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Chemed Corp. (NYSE:CHE)

Q4 2007 Earnings Call

February 22, 2008 10:00 am ET

Executives

Sherri Warner - IR

Kevin McNamara - President and CEO

David Williams - VP and CFO

Tim O'Toole - EVP and CEO of VITAS

Analysts

Darren Lehrich - Deutsche Bank

Jim Barrett - CL King & Associates

Eric Gommel - Stifel Nicolaus

Kevin Fischbeck - Lehman Brothers

Operator

Good morning, ladies and gentlemen, and welcome to Chemed Corporation's fourth quarter 2007 conference call. (Operator Instructions)

I would now like to turn the call over to Sherri Warner with Chemed Investor Relations. Please proceed.

Sherri Warner

Good morning. Our conference call this morning will review the financial results for the fourth quarter of 2007 ended December 31, 2007. Before we begin, let me remind you that the Safe Harbor provisions of the Private Securities Litigation Reform Act of 1995 apply to this conference call.

During the course of this call the company will make various remarks concerning management's expectations, predictions, plans and prospects that constitute forward-looking statements. Actual results may differ materially from those projected by these forward-looking statements as a result of a variety of factors including those identified in the company's news release of February 21 and in various other filings with the SEC. You are cautioned that any forward-looking statements reflect management's current view only and that the company undertakes no obligation to revise or update such statements in the future.

In addition, management may also discuss non-GAAP operating performance results during today's call, including earnings before interest, taxes, depreciation and amortization, or EBITDA and adjusted EBITDA. A reconciliation of these non-GAAP results is provided in the company's press release dated February 21, which is available on the company's website, at www.chemed.com.

I would now like to introduce our speakers for today, Kevin McNamara, President and Chief Executive Officer of Chemed Corporation; Dave Williams, Executive Vice President and Chief Financial Officer of Chemed; and Tim O'Toole, Chief Executive Officer and Chemed's VITAS Healthcare Corporation subsidiary.

I will now turn the call over to Kevin McNamara.

Kevin McNamara

Thank you, Sherri. Good morning, everyone. Welcome to Chemed Corporation's fourth quarter 2007 conference call. I will begin with an overview of the quarter. I will then turn over the call to David Williams, Chemed's Chief Financial Officer. This will be followed by Tim O'Toole, Chief Executive of our VITAS subsidiary, for a discussion on some of our hospice metrics. I will then open this call up for questions.

Chemed consolidated revenue in the quarter totaled $286 million and net income from continuing operations was $20.2 million. This equated to diluted earnings per share from continuing operations of $0.83. If you adjust for non-cash items or items that are not indicative of ongoing operations, earnings per diluted share were $0.92 in the quarter, an increase of 26% over the prior year.

In the fourth quarter of 2007, our VITAS subsidiary had revenue of $197 million and generated income from continuing operations of $17 million. Adjusted EBITDA for VITAS totaled over $28 million in the quarter, equating to a 14.4% margin.

Throughout 2007, we have seen excellent growth in routine homecare hospice revenue. This level of care, which is provided in the patient's home, has expanded 11.2% in 2007. Partially offsetting this strong growth has been relatively flat year-to-date revenue growth in our high acuity levels of care, inpatient and continuous care.

The higher acuity settings typically involve hospice care that is episodic in nature. What this means is that the majority of the days of care in the high acuity setting involve patients in routine homecare that have medical issues that require continuous or inpatient care for roughly three to seven days. Once the medical issues are resolved, the patient would then be transferred back into routine homecare.

As patients elect to enter hospice earlier and earlier into their terminal illness diagnosis, it does not necessarily result in an equivalent expansion of these episodic events. Accordingly, we anticipate routine homecare to continue to grow at a somewhat faster rate than the higher acuity settings.

VITAS did not any billing restrictions related to Medicare Cap for its fourth quarter 2007 operating activity. As of December 31, 2007, we have not accrued any Medicare billing restrictions for the 2008 or 2007 cap years. VITAS measure its Medicare Cap cushion or Medicare Cap liability on a program-by-program basis.

Of VITAS's 37 unique Medicare provider numbers, 29 provider numbers or 78% had a cap cushion greater than 20% on a trailing 12-month basis, 4 provider numbers are between 15% and 20%, and 1 is between 10% and 15%. Three provider numbers have cap cushion ranging between 4% and 9%. We have aggregate cap cushion in excess of $219 million on a trailing 12-month basis.

Roto-Rooter had a good fourth quarter generating $89 million in revenue, earnings of $9.7 million and adjusted EBITDA of over $19 million. Adjusted EBITDA increased 10.5% and equated to an adjusted EBITDA margin of 21.5%. David will go into more detail on the operating metrics, but suffice it to say Roto-Rooter's 2007 performance has been outstanding in terms of revenue, margins, profit and cash flow.

Both VITAS and Roto-Rooter are operating fundamentally sound business models that we believe are recession-resistant. Although there are risk factors impacting both business segments, we believe these risks are manageable and Chemed is well positioned to continue to generate strong revenue earnings and cash flow growth in 2008 and 2009.

With that, I would like to turn this teleconference over to David Williams, our Chief Financial Officer.

David Williams

Thanks, Kevin.

Net revenue for VITAS was $197 million in the fourth quarter of 2007, which is an increase of 5.9% over the prior year period. This revenue growth was a result of increased ADC of 4.3% and Medicare price increase of approximately 3%, partially offset by the continued shift in revenue mix from high acuity care to routine homecare.

In the fourth quarter of 2006, high acuity days of care were 8.68% of total days of care. High acuity days of care averaged 8.39% in the first quarter of 2007, 18.04% in the second quarter, 18.01% in the third quarter and 7.97% in the fourth quarter of 2007. As you can see, over the last three quarters this has stabilized significantly. This mix shift from high acuity care to routine homecare negatively impacts our revenue growth by $3.8 million in the quarter or took away approximately 2 percentage points of sales growth.

Routine homecare reimbursement average $144.97 and high acuity care averaged $632.49 per patient per day in the fourth quarter of 2007. Given this significant disparity in reimbursement per diems, any shift in days of care mix will have a notional impact in overall revenue. However, given the relatively low profitability margin on high acuity care, this mix shift had minimal impact on gross profit and net income.

Gross margin in the fourth quarter of 2007 for VITAS was 23.2%. This is a 70 basis point improvement over the prior year quarter.

Selling, general and administrative expense was $17.3 million in the fourth quarter of 2007, which is an increase of 5.2% over the prior year.

Adjusted EBITDA totaled $28.4 million, an increase of 11% over the prior year and equates to an adjusted EBITDA margin of 14.4%, an increase of 63 basis points for the fourth quarter of 2006.

During the fourth quarter of 2007, VITAS's direct patient care margin for routine homecare was 51.6%. This compares to 49.7% in the prior year quarter.

Direct inpatient margins in the quarter were 18.8%, which compares to 19.4% in the prior year. Occupancy of our inpatient units averaged 76.6% in the quarter and compares to 79.7% occupancy in the fourth quarter of 2006.

Continuous care, the least predictable of all levels of care, had a direct gross margin of 17.6% in the quarter, which compares to 17.0% in the prior year.

Now let's turn to the Roto-Rooter segment. Roto-Rooter's plumbing and drain cleaning business generated sales of $89 million for the fourth quarter of 2007, 3.3% higher than the $86 million reported in the comparable prior year quarter. The prior year quarter was exceptionally strong in terms of revenue and job count. Given the way the holidays fell in the fourth quarter of 2007, we are very pleased with the overall revenue growth in the fourth quarter.

Net income for the quarter was $9.7 million. This net income includes $1.2 million of an after-tax charge for a tentative settlement of a class action lawsuit that alleged wage-and-hour violations in California. This suit claimed Roto-Rooter failed to provide meal and break times, as well as credit for work beginning from the first call to dispatch, rather than from arrival at the first day's assignment. Excluding this tentative settlement, net income in the fourth quarter of 2007 increased 12%.

Adjusted EBITDA in the fourth quarter of 2007 totaled $19 million, an increase of 10.5% over the fourth quarter of and equated to an adjusted EBITDA margin of 21.5%, an increase of 140 basis points over the prior year period.

Job count in the fourth quarter of 2007 did declined 2.8% when compared to the prior year period. However, as I noted earlier, the fourth quarter of 2006 was exceptionally strong. Roto-Rooter did experience a typical seasonality of the fourth quarter of 2007, which is demonstrated by job count increasing 3.3% sequentially from Q3 to Q4.

Total residential jobs declined 0.8% and consisted of plumbing jobs increasing 4.5% and drain cleaning jobs declining 3.1% when compared to the fourth quarter of 2006. Residential jobs continue to represent approximately 70% of total job count.

Total commercial jobs declined 7.3% with plumbing jobs declining 1.6% and drain cleaning decreasing 10% over the prior year quarter. A significant portion of the commercial job count decline is attributed to the elimination of low revenue, low margin commercial business. This mix shift had a very positive impact on the average revenue for commercial job, which increased 8% in the fourth quarter of 2007 and has increased 10.6% on a year-to-date basis.

Consolidated cash flows remained strong with Chemed generating $100 million of net cash provided by operating activities for full year 2007. Capital expenditures aggregated $26.6 million in 2007 and are roughly equivalent to our full year depreciation and amortization of $25.4 million.

Our 2008 earnings guidance is as follows. VITAS is estimated to generate full year revenue growth from continuing operations prior to any Medicare Cap of 7% to 8%. Admissions are estimated to increase 4% to 5% and VITAS's adjusted EBITDA margins, prior to Medicare Cap, is estimated to range from 14.2% to 15.0%. This guidance assumes the hospice industry receives a full Medicare basket price increase of 3% in the fourth quarter of 2008.

Full calendar year 2008 Medicare contractual billing limitations are estimated at $5 million, which equates to $0.13 per share of expense. Roto-Rooter is estimated to generate a 6% to 8% increase in revenue in 2008, job count growth from flat to 1% and adjusted EBITDA margins in the range of 19.5% to 20.5%.

Based upon these factors and effective tax rate of 38.5% and an average diluted share count for 2008 of 24.55 million shares, our estimate is that full year 2008 earnings per diluted share from continuing operations, excluding non-cash expense for stock options and charges or credits not indicative of ongoing operations, will be in the range of $3.60 to $3.70.

With that, I'd like to turn this call over to Tim O'Toole, our Chief Executive Officer of VITAS.

Tim O'Toole

Thank you, David.

VITAS generated 13,594 admissions in the fourth quarter of 2007. This was a 2.3% increase over the fourth quarter of 2006. On a year-to-date basis, admissions totaled 54,798, an increase of 3.9%. Based on our historical quarterly admissions pattern, admissions growth should average between 4% and 5% in 2008.

January of 2008 generated an all-time monthly high in terms of admissions, increasing 8.6% over January of 2007. Average daily census in the quarter increased 4.3% to 11,660 compared to the prior year quarter. Our discharge rate has been unusually high throughout 2007. However, over the past quarter, we have seen this rate begin to return to more normalized levels.

VITAS's average length of stay in the quarter was 75.7 days, equal to the prior year quarter. Our median length of stay remained at 14 days. Our days of care totaled $1,072,749 in the quarter. Routine home care days increased 7.3%, inpatient days of care increased 1.6% and continuous care days declined 8.4%.

We continue to focus on increasing admissions, managing staffing ratios and operating within Medicare billing limitations. Increased admissions are being generated from educating referral sources in the community and to the benefits of hospice.

VITAS tailor its approach to these communities based on the unique issues that may be impacting these individual markets. At the end of the fourth quarter of 2007, VITAS employed 250 sales representatives, 116 admission coordinators and 290 admission nurses. Our staffing in the admissions area has increased 11% over the prior year period.

Admissions by major diagnosis continue to be relatively stable with 37% of our fourth quarter admissions being cancer-related, 19% neurological, 12% cardio, 7% respiratory and 25% in the all other category.

Our staffing ratios continue to stay in line with our historical levels. In addition, we continue to average more than 5.4 visits per patient per week, well above the industry norm. Our nursing staff remained relatively flat sequentially totaling 3,522 at the end of the fourth quarter. We currently have a 195 hospice teams which compares to 186 teams in the prior year quarter and 194 teams sequentially.

Our turnover rate has declined slightly on a trailing 12-month basis, averaging 24.5% compared to 25.9% in 2006. Salary increases remain in line with the industry and are averaging around 3.5% per year.

We currently have four programs classified as start-ups, three are licensed, two of which are Medicare certified. These start-up programs had an ADC of 51 patients with revenues of $552,000 and pre-tax operating losses of $630,000. These same programs had an ADC of 5 and revenue of $70,000 and operating losses of $387,000 in the prior year quarter.

With that, I would like to turn this call back over to Kevin McNamara.

Kevin McNamara

Thank you, Tim. I will now open this teleconference to questions.

Question-and-Answer Session

Operator

(Operator Instructions)

Your first question comes from the line of Darren Lehrich with Deutsche Bank. Please proceed.

Darren Lehrich - Deutsche Bank

Thanks. Good morning, everyone. I just have a question with regard to your admissions guidance, and obviously, you started up the year pretty strong. I'm just wondering if you can give us a sense for how that builds up at the program level. You still have some pretty fast-growing markets that are ramping up.

And I think you've commented previously that some of your larger programs would be driving more ADC growth from length of stay than admissions, and I'm just wondering if you could give us some color around that point and where you are seeing the admissions growth coming from?

Tim O'Toole

This is Tim. I mean the admissions growth, as you say, we're pretty optimistic based on how we started the year off. And we are seeing similar trends that we've seen in the prior years that we've talked about. That would be a higher growth rate in the small units compared to the large units. I think the good news is we're still seeing pretty healthy growth in many of our large units and that's very helpful. Obviously, we have a lot of large units.

So the trends are that, this time of the year, it's quite healthy because there is a build of the opportunity in the South Florida markets as people come down for the winter and the hospital census fills. And that's been our historical trends and we've seen it again this year. So we're optimistic about that. And that usually is a very strong trend until the summer, and then the business slows down a little bit in the summer as there is less activity in the hospitals and people take vacations, and then seems to build back in the fall, and stay pretty strong until the very end of the year when there is a slowdown around the holidays of Christmas, Thanksgiving and the first.

So, we're still seeing the same trends, but the good news is our small units are growing nicely. And we define that is as size of under a couple hundred, and we are getting 15%, 20% growth there in some of them. And those small numbers and the opportunity is to be able to grow them rapidly. And that's where a lot of our focus is, as you know, is to turn units that we developed in our new stock program over the last several years from 50 or 70 census program and double that to 150 or 200. And we're very optimistic those plans are on track.

So, we've seen historical trends and we're pretty optimistic as a result of how the year is starting.

David Williams

Darren, this is Dave Williams. Actually the quarter was pretty well for admissions. December was a little light, but that actually accounts for why we're running 8.6% in January in terms of admission growth. So overall, though, I think we're pleased with the January effect on admissions as well as the overall quarter.

Darren Lehrich - Deutsche Bank

Okay. And then just also a question about provider numbers, I think you have you have 37 now with consolidation of provider numbers. Can you just remind us how many provider numbers you consolidated throughout '07 and whether there's more of that going forward and how many provider numbers do you expect to add through de novo in '08?

Tim O'Toole

We're trying to remember exactly, but I think we did about four in 2007, a couple the year before. And we would probably expect to do at least two or three in the current year. We are studying that and working on it. As we all know, you want to make sure if the separate licenses are working fine for you, you don't want to do it. So what we do is monitor.

Looking forward, we have plans in place where we see any Medicare Cap issues potentially looming to do some consolidations where we can. We can't in all cases. But we're feeling pretty good about where we are at, and again, obviously, a strong start with the admissions number, which is what drives the cap, as well as keeping control of your length of stay. We're feeling pretty good about where we're at right now. So it's encouraging.

David Williams

Somewhat related to that, Darren, as you know, our guidance has $5 million of cap liability for 2008 or $1.250 million a quarter, that's consistent with what we've been guiding since Q2 of 2007. However, currently we don't have any programs that are projected be in cap in 2008. We're keeping that $5 million in our guidance as a reminder, a placeholder for the fact that Medicare risk does exist. But at this point we don't have any one projected to be in cap.

Darren Lehrich - Deutsche Bank

Sure. And then last question and I'll come back in the queue. Dave, can you update us on the ADR situation? I believe it was with Palmetto and what your expectation is to clear some of that backlog, obviously, AR built a little bit more here?

David Williams

I'll defer that one to Tim.

Tim O'Toole

Yeah. I mean I think we've reported this over the last three or four quarters as it's a trend that's hit the industry that they are looking at some of the patients. And we being the largest player, they are looking at a lot of ours. I think the good news is we've seen a peak, we believe, and we're beginning to see some of the programs that were on the review come off. And as you know, that then allows you to begin to bill. It takes a period of time because you have to bill sequentially. But then you begin to bill for the open receivables which we're doing. So I actually expect that we're peaking now, and over the next several quarters, we'll see that issue return to more normal rate.

Kevin McNamara

And the other thing I would say, which isn't directly to your question, I've been very happy with our success rate in ultimately collecting amounts we've billed. Once they go through this extensive review process, that's still near 100%.

Darren Lehrich - Deutsche Bank

Okay.

David Williams

And that did impact our days sales outstanding a little bit. It went from 38.7 days to 43.4.

Darren Lehrich - Deutsche Bank

Right.

David Williams

But didn't bother us overall, and our cash flow remained strong, and we eventually collected all of those receivables.

Darren Lehrich - Deutsche Bank

Just the dollar amount of receivables that are tied up, just round number, and would you expect with your reserving policy to see bad debt come up a little bit in the next quarter or two?

David Williams

No. Not at this point. We expect the reserve to remain at about 90 basis points of revenue.

Tim O'Toole

The number is running at about $15 million, a little higher of the receivables in the backlog. Keep in mind that our bad debt expense is about 1% of our revenue. And probably half of that comes from Medicaid and commercial, and the other half comes from the Medicare. And the great amount of that comes from basically these FMR reviews. And that's very consistent with what we've seen historically. It could possibly creep up very modestly as a result of this issue and we're keeping an eye on it, but we're encouraged by the progress we're making and we have a very good handle on it, we believe.

Darren Lehrich - Deutsche Bank

Thanks a lot.

Operator

Your next question comes from the line of Jim Barrett with CL King & Associates. Please proceed.

Jim Barrett - CL King & Associates

Good morning, everyone. Kevin, I had a question for you on plumbing. When we look back to the last recession, is Roto-Rooter better positioned to weather a consumer slowdown, especially on the topline than possibly historically?

Kevin McNamara

Well, I don't know that it's to say that we're better positioned. I think we're well positioned. If you remember, and you've been a follower of the company for a long time through a couple of cycles, what we see is a little difficult in the commercial side. And one of the reason we see more having some difficult in the commercial side is as new construction, plumbing plummets, the plumbers look to be employed and they can't really do much on the residential market. In other words, they don't have a big yellow ad. There's not much they can do to get back into it. But they can start having feet on the street and bidding for commercial work. We don't, but to the extent our competition might.

I think in a recession, we'd see more of that. To the extent, on the residential side, one thing that we noticed last time, last time there was a significant downturn in the economy, something we described at the time as the Home Depot effect where homeowners for relatively small residential jobs, they would run a drain cleaner or get different plumbing help from a Home Depot person who's just working there in the aisle and they made a big push at that time to do what we considered assisted repairs.

We saw more of that and I think that some of those jobs didn't come back. But that was not bad for us because we weren't very efficient in doing that service work. In other words, the bill will be pretty high because we had to charge for putting that guy in the truck and driving him across town and getting him there, and the value that he really brought once he got on site wasn't necessarily commensurate with the invoice total.

So, with regard to the plumbing, we think that around the Roto-Rooter side very clear to say recession-resistant to the extent that we've been doing a much better job with hiring and retaining plumbers. That probably puts us in a little better position, but that's almost ancillary to your question.

Again, if there is a severe recession, it hurts on the fringes of Roto-Rooter. And let me amplify a little bit a point that Dave made with regard to commercial jobs. One of things, we're carefully to say, for instance, is we do no new construction plumbing. But one of the things we've seen in the last year, we expect this to continue this year, we saw little niche develop, mostly in the Southern units.

With regard to new construction, builders who are kind of mass building, when they finished a job, they would pay us to camber the line just to make sure it wasn't an excess of construction debris blocking the lines. Again, it was low margin for us, but it was schedulable. A lot of the sticker, a lot of the equipment, it was something that we were happy to do. That business has disappeared in those units, affected the job numbers, but not, as Dave said, not the profit numbers. We don't like to amplify that point, in a sense very indirectly ties us to the new construction home industry.

But that is one effect of the recession that we've seen already, the decline in those commercial jobs. But I don't want to be long winded here. We have always said that Roto-Rooter have a fully commissioned sales force, which is a boon on the downside. Everyone shares the pain. It takes a little bit of our upside away when times are good, but it positions us well and we're comfortable with that system.

Jim Barrett - CL King & Associates

Speaking of your home buildings, a couple of your largest franchisees are in states with very bad housing markets. Is your outlook when we look out over the next couple of years for making acquisitions, first in Roto-Rooter, is that improving at all?

Kevin McNamara

Well, here is what I'd say about that. As you said, our two largest multi-location franchisees in Roto-Rooter have substantial California operations. And our repots from them are that they are struggling mightily on the commercial side more than the residential side. That cheered us.

One of the things we've noted before is an awful lot of our efforts in Roto-Rooter are coming at the commercial side of business. We really think it's an example of all those efforts aren't unnecessarily driving the topline, but they are softening the effects of what has been a difficult market on the commercial side.

But the bigger issue really goes to the operating environment in California. As I said, as we've indicated, we had two wage hour matters with VITAS in California. And these are matters, which there is largely no defense, and our research has indicated that no one has litigated this on the company side and won one of these cases. I mean the deck is stacked against you.

We only have one significant operation of Roto-Rooter in California. We settled that case, got it behind us on what we think are very advantageous terms. We would be reluctant to make major acquisitions in California until that situation was addressed by the California legislature or the court system. It's a trap for the unwary. It's a tough situation.

So I think that would have a bigger effect on us then the housing market in California or other aspects of the operating environment.

David Williams

Jim, I would say, this is Dave Williams, we have seen an increase in inquiries from some of our franchisees about whether we'd be interested in acquiring them, but nothing, I would say, was heating up. I think typically a recession, though, brings reality to some people in terms of an exit strategy under ownership.

Jim Barrett - CL King & Associates

Right.

David Williams

So we're anticipating a pickup, but we haven't seen it yet.

Jim Barrett - CL King & Associates

Thank you both.

Operator

Your next question comes from the line of Eric Gommel with Stifel Nicolaus.

Eric Gommel - Stifel Nicolaus

Good morning. My first question relates to Florida. I saw a recent headline discussing the Governor's potential intent to eliminate the CON rule for hospitals or discussing that. I was curious if you could shed some light as to whether or not he is considering that for hospice as well?

Kevin McNamara

I will turn it over to Tim and Dave here, but let me start by saying that we've analyzed this situation and we think that, again, maybe whistling past the graveyard, but we think we'll be in favor of it. It would hurt us a little bit in the short run that is in areas where we have a very dominant share; there might be some more competition. But we're very well situated in those areas. But it would open up several markets in Florida that we would jump in.

So let me start by saying we are in it for the long-term, we'll be in favor of that, at least, I would. Now, I'll turn it over to the Florida residents to say if they know any more about it as far as the likelihood and its applicability to hospice.

Tim O'Toole

I mean we have heard what you have heard. So yeah, we're aware that the CON for hospitals is on the table. Whether or not that has any likelihood, we don't know. There is nothing on the table that we're aware for repealing the CON for hospice. But it probably will come up. It comes up every year. Someone is going to suggest that.

Kevin McNamara

It will be fought by the not-for-profit hospice.

Tim O'Toole

Keep in mind that hospice is very mature in Florida. It was one of the first states for hospice licensure. And there are many, many, many, many, many not-for-profits and they would all be not happy with that happening and they have strong connections and lobbies. And so, we're not taking a strong position, as Kevin says. We're pretty neutral on it. There are some pros and cons, either way. We're positioned to deal whatever happens.

So nothing is on the table now. As you know the recession is in March in Florida. It's a short session, lot of activity, but who knows if it would even come up. But I would be very surprised if that happens this year.

David Williams

It will be very disruptive to the Florida healthcare system for the elimination of CONs. And I think that always gives some cause for pause.

Kevin McNamara

They have a process in Florida where when they do open up a new license in one of the regions because need is shown. And if you look at the history of the last couple of years, actually those studies indicate that there really is not much need shown that the existing hospices are providing the appropriate care needed. One or two licenses come up every year. So the statistics are there to show that there is not a need for a bunch of new hospices. So with that behind it, I'd be pretty surprised if it ever carried the day.

Eric Gommel - Stifel Nicolaus

Great. And then actually some of the comments you made answering my first question lead into my second question. I mean how should I look at, I guess, mature growth in a program, a program that's mature, that's large, I mean what is a consistent growth rate that we could use to model such a program?

Tim O'Toole

Well. I mean every place is different, but we always still have, as you know, demographics working for us. So the population is growing over in all markets in this country. And we also believe that the acceptance rate of hospice, people that are becoming aware of hospice want it. Many, many people are familiar with it now just by word of mouth. And there is a lot of information being put out there. Hospice is being taken on by all the managed care providers to understand that the public demands hospice, wants it, and it's an appropriate service.

So we still believe that there is good opportunity for growth, and it's our job in the markets where we have large presences to always find new opportunities with new customers, have incredible presence of inpatient units which we're expanding and continue to market in a strong way. And again, like in many cases, many of our competitors are not looking necessarily to grow and penetrate the market beyond where they are at and we always are.

So we're optimistic in the trends for utilization of hospice demographics, and we believe we're continuing to raise the bar on the product and quality we put in the marketplace, so all those things being pretty well for our opportunity in the future. And we've done better than we had expected on the last couple of years in these large programs, and I expect that to continue.

Kevin McNamara

And to give you a number I would say, and Dave jump in here, but those would grow in admissions and revenue, two or three largest at half the rate that we would look at overall.

David Williams

Yeah. I'd say it would certainly anticipate a price increase, so that would give you three points of growth. We'd expect roughly half relatively flat on admissions of population growth as well as just even a slight increase by one or two days on length of stay would put you in the mid single digits topline.

Eric Gommel - Stifel Nicolaus

Great. Thank you.

Operator

Your next question comes from the line of Kevin Fischbeck with Lehman Brothers. Please proceed.

Kevin Fischbeck - Lehman Brothers

Hi. Thank you. Good morning. I had a question about your guidance. You didn't provide ADC guidance. Is it safe to assume that given you're looking for 3% pricing and 7% to 8% revenue growth that you're looking for ADC growth of 4% to 5% in line with admission?

David Williams

That would be correct and that's percepted as one underlying characteristic. We're anticipating in that guidance no change in our length of stay. Historically, we've always had somewhat of an increase. So that would be kind of what I call cushion on our guidance. But you are correct on the ADC assumptions and if we have an expansion of length of stay that would expand on the average daily census in revenue as well.

Kevin Fischbeck - Lehman Brothers

Okay. So I guess, given Kevin's comments earlier about routine care growing faster, I mean that would imply the length of stay would increase just kind of conservatism in the guidance then?

David Williams

That's exactly right.

Kevin Fischbeck - Lehman Brothers

Okay. And I appreciate the increased disclosure about the cap cushion at your sites, breaking out the number of sites in the 10% to 15% and 15% to 20%. Do you have those numbers over the last couple of quarters?

David Williams

It's roughly the same. On the top end where we have significant cushion they all stay up there. What we do is we typically see one or two programs cycles in and out of the below 10, above 10. So you certainly can assume that we add two or three two quarters ago as to same two or three today. So I'd just leave it at that.

Kevin McNamara

We have given that information generally speaking in the past.

Kevin Fischbeck - Lehman Brothers

Below 10% you guys have been giving pretty consistently, but 15% to 20%?

David Williams

After that, it's all about the same. And the only reason we went to a little more detail this time is the 2008 cap year really only has two months into it. They are looking at admissions for our November and December. So a trailing 12 months and kind of a recap for the past year, we think is useful. I wouldn't actually anticipate going into this kind of detail every quarter. But we'll certainly continue to talk about the above 10%, below 10% cap cushion programs.

Kevin McNamara

And let me just add one thing. It's something we look at. I mean we're not laughing it off. I mean Medicare Cap is a serious issue for the industry. We think we're, I'd say, overall $219 million of cap cushion just indicates that our general operating conditions suggest that we should be able to develop programs that are within the guidelines. But it's one that certainly we'll pay a lot of attention to. We think it's going to create opportunities for us. As more and more programs go into a cap problem, it's going to create opportunities for us. We think we can continue to run ahead of the pack a little bit.

But it's, again, one of the reasons we have cap cushion in our guidance is it's a real issue and it's one that's going to be facing the industry. And I anticipate over the next couple of years it will be addressed in some way.

Kevin Fischbeck - Lehman Brothers

Okay. Switching gears a little bit, going to Roto-Rooter, can you talk a bit more about what happened in the quarter? It sounds like you are highlighting the same trends that you've seen really throughout 2007 getting out of the low margin commercial business. But this quarter the pricing benefit really wasn't able to offset the volume loss that you saw. So you were showing 7% to 10% growth in the first half of the year, it was 3% this quarter. Can you kind of go over what changed this quarter and what makes you think that you'll get back to 6% to 8% in 2008?

David Williams

I hate doing this, but the facts are the facts are the facts, last year's fourth quarter was just so incredibly strong it was just difficult to compare to. On a net basis, we are actually very, very pleased with the quarter and that's why it took me time to point out. We typically see seasonality going from the third quarter to the fourth quarter, and our seasonality remained exactly where we expected, growing 3.3% from the third quarter of 2007 to the fourth quarter. So last year's fourth quarter was very unusual in terms of strength and depth across both commercially and residential.

Tim O'Toole

Although the fourth quarter of 2007 was strong with regard to things like turnover, accident rate and whatnot, even though they were all good, the fourth quarter of 2006 was just almost unheard of good by comparison. So, all those things added up for some negative comparisons. But generally speaking, given a little bit of the difficulty at the topline, we were very happy with the Roto-Rooter results for the quarter and the year. We don't see much of a deterioration in the base businesses at this point.

Kevin Fischbeck - Lehman Brothers

So the 10% type growth that you were showing in the first half of '07 that you don't believe to give you the same type of difficult comp in the first half of '08?

David Williams

No. And that's why we kind of pull down the topline a little bit in that regard for our forecast, although we continue to see strength in our margins and our costs containment. We think we've actually in the last couple of years, have been exceptionally strong in Roto-Rooter. And you continue hear saying us, don't expect it to continue, and our guidance is assuming the growth rate declines a little bit, but continues, obviously, in the mid to upper single digits.

Kevin Fischbeck - Lehman Brothers

Okay. And what is the long-term growth rate for that business?

David Williams

I would probably put it at that about 5% to 8%.

Kevin Fischbeck - Lehman Brothers

Okay. And then last question from me. Any comments about the commentary of CMS that they were looking to make some wage index adjustments to hospice administratively that would kind of cut reimbursement in that kind of 3% to 3.5% range?

David Williams

Yes. This is Dave Williams. What Kevin is referring to, as some of you aware, the President's 2009 budget basically proposed a five-year phase-out of something called the budget neutrality factor. When the President puts out a budget, although, obviously there's going to be a change in the White House, the Deputy Administrator of CMS, Herb Kuhn said in an interview that most of you picked up on that, but the agency is going to consider administratively adjusting payment formulas in kind of their annual proposal for several reimbursement systems, including hospice later this year.

Basically, proposing eliminating the budget neutrality factor over a five year period, which would have the net effect of reducing hospice reimbursement below inflation rates since 1998 because this budget neutrality factor grows every year. For a little historical background, Congress through the Social Security Act has specifically mandated or required by law that hospice receive an annual increase in our hospice per diem to offset inflation. Then they mandate, we get an inflation adjustment, and now it's up to CMS to come up with a formula to calculate that. And the calculation has gone through a number of iterations over the past 25 years. Its utilized indices from the Bureau of Labor and Statistic, hospital survey data, and as well as adjustments for differences in metropolitans statistical areas, or the MSAs, basically inflation throughout different parts of the country.

But now over the past 10 years, HCFA and then CMS has calculated inflation for hospice using a combination of a hospital wage data, then they further refine the inflation with this budget neutrality factor. Again, the purpose of the neutrality factor is to determine the aggregate dollar amount of inflation from one year to the next, and then they wait or redistribute those inflation dollars among the various MSAs to reflect their varying inflation rate.

What this really means is a portion of inflation is calculated with this neutrality factor. Now, CMS has the ability and a responsibility to revise the inflation calculation methodology if they say there's a more appropriate way to measure inflation. However, given the fact that the social security mandates reimbursement to be adjusted for inflation, any change that CMS proposes in a methodology can't be arbitrary. It has to be based upon a reasonable set of facts and data in terms of measuring true inflation. So, they are largely constrained. They can measure inflation, but they can't arbitrarily take away a piece of that inflation into our reimbursement.

Kevin McNamara

And let me just add one thing, and again, because it's just proposed, I can't say that our level of analysis is something that I could fully rely on, but I will just say this. With regard to the effects of the budget neutrality act, it has helped us in some years and hurt us in some years. I was just saying with regard to proposed change.

I mean anytime I'll just say that to the extent that if you are in the healthcare business, there's a good chance that government is your most significant customer. There are issues dealing with the government. We can't see in the future other than to say last year, for instance, they were talking about reducing the increase by 40 basis points. It didn't happened, could have happened, I mean if Congress had acted, we don't know.

I would say this regardless what the government with regard to reimbursement, we believed we are nimble enough and have the systems in place that we'll be able to respond to whatever is required. I mean we are not a niche player. We are right in the center of hospice providers in that this country with regard to length of stay, type of patient we're serving. Again, come what may, the only thing we're sure of is over the next coming years there will be changes, and we just have a high level of confidence that we'll be able to adjust to them.

Tim O'Toole

CMS, again, we debate what that CMS can't do a relative basis, but they weren't even proposing of wiping out the budget neutrality in a single year. They are talking about the multiyear phase-out. I know someone had a report out that says, you know, if it all came in and one fell swoop, they would have a huge impact on our '09 earnings, but the fact is even CMS isn't been proposing that. So basically this has a long way to run, has come up multiple times before, and at this point, unless Congress intervenes, we anticipate getting an adjustment for our full year inflation in 2009.

Kevin Fischbeck - Lehman Brothers

Okay. Great. Thanks.

Operator

With no further questions in the queue, I would like to turn the call back over to Mr. McNamara for closing remarks.

Kevin McNamara

Thank you. I have no closing remarks of substance other than to say we've given guidance for the year. We have a high level of confidence we will be able to deliver on those and we believe we had an excellent fourth quarter and thanks for your kind attention. Thank you.

Operator

Thank you for your participation in today's conference. This concludes the presentation. You may now disconnect and have a good day.

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