Good morning, everyone. Welcome to Enhabit Home Health and Hospice's Fourth Quarter 2023 Earnings Conference Call. Today's conference call is being recorded. If you have any objections, you may disconnect at this time. I will now turn the call over to Crissy Carlisle, Enhabit's Chief Financial Officer.

Thank you, operator, and good morning, everyone. Thank you for joining Enhabit Home Health and Hospice's fourth quarter 2023 earnings conference call. With me on the call today is Barb Jacobsmeyer, President and Chief Executive Officer. Before we begin, if you do not already have a copy, the fourth quarter earnings release, supplemental information and related Form 8-K filed with the SEC are available on our website at investors.ehab.com. On Page 2 of the supplemental information, you will find the safe harbor statements which are also set forth on the last page of the earnings release. During the call, we will make forward-looking statements which are subject to risks and uncertainties, many of which are beyond our control. Certain risks and uncertainties that could cause actual results to differ materially from our projections, estimates and expectations are discussed in our SEC filings, including our annual report on Form 10-K, which are available on our website. We encourage you to read them. You are cautioned not to place undue reliance on the estimates, projections, guidance and other forward-looking information presented, which are based on current estimates of future events and speak only as of today. We do not undertake a duty to update these forward-looking statements. Our supplemental information and discussion on this call will include certain non-GAAP financial measures. For such measures, reconciliation to the most directly comparable GAAP measure is available at the end of the supplemental information and the earnings release. With that, I'll turn the call over to Barb.

Thanks, Crissy. Good morning, and thanks for joining us. Persistent focus on our company strategies drove our positive fourth quarter results. Payer innovation success, including the execution of another new national contract, continued success with our people strategy and strong performance in quality outcomes are but a few of our high points for the end of 2023 and our start to 2024. I cannot thank our employees enough for the high-quality care they provide to our patients every day. Our strongest factor in negotiating with payers and conveners and in creating strong referral relationships remains our 30-day hospital readmission rate that is 20.5% better than the national average. This quality is a solution to the challenge of rising health care costs and helping payers manage their MLRs, helping to control emergency room visits, hospitalizations and readmissions results in higher patient and family satisfaction and control of health care dollars. Significant dollars are also spent at the end of people's lives. High-quality hospice care, and in particular, consistent and attentive clinician visits during the last days of life are critical in preventing revocations and unnecessary hospitalizations because of the benefit it provides our patients and their families. We are proud that our team provides hospice visits in the last phase of life 53.2% better than the national average. We anticipate our home health and hospice quality will continue to drive our future growth as well as employee retention. Now let's talk about some of our key 2024 focus areas and how the fourth quarter set us up for success. With our traditional Medicare mix of home health revenue now in line with peers, we expect the continued decline in our traditional Medicare volumes to slow at a rate consistent with the industry in 2024. Episodic admissions are beginning to stabilize as…

Thanks, Barb. Consolidated net revenue was $260.6 million for the fourth quarter, down $2.6 million or 1% year-over-year. Adjusted EBITDA was $25.2 million, down $5.1 million or 16.8% year-over-year. We estimate the continued shift to more non-episodic payers in home health decrease revenue and adjusted EBITDA of approximately $8 million year-over-year net of the impact from improved pricing of payer innovation contracts. In our home health segment, total admissions growth of 3.9% year-over-year was driven by 34.2% growth in non-episodic admissions. Our non-episodic visits grew to approximately 33% of our total home health visits in the quarter. While we are making significant progress demonstrating our value proposition to payers as we negotiate new agreements with improved rates and are successfully shifting Medicare Advantage volumes into our payer innovation agreements, the revenue and adjusted EBITDA impact from this volume shift has not been enough to overcome the financial impact from the erosion of Medicare fee-for-service volumes. Our home health team successfully managed cost of services, resulting in cost per visit flat year-over-year as the reduction in nursing contract labor offset the impact of merit market increases. For full year 2023 compared to 2022, cost per visit increased approximately 2%. That's less than the 3% average merit market increase for the year, thus demonstrating our ability to control costs through productivity and optimization of staff. In our hospice segment, revenue increased $3.7 million or 7.8% year-over-year, primarily due to an increase in revenue per day that resulted from changes in our estimated recoverability of net service revenue in the fourth quarter of 2022 an increased Medicare reimbursement rate that went into effect on October 1, 2023. Admissions decreased 1.5% year-over-year, while average daily census decreased 4.3% year-over-year. Sequentially, our average daily census increased 1.3% over the third quarter. Adjusted EBITDA increased $6.1…

[Operator Instructions] Our first question comes from the line of Brian Tanquilut with Jefferies.

Congrats on the quarter. I guess maybe Barb, my first question, you announced that national episodic contract, and it sounds like you're gaining traction with expanding or shifting the contracting strategy a little bit here. So just curious, number one, how are you thinking about the remaining opportunity there and what it would take to ramp that business up or that relationship up? And then maybe broadly speaking, how are you thinking about how the pressures on Medicare Advantage plans are translating to you guys? And how does that impact your ability to negotiate or renegotiate your biggest Medicare Advantage relationship?

Sure. Well, I think the ability to particularly ramp up with the new national agreement is strong. It's been good that we have always had that care transition coordinators that are inside a facility so they actually can help us really ramp up quickly in being able to accept this payer, particularly from these institutional settings. So I think there's -- the ready, the ability and the staff there to take advantage of that. I do think actually some of the challenges that the payers are facing almost work to our benefit as we're sitting at the table, particularly because of our high-quality outcomes. I think if they're really looking to control those high-cost areas like hospitalizations and emergency room visits and things like that, we can help with that. But a provider has to have the high quality to be able to help with it. So it really has given us, I think, an advantage sitting at the table with these payers.

And then maybe, Crissy, my follow-up, just as I think about guidance, right? So just curious what your assumptions are in terms of -- I know you said you're still expecting payer mix shifting there. But how should we be thinking about the moving pieces on payer mix shift, maybe a little bit on wage inflation? I know you talked a little bit about cost per visit. But what are you seeing there? And then the other area would be like what does the recruitment pipeline look like for both nurses and therapists?

Yes. So I'll take kind of the guidance part of that and then turn it back to Barb for the recruitment and retention aspect of the question. When I think about 2024 and guidance and kind of bridging 2023 to 2024, I'm really focused on the expected increase due to increased reimbursement rates in both segments, volume growth, efficiency improvements in our cost per visit, cost per day. And then some of that will be partially offset by wage inflation that new DME contract that I just talked about as well as some of that payer mix shift. Again, Brian, we're not expecting what I historically referred to as the Enhabit cliff. Remember that we've now entered that zone where our Medicare fee-for-service and Medicare Advantage mix is very similar to our peers. So we're expecting a more industry-like shift. We're not saying that Medicare is not going to continue to decline. They continue to choose Medicare eligible -- continue to choose Medicare Advantage plans, where we're saying we shouldn't have those same double-digit declines that you've seen for us because we made that shift over 12 to 18 months. Whereas the peer group made it over 6 to -- 7 to 8 years. So we think that we kind of again normalized ourselves into the peer group now. And so that the $30 million of payer mix impact that we saw in 2023, we don't expect to recur at that same level given where we are with our volumes and the payer mix as well as just the improved rates that we're getting. And I think it's also important, Brian, to remember that we're starting 2024 with 2 national contracts. We weren't in that position at the beginning of 2023. We'll have the full benefit from the national agreement that became effective May 1 of 2023. And then, of course, the one that we announced last night, that became effective January 1. So we feel we're in a much better position.

And then on your question, Brian, on labor, it was good to see Quarter 4 tends to be a slower quarter on labor, just folks just don't look to switch over the holidays. So we were pleased to see year-over-year that our applicant pool was up over 21%. So that was really good to see. And then again, we had another successful quarter with those full-time net new hires.

Our next question comes from the line of Jason Cassorla with Citigroup.

Great. Maybe just a follow-up on Brian's question. Just any other color or consideration for us as we think about earnings cadence, right? You discussed fee-for-service kind of volumes kind of returning closer to industry norms. But I guess, are you of the position kind of exiting '23 into '24 where that should develop kind of in line with that expectation? Or do you think that you're going to still see outsized kind of moderation in that context? Just -- so anything else on the earnings cadence would be helpful to start.

Sure, Jason. So we expect what I would call a moderate adjusted EBITDA build throughout the year. I think when we attended your conference last spring, we talked about a steep ramp in 2023. We're not really expecting that in 2024. Again, it's more of a moderate adjusted EBITDA build throughout the year. Q1 and Q4 tend to have higher volumes a little bit. I think one of the things that we're excited about in 2024 is given the success we've had with the recruitment and retention of our clinical staff, when you have more staff, you're able to manage through some of those summer anomalies around paid time off and vacations and such. So we expect to be able to manage those labor needs in Q2 and Q3 around PTO just via increased staff and productivity. And then, of course, there will be a slight ramp of some of these new Medicare Advantage contracts, especially the new one that came into effect January 1.

Okay. Great. That's helpful. And I guess, thinking about the 59 agreements you signed, right, in the 25% of your non-episodic visits. Do you think -- maybe just building on your comments, Barb, but just do you think perhaps you're in a strong position to really bulk against taking volumes from these lower-paying contracts kind of without sacrificing the volume density within your markets? Or how should we think about that balance between generating volume density against kind of the reimbursement dynamics within your overall book? And then just really quickly on a follow-up on the hospice cost per day. Can you give us a sense on what that would have been otherwise that if it wasn't for this DME issue, just for us to get a sense?

Sure. On the volume as it relates to the contracts that we've signed, I do think that there's an ability to grow the volume. A lot of it -- particularly the regional contracts we signed has really been based on feedback from the field on which thing could make it a meaningful difference for them with their referral sources. I also think an opportunity for us now, if you think back to last year this time, we had a really short list to bring in to referral sources on the payers we could take. And frankly, it was -- what you hear from our referral sources is we need to have a partner that can really help us take almost all of our patients, not just 1 or 2 particular kind. And so I think we're entering referral sources today very differently with a much longer list, and that should help us to be able to, frankly, grow all volumes but particularly focused on those in the payer innovation contract and fee-for-service Medicare.

And on your question regarding the hospice cost per day, I think what you're asking me is the 2024 number because this new DME contract was really a Q1 2024 effective date. And so I think it's fair to say, Jason, that if it weren't for this durable medical equipment agreement that we had to sign, that instead of our cost per day guidance consideration being 2% to 4%, I think it would have been in the range probably of 0% to 2%.

Our next question comes from the line of Joanna Gajuk with Bank of America.

So I guess, first, a follow-up when it comes to the episodic. So you said you expect that sort of admissions to stabilize going forward since the mix is similar to peers. But still when I look at the payer mix in terms of the revenues, the mix you're shifting and growing the MA that you do not have. But then so the Medicare revenue was down 14% for the year and, I guess, 16% in this quarter, year-over-year and down 7% sequentially. And when I look at the peers, they show either a much smaller decline or even some show growth year-over-year. So I guess the question is why Enhabit is losing market share?

Joanna, I don't think we're losing market share. Again, I think as part of this Medicare eligible choosing to enroll in Medicare Advantage. And if you go back in history, as you well know about this company, is historically this company did not pursue Medicare Advantage. And again, we made that shift over the last 12 to 18 months to pursue that business, whereas the peer groups have been doing it over 6 to 8 years. So their drop in the traditional Medicare wasn't like the Enhabit clip, as I referred to it over the past year. So I think that's what you're seeing when you try to compare us to peers. And what we're saying now is that we're not saying that we're going to suddenly start increasing traditional Medicare in 2024. Again, there has been a market shift and it continues to more Medicare-eligible choosing Medicare Advantage. What we're saying is that we think that we're starting to get in a path where we're not on that clip anymore and it's starting to stabilize more like the industry.

Okay. And I guess another follow-up or maybe that's a new topic, but related to this payer mix situation here. When I look at the average revenue per visit for the non-episodic visits, right, versus the revenue per visit for the episodic portion, which that includes obviously Medicare and MA, but still that average is like 43% below. So like the non-episodic average, 43% below the average for the episodic volumes. So how should we think about that metric? It sounds like maybe you're going to change some disclosures and we will be able to kind of clearly see Medicare and then some other episodic separately. Is that what you're trying to do to kind of give us more visibility? But I'm still surprised that, that average is still down much lower. So I guess how should we think about this going forward?

Yes. So I think one thing is part of the numbers you're seeing, of course, after revenue reserve, and those can sometimes cause noise, as you're well aware, in any quarter and for the year as well, especially given the adjustment we had to make in the fourth quarter of 2022 and then throughout 2023 as we enhance those controls and updated our reserve methodology. Yes, going forward, as Barb mentioned, especially given the fact that we now have this national agreement that is an advanced episodic model when we start reporting Q1 later this year, instead of just getting episodic admissions and non-episodic admissions and information that way, episodic will be broken out between traditional Medicare and then everything else that's episodic. And we believe that's important, again, primarily being driven by this new national agreement.

And if I may squeeze in just on that national agreement. Any way to help us quantify like incremental, I guess, revenue or volumes from the contract? It sounds like some of these markets you already have been serving. So you kind of keep the volumes, But rate is higher but then it sounds like you also added more markets. So kind of any way to help us give us some size of that incremental?

Sure. So we did not aggressively pursue that volume in the past. I would say when we look back in '23, it was about 5% of our admissions historically. And to your point now, we do have coverage throughout the country. And so that is certainly going to give us better access to those members. One thing that we've consistently said in our payer innovation contracting is that we were looking for rates that were much improved over the historic contracts. And so this does align with the focus of the payer innovation team from a rate perspective.

Our next question comes from the line of A.J. Rice with UBS.

This is Enjia on for A.J. So in Q4, the company got to around 25% of visits as a percentage of total non-episodic visits in these payer innovation contracts. I mean, just run-rating that, there will be a degree of a tailwind for next year. Does the company expect the fast pace to continue in '24 as well? Just trying to size the momentum of getting more visits into these higher-paying contracts.

Yes, I think it's a reason why it's going to be important for us to give you information as it relates to episodic fee-for-service and payer innovation and non-episodic. Because as we are having more success getting these payers signing with episodic, you may see some moderation in this non-episodic move mainly because our addressable market is becoming now greater and where we have our episodic contracts. So I think, again, as Crissy mentioned, that's why it's going to be important for us to give more detail on those various groups into 2024.

Got it. I guess a follow-up on that would be in these MA episodic contracts versus the non-episodic contracts, how much of a rate increase would that create for the company in '24, I guess?

So I think historically we have talked about a 0% to 10% rate differential to Medicare fee-for-service for our episodic MA contracts. And we talked about kind of a 25% to 30% discount for the non-episodic MA contracts compared to Medicare fee-for-service. Well, now this is part of that shift given that we now have a national advanced episodic model contracts, we no longer can talk really about episodic versus non-episodic. It's just got to be what's in this payer innovation contract as we refer to them? So I think the answer to your question is that all of our contracts currently have somewhere between a 0 and about a 25% discount to Medicare fee-for-service.

Got it. Maybe one more just to clarify. On the hospice side, there seems to be an estimated recoverability of net service revenue in the quarter. Is that a onetime benefit? And how much of a revenue and EBITDA effect did that have?

Yes. I think that, that is -- it's more about Q4 of 2022. You may recall that there was a rather significant adjustment made to our revenue reserves in the fourth quarter of 2022. For the total company, it was about $12 million, and $7 million of that went to the hospice segment. So that's the noise that we're talking about in the slide just talking about a year-over-year change for the segment. And so that estimate and the change in recoverability really relates more to Q4 2022 and entry we made then more so than anything that happened in Q4 of 2023.

Our next question comes from the line of Ryan Langston with TD Cowen.

Just 2 quick ones for me, maybe I'll try the payer innovation question a little differently. Obviously, it's jumped from, I think, 5% to 25% a year, which is pretty good success. Maybe just more broadly, what do we think about that percentage maybe into '24 into '25 given maybe where your staggered contracts are up for renewal or you can go for maybe outside of normal renewal schedules. And then can you maybe give us a little sense? I mean, you've already had 2 months of experience now this year. Just maybe more generally, where the mix shift has moved from fee-for-service to MA between 4Q and 1Q just to maybe give us a little help with the modeling.

Sure. Well, as it relates to the -- we do think there continues to be opportunity to move those non-episodic visits in the payer innovation contracts. So as you mentioned, going from 5% to 25%, we felt was really good improvement this year. The piece that's the hardest to determine what '24 looks like is really because of the success in getting the episodic contracts, and in particular, a new national episodic. So as you think of the move, it may be the move into payer innovation contracts, not necessarily the non-episodic into non-episodic payer innovation contracts, if that helps. So that's why it's a little bit hard to talk about that percentage. Because historically, we've been focused on moving from kind of our really low-paying which were all non-episodic in the past and improving that. Whereas now we're going to have a much more broader market to go after, including a fair amount of episodic contract patients.

Got it. And then I don't know if you can give us a sense on just the first 2 months of this year just in terms of the mix. It sounds like you're obviously expecting that to moderate, and I would expect that, too. But any sense on where that's actually gone into the first part of the first quarter?

I mean, I think we'll obviously have a lot more of that when we report quarter 1 because, again, breaking this out in different buckets, I think, is going to be helpful. I would say as it relates to quarter 1 from a financial perspective, that does take time because you still have a fair number of patients that are on your census that started sometime within quarter 4. Many of that could still be in maybe what would have been like our reset desirable contracts. And so it takes time for those patients to be discharged and replace those with the higher-paying contracts.

Our next question comes from the line of Jason Cassorla with Citigroup.

I just wanted to hone in on capital deployment priorities, more specifically around your leverage. I guess how should we be thinking about the uses of your free cash flow for '24? Do you anticipate using the bulk of it for debt or paydown on your revolver? Or are you just anticipating leverage would naturally kind of improve as EBITDA grows? Just any color around priorities and debt repayment.

Yes. So we are more focused on deleveraging. Our free cash flow will go towards $20 million of required amortization on our term loan A. We also have the de novo strategy, which is probably $2.5 million to $3.5 million as disclosed in our supplemental slides. But again, we think that's ample to do that. Anything above that would likely go towards revolver paydowns. And that's the kind of the easy way to think about it, Jason, is to think -- assume 50% free cash flow conversion, you got $20 million of required amortization on the term loan. That money for the de novo spend as well, and then everything else is a potential revolver paydown.

Okay. Great. If I could follow up with one more, just on the de novo side. The 8 that you opened up in '23, just curious on how the ramp has progressed across those locations so far. And in the past, you've mentioned a focus on hospice build-out and just in context of building your co-location strategy. 2023, the de novos are about evenly split between home health and hospice. I guess, for the 10 that you're planning on for '24, how should we think about those locations? Are they evenly split between home health and hospice? Or just any color there would be helpful on the de novo front.

Yes. That continued to be geared a little bit more towards hospice with our strategy being opening up hospice wherever we have an existing home health. So they're geared a little bit more towards hospice. The de novos that we opened up in 2022 and 2023 are doing well. Some are running at plan, some are running ahead of plan. And so in 2024, I think it's fair to say that the investments that we continue to make in the 10 will be offset by the earnings of those that we opened up in 2022 and 2023.

Our next question comes from the line of Joanna Gajuk with Bank of America.

So I guess I have 2. One is on the payer sources, Slide 31, where you have the fourth quarter hospice and the managed care is 6.5%. So can you explain why there is such a big number? Because it also talks about just an increase in the non-Medicare patient revenue, but also again talks about this recoverability or estimated recoverability of the revenue. So can you help us understand like what does the 6.5% really represents?

Yes. So it represents exactly what it says. It is managed care in our hospice some are the bid contracts and other contracts that were in 2023. You noticed that the 2022 column is blank, it's 0. And again, that's because a lot of that reserve for hospice that we made in the fourth quarter of 2022 went to that line item.

Okay. And my other question, I guess, when it comes to regulations so what is -- what do you expect to see in 2025 home health proposal that is going to be coming out? I guess, still a couple of months. But any initial thoughts around productivity adjustments and recruitment? And also, I guess, first, we're going to get a hospice proposal for 2025. So anything around what you expect to see in that one?

Sure. I would say for home health, I mean, I think they already kind of signaled last year that they would go after the other half of the adjustments that they ended up cutting in half last year. So I think that -- we anticipate that being part of the proposed rule. I think it's a good question on the temporaries. I don't know at this point. As you know, in the previous rules, it hasn't been discussed or mentioned yet on how, if and when, what that would look like. So I think that is a big question mark on whether that will appear in the proposed for '25 or if that's something that will happen after they finish the permanent adjustments. So I think for sure, we would expect to see something about the permanent continuing, but a big question mark, I think, on the temporary. And then on hospice, at this point, don't really anticipate there's going to be anything different as far as their proposed rule.

There are no further questions at this time. I would now like to turn the call over to Crissy Carlisle for closing remarks.

Thank you, operator, and thanks to each of you for joining today's call. If you have additional questions, please e-mail investorrelations@ehab.com.

This concludes today's call. You may now disconnect.