ACHC - NASDAQ

Good day, and welcome to Acadia Healthcare's Third Quarter of 2024 Earnings Call. All participants will be in a listen-only mode for the duration of the call. [Operator Instructions] After today’s presentation, there will be an opportunity to ask questions. [Operator Instructions] Also, please be aware that today's call is being recorded. I would now like to turn the call over to Patrick Feeley, Head of Investor Relations. Please go ahead.

Thank you, and good morning. Yesterday after the market closed, we issued a press release announcing our third quarter 2024 financial results. This press release can be found in the Investor Relations section of the acadiahealthcare.com website. Here with me today to discuss the results are Chris Hunter, Chief Executive Officer; and Heather Dixon, Chief Financial Officer. To the extent any non-GAAP financial measure is discussed in today's call, you will also find a reconciliation of that measure to the most directly comparable financial measure, calculated according to GAAP in the press release that is posted on our website as well as the 10-Q filed yesterday afternoon. This conference call may contain forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995, including statements, among others, regarding Acadia's expected quarterly and annual financial performance for 2024 and beyond. These statements may be affected by the important factors, among others, set forth in Acadia's filings with the Securities and Exchange Commission and in the company's third quarter news release and consequently, actual operations and results may differ materially from the results discussed in the forward-looking statements. At this time, I'd like to turn the call over to Chris.

Thank you, Patrick, and good morning, everyone. Thank you for being with us for Acadia's third quarter 2024 conference call. We have a lot to cover today, but I want to begin with our results and key highlights of the quarter. I'll then provide a broader update on our quality standard here at Acadia, followed by a legal update. I will close with the discussion of how we drive outcomes for the vulnerable populations we serve and how we are expanding access to high quality care for a patient population that so desperately needs it. During the third quarter, we reported strong results with total revenue of $816 million, representing growth of 8.7% over the third quarter of 2023, driven by both rate improvement and patient day growth. This top line growth combined with solid operating leverage led to adjusted EBITDA growth of 10.5% over the same quarter last year. Underlying labor costs continued to trend favorably in our initiatives around recruitment, retention and engagement have helped attract and maintain talent. We've also made consistent progress against our bed growth targets. We are on pace to complete construction on approximately 1,200 beds this year, including nearly 700 beds in the fourth quarter from several new wholly-owned and joint venture facilities. This includes hospitals and partnerships with Henry Ford Health in Detroit and Intermountain Health in Denver, Colorado as well as a new acute care de novo facility in Madison, Wisconsin, that was completed earlier this month. We're also on track to add over 400 beds to our existing facilities for the year, including over 300 expected in the fourth quarter. With that, I'd like to take this opportunity to remind you about our ongoing commitment to quality, safety and compliance. At Acadia, our mission is to provide compassionate care that improves lives, inspires hope and elevates communities. And when you consider the patient populations we serve in behavioral health and addiction treatment, they are truly amongst our nation's most acute at risk and underserved. We play an incredibly important role in supporting these patients, and we take that role seriously. With respect to recent and accurate media reports about Acadia behavioral health facilities, we want to share more about how our facilities operate and how we aim not only to meet, but exceed the standards that regulation requires. First, I want to be clear, medical necessity drives patient care decisions at Acadia. These decisions are made by licensed providers and adhere to all associated legal requirements. The allegation that Acadia systematically holds patients longer than medically necessary is false and goes directly against everything we do and stand for when it comes to patient care. If you've not already done so, I would encourage you to read our response at quality.acadiahealthcare.com, which importantly includes data that shows the average length of stay across Acadia's hospitals is in fact in line with the industry average and below those in government and nonprofit run facilities. Behavioral health is complex, but it is clear that the need has never been greater for high quality behavioral health care, given the severe mental health crisis that our nation faces. It is estimated that more than one in five Americans live with a mental illness and one in three Americans with serious mental illness are still receiving no treatment. Yet the United States has 40% fewer psychiatric beds per capita than comparable countries. It's a disease that impacts every family in our country. And every day, our 23,500 Acadia employees help fulfill our mission to provide compassionate care that improves the lives of patients and their families. We operate in one of the most highly regulated and supervised subsectors of health care. Our facilities, clinicians and practices are routinely subject to oversight in inspection by various agencies to ensure compliance with regulatory requirements, including, but not limited to robust CMS guidelines on all aspects of patient care, documentation and billing. To give you just a sense of the oversight at our facilities, consider that over the past five years, our acute psychiatric hospitals have been subject to routine inspections and surveys by independent third parties and government agencies, such as the Joint Commission, CMS and various state agencies, an average of roughly 5x per hospital per year. Like other well-run provider organizations, these hospitals are routinely subject to third-party audits, including chart reviews, both as part of routine regulatory reviews and part of our own internal compliance programs. They are also routinely subject to oversight from third-party payers, with utilization management efforts taking place before, during and after patient stays. This oversight ranges from payers' own clinicians rounding with local providers within our facilities, to retroactive chart reviews and payer audits. I want to stress that this type of oversight is important to help ensure that patients receive the best care available. The work we do matters, and our clinicians often must make difficult critical decisions about life-saving care on a daily basis. We also believe it is important not to perpetuate miss that psychiatric care is ineffective or even harmful. At Acadia, clinicians follow industry standard, clinically driven admission and discharge criteria, and we hold ourselves to an incredibly high standard. With that, I'll provide a brief legal update. As we disclosed last month, in September, we received a voluntary request for information from the U.S. Attorney's Office for the Southern District of New York as well as a subpoena from the U.S. District Court for the Western District of Missouri related to admissions, length of stay and billing practices. On the same day, one of our acute care hospitals also received a subpoena from the Western District of Missouri regarding similar subject matter. Since that time, the Southern District of New York has withdrawn its request. Furthermore, the Department of Justice, which issued the original subpoenas from the Western District of Missouri has since withdrawn both of those subpoenas and is permitting the company to produce documents and information on a voluntary basis. As the organization within the federal government tasked with law enforcement, the Department of Justice is leading and coordinating efforts on behalf of multiple federal agencies and departments investigating similar matters, any of which may make their own request. The company recently received a subpoena from the SEC requesting similar information, and it's reasonable to assume that we could receive additional requests for information from other federal agencies in the future as long as the investigation is ongoing. We are fully engaged and will continue to work through this process. We believe strongly that quality care is foundational to everything we do. This is not new. We believe that quality, compliance and safety, not only are important from a patient experience and regulatory standpoint, but also our simply good business practices in the best interest of all stakeholders. I'd like to share some updates on our quality focus and effort since I joined the company back in 2022. For those who may have covered us for a while, you will recall that in 2022, we committed to spending approximately $100 million in incremental technology investments to enhance patient and staff safety as well as augment care coordination. As a result, our acute care hospitals today employ wearable remote patient monitoring systems to make sure we're doing the best job we can of keeping patients safe. Similarly, our hospitals have implemented wearable safety technology for staff that enables expedited response times and mitigation of adverse events. We've also implemented software solutions that provide real-time tracking and oversight on clinical and quality operations at our facilities, including compliance with regulatory requirements. You will also recall that psychiatric facilities were specifically excluded from the 2009 HITECH Act, which provided billions in funding to hospitals and physicians for the implementation of electronic health records. As a result, the prevalence of EMRs in psychiatric facilities has lagged other parts of the health care industry. At Acadia, we found that unacceptable and over the past two years, have been implementing electronic medical records across our acute hospitals. This is enabling our clinicians to spend more time doing what they do best, focusing on patient care, while enhancing our ability to leverage data and analytics as well as enabling our providers efficient access to care information to provide the very best in care. Part of our quality reviews include an executive committee review, a peer review and a review by the Joint Commission of patient charts, all of which are facilitated on a much more granular and simplified basis with EMRs in place. To highlight a few other areas of focus, two years ago, we separated quality and compliance into two distinct specialized teams. Our Chief Medical Officer and Chief Quality Officer, provide direct oversight on patient safety, clinical quality and regulatory compliance initiatives while our Chief Compliance Officer provides direct oversight of our corporate compliance program, including ongoing chart audits to ensure accurate documentation, coding and billing. Over the past two years, we have also implemented quality dashboards across our hospitals and last year, implemented monthly quality reviews to hold leaders accountable for quality. These efforts are resulting in better care, better outcomes and better lives for our patients. In 2023, for instance, 81% of our patients who responded to follow-up surveys, including involuntarily admitted respondents reported feeling hopeful as a result of the care they received in our hospitals. And our payer partners have seen these results and their members as well. Many of our facilities have received center of excellence designation from some of the largest payers in the market. I'd like to conclude by speaking briefly about our ongoing commitment to expanding access to life-saving treatment. As I noted, there remains a significant unmet need for behavioral health care services in our country. Behavioral health related deaths in the United States remain at or near all-time highs. According to the CDC, 49,000 Americans died of suicide in 2022. During that same year, more than 100,000 Americans died due to drug overdose deaths. Meanwhile, the inpatient psychiatric industry remains fragmented and underbedded, a result of decades of underfunding and underinvestment that has exacerbated the supply-demand imbalance. Notably, based on standard clinical benchmarks, it's estimated that approximately 75,000 additional beds are required across the country to meet estimated needs. And according to SAMHSA, nearly 30 million Americans with mental illness receive no mental health treatment. Put simply, the need for behavioral health care in this country is increasing while the number of available beds has been decreasing, creating a broadening gap and leaving those patients who need the most care unable to get it. So to meet that need, Acadia is in the process of investing billions of dollars to expand access over the next several years, including the expected construction of over 2,000 beds over the next two years. This continues to be an attractive use of capital, and we expect new bed capacity will help drive accelerating volume growth in 2025 and beyond. We remain committed to investing to expand access to the high-quality behavioral care that is so desperately needed in this country. Finally, and has always been the case, we also cannot indefinitely fund facilities if there is not a path to viability or strong patient utilization. That would be an irresponsible use of resources that could be deployed where more acutely needed. Therefore, as we've done historically, from time to time, we will take action to deploy resources or close facilities. During the third quarter, we made the decision to close two subscale satellite programs in one of our markets that together, comprise 104 beds. With that, I'd like to turn the call over to Heather to discuss our financial results for the quarter and forward guidance.

Thanks, Chris, and good morning, everyone. For the third quarter, we reported $816 million in revenue, representing an increase of 8.7% over the third quarter of last year. Same facility revenue grew 8.6% compared with the third quarter of 2023, which included patient day growth of 4.7% and an increase in revenue per patient day of 3.6%. Revenue per patient day, excluding the CTC business, which, as you will recall, does not have associated patient days increased 4.9%. Adjusted EBITDA for the third quarter of 2024 increased 10.5% over the prior year to $194.3 million, excluding income from provider relief funds in the third quarter of 2023. Adjusted EBITDA margin was 23.8% compared with 23.4% for the same quarter last year, an expansion of 40 basis points. On a same-facility basis, adjusted EBITDA margin increased 100 basis points over the prior year's quarter to 29.7%, excluding the income from the provider relief fund last year. Adjusted income attributable to Acadia stockholders per diluted share was $0.91 for both the current and prior year period, excluding the income from the provider release fund in the third quarter of 2023. Consistent with previous periods, adjustments to income for the third quarter of 2024 include transaction, legal and other costs and loss on impairment. Maintaining a strong financial position remains a top priority for Acadia, providing the flexibility to make strategic investments that are in line with our disciplined capital allocation strategy and support our continued growth. As of September 30, 2024, we had $82.1 million in cash and cash equivalents and $321.5 million available under our $600 million revolving credit facility with a net leverage ratio of approximately 2.5 times. Moving on to our outlook for 2024. As noted in our press release, we have updated our previously announced guidance for the year, which includes revenue in the range of $3.15 billion to $3.165 billion, adjusted EBITDA in the range of $725 million to $735 million, and adjusted earnings per diluted share in the range of $3.35 to $3.45. As we discussed on the second quarter earnings call, coming into the back half of the year, we expect same facility patient day growth to accelerate into the mid-single-digit range. As you saw in our results, we achieved that in the third quarter with same facility patient day growth of 4.7%, an acceleration of 230 basis points over the first half of the year. While volume growth in September remained above 5%, we have experienced lower volume growth than expected in October, with same facility patient day growth of approximately 3% for the month, which we believe is a result of the recent headlines and reporting in the media that Chris addressed at the top of the call. As such, our revised guidance reflects expected fourth quarter year-over-year same-facility volume growth of approximately 3% to 4%, which is 200 basis points to 300 basis points below our previous expectations for the quarter. We do expect these headwinds to be transitory in nature, however, and as we have been doing for some time now, we continue to engage with our referral sources and our local communities to ensure that we are addressing any concerns as they arise. This change in our volume growth outlook for the fourth quarter resulted in a $20 million to $30 million impact to our revenue guidance and a $10 million to $15 million impact to our EBITDA outlook. Of note, our updated EBITDA guidance reflects the expectation that we will not make material reductions to the cost structure in response to the anticipated lower volume growth in the fourth quarter as we do believe this recent disruption to be temporary. Therefore, we do not view the anticipated $10 million to $15 million reduction to fourth quarter EBITDA as reflective of the potential run rate impact. Should lower-than-expected volumes persist longer than we anticipate, we will, of course, reduce facility level costs accordingly. Beyond these near time – near-term headwinds, we are also highly confident in the future for Acadia as we are on the cusp of a significant acceleration in capacity expansion. As Chris noted, we have a large pipeline of over 2,000 beds under construction. This includes approximately 1,000 beds expected to open over the next few months, which represents an expansion of our inpatient capacity of nearly 9%. We've also been able to accelerate certain construction projects ahead of schedule and as a result, we expect to deliver multiple new facilities in the first half of 2025. You will see this reflected in our guidance revision for expansion capital expenditures. Additionally, as Chris noted, our revised guidance reflects the exit of two subscale satellite programs in one of our markets during the third quarter. Prior full year guidance contemplated approximately $17 million of revenue contribution and approximately $1 million of EBITDA contribution from these programs in the second half of the year. Finally, as a reminder, 2024 guidance excludes any contribution from the Tennessee supplemental payment program, payments which we expect will be retroactive to July 1, 2024, upon program, approval and implementation. The company's guidance also does not include the impact of any future acquisitions, divestitures, transaction, legal and other costs or non-recurring legal settlement expense. With that, operator, we are ready to open the call for questions.

[Operator Instructions] At this time, we will take our first question, which will come from A.J. Rice with UBS.

Hi everybody. Thanks for all the comments. Obviously, as you're seeing this sort of deceleration in growth, I know 3% is still decent growth in volumes, but obviously, you'd expect more. Is that – can you give us – I know this is pretty granular, but obviously, the question is in light of the media dynamics. Did you take a step down and then it seems like it's stabilized? Or has it subsequently deteriorated as you progress through the first part of the fourth quarter and it's still trying to figure out where the bottom would be? And is it concentrated in certain markets where maybe the New York Times had focused its article on and subsequent inquiries? Or is it more broad-based than that? And then I may have one more follow-up.

Okay. Thanks, A.J. Thanks for the question. I'll start with your question about sort of the step-down and what we saw. We did see that step down beginning at the start of October. And we saw that run pretty consistently throughout the month of October. So to answer your question, we didn't see a continued decline throughout the month. We saw relatively stable volumes for the month of October. In regards to your question about sort of any concentration or where we saw this, we do, as I mentioned, expect that the recent news coverage and the news of the investigation has had some moderating effect on the growth that it's early days. We see this as largely temporary, and we've been working with our partners to sort of identify any specific questions that they have.

Okay. And maybe just – you've obviously got a number of JV discussions in the pipeline, some that have been announced, and you've also worked hard to get your recruitment of clinicians there. Are you seeing any impact in either of those areas from the news articles and the inquiries?

Yes, A.J. this is Chris. Thanks for the question. I would say on the JV pipeline front, we continue to just have a really robust pipeline. As you would expect, we have given that we have 21 JV partners, those that have been with us for some time, and you remember that we actually have multiple facilities with many of these partners that we're talking about adding additional facilities, too. Our pipeline looks good. I think they're further down in the pipeline, clearly, there are questions that come up across the board. And I think that's the case with employees as well. But I think we have done a really good job as a company this year, continuing to talk about all the investments that we're making on the technology front, continuing to work hard on our employee engagement, and we've actually been very encouraged by our ability to continue to attract and retain talent.

Okay, thanks a lot.

Our next question will come from Whit Mayo with Leerink Partners. Please go ahead.

Yes. Thanks. I appreciate the comments. I was just hoping maybe to if you guys could maybe provide a little bit more color as to your preliminary thoughts around 2025. I heard Tennessee DPP comments, Chris mentioned, I think, accelerating growth with the bed additions as they feather into the business. Anything to share just headwinds, tailwinds, maybe any preliminary thoughts around the start-up costs that you might have in 2025?

Whit, I'll take that. So I'll maybe talk about a few different categories here. But let me start with volume, and then I'll move on to rate. And then finally, your question about start-up costs and the impact of the bed additions. So of course, we're not going to give guidance today. It's a little early for that. We'll give that sort of in another few months. So, I won't attempt to size this, but I'm going to give you some of my thoughts. So what I would say is going back to the first quarter in regards to volume, we talked about an expectation of volume improvement over the course of the year, and that's what we've seen. Volume growth improved throughout the second quarter. And then into the third quarter, as you can see, we were back in the mid-single-digit volume growth range, and we exited the quarter in September above the 5% same-store volume growth rate. So that continued acceleration that we expected that we saw coming through. And while that growth stayed above 5% in September, as I just discussed in the prepared remarks, we've seen some moderation to that volume growth in October. And again, we believe that's a result of the headlines in the reporting. But we are seeing October run at around 3%, and that's about 200 basis points to 300 basis points below where we would have expected to be. As we mentioned, we think that's temporary. So as we look forward to 2025, we don't know the exact timing, but certainly, we would look to be back on track throughout the year, but we'll need to wait and see where we exit at the end of the year. And then, of course, don't forget, as we know from a volume perspective, we expect the benefit from the continued ramp-up of beds that we added over the last several quarters to continue to come through. Those new beds that are expecting to contribute and come online in the coming quarters will continue to ramp and they'll continue to contribute to the growth over the course of 2025. So of the volume that we expect will come back based on what we're seeing now and then combined with the volume from the incremental beds. From a rate perspective, we continue to feel really good. As you know, the states are continuing to just invest in psychiatric care, which has long suffered from the lack of investment. And the conversations with our payers continue to be positive. Tennessee is the latest state that's on the path to improving reimbursement, and we're very optimistic that we'll see that net benefit next year once the program is approved. There are other states that we think may follow, but the timing of those are a little less clear than the timing indications we have for Tennessee. And then as always is in the case, the timing of supplemental payments can be uncertain. For example, we expect Tennessee will be retroactive to July 1. So there's likely going to be some sort of an out-of-period benefit associated with that, and we'll call that out once it's approved, but we just have to continue to wait and see on the timing. So overall, as we said in the past, we continue to expect rates to normalize back to the low mid-single-digit range at some point in the future, but it doesn't seem like we're going to see that happen in the short term. And then maybe finally, I'll talk about start-up costs. As you know, this year, we have embarked on a pretty significant step-up in the investment in bed growth over multiple years. And I think as you all are aware, the start-up cost is another factor that we need to think about for 2025. Just a reminder, we have over 2,000 beds currently under construction. And in total, we expect to complete construction on about 1,200 for the full year this year. And of course, we have a pipeline of the opportunities that we continue to see, and then we’ll backfill that construction pipeline and pull things in as soon as we can. The pace of bed additions this year is a material step-up over the prior year versus the 500 to 600 beds that we’ve added over the last few years each. And finally, as we discussed back in February, this year’s bed additions were also disproportionately weighted towards the end of the year. If you’ll recall, our initial guidance included start-up costs of around $20 million to $25 million in total, which was roughly flat relative to 2023 due to the back-end loaded 2024 cadence. And as we’ve talked about previously, the start-up costs for the 2024 class of de novos will mostly fall in 2025 due to the back-end timing. So with the number of new beds being added this year roughly doubling, that will result in a new step-up in the starting costs beginning next year, particularly in the first part of the year. It’s too early for us to provide numbers on that today, Whit, but in part because that 2025 cadence and cost amount is going to depend on the timing of the openings of the bed additions, and it’s a little too early for us to have those specifics. But hopefully, this at least gives you a framework of how to think about it. Of course, we’ll expect that those new beds will ramp towards breakeven over the course of next year. And by the end of 2025, we’d expect them to be contributing to the EBITDA growth. And by that point, we’d also be rolling them into the same facility bucket. So they would contribute to the same-store volume growth as well. And then beyond 2025, we would expect start-up costs to level off, if not outright decline. And at the same time, we would expect to have the continued benefit of those new cohorts of beds over the past several years ramping throughout that period. So that was a lot, Whit, I hope that answered your question and gave you some.

Not really. Yes, not really. I mean, like $20 million to $25 million is what we had this year. I mean you have a pretty good idea of timing factors as it relates to the opening of some of this $30 million, $35 million, $40 million. I mean, like any help within a range as to like what we could see?

No. Whit, I appreciate the question. I think it’s just too early for us to put a number on it. I would just point to the factors and how the cohorts stack up with the beds sort of from last year, this year and next year coming into confluence and then the timing of those beds that are back ended this year versus a more moderate pace next year.

Okay. That’s all I got. Thanks.

And our next question will come from Brian Tanquilut with Jefferies. Please go ahead.

Hey, good morning. Chris, maybe just circling back to the conversations you’re having with the referral sources and your JV partners. I mean, obviously, you have a lot of referral sources, right? So if you can walk us through what that looks like. And so far, what’s the feedback? And are you seeing any change in behavior from those referral sources at this point?

Yes. Thanks for the question, Brian. I mean, as you can imagine, I mean, we’ve been highly engaged with outreach to really multiple stakeholders. I mean, certainly, key referral sources as well as JV partners for the last several months. I would also say that we all know health care is local. And with so many of these literally thousands of referral sources being on the ground across the country, we’ve had to be even more deliberate about the outreach, I think, particularly to shore up any misunderstandings that sometimes have been the case due to media reporting. And so we’ve been really consistent about emphasizing the quality of the care that we provide, the investments that we’re making in safety, compliance, quality over the last two years, which is nothing new. We’re just reaffirming that. And we placed a lot of emphasis on ensuring that our most important referral sources understand these facts and understand where we believe some of the media reporting has been inconsistent or inaccurate. And so – and that’s with referral sources as well as JV partners. I would say when we sit down and we present them with the five key points from the recent release that I cited the website, quality.acadiahealthcare.com, the setting the record straight that’s in our – that was in my prepared remarks, there’s kind of five key points that we take them through that seem to be resonating. The first is that patient care decisions, including whether treatment is necessary and for how long are medical decisions that are made by licensed providers. The second is that the average length of stay at Acadia acute hospitals is in line with national averages. The third is that independent third parties make the initial determination that a patient requires hospitalization and evaluation. The fourth is that our hospitals are highly regulated and required to meet policies and standards set by federal, state and local governments. And then finally, it’s widely recognized within the medical community that discharging psychiatric patients, particularly those that are a danger to themselves or others, too early can result in catastrophic consequences. And I think these referral sources understand this. And I think it resonates based on the feedback that we’ve continued to get. I think in the small percentage of cases where we have heard any concern, these really tend to be a little bit more correlated with intense local media coverage within that facility local market rather than any broader news at the national level. And so we’ve only been experiencing this, as we’ve said in the prepared remarks, over the past month. But I’s would just say, based on the conversations that we’re having, we do feel confident that we’re having the right conversations with these referral partners. We’re trying to be intentional about getting in person when we can. And that we have the right programs in place with these referral sources going forward as well as our JV partners. And I think any opportunity for us to meet in person and to have even greater touch points is something that we’re just very focused on literally on a daily basis. So I hope that helps.

That helps. And then maybe, Heather, you mentioned in your prepared remarks that the volume impact on EBITDA is like $10 million to $15 million. I think you cut the midpoint by $20 million. So just curious what’s the bridge there? And then how should we be thinking about the levers that you can pull if this volume weakness persists into 2025? Like from a staffing or capacity perspective, how easy or what does that look like?

Yes. I’ll take those in turn. So first, maybe just to give a little more clarity on sort of the revision to guidance. You are correct that certainly the largest driver was the volume trend that we saw. And just again, to reiterate the numbers that we were looking at when we made the decision, we exited September same-store patient day growth over 5%, which was a significant acceleration over the first half of the year as we expected. And originally, of course, we would have expected that to continue into Q4 as we accelerated on those even further. Whenever we exited – or as we exit October, we are expecting around 3%, so a drop of 200 to 300 basis points from our expectations. So that is what drove that $10 million to $15 million in EBITDA reduction for the balance of the year. What I would say is that on top of that, we had a couple of other things that were moving throughout there. There was a little bit of impact from the hurricane, just a couple of million dollars, although it did have some impact on the cadence of some of our construction projects. And then there was about $1 million, as we mentioned in the prepared remarks, related to the closing of those satellite facility beds during the quarter. But that’s really what drove that. Maybe just to the second part of your question in regards to leverage, we mentioned or I mentioned in the prepared remarks that the revenue guide was coming down related to that volume discussion by about $20 million to $30 million and the EBITDA related to that was about $10 million to $15 million. So that’s a higher impact proportionately on EBITDA than on revenue for what you would normally expect to see from us. And that is certainly the area where if this were to become a longer-term impact, we would look to make the appropriate revisions there to the cost structure. But as we mentioned, because we do feel this is temporary, we have not made some of those more significant changes to our cost structure, and we remain ready to welcome those patients back at any time. So that would be, I would say, the biggest lever that we would call on to really focus on a sustained downturn.

Right. Thank you.

And our next question will come from John Ransom with Raymond James. Please go ahead.

Hey, good morning. Just going back to this referral management issue, how much more work do you think you have to do to kind of carry the initial flurry of effect? And then how long are you giving yourself to where you would say, okay, this just seems like we may have lost a permanent 2%, 3% of our referrals. I’m just trying to get a sense of timing on this.

Yes, John, I would just say, I mean, this is something that we continue to work on every single day. It’s just really difficult for us to put a time parameter on that. But I think we are having regular touch points, of course, with all of these referral sources regularly. We've continued to dial that up where it makes sense. We've tried to meet in person, certainly where it makes sense even more frequently. But I just could not speculate on the timing as of right now. I would just say this hasn't just started this month. This has been something that we've been working on very consistently. And of course, in normal course, we're always talking to our referral partners regularly, and that will continue.

Well, it's interesting. I mean the original article was late August and then it took a month for this effect to be felt. So I guess there was a lag, right? I mean there was a 30-day lag before you saw it. The other question I had was, I know you've said before the VA was a bit of an air pocket. So maybe that was down 200, 300 bps. Has there been any additional pressure from that particular referral source given that they are also looking at you?

No. I mean nothing that we would call out on the VA to answer your question.

Okay. Thank you.

John, maybe I'll just jump into the first part of your question and just remind you that we did talk about what we think on a go-forward basis. I know it's – as Chris mentioned, it's too early for us to think about what that duration looks like because it's early days here. But just reminding you that we do not think that the Q4 reduction, sort of that relative reduction for revenue and guidance is how you should think about the go-forward run rate related to that, for EBITDA, of course.

Yes. Thank you.

Yes.

And our next question will come from Joanna Dudek with Bank of America. Please go ahead.

Hi. This is Christian Porter on for Joanna. Thank you for taking our question. My first question was just wondering with the legal scrutiny that you guys are facing, have you seen any impact to your hiring or retention or just ability to find people to staff your facilities? And then I have one follow-up.

Yes. Thanks for the question. I would say, overall, nothing material that I would call out. I think we're a company that continues to build capacity, as we said in the prepared remarks. Obviously, a key factor is us continuing to attract talent in to fill these new facilities as well as to retain the existing excellent staff that we have. We do lean heavily on the extensive investments that we've made, not only in these new facilities, but also in technology, EMRs, remote patient monitoring, patient staff safety devices that really resonate with our employees. We also have just done yet another employee engagement survey, and we take those results, which we think really factor into our ability to attract and retain as well. So I would just say, overall, it's normal course. We're certainly available for questions that periodically come up. We're trying to be very communicative and transparent with our leadership and our staff, and we'll continue to do that. But nothing else I would add on that front.

All right. Thank you. And then my follow-up question was, you guys have mentioned that you guys are implementing people, technology, clinical protocols and training just to make sure that quality is at its best. We were wondering how do you measure your results from these initiatives? So yes. Thank you.

Yes. I would say, I mean, this is something that we have invested in now for over two years with respect to the quality protocols that we put in place. So this isn't anything new. I would say that, again, as we – as I cited, it's not just one thing. It's not just the fact that we've put an EMR in place or that we've put patient monitoring in place. We've been really intentional on the quality front about literally putting entirely new all-in-one dashboards in place for our facilities that are providing all metrics that we're tracking routinely, patient safety, staff training and experience, patient experience, incidents and observations, all of these things. And we use this in a way to look at our Chief Quality Officer also has done a phenomenal job of putting a heat map in place that we're holding our facilities accountable to. And we're also – we've implemented for the last several years, not just a monthly operating review, but a monthly quality review, where we're holding our operators accountable for coming in and specifically talking about the advancements that they've made on the quality front. I think maybe the final thing I would point out is that we've also implemented the Joint Commission's AMP [indiscernible], their software program at all of our acute facilities in the middle of this past year. And this is a cloud-based solution that's produced by the Joint Commission that reflects all the up-to-date CMS standards and conditions that will modernize all of our quality assurance and performance improvement tactics. So having that in place, this software ensures that our teams are auditing, that they're educating that they're monitoring clinical and operational practices that all coincide with the joint commission standards as well as the CMS conditions on participation. So just overall, really modernizes our approach to serve preparedness to accreditation readiness. It puts us in a position where we're proactively looking for troubled spots across the portfolio. And we're able to mobilize resource and proactively hold our operators accountable for quality standards. And it's early days here because we literally have just implemented the software by the middle of the year, but we're very encouraged by just the cultural change. This will continue to enhance and manifest for the company.

Thank you.

And our next question will come from Ben Hendrix with RBC Capital Markets. Please go ahead.

Thank you very much. I was wondering if you could talk about the volume softness in October. It sounds like most of that is referral related and acute related. I just wanted to see to what degree you're seeing RTC pressure as well or not? Or then any overall volume trends across the other segments as well?

Yes. Thanks for the question. I'll take that. We – as we look at that volume pressure, of course, we have done a lot of deep diving into the trends or looking for trends. What I would say is that, as Chris mentioned, there's not a very specific outlier here in any one area or business line. As you mentioned, we do see a little more impact where some facilities have had a preponderance of local media focus as opposed to the National Media focus. But then more broadly, we've seen it relatively consistent throughout the month, as I mentioned, that sort of what we saw from a volume impact perspective, sort of started right at the beginning of the month, and we saw it consistently at relatively the same level throughout the month. Of course, there's always normal fluctuations as you go through the month, but really pretty consistent there. From a business line perspective, I'd say it was consistent, relatively speaking, across acute and specialty. Both of those saw relatively the same impact. Specifically, to your question on RTCs, there were normal fluctuation here and there, but what I would say about RTCs is that in a typical month, very sadly, the total number of adolescents in native care far outweighs the available beds across the board. And our RTC facilities are typically operating at or near capacity throughout the year, of course, with normal variation. So that's sort of a view of what we saw and where we looked into things, but it's pretty consistent across acute and specialty.

Appreciate that. Just as a follow-up, kind of same question on the quarter on the revenue per patient day, 3.6%. It looks like that slowed a little bit from typical trends and maybe lower than you had expected. Just wanted to see kind of how that falls across the various segments and any observations you can offer there?

Yes. Sure. Good question. So for fourth quarter, sorry, sorry, I'm correct in myself. So for third quarter, what we saw coming through would have been impacted by the CTC portion that contributed to that. And if you recall, CTC had a very strong year last year, sort of growing each quarter significantly. If you exclude the impact of CTC from Q3, it would have been 4.9% revenue per patient day growth. So that's probably a good way to look at that and hopefully answers your question.

Yes. Thank you very much.

And our next question will come from Pito Chickering with Deutsche Bank. Please go ahead.

Hey, good morning guys. Looking at the referral sources on acute, have you seen any channel of those referrals more impacted than others? Just thinking about the ERs versus courts versus police, schools or self-referrals?

Yes, there aren't any that I would we call out. Sorry, we're picking up an echo. I would say the hospitals and the EDs are always an area of focus, but you've listed a number of them. I mean there are so many are community-based shelters, law enforcement. I mean, again, as we've said at the outset, we literally have thousands of referral sources. So I wouldn't say that there are any specifically that we would call out. We continue to be even more intentional about reaching out to all of them and increasing the frequency of touch points.

Okay. And then looking at specialty, was there any impact within any specific division within specialty versus the others to think – like how should we think about that recovery? Is it more of a consumer-driven business versus the others that was just more of a sort of medical referral? Thank you.

Yes. I wouldn't say any really to call out there either 50%.

Great. Thanks so much.

And our next question will come from Andrew Mok with Barclays. Please go ahead.

Hi, good morning. I just wanted to follow up on the referrals. In the areas where you are seeing pressure, is the referral decision typically made at the organization or department level or is it select individuals within a department making decisions autonomously? And then secondly, I'm still struggling to reconcile this notion that the volume headwind is temporary with the fact that referral sources tend to be sticky. So have you seen any evidence or early signs of recovering lost referrals? And if not, is there a push to open the door into new referrals to pack fill these volumes? Just want to understand what's behind the temporary outlook. Thank you.

Yes. Thanks, Andrew. I would say that to answer your first question, these are decisions that are made by individuals. And I would say specifically, there have been instances where there have been concerns that have been raised, and we've mobilized leaders to move on the ground and to meet directly. And I think in many instances, we have been able to improve the referral situation, certainly, to answer a lot of questions and to get those referral patterns back on track. There also have been some situations where it's just harder to get in front of that referral source. But I would say, overall, the strategies that we are putting in place, this is a ground game, health care is local, and we really like the approach that we're putting in place and can continue to execute on that.

And our next question will come from Sarah James with Cantor Fitzgerald. Please go ahead.

Thank you. One clarification on your last response. It sounds like you're saying you have seen proof of concept where a face dip is meeting had a positive impact on referral pattern after that meeting. Is that the right way to read that, that in some cases, you have seen the actual trend move after the meeting?

Yes, sure. I mean I would, again, remind you that we have thousands of referral sources. We'd love to get in front of all of them face-to-face all the time. That just isn't possible with so many. I've personally been in front of so many of our JV partners just over the course of the last few months. That's always preferred as opposed to doing a phone call or doing a video. But I think just overall, the way that our operators function in the local market and again, health care being local, is they try to get in front of these referral sources as frequently as we can. I just think that we have dialed up the expectation and asked them where possible to make that happen. But these are literally daily interactions that are already happening in normal course, and we'll continue to. So I hope that's helpful.

Got it. Great. And then can you give us an idea of the normal patient-based seasonality throughout 4Q? Is October usually the high watermark? Or does it ramp through the year?

Yes, for fourth quarter, that's a great question. You are correct. October is normally the strongest month out of that quarter. The normal seasonality patterns that we see during fourth quarter are very specifically related to the holidays that occur throughout the end of November and through December. Typically speaking, families that have an option or an alternative to bring someone home over the holiday period, will do so. And so we typically see that impact in our volumes, and we factor that in. We expect that, yes, directly. October is the strongest month.

And our next question here will come from Matthew Gillmor with Baird. Please go ahead.

Thanks. It's and actually KeyBanc. I'll just keep – keep it to one. I think Chris had mentioned that labor was trending favorably. I was hoping you could provide some color in terms of wage inflation or turnover and just how that's been trending in the recent months.

Yes, sure. I'll take that. I'll jump in. So from a wage inflation perspective, we have seen that continue to track favorably – at the beginning of the year, we said we would anticipate for that to trend below 5%, and we have seen that continue to play out. The highest watermark was the end of 2022, where it was up around 8%. So we've seen that moderate significantly. And then for this year, has held steady. And again, just to mention throughout the first nine months, we have seen it stay in that sort of sub-5% range. And we would expect that to continue.

Got it. Thanks guys.

And our next question here will come from Raj Kumar with Stephens. Please go ahead.

Hi, this is Raj on for Scott Fidel. Thank you for taking question. I just had one around one that we get particularly around Desert Hills and related to the, tell of those cases with six being settled earlier and then two kind of remaining. Just kind of any update on that. And then just another one on just the legal strategy kind of going forward around like settlements versus contesting and what actions Acadia has taken internally or externally to kind of counteract those?

Yes. Thanks for the question. I would start and just say with your question on Desert Hills, we just can't comment on individual cases. But I would say, we have and we will continue to disclose litigation matters that we view as material in all of our filings. We have bolstered our team on the legal front. And I think we have also disclosed that we've hired Kirkland and Ellis, as our outside counsel and for the broader investigations and consulting with them very closely. But just with respect to ongoing investigations and cases, it's just very – we're very limited in what we can say publicly, and I would just leave it at that.

And this concludes our question-and-answer session. I'd like to turn the conference back over to Chris Hunter for any closing remarks.

Thank you. In closing, I just want to again thank our committed facility leaders, clinicians and approximately 23,500 dedicated employees across the country, who have continued to work tirelessly to meet the needs of our patients in a safe and effective manner. We are together doing incredibly important work for our patients across the country and remain committed to serving them with care, compassion and excellence. Thank you all for being with us this morning and for your interest in Acadia.