Good day, and thank you for standing by. Welcome to the AMN Healthcare Second Quarter 2024 Earnings Conference Call. [Operator Instructions] Please be advised that today's conference is being recorded I would now like to turn the call over to Randle Reece, Senior Director of Investor Relations. Please go ahead, Randy.

Good afternoon, everyone. Welcome to AMN Healthcare's second quarter 2024 earnings call. A replay of this webcast will be available at ir.amnhealthcare.com at the conclusion of this call. Remarks we make during this call about future expectations, projections, trends, plans, events, or circumstances constitute forward-looking statements. These statements reflect the Company's current beliefs based upon information currently available to it. Our actual results may differ materially from those indicated by these forward-looking statements because of various factors and cautionary statements, including those identified in our most recently filed forms 10-K and 10-Q. Our earnings release and subsequent filings with the SEC. The company does not intend to update guidance, or any forward-looking statements provided today prior to its next earnings release. This call contains certain non-GAAP financial information. Information regarding and reconciliations of these non-GAAP measures to the most directly comparable GAAP measures are included in our earnings release and on our financial reports page at ir.amnhealthcare.com. On the call today are Cary Grace, President and Chief Executive Officer, and Jeff Knudson, Chief Financial Officer. I will now turn the call over to Cary.

Thank you for joining us for a review of our latest financial results and updated outlook against some continued challenging market conditions, we made progress on stabilizing our performance. Demand for healthcare was impressive this quarter and the market for skilled caregivers shows signs of improvement. Patient demand and labor supply are crucial drivers of long-term growth in our businesses. Our consolidated revenue for the second quarter was $741 million, which enabled us to produce $16 million in net income, $100 million operating cash flow, and adjusted EBITDA of $94 million. The adjusted EBITDA margin for the quarter surpassed the high end of guidance. Excluding some discrete items that favorably impacted SG&A, adjusted EBITDA margin would have been above the high end of our guidance range. While we continue to see some pressure on placement, volume, and revenue from larger clients, we expect our third quarter adjusted EBITDA margin to be higher than sell-side analyst expectations. Our third quarter outlook at the midpoint implies that adjusted EBITDA and adjusted EPS would be in line with expectations though our revenue outlook is approximately 4% below consensus. AMN continues to improve how well we are aligned with all segments of the market for total talent solutions in healthcare. These efforts are vitally important to our long-term success. Coming off 2023, when we were in a net loss position with MSP contracts year-to-date, we are net neutral with wins and losses with last year's RFP behind us, and we are better situated with our clients today. The diversification of our business portfolio, including several high-margin, technology-enabled revenue streams, has enabled AMN to maintain profit margins at attractive levels. At the same time, we are delivering to our staffing customers pricing and value that are in line with our industry peers. Across our staffing…

Thank you, Cary, and good afternoon, everyone. Second quarter consolidated revenue was $741 million, down 25% from the second quarter of 2023 and down 10% sequentially in line with expectations. The sequential decrease was primarily due to lower volume in the nurse and allied segment and the locum tenens and VMS businesses. Consolidated gross margin for the second quarter was 31%, also in line with expectations. Year-over-year, gross margin decreased 230 basis points driven mainly by lower margins across all three segments, partly offset by a favorable segment mix. Sequentially, gross margin decreased 40 basis points, primarily due to lower nurse and allied segment and locum's gross margin partially offset by a favorable revenue mix shift. Consolidated SG&A expenses were $149 million, or 20.1% of revenue, compared with $202 million, or 20.4% of revenue in the prior-year period and $175 million, or 21.3% of revenue in the previous quarter. The decrease in SG&A expenses year-over-year was primarily due to lower employee and professional service expenses as we remain steadfast in reducing costs to match the revenues, lower employee expenses and favorable actuarial adjustments for professional liability insurance drove the decrease sequentially. Adjusted SG&A, which excludes acquisition, integration and other costs, legal settlement, accrual changes, and stock-based compensation expense was $137 million in the second quarter, or 18.5% of revenue, compared with $170 million, or 17.1% of revenue in the prior-year period and $162 million, or 19.7% of revenue in the previous quarter. Discrete items that we do not expect to recur in the third quarter included an actuarial adjustment for professional liability insurance and a change in the accrual for incentive compensation. These items reduced SG&A by 7 million in the quarter. Nurse and allied revenue was 442 million in the second quarter, down 36% from the second quarter of…

[Operator Instructions] Our first question for today will be coming from Trevor Romeo of William Blair. Your line is open.

Good afternoon. Thanks for taking the questions, team. I think, one, it would just be great if you could provide any details you have on the bill rate and volume assumptions for nurse and allied that are embedded in the Q3 guide. And then thinking to Q4, I think Cary talked about a range of potential outcomes relative to Q3. And Jeff, I kind of always appreciate the look you tend to give on these calls for two quarters ahead. So, any thoughts on how you'd see Q4 shaping up for bill rates and volumes, just based on what you could see at this point would be really helpful.

Yes. Thanks, Trevor. So, as it relates to the Q3 guide, we have bill rates down low-single digits sequentially from Q2, and volumes down low-double digits in nurse and allied from Q2 levels. When we think about the fourth quarter, Cary mentioned the range of scenarios, excluding international. So, with the impact of visa retrogression on international business, we would expect that business in the fourth quarter to be down $6 million to $8 million sequentially from Q3. So, that's about a 200-basis points drag on the growth within the segment. And so, when we look at bill rates and volumes quarter-over-quarter, again, winter orders will be a big swing factor for us within the quarter were not only those volumes come in, but the start dates within the quarter, and then also where the bill rates land. So, we would see bill rates within those range of outcomes being anywhere from flattish to maybe down slightly in the fourth quarter. And then volumes ranging from a low-single digit increase to low-single digit down quarter-over-quarter.

And, Trevor, we've gotten some indications from clients to accept those orders, but we wouldn't see them until later in the quarter.

Got it. Okay, thank you both. That was helpful.

[Operator Instructions] And our next question will be coming from Brian Tanquilut of Jefferies. Your line is open.

Hi, good afternoon, guys. Maybe I'll follow up to Trevor's question. So, if we're seeing orders up 20%, Jeff, like you just said, plus low single to minus low single in Q4 maybe help us bridge that. Like, how does the order number translate to a different volume expectation? And then also, how are you thinking about typical seasonality this year? You're seeing plus 20% orders here? I think normally seasonal patterns are even more pronounced than that. So just curious what you're thinking or what you're seeing?

Yes, Brian, on the seasonality, we went back and looked at the couple of years leading up to 2019, and normally, we would have seen demand increase somewhere in the 25% to 30% range versus what we've seen here this year, up 20% and off a lower trough, quite honestly. So, yes, the demand trends are improved, but it was off a lower base and not quite back to where we were pre-pandemic. I think when we just think about the volumes within nurse and allied, one thing I would say is, as we look at the monthly sequence within the third quarter, the traveler count is stable July through September, albeit with a lower starting point in July than we were at the end of Q2. So, that's a much-improved trend from where we were in the second quarter, where June was the low point within the quarter. And so, with that demand, I would just say when we're -- you know, it gets back to what Cary said about some of our MSP clients, we're still seeing reductions in utilization, and we're seeing extension rates at the low end of what would be historically normal from a continuation standpoint, about 500 basis points off the average, but it's within the norm. But at the low end of that range.

Okay, that makes sense. And then maybe, just as I think about SG&A, any discrete items or one-timers in the SG&A line that you would call out and maybe just how you think we should be modeling SG&A going forward.

Yes. So, within the second quarter, we had about $7 million of discrete items that added 100 basis points to adjusted EBITDA margin. So, ex those, we would have been at 11.7%, which was 20 basis points above the high end of the guide. About $4 million of that, $7 million related to an actuarial adjustment on professional liability insurance, which we throw up twice a year in Q2 and Q4. The remaining $3 million was related to some variable and incentive compensation accruals. We wouldn't expect those to recur in the third quarter, but despite that, we would see adjusted SG&A dollars pretty flattish in the back half to Q3 levels, you know, as reported on adjusted SG&A.

Got it. Thank you.

Thank you. One moment for the next question. And our next question will be coming from the line of Jeff Silber of BMO Capital Markets. Your line is open.

Thanks so much. I wanted to dig into some of the demand trends that you've been talking about. I know it's tough to gauge, but do you think most of your hospital clients are comfortable with the mix of permanent to temporary staff? Do we think that's going to go lower? What it'll take it to get moving in the right direction?

So, Jeff, maybe I'll talk a little bit about what we're seeing from a macro standpoint. So, across the Board, for most of our clients, we're seeing higher patient utilization. Against that, what we've been seeing over the past four to five quarters is very strong permanent hiring. They've also seen higher retention rates. Now those retention rates were coming off of unusually low retention rates during COVID. And we've also seen a lot of efforts to hire lower paid workers to support some of the clinical roles. But even with all these efforts, and they've been very strong, especially around the permanent hiring, you're still seeing open rolls, you know, 2.1 to 1 from a higher standpoint. And so, we're seeing still pressure as you increase, you know, patient utilization against the workforce that's available. And if you look at the contingent premium, we're now in the back half of the year getting back, and we're in normal ranges of 15% to 20%. And so those sets of dynamics, I think, are making it more interesting from a demand standpoint. What we're seeing from clients is even if they have a target of where they want their contingent spend to be, they may have underestimated some of the efforts of permanent hiring or not factored in some of the retention efforts. So, we're seeing those factors play in, I'd say, particularly over the past quarter or two and where they're coming out.

All right, that's helpful. If I could ask a similar question about your own workforce. Are you at the point where you think you've rightsized enough that your workforce can handle the current demand environments? And how quickly can you turn if things start to move in the right direction?

Yes, we feel good about where we are we've been very conscientious about rightsizing as we saw demand shake out in different parts of our business. But we are positioning ourselves both in terms of our workforce and our capabilities to be able to meet rising demand conditions.

All right, thanks so much for the color.

Thank you. And one moment for the next question. And our next question today will be coming from the line of A.J. Rice of UBS. Your line is open.

Hi. Thanks, everybody. Maybe just following on Jeff's comment about, and I guess Cary due to some degree of fourth quarter, with what you're envisioning with revenue, how does that translate into, do you think we're at a stable point with gross margin from Q3 to Q4? How about SG&A? Is that sort of flattened out? Is there any reason that would step up or down thinking -- not looking for necessarily a specific estimate, but directionally where we're at as we think we're bottoming out here generally?

Yes, I would say, A.J., on the gross margins, both from a nurse and allied standpoint and also from a consolidated standpoint, I think something in the high 30s, you know, 30%, 30.8%, 30.9% to the low 31%, is a reasonable estimate, which is essentially the midpoint of the guide for Q3 and where we were in Q2 that that's reasonable to think about the fourth quarter that same way. And then from an adjusted SG&A standpoint, dollars being relatively flattish over Q2 levels would also be the right way to think about the fourth quarter.

Okay, that's helpful. Just thinking about use of cash flow from here. I guess by our calculation, you ended the quarter at 2.6 times debt to EBITDA. I think you'll be at three or above as you exit the year. Is paying down debt a priority? Where are you comfortable on that leverage ratio as you go forward?

Yes, debt pay down has been a priority as we've been gone through the first half of this year. We've paid off 115 million year-to-date, and that includes 80 million in the second quarter alone, A.J. So, we'll continue to prioritize debt pay down with excess free cash flow for the remainder of this year and probably into the early part of '25 as well.

And how -- I guess I'm trying to get at what is the -- what leverage ratio would you sort of be back to a balance between potentially acquisitions, buybacks and leverage? Where would you guys feel comfortable? And it's sort of at a good point.

We'd want to see it back below 2.5 before we would deprioritize debt paydown.

Okay. Thanks a lot.

Thank you. And one moment for the next question. Our next question will be coming from the line of Mark Marcon of Baird. Your line is open.

Good afternoon and thanks for taking my questions. Really found the comments on the volumes helpful. I was wondering, can you talk a little bit about what you're seeing just in terms of the pay rates that some of the traveling nurses are looking for? You did mention that the premiums are coming down to 15% to 20% above perm for contingent. And so, is that sufficient to fill demand? That's the first question.

Yes. I think historically if you look at that premium, that has typically been sufficient to fulfill demand, obviously, you're going to have differences in geography and specialties. I think, Mark, when you look at one of the things that we look at from a macro standpoint is the premium is off of an increasing permanent wage. And so, I think that's going to be one of the dynamic factors that you look at where over the past year and a half, we really had the contingent wages at, you know, a very high premium coming down. But now as you've gotten into these normalized, you know, ranges, it's off of a base that is increasing.

Right. So, it sounds, Cary, like the fill rates are in line with what your expectations would be and filling the orders is not an issue. It's still this demand from the clients. Is that correct?

Yes, I say largely that's it. I mean, if you have specialties that are hard to fill, they're going to be hard to fill. But if you have orders that are priced at market, you see high-sell rates. So, it really is about the demand coming back.

Okay, great. And then can you just talk a little bit? I mean, obviously, everybody in the entire space is facing the same sort of demand characteristics. It sounds like the bill rates are holding up relatively well. Can you just talk a little bit about competition and what you're seeing on that front? And how confident are you in terms of the prognostication that you gave with regards to how you would expect the bill rates to flow through the balance of this year?

Yes, let me talk a little about competition, and then Jeff can talk a little about the transparency we have on bill rates. We have been in a competitive environment. We continue to be in a competitive environment. So, I don't see that changing in the short and intermediate term. And so, we've seen pressure, as everyone in the industry has over the past year. So, that's reflected in, you know, both what you have seen from a performance standpoint, but also our forecast.

Yes, Mark. And then I would just say on the bill rates for the third quarter, when we look at the bill rates that we have in July for our travelers on assignment and where we're booking future TOA that supports that low-single digit down into the third quarter, and then obviously, seasonally, we'll get some influence on the bill rate from those winter needs orders. And that we believe in a flattish scenario would offset any pressure on bill rates in the non-winter needs orders.

Great. And then on a positive note, you're seeing really nice traction with ShiftWise. You mentioned getting up to 50%. Where do you think that can get to, and what would be the implications of that?

Yes. So let me give context for what the 50% is. So, we are very happy with how we are doing on ShiftWise Flex. And so, our number one goal is to re-platform our ShiftWise clients into ShiftWise Flex. So that 50% number is we are over halfway in terms of client spend under management, putting them onto ShiftWise Flex. We also started with our first MSP clients, and we expect, as we end this year, to have the majority of our VMS clients completed, and we would expect to have made significant progress with our MSP clients. So, first priority for us is re-platforming existing clients. The second piece, Mark, is building our pipeline, which we saw very healthy progress against when we look at it from a quarter-over-quarter basis.

Great. What are the financial implications of that?

So, if you think about the financial implications, the first one on re-platforming should not be accretive from a revenue standpoint, they're existing clients. We think that there's opportunities, especially because ShiftWise Flex has enhanced capabilities from a technology standpoint for that to be a platform that we can do more with some of those existing clients. If you look at our pipeline, that pipeline revenue impact really wouldn't have any impact until 2025 as you started to work down the pipeline and then onboard wins from that pipeline. So, it won't have an impact this year. You should expect it to have more of an impact as you get into the back half of 2025.

Great. Thanks for the color. Appreciate it.

Thank you. And one moment for the next question, please. Our next question will be coming from the line of Kevin Fischbeck of Bank of America. Your line is open.

Great, thanks. I guess you're the second company to say that the orders are up about 20% since the beginning of Q2, but still talking about stable but below Q2 average revenue, and then Q4 sounds like still also kind of stable-ish, despite the orders going up. So, does that that mean something around, I guess you mentioned that orders are able to be filled if they're at market. Does that mean that these orders that are coming in are not at market? Or why isn't there a better correlation between 20% and the revenue numbers over the next couple of quarters?

Yes, I'd say two things. One is you always have some mix of orders that are going to be at market rates or below. And so, what you tend to see is for orders that come in that aren't at market, they have very low fill rates, and they tend to age. So that's going to be true. As you see increased demand, you're going to have some of those orders that are not going to be at market. And you tend to see them age. In terms of when you look at what we're seeing overall from the demand increases and open orders that we've seen since the beginning of April, and it's a little bit of what Jeff had talked about earlier. We're also seeing for some large clients where they have reduced utilization. We've seen this, you know, a lot in our extension rate. And so that's the piece, Kevin, where we're seeing, you know, promising signs around the demand, but we still have some stabilization that we are seeing with some of our clients.

Okay. And then I guess the winter orders, I think historically you'd have a little bit of color at this point. It sounds like it's kind of been pushed back a little bit as far as when those orders come in. Is that --is there an implication for that like in -- in the past, if they come in a little bit later, does that, you know, mean that the orders are going to be lower or does that not necessarily follow through?

Yes, I think, Kevin, from a timing standpoint, we're expecting it to look like last year. I don't know that coming in later signals anything in terms of volume, but what we did see last year versus pre-pandemic was a shift where more of those Q4 starts were in the mid-to late-November timeframe, which was a couple weeks later than normal, what we had seen 2019 and prior.

And is that a new normal? Does that mean that hospitals are just waiting a little bit longer to use temp staffing and that's just the way it's going to be, but the view is that if they need it, they need it and they'll eventually?

Yes, it could look, I don't know if it's a new normal, it could look like last year. But we also then did see some of the benefit into that, into the first quarter. I would say the total duration of those orders was probably on par with what we had seen in 2019. They started later, but then maybe went a little longer into the first quarter.

And Kevin, the other part that I'd say, and again, I don't know that we can call this the new normal, but we're seeing some of these delays just across the Board. It's not just with winter orders. So, I don't know that I would read anything into that.

Okay. And then I guess last question on the SG&A side, you spiked out to $7 million. Is there anything else there -- because I guess in the press release there's commentary about lower compensation costs and with lower demand, is that something that we should be on the lookout for? If demand does improve, will there be pressure on the SG&A next year, or is this a good base to be thinking about SG&A as a percentage of revenue going forward?

I think probably the biggest thing for next year from a base standpoint is similar to last year's. We would have a reset on incentive and variable compensation, just again, given the year that we've had in 2024, and then you would have your normal merit and other inflationary type adjustments that would hit in '25 that aren't in that base right now.

Is there a way to size that?

On the incentive and variable side, you can think about that probably in the $3 million to $4 million per quarter range.

Okay. Perfect. Thanks.

Thank you. One moment for the next question, please. And our next question will be coming from the line of Tobey Sommer of Truist Securities. Your line is open.

Thank you. I was wondering if you could talk about how you feel you're doing with all the internal idiosyncratic changes you could make to address the marketplace as demand is falling now for a protracted period of time. You consolidated some brands. You're trying to cross sell more services, is my understanding. How do you feel like you're prosecuting the changes you can control?

Yes. So, if you think about some of the core pieces, Tobey, that we've talked about, that we are changing our model to ensure that we are aligning ourselves to a bigger market TAM, you know, the first is our go-to-market strategy. So, we had been for a number of years focused on a very important, but, you know, a minority part of the market in MSPs. So, we have aligned ourselves to all segments of the market, and we're seeing progress on that. So, if you look at Q1 to Q2, we saw healthy increases in the positions filled in third-party and direct relationships. So, we had a number of initiatives that were aimed against that including operational automation. We made significant progress in our speed to fill so there were operational and technology enhancements behind being able to achieve some of those increases. From a brand standpoint, we are completed with the brand integration, and so we've consolidated the staffing brands. We're keeping B.E. Smith, which serves a very different audience, separate, and you will see a reinvigoration of that brand. So, we're seeing strong outcomes in our overall brand testing. We're seeing over 250,000 clinicians who are now on our Passport App. So, we're seeing progress on our go-to-market strategy to align ourselves against the entirety of the market. On our digitization of the company, again, and I know I talked about a number of these initiatives in my opening comments, but we've been very focused on how we align and innovate with our clients to help them build sustainable workforces. So, a lot of that's what we've done with ShiftWise Flex and the data and analytics and the market data, as well as AI-enabled workforce planning and scheduling. Our scheduling platform was rated number one in class for the second year in a row. So, we've done a lot of work around ensuring that we have a tech-enabled set of services to help clients with where they want to go. And I'd say the same thing for clinicians with the enhancements that we've done on Passport and connecting our clinician app to really important client technology so that we can connect clinicians to clients.

In -- at this juncture, how do you think it's influencing market share and/or wallet share? How do you choose to think about it?

Yes. So, from a market share standpoint, what we experienced going focused on MSP clients during, you know, a significant period of growth during COVID that was not favorable to us. If we look at this year versus last year in terms of net wins and losses, we came out of last year where we were in a net loss position. We are and expect to be net neutral on clients from this year and so that is progress. Obviously, we want to translate and get to a position where we're getting into net growth.

And what are the signs telling you with respect to your international business and visa retrogression? Are there any updates that you've either seen that indicate when you could see a turn or dates out in the future that you're anticipating some sort of an update? Thanks.

There was a bulletin release today, and I would say it was largely neutral. What we're looking for is the October bulletin, which typically comes out in late September, that will set the visas for next year. And so, we should have a better idea, you know, as that bulletin comes out about what we would expect in terms of visas for the future. Our strategy on the international side is we are, you know, very intentionally keeping our pipeline very up to date. So as those visa numbers get clarified and get awarded that we have all of our commissions in place and ready to go.

Thank you.

Thank you. One moment for the next question. Our next question will be coming from the line of Bill Sutherland of Benchmark Company. Your line is open.

Hi, everybody. I was just wondering at this point; I think we've checked all the questions here. Jeff, on -- in locum, the MSDR acquisition, did you call out the impact in 2Q and what's in it? What's in the 3Q guidance?

Yes, it was $34 million of revenue in the second quarter, Bill, so -- and we would expect that to be maybe down modestly, sequentially into Q3.

Is that seasonality?

No, I think that gets to what Cary was talking about earlier with what we're seeing probably more broadly in locums, where we're seeing delays in client decision making and just in lower extensions, and probably more of a focus on the cost of locums. Demand is still healthy, but it is down from the beginning of the year, and it's certainly down year-over-year.

And what I was sort of taking away from earlier comments is that the bill pay spread in the travelers is getting kind of back to something that is normal, but that what's weighing on the spread gross margin is lodging and other costs related to the traveler's expenses. Is that what you guys are seeing?

Yes, that's accurate. When we think about nurse and allied gross margins in the second quarter, you know, all other elements of the bill pay spread actually improved slightly over Q1 levels, and the downdraft came from the housing and the per diems as well as we had a favorable worker's comp adjustment in the first quarter that didn't repeat in Q2 within nurse and allied.

Okay. And then just zooming out a little bit, I'm kind of curious about the marketplaces impact on your, you know, just competitively. And in the past, they haven't, I don't think, made a big difference in how you do, but curious help me know what it looks like today? Thanks.

What marketplace, Bill?

The marketplaces that are, you know, designed to be very automated as far as building positions.

Got it. I think what we've seen like particularly over -- in the past six quarters, is that when you look at the supply demand equation, it's actually been the premium spin on, you know, who has access to the demand. And so, the marketplaces tend to be a conduit for supply, but they're not always connected in as directly to the demand side as you would see vendor-neutral, direct MSP relationships. So, you know, they obviously are out there, I think -- but we haven't seen them be as much of a factor in this lower demand environment.

Makes sense. Okay. Thanks, everybody.

Thank you. This does conclude today's Q&A session. I would like to go ahead and turn the call back over to Cary for closing remarks. Please go ahead.

Thank you all for your continued interest in AMN. We look forward to continuing to update you on our important mission of empowering the future of care.

Thank you. This concludes today's meeting. You may all disconnect.