The Ensign Group Q1 2024 Earnings Call Transcript

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Provided by Quartr
May 2, 2024

There are 7 speakers on the call.

Operator

Thanks for standing by. My name is Mandeep, and I'll be your conference operator today. At this time, I would like to welcome everyone to the Ensign Group, Inc. First Quarter Fiscal Year 20 24 Earnings Conference Call. All lines have been placed on mute to prevent any background noise.

Operator

After the speakers' remarks, there will be a question and answer session. Thank you. I would now like to turn the conference over to Mr. Keetch. You may begin.

Speaker 1

Thank you, operator, and welcome, everyone. We filed our earnings press release yesterday, and it is available on the Investor Relations section of our website at enzinegroup.net. A replay of this call will also be available on our website until 5 pm Pacific on Friday, May 31, 2024. We want to remind anyone that may be listening to a replay of this call that all statements made are as of today, May 2, 2024, and these statements have not been or will be updated subsequent to today's call. Also, any forward looking statements made today are based on management's current expectations, assumptions and beliefs about our business and the environment in which we operate.

Speaker 1

These statements are subject to risks and uncertainties that could cause our actual results to materially differ from those expressed or implied on today's call. Listeners should not place undue reliance on forward looking statements and are encouraged to review our SEC filings for a more complete discussion of factors that could impact our results. Except as required by federal securities laws, Ensign and its independent subsidiaries do not undertake to publicly update or revise any forward looking statements where changes arise as a result of new information, future events, changing circumstances or for any other reason. In addition, The Ensign Group Inc. Is a holding company with no direct operating assets, employees or revenues.

Speaker 1

Certain of our independent subsidiaries collectively referred to as the Service Center provide accounting, payroll, human resources, information technology, legal, risk management and other services to the other independent subsidiaries through contractual relationships with such subsidiaries. In addition, our captive insurance subsidiary which we refer to as the insurance captive provides certain claims made coverage to our operating companies for general and professional liability as well as for workers' compensation insurance liabilities. Ensign also owns StandardBear Healthcare REIT Inc, which is a captive real estate investment trust that invests in healthcare properties and enters into lease agreements with certain independent subsidiaries of Ensign as well as 3rd party tenants that are unaffiliated with the Ensign Group. The words Ensign, company, we, our and us refer to the Ensign Group and its consolidated subsidiaries. All of our independent subsidiaries, the Service Center, StandardBear Healthcare REIT and the Insurance Captive are operated by separate independent companies that have their own management employees and assets.

Speaker 1

References herein to the consolidated company and its assets and activities as well as use of the words we, us, our and similar terms are not meant to imply nor should be construed as meaning that the Ensign Group has direct operating assets, employees or revenue for the any of the subsidiaries are operated by the Ensign Group. Also, we supplement our GAAP reporting with non GAAP metrics. When viewed together with our GAAP results, we believe that these measures can provide a more complete understanding of our business. They should not be relied upon, upon the exclusion of GAAP reports. A GAAP to non GAAP reconciliation is available in yesterday's press release and is available in our Form 10 Q.

Speaker 1

And with that, I'll turn the call over to Barry Port, our CEO. Barry?

Speaker 2

Thanks, Chad, and thank you everyone for joining us today. We're pleased with the continued and consistent performance that our local teams achieved again. After another record quarter, we're excited about the remarkable momentum our teams have created across our entire portfolio and look forward to seeing that continue throughout the year. As strong as our performance has been, we continue to see enormous opportunities inherent in our portfolio, both in existing operations and the growing number of new acquisitions. We were encouraged to see an increase in skilled mix during the quarter with an increase in same store skilled mix days of 5.6% and an increase in same store skilled mix revenue of 1.9% sequentially over the 4th quarter.

Speaker 2

This continued strength in our skilled mix demonstrates the ongoing trend of increasing demand for skilled post acute services. We were also excited to see same store occupancy for the quarter reach 81%, which grew by 2.7% over the prior year quarter and surpassed pre pandemic same store occupancies for the first time since Q1 of 2020. While we celebrate this milestone, our same store portfolio still has an incredible amount of built in upside as dozens of our most mature same store operations operate in the 90 plus percent occupancy range. As our operators continue to build on a solid foundation of strong clinical results, cultural excellence and sustainable real estate costs, they will continue to realize the occupancy and skill mix growth potential inherent in our same store portfolio, which will allow us to continue achieving the consistent financial results that we have delivered over time without depending solely on acquiring new operations. That said, as you saw in our press release yesterday, we have been busy acquiring new operations and are transitioning and newly acquired buckets now represent over 25% of our total operational beds.

Speaker 2

We have enormous organic growth potential within those growing buckets. To give some perspective, our occupancy and skilled mix days for the skilled nursing operations in the transitioning bucket were 74% 22%, respectively, while our same store occupancy and skilled mix days were 81% 32%, respectively. As we've shown over 2 decades, we expect our teams to unlock significant upside in each of these new operations as they mature. As most of you know, CMS issued a final minimum staffing rule last week. As expected, the final rule is very much in line with the proposed rule they issued last year with a few minor differences despite the overwhelming amount of feedback CMS received from various stakeholders, including operators of all sizes and in all geographies.

Speaker 2

While we are deeply committed to increasing access to quality care for our seniors, we strongly disagree with this rule and believe especially in light of the nationwide shortage of nursing labor that the rule only exacerbates an already precarious staffing problem and if it survives as is, would severely limit the ability of the skilled nursing industry to serve the growing long term care population. We believe it would be much more constructed to focus policy on rewarding quality outcomes and assisting providers to increase the supply of caregivers. Unfortunately, this rule will have its largest impact on smaller and more thinly capitalized operators, many of which are quality providers and will ultimately result in limiting quality care options for the senior population. However, we are optimistic that this rule will be either eliminated entirely or its effects will be mitigated long before the rule takes effect in 2 to 3 years. We're encouraged to see bipartisan support in the legislature that can result in this rule being over turned or significantly altered.

Speaker 2

In addition, our industry representatives and their legal experts have been preparing to challenge this rule in the courts on several grounds and believe this rule is highly likely to be overturned in federal court. Lastly, because this rule is being driven by political ideologies, its survival also depends on the outcome of several elections that will take place before the rule would be implemented. In the meantime, our locally driven operational model is built to respond to changes like these. As we've shown over and over again, when change comes, our leaders respond. Whether you look back to seismic changes in reimbursement like RUGS 4 in 20112012 or PDPM in 2019 or the frequent regulatory changes imposed on our business during the COVID pandemic, our local CEOs and COOs have been able to adjust their individual operation strategy and rapidly respond to any shift in market dynamics in a very thoughtful and specific way.

Speaker 2

In addition, when the industry is out of favor or regulatory uncertainty leads to less capital being invested in our space, our local acquisition approach has allowed us to continue to add new operations at attractive prices. As our local teams have done so, they have demonstrated their capabilities to their healthcare partners and have grown market share. It's ultimately because of them that we have so much confidence that no matter what happens with minimum staffing or other unforeseeable regulatory changes in the future, we are built not only to survive, but to thrive and grow with change. Our focus over the coming months years is to continue the strategy that has always been paramount to our success regardless of staffing mandates or any other change. Good care depends entirely on attracting and training great talent.

Speaker 2

Becoming the employer of choice in each of our markets has been and will be our relentless focus. We've seen evidence of the fruits of these efforts during the quarter and are encouraged by the reduction in the use of third party nursing agencies, which improved again for the 5th quarter in a row, representing a reduction in agency usage of 59% since its peak in December of 2022. We're also thrilled to continue to see lower turnover for the 10th quarter in a row, which is a result of our local leaders' focus on a customer second philosophy. Likewise, we continue to see the pace of wage inflation slowing while we simultaneously successfully recruit new talent. As of the end of the quarter, we saw net new hires increase yet again.

Speaker 2

We are confident that by being true to our cultural values, strong clinical results and proven operating principles, our ability to attract talent to our organization will shine through. We're affirming our annual 2024 earnings guidance of $5.29 to $5.47 per diluted share and annual revenue guidance of $4,130,000,000 to $4,170,000,000 The midpoint of this 2024 earnings guidance represents an increase of 13% over our 2023 results and is 30% higher than our 2022 results. This annual guidance comes on top of the extraordinary growth we've experienced in the last few years. Put this performance in perspective, since we've spun out the Pennant Group in 2019, the midpoint of our 2024 guidance represents growth in adjusted EPS of 201.1 percent with a compound annual growth rate of 24.4%. This performance is not due to some large event or a single transformative transaction, but instead as a result of consistent growth and performance quarter after quarter, which comes from following proven Ensign principles.

Speaker 2

All these achievements entirely due to the efforts and commitment of our local leadership teams, caregivers, field resources and service center partners. There are so many opportunities in front of us to improve and expense management and drive occupancy and skilled mix as we continue to successfully unlock value in all of our operations. We remain poised to again showcase our ability to find, acquire and transition performing and underperforming operations by applying proven Ensign principles developed over 2 decades. Next,

Speaker 1

I'll ask Chad to add some additional insights regarding our recent growth. Chad? Thank you, Barry. As we expected, we continue to add to our growing portfolio and we are very excited about the 13 new operations and 6 real estate assets we added during the quarter and since, bringing the number of operations acquired since January 2023 to 39. These acquisitions span 8 of our 14 states and represent a significant opportunity to either strengthen our current clusters or to establish new clusters in new markets.

Speaker 1

These new acquisitions include the following new operations: 3 in Tennessee, 1 in Iowa, 2 in Kansas, 1 in Texas, 2 in Colorado, 2 in Utah, 1 in Arizona and 1 in Nevada, totaling 12 16 new skilled nursing beds, 2 0 2 senior living units and 43 new LTAC beds. Of these 13 new operations, 6 of them included the real estate assets which were required by StandardBear and will be leased to an Ensign affiliated operator. Each of these additions were all carefully selected amongst the many opportunities available to us and were chosen because of the huge clinical and financial potential. We continue to prioritize growth in our established geographies as it allows our clusters to work together with their acute care partners and to provide a comprehensive solution to their healthcare needs. However, we are also excited to build clusters in new states or in markets where we have significant room to add more density.

Speaker 1

In particular, we are very excited to grow in Nevada and to add our second and third operations in Tennessee, which along with the acquisition we completed earlier this year creates our first Tennessee cluster. We are very optimistic about our ability to continue growing in Nevada, Tennessee and the surrounding regions. We are also pleased to see some growth in the Midwest with the additions in Iowa and Kansas. And we've already seen the benefits from our recent growth in Kansas and look forward to a similar boost in Iowa. We were also excited to add a dynamic healthcare campus in Northern Utah that includes a skilled nursing operation and a long term acute care hospital or an LTACH.

Speaker 1

Those of you who have followed us over time will note, we often make small investments in new lines of business. Once we've proven the model works, we expand from there. While the LTACH operation will remain a very small part of what we do in Utah, we are pleased to be adding another service offering to our acute care partners in Utah, all of which rely very heavily on us for a variety of post acute services for some of their most complex patients. We continue to see a very healthy pipeline of new acquisition opportunities and are lining up some exciting new additions that we expect to close in the 2nd and third quarters. Our decentralized growth model is driven by leadership in each market who have a built in incentive to attract talent, train them and then acquire operations that will be accretive to their clusters and ultimately the entire organization.

Speaker 1

As co owners of the organization, our team's bandwidth to acquire expands as they grow and the model is not dependent on a centralized team of deal experts. This scalable approach to growth has allowed us to continue to acquire or lease new operations at disciplined prices, which has led to a cost structure that has allowed us to drive consistent organic growth over time at healthy margins. However, we don't grow just for the sake of growth or acquire revenue or by earnings. We have and will continue to grow when we see deals that will be accretive to our shareholders in both the near term and over time. We continue to provide additional disclosure on StandardBear, which is now comprised of 114 properties owned by the company and leased to 85 affiliated skilled nursing and senior living operations and 30 operations that are leased to 3rd party operators.

Speaker 1

Each of these properties are subject to triple net long term leases and together generated rental revenue of $22,200,000 for the quarter, of which $18,000,000 was derived from Ensign affiliated operations. Also for the quarter, we reported $14,100,000 in FFO and as of the end of the quarter had an EBITDAR to rent coverage ratio of 2.5 times. And with that, I'll turn the call over to Spencer, our COO to add more color around operations. Spencer?

Speaker 3

Thank you, Chad, and hello everyone. Today, I'd like to share 2 examples that demonstrate how frontline teams throughout the organization are continuing to grow earnings, improve culture and elevate their clinical outcomes. The first facility is Olympia Transitional Care in Washington, currently led by Director of Nursing, Jenica Kautz and Executive Director, Mindy Bradley. When it was acquired back in 2015, Olivia Transitional had low star ratings and a poor clinical reputation with state regulators and with the local healthcare community. As a result, occupancy, especially skilled payers was low and the facility consistently lost money.

Speaker 3

Despite the enormous challenges, the local operators who make acquisition decisions recognize the latent potential that the facility had, especially given its discounted purchase price. And over the course of the past 9 years, the Olympiad team has pushed relentlessly, transforming the culture of the facility and methodically adding clinical capacities. Today, Olympiad transitional is completely transformed, as evident in its CMS 5 star rating for quality measures and overall. The local hospital and health system have embraced the change and today the facility actively participates in their ACO and is a preferred provider for numerous managed care plans. As you'd expect, skilled mix has improved by 2 27% since acquisition, with a 37% increase since prior year quarter.

Speaker 3

Since acquisition, revenues have grown by 87% and the facility has become one of the top EBIT producers in the state of Washington. The second facility example is Berthoud Care and Rehabilitation in Colorado. This operation currently led by COO, Emily McDonough and Executive Director, Andy Lafomme was acquired in 2021 and exemplifies what typically happens in our transitioning category. Notably, this acquisition occurred in the midst of the COVID pandemic and staffing crisis. Yet during the past 3 years, enormous strides have been made.

Speaker 3

For example, the Berthoud leadership team created and implemented a unique incentive system that rewarded existing staff for recruiting and retaining additional caregivers. And as a result, turnover among caregivers has been cut by over 50% and contract staffing is now seldom used. The facility has developed a fun yet results driven culture where the whole team pushes for admissions and occupancy has grown from 70% at acquisition to 95% in Q1 of this year. They have simultaneously expanded their ability to care for clinically complex patients. And as a result, rates for both long term and short stay residents have increased substantially.

Speaker 3

As a result, revenues continue to rise, increasing by 24% in Q1 from prior year quarter and the EBIT has soared by 155% during that same period. And before I turn it over to Suzanne, I want to highlight one more principle that is essential to the ongoing health of our organization and that is illustrated perfectly by these two facilities. That principle is diligent succession planning. In the case of both Olympia and Berthoud, the CEOs who were instrumental in transforming the facilities post acquisition have both recently moved into new roles. In the case of Olympia, CEO Vivian Curie transferred to a recently acquired sister facility and is applying her skills and experience to elevate quality and results.

Speaker 3

In the case of Berthoud, CEO, Joey Graham recently took on the role of market leader and is helping accelerate quality and acquisition growth for the northern half of the state. We can't thank these leaders enough for their sacrifices made in order to continue to elevate their markets, while also honoring the teams who are on boarding new leaders and continuing to drive exceptional results at both Olympia and Berthoud. With that, I'll turn the time over to Suzanne to provide more detail on the company's financial performance and our guidance, and then we'll open it up for questions. Suzanne?

Speaker 4

Thank you, Spencer, and good morning, everyone. Detailed financials for the quarter are contained in our 10 Q and press release filed yesterday. Some additional highlights for the quarter compared to the prior year quarter include the following. GAAP diluted earnings per share was 1 $0.19 an increase of 13.3 percent. Adjusted diluted earnings per share was 1 $0.30 an increase of 15%.

Speaker 4

Consolidated GAAP revenue and adjusted revenues were both $1,000,000,000 an increase of 13.9%. GAAP net income was $68,800,000 an increase of 15%. And adjusted net income was $75,400,000 an increase of 16.6 percent. Other key metrics as of March 31, 2024, included cash and cash equivalents of $512,000,000 and cash flows from operations of $35,300,000 We also continue to delever our portfolio, achieving a lease adjusted net debt to EBITDA ratio of 1.98 times. This deleverage in a period of growth is particularly noteworthy and demonstrates our commitment for disciplined growth as well as our belief that we can continue to achieve sustainable growth in the long run.

Speaker 4

In addition, we continue to have approximately $594,000,000 of availability on our line of credit, which when combined with cash on hand on our balance sheet give us over $1,000,000,000 in dry powder for future investments. We also own 119 assets, of which 114 are held by Canterbury and 95 of which are owned completely debt free and are gaining significant value over time, adding even more liquidity to help with future growth. In order to give you insight into our transformation of acquisitions, we have presented our skilled nursing operations into 3 buckets: same, transitioning and recently acquired facilities. You heard Barry refer to these different buckets earlier, and I thought it would be helpful to further explain what we mean when we are referencing 2 buckets and how we treat them for comparison purposes. Same facility represents all facilities purchased more than 3 years ago.

Speaker 4

Transitioning includes all facilities acquired between 2 3 years. Recently acquired facilities represents facilities acquired within the last 2 years. For the same and transitioning facility buckets, we include the exact same facilities in the applicable bucket for the comparison time period, meaning the same operations and the same number of facilities are included in these buckets for an identical duration, whether it's on a yearly or quarterly basis in the prior accounting period. For comparison purposes, we show service revenue, field revenue, occupancy and skilled days. The purpose of it doing it this way is twofold.

Speaker 4

1st, to show the organic growth produced by the same group of facilities over a comparable period of time on an apples to apples basis, rather than showing growth that would come from simply adding new acquisitions into a bucket that weren't included in the bucket in the prior period, making it impossible to see what true organic growth of that group of facilities. The second is to demonstrate that historically, our recently acquired and transitioning buckets have substantial organic growth potential. We hope that this extra disclosure is helpful and to show the progress that our operations make over time. But we also want to make sure we emphasize that just because an operation is in the same store bucket does not mean it's fully matured and operating at maximum capacity as we continue to see enormous upside within our same facilities. As Barry mentioned, we are reaffirming our annual earnings guidance of $5.29 to $5.47 per diluted share and annual revenue guidance of $4,130,000,000 to $4,170,000,000 We've evaluated multiple scenarios and based upon the strength in our performance and positive momentum we've seen in occupancy and skilled mix as well as continued progress on agency management and other operational initiatives, we have confidence that we can achieve these results.

Speaker 4

Our 2024 guidance is based on diluted weighted average common shares outstanding of approximately 58,500,000 a tax rate of 25 percent the inclusion of acquisitions closed in the first half of 2024, the inclusion of management's expectations for Medicare and Medicaid reimbursement, net of provider tax, with the primary exclusion coming from stock based compensation. Additionally, other factors that could impact quarterly performance include variations in reimbursement systems, delays in changes in state budgets, seasonality in occupancy and skilled mix, the influence of the general economy on census and staffing, the short term impact of acquisition activities, variations in insurance calls and other factors. Also, as Barry explained, CNS issued the final federal staffing rules last week. Given the rules' phased and period, the rule will have no material effect on us in 2024. And with that, I'll turn it back over to Barry.

Speaker 4

Barry?

Speaker 2

Thanks, Suzanne. As we wrap up, I need to reiterate again how incredibly honored and grateful we are to work alongside our facility leaders, field resources, clinical partners and service center team that are behind these record setting results. We're always impressed by their incredible resiliency as they focus on supporting this mission in new and innovative ways. This commitment has blessed the lives of so many, including our own, and we're excited about our future because of these amazing partners. We have complete faith in them and the culture they have collectively built and continue to improve.

Speaker 2

So thank you to all of our field leaders and service center partners. And with that, we'll now turn it over to our Q and A portion of the call.

Operator

Thank you. We will now begin the question and answer session. Our first question comes from the line of Ben Hendricks with RBC Capital Markets. Please go ahead.

Speaker 5

Thank you very much guys. Congratulations on the quarter. Appreciate all the color around the minimum staffing rule and appreciate that you're not expecting any impact assuming it goes through on 2024. But next year, it seems like the bit associated with the nurse aide minimum goes into effect. And I know it seems like there would be opportunities there to shuffle some staffing mix to, especially with your LPN utilization to kind of help offset that.

Speaker 5

Just wondering mechanically what that looks like? How feasible that is? Is it something that could be done on a financial neutral basis and on a star ratings neutral basis? Thanks.

Speaker 2

Thanks, Ben. It's a good question. Just to be very clear, the staffing ratios that are specific to overall RNs and CNAs wouldn't go into effect for 3 years from when the rule is registered in the federal register. So 2025, there would be really no need for us to do any shuffling quite yet either. 2026 really the same.

Speaker 2

But that's a year we'd probably start gearing up or preparing and doing a little bit more. You probably hear a little bit more from us on what we'd be doing in preparation for that to go into effect in 2027. So we don't anticipate doing a whole lot different operationally really include all the different dynamics around labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, labor, really include all the different dynamics around labor control and also being an employee centric kind of customer second environment where we focus relentlessly on people systems and making sure we've got world class orientation and training and support for our employees. And also focus on eliminating registry as universally as we can, making sure that we're not relying on 3rd party staffing agencies for any staffing needs. And those are things that we can do a whole lot around to make sure that we're in a really strong and healthy place when and if those staffing ratios come into play.

Speaker 5

Thank you.

Operator

Our next question comes from the line of Scott Fidel with Stephens. Please go ahead.

Speaker 6

Thanks. Hi, everyone. First question, just wanted to talk about the deals you just announced and one nuance of them and then put it in a longer term perspective, which was it was interesting how there was a bit of a higher mix of non SNF beds that you acquire with some IL and AL and then even the LTAC as Chad talked about. But that could have just been coincidence as well around some of the campuses that you acquired as part of this package. So my question is whether that was more of a coincidence or whether you are now looking to do more expansion in some of those adjacent lines of business outside of just SNF?

Speaker 6

And then if we do end up in a scenario where the staffing regs actually would go into effect in 3 years, whether that may further sort of influence your thinking on diversifying more beyond skilled nursing into some of those adjacent areas like IL, AL, LTACs and even theoretically IRFs down the road?

Speaker 1

Yes. Thanks for that question. So I would say that it certainly wasn't something we set out to do this quarter and acquiring more senior living or independent living beds. We are always looking for what we call consider healthcare campuses, which are primarily skilled nursing operations that happen to have those other offerings on the campus. And I think in every case that was what was going on.

Speaker 1

And so from that point of view, no, our strategy really hasn't changed. We've always liked those. We'll continue to seek those. It just happened to be that we had more of those kinds of deals this particular quarter. So I don't think you'll see us look to go acquire lots of standalone living and independent living.

Speaker 1

Again, our focus would be on primarily Smith that has those service offerings on the campus. As for the LTACH, I mean, as I said, we're really excited about that service offering. It's only 43 beds, but operationally, we already operate subacutes and very high acuity skilled nursing facilities in many states. And so it doesn't feel very different from a lot of what we already do. There are clear differences though in the regulatory environment, some of the technical aspects of billing with the DRG kind of coding system and those sorts of things will be new to us.

Speaker 1

But this is what we call a small bullet type of investment that again is part of a larger skilled nursing campus. And certainly hope that it goes really well and to the extent we can learn that business and show that Ensign operating principles apply and work, which we think they will in a beautiful way. That's certainly something we like we've done in other cases, right, in other lines of business, certainly could expand it, both LTACH and IRF. But not saying that that's like comprise a big chunk of our investment dollar, but it is something that as we learn and get good at that we certainly can expand into. As for the diversification question, again, I would say that the staffing stuff really, if anything, it probably just creates even more opportunities for us to continue doing what we've done.

Speaker 1

And so I don't think that that will impact our overall strategy. To the extent we do decide to go down some of these other paths, it will be much more driven by sort of the operational dynamics and the local dynamics in those healthcare markets that are responding to the needs of our acute partners in those areas. That will drive it much more than any sort of regulation would.

Speaker 6

Okay, got it. Thanks, Chad. Next question, just wanted to get, I guess, sort of in the updated guidance, which is obviously reaffirmed, but now you have visibility into the Q1. How you're thinking about both occupancy and skilled mix as sort of thinking about trending in the second quarter and then in the back half of the year, just when considering things like historical seasonality, the fact that you have now eclipsed the pre pandemic same store occupancy, but then you also have over 25% of operational beds in the transitional and new bucket where there's obviously a lot of opportunity to harvest improvements there?

Speaker 2

Yes, great question, Scott. I mean, we obviously feel pretty bullish about our occupancy trends as they've been really strong lately. Certainly in the times we'd expect them to be, but even as we are looking at trends now. We feel like demand is really, really strong and we feel like we've got we're poised to in spite of seasonality have a pretty strong summer. Certainly that can change and as we get into the deep into the summer months, we could see a little bit more of a drop off, which is usually more evidenced in our skilled mix.

Speaker 2

And I think if there is some seasonality to be seen, it'll probably be more evident there than it will be in our overall occupancy, which might just go sideways for a little while. But as is typical, that should start picking up as we get it late into the 3rd quarter and starting into the Q4. But we don't anticipate anything unusual or abnormal and nor do we feel like getting to pre pandemic occupancy is some kind of artificial ceiling or target. Our expectation is that we continue to grow and we've the trends that we've seen are great indications of that.

Speaker 4

And I would add, Scott, that when you have a look at the guide, really on the low end of the guide, we've factored in a higher level of seasonality. And then kind of moving up the guide would be less seasonality as Barry was talking about. And so as we continue to have the year play out, that seasonality aspect of historically having lower occupancy, lower skilled mix in Q2, Q3 would really play into that lower end of the guide. And as we if we end up experiencing better seasonality, less seasonality in other words, we would kind of guide to the high end of the guide with that. And it's right now, we feel pretty strong about where we're at in the season less seasonality than we've experienced historically, right now in the quarter.

Speaker 6

Okay, great. And then I'm going just sneak one more question here. And that would be around, if you could update us on the visibility that you feel you have now into rates over the course of the full year? It seems like the rate backdrop has developed pretty favorably for 2024 when we think about the rebasings that have gone on in Medicaid in a number of key states and then we already do have visibility into the proposed FY 'twenty five rates for Medicare coming in a little bit over 4%. But maybe just sort of help us fill us in, in terms of the overall picture and any sort of emerging insight that you have into FY 2025 Medicaid rates.

Speaker 6

I know it's early here, but just any visibility would be helpful. Thanks. That's it for me.

Speaker 4

Thanks, Scott. So just one reminder, when you're looking at the numbers in our rate tables, remember that if you're doing a compare last year to this year, last year's numbers would not include the FMAP dollars. And so you're going to see some pretty big increases in those rate tables, that might not look like they're translating into the overall impact. But what we feel about the current year's rates is that they're very strong and very solid. As you mentioned, the Medicare rate came out.

Speaker 4

We're very pleased with where that came out as a preview. I'm excited to have that come in. That doesn't come in until the beginning of Q4, so October 1. Everything else is really panning out to be pretty nice overall. Really having all of those states as we were talking about through all of 2023 really roll those FMAP dollars into the underlying rates.

Speaker 4

States did in a very different way. Some built it into the base rate. Some put it into supplemental. Some put it into supplemental programs, including quality programs. But we're very, very pleased with where everything landed.

Speaker 4

And that's why you see those large jumps when you look at our rate table is because now they're included in base rate, which is way more stable for us and creates long term visibility for us to continue to be successful.

Speaker 6

Okay, great. Thank you.

Operator

That concludes today's Q and A session and today's conference. You may now disconnect.

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Key Takeaways

  • Ensign delivered a record first quarter with consolidated revenue up 13.9% to $1 billion, GAAP EPS rising 13.3% to $1.19, and same-store occupancy reaching 81%, surpassing pre-pandemic levels for the first time since Q1 2020.
  • Acquisition momentum remains strong, with 39 operations added since January 2023 (including 43 LTAC beds and 202 senior living units) now representing over 25% of total beds, and a robust pipeline of new deals across eight states.
  • The company expects the new CMS minimum staffing rule to worsen industry labor shortages and plans to challenge or mitigate its impact, but cites its decentralized operating model and proven track record of adapting to regulatory changes to continue driving growth.
  • Talent management initiatives are yielding results, with agency usage down 59% since its peak in December 2022, caregiver turnover falling for the tenth consecutive quarter, wage inflation moderating, and net new hires increasing.
  • Ensign reaffirmed 2024 guidance of $5.29–$5.47 EPS (up ~13% year-over-year) and $4.13–$4.17 billion in revenue, underpinned by $1 billion in available liquidity and disciplined growth strategies across same-store and transitioning facilities.
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Earnings Conference Call
The Ensign Group Q1 2024
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