US Physical Therapy - Q2 2024
August 14, 2024
Transcript
Operator (participant)
Good day, and thank you for standing by. Welcome to the U.S. Physical Therapy second quarter 2024 earnings conference call. At this time, all participants are in a listen-only mode. After the speaker's presentation, there will be a question and answer session. In order to ask a question during the session, please press the star key followed by the number one on your telephone. Please be advised that today's conference is being recorded. Should you require any further assistance, please press star zero. I'd now like to turn the call over to Chris Reading, President and CEO. Please go ahead, sir.
Chris Reading (CEO)
Thanks, Jamie. Good morning, and welcome everyone to our second quarter 2024 U.S. Physical Therapy earnings call. With me on the line this morning, I've got Carey Hendrickson, our Chief Financial Officer, Eric Williams, our President and COO, East, Graham Reeve, our Chief Operating Officer, West, Rick Binstein, our Executive Vice President and General Counsel. Before I make some prepared remarks relating to our quarter and year, I'll ask Jake Martinez to cover a brief disclosure.
Jake Martinez (Head of Investor Relations)
Thank you, Chris. This presentation includes forward-looking statements which involve certain risks and uncertainties. These forward-looking statements are based on the company's current views and assumptions. The company's actual results may vary materially from those anticipated. Please see the company's filings with the Securities and Exchange Commission for more information. This presentation also contains certain Non-GAAP measures as defined in Regulation G. The related reconciliations can be found in the company's earnings release and the company presentations on our website. Chris?
Chris Reading (CEO)
Thanks, Jake. So let's get started. My discussion this morning will cover a variety of highlights. We've definitely made some progress in some key areas. It will also touch on one of our primary challenges as well. Let's start with the fact that this was a very solid quarter from volume perspective, the best visit per clinic per day quarter in our history. April was our high month at 31.2, marking a high also for the year, followed by May, nicely over 30, June, just under 30 at 29.8. And all this follows our normal seasonal progression, with school finishing and summer vacations kicking off for a bit before things get back to normal, as they've begun to do with school starting up here in Texas this week in many places.
Speaking then to our expectations, our total visits are ahead of where we budgeted them to be the midpoint this year, better by approximately 6,600 visits and ahead of last year, same period, by over 108,000 visits. Our partnerships are doing a great job addressing demand and doing, and doing a terrific job with patients in what continues to be a rather tight labor market. More on that in a minute. Big kudos are due to our contracting team. We're starting to see their hard work over the past 18 months really beginning to bear fruit. Net rate for the quarter progressed nicely and finished at $105.05 per visit, up a little bit more than $3 per visit over the same quarter in 2023.
As you might remember, last year, we renegotiated a large volume of commercial and work comp-related contracts. While those adjustments took a little time to phase in and show up, they're doing so now in a really nice progression that we are seeing and expect to continue as the year goes forward. We have also seen our work comp volume move up, and while the aggregate percentage has changed a little, it really shows up when you see the number and rate of year-over-year change in work comp visits, which I'll have Eric cover as we open it up for a discussion after these prepared remarks. The combination of rate for commercial plans and our faster than average work comp growth is resulting in a very nice uptick in our net rate so far for the year.
And actually, we expect that to continue as we go forward. On the injury prevention side of things, we had a very good quarter. Revenues grew by more than 23%. We also saw a nice margin improvement of about 70 basis points to 21.4%, with an increased profitability of more than 27%. And I was just out in Denver, spent a few days with our Briotix partners. They're working to integrate our recent Atlas acquisition. That opportunity is going very well, and the integration of our teams is progressing nicely with what I think will be some enhancements that will be beneficial to us in the long run once this combination is fully complete. Both of our injury prevention partnerships, East and West, are doing well in gaining new customers and have a better than expected, better than budget trajectory on the year so far.
Where we have more work, and frankly, we are behind where we expected to be at this point, and really our primary point of struggle is around our PT-related costs for labor. Carey will cover the per visit and percent of revenue costs in detail, but the sum of it all is that the people we have hired this last year and likely in the period slightly preceding that are at a higher rate given inflation and employee scarcity than we've experienced in the past. Therapists overall are about 4% more on average before incentives. Front office personnel are about 5% more. Additionally, in a handful of markets, we have greater than expected use of contract and travel-based labor. That obviously has hurt us in impacting our performance and our margin, despite the strong gains in net rate that we've made.
It's a little bit of a two-edged sword in that we have good demand in and across most of our partnerships, and addressing that immediate demand in the current environment has necessitated that we bring on more contract labor than we initially envisioned. Our ops teams are very aware of where we are and where we would like to be, and working hard to ensure that we have the staffing balanced appropriately for the season, and we have sufficient resources to meet the demand, but remain highly efficient at the same time. Additionally, we have made numerous investments in the areas of recruiting that we expect to bear fruit, and some longer term initiatives with respect to school relationships, partnerships, and affiliations.
These are all things you should expect us to be doing over the coming months and quarters as we look to readjust to the market factors that are currently influencing our outlook for the remainder of the year. Let me say this: while I know our cost issue is an unfavorable development we have to overcome, when you look at our key focus areas over time, we have a very good history of overcoming obstacles. We have a dedicated and capable group, capable group of partners and great ops team, all of whom are working to get this dialed in over the coming period. One final note: we're busy and remain committed on the development side of things.
A few of our deals have pushed out a little bit due to factors that we don't control on the seller side of the equation, but rest assured, we are working hard and we expect a strong finish to the year for our development efforts with some exciting markets and partners who we are anxious to make part of our family as we look ahead. That concludes my overview and prepared remarks. Carey, as he always does so well, will cover the detail behind these themes. Go ahead, Carey.
Carey Hendrickson (CFO)
Great. Thank you, Chris, and good morning, everyone. We saw some really good things inside of our numbers for the second quarter, things that we expect to continue to benefit us through the remainder of the year and beyond. Chris mentioned some of them in his remarks, but they're particularly notable and worth repeating a few of them. Our hard work on rate negotiations and our focus on increasing workers' comp as a percentage of our overall business continued to take root in the second quarter, resulting in a substantial year-over-year increase in our net rate. Also, our average visits per day in the second quarter are a record, record high for the company, and our IIP business grew at a mid-teens rate in the second quarter, even before adding the acquisition that we made on April 30.
Our salaries and contract labor were higher than we would have liked in the quarter, but the business itself is strong as we continue to see meaningful growth in these key indicators. We reported Adjusted EBITDA for the second quarter of 2024 of $22.1 million, compared to $23.6 million in the prior year. Our Adjusted EBITDA margin was 16.4% in the second quarter of this year, compared to 17.7% in the second quarter of the prior year. Traditionally, most calculate our EBITDA margin without the benefit of knowing what our adjusted revenue per minority interest is, which makes it appear that our margin is lower than it actually is.
This Adjusted EBITDA margin that I just quoted, the 16.4% for the second quarter, is calculated on an apples to apples basis, with both revenue and EBITDA adjusted for minority interest. Our operating results were $11 million in the second quarter of 2024, which is an increase of $600,000 over the second quarter of 2023. On a per share basis, operating results were slightly lower than 2024 than 2023. It was $0.73 this quarter and $0.76 in the second quarter of last year. That small decrease is related to the increase in shares that were associated with the secondary offering that we completed in May of last year. Our average visits per clinic per day in the first quarter was 30.6, which is the highest volume for a quarter in the company's history.
Chris noted what the progression was throughout the month. The lower number in June, as he mentioned, is our typical seasonal pattern, as both patients and our clinicians take vacations and, you know, the, the schedule just changes a little bit in the summer there for families. In July, our average visits per day was 29.8, which is consistent with July of last year, and it's in sync with our seasonal expectations. Our net rate was $105.05 in the second quarter of 2024, which was $3.02 per visit, or 3% higher than the second quarter of last year, even with another 1.8% Medicare reduction by CMS that was in effect in the second quarter of 2024.
This was the highest quarterly net rate we've had since 2020, while enduring four Medicare rate reductions by CMS since that time. Excluding Medicare, our rate was up $4.80 per visit, or 4.5% over the second quarter of last year. The increase was largely related to our strategic priority of increasing reimbursement rates through contract negotiations with commercial and other payers, and our focus on growing our workers' comp business. We're also focused on maximizing our cash collections through improvements in our revenue cycle management. Each of our major category of payers increased year-over-year. Workers' comp, which is one of our highest rate categories, increased from 9.6% of our revenue mix in the second quarter of 2023 to 10.1% in the second quarter of 2024.
These rate-enhancing initiatives will remain high priorities throughout 2024 and beyond. Physical therapy revenues were $143.5 million in the second quarter of 2024, which was an increase of $11.2 million, or 8.5% from the second quarter of 2023. This increase was driven by having 25 more clinics on average in the second quarter of 2024 than in the second quarter of last year, as well as an increase in our visits at mature clinics and of course, the increase in our net rate.
Physical therapy operating costs were $114.7 million, which was an increase of 10.3% over the second quarter of last year, due in part again, to having 25 more clinics on average in the second quarter of last year, as well as the increases in salaries and wages and contract labor costs that we've mentioned. On a per visit basis, our total operating costs were $84.46 in the second quarter, which compares to $80.61 in the second quarter of 2023. Our salaries and related costs per visit were $59.66 in the second quarter of 2024, compared to $57.59 in the second quarter of 2023. Our physical therapy margin was 20.1% in the second quarter of 2024.
As Chris noted, our IIP team produced excellent growth in the first quarter. IIP net revenues were at $4.5 million, or 23.2% over the second quarter of 2023, with IIP income up $1.1 million or 27.4%. Excluding the acquisition that we closed on March 31, 2024, our net revenues were still up 13.5%, with our gross profit up 15.7%. Our IIP margin increased from 20.7% in the second quarter of 2023 to 21.4% in the second quarter of 2024. Our corporate office costs were $14.2 million, which is 8.5% of revenue, right in line with expectations in the second quarter of 2024.
That compared to $12.1 million, or 8% of revenue in the second quarter of 2023. The second quarter of 2023 included a downward revision in our bonus accrual, causing it to look a little bit better as a percent of revenue than in the second quarter of this year. Our corporate costs in the second quarter of this year were actually lower than our budget by about $400,000. Quickly turning to our balance sheet, it continues to be in excellent position. We have $142.5 million in debt on our term loan, with a swap agreement in place that places the rate on our debt at 4.7%, which you know is a very favorable rate in today's market and well below the current Fed funds rate even.
In the first half of 2024 alone, the swap agreement saved us $1.8 million in interest expense, with cumulative savings of $5.1 million since the third quarter of 2022 in interest expense. In addition to the term loan, we also have a $175 million revolving credit facility that had nothing drawn on it during the second quarter. That's all available capacity. We have approximately $90 million of excess cash over and above what we need for working capital, ready for deployment into growth initiatives. We deployed $40 million of cash and acquisition so far this year and expect to deploy more before the end of the year.
As we noted in our release, we're updating our EBITDA guidance for full year 2024, returning to our original range of $80 million-$85 million. The change in guidance reflects our updated expectations for salaries and related costs and contract labor through the remainder of the year, related to the continuing challenging employment environment, particularly for our clinicians and our front office staff. We expect our patient volumes to continue to be strong during 2024, and we expect to make additional progress on net rate throughout the year. With those details, Chris, I'll turn it back to you. We'll take questions.
Okay, Carey, great job. Thank you. Jamie, let's go ahead and open it up for questions.
Operator (participant)
Certainly. At this time, if you would like to ask a question, please press star one on your telephone keypad. Should you find your question has been answered, you may remove yourself from the queue by pressing star two. Once again, that is star one to signal for a question and star two to remove yourself. We will pause for just a moment to allow questions to queue. We'll go first to Brian Tanquilut with Jefferies. Please go ahead.
Brian Tanquilut (Analyst)
Hey, good morning, guys. Good morning. Chris, maybe I'll start with you. So the labor challenges that we're seeing here, right? I mean, I guess two questions. It doesn't seem like it's impacting your ability to drive volume growth. So is this just a matter of basically a reset in the baseline for what your therapists are making? And then maybe the second part of the question would just be: You know, how are you thinking about strategies and initiatives to drive and improve that labor, you know, situation?
Chris Reading (CEO)
Yeah, good, two good questions. So, first part is, you know, the, the perspective that it, that it hasn't impacted our volume because the volume's been pretty good. I think it has impacted our volume in a negative way. I mean, it's... You know, we're, we beefed up our recruiting teams. We're doing better, but we still have markets where, you know, if, if somebody does leave us and turnover has been good, if somebody does leave us, they relocate their family to, you know, to another state or another place, it takes a while to fill that spot, and we do feel it. And so I think if the labor market eases, I think it reciprocally will have a, you know, a, a, a further uplift on volume. But demand is good.
Look, the operations team, it's a tough balance, particularly as we have gone into, you know, and through now vacation season, with our staff working hard to deal with the volume that they have and, you know, the necessity to bring in some other or ancillary staff to fill those gaps to keep volume up. Ops team's very aware of it, Eric and Graham and our regional presidents. And it's, you know, tough, but we've got to just keep everything very dialed in. We had a greater number of techs hired in the period than I kind of expected, so they're digging into that a bit. That may just be a seasonal thing, and we're coming out of that season now that school's back in.
And then just on the demand side, you know, anytime that there's pressure around hiring, the tendency is to pay more, to just lock it down. And so we need to do a better longer-term job on widening the funnel. And so we're making some adjustments and some investments in the part of our business that really interfaces most closely with the PT schools around the country and offering, you know, I think a wider complement of things that we can do for those programs to help them and reciprocally help us as well. And so that's a little bit longer-term program and project, but all those things are in the works right now.
Brian Tanquilut (Analyst)
Okay, that makes sense. And then maybe just my follow-up question would just be on turnover. Are you seeing any change there, and is... Or is that something that's just stable, and then what we're seeing is just kind of like a replacement cycle that's consistent with historical trends?
Chris Reading (CEO)
Yeah, I think as turnover, it's been actually been pretty steady. Steady meaning it's been good, you know, for the last year and a half, two years. We've I think the group's done a good job on that. You know, where we've seen pressure is, you know, this year we gave probably larger than average raises just because people were pressed, and the market's tight, and it's very competitive. And then the newer people coming in, you know, we know we're paying a bit more than we were a couple of years ago, and so I think it's that combination.
Where I think we're going to have to retest, and I don't know that it'll be on the clinician side of the market, but, you know, on our hourly wage area in our front desk and looking maybe for some more efficiencies there, or retesting the you know, the numbers that we've been paying this last year to see if we can, now that inflation has abated a bit, to see if we can get those back down a little. And so all those factors, along with making sure, and our cash flow's been fantastic, our collections have been really good, and our executive who handles that area is doing a great job and just making sure we're as efficient as we need to be and can be on the backside of our operations as well.
And so that, in combination with the fact that I expect that we'll still see some more rate growth, I'm really pleased with, you know, all of, the reports and, and how that is lining up. And Carey and I both expect to see that to continue to progress, you know, over the coming period. And so it's gonna have to be that combination of operational focus, you know, seeing what we can do in terms of rate at the front desk and some efficiencies in some other areas, and hopefully, we can get it down a bit.
Brian Tanquilut (Analyst)
Awesome. Thank you.
Chris Reading (CEO)
Thanks, Brian.
Operator (participant)
We'll hear next from Larry Solow with CJS Securities. Please go ahead.
Chris Reading (CEO)
Great.
Lawrence Solow (Analyst)
Thanks, Kim. Good morning, Chris. Good morning, Carey. I just wanted to ask just a question on the volumes and maybe a little bit of a follow-up to Brian's question just on the staffing constraints. So for volumes, they're, you know, as you, you know, pointed out, at record levels in a seasonally strong quarter. Just curious of, like, if we look year to date, we're, we're pretty much flat, right, on a same-store basis. I know Q1 was maybe it's a little unfair because there was some weather, but, you know, so you've grown 2%-3% volume in the last 10 years. So is there... You know, as we get above this 30 per visit per day, and I've asked this question before, are there constraints?
I mean, clearly, it sounds like, I would guess staffing is one of them. You know, just, and you did mention that volumes are sort of in line with your expectations. So do you kind of bake in a, you know, a little bit of a slower volume year this year, or just, just any color around that would be great?
Chris Reading (CEO)
Yeah, I don't think 30 is the threshold for anything. You know, I mean, a lot of our workforce are part-time, you know, regular, committed part-time, but part-time, moms that are working, you know, part-time with kids still at home, other things. And so we do have the ability to flex staffing, assuming that staffing is available and people are available, and I think that's been the biggest limiting factor so far this year. And you're right, we're flat on the year after having a lighter than expected first quarter. Second quarter came in about where we expected. It was a little bit lighter in June than I think we had modeled, particularly after a strong April. But volume, generally speaking, demand for new patients is there.
We just have to be able-
... to adjust it from a staff perspective. And so I don't think this is a ceiling for us. We certainly don't have a ceiling from... a facility standpoint, when you look at physical plant and things like that, and, you know, it's all about creating incremental staffing so that we can continue to grow.
Lawrence Solow (Analyst)
Right. And I'm pricing. You've done a great job, obviously made some good strides. It feels to me like hopefully, you know, you continue to negotiate and renegotiate, right? Because physical therapy, as we know, is a cost saver, right? And with these inflationary pressures, you should be able to go back, and some industries are getting so much more price, right? So I feel like you guys have, right?
Chris Reading (CEO)
Had 4 years worth of cuts.
Lawrence Solow (Analyst)
Right. And just on the Medicare side, any update there? I think they came out with their proposals. Maybe this is the last year of proposed cuts. Any thoughts longer term, maybe, you know, going to a CPI-based index pricing on the government side?
Chris Reading (CEO)
Yeah.
Lawrence Solow (Analyst)
Anything there... Yeah.
Chris Reading (CEO)
But that's what we're supposed-- That's what's supposed to happen now in the, in the interim period, this, this comment period following the July release. You know, we're, we're pressing hard. I mean, having five years' worth of cuts, you know, in a row, in succession, it just, it, it makes making operational adjustments very, very difficult. And I think we've squeezed and, and maneuvered and managed, you know, not perfectly by any stretch, but I think pretty well. And yet, I don't know that I can name another industry that's had, you know, maybe home health in some stretches, you know, this kind of punishment unnecessarily. It all frankly comes from a mistake that MedPAC made when this all began, where they didn't realize that physical therapy was part of the code set that they were impacting.
They thought they were impacting interventional pain management specialists, PM&R doctors, and orthopedic surgeons, the guys at the top of the food chain. And, you know, it's unfortunate, but we're in it. We're almost out the other side. I can't imagine that this is going to continue without some reversal. And we're spending a lot more time in D.C. with the lobby group, our industry group, APTQI, with the APTA, with our congressmen and women. And hopefully, once this election cycle is through and, you know, we get some daylight on the other side and people can focus on governing, you know, we can make some progress.
Lawrence Solow (Analyst)
Got it. And the proposed cut, I guess, for 2025 is, I believe, just on the, similar to the initial proposal for 2024, just under 3%. Is that right?
Chris Reading (CEO)
Yeah, I think that.
Carey Hendrickson (CFO)
Five percent.
Chris Reading (CEO)
I think that.
Lawrence Solow (Analyst)
2.5%.
Chris Reading (CEO)
Okay.
Lawrence Solow (Analyst)
Yeah. All right. Okay.
Carey Hendrickson (CFO)
And just lastly, hard-
Lawrence Solow (Analyst)
Yeah. Yeah.
Carey Hendrickson (CFO)
Go ahead, Larry. Go ahead.
Lawrence Solow (Analyst)
No, no, go ahead. You, your comment. I just had a quick question, a random one. Just go ahead. What was your thought there?
Carey Hendrickson (CFO)
I was just saying, in the meantime, you know, we're working, we can't control what Medicare does, what CMS does, unfortunately. But in the meantime, we're trying to control what we can control, and that's putting a lot of effort towards contract rate negotiations in for commercial, for workers' comp, for other things. We're seeing really good progress there. And you'll remember, when we did these negotiations, many of them, we built in three-year step increases, so they continue to produce fruit, you know, each year, you know, to have continual step increases in our rates. So that's good, and that's going to benefit us going forward. It's already benefited us.
We're seeing, really starting to see the impact of it now, and I'm pleased with our team that's done a really good job on that, as well as the increase in workers' comp, that you know, the number of visits in particular, and as a percent of our mix, it's a really good thing because that's one of our highest rate categories. So, you know, we're working hard to move that rate, even with the pressure from CMS.
Lawrence Solow (Analyst)
Great. I was just going to ask you to start to hog the ball, but just with the Hurricane Beryl, I know it caused a little bit of a lateness in your results and some shutdowns around in the Houston area. I know you guys have a decent amount of facilities down there. Was there any volume impact we should expect in the future? Thanks.
Carey Hendrickson (CFO)
We lost about 2,600 visits as a result of that, but I noted in my comments that our average visits per day in July was 29.8, so it's still right in line with what June was and, you know, right in line with our expectations and right about the same place it was last year, in July of 2023.
Lawrence Solow (Analyst)
Great. I appreciate all the color. Thank you.
Chris Reading (CEO)
Thanks, all.
Operator (participant)
We'll go next to Joanna Gajuk with Bank of America.
Joanna Gajuk (Analyst)
Hi, good morning, everyone.
Chris Reading (CEO)
Good morning.
Joanna Gajuk (Analyst)
Thanks so much. Hey, thanks so much for taking the question here. So I guess on the labor, since, you know, very topical here, but my question is, you know, because to your point, you know, you've been hiring these workers for a year or maybe even longer at this higher rate. So my question is, like, why such a surprise on labor during this quarter? Right, I mean, you've been talking about, like, you know, staffing improving and turnover below the industry, which I guess that still holds, but I guess, you know, why were you so surprised with this quarter? Why, I guess it didn't transpire, you know, in Q1?
Chris Reading (CEO)
Yeah... Go ahead, Carey.
Carey Hendrickson (CFO)
I was just going to say one of the things that play into, I think, is we expected to be able to transition from contract labor to permanent employees in some of these markets that we're really challenged with. And so, that would have helped us, but we had higher contract labor and, you know, that was part of the equation. But Chris, go ahead.
Chris Reading (CEO)
No, I think, you know, I think part of it was we had a really strong April. A really, really strong April. And spring quarter is usually a very strong volume quarter for us. And I think the combination of starting the quarter, you know, with a lot of demand resulted maybe in us having, you know, slight increments here and there of staff, you know, beyond where we needed as the quarter progressed. You know, we're still peeling this onion a bit. As Carey said, we have a handful of markets that kind of stand out as markets where at least I believe that we shouldn't have as much contract labor as we do.
We should be able to find, you know, long-term employees that, you know, are committed and part of our staff. We have good teams there, but for whatever reason, we're struggling in those handful of markets. And so Eric and Graham and the rest of the team, meeting with partners, working on that. We're trying to look at some of the underlying factors. But, you know, as Carey mentioned, we didn't expect to be carrying as much of contract labor as we have. Then, honestly, you know, I thought as inflation began to subside a bit, we could get our offered hourly rates down. I don't know that we've seen that transpire yet, but we're gonna have to test it, because I think, you know, particularly at our front desk, we're too high.
And we're gonna have to see what we can do there. And so combination of factors, I wish it was perfect. It's not, of course, and we have to make some adjustments.
Eric Williams (COO)
Chris, this is Eric.
Carey Hendrickson (CFO)
Oh, go ahead.
Eric Williams (COO)
The only other comment I would add to that is, while our turnover rate is low and we are backfilling clinical and nonclinical positions at a high rate, there's also an impact on the existing staff within the business. I mean, when you start bringing in newer people, potentially less experienced, it does have an impact in terms of doing market adjustments to hang on to existing staff. So it's something that we're battling right now. There's no question, I think there's a couple of things that we're in the process of doing now that will have an impact for us.
We're certainly going, to Chris's point, where we saw labor adds in the business, taking a hard look at ensuring that the productivity we have within that clinic is consistent with our staffing ratios for clinical and non-clinical staff. So the people that added staff, did we get the volume to leverage, you know, those additional expenses? I will say that looking a little bit deeper in this, and to Chris's point, we still are peeling the onion a little bit. The 23 de novos that we had in place didn't lever costs as effectively as they should, so we're in the process of evaluating those businesses to see what we can do in terms of changing their trajectory.
We did expect them to, to contribute a little bit more than they did from a net income perspective, so that's a place we're gonna have to revisit. There's no doubt that the additional resources that we're putting in here will help us, and particularly in recruiting, are gonna help us. I think we've added roughly a 40% increase in recruiting staff to help us in those problem markets where we've over-relied on contract labor. So I think those additional resources will help us there. And my hope is the additional resources will also decrease fill times to bring PTs on board where we do have turnover, because to Chris's point, there is a volume impact associated with turnover that's reflected in these first two quarters of numbers for us.
It's an area that we're just gonna continue to have to focus and invest in, and going forward here over the balance of the year.
Joanna Gajuk (Analyst)
This is great. Thanks, thanks so much. And if I may, it sounds like there are, I guess, a handful of markets that would stand out. So, and I guess the question there is like, you know, did something change competitively? Are you seeing, like, more competition from other therapy providers, you know, physical therapy, or is it nursing homes, or is there anybody else that, I guess, changed their behavior that made it kind of more competitive?
Chris Reading (CEO)
Yeah, let me, let me take that, I think. We're seeing young people come out of school right now. Now that, you know, some years ago, everybody moved to mandatory doctorate program, seeing younger people come out of school with higher and higher levels of debt. I mean, those of us who have kids in college, we know that the progression for just general college, let alone graduate-level programs, has increased every year. And so what we're also seeing, which differs from, you know, years and years ago, is we're seeing people with debt levels that are so high that while when I came out of school, I knew the only thing I wanted to do was orthopedic outpatient physical therapy.
And while some of these kids would like to be in the settings that we offer, because they're fantastic settings, they have to go where the money's the highest. And so in some cases, it may mean a hospital, it may mean a physician-owned practice, it may mean, you know, home health, nights and weekends. And so, you know, while the competitive market hasn't necessarily seismically shifted. What has shifted is the amount of debt that these kids have and the necessity to make choices that are purely based on, you know, how many dollars they can put in the bank at any given time. And we haven't been a profession that's been driven that way, but, you know, we're seeing more and more people that, you know, are faced with those realities.
We've got to, you know, as an industry, we've got to adjust.
Joanna Gajuk (Analyst)
Thanks for that, color. If I may, last one on this topic, and I guess my last question. So you also mentioned that you look to obviously try to, you know, manage down the costs, but you also mentioned some efficiencies. So can you maybe elaborate a little bit, maybe Eric can chime in, in terms of, like, what exactly you can do to kind of, you know, improve, like, the efficiencies, which would result in, you know, improved labor? Thank you.
Eric Williams (COO)
Well, that's definitely volume. I mean, volume, volume is our, is our best way to leverage our costs. But the point that I was referencing earlier is, you know, going back and taking a look at where we had headcount adds, particularly in the tech and front office space, which is where a lot of our headcount adds did take place, and making sure that those clinics with those additional heads are really at the threshold that we would expect from a visit perspective to support that kind of staffing. So that's a clinic-by-clinic analysis that's going to result in, you know, if we're overstaffed, shuffling people around and putting them in the right place, or taking labor out, in the event that they don't have the volume to support it.
Joanna Gajuk (Analyst)
Great. Thank you so much.
Chris Reading (CEO)
Thank you.
Operator (participant)
Our next question will come from the line of Jared Haase with William Blair. Please go ahead.
Eric Williams (COO)
Good morning, Jared.
Jared Haase (Analyst)
Hey, good morning, and thanks for taking the questions. Carey, maybe for you, I just want to make sure I understood kind of the, you know, going back to the original guidance range for Adjusted EBITDA for the year, some of the assumptions in the second half of the year, just want to understand kind of the puts and takes there. Is that largely reflecting those swing factors in the labor environment in the second half of the year, or anything else that you'd call out in terms of assumptions for the guidance? And are you assuming further increases in labor costs for here, or is that largely, you know, kind of based on current trends?
Eric Williams (COO)
The guidance, it includes. It's based on current trends in our labor, and that really is. There's really no impact on the revenue side. We're doing what we thought we'd do from our previous guidance and forecast on that side. It's just on the cost side, we had to bump it up a little bit to kind of reflect what we've seen so far this year.
Chris Reading (CEO)
Carey, if I may, I want to add one thing.
Eric Williams (COO)
Yeah.
Chris Reading (CEO)
When we originally did guidance, we had a pretty good-sized deal that we had, you know, close to done, and we had baked in, and unfortunately, as life happens sometimes, one of the owners went and probably is still going through a difficult divorce that put the kibosh on that opportunity. And so that, in combination with some of the other factors that we've discussed at length here, but that was a pretty good chunk of both revenue and EBITDA that we expected to be in the door by the end of June, but, you know, we had to adjust that.
Jared Haase (Analyst)
Understood. That makes sense, and that's helpful. And then I guess just as a follow-up, maybe taking a step back, this is a bit more of a strategic question, but, you know, I'm curious how you think about the balance between growth and profitability going forward. You know, obviously, you're seeing strong demand and very nice volume trends. That, of course, is leading to some of the incremental contract labor utilization to help support that. Would you, do you start to consider at all kind of pivoting the strategy a bit and maybe capture a little less volume growth, but you have a little bit more stability on the expense side?
Chris Reading (CEO)
Yeah, you know, it's tough. I mean, it's a fair question. It's a good question. You know, we're in the service business to take care of people, and so when somebody's at your door, and they've had surgery, and they want to be seen, we just, as caregivers at heart, we have a hard time saying no to that. And so generally speaking, you know, most of our facilities, probably with a few exceptions, we don't have waiting lists. They don't have, you know, a lot of patients that they turn away. You know, it's not to say that we shouldn't look at our mix of patients and how we prioritize, you know, based on acuity and maybe even based on, in some cases, payer dynamics, you know, who gets to the front of the line.
And we're having to look at all those things, quite honestly, to make sure that, you know, over the next 10 patients come in, aren't patients that are just barely above, you know, our cost to deliver care. You know, we've got to be focused. That's why the focus on more comp has been so important. And I guess on that, just to create some perspective, I'd like Eric to talk a little bit about the growth in that comp area, because I do think it relates to your question and how we prioritize what we do and, you know, when we make step adjustments and other things. Eric, you want to touch on that?
Eric Williams (COO)
Sure. Yeah, sure. I'm happy to talk about that. I know it's been a focus of our quarterly calls here for a little while. There was a lot of work that was done to really, you know, properly position the organization to grow work comp. You know, Carey referenced it, you know, work comp went from 9.6% of revenues Q2 last year to 10.1% this year. And while that may seem relatively slow or light when compared to what work comp percentages looked like in the past, we're making substantial strides in terms of visit growth. Our visit growth in Q2 on work comp was 12.6%. We're running about 9.3% year to date, so this category is growing really, really well.
I think it's directly tied to, you know, the, the efforts we've had in terms of substantially increasing network participation. And we have another nine work comp contracts that are going to be coming online here in Q3 and Q4, that I think will further drive growth in the work comp category. And it's absolutely our highest paying segment of the business and growing well. So it's, it's gone, it's gone great, and I think it'll continue to grow going forward as we move through the year.
Chris Reading (CEO)
Yeah. Thank you.
Operator (participant)
Any additional questions, Mr. Haase?
Jared Haase (Analyst)
No, that, that was great. Appreciate all the color.
Eric Williams (COO)
Thank you.
Operator (participant)
Once again, ladies and gentlemen, if you would like to ask a question, please press star one on your telephone keypad. We'll go next to Michael Petusky with Barrington Research. Please go ahead.
Chris Reading (CEO)
Hey, Mike.
Michael Petusky (Analyst)
Hi. So I guess I wanted to circle back in terms of things that you can do. I know that you guys have done some initiatives in terms of automation, you know, particularly with the front desk, and I'm just wondering, have you guys sort of maxed out what you're going to do there, you know, can do there? Or is there more that can be done to sort of maybe alleviate some of the pressures you're feeling around labor in that part of your business?
Chris Reading (CEO)
Yeah, I don't think we're maxed at the front desk, Eric. I don't know if you or Graham want to touch on that, but, you know, we're still, fortunately and unfortunately, I think we still have opportunity there, and we're early innings yet, I think on some of that automation change.
Eric Williams (COO)
Yeah. Yeah, Chris, I think that's, that's a, a very fair description of, of where we're at. I think there's still opportunity here. We, we haven't taken advantage of all of the functionality that is available to us, and that really goes back to some integration issues that we're having with our EMR vendor that we're working through as it relates to the ability to turn on some of that functionality. So it's going slower, but it's not going to be the magic pill. I think it's going to help some, but it's, it's, it's not gonna have this major, major impact in terms of decreasing front office staff. I think at our larger facilities, it creates efficiencies for us, but we're continuing to look at other opportunities besides automation-
Chris Reading (CEO)
Yeah
Eric Williams (COO)
... in terms of how we can leverage administrative costs within our business. And, more to come on that as we go down that path, and we'll share it with you guys as that vision unfolds.
Michael Petusky (Analyst)
Okay. And one other initiative that was talked about maybe 12, 18 months ago that I haven't heard a lot about since is GPO. And I mean, is that it? Is that something that's still at all, you know, a meaningful focus or is that also sort of very marginal in terms of impact?
Chris Reading (CEO)
Yeah. Mike, Mike, Mike. Go ahead, Graham.
Graham Reeve (COO)
Yeah, go ahead, Graham. Well, we're still-
Chris Reading (CEO)
No, no, go ahead.
Graham Reeve (COO)
... working through it. We're still working through it. It's been challenging in some areas. We're looking at different options for how we can do different savings mechanisms. We do have it stood up. It's rolled out to probably about 45%-50% of our clinics. We've seen some savings, but it hasn't moved the needle as much as we were thinking it might. So we're looking at some different options on how we might be able to get some more movement on that sort of spend.
Michael Petusky (Analyst)
Okay. And then I guess just to sort of wrap up this idea, I mean, is there an issue, Chris, do you feel like, in terms of getting partner buy-in on some of these initiatives that really is needed? Where, you know, you want to let these guys... they're entrepreneurial guys, you want to let them run their business, but at some level, maybe they're not taking advantage of all that you guys, you know, could help them with in terms of optimizing. I'm just curious if maybe-
Chris Reading (CEO)
Yeah
Michael Petusky (Analyst)
... the recalibration of how this works is, you know, would be helpful.
Chris Reading (CEO)
Yeah, no, I actually don't think that. And that's not to say that in any initiative that we don't have, you know, people who are excited and early adopters, and other people who, you know, are going to come on, you know, with a little different perspective, but I think our partners have done a great job, and we've built a lot of trust over the years. You know, it varies by category and by, you know, by specific activity, whatever it is we're doing. For instance, right now, and we've been working on this for a while, and it really has been, as Eric mentioned, a systems issue, but remote therapeutic monitoring, which is an opportunity that-...
CMS provides to us to interface with patients in as they perform their home program and maintain a level of consistency. We think that's really important, and we thought it was important a year ago, but we couldn't get the vendors and the systems to talk efficiently, and while we had partners who were interested in it, it was too clunky, and it was difficult. And we've finally gotten the vendor interface worked out, taken a lot longer than we had hoped. That's the nature of things sometimes, is you bring different companies together and, you know, you try to get things to work and try to push as hard as you can, and if it's too inefficient, it, you know, it doesn't get adopted as readily.
So there was a period of time, for instance, on that initiative and rollout, where we just had to press pause because it wasn't worth beating, you know, the drum on and getting people frustrated. So we had to focus on other things, and that's the nature of operations. I mean, you know, you live on relationships, and you focus where you think you can get the greatest return. And if you're working on 100 things, you know, you're probably not getting a lot done. You have to focus on the key things that are gonna make a difference. And so I think our partners do a good job. I think they understand. They're certainly not fighting.
But, you know, these are day-to-day and minute-to-minute kind of issues that just require a lot of attention and precision, and, you know, in some places, we've got to dial in a little better. In other places, we're gonna have to just figure out that the reality is it's gonna be a little bit more expensive, and we're gonna have to, you know, come up with some other revenue opportunities to offset it. And that's just the nature of, you know, the business right now.
Michael Petusky (Analyst)
Let me just sneak one last one in, and then I'll get off.
Chris Reading (CEO)
Yeah.
Michael Petusky (Analyst)
In terms of, you know, sort of the labor headwinds and just the, on the other side, the CMS, you know, cuts of the last several years, I mean, is there, do you think there's an opportunity for APTA, you know, other sort of leaders, you know, in terms of this industry, to sort of go and say, "Look, at this point, like, something's going to... You know, we're at a place where something's going to give," and,
Chris Reading (CEO)
Yeah
Michael Petusky (Analyst)
... access to service and all the rest of it is gonna be impacted? Like, this just feels like it's gotten to a point where, you know, it's almost enough is enough. And I'm just curious if you guys, you know, have been talking about a, you know, sort of a way to go to the powers that be and say, "Look, we need some help here. Everybody else gets price increases, you know, relative to inflationary pressures, and we continue to face these headwinds." But we still face the headwinds in pricing and then headwinds in paying clinical and front office staff. Thanks.
Chris Reading (CEO)
Yeah, you know, Mike, it's, you know, the world's complicated, but this particular issue isn't complicated. We know that we save on the medical side of things, we know that we save significant costs. We know that patients who go through a course of physical therapy spend less on the entirety of their healthcare in the year, 18 months following a course of PT. We know that for a Medicare-age patient, they're gonna spend less, particularly be more active, more socially engaged, you know, more activity, lower A1C, all of that. You know, it's not lost on anybody. In most APTQI, which is a group that I'm a part of, and all of the big companies, for the most part, are a part of, along with the APTA, we're in D.C. now a lot.
And we don't run into many lawmakers who think that, you know, we should have had these cuts or they're necessary or they make sense to them. But Washington's been a bit of a dysfunctional place of late, and I think we've all, you know, we've all noticed that. And so, you know, unwinding these, which have a secondary budget impact relative to, you know, the neutrality, you know, has been difficult. They've been mitigated, but they haven't been unwound. I hope we can partially at least mitigate the cut for 2025, as we have in the more recent period, and then we should move into a system which allows us to have cost-of-living-based rate changes.
I mean, if you look at the accumulation, I don't know exactly, I have to look at it, what it's been, but it's close to 10% that we've absorbed. And in this year, you know, on an accumulated basis, but in this year, if you look at, you know, where we are compared to where we were in 2019, it's $10s of millions that fall straight to the bottom line or specifically get removed straight from the bottom line. And it's been an every year thing, and, you know, I'm not whining. It is what it is. We've got to deal with it. But if you'd given me, you know, a neutral to a 1%-2% increase every year... what we could do with that would be amazing.
And I think we're about to turn the page, and it's been a long time coming, and we're kind of tired of being in this, you know, wash cycle that we've been in. But, you know, I think we're nearing the end, and we will continue to press our D.C. constituency hard. With the way the world is, it's just hard to get necessarily the aggregated attention that you need to make dramatic change, but, you know, we're not giving up. Very good. Thanks, guys. Appreciate it. Thanks, Mike.
Operator (participant)
Our final question in queue will be a follow-up from Larry Solow with CJS Securities.
Lawrence Solow (Analyst)
Great. Thank you, guys. I just... question on the workers' comp, I guess more from a high level. This used to be like a mid-teens percentage of your business, right? Pre-COVID, and obviously, the world has changed a little bit, or remote, you know, work and all accelerated. But I feel like your target audience can't really be remote, right, in terms of the working field. So I'm just curious, what structurally is there anything different that has caused a dramatic decline in workers' comp volume over the years, you know, I guess since COVID, really?
Chris Reading (CEO)
You know, Larry, I wish I had a perfect answer for that. I mean, you know, all of our companies that I'm aware of, post-COVID, saw a drop in a pretty significant drop in work comp percentage. I can't tell you that I know why that makes sense or why it would happen, but it has happened, and you know, all we can do is to focus on what we do, and that focus has been to retrain, particularly our front office, to make sure that communication and follow-up across in the comp world, multiple constituencies who have interest in the case. It's, you know, it's the payer, it's the case manager, maybe the company, the doctor, of course, always. But it's just that continuous retraining, and we've focused on that.
And, you know, as Eric said, we've gotten access to a broader network. And to be honest, you know, through COVID, we were dealing with other things at the time, and, you know, all over that period, which was a couple of years, give or take, you know, with constant turnover, you lose people, and you lose some traction. So we're trying to get back. I'm not gonna promise that we're gonna get back to 14%, but as Eric said, we are growing our comp visits at a rate that's a pretty nice rate, so we'll see where it ends up.
Lawrence Solow (Analyst)
Okay. If I just may squeeze one last one on a more positive note.
Chris Reading (CEO)
Sure. Sure, sure.
Lawrence Solow (Analyst)
Carey said the industrial prevention business obviously grew nicely, I think you said, low double digits or excl- on an organic basis. What's the driver there, and does that business, is that contra indicator as, you know, employment gets a little, you know? Because obviously, although I know the labor market is tight, things are maybe getting. Unemployment's coming up a little bit, so things are maybe not, you know, loosening a little bit or getting worse, I guess, you know, maybe better for you guys in a sense. But what's going on in the job, you know, in this business that's driving that growth?
Chris Reading (CEO)
Yeah. Yeah, yeah. So simply, it works. It works really well. We now have more programs and services and, and kind of program lines than ever before. When we started, we had, you know, one primary and a couple very peripheral, and now we have 15 or 20 different, you know, individualized programs. As a result of some of the acquisitions that we've done, and those have all integrated well, and some of the growth that we've had, both in the team and in our, in our service offering. So one, it works, it saves money. We're seeing companies where we get a foot in the door, be willing to expand from just their most problematic site to sites across the country, so that there is a really nice organic, intra-customer, you know, growth opportunity.
We're seeing, as you might guess, you know, as risk managers and heads of HR move within an industry or within an industry area to different companies, and they've had good luck with us, good success before. It's not luck, good success. You know, they're bringing us in. And look, companies are dealing with a musculoskeletal issue that is, you know, a significant problem for them. And you know, it's the word's getting out that this, these types of programs, they work. And so it's a combination of things, but I'm really proud of our teams. We've added and grown and strengthened these teams over time, and they're doing a good job right now, and, you know, I expect the momentum that we have will continue.
In terms of the question about how it relates to where the economy is, I would say some of these programs are cyclical in that when the economy is blowing and going, they're busier, and some are countercyclical. So in other words, maybe when labor gets really tight, you know, our post-offer testing, which is meant to screen out people who might get injured down the line or likely to be injured, you know, we have companies in some segments say: "We can't find anybody. We can't screen anybody out." And so as labor gets tighter, some of those programs slow down, but that's always in the mix. Now we have enough diversity across our programs to where, you know, if we see a slowdown in one, we're seeing a pickup in another, and it doesn't show up as much. So it's just pretty steady overall.
Lawrence Solow (Analyst)
Got it. Great. Thank you, guys. Appreciate it.
Chris Reading (CEO)
Thank you.
Operator (participant)
Ladies and gentlemen, at this time, as there are no further questions, I'd like to turn the floor back over to Chris Reading for any additional or closing comments.
Chris Reading (CEO)
Okay, Jamie, thank you. Listen, I know this was a long call. I wanna thank everybody for your questions, your attention. I know we have some follow-up calls scheduled, so please reach out to Carey or I, and we're happy to spend time with you. And just know that we're working hard on these opportunities. So have a great day. Thanks again. Bye.
Operator (participant)
Once again, ladies and gentlemen, that will conclude the U.S. Physical Therapy second quarter 2024 earnings call. Thank you for your participation. You may disconnect at this time.