ATI Physical Therapy - Q2 2022
August 8, 2022
Transcript
Operator (participant)
Good afternoon, and welcome to ATI Physical Therapy's second quarter 2022 earnings conference call and webcast. All participants will be in a listen-only mode. After today's presentation, there will be an opportunity to ask questions. If you would like to ask a question in this time, press star followed by the number one on your telephone keypad. If you would like to remove your question, again, press the star one. Please note, this event is being recorded. On the call today is Sharon Vitti, Chief Executive Officer, Joseph Jordan, Chief Financial Officer, Ray Wahl, Chief Operating Officer, and Joanne Fong, Senior Vice President, Treasurer, and Head of Investor Relations. I would like to now turn the call over to Ms. Fong to read the safe harbor and forward-looking statements.
Joanne Fong (SVP, Treasurer and Head of Investor Relations)
Thank you, Emma. Good afternoon, everyone, and thank you for joining us for today's call. Before we begin, we'd like to remind you that certain statements made during this call will be forward-looking statements that 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 these 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 in evaluating performance.
Details on the 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. With that, I'd like to turn the call over to Sharon Vitti.
Sharon Vitti (CEO)
Thank you, Joanne, and welcome to all of you joining us for our second quarter earnings call. I'm here today with Joe Jordan, our Chief Financial Officer, and Ray Wahl, our Chief Operating Officer. We have a lot to cover today, so let's jump in. I will begin by sharing some initial thoughts after my first 100 days with the company. Next, I'll provide highlights on Q2 results and perspectives on the landscape, where we are now, and what we are doing in the immediate term. We know our expected financial performance is important to the investors, and we will walk through revised guidance as announced in the earnings press release earlier today. Ray will further discuss operational and provider performance during the quarter, and Joe will take you through a detailed financial review and the basis for the guidance revision.
Finally, I'll wrap up with closing comments before we open the call to Q&A. In the past three months, I've started to learn about ATI from the inside out. Through clinic visits and most recently attending our mid-year field operations meeting, I'm encouraged by the talented teams and their strong commitment and passion for ATI's purpose. The operating chassis and resilient culture are the foundation that ATI has grown on and will continue to be the basis for our future. The team has also made strides in launching technologies that generate evidence-based data for our providers to use in developing high-quality treatment plans, coordinating care across providers, and measuring clinical outcomes along the patient journey. I'm excited to lead the company, drive the ATI mission forward, improve patients' quality of life, and leverage the existing foundation to grow our national practice.
Right now, we are focused on the three Ps of the practice, our pipeline, provider productivity, and our provider base. All are critical contributors to our near-term growth targets. Physical therapy is an important care offering and continues to have strong demand. Following market trends, the demand for ATI services is also strong. The Q1 investments to drive sales and marketing are producing meaningful results. Referrals continue to grow in the second quarter, giving us confidence that our investments in relationship building with partner providers have been effective and well-placed. This is a good start, and we are continuously iterating to advance the pipeline. On provider productivity, I've been working closely with Ray and the field leaders to ensure we support our clinicians, remove barriers, and allow them to focus on treating patients.
The performance metric we track is visits per day per clinical FTE, and we seek to strike a balance between increasing access for patients so they can get back to their best physical health and affording our therapists the space and resources to provide outstanding patient care. In the second quarter, the metric was 9.1, which is a quarter-over-quarter increase of 0.6 visits and represents solid performance by the field team. At the same time, the Net Promoter Score remained high at 75. With the investments made in clinical support in the past year, we can sustainably execute visits per day per clinical FTE across our national platform higher than 9. Related to our provider base, the tight labor market has impacted our pace of hiring and our ability to meet patient volume projections.
Offers with increased wages stimulate movement of providers from one PT organization to another and creates a higher reliance on interim contract labor, both adding to our cost per visit. While referrals and requests for ATI services has grown quarter-over-quarter, our ability to meet demand is constrained by the size of our provider team. We have been prudent with our actions as the labor market has tightened and wages have increased. We remain driven to overcome the market labor headwinds and are taking targeted actions to attract the providers to ATI, including expanded recruiting efforts and a steady focus on fostering our employee-first culture. Within the next few weeks, we will also be announcing a new chief people officer, and she will bring a renewed focus and seasoned guidance to our talent acquisition and people development strategies.
Despite the positive trends in our performance, the gap in adding providers is having a direct impact on our ability to deliver our 2022 growth plan. We are revising our revenue and adjusted EBITDA guidance for full year 2022 to reflect the current labor market, and Joe will speak to the details shortly. It is important we establish a realistic outlook for ATI that acknowledges the labor shortfall balanced with the need to grow our bottom line. Looking ahead, we are evaluating our baseline operations to position ATI for the long term. We are reviewing our people, processes, and technologies and digging deeper to understand costs and investments associated with growing the business, operating with excellence, and serving our patients. We are gaining insight into the path for near and long-term earnings and cash potential of this business.
This work is in progress, and we will be providing updates in the months and quarters ahead. While I don't have all the answers after three months, I can share a few additional near-term priorities to drive ATI's performance. Across our national practice, we are undertaking a comprehensive location review to assess return on investment and form an action plan. At corporate, we're evaluating SG&A spend and acting on opportunities to be more efficient. Regarding care delivery, we have identified specific opportunities where our ATI Connect virtual care can increase access and allow us to treat patients sooner. We expanded our workers' compensation program and auto personal injury programs in June this year in Illinois and Texas.
In our Texas pilot, we saw greater than 50% year-over-year growth in the first half of 2022 and a higher rate per visit in Texas due to the workers' compensation and API mix. Moreover, we are capitalizing on pent-up demand for our ATI Worksite Solutions service and are working to execute numerous contracts in the pipeline before year-end. My first quarter as CEO of ATI has not been without its challenges. I remain optimistic about the company's future and want to thank our employees, patients, and investors for their dedication and support. It is from weathering challenging times that good companies get stronger. I'm proud of our accomplishments through the first half and am eager to drive forward with intensity and purpose as we deliver on our commitments in the remainder of the year.
With that, let me turn it over to Ray for a detailed discussion of clinical operations.
Ray Wahl (COO)
Great. Thanks, Sharon. I'd like to provide a review of our operational performance in the second quarter, discuss some of our field activities, and comment on the labor market, which has created some near-term challenges for ATI and drove the reduced outlook that Joe will expand upon shortly. As we progress through the first half of the year, visits per day during the second quarter was approximately 22,400, which was 1,300 visits or 6% higher than the first quarter. The increase was delivered by essentially the same number of clinical FTEs performing at a higher level of productivity. As Sharon mentioned, we saw the provider productivity metric increase to 9.1 from 8.5 in the first quarter.
We were able to execute this due to the increased support staff added in the clinics over the past year, allowing our providers to focus on patient care. While we work on optimizing daily operations in the clinics and the scheduling hubs, the priority is adding more providers to the team to increase referral conversion and capture additional demand. We are not where we want to be with growing our clinical team as a competitive labor market is impacting both the pace of hiring and staff retention. Annualized clinician adds was 38% in the second quarter of 2022, the same rate as in the first quarter. Excluding contractors, annualized hiring was 27% in the second quarter, a 1% increase compared to the first quarter. As we work to fill open positions in this labor market, we are continuing to rely on contractors to fill gaps.
On our last call, I discussed PT school graduations in May, traditionally our biggest hiring season. We're excited to welcome new grads who are joining ATI teams with rolling start dates throughout the third quarter. Furthermore, we are currently deploying new tools and tactics to accelerate experienced clinician hiring. Annualized clinician turnover in the second quarter of 2022 was 37%, a 9% increase from 28% in the first quarter. When excluding contractors, annualized turnover was 27% in the second quarter compared to 23% in the first quarter. More than half of the quarter-over-quarter increase in turnover came from contractors as their engagements ended. Annualized turnover in the prior year comparative quarter was 44% in total and 43% excluding contractors.
Our employee engagement survey results show that the staffing and programmatic changes made in the past year have been viewed favorably by the field. We believe the culture in our clinics is special, and the ATI platform provides an outstanding place for providers to start, build, and accelerate their careers. We continue to install and refine talent management programs to enable our providers to perform at their best and elevate the PT profession to the benefit of our patients. As one example, I'm proud to report that the CMS recently awarded ATI an exceptional rating under the Medicare Merit-based Incentive Payment System program for the third consecutive year and a score in the 100th percentile for the second consecutive year. With this rating, we will receive MIPS bonus payments next year on top of the 2023 Medicare standard rate.
While I am pleased by the progress we have made with attrition and our culture over the past year, we have a lot of work ahead of us, and I believe this team is up for the challenge. The clinic leadership team's ability to manage their business and simultaneously oversee outstanding patient care has been impressive. Many of the programs we implemented to engage our workforce take time to see the full impact, and initial indicators show that we're on the right track. I'm really proud of the entire team who continue to work with one goal in mind, which is getting our patients back to their best selves, and I look forward to what this team can achieve going forward. Now, I'd like to turn the call over to Joe for a financial review.
Joseph Jordan (CFO)
Thank you, Ray, and thanks to everyone for joining the call today. I will cover our second quarter 2022 financial results and then go into the company's full-year outlook. Net operating revenue in the second quarter of 2022 was $163.3 million, essentially flat from $164 million in Q2 of 2021. Net patient revenue was $148.5 million, increasing 1% year-over-year, driven by higher volumes, partially offset by a lower rate per visit. Other revenue was $14.8 million, decreasing 15% year-over-year, primarily due to the sale of our home health service line in the fourth quarter of 2021. Visits per day per clinic during the quarter were 24.2, sequentially increasing 1.3 visits from 22.9 in the first quarter of 2022.
The quarter-over-quarter increase was driven by higher labor productivity. As Sharon discussed, while referrals continued to be strong in the second quarter, the tight labor market limited our ability to see more visits in our clinics. Visits per day per clinic decreased 0.1 from 24.3 in the second quarter of 2021 as we integrated new team members while continuing to optimize the staffing model and clinic operations year-over-year. Rate per visit was $103.57, sequentially increasing 0.5% from $103.06 in the first quarter of 2022 and decreasing 3% year-over-year from $106.26.
Despite the Medicare sequestration reduction of 1% that began in the second quarter, there was a small increase in rate per visit quarter-over-quarter and an indication that rates may be stabilizing since the onset of COVID and the concurrent payer, state, and service mix volatility. The year-over-year decrease was due to lower Medicare rates on account of the 2022 Medicare Physician Fee Schedule changes and sequestration, as well as unfavorable mix shifts in payer, states, and services. Salaries and related costs in the second quarter of 2022 were $89.6 million, an 11% increase year-over-year from $80.9 million in Q2 of the prior year due to more clinical FTE, a higher level of support staff in the clinics, and wage inflation.
PT salaries and related costs per visit during the quarter were $53.64, a 3% decrease quarter-over-quarter compared to $55.47 in the first quarter, driven by improved labor productivity and partially offset by continuing wage inflation. Comparing year-over-year, we saw an 11% increase from $48.22 in the second quarter of 2021, primarily due to increased support staff per clinician, wage inflation, and lower productivity. Rent, clinic supplies, contract labor, and other in the second quarter of 2022 was $50.4 million, a 14% increase year-over-year from $44.1 million in Q2 of 2021 due to more clinics and a higher cost per clinic driven by greater contract labor usage.
PT rent and other costs per clinic during the quarter was $53,000, sequentially decreasing 3% from $54,000 in the first quarter of 2021, primarily due to seasonal spend related to clinic events and increasing 11% year-over-year from $48,000, driven by greater use of contract labor given the continuing tight labor market relative to 2021. Provision for doubtful accounts during the second quarter was $3.5 million or 2% of net patient revenue, consistent with the second quarter of 2021 at $3.6 million and 2% of net patient revenue.
SG&A during the quarter was $31.8 million, a 21% increase year-over-year from $26.4 million in Q2 of 2021, primarily due to higher public company operating costs, non-ordinary legal and regulatory costs, and a contingency recorded related to a probable settlement arising from a payer dispute on historical claims. This increase is partially offset by lower transaction costs from the business combination in the prior year. Impairment charges in the second quarter of 2022 were $87.9 million for goodwill and $40 million for our trade name, both non-cash charges. The impairment was primarily due to an increase in market interest rates and revised near-term company expectations. Operating loss in the second quarter was $139.9 million, decreasing year-over-year from $444.3 million.
The second quarter of 2022 included an impairment charge of approximately $127.8 million, while the second quarter of 2021 included an impairment charge of $453.3 million. Excluding these non-cash charges, the remaining $21.1 million increase in operating loss was primarily due to a continuing tight labor market, resulting in wage inflation, a greater use of contractors, and higher SG&A expenses as previously discussed. Notable below-the-line items during the quarter included a decrease in the fair value of certain warrants and contingent common share liabilities totaling $2.7 million. The mark-to-market to fair value was based on a valuation analysis as of June 30th, 2022.
Interest expense during the quarter was $11.4 million, compared to $15.6 million in the second quarter of the prior year, consistent with the reduced outstanding debt pursuant to the business combination in 2021 and subsequent refinancing of our debt earlier this year. Income tax benefit for the quarter was $13 million, compared to $19.7 million in the second quarter of 2021. Net loss during the quarter was $135.5 million, compared to $439.1 million in the second quarter of 2021. Adjusted EBITDA during the quarter was $5.4 million or a 3% margin, decreasing year-over-year from $24 million or a 15% margin.
Similar to the year-over-year changes in operating loss, the year-over-year decrease in adjusted EBITDA was primarily due to the impact from the continuing tight labor market, higher support staff in the clinics and higher SG&A costs. Cash generated year to date 2022 was $31 million, broken down between $33 million used to fund operations, $18 million used in investing activities, and $81 million provided by financing activities. Cash used in operations included $11 million repaid in connection with the Medicare Accelerated and Advance Payment Program under the CARES Act. As of June thirtieth, available liquidity was approximately $128 million, comprised of $80 million in cash and cash equivalents and $48 million in available revolver capacity. Looking ahead, we are revising our full-year 2022 guidance.
Revenue guidance is $635 million-$655 million, down from $675 million-$705 million. We are also revising adjusted EBITDA to be in the range of $5 million-$15 million, down from $25 million-$35 million. We continue to face labor challenges as provider availability is constrained in the current environment, and there is aggressive competition for physical therapist talent. ATI's provider capacity has limited the number of referrals that we're able to convert and the visit volumes we're able to see. While we have been prudent in the face of labor inflation and maintained our headcount in the second quarter despite a tight labor market, we need to grow clinician count in order to keep growing the business and improve profitability. As Sharon mentioned, we're taking targeted actions to aggressively attract talent to ATI.
The revised guidance reflects the anticipated impact of the current labor market, and it captures the expected pace of adding clinical FTE in the second half of the year. We have capacity and demand to see more volume. Our platform is built to support more clinicians, and as a result, every 100 clinicians we add in our existing clinics allows ATI to realize approximately $2 million of additional revenue each month and approximately $1 million of additional adjusted EBIT each month. The revised guidance range is driven by the magnitude of the operating leverage each new clinician provides to ATI, and it reflects the pace at which we foresee growing clinical headcount. Finally, regarding new clinics, we opened 22 de novos year to date in 2022.
We will continue to capitalize on growth opportunities in local markets that provide an attractive return and have labor availability, and thus continue to expect to open approximately 35 new clinics for the year. With that, I'd like to turn the call back over to Sharon.
Sharon Vitti (CEO)
Thank you, Joe, for the detailed review of financial performance and outlook. In summary, ATI has and will continue to have a strong commitment to all its stakeholders. We are making ATI a stronger company operationally and financially. I continue to look forward to leading this talented team as we write ATI's next chapter. I have a lot more to learn about the ATI business and physical therapy ecosystem, and will share with you what I know and can today. I will also be back to you with more definitive plans and views in the months ahead. Operator, let's open the call for Q&A.
Operator (participant)
As a reminder, if you would like to ask a question, press star, then the number one on your telephone keypad. Your first question today comes from the line of Larry Solow with CJS Securities. Your line is now open.
Stefanos Crist (Equity Research Analyst)
Hi, good afternoon. This is Stefanos Crist calling in for Larry. Thanks for taking our questions.
Joseph Jordan (CFO)
Hey, Stefanos.
Stefanos Crist (Equity Research Analyst)
First I just wanna start on the referral pool. You know, just the increase. Is that predominantly new doctors or perhaps maybe some of the lost referral sources coming back? Is there a reasonable time period to, you know, to revamp referrals back to pre-COVID levels?
Sharon Vitti (CEO)
Great. Stefanos, hi, it's Sharon. Thanks for the question. The first part of the question relates to, you know, we've grown the sales team by about 60 BDM, business development managers, and that's about 10 less than what we had pre-COVID. We have a combination of using data to be more sophisticated about where we go in the field. We also have over 600 clinicians that are actually working in partnership with our BDM folks around, you know, developing those referral bases in the community. A few things specific to your question. One, the majority of referrals are from traditional referral sources, our relationships with providers, employers, and sports medicine.
I'll say it's a mix of existing and new. We're at about 96% of pre-COVID levels for referrals. You know, we're moving in that direction. I'd say the other big piece here is when I said the 60 folks that we've brought on, a good percentage of them have come on in the last six months. We're feeling confident that, one, the team is strong, two, they're ramping, and three, we're pretty close to our pre-COVID levels with our referrals right now.
Stefanos Crist (Equity Research Analyst)
Great. Thanks so much. Then you mentioned visits per day per clinic about 24.2. You know, is the goal still to get to the high 20s versus, I think, 30 in 2019, I guess, is that achievable in the next couple of years?
Sharon Vitti (CEO)
Joe, why don't you take this.
Joseph Jordan (CFO)
Hey, Stefanos. Hey, Stefanos, this is Joe. I could talk to that. I think and you heard this on the call, I think in the near term, the focus is to add clinicians. As Sharon mentioned, the referral volume level is pretty high. It's getting close to pre-COVID levels. Say if we had the clinicians today, certainly we could get a lot closer to that high 20s. But our short-term focus has to be on adding people back in. If we do that, I think the volume will take care of itself. As we start to add more clinicians, I think we'll hone in on what exactly that target is, whether it's high 20s or getting even back to what a 2019 level might have been.
Stefanos Crist (Equity Research Analyst)
Great. Thanks so much.
Operator (participant)
Your next question comes from the line of Stephanie Wissink with Jefferies. Your line is now open.
Stephanie Wissink (Managing Director and Equity Research Analyst)
Thank you. Good afternoon, everyone. I wanted to just pick apart the prior question a bit more. It sounds like there is no structural reason why you couldn't get back to 2019 if you had the labor pool to support it. I just want to make sure that we're hearing you correctly, that nothing has changed in the capacity to see the throughput, really just the labor constraint is the only missing piece. Is that the case?
Sharon Vitti (CEO)
Yeah. I think, you know, the good news is we know exactly what the issue is, and it is the adding of FTEs. The demand is there. The infrastructure to support those FTEs or those providers in being productive, all of those pieces, as Ray had spoken, we've put in place. The real key here is having providers to meet the demand.
Joseph Jordan (CFO)
I think, Steph-
Stephanie Wissink (Managing Director and Equity Research Analyst)
My second question.
Joseph Jordan (CFO)
Hey, Steph, maybe just to add onto Sharon's.
Stephanie Wissink (Managing Director and Equity Research Analyst)
Go ahead.
Joseph Jordan (CFO)
I mean, we're not quite to the pre-COVID referral levels yet. I mean, I don't want to dismiss. We do have a little bit of work to do, but it's significantly closer than where we're at from a capacity perspective by having clinicians.
Sharon Vitti (CEO)
Yeah.
Stephanie Wissink (Managing Director and Equity Research Analyst)
Okay. That's helpful. I wanted to just break down. I think, Joe, you may have talked about the incrementals, every 100 clinicians, $2 million in revenue, $1 million in EBITDA per month. Talk a little bit about the realization of that incremental benefit as you do recruit. Do you expect it to be relatively linear, or are there certain kick points, as you hit certain thresholds that you could see the incrementals even get slightly better?
Joseph Jordan (CFO)
There is a ramp. I guess there's two ways to answer that question, Steph, but I'll approach both of them. There is a ramp time for clinicians, and that ramp time is they get pretty close to productivity over the first six weeks to what would be a normally full productive clinician as they build up their caseloads. But the other wild card in how quickly we realize the throughput is how quickly we're able to or to hire and grow our clinician base. In the first half of the year, we stayed pretty steady from a headcount. You see it in the KPI table at the back of the earnings release. That's part of why we revised guidance. Certainly, Sharon mentioned the aggressive actions that we're looking to take.
You know, we think, hope that those aggressive actions will pay off, but we revised the guidance down to reflect what experience we had in the first six months, essentially.
Stephanie Wissink (Managing Director and Equity Research Analyst)
Okay. That's very helpful. My last one is just on the contract labor. If you could just help us think through the cost burden, whether it's on a per visit cost or per day cost, however you think about it, of a contract labor versus a FTE.
Sharon Vitti (CEO)
Yeah. Good question. I mean, a few things here. One, we are certainly relying on contractors more this year than we have been in the past, you know. We look quarter-over-quarter. It's still not, you know, 6% of our overall provider base, but it's relative to this year, we certainly have more contractors. The cost of the contractors is adding. It's increased our cost per visit by approximately 15%. You know, obviously the wage difference for the contractor versus the full-time PT is about 60%. That's grown year-over-year because of, you know, the increase, if you will, in the demand for contractors, which in turn has caused their wages to go up.
Steph, did that answer your question around the increase in the cost per visit?
Stephanie Wissink (Managing Director and Equity Research Analyst)
Yes, I think so. I guess the interpretation then would be as you bring on more vertical labor versus contract labor, we should start to see some benefits both from capacity but also on the wage differential.
Sharon Vitti (CEO)
Yes.
Stephanie Wissink (Managing Director and Equity Research Analyst)
That could also be a tailwind.
Sharon Vitti (CEO)
Absolutely.
Stephanie Wissink (Managing Director and Equity Research Analyst)
Very helpful. Thank you so much.
Operator (participant)
Your next question comes from the line of Pito Chickering with Deutsche Bank. Your line is now open.
Pito Chickering (Managing Director and Senior Equity Analyst)
Yeah, good afternoon, guys. A couple of quick questions here. I guess looking at the back half of your guidance, there's just a lot of moving parts right now. Can you just remind us what the seasonality should be as you think about sort of 3Q-4Q? Kind of if we use that perspective, 4Q, where should the exit rate be for this year?
Joseph Jordan (CFO)
Hey, Pito, this is Joe. I can take that. Exit rate, as you can imagine, is gonna be highly dependent on how successfully we are with adding clinicians. Maybe if I just even step back for a second and think about our original guidance and forecast. As I look across the KPIs, revenue rate, productivity of our clinicians, even the expenses in the middle part of the P&L, and frankly, our referrals, which don't directly make it into the P&L. They've all been pretty in line with the original guidance that we put out to the public. The one item that's been off is the number of clinical FTEs, and that's what led to the revised guidance.
As I think through the second half of the year, and in particular, the exit rate from Q4, it's gonna be highly dependent upon how successful we are with adding people. To the extent that we're able to add 100-150 people to our overall clinician base, that probably puts us closer to the high end of the range and, in turn, higher exit rate. But as you can see, the midpoint of the guidance has us doing Q3 and Q4 relatively consistent with Q2, and that would suggest that we're relatively flat with headcount. You know, not a perfect answer there, but I think as we make progress over the next quarter or two with aggressive actions, it'll start to become clearer, not only to us, but to you and investors that see our results.
Sharon Vitti (CEO)
Yeah. I would just add, of course, there's always a timing factor here. I think that it'll also be, you know, how quickly through from August and September, will we be able to pick up the headcount versus it be a trickle over the course of the next five months.
Joseph Jordan (CFO)
Maybe one other thing, Pito, to just add on to the end of that. Ray commented on our attrition rate, which we've seen come down. Granted, there was a small increase Q1-Q2, but a couple percent. If we look at it compared to where we were last year, there's a pretty significant improvement in our attrition rate. As I just talked about the KPIs, and then you layer attrition on top of that, I think it really comes down to hiring. Hiring does feel like something that we will be able to solve over time. The question is just how much time. That's why it's hard to predict the Q4 exit rate.
That's why, frankly, in the script, we talked about the flow through the incremental margin on clinicians so that we and you could make an assessment on the results of the business moving forward.
Pito Chickering (Managing Director and Senior Equity Analyst)
I guess digging on the labor question, the PT salaries per visit in 2Q 2022 is down versus the second quarter of 2019, so pre-COVID. I assume that's an attempt to shore whole margins as revenue per visit has decreased. Is that what's leading to the spike of turnover sequentially? Because if you exclude contract labor that you have in 2022 versus 2019, in theory, the FTE rate is actually even lower than it was in 2Q 2019. I guess the question is, how sustainable is that rate, and can you guys hire with that rate, or do you guys need to start increasing those rates?
Joseph Jordan (CFO)
Hey, Pito. Let me jump in on that as well. The PT rate is actually higher in Q2 of 2022 versus 2021. It's probably up 4% year-over-year on average. If we looked across kind of our CDs, PTs, PTAs, somewhere about the 4% range. We could always take it offline, work through the math of how you're getting to lower.
Pito Chickering (Managing Director and Senior Equity Analyst)
And, and-
Sharon Vitti (CEO)
I would just add, I mean, we obviously need to be looking at the competitive nature of our salaries both from a retention and an attraction. We're hyper-focused on that and staying up with the market and actually making sure that we're in sync.
Joseph Jordan (CFO)
Pito, I suspect the delta between your math and our math is that contractors are included in our clinical FTE number. However, contract labor, the dollars, is in a separate line that's called out on the P&L.
Sharon Vitti (CEO)
Mm-hmm.
Pito Chickering (Managing Director and Senior Equity Analyst)
Okay. Yeah. This is just coming from your KPI saying that the PT salaries per visit is $53-$64 in 2Q 2022, which looks down, which is $55.21 in 2Q of 2019.
Sharon Vitti (CEO)
Yeah.
Pito Chickering (Managing Director and Senior Equity Analyst)
Okay. I guess just one more follow-up here. I mean, you know, a lot of people are, you know, graduating from schools. I guess, are you guys losing to your peers? Are PT going into other sort of areas within healthcare? I guess, you know, just a broad question. Where are these PT going and kind of what, you know, what changes that math to get them to work for you guys? Thanks so much.
Sharon Vitti (CEO)
Pito, I'll jump in with a few pieces. First of all, you know, there's a strategy for folks that are coming out of school, new grads, and, you know, that period is right now. I think Ray can talk to it a little bit. We've seen changes in just the whole behaviors of people coming out of school and taking their tests and whatnot. That's one piece. I'd say the second piece is how do we continue to refresh our strategies around attracting existing PTs? We actually have, in the last three weeks, enhanced our tactics and different ways of doing that, just continuously looking at how to reach folks and let them know how great a place ATI is to work.
Ray, why don't you talk a little bit about what you have seen from a PT lens?
Ray Wahl (COO)
Sure. I mean, I think we all know it's a tight, competitive market. As PT students come out, there's a subset of those students that wanna work in outpatient physical therapy, and that's the subset of folks that we really wanna make sure that we're getting out in front of. We've used new
You know, having the process and procedure, as Sharon mentioned, to get in front of those people. Ultimately, at the end of the day, it's something that you just kinda touched on in terms of making sure our salaries, our comp is competitive. It's also really around two things. Making sure that we have the support that they need to do what they wanna do, which is treat patients and not do admin work and things like that. It's also the professional development, making sure that CEUs, internal development, mentoring programs, making sure all of those things are in place so these candidates see us as somewhere where they can not only start their career, but they can grow their career over the years.
That's really what we're focusing on, and making sure we're putting our best foot forward for those, that subset of students that want to work in the outpatient setting.
Sharon Vitti (CEO)
Yeah.
Pito Chickering (Managing Director and Senior Equity Analyst)
Right.
Sharon Vitti (CEO)
I'd say the last piece that we've touched upon is contractors, right? Contractors churn quite frequently. They're obviously a higher cost to us and, you know, they're not the stable team that we need. Our ability to move away from contractors over the course of the next month, six months is very important.
Pito Chickering (Managing Director and Senior Equity Analyst)
Yeah.
Joseph Jordan (CFO)
Pito, the only other thing that I'd add is we have been hiring people. We're maintaining our head count. We're not losing our head count. To build on what Sharon was just saying, contract labor is definitely different than where it's been in the past, which means that that's a new employer. So when we go and we compete for new hires, we're not only competing against our peers, but we're competing against contract labor companies that are hiring new grads to be contract laborers, which is a little bit different. I think, you know, holding our own in this market, it feels consistent with at least what we can see from other public companies. We do need to grow, and I talked about that in the script, Sharon talked about that in the script.
We're, you know, we need to be more aggressive and that probably involves not just new hires, but experienced hires as well, and that's a different strategy for us.
Pito Chickering (Managing Director and Senior Equity Analyst)
Okay. Last question here, apologies. Can you go over sort of free cash flow generation sort of this year with the revised guidance and any issues with covenants with this new guidance? Thanks so much.
Joseph Jordan (CFO)
Yeah. Yeah. This is Joe. I'll start with the second part of that question, Pito. No issues with covenants. Our covenants are pretty light until we get to Q2 of 2024. There's just a minimum liquidity covenant that requires us to have $30 million of cash/availability. No covenant issues, and we don't foresee any in the near term. From a liquidity perspective, we ended the quarter with roughly $128 million of liquidity. Do expect the second half of the year to still be a cash burn, and likely gets us to somewhere around $90 million of liquidity as we exit the year.
Right now, as you can imagine, we're focused on not only our near term actions, but we're thinking about 2023 and that planning process for 2023, and ultimately wanna work back to being a cash flow break-even company. I don't think that that's going to be the answer for 2023, but making progress against where we were in 2022 will be important. Adding clinicians to our business to meet demand will help us take care of that.
Pito Chickering (Managing Director and Senior Equity Analyst)
Great. Thanks so much, guys.
Operator (participant)
Your next question comes from the line of Michael Petusky with Barrington Research. Your line is now open.
Joseph Jordan (CFO)
Yeah.
Sharon Vitti (CEO)
Hi, Mike. Hi, Mike.
Michael Petusky (Managing Director and Senior Investment Analyst)
Hey.
Hi. Joe, I just wanna make sure I caught the end of the end of that last answer. Did you say in 2023 that you didn't see a possibility of being cash flow neutral? Is that what you said?
Joseph Jordan (CFO)
I said we're still working through 2023. I don't expect it. Possibility is. It feels a pretty strong word. We still have to work through it, as you can imagine, Mike. Expectations are we're gonna improve from where we are this year, which is a pretty significant cash burn, and then, you know, go from there beyond 2023.
Michael Petusky (Managing Director and Senior Investment Analyst)
Okay. Sharon, I think at the top of the call, you mentioned a location review. I guess what I'm wondering is, you know, what specifically is being reviewed and to what end? I mean, is there a possibility that at the end of this year, there are less facilities, even with the de novo plans you have, but less facilities on a net basis than where we are today? I mean, is that possible as you conduct this review?
Sharon Vitti (CEO)
It's a good question, Mike. It's a comprehensive review at the clinic level looking at all aspects, right? It's looking at the market, the profitability, the future potential, the synergies within the market, and all the relationships that we have. That will, you know, that will be, that assessment will allow us to think about investment decisions and what we may be doing in particular markets. I don't see that playing out between now and the end of the year from an action perspective, but certainly the assessment and then the ability to look at that. There are no significant plans for decreasing the footprint. Obviously we'll look at that as it relates to 2023, our capital framework, and where we'll be going with additions.
It's a work in progress, Mike, but it's something we take very seriously, and the work is going on to help us take a look at it.
Michael Petusky (Managing Director and Senior Investment Analyst)
Okay. Sharon, I think on the last call you said, "Hey, I'm gonna take the next 100 days. I'm gonna really do a deep dive. I'm gonna learn as much as I can in this next 100 days." I guess, understanding that there's still more to dig into here, what do you feel like you've learned in the last 100 days?
Sharon Vitti (CEO)
Great question. I've learned a lot in the past 100 days. I would say, first of all, that, you know, ATI has a very strong culture, and it's something that has carried them through many years, and it's something that we, you know, that's most important to the foundation of the organization. The national footprint and just having that geography, 900 clinics over 25 states is very valuable. The fact that we have a standard platform, evidence-based guidelines, that standard EHR is a great asset to the organization. I mean, it's a great asset to the organization. You know, I would say that, you know, the demand is here. The demand is here for ATI, and we've shown that through the referrals, and through our ability to get back to, you know, our almost pre-COVID levels.
I would say people are really proud to be working for ATI. They, you know, either are recently joined or been here for a little while, and they're really proud of what we have to offer here and just being part of a leading organization. I'd say the last is our patients appreciate us. We've started digging into, you know, our NPS and what we're hearing from our patients, and they very much value the care they receive. I think that the clinical reputation is enhanced or a fine point is put on it by our, you know, recent announcement of having our MIPS award at 100% excellence. I'd say, and then the last I said before in my comments, you know, the chassis, right?
We have a chassis that is allowing us not only to support the clinics we have now, but it's been developed to grow the organization and to scale. I think all of those pieces have been really both informative for me and create a situation where I'm A, excited to be here, and B, I can see a lot of potential going forward as we move past this provider challenge.
Michael Petusky (Managing Director and Senior Investment Analyst)
Gotcha. Can I throw in one last one? Let's
Sharon Vitti (CEO)
Sure.
Michael Petusky (Managing Director and Senior Investment Analyst)
Not an easy one.
Sharon Vitti (CEO)
Okay.
Michael Petusky (Managing Director and Senior Investment Analyst)
In terms of as you sort of are out there and assessing the big issue in terms of hiring, is there any way for you guys to assess how much sort of lasting damage was done by sort of the change in benefits and sort of what kicked this whole thing off in terms of your clinician attrition issue? I mean, is there any way to sort of assess, you know, has that sort of reputational damage sort of hurt you guys, you know, sort of on an ongoing basis? Is it dissipating? Is there any way for you guys to actually assess how much that's affecting you in terms of hiring people? Thanks.
Sharon Vitti (CEO)
Yeah. I'll start, Mike, and then I'll look to my colleagues who have been here a little longer than I have. But I would say the biggest challenge we have right now that is a result of some of the previous, you know, some of the previous challenges is we're not just trying to maintain our FTEs. We have aggressive targets to grow our FTEs. Coming out of, you know, COVID and some of the actions that we took that may have increased the attrition levels, the kind of the macro level situation of the workforce tightening up post-COVID, and then our gap that we wanted to fill is very, you know, really what's making it challenging for us. I would say, you know, clearly our patients and providers want to use ATI and send us patients.
I would say both the strength of our culture and our attrition numbers are really confirming that ATI is a great place to be. I think, you know, it's less about. I don't think we damaged our reputation to the extent that people don't wanna come here, whether it be patients, providers, or employees. I think the challenge is we just have a bigger gap than other organizations to be able to grow versus just maintain and, you know, make sure that our workforce is steady. I look to my colleagues who have been here a little longer than me. Wanna add anything?
Ray Wahl (COO)
I would just highlight what you mentioned, Sharon, in terms of when I think about the brand. It's the brand, what it means to our referral sources, and referral counts kind of reflect that. We have work to do, but referrals have been positive. They continue to grow. That makes me feel good about what the outside referral community thinks about ATI. Then internally, what do the employees, what does the PT industry think about ATI? Our attrition continues to get better, continues to improve. We're not there yet. Still work to do. Also we've done some employee surveys over the, you know, the past few months. Again, indicating that we're focusing on the right things, that we're engaging with our people in the right way. Things are slowly getting better. We still have work to do.
There's still things that we wanna roll out, improve upon. I think overall it tells a good story about what we've been focusing on, and that's the right things over the past, you know, several months and years. That's how I think about what our brand is all about these days.
Sharon Vitti (CEO)
No, there's a lot to work from here. I am not concerned that we are damaged and cannot move forward.
Michael Petusky (Managing Director and Senior Investment Analyst)
Gotcha. Thank you so much.
Operator (participant)
Your next question comes from the line of Stephanie Wissink with Jefferies. Your line is now open.
Stephanie Wissink (Managing Director and Equity Research Analyst)
Thank you. I had a follow-up question on your hiring to date. I'm wondering if you can talk a little bit about the trend line. I can see quarter-to-quarter that it looks pretty stable. The turnover has stepped up a bit. Just can you talk about the inbound hiring? Has it improved at all as we've entered the back half, or has it gotten moderately worse? Thank you.
Sharon Vitti (CEO)
Steph, thanks for the question. You're saying the back half of the year, so I'm sorry.
Joseph Jordan (CFO)
Thanks, Sharon. It's for Q1-Q2, Steph.
Sharon Vitti (CEO)
Sorry.
Stephanie Wissink (Managing Director and Equity Research Analyst)
Yeah, Q1-Q2, and I don't know if you wanna possibly talk about quarter to date into the third quarter, but just trying to get a trend line assessment year to date.
Joseph Jordan (CFO)
Yeah, I can take that, Sharon.
Sharon Vitti (CEO)
Yeah, go ahead.
Joseph Jordan (CFO)
Yeah, from Q1-Q2, the hiring has stepped up modestly as well. As Ray talked about in his part of the call, our turnover has gone up slightly from Q1-Q2. Our headcount has stayed relatively stable, which means that the hiring has also improved or increased slightly to offset that minor increase in turnover. As we look ahead to Q3, we have pretty limited data at this point. If I combine July and August, which is really where we have some insight into, the net of those two is adding people, but it's not enough to talk about a trend for the second half at this point.
Stephanie Wissink (Managing Director and Equity Research Analyst)
Thank you. That's very helpful.
Sharon Vitti (CEO)
Steph, I was just gonna add, we have more of a focus on hiring PTs versus PTAs, which we've had, you know, in the past. The PTs are a little bit tighter right now to hire. That's the other kind of the focus we've had over the course of the last two months, I mean, quarters, excuse me.
Stephanie Wissink (Managing Director and Equity Research Analyst)
Okay. Thank you so much.
Operator (participant)
There are no further questions. This concludes today's Q&A session. I turn the call back over to the speakers.
Sharon Vitti (CEO)
Great. Thank you everyone for your time today. I certainly appreciate everyone's participation, and all the questions, and I also am grateful to everyone's support for my first quarterly earnings call at ATI. We look forward to future opportunities to connect, and thank you for your time today.
Operator (participant)
This concludes today's conference call. Thank you for attending. You may now disconnect.