Jobie Williams; Senior Vice President of Strategic Finance, Treasurer; Enhabit Inc
Barbara Jacobsmeyer; President, Chief Executive Officer, Director; Enhabit Inc
Ryan Soloman; Chief Executive Officer; Enhabit Inc
Brian Tanquilut; Analyst; Jefferies LLC
Ryan Langston; Analyst; TD Cowen
Operator
Hello and welcome to the Enhabit Inc fourth-quarter 2024 earnings call. (Operator Instructions)
I would now like to turn a conference over to Jobie Williams and Enhabit's Senior Vice President and Treasurer. You may begin.
Jobie Williams
Thank you, operator, and good morning, everyone. Thank you for joining our call today. With me on the call is Barb Jacobsmeyer, President and Chief Executive Officer; and Ryan Solomon, Chief Financial Officer.
Before we begin, if you do not already have a copy, the fourth quarter earnings release, supplemental information and related Form 8-K filed with SEC are available on our website at investors.ehab.com. On page 2 of the supplemental information, you will find the safe harbor statements which are also set forth on the last page of the earnings release.
During the call, we will make forward-looking statements which are subject to risk and uncertainties, many of which are beyond our control. Certain risks and uncertainties that could cause actual results to differ material from our projections, estimates and expectations are discussed in our SEC filings, including our annual report on Form 10-k, which are available on our website. We encourage you to read them.
You are cautioned not to place undue reliance on the estimates, projections, guidance and other forward-looking information presented, which are based on current estimates of future events and speak only as of today. We do not undertake a duty to update these forward-looking statements.
Our supplemental information and discussion on this call will include certain non-GAAP financial measures. For such measures, reconciliation to the most directly comparable GAAP measure is available at the end of the supplemental information and the earnings release.
With that, I'll turn the call over to Barb.
Barbara Jacobsmeyer
Good morning and thanks for joining us. I'm going to start with a review of the fourth quarter and then highlight how executing on our strategies in 2024 has laid the foundation for improved performance in 2025.
Home health executed on specific growth strategies in 2024. Throughout the year, we focused on stabilizing our Medicare fee for service admissions as a percentage of overall home health admissions, growing the percentage of home health visits in our payer innovation contracts, and leveraging visit efficiency to increase clinical capacity.
Similar to past quarters, fourth quarter Medicare fee for service constituted 44% of our home health admissions. Fourth quarter non-Medicare admissions were up 10.7% year over year, driving our total admission growth of 1.8%. Our home health team achieved total admissions growth even while replacing UnitedHealthcare volumes for much of the fourth quarter and managing through the impacts of Hurricane Elaine and Milton.
If UHC volumes had remained flat and there had been no hurricanes, emission growth would have been 5.4%, which would have been in line with quarters two and three. We enter 2025 in a stronger position.
With our new UHC contract in place alongside our other two fully ramped up national contracts, our home health teams are again able to be a full-service provider for our referral sources. Our teams are motivated and re-energized by the ability to turn their sole focus to admission and census growth. That focus is already driving results with our census growth of 7.2% sequentially from January to February.
January's ADC was 38,721 and grew to approximately 41,500 in February, with February exiting above 42,000. In 2024, we also increased the percentage of home health visits and payer innovation contracts. In the fourth quarter of 2023, 22% of non-Medicare visits were in payer innovation contracts. That rate grew to 48% in the fourth quarter of 2024.
Payer mixed progress to payer innovation contracts throughout 2024 resulted in a 5.7% improvement year over year in non-Medicare revenue per visit.
With over two-thirds of our payer innovation contracts and episodic arrangements, managing our visits per episode while maintaining high quality outcomes is an important part of our strategy. Our teams continue to use pulse technology to manage a just right care plan for each of our patients, which allows us to be more efficient with episodic payers.
Reflecting this trend, total visits per episode were 13.9 in quarter-four 2024 versus 14.3 in quarter-four 2023. Continued progress with managing visits per episode will allow for additional clinical capacity in 2025.
On the advocacy front, we joined others in the home health industry to make the new administration aware of the detrimental effects of the permanent and temporary payment adjustments CMS has written into the home health final rule in recent years.
We fully support the recent consolidation of industry trade associations and believe this will create a stronger and unified voice for reversing CMS's negative adjustment trend. The changes include shutting down the partnership for Quality Home Healthcare, and that group joining efforts with the National Alliance for Care at Home.
The Alliance, which is a combination of the National Association for Home Care and Hospice and the National Hospice and Palliative Care Organization, has hired Scott Levy as its Chief Government Relations Officer, a position he formerly held at a Amedisys. We appreciate the alliance's efforts and determination to support the industry and look forward to seeing its impact.
Moving now to our hospice segment, hospice has remained dedicated to executing the strategies established in 2023 and as a result, realized significant growth in 2024. The strategies and processes we implemented in our hospice operations allow us to admit patients timely, provide top quality care, and grow this business. We exited 2024 with our highest hospice census since the spin.
Throughout 2024 we focused on growing census and gaining the operating leverage against the fixed cost structure associated with the case management staffing model. We met our census growth goal and concluded the year with sequential census growth each month of the year.
In the fourth quarter, our average daily census increased 8.6% year over year, with same store up 7%. Our total emissions grew 6.5% year over year, with same store up 4.4%. We also met our goal of gaining operating leverage against the fixed cost structure.
Our 2024 full year cost per day increased 2.6%, less than inflationary cost increases, and at the positive end of our guidance range. Execution of our case management model, the build out of admission departments, and growth of business development teams collectively drove positive results in the hospice segment.
We will build on these drivers and momentum in 2025. We have seen continued growth momentum. Our hospice average daily census continues to grow sequentially in January and February. To complement our organic growth strategy in both segments and to enter new markets with low capital cost, we continue our de novo strategy.
In 2024, we successfully opened six de novo locations, five hospice and one home health. We funded 2024 de novo projects with EBITDA generated by 2022 and 2023 de novos. We have 14 de novo projects in process, including the four continuing projects from 2024.
Our concentration continues to be weighted towards adding hospice locations adjacent to home health operations because we benefit from talent recruiting and market brand recognition, as well as referral source awareness.
Turning now to cost structure strategies updates. On the Q3 call, we mentioned we would be closing or consolidating a number of branches. We are closing five home health and two hospice branches, and we'll be consolidating one home health and two hospice branches. While notice has been given to staff and patients, branch closing dates vary by state due to notice requirements.
We expect seven to be closed or consolidated by the end of quarter one 2025, with the remainder by the end of quarter two. We anticipate the impact of these closures and consolidations will improve 2025 adjusted EBITDA by approximately $1 million or by an annualized rate of $1.5 million.
We also indicated we were outsourcing coding functions as another cost savings measure. All branches will be transitioned by the end of the first quarter, which we estimate will deliver $1.5 million in cost savings for the remainder of 2025.
And now I will turn it over to Ryan, who will cover the financial results of quarter four and our 2025 guidance.
Ryan Soloman
Thank you, Barb. Before recapping the results for the fourth quarter, I would like to thank Barb and the broader Enhabit Board for the opportunity to join the team here as CFO back in December. In my short time in the role, it is clear to me that our strategy is sound, and we are well positioned to deliver meaningful shareholder value.
Many of the key elements are in place to deliver revenue growth across both segments while also creating leverage on our cost base. Combining these elements with a continued focus on a healthy payer mix in our home health segment should improve the overall margin profile of our business.
As we execute this strategy, we will continue to focus on deleveraging our balance sheet to provide more flexibility under our capital structure and open additional avenues for growth.
Shifting to our Q4 consolidated results, we delivered improved performance sequentially both in revenue and adjusted EBITDA despite one-time challenges within the quarter. In the fourth quarter, consolidated net revenue was $258.2 million, an increase sequentially of $4.6 million or 1.8% quarter over quarter, while a decrease of $2.4 million or 0.9% year over year.
Consolidated sequential revenue growth was led by continued strong momentum in our hospice segment on both volume and rate, partially offset by lower revenue from the home health segment, primarily related to hurricane volume impacts early in the quarter.
Consolidated revenue growth in the quarter translated into improved profitability sequentially. Consolidated adjusted EBITDA of $25.1 million in the quarter, an increase sequentially of $0.6 million or 2.4%, while remaining relatively flat year over year. Drivers of Q4 consolidated profitability improvement sequentially include improved revenue performance partially offset by our annual merit increase effective October 1.
Before shifting to our Q4 segment performance commentary, I would like to highlight that we have incorporated new segment performance views recapping both revenue and margin performance into our supplemental materials that we intend to provide on a go forward basis.
We believe these to be helpful in visualizing performance both year over year and sequentially in terms of volume, unit revenue, unit cost and adjusted EBITDA for both segments.
The performance views for both segments will use census, which we will use interchangeably with the term average daily census or ADC for volume and unit metrics. Growing census is the ultimate driver of financial results in each of our business segments.
With 72% of our home health census now in episodic payers, we believe we can move to a more direct way of presenting our home health business metrics using census. For home health, both admissions and recertification contribute to growing overall census, and growing census with the right payer mix ultimately drives increasing revenues.
On the cost side, optimizing staffing while maintaining high quality outcomes should create more clinical capacity and allow us to support more census on similar costs, thereby improving cost per patient day.
Now shifting to Q4 home health segment performance, revenue came in at $200.4 million, a decrease of $0.6 million, or 0.3% sequentially on a volume decrease of 0.5% in average daily census, primarily due to hurricane-related impacts early in Q4. This was partially offset by unit revenue for patient day increase of 0.1% sequentially which was driven by growth in Medicare ADC of 1%, partially offset by lower patient acuity mix.
Home health adjusted EBITDA totaled $35.5 million in Q4, reflecting a sequential decrease of $1.0 million or 2.7%, with a growth margin decrease of $0.2 million and an increase in back-office operations G&A cost of $0.8 million.
The gross margin decrease sequentially reflects lower patient volumes and a flat gross margin as a percent of revenue. We were able to offset the impact of merit with productivity gains at the gross margin level while increased back-office G&A is primarily due to an annual merit increase effective October 1.
A few key items to highlight in home health outside of broader revenue and adjusted EBITDA performance include the following. Medicare ADC improved sequentially in Q4 to 19,818. We have seen continued growth thus far in Q1 2025, with current Medicare ADC above 20,000. Based on current trends, we expect this sequential improvement to continue in Q1.
In addition to Medicare ADC improvement, our overall episodic ADC, which includes both traditional Medicare and non-Meddicare episodic payers grew to 72% in Q4 and the third straight quarter of sequential improvement. This improves our mix of episodic ADC, which generally has a unit revenue advantage to non-episodic payers.
We successfully managed costs of services in Q4, keeping our cost per patient day year over year to a 1% increase. This reflects improved productivity offset by the impact of merit and market-related increases. The unit costs results to demonstrate our continued focus on controlling staffing costs through productivity and optimizing staff while maintaining patient care and quality.
Now shifting to Q4 hospice segment performance. Revenue came in at $57.8 million, an increase of $5.2 million, or 9.9% sequentially on both a volume increase in average daily census of 3% and a unit revenue improvement of 6.9% as the new CMS rate for hospice became effective October 1, coupled with hospice cap accrual favorability versus the prior quarter.
Hospice adjusted EBITDA total $13.3 million in Q4, reflecting a sequential increase of $3.3 million, or 33% on increased revenues combined with gross margin expansion as unit revenue growth outpaced unit costs increases primarily related to annual merit increase. A few key items to highlight in hospice outside of broader revenue and adjusted EBITBA performance include the following.
Hospice adjusted EBITDA margin as a percent of revenue at 23% in Q4 reflects four straight quarters of sequential improvements and the highest adjusted EBITDA as a percent of revenue for this segment post-spin. We continue to realize leverage benefits from growth as we mature the case management model.
Q4 hospice ADC of 3,729 is 3.9% higher than the previous post-spend segment peak in Q4 of 2022. Q1 2025 trends indicate sequential ADC growth will continue in early 2025. Our de novo strategy continues to plant the seeds for future growth as we open five hospice de novo locations in 2024.
Confidence in our de novo strategy remains strong, a contribution from the seven hospice locations launched in 2022 and 2023 generated $6.2 million of revenues and $1.2 million of adjusted EBITDA in full year 2024.
Shifting to Q4 home Office general and administrative expenses, which totaled $23.7 million, or 9.2% of revenues in Q4, an increase of $1.7 million or 7.7% sequentially. This increase is primarily related to the merit increase effective October 1 and an unfavorable increase in group insurance claim costs.
Year home office general and administrative total of $100.8 million or 9.7% of revenues. This reflects a $7 million improvement to prior year while also lowering our home office expenses as a percentage of revenue by 60 basis points to full year 2023.
Improvements are primarily due to targeted cost savings initiatives and lower incentive compensation which more than offset merit and other inflationary increases.
Let's now transition to the balance sheet and cash flow performance. We remain focused on using free cash flow to improve our leverage profile, having reduced outstanding debt by approximately $40 million in 2024. We have available liquidity of approximately $80 million, including approximately $28 million of cash on hand. We believe this is adequate to support our operations, including our de novo strategy.
In regard to cash flow, we generated approximately $54 million of adjusted free cash flow during 2024, which equates to an adjusted free cash flow conversion rate of approximately 54%.
Let's now turn to 2025 guidance. Please note that our 2025 guidance and related considerations can be found in our supplemental materials. Our 2025 guidance range for net service revenue is [$1.050 billion to $1.080 million] with adjusted EBITDA in a range of $101 million to $107 million, reflecting growth of approximately 7% at the wide end of the range.
We believe the quarterly cadence of our full year adjusted EBITDA guidance will reflect incremental sequential improvement each quarter throughout 2025 with acceleration post Q1, where we expect 23% to 24% of full year adjusted EBITDA to come in.
The quarterly cadence outline reflects a trough in our home health segment as we pivot from replacement to growth mode throughout Q1 following the signing of our national agreement in late Q4 2024.
I will now briefly summarize the building blocks of our guidance beginning with home help. As Barb mentioned in her remarks, we believe that 2024 was a foundational year to set the stage for consistent census growth while using the results of our payer innovation strategy to differentiate ourselves in the market as a true full-service provider to our referral sources, allowing us to both grow and improve mix.
This combined with continued staffing and cost discipline should allow us to expand home health margins as we exit 2025 despite CMS rate reimbursement increases, not keeping pace with our overall market inflation.
For home health volumes, we assume full year ADC growth of 4% to 5%, which assumes a lower volume beginning entry point in 2025 than where we entered 2024, limiting full year growth rates. In addition to volume growth, we assume that we slow the rate of decline in Medicare volumes. We anticipate reducing our rate of Medicare volume decline approximately in half from what we saw in 2024 and more consistent with overall industry trends.
In regard to home health unit revenue, we expect revenue per patient day to decrease 0.5% to remain flat on the full year, which reflects improvements in CMS Medicare pricing of approximately 1% in 2025 based on the home health final rule.
We also expect our Medicare Advantage pricing to improve based on the success of our payer innovation team, including a full year impact from the renegotiated national agreement with improved rates that became effective in January of 2025.
These rate improvements will be largely offset by assumed unfavorable mix primarily related to lower Medicare volumes. While we anticipate reducing our Medicare year over year ADC declines, we still anticipate this to be a mixed headwind, particularly in the first half of 2025 as we build back Medicare volumes from our trough in late 2024.
For hospice, we remain focused on building our 2024 momentum and growing senses, resulting in additional operating leverage in this segment. For hospice volumes in 2025, we assume hospice ADC growth of 7% to 8.5%. We anticipate building on the strong exit rate volumes from 2024 as we remain clinically staffed to grow and continue to execute on our broader de novo strategy.
For hospice pricing in 2025, we expect our hospice unit revenue per patient day to improve in the 4% to 5% range, which reflects the hospice final rule effective October 1, combined with anticipated favorable hospice cap liability development and an inception of a prospective CMS rate increase in October 2025.
On the cost side of the equation, we faced two primary headwinds in 2025. Wage inflation and normalization of our incentive compensation expenses as we improve performance. In regards to wage inflation, we assume similar 3% merit and other market-related increases in 2025 to what we experienced in 2024.
The assumed continued wage inflation more than offsets our net reimbursement rate increases. We received from Medicare in both segments as well as our payer innovation efforts.
In both our home health and hospice segments, we believe we can partially offset compensation inflation through productivity and optimization improvements. We currently believe our unit costs will increase between 2% and 3% year over year.
We expect our home office costs to remain relatively flat as a percent of the consolidated revenue and 9.7% of revenues as merit increases and increased incentive compensation year over year are partially offset by run rate value of savings of 2024 reductions in continued cost discipline in 2025.
As previously outlined, key components of our strategy in 2025 are to grow while optimizing our payments, with a particular focus on limiting our rate of decline relative to prior years. The assumptions around the mix are challenging to forecast and have an outsized impact on overall guidance assumptions.
With this in mind, the difference between the low and high end of our guidance range primarily is dependent upon our ability to optimize our payer mix. We expect to generate $47 million to $58 million of adjusted free cash flow in 2025.
Adjusted free cash flow in 2025 will be impacted by a return to cash income tax payments, which represents a $7 million to $8 million incremental use of cash in 2025 that we did not experience in 2024, largely offset with improved cash flow from operations and assumed improvement in working capital related to speeding up accounts receivable collection cycle. With our assumed free cash flow generation, we remain focused on reducing leverage through 2025.
With that, thank you for the time this morning, and I will turn the call back over to Barb for a few final comments.
Barbara Jacobsmeyer
Thanks, Ryan. Before we open the line for questions, I want to reflect on our team's drive in 2024. We remain committed to executing our strategies and delivering results. This was evidenced by our strong results in hospice, particularly in the second half of 2024.
We made a large investment in our case management model in 2023, believing it key to changing our hospice business trajectory in a meaningful manner. Solving our capacity challenges through this investment allowed us to turn focus to our business development strategy, which resulted in increasing census growth throughout 2024 and into 2025.
Similar for home health, we believe that executing on our payer strategy has laid the groundwork for long-term home health success. At the end of the fourth quarter, we were forced to turn our focus to replacing business. That noise is behind us. We are attacking 2025 laser focused on growth.
Operator, we will now open the lines for questions.
Operator
(Operator Instructions) Brian Tanquilut, Jefferies.
Brian Tanquilut
Hey. Good morning. Maybe Barb, as I think about the momentum that we've seen you guys deliver in Q4, just curious how you're thinking about that carrying over into 2025, especially now that you have the BD team built out and then maybe related to that just that what are your thoughts on fee for service and your ability to gain share there going forward?
Barbara Jacobsmeyer
Sure. So first on the hospice, we do feel confident that now that we have the case management model fully implemented and no capacity constraints. We've really started to build on that business development team. We do have the admissions department in every region now. That was something that was feedback from our referral sources that the key to really converting referrals is how quickly can we respond.
So we believe those admission departments have been critical and so you know you saw that sequential growth each month of '24, and it's continued now in January and February. So we don't see any reason why that should not continue.
And then on the home health side really being able now to turn fully to being that full service provider, I mentioned the census growth that we've seen just from January to February that has been with a nice mix. We're seeing a nice blend of adding the non-episodic, the episodic and the fee for service. So we're seeing the teams really balance that payer mix as we're growing our senses here in the new year.
Brian Tanquilut
Got it. And then maybe as I think about your comments and in the press release about the payer innovation contract and then your preparing partner remarks as well, what kind of visibility do you have there and how are you thinking about the leverage that you have to convert non-payer contracts into better paying deals with MA plans.
Barbara Jacobsmeyer
Sure. So we still have a lot of regional in the pipeline that we're working with. There is, I think, a renewed interest in moving towards episodic. I think one of the things we've really been able to help payers realize is that when you get into an episodic arrangement, it puts the responsibility on the provider to manage those visits and maintain or grow their quality outcomes. And so, there continues to be good discussions with regional plans on episodic contracts. So I don't see our payer innovation team slowing down in any way.
Operator
Ryan Langston, TD Cowen.
Ryan Langston
Thanks. Good morning. Maybe to follow up on Brian's question on the home health payer innovation side, I think in the slides you have 49 new opportunities, 31 historical agreements you're renegotiating. How does that relate back to '25 guidance. I guess, is there some potential maybe upside to the guide depending on how the outcome of those negotiations happen?
Ryan Soloman
Yeah. Ryan, thank you. This is Ryan here. In regards to the guide, the way we thought about that, it's really consistent with the information that we provided in our investor presentation in December. We believe that $19 million to $21 million of overall revenue improvement based on pricing is intact.
When we think about the building blocks around that, it's really the CMS final rate rule, the recently negotiated national agreement that we saw in place. We haven't assumed any sort of material kind of payer innovation incremental unit revenues in that overall kind of revenue guide that we provide.
Ryan Langston
Got it. And then just last one for me, the hospice revenue per day was up pretty nicely despite a pretty tough comp from last year. I think Ryan, you said maybe some benefit from hospice cap accruals versus the third quarter. Anyway, you could break down sort of the components between maybe sort of true rate and what those accruals were. Thanks.
Ryan Soloman
Yeah. I think so when we think about the hospice cap accrual benefit, when we look at that, overall, what we saw, and we included in our supplemental materials was about a $1.4 million benefit. And so, when you normalize for that, you're going to see it more consistent with what you would have expected in the overall kind of Medicare rate increase that we saw within the quarter. So once you set that aside, I think it would be pretty consistent with what we would have expected from the Medicare rate increase perspective.
Operator
There are no further questions at this time. I will turn the call to Jobie Williams for closing remarks.
Jobie Williams
If you have any additional questions, please email investorrelations@ehab.com. Thank you again for joining today's call.
Operator
This concludes today's conference call. Thank you for joining. You may now disconnect.
