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Good day, everyone, and thank you for standing by. Welcome to the U.S. Physical Therapy First Quarter 2025 Conference Call. At this time all participants are in a listen-only mode. After the speakers’ presentation, there will be a question-and-answer session. [Operator Instructions] Please be advised that today's conference is being recorded. [Operator Instructions] I'd now like to turn the call over to Chris Reading, Chairman and CEO. Please go ahead, sir.

Good morning, everyone, and welcome to our U.S. Physical Therapy First Quarter 2025 Call. With me, as usual, on the phone this morning, Carey Hendrickson, our Chief Financial Officer; Rick Binstein, our Executive Vice President and General Counsel; Eric Williams, our President and Chief Operating Officer; Graham Reeve, our Chief Operating Officer, West; and Jason Curtis, our Senior Vice President, Finance and Accounting. Before we start the call today, I'll ask Jason to cover a brief disclosure, and then we'll get going.

Thank you, Chris. The presentation includes forward-looking statements, which involve certain risks and uncertainties. These forward-looking statements are based on the company's current views and assumptions. The company's actual results may vary materially from those anticipated. Please see the company's filings with the Securities and Exchange Commission for more information. This presentation also contains certain non-GAAP measures as defined in Regulation G, and the related reconciliations can be found on the company's earnings release and the company's presentations on our website.

Thanks, Jason. So I'm going to do this call this morning a little bit differently than I generally do it. I've done this a few times. Rather than read prepared remarks, I'm going to walk through this in a little bit more fluid way. I think I can tell the story a little bit better, so if you'll hang with me. We started this quarter out, and we had some tough weather to begin. And by the end of it, was still the best first quarter on a visit per clinic per day perspective than we've ever produced. And that was against the year last year, which was uniformly very strong. Nine out of last year's 12 months were the best highest months that we've ever experienced. So January, again, a little slower than we would have liked, at 29.4%, moved up in February, still weather impacted, unfortunately, at 31.4%. And then we finished really strong in March at 33.2 visits per clinic per day. And that really has continued as we've gone forward. Remember, for us, Q1 is the lightest volume quarter typically of the year. I want to talk a little bit about Metro physical therapy for a minute. I just got back. I spent last weekend – the end of last week and part of the weekend with the Metro team. Metro was our largest acquisition that we completed in November. They had a similar visit progression. I just mentioned it just because they're our biggest partnership now. We started out a little slow in January, 44 visits per clinic per day, still outstanding. By the end of March – by March, we finished at around 50 visits per clinic per day there. Again, I mentioned I was in – with them this weekend, and they had a leadership – they have an annual leadership team meeting that they do an off-site meeting, and I was able to go and spend a few days with the team, had met the executive team and spent a lot of time with them. And of course, the owner, Michael Mayrsohn, a lot of time with them. I got to meet the rest of the folks, 80-some people running their clinics and supporting those facilities, people like Dan and Phil and Joe and Rachel, Jenna, Melissa, John, on the operations side of things, Victoria, who did just a phenomenal job with this meeting. I can't tell you, I came out of that meeting just so impressed and encouraged at the talent and the team and the mentorship and the leadership and just the direction of that partnership, just really, really strong. Another thing I'll call out for the quarter. When you look at our numbers – Carey is going to go over them in a good bit of detail. Our margin for the quarter was okay. But if you look at our margin progression, particularly where we ended up in March, March was a 21-day month for us this quarter, average month over the course of the year. We ended up with nicely above a 20% margin in March. And we've got to continue that. We're working very hard with the ops team, directly involved with our top 40 partnerships on trying to move the needle directionally where we need it to be. You guys are familiar with the headwinds that we faced. We're making progress. We expect to make continued progress. I feel better about that than I have in some time. On the rate side, our team has been really busy. They've done a really good job. We've got rate up nicely over $2 a visit despite the Medicare rate cut this year, which is about 2.9%. And when you look at the aggregation of those rate cuts beginning in 2021, so this is our fifth year now of reductions, the accumulated reductions, if you apply it to our revenue this year in our Medicare business, it's a $20 million – approximately a $20 million profit impact. And even with that, we're finding a way to grow. We're – it's taken us some time. Obviously, these – that are happening every year, and we believe this will be the last year. They're not easy to overcome, and yet we've been making progress. Our payer contracting team has done a wonderful job. Our work comp focused contracting group. Carey will cover those details, have done just a wonderful job. And we're working with a new group that's really helped give us some intelligence on a market-by-market, city-by-city, even clinic-by-clinic basis. I just want to give a shout out to them, the team at Careology, Mitch and his team, a wonderful job for us and with us helping to address some of these market challenges. And we are making progress. So I'm very encouraged by that. This quarter, adjusted EBITDA is up 16.5% again, in spite of these headwinds. And again, the first quarter, not usually our best quarter. In fact, it's usually our lightest quarter. So we're ahead of where we thought we would be largely on the performance of March, and we continue to see a great deal of volume demand as we look forward. On the injury prevention side, I can't say enough about that group. And when we talk about injury prevention in general, we generally talk about it as a unit. We've really got two partnerships within that section of our business. And remember, we started this with a very, very small acquisition, with one of our teams back in early 2017. This has grown dramatically over the years. This year, again, coming off a great year last year where I didn't get a chance to look it up this morning, but we grew somewhere in the mid-20s on a revenue and similar profit basis. This year, revenue up – or this quarter, revenue up quarter-over-quarter, year-over-year 29%, profit up the same. Our growth is both organic, meaning existing clients, but new locations. That part of the business has been very strong. Last year we had an acquisition, which has done well, and that's been part of our story over a period of time. And then both of our partnerships – and I'll just give a shout out to our second – of our more recent acquisitions in the injury prevention subset. We started out and they had – this is going back a few years, I think, late 2022 when we did that deal, if my memory is right. And we just at the outset, lost a fairly large auto manufacturer contract. So we backed up to begin, which is always a hard way to start. The team has really demonstrated a lot of grit and tenacity and that's paying off over time. And we've recently added some really large contracts. We have another one that will come on sometime soon, waiting to get the final. We've gotten verbal on it, a fantastic company, a lot of locations, really, really good competitive process. And so they're making great things happen as well. And even though – and we added back in the fourth quarter, large auto manufacturer contract. It brought our margins down a little bit just because margins are a little tighter in that subset of the business. Even with that, our margins were really pretty good this quarter across that entire injury prevention front. On the development side of the business in the quarter, we got another nice outpatient deal done. This marks our third in the state of Wyoming, really high net rate state with a great partner. So we're excited about that. We also just announced our most recent acquisition, again, with the Metro team. We got to meet James. James leads a group that's involved in delivery of care at home, which is something that Metro did historically and that we're introducing to our partners across the country. And so we're excited about that acquisition. Additionally, for the quarter, either in combination between the acquisition in Wyoming or the organic openings, we added 14 centers this quarter, which is a good start for us for the year, and I think clinics that have a lot of opportunity as we go forward. We've got a number of deals in diligence right now, and we're hopeful that those will all get across the finish line and make for a good year to come. I wouldn't be right if I didn't – and I should have started out this way. And I want to thank our team, our partners, our clinicians around the country, people that provide care and do such a phenomenal job. Truly, I talk about it. For those of you who haven't ever – you've been lucky enough not to have ever had a serious injury. When that happens to you, your world kind of goes upside down. Our clinicians are in the clinics every day, 1 hour or so at a time with our patients, do well over 6 million visits this year, a lot of interactions. They're helping these people get their lives back and they're doing just a phenomenal job. Our demand wouldn't be as high as it is without that. So I need to thank them. I need to thank our operations team and our support groups and again, contracting and work comp and just all the groups working together, our IT infrastructure team who helps us with so many things. These have been more years with headwind than I can remember in a long time, and yet they've found a way to stay focused and to deliver for our partners and our partners to deliver for our patients, and they've just done a phenomenal job. So despite the obstacles, we know we have more work to do. We're on it though. I'm encouraged. For some of you, I'm guessing that you would expect and hope for us to update guidance. I'm hopeful that we'll get there. I'd like to get a couple more months under our belt before we do that. Clearly, we know we're ahead of where we projected our own internal numbers to be at this point. Give us a couple more months to kind of get comfortable with what that looks like and where that's headed. And hopefully, we'll be back sometime either before or by the second quarter and give you a reference point on guidance. That concludes my comments. Carey, if you would go ahead and cover the financials in a little bit more detail.

Sure. We'll do. Thank you, Chris, and good morning, everyone. Like Chris, I was really encouraged by our performance in the first quarter, particularly how we finished the quarter. It really sets for the foundation, I think, for a good year to follow. So really pleased about that after some headwinds to start the year from weather, which is normal in the first quarter. Our volumes really picked up nicely. Net rate increased from the fourth quarter despite the Medicare rate reduction that went into effect at the beginning of the year. Our IIP business continued to grow at a double-digit rate even before acquisitions. Our EBITDA increased by $2.8 million over the prior year. And then using minority adjusted revenues to align with our adjusted EBITDA, which is also after minority interest, our adjusted EBITDA margin improved from 13.2% in the first quarter of 2024 to 13.7% in the first quarter of 2025. So all in all, I think a really positive start to the year. Our average visits per day in the first quarter were a record high for any first quarter in our history at 31.4%. We lost about 26,000 visits due to weather in the first quarter. A good chunk of that was in January, about 16,000 in January, about 9,000 in February and then just a smattering in March. But the underlying volume in the business was strong. So our average daily volumes picked up really nicely as we got on the other side of the weather events in the early part of the first quarter, so that our average visits per day grew from 29.4% in January to 31.4% in February and then 33.2% in March. Our net rate for the first quarter was $105.66. That was a really good mark, particularly when you think about the fact that we had the Medicare rate reduction that went into effect at the beginning of the year. That was almost 3%, 2.9%. So our net rate was $2.29 per visit ahead of the first quarter of last year, and it was $0.93 ahead of the fourth quarter of last year, even with that Medicare rate cut again this year. So with that as a backdrop, we feel particularly good about our increases versus the first and fourth quarters of last year in that rate. We continue to benefit from our strategic priority of increasing reimbursement rates through contract negotiations with commercial and other payers and then also our focus on growing our workers' comp business. As Chris noted, we put a lot of effort into building our workers' comp business over the last couple of years, and we're really starting to see that come through. We've seen a really nice progression of workers' comp as a percent of our revenue mix. In the first quarter of 2023, going back two years ago, workers' comp was 9.3% of our revenue mix. It moved up to 10.0% in the first quarter of last year. And then this year, in the first quarter, it was 10.9%. That's the highest that's been since 2020. So we feel really good about how that's coming along. We're also, of course, focused on maximizing our cash collections through improvements in our revenue cycle management. And then we're going to remain focused on the rate-enhancing initiatives, of course, throughout the rest of the year. Our physical therapy revenues were $156.4 million in the first quarter of 2025, which was an increase of $22 million or 16.4% from the first quarter of 2024. That was driven by our higher net rate and the acquisitions that we've completed since the first quarter of last year, particularly our November 2024 acquisition, Metro, which Chris noted, which added almost $17 million of revenue to our first quarter. Our physical therapy operating costs were $130.9 million, which was an increase of $20.6 million over last year. That's about 18.6%. Our salaries and related cost per visit was $63.53 in the first quarter of 2025. That was up 3.4% from $61.42 in the first quarter of 2024. However, if you look at it on a comparable basis, excluding our 2024 acquisitions, which happen to have a higher average salary and related cost per visit than the rest of our company, the increase was just 1.4% over the first quarter of last year. So a more modest increase when you look at it on that basis. Our total operating cost was a similar story. They were $89.28 per visit compared to $85.50 in the first quarter of last year. That was an increase of 4.4%. If you exclude the acquisitions, the total operating cost per visit increased 3%. So that was also a more modest increase when you look at it without acquisitions. Our physical therapy margin was 16.3% in the first quarter of 2025, which compared to 17.9% in the first quarter of last year. As Chris noted, though, our margin was north of 20% in March, which was really nice to see. Our IIP team produced excellent growth again in the first quarter. Chris noted, they were up 28.8% in revenue over last year, 29.1% up in operating income over last year. If you exclude the IIP acquisition that we had in the second quarter of 2024, our IIP revenues were still up 15.1%, with our gross profit up 13.1%. And then our first quarter industrial injury prevention margin was 20.4%, which is the same as it was in the first quarter of last year. So another really, really good start to the year for IIP. Our corporate office costs were in line for the first quarter of 2025. They were 8.8% of our net revenue, which is down from 9% of revenue in the first quarter of last year. And then our operating results were $7.3 million in the first quarter of 2025, which compared to $7.7 million in the first quarter of 2024. Our balance sheet continues to be in an excellent position. We have $129.4 million of debt on our term loan with a swap agreement in place that places the rate on that term loan at 4.7%, a very favorable rate. That rate will extend through the middle of 2027. And then in addition to the term loan, we have a $175 million revolving credit facility, which had just $28 million drawn on it at March 31, 2025. Our cash balance at the end of March was $39.2 million, and acquisitions will continue to be our primary focus of capital allocation and our capital structure is well positioned for it. So as I noted at the beginning of my remarks, we feel really good about our first quarter results, and we're very hard at work executing on our plans to grow revenue and EBITDA in 2025 and beyond. And with that, I'll turn the call back to Chris.

Yes. Thanks, Carey. Great job. Operator, let's go ahead and open it up for questions.

Thank you. [Operator Instructions] We'll take our first question from Joanna Gajuk with Bank of America. Your line is open.

Good morning, Joanna.

Hi, good morning. This is Joanna Gajuk. Hi, how are you? Thanks so much for taking the question. So I guess maybe first, the question on, mature clinic revenue was actually down year-over-year. So what was the guiding volume inside that negative number? It sounds like it was negative because it sounds like pricing was positive. So how much, I guess, was the weather in that number, which I guess you gave some stats. And I assume there's calendar impact equal revenue as well, right, one fewer day. So can you walk us through that? Thank you.

Yes. Let me go ahead and start. Carey, you can fill in the gap. So the weather – we got hit particularly hard. We always have weather in the first quarter. We got hit particularly hard in some of our really long-established largest partner markets, markets like Nashville, where we have close to 80 service locations in North Texas and really all of Texas, we had a week of weather that was just very uncommon for us, extraordinary cold and winter weather. And so, in those markets – in some of those markets, we were down for multiple days, closed in a row either without power or without people being able to reliably come to the facility. So that had the biggest impact. Our demand particularly remains high. We expect that to bounce back with demand both in March and forward. That was really a good indicator of what we think this year could look like. Obviously, we have to deliver on that, but not particularly concerned about demand right now.

Okay. Because I want to ask – yes, go ahead, Carey. I don't know, did you have any...?

No, I'm just saying I agree that – nothing to add really. Just it was – a lot of the weather impact that we had in the first quarter happened to be at our mature clinics, and that's what caused that to be a little weaker than the rest of the group.

Okay. And I guess staying on the topic of volumes and I guess as it relates to economy, so it sounds like based on this March stat, it doesn't seem like you're seeing anything right now. But can you remind us how in the past your business has done through an economic downturn? It seems like market is worried a little bit about that.

Yes. There's definitely talk about whether and if we dip into a recession. The thing that we would point to is back in the 2008, 2009 time frame, where it was very difficult. We made some adjustments there, and we have a playbook from that point in time on what we did ahead of that to get us through that period. And we had, again, significant earnings growth. We had a little bit of an impact on our same-store volume. We were negative, and this is going back a long way. So from memory, a couple of percent maybe on same-store. But we continue to acquire facilities. We continue to grow. We continue to make improvements in the business other places. And we really positioned ourselves by doing some things within our sales team to come out of that in a really strong fashion. So not saying that any of it is easy. I would rather us not face a recession. We don't know whether we will or not. But I think demand is pretty significant right now. Staffing continues to be a bit tight. And so, I think we'll be okay. But we have a playbook. We've been there before, and it's been dusted off.

And to your point on staffing, would you say that the – there will be expectation for staffing to get a little bit better if there is an economic slowdown? Have you seen it in the past?

I'm sorry, I missed the word. An expectation on what Gajuk?

In a recession. Yes, in a recession, would staffing be better? I guess, easier for you to staff as an offset to volumes?

Yes. I mean, hard to say, different times, different reasons, different economy even. Look, I can't accurately say whether we're going to dip into something or not and then for me to try to predict what staffing will be like in that period. Generally speaking, when there's a downturn, people belt tighten. We didn't – interestingly, in the last, what you would call, major recession, we kept everybody intact, and we were able to grow through it. So – but there was more availability of people the last time through. Whether that will hold true this time or not is, I mean, anybody's guess. But I think we're in a pretty good spot right now.

Great. Thank you. I'll go back to the queue.

Thank you.

Thank you. We'll take our next question from Benjamin Rossi with JPMorgan. Your line is now open.

Great. Thanks for the question. So just thinking about the IIP outperformance, certainly a bright spot there with both revenue and gross profit up nearly 30%, while your gross margin remains intact year-over-year. What are you seeing as some of the drivers within that segment? And in thinking about that segment more broadly with your interest in IIP, how would you describe some of the growth vectors across that space in terms of volumes and rates? And then what do you see as the potential runway done within IIP?

Yes. Ben, those are all great questions, and I'll do my best. But IIP is a little bit hard for me to answer in terms of what the universe looks like. And I can break out that because we report it, what kind of our organic non-acquired revenue is. And there's a good part of the business that continues to be fueled by that. And what underpins that is really the fact that it works. These companies that bring us on the new company, let's say, they usually give us the worst problem. And our team is able to deliver a result which is generally around injury prevention and a measurable reduction in reported injuries, which helps on the work comp, insurance rates and claims, keeps people at work, employees are happier and healthier. And there's a pretty significant return in terms of what they pay us and what they're saving. And so then we get the next two or three worst issues, sites, locations, and then it goes from there. And so there's a good organic – good healthy organic element. I don't know that there are massive – I mean, in some of these contracts, and it varies, and it varies enough that – on the rate side that it isn't uniform. And I'm not able to give you just a completely uniform answer. Where we can, we build in rate escalators and where the processes are really competitive. These contracts go for 1 year at a time and then have renewal provisions and they're very sticky. So they don't – they tend not to go away very rarely, unless there's a big economic – or big section of the economy which is impacted or the company is impacted in some kind of way. And then we negotiate over time increases as we need to. And by and large, you've seen our margins be relatively steady in there with some mix adjustment for the auto industry, which tends to be much larger customers, much larger footprint in terms of number of employees and large magnitude in terms of contract dollars, but slightly smaller margin there. But margins have been pretty steady. And then, when you look at the entirety of the market, that's where it gets a little murky, because majority of the companies out there aren't doing this yet. Many are. Many good companies that we've been with for a long time, are. But many companies aren't. And it's not like the same universe where you can count coming an outpatient physical therapy clinics there are, estimate size in the market. This is a little bit different. And I think there's more of a greenfield opportunity that exists in this business than exists in a lot of places. Less on the acquisition front, probably less companies, potential companies to acquire, but more – certainly more greenfield opportunity in part because it works.

That makes sense. Certainly appreciate the commentary. Just a quick follow-up there. On the rate escalators, do those contain automatic inflation adjustments, just a clarification?

Yes. I can't tell you whether I know for sure or not. I don't know that they're indexed against an inflation index per se or whether they're fixed dollar adjustments. We can follow back up and see. Again, I'm not suggesting either that, that's a preponderance of our contracts that are out there in the injury prevention side that have automatic escalators. I think they're probably a lesser amount of those than just having to renegotiate once you're proving yourself.

Chris, that's right. Yes, this is Eric. The escalators there are now built into an inflation index. There's percentages that are added into some of those contracts, and they are renegotiated as those contracts do come up, and we certainly take a look at cost structure at that point. And certainly, with a lot of these relationships that we have with employers, distribution companies, the folks that are driving the injury prevention business, there's a lot of product line expansion, service line expansion that happens. And so, as that comes up real time, we have an opportunity to sit there and adjust pricing to take some of those other things into consideration.

Great. Appreciate the additional commentary there. Thank you.

Thank you.

Thank you. We'll take our next question from Brian Tanquilut with Jefferies. Your line is now open.

Hey, good morning guys.

Hi, Brian.

Congrats on the quarter. And Chris, I appreciate the candid remarks instead of prepared remarks. So maybe as I think about the improvement that you see in the business here, I mean, do you think this is just durability of demand that you're seeing and the fact that you're driving a little more productivity out of your clinicians and recruiting and retention has stabilized? Is that a good way of thinking about where you think the business is inflecting from at this point?

Yes. So I think, again, demand is strong. Recruiting, we've made a lot of investments in and our partners are focused on it along with our corporate support team. And those investments, I think we're seeing begin to pay off. We've also invested in school relationships and bringing value-added programmatic things to the PP schools and therefore, to students. We focused hard on our student internship program and making sure that our partnerships and our locations are plugged in the right way because that's the farm team as it is for new potential hires. So all those things kind of working together for us right now. I – again, the teams worked hard at it. It's not been one particular thing, but – it's still not easy, but it's moving in the right direction.

And then, Chris, just curious what you're hearing in terms of – I know you're very involved in lobbying for the industry. So just curious what you're watching for, if there's potential positives there or as you try to get the physician payment rates pushed higher?

Yes. So we've spent a lot of time – when I say we – there's an organization that I was involved in about 10 years ago to help create called the Alliance for Physical Therapy Quality and Innovation, kind of a mouthful, but APTQI and along with the APTA and other groups, including groups within the AMA, or the AMA itself, we've been spending a lot of time in Washington. We've had a lot of congressional dinners, most recent of which was with Susan Collins 1 week or so ago. I was up there just a few weeks ago, where we had about a dozen meetings, particularly with key congressional members in key committees. And I can tell you uniformly, there's nobody that we've talked to really in the last couple of years who sees these cuts that were kind of put upon us somewhat as a mistake as a part of the code set that they thought they were extracting savings from orthopedic surgery and physical medicine procedure-based folks, who kind of got caught up in that as a bit of an afterthought, been really significant negative impact. Nobody we've talked to, Brian, in a long time thinks that those should have happened or given the fact that they can't and haven't undone it, that they should continue. We have a couple of proposals right now. We have a bill, which we know is a saver, which is called the SAFE Act. It helps with balance and fall prevention screening among our seniors as part of their annual health benefit. There is a program in the state of Maryland called EQIP, which is in conjunction with CMS. And that program utilizes physical therapists the same way that the Department of Defense utilizes PTs in those circumstances, both in Maryland and DoD. PT is in charge of the musculoskeletal case, not an orthopedic surgeon, not a primary care doctor, but the physical therapist. And what we're finding in the tens of thousands of patients in the state of Maryland, the early results really were coming up on a year here pretty soon is that there's a 10% to 15% case savings when a physical therapist manages the case. And we're not talking about just PT savings, we're talking about the entirety of the case. So it's large dollars. And I know – I haven't done the math personally, but our Liberty Partners group, our lobby group has estimated that if you took the results from Maryland, and this is – this will take a while for us to get traction with this, but we have a good study right now where if you took that Maryland result and you spread it to all 50 states, it would be enough – approximately enough to pay for the proposed physician fee schedule fix with the medical economic index adjustment factors, which is about $100 billion spend. And that's just with musculoskeletal savings alone. So again, we're spending a lot of time on it. My brothers and sisters at APTQI, they've devoted a lot of time, money and resources to being there, and we're all very focused on it. CMS obviously doesn't come out with the final rule – or their proposed rule, I'm sorry, until middle of July. And so we have a little time to wait. But I'm hopeful that this is in the rearview mirror and we get to something that's more reasonable because it's not sustainable, frankly, and they're picking on the wrong people, unfortunately.

Appreciate that, Chris. Thank you so much.

Thanks, Brian.

Thank you. We'll take our next question from Larry Solow from CJS Securities. Please go ahead, your line is now open.

Great, thanks. Thanks for all that color on the pricing there, too, Chris. I hope that all holds up and that just being flat, you get some actual benefit this year. On that – yes, absolutely. On the commercial side, obviously, I think overall rates were up a little over 2% this quarter, and that was about approximately 1% headwind, I guess, on Medicare. So just can you give us a little more color on that? I guess commercial was up over 3% this quarter, part of that due to the workers' comp or anything – any more breakouts there?

Yes, I appreciate it. Yes, we had a nice increase in commercial. It was up about 2%. Workers' comp – our workers' comp rate, which we've been working on at the same time as the visits, we – that was up actually about 10%. That rate was up that much over the first quarter of last year and up about 3% or 4% over the fourth quarter of 2024. So, we really saw a lot of really good movement there on rate in workers' comp. Commercial was up, like I said. Our Medicare was very stable. Actually it was up just slightly. It was up slightly despite the 2.9% Medicare rate reduction. So, that was a good place to be too. So, really just overall strength in the rates. Yes, so I hope that helps.

Yes, absolutely. And then on the visits, just coming back to the volumes and the visits per day, obviously, very strong on an average basis. And I guess some of that benefit is due to the closing of some underperforming clinics last year. So, was there – on a same – on an apples-to-apples basis, was same clinic volume, I guess, down year-over-year? It sounds like a little bit.

Yes.

Although it obviously kind of inverted from a slow start to a positive in March and April, it sounds like. Is that a good way to read it?

Yes, it is. So, yes, same clinic affected by the weather more so than the rest of our business. And that – so, that was down in January and then again in February, but then was positive in March from a volume perspective. And so, kind of things settled out in March, and I think we're going to be in a better – we're going to be in a really good place for that for the rest of the year, I think, on our mature clinics from a volume standpoint.

So, you still believe you'll grow same-center volume for the year?

Yes. I do believe we'll grow same-store volume. We just – now that we're through January and February, we – I expect us to do really well on volumes for the...

Right. And I imagine March – I don't know if March – April – March volumes were up on a same-center basis I gather. Okay. And then just on the margin side of things. So, you had a really nice progression, as you mentioned, through the quarter. I guess the year-over-year decline, is that driven more by – it feels like more by the acquisitions – you acquired some lower margin – a little bit lower margin stuff on the acquisition front. And maybe does the – as Joanna mentioned, does the leap year and the 1 less day, does that maybe hurt your revenue more than your costs? Or is there any – does that skew your numbers at all?

Yes, a little bit. I mean we do have one less day of revenue in the quarter, but the costs are relatively the same on a month-to-month basis. So, that does impact a little bit. I think the bigger piece of it is that we had some cost increase that came about the middle of last year. And so, still absorbing that in the first quarter is – yes, so that kind of caused that margin to go down. But like Chris said, and I noted, we were really encouraged by March, and we're focused – believe me, margin is a focus for us. And so, we're really working on – that's why we're working – well, we would do this anyway because it's a good business. We're working on that net rate to try to just continue to increase that and then stabilize our operating costs as well, so that we can see margin growth from that net rate growth.

Yes, Larry, I would...

Yes, go ahead, please.

Yes. Just real quickly, particularly January and February, Metro, which we acquired, I think, beginning November, Metro had particularly low margin. Weather impacted months in January and February, and then bounce back in April. And so, certainly, that acquisition skewed the quarter a little bit. I expect that to stabilize as the year goes on, but a little bit lower than our core.

Got it. No, that's fair. Obviously, now that's a big piece of your business, relatively speaking. And Chris, you had mentioned at the end of the year last year, I guess, just about kind of putting a little bit more focus on costs where you can across the clinics. I know it's – obviously, it doesn't happen overnight, but any update on that kind of initiative?

Yes. We're – we've taken a different approach here. And I mean just because I've been here for a long time and I know the partners pretty well, I've gotten directly involved with our ops team, and we're working our way through – should be done next week ahead of our Board meeting, but our top 40 partnerships, which make up, frankly, roughly 75% or 80% of our earnings. And looking at a comparative set of very important measures, everything from volume to rate, to rate per hour across certain employee subsets, growth in FTEs, productivity, a number of things, all in one sheet, call with the partner. The reason we're looking at 2021 is we came out of the pandemic that first year, not that we were fully done with it, but in 2021 and volume bounced back to where it had barely leaned then, not overly lean, but kind of where we – in shape where we should have been. And so, we're looking at a comparison over time and across our largest partnerships. And we're really getting an understanding – a bilateral understanding with our partners on what's happened, what is – what we can't completely control. We're kind of pushing aside, but we're focusing on what we can control. And we're creating a plan with a follow-up that's either monthly or quarterly depending upon the nature and width and breadth of the opportunity, and the amount of adjustment we need to make. And then we're also looking at what we need to do from a corporate support perspective to help them better address whatever the issues are that need to be addressed. And so, this has become a very, very important exercise that I, kind of, call it pulling on the rope. We're going to keep pulling on this until we get it to where it needs to be, and we're not going to let go until we get there. And so, everybody is on board. Partners have been great. But it's a work in progress.

Got it. Okay, great. Appreciate all that color. Thanks.

Thank you. We'll take our next question from Jared Haase with William Blair. Your line is now open.

Good morning. Thanks for taking all the questions. Chris, you talked a little bit about the leadership meetings with the team at Metro in your remarks at the top of the call. I wanted to double-click on that a little bit further. I guess what were some of the biggest learnings that you picked up on, maybe in terms of what's working well with that business? And then I guess this is somewhat related to your remarks on the last question there. But I guess I'm wondering if there's anything specific you picked up from them that could be translated across the other partnerships?

Yes, for sure. First of all, it's just a great team – great leadership team, really can do group. I mean it's easy when you have a lot of headwind over a period of time to kind of succumb a little bit and do the whatever is me thing. And I didn't see any of that with them. They're very focused on the growth plan. I have a very tangible growth plan in terms of acquired and organic openings. I was really impressed. Those names that I rattled off, their senior operating team and along with their exec team whose names I didn't rattle, but who I know really well, I got to meet their senior leadership. The mentorship, the way they guide people back home, the stories and just the values and the vision, and how it all comes together, no surprise that they've got some of the biggest clinics that I've seen anywhere. I mean the visits per clinic per day right now are around 50. I mean they're doing a fantastic job. And they've taken kind of a cradle-to-grave approach. Meaning everything from pediatrics all the way through to elder care and home care. We recently had a partner meeting that Eric and Graham pulled together, the team pulled together, and Michael Mayrsohn, who's the founder and the CEO of Metro, was part of that along with some of our other large partnerships. The nice thing about our company is when it comes to delivery and the kind of programs that are offered, they're not all exactly the same because it really is determined by the partner and their experience and the community demand and where they see it fit. But Metro has done a great job on the home care side, which is a bit unique for us. They typically have PT, OT and speech in all their facilities, which is a little bit unique. We're always PT and sometimes we have OT, don't generally have speech. So, they've done well with that. And there definitely will be some tangible things that come out of that transaction that will be positive for our partners, and that's already begun. We just announced another home care acquisition just last week, or in the last week or so. You'll see – we have more partners looking at that right now and seeing that opportunity, and it's going to take a little time, but I think that will broaden our offering, but just really impressed with the people.

Got it. That's great. And I think the home care opportunity ties in nicely to my follow-up. And I think you've obviously talked about some of the capabilities that Metro had, but then thinking about expanding the home care capabilities across the other partnerships as well. I guess just to put a fine point on it, what are you seeing that makes the home care opportunity attractive? Is that largely a function of sort of patient demand or it's just a desire to get more and more care delivered in the home because it's more convenient? Are you hearing from therapists maybe that they would like the ability to have a little bit more flexibility in their work environment versus just sort of being tethered to the four walls of the clinic?

Yes. I think it's combinations of all of that and not one thing. So, it's not me who thinks that we would rather perform care in the home. Most of these are – I would characterize it different than from a convenience perspective. Because sure, if I can have somebody come to my house, that's great. By and large, the people who can come to the clinic and are able to come, they come. And we can do a really fulsome job in the clinic with all the equipment that we need and the right resources and particularly from an equipment perspective, it's just a lot easier to deliver. Now there's a subset of patients who can't come in. Maybe they can't drive yet. They don't have a caregiver to bring them. They're kind of homebound at least temporarily until their physical function improves. And so, those people that we can see in their home ensure there's a subset, not a complete set, but a subset of our clinicians or Metro's clinicians who do this exclusively and they just want to really do home care. There's another set that crosses over where they're largely in the clinic, providing care, but they're able to do home care and make a little bit more money because we pay on a per visit basis. And so, I just think it's another point of, call it, flexibility that we need to be good at in order to meet people where they are and deliver care that we know we can deliver. We just have to be a little bit site agnostic in terms of where we prefer to do it because sometimes there's no other option. You either do it or you don't. If you don't, you're missing part of the opportunity.

Got it. Makes a lot of sense. Thank you.

Yes. Thanks for the question.

Thank you. We'll take our next question from Constantine Davides with Citizens. Your line is now open.

Yes, thanks.

Good morning.

Good morning, Chris. Maybe just following up on that last question. How do you deliver to the home profitably? Obviously, there's more of a windshield or downtime issue with the clinician. So, how do you kind of structure that with – from a reimbursement standpoint to sort of account for that?

Yes. Well, I will tell you, first of all, that I'm not the expert, not yet, and we're really relying on Michael and his team, and looking at what they've done and the way they've structured it. It has nothing to do with windshield time. It has everything to do with just paying for a visit. You pay for that visit and you don't have other costs involved. You're able to do it in most markets in New York and particularly because they have a very high geographic index adjustment factor because of where they are and what costs are. So, the Medicare rate is higher. And so, the differential between what you're being paid by the government and what you're paying somebody, there's definite margin there. You don't have other costs, other than maybe a laptop. And so, it is margin – it is accretive certainly and whether it's exactly the same margin, but it's going to be profitable. And, again, these are people that probably you're going to miss unless you do it, because it's not like they have a choice. Most of these people are kind of home bound, at least temporarily.

That's helpful. And then just another follow-up on IIP. I'm just curious, there's certainly a lot of focus by this administration on bringing manufacturing home. Is that something you're in dialogue with, with prospects or current customers in that business? To the extent you think that's something that could move the needle in the next couple of years? Or is it still just too early at this point, more theoretical in nature?

I could give you an answer, that's what I think, but it's going to still be theoretical. So, I would tell you there are definitely certain industries. I mean, first of all, we're going to have to see where all of this tariff stuff goes. And even to the extent in the auto industry that the domestic providers who produce cars in this country still access a significant part of the pieces parts they need to make the car here from other places. So – and I'm not sure how much of that, honestly, is going to change acutely, different issues, again, for different industries. I think it's a net positive over a much longer period of time. If you're building an auto plant in this country – I've never done one. I don't know, but it's going to take years. And so, I think some things will happen sooner than later. And I think it's a net directional positive. But there's a lot of puts and takes right now really around uncertainty of what is the trade policy and how does that affect us in the near term. I think longer term, the more we can do here, the better off we are. And I think that will help our business, frankly. The people who are skilled at those jobs are aging just like the rest of our population. And with that, there's wear and tear involved. And so, again, to keep these folks as healthy as possible for their 24-hour self, meaning all the things they do at home in combination with what they do at work, really important to these companies. And I think people are beginning to recognize that more than they have historically.

And is there – are you seeing benefits from the IIP business on the outpatient clinic side yet? Or is that still just very early innings?

I think it's early innings. Eric, do you want to take that?

Yes. It is early innings, and we're trying to do this a couple of different ways. One of the things that we're really encouraged by is we finally, for the first time, really gotten into some government contracts. We really haven't done that before. Obviously, taking any sort of government contract requires some additional reporting just around some of the affirmative action reporting that needs to be done. And we have an applicant tracking system in place that allows us to do that. So, historically, we've never chased that business before, but that also now gives us a lot of opportunity with that government business we have coming in. It's a lot of testing business to funnel that down through our clinics. And so, that's working pretty well. We've also reached out to our clinics, and there's an opportunity for our clinics to strengthen and deepen the relationships that they have with employers in the market where they're only providing work comp services, but the stickiness to that relationship would be much better if they had an opportunity to also bring more value through the offering of injury prevention services. So, we have been working in a couple of markets where we knew some of our physical therapy partners had really, really strong relationships with employers. They've been meeting with members of our industry – our injury prevention teams, both on the progressive embryotic side, and they've been able to get some really, really good meetings with those employers in the market, that's going to open up the door for injury prevention services, create more stickiness as it relates to that work comp injury business that would flow into the physical therapy clinic. And it also creates an opportunity for our physical therapy partners to profit from a commission perspective for the additional injury prevention revenue that's generated on that side of the business. So early innings, but those meetings have gone really, really well, and we're really looking forward to seeing that expand in 2025.

That's interesting. Thank you. I guess one more for me. Your response to an earlier question around the physical therapist is, I guess, a gatekeeper. Aside from some of the government programs you mentioned, like the one in Maryland, is that something you're starting to discuss with commercial payers, I guess, more specifically in terms of a less episodic reimbursement arrangement? Thanks.

Yes. Episodic care and pay for performance and outcomes and all those things have been discussed for a really long time. And yet amazingly, even on the most simple basis with some payers, it's still a challenge to be paid correctly, let alone to take it into an episode and think about sharing and cost savings and other things. A lot of people talk about it. We don't see a lot of it. But I do think that this EQIP program, which again, is all Medicare-based, it's in conjunction with CMS. And it's with the most complicated population really that we see. And the results are really quite significant. And so, I think that will give us some very tangible results to lean on, to begin to have more interesting discussions with payers around maybe how to change and how to think about the model a little bit. And we do all of that in APTQI. We believe that physical therapists are the right subset of health professionals to care for and lead really on a primary care basis, everything that's musculoskeletal. These people are well trained. They're much better trained than – not to diminish primary care doctors' role, but the range at which primary care doctor – the range of issues that they have to be versed in. It's just so significant. Musculoskeletal is what we do and the training that we get, which is neuromuscular, musculoskeletal based, so much more than what these other physician subgroups get. It just makes sense. So there's so much waste that happens, waste in time, waste in procedures, waste in diagnostic imaging, things that happen that are really quite unnecessary and very, very expensive. And a lot of that – not all of it can be eliminated because some of it clearly is necessary, but a lot of it could be eliminated, if we had case control. And so I think this will be good way to open the door and look at really tangible results for an even healthier commercial population. And we're beginning to have those efforts in those discussions, but we're early innings.

Thank you. [Operator Instructions] We'll take our next question from Mike Petusky with Barrington Research. Your line is now open.

Hey, Mike.

Hey, good morning. So on Metro, one of the things that you guys called out, I think, last conference call was, hey, we have some opportunity to maybe renegotiate some rates. And I was just wondering, has any of that started or any anecdotal evidence that, hey, we actually are able to sort of move the needle there? Or is that still sort of to come?

Yes. Let me take a part of that, and it's a part you didn't – it's related to that, but you didn't ask, and then I'll let Carey address the rate because we have a schedule of things that we've gotten done and then some that are soon to come. One of the nice things about Metro is – and we're going to get rate up there and rate is going up already. The rate differential between where Michael and his team are able to deliver care and that we get compared to the private practices up there, it's a massive differential, $20 to $30 a visit difference. And so it's given Michael and his team, now us together with our resources, the ability really to press the gas from a development perspective and do some of these acquisitions, these aqua novos which are smaller practices and even some larger practices that are profitable, but just don't have rate. And even with just where we are today, the rate lift is really significant. So Carey, why don't you take the real part of Mike's question on what have we gotten done and what do we have to do yet?

Yes. So Mike, we're – we've gotten – it's a continual process, right? We go through contract negotiations. We get rate increases, but it doesn't stop there. We just – we come back and revisit those rate increases. So I'd say, it's – I don't know that there's – that I could say it's this much done or whatever, but we've been through a number of our largest contracts and – but then we're going back through them again. We have a schedule that we keep of our top 30 partnerships and their top five payers. And we are very focused on that because that will catch a lot of our other partnerships as well because they're across the country and in different areas too. But we're really focused on our top five payers and our top 30 partnerships and making sure – so we've got a schedule that says, look, this one is in process. This one was – the last time this one was done. And one of the more significant ones we have gotten done this year is Blue Cross Blue Shield of Texas, which should provide us a nice little increase in that as we go throughout 2025. And then Chris talked about Metro. We've got some Blue Cross Blue Shield contract with Metro that took effect in – on May 1. That should be a nice lift for Metro as well. So focus on the big payers primarily. And then we have a – so that's our – we've got the strategic negotiating group that's two or three people that focus on the large payers. And then we've got a contract – a team that also focuses on some of the more regional contracts and local contracts that they're working on continually as well. So I hope that gives you some color as to how we're approaching it.

But Carey, specific to Metro, aren't we up? I don't have it in front of me right now, a couple of dollars a visit and then on May, I think...

Yes. Metro specifically...

May 15th. We have another big contract that's going to kick in here in the next week.

Yes.

So you've seen a little bit of progress in...

Yes. Metro in the fourth quarter, the rate was $102.40 and it moved up to $104.50 in the first quarter, and it was actually at $106 in March. So really good movement there. And that's just from the renegotiations that have taken place since we moved those contracts over to us and continued work there.

Okay. Great. A couple more semi-quick ones, I guess. Chris, in terms of the conversations you're having with top partnerships, I mean, how much interest is there in sort of adding on a home care PP, I guess, capability? I mean, is that something you guys are like excited about? Or are they sort of looking at you sort of with a side eye saying, that's not really what we do? Or can you just sort of describe the reaction to sort of how – what Metro does versus what the rest of your partnerships have done?

Yes. Well, let me kick it to Eric. And Eric, if you would, not just home care, but cash-based programs. We had a partner meeting focused around additional revenue-generating opportunities, and Eric can give you a complete answer on that, Mike.

Yes. The one thing we have, obviously, visibility to – across the 125 partnerships is – some partners do some things really, really well. Others don't do it as well. And so for example, we have partnerships out there who just due to a very competitive market have not really been able to control referral sources, getting referrals from physicians. And as a result of that, they really grew their practice by direct-to-consumer campaigns to the point where 95% of referrals they have coming in the door are through direct-to-consumer marketing, significantly higher than any other partnership we have in the portfolio. We have partners out there who have done a phenomenal job in terms of cash-based laser sales, laser treatment being a part of physical therapy, not reimbursed by insurance companies, but patients love it and are willing to pay cash for it. We've got a partner out there who generates significant revenue based on his team's ability to offer and utilize laser sales. We brought all these people in with their various successful programs and presented for 1.5 days in the Houston market. I think we had, I don't know, 15 of our top 40 partners there to expose them to all these other things that we're doing across the country with different partnerships. And people took away from that meeting different things. There were a lot of people that love the laser approach from the standpoint that didn't really require them to go out and market at all outside the clinic. This is being marketed to the patients that are coming in every single day and taking advantage of the opportunity to use that laser sale. There are some people that show an interest in home care. I'll talk about that a little – in a bit. But that's really hard to scale just saying, "Hey, I'm going to take my staff and we're going to take these people out of the clinic, we're going to have to do a home care business." I still believe that the best way for us to grow the home care side of our business is to sit there, very fragmented industry, just like outpatient physical therapy is, but to target markets and start looking at acquisitions where you can offer that as part of a portfolio of services combined with what we're doing on the outpatient side. We actually had a couple of other partners, who have been very successful going into prisons and cash-based programs, providing physical therapy services to prisoners and every one of those communities as well. And so we presented a portfolio of things that people take interest in. On the home care side, I do think there's a lot of opportunity for growth there, and it's something that we'll probably look at focusing on acquisitions to really help us grow that and then organic from there.

Great. Last one, Chris. Just in terms of the outlook for pricing going forward in – relative to CMS, I mean, have you gotten back from legislators, Susan Collins or anybody else that you guys are talking to, hey, there's an awful lot going on in D.C. right now. Besides that, cost cutting is what everybody is looking at, not looking for ways to pay – like essentially, this is just not going to get traction because there's so much going on and a bias towards cost cutting? Even though I know you explained your proposal would save money, et cetera. But I'm just wondering, do you feel like it's hard to sort of get people's attention given the environment out there? Thanks.

Yes. No, I think it depends on the question. So if you're asking me to handicap and to give you feedback on a permanent fix to the physician fee schedule, we know it's a $100 billion spend, the way it gets scored. And I think the chance of that happening without really significant offset, like a full-scale EQIP program, which is not ready to – for prime time yet necessarily. I think that's dead in the water. The – and again, the longer we go this year, any kind of a fix, which would be a part year fix this year and maybe relief next year to roll back the 2.9% that we're hit with this year. I give that a small chance, but Washington is pretty dysfunctional right now. There's a lot going on. There is a bias toward the cost side. But I think that aside, there's an appreciation for the fact that the system that we've been in, which requires budget neutrality, particularly overlaid in, call it, broadly medical technology, which is advancing rapidly, where there are breakthroughs in certain areas, which are not cheap. In fact, they're very, very expensive, robotics and other breakthroughs across, lots of different specialties. Those have to be paid for. So to continually take from people in order to do the thing that's going to provide the best outcome, is not sustainable. You're going to get providers just like we have in many of our other companies, who said Medicare Advantage doesn't – isn't going to work for us. You can't pass $0.60, $0.70, $0.80 on the dollar. We're not going to lose money on every patient. And so there's going to – there's an understanding that a lot of the stuff has to be retooled. I just don't think, given the nature of our hits, that we'll be in the crosshairs in the coming period. I can't even imagine that, that's going to happen. So longer term, there's a lot of stuff to figure out and none of it's easy.

Thank you.

Thank you. We have no further questions in the queue at this time. I'll turn the program back over to our presenters for any additional or closing remarks.

Sure. Well, thank you, everybody. Those were good questions. And hopefully, what you found was good, honest, transparent discussion. And Carey and I are available later today and later this week, and we'll be at the Bank of America conference next week. So we appreciate the opportunity to speak there to our shareholders. And just call us if you have anything that you want to go over as a result of today's call. Thank you, and have a great rest of your week. Bye now.