Enhabit Home Health & Hospice (NYSE: EHAB) has reported a mixed performance in its second quarter 2024 earnings. While consolidated net revenue saw a slight decrease of 0.6% year-over-year to $260.6 million, the company experienced growth in its Home Health and Hospice segments.
The increase in total Home Health admissions by 6.4% was a highlight, attributed to payer innovation strategies and efficient clinical resource utilization. Adjusted EBITDA for the quarter was up 5.4% to $25.2 million.
Enhabit also updated its full-year 2024 guidance, narrowing the expected net service revenue and adjusted EBITDA ranges, reflecting confidence in the company's long-term outlook.
Key Takeaways
- Enhabit reported a 6.4% increase in Home Health admissions and steady growth in Hospice average daily census.
- The proposed 2025 home health payment rule could lead to a 1.7% net decrease for Enhabit.
- Q2 consolidated net revenue was $260.6 million, a slight decrease from the previous year.
- Adjusted EBITDA for the quarter increased by 5.4% to $25.2 million.
- Enhabit's leverage ratio improved to 5.1x with available liquidity of approximately $72 million.
- The company expects mid to high single-digit growth in volumes for the next three years, driven by organic growth and de novo locations.
Company Outlook
- Enhabit narrowed its full-year 2024 guidance, with expected net service revenue between $1.060 billion and $1.063 billion, and adjusted EBITDA between $100 million and $106 million.
- The company anticipates mid to high single-digit growth rates in both home health admissions and hospice volumes over the next three years.
- Enhabit plans to open approximately 10 de novo locations annually, subject to licensing and regulatory approvals.
Bearish Highlights
- The proposed 2025 home health payment rule presents a challenge with a potential net decrease of 1.7% for Enhabit.
- Consolidated net revenue experienced a marginal decline of 0.6% year-over-year.
- Acquisitions are currently limited due to the company's credit agreement and leverage.
Bullish Highlights
- Home health adjusted EBITDA increased due to a reduction in cost per visit and a shift to non-Medicare visits.
- Hospice revenue grew, benefiting from higher Medicare reimbursement rates and patient days.
- The company has successfully implemented strategies leading to positive results, such as the centralized admissions department improving referral processing.
Misses
- The termination of the United contract did not significantly impact revenue guidance.
- The DME issue has affected cost per day, although Enhabit expects to gain leverage against it with increasing volume.
Q&A Highlights
- Enhabit is focused on growing its Medicare business by understanding payer mix shifts and working with referral sources.
- The company is advocating for a legislative fix to reduce pressure on home health and is participating with trade associations.
- A $1 million positive benefit was reported from payer mix changes due to newly negotiated contracts.
Enhabit's second quarter performance reflects a company navigating industry challenges while capitalizing on strategic initiatives to foster growth. Despite a slight dip in net revenue, the company's operational improvements and focus on payer mix changes have contributed to a positive outlook.
With a strategy that includes opening new locations and organic growth, Enhabit is positioning itself for sustained success in the evolving home health and hospice care landscape.
InvestingPro Insights
Enhabit Home Health & Hospice (NYSE: EHAB) has presented a nuanced picture in its recent financial performance. In the context of the company's strategic initiatives and the broader market, certain data points from InvestingPro provide additional insights:
InvestingPro Data highlights that EHAB's market capitalization stands at $425.4 million, reflecting its current valuation in the market. Despite the company not being profitable over the last twelve months, analysts predict that Enhabit will turn a profit this year. This anticipated shift towards profitability is underscored by the company's strong free cash flow yield, a metric that suggests Enhabit is generating ample cash relative to its share price. However, it's important to note that the stock has experienced a significant downturn over the past week, with a 1-week price total return of -11.88%.
InvestingPro Tips offer a mixed outlook. While net income is expected to grow this year, which aligns with Enhabit's own positive revenue and adjusted EBITDA guidance for 2024, four analysts have revised their earnings estimates downwards for the upcoming period. This could indicate potential concerns about the company's future earnings potential. Additionally, Enhabit does not pay a dividend, which may influence investment decisions for income-focused shareholders.
For those seeking a deeper dive into Enhabit's financial health and future prospects, additional InvestingPro Tips are available, providing a comprehensive analysis of the company's performance and potential. Visit https://www.investing.com/pro/EHAB to explore a total of seven detailed tips that could guide investment decisions and strategies.
Full transcript - Enhabit Inc (EHAB) Q2 2024:
Operator: Good morning, everyone, and welcome to Enhabit Home Health & Hospice's second quarter 2024 earnings conference call. [Operator instructions]. Today's conference call is being recorded. If you have any objections, you may disconnect at this time. I will now turn the call over to Crissy Carlisle, Enhabit's Chief Financial Officer.
Crissy Carlisle: Thank you, Operator, and good morning, everyone. Thank you for joining our call today. With me on the call is Barb Jacobsmeyer, President and Chief Executive Officer. Before we begin, if you do not already have a copy, the second quarter earnings release, supplemental information, and related Form 8-K filed with the SEC are available on our website at investors.ehab.com. On page two of the supplemental information, you'll find the safe harbor statements, which are also set forth on the last page of the earnings release. During the call, we will make forward-looking statements which are subject to risk and uncertainties, many of which are beyond our control. Certain risks and uncertainties that could cause actual results to differ materially from our projections, estimates, and expectations, are discussed in our SEC filings, including our annual report on Form 10-K, which are available on our website. We encourage you to read them. You are cautioned not to place undue reliance on the estimates, projections, guidance and other forward-looking information presented, which are based on current estimates of future events and speak only as of today. We do not undertake a duty to update these forward-looking statements. Our supplemental information and discussion on this call will include certain non-GAAP financial measures. For such measures, reconciliation to the most directly comparable GAAP measure is available at the end of the supplemental information and the earnings release. With that, I'll turn the call over to Barb.
Barb Jacobsmeyer: Good morning, and thanks for joining us. Quarter 2 2024 marks our third sequential quarter demonstrating the success of our strategies. Our team deserves great praise for keeping a strong focus on operational performance amidst many potential distractions, and the results we share with you today are a testament to the tremendous job they've done. I'm extremely proud to lead such a dedicated group of professionals. I also want to acknowledge the opportunity we've had over the past couple of months to discuss our strategies with many of our stockholders and the valuable feedback we have received those discussions. Before we discuss quarter two results, I want to comment on the proposed 2025 home health payment rule. CMS is proposing a permanent adjustment of negative 4.06%, resulting in a net decrease of 1.7%. Based on our current home health patient mix, our estimated impact is negative 1.05%. The home health community is united behind PDGM legislation, the Preserving Access to Home Health Act, which would prevent CMS from making any further permanent cuts or temporary cuts. NAHC, the National Association for Home Care and Hospice, and PQHH, the Partnership for Quality Home Healthcare, have continued to work with our congressional allies to streamline the focus of the bill and draft offsets that would provide pay-fors. We understand that important committee stakeholders are working to score the legislation and pay-fors. We remain actively engaged with our trade associations and the industry on these advocacy efforts. Let's move now to our progress on our key strategies and how they continue to produce positive results. In our Home Health segment, 6.4% total admission growth was driven by our payer innovation strategy, and our focus on improved utilization of clinical resources. Our payer innovation strategy continues to succeed, with our field teams successfully shifting admissions out of historically lower-paying contracts to better paying contracts that recognize our better way to care. In quarter one of 2023, only 6% of non-Medicare visits were in payer innovation contracts. That rate grew to 43% in quarter 2 2024. This shift into payer innovation contracts is driving an increase in non-Medicare revenue per visit, and equally as important, demonstrates our commitment to relationships with payers who understand the value of our care. Looking back at 2022, that rate approximated $136 per visit. In 2024, it has grown to $147 per visit. As we look to the future, the quickest way to get the majority of our non-Medicare business to the payer innovation contracts, is to continue to focus on referrals within the payer innovation contracts, negotiate improved rates with non-payer innovation contracts, and when necessary, terminate the lower reimbursing contracts. After over nine months of unsuccessful negotiations with UnitedHealthcare, we submitted our termination notice on August 1st. We will dedicate our clinical resources to fee-for-service Medicare patients, and those that are members of the 68 favorable contracts. We remain committed to providing our strong quality of care to UnitedHealthcare members if at some point they decide to contract with acceptable rates. In quarter one of 2023, 58% of admissions were in combined Medicare fee-for-service and payer innovation contracts. That left 42% of admissions in unfavorable contracts. In 2024, the percent of admissions in Medicare fee-for-service and payer innovation contracts has grown to 71%. This will continue to accelerate with this recent decision to terminate this national agreement. In regards to Medicare fee-for-service, we still have work to do. However, our strategy is working, as one third of our branches experienced year-over-year fee-for-service Medicare admission growth in quarter two. We have done a deep dive into the branch-level data to identify the branches that are successfully implementing our strategies and those that are not. We're using this analysis and the identified best practices to make meaningful changes across the company, that we believe will result in overall stabilization of fee-for-service Medicare business, and we've established a project team to concentrate on retaining fee-for-service business. Additionally, our scale and density within key markets, along with our reputation for strong clinical outcomes, continues to attract opportunities to collaborate with both legacy and new accountable care organization operators. ACOs offer an opportunity to serve Medicare fee-for-service members and often to be recognized for outstanding clinical performance via value-based quality incentives. We are grateful for both our legacy and new ACO relationships. We are encouraged to see the growth and maturity of ACO reach organizations, and we're equally excited about opportunities in the new guide and team models from CMS. Growth has also been fueled by increasing the utilization of existing clinical staff through our technology. Creating the just-right care plan through our Medalogix Pulse tool, resulted in visits per episode of 14.0, 3.8% lower than last year. Lowering visits per episode increases revenue per visit, and with the majority of our clinicians in a salaried position, increases clinical capacity for growth. Turning now to the Hospice segment, we continue to make steady progress in growing our census, and we are pleased that the average daily census has increased sequentially each month since January 2024. In addition to the implementation of the case management model, which eliminated staffing constraints in contract labor, we also implemented a centralized admissions department to support each of our hospice sub regions that allows for more efficient processing of referrals. As a result, our conversion rate of referrals to admissions increased from 73% last year to 76% this year. With our focus on growth, we continue to strategically invest in our de novo strategy. This strategy complements our organic growth strategy in both segments and allows us to enter a new market at a low capital cost. In April, we opened a new home health location in Melbourne, Florida. Our growth depends on clinical staffing. Success in recruitment and retention helped us eliminate nursing contract labor in 2023, and has positioned us for long-term growth, as evidenced by our performance over the last three quarters. Today, we have 243 more full-time nurses on the front-line taking care of patients than we did at the time of our spin in 2022. We've enhanced our people capabilities to better understand what drives both engagement and retention of our employees. This allows us to better understand how we can best support our employees as they support patients and their families. We have listened to our staff. They want career opportunities. We've developed leadership tracks that enable employees to grow into such roles, such as branch directors, clinical team leaders, and clinical sales positions. In fact, over the last 12 months, 85 of our full-time nurses have been promoted into these types of roles. We are proud of the culture of growth we have created, and we look forward to the continued success it fuels for Enhabit. We're very pleased with the execution of our strategies and the continued progress our teams have made. A great benefit of the size of our company is the ability to experience the various levels of success from our strategies on things such as recruitment, retention, payer strategy, and quality outcomes, and understand how and who is executing them in ways that drive positive outcomes so we can share those across the organization. We remain confident in the need for our services and in the long-range growth potential for Enhabit. Before turning the call over to Crissy to discuss our results in more detail, I wanted to acknowledge the announcement we made yesterday that Crissy will be stepping down as Enhabit’s Chief Financial Officer. We are grateful for Crissy's important contributions to Enhabit since our spinoff from Encompass. I have enjoyed working side by side with her and witnessed firsthand her passion for Enhabit’s mission and her deep commitment to all our stakeholders. She has played a large role in helping the company achieve stability across the business and position our organization for growth. Most importantly, Crissy has been an incredible partner and true friend, and I look forward to her continued leadership as we search for her successor. Crissy.
Crissy Carlisle: Thanks, Barb. Consolidated net revenue was $260.6 million for the second quarter, down $1.7 million or 0.6% year-over-year. Consolidated adjusted EBITDA was $25.2 million, up $1.3 million or 5.4% year-over-year. In our Home Health segment, revenue declined $3.6 million or 1.7%, primarily due to lower Medicare re-certification. Our payer innovation strategy continues to foster non-Medicare growth. Non-Medicare admissions grew 25.2%, driving total admissions growth of 6.4% year-over-year, with 6.2% growth on a same-store basis. 43% of non-Medicare visits are now in payer innovation contracts at improved rates. This shift into payer innovation contracts lessens the impact of mix shift to Medicare advantage. On a net basis, the impact of improved pricing and the mix shift to non-Medicare visits, increased revenue and adjusted EBITDA by $1 million in the quarter. Home health adjusted EBITDA increased $1.4 million or 3.3% year-over-year as a reduction in cost per visit offset the revenue decline. Cost per visit decreased 2.2% year-over-year, primarily due to a reduction in contract labor and favorable experience in workers' compensation and group medical claims. In our Hospice segment, revenue increased $1.9 million or 3.9% year-over-year due to increased Medicare reimbursement rates and an increase in patient days. We made steady progress in growing our average daily census, with our census growing 2.7% year-over-year and increasing sequentially every month since January 2024. This trend continued in July. As we continue to ramp up our business development team and balance our referral portfolio, we expect average daily census to grow throughout the remainder of the year. Adjusted EBITDA increased $0.8 million or 9.6% year-over-year, primarily due to increased revenue. Cost per day increased 1.3% year-over-year, primarily due to increased costs associated with patient supply, including durable medical equipment and pharmacy. We continue to expect patient volume to increase without the need to hire a significant number of additional staff, resulting in operating leverage against the fixed costs associated with our case management staffing model. Our home office general and administrative expenses increased $0.9 million year-over-year to 10.8% of consolidated revenue, as merit market and anticipated bonus compensation increases in 2024, offset cost structure changes implemented in the back half of 2023. Let’s transition now to the balance sheet. Our leverage decreased for the second quarter in a row. We ended the second quarter with a leverage ratio of 5.1x, well within our covenant maximum of 6.5x, and less than our year-end 2023 leverage of 5.4x. In June, in addition to the $5 million required amortization on our term loan, we made a voluntary $10 million payment to reduce the outstanding balance of our revolving credit facility. Since our spinoff in July 2022, we have reduced outstanding debt under our credit agreement by $40 million. We have available liquidity of approximately $72 million, including approximately $29 million of cash on hand. We believe this is adequate to support our operations, including our de novo strategy. Our free cash flow remains strong. For the year-to-date through June, we generated approximately $29 million of free cash flow, which equates to a conversion rate of approximately 57%. Let's turn now to guidance. Based on our year-to-date performance through June, we are narrowing our guidance ranges for full-year 2024. Using our current payer mix trends, we are updating our outlook for net service revenue to a range of $1.060 billion, to 1.063 billion. With costs coming in better than our initial guidance consideration, we are narrowing our adjusted EBITDA range to $100 million to $106 million. We expect to generate $39 million to $58 million of free cash flow in 2024. The primary difference between the low and high ends of the range is Medicare fee-for-service volume. As we think about the cadence of the remainder of the year, I remind you that Q3 tends to be a lower volume quarter to Q2, while Q4 tends to be a higher volume quarter. Similar to 2023, we may experience a slight decline in adjusted EBITDA sequentially from Q2 to Q3, with adjusted EBITDA increasing in Q4, given the expected increase in volume and the benefit of the hospice rate increase effective October 1st. In addition to 2024 guidance, in June, as part of our participation in the Goldman Sachs Healthcare Conference, we issued longer-term volume growth targets for both Home Health and Hospice. Those slides are included on Pages 25 through 27 of the supplemental slides that accompanied our earnings release yesterday. We remain confident in the long-term outlook for Enhabit. The demographics haven't changed, and care at home remains the lowest cost setting for healthcare. As payers continue to manage their costs, home care is a great place to turn. When we consider these factors, along with our payer innovation strategy, clinical capacity and current trends, we expect to continue to grow home health admissions at a mid to high single digits growth factor over the next three years, and we expect hospice volumes to grow at mid to high single digits over the next three years after investing in the case management model and the buildout of our development team. With that, we will open the line for questions.
Operator: [Operator Instructions] Our first question will come from the line of Brian Tanquilut with Jefferies. Please go ahead.
Noah Erni: Hi. This is Noah in for Brian. Thank you for taking my question. As we think about the turnaround process for the company, how are you strategizing to turn Medicare fee-for-service admissions around? And is that a sales force thing or are there other moves that can be made to show of admin?
Barb Jacobsmeyer: Sure. So, well, the initial strategy focused on building out payer innovation and payer contracts, because what we heard loud and clear from both our sales team members and our referral sources is they want full-service providers that could come in and take the majority of their types of patients. And so, as that success has occurred, we've been working with the teams to continue to develop that and script that to our referral sources. As I mentioned this morning, a third of our branches actually had nice growth in fee-for-service over second quarter of this year versus last year. So, we are seeing that that strategy is working, and now it's really about making sure that we are taking those best practices across all of the company. So, some of that is really about not only the scripting but really doing a deep dive on their referral sources. What has happened to that referral sources payer mix over the last year or so? Deciding is that where we can still have focus from our business development teams, or do we need to build out their book of business to get more referral sources that have a stronger mix from a payer standpoint?
Noah Erni: Got it. Thank you for that. And then to follow up, there was pretty good success in bringing down cost per visit. Just curious to know how much room you see in driving that figure down. And as we think about visits per episode, is there room to drive improvement there, and understand you're already using Metalogix.
Barb Jacobsmeyer: Right. on the cost per visit, what I would say is that we're certainly experiencing the benefit of eliminating all of the contract labor last year. So, in home health, that was eliminated by the end of 2023. So, we will have the full value of that by January of 2025. We do, though, continue to work on our productivity and optimization, which has always been a big focus of ours to manage that cost per visit. And then as you mentioned, our visits per episode have seen a decline, and that focus will remain on making sure we are using those freed up capacity to serve more patients, because if you don't use it to serve more patients, then you can actually see an increase in your cost per visit as your visits decline. So, kind of keeping a focus on all those together.
Noah Erni: All right, thank you.
Operator: Our next question will come from the line of Jason Cassorla with Citi. Please go ahead.
Ben Rossi: Good morning, everyone. Thanks for the question. You have Ben Rossi on the line for Jason. So, thinking about home health demand, your overall admissions growth has had a solid first half, and you also provided those details regarding your long-term outlook for admission growth in the mid to high single digits over the next three years. What makes you feel comfortable in balancing this growth with a now lower outlook on cost per visit, and how should we be thinking about the contribution split here between Medicare and now Medicare admissions?
Crissy Carlisle: If you're talking about - there was a lot in that question. We're trying to kind of digest that. So, in regards to the mix, I think is ultimately what you're asking because that's the most sensitive factor in any outlook, guidance, anything that we give, and the Medicare mix specifically within them. We don't provide or talk specific and give outlook in regards to volume information because it remains difficult to predict. As Barb noted, we have plans in place to strategically spread the best practices that we've learned from our strategy and from what we're learning from the third of the branches who are growing fee-for-service business, and how we educate and use that for our branches that are struggling a little bit with the Medicare fee-for-service. And then in addition, as Barb mentioned, we have given notice to United, and our ability now to go to those referral sources and say, we can't take those patients, we're not contracted, is expected to speed up the process of having existing volumes move into higher paying contracts as part of that overall payer innovation strategy. We know we have two national agreements that do recognize the value of the services we provide. And so, we're going to focus our clinical capacity on those.
Ben Rossi: Got it. Thanks. And I guess just as a quick follow-up on the contract termination with United, how are you thinking about the impact here to top-line contribution in your, I guess, that long term admission growth outlook? Can you provide some details on the overall impact of this termination?
Barb Jacobsmeyer: Sure. So, certainly, a year or so ago, we would not have been in this position to terminate that contract, but now with 68 agreements, including two national agreements, we feel confident that we're going to be able to replace that census. Our current non-Medicare conversion rate is only at 48%. So, we do have some non-Medicare that we don't convert. And so, it's really now going to be about replacing that census over this notice period.
Ben Rossi: Got it. Thanks for the color.
Operator: Our next question comes from the line of A.J. Rice with UBS. Please go ahead.
A.J. Rice: Hi, everybody. Best wishes, Crissy, on future endeavors. Maybe on, I think your target for this year on permanent labor cost growth was zero to 1% per visit. Is that where you're trending? Any updated thoughts on what you're seeing on the permanent labor side, wage rates, et cetera, turnover?
Crissy Carlisle: Yes. So, we are expecting that no change in the wage rate. I would say about 3% is where we're landing from a merit and market standpoint on average. There are markets where we continue to have to examine market increases just based off the competition there locally. A lot of this benefit is coming from the elimination of that contract labor and replacing it with full-time labor that doesn't have the premium associated with those 13-week contracts. And then as we also noted, we've had some favorable claims experience on insurance type receivables related to workers' compensation and our group medical costs. And so, that is helping. As Barb also mentioned, as we continue to work with Medalogix and our teams on developing that right care plan and lowering our visits per episode, it's really important that we monitor that to keep our staff productive, and that is another way that we're creating clinical capacity without the need to hire additional staff in order to grow the business.
A.J. Rice: Okay. And you did call out the workers' comp and a couple of other, what was it, group medical or something. Is that just a one-time reserve adjustment that you took in the second quarter as you looked at your claims experience? Or is this something that flows through to the back half as a potential savings going forward?
Crissy Carlisle: Well, it’s something, A.J. that we're monitoring very closely. I can't say it's one-time. I can't say that it's going to recur. It's just something that we're monitoring very closely. We are currently experiencing favorable claims experience. But as you well know, one big claim can change that in a second, right? So, it's difficult to predict those. But right now, as of today, we have favorable claims experience,
A.J. Rice: So, you're not changing the rate of accrual on those items in the back half the year. You're continuing to monitor and there may be more opportunities to do a catch-up reserve adjustment, but it's not something that's that tailwind in the back half.
Crissy Carlisle: That's right. We can't count on it.
A.J. Rice: Okay. Thanks a lot.
Operator: Our next question comes from the line of Joanna Gajuk with Bank of America. Please go ahead.
Joanna Gajuk: Hi, good morning. Thanks so much for taking the question. So, I guess first as a follow-up on the portion United contract and the revenue, so can you talk about the drivers for the $30 million or so, I guess reduction in the revenue guidance? Is that the United contract termination or is there something else?
Crissy Carlisle: No, Joanna, the United contract has not really been a significant part of our guidance going forward because we have been in negotiations with them, and as you can see, they've not been successful to date. The change in the revenue guidance, as we've noted previously, the most sensitive factor in our guidance is Medicare fee-for-service. And as Barb mentioned, we're still working on that. We have some more work to do in regards to Medicare fee-for-service. So, that's the main driver.
Joanna Gajuk: Okay, I see. Thank you. And of that note, because the home health revenues were fine, but I guess yes, to your point, Medicare admissions were still down 11% year-over-year, and sounds like there's third locations that did better than this. So, I understand, yes, you're trying to kind of change some things and learn from this third. But is there a specific action plan to grow the Medicare business? I mean, what can you do? Because it sounds like you keep losing market share there. So, I wonder what action needs to happen for you to grow across the platform, the Medicare volumes?
Barb Jacobsmeyer: Sure. So, I can mention a few of the things that have come out of those that had a very successful second quarter as it related to year-over-year fee-for-service growth, and that has been those that have really done a deep dive into each book of business, looking at - we use Trella for our Medicare claims information. And when - and I'll just give an example of, we've historically had a big program of what we called community care. So, that was, we would go and provide care inside senior apartment settings, assisted living facilities. And that is a very efficient place to provide care, because a clinician can go and instead of having windshield time, they can actually provide that care to multiple residents in a efficient amount of time. We can see in cases where really overnight, they can have a dramatic change in the payer mix in those buildings. They can have one MA provider come in and do a lunch, and the next thing you know, a good number of residents have signed up. And so, it's really been about looking and saying, we need to understand what is that payer mix shift that is happening. So, for example, if the payer mix shift is happening, but it is still a strong fee-for-service, and if it's complimented by an MA plan that we have good rates with, well, then it may make sense for us to continue to stay in that setting, both from a business development and operation standpoint because of the efficiency that's created. But for overnight, that has changed and now it is almost significantly MA, and particularly if it's an MA that doesn't recognize our great value, then it may mean that it is time for us to redeploy that business development team to other referral sources. So, that's an example of some things that have happened in some of the markets that have had success, as well as just the ability to go in and really work with the referral sources to understand that we now are able and willing to take more of their types of patients, but it does need to continue to be a healthy payer mix so that we can remain committed to that referral source.
Joanna Gajuk: Thank you. If I may, just one number question on hospice, the same-store admissions improve, I guess were kind of flattish, but what was the same-store census growth in the quarter? Because I wasn't sure whether there are some de novos and acquisitions that kind of explain the delta in admission. So, the question is, yes, what was the same-store census in the quarter for Hospice? Thank you.
Barb Jacobsmeyer: Sure. Same-store ADC growth was 1.2% positive.
Joanna Gajuk: Great. Thank you.
Operator: [Operator instructions]. And our next question comes from the line of Ryan Langston with TD Cowen. Please go ahead.
Ryan Langston: Hi, good morning. Just looking for an update on the DME issue you called out in the fourth quarter. How's that new contract progressing, and is there any further pressure on DME, or was that just more of an isolated issue?
Crissy Carlisle: So, as you can see from our comments both in the earnings slide and the release, DME and the supplies did have an impact year-over-year within our cost per day. So, we had said it was about a $2 million impact annually based on the new contract. And I think we're kind of in line with that right now. But again, as we continue to grow the volume, we expect to gain leverage against that fixed cost structure.
Ryan Langston: Got it. And then maybe kind of a higher-level question, obviously since the Chevron-SCOTUS case came down, there's maybe some thought that maybe some rulemaking, especially in home health, there could be some opportunity to reduce some of that potential pressure either from the temporary or the permanent cuts. Just wondering if you guys have any thoughts on that. Thanks.
Barb Jacobsmeyer: Well, we continue to watch that to see from a - but that will play the majority of the focus from us as we're involved is more on that legislative fix, and that's where our advocacy efforts. Obviously, NAT continues to have the litigation out there. But I would say that the focus that we have is our participation with the trade associations on the legislative fix.
Operator: Our next question will come from the line of Jason Cassorla with Citi. Please go ahead.
Ben Rossi: Hey, thanks for squeezing me in for another one. Just wanted to touch on some of the payer mix trends. So, in your deck, you mentioned the $1 million positive benefit from payer mix changes as a result of the newly negotiated contracts. Do you think the headwind impact here from the mix of changes has reached an inflection point?
Barb Jacobsmeyer: I do think when we look at it both from - again, we see the positive in the third of our branches that were able to grow fee-for-service. So, it is good to see that the strategies that we felt would work are working. And then again, when you look at how we've been successful moving into the payer innovation contracts, and frankly, it's going to be easier to make that shift faster when we can say that we're not contracted with a large national provider that has not recognized the benefit of the value we bring. So, I think we are kind of at an inflection point, both from what we've seen in some of our branches on fee-for-service, as well as the payer innovation.
Ben Rossi: Great. Thanks.
Operator: And our next question comes from the line of Joanna Gajuk with Bank of America. Please go ahead.
Joanna Gajuk: Oh, hi. Thanks for following up or letting me ask a follow up question here. So, on your sort of three-year growth targets on volumes, right, so home health mid-single digits, this admissions and hospice volumes. So, I just want to clarify that census or admissions. And the other clarification is, in those kind of three-year growth targets, how much do you assume from de novos in those targets and acquisitions, if at all? Thank you.
Crissy Carlisle: Right, so the de novos would be included. We continue to think about 10 per year. Now, that is going to be based off us being at the mercy of the licensing and regulatory agencies. We will be ready to open 10. It's a matter of getting people out to surveys and actually getting the license and the final touches, if you will, for those to open. In regards to acquisitions, we continue to diligence opportunities. Right now, our credit agreement limits our ability to do that as well as our leverage, but we're not going to let that drive the long-term outlook. But right now, the actual mid to high single digits is based off of organic growth as well as the de novos alone.
Joanna Gajuk: And would you be willing to quantify the de novos, how much they add in that mid to high single digits? Is it like 100 basis points of that, or 200?
Crissy Carlisle: Yes, it’s mostly in hospice. Remember, we have a (preferential) (indiscernible) hospice where we have home health, but we're not going to quantify that separately.
Joanna Gajuk: And then, so you'll have to start at, right, that's admissions or that's census or both, I guess maybe?
Crissy Carlisle: It's kind of both really. Admissions (indiscernible) ultimately.
Joanna Gajuk: Great. Thank you so much.
Operator: And that will conclude our question-and-answer session. I'll turn the call back over to Crissy Carlisle for any closing remarks.
Crissy Carlisle: If you have additional questions, please email investorrelations@ehab.com. Thank you again for joining today's call.
Operator: This concludes today's conference. You may now disconnect.
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