Acadia Healthcare Company, Inc. (ACHC) Earnings Call Transcript

Good afternoon. Welcome to the Acadia Healthcare presentation. My name is Ting Zhang. I'm from the JPMorgan Healthcare Investment Banking team. It's my pleasure to introduce Chris Hunter, CEO; and David Duckworth, CFO of Acadia Healthcare. Without further ado, I'll pass it over to the company.

Thank you, Ting, and good afternoon, everyone. Before we get started, we'd ask that you please review our safe harbor statement on Slide 2. There are going to be 3 parts to our prepared remarks today, and I'm going to cover the first 2, the introduction to Acadia in our industry and the overview of our strategy and then David is going to clean up with a deep dive on our growth and financial projections. Maybe just to start, we believe that Acadia is the leader in behavioral health in a moment, really of unparalleled need in our country. We're the single largest stand-alone behavioral health company in the country with 246 facilities, 75,000 patients that we have the true privilege of serving every day. And today, we have a strong foundation to build on during a time of record demand for behavioral health services particularly coming out of this COVID pandemic. So we feel like this is an inflection point for the industry and that we can become the company that takes a leadership role and really helps lead and drive the industry moving forward. Acadia, as the leading pure-play behavioral health provider in the country, has both national and regional scale, as you can see on this map of our 246 facilities. We have programs, services and facilities that are spanning the full continuum of care in locations across 39 states in Puerto Rico. We have 4 complementary service areas. So in green, you can see the 51 acute facilities where we're treating high acuity patients in inpatient facilities. In orange, you can see our 37 specialty facilities where we're treating primarily substance use and eating disorder patients. In blue, you can see our 148 comprehensive treatment center or CTC facilities where we treat opioid use disorder patients in outpatient settings. And finally, in purple, you can see our 10 RTC facilities, residential treatment centers, where we are treating children and adolescents with behavioral health disorders. This slide demonstrates our strong revenue diversification across not only our service lines, but also payers and geographies. So our service lines on the far left are acute inpatient service line accounts for slightly more than half of our revenue, 51%. Our specialty segment represents just under a quarter at 22% and the rest being comprised of our CTC at 16% and RTC business at 11%. In the middle, on the payer front, we treat patients with both government and commercial insurance with 50% of our revenue generated from Medicaid and commercial accounting for about 30% in Medicare, 15% with some modest self-pay. And then we also have strong diversification with facilities across 39 states in Puerto Rico. You can see Pennsylvania is our largest state, the only double-digit state that we have at 13%, followed by California at 8% and significant fragmentation after that. This is a quick overview that we shared at our Investor Day of our executive team that we're really proud of and that brings over 300 years of combined experience in the healthcare space and a healthy mix of tenure at Acadia as well. So our experience as a team is fast and diverse. We have executive leaders that have very complementary backgrounds in health insurance, technology, healthcare services, financial services and of course, extensive behavioral health experience that they bring as well. Last week, we announced Laura Groschen as the newest leader on our team. You can see her picture at around 10 o'clock on this wheel. Laura brings significant IT and business leadership experience and a real history of leveraging technology and supporting a culture of innovation for leading healthcare companies. She's going to be an integral part of the transformation that we lead as a company, and we're really looking forward to the renewed IT focus that we will have as an organization to execute on our growth strategy moving forward. A few comments on the industry dynamics that our team is tackling. Just to start on the left-hand side of the slide, you can see the significant unmet need that is universally recognized across the world coming out of the pandemic. So 30 million Americans with mental illnesses that receive no mental health treatment at all. There's been a 3x increase in depression symptoms for adults in the United States during the pandemic and a 30% increase in death by suicide just in the last decade. That was really exacerbated by the issues that are coming out of the COVID-19 pandemic. I would contrast the left side of the slide with what you see on the right. The industry that we are in right now is still highly immature and fragmented characterized by a lack of integration between behavioral health and physical health as compared to other parts of healthcare, which we believe presents a real opportunity. Someone today that is diagnosed with a behavioral health condition is going to consume 4x the amount of resources that someone that does not have a behavioral health condition. And on the technology front, there are very few parts of the healthcare industry today that still have the level of paper that we still see in the behavioral health industry. And there are several reasons for that, really stemming back to the 2009 HITECH Act, which did not include behavioral health as part of the $25 billion that was allocated at that time. There's still a real lack of EMRs and analytics in our industry that are not leveraged to the extent that you see in other parts of healthcare and the broader economy. And all of that together, this large unmet need that's highly recognized, the low industry maturity together with, we think, provides a significant opportunity for our company moving forward. So I'm going to move on to a quick review of our strategy. Our strategic vision is very simply to become the indispensable behavioral health provider for high acuity and complex needs patient populations. We have 3 core strategic priorities that we laid out in our Investor Day last month. The first is to accelerate our pace of growth in new facilities. We have high confidence in our ability to increase our pace of new market entry and we'll be doing so through multiple paths through joint venture partnerships, de novo builds and mergers and acquisitions. Secondly, to expand our care continuum, particularly for patients with opioid use disorder and other substance use disorder conditions. We plan to grow both our inpatient and our outpatient services across our markets and continue to expand the way that our patients seek treatment. And the third part of our strategy is to further strengthen our capabilities, including through selective technology investments to continue to differentiate and improve the way we deliver care to our patients. This will be reflected as an increase in our historical level of investment in these areas. And let me just spend a few minutes on each one of these 3 strategic priorities in the next 3 slides. First, our first strategic priority is to fuel facility growth. And we believe that we're uniquely positioned to execute against a broad range of opportunities across our service lines. So first, our facility expansions. We have an opportunity to add beds to our existing 246 existing facilities. We've been able to average about 300 beds a year, and we expect that number to continue moving forward. Second, joint ventures. We continue to work hard on joint venture partners. We have 18 joint venture partnerships that we've signed with definitive agreements, 9 of those are actually operational and another 9 will be coming online in the coming years. Third on de novo facilities. We believe there's a significant opportunity not only on the acute and specialty side, but also with our CTC business as we canvass the landscape of attractive MSAs and underbedded markets to continue to fill in, add and bring differentiated services. And fourth and finally, on the M&A front, we've been very active in M&A historically. We had high leverage levels during the U.K. acquisition that we've done. But since that has been divested, we've continued to delever the company down to 2.1x today, and our strong balance sheet, we believe, will provide an important part of our growth going forward. Finally, at the very bottom, we have a strategic imperative to expand our continuum of care. We're focusing on adding additional partial hospitalization programs and IOP programs, which are step-down programs that expand our virtual level -- our virtual care offerings that are going to continue to play an important role moving forward. This ability to fuel facility expansions is really the first prong of our strategy. Again, the second prong of our strategy is to accelerate expansion across the care continuum. So we provide an extensive range of services for behavioral health patients with high needs. We have 24/7 facilities that include inpatient care, detox, residential treatment, partial hospitalization programs, intensive outpatient treatment, standard outpatient treatment, opioid treatment programs, virtual care delivery and mobile units that you can see on this slide that all work together to extend our reach. And this expansive set of services, both in institutional care and in the community gives us an opportunity to follow our patients across the behavioral health journey and meet them where they are and where they need us most. And I would say this is not only beneficial for patients but also remains the top priority among referring providers today as it affords them an opportunity to positively impact the quality and the cost for our patients. Third and finally, we have a strategic priority to strengthen our capabilities and selectively invest in technology to drive clinical excellence as well as financial results. So we're going to continue to focus on clinical integration and whole person care to address the historical lack of integration in the market. For example, this is done through our JV partnerships with health systems. We're also innovating with clinical treatments which differentiates us with other behavioral health providers. We're going to continue to work with operational improvements and efficiencies with the ambition to elevate our return on invested capital. And we know that in a tight labor market, our people will continue to remain our greatest resource, and we'll continue to enhance our people practices to recruit, retain and develop the best clinicians and staff that we possibly can. So we're going to continue to make selective investments in technology to advance our strategy with returns and performance, clinical outcomes and ultimately, in patient experience as well. So with that, I'm going to turn things over to David Duckworth to provide a little bit more detail on our growth strategy as well as our financial projections.

All right. Thank you, Chris, and following that review of our strategy. What I would like to do is review the growth outlook that we have for the company. And where Chris talked about fueling the facility growth and the different growth pathways that we have. We have developed a projection that we'd like to share as to how each of those growth pathways contributes to the company's growth over the next several years. It's an area where we have a lot of visibility as to how the company is growing, and so we'll talk about that. For each of the pathways that you see on this page, those include joint ventures, facility expansions, and de novo facilities that we are opening across our service lines. We will not spend time on the next couple of slides on M&A or the continuum of care initiatives. Those are initiatives that would be incremental to the growth outlook that we're sharing today and the EBITDA growth that we're projecting that we'll share on the final page. So let me start with joint ventures. We are drawn to joint venture partnerships in a number of markets where we think there is a clear leader in a health system that we think would be beneficial to partner with. We are brought into those joint ventures because we have the clinical excellence and expertise and we're brought in to really help enhance the behavioral health service offering that, that health system is providing today. They are interested in doing more. They are more aware than they've ever been around the connection between their patients, behavioral health and their physical health needs and looking for us as a partner that can help them really enhance their behavioral health offering. As Chris mentioned a minute ago, we have 18 partnerships that we have signed today and announced over the last several years. We are incredibly proud of the systems that you see on this page. Of those 18, our ninth just opened right at the end of the year, and we have 9 more that we'll be opening over the next several years. There is a -- let me flip a page to show you the history and the projection of our joint ventures. But there's a tremendous amount of work associated with each one of these, the level of discussion that we have with health systems as we plan for what a partnership might look like in their market and really get to know each other as a company, the track record, the reputation, the focus on quality that our partner has as it gets to know Acadia and that we have as we get to know the health system does really take a lot of time. And it's been an initiative, as you can see on this page that we've had in place going all the way back to 2015 when we opened our first partnership which has been a great facility, Southcoast Behavioral Health in Massachusetts. And since then, we're really on a pace of opening around 1 joint venture facility per year with the focus on behavioral health, with an increase in the number of discussions that we've had across different health systems. We have already seen that accelerate to for the past couple of years, really being 2022 and 2023. We're seeing 2 joint venture facilities a year. And as you think about the timing of those 9 facilities that we've signed today that are not yet open, we're setting up for that to further accelerate going into 2024 and 2025 to 4 new joint venture facilities in each of those 2 years. And I'll say the pipeline of additional discussions continues to be strong, and we think will support an ongoing joint venture number around that level even beyond 2025. We included at the bottom of this page, just the timing of when each 1 of those announcements will come online over the next few years, just knowing that we have these specific partnerships that are already in the development phase. Many of those have broken ground. We're constructing a building with our partner, gives us a lot of confidence and visibility into the growth that we will see in our joint ventures. Secondly, the facility expansions are a tremendous opportunity for the company. We are seeing expansions across all of our service lines. Our acute, our specialty, our CTCs and our RTCs are all seeing expansion opportunities as they have a strong business locally in our existing markets, and they are seeing demand growth, they're seeing specific demand for certain types of programs that they're really able to partner with their local referral sources, others in their community identified the additional need for services in that market and leverage the existing operations that we already have to open a new program and really meet that rising demand that exists in our local markets. This is the highest return opportunity for the company because we do have an existing operation that we're able to leverage from just the building that we already have and the people and resources that we already have locally. Some examples at the bottom are included really to indicate the different types of opportunities that we have across acute and specialty facilities. Our operators and our operations leadership team do a tremendous job planning ahead for this expansion in our facilities. We do not want to get to the point for any of our facilities where we're not able to provide care to that patient that needs care. And many times, we have a very high occupancy. And in order to continue to treat as many patients as we can, we need to be growing our existing facilities so they can continue to treat more patients. On our de novo opportunity, a few details here. At the top of the page, we're summarizing the number of CTC de novos that we've opened over the last several years. If you didn't pick up on it a minute ago, our CTCs, our comprehensive treatment centers, treating opioid use disorder. This has been an area of growth for the company. And we see this opportunity accelerating from around 6 de novos a year to 14 de novos a year starting in 2024, supported by the need for more people that have opioid use addiction to receive treatment. And we don't want the lack of a treatment location around where that patient is that needs treatment to be a reason that they don't get care. So that is the support for the acceleration in our CTC de novos. Additionally, our inpatient de novos have been around 1 new de novo a year. Those are similar to joint ventures, except we open a new facility, not having a partner which is attractive in certain markets where we think there's a fragmentation of health systems in that market. And that's been around 1 de novo a year. Going forward, we have profiled and really applied filters across all the MSAs of the country and believe that there's still a significant underbedded situation in our industry. And there's 100 markets that we believe are significantly underbedded and in need of acute facilities. To meet that need, we have a plan to increase our de novos from 1 to 2 a year. And hopefully, we can do more than that, just knowing how significant the need is, but our outlook is that those acute de novos would grow from 1 to 2 a year. And additionally, something the company has not historically done, but is part of our outlook starting in 2024 is to open specialty de novos. There's also a significant need for specialty locations in markets where there's not enough treatment options and specialty programs. And there's a number of markets that we are in, in our acute service line, where we believe to have the right continuum of care in that market, we need to open a specialty de novo, and so our outlook includes specialty de novos being a part of the company's growth. Ting, I'm sorry, I'm over time, but I'll wrap it up here in a minute. Just to present real quick, a combined outlook across those different pathways that we just reviewed with the growth that we talked about in our joint venture facilities, along with specialty de novos and acute de novos growing and our facility expansions continuing to be an opportunity. We see the number of beds that we're adding to the company growing from 600 to 700 a year, which is where we've been the past several years to over 1,100 beds a year starting in 2024 and I'll reiterate here, given the visibility that we have into our joint ventures, we have a high level of confidence in opening these new beds to the company in 2024 and 2025. The impact of that, we have, for the last couple of years, had an EBITDA growth target for the company, which is an organic EBITDA growth target, not including M&A of around 10%. We listed here on the page as 9% to 10% that we see growing because of the incremental facilities and the acceleration in facilities being added to the company. We see that growing to a range of 10% to 12%, which we believe starts in 2024. And really, as those new facilities open and as they mature and build their operations, we see that growth rate opportunity continuing for the company, and it's in that range of 10% to 12%. And again, that does not include M&A. As Chris mentioned a minute ago, we have a very strong balance sheet, but we also have the ability to be disciplined on M&A, knowing that we have these different ways of growing, we can really be selective and look for the right M&A opportunity that is at the right valuation and provides the right return for the company, and we can compare that against what we can do through these other growth pathways. But we do believe M&A opportunities will be there and will be attractive and will be incremental to these numbers that we're sharing on this slide. Okay. That concludes the slides that we brought, and I'll turn it over to Ting to moderate a Q&A session.

Thank you, Chris and David, for the fantastic presentation. We're now transitioning to Q&A. Please feel free to raise your hand if you're in the room with us. And for people joining online, please feel free to enter questions in your portal and we'll read out them. Okay. We have a question online. Are you planning to expand in Europe or Asia?

No. I mean I would elaborate on. I mean, we clearly had done a U.K. acquisition before I came into the company. We feel like our focus on the U.S. over the last couple of years and the opportunity that we have, particularly coming out of the pandemic, the significant tailwinds that we see as an industry that there's more than ample opportunity for us to grow domestically. So in the near term, the answer is no.

I just have a question here about [indiscernible] discussion with the states in terms of capacity of opioids obviously [ litigation ] being resolved. How is that added in the forecast [indiscernible].

Yes. And I guess we can repeat the question just to make sure everyone heard it. The question was about the state's focus. We're in 32 different states in our CTC business, and the question was about how we're working with those states on adding capacity, knowing that those states are receiving and are in the early innings of deploying settlement money related to the opioid epidemic. And we have had, for a number of years, close working relationship with the states that we're in for that business. And even in advance of this settlement, states have been receiving some federal dollars around other grants that have been given through SAMHSA over the last several years, just knowing that even before this settlement, there was a focus at the state level on the opioid epidemic. We're working very closely with the states, believe that there are a number of ways we can improve the situation where less than 10% of people that need that treatment are receiving treatment today. There's a number of initiatives focused on access that we are bringing to states and counties that are at work today on deploying those dollars. It is early. So we -- over time, I think we'll be sharing more detail as to how we fit into that. And because of that, we would say it's not directly included or quantified within our outlook. But indirectly, as we think about our CTC de novos growing from 6 a year to 14 a year, part of that is supported by the expectation that states will be using that settlement funding to add additional treatment locations and looking for us to be a partner to them as they do that.

I would just add that in this country alone last year, we saw over 100,000 deaths due to overdose. And we have over 60,000 patients in treatment in our OUD centers. This is an area where we need more access. In this country, we think we can play an important role. I think the settlement dollars are going to help us to that end. We have a new leader in Dr. Nasser Khan, who's leading this part of the business, but it's still very early in terms of exactly the mechanics of these settlement dollars, but we feel like we could be a great resource to these states and are positioning ourselves to come alongside and help them accordingly.

Okay. I have a question. You had mentioned you did a first Investor Day, congratulations. What do you hope investors took away from that? And what did you accomplish?

Sure. I'll start. This -- we've been a public company for 11 years, and we had never done an Investor Day before. We did our first last month at Carnegie Hall on December 7. There were a number of things that we were trying to accomplish in that Investor Day. I think, first of all, we needed a little bit more time than the traditional 30, 40-minute investor presentation to go through the demand characteristics that I lost over quickly in the opening remarks. I think we also wanted time to go into more depth with our service lines and to really lay out for investors the opportunity that we see there. Likewise, we wanted to profile our management team. Investors frequently hear from David and myself, but we have built a really strong team that clinical leaders and really talented leaders that we've been able to attract into the company that we wanted to give an opportunity to also present. And then I think also just given the historical underinvestment in technology in the company, we wanted to have a little bit of time to talk about our expectations with respect to deploying technology and what investors can expect on that front. But David, what would you add?