Encompass Health Corporation (EHC) Q1 2017 Earnings Report, Transcript and Summary

Good morning, everyone, and welcome to HealthSouth's First Quarter 2017 Earnings Conference Call. At this time, I would like to inform all participants that their lines will be in a listen-only mode. After the speakers' remarks, there will be a question-and-answer period. [Operator Instructions] You'll be limited to one question and one follow-up question. This conference call is being recorded. If you have any objections, you may disconnect at this time. I will now turn the call over to Doug Coltharp, HealthSouth's Chief Financial Officer.

Thank you, operator, and good morning, everyone. Joining me on the call today are Mark Tarr, President and Chief Executive Officer; Barb Jacobsmeyer, Executive Vice President of Operations; April Anthony, CEO of Encompass Home Health and Hospice; Patrick Darby, General Counsel and Corporate Secretary; Andy Price, Chief Accounting Officer; Ed Fay, Treasurer; and Julie Duck, Senior Vice President of Financial Operations. As a reminder, Crissy Carlisle, our Chief Investor Relations Officer is on personal leave for couple of weeks and is not participating in today’s call. We look forward to having Crissy back shortly. Before we begin, if you do not already have a copy, the first quarter earnings release, supplemental information and related Form 8-K filed with the SEC are available on our website, at www.healthsouth.com. On page two of the supplemental information, you will find the Safe Harbor statements, which are also set forth in greater detail on the last page of the earnings release. During the call, we will make forward-looking statements which are subject to risk and uncertainties, many of which are beyond our control. Certain risk, uncertainties and other factors that could cause actual results to differ materially from management's projections, forecasts, estimates, and expectations are discussed in the company's SEC filings, including the earnings release and related Form 8-K; the Form 10-K for the year ended December 31, 2016 and the Form 10-Q for the quarter ended March 31, 2017 when filed. 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. Statements made throughout this presentation are based on current estimates of future events and speak only as of today. The company does 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, at the end of the related press release, and as part of the Form 8-K filed yesterday with the SEC, all of which are available on our website. Before I turn it over to Mark, I would like to remind everyone that we will adhere to the one question and one follow-up question rule to allow everyone to submit a question. If you have additional questions, please feel free to put yourself back in the queue. With that, I'll turn the call over to Mark.

Thank you, Doug, and good morning to everyone joining today's call. We were off to a good start in 2017. Inpatient rehabilitation segment volume rebounded in Q1 and remained strong in our Home Health and Hospice segment. These volumes increases combined with growth in revenue per discharge in our IRF segment drove top line growth of 7.1%. Our teams continue to actively communicate the HealthSouth volume preposition to referral sources, patients, caregivers and payers. In the first quarter of 2017, we saw improved conversion rates from referral to admission for managed care payers including Medicare advantage and we continue to see increases in the number of stroke patients sent to our hospitals. We also continue to advance the clinical collaboration efforts between our IRFs and Encompass Home Health locations. The Q1 clinical collaboration rate as shown on page six of the supplemental information accompanying our earnings release was 28.9%, up 630 basis points over Q1 of last year. In February, we launched our TeamWorks initiative to identify, qualify and extrapolate best practices across all overlap markets. In addition, we enhance our use of clinical data analytics to further improve patient outcomes by minimizing preventable readmissions to acute care hospitals. This same focus on clinical collaboration has also resulted in more patients with a discharge path back home versus a skilled nursing facility. These combined efforts between our facility-based and home-based services are assisting in our quality metrics as our discharge of community was 78.5% or 340 basis points better than the UDS expected outcome and our discharge to SNFs was 9.7% or 360 basis points better than the UDS expected outcome. While we made progress with our strategic priorities and our top line growth was good, we did experience margin pressure in both segments. In our IRF segment, this was primarily due to a planned increase in fulltime equivalents resulting from additional staffing year-over-year at the former Reliant hospitals and a planned investment in additional clinical staff due to additional regulatory reporting requirements for hospitals. These staffing increases are important for hospitals to maintain the high quality outcomes we expect for our patients. Margin pressure in our Home Health and Hospice segment was due primarily to the Medicare Home Health reimbursement rate cuts that became effective January 01, 2017. These factors notwithstanding, we grew consolidated adjusted EBITDA for Q1 by 4.5%. We also continue to generate high levels of free cash flow. Adjusted free cash flow for Q1 of $147.5 million was up 5.8% over Q1 of 2016. I like to turn now for a moment to provide you with our thoughts on the developments in Washington related to the Affordable Care Act, bundling pilots and the pre-claim review demonstration in home health. First, for the Affordable Care Act, while we continuously and closely monitor the legislative process in Washington around the Affordable Care Act working both with internal and external [indiscernible] and the major trade associations for the industry, we do not need to take a position on any repeal and/or replace legislation at this time, nor does it lack of universal support in Washington cause us immediate concern. The Affordable Care Act does not directly impact key Medicare policy areas that enable us to provide care and services to our primary patient Medicare. Our primary concern on our Affordable Care Act is connected to the reimbursement cuts to which hospitals including our inpatient rehabilitation hospitals are subjected. These cuts were imposed in order to help offset the cost of the Affordable Care Act’s expansion of consumers’ access to insurance coverage. If the Affordable Care Act’s coverage expansion is substantially scaled back, then the hospital cuts intended to pay for the expansion especially the permanent productivity adjustment cuts should be commensurately reduce or eliminated as well. Moving to bundles, neither delays nor any potential movement of bundles from mandatory to voluntary programs changes our strategy or desire and willingness to participate in alternative payment models. Longer term, we believe healthcare will migrate to an episodic environment and we embrace any movement where a more focus is placed on the patient and the patient’s total episode of care. As Doug will discuss in more detail during his comments, we believe based upon the feedback we are receiving from the various acute hospitals we approached, we are well ahead of other post-acute providers in the development of strategies and capabilities to effectively address pilots such as CJR. We package the information, HealthSouth’s value proposition using data specific to each market and in manner that is adjustable for acute care hospitals. So whether or not bundles stay mandatory or become voluntary, we believe the progress we’re making to educate the acute care hospitals will result in more collaboration with our inpatient rehabilitation hospitals and home health agencies. Turning now to the Home Health pre-claim review demonstration, as you know at the end of March, CMS decided to pass the Illinois pre-claim review demonstration and postponed its expansion to Florida. We are pleased with the pause and believe it will allow the industry to work collaboratively with CMS to more effectively identify and prevent fraud. We are focused on the long term success of our company, our strategy is clear, the IRF segment is going to continue to be very attractive because of the types of patients we treat. We also believe that Home Health is part of any long term post acute solution given its cost effectiveness. Our combined platform of these two businesses facility-based and home-based services position us to be highly effective and partnering with acute care hospitals and treating post acute patients over the entire episode of care. In addition, both of our segments benefit from a demographic tailwind resulting from the aging of the baby-boomer and the expanding Medicare beneficiary population. As I mentioned in the beginning of my remarks, we are pleased with the start of the year and we remain confident in our strategy and ability to execute on our key operational initiatives, therefore, we are reaffirming our full year guidance ranges of revenue between $3.85 billion and $3.95 billion, adjusted EBITDA of $800 million to $820 million and adjusted EPS of $2.61 to $2.73 per share. And with that, I will turn it over to Doug.

Thanks, Mark, and good morning, again, everyone. I will take a few moments to walk through the details of the quarter and elaborate on a number of the concepts that Mark alluded to in his discussion. As Mark just summarized Q1 was a solid start to the year characterized by solid operating performance in both segments. During Q1, consolidated net operating revenues increased by 7.1% and consolidated adjusted EBITDA rose by 4.5%. Diluted earnings per share of $0.70 for Q1 increased by 14.8% over the prior year period benefit from lower interest expense, a lower effective tax rate and reduced share count. As Mark mentioned, we continue to generate high levels of free cash flow. As can be seen on Slide 13 of the supplemental materials, Q1 adjusted free cash of $147.5 million increased by 5.8% over Q1 2016. We extended our track record of utilizing free cash flow to expand the capacity of our two business segments via high quality growth opportunities and complementing these investments and growth with shareholder distributions. As depicted on Slide 17, during Q1 approximately $39 million of free cash flow was deployed to core growth opportunities and approximately $40 million was returned to our shareholders in the form of common stock dividends and share repurchases. As we think about cash flow for the final three quarters of the year, please note that we have revised our estimate for 2017 cash taxes to a range of $95 million to $115 million from the previous estimate of $120 million to $175 million. This revision stems from the approval we received from the IRS for a tax accounting method change related to billings denied under prepayment claims reviews. This is good news and that we are no longer required to pay taxes on revenue that has not been received because of our prepayment claims denial. The immediate impact was to replenish our NOL by approximately $130 million creating a tax benefit of approximately $54 million. Please note that this results in a tax deferral as income taxes will be payable if and when the denied claims are paid. As maybe seen on Slide 16, we essentially consumed the replenished NOL in Q1 and thus we estimate that cash taxes for 2017 will be ratably spread over quarters two through four. Our funded debt was reduced by $63 million during Q1 resulting in a leverage ratio at the end of quarter of 3.7 times. We have no significant debt maturities prior to 2020 and ended Q1 with approximately $479 million of unfunded availability under our revolving credit facility. We continue to enjoy one of the strongest balance sheets in the post-acute sector and given our real estate ownership position, this advantage will be further highlighted with the adoption of the new lease accounting standard beginning in 2019. Turning to our business segment results. IRF revenues increased by 5.8% in Q4, driven by a combination of pricing and volume. Net revenue per discharge increased 3.6% owing to our patient mix as we made further progress on treating stroke and neurological patients. For Q1, neuro was approximately 22.1% of our patient mix and stroke was approximately 18.3% both representing year-over-year and sequential quarter increases. Discharge growth for Q1 was 2.8% including same-store discharge of 1.6%. I will again remind you that the 2.8% same-store discharge growth we posted in Q1 2016 benefited by an estimated 80 basis points to 100 basis points due to leap year. IRF segment adjusted EBITDA of $205.4 million for Q1 rose 4.3% over the prior year period. SWB for Q1 was 50.2% of revenues, an increase of approximately 80 basis points over the same period last year. As Mark discussed, the year-over-year increase in SWB was primarily attributable to an increase in FTEs arising from achieving target staffing levels in the former Reliant hospitals, our planned investments in additional clinical staff due to increased regulatory reporting requirements and also the ramp-up of new stores. Bad debt expense for Q1 was 1.9% of revenue, down from 2.1% in Q1 2016. The decrease was primarily attributable to the resolution of the administrative payment delays that impacted collections in 2016. As can be seen on Slide 20, the level of new prepayment claims denials during the quarter was relatively consistent with that experienced over the course of 2016. As may also be glean from Slide 20, we continue to see no evidence of progress on reducing the very substantial and growing backlog of claims awaiting adjudication. Moving to the home health and hospice segment, Q1 revenue increased by 13.5% and adjusted EBITDA rose 5.8%. The segment growth was driven by volume with admissions increasing 19.6% including 13.9% attributable to same-store growth. And similar to Q4, approximately 20% of the same-store admissions growth can be traced to the clinical collaboration with HealthSouth IRFs. The effects of higher volume were partially offset by a decrease in pricing as revenue per episode for Q1 declined by 1.4%. The pricing decline was a result of the Medicare reimbursement reductions partially offset by a higher therapy mix primarily related to clinical collaboration. While we are on the topic of clinical collaboration and as Mark mentioned in his remarks, we continue to make tangible progress on this important initiative, which is focused on improving patient outcomes over a longer episode of care and doing so in a cost effective manner. As is depicted on Slide 6, our clinical collaboration rate for Q1 was 28.9% an increase of 630 basis points over Q1 2016. As Mark also discussed, we launched our clinical collaboration TeamWorks initiative in February and our teams are actively engaged in identifying and quantifying best practices to be standardized across all overlap markets. It will take some time for these new practices to be fully implemented in all overlap markets but based on our previous success with TeamWorks initiatives and the enthusiastic commitment of our associates at HealthSouth and Encompass, we are confident this approach will help facilitate the achievement of our 35% to 40% collaboration rate target in the intermediate term. As I have mentioned in the past, the progression towards this objective is more likely to be step function than a smooth linear ascension. And I note specifically that as we move into the back half of this year, we will be comping against 2016 collaboration rates that already reflected substantial gains. Just to conclude my comments on the home health and hospice segment, Q1 adjusted EBITDA increased 5.8% over the prior year period to $23.9 million. Operating expenses rose as a percentage of revenue due to the reduction in Medicare reimbursement rates, a higher cost per visit, which was driven by an increase in therapy patients and salary and benefit increases. I will take a moment to elaborate on the therapy mix impact here. We have stated previously that more than 55% of the patients discharged from our IRFs require and qualify for home health services. Not surprisingly given the conditions we treat in our hospitals, there is a heavy component of therapy continuation embodied in the home treatment plan on patients discharge from our facilities. As compared to home nursing services, therapy services generally carry both a higher reimbursement and a higher cost per visit resulting in a lower gross margin percentage but higher gross margin dollars. Please also note that the home health pre-claims review demonstration which was schedule to expand into Florida has been postponed for a minimum of 30 days with a 30-day notice to be provided prior to reinstatement. We believe we are fully prepared for the PCRD expansion with the exception of hiring additional FTEs, which can be initiated when notice of reinstatement is received. I will close my remarks with a brief update on our risk sharing pilot strategies. As we have discussed on these calls beginning with Q3 of last year, our initial focus has been on developing a proposal to serve as a collaborator with certain acute care hospitals on fracture DRGs in certain CJR markets. We established the goal of approaching 20 to 25 acute care hospitals located within 18 to 20 CJR markets by the end of Q1 with the further objective of having 46 collaborator agreements in place by mid-year. As I updated you on our Q4 call, speculations at the new administration would convert CJR from mandatory to volunteer together with low degree of financial risk faced by acute care providers related to CJR in 2016, as a reminder, the risk corridor is at 5% for the current year, has significantly decreased the prioritization and sense of urgency on the acute care hospitals to engage in risk sharing on this program. The delayed implementation of the cardiac shift to bundled payment program until at least October 1 has only served to endorse this view. Nonetheless, we believe the data we have assimilated and the value proposition we have articulated in the preparation for the collaborator discussions are resonating with acute care hospitals and in a number of instance have lead to request a preferred provider agreement specific to the CRJ DRGs. As Mark stated, regardless of the timing or mandatory nature of these pilots, we continue to believe that the progression towards episodic and value based payment models will continue and eventually accelerate. We continue to focus on building the tools necessary to serve as a value added partner to payors and acute care hospitals for all of their post acute needs. This includes developing the analytical and clinical capabilities to effectively serve as a true post-acute care navigator, a role we expect to being piloting later this year. And now, operator, we will open the line for questions.

[Operator Instructions] Your first question comes from the line of Sheryl Skolnick of Mizuho.

Good morning, Sheryl. This is Mark.

Good morning, Sheryl.

Good morning, Mark, and the entire HealthSouth family. And congratulations, this is a good result and a nice first quarter for the year.

Thank you.

I do want to – and I know it’s not easy, although you make it look that way. I do was to just focus if I may on home health and try to understand a little bit more of what’s going on with the support and overhead cost here because as I look at your cost of services from that Slide 10, which is extremely helpful, but you managed to keep the expense ratio flat year-over-year for cost of services despite the mix and despite the increase in therapy and therapist cost, but it looks to me more like the support and overhead cost rose as a percent and that seems to have driven more of the operating cost increase. So, is that some – first of all, what’s going on there – help me to understand why we are not talking about that cost increase a little bit more rather than the cost per visit and therapy cost? That’s number one. And number two, is that something that can be addressed to further offset the – what’s clearly margin compression or compression of growth rate due to the pricing change?

April, would you like to give insight to that?

Sure. Sheryl, I don’t think there is anything systemic happening there. I think overall you are seeing the rate pressure cause all of the categories to go up as a percentage when we are seeing that top line rate pressure. Our first quarter does always tend to be a quarter from a support and overhead cost where we make a few core investments, things like our annual leadership happen in that first quarter and as our organization grow that as a total number continues to increase on an annual basis. So I think there is handful of things that are sort of unique to Q1. If you look back over the history that tends to be true. If we generally see that improving margin as we get out away from the Q1 kind of start of the year expenses that hit us, but I don’t there is anything really systemic there. I think that we are beginning to absorb the impact of that rate pressure and create the incremental volume that can help us manage through that and I think that’s really been the focus. We did make some improvements in sales, if you look at our sales expenses up a little bit and that’s because we’ve got to really support that strong revenue growth. I don’t think that’s going to stay at a high-level because those people that have been added to our team in the late fourth quarter and early first quarter, obviously, it takes a little while for a sales person to become a productive resource within the organization. So we see a heavier weight of their cost to the first quarter without the corresponding revenue implication. I think as we move into the second quarter, we are already beginning to see this early year hires being to perform. But I think we will see improvement in that trend throughout the year and I just don’t think there is anything substantive going on in that category that concerns us.

Sheryl...

Yeah, but you did answer my questions, just that it begins to abide as a percentage and also because there were some first quarter items. So you can make some progress through the year on that.

Absolutely, and if you go back and look at last year you will see the same trend occurring.

Yeah, okay.

And, Sherly, this is Doug, am I point to just a couple of other things in there, one of which is corollary to what April just mentioned and that is for instances we are adding care transition coordinator position to all of our overlap markets, which is an important investment. Some of that investment is ahead of the volume that will eventually flow from the clinical collaboration activities and then the second piece there is that Encompass within its group medical program is seeing a little bit of the trend we experienced in 2015, they hadn’t experienced it then, they are seeing it little bit now. We think we’ve got our arms around that, but there is a higher benefits cost that’s flowing the statement as well.

Okay. Can I just switch gears from my follow-up question? Can you explain to me on that one slide where you – I think, it was 20, but I’m not sure, where you went through what’s going on with the backlog of payments on denied claims and review of denied claims, so I must have misunderstood something from your press release. Exactly what where you referring to that seems to have eased versus what’s still a problem?

So, we basically have two components to our bad debt expense. We have the normal regular way aging based reserve where for whatever reason we see a slowdown in AR collections, overtime we begin to reserve a percentage of that based on the perception of uncollectability and then we have prepayment claims denials where instead the reserve is established based on our historical track record for moving those through the adjudication process and getting to favorable resolution. Last year we saw an uptick in AR that was specifically related to an increase in the aging based reserve and the specific cost for that was an administrative payment delay at Cahaba, it had to do with staffing issues, it had to do with some software upgrades and so forth. It took longer than it should have, but that eventually got resolved and when it did get resolved we were able to take down that reserve. The activity on the second piece, the prepayment claims denials as can be seen in the chart on the right hand side of Slide 20 has been relatively consistent with that exhibited over the course of the last four quarters or so.

Okay. Now I’ve got it. Now I recall what was going on there. Thank you very much. I appreciate that Excellent.

Thanks, Sheryl.

Your next question comes from the line of Gary Lieberman of Wells Fargo.

Good morning, guys.

Good morning, Gary.

Good morning. Thanks for taking the question. Maybe just a follow-up on that last comment Cahaba, can you give us any more detail on any conversations you’ve had over last quarter with Cahaba or with CMS and maybe your thoughts on if the new administration will approach any differently than the prior?

Hi, Gary. It’s Mark. So, we continue to have dialogues with Cahaba and actually they’ve been very open to discussions, it’s – we last had our meeting, I think, about a month ago now. It’s still early on with Dr. Price’s influence and his new role within the administration. So they didn’t – weren’t able to provide any additional insights, but we do continue to have dialogue, we have discussions, it’s positive in nature in terms of expressing our thoughts and in terms of how we view things, but we’ve not seen a lot of moment one way or the other in terms of improvement in situation.

Okay. And then maybe, Doug, just going back to your comments on the increase in the collaboration rate being a step function, can you just provide some more detail around why it is a step function and not more of kind of a linear increase?

Yeah, I think, if you look back, we’ve essentially already gone through two ways with regard to the implementation of our clinical collaboration practices and protocols. You may recall that we really didn’t launch at all until the second quarter – late in the second quarter, really the end of the second quarter in 2015 and that is because as the partnership between Encompass and HealthSouth was formed even recognizing the opportunity, we’ve first had to make sure that anything that we were going to be doing with regard to approaching referral sources and patients about clinical collaboration had to vetted by legal and compliance and then we also had to put together at least a baseline of standardized practices for our associates to follow. We took first six months following the formation of the partnership to form those and then began rolling those out. Those were what I would call a real base line practice. Over the course of the next year or so, we develop some additional learnings, we got more comfortable with what was working and what was not working and in an informal way, we began to rollout best practices. It was also during that time that we were able to increase the clinical collaboration rate based on two important staffing components that I’ve mentioned before. The first is we identified that one of the keys to success was to take the role of care transition coordinator that Encompass has historically used effectively with other referral sources and to get one in each overlap market specifically dedicated to one our IRFs. It has take time to go out and recruit and train and have those folks put in place and form relationships with our hospital CEOs, but as they have been doing that, we’ve seen the benefits in clinical collaboration from rolling that out, at the same time, we had to reorient some extend the Encompass clinical workforce from that had been heavily focused on nursing services to one that had a larger therapy component. And so that required recruiting a different type of field technician. And again we’ve been doing that. Those things have been largely in place and we really started to see the benefits of those types of activities beginning in the half of 2016 and that’s when you saw some very large year-over-year increases in the collaboration rate. The marginal utility related to those specific actions is diminishing as you’d expect to be the case and that is why we have launched the clinical collaborations TeamWork, it’s to get much more detailed and much more formalized about what best practices really mean and then to be able to extrapolate those and make sure that if there are additional staffing changes that need to be made that we get those in place. That’s going to take a little while and so it is conceivable that as we move into the second half of this year, we will not see the same year-over-year rate of increase although we do continue – we do expect to continue to see a forward progressing.

Gary, it’ Mark. As Doug said, we are very positive on the outlook, so TeamWorks and its ability to continue to increase the collaboration rate. We had a change to be out in Dallas last week and address the entire group that’s participating as part of this TeamWorks initiative with our subject matter experts along with the KPMG [ph] helping us from a process standpoint and they had the enthusiasm in that room and the willingness and eagerness to work together in a collaborative manner between both the IRF staff and the home health staff was very, very encouraging.

And Gary, please don’t interpret any of comments as either walking back our stated goal of getting to a 35% to 45% collaboration in the near-term or as any diminished enthusiasm about the importance and the effectiveness of the partnership between our IRF and home health business segments.

Got it. That’s very helpful. Thanks a lot.

Your next question comes from the line of Kevin Ellich of Craig-Hallum.

Good morning, Kevin.

Good morning, Kevin.

Good morning, guys. Thanks for taking the questions. Kind of just following up on Gary’s question with the collaboration, a lot of very good information and I see the target is going to be 35% to 40% over the next few years. I guess it makes a lot of sense with the discharges. Have you guys ever quantified what the revenue and EBITDA impact could be as you get to 35% to 40%?

We have and I think the pieces are out there for really anyone to do that because some of it, we don’t put that out there because it would be a financial projects, all right. But you can look for instance of the fact that and what we’ve stated is in general each one of the patients that comes out of a – one of our IRFs and goes into home health requires about 1.2 episodes of home healthcare and those episodes generate about $3,100 to $3,200 in revenue per episode and then as I just mentioned some in my remarks, they have a slightly higher cost per visit than standard nursing services, so a little bit of a lower gross margin, but it’s a pretty profitable patient.

Gotcha and understood that with therapy. And then the only other question I had was, what sort of impact do you expect from Easter holiday or do you expect one this year?

We’re more folks in terms on the year-over-year comparison. We are a little bit more focused for Q1 on the impact of leap year. Having said that, the shift in the Easter holiday does make a difference. The movement of a holiday like Easter is a lot more difficult to quantify, so we are not making any excuses regarding Q2 volume based on the shift in Easter.

Got it. Thank you.

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

Good morning, A.J.

Good morning, A.J.

Hey, how are guys? A couple of question to follow-up I guess. On the payor mix trends, I see that both in the IRF and the Home Health side, MA continues to be up 90 basis points in IRF, 160 basis points in Home Health, and then you also manage care generally higher and Medicaid on the Home Health side at least under pressure. Can you drilldown what’s driving those changes and do you see those continuing shift the payor mix?

Yes, we would continue to see payor mix shift especially on the IRF side. Medicare advantage has been growing a little bit faster rate than most of the other segments. It currently is about 9% of our total case. It grew about 10% in Q1, so we would continue to see Medicare advantage. One comment on Medicare advantage growth is that we’ve been successful in having more and more of our contracts now rather than be linked to a per diem there linked to the CMG. So that’s a trend that we’ve seen in the last several years and we continue to see that make progress. We’ve also seen as Doug pointed out, we’ve seen a larger increase in our stroke mix in terms of the conversion rate when we get a stroke patient that’s covered with Medicare advantage plan. Referred to our hospital, we are seeing more and more success in getting them converted to an admission. So those are all factors impacting that payor mix.

And A.J., to elaborate on Mark’s comments, in each of the last five years, we have seen the percentage of Medicare advantage contracts that are paid on a case rate versus a per diem basis increase and its now approximately 55% of our MA contracts are paid on a case rate basis. It’s also the case that over each of the last five years, we’ve seen the delta between the Medicare advantage payment and Medicare fee per service rates decrease. And in the most recent quarter, we are at about a 14% gap between them. If you roll the clock back five years, we were close to the 25%.

Okay, interesting. Maybe just quickly on the labor front, you commented on that in your prepared remarks, but it’s interesting in the comments about some of the pressures you felt, you didn’t say anything about just absolute rate increases. Are those remaining pretty steady and maybe I’ve missed this from previous comments but your comment about increased staffing around new reporting requirements maybe I should know that but what is that referring to?

A.J., I’m going to ask Barb Jacobsmeyer to comment on that.

So two things, on the salary pressures, we are not feeling that enterprise wide. We do have particular markets that are more challenging than others and we’re addressing those as needed. To the comment on the regulatory, there was added information that needed to be put into our IRF pie which is a document that submitted with each of our claims. That required additional information that the clinicians needed to be able to pull, so we needed to add some of the clinical staff to be able to handle that. We’ve estimated about 40 minutes per claim has been needed for additional staffing for that.

A.J., the additional information was tied to the care tool implementation and as Barb said, that affected all the information that submitted particularly from a therapy standpoint on everyone of our patient. So that had an impact about 40 minutes per patient so that adds up.

Okay, thanks a lot.

Your next question comes from the line of Josh Raskin of Barclays.

Hi, Josh.

Hi, Josh.

Hi, good morning guys. Just on the IRF update, the Medicare IRF update and macro sort of superseding the normal process with a 1% increase. I guess two questions on it, one, how are you guys thinking about next year and offsetting little bit of that pressure. And then as we think about 2019, I can’t find in macro, is there a potential give back or some sort of catch up in 2019 to make up for that, the wage component catch up or how does that work in the next year? Do you guys know?

Josh, I’m not aware of any makeup or any catch up out there in 2019. Relative to the update that was rolled out late last night or yesterday afternoon, we’re still doing our research and homework on the numbers to see the impact. The 1% at least on the first blood, it does seem to be in line with what our expectations were and it’s what we had in our outlook slides, our business outlook slide so that seem to be in line.

Okay, all right, that’s fine. And then just on the staffing levels, the Reliant hospitals and I appreciate the answer to A.J.’s question but are you guys now at target staffing levels at the Reliant hospitals? And then I guess on a related note, is there any wage pressure in hiring those clinicians or is this just simply we needed more body?

We are now at our staffing metrics at the Reliant hospitals and have been now for a quarter or two. A year ago, we were still ramping up, so that’s why you’re seeing the increase year-over-year but we are there now. And so relative to labor salary increases, majority of those staff that were hired were therapist and somewhat additional nurse as well in some of those hospitals. But that’s all has been factored into what we put in terms of our 3% expected increase this year in salaries.

We did have to do some salary adjustments to the Reliant staff that were remaining with us after the acquisition, but virtually all of that took place in the first half of last year. So we are already anniversarying that component, Josh.

Okay, all right, so it’s just bodies it sounds like.

It is.

That’s right.

Okay, perfect. Thanks guys.

[Operator Instructions] Your next question comes from the line of Kevin Fischbeck of Bank of America.

Morning, Kevin.

Morning. So just on that labor question, if you didn’t have these kind of discrete items, what would labor cost have been on the IRF side?

I think it accounted for most of the 80 basis point increase. When we looked at the – what drove the year-over-year change in SWB, it was almost specifically FDE related because the pricing increase for the IRF segment was really sufficient to offset the increase in SWB in terms of the merit increase and other increases there.

Okay, so you would have kept it flat year-over-year if not?

Slight to maybe some modest leverage on top of that.

Okay, so you [indiscernible] leverage, so I guess what you think about next year’s rates about being a little bit less than this year’s rate labor costs, you would still expect it to be at least flattish, is that the way to think about it?

Well, there are a lot of ifs in there. We would hope so but it really going to depend on whether or not there are any additional regulatory requirements on us but it’s certainly the case that our response and this applies to both business segments to the rapidly changing environment in healthcare has been to invest in the business and invest in the business in a manner that we think is producing higher quality outcomes for our patients and underscoring our value proposition and also preparing us better to serve effectively as a partner with payors and acute care systems in episodic payment models. There is going to come off time when pricing normalizes for both business segments. Right now, it looks like that’s more 2019 and 2018 and there is also going to be a time when the investments that we’ve made in the business lead to productivity gains.

Okay, that’s helpful. Just the second question then, anything in the nursing home last night that you thought might be good for your business because I guess they’re going to change the way that they pay for therapy in 2019. Does that potentially keep more people into IRF or push people more quickly into Home Health. Is there any impact from that in your mind?

Kevin, we’ve not had a chance to get – to dig into the SNF update. We certainly spent the majority of our time trying to address the IRF rule that it came out late in the yesterday. So can’t really comment on any impact positive or negative from the SNF update.

We do believe that the trend of disintermediation that the SNFs have been experiencing is going to continue and we know it’s our own efforts on Home Health that we’re being effective and contributing to that disintermediation.

Okay, thanks.

Your next question comes from the line of Whit Mayo of Robert Baird.

Morning, Whit.

Morning, Whit.

Hey, thanks. Just maybe a couple random ones. Can you just remind us where you are on some of your IT investments? I think you’ve called it ACE IT or something and maybe how many installs you’ve made at this point, how many more forthcoming and are you seeing any noticeable benefit from these investments on ADRs or anything? Or just any broader update on where you are on in the benefit would be helpful. Thanks.

So we are now well over 100 hospitals of full permutation for ACE IT. This year 2017 will be the final year of the initial roll out. We will have all of our hospitals have it implemented by the end of the fourth quarter. We do have two hospitals in Puerto Rico that will have it installed in Q1 or at least the first half of next year. Relative to overall documentation or impact on ADRs, we anecdotally have gotten positive feedback in terms of the quality of our documentation that is tied to ACE IT and our ability to ensure that we have complete documented items complete with the signatures and dates and other areas of aspect that are reviewed from a documentation standpoint. We think longer term, it will absolutely help us on the ADR front. We think it also helps us in our ability to position ourselves from episodic standpoint with eight teams going forward.

Got it. Nudging physician satisfaction and recruiting has been helpful too.

It does.

Yes. And maybe my second question for Doug is, the lease accounting changes that you’ve referenced. I mean you’ve seen some of the stuff we’ve published on it and you and I have discussed this in some detail, but I’m just maybe curious how you think it really differentiates HealthSouth versus the peer group and really curious how your conversations with the banks are going and how the banks will actually treat this accounting change going forward? Thanks.

So first we like our position. We’ve always liked our position with regard to real estate ownership because of the flexibility it gives us in managing our portfolio of hospitals and also because of the protection it gives us in a typical rate environment against the increases in your occupancy expense that can reside in a lease arrangement. At its core, a lease is a highly inflexible non-prepayable debt obligation with an escalating interest rate, really sounds pretty attractive. So the fact that two-thirds of our real estate is owned is a real advantage. And when that comes on to the balance sheet when the disclosures related to that are made, I think as the saying goes when the tide goes out we’re going to find out who is swimming naked. In terms of the reaction from the banks, I really can’t comment on that. I know it’s not a factor for us in our discussions with the banks because of the position that we hold. My guess is if we get into an environment where the debt markets aren’t nearly as liquid as they have been over the last several years and that will come because they cycle through. It’s those kinds of factors they’re going to lead to a differentiation in borrowing rates and availability of funds.

Okay, thanks. Appreciate it.

At this time, there are no further questions. I will now turn the call to Doug Coltharp for any additional or closing remarks.

Thank you. If anyone does have additional questions, please send them to Travis Wilson of our Investor Relations department at travis.wilson@ healthsouth.com. We ask for a little bit of your latitude and patience in Crissy’s absence to work with us. We want to be responsive to all of your questions. The protocol that we have put in place is that Travis will work with me and other members of our Executive Management Team to respond to your question via phone or email as quickly as possible but initially he is going to just gather your questions up and then consult with us. So thank you again for your time and attention today and for joining today’s call.

Thank you for participating in HealthSouth first quarter 2017 earnings conference call. You may now disconnect.