AMN Healthcare Services, Inc. (AMN) Q4 2014 Earnings Report, Transcript and Summary

Ladies and gentlemen, thanks for standing by, and welcome to the AMN Fourth Quarter and Full Year 2014 Earnings Conference Call. At this time all participants are in a listen-only mode. Later we will conduct a question-and-answer session. Instructions will be given at that time. [Operator Instructions]. As a reminder, this conference is being recorded. I would now like to turn the conference call over to our host, Vice President of Investor Relations, Amy Chang. Please go ahead.

Thank you, Greg. Good afternoon, everyone. Welcome to AMN Healthcare’s 2014 full year and fourth quarter 2014 earnings call. A replay of this webcast will be available until March 5, 2015, at amnhealthcare.investorroom.com. Details for the audio replay of the conference call can be found in our earnings press release. Regarding our policy on forward-looking statements various remarks and characterizations we make during this call about future expectations, projections, plans, prospects, events or circumstances constitute forward-looking statements. Forward-looking statements are identified by words such as believe, anticipate, expect, intend, plan, will, should, would, project, may, variations of such words and other similar expressions. It is possible that our actual results may differ materially from those indicated by these forward-looking statements as a result of various important factors, including those identified in our Annual Report on Form 10-K for the year-ended December 31, 2013, and our other filings with the SEC, which are publicly available. The results reported in this call may not be indicative of results for future quarters. These statements reflect the company’s current beliefs and are based upon information currently available to it. Developments subsequent to this call may cause these statements to become outdated. The company does not intend however, to update the guidance provided today prior to its next earnings release. This call may also contain certain non-GAAP financial information. We make available additional information regarding non-GAAP financial measures in the earnings release and on the company’s website. On the call today are Susan Salka, our President and Chief Executive Officer; as well as Brian Scott, our Chief Financial Officer. Ralph Henderson, our President of Healthcare Staffing and Dan White, our President of Workforce Solutions will be joining us during the Q&A session. I will now turn the call over to Susan.

Thank you so much, Amy. Good afternoon everyone and welcome to AMN Healthcare's 2014 full year and fourth quarter earnings conference call. Over the last year AMN continued to deliver revenue and profitability growth, while further solidifying our leadership position as the innovator in healthcare workforce solutions. The market environment accelerated mid-year as a stronger economy and millions of newly insured patients released pent up demand for both healthcare services and the underlying clinical labor that provides their care. With the momentum of the higher demand and strong execution by our team we delivered fourth quarter consolidated revenue growth of 12% over prior year and an adjusted EBITDA margin of 9%. This strong performance was led by our Nurse and Allied Staffing business with 17% revenue growth followed by Physician Perm Placement, which grew revenue by 14%. To bolster our recruitment capacity and candidates supply amidst the rising demand in January of this year we acquired two well respected staffing companies, Onward Healthcare and Locum Leaders. To further evolve our portfolio of workforce solutions in December we acquired Avantas, a leading provider of clinical workforce consulting analytics and predicted modeling and scheduling technology. More and more our clients want to use analytics to drive their population health and cost efficiency initiatives. With critical labor being more than half of a hospital budget, Avantas enables clients to achieve their efficiency goals through better workforce planning and scheduling. In January of 2015, we also acquired Medefis, a leading vendor management system for healthcare organizations. Through Medefis and ShiftWise AMN now provides two differentiated VMS technologies to assist clients in managing their staffing vendors, workflow and credentialing through one single platform. These VMS solutions are widely recognized as the top two technologies within the healthcare industry. All four of these acquisitions bolster and complement AMN's current businesses and solidify the breadth of workforce solutions we offer. We are very pleased to have them joined the AMN family and the integrations are proceeding very well. These are top quality brands and even higher quality people. These additions will also enable AMN to deepen our client relationship and maximize our current and future market opportunity. Another key part of our strategy is our focus on managed services program. In 2014, AMN further strengthened our market leading position in MSP with new contract wins and expansion expected to contribute over $50 million in direct revenues at maturity, a third of our consolidated 2014 revenues flow through MSP relationships where we are the exclusive provider of supplemental staffing to our clients. In MSP contracts we typically deliver higher fill rates than in traditional contracts which enables efficiency and contributes to our operating margins. Through our VMS technologies and MSP contracts, AMN has annual growth staffing spend under management of over $1 billion. It's clear that these workforce solutions are having an impact in enabling clients to efficiently manage and deploy their contingent labor. Now let's review the fourth quarter results and outlook for each of our three business segments. As mentioned, in our largest segment of nurse and allied staffing fourth quarter revenue rose 17% year-over-year and 10% sequentially. This performance is being led by the travel nurse business which experienced a fourth quarter revenue increase of 20% over prior year and 12% sequentially. We believe the significant order growth is due to a combination of hospital census, increased nurse turnover and the improving financial performance of hospitals. For the first quarter we expect travel nurse revenue to be up over 30% year-over-year and 10% sequentially. Excluding the impact of Onward Healthcare, we expect travel nurse revenue to be up approximately 25% year-over-year. In our allied healthcare staffing business, fourth quarter revenue grew 14% year-over-year and 6% sequentially. Orders are up significantly year-over-year across therapy, imaging and lab specialties. For the first quarter we expect allied staffing to be up approximately 40% year-over-year and 15% sequentially. Excluding the impact of Onward Healthcare we expect allied staffing to be up nearly 20% year-over-year. Our ShiftWise, Medefis, Avantas and then RPO businesses which are all included in this segment are also experiencing very positive trends. As we begin the year they're all expecting to deliver strong year-over-year revenue growth. This performance enables us to continue investing in the technology to open up new market channels and ensure we're delivering greater value to our clients and our affiliate vendors. Overall, for the nurse and allied healthcare staffing segment we expect first quarter revenues to be up over 30% year-over-year and 15% sequentially. Excluding the impact of our recent acquisitions of Onward Healthcare, Avantas and Medefis we are projecting year-over-year revenue growth of approximately 20% for this segment. Now turning to Locum Tenens. Fourth quarter revenue was up 3% year-over-year and down 3% sequentially due to seasonality. The year-over-year growth was attributable to the increases across most specialties and the improved demand of nearly 10%. For the first quarter we expect revenues will be up approximately 25% year-over-year and 10% sequentially. Excluding the impact of the Locum Leaders acquisition first quarter year-over-year revenue is expected to be up approximately 15% and flat sequentially. The total year-over-year growth is across most specialties, hospitals and internal medicine sub-specialties make up the largest share favorability. Locum’s NSP programs continue to grow and are projected to comprise approximately 14% of first quarter revenue. The Locum segment entered 2015 significantly stronger than in 2014 with higher demand and improved execution by the team. Q1 will represent the 9th straight quarter of year-over-year revenue growth for the Locum division. In our Physician Perm Placement segment fourth quarter revenue was up 14% year-over-year and up 4% sequentially. The year-over-year growth was driven by increased search and placement volume along with higher project revenues. Going into the first quarter placement activity is trending upwards and revenue expected to be up year-over-year approximately 10%. Sequentially first quarter revenue is expected to be down slightly due to the fourth quarter having more higher value executive search placements and project activities. Merritt Hawkins was the first AMN business to implement our new front office platform that will eventually be used across all of our businesses. The new system was launched in early Q1 and is already providing improved collaborations, data capture and efficiencies for the team. Healthcare continues to undergo dramatic change with stronger market trends unfolding, the investments we continue to make have enabled AMN to differentiate itself in the market. The offerings we provide from workforce optimization and predicted analytics to BMS, MST and RPO enable AMN to have a deeper and more value added relationship with our clients. We are pleased with our evolution into healthcare’s innovator and workforce solutions and we’ll continue to look at acquisition opportunities in the areas of new workforce solutions and emerging healthcare world. Throughout 2015 we will continue on our investments in systems and infrastructure to ensure our efficiencies, scalability and best in industry service delivery as we advance towards the long-term adjusted EBITDA goal of 10%. In just a month AMN will celebrate its 30th anniversary. Our value based and highly engaged culture has been a significant driver of our long standing success and results. We are proud to have been recently recognized for the third consecutive year as one of Achievers 50 Most Engaged Work Places. I would like to thank our very talented leaders and team members for their passion and exceptional commitments every single day in serving our clients and healthcare professionals with excellence. I will come back to you in our Q&A along with Ralph and joining us today is Dan White, who was recently promoted to President of Workforce Solutions. This will be Dan’s first time participating in our earnings call. So welcome Dan. For now I will turn the call over to Brian.

Thank you, Susan and good afternoon everyone. The company’s fourth quarter reported revenue of $279.6 million was up 12.5% from last year and 5.7% from last quarter. This result exceeded our guidance of $265 million to $269 million driven by stronger than expected performance in all three reportable segments. Our gross margin for the quarter was 30.3%, up 50 basis points from last year and down 10 basis points from last quarter. The year-over-year increase was due to gross margin improvement in the Nurse and Allied and Physician Permanent Placement segments with Nurse and Allied improvement driven mainly by having a full quarter of the higher margin ShiftWise business. The sequential decrease was due primarily to a normal seasonal decline from fewer billable work during the holiday as well as some reductions in the bill to pay spread. SG&A expenses in the quarter totaled $61.7 million or 22.1% of revenue, compared to $54.5 million in both the same quarter last year and $60.3 million in the prior quarter. The year-over-year increase in SG&A was due primarily to the higher expenses associated with our information technology initiatives, higher variable expenses to support our current volume growth and future growth initiatives as well as the addition of the ShiftWise business. The sequential increase in SG&A expenses was due primarily to the same growth related drivers including recognizing a full quarter of expenses associated with a significant addition of sales resources hired in late Q3. This increase was partially offset by a $1.8 million favorable professional liability actuarial adjustment recorded in the Locum Tenens segment. SG&A expenses in the quarter also included approximately $400,000 of costs related to our recent acquisitions. Excluding the actuarial benefit and acquisition related expenses SG&A was in line with expectation at 22.5% of revenue. Our fourth quarter Nurse and Allied segment revenue increased 16.7% from the prior year and 9.9% sequentially to $191.6 million. Volume of 6,030 average clinicians on assignment was higher by 7.5% year-over-year. The average bill rate for the segment was higher by almost 4% from last year. Nurse and Allied gross margin of 28.6% was higher year-over-year by 90 basis points and lower sequentially by 10 basis points. Most of the year-over-year improvement was due to full quarter inclusion of the higher-margin ShiftWise business while the lower sequential gross margin was due to seasonally lower hours worked and reduced bill to pay spread. Fourth quarter Nurse and Allied segment operating margin of 12.5% was higher by 60 basis points year-over-year and by 30 basis points in the prior quarter. The year-over-year improvement was gross margin driven, whereas the sequential improvement resulted from operating leverage. Fourth quarter Locum Tenens segment revenue of $76.29 million was up 2.8% from prior year but down 3.4% sequentially. Compared to prior year, an average bill rate increase of 6.3% was partially offset by a 4.2% decrease in the number of days filled during the quarter. Locum Tenens gross margin of 28.8% was lower year-over-year by 110 basis points and sequentially by 20 basis points, due mainly to lower bill-to-pay spreads. Fourth quarter Locum Tenens segment operating margin of 10.7% was higher by 80 basis points year-over-year and lower by 40 basis points from the prior quarter, driven by the previous noted $1.8 million favorable professional liability adjustment recorded for this quarter. Our fourth quarter Physician Permanent Placement segment revenue of $11.9 million was up 13.10% year-over-year and up 3.8% sequentially. Gross margin of 66.1% was higher by 310 basis points in the prior year and 120 basis points in the prior quarter driven in part by the previously noted higher margin executive search and project activity. Physician Permanent Placement fourth quarter operating margin of 23% was higher by 200 basis points year-over-year and lower by 100 basis points from the prior quarter. Interest expense in the fourth quarter was $1.3 million, which compares to $1.8 million last year and $1.4 million last quarter. Our tax rate in the fourth quarter was 44% in line with our expectation. We reported net income of $9.9 million in the fourth quarter. Diluted earnings per share was $0.20 for the fourth quarter. Excluding the one-time transaction cost associated with the acquisitions adjusted diluted earnings per share was $0.21. This compares with $0.17 in the prior year quarter. Cash provided by operations was $5 million for the quarter and $27.7 million for the year. Days sales outstanding were 61 days, compared to 57 days in the last quarter, and 55 days last year. The increase in DSO was attributable to several factors including slower payments by a few large customers, extended billing processes for some clients utilizing third-party VMS technologies and to meeting billing requirements for several staffing projects which delayed payments. We do not see any [ph] change in the credit of our overall client base and do expect DSO to improve during 2015. Capital expenditures for the fourth quarter were $4.8 million and for the full year were $19.1 million. These expenditures were primarily related to investments made in conjunction with our multi-year initiative to upgrade our front and back office systems on to more scalable and efficient platforms. The current year also included certain infrastructure upgrades required for our future sales systems and to improve productivity and collaboration. As of December 31, our cash and equivalents totaled $13.1 million and our total debt outstanding was $162.4 million. The year-end leverage ratio as calculated for our credit agreement was 1.9 times to 1 as compared to 2.0 times in the prior year. Now let's turn to our first quarter 2015 guidance. The company expects consolidated first quarter revenue of $310 million to $314 million. Gross margin is expected to be approximately 30.5%. SG&A expenses as a percentage of revenue are expected to be approximately 22.5%. This excludes any transaction or integration expenses related to the acquisition which will be separately reported during 2015. Adjusted EBITDA margin is expected to be 8.5% to 9%. This guidance includes the expected results for Avantas for the entire quarter and the Onward Healthcare, Locum Leaders and Medefis companies from the January 7th acquisition date. First quarter interest expense is projected to be $1.8 million. Depreciation expense for the first quarter is projected to be $2.5 million and amortization expense is projected to be $3 million. This amortization estimate is subject to change once the valuation analysis of the amortizable intangibles for the Onward, Locum Leaders and Medefis acquisitions is finalized. The effective tax rate for the quarter and full year is expected to be 44%. Capital expenditures are projected to be $17 million to $18 million for the full year including $2 million to $3 million related to certain integration activities of the recently acquired companies. Non-cash stock-based compensation expense is expected to be approximately $2.1 million per quarter during 2015. Diluted share count is projected to be 48.6 million shares for the first quarter and 48.8 million for the full year. Before we open up the call for questions, on behalf of AMN Board, management team and team members, we would like to say congratulations to Susan Salka. Today happens to be her 25th anniversary with AMN Healthcare. It’s been terrific working with you through the years and we thank you for your passion, commitments and inspirational leadership in driving the long-standing performance of our company. And with that we'd like to open up the call for questions.

Thank you. [Operator Instructions]. And we go to line of A.J. Rice of UBS. Please go ahead.

Hey hi everybody. Maybe just a couple of questions if I could do a settlement [ph] there. First of all fairly directed question but your guidance in Q1 obviously has some robust growth numbers on a same store basis. Is weather not having any meaningful impact on the business?

Hi A.J. thanks. Not as much as last year and we are currently estimating that the impact will be something less than a $1 million for the entire quarter. You might recall last year when all was said and done we felt it had more of a $3 million to $4 million maybe even $5 million impact. And I think it has to do with where the weather impact is occurring not coming in quite as far south and not being as widespread. But it hasn't seemed to have made the same type of impact that we saw last year.

Okay I think referencing the prepared remarks as one of the drivers, things you're seeing in the underlying market is a pickup in nurse turnover. I wondered if there was some way to elaborate that or is that just sort of a qualitative sense or do you actually, is there any place you can go and get an actual sense of the numbers behind that potentially.

Well there are some reported numbers that are out there and they show, I guess the latest reported number that we have from the BLS back in November were job openings were up 20% year-over-year and the number of quits were up 25%. And so that's definitely an acceleration. We also do our own survey and we saw that nurse attrition and vacancies were up in the high-teens and which is definitely different than single-digit numbers that we saw five years ago. So we feel there is definitely directionally a higher attrition.

Okay. And I think Brian in your comments you've mentioned a couple of times a little bit of a tightening on a bill paid spread. Can you maybe elaborate a little bit more on where you're seeing if you are seeing a little bit pressure and is there -- with tighter demand are you seeing the rates that hospitals are paying for nurses start to increase and accelerate?

This is Brian. I will give a little color and then I’ll hand it to Ralph to add to as well. As I mentioned we saw a little bit of compression at the bill pay spreads in the nurse and allied and Locum segments. And I think we’ve talked that in last call that we would start to see a little bit as we will trying to pull more supply in to meet the very robust demand environment. As we look into the first you see the gross margin starting to up a little bit and that is a reflection of that starting to normalize a little bit. In the first quarter we see Locums margin improving on the spread and we expect the nurse and allied to see some of that as well. Ralph?

Yes, on the pricing side we see positive -- I think we talked about 4% increase in the nurses and allied segment, 6% in Locums business. We described it as accelerating and it seems to be doing well and should be priced at the market levels, of course most of those does go to the position and the foundation bar assignment. We see some leverage built out of house cost which don’t rise as quickly and they actually lately one of the things has been helpful has been [indiscernible] has been a positive trend for us. So that’s what keeps the margin as good as it is despite maybe a little bit of short term pressure compression.

Okay, great thanks a lot.

Thank you A.J.

Your next question comes from the line of Tim McHugh from William Blair Company. Please go ahead.

Yes, thanks. Can you just maybe first talk about I guess kind of where we sit relative to order volume, I guess the story in the second half of year was at least as I thought orders were outpacing even what you could sale and I know you invest in sales resources. So I get sales are -- recruiting resources so where do we sit at this point? Is that what we are seeing in Q1 you are capturing more, or you expect to capture more of it and I guess what does that say about the need or the desire to further invest in recruiting staff from here?

Hi, Tim this is Ralph. I will handle that one. Yeah, we are seeing demand is up more than double in our nurses and allied business where it was same time last year and doesn’t show only any type of slowing down from what we have been talking about the last couple of quarters. In that segment we are executing better against than demand. We increased the number of resources we have and I think we said takes a while, right, for orders to catch up to volumes and that’s pretty much what we are seeing in that segment now. On the Locums side the demand is up about 10% over the same point of time last year, given the [indiscernible] available number shifted [ph] and so that’s a bit stronger than we anticipated as well, it’s been running at kind of 7% to 8% range. We have had a significant number of recruiters and account managers and we anticipate adding more stable pace of adding those recruiter and account managers then we did in Q3 of last year. One of the things I think that’s a huge positive is acquisitions are going to add to our account management recruitment workforce considerably. We do think there are some efficiency gains and there production is less than our normalized production and so we expect to take advantage of that and get a little bit of leverage out of there. That’s created the variance in the programs where we get the first shot at filing most of those orders and so by introducing those recruiters into those accounts I think we see some jump from that as well.

Okay, great and then there was comment I think Susan made it earlier about, I think it was new MSP contracts work $50 million expected revenue contribution once they mature, I am not sure if I heard that right though can you I guess…?

We did, yeah you did Tim and we are referring to our 2014 wins, a different ways that we measure but the most important to us is how much direct revenue and annual capture at maturity and keep in mind that could take 12 to 24 months from now, at a time those new accounts are implemented and fully at their maturity run rates but the actual growth spend under management for the contract was more in the range of $100 million and so it gives us more opportunity if we can increase our bill rates, obviously we can take that $50 million and move it upwards. It might be a good time actually Dan for you to comment on what we saw in the fourth quarter and how we are coming in to 2015 with our MSP pipeline.

So one of the things that I want to comment on before I get too far in to that answer Susan is, just want to thank our AV network out there today because they really are the backbone of that delta between $50 million and $100 that you just referred to. They really do power our capabilities a great deal. In terms of contracts that came through in the fourth quarter, there were six MSP deals that were closed. I would characterize them really as two medium and four small size deals. And the other question Tim?

I guess what the pipeline or I guess Susan [ph] asked just as we look forward to '15 I guess RFP opportunities that you're seeing?

Q1 pipeline looks also equally strong. I would say, again using my small medium large characterization, I would say most are small but there is a few large and medium under contract today. We anticipate that the quarter will just as good or maybe even a little bit better than what we saw in Q4. And again I'm really pleased to see that the diversity of these particular contracts continues to be quite strong. I would say the majority of those opportunities have a good percentage of Locums tenant in them. And I think to tag onto the comment about gross spend under management, Q1 would bring us to a spend year-over-year being up by 50%.

Great that's helpful. Thank you.

Thank you Tim.

Your next question comes from the line of Tobey Sommer from SunTrust. Please go ahead.

Thank you. Susan I guess gets to the silver anniversary, so congratulations.

Thank you Tobey.

I was curious, I mean what your long-term EBITDA margin target and I kind of know what you've been talking about over the last several years but I wondered if you may have a new one for us that you could share.

Well we have our sights set on hitting the 10% first. I do think there is opportunity beyond that but we're not quite ready to publicly put the next target out there. We want to make sure we get to that 10% and sustain that for a period. But going into the low double digits is certainly the territory that we think we ought to be and particularly as we continue to see such strong demand and we move into more of the workforce solutions business as they typically come with higher margin, most of them these technology business exceeding 20% in EBITDA even the RPO margin, which is doing extremely well. While small today as it grows it will be a bigger contributor to our overall EBITDA margin. So those are the types of things that I can think can take us above the 10% overtime.

Okay you may have mentioned this, if you did I apologize. What was pricing like particularly build rate growth in travel nurse.

We did about 4% year-over-year, we see that…

You think there is momentum.

There is momentum we see that probably increasing on a year-over-year basis going into Q1. Some of it is due to rate increases that were put into place last year and even might just now be continuing through. We may get a little bit of an uplift from some of the bill rates from very critical to fill positions where they are having challenges and the client is wanting to put a premium on the bill rate for a short period of time to ensure that they get that supply. But that's a fairly small percentage of our overall orders that have that premium rate attached to it. But it does certainly help when they do.

Sure. And then I mean what how much of your increased recruiter headcount to the extent you can talk about as the Americas maybe to some competitive information don't want to convey. But could you frame it for us that we understand the size of the increase and the timing, I know in the first quarter call you said September with a particularly the [indiscernible] month. Have you hired more in a significant fashion since that time?

This is Ralph. I will handle that. We're up on year-over-year basis about 30% on recruiter count and a lot of those people are still in their training and not in full production mode yet and we'll -- and what percentage 15%, 20% of them could even drop out before they complete training. So we'll exit at a little bit less than a 30% increase in full production. We've been keeping up with kind of that level. We're looking for opportunities to expand it all the time. So the acquisition was one way to help us get there a little quicker but I would we anticipate we continue hiring into Q2 based on order demands right now.

At this point, can you feather them in at a lower rate and therefore demonstrate, is your anticipation and your projection to demonstrate leverage in 2015?

We do expect to see improved leverage throughout the year. We'll say we won't want to restrain ourselves from hiring sales and support staff that we need to deliver in this high volume business in order to accelerate that leverage. So I think we can do both to answer your question appropriately.

Okay. Then just two questions and I'll get back in the queue. What was the professional liability adjustment expressed in EPS and was there any straight revenue of notes [ph] either in the fourth quarter or first quarter guidance?

This is Brian; I'll take the first question. The $1.8 million that we've mentioned in the fourth quarter that's equates to about $0.02 impact on our result.

And on the labor disruption question we have seen increased activity and so in the fourth quarter we had a little under $2 million in related revenues and we're actually seeing that repeat itself in the first quarter.

Okay. I guess I have said I want to speak one more, how influential is the flu season in guidance and are you concerned that order flow maybe temporarily boosted by the seasonal phenomenon. Thank you.

We have seen some orders relative to flu and as best as we can we ask our clients what the purpose of the staffing need is and whether it will sustain and surprisingly maybe flu has been a very small percentage of our overall orders and we don't think that it is really lifting up the volumes in a meaningful way in the first quarter. So certainly it is a factor but it's a very small factor.

Thank you very much.

Thank you Tobey.

Your next question comes from the line of Jeff Silber from BMO Capital Markets. Please go ahead.

This is Henry Chen calling in for Jeff.

Hi Henry.

Hi, just a quick modeling question, I don't think you guys gave out your G&A guidance for ’15 or sorry if I missed that?

This is Brian I'll just take the first one, the amortization expense I gave of $3 million that would be the same through the entire year and again once we -- in the next call we'll have the valuation report down on the acquisitions, but we don't expect it to move much from that if at all. The depreciation expense in the first quarter of $2.5 million that will go up a little bit and as we go through the year, in part just from the some of the IT initiative we have in place as well as some of the integration activity so probably exit the year closer to $2.7 million.

And this might be little bit early but in your guidance and for first quarter does that incorporated any revenue or earnings synergies from the recent acquisitions or is that just too early to tell.

So for the first -- this is Brian again. For the first quarter guidance it does not really attribute any revenue synergies. I think as we look through the year we talked about when we announced the acquisition and we do see opportunities for synergies, both revenue and cost synergies overtime, particular the revenue synergies we are - as we act -- give them access to orders and move them on to our travel nurse and allied platforms, that would really create the biggest opportunity for synergy, that would really be seen in the very back half of the year. So we do think there are some opportunities as we move into that -- late in the first quarter and the second quarter but the bigger real revenue synergy opportunities will be in the late in the third and into the fourth quarter.

And we’ll obviously have a much more meaningful impact in 2016 with Avantas as an example. We are actually already seeing some terrific collaboration and were actually able to already close a new client based on introductions and working together. So I think that is an area of focus for us across all of the new businesses. I would say that all of our workforce solutions businesses are working much more collaboratively and it’s because clients are wanting to hear about multiple and different kinds of services, as we are out talking with them about the full capabilities of AMN and maybe they are interested in initially in MSP, we can also be talking with them about RPO and what we can do to help them with their permanent hiring going back to the commentary earlier on attrition and vacancies. One of reasons their temporary staffing is maybe through the roof today is because they are seeing such high turnover. And so we can be a value added partner in helping them to address that issue while we are also helping them with the short-term needs.

Okay that’s great, thank you.

Your next question comes from the line of Randy Reece from Avondale Partners. Please go ahead.

Good afternoon.

Hi Randy.

Good afternoon. I have a question about the how the professional liability adjustments effect your management of expenses, is that something that happens after the quarter’s close and it’s just an accounting exercise, do you have any idea inter-quarter how it’s going to come out, does it affect your spending plans whatsoever?

This is Brian. Yeah you characterize it pretty well. It is more of an accounting exercise. We have a third party doing actuarial study for us twice a year. So in June and December we have our reserves, NOIs for Nurse and Allied and the Locum segments. We have some insights into trends in our clients but really it’s difficult to use that to predict exactly what adjustment it’s going to be. So we don’t typically factor that into our guidance for the quarter or and we certainly don’t layer it into our spending plans because our deals [ph] are typically longer term. So we don’t really know that number until the end of the year which we found out early January what the fourth quarter adjustment was going to be and it was more than we would have anticipated but that’s the positive and we are seeing clients settle at lower amounts and we’ll always take to [indiscernible]

So and the converse here you still have a very robust surge in spending and presumably in advance of anticipated revenue growth, is that correct?

No, I think our spending, we talked about the fourth quarter what our percentage of revenue and it came in right in line with that. So if you look at the third quarter to fourth quarter SG&A it went up some which was really driven by the additional sales resources that we hired additional commissions on higher revenue. There wasn’t really other major from the third to the fourth quarter and as we look into the first quarter the guidance we gave for the SG&A as a percentage of revenue it really implies not a big change in the SG&A from Q4 to Q1. The increase is really driven more from the acquired companies.

You talked about the flu effect, my observation, direct observation in the hospitals with regard to the flu effect on staffing is that these facilities can’t and don’t and are unwilling to adjust nearly as quickly as their populations change and everything I saw was running way understaffed, which seems to have future implications for staff turnover. Am I interpreting that right, is this sort of experience going to have a tail in terms of elevated turnover over the next few quarters?

Yes, Randy I think you are interpreting that exactly right, burnouts and having too heavy a rotation load are some of top reasons why nurses leave their jobs because it has become too much for them. So it becomes somewhat a vicious cycle for clients unfortunately when they are understaffed that it can drive more attrition which leads to greater need for both permanent and temporary staff. So I don’t think we will see the end of this anytime soon and in fact I think it is one of the reasons we are seeing such strong demand for all of our services, including as I mentioned RPO which really gets to the core staffing need that they have going forward. And I also agree with you that I don’t think that they adjust their staffing too much for flu, if they do it is through the per diem business and getting local staff to work on an as needed basis because they don’t know how long a flu season is going to last, just because census [ph] goes up we are weaker too for flu, we are going to hire a traveler for that. In fact the travelers are probably going to -- the travelers that they are procuring from us today aren’t likely going to start for another month and then they will be there for three months. So the orders that we are seeing today would not likely be flu related because hospitals know that the flu season is going to over by likely the end of February. I think you are seeing it exactly right, Randy.

Thank you very much.

Your next question comes from the line of Mark Marcon from Robert W. Baird.

Good afternoon, and let me throw in my congratulations as well as happy anniversary

Thank you, Mark.

So in terms of your actual headcount, I guess we will see it when the 10-K comes out but can you give us a sense for what is your internal headcount is now?

At the end of year it was 1,800. Obviously it will be a little bit higher -- this is Brian. It will be higher from the recent acquisitions as well. We will add another 200 and change from the Onward, Locum, Medefis and Avantas companies as well. So we are probably closer to 2,100-2,200 at this point.

Okay and how are you thinking about growing that over the course of the year? I mean obviously it was accelerated in September, how should we think about that?

The primary growth will come in the sales resources and support service areas and that will be in conjunction with anticipated revenue growth. So I would consider those to be variable but we do have to hire in advance due to the training cycle and ramp time to get the people up to speed and be productive in their roles and then as Ralph mentioned earlier we have now the benefit of the teams at Onward and Locum Reader who are doing a fabulous job but we think we can have them be even more productive and have higher travel accounts per recruiter by getting them onto our systems and introduced to our MSP accounts. There’s no reason they shouldn’t be at the same higher productivity levels as the other AMN recruiters and so I think we will have the benefit of not having to hire as many recruiters as we would otherwise because of this acquisition and it was fantastic, those are very experienced and talented recruiters. So I think that their ramp time to get onto our systems will be very fast.

Great. And in terms of the fill rate off of your MSP programs, in terms of what your direct fill could go from and to, how should we think about that with those additions?

Yeah, Mark this Ralph. I will answer that one. The fill rates when orders jump like this to the extent our trend down just a little bit, so there are others still a lot higher than our traditional fill rates they are a little bit less than they work on the same time period last year with the order growth less than half of what we have. So there is quite a bit of upside in fill rates there and you know an average recruiters takes -- to get to kind of average production that calls for 18 months. So probably kind of that timeframe before we -- these recruiters have the same kind of effect as their counterpart who have been with us for a long time. So you are right in it, there is upside, it just takes a while to get there.

And with regard to just the behavior that you are seeing in terms of the travelers, can you comment a little bit in terms of the willingness to travel the number of nurses that are registering with you?

We are seeing positive trends on the number of people that are applying, I will start there but our travelers come from three different groups. They are people who are rebooking and people who are lapse who use the travel and are coming back into the industry and then new supply which we recruited and haven’t worked for us before. We’re seeing increases in all three which is great news. So the people who are already traveling like it, people who used to travel are coming back and people who have never travel are beginning to in greater numbers. And that new category is the fastest growing category of the three. So those are all positive signs and still insufficient to keep up with the demand levels. I would love to say that we could double the business but there is still caution and the wages were kind of flat for several years due to the recession. So I think as pricing has begun to move up in the last few quarters that will attract more people back into the industry and you will see the type of improvement we had kind of in the last couple of quarters continue.

That’s terrific. And you mentioned the DSOs earlier, where do you think they could go to?

This is Brian. I think we can go down from where it has at 60. I’d hesitate to put out an exact target there. We’ve already seen I kind of mentioned a couple of different factors, one being a couple of larger clients that were just little slower in paying. I mean couple of those have already gone back to current again. So that already would move the DSO down by a day or so. We can move it down by a few days this year but I also recognize that we are in this growth model as they are certain things that are not completely in our control, when our clients are interfacing with BMS technology and they have to interact with it, approve certain things that we have to keep educating and training our clients in how to use the technology appropriately and that will take some time as well. So I think we will continue to move it down little bit over the year but the 55 we had last year is going to be what we expect to get to in the near-term.

Okay. And where do you anticipate total debt being at the close of the quarter?

We will be at about $240 million or so. We had $142 million on our existing facility and we borrowed the revolver for the acquisition. We may pay down a little bit of that by the end of the quarter but right around the $240 million range.

Great. And then can you just give us some anecdotal color with regards to the reaction of clients to the acquisitions?

It’s been very positive, as I mentioned with the starting with the first acquisition that we closed, Avantas, we have already been able to share contacts and leads. And I myself have been in meetings with clients where we’ve talked about this capability and their eyes light up and they get very interested and very much want to include that as at least a potential solution that we bring to the table. And so I think a lot of great opportunity there between the organizations and then regarding Onward and Locum Readers a lot of positive response about us being able to just do that much more to serve the needs of our clients. It immediately bolsters our supply. It gives us more power on the recruitment front, more capabilities there and then Medefis. Medefis has just done an outstanding job in building their business and they in fact as well as ShiftWise are having the best quarters the company has ever seen and are coming into the first quarter very strong. And what’s fantastic is they approach the market in a slightly different way. They are trying to solve the same problem but they have different features and ways that they deliver technology and their solutions that are going to appeal to different clients and so we are able to as appropriate bring both solutions to the table or sometimes it may just be obvious which solution is better for the clients. And that what’s really rewarding is when you can go to a client and say we just want to serve your needs and help you achieve your goals and we have multiple solutions and ways that we can help them do that and Medefis is just one more offering that can help them solve their problems in a different way. So it’s been extremely positive and I will also say the collaboration between the team members at those companies and the AMN team members has also been exceptionally strong. As you know we’ve been through several of these integrations before and so it’s helpful we’ve got Playbook [ph] and we've got a good history of walking through these things. But the willingness and the sheer talent of the teams is the most critical part in the success and I've been in fewer of the integration meetings as the teams have come together and it's a very, very impressive group of people on all sides of the table and that's to me the most important ingredient for us to really get the benefit and synergies out of these businesses.

That's great to hear. Congratulations.

Thanks Mark.

You have a follow-up from the line of Tobey Sommer from SunTrust. Please go ahead.

Thanks. I was just hoping you could repeat the itemized guidance details that are in the press release, because my penmanship wasn't quite quick enough to get all that down.

Sure, give me one second.

Thanks Brian.

I got to get back.

So Tobey are you asking about the individual segments or?

No, the smaller items down the P&L depreciation amortizations.

Okay.

Got that, this is Brian. So the interest expense that’s a $1.8 million for the quarter; depreciation $2.5 million; amortization $3 million tax rate 44% non-cash stock based compensation expense $2.1 million and share count of $48.6 million for the first quarter $48.8 million for the full year.

Okay. Thank you very much.

Thanks Tobey.

And at this time there are no further questions.

Terrific. Thank you everyone for joining us today and for your continued support of AMN. We look forward to updating you on our progress next quarter.

Ladies and gentlemen that does conclude your conference for today. Thank you for your participation and for using AT&T Executive Teleconference. You may now disconnect.