Earnings Labs

Cross Country Healthcare, Inc. (CCRN)

Q2 2018 Earnings Call· Wed, Aug 1, 2018

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Transcript

Operator

Operator

Good afternoon, ladies and gentlemen, and welcome to the Cross Country Healthcare Earnings Conference Call for the Second Quarter of 2018. This call is being simultaneously webcast live. A replay of this call will also be available until August 15, 2018, and can be accessed either on the company's website or by dialing 800-391-9846 for domestic calls, and 402-220-3132 for international calls and by entering the passcode 2018. I will now turn the call over to Christopher Pizzi, Cross Country Healthcare's Chief Financial Officer. Please go ahead, sir. [Technical Difficulty]

Christopher Pizzi

Management

Operator, could you do the intro again for me please?

Operator

Operator

Sure, give me one moment, please. Good afternoon, ladies and gentlemen, and welcome to the Cross Country Healthcare Earnings Conference Call for the Second Quarter of 2018. This call is being simultaneously webcast live. A replay of this call will also be available until August 15, 2018, and can be accessed either on the company's website or by dialing 800-391-9846 for domestic calls, and 402-220-3132 for international calls and by entering the passcode 2018. I will now turn the call over to Christopher Pizzi, Cross Country Healthcare's Chief Financial Officer. Please go ahead, sir.

Christopher Pizzi

Management

Thank you, and good afternoon, everyone. I'd just like to apologize for the technical difficulties we just experienced. Joining me today is our Chief Executive Officer, Bill Grubbs, and our Chief Operating Officer, Bill Burns. This call will include a discussion of our financial results for the second quarter of 2018 as disclosed in our press release as well as a discussion of our financial outlook for the third quarter of 2018. After our prepared remarks, we will open the lines for questions. A copy of our press release is available on our website at www.crosscountryhealthcare.com. Before we begin, we need to remind you that certain statements made on this call may constitute forward-looking statements. As noted in our press release, forward-looking statements can vary materially from actual results and are subject to known and unknown risks, uncertainties and other factors, including those contained in the company's 2017 annual report on Form 10-K and quarterly reports on Form 10-Q as well as in other filings with the SEC. I would encourage all of you to review the risk factors listed in these documents. The company undertakes no obligation to update any of its forward-looking statements. Also, comments made during this teleconference reference non-GAAP financial measures such as adjusted EBITDA or adjusted earnings per share. Such non-GAAP financial measures are provided as additional information and should not be considered substitutes for, or superior to, financial measures calculated in accordance with U.S. GAAP. More information related to these non-GAAP financial measures is contained in our press release. Lastly, in order to facilitate a better understanding of underlying trends, we may refer to pro forma information on this call, giving effect to acquisitions and divestitures as though the transactions had occurred at the start of the periods impacted. As a reminder, we completed the Advantage RN acquisition effective July 1st, 2017, and the results of its operations have been included in our reported results beginning with the third quarter of 2017. With that, I will now turn the call over to our Chief Executive Officer, Bill Grubbs.

William Grubbs

Management

Thank you, Chris. Thank you, everyone, for joining us this afternoon. As we stated in our last 2 earnings call, our focus for the first half of 2018 was to recover from the 550 billable headcount we lost in Q4 of 2017. We made very good progress in Q1 and through April of Q2, receiving approximately half of that headcount. In May and June, we saw a pullback in spending from some of our larger customers, particularly in travel nurse. Our newer accounts have continued to ramp as expected, but that ramp has been fully offset by the decline ins pend from some of our larger existing accounts. We've seen this pattern of behavior before where accounts pull back quickly on costs and subsequently reverse, but are unclear at this stage how long this is expected to continue. IT's a trend we are monitoring very closely and we are hopeful that it will rebound in the second half of this year. We believe the market is strong enough for us to grow revenue in spite of this pullback, but we need to make some adjustments to account for these changes. Bill Burns and I will discuss the actins we're taking in more detail during this call. First, let me add some color to our revenue trends. The revenue shortfall was almost exclusively the result of pullback in spend from existing customers. Solet me give you a feel for the trends based on our MSP customers which tend to be our largest customers anyway. So the numbers I'm going to talk about are the overall MSP spend under management. So there aren't revenue numbers, these are spend under management. I can translate them to revenue numbers later if you want, but I just want you to get a feel for how…

William Burns

Management

Thanks, Bill. Let me start with a discussion on our segment performance for the quarter and then give some color on several initiatives and out outlook. Revenue for Nurse and Allied Staffing, our largest segment, was below expectations and down 1% year-over-year. The biggest driver, as Bill mentioned, was the underperformance within our travel nurse division which experienced a slowdown in demand at certain large MSP accounts through the second half of the quarter and a slightly lower renewal rate for healthcare professionals on assignment than we anticipated. Overall, our spend under management remained unchanged sequentially thought here wholesale some negative impact from eh mix that Bill mentioned between new and existing MSPs. As Bill noted, several larger existing accounts which historically have had fairly high capture rates, reduced their spend while spend from new MSPs, which generally have a slightly lower capture rate in the earlier days of implementation, increased their spend. Revenue for our branches was flat sequentially as the pullback in spend was not as impactful on that business. And as we enter the third quarter, I'm encouraged by the weekly trends we're seeing in our benches and expect to see continued sequencing improvement from that business. Our Travel Allied business saw double digit revenue growth which we expect to continue moving forward. Demand remains strong and we continue to grow Allied Specialties with our MSP clients. Also with the Nurse Allied segment, our education staffing business reported strong double digit growth for the quarter. As you might expect, demand does slow in the third quarter with the summer school break, but we are steadily ramping the headcount on billing and expect to see continued double digit growth starting with the new school year for that business. Turning to physician staffing, revenue declined primarily due to a…

Christopher Pizzi

Management

Thanks, Bill. While our revenue was slightly below the low end of our guidance range for the quarter, our gross profit margin, adjusted EBITDA and adjusted SPE were all within our guidance ranges. For the quarter, total revenue was $204.6 million, down 2% from the prior year and down 4% from the prior quarter. The year-over-year decrease was primarily due to volume declines mainly in our legacy Nurse and Allied and Physicians Staffing businesses, which were partly offset by the Advantage RN acquisition. The sequential decrease was primarily due to volume declines in our legacy travel nurse business and partly due to seasonal trends in our education healthcare staffing business. Gross profit margin for the quarter was 26.2%, down 80 basis points from the prior year and up 60 basis points sequentially. The year-over-year decrease was driven by the dilutive effect the Advantage RN acquisition as well as lower bill rates in our physicians staffing business due to mis. The sequential increase was mainly due to the annual payroll tax reset which primarily impacts the first quarter of each year. Moving down the income statement, SG&A for the quarter was $45.3 million, down 3% from the prior year despite adding $3 million related to the Advantage RN acquisition. SG&A was down 1% sequentially, primarily due to our cost-savings and efficiency initiatives which I will discuss in a moment. As discussed on our last 2 earnings calls, we remain focused on targeting n adjusted EBITDA margin of 8% as we exit the fourth quarter of 2019 on a run-rate basis. This target is an important milestone for us and it is dependent upon executing on our organic growth strategy in addition to our cost savings and efficiency initiatives. During the quarter we incurred a restructuring charge of $200,000 in connection with…

Operator

Operator

[Operator Instructions] Our first question comes from Jeff Silber from BMO Capital Markets. Your line is now open.

Jeff Silber

Analyst

Thank you so much. Just wanted to get a little bit more clarity regarding an issue you talked about at the beginning of the call. I know you went into some detail, but in terms of the pending decline on legacy accounts, you're talking about volume declines, not necessarily pricing. Or are you talking about both?

William Grubbs

Management

No, pricing is fairly flat. This is all volume, them using less headcount.

Jeff Silber

Analyst

Okay, good, just wanted to doublecheck that. And again, I know you don't have a lot of visibility and that things are a little bit choppy, but I mean there doesn't seem to be -- maybe it was a little bit new this quarter, is this something that we should expect to continue? I know you're somewhat confident that it will pick up, but why do you have that confidence?

William Grubbs

Management

Well, we see these customers on a regular basis. We knew they had some internal pressures and some cost savings initiatives. And as I said we expected some of this to come through, but it came through much higher than we had anticipated. But because we know these customers well, we go and see them on a regular basis and have quarterly business reviewed with them. Wek now that many of them, this is just a kneejerk reaction and that it will catch up to them at some point where they can't do without the people. We know they're not finding them on a permanent basis, so what they're doing now is they are using overtime, they're doing without, they're spreading people thin. And we've seen that happen before and eventually the clinical people will win out over the cost savings people and we'll see some of this come back.

Jeff Silber

Analyst

Okay, fair enough. And switching gear over to margins, you've reiterated your expectations to hit the 8% adjusted EBITDA margin target by the end of next year. We're already halfway through this year. Guidance for the third quarter might have been a little bit lighter than most people expected. I get that it implies a pretty steep ramp up in margins or next year. What gives you the confidence? Are you expecting a rebound in revenues? Is that on the costing side? How are we going to get there?

William Grubbs

Management

Yeah, we are expecting a rebound in revenues and we need that to get to that, that target. So we can't do it by just costs. But Chris outlined $11 million to $13 million annualized cost savings. We believe that, along with getting back some of this pullback from our customers along with the ramping of our new wins will get us back to growth next year as well. It's not an easy task to get there, but we modeled it out, we can get there, and we made that commitment to get there come hell or high water. But we do need growth to come back in order to get here.

Operator

Operator

Our next question comes from Kevin Steinke from Barrington Research. Your line is now open.

Kevin Steinke

Analyst

In terms of the third quarter revenue guidance, what does that imply in terms of what will happen at those clients that pulled back their spending in the second quarter? Does the guidance just assume that there's no bounce back among those clients?

William Grubbs

Management

Yeah, so it pretty much implies kind of flat at those clients. And we are seeing that so far in the quarter. So we feel good about it. Our conversations with the customers, we're out there prodding them again to not surprise us and to tell us what's going on. And we're hearing mostly that things are more level and stabilized than they were in the second quarter.

Kevin Steinke

Analyst

There was a comment in the press release that although you don't provide full year guidance, organic growth for the full year is still expected. Assuming you come in line with your guidance for the third quarter, I know you said you expect a sequential improvement in the fourth quarter, but to get to organic growth for the full year, that would seem to imply a pretty dramatic ramp up in the fourth quarter. Am Thinking about hat correctly? Or how significant or dramatic would it have to be to get to growth for the full year?

William Grubbs

Management

I'm trying to see -- if that's in the press release, it's a mistake and we have 50 people read it.

Kevin Steinke

Analyst

It's in the outlook for the third quarter 2018.

William Grubbs

Management

I see it now. No, we do not expect to get full year-over-year organic growth this year. We can't recover from the headwinds that pulled us back in Q1 and Q2. We obviously expected a better Q3 and we do expect an improvement in Q4, but we will not get back to full year growth. We can't improve the fourth quarter that much. That's a mistake. I don't know how that got in there. It must have been left over from before.

Kevin Steinke

Analyst

No problem, thanks for clarifying that. So you talked about some of the savings, I think $4 million to $4.5 million now expected in 2018. What -- I think you had segmented those cost savings into several buckets in the past in terms of corporate level and then within the segments and also operational improvements. Can you just kind of segment the cost savings that you expect to realize, what buckets those are falling in and progress on each of those categories?

William Grubbs

Management

Let me give you just a bigger picture then I'll let Chris, see if he has some of the detail behind it. So just so you know, the $4 million to $4.5 million that we targeted, the first trench that we targeted for this year, we've realized about $1 million so far. So we expect $3.5 million to come I the third and the fourth quarter. So there's still some of this that we haven't seen in the numbers yet. And now we have a second wave of cost cutting that we expect to get all those costs out by the end of Q3. So we might actually see a little bit more in Q4 of this year as well related to the second wave of cost saving initiative. Off the top of my head, I don't know where they're coming from in buckets, do you have that?

Christopher Pizzi

Management

Yeah, I can give a little bit more color on that. Ad you know, we had identified about $5 million. We had a target of $15 million, $5 million from the underperforming businesses for physician staffing and checkup and then $10 million coming from corporate and field cost savings and efficiencies. So that was the target we laid out. At the moment we have about probably half identified from the underperforming businesses and about pretty much the entire $10 million has been at least targeted and identified for field and corporate at this point in time. So while we're not quite all the way to the $15 million, we said we would get there by the end of 2019 and we have a pretty good line of sight on that at the moment.

Kevin Steinke

Analyst

Thanks, that's helpful. Just lastly, did you add any new MSP spend under management in the quarter? How much have you added new year-to-date?

William Grubbs

Management

Yeah, so we won 2 deals in the first quarter, 2 deals in the second quarter for a total of about $25 million. We expected to be at about $35 million. That's a little behind where we expected to be. We hope to win $70 million plus this year. We believe we're still on track to that, the pipeline looks pretty good. We looked at it again right before we got on the call here and we have some good things coming up in the next, well in Q3 and Q4. So a little behind where we expected to be, but still good pipeline and we think we'll get to that $70 million plus of additional spend won this year.

Operator

Operator

Thank you. Our next question comes from AJ Rice from Credit Suisse. Your line is now open.

AJ Rice

Analyst

Let me start out to just make sure I understand. So it sounds like when you're talking about this softness in these orders that you're mainly attributing that to travel nursing. But it also sounds like with some of the specific comments, that the branch network saw some softness as well. Am I hearing that right? And was none of this softness in order flow in the branch side?

William Grubbs

Management

Most of the branch was a hangover from the Q4 hurricane issue. I don't think in Q2 they were very impacted by the pullback. Probably a little bit --

Christopher Pizzi

Management

The branches were sort of down in that low single digit range year-over-year but that was expected. So they've --

William Grubbs

Management

But that's still the hangover from Q4.

Christopher Pizzi

Management

Yeah, again, most of the pullback that we saw in Q4 from the hurricane was primarily in our travel business. But the branches had a little softness. But AJ, to answer your question more specifically, the pullback that we've seen was predominantly and I mean the majority of it was really pointed toward the travel nurse business. That's where they experienced it.

William Grubbs

Management

And branch has had a steady recovery trend ongoing throughout the second quarter and as we get into Q3, we're seeing sequential improvements weekly there. So they seem to be on a good trajectory to get back to growth and recover.

AJ Rice

Analyst

I will take you up on your comment earlier as you did your prepared remarks on the $34 million you described as MSP spend. Maybe a little more perspective on that. Either in terms of your percentage revenue decline with these accounts or even what's that year-over-year percentage decline. With $34 million out there, it's hard to put that in perspective, but how much either year to year, I guess year to year, are we looking at in terms of a decline percentage wise?

William Grubbs

Management

Let me put it in the bigger picture. When we were exiting 2016, we were bumping up on just about $500 million of spend under management. And right now, we're between $400 million and $450 million. So even with additional business wins, the pullback from what we lost in Q4 and now the additional pullback here in Q2, has pulled us back to that $400 million to $450 million run rate range. So it's down quite a bit over the 18-month period of time, but mostly due to the fourth quarter and the second quarter, 41 of last year and the second quarter of this year.

AJ Rice

Analyst

When you describe it as some key clients, any way to size? I mean are we -- I'm assuming these are multi hospital systems of some sort. Any way to size how many hospitals we're talking about or how big a portion of your customer base it is?

William Grubbs

Management

We always have a mix of growth versus decline and luckily over the last few years the growth has offset any of the normal declines. But there were several large ones that really drove the variance for us. We have one large customer that we've had for a long time that we expect to have for a long time, they're down $14 million in spend under management on their own just in the first half of the year. If you take the top 5, 1-2-3-4-5, they are down about $30 million in spend under management in the first half of the year. So it really is just a few of the big ones. When you get past the big ones, it gets smaller numbers that you'd normally expect. There's just a bunch of big ones that all pulled back at the same time.

AJ Rice

Analyst

Okay, and I know when the ones that are your traditional customers as opposed to MSPs, you don't have the same level of dialogue with them and visibility, but do you perceive that they've made the same decisions or is it really concentrated in handful of clients?

Christopher Pizzi

Management

Once you start to look at the midsized kind of smaller MSP clients you see it moving in both directions. We had some growing, some pulling back. But the dynamic really was at the larger systems and they are multi facility systems generally speaking. And our MSP customers is where we saw it. So it's just this dynamic where you had tremendous ramp at newer accounts, slightly lower capture rate, and you had a pullback in some of the larger MSP clients.

William Grubbs

Management

This is why, as much as I hate missing our numbers and I hate putting guidance out there that's below where our expectations and everyone else's expectation are, I'd feel lot worse if we were missing because our delivery got screwed up or we lost a bunch of accounts and were losing market share out there or we made a bad mistake or something else like that happened. But we're not. We're hanging onto our accounts, we still have our accounts, we're still growing our new accounts, we have a good pipeline, our delivery operations are sound. There's not much I could have done to anticipate this even with the conversations we regularly have with the customers. They still surprised us in magnitude.

AJ Rice

Analyst

I guess I'm thinking one of the theories on the MSP side was that as the order flow comes down, you might be in a position to fill a higher percentage. It sounds like you're describing the situation as you just sort of maintain the 60% fill rate. Any comment on that aspect of it?

William Grubbs

Management

Yeah, so -- and that's almost exclusively due to the mic of accounts. So we tried to explain that both in my section and in Bill Burns' section where we talked about the pullback accounts were a higher capture rate than the growing accounts. So generally, yes, our capture rate is moving in the right direction. Except that the pullback happened at the higher capture rate accounts and that's why the overall number is staying fairly flat.

AJ Rice

Analyst

All right. Just a couple of loose ends here. ON Advantage RN, we're calculating about $18 million to $19 million quarterly run rate. And I thought prior to acquisition it was running more like $25 million. Maybe our math is wrong, but just wonder if anything has happened there.

William Grubbs

Management

It's not standalone anymore. We can't see it on a standalone basis anymore. We're integrated their branch offices into our branch offices. We took the small locums business and rolled it into our operators. It doesn't run as a standalone other than the travel nursing piece of it. So we see what they do on our MSPs because there's a special delivery operation there and we can see where the travel nursing -- we don't see the whole $100 million trend that we had before, so I don't think I can do that. But I think that number is too low, I'd have to go to the pieces and add it back up again.

AJ Rice

Analyst

So the MSP business didn't get particularly hit by the phenomenon you're talking about or anything?

William Grubbs

Management

No, they actually have continued to do very well at our MSPs. Bill, you had the percentage increase I think?

William Burns

Management

Yeah, they were increasing about 31%.

William Grubbs

Management

31% on the revenue side. So I mean -- and from what they're filing today at our MSPs, it's drastically up from where before we acquired them. So they've done a great job at sequentially every quarter increasing their headcount on billing at our MSPs and we expect that to continue. Where we had softness initially was we had two things with them. One was, they felt the same kind of market dynamics late in 2017 with their legacy accounts, they had some pullback there. And we hadn't gotten out of the gate fast enough at filling at our MSPs. We've certainly corrected that now and their trends are, from what we can tell how they're filling, their trends are slightly better than our legacy travel nurse business at the moment. Which goes to the reason why we acquired them which was we think that they can continue to move in the right direction with filling a larger share of our MSPs.

AJ Rice

Analyst

Okay, then the last question, it looks like FTE per day was relatively flat in the nursing side, Nurse and Allied. I know you talked about a headwind of a few million dollars on the premium going away. Has that played like you expected or is that embedded in there somewhere? Anything updating us on what is happening with the premium rate business?

William Grubbs

Management

Yeah, the premium rates still are going down. But as I said last quarter, we're probably not going to talk about a whole lot. It's not the driver anymore. It's leveled off a little bit more than it was, but it still is moving down. This revenue per FTE per day, my financial planning analysis guy was in today saying I don't want to use that metric anymore. Because the change quarter to quarter tends to do a lot more with mix of Allied versus travel nursing versus branch operations. That's all mixed in together. When we stated using that metric, we were predominantly a travel business. We really see the underlying actual bill rates. And the actual bill rates, they're pretty much flat year-over-year. Maybe down slightly. It's minor. Just a bit, but it could be a mix.

Operator

Operator

Our next question come from Jason Plagman from Jeffries. Your line is now open.

Jason Plagman

Analyst

So just in following up on the questions on the capture rate, I would have thought just for those large clients where we saw pullback in demand, shouldn't the capture rate move higher for those clients isolated given that you can prioritize your candidates? Can you just explain just for this subset of clients what was the trend in capture rate?

William Grubbs

Management

I don't know If I would have that particularly, but no, when this pullback -- we don't get to dictate just pull back my subcontractors and keep all my nurses. They pull back in the departments and in the areas and the shifts that they want to pull back on. So it tends to be all boats rise or sink with the change in any given quarter. There's no manipulation of we're going to get rid of all the subcontracts and keep all our nurses. It doesn't quite work that way.

Christopher Pizzi

Management

Yeah, you certainly can't adjust in the near term as fast. When the orders pull back, it depends what, it does -- as Bill said, it affects all the vendors at once.

William Grubbs

Management

So if we had a 60% capture rate there, all the pullback, we'd probably have a 60% capture rate today.

Christopher Pizzi

Management

There's been some movement. As we look at this, we can see in certain pockets where the spend came down and the capture rate did move up a little bit. But not enough to offset. Because as I said, it takes a little time to accommodate that change when --

William Grubbs

Management

We do believe that as it starts to grow back, so if somebody pulled back $5 million, and they're going to grow that crack again, we should get a higher capture rate on that business going forward. That's where the real opportunity is.

Jason Plagman

Analyst

Then just on the market demand, what are you seeing form your non-MSP clients? How are orders trending there?

William Grubbs

Management

They're pretty good. Bill has it right in front of him. Actually, our MSP orders were up again this quarter. So again, as we left the quarter it seemed to be showing some signs of improvement, but there was a very sharp pullback late in the quarter, from probably the second, third week of May and through June, there was s harp pullback. It seems to be turned around the last couple of weeks and through July, but I wouldn't call it a trend just yet.

Jason Plagman

Analyst

That's helpful. And then just in Q2 and what you've seen on the non-MSP book, what are you seeing there?

Christopher Pizzi

Management

Sorry, for the second quarter did you say?

Jason Plagman

Analyst

Yeah, and for your non-MSP clients. Just in the overall market, traditional arrangements?

Christopher Pizzi

Management

I think the pullback, as we talked about predominantly in our MSP clients. I don't think we saw any drastic changes in the non-MSP or direct business that we have. I think that's holding up fairly well.

Operator

Operator

Our next question comes from Brooks O'Neil from Lake Street Capital Markets. Your line is now open.

Brooks O'Neil

Analyst

Good afternoon. Obviously a lot of questions have come and gone, but I'm just trying to be sure I understand. I have a sense that the hurricanes were very disruptive, kind of end of Q4 into the early part of the year. And if I'm listening correctly, that was primarily affecting the local branch business and seems to be recovering now. At the same time, you had this sort of sudden and somewhat unexpected falloff in the travel business now. Is that -- do I have it right kind of what you're trying to say to us?

William Grubbs

Management

No. The impact of the hurricanes was predominantly travel nursing believe our travel nursing operation is based here in Boca Raton, Florida and that's the delivery operation that got impacted and we lost about 550 travelers out on billing in the 41. Which actually if we hadn't lost those, it would have mitigated some of what happened in the 41 here. But we did lose them then and we had further pullback in Q4. But both of those issues, both the fourth quarter issue and the second quarter issue are predominantly travel nurse.

Brooks O'Neil

Analyst

So the branch business is doing pretty well then?

William Grubbs

Management

It was affected by some of the pullback, but not as much and it's recovering very well.

Brooks O'Neil

Analyst

Basically, despite the fact that these issues were sort of unexpected in 2Q, you think there's a high likelihood that things are improved by 4Q?

William Grubbs

Management

Yeah. Look, it's more volatile than we expected over the last 3 quarters which is why you see a little bit bigger revenue range for us in our guidance this quarter. We don't really have the visibility. We do believe from our conversations and from what we know about customers and the needs that they have, that we believe some of it will come back. How quickly it will come back, it's hard to tell, but we're hoping it comes back in the third quarter and that we get appositive boost in Q4. But it's hard to tell right now.

Operator

Operator

Our final question comes from Lalishwar Ramgopal from Sidoti. Your line is now open.

Lalishwar Ramgopal

Analyst

Good afternoon. I just wanted to get back to the comment in terms of revamping the salesforce in light of some of the shifts you're seeing on the ambulatory care side. Is it a case where you need to add headcount there or just because it's different call points, etc., reorganize how you're going to do the sales calls?

William Grubbs

Management

I'll let Bill do it. It's a little bit of both. We're going to do a reorg and I think we're going to add some resources.

William Burns

Management

That's exactly right. It's adding resources into the regions for the branch so that we have additional salespeople to be able to call on. And it's also making sure that we've got the right focus from our national sales team. Based note customer segmentation and the markets, how we want to go after those or pursue those customers. But there's going to be some investments necessary we would expect, but it's kind of contemplated in what we are looking at for our cost base.

William Grubbs

Management

Yeah, people don't understand sometimes the dynamic associated with these ambulatory and outpatient facilities. Quite a few of them are owned by the big hospital system, but they don't consolidate that spend under our MSPs. We have to actually go to those individual facilities and sell our services into them. Now if it happens to be a hospital system that we have the MSP, it's a bit easier sell because we have a big contract with the. And if it's not, it's a little bit harder sell. But if you look at the market, if you look at spend in healthcare in the market overall, about 42% to 43% of total spend in healthcare is at acute care hospitals and about 40% is at ambulatory and outpatient facilities. Our business is 70% acute care hospitals and 30% nonacute care hospitals, so we'd like to balance that more with the marketplace overall. But we have to go out there and knock on the doors and be there in person to do it.

William Burns

Management

That's certainly the case for the smaller and the midsized kind of customer. But we are, and we don't call this out because it's just not something we've historically done, but we continue to expand our services at our MSPs including some of the larger accounts, to pick up per diem and allied. So that's a very big area of focus for us as well.

Lalishwar Ramgopal

Analyst

Okay, thanks, that's very helpful. ON the physicians staffing side, I was wondering if you think, as you look at the first half of the year now, it seems like the second quarter almost flat sequentially, if you think you've kind of bottomed there?

William Grubbs

Management

Yeah, I mean we've been talking about physicians for so long and not seeing the year-over-year improvements. We did see 2 of the last 4 quarters with small year-over-year improvements that we knew there was a tough comp in Q2. But we are looking at them more sequentially. IF we can maintain it sequentially and then start to slowly move that upward, then we'll get to the year-over-year growth. So we are starting to see some stability. It was flat basically on a sequential basis from Q1 to Q2. It will probably maybe flat from Q2 to Q3, maybe slightly up if we get a boost in August and September. And we're working on -- they're doing all the right things there. We feel really good. Bill Burns and I have both been up there. The attitude is better, the activity is better, it's just not showing in the numbers yet.

Lalishwar Ramgopal

Analyst

Thanks. Then just finally on the capital allocating and acquisitions were mentioned as one possible use. I was just curious in terms of on that front, would you be looking to do something more on the service side or it for example on technology or software? Is that anything you feel you really need to add?

William Grubbs

Management

I wouldn't look at acquisitions at all if I really thought our business was broken. This revenue decline and the headwinds we're facing today have nothing to do with how well we're running the business. So I will consider acquisitions. Originally I was focused more on the school business and we would like to do something in the school sector if possible. We have been looking at different technologies from a variety of reasons from a competitive standpoint, I'm not going to tell you what those are and why we're looking at them, but we think there are some technology advances in the marketplace that would create efficiencies in our business, not only internally but how we interact with our customers and how we interact with our healthcare professionals. So we're looking at some technology businesses as well. And we love the fact that Advantage RN is servicing our MSPs so well. We wouldn't mind if there was another bolt-on to help us do that as well. Operator, is that it? Okay, then, I want to thank you very much, we'll be back in November with our third quarter results. Thank you.

Operator

Operator

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