Cross Country Healthcare - Q2 2023

Transcript

Operator (participant)

Good afternoon, everyone. Welcome to Cross Country Healthcare's earnings conference call for the second quarter, 2023. Please be advised that this call is being recorded, and a replay of this webcast will be available on the company's website. Details for accessing the audio replay can be found in the company's earnings release issued this afternoon. At the conclusion of the prepared remarks, I will open the lines for questions. I would now like to turn the call over to Josh Vogel, Cross Country Healthcare's Vice President of Investor Relations. Thank you, and please go ahead, sir.

Josh Vogel (VP of Investor Relations)

Thank you. Good afternoon, everyone. I'm joined today by our President and Chief Executive Officer, John Martins, as well as Bill Burns, our Chief Financial Officer, Dan White, Chief Commercial Officer, and Marc Krug, Group President of Delivery. Today's call will include a discussion of our financial results for the second quarter of 2023, as well as our outlook for the third quarter. A copy of our earnings press release is available on our website at crosscountry.com. Please note that certain statements made on this call may constitute forward-looking statements. These statements reflect the company's beliefs based upon information currently available to it.

As noted in our press release, forward-looking statements can vary materially from actual results and are subject to known and unknown risks, uncertainties, and other factors, including those contained in the company's 2022 annual report on Form 10-K and quarterly reports on Form 10-Q, as well as in other filings with the SEC. The company does not intend to update guidance or any of its forward-looking statements prior to the next earnings release. Additionally, we reference non-GAAP financial measures such as adjusted EBITDA or adjusted earnings per share. Such non-GAAP financial measures are provided as additional information and should not be considered substitutes for or superior to those calculated in accordance with U.S. GAAP. More information related to these non-GAAP financial measures is contained in our press release.

During this call, we, we may refer to pro forma when normalized numbers pertain to our most recent acquisitions, as though the results were included or excluded from the periods presented. With that, I will now turn the call over to our Chief Executive Officer, John Martins.

John Martins (President and CEO)

Thanks, Josh, thank you to everyone for joining us this afternoon. For the second quarter, consolidated revenue of $541 million and adjusted EBITDA of $44 million were above or near the high end of our guidance ranges. Our results reflected strong execution in an environment where clients remained focused on controlling their labor costs. It is evident to me that our ongoing investments in technology are driving efficiency and productivity gains, enabling our dedicated employees and healthcare professionals to deliver best-in-class service. Bill will get into more detail on the numbers, but I wanted to spend a few moments discussing our second quarter performance. I'll start with our largest business, travel. Revenue is down approximately 16% from the first quarter, driven by a mix of lower rates and billable hours.

As expected, average bill rates declined approximately 7% sequentially and are expected to decline by mid to high single digits in both the third and fourth quarters. This would place travel rates on track to settle in roughly 35% above pre-COVID levels as we enter 2024, in line with our prior expectations. As we reported last quarter, demand troughed in April and has been slowly rebounding. In particular, we saw notable pickups in med surg, ER, labor and delivery, and pediatrics. In allied, we saw strength in imaging and lab specialties. Though demand has rebounded, the corresponding growth in the number of travelers for the third quarter has been slower than anticipated, as there appears to be a gap in open order rates relative to the compensation that nurses are seeking.

Accordingly, we still expect revenue for the third quarter to be the trough, though a little softer than we previously envisioned. For the fourth quarter, we continue to expect sequential volume growth in the business, in part due to the improving outlook for orders as well as the likely seasonal needs we expect to see ramping in coming months. Turning to our other businesses, I'd like to highlight physician staffing revenue, which was up 32% year-over-year organically and 12% sequentially in the second quarter, driven by an increase in the number of days filled across most specialties and revenue per day filled.

When we include our most recent acquisitions of Mint and Lotus, which continue to operate above expectations, our physician business was up 105% year-over-year and now is on an annual revenue run rate of more than $180 million. Education also performed very well in the second quarter, up 42% year-over-year. This division is now close to an annual revenue run rate of $100 million. Now, let me spend a moment on our technology initiatives. As you know, we have been successfully redesigning our entire technology landscape using a data-centric model that provides analytics and insights in real time with Intellify, our proprietary vendor management system, at the center of our ecosystem.

Since introducing Intellify at our Investor Day event last year, we have successfully migrated nearly half of our managed service programs onto this platform, with plans to convert the balance over the coming months. As a reminder, this will save us millions of dollars annually in tech fees paid to third parties. However, the real driver for long-term revenue growth and margin expansion, in my opinion, is the multi-billion dollar opportunity Intellify opens within the vendor-neutral space. When meeting with prospective clients, conversations go beyond just contingent labor by offering a comprehensive technology-enabled platform that empowers the user, user with intuitive data and analytics, as well as greater levels of efficiency and transparency. We believe Intellify to be highly differentiated in the industry, and the feedback we've received thus far from clients, prospects, and our subcontract partners has been extremely positive.

For example, one of our partners recently noted that the data Intellify introduces helps staffing agencies track their efficiency within the marketplace, which is a very useful tool. As I mentioned on the last call, we signed our first vendor-neutral contract in March, which went live on May first. Today, I am thrilled to announce that we are actively implementing Intellify Talent Solutions at another new customer. We have a very robust pipeline of clients interested in this technology, evident in the numerous live demos we have done so far, and we look forward to updating you on our new business opportunities on future calls. An equally exciting technology initiative underway is on the candidate-facing side.

In mid-May, we released the latest version of our Experience app, which allows travel nurse and allied professionals to utilize a self-service model, easily searching and applying for jobs with convenience, functionality, and pay transparency. Since the launch, there have been thousands of downloads, with KPIs showing positive daily active user retention and job view trends. This app is a crucial piece of Cross Country's ongoing digital transformation. As we pivot to a tech-enabled platform, our mobile-first ecosystem will assist in optimizing candidate and client experiences, rationalizing business operations, and streamlining our delivery models. The full year, we continue to target an investment of nearly $30 million on technology-related initiatives that we believe will further improve our go-to-market strategy as well as our efficiency. This brings me to our outlook.

Given the market backdrop and the seasonality in parts of our business, like education, we anticipate that the third quarter revenue will be between $440 million and $450 million. Beyond the third quarter, our expectations for continued improvement in travel demand, as well as potential growth in many of our businesses like education, physician staffing, and home care, point to a full year revenue that will be above $2.05 billion and an adjusted EBITDA margin of approximately 8%. I remain confident in our ability to drive long-term, sustainable, profitable growth, we are focused on increasing shareholder value through our deployment of capital. As you can see in today's press release, our cash generation was very strong in the second quarter, allowing us to fully repay the remaining $74 million on our term loan in June.

You will also recall that we announced the restoration of our $100 million share repurchase plan in May. With the term loan now gone, given we believe our shares are undervalued, share repurchases remain an attractive use of capital. We will also look to leverage our technology investments and robust balance sheet to further diversify our platform by following the patient across the continuum of care, as well as by entering new markets like we did with interim leadership through the Hireup acquisition late in 2022. In closing, we are confident about our prospects and ability to build upon the early momentum from Intellify, which we believe is a game changer for Cross Country and the industry. All of our success would not be achievable without our dedicated employees, and I want to thank each of them for their hard work and contributions.

We have such an incredible team. We recently won a 2023 Top Workplaces Healthcare Industry Award from Energage, and I'm also humbled to highlight our recent award of Newsweek Magazine's Most Loved Workplace Certification, which recognizes organizations where employees are the happiest and most satisfied. Our workplace culture is second to none, in my opinion, and this award is reflective of that as it surveys employees on various elements such as respect, collaboration, support, and a sense of belonging inside the company. Lastly, I want to thank all of our professionals who made Cross Country their employer of choice, as well as our shareholders for believing in the company. With that, let me turn the call over to Bill.

Bill Burns (CFO)

Thanks, John. Good afternoon, everyone. As John highlighted, consolidated revenue for the second quarter of $541 million was above the high end of our guidance range, fueled by overperformance across both physician staffing and education. Compared to the prior year and prior quarter, revenue was down 28% and 13% respectively, driven in large part by the expected normalization in travel bill rates and, to a lesser extent, the decline in number of professionals on assignment. I'll get into more details on the segments in just a few minutes. Gross profit for the quarter was $123 million, which represented a gross margin of 22.8%. Gross margin was up 40 basis points sequentially, due primarily to the impact from the annual payroll tax reset at the start of the year.

Moving down the income statement, SG&A was $79 million, down 6% sequentially and 8% over the prior year. The majority of the decrease relates to lower variable compensation following the historic performance throughout the pandemic, as well as the reductions in salary and benefit costs we mentioned last quarter. Our goal remains to proactively balance investments with current market conditions to maintain our profitability while ensuring we have sufficient capacity for future growth including actions taken throughout the second quarter and into the start of the third quarter, we've reduced our internal headcount by more than 10% since the start of the year, while continuing to invest in areas of the business with the highest growth potential, as well as in our technology initiatives.

Based on the cost actions taken to date, as well as lower compensation associated with the sequential decline in revenue, we anticipate our SG&A will decline in the mid to high single digits for the third quarter. As a percent of revenue, SG&A was 14.6%, up from 13.5% last quarter, as the decline in revenue outpaced the reductions in SG&A. The better-than-expected top-line performance, coupled with tight cost management, drove another quarter of strong earnings with adjusted EBITDA of $44 million, representing an adjusted EBITDA margin of 8.2%, consistent with our goal to maintain margins in the high single to low double-digit range. Interest expense was $3.1 million, which was down 15% sequentially and 18% from the prior year.

The decline was entirely driven by lower average borrowings during the quarter, partly offset by higher interest rates. Our effective interest rate for the quarter was 12%, reflecting the reduction in borrowings under our ABL. At the end of the quarter, we prepaid the remaining balance on the subordinated term loan and therefore expect to see interest expense materially lower for the third quarter. As a result of the prepayment of our term loan, we incurred $1.7 million on the extinguishment for the write-off of the debt issuance costs. Also, on the income statement, we recorded $900,000 in restructuring costs, primarily related to the severance associated with the reduction in headcount I mentioned a moment ago.

Finally, on the income statement, income tax expense was $9 million, representing an effective tax rate of 29.6%, in line with expectations for a full year effective tax rate of between 29% and 30%. Our performance resulted in an adjusted earnings per share of $0.69 above the high end of guidance, driven by the overall strong performance and lower interest expense. Turning to the segments, Nurse and Allied reported revenue of $495 million, down 15% sequentially and 32% from the prior year. Our largest business, Travel Nurse and Allied, was down 16% sequentially and down 36% from the prior year. Bill rates for travel were down 7% sequentially, in line with expectations, while billable hours were down almost 10%, following the softness we experienced in orders throughout the first half of the year.

The decline relative to the prior year was fairly evenly split between lower bill rates and fewer billable hours. Looking to the third quarter, we continue to expect bill rates to decline in the mid-to-high single digits, while billable hours are expected to decline in the low double digits. Let me just spend a moment on that. As we called out, demand softened considerably coming into the start of the year before troughing in the second quarter. While total orders are gradually improving, average bill rates continue to soften, which is creating a gap with pay expectations by clinicians. As a result, we are not yet seeing an improvement in weekly production, leading to a slightly softer third quarter than we anticipated a few months ago when we saw orders rebounding.

That said, we remain optimistic that as seasonal needs pick up, we will start to see our travelers on assignment grow once again. It's worth noting that we continue to have more than double the number of travelers as we did prior to the pandemic. Our local or per diem business continues to feel the impact from the softness in demand, with revenue down approximately 9% from the prior quarter, predominantly due to a decline in billable hours. Also, within the Nurse and Allied segment, our education business continued its trend of robust growth, growing more than 40% over the prior year. Home care staffing services performed within our expectations, though down 2% over the prior year, predominantly due to lower needs from a single client. Both of these businesses remain on track to achieve an annual run rate of approximately $100 million each.

Finally, physician staffing once again exceeded our expectations, delivering $45 million in revenue, which was up 12% sequentially and more than double the prior year, thanks to the impact of our acquisitions completed late last year. Turning to the balance sheet, we ended the quarter with $673,000 in cash and $31 million in outstanding debt under our ABL facility. Given our continued strong performance and positive cash flow, our total leverage fell to less than 0.2x. With the help of our balance sheet and incredibly low leverage, we remain well positioned to make further investments in technology and acquisitions, as well as to continue repurchasing shares under our $100 million share repurchase plan.

From a cash flow perspective, we generated $119 million in cash from operations, our second highest quarter on record, as compared with $18 million last year and $46 million last quarter. The $166 million in cash generated from operations on a year-to-date basis represented 172% conversion on the $97 million in year-to-date adjusted EBITDA. Fueling this performance was strong collections that drove a further reduction in DSO, which now stands at 63 days. Our goal remains to bring DSO below 60 days, which is more in line with our historic performance, and we believe that we can continue to make progress towards that in the second half of the year. Cash used in investing activities was $4 million, reflecting our continued ramp in technology investments.

From a financing activity perspective, we paid down $110 million in debt and repurchased almost 200,000 shares under our 10b5-1 trading plan during the blackout windows. Having retired our expensive subordinated debt and paying down a considerable, considerable portion of the ABL, we anticipate being opportunistic in making additional share repurchases when possible in the third quarter. This brings me to our outlook for the third quarter. We're guiding to revenue of between $440 million and $450 million, representing a sequential decline of 17%-19%, driven predominantly by the softness in travel bill rates and volumes, as well as the impact from summer vacation on our education business. We're expecting adjusted EBITDA to be between $27 million and $32 million, representing an adjusted EBITDA margin of approximately 6%-7%.

As John has mentioned previously, we're managing this business for the longer-term success and not to a single quarter. We continue to believe this business can achieve and maintain high single to low double-digit adjusted EBITDA margins.

Adjusted earnings per share is expected to be between $0.35 and $0.45, based on an average share count of 35.5 million shares. Also assumed in our guidance is a gross margin of between 22.5% and 23%, interest expense of $1.5 million, depreciation and amortization expense of $4.5 million, stock-based compensation of $2.5 million, and an effective tax rate of 30%. That concludes our prepared remarks, and we'd now like to open the lines for questions. Operator?

Operator (participant)

Thank you. We will now begin the question-and-answer session. If you would like to ask a question, please press star one, unmute your phone, and record your name clearly. If you need to withdraw your question, please press star two. Again, to ask a question, please press star one. Our first question comes from Brian Tanquilut with Jefferies. Your line is open.

Speaker 11

Hi, this is Noor in for Brian. Congrats on the quarter. I guess I just wanna take a step back and get your opinion on where you think your relationship with MSPs will be moving forward. Would love to get some clarity on that front. Thanks.

John Martins (President and CEO)

Sure. Hey, Noor, this is John. MSPs are still a vital part of Cross Country's strategy. What we've seen since probably last summer, that the sentiment has changed in the marketplace, where hospitals are moving more towards the vendor-neutral space. That in this industry, that has been cyclical, where throughout the years, it changes, which is the flavor of the day, going back from predominantly vendor-neutral to predominantly MSP. We're in a market right now where it's moving towards that vendor-neutral VMS. Cross Country, we feel very, we're very excited about our prospects in the vendor-neutral space right now and being able to compete in that vendor-neutral space. When we launched Intellify at our Investor Day in September, that was showing.

It was originally when we invested in Intellify, it was to be a replacement for the third-party VMSs we had for MSPs. As we saw the sentiment of the market change to the VMS vendor-neutral space, we were able to quickly pivot Intellify into a vendor-neutral platform. We then, in January, officially launched our Intellify Talent Solutions business, or vendor-neutral business. We hired Eric Christianson, who has been a pioneer in the vendor-neutral space, to come on board. Within, as we mentioned in our, my prepared remarks, in the first quarter, we won our first vendor-neutral deal, and by May, we had implemented that deal, and we are implementing our second deal in vendor neutral.

We're, we're very excited about the prospects about what the vendor-neutral business and Intellify brings to the market, because from what we are hearing from our prospects, our clients that are on it, and, and, and our vendor partners, is it is a totally differentiated model than the other vendor, vendor management programs out there in, in, in the, on the market. We're really excited about that aspect, but we also, at Cross Country, are still working and have a full sales team selling MSPs, but it's really making sure that we deliver to the client what is the model that they want and is going to be most effective for them.

Dan White (Chief Commercial Officer)

Noor, this is Dan. I'm gonna add just a little bit, as John said. You know, our, our pipeline remains really strong, and I would say, just thinking about the mix between the vendor neutral and MSP, there's probably close to 60%-65% that are more in this neutral sort of desired state and maybe 35%-40% in the, in the MSP category.

Speaker 11

All right. Thank you.

Operator (participant)

Thank you. Next, we will hear from Trevor Romeo with William Blair. You may proceed.

Trevor Romeo (Research Analyst)

Hi, good afternoon. Thanks, thanks a lot for taking the questions. First, I kind of just wanted to, to ask about your confidence in demand trends and visibility. Just kind of given the step down in revenue you're guiding to for Q3 and a reduction to the minimum full year guide. Just a couple questions on that front. I guess, one, have you built any extra conservatism into the guide, kind of given the environment? Specifically, could we dive a bit more into that comment about, you know, the gap in order rates and the compensation nurses are seeking? Could you maybe flesh that out a bit more?

Bill Burns (CFO)

Yeah, Trevor, this is Bill. Thanks for the question. I'd start with your first question, which is, you know, do we build in conservatism? I mean, I think we try our darndest to give you the numbers we have the utmost confidence that we can continue to exceed. You know, it wasn't, it was not something we took lightly to, to reduce the min guide to $2.05 billion from the $2.1 billion. In the context of the market, and this kind of gets into the second part of the question, where demand has rebounded, the net weeks booked or how we look at, you know, our production, our weekly production, hasn't bounced up as high as we'd like.

We're just seeing a little bit of a softness in that third quarter going into the fourth quarter. We still anticipate the third quarter as the trough. Now, that min guide that we have, if you squeezed out the numbers to what does that imply for the fourth quarter, you would say it doesn't show a big bounce off of the third quarter. In fact, it's, you know, virtually flat if you took the midpoint of the guidance range. I would not read into that. I still think that the fourth quarter at this point is an upward trend off of the third quarter. That said, you know, there's still some headwinds in the marketplace. We still have bill rate pressures.

If there's one little silver lining, although demand has trended up over since the trough in kind of mid-April, we've not seen a continued deterioration in the open order bill rates. Those bill rates have been remained pretty stable over the last, you know, call it, three-plus months. We're still winding those through our entire book of business, and that's what really gives us the rate pressure going into Q3 and Q4.

John Martins (President and CEO)

I would add, Trevor, this is John Martins, that what we're seeing in, for the second part of your question, is that the nurse pay expectation, there's a disparity between what the bill rates for the hospitals are right now, and it's, it will come to an equilibrium, we believe, in the upcoming months.

Part of that will be as we start seeing the flu orders coming in and demand, potentially spiking higher, we'll see, you know, the bill rate and pay rate equal to where it will be, where both sides will come together to feel that. The, the adequate bill rate and the appropriate pay rate, and that's when we'll start seeing really, the volumes to start picking up, in the, in the back half of the year.

Trevor Romeo (Research Analyst)

Okay. Thanks, John, and Bill, that was a helpful color. I guess, as my follow-up, just kind of on the levels of contingent or contract labor at the hospitals right now, I think some of the public, you know, facility operators have reported in the last week. Sounds like some are kind of comfortable with the levels that they have now. Some might be expecting further moderation. Just kind of wondering if you could give us your view of kind of broadly how your clients are, you know, thinking about the level of contingent staff they have now and, and where they are in that normalization process.

John Martins (President and CEO)

Yeah, I, I think most majority of the clients right now feel that they've gotten to the appropriate levels, where bill rates are trending down, especially the bill rates that we're opening up are trending more down towards that 30%-35% above COVID levels. In terms of volumes, I think that we're still hearing that there is still the need on the floor for more nurses. So I think as we get to that right bill rate, the hospitals are more willing now to see it as a strategic key to bring in travelers to help them grow their, their revenue and volumes.

Trevor Romeo (Research Analyst)

Okay, thank you. That was helpful. Appreciate it.

Operator (participant)

Our next question will come from Tobey Sommer with Truist Securities. Your line is open.

Tobey Sommer (Managing Director)

Thanks. I wanted to ask you about the, the seasonal orders that, that typically come in over the winter, perhaps, for a slightly higher rate. What's your anticipation of how that'll play out? Do you have any visibility into that at this point, or is that still forthcoming?

John Martins (President and CEO)

This is John, Tobey. So it's still forthcoming. What we're seeing right now, we're seeing our clients looking toward to bringing on 26-week contracts that will get them through the early part of the flu season and get them through the new year. We're seeing a trickle of some of the flu or winter needs, and we're seeing more of the 26-week needs. The sentiment we're getting from our clients are that they're still waiting, and it will be a little bit more just in time, if you will, rather than preparing and planning out further, as we've seen previous pre-COVID, of looking and really trying to get ahead of winter needs.

Tobey Sommer (Managing Director)

And just to be clear, as we head into 2024, annualizing that kind of slightly higher, higher fourth quarter revenue number and sustaining an 8% EBITDA margin, is that how we think of that, or is that in, in flux at this point?

Bill Burns (CFO)

Hey, Tobey, it's Bill. Yeah, I think that's a, a good run rate to assume going into 2024. I think, you know, there, there's potential, of course, for some continued bill rate pressure but, you know, not, not expecting. We've been pretty close on, on how we've modeled out the bill rate so far. If that plays out that way, I think that's a good jump-off point. If there is a little headwind, it really comes down to the ability for volumes to offset or the other lines of business that have been, you know, having pretty robust growth, like locum tenens and education and so forth.

Tobey Sommer (Managing Director)

Could you talk about MSP churn, something we've heard about in the industry. A lot of people are describing it, the move to vendor neutral. Even many staffing-led MSPs kind of looking and seeming like vendor neutral at this stage. Love to get your perspective and whether you think we're kind of more than half the way through the post pandemic churn that is likely or there's still a lot to come?

John Martins (President and CEO)

Sure. This is John, Tobey. I think there's, we're probably not halfway through the churn going through out there in the market. The sentiment has turned over the last year towards the vendor-neutral, moving towards vendor-neutral platforms. We've been pretty transparent that we've had a higher churn than we've historically seen as well, and those losses have come to, for the most part, to the vendor-neutral players. And that's one of the reasons, as I mentioned earlier, why it was important for us to launch Intellify, to be able to play in that space and having our first two wins of the year and implementing both of those is key for us to gain market share in that space. It's very typical.

I'll tell you, back right after the great recession in 2008, 2009, we saw a move to vendor neutral at that point as well. Once the Affordable Care Act came into play in 2014, 2015, we saw MSPs become the flavor of the day for about a five year period. Or actually, actually probably through the pandemic, where it was probably a 50/50 split between MSP and VMS, and now it's moving towards that VMS. To your point, yes, even strategically-led MSPs are now looking a lot like vendor neutral. Here's what I'll tell you, why that's not bad for us, and even in some of the churn that we've had ourselves. We have developed great long-term relationships.

Because how we've acted ethically with our clients and how we've performed for our clients over the years, when we do lose a client of churn to a VMS, in most cases, we actually become a preferred vendor or even a Tier 0, which means we actually still receive the orders first. The other thing that we've seen when we do go and have this churn on these clients, is that many times we're only a portion of a large health systems MSP, and there'll be another MSP vendor in there. When they consolidate under one platform, we'll then be able to be Tier 0 in the whole system. We had one last year that we had lost, and now we actually have more travelers on assignment in that former MSP because we have access now to the whole system.

You know, to answer your question, yeah, we're definitely seeing it more towards go-to-vendor neutral. We think we position Cross Country very well with the Intellify rollout. We believe our technology, Intellify, with our internal resource pool, our technology, our apps that all support clients to white label this technology for themselves, to create and utilize Intellify for their own internal travel pools as well, positions us well to capture market share in that vendor neutral space. Dan, did you have something?

Dan White (Chief Commercial Officer)

Yeah, Tobey, I just wanted to add a little bit more color to this idea of churn. It's, it's really important to remember that these contracts, whether they're vendor neutral or not, are typically three years. When you take into consideration that no one was doing anything through the pandemic, it just makes sense, right? That a lot of this activity is happening because it's just sort of supply chain hygiene, if you will, right? To get back on track with that, with that activity. We expect there to be a lot of activity. We see, you know, lots of RFPs and lots of activities coming from all kinds of sources.

John Martins (President and CEO)

This is John again, Tobey. I would just add the other thing is, this is probably the biggest pipeline we've had between vendor neutral and MSP that Cross Country has ever seen. There is a lot of churn in the market, and it seems like healthcare systems are all reevaluating what they're going to do and which model they're moving forward with.

Tobey Sommer (Managing Director)

Thanks for all that, that context. Just as, as a follow-up, are, are you, are you winning or losing share amid all of those, all that pipeline and activity in the marketplace?

John Martins (President and CEO)

You know, right now, I think we probably lost a little bit of share. You know, you have a couple factors, right? You have bill rates coming down, volumes coming down. We're, we're still, you know, well over $1 billion of spend under management in our MSPs, and now we're adding on to vendor neutral. As I think we, we will dip a little bit, I think, you know, this is a long-term game for us, and as we're just getting into the vendor neutral space, I think we'll quickly make that up.

Bill Burns (CFO)

Tobey, it's Bill. You know, look, I mean, I think you, you asked the state question of where we are in the process. I'd say it's, it's still early innings for Intellify. John called out the 50% converted on the MSP program, we've got that much of our spend already live. We've obviously got a roadmap to convert more. By the end of the third quarter, I think that number will be north of 75%, and we've got one vendor neutral live, one being implemented. It's, it's early innings for Intellify, but it's, it's making great strides.

Tobey Sommer (Managing Director)

Thank you.

Operator (participant)

Once again, if you would like to ask a question at this time, you can press star one and record your name when prompted. Our next question comes from Bill Sutherland with the Benchmark Company. Your line is open.

Bill Sutherland (Director of Research)

Thank you. Nice work, guys, on the quarter. Bill, can you go through the 4Q seasonality? Just remind us, I know education rebounds strongly. What else do you see usually?

Bill Burns (CFO)

I'd, I'd say that the businesses that usually see some seasonality in the fourth quarter, locum tenens, and this is historical, not what we expect to play out because there's such tailwinds there. Historically, locums would see a small, low single-digit sequential decline going in the fourth quarter. We're not anticipating that. I would actually say we'll probably see sequential growth going into the fourth quarter in that business. Education, you mentioned, they, they come off of a, a, you know, their, their lowest point of the year. In fact, they'll be down about 25% sequentially, but the growth going into the fourth quarter because of the new school year, that they could be 30%-35% sequential growth. They usually bounce up even higher than they were in the quarter before that. I think we'll see really good growth there.

The travel business, we don't tend to see a lot of seasonality in the fourth quarter for us. Believe it or not, that's actually a little bit of a slower start to the first quarter. Then in our local business, I'd say the holidays tend to impact us a little bit more as you go through, you know, the Thanksgiving and, and the year-end holidays, Christmas, New Year's, et cetera. Those, those are the, the general impacts that we see into the fourth quarter. They, they tend to get muted out. I mean, you have education come back, you have a little bit of headwinds on the local side, and I think, you know, in this case, locum tenens will be a, a tailwind. I, I don't anticipate a, a big seasonal change in the other businesses that's gonna drive the revenue numbers.

Bill Sutherland (Director of Research)

Okay. Hey, John, is your physician staffing business all locums now, or do you still have recruiting and placement?

John Martins (President and CEO)

It's 99% locums. I think there's very, very, very little. It's a 99.5%, probably very high, or Bill can give you that number, but it's majority of it is locums. You know, look, that's one of the areas that we're excited with, along with education and home care, where we're growing those businesses. It's, it's a very good market for locums, Bill. As Bill Burns mentioned, that business is up 32% year-over-year organically, 105% with our acquisitions of Mint and Lotus. We're gonna make-- that business will be a $180 million business. It's interesting when you start looking at the diversification of, of Cross Country.

As we start to grow significantly into locums, become a, a much more major player in the locum space. Our education business is a business that we acquired in 2015, and it has done well historically for us, but on higher revenue, we grew it year-over-year, 42%, and that's a business that will be a $100 million business as well. Our home care business we acquired a little over two years ago, that is a business that will be over a $100 million business. As you start looking at Cross Country and how we've really executed at such a different level over the past four years, it, it's really been an amazing turnaround of what's happened.

Yeah, as we look at our Nurse and Allied business, our Travel Nurse and Allied business, yes, we've had these COVID tailwinds, we believe we've executed at market or above market during the whole pandemic and still to currently to today. As the market is the market in travel nursing right now, obviously, the bill rates have come down and volumes have come down, and we anticipate those to go up through the end of the year. Cross Country continues to execute a very high level. If we look at our nursing, rather, I'm sorry, our locums, our education, and our home care business, those are all executing at a high level. We're very excited about the prospects. Dan?

Dan White (Chief Commercial Officer)

Hey, Bill, I just figured I would add some color since you were asking a little bit about sort of perm placement, if you will. I, I think it's important to note that in addition to whatever new sales we're making, we've had really great success cross-selling into the accounts that we already have. You know, we've had 18 different services added into our client base. Six of those are in that RPO search kind of business, but as John mentioned, you know, interim leadership, locums, are all, all really doing nicely in our, our base accounts. I, I figure I would also add, we had our first home care, you know, PACE program go live also on Intellify. It's really, you know, getting hitting across all of the businesses, locums, our PACE centers, et cetera, are all now on that same tech platform.

Bill Sutherland (Director of Research)

Dan, is that with that Intellify for PACE centers, is that your second vendor neutral?

Dan White (Chief Commercial Officer)

No, that is not a new customer. That is implemented in an existing PACE customer.

John Martins (President and CEO)

This is John, Bill. That is actually a MSO or an MSP. It's technically an MSP, that one.

Bill Sutherland (Director of Research)

Right.

Okay. Allied is, I don't think I got mentioned. I'm just kind of curious, kind of, how that's doing, and the size of it inside Nurse and Allied.

Bill Burns (CFO)

Yeah, I mean, the travel allied side of the business is actually faring quite well. When you look at, at that relative to travel RNs, I'd say that the, the rate reductions haven't been as steep, the volume declines haven't been as steep. It's on track, I would say, you know, to be north of a $400 million business and well north of that. It depends how the year trajectory plays out, it's a good size of the travel business.

Marc Krug (Group President)

Yeah. This is Marc. Just to add a little more. imaging continues to see robust demand, cath lab, X-ray, MRI, we term it the path of the surgery. you know, pre, post, continues to see, very heavy demand. anything related to cardiovascular services, also very high demand on the allied space.

Bill Sutherland (Director of Research)

Then just when we wrap up with just revisiting this situation here with the nurses and their pay expectation. If you're, you're, you're just figuring that, you know, as the recs go unfilled, hospitals get frustrated, they start to put out the, you know, give you the pay rates, so you can actually, you know, fill the rec, that's kind of just the natural progression you're expecting?

John Martins (President and CEO)

I think it's more of a combination. I think, you know, nurses, and rightfully so through the pandemic, right? Going into the burning building as we needed them, their pay had increased during these crisis needs quite high. Now the expectations as these bill rates are coming down, as the pay rates are coming down. I think there's a natural, natural equilibrium that we will hit, where bill rates will still settle in, where we think they will 30%-35% above pre-COVID levels, and the nurses will understand that that's where the market is now of the pay rate. We think that will happen as demand continues to increase.

Maybe hospitals will bring some of their. And I would say, you know, about half our orders that we have on open demand, half of them are probably below the market of where we need to fill, and half of them are probably at or at the market where we need to fill. Those ones that are below the market, yeah, we do anticipate some of those rates will come up, but we also anticipate that the nurses' pay expectation on the higher end of the market will come down more to where the market rates are. Would that make sense?

Bill Sutherland (Director of Research)

Yeah. So what happens with the spread, John, in that case?

John Martins (President and CEO)

The, the spread should have very little impact to us on the gross margin spread, because the nurses' pay will come down as in line with the, with the gross, with the, the pay, with the bill, I'm sorry. With that said, in a tighter market, you know, you, you could see a little bit more pressure on, on margins. But up to this point, we have not seen a tremendous amount of pressure on, on margins. Bill, I don't know if you want to add to that.

Bill Burns (CFO)

Yeah, Bill, I would just add that for the second quarter, we saw bill pay housing spreads. It's important to include that as well, because that was part of what was holding down gross margin on a year-over-year is up over 40 basis points. We're seeing that the bill pay spread is holding up as bill rates are coming down, it is slowing down some of the production, you know, for, for folks making a decision to take an assignment. Those two pieces need to, need to settle into that equilibrium John mentioned.

Bill Sutherland (Director of Research)

Okay. Thanks again.

Bill Burns (CFO)

Sure.

Operator (participant)

Our next question will come from Kevin Fischbeck with Bank of America. Your line is open.

Kevin Fischbeck (VP)

Hey, hey. I just wanted to maybe go back to another question about the visibility that you have. I guess this is the second time you've cut guidance this year. When you think about kind of where that shortfall has, has materialized versus your initial expectations, you know, where has that been? I guess, you feel like, you know, that you have better visibility today on, on that driver, or is that still kind of a in flux, moving target that's, that's hard to, to fully pin down?

Bill Burns (CFO)

Hey, Kevin, it's Bill. Look, I think the expectation was a few months ago that we would see that curve bending on the number of travelers on assignment starting to regrow earlier in the third quarter. We've seen it level off, and we're seeing some modest improvement throughout the quarter, but not to the degree we wanted. That's really what it is. It's, it's coming back to saying the third quarter seems to be, still be the trough, you know, the outlook improving. We have bill rate, bill rates that have stabilized in the market, improving, still improving demand in the backdrop. It, it points to that fourth quarter, and as you get the seasonal needs that we expect, it's been, you know, something we've seen, you know, for every year. It, it is, it is expected to come through.

That'll, that'll give it that extra little bit of uplift that we're expecting to make the fourth quarter, the, that turning point on the volume side.

Kevin Fischbeck (VP)

I guess maybe that earlier point that John made, though, about that some of these orders, these 26-week orders are, people are waiting on it, and that you expect them to be more just in time. I mean, is there a reason why people would be waiting on it, or does that increase the risk that you won't see that seasonal increase that you would normally be expecting?

John Martins (President and CEO)

I think it's two parts. Two parts is we're seeing the 26-week orders come in now as hospitals want to lock in the clinicians longer, but it's for the flu, for the flu season. What we're, what we're seeing is, historically, pre-COVID, we would see these flu or winter orders start coming in in July, and certainly by now, entering August, we'd start seeing them come in in a, in a much more higher volume. That's not happening now, and the sentiment we're hearing from our clients is that they're just waiting, because these orders, while we receive them now, the clinicians will start in the fourth quarter and then into the first quarter. They're just waiting a little closer to see where their needs are going to be and how they want to manage that contingent labor.

The other thing we're also hearing is that, there is, for the RSV, which hit hard last year, there is now a vaccine that is going to come out on the market and get approved. It depends what age group that will be approved for. When the pediatric hospitals find out what age group that'll be approved for, that will also depend on how many clinicians they'll need, because if it's approved for a infant, they'll need less contingency labor. If it's only approved for a five-year-old or older, they will need more. There, there's a couple of factors why they're waiting.

Kevin Fischbeck (VP)

Okay, thanks.

Operator (participant)

Thank you. Our last question will come from A.J. Rice with Credit Suisse. You may proceed.

A.J. Rice (Managing Director)

Hi, everybody. Thanks. I missed at the beginning a little bit, so I'm sorry if I do duplicate this. It sounds like you were down about 9% in travelers on assignment in Q2 from Q1, if I got that right. It sounds like you're saying orders were there, it's just that the people became unwilling to fill those to fill those orders because they had higher expectation on pricing. Is that, is that right, or is this more a go-forward phenomenon that you're mainly trying to call out today?

Bill Burns (CFO)

It's not a perfect correlation, to be clear. I think orders had fell so sharply that the decline in TOA was, was going to happen. We had signaled that last quarter. The rebound in orders is there, but as we said, that we're just not seeing the weekly production ramp as quickly following the order trends. It's, it's a timing issue of building back the travelers on assignment rather than whether there's enough orders. The orders are there, I think, to, to be able to put the travelers back on assignment, but it's a, it's, it's a little bit of what John had talked about, about the pay expectations, relative to the open orders that are there today.

We, we have every expectation that we're going to see the TOA grow as we move through the quarter and as we get into the start of the fourth quarter.

A.J. Rice (Managing Director)

Okay. I mean, there's a couple things, and maybe these are dumb questions, but I'm going to ask. You know, we hear this anecdotal stuff of people on-- that are travelers, and they're making so much money, for nine months, that they take the summer off. Is any of this a phenomenon in your mind that travelers haven't engaged for the summer, and when they come back in the fall, then you'll see more plentiful supply to fill these, some of these orders?

Marc Krug (Group President)

Hey, it's Marc. I mean, we, we see a little of that. I think that's a little overblown. Most of our travelers, you know, will do two or three assignments and take time off. It's not just necessarily seasonal. But, you know, I think the notion that they made all this money, and they're taking the time off, is actually not true.

A.J. Rice (Managing Director)

Okay, okay. Another thing we are hearing from the hospital side is that they're, they're accelerating their hiring of permanent labor. As you run through the people that you've been recruiting for travel assignments, are you finding that a percentage of them are just choosing to go back in this environment and back to their traditional permanent assignment? Is that part of what's going on?

John Martins (President and CEO)

That's not a large part. Of course, there's always a portion of nurses who came into the marketplace during the pandemic, who were not travelers, who now are going back to their permanent jobs. There's I would say there's more nurses that we've gained into the travel nurse pool because of the pandemic, than we've lost going back. So, yes, so there's a small portion that have gone back, but most travel nurses still want to stay in the market and remain to have that flexible workforce and be part of that gig economy.

Dan White (Chief Commercial Officer)

A.J., this is Dan. I, I would add, though, so while it has, you know, I, I'm not disagreeing with anything that's just been said. I would also mention that our RPO customers and our, our, our existing client base absolutely are ramping up their own internal, you know, TA functions and getting better at this. And, and that's an area. You, you might be mixing the two, and you don't necessarily have to.

John Martins (President and CEO)

Well, this is John again, A.J. Yeah, hospitals have done a tremendous job of reducing the contingency spend and bringing on permanent nurses. With that said, there is still such a systemic issue in the shortage of clinicians, nurses in particular, that this is a issue that's not going to be solved by bringing in some of these nurses. The hospitals that are bringing down their contingency labor spend, they're still, in most cases, still double of where they were pre-COVID. There's still a lot of need for contingency labor and, you know, frankly, especially as Dan was saying with our RPO business, there's still a lot of need for more nurses to go back permanently into the perm jobs. I, I think, you know, this is why we're very excited and very bullish upon our industry.

While travel nursing has normalized, moving back to normalization during COVID, and now we're seeing where the bill rates will, in the next couple quarters, will come and plateau, and we'll be 30%-35% above pre-COVID levels. We're seeing demand start to tick up, and we'll get that equilibrium for the pay and the bill balance. We'll start to see those sequential growth throughout the back, you know, during the back half of the year. What excites us and why we're bullish is because the systemic issues aren't going away. Whether it's the BLS data or the reports, the surveys are coming out, there's just not a solution that will solve this problem in the near future.

A.J. Rice (Managing Director)

Okay. Let me just ask one other one. On the comment about seeing more hospitals being willing to consider vendor-neutral alternatives to MSPs and so forth, and you're getting called in to bid on that. I wonder, did you have perfect view before, before you had Intellify? Because it seems like to me, Intellify has made you competitive there and really upped your game on the vendor-neutral side. I'm wondering, are you just seeing more of what may have, in some ways, already been out there? Or is it really indeed a big shift in the way people are thinking about whether they want to try a vendor-neutral or not?

John Martins (President and CEO)

This is John, A.J. We have more visibility now to all the programs that hospitals are wanting than we had before, because prior to having Intellify, we didn't have a vendor-neutral offering. So when our sales teams, and we have, you know, multiple sales teams going in from a vendor-neutral perspective and from a MSP perspective, when we didn't have the vendor-neutral sales team, when we were calling in with the MSP, if a client didn't want an MSP, we were essentially shut down. Now that we have two different offerings, we're able to go and have visibility onto which of the clients that are focusing on having a vendor-neutral VMS. We're getting a seat at that table. Dan, did you want to add something to that?

Dan White (Chief Commercial Officer)

Sure. A.J., you might also think about it this way: many customers who went into the pandemic with a vendor-neutral solution are now coming to us saying, "Gosh, I wish I had more support and more services." Whether, you know, that's a traditional staffing-led MSP or just, you know, some additional set of services, they're coming to us with, "I wanted something different than, you know, what I had going in." I think a lot of this is just customers, number one, having to go to market, and number two, seeing alternatives out there that they might not have had before. You know, I'll, I'll use the example of an internal resource pool. That really-- the technology for that really wasn't, you know, that available prior to the pandemic, and a lot of us have built some pretty sophisticated tools now that allow them to do that.

You know, coupling on those and, you know, internal travel agency capability and a just a lot more sophistication, it you know, it's very hard for me to just tell you that: Oh, this one is purely vendor neutral, and this other one is purely a traditional MSP. It's just not like that anymore. We have a much more sophisticated and, you know, and needy in, in the proper sense, client.

A.J. Rice (Managing Director)

Okay, great. No, that's helpful. Thanks so much.

Dan White (Chief Commercial Officer)

Uh-huh.

Operator (participant)

Thank you. Ladies and gentlemen, this does conclude the Q&A period. I'll now turn it back over to John Martins for closing remarks.

John Martins (President and CEO)

Thank you, Sheila. In closing, I'd like to thank everyone for participating in today's call. We look forward to updating you on the progress of the company on our next call.