Amedisys Inc (AMED) 2008 Q3 法說會逐字稿

Good day, and welcome to the Amedisys third quarter 2008 earnings conference call. Today's conference is being recorded.

At this time, I would like to turn the conference over to Mr. Kevin LeBlanc. Please go ahead, sir.

Thank you. Good morning, and thank you for joining us today for the Amedisys investor conference call to discuss this morning's third quarter 2008 earnings announcement and related matters. By now you should have received a copy of our earnings press release. If you have not received the press release, you may access it on the Investor Relations page on our website at www.Amedisys.com.

Joining me on today's call from Amedisys are Bill Borne, Chairman and Chief Executive Officer; Larry Graham, President and Chief Operating Officer; and Dale Redman, Chief Financial Officer. Also speaking today will be Alice Ann Schwartz, Chief Information Officer and Senior Vice President of Clinical Operations; and Jeffrey Jeter, Chief Compliance Officer.

Before we get started with our call, I would like to remind everyone that any statements made on this conference call today or in our press releases that express a belief, expectation, or intent, as well as those that are not historical facts, are considered forward-looking statements and are protected under the Safe Harbor of the Private Securities Litigation Reform Act.

These forward-looking statements are based on information available to Amedisys today, and the Company assumes no obligation to update these statements as circumstances change. These forward-looking statements may involve a number of risks and uncertainties, which may cause the Company's results to differ materially from such statements. These risks and uncertainties include factors detailed in our SEC filings, including our Forms 10-K and 10-Q.

Also the Company urges caution in considering any current trends or guidance that may be discussed on this conference call. The home health and hospice industry is highly competitive, and trends in guidance are subject to numerous factors, risks, and influences, which are described in the Company's reports and registration statements filed with the SEC.

The Company disclaims any obligations to update information on trends or targets, other than its periodic filings with the SEC. In addition, as required by SEC Regulation G, a reconciliation of any non-GAAP measures mentioned during our call today to the most comparable GAAP measures will be available on our website at www.Amedisys.com on the Investor Relations page under the link -- Press Releases.

Thank you. And now I will turn the call over to Bill Borne. Please go ahead, Mr. Borne.

Thank you, Kevin, and good morning. First, let me welcome each of you to this call. We appreciate the opportunity to update you regarding the Company's performance for the quarter, and share our vision for Amedisys.

Today's call will be a little different than past calls. As Kevin mentioned, we will have two additional speakers. Alice Ann Schwartz will be speaking today to provide more detail on our clinical approach, and results of caring for our patients. In addition, Jeffrey Jeter will be providing an overview of our compliance program.

High clinical care is a top priority, and compliance is central to everything we do as a Company. We would like investors to fully understand our commitment to both of these components of being a health-care provider, and we believe today's call is a great forum to provide that information.

Amedisys is a leader in disclosing detailed information. In our effort to even be more transparent, we have changed the format of today's call to provide a comprehensive, detailed review of our process and controls as it relates to our clinical population and compliance program. The narrative part of this call will last approximately one hour, and then we will take questions. We will file an 8-K posting this narrative for your review, as necessary.

As background, Alice Ann is our Chief Information Officer and Senior Vice President of Clinical Operations, and she has been with Amedisys for 11 years. Prior to joining the Company, she was employed as a nurse in the acute care, trauma, and cardiovascular surgery intensive care unit at Johns Hopkins Hospital, and Adams Cowley Shock Trauma Center. In the industry she is published in Outcome Improvement Measures, and has ingrained many clinical measurements within our organization.

Jeffrey Jeter has been with Amedisys since 2001, and brings a background of prosecuting health-care fraud and nursing-home abuse as an Assistant Attorney General for the State of Louisiana's Department of Justice. Both Alice Ann and Jeffrey have brought a tremendous amount of value to the Company and have been an integral part of growth and success of Amedisys over the years. We're very proud of both of them, and welcome this opportunity for them to share their knowledge and insight with our investing public.

We had outstanding results for the third quarter, recording net revenue of $322 million and adjusted earnings per share of $0.89. This represents growth of 78% and 46%, respectively, over the third quarter of 2007.

For the nine-month period, we had revenue of $847 million and adjusted earnings per share of $2.33. This represents growth of 68% and 38%, respectively, over the first nine months of 2007. Based on this performance and our expectations for the remainder of the year, we have increased guidance for '08.

During the quarter, we opened seven new home-health agencies. As a result of de novo growth and acquisitions in previous quarters, we ended the quarter with 461 home-health locations, 150 more agencies than the third quarter of '07. In addition, we owned 44 hospice agencies at the end of the third quarter of '08, 17 more hospice agencies than the prior year.

Subsequent to quarter end, we closed on two acquisitions that added seven home-health and one hospice agency in four states. In addition, we opened a startup in New Mexico last week, which is a new state for us. With these additional agencies, we have increased the number of states that we are now servicing to 37.

Frequently, we hear that our country is headed for a health-care crisis. Over the next decade, if no significant changes are implemented, we will see a continued erosion of the Medicare trust fund. Currently, 12% of all Medicare beneficiaries account for 69% of Medicare spending. The time is now to develop ways to control future spending.

There are several legislative initiatives that are currently being considered to help better manage health-care resources utilized by the chronic comorbid population. Amedisys and a coalition of leaders from the home-health industry are at the forefront of this effort.

Amedisys will continue to benefit from favorable demographic trends for the foreseeable future. But more than just riding this wave, we want to position the Company to address the care-management needs of this aging demographic, and thus maximize our growth opportunities. That is why delivering high-quality, cost-effective care to elderly patients with multiple chronic conditions is our core business.

With a nationwide footprint, a highly skilled and compassionate team of clinicians, best practices care-management programs, and a best-in-class technology platform, our focus at Amedisys is to be a key part of the solution for the health-care crises in our country.

I would like to extend a warm welcome to all of the new employees of the agencies we have acquired since our last earnings call. We're very excited that you are a part of the Amedisys family.

In conclusion, we are grateful to the talented employees of Amedisys that provide our competitive advantage of cost-effective, quality health-care services to the patients entrusted to our care. Our passion for servicing our patients, our commitment to our core values, and the culture of hard work are the intangibles that separate us from our competition.

I will now pass this call to Dale for his financial overview. Thank you.

Thank you, Bill, and good morning.

Our third quarter was another excellent quarter for Amedisys, highlighted by record revenue and earnings. Revenue grew 78% over the third quarter of 2007 to $322 million, and for the nine-month period grew 68% to $847 million. Acquisitions accounted for approximately $93 million of this increase in the third quarter and $218 million for the nine-month period.

Our net income for the third quarter was $23.5 million, or $0.87 per share. This was a 13% increase over the $20.2 million for the third quarter of 2007, or $0.77 per share. Net income for the nine-month period was $60.3 million, or $2.25 per share, while 2007 was $48.4 million, or $1.85 per share, an increase of 22%.

Included in the third quarter -- excuse me -- in the three-month and nine-month periods ended September 30, 2008, are certain TLC integration costs. These costs totaled $1.1 million, or $0.02 per share, during the three-month period, and $3.7 million, or $0.08 per share during the nine-month period. They primarily consisted of severance costs and costs related to the conversion of the TLC agencies to our operating systems.

In addition you may recall, in the third quarter of last year we had a onetime, non-cash gain of $4.2 million, or $0.16 per share. After adjusting for these items, our earnings per share increased by 46% to $0.89 for the third quarter, and 38% to $2.33 for the nine-month period. We have included these adjustments in the rest of our discussion this morning.

Our gross margin was 53% for the third quarter of 2008 compared to 53.3% in 2007, and 52.7% for the nine-month period compared to 53.2% for the same period in 2007.

Our G&A expense including depreciation and amortization as a percent of revenue remained flat at 39% for the third quarter compared to 2007, and increased to 40% for the nine-month period compared to 39% in 2007.

EBITDA for the quarter was $49.4 million, or 15.3% of revenue, versus $33.7 million, or 18.6% of revenue, during the third quarter of 2007. EBITDA for the nine-month period was $126 million, or 14.9% of revenue, versus $83.6 million, or 16.6% of revenue.

Let me now take a minute and talk about our accounts receivable. As you know, we adjust our Medicare home-health and hospice revenue for amounts we do not expect to collect from Medicare through an estimated revenue adjustment that reduces both revenue and accounts receivable. This estimated revenue adjustment was for $2 million and $4.1 million for the three- and nine-month compared to $900,000 and $2.5 million for the comparable periods last year.

On our non-Medicare accounts receivable, we provide an allowance for doubtful accounts, which is netted against patient accounts receivable in the balance sheet. Our private and Medicaid accounts receivable totaled $66.9 million at quarter end, $34.4 million at year-end 2007, and $32.3 million at the end of the third quarter of last year.

Bad debt expense for the current quarter was $6.2 million, or 1.9% of revenue, compared to $3.7 million, or 2% of revenue, for the third quarter of last year. Bad debt expense for the nine-month period was $15.5 million, or 1.8% of revenue, compared to $9 million, or 1.8% of revenue, for the same period in 2007. For the last seven quarters, this percentage of expense to revenue has averaged 1.8%.

Let me now walk you through the allowance for doubtful accounts for the quarter. We began the quarter with an allowance of $16 million. We expensed $6.2 million. We wrote off $2.2 million for an ending reserve of $20 million.

Days revenue outstanding increased in the fourth quarter of 2007 and the second quarter of 2008 by 5 days to 56.7 days. Our significant acquisition activity over the last nine months has had an impact on our billed and unbilled accounts receivable. However, we've seen a substantial increase in collections during October, and we anticipate improvement in this metric by year end.

We generated cash flow from operations of $87 million during the nine-month period. We spent $447 million on acquisitions, $21 million on capital expenditures, and we issued $412 million in new debt.

During the third quarter, we reduced our notes payable under our bank agreements by $18 million with cash generated from operations. At September 30, our leverage ratio was 1.84 times, and our fixed-charge coverage ratio was 2.3 times. This reduction in our leverage ratio below 2 times will reduce the margin on our bank debt facilities by 25 basis points. For the quarter, the average interest rate on our bank debt was 4.1%. We have $139 million available under our revolving credit facility at September 30.

Today, we are increasing our revenue guidance to the range of $1.15 billion to $1.175 billion, and earnings per share guidance to the range of $3.20 to $3.25 per share based on an estimated 26.9 million shares. This guidance includes the anticipated results of our recently completed acquisitions after adding back the TLC integration costs. It does not include any future acquisitions.

We made these changes to our 2008 guidance primarily for the following reasons. First, the integration of TLC was completed during the third quarter ahead of schedule. Second, the rollout of our clinical programs under our new specialty division is also ahead of schedule and producing positive early results. Finally, the extension of the Hurricane Katrina employment credits to August of 2009 from the prior expiration date of August of 2007 will cause our full-year effective tax rate to be lower than we originally expected.

Now I'll turn the call over to Larry for his operational comments.

Thank you, Dale.

Our internal growth rate of episodic-based revenue for the quarter grew 28% year-over-year. We define internal growth as episodic-based growth from all agencies except agencies we have acquired in the last 12 months. We believe this metric is indicative of the Company's true growth performance. The components of this metric include internal admissions, internal recertifications, and average revenue per completed episode.

For the quarter, our internal growth rate over last year in episodic-based admissions was 14%. Our internal recertification growth over prior year was 23%. The increase in our recertifications are the result of our admission growth, our startup initiative, and our agencies acquired over the past two years that have transitioned into our base agencies. As an agency opens, we first develop our census by obtaining patient admissions. However, as time progresses, these patients may require an additional episode of care and thus cause our recertification rate to increase.

It is also important to note that 67% of all of our patients have only one episode of care. Alice Ann will discuss this in more detail later in our call. To summarize this, our internal episodic-based revenue growth rate in dollars grew 28%, which consists of volume growth of 19%. As a reminder, volume growth is total episodic growth, which is admit plus recert growth.

Our revenue rate growth is our revenue-per-episode increase of $196 applied to all of our episodes. This revenue rate growth was 9%. Therefore, our volume growth rate of 19% plus our revenue rate growth of 9% equals our total growth of 28%.

During the third quarter, we opened seven new locations. We have approximately 130 startups in various stages in the pipeline. Of these, approximately 40 are incurring expenses but have not yet opened. During the first three quarters, we opened 20 new locations, and anticipate opening an additional 15 agencies in the fourth quarter, making our 2008 target 35 new home-health agencies.

Regarding hospice, while we did not open any new agencies in the quarter, we have opened four so far this year and expect one more opening in the fourth quarter.

Moving to external growth, as Bill mentioned, we closed two acquisitions on October 1. We acquired six agencies from Home Health Corporation, which consists of two agencies each in the states of Pennsylvania, Maryland, and Delaware. Revenue for these agencies for the previous 12 months ended June 30, 2008, was approximately $23 million.

The second acquisition we closed was a regional home health and hospice located in the State of Washington. These agencies had revenue for the past 12 months ended August 31 of $1.7 million.

I would like to welcome all of the new employees to Amedisys who have just joined us from Home Health Corporation and the State of Washington.

Our acquisition pipeline continues to be robust, and we continue to analyze potential opportunities as they become available.

Our quarterly revenue and contribution margin are broken down as follows. Contribution margin is pretax and pre-corporate overhead.

$211 million in home-health revenue related to agencies we have owned longer than 12 months, with a contribution margin of 33%.

$6 million in home-health and hospice-startup revenue related to startups open less than 12 months, with a negative 1% contribution margin. Also in the quarter, we incurred approximately $3 million in costs associated with home-health and hospice agencies we plan to open in the future.

$12 million in hospice revenue related to agencies we have owned longer than 12 months, with a contribution margin of 22%.

$93 million in home-health and hospice acquisition revenue associated with acquisitions completed during the last 12 months, with a contribution margin of 18%.

The agency integration and corporate department transition of TLC is complete. The wind down of TLC corporate staff continues to progress according to schedule. The two remaining regional billing centers were closed on Friday, October 24. From approximately 210 employees at the time of acquisition, TLC's corporate staff is currently at 38 and will be reduced to 14 after Friday of this week.

We believe that now as the conversion process is complete, we will see growth in revenue and contribution margin from TLC. I want to thank all of the employees of TLC for their cooperation and efforts throughout the integration process.

We launched the Balance for Life specialty division earlier this year, and we have set up the program in 97 locations. We intend to roll this program out to 160 locations by the end of the year. It helps the elderly with their balance through more intensive therapy sessions, and as a result reimburses at a higher rate than our average episode.

Some facts about the falls related to the elderly. In the United States, more than one third of adults 65 and older fall each year. Among older adults, falls are the leading cause of injury death. They are also the most common cause of nonfatal injuries and hospital admissions for trauma.

Balance for Life is one of our 13 evidence-based clinical programs aimed at improving the health of our senior population.

Before I turn the call over to Alice Ann, I want to highlight some key points related to the chronicity of our patient population. OCS, an independent health-care benchmarking firm, has just published a white paper, which will be posted on our website. I will now read from that report.

I quote --

There is a difference in distribution of risk at the provider level. Not all providers have a patient-risk profile that matches the national norm. Some have a higher distribution of lower-risk patients. Others have patient populations disproportionately representative of higher-risk patients.

Amedisys is a clear example of a home-health provider with a higher distribution of patients on the high end of the risk scale. More than one half of all patients admitted by Amedisys agencies are predicted to be of high or very high risk of hospitalization compared to just one third of patients nationwide. Conversely, only 10% of the Amedisys patients are assessed as low or very low risk compared to 23% of patients nationally.

Another indicator of overall patient severity is length of stay, with higher-severity patients requiring more days of service, as a general rule. As patient length of stay increases, hospitalization rates also increase, and many measures of patient outcomes typically decrease. The higher severity of Amedisys patients is also shown by longer length of stay than the national benchmarks, based on 2008 data.

The average Medicare patient requires approximately 1.55 episodes of care. The average Amedisys Medicare patient receives about 1.85 episodes of care. The logical result of a high-risk patient population is overall lower quality outcome scores. Yet despite caring for a population that is considerably higher risk and requires a longer length of stay than the national norm, Amedisys has shown consistently higher overall quality of care, as measured by the OCS Standardized Outcome Index, referred to as SOI, a proprietary measure that offers a single number representative of overall quality.

Amedisys not only has a higher SOI than the national database but an increasing SOI score over the past several years.

End quote.

In conclusion, Amedisys excels in a complicated care-management environment, as evidenced by a patient population with higher than national risk characteristics requiring a longer length of care and yet producing quality patient outcomes.

I will now turn the call over to Alice Ann, where she will go into more detail of why we service a higher-acuity patient. Alice Ann?

Thank you, Larry. I will begin by sharing with our investors the clinical profile of our average patient population, some information on clinical acuity -- meaning how sick or debilitated our patients are -- the risk of hospitalization, length of stay information, our focus on intensive clinical strategies. And in addition, web-based information will also be posted on the Company's coding, clinical auditing, billing, compliance, recertification controls, and state survey quality trends.

Amedisys's average patient age is 82 years old. 25% of our patient population is between 80 to 84 years old. If you extend that percentage segment beyond, almost 50% of our population is between the ages of 75 to 84. We service a more elderly senior, as opposed to the newly benefit-eligible recipient. We will provide on our website a graphical age distribution breakdown of our population.

Clinical acuity, meaning how sick or debilitated a patient is, is expressed in home care by what is known as a case-mix weight. This single score is the summary of a patient's clinical needs, functional impairment -- meaning how difficult it is for patients to move about -- and their service requirements, whether they came from a hospital or a rehabilitative setting.

We will post a three-year trend of case-mix weights on our website. You will note that Amedisys's case-mix weight is higher than both national and regional norms.

To better understand our patient population compared to external norms, we frequently engage outside benchmarking firms to perform clinical comparisons. The most recent report from OCS, which Larry just referenced, has risk stratified our clinical population according to very high risk for hospitalization, high risk, moderate, and low risk. As Larry explained, we service a sicker population than average.

To further cross validate the acuity of our patients, I will review their medication trends. Polypharmacy trends are a consistent indicator of comorbidity increases. Simply stated, a doctor orders medications for a patient to treat certain diseases. We have no control over these trends, and they are a very good indicator of how sick or how many clinical conditions the physician is treating.

In 2006 our patients took on average of eight medications per day. In 2007 our patients took on average of nine medications per day, and in 2008 our patient population is now taking over an average of 12 medications per day.

Further breaking down episodic categories to illustrate that the patients who stay on service longer have more comorbidities, patients receiving care in one or two episodes take an average of 12 medications per day, patients receiving care in episodes of three or greater take an average of 15 medications per day.

Using that same type of cross-acuity validation, functional scores -- and they're trending -- are also a useful metric in understanding a population's impairment level. In home care, patients are ranked on functional impairment scales ranging from F0, meaning minimal impairment, to F4, maximum impairment. This would be a patient that is close to being bed-bound. The new payment system does not have an F0 ranking.

We will post the Organization's past three years of functional trending scores. Investors reviewing these graphs will note a year-over-year decline of patients entering the system with minimal functional impairment, meaning scoring F0 to F1, coupled with a simultaneous year-over-year increase in patients with more debility and more chronicity, scoring F2 to F4.

Further breaking down these episodic categories, to illustrate that those patients who stay on service longer are our sickest and most debilitated -- patients with one or two episodes, 86% of those patients have a functional severity level of 2-plus or greater; patients with three or four episodes, 88% of those patients have a functional severity level of 2-plus or greater; and patients with five or greater episodes, 93% of those patients have a functional severity level of 2-plus or greater. We service a sicker population requiring greater resource needs.

You will see that our length of stay is longer when compared to the national averages. The OCS external report states that the average episodes per patient nationally for the first half of 2008 is 1.55 episodes per patient. Amedisys's episodes per patient is 1.85. This longer length of stay is supported by a higher case-mix weight, increased polypharmacy needs -- indicating more clinical comorbidities -- and increased functional debilities.

We will also post a patient-on-service graphical breakdown for all of last year. To give investors a gauge -- 67% of our population complete their care in the first episode only, 18% extend into the second episode, 7% extend into the third episode, 3% extend into the fourth episode, and so forth.

Stated another way -- 85% of our total population receives care within two episodes or less, 10% of the population goes into a third or fourth episode, and the remaining 5% is the more chronic, debilitated population extending beyond four episodes.

So as a clinical summary, our average patient age is 82 years old, with a higher case-mix weight, more pronounced functional debilities, on an average of 12 medications, and has a much higher risk of hospitalization when compared to external metrics.

I have given a snapshot at this point at the patient level. Internal and externally-validated data reveals that the Organization's burden is one of year-over-year increasing chronicity, year-over-year increased polypharmacy needs, year-over-year increases in patient debility.

With a trend of sicker patients receiving services each year, our approach has been to continue to develop our care-management systems and evidence-based clinical programs, with a focus on better servicing our senior population that has multiple clinical needs. The advanced senior who is sick and has multiple clinical needs is not going to go away. This population will only increase year-over-year.

Providers will be faced with the challenge of insuring their care-management systems remain robust enough to handle these increasingly complex patients and that their disease-management specialty programs are intense enough treatments and modalities to adequately improve chronic patients' functioning and clinical outcomes. These types of clinical programs or strategies are extremely important when faced with improving outcomes in the complex patient.

To give you several examples of intensive services, our centralized cardiac telehealth program monitors the care of over 800 patients throughout seven states. Telehealth increases the standard of care by monitoring a patient's vital signs daily, as opposed to intermittent nursing visits. We deploy this to a frail subset that requires a more intensive clinical monitoring.

Our multi-disciplinary wound program pairs nursing and therapy to provide a more intensive program focused on aggressive wound treatment in the patients with very complex wounds. Multi-disciplinary care of complex disease is considered a best-practice standard in geriatric medicine. In this program, the nursing aspect focuses on traditional nursing intervention, such as advanced wound-dressing practices, teaching in nutritional needs, and disease teaching to enhance behavioral modification and improved patient self-management.

The therapy aspect focuses on advanced modalities that only a therapist can provide that have proven effective in wound healing, such as electrical stimulation, ultrasound techniques, balancing and offloading, and Sharpe's debridement. Each discipline provides a unique skill focused on complex wound healing.

Therapy wound modality research will also be available to investors on our website.

Our centralized ET nursing division is a team of advanced practice-certified clinical nurse specialists who provide consultative wound-care services and clinical education. Working off specialized clinical reports, they are able to identify the complex, high-resource wound patients we have throughout the system, and work with the specific agencies directly to ensure our patients are receiving the appropriate evidence-based wound protocols.

Our Balance for Life specialty program focuses on improving the functional outcomes of that more chronic patient with an increased fall risk, through the implementation of evidence-based vestibular balance retraining modalities. Fall risk and safety concerns are a prime reason patients end up having to leave their home for a more intensive setting.

Through our disease-management data tracking, we have also found that the number-one reason discharged patients were going back into the hospital, post-home health services, was because they had sustained a fall. This program focuses on increasing functioning and improving balance, thereby allowing seniors to live more safely and longer at home.

Mitigating fall risk is a key strategy in saving overall health-care costs by reducing unanticipated hospitalizations. This is central to our mission. For investor interest, vestibular modality research will also be posted on our website.

We are often asked why we have a higher-acuity, or sicker patient. There are several reasons for this clinical trend. First, we spent the first two years prior to the implementation of PPS in 2000 developing our evidence-based clinical disease management programs. We were prepared, day one, to clinically service complex, resource-intensive patients.

Many providers at the time were unsure if they had the resource requirements that would allow them to service a complex wound patient and/or a multi-disciplinary need patient. Because our standardized clinical protocols and systems were in place, we were immediately prepared to go to our physicians and referral sources, and ask to service those sicker patients at a time when the industry was unsure.

Second, since PPS we have continued to focus on the highly complex patient. Rolling out our Partners in Wound Care program, Chronic Kidney Disease at Home, COPD at Home, Stroke Recovery at Home, Surgical Recovery at Home, Rehab at Home, Behavioral Health at Home, Orthopedic Recovery at Home, Heart at Home, Pain Management at Home, Diabetes at Home, Balance for Life, Telehealth at Home, and Dysphagia at Home. These are the clinical programs that differentiate our service.

Third, our strategy has always been to approach our physician base, encouraging them to use home care as a first stabilizing alternative to the hospital setting, as opposed to the latter. For example, 41% of our patient population comes directly from the doctor's office, as opposed to 29% when compared to the national level. 43% of our patients come directly from the hospital, as opposed to 56% when compared to the national level.

External benchmarking referral source statistics will be posted for our investors.

As a reminder, patients who have not been stabilized by a hospital stay originally, tend to be sicker and require greater resource needs.

Fourth and final, as we have conveyed to our investors in the past, our strategic goal has been to migrate into a chronic-care-coordination Company. With that in mind, our systems, clinical infrastructure, clinical programs, and referral strategies have all been geared to focus on the more complex population.

Shifting gears now, I would like to review with investors our field automation and business system controls.

We have 461 home-care locations that are all connected via a wide area network. All of our full-time and consistent PRN employees in home care have laptops and are using those to input clinical-visit information in the patient's home.

We had three goals when developing this system -- enhanced standardization with consistency and compliance control, the ability to have most all of our notes in digital format, and the ability to provide more intensive care-management services to our population.

We currently have 11,200 laptops deployed nationwide, making it the largest company-centered deployment in the industry. I would like to take a brief moment to congratulate the IT staff on most recently being recognized as one of the top 50 most innovative IT divisions by Information Week. Each year, this national publication recognizes the top 500 companies who have implemented business technology innovation.

You will continue to see the Company further integrate evidence-based clinical management standards in its technology, and expand its system capabilities. Details on our business system infrastructure will be posted on the website, including our organizational coding controls, clinical auditing controls, billing controls, compliance controls, patient recertification controls, and clinical auditing state survey trends. We highly encourage our investors to review this infrastructure information, because these processes are ingrained in all levels of the organization and are key to understanding our business systems and control environment.

Once investors review the information posted today, they will see clinical trends from past to present that reflect the following clinical dynamics -- an increasing trend of sicker patients entering the Company each year; a recurrent clinical auditing infrastructure that is proactive and aimed at reducing clinical risk; a point-of-care technology rolled out in 2007 that enhanced many clinical documentation, chronic care management capabilities and compliance controls; an organizational commitment to quality with defined trends of improving quality scores; a reduction in local state survey citations from 2006 to present; an increase in deficiency-free perfect surveys from 2006 to present; using CMS's survey deficiency percentages as a benchmark, Amedisys's better-than-national citation percentages in 14 of the top 15 categories; using CMS's publicly reported outcomes as a benchmark, Amedisys is at or better than its footprint in 12 out of 12 categories, at the national level, at or better in 10 out of 12.

Since the beginning of the PPS environment in 2000, Amedisys has focus on caring for the complex patient. Our focus on delivering evidence-based care to the sickest seniors will not change, because the demographic trends support this is where our clinical emphasis should be.

Clinically, we have a commitment to improving the quality of care and outcomes of our elderly sick seniors, and enhancing our evidence-based programs and chronic-care management clinical systems to best serve the elderly patients who want to remain at home for their care during their latter years.

I will now turn the call over to Jeffrey.

Thanks, Alice Ann.

As Bill stated earlier, I will address the compliance functions that occur at Amedisys each and every day. I also recommend that you review the information contained in our investor materials with respect to our compliance program, which you can find on our website.

Our compliance program features a multi-layer and recurrent approach designed to ensure the propriety of both our services and our billings. At the outset, it must be noted that the Amedisys compliance program is based on the OIG's model, Compliance Guidance for Home Health and Hospice. As Chief Compliance Officer, I am the person responsible for oversight of the compliance functions of Amedisys.

I came to Amedisys seven years ago, after serving as an Assistant Attorney General with the Louisiana Department of Justice, where I prosecuted health-care fraud and nursing-home abuse.

It should be noted, however, that I'm not the sole person responsible for compliance at Amedisys. We have an experienced team of people, not only within the compliance department, but across numerous Company divisions, who all play a vital role in the overall compliance efforts of our Company.

We also stress compliance as a responsibility of all Amedisys employees, such that compliance is part and parcel of everything we do. Moreover, we have leveraged technology and automation to support the compliance functions of the Company with the same mind set of efficiency and effectiveness that we have deployed throughout the other segments of the organization.

First and foremost, it is well established that one of the strongest compliance protections that an organization can have is a commitment to compliance training and education. Conducting adequate training often prevents problems from ever materializing. It is my belief that the vast majority of people want to do the right thing. However, as so often is the case, the regulations surrounding our business are complex and can be confusing. The goal of training is to raise awareness and educate staff on the pitfalls and risks of our business so as to avoid problems in the first place.

Therefore, as the government clearly recognizes, training and education of staff is paramount. And Amedisys has implemented a targeted and tiered training strategy to train all of our staff about the seminal importance of compliance in our day-to-day jobs. Every employee in the Company is required to complete general compliance training upon hire, and then annually thereafter.

In addition, any staff involved in billing and coding functions, both from a corporate level as well as a local agency level, must participate in a separate billing-compliance training. We also require that all of our billing personnel complete annual competency testing and training. Similarly, our sales force is required to receive special compliance training concerning how they market, and the constraints and legal limitations placed on their marketing activities by the federal anti-kickback law and the Stark law.

Compliance experts will also tell you that the tone at the top is essential in establishing a resounding culture of compliance. Amedisys embraces this sentiment. Every other month we host a program called new employee orientation, where we bring in newly hired employees to a regional location, where the entire meeting is devoted to the Company's core principles and values.

During this orientation, Bill Borne, Larry Graham, and I each speak on individual responsibility and accountability, as well as the role that each employee plays in both our success and our compliance.

Beyond all the training that Amedisys requires, we also monitor our compliance and the propriety of our day-to-day activities through a number of technological and auditing controls. I find it most useful when describing these ongoing compliance controls to stratify them in terms of their local, regional, and corporate scope. Consequently, I will briefly detail each strata of compliance control.

Our compliance controls actually begin on the local level with our standardized clinical tracks, which are used in the delivery of care to our patients. We employ these guidelines in an effort to ensure the consistency of care across all of our markets. Therefore, our diabetic patient in San Diego, California, receives the same high quality of care and the same type of services that are received by our diabetic patient in Charleston, South Carolina.

These clinical tracks are rooted in best practices and demonstrate clearly how we can consistently meet and exceed national quality benchmarks for outcomes across all of our many markets.

Additionally, our point-of-care system represents a fundamental compliance control and is the sort of technology that helps us improve not only what we do in terms of clinical care but how we do it in terms of our adherence to Medicare rules and regulations. Through our point-of-care system, we're better able to ensure the accuracy and completeness of our documentation, and when used in concert with our clinical management dashboards, allows for real-time assessment and review of our coding and documentation. One simply cannot overemphasize the importance of this technology as a means for strengthening our compliance with the law.

Based on my experience as a health-care fraud prosecutor, I have found that a provider's documentation is often a make or break aspect to their overall compliance. A home-health agency can be delivering the best and most appropriate care in the world. But if the documentation of the services being provided is not reflective of the billings being submitted, then the agency is placing itself at substantial risk.

Amedisys's point-of-care system elevates the quality of our documentation, which goes hand-in-hand with better compliance. Amedisys saw firsthand the importance of improved documentation back in 2003 in a matter that we self-reported to the OIG related to our agency in Monroe, Louisiana. As our investors will recall, we disclosed the settlement of this issue several years ago. Ultimately, several thousand dollars in overpayments because of insufficient documentation led to a $1.1 million settlement.

This experience underscored for us the inherent compliance value of an improved system of documentation, which was ultimately manifested as our point-of-care system. The point-of-care system used by Amedisys clinicians now helps to avoid inadvertent or erroneous omissions of information that may subsequently affect clinical quality, impact reimbursement, or create survey deficiencies and legal liability.

A fundamental compliance control of our point-of-care system is the system requirement that clinicians fully complete their documentation prior to submission. And where their responses are inconsistent with one another or are potentially erroneous, we have the means to identify and catch problems before these mushroom into major issues.

While we still require that the actual remediation of these problems be undertaken only with the approval of the clinician actually seeing the patient, our technology affords us the ability to scrutinize for gaps and potential problems, and thereby reduce the occurrence of porous or errant documentation.

Our point-of-care system also requires that the visiting staff obtain patient signatures during their visits, which are both time and date stamped. This process significantly inhibits staff from falsifying visits, because we're able to note inconsistent signatures, and we can identify discrepancies in visit times, suggestive of a staff member not making scheduled visits.

It is also not coincidental that as Amedisys has moved our agencies to the point-of-care system, we have noted a marked increase in the number of deficiency-free state surveys that we undergo. This is a direct benefit of the better documentation afforded by our point-of-care system.

From a technology standpoint, we utilize a series of data scrubs and edits in an effort to assure that our OASIS information makes sense from both an accuracy and consistency standpoint. For example, if a clinician answers in one portion of an assessment that a patient cannot safely ambulate, but in another portion of the assessment, the clinician indicates that the patient needs no assistance to get in and out of the bathtub, then these answers are inconsistent with one another, and one of the responses may not be accurate. Our systems are programmed to catch these types of inconsistencies, such that potential problems can be resolved on the front end.

We also employ other types of technology, such as 3M coding software, to further support the propriety of our billing practices.

At a regional level, Amedisys conducts unannounced compliance and billing audits, led by our regional staff, to monitor compliance, review agencies deemed to have elevated clinical risks, and resolve any problems that are identified. We also require that our operational leadership participate in the audit process in order to actively engage those responsible for shaping and implementing corrective action plans, and getting the necessary buy in to resolve any issues identified.

Lastly, at a corporate level, we conduct quarterly compliance oversight audits, which warrant additional discussion. This compliance oversight audit program is conducted by clinical auditors reporting to me. Let me start by saying that we have seen no trend of fraud or abuse, nor a pervasive pattern of improper activity in our audit findings since the inception of our compliance oversight audit processes in 2005.

It would be fair to say, however, that we routinely identify problems in the course of our audits, as one might expect as part of any serious quality assurance process. However, these are generally found to be problems where agencies are not following the prescribed processes, or staff are not consistently documenting their work, or there are educational deficiencies.

Let me briefly describe for you the compliance oversight audits that Amedisys conducts each quarter. Beginning in early 2005, we identified three key areas to which any home-health-care agency may be susceptible because of the inherent revenue impact of each. These are, first, excessive therapy, where a high number of therapy visits are conducted, which results in increased reimbursement and may be potentially suggestive of fabricated or unnecessary visits just to increase reimbursement.

Second, LUPA exaggeration, which is where an agency has an exceptionally low number of low utilization payment adjustments, otherwise known as LUPAs, which may be suggestive of potentially fabricated or unnecessary visits so as to avoid having reimbursement automatically reduced by the government.

And third, up-coded case mixes, where an agency has a higher-than-average case-mix weight that may be suggestive of possible manipulation of coding occasioned by scoring patients as sicker than they actually are.

These are big-bang-for-the-buck kinds of risk areas for fraud. Since 2005, one of the primary functions that my compliance auditors have performed is the proactive review of agencies that perform well in each of these areas. We have focused on those Amedisys agencies performing very well with respect to having a higher percentage of high profitability therapy episodes and having a lower incidence of low reimbursement LUPAs and in having overall higher-reimbursement case-mix scores.

Now, it should be noted that just because an agency has a high percentage of high profitability therapy or a low occurrence of LUPAs or a higher case mix does not necessarily mean that there is something improper or untoward occurring. In each instance, there may well be wholly appropriate justifications for each risk category. However because of the revenue implications of each, there exists a potential for improprieties, which we feel warrants a compliance review.

Since 2005, my staff has audited those agencies that stand out based on these high-revenue audit-focus areas. In these audits, my compliance staff selects the agencies to be reviewed, conducts the clinical chart reviews and billing reviews, develops corrective action plans where problems are identified, conducts remedial training and education where necessary, and ensures that any billing adjustments are processed if warranted. They are also responsible for monitoring the ongoing improvements that occur in those agencies.

We are also continuously refining our audit processes and risk controls. For example, this year we have developed a compliance-risk scorecard that expands on the three compliance-risk areas previously detailed. Under this compliance-risk scorecard, we have identified some 43 individual risk measures, drawing on data points that are reflective of financial risks, operational risks, regulatory risks, and environmental risks.

For example, we still consider whether an agency has excessive therapy, exaggerated LUPAs, and high case mix. We also now take into account considerations such as high turnover, changes in agency leadership, inexperienced agency leadership, startup or acquisition status, missed visits and survey deficiencies, among many other risk factors. All of these data points are weighted and scored, and agencies are audited based on the scorecard results.

Additionally, my compliance auditors are responsible for conducting audits related to complaints that are made on our Company hotlines, as well as issues identified in exit interviews. They also conduct special audits in my direction, which have included reviews of high-risk clinical events, such as Coumadin administration, as well as other compliance risks, such as outliers and high recertification patients.

Furthermore, I would be remiss not to point out that we also have annual Sarbanes-Oxley audits that are conducted by a separate department within the Company, as well as audits that are conducted by KPMG, who are our independent auditors. Both of these groups look at our internal controls over financial reporting related to our billing compliance and revenue practices. We also have a substantial internal audit department that conducts its own independent reviews of our processes and practices.

In addition to our audit capabilities, Amedisys attempts to glean problems that may be festering by providing ample opportunities for staff to report their concerns. In so doing, we have implemented several avenues for fielding complaints from both current and former employees. We use a confidential compliance hotline that is available 24 hours a day, seven days a week, and permits employees to report problems directly to me, and allows them to even remain anonymous if they so choose. This hotline also serves as our SOx whistle-blower hotline. All calls that come in to our hotlines are reported to the Company's Board of Directors on a quarterly basis.

In addition, we maintain separate hotlines to report HIPAA violations as well as harassment issues. We also provide every employee who leaves the Company with an opportunity to complete an online exit survey, which includes several specific questions about potential compliance concerns. When a former employee alleges compliance problems, my department conducts a special audit of that agency.

Moreover, earlier this year we implemented a process in which we randomly select 30 active employees each month, and my office contacts them confidentially to inquire about whether the employees have any ongoing compliance concerns that have not otherwise been reported through the compliance hotline. Any report of potential wrongdoing will be investigated, and those agencies about whom complaints are voiced will be subject to a special complaint audit. However, to date, we have had no allegation of fraud identified in these survey calls.

Finally, Amedisys has long had stiff enforcement policies for compliance violations. Our compliance plan articulates a zero-tolerance policy for health-care fraud and abuse. Therefore, if an employee is found to have engaged in fraud, we take disciplinary action.

However, in the last few years we have expanded our zero-tolerance policy. Now it is not only instances of wrongdoing that subject staff to zero tolerance. Rather, we also apply our zero-tolerance policy where staff place the Company at risk by not following key processes, even if the failure to follow those processes has not resulted in an actual problem.

Back in 2006, we identified certain key compliance-related procedures that safeguard our billing practices. Given the importance of these controls, we regard the failure to scrupulously follow each as placing the Company at greater risk.

For example, we have a series of system billing holds that will prevent a claim from being billed if it has certain unresolved problems, such as missing physician orders. If in the course of an audit we find that these controls were circumvented, then the staff member responsible for so doing is terminated. In fact, we have terminated several dozen employees for these kind of zero-tolerance violations over the past two years.

Therefore, in summation, Amedisys's compliance program is driven by technology with an emphasis on training, documentation, and risk-based auditing. I hope this gives our investors a good flavor of the compliance program and practices at Amedisys.

With that, I would like to turn the call back over to Bill.

Thank you, Jeffrey and Alice Ann. I hope the additional information provided today brings a clearer understanding of our clinical and compliance processes.

At this time we'll open up the call to your questions. Because of the extra time we have taken today, we ask that you please limit yourself to two questions. We may not be able to answer everyone's call today. If your question was not answered, please contact our Investor Relations department, and they will be able to answer your questions.

Brian, please open the line to questions.

(Operator Instructions). John Ransom, Raymond James.

I have writer's cramp. That was quite an hour. It's good. The question I had -- if you look at your clinical mix -- I know your recerts have gone up and your case mix has gone up. But if you just look at your pure raw clinical mix, what is different about your -- the distribution of your population today say versus pre this new Medicare PPS change?

Just to give you a gauge, when we look at our population in total, 60% of our population is divided into four categories -- cardiac patients, wound-care patients, diabetes, and stroke patients.

From -- currently, the cardiac category represents about 27.4% of our population. That's increased from 2007 to 2008 by a little under one percentage point.

The wound-care population right now runs a little under 15%, 14.95%. That's increased approximately 1% from '07 to '08.

Diabetes, the third category, is at 11.85%. That's gone down a little bit, 0.83%, from the prior year.

And then our stroke category currently represents about 5.5% of the episodes, and that's gone up almost 2% -- 1.7% -- from the prior year.

The remaining 40% are just various clinical conditions -- non-categories that happen throughout the system. So those are the macro trends.

My second question -- and this is for Dale. Dale, could you give a little more color on your -- the process by which you reserve for the bad debt, particularly the Medicare Advantage Plans, and when that receivable goes -- when it gets written out to -- written down to the income statement and then when ultimately it gets charged off on the balance sheet? Thank you. And I'll get back in queue.

Yes. On the allowance for bad debts, which is our non-Medicare receivables, we age those receivables, and we look at it on aging basis. We also look at it on a vintage basis, where we look at the amount collected over time. And as a balance between those two, we provide a provision on a quarterly basis against future bad debts. And as we talked about today, that was $6.2 million in the third quarter.

On our Medicare receivables, which would be home-health Medicare and hospice Medicare, as well as MA, we provide a revenue adjustment, which -- we collect almost 99 -- over 99% of our Medicare receivables. And when we do that, we end up with a revenue adjustment that we provide against revenue and accounts receivable.

I'm sorry. MA is not included in that issue. That's only on Medicare we provide the revenue adjustment. MA is a part of the allowance for doubtful accounts.

So that's a breakdown on how we do that, and as we also pointed out in our discussion this morning, our allowance for -- our provision on our allowance for bad debts has averaged about 1.8% of revenue for the last seven quarters.

He also asked about write-offs, when you write stuff off.

We have a policy that we evaluate our receivables on a regular basis. We do not have an arbitrary deadline in which we charge off a particular receivable. But as a practice, almost all of the receivables that we charge off are fully reserved. And that means, in the period in which we charge them off, there is no impact on income in that period. The income effect of that charge of was taken in prior periods as we build that reserve as it ages. And when we get to the point of charging if off, it really has no impact on income.

Thank you Dale. Next question?

Art Henderson, Jefferies & Company.

Thanks for all the color on compliance. It's very helpful.

Larry, I know in the last conference call you had discussed, as far as your de novo developments are concerned, some delays in getting Medicare provider numbers for those agencies that are incurring expenses at the moment. I was curious, are you seeing any sort of change there as far as any acceleration of those issuances?

Yes. We only opened up seven in the third quarter. We expect to open around 15 in the fourth quarter. So we have seen and we have improved our communication with the intermediary about the status of our startups. It's still totally out of our control. And this quarter, I gave some more color to let you know that we have 130 startups that we've identified that we want to open, of which about 40 are incurring expenses, which cost us about $3 million in the fourth quarter.

I'm trying to send the signal that even though the startup process has slowed, we are aggressively pursuing startups. It's a significant part of our growth strategy, and we feel good about the accretion that they provide over time.

And then the follow-up question is kind of for both, I guess, Bill, you and Larry, whichever one would want to take it. Just in light of the presidential election next week and the platforms that are currently out there, as well as the economy weakening, could you kind of give your thoughts about how home nursing is positioned as we move ahead? How resilient do you sort of feel the space is, and what sort of opportunities may exist moving ahead under either of those two candidates?

Well, as you've heard from both candidates, that everybody has a focus on caring for the chronic and complex population. There hasn't been a clear formula yet as a today on how we're going to move forward, and that's why Amedisys has really targeted that population.

With McCain you'll probably see less change. With Obama you may see more overall change. Either way, we think that both of the dynamics of either change will include a better and more effective way to care for the exact patients that we have been managing over the years.

So we feel as an industry and through our efforts with the alliance, we have brought a value proposition to the regulators and the administrators in Washington, and we think we're well-positioned, no matter who becomes President, to be able to show the value of managing these very costly patients in our system through the home-health process.

Kevin Ellich, RBC Capital.

Just kind of following up on that question, given the challenging economy, have you seen or do you expect to see any changes in utilization of any of your services?

This is Larry. No. We're pretty recession proof because we're in health care. Bill mentioned that we service the chronic comorbid population -- 82 years old. So their need for services do not ebb and flow with the economy.

Okay. And then, going back to some of the prepared remarks on the compliance and clinical care, it looks like you guys are servicing more acute or sicker patients, and you're getting a lot more of your referrals from the physicians versus the hospitals. How do you go about targeting that subset of patients?

I'll answer that question. It's not targeting patients. A couple of key points. Our sales force calls on physician offices, calls on hospital discharge planners, and they utilize those 13 programs that Alice Ann articulated as a sales point. They are also only incentivized on admissions from those facilities. They are not incentivized on revenue or types of patients.

So once they identify a doctor that has a high Medicare population, they go in there and present the disease program that maybe represents a higher percentage of that doctor's patient population, and they take all of the home-care referrals from that physician.

So we do a lot of calls to physicians and hospital discharge planners, and have been doing that for a long time. And Alice Ann articulated that we started out of the gate calling on physicians, encouraging them to discharge their frail and comorbid population directly to home-care and allowing us to stabilize where appropriate, versus going into the hospital, which obviously costs the system more dollars. And our stats back up that, as you mentioned.

Darren Lehrich, Deutsche Bank.

I have one area of questioning about your receivables, and then I want to just ask a question about the compliance.

Dale, the DSO was up a little bit in the quarter. I just wanted to flesh that out a little bit more. Was the balance of the acquisitions you made in earlier October included -- I don't think that you paid for them in the quarter. So I don't know if the assets hit the balance sheet. But can you just confirm that?

And then as far as the change or improvement in collections you referenced for October, how much impact do you think that will have on DSOs here in the fourth quarter? And I just want to get your view on where you think DSOs go?

Okay. Let me address that issue. As you know, we are in the process and we've completed our TLC integration. But a large part of that integration in terms of revenue occurred in August and September. And as you are also probably aware, there is oftentimes a 30 to 35 day lag when you convert to systems to get your billing processes completely through the system. So what we saw in August and September was some degradation in collections. We've seen that turn around in October, and we're optimistic that our numbers will be substantially improved by year end.

And your DSO -- any guidance or thoughts on where that will fall in the fourth quarter?

We don't have a specific target that we've publicized, but obviously, we're optimistic that that number is going to come down substantially by the fourth quarter.

Okay. And then compliance -- my question really is about your compliance-risk scorecards that you -- it sounds like you began in maybe recently or in the last year or two. Can you just maybe give us a sense for the baseline of where you are across your portfolio, just so we can understand how you are viewing the risk of your agencies at corporate against this scorecard that you've developed. I just would like to get a little more commentary about that, please.

Okay, Darren. I think the answer ultimately is, it depends on which of the different 43 risk factors we're talking about. Each of them are awaited and gauged differently. But I can tell you from an overall standpoint, we look at the Company average as a whole, and then we examine those agencies who perform better than the Company average in good categories or worse than Company average in bad categories, and we assess them based on where they fall in terms of standard deviation from the mean.

Derrick Dagnan, Avondale Partners.

Thanks for the access to Alice Ann and Jeffrey. One question on the oversight audits that Jeff's team completes, and I guess it's -- when you identify problems with an agency, is it usually the older same-store agencies that maybe need retraining or haven't adjusted well to some sort of operational change, or are you typically looking at new, acquired agencies or startups?

Sure. Prior to the implementation of our scorecard, we were really seeing it across the board. There wasn't a whole lot of rhyme or reason to it. We would occasionally see spikes after we had done larger acquisitions, such as after we did the Housecalls acquisition, for example.

But one of the things that we've done as part of the new compliance risk scorecard is that we actually take agencies that are either acquired via acquisition or established as a startup, and they get extra credit for being in those positions. Then if their risk in our view is actually greater, either because of an acquisition is transitioning over to our policies and our procedures or a startup is fresh out of the gate and so we don't have a history there of strong leadership in the market, and so because of those factors, the acquisitions and startups are actually given a greater risk score just by virtue of falling in those categories.

Newton Juhng, BB&T Capital Markets.

I have a couple of questions here. The first one just built around the sequential decline in episodic-based admissions. Just trying to get an understanding. With the higher internal admissions growth number that we're seeing there, can you just give me a little better idea as to why there was an actual decline in the number there on an absolute basis?

Yes. I'm trying to figure out the decline, because our admission growth year-over-year last quarter was 13%. The quarter before that was 7%, and this quarter it's 14%.

Yes, Larry. I'm looking at a 53,203 number, down from 53,561. If I'm looking at apples-to-apples here.

I think you might be talking about the gross margin percentage?

No, the episodic-based admissions number.

Okay, I'm trying to (multiple speakers)

You know, I'll take that one off-line with you, Larry. Okay?

(multiple speakers) material issue associated with that small decline you're talking about from the second quarter to the third quarter?

Correct. The special (multiple speakers)

Oh, okay. All right. Typically, the back half of the year, we experience a couple more holidays than we do in the second quarter. But I've seen that year-over-year from the second to third quarter, about the same, maybe a slight decline, but there is no overall reaching issue there. In the fourth quarter you might see a little bit of a decline, because we have four holidays and those type of things. But that's more historical trends than it is anything indicative of quarter two to quarter three.

Okay. Then just changing gears here, just on the secondary recertification front, growth at the 23% level. If I'm looking at the nine-year -- nine-month number, it implies that the first half was around a 32% growth level. Can you just kind of give us a little bit of understanding as to where that kind of difference is on the secondary recertification growth?

The number I gave was based on internal recertification growth, which was the agencies year over year. The numbers you're looking at would be total, which would be acquisitions all in.

Okay. But in terms of the difference in the first half of the year versus what we're seeing in the third quarter, is there kind of a way of explaining where the -- this kind of slowdown is occurring there? Not that it's -- it's still a big, robust number, but just understanding the difference there.

There's no single-shot answer with recertification. That has more to do with the acuity level of our patients and the mix. And Bill mentioned we have 150 locations this quarter that we didn't have a year ago that we acquired. So it depends on their case mix then and now. So that's not just an easy answer. You'll see variations in recertification rates just like you see variations in admissions.

Eric Gommel, Stifel Nicolaus.

Good morning, and thank you for all the information you've provided on the conference call today.

I had a question about your revenue per episode and the growth there. I think you talked last quarter about the impact of greater exposure of programs in I think the Northeast and mid Atlantic through acquisitions and having an impact on the revenue per episode. Have you any information as to how much the percentage increase in that revenue per episode is attributive to that versus this growth in sort of your case mix?

Don't have the specifics of geographical breakdown, other than there's a wage index component, and like you stated, there are certain areas of the country -- California and the Northeast -- that have a higher wage index component.

But the revenue per episode is made up of that fact that you just mentioned, wage index. It's made up of -- that we have a new case-mix reimbursement system this year, as opposed to last year, and our acuity level going up, and our therapy programs to address that acuity level have a higher revenue per episode. But we haven't broken that growth [data] down into those three categories.

Fair enough. And then my follow-up question really is on the SG&A. I'm noticing a lot more leverage there relative to our model. And I'm just curious. How you think about -- as you grow this revenue, make acquisitions, startups and things, how much leverage -- how should we think maybe about the leverage at that line?

Well, I think generally we can comment that as time progresses, we are looking for our technology and our growth in revenue without a commensurate growth in either cost of revenue necessarily or G&A, in other words, an efficiency concept there, to improve that leverage over time. I don't know that we're in a position to give you a specific number.

But that being said, I articulated that TLC -- we expect improvements now that we are fully converted. Both at SG&A in the field, we have been experiencing improvements of SG&A with the corporate employee staff going from 210 down to 38 down to 14 this Friday, closing the four regional billing centers. And we will continue to see improvement in SG&A efficiency levels as we mature the agencies we have and acquire more agencies. That's part of our strategic plan.

Whit Mayo, Robert W. Baird & Company.

Just turning back to the recert rate for a second, it just might be a little helpful to get a sense of how your recert rate growth -- how that's been coming from startups as they mature versus your base agency? Is there just any way you could parse that out for us to get a sense from where that growth is really coming from? I'd just like to get a little bit more granularity around that. Thanks.

Sure. As a reminder, when we do a startup, historically, a lot of them have been a peel-off of an existing agency, so you may end up taking census from a mature agency, and that begins -- the beginning census of a startup.

So with that being said, historically, about -- at least over half of our recertification rate growth has come from startups, understanding some of it has been a pull-off of existing agencies. We haven't broken down the recertification growth between startup and acquisition and mature. Again, that is highly dependent on the case mix inside the agency.

What we did want to clearly articulate is, over the last three years, our case mix has been going up, as backed up by our functional debility of the patients, as backed up independently by the number of medications they are on. Even go so far as telling you that the number of medications they are on increases with their length of stay.

So we feel very good about our recertification process, and it's also important to note that 85% of our patient population has either one or two episodes. So it's a small percentage of the total population that gets recertified based on the clinical severity of that patient.

Okay. That's helpful. Just to shift gears to TLC for a second. Can you just remind me what IT system that they were on, and whether or not you have addressed a contract that they may have had, and whether or not you have bought that out -- plan on buying that out? And if you do plan on it, what kind of timing? Anything along those lines would be helpful.

From a systems perspective, they used McKesson in their field locations. And as we were rolling out and converting our agencies, the act of converting those agencies took TLC off of that converted system, that McKesson system. From a contractual standpoint, as far as the contract.

We may have some legacy issues with either contracts or with the -- as an example, the lease in the Lake Success home office building that may be -- we may be able to mitigate, we may not. Generally, those will go to goodwill if we end up having to buy out those at some price.

That is all the time we have for questions today. I would now like to turn the conference back to the Amedisys Management for any additional or closing remarks.

Thank you, Ryan. And as a reminder, all of the narratives will be posted in the 8-K that we will file in their entirety today, so if you have any additional questions or you want to go back and review, that information will be available to you in script.

I would also like to thank everyone for taking their time to call in and join us for our third-quarter results call. We're excited and passionate about our Company and the prospects for the future. We look forward to speaking to you again and sharing our year-end results. Thanks for calling in this morning.

This does conclude today's Amedisys hosted conference call, and we appreciate your participation. Have a wonderful day.