ATI Physical Therapy - Q3 2022

Transcript

Operator (participant)

Good afternoon, and welcome to ATI Physical Therapy's third 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 during this time, simply press star followed by the number 1 on your telephone keypad. If you would like to withdraw your question, again, press star 1 on your telephone keypad. Please note this event is being recorded. On the call today is Sharon Vitti, Chief Executive Officer, Eimile Tansey, Chief People Officer, Ray Wahl, Chief Operating Officer, Joseph Jordan, Chief Financial Officer, and Joanne Fong, Senior Vice President, Treasurer, and Head of Investor Relations. I would now like to turn the call over to Ms. Fong to read the safe harbor and forward-looking statement.

Joanne Fong (SVP, Treasurer, and Head of Investor Relations)

Thank you, Operator. 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 our 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 could 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 as posted on ATI's website and filed with the SEC. With that, I'd like to turn the call over to Sharon.

Sharon Vitti (CEO)

Thank you, Joanne. Welcome everyone to our third quarter earnings call. I'm joined today by Eimile Tansey, our Chief People Officer, Ray Wahl, our Chief Operating Officer, and Joe Jordan, our Chief Financial Officer. Since our last call, I continue to learn about the ATI business and the physical therapy ecosystem and afford more definitive views on what the business needs. I've enjoyed meeting with many of our therapists, patients, and stakeholders across the country and will begin by sharing some observations. Next, I'll provide highlights of Q3 results with a focus on our most impactful operational levers, the three Ps of our practice, pipeline, provider base, and provider productivity. These are critical drivers to achieving our near-term growth targets. Eimile will discuss the labor environment and key activities around our provider base.

Ray will walk through operational performance during the quarter, and Joe will take us through a detailed review of financial results. Finally, I will wrap up with closing remarks before we open the call up to Q&A. To start, I wanna thank ATI's talented and dedicated team of clinicians and leaders that emotionally invest and are passionate about enriching the lives of the patients and communities they serve. Over the last few months, I've had the pleasure of visiting clinics and hosting in-person town hall meetings across the footprint. Altogether, I've probably met and spoken with close to 1,000 team members, and my reaction to what we offer remains strong and proud. The passion of the teams and the commitment to helping patients get back to their lives is consistent and visible.

I observed firsthand the dedication of our teams to help patients on their healthcare journey and ensure that everyone feels like a member of our ATI family. From our patients, new hires, established colleagues, and corporate teams, when I ask them why they love ATI, it's the people. ATI was built on a solid foundation, and the company is poised for success with the work ahead. While demand for physical therapy remains strong, the healthcare provider labor market and economic environment continue to present challenges. We are eager to demonstrate to our investors, board, and employees our ability to define, execute, and deliver on the right actions for both short and long-term success. Regarding our first operational pipeline, sustained demand for physical therapy care reiterates the value of this offering, and in the third quarter, the pipeline for ATI services continues to be strong. Referral grew.

Referrals grew quarter-over-quarter and are just shy of pre-COVID levels. Our business development team is focused on local relationship building alongside our clinicians with targeted referral sources and employer customers. The second P, provider base. The headwinds we discussed previously with recruitment and hiring persisted through the third quarter. Despite the tough labor market, our ATI employee attrition rate, excluding our clinician contractors, has improved since the beginning of this year and is currently in the mid-twenties. Moreover, in the third quarter, the clinical FTE count remained stable. The labor challenges affecting ATI and the broader PT market will take some time to dissipate. In the meantime, we are not standing still and are making investments and executing on tactics, both short and long term, to accelerate the way we grow our provider teams.

One of my first priorities in this regard was to fill the Chief People Officer role. I'm delighted to introduce Eimile Tansey on this call. She joined as CPO just over two months ago. Eimile is a strong and seasoned leader with more than 20 years experience in human resources and operations in healthcare and provider organizations. Eimile will share some perspective shortly on the labor market and discuss new approaches in talent acquisition and people development to advance the business. We are delighted to have her. For the third P, provider productivity, our teams across our national footprint saw an average of 8.7 visits per day per clinical FTE in the third quarter, and 8.8 visits per day per clinical FTE in the year-to-date period. Now, when we break this down, we rank our clinics based on productivity in Q3.

The providers in the top 80% of our clinics saw an average of 9.5 VPD per clinical FTE, compared to the bottom 20% of our clinics that are at a 6.5 VPD. The top 80% of clinics are doing well, seeing patients and achieving or exceeding our productivity targets. We believe there's room for incremental improvement in both groups, and Ray will discuss our roadmap later in the call. We completed a first pass in reviewing our clinic footprint and observed a similar clustering related to financial and operational performance. We see the top 80% of our clinics meeting or exceeding performance targets, while 20% are underperforming. We are currently pursuing different approaches to optimize half of the underperforming clinics, including consolidation, closure, and divestiture. We will also continue to closely monitor the remaining lagging clinics.

In addition to boosting financial returns, rethinking select clinic locations will strengthen operations and facilitate redeployment of displaced providers to clinics with more demand. Now, historically, ATI has increased the number of clinics every quarter since the company's inception in 1996. While we plan to continue opening de novos in attractive geographies and markets, we are taking a hard look at the existing fleet and will exercise discipline in pruning underperforming locations. Looking ahead, in 2023, we may have a decline in the total number of clinics year over year as we prioritize same-clinic growth over expanding clinics. We continue to gain insight into the paths for near and long-term earnings and cash potential of this business.

In the third quarter, we have identified and developed work plans on a portfolio of initiatives with the deliberate aim to strengthen our financial position, including execution of several quick sprint efficiency and improvement projects in 2022. The priority areas for review, organizational change, and/or process transformation includes streamlining the corporate SG&A function, redesigning our referral and patient intake structures, and leveraging technology to improve revenue cycle performance. We are moving with speed and are focused on being prudent with our spend and conserving cash. I'm pleased with the focus, the intensity, and the progress that our teams have made. Finally, we need to celebrate our exceptional rating under the Medicare Merit-based Incentive Payment System, otherwise known as MIPS, and our outstanding NPS and Google Star rating customer satisfaction scores. Both are testaments to our purpose-driven culture.

As I said before, ATI has a solid foundation and talented team of leaders. I am confident we will continue to make progress toward our goals. With that, I will turn the call over to Eimile for a discussion of talent acquisition and people development.

Eimile Tansey (CPO)

Thanks, Sharon. I'd like to provide perspective on the current labor market and discuss some of our activities aimed at our provider base. Through the pandemic, the overall healthcare industry has seen the number of providers decline. This is also true in the outpatient physical therapy sector. The American Physical Therapy Association recently issued a benchmark survey showing most PT practices reported hiring challenges and significant vacancy rates. With this backdrop, I am focused on developing programs that will further advance ATI as an outstanding place for providers to start, build, and accelerate their careers. In the short time I've been here at ATI, I've had the distinct pleasure of joining several listening tours and getting on the road out to clinics to personally connect with the front line and understand our care delivery model. It has been great to meet with providers and hear their questions, concerns, and goals.

Being a large national operator has certain advantages that allow us to offer unique talent programs for providers to gain a wide range of medical experiences and stay in the ATI family. One new program I'm really excited about is called Explore ATI. This program is geared towards our providers who are mobile and want to accelerate their learning. Explore ATI is an opportunity to spend one year at a clinic and then rotate each year to a different clinic while the person remains in the program. Participants can travel and live in potentially any of the 25 states where we currently operate while gaining experience treating different patient populations, and all of this while building relationships and tenure with the company.

If a clinician is interested in the business side of physical therapy, we have the Pathways program that is an opportunity for career progression through managing a clinic, a district, and even a region. In the third quarter, we also began refining our hiring tactics. We are testing and iterating with various forms of digital outreach, including social media, geofencing, and programmatic media, to better engage passive candidates with on-point messaging. The aim is to garner more than our fair share of candidates in this competitive environment as we look to grow. The key performance metrics I'm tracking at the macro level are clinician turnover and clinician hire rates, with the business goal to grow and balance the provider base in line with referrals at the local market level. My focus areas are workforce development, performance management, and team member engagement.

ATI has an amazing culture, and I'm excited to do my part to locate, attract, acquire, engage, and develop the next generation of skilled therapists for future leaders. Now I'd like to turn the call over to Ray for a discussion of clinic operations.

Ray Wahl (COO)

Great. Thanks, Emily. I'd like to provide a review of operational performance and discuss some of our activities in the field during the third quarter. Before I forget, though, since we just finished National Physical Therapy Month, Physical Therapy Month in October, I'd like to take a quick moment to say thanks and to appreciate all of our PTs and PTAs, along with our clinic support staff for what they're doing day in and day out and impact they're having on our patients' lives. We had a lot of fun in October celebrating the profession and each other's accomplishments, and it was great to see. As Sharon mentioned, demand for physical therapy continues to be strong with ATI referrals continuing to increase quarter-over-quarter.

Our business development team, alongside our clinical directors, are doing a great job in getting out to the communities they serve and building meaningful relationships with the medical community. As Eimile and her team work to grow the ATI provider base in the clinics, we are continuing to be focused on optimizing patient intake and scheduling, coordinating handoffs, advancing accountability, and onboarding new team members to the ATI way. From the work done during this past year, I feel good we have improved the amount of support in the clinics, and our team is growing and can focus on providing excellent care to our patients. In the third quarter, our provider team averaged 8.7 visits per day. While this was lower than the second quarter, this pattern is consistent with seasonal trends considering summer PTO.

As previously discussed, we are in the process of assessing our national footprint in clinics at the local market level. As Sharon mentioned earlier, when looking at individual clinics during the third quarter in 2022, 80% of our clinics are at the 9.5 visits per day or greater. This is encouraging as it shows when providers, referrals, and support staff are at the right levels, the team is then able to execute the playbook, and this results in excellent patient experiences and high-functioning clinic operations. As we progress in assessing the real estate footprint, there will be opportunities to consolidate locations with the dual benefit of adding much-needed providers to these busy locations and offering a vibrant work environment, which is what we're all striving for.

Each of our clinics is unique with their own local market considerations, so balancing the right level of staff and productivity expectations is always a work in progress. With the work we are doing to ensure the foundation is in place, and with many of our providers already achieving productivity targets, I feel we are positioned for further growth, not only in these clinics, but across the entire platform. Q3 has shown our ability to exceed performance expectations in many clinics. I think our Northwest region is a great example of a market where referral support has been solid. We've made some leadership changes that are having a real impact. Staffing is starting to take hold, and we're seeing high patient volumes and great clinical outcomes because of it. We look forward to replicating these types of results as we move forward.

I just wanna say I'm really proud of the entire ATI team. This group continues to work hard every single day towards our overarching mission, and that's helping patients reach their full potential. I'm excited as we finish the year, and I look forward to delivering on our commitments to our investors and our stakeholders as well. With that said, I'd like to turn the call over to Joe for a financial review.

Joseph Jordan (CFO)

Thank you, Ray. Thanks to everyone for joining the call today. I'll jump right into the third quarter 2022 financial results. Net operating revenue in the third quarter was $156.8 million, down 1% from $159 million in Q3 of the prior year. Net patient revenue was $142.3 million, which is essentially flat with the prior year. Other revenue was $14.5 million, decreasing 16% 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 23.2, sequentially decreasing 1 visit from 24.2 in the second quarter, with the quarter-over-quarter decrease following normal seasonality trends.

Visits per day per clinic increased 0.1 from 23.1 in the third quarter of 2021 as we increased the number of clinicians year-over-year to see more patients. Our rate per visit was $103.46, essentially flat from the second quarter of 2022 and decreasing 2% year-over-year from $105.56 in the third quarter of the prior year. The year-over-year decrease was primarily due to lower Medicare rates on account of the 2022 Medicare Physician Fee Schedule changes and sequestration, as well as unfavorable mix shift in both payers and states.

Salaries and related costs in the third quarter of 2022 were $90.3 million, a 4% increase year-over-year from $86.8 million in the third quarter of the prior year due to more clinical FTE and wage inflation. PT salaries and related costs per visit during the quarter were $56.20, a 5% increase quarter-over-quarter compared to $53.64 in the second quarter, driven by lower labor productivity and continuing wage inflation. Comparing year-over-year, we saw a similar 5% increase from $53.70 in the third quarter of the prior year, primarily due to wage inflation and added clinic support.

Rent, clinic supplies, contract labor and other in the third quarter of 2022 was $51.4 million, a 12% increase year-over-year from $45.8 million in Q3 of the prior year due to more clinics and greater use of contract labor. PT rent and other costs per clinic during the quarter was $54,000, sequentially increasing 2% from $53,000 in the second quarter and 9% year-over-year from $49,000, driven by greater contract labor use. Provision for doubtful accounts during the second quarter was $2.8 million or 2% of net patient revenue, which is consistent with the third quarter 2021 at 2% of net patient revenue or $3.5 million.

SG&A during the quarter was $25.3 million, an 18% decrease year-over-year from $30.8 million, primarily due to lower severance and transaction costs. Non-cash goodwill and intangible asset impairment charge in the third quarter of 2022 was $106.7 million. The impairment was primarily due to an increase in market interest rates. Operating loss in the third quarter was $119.7 million, decreasing year-over-year from $516.9 million. The third quarter of 2022 included an impairment charge of $106.7 million, while the third quarter of 2021 included an impairment charge of $509 million.

When excluding these non-cash impairment charges, the remaining $5 million increase in operating loss year-over-year was primarily due to lower revenue and the continuing tight labor market, which resulted in wage inflation and a greater use of contract labor, as previously discussed. These costs were partially offset by SG&A cost containment. Notable below-the-line items during the quarter included a decrease in the fair value of certain warrant and contingent common share liabilities totaling $7.7 million. The mark-to-market to fair value was based on a valuation analysis as of September 30, 2022. Interest expense during the quarter was $11.8 million compared to $7.4 million in the third quarter of the prior year, consistent with the reduced outstanding debt balance pursuant to the business combination in 2021, and then the subsequent refinancing of our debt earlier this year.

Income tax benefit for the quarter was $7.2 million, compared to $35.3 million in the third quarter of 2021. Net loss during the quarter was $116.7 million, compared to $326 million in the third quarter of the prior year. Adjusted EBITDA during the quarter was a loss of $0.4 million or 0% margin, decreasing year-over-year from $8.5 million or 8.5% margin. Similar to the year-over-year change in operating loss, the year-over-year decrease in Adjusted EBITDA was primarily driven by lower revenue and the continuing impact from the tight labor market, partially offset by lower SG&A.

Cash flow year to date 2022 was essentially break even, with $59 million used to fund operations, $22 million used in investing activities, offset by $81 million provided by financing activities. Cash used in operations included $12 million repaid in connection with the Medicare Accelerated and Advance Payments Program or the MAP program under the CARES Act. All MAP funds have been repaid as of September 30, 2022. During the third quarter, cash used was $31 million. Of that amount, $26 million was used in operations, which included $2 million repaid in connection with MAP. $4 million was used in investing activities, and $1 million was used in financing activities. As of September 30, available liquidity was approximately $97 million, which was comprised of $49 million in cash and cash equivalents and $48 million in available revolver capacity.

While cash used in operating and investing activities in 2022 year to date was approximately $80 million, we're focused on driving operational performance, as Sharon talked about, controlling costs and making investment decisions to improve cash flows over the next 12 months as compared to the last 12 months. As we move forward as a company, we'll continue to closely monitor the business performance and our financial covenants under our credit agreement. Finally, when considering financial performance through September, along with October results and early November trends, we're tracking to deliver against the low end of our full year 2022 guided ranges, and those ranges are for revenue $635 million-$655 million and adjusted EBITDA of $5 million-$15 million. With that, I'd like to turn the call back over to Sharon.

Sharon Vitti (CEO)

Thanks, Joe. As you can see, ATI has a strong commitment to all its stakeholders. We have a plan and are continuing to make progress on multiple fronts to ensure the company continues to improve operational and financial performance. We are aggressively working to implement planned changes and are confident that our talented team will fulfill our mission to provide the highest quality of care to our patients while delivering on our financial targets. Operator, let's open the call for Q&A, please.

Operator (participant)

At this time, I would like to remind everyone in order to ask a question, press star, then the number one on your telephone keypad. We'll pause for just a moment to compile the question and answer roster. Your first question comes from the line of Larry Solow from CJS Securities. Your line is open.

Stefanos Crist (Analyst)

Hi, this is Stefanos Crist calling in for Larry Solow. Thanks for taking our questions.

Sharon Vitti (CEO)

Hey, Stefanos.

Stefanos Crist (Analyst)

I think you mentioned lower clinics next year. Can you talk about that just in terms of additions and closures? Is that you're gonna continue to add while closing or mostly closures?

Sharon Vitti (CEO)

Hi, Stefanos. Thanks for the question. We will finish out the year with the de novos that we have on the docket.

Stefanos Crist (Analyst)

Roughly 35 for the year.

Sharon Vitti (CEO)

Yep.

Stefanos Crist (Analyst)

A couple that are opening in the fourth quarter.

Sharon Vitti (CEO)

We, you know, as you know, there's a long lead time to pulling together the de novos. We will continue with a lower rate of de novos in 2023, probably in the mid-teens. That's on the growth side. In parallel, as I mentioned, we have done a full review of our real estate, and we've looked at it at a clinic level. We've looked at profitability, prospects, local operational synergies, et cetera. We're focused on all of our clinics. The ones that we are taking action on are the 20% that, you know, don't have sufficient market demand or for one reason or another, they're not achieving our target unit economics.

With that, you know, there's obviously a lot of things that go into consideration here. I'd say half of that 20% is on a watch list. Some of them are newer clinics, some of them have seen growth, but not necessarily, you know, up to the levels that we need. We call that our watch list. Then the other half of that 20%, we've developed a plan for each of those clinics, and we will be taking actions starting now, and over the next 3-5 years. Obviously, the lease terms are one of the, you know, factors that plays into the decision.

We're moving on those that we can relative to a lease term or those that we have made a decision on, closing or divesting.

Stefanos Crist (Analyst)

No, it's great color. Thank you so much. Just a follow-up. Can you just give a little more color on PT availability, if that's improved over the last few months? Maybe talk about turnover specifically at ATI.

Sharon Vitti (CEO)

Sure. Why don't I let Eimile jump in?

Eimile Tansey (CPO)

Yeah, absolutely. I think that the market has remained extremely competitive, and we're working to, you know, a variety of different channels to make sure that we can continue to attract and retain talent. You know, we've experienced reduction in attrition as we've gone through quarter-over-quarter, year-over-year, so we're really encouraged by that. We think that through the programs that we put together, we continue to listen to our employees. You know, we think that internal attrition in the mid-20s is pretty good. We think we can continue to drive it down several more points, but we probably think that the industry has changed since the pandemic, you know, not just with PT, but healthcare broadly.

We believe we can continue to maintain levels, drive them down a little bit more with our programs and focusing on our culture, which is fantastic, and making sure that we're putting programs together with development. Development is a big focus of ours, so we feel pretty good about it. It takes time, you know, and we're actively creating mechanisms for open and frequent communication with our providers.

Sharon Vitti (CEO)

Let me just add that.

Stefanos Crist (Analyst)

Great. Oh, sorry.

Sharon Vitti (CEO)

Just to clarify, that attrition rate is without our contractors. Obviously, we know the contractors turnover. We're measuring it without our contractors in it to make an apples to apples comparison.

Stefanos Crist (Analyst)

Got it. Thank you. Thanks for taking our questions.

Sharon Vitti (CEO)

Sure.

Operator (participant)

Your next question comes from the line of Brian Tanquilut from Jefferies. Your line is open.

Brian Tanquilut (Senior Equity Research Analyst)

Hey, good afternoon, guys. I guess just to follow up on some of the questions there. As I think about, I know we've been talking about turnover, but as I think about lead generation for new hires and what does that look like right now, in terms of, you know, new applicants coming in?

Sharon Vitti (CEO)

Wanna take that, Eimile?[crosstalk]

Eimile Tansey (CPO)

Yeah, absolutely. Thanks for the question.

Sharon Vitti (CEO)

Thanks, Brian.

Eimile Tansey (CPO)

You know, lead generation is obviously incredibly important to us, and we really are looking at a lot of different ways that we can drive the top of the funnel for recruiting. It really looks like it's a multi-channel strategy, maximizing university channels, integrating and focusing on our rotational programs for conversion. You know, really activating those opportunities through the universities. We're also doing a lot of work with internal digital outreach, increasing our sourcing capability and, you know, focusing on our recruiter capability through additional digital channels. We're looking at being able to pull in not just new grads, but with a heavy focus on outreach.

For passive candidates out in the market. I think that all of these tactics are widening the top of our funnel, and we're really focused on converting all those people to be ATI employees.

Sharon Vitti (CEO)

I would just add, so under Eimile's short tenure, she has brought on a new VP of talent acquisition to complement the existing team and to add a level of both experience and quite honestly, a new way of thinking about our go-to-market tactics. I will say some of the activities that we put in place August to September, we have seen an increase in the top of the funnel. Obviously, we need to convert those, but we've been pleased with some of the activities that have generated a higher number of candidates, quality candidates. Those were good learnings for the types of tactics that Eimile referred to. Then the last would be, you know, we've also increased our spend in the area to support those tactics.

Brian Tanquilut (Senior Equity Research Analyst)

Got it. I guess as I think about the clinic closures coming up, I mean, do you retain some of those clinicians and redeploy them? How does that work? I'm just curious.

Sharon Vitti (CEO)

Yeah. No, great question, Brian. Thank you. You know, absolutely, that is our goal. You know, when you look, I mean, there's a bunch of different things that we see out there. One relates to just dense markets that have a lot of, you know, duplication or a lot of capacity. So those are obvious, where we might do a consolidation there. There's some other markets where we have staffing challenges, and so closing clinics and consolidating makes it a way for us to move the staff. Then also that makes it a more vibrant clinic setting when you have more than a single provider. So our intentions would be to maintain or to keep those staff.

If there's a divestiture that, you know, we'll have to see how that plays out. That one's a little bit harder.

Brian Tanquilut (Senior Equity Research Analyst)

Got it. Last question for me. Joe, as I think about free cash flow, as we think about clinic closures, I mean, is that something that we should be thinking about as a potential contributor to driving improvement next year and kind of pulling back into de novos?

Joseph Jordan (CFO)

Yeah. Certainly can, Brian, drive improvement next year. You know, to Sharon's point, it depends on how the closure happens. Divestiture, right? That's one way to get an improvement in free cash flow. But closing money-losing clinics is another way. Plus there's the resources that are allocated to those clinics too on top of it. The other important thing for us to do as a business is make sure that as we close clinics, we're scaling our corporate cost structure appropriately with those clinics.

Sharon Vitti (CEO)

I think, you know, there's some action we're taking right now. There'll be some action we'll be taking in 2023. I would say the majority of the action is gonna happen over the next three years.

Joseph Jordan (CFO)

Yeah

Sharon Vitti (CEO)

It's all predicated on both the action we're gonna take and then the lease.

Brian Tanquilut (Senior Equity Research Analyst)

Awesome. Thank you, guys.

Sharon Vitti (CEO)

Thanks, Brian.

Operator (participant)

Your next question comes from the line of Jason Cassorla from Citi. Your line is open.

Sharon Vitti (CEO)

Hi, Jason.

Jason Cassorla (Senior Equity Research Analyst)

Hey. Great. Thanks, guys. Just, you know, as we think about just thinking about mix, like payer mix. As you staff up, you've talked about referrals, but maybe, you know, could you when do you think you'll get back to sort of a pre-pandemic level of payer mix? And then just maybe, you know, broadly how you're thinking about the puts and takes on the revenue per clinic line for next year, right? Just given, you know, your new hires, the focuses of, you know, referral channels and the like, but also in context of those final Medicare rates that came out. Anything just on, one, payer mix, you know, if you think you can get back to pre-pandemic levels.

Two, how you're thinking about, you know, revenue kind of per visit next year, and the puts and takes there.

Sharon Vitti (CEO)

Sure. Joe, do you wanna-

Joseph Jordan (CFO)

Yeah.

Sharon Vitti (CEO)

Do you wanna take us through those two?

Joseph Jordan (CFO)

Yeah. Hey, Jason. It's Joe. I'll unpack that because you asked kind of a lot there. Maybe I'll start at the highest level on rate. From a rate perspective, we're monitoring what's happened with Medicare pretty closely. They've come out and said 4.5% cut. In the past couple of years, the Medicare rate cut that's originally been quote-unquote final has not equaled where it landed at the end of the year. Congress has stepped in and often that's then come down. We're monitoring because there's a chance that happens again like it has the last couple of years. If it stays as is, that 4.5% rate cut would impact roughly 20% of our volume.

Now, we do have, as Sharon mentioned when she was speaking during the scripted part of the call, we do have our exceptional rating under the MIPS program, which would give us a bonus, which would help to offset the 4.5% rate reduction. I think overall on our volume, it will have some impact, but it gets pretty diluted quickly. I think we think about rate as being flat if we could have some wins elsewhere. From a payer mix perspective, as it relates to getting workers' comp and auto personal injury back to where it once was, we are focused on driving mix, and we're rolling out through states.

Illinois is one where we built up our workers' comp and API historically, and it's not back to where it once was, so we're trying to drive that business back. So far, the mix has stayed pretty flat. We haven't seen the improvement, which, you know, as a result, we're not prepared to make a prediction on where the mix is in 2023.

Jason Cassorla (Senior Equity Research Analyst)

I think I understood. Yeah, no, that was very helpful. Thank you. Then just quickly as a follow-up, you talked about divestitures on this call, then apologies, I missed this. What? You know, are you thinking about it more broad-based? Is it regionally focused or concentrated? Then just thinking about, I think, you know, back, you know, a couple of years ago, you were talking about your growth and the areas of white space. You know, the way that you've seen regional development play out, do you still think a lot of that construct around white space and growth opportunities, you know, still exists in this framework? Or do you think you'd have to be more, you know, choosy as you think about, you know, growth, off of a, you know, this kind of revised baseline of clinics?

I'm just trying to understand, you know, as you rightsize the business, what, you know, where you could think growth could ultimately be achieved in the white space that's available to you, on the go forward. Thanks.

Sharon Vitti (CEO)

Great question. On the divestitures, you know, from a divestiture perspective, I'd say the actions we're taking are across the footprint. As it relates to the divestitures, it's definitely clusters of clinics. Predominantly, you know, within a market. We'll, you know, a little bit of that is TBD. I would say we're being pretty selective on where that is, both from what makes sense to us and then what would make sense to a buyer.

On the, you know, the growth in the white space, we're slowing down our growth for the right reasons because we've gone through such a large growth sprint, you know, kind of pausing and taking a look at where we are, but absolutely see the white space and the opportunities going forward and anticipate getting back to that, after we finish this, you know, internal, you know, sort of review. I would say, you know, obviously, how we look at things now may be different than we looked at them before because things are pretty different post-COVID, and the whole landscape has changed. I would say we're also smarter. We have a lot of experience.

The review of our fleet tells us, you know, gives us great insight onto where we made a bet, and it came through, and where we made a bet, and maybe it wasn't, you know, what we thought it would be. I think, you know, we're positioned nicely. You know, we haven't shut that off. We're still active in that area, but because you need to, you know, keep a seat at the table, but we will, you know, I think there's plenty of opportunity going forward.

Joseph Jordan (CFO)

Yeah. Maybe, Jason, this is Joe, just to add to Sharon's point. You know, she mentioned earlier that de novos next year is probably somewhere in the mid-teens. The white space, certainly to Sharon's point, still exists. The two challenges that we have, which causes us to pause and slow down, one is labor availability. Where we are adding de novos, those are areas where we generally believe we can add labor. We want to add people across our platform. If you do a lot of de novos, you're stressing a talent acquisition team that already has a requirement to add. We certainly recognize that. The second is the CapEx need. There's an investment to open these de novos.

Even though they pay back pretty quickly, we do see the cash burn of the business, and we need to Sharon's point, get the underlying fleet running how we want it to run, be pretty diligent with the capital spend that we have in 2023. Obviously, we have plans in place to drive the business forward and make improvements to our cash burn, but it's another reason why it makes sense to slow down.

Jason Cassorla (Senior Equity Research Analyst)

Got it. Okay. Thank you for all the color.

Sharon Vitti (CEO)

Thanks, Jason.

Operator (participant)

Again, if you would like to ask a question, please press star then the number one on your telephone keypad. Your next question comes from the line of Mike Petusky from Barrington Research. Your line is open.

Sharon Vitti (CEO)

Hi, Mike.

Mike Petusky (Managing Director and Senior Investment Analyst)

Hi. I guess I wanna understand the commentary around the guidance. It looks to me like the guidance was pulled out of the release itself versus Q2, unless I've missed it somehow. Then it sounded like Joe maybe said, "Well, the guidance that we gave previously, we're sort of reaffirming, but maybe at the low end." I mean, is that essentially what you're communicating? I guess if that's what you're communicating, why was it pulled out of the release? Thanks.

Joseph Jordan (CFO)

Hey, Mike. I mean, we didn't pull it out of the release. Yes, your understanding is correct that we are reaffirming the guidance. Maybe I'll just state that. We do think that we're gonna be at the low end of the guidance. I guess we just didn't put it back in the release to say that we're reaffirming the guidance. I'd say in practice, we've seen companies do both. If you're still in line with guidance, then sometimes there's just no need to update because it's assumed unless you go out and say something different. You're correct. You heard me right on the call, and we're tracking towards the low end of guidance.

You might recall that when we talked about that $5 million-$15 million adjusted EBITDA range, the low end of that range assumed that our clinical FTE stayed pretty flat, or headcount stayed pretty flat. We tracked that way in the third quarter. The rest of the operating KPIs followed seasonal trends based on what we've seen here in October with an uptick, early trends in November. It gives us some comfort that we're moving towards the low end of the range, within the low end of the range.

Mike Petusky (Managing Director and Senior Investment Analyst)

Okay. Good. 'Cause, you know, Q4 was your worst quarter last year for adjusted EBITDA, and typically it's one of the two, you know, weaker quarters for most PT companies. You're saying what you've seen in October and early November gives you confidence that this is gonna come in as, you know, your second best quarter for EBITDA or maybe even close to your best quarter?

Joseph Jordan (CFO)

Correct.Correct.

Mike Petusky (Managing Director and Senior Investment Analyst)

Okay.

Joseph Jordan (CFO)

Not to unpack Q4 of last year, but last year in Q4, you may recall, we had a couple things going on. We had some relatively significant severance. We revamped our sales team, brought in a consultant to help us do that, which was some spend. Omicron picked up pretty heavily in December and then into January.

Mike Petusky (Managing Director and Senior Investment Analyst)

Okay. I guess, Sharon, going back to this idea of optimizing the bottom 20%, and it sounded. I think I heard you say that, you know, a lot of this will be accomplished over three years. I mean, is it likely on some of the divestitures that we'll see that action, you know, more at the front end of the three years, you know, in order to give you guys a little extra liquidity, et cetera?

Sharon Vitti (CEO)

Yeah, Mike, we, you know, a lot of this, we were able to A, process, and B, work with our board on the plans. We had our board meeting last week. I would say we are actively pursuing the activities that we've laid out per clinic, and I would say that this divestiture work is actively in progress. I would say those. Who knows, right? I think we have a few different clusters that I'd say half of the clusters we already have real meaningful activity. The other half, you know, we're not sure. All of them are out. They're all out and being actively pursued at this point, which has been very recent in the last, you know, the last few days.

Mike Petusky (Managing Director and Senior Investment Analyst)

Yeah. Can I just ask, and maybe I missed this earlier. When you're talking about the bottom 20%, you're talking about closure, consolidation, divestiture. I mean, is it roughly a third when you think about that? Or are there more facilities to hopefully divest? Or how can you give some sense of that?

Sharon Vitti (CEO)

Well, first of all, the 20%, the bottom 20%, we're acting on 10%. The other 10% I classified as underperforming, but on a watch list because there's still. You know, we look at holistically at the clinic. We look at every, you know, the demand, the competitors, the staffing levels, et cetera. On the 10% that we have that are not on the watch list that we've identified we're gonna take an action on, I'd say, yeah, I'd say it's about a third off the top of my head.

Mike Petusky (Managing Director and Senior Investment Analyst)

Yeah.

Sharon Vitti (CEO)

In regards to some other activity, like maybe a closure with a sublease, depending on the lease terms, and then on the divestiture.

Joseph Jordan (CFO)

Mike, maybe just the one thing that I'd add on to that is you shouldn't walk away thinking that 10% of our clinics are gonna be closed in 2022, 'cause there's lease lives remaining on these clinics. They are open. They are seeing volume for the most part. There's a handful of dark clinics. They're just underperforming. Over some period of time, they will be closed, most likely. Certainly, some of them can turn around, but that's kinda how to think about it.

Sharon Vitti (CEO)

Mike, I'd say the thing is we're actively we know the list, and we're actively working with all of them to take an action, and if that action doesn't pan out, we may look at a different action. I think, I don't know, maybe what do we think about 80% of the actions will happen in the next three years based on the action we're taking and based on the timing, right? You know, we're not gonna close a clinic that has a longer lease.

Mike Petusky (Managing Director and Senior Investment Analyst)

Right.

Sharon Vitti (CEO)

It wouldn't make sense. We've done a full analysis and have this down at a clinic level, and then I guess, you know, we'll see. We'll see how our actions, how fruitful we are with our actions. I think we're being pretty, not trying to be coy here, more we have a plan, and we have a commitment to take an action, and we're gonna see how the market responds, and then we may modify the action. The taking these 10% off the grid is really important because we spend a lot of time on this 10%, and they obviously weigh down the performance of the other 80%.

Mike Petusky (Managing Director and Senior Investment Analyst)

Right. Of the 10% above that bottom 10% that are sort of on-

Sharon Vitti (CEO)

That-

Mike Petusky (Managing Director and Senior Investment Analyst)

On what you described as a watch list.

Sharon Vitti (CEO)

Yeah.

Mike Petusky (Managing Director and Senior Investment Analyst)

Are those situations where you know finding an extra therapist or a therapist assistant could make a difference? Or are those, you know, mostly, you know, staffed appropriately, they're just underperformers?

Sharon Vitti (CEO)

No, I think there's definitely, you know, could be a de novo where we just haven't been able to get it fully ramped from a staffing perspective. We could've had a lot of, you know, some certain geographies were really just hit with a higher amount of attrition, and so rebuilding that staff. They're typically also markets that have less, you know, less available staff. I'd say, you know, some of them, they're just not ramping as quickly as we thought, and so they're questionable whether they will get there or not. You know, they're not, there's not enough here to say, "Oh, these need to go on the close list." We are watching. You know, now we know what that list is. Our TA group is hyper-focused on trying to rec...

You know, trying to recover from a staffing perspective on these. You know, they could be referral-starved areas. Our business development group is working hard to see if we can accelerate the referrals. It's typically one of those three levers, right? You know, the staffing, the referrals, or it just hasn't been long enough to kind of write this one off.

Mike Petusky (Managing Director and Senior Investment Analyst)

Okay. Fair enough. Thank you so much. Appreciate it.

Sharon Vitti (CEO)

Sure.

Operator (participant)

There are no further questions at this time. Ms. Sharon Vitti, I turn the call back over to you.

Sharon Vitti (CEO)

Okay. I thank everyone for their participation in the call today. Thank my team for joining me and helping share where we are. We look forward to seeing everyone Q4. Thank you.

Operator (participant)

This concludes today's conference call. You may now disconnect.