adjusted EBITDA, which Heather will provide further detail on later in the call. Moving to volumes, same-facility patient days grew 2.2% in the first quarter, which included an unfavorable leap year impact of roughly 110 basis points over the first quarter of 2024.

The strong relationships we've built with our referral sources and our 21 joint venture partners continue to be an important part of our strategy for success. Acadia continues to be the preferred partner for leading health systems with both local and national brand recognition across the country to better serve patients by bridging the gap between physical and behavioral healthcare. Along those lines, I'd like to provide a progress update on our strategic initiatives. In the first quarter, we added 378 new beds, comprised of 90 beds to existing facilities and 288 beds from two new facilities that were opened in the quarter, which includes a joint venture hospital in partnership with Henry Ford Health in West Bloomfield, Michigan, and a De Novo facility in Northport, Florida. In addition, Acadia added seven new comprehensive treatment centers in the first quarter, extending the company's market reach to 170 CTCs across 33 states.

For the full year 2025, we expect to add between 800 and 1,000 total beds. Looking forward, we have a solid pipeline of potential opportunities in attractive markets and expect to add between 600 and 800 beds annually over 2026 to 2028. Before I turn the call over to Heather, I would like to spend a few minutes discussing the numerous efforts this company continues undertaking to support our quality initiatives and share a few thoughts on the policy landscape. At Acadia, our commitment to quality and safety is a foundational element of our strategy. Our facilities are licensed, accredited, and regularly inspected to uphold high regulatory and quality standards, including rigorous requirements for employee training and patient safety. We employ a multi-layered approach to patient protection that often exceeds industry and regulatory standards.

These measures, such as 24/7 patient monitoring systems, mandatory de-escalation training, and regular safety rounds, are designed to meet the specific needs of the patients and staff at each Acadia facility. Our ability to use data has continued to advance significantly. Our hospital CEOs and leadership teams also use a variety of sophisticated cloud-based systems with deep data capabilities to monitor care quality. Further, our integrated quality dashboard now provides real-time visibility into over 50 distinct safety, patient experience, and regulatory compliance-related key performance indicators. At the corporate level, our team supports this work with weekly, monthly, and quarterly operational and quality performance reviews. We believe the supportive multidisciplinary relationship between the field and the corporate teams ensures we find and eliminate sources of operational and clinical variation and helps us translate behavioral science to practice with consistency.

Behavioral health is complex, but it is clear the need has never been greater for high-quality behavioral healthcare given the severe mental health crisis that our nation faces. Our strategy at Acadia remains centered on high-quality care and clinical health outcomes, and we will continue to prioritize our quality initiatives and expand them when necessary. Turning to labor, we believe our differentiated quality initiatives are having a positive impact on our ability to recruit and retain our staff. These efforts are directly connected to our emphasis on employee engagement and talent acquisition, ensuring we have appropriately staffed facilities with trained employees, which have improved underlying labor trends for our company. This is further reinforced by our premium pay, which declined on both a sequential and year-over-year basis in the first quarter.

We are extremely proud of the commitment of Acadia's nearly 26,000 employees that have chosen to join our mission to provide compassionate care that improves the lives of patients and their families. Now, I would like to briefly touch on the policy landscape. First, let me say that we believe government policy has an important role to play in continuing to strengthen the behavioral healthcare system, and we remain highly engaged on the policy front so that we can continue advocating strongly on behalf of patients in need. While the situation in Washington is fluid, we believe that the essential care we provide to underserved and vulnerable patient populations will continue to be recognized and supported.

To cite one example, supplemental payment programs have been a key enabling force behind not only our ability to serve high-acuity behavioral health patients, but also patients in many other essential parts of the healthcare system, including rural hospitals, children's hospitals, and nursing homes. With this in mind, we expect these programs to remain an important funding mechanism for Medicaid populations. We remain focused on providing programs and facilities that provide these patients with the best possible care and will provide updates to the investment community as we receive clarity on any potential policy-related impacts to our business. With that, I would now like to turn the call over to Heather to discuss our financial results for the quarter.

Heather Dixon (CFO)

Thanks, Chris, and good morning, everyone. Our first quarter financial performance for both revenue and adjusted EBITDA fell within our guidance ranges, with adjusted EBITDA performing at the high end of the range. We reported $770.5 million in revenue for the quarter, representing a slight increase over the first quarter of last year. Recall, we had expected Medicaid supplemental payments to be down $10 million-$15 million year-over-year in Q1, and these came in near the midpoint of that range. Same-facility revenue grew 2.1% compared with the first quarter of 2024, driven by patient day growth of 2.2%. As Chris mentioned, both same-facility revenue and patient day growth included an unfavorable impact of approximately 110 basis points from the leap year. Q1 same-facility revenue per patient day growth was roughly flat on a year-on-year basis, primarily due to the timing of supplemental payments.

Adjusted EBITDA for the first quarter of 2025 was $134.2 million, reflecting an adjusted EBITDA margin of 17.4%. As reflected in our prior guidance, these quarterly results included an approximate $5 million year-on-year EBITDA impact due to the decision to close the facility in the first quarter as a part of our ongoing portfolio management efforts. Also included in our results were startup losses related to new facilities, which were higher on both a year-over-year basis and a sequential basis, reflecting a step up in the number of newly constructed facilities. On a same-facility basis, adjusted EBITDA was $191.6 million, and adjusted EBITDA margin was 25.2% in the first quarter of this year. Our same-facility results continued to be affected by a small group of underperforming facilities that you will recall started to have a material impact on our results near the end of the third quarter of 2024.

To date, these facilities have performed in line with our expectations. While we continue to work diligently to improve performance of these facilities, we acknowledge that it will take time, and our 2025 guidance continues to reflect no material improvement at these underperforming facilities as we move throughout the year. We continue to maintain a strong financial position, providing us the ability to make the right strategic investments to enhance our operations and support our growth strategy. As of March 31st, 2025, we had $91.2 million in cash and cash equivalents and approximately $900 million under our $1 billion revolving credit facility, with a net leverage ratio of approximately 3.2x. The company repurchased approximately $1.6 million shares during the first quarter for a total of $47.3 million.

Moving on to our outlook for 2025, as noted in our press release, we are reaffirming our full-year guidance ranges for revenue, adjusted EBITDA, and adjusted earnings per share. As a reminder, our 2025 guidance includes the following considerations. For 2025, we expect to add between 800 and 1,000 total beds. As I just mentioned, we expected that a small subset of underperforming facilities would result in an approximate $20 million year-over-year headwind to our 2025 adjusted EBITDA. As I mentioned, to date, these facilities have performed in line with our expectations and negatively impacted our same-facility patient day growth by approximately 90 basis points in the first quarter. We expect to begin to comp over this headwind to volumes in the fourth quarter of 2025.

We continue to expect Medicaid supplemental payments to be flat to up $15 million in 2025 on a net basis, inclusive of the new Tennessee programs once approved. We continue to expect $50 million-$55 million in startup losses for full year 2025, of which we anticipate approximately $15 million in the second quarter. Before we move to Q&A, I would like to offer some additional color on our bed additions and growth plan. Since last quarter, some of you have asked us questions about our long-term EBITDA growth guidance, so we want to take a moment to clarify some of the assumptions that are contemplated in that guidance range.

The previously announced expected revenue growth of 7%-9% and EBITDA growth of 8%-10% over 2026-2028 is underpinned by annual bed additions of 600-800 beds beginning in 2026, as well as the roughly 1,600-1,800 beds being added over 2024 and 2025. First, we want to highlight that most of these bed additions come in the form of brand new facilities, which on average typically ramp to run rate occupancy and EBITDA margin within a five-year period. As a result, we expect to recognize incremental EBITDA for a majority of this cohort beyond 2028, as these beds continue to ramp to mature occupancy and margin levels.

Keep in mind our three-year outlook also contemplates the inherent uncertainty that always exists with regards to construction timing, licensing timing, and time to ramp, and we will remain cognizant of this uncertainty as we continue to execute on the largest expansion of bed capacity in our company's history over the next several years. Accordingly, our three-year outlook assumes that the occupancy and EBITDA ramp for new hospitals will trend towards a five-year ramp period, which is at the upper end of our historical ramp model and leaves a significant amount of inherent earnings power beyond 2028. Second, with regards to payer rates, we included an element of conservatism in our assumptions as it relates to revenue per patient day and rate growth, given some of the uncertainty surrounding the policy and macro environment.

We see embedded upside in these projections if the next few years' updates from government and commercial payers more closely resemble that of the last few years versus what is currently contemplated in our three-year outlook. This base of new behavioral health hospitals we are currently building will provide a multi-year runway for growth, not only as occupancy ramps over the next few years, but also as we're able to add expansion beds to these facilities over time. As we decrease the accelerated pace of bed additions in 2026 to a rate of 600-800 per year, we expect startup losses to ease in the back half of 2026, helping to fuel strong and self-sustaining free cash flow generation as we exit 2026.

Note this bed growth is still well above the historical pace prior to 2024, which will contribute meaningfully to our performance in the outer years, including in 2028 and beyond. With that, we're ready to open the call for questions.

Operator (participant)

We will now begin the question and answer session. To ask a question, you may press star, then one on your telephone keypad. If you're using a speakerphone, please pick up your handset before pressing the keys. To withdraw a question, you may press star, then two. We ask that you please limit yourself to one question and one follow-up. At this time, we will pause just momentarily to assemble our roster. Our first question here will come from A.J. Rice with UBS. Please go ahead.

A.J. Rice (Managing Director of Equity Research)

Hi, everybody. Just maybe first, there are a lot of moving parts in this year's numbers. I know you got the timing on different supplemental payment programs. You got the pacing of startup losses on the bed additions, and then the annualizing of the Q4 challenges from last year start to make the comps easier later in the year. Can you just give us some perspective on how you see the progression of EBITDA from here, maybe a little bit of more color on how to think about the seasonality of the business this year, given some of those dynamics?

Heather Dixon (CFO)

Yeah, sure. Hi, A.J. Good morning. Thanks for the question. I'll just kind of walk through a little bit of the phasing. If we think about Q1 versus the rest of the year, you're right, there are several moving parts, and we had talked about a few things that will specifically impact Q1 a little bit more predominantly. To defactor those in or normalize them, then you can see the normal cadence that we would expect. The first thing I would say is nothing's changed since we talked last time and where we set our guidance and all of the multiple factors we went through.

I think the most obvious piece is that from a timing perspective, the Tennessee DPP is clearly going to be the biggest swing factor, thinking about the cadence throughout the balance of the year, A.J., as we look at it, depending on which quarter that will be recorded in. I mean, beyond that, there's just a couple of other things that I would talk about that would really lead to the improved EBITDA performance as we move throughout the year. I mean, first, Q1 had the highest level of startup costs and the lowest contribution from the new beds just because of the timing of when we added them. That alone implies a steeper ramp as we work our way through the year. As we assumed in our guidance, supplemental payments were down year-over-year in Q1.

We had said those would be down $10 million-$15 million, and we landed sort of right in the middle of that for Q1. We expect that those supplemental payments will actually be flat to up $15 million on a net basis for the full year. That is a pretty big swing between Q1 and the balance of the year. As I mentioned, obviously, Tennessee is the largest piece of that. If I just think about the other swing factors from a volume perspective, we will have a growing contribution from the new beds as we move throughout the year. We are also going to comp over a headwind that we started to see from some of those underperforming facilities as we move into the fourth quarter of the year. That is another piece as you think about comping last year's fourth quarter.

Maybe just one more thing to point out is rates. Again, the timing of the supplemental payments and Medicaid mix shift in the specialty business were impacting Q1, and those should start to moderate as we head into Q2 and then further on throughout the year. That means that low single-digit rate growth for the full year really moves throughout the year, and it is there where we expect it to be for the full year versus where it was for Q1, where it was slightly down. I think that covers the highlights, the big points. Again, I pointed out a lot of different moving parts for the full year guide for EBITDA on the year-end call, but I think those are the highlights, and hopefully that helps.

A.J. Rice (Managing Director of Equity Research)

Yeah, no, that's very helpful. Maybe just my follow-up question is, I know you've got a cautious view on rates this year, but technically, what are you actually seeing in your Medicaid rate updates? I assume a lot of states updated January 1, and you'll have some more update July 1. You probably also got your Medicare rate update, which we pretty much know, but if there's any variance there for you specifically, and then any comment on commercial and what you're seeing there.

Chris Hunter (CEO)

A.J., this is Chris. I'll go ahead and take that one. I would just say overall that we continue to have very good discussions with our payer partners, and we remain very optimistic that they're going to continue to recognize our focus on providing high-quality care. I wouldn't call anything out with respect to Medicaid versus commercial or Medicare. Our outlook, as Heather has discussed, always assumed a low single-digit, same-facility revenue per day growth. Historically, we've talked about that in kind of a low to mid-single-digit range. We decided, just given the noise on the policy front, that it was prudent to just incorporate a more conservative approach in our thinking about rates, just given the broader environment.

There is nothing specific on the horizon that we see as concerning, and I would say underlying rate growth has been relatively stable and in line with our expectation as we have gotten into the year.

A.J. Rice (Managing Director of Equity Research)

Okay. Thanks a lot.

Operator (participant)

Our next question will come from Brian Tanquilut with Jefferies. Please go ahead.

Brian Tanquilut (Senior Equity Research Analyst of Healthcare Services and Healthcare Information Technology)

Hey, good morning, guys. Chris, maybe take a step back. As I think about, obviously, 2% same-store volume performance in the quarter, despite some of the headwinds you're facing with the units that are dealing with the headlines, how are you thinking about what the broader demand environment looks like right now? I mean, obviously, you're one of our data points and you're a peer that's public. Outside of that, if you can share with us what the demand environment looks like for behavioral health today.

Chris Hunter (CEO)

Yeah, I would say, Brian, thanks for the question, that our expectation is that it just continues to be consistent with what we're seeing. I mean, I think, particularly given our strategy of focusing on the higher acuity patients, when you look across our various lines of business, whether it's on the acute front, CTC, specialty, RTC, we just continue to see increasing demand. I think we've done a very good job of pointing out our commitment to quality. We have obviously invested heavily in being able to quantify outcomes, and we've shared that with our payer partners. I think all of that has led to a consistent demand environment. I mean, Heather, anything that you would want to add?

Heather Dixon (CFO)

No, I think that's right. I think the demand environment remains, and we are doing our part to meet that demand. We're working hard to look at new facilities and bed additions where those are necessary. Nothing to add there.

Brian Tanquilut (Senior Equity Research Analyst of Healthcare Services and Healthcare Information Technology)

I appreciate that. Maybe, Heather, thank you for all the color on the five-year ramp to maturity. Just curious, as you think about the cohort of beds added in 2024 and 2025, maybe even into 2026, has your view on the path to break even changed, or is it still the same kind of laying out that five-year kind of ramp up to kind of mature levels of margins and occupancy?

Heather Dixon (CFO)

Yeah, thanks for the question. Our view has not changed. Let me just walk through a little bit of how we're thinking about it and specifically how we thought about it whenever we thought about the long-term guide, the three-year guide that we put out. I mean, first of all, you mentioned the three to five-year ramp period that we've experienced historically. That's our average. Now, keep in mind, there's multiple factors that impact how those ramp, and we've seen some really good success in recent facilities as they've been ramping. One of the factors that impacts it pretty significantly is whether it's a bed addition to an existing facility or whether it's a newly constructed bed. Obviously, those take much longer to ramp.

In our longer-term guide, we have assumed a higher mix of new facilities constructed and new beds from construction than what has historically over the last few years been contemplated and what's actually played out. That shifts a bit towards the higher end between the 3-5 range. Those obviously will be at the higher end of that range versus others. That is part of it. What that means actually is that there is incremental EBITDA that is beyond 2028 because those beds, you just mentioned the years that are ramping, all of those would continue to be ramping and really hitting their stride in what we have modeled out post-2028. There are a couple of other things that I would think about. There is always uncertainty with construction timing, and that is not just construction, construction licensing timing, how long does it take to ramp, all of those different things.

We are just very cognizant of all of that uncertainty. As we are executing and continuing to execute on what is clearly the largest expansion that the company has had, we have been in that position for the past several years, and we are going to continue. We are just very cognizant of that, and we want to make sure that we factor that uncertainty appropriately into the guide. If I think about how far our outlook goes, we think about four years from now effectively will be when that outlook, when those things are actually happening. That means the EBITDA growth that is included in sort of the longer tail of that 2028. We have not even started construction on those beds yet, so we feel like it is more prudent to just assume the higher end of the ramp range between that three- to five-year period just because it is further out into the future.

I talked about on the prior call that that's some conservatism that's built in. Hopefully, that helps you understand a little bit of what we're thinking about with conservatism whenever I say that. I mean, again, what that points to is that the occupancy and the EBITDA ramp for those hospitals, there will be certainly incremental amounts of inherent earnings that are, again, showing up beyond 2028 there. All that said, we are still experiencing strong performance. I just mentioned that we had some in our recent cohorts, 2023 cohort specifically that we're watching because of where it is now and sort of the ramp. We're seeing some really good outcomes and results, but we just thought it was more prudent for the reasons I just walked to, to assume sort of the higher end of that ramp period.

That was a long-winded answer to your question, but back to your original point, our view hasn't shifted. We've just factored in some conservatism, and hopefully, that helps you understand why and how we factored it in.

Brian Tanquilut (Senior Equity Research Analyst of Healthcare Services and Healthcare Information Technology)

No, very helpful. Thank you.

Operator (participant)

Our next question will come from Whit Mayo with Leerink Partners. Please go ahead.

Whit Mayo (Senior Managing Director and Senior Research Analyst of Healthcare Providers and Managed Care)

Hey, thanks. When you just look at the first quarter and your performance, was there anything better or worse in the quarter versus your original expectations? Just wondering if there was any favorability on any of the key assumptions or expense items. Thanks.

Heather Dixon (CFO)

Yeah, hi Whit. Sure. I'll talk about two things. I mean, the first thing I would talk about is labor. We saw the continuation of those favorable labor trends that we have been seeing, and our base wage inflation continued to trend lower. Contract and premium labor expenses both fell year-over-year and sequentially. That's the first thing that I would point to. The second thing I would point to are startup losses. Those came in a couple of million dollars better than our expectations for the first quarter. That's just timing. That's just all the things I just marked through in regards to construction and some of the uncertainty. That's just some timing differential. We still expect that those will continue to be in the range of $50 million-$55 million for the full year, just to be clear.

They were around $16 million in Q1, and that's a little lower than what our expectations were. But that's really, I think, the only two things that I would point out from a quarterly perspective.

Whit Mayo (Senior Managing Director and Senior Research Analyst of Healthcare Providers and Managed Care)

Okay. So a couple of million dollars of favorability on the expense side, and you were still within the range that you targeted. I mean, is that the way that you're looking at the performance? I'm just trying to figure out how you perform versus the internal plan versus the guidance that you provided.

Heather Dixon (CFO)

Yeah. I mean, we were up towards the higher end of our guide, Whit, and that is very the things I just walked through, I think specifically the startup losses, those were what contributed us being at the high end of the guide, but we were performing right in line with our internal plan.

Whit Mayo (Senior Managing Director and Senior Research Analyst of Healthcare Providers and Managed Care)

Okay. I know this isn't a metric that you talk about, but when I look at the revenue per average CTC, it's been declining for several quarters now. And just trying to maybe better understand why that metric would look like that.

Heather Dixon (CFO)

I'll start, and Chris, you may want to jump in, but from a revenue perspective for CTC, I mean, as you know, the CTC business has experienced just significant growth. I'm very, very pleased with the growth over the past few years. There was a lot that we could do to apply some muscle behind it and really get the most out of that business. The other thing that I would point out is if you look at the CTC business, we have found a very capital-friendly way to add facilities to the lineup, and those are effectively acquiring subscale sort of ramping CTC facilities that we can buy for a very good price. Then we can put those in, put those in, apply the Acadia methodology for running the operations, and really ramp those pretty quickly.

As we add those in, and they are similarly in the ramp position, you'll see that those will kind of pull down the average overall as we're ramping them. In the first quarter, we opened three new CTCs, and then we acquired an additional four, excuse me, that would fall into that category that I just mentioned. When you think about that, that really is part of the timing of what you're seeing impact the revenue for clinic. I think just generally speaking, the revenue can clearly vary based on the size of the clinic, maturity, all those things. I think what you're seeing, Whit, and to your question, is those different nuances I just walked through.

Chris Hunter (CEO)

Yeah. I would just add one thing, Heather, and I think that's that so frequently the CTC market continues to be highly fragmented. As a result, when we do find these subscale acquisition opportunities that we can tuck in, they have frequently underinvested across the board, and they very frequently have a limited digital presence, frequently do not even have a website, and they certainly have not invested in the capabilities that we're able to bring in. All of that enables us to buy these subscale assets and ramp them more quickly. I think that ties into your question in terms of the revenue per average CTC.

Whit Mayo (Senior Managing Director and Senior Research Analyst of Healthcare Providers and Managed Care)

Okay. Thanks.

Operator (participant)

Our next question will come from John Ransom with Raymond James. Please go ahead.

John Ransom (Managing Director of Healthcare Research)

Hey, good morning. I'm just wondering on the new facilities, not the bed adds, but the new facilities, what sort of return target do you look at once the facility is fully ramped? Maybe it'd be helpful to kind of put that as an EBITDA as a numerator and total investment as a denominator. Kind of as a core layer, are you sharpening your pencil on new opportunities to try to drive higher returns, or are you still kind of sticking with the historical? Thanks.

Heather Dixon (CFO)

Hi, John. Thanks for the question. If I think about just in general, the first part of your question, what do we do? We look at typically a couple of things. First, as you can imagine, we look at our cost of capital, and we make sure that we understand all the moving parts. We also then ensure that we are applying sort of a margin or a cushion on top of that to make sure that we have returns that are well above that cost of capital. One of the primary measures, obviously, that we use is return on invested capital. We typically look at that on a very detailed basis for every project consistently, whether it's a De Novo, a bed addition, an M&A, a potential transaction, etc.

We look at all those in the same way and just sort of apply a very disciplined approach across the board from a capital perspective. That is certainly something that we look at. To the second part of your question, what are we doing now? I think you asked for rethinking what we have done. I'll give a little bit of detail on the process. First, we have multiple check-in points as we go throughout any project. As you can imagine, it's quite a large undertaking to make sure that we have all of the right pieces in place before we move forward with the decision. We check in multiple times before we ultimately move forward as we gather more information. Those checkpoints have always been there. Very disciplined approach we have. Second, we've gone through a couple of pieces.

First, everything that we had currently had in our pipeline, we've gone back and we have made sure that when we rerun sensitivities and we look at any perspectives that we think we need to have a different lens on, that those still meet the thresholds that we originally set out to meet whenever we think about capital deployment and ensure that those are still sort of all viable projects that we would like to do. Fortunately, we have a lot of different opportunities to deploy capital. If we find something that no longer meets what we think we should have as a required return, then we can move to the next thing.

Maybe the other thing that I would point out is for future projects, we have obviously incorporated some sensitivity analysis both on a rate and a construction cost side so that we can ensure we have a flexible view and we can sensitize those and ensure that we have the right perspective as we move forward. Maybe if I just sum all that up, I think we would say very, very disciplined approach. We're very careful with how we select investments. We have a very thorough conversation over multiple periods.

John Ransom (Managing Director of Healthcare Research)

Second question is, when we think about the future of you had a pretty sizable legal accrual in the first quarter, how do we think about is that the high watermark or how should we think about that number for the rest of the year? Thank you.

Heather Dixon (CFO)

Yeah. I think you're referring to the legal costs and not a legal accrual, I'm assuming.

John Ransom (Managing Director of Healthcare Research)

Right. Yep.

Heather Dixon (CFO)

Yeah. Okay. Good. Just want to make sure I'm answering the right question. If I think about that, obviously, we're working through multiple things right now. We have both the DOJ and the SEC that we are working very cooperatively and diligently with. We have engaged an excellent law firm to help us with this so that we can continue to work and participate with them. We've undertaken significant efforts to respond as quickly as possible to all of the inquiries that we have. What you're seeing, I think, John, is the bullets of work that's being done in order to respond to and participate with all of those questions. That is really what's driving that.

From a cadence perspective, it's hard to say and to predict the future, but certainly what I would say is at the earlier stages of the investigation, certainly there is a lot of preliminary work to do and certainly a large amount of work that needs to get done. Again, working as quickly as we possibly can. Hopefully that's helpful.

John Ransom (Managing Director of Healthcare Research)

Thank you.

Operator (participant)

Our next question will come from Pito Chickering with Deutsche Bank. Please go ahead.

Pito Chickering (Analyst of Healthcare Facilities and Medical Devices)

Hey, guys. These are technical questions. I can confirm that the webcast is down, getting about a dozen reports of that right now. People are unable to join right now. It falls to A.J.'s question. Just can you give us some guidance of how we should think about sort of 2Q, percentage of annual guidance, and bridge is sort of how you can get to that number? I believe that you talked about a $15 million beneficial supplemental payment coming in 2Q, but any bridge would be helpful as you think about the ramp from the first quarter results.

Heather Dixon (CFO)

Yeah. Sure. Hi, Pito. I'll start by saying I'm not going to get into Q2 guidance, but let me just point out a couple of things. I mean, very clearly, the biggest swing factor is sort of the supplemental payments and specifically the Tennessee program. That is certainly one that we're watching and thinking about timing. To the extent that that is approved, there would be a significant impact to whichever quarter that that is approved in. From our perspective, we pointed this out in the fourth quarter call. Just to reiterate for our perspective, we've assumed that that comes in the second half of the year. To the extent that that comes in earlier in Q2, that would be a swing factor for what we have thought through.

The rest of the things that I talked through a little bit earlier in regards to how you can think about the ramping, there is the bed additions and the new beds. Those are going to continue to steadily improve. Again, supplemental is very much the largest swing factor here. Just thinking about how we move throughout the balance of the year, Q4 is when we are going to lap things. If you think about the balance of Q1 versus Q2, Q3, Q4, there will be some significant differences between Q4 and the rest of the year. That is probably the best guidance I can give you. I talked about a little bit earlier that we expect startup losses still to be in the $50 million-$55 million range for the full year.

I think Q2 will look fairly similar to Q1, maybe a little bit less, but that's probably about the only things that I could point to.

Pito Chickering (Analyst of Healthcare Facilities and Medical Devices)

Okay. Okay. Fair enough. If I could ask a question on CTC, you would ask a different direction. CTC revenues were flat sequentially. The number of patients grew, I think we'll say 2,000 or almost 3%. Can you talk about what you're seeing on CTCs from a pricing perspective? I'm just trying to sort of look at the flat revenues while patients are growing to figure out is pricing under pressure or what are you seeing there? Thanks so much.

Chris Hunter (CEO)

Yeah. Pito, this is Chris. Let me take that one. I would say CTC revenue grew 3.6% year-over-year in Q1, and that was generally in line with the growth rate that we reported in the second half of 2024. The service line, as we've discussed before, it's stepping over some pretty tough comps from the first half of 2024. There was also some modest unfavorable impact from weather that we also saw in Q1. As we discussed, in the first quarter, we opened the three new facilities, the three new CTCs. We acquired an additional four, as Heather said earlier, and those are progressing well. There isn't anything that we would call out with respect to pricing, though, on CTC.

Pito Chickering (Analyst of Healthcare Facilities and Medical Devices)

I mean, just to follow up there, because you're disclosing the patients in CTC, the end of December is 72,000, now it's 74,000. That implies you have 2,000 more patients, but revenues are flat sequentially. I guess how would growing census by 2,000 from 4Q to 1Q not impact revenues increasing sequentially? Thank you.

Heather Dixon (CFO)

Let me just understand your question. You're saying how if we grew the volume of patients, why did revenue not grow sequentially? Is that your question?

Pito Chickering (Analyst of Healthcare Facilities and Medical Devices)

Correct.

Heather Dixon (CFO)

I think there's some timing factors in there from a payment perspective. They're not nearly to the extent of the acute side of the business, but there can be some supplemental payment streams, much, much smaller, that can really impact some of the timing of the revenue. We have different rates in different states, and as those rate updates come through, that can add a little bit of what seems like supplemental lumpiness, but that's really just rate changes that come through. We closed a few facilities as well, and so that will affect. Those are obviously, we're not going to close them if they're high-volume facilities, but they could have been facilities that were contributing some revenue, but really on a scale basis weren't the right mix for our business on an EBITDA contribution perspective.

That can certainly affect the revenue and the top line, but would not impact the EBITDA contribution. That is probably the only couple of things that I would point to. Hopefully, that helps a little bit.

Pito Chickering (Analyst of Healthcare Facilities and Medical Devices)

Great. Thanks so much.

Heather Dixon (CFO)

No problem.

Operator (participant)

Our next question will come from Matthew Gilmore with KeyBanc. Please go ahead with your question.

Matthew Gilmore (Equity Research Analyst)

Hey, thanks for the question. I wanted to follow up on some of the policy comments and ask about work requirements. I know there's normally exceptions for people with substance abuse and psychiatric issues, but I just wanted to get your thinking in terms of that proposal and if that would have any impact on Acadia.

Chris Hunter (CEO)

Yeah. Thanks, Matt. This is Chris. I'll take that one. I would say overall, we're still far from having a clear view of what potential Medicaid adjustments will be. Obviously, the energy and commerce draft we have been scrutinizing, and it's over 100 pages and a lot of nuanced language in there. Overall, I think we continue to believe that the patient populations that we serve, including some of the highest acuity mental health issues in the country, are going to be relatively less impacted in terms of the risk of losing Medicaid access. I would say as it refers to work requirements specifically, I would just iterate that while the language may change, we remain really optimistic that a good portion of our population could be exempt, both based on existing structures that are in place and based on our initial interpretation of what we're seeing there.

We have just seen in the past that if you remove access to high-acuity mental healthcare for these populations, you tend to get exploding costs in other parts of the system. We have seen examples of that in the past where the populations have been carved out of things like work requirements. I think what you are seeing in the bill appears to have some significant carve-outs related, but we are just going to have to continue to work through it and obviously continue to lobby with the broader NABH and broader industry groups.

Matthew Gilmore (Equity Research Analyst)

Got it. I wanted to see if Heather had any comments on the cash flow from operations in the quarter. I think the legal expenses probably had an impact there, but were there any other sort of timing things to think through and when those would normalize?

Heather Dixon (CFO)

Yeah. The only thing I would point to is, obviously, as we've talked about, we are clearly at the peak from a CapEx perspective as we are in the middle of the highest number of new beds that the company has experienced, both with the end of last year, the significant number of beds coming on. Some of those costs continue to flow through related to those in Q1. CapEx and cash is obviously cash-based. It's not accrual. Even though we opened the beds in Q4, the costs are still going to come through in Q1. That's part of it. Incrementally, just to add on to that, obviously, we have added a large number of beds already this year. With Q1, we've added almost 400 new beds already. That's a piece of it as well.

Keep in mind that startup losses are also part of that, and those are clearly at a peak in Q1 of what we expect for the full year, as we've talked about as we move through the year. $50 million-$55 million for the year, but there was a predominance in Q1. That is also a piece of what you're seeing. You're correct. Obviously, the legal costs, those come through, and that's part of what is coming through from a legal perspective and impacting cash flow. I think those are the primary moving parts. Hopefully, that's helpful and answers your question.

Matthew Gilmore (Equity Research Analyst)

Got it. Thank you.

Operator (participant)

Our next question will come from Andrew Mok with Barclays. Please go ahead.

Andrew Mok (Director of Equity Research)

Hi, good morning. There's been a year-over-year decline in specialty revenue, looks like for five quarters in a row now, which has contributed to the broader deceleration in same-store revenue. Can you help us understand what's going on with that line specifically and when you expect to get back on track for growth? Thanks.

Heather Dixon (CFO)

Yes. Yeah. I'll jump in. Hi, Andrew. So a couple of things I would point to. First is we have closed some specialty facilities over the past several quarters. Obviously, we closed one in Q1 of this year, and then there were a few others that we've closed over the past handful of quarters. That is part of what is contributing to that. It was about 5% down in the first quarter, and that is really mostly driven by the facility closures. Over the past, I would say, a year and a half, we've wound down four specialty facilities, and that includes the one that I just mentioned in the fourth quarter. That is part of it. The other part is if you think about just from a revenue perspective, we have seen some nice growth in the Medicaid specialty inpatient business.

Obviously, that has a differential from just a year-over-year perspective on the overall revenue contribution for that, depending on the type of treatment that those patients need. Really, I think it's mostly driven by the closures.

Andrew Mok (Director of Equity Research)

Got it. That's helpful. As we contemplate the recognition of state supplemental payments from Tennessee, is that mostly an acute inpatient item? It would hit that revenue line?

Heather Dixon (CFO)

Yes.

Andrew Mok (Director of Equity Research)

Okay. Understood. Thank you. Thanks for the call.

Operator (participant)

Our next question will come from Sarah James with Cantor Fitzgerald. Please go ahead.

Hi, guys. This is Gabbian for Sarah. I just have a quick one. Could you elaborate if there was any weather impact on your facilities in the southeastern states when your peers had seen that? Could you just elaborate on how trends are going on some of the underperforming facilities spoken to last quarter.

Heather Dixon (CFO)

Yeah. I'll start. Then, Chris, I'm sure you want to say some things about some of the operations of the facilities. From a weather perspective, nothing material for us to call out. Obviously, it's seasonal, and every year we see some sorts of weather in different parts of the business, but nothing I would really call out and point to. Chris, do you want to give some color on those facilities, the underperforming facilities?

Chris Hunter (CEO)

Sure. Thanks for the question, Sarah. As we discussed in the prepared remarks, our 2025 guidance has assumed a roughly $20 million EBITDA headwind for the full year from this group of underperforming facilities that we had first called out in the fourth quarter, which you are asking about. I would say those facilities have performed overall in line with our expectations. They had a negative impact on our same facility patient growth of about 90 basis points in the first quarter, and we would expect to begin to comp over that headwind to volumes in the fourth quarter of 2025. The underperformances tended to be correlated more with local media coverage that is more intensive. Healthcare is obviously local rather than any news at the national level.

It is difficult to put an estimate on the timing, but we continue, as we had said at the outset, to be prudent and taking a more conservative approach when we set guidance. I think this is an example of that. We continue to execute and just feel very good about the path that we are on, but nothing additional that I would call out.

Okay. Great. Thank you, guys.

Operator (participant)

Our next question will come from Joanna Gajuk with Bank of America. Please go ahead.

Joanna Gajuk (Equity Research Analyst)

Hi, good morning. Thanks for taking a question. I guess first follow-up on the Tennessee DPP, did I miss it? I know you said that you assume second half of this year, but did you say how much you expect from that program?

Heather Dixon (CFO)

Hi there. No, we did not say how much we expect from that program in particular. We have said historically, not historically, since our earnings call for Q4, we said that we expect total supplemental payments on a net basis to be flat to up $15 million for the full year inclusive of Tennessee, but we haven't called out any numbers for Tennessee specifically or for any other states for that matter.

Joanna Gajuk (Equity Research Analyst)

Okay. I guess would you remind us, was there any out-of-period payments last year in 2024? When we think about the numbers flat to up 15, is there something we should adjust out from last year?

Heather Dixon (CFO)

Yeah. No, that's a great question, and thanks for the reminder. We did call out last year approximately $10 million in payments that we saw predominantly in Q1. About $7 million of those were in Q1, and then the rest were in the balance of the year. Yes, we did.

Joanna Gajuk (Equity Research Analyst)

All right. Thank you. If I may, another follow-up on a different topic on these handful of problem facilities. I understand you're saying things performing inland there. Is there anything you continue to do there to try to improve the situation? As in, can you give us an update on these referral sources, outreach that you've had, and any traction, I guess, you're getting there? Thank you.

Chris Hunter (CEO)

Yeah. I would say there's a number of things that we can continue to do. I mean, obviously, we have been very deliberate about meeting with our referral sources, particularly in person, and also inviting them to these facilities as well, which we do all the time, but we've tried to be even more intentional about making that happen since the fourth quarter. We've obviously done everything from talent reviews and taking a look at the existing staffing, making sure that we don't have key positions that are unfilled, working with our talent acquisition team very closely on that. Obviously, working with our other corporate functions, including our quality team, to make sure that we have everything in place that we need to continue to provide high-quality services. We're looking at a range of things in any given facility.

There isn't one step that I would call out, but just in totality, we're just very, very much cognizant of making sure that we're continuing to deliver high-quality care and that we have the right staffing in place and that we're continuing to focus on the right referral sources and that we're able to provide a great patient experience when the opportunity avails itself. We'll continue executing on that plan. This concludes our question and answer session. I'd like to turn the conference back over to Chris Hunter for any closing remarks. Thank you. In closing, I just want to again thank our committed facility leaders, clinicians, and approximately 26,000 dedicated employees across the country who've continued to work tirelessly to meet the needs of our patients in a safe and effective manner.

We are together doing incredibly important work for our patients across the country and remain committed to serving them with care, compassion, and excellence. Thank you all for being with us this morning and for your interest in Acadia. Have a great day.

Operator (participant)

The conference has now concluded. Thank you for attending today's presentation. You may now disconnect your lines.