ATI Physical Therapy, Inc. (ATIP) Q1 2023 Earnings Call Transcript

ATI Physical Therapy, Inc. (ATIP) Q1 2023 Earnings Conference Call May 8, 2023 5:00 PM ET

Corporate Participants

Joanne Fong - Senior Vice President, Treasurer and Head of Investor Relations

Sharon Vitti - Chief Executive Officer

Joe Jordan - Chief Financial Officer

Chris Cox - Chief Operating Officer

Conference Call Participants

Taji Phillips - Jefferies

Benjamin Shaver - Deutsche Bank

Mike Petusky - Barrington

Operator

Good afternoon and welcome to ATI Physical Therapy's First Quarter 2023 Earnings Conference Call and Webcast. [Operator Instructions] Please note, this event is being recorded.

On the call today is Sharon Vitti, Chief Executive Officer; Chris Cox, Chief Operating Officer; Joseph Jordan, Chief Financial Officer and Joanne Fong, Senior Vice President, Treasurer and Head of Investor Relations.

I would now like to turn the call over to Ms. Fong. Please go ahead.

Joanne Fong

Thank you, Liza. Good afternoon, everyone, and thank you for joining us today.

Before we begin, we'd like to remind you that certain statements made during this call will be forward-looking statements that are subject to various risks and uncertainties and reflect our current expectations based on our beliefs, assumptions and information currently available to us.

Although we believe these expectations are reasonable, we undertake no obligation to revise any statements to reflect changes that occur after this call. Descriptions of some of the factors that could cause actual results to differ materially from these forward-looking statements can be found in the Risk Factors section in the company's filings with the Securities and Exchange Commission.

In addition, please note that the company will be discussing certain non-GAAP financial measures that we believe are important in evaluating performance. Details on the relationship between these non-GAAP measures to the most comparable GAAP measures and reconciliation of historical non-GAAP financial measures can be found in our earnings press release as posted on ATI's website and filed with the SEC.

With that, I'd like to turn the call over to Sharon.

Sharon Vitti

Thanks, Joanne. Welcome, everyone.

Earlier today, we reported our first quarter 2023 earnings results and announced that we achieved an important milestone toward closing our previously announced capital transactions. On our last call, I said 2023 was off to a good start, and it has been quite a journey.

Now that the first quarter has concluded, I'm happy to share highlights of the exceptional performance we achieved as a result of the deliberate actions we are taking to improve access to high-quality patient care and deliver excellent customer service across our organization.

To start, I must congratulate the entire ATI family, our providers in the clinics, those in the field in our health services offerings and our corporate team on their accomplishments. This team saw more than 22,700 visits on average each day in the first quarter, helping hundreds of thousands of patients across the country to attain their individual health goals.

In January, we held our National Leadership event with our field teams and corporate leadership to align our 2023 strategies and goals for each of our clinics. It was great to have the team back together post-COVID. Throughout the first quarter, our providers exceeded established targets with visits and visits per day per clinic reaching a post-pandemic high. We recently completed ATI's management transformation, which started over the last 5 months, adding on to our experienced team of high-performing health care leaders that are the basis for our new operating structure.

As I reflect on my first year as CEO, I'm pleased we have had early successes to report and an incredibly strong foundation to drive our momentum. While a central priority at ATI continues to be achieving our near-term growth targets, we now have Scott Gregerson, our new Chief Growth Officer, who is focused on ensuring we deliver on ATI's long-term potential in the musculoskeletal sector and that the decisions we make today position us for the future.

So now turning to our near-term growth drivers, specifically the 3 Ps of our practice; our pipeline, provider base and provider productivity.

So first, if we look at pipeline. Referrals remained above pre-pandemic levels through the first quarter. Our business development team continues to strengthen our existing referral relationships, build new relationships, and they've done a nice job executing on market-specific strategies.

For the second P, provider productivity, visits in the first quarter of 2023 were the highest since the pandemic began. Additionally, our productivity per provider performed at an all-time high, even surpassing pre-pandemic levels. Our providers continue to focus on their commitment to our patients in meeting the high demand for care, and they increased productivity to an impressive 9.5 visits per day per clinical FTE in March 2023 to finish the quarter at an average of 9.4 visits per day. Chris will talk more about this and provide details on how we achieved this milestone and what lies ahead.

For the third P, provider base, the labor market continues to be a headwind across the industry and at ATI, with labor scarcity and elevated competition for providers at all-time highs. Eimile, our Chief People Officer, has thoroughly evaluated the overall provider landscape and has spent time with many of our teams listening and hearing about the dynamics at play in the current environment.

Our conclusion is aligned with many in the PT space. We do not foresee an immediate improvement in the labor market. At the same time, we are hyper-focused on evolving our people strategy to aggressively attract and retain vital providers. Our newly formed talent acquisition team is making progress and has positioned ATI as an employer of choice for the new cohort of PT graduates entering the workforce.

The ATI culture is strong, and Eimile is leading a multitude of tactics to support and engage our employees, learning real-time what works and where to invest in our team members.

As we move forward, we're continuing to execute on our fleet review and geographic footprint optimization. The review of our footprint is designed to enhance convenience for our customers and optimize the underperforming clinics through consolidation, closure and divestiture.

In the first quarter of 2023, we opened 4 de novo clinics. We closed 12 clinics and divested 6 clinics as we executed on the plan. We are continuously monitoring clinic performance and taking swift action when appropriate.

So as I said before, 2023 is off to a good start, and demand for ATI Physical Therapy services remains high. ATI's success is fueled by the contributions of every member of our team pulling in the same direction to deliver on the company's mission. To exceed customer expectations by providing the highest quality of care in a friendly and encouraging environment with impactful outcomes.

As we move into 2023, we're acting with urgency to harness our recent momentum and continue driving improvements in the business.

Now, I will turn the call over to Chris to discuss our operations and what he's seeing in the field.

Chris Cox

Thank you, Sharon.

I'm excited about our strong operational start to the year, and I'm even more encouraged by the tremendous opportunities ahead as different functions across our operations team are continuing to optimize workflows and processes while elevating the patient experience.

As Sharon highlighted, labor productivity during the quarter was at an all-time high, which goes hand-in-hand with providing increased access to high-quality physical therapy for our patients. In addition to our frontline providers in the clinics, there are multiple teams working in the background to allow us to reach this level of performance. It starts with patient intake, using technology to enable a seamless onboarding experience for both patients and agents.

For example, we recently deployed a new call center technology and are already seeing improvements in efficiency and customer interactions.

Next is patient scheduling. We are working towards scheduling excellence, intelligently matching patients with providers as we move toward an optimized centralized scheduling. We've already implemented several tools that have provided clarity of focus on scheduling behaviors and demonstrate what good looks like, which contributes to a predictable operating rhythm in our clinics. Importantly, this enables clinic directors to keep their weeks more organized and efficient through upfront planning and coordination. It also reduces stress on our providers, an important attribute as we focus on retention and new recruitment.

Additionally, centralized scheduling helps our clinic directors take more ownership of their business by reducing administrative burden and allowing them to focus on patient access and patient care, which drives clinic four-wall performance and operational excellence. We have been rolling out this centralized scheduling support across the country and will continue to do so over the coming months.

As these practices have been implemented, we've seen the significant increase in productivity that Sharon and I referenced. But notably, along with that increase, we have not seen a decrease in engagement or an increase in burnout. We've also seen continued stability in our retention trends in Q1.

In the past few months, I've had the opportunity to visit multiple clinics across all of our regions and met with hundreds of our providers. I'm energized by the passion our providers have for delivering high-quality patient care and all that entails. And in fact, on a recent clinic visit to New England, one of our clinic directors remarked that they were surprised that they were seeing an extra patient per day per clinician because they don't "feel busier." The tools, practices and support we have provided have increased patient access and given our providers a sense of calm and readiness.

On our last call, I said that we have several opportunities to reduce costs in different areas, enhance revenue and drive improved customer service and outcomes. In addition to patient intake and scheduling, one of these areas is revenue cycle management.

Accordingly, during the quarter, we focused on collections of certain aged accounts receivables and drove days sales outstanding to below 45 days for the first time. Additionally, we enhanced our pre-visit authorization workflow and integration with our EMR system. These 2 initiatives were initial quick wins, and we are in the process of proceeding with a larger transformation to move our RCM function to best-in-class performance. We believe there is an opportunity to unlock significant value with investments in technology and automation.

A priority of mine continues to be innovation of our processes and systems to support our clinic and field teams. We are building more structure and capabilities to reduce non-value-add work and drive consistency. While these actions have allowed us to increase patient access to high-quality care, the team has only begun to scratch the surface to identify ways to improve and drive new actions. I look forward to keeping you appraised of our progress.

Now I'd like to turn the call over to Joe to provide a discussion of financial results.

Joe Jordan

Thank you, Chris, and thanks to everyone for joining the call today. I will cover our first quarter 2023 financial results and provide a brief update on our TSA.

Starting with financial results. Net revenue in the first quarter was $167 million, which is an 8.5% increase year-over-year from $154 million in Q1 of the prior year. Net patient revenue was $151 million, also increasing 8.5% year-over-year; while other revenue was $16 million, an 8.6% increase year-over-year, with the primary driver being management services agreement revenue.

Visits per day per clinic during the quarter was 25. It increased 0.9 visits quarter-over-quarter sequentially from 24.1 in Q4 of 2022 and it increased 2.1 visits year-over-year.

As we've discussed before, one of the benefits of higher clinic capacity utilization and the associated increased leverage of fixed costs, such as rents, will be higher clinic profit, which we experienced during the first quarter.

Rate per visit during the quarter was $103.76, which sequentially decreased 0.2% from $103.99 in the fourth quarter of 2022 and was up 0.7% year-over-year from $103.06 in the first quarter of 2022. The year-over-year increase was primarily due to commercial rate per visit improvement, which has more than offset Medicare rate cuts.

Salaries and related costs in the first quarter of 2023 were $91 million, which is a 3.8% increase year-over-year from $87 million in Q1 of the prior year, primarily due to wage inflation, in addition to a higher proportion of more senior-level clinicians.

PT salaries and related costs per visit during the quarter was $52.98, sequentially improving 3.5% from $54.92 in the fourth quarter of 2022 and 4.5% year-over-year from $55.47 in the first quarter of the prior year. The improvements in cost per visit were primarily due to higher labor productivity as visits per day per clinical FTE was 9.4 during the quarter, which has improved from 9 in Q4 2022 and 8.5 in Q1 of the prior year. These improvements were partially offset by higher per clinician labor costs.

Rent, clinic supplies, contract labor and other in the first quarter was $53 million, a 2.4% increase year-over-year from $52 million in Q1 of 2022. PT rent, clinic supplies, contract labor and other per clinic during the quarter was approximately $56,000, which is an increase of 9.9% quarter-over-quarter from $51,000 in Q4 and 3.4% increase year-over-year from $54,000 in the first quarter of 2021. The sequential increase and year-over-year increase were primarily driven by the cost of the annual National Leadership event in January 2023, which approximated $3 million.

Our provision for doubtful accounts during the quarter was approximately $4 million or 2.7% of PT revenue compared to $5 million or 3.7% of PT revenue in the first quarter of the prior year. The favorable performance in the first quarter of 2023 was the result of the company's focused collection efforts and process improvements, which Chris talked about earlier within RCM.

SG&A during the quarter was approximately $31 million, a 1.9% increase year-over-year from $30 million in Q1 of the prior year, primarily due to transaction costs from completing the TSA and the definitive documents in the first quarter of 2023, and those costs were partially offset by lower professional fees and non-ordinary legal expenses.

Operating loss, excluding impairment charge in the first quarter of 2023 was $11 million, which improved year-over-year from $20 million in Q1 of the prior year, reflecting higher revenue. In addition to early results of the multi-year business improvement initiatives that we started implementing in the second half of 2022.

Interest expense during the quarter was $14 million compared to $9 million in the first quarter of the prior year, with the increase primarily driven by higher interest rates under the company's credit agreement, which we closed in February 2022, compared to the previous credit agreement as well as the higher interest rate environment overall. And those increases were partially offset by payments received from our interest rate cap hedge.

Income tax expense for the quarter was $100,000 compared to income tax benefit of $23 million in the first quarter of 2022. Net loss during the quarter was $25 million compared to $138 million in the first quarter of the prior year.

Our adjusted EBITDA during the quarter was $5 million or a margin of 2.9%, and that was a substantial increase over last year where we had an adjusted EBITDA loss in the first quarter of $4.7 million. Similar to the year-over-year change in operating loss I talked about earlier, the year-over-year increase in adjusted EBITDA was primarily due to higher revenue, combined with the impact from business improvement initiatives.

Our cash flow use year-to-date was $20 million, with $14 million used to fund operations, $5 million used in investing activities and $1 million used in financing activities. As of March 31, 2023, available liquidity was approximately $63 million, consisting of cash and cash equivalents with no available revolver capacity.

Finally, I'd like to provide an update on the transaction support agreement. We completed drafting the substantially final form documents, which we filed just over 2 weeks ago with the SEC and Form 8-K. And I'm pleased to report that the key economic terms were finalized in the definitive documents as outlined during our last call. Subject to shareholder approval, the transactions are expected to close in mid-June, and we look forward to keeping you updated.

Given the significant progress ATI has made over the last quarter, and the multitude of changes we have made to our business, including our upcoming transactions, we're not providing guidance at this time. We believe that today's quarterly update and the key KPIs provided as part of our 8-K are the most appropriate for the time being, and we look forward to providing guidance at a later date.

With that, I'll turn the call back over to Sharon.

Sharon Vitti

Thanks, Joe.

So as you can see, our first quarter results demonstrate that our strategy is working. I am proud and grateful to the entire ATI family for their focus and efforts in Q1, allowing us to care for more patients. I look forward to keeping you up to date on our progress as we continue optimizing our operations, implementing our talent enhancement initiatives, investing in innovation, and streamlining our geographic footprint.

While we remain confident in our ability to sustain progress and execute on our road map, we are looking to close the TSA transactions ahead of providing formal earnings guidance, as Joe stated. Completion of these transactions will provide ATI with additional financial flexibility to support our future-facing value creation initiatives. I remain optimistic for the year to go and our future.

Thank you again for joining us today. Now we will open up the line for Q&A.

Question-and-Answer Session

Operator

Thank you. [Operator Instructions] Your first question today comes from Brian Tanquilut, Jefferies.

Taji Phillips

You have Taji on for Brian today. So as I look at your KPIs in terms of visit per day and visit per clinic, I'm just curious if you can break that out between some of the operational efficiencies that Chris had called out on the call versus it being a function of increased patient demand for physical therapy services.

Sharon Vitti

Great question. Thank you, Taji. We're moving quickly and there's a lot going on at once. And I would say that we are able to capitalize on the demand by creating more efficiencies in the clinics and then supporting our providers so that they can increase their productivity. So that's the executive summary level.

Let me let Chris add some commentary. I think it's difficult to tease it out because everything is happening at once, and both are moving in the right direction. But let me let Chris comment.

Chris Cox

I think the other key thing I would add is, as we look quarter one of 2023 versus quarter one of 2022, we have seen approximately the same improvement in productivity in every region across the country. Some of those regions have referral starves, some of those regions have referral surpluses. So I think we're definitely seeing that improvement both with and without the increase in patient demand.

Taji Phillips

Great. And just a quick follow-up, I know that you had called out still a potential of contract labor use. Can you tease out, how much that is this quarter as a percentage of revenue or spend?

Joe Jordan

Yes. I have it, Taji. This is Joe. It's roughly 6%.

Taji Phillips

Thank you. And then just last question, too, I guess, how do you foresee that trending throughout the year? I know it's a high priority for companies to try and tease out that contract labor, just curious on what's the balance between optimizing those patient volumes but also making sure that you're controlling costs.

Sharon Vitti

No, it's certainly a balance, as you saw for sure. We see our talent acquisition strategies really ramping up. We rebuilt the whole group in Q1, or during Q1, I should say. And so we're starting to see some traction there. So my hope would be that, as we continue to both retain and recruit more full-time, our ATI providers will be able to move away from the contractors. For the first quarter, we certainly had some good progress, but we would rather have a provider even if it's a contract than not have a provider given the demand that we're seeing.

Joe Jordan

Taji, this is Joe. Contractors, to Sharon's point, we'd rather have a full-time provider because contractors, the same as contracting companies is more expensive. But it is important to note that it's still a profitable business and there's demand out there for Physical Therapy services at ATI, and we want to be able to meet that demand.

Operator

Next, we'll hear from Pito Chickering, Deutsche Bank.

Benjamin Shaver

You got Benjamin Shaver on for Pito. I was just wondering if you could give maybe a little more color around some of the expectations for the labor KPIs, most notably hiring and turnover going forward? Thank you.

Sharon Vitti

Sure, Benjamin. Thanks for the question. Well, we are gearing up for the busy season. We have certainly been seeing it's a combination of the hiring and the attrition that put the numbers on the board. So we're certainly seeing the hiring. And we've seen the attrition stabilize over the course of actually the last six months.

And so we've got a lot of tactics and a lot of new initiatives. We're constantly looking at adjusting those as we learn. And I think we're positioned well for the graduates coming out of the programs, which we call this the busy season. We have some indications. April was a strong month for us, and we have some indications as we look 90 days ahead that we've positioned ourselves to get our fair share.

Chris, I don't know if you want to talk about some of the work we're doing around the retention of our colleagues.

Chris Cox

Yes. I think it goes back to, number one, just how we're focusing on patient access and really making it about high-quality patient care, showing our providers what best practices look like as it relates to scheduling, providing them playbooks and kind of that upfront planning I mentioned in my prepared comments, that really allows them to feel more prepared, more at ease about their workload.

That's the core of it with the operations but then also focusing on market-by-market engagement plans, understanding the various cultures that exist within the different ATI clinics across the country. Looking at compensation on a market-by-market level where there may be discrepancies in the market level. As well as really taking a coordinated approach with our field leaders to have a discussion with every single one of our clinicians across the country to understand what's on their mind.

We talk about basically doing an interview with our existing employees to say, "What are you concerned about, what feedback do you have, and what is currently on your mind that could be a concern that we can address," and then taking that feedback centrally and saying, "Okay, what are the additional things we can do," focusing on things like our CEU programs and continued professional development and education.

Sharon Vitti

So Benjamin, I'd say very deliberate actions on both sides of the equation, both on the recruitment and the retention, and really, quite honestly, listening to what new grads are looking for, listening to what our employees are looking for and then certainly trying to meet the needs of what's important to them. And I would say our culture is really strong here and so I think we've got a lot to offer and a lot of what we're doing is getting that message out there, whether it be through our recruiting team or through our existing in place.

Benjamin Shaver

For sure. So just a quick follow-up, is there any way you could quantify either of those metrics? And just one more. So you mentioned that you had more senior clinicians and you also mentioned some wage increases. Can you maybe break down a little bit how much of those wage increases are coming from the market rate increasing versus just having more of the senior clinicians that demand a higher wage?

Sharon Vitti

So on that, let's start with the retention. So we've seen in Q1, we're at about 27% annualized, did I get that right?

Joe Jordan

Turnover.

Sharon Vitti

Turnover. I'm sorry, yes, turnover. We have struggled with retention in the past, so we've seen that stabilize. And we're continuing to work to improve that, but that's what our number is right now. And, again, much improved from what it has been in the past. So our compensation, I mean, I don't know, Joe, if we can break that out, but our comp is up.

Joe Jordan

Yes. It's roughly 3.5% to 5% is what we'd expect. As far as breaking down how much of that is attributable to more senior hires versus non that level detail we have at some level but not at the granularity to share that here.

Sharon Vitti

Yes. I mean it's been a combination of two things, clearly wanting to certainly reward our more senior providers and then, as everyone knows, to attract new folks. There's a pretty aggressive package that is put out there for new hires. So I think it's a combination of the two when we look at this that are both causing that increase.

Joe Jordan

And Ben, maybe the only other thing I'd say is like to the extent you're trying to think about modeling out the 3.5% to 5% wage inflation that we're seeing, that's probably around what we expect for the rest of the year. But what you saw in our release, if you're looking at the KPI tables, the lower labor cost per visit is because productivity has been up and beneficial. So to the extent that we're able to hold that and that helps to offset some of the inflation that we're seeing.

Sharon Vitti

Yes. We're certainly not leading the market, but we're definitely trying not to over-index there where possible.

Operator

Your next question comes from Mike Petusky, Barrington.

Mike Petusky

So I guess sticking with the clinician labor force item, you guys have been tracking between 2,600, 2,700 clinical folks for the last several quarters. And it's actually gone down in the last, on a net basis, gone down about 60 or so the last 2 quarters. I mean assuming your facility count stayed around 900. I mean what should be the number? I mean is it 2,800? Is it 3,000? Like, what number is the right number that's sort of aspirational based on the number of clinics you have? Thanks.

Joe Jordan

Hey, Mike, it's Joe. It's probably somewhere between 2,800 and 2,900, maybe closer to 2,900.

Sharon Vitti

Yes. And then, Mike, the end of the year, Q4 is usually a quarter, a time of the year, where we do see a larger attrition than we normally do. And so then recovering from that at the beginning of the year is a little bit of an uphill for us. So I will say that April was a good month for us. And so we haven't seen a consistent trend yet. We certainly are hiring and then we're watching the retention, but we haven't seen the level of traction to get to those numbers yet. We certainly have the demand to support that.

Mike Petusky

Okay. Just curious, your publicly traded competitor made comments around the labor market, suggesting that they'd seen strong improvement and had really seen dramatically shorter times to fill openings, and retention was super high. I guess, one, were you aware of those comments? And two, any sense of why maybe you guys are not seeing that?

Sharon Vitti

You know what, I can't speak for USPH, I'm not sure what's going on over there. But I will say, at a national level, having attended some of the national conferences, this is the hottest topic. And I feel like we're in pretty good company with some of these other organizations that have very similar both challenges and approaches to the workforce. So I would say, I mean, our challenge is that we're not only trying to keep up with attrition. As you pointed out, we've got a large number that we're trying to move back to pre-COVID. And so that's been our biggest challenge. We can keep up with attrition. That's not the problem. It's adding significant numbers to get back to where we were pre-COVID.

But there's nothing I've heard from any of our competitors that leads me to believe that they're not in a similar situation around a challenging workforce, wage inflation and just a very tight workforce.

Operator

And everyone, at this time, there are no further questions. I'll hand the call back to Ms. Sharon Vitti for any additional or closing remarks.

Sharon Vitti

Just wanted to thank everyone for joining us today, and we look forward to keeping folks up to date in our next quarterly earnings call. Thank you.

Operator

Once again, everyone, that does conclude today's conference. Thank you all for your participation. You may now disconnect.