Good morning, John Ransom. We've got Heather and Chris from Acadia. The company made some news last week, and I think the timing is impeccable. So we're going to do some brief comments and go to Q&A, and we'll probably have a little time at the end to ask a couple of questions from the lovely studio audience. So, Chris, take it away.
Great. Thank you, John. I want to start by doing a quick introduction to Acadia for those that might be newer to our organization. Also wanted to share a quick overview on how quickly the behavioral health sector just continues to evolve and why that's such an important driver of our overall growth and ambitions. So just to start, we as Acadia are the largest pure-play behavioral health provider in the country. National scale and regional densities, you can see this is our map of 262 facilities. We have program services and facilities spanning 39 states in Puerto Rico in four complementary lines of service. So you can see on here the green dots represent our 55 acute facilities. These are where we treat high acuity patients and inpatient facilities.
The orange dots represent our 35 specialty facilities, and this is where we primarily treat substance use and eating disorder patients via a residential care model. The blue dots represent our 163 opioid use disorder outpatient clinics, and we call these our comprehensive treatment center, or CTCs for short. And finally, the purple dots represent our nine child and adolescent residential treatment centers, or RTCs. So across these service lines, we are servicing more than 80,000 patients daily, and the overall breadth of our service lines is a key differentiator. So many of our patients have comorbidities that cut across service lines and acuity levels. Combined with our clinical quality and operational track records, we really believe this gives us a unique platform to lead the behavioral health industry during a time of unprecedented demand and crisis.
This slide shows just the incredible unmet need in our industry, and just going to do some quick industry stats in the next two slides. Last year, the U.S. Surgeon General called behavioral health the defining public health crisis of our time, and we really believe that's not hyperbole. There remains a very large unmet need. You can see on the left side of this slide over 75,000 additional beds that are required just in the U.S. to meet optimal levels. Suicide rates continue to increase, and ultimately 30 million Americans have some form of mental illness and yet receive no care for it today, and at the same time, this industry is highly fragmented and has generally suffered from underinvestment for a long period of time.
You can see in the bottom right of this slide, there's a reference to the 2009 $25 billion HITECH Act, which expanded the adoption of health IT, particularly Meaningful Use, but the behavioral health companies were carved out of those dollars, and that has led to the continued underinvestment that we've seen across the industry. This next slide just quickly shows the intensification of behavioral health prevalence just across the industry. Just as deaths by suicide are at an all-time high, so is behavioral health disease burden. And this is really true across the spectrum, from mild to moderate acuity illness to serious mental illness that you can see on the left side of this slide, to opioid use disorder. The overall acuity of the patients that we are serving has become more and more pronounced over the last several years.
And as the leading pure-play provider of behavioral health services, we really believe that we're playing a vital role in addressing this crisis head-on and believe that the demand for our services has never been greater. This slide is just a quick overview of the diversification across service lines, payer, and geography overall. So on the service line side, acute, it remains our largest service line by revenue, just over half, but each of our service lines has significant scale. On the payer front, we treat patients with both government and commercial insurance. Over half of that is for Medicaid, commercial next at a little over 25%, and Medicare is around 14%. We also have strong geographic diversification, again, with facilities across 39 states and Puerto Rico.
Our strategy back to our first ever Investor Day that we did at the end of 2022 has been very consistent over the last several years. And our strategic vision is to lead the industry as the indispensable behavioral health provider for high acuity and complex needs patient populations. And to achieve that, we first continue to grow our facility footprint and the number of beds to keep pace with this growing demand that we just went through across the industry. Secondly, to expand across the continuum of care from the most highly complex inpatient care to outpatient care for individuals with opioid use disorder and other substance use disorders. This will improve clinical outcomes, allowing us to win on quality and ultimately driving growth.
And then third, part of our strategy is to further strengthen our core capabilities through selective technology investments that we've been making for the last several years, and that's to continue to enhance our quality and operational effectiveness across all of our service areas. This slide shows the commitments that we've made on the investments in technology going back to 2022. Just to cover this very quickly, first and foremost, we really believe that quality is what drives clinical outcomes and patient experience, and we've invested heavily accordingly. Quality also drives operational effectiveness and a diverse array of stakeholder relationships, including payer relationships and ultimately growth. So we're very proud of the quality our clinicians and our frontline staff offer every day. Quality is really the product of everything we do.
On the technology side, we've talked extensively about the implementation of an electronic medical record that we've put in place in our acute facilities and continue installing those acute and RTC EMRs, while they're commonplace across the rest of healthcare and med-surg facilities. We are really leading the way on the behavioral health side with our approach. Another example is the investment that we've made in remote patient monitoring devices to ensure adherence to care requirements consistently across our facilities on the acute side, as well as providing critical documentation of patient care and outcomes. And then a final example I'll cite, which spans really not only technology, but also people and process, is that we've implemented really robust analytics for managing quality across our portfolio of facilities. And overall, I think we're very proud that our strategy of winning on quality is working.
Our uniquely broad and diversified ecosystem, you can see several examples of this. So one example here on the right side, we are regulated with our comprehensive treatment centers. These are the facilities that serve patients that have OUD by the regulatory body CARF, the Commission on Accreditation for Rehabilitation Facilities. CARF has assessed our opioid clinics as having 99% quality scores across each of the 13 quality dimensions that they have. To cite another example, in our acute psychiatric hospitals, we score approximately two times better versus CMS national benchmarks on the use of restraints and seclusion. Those are two of the most fundamental quality measures for psychiatric hospitals because they're both reflective of high-quality care, but also themselves enablers of high-quality outcomes in the inpatient setting.
And then just to say a little bit more about our comprehensive treatment centers, we offer much more at these facilities than just dosing. The medication management with individual and group therapy, as well as other support services, we believe are critical to achieving the outcomes we've been able to deliver. We've continued to make significant strides in how we manage these clinics to the highest quality and best patient outcomes. So as an example, we realized very early on that access and wait times were critical pain points for patients.
And through a number of studies and analyses at our various clinics, we put in place a number of process improvements to ensure that all patients can receive care to a point that we no longer have waitlists at any of our facilities and the patients can receive care with wait times in our clinics under five minutes on average, which is a significant change from only a few years ago. We also have invested to ensure that we can meet our patients where they are. So for example, not only virtual counseling options, but we've also invested heavily in mobile vans that have access to remote areas. And those vans are fully functioning clinics with dispensing and counseling capabilities as well. Another critical component of our growth strategy is our partnership with health systems across the country and the joint ventures that we've put in place.
We have currently put in place 21 different JV partners. These are just high-profile health systems for acute psychiatric care. These health systems either seek us out directly or they choose us as part of an RFP process that they run. Over the last several years, we've been able to continue to build our pipeline here, and we're just extremely proud of the track record that we have here. The two most recent joint ventures that we've opened are Intermountain Health in Denver, Colorado, and earlier this year with Henry Ford Health in Detroit, Michigan. These are some of the most premier names in healthcare: Ascension, Geisinger, Tufts, Intermountain, and even here in Florida, Orlando Health. This is a quick overview of our continued growth from a bed addition standpoint.
I mentioned earlier that clinical benchmarks suggest that in the face of this behavioral health epidemic, the U.S. needs roughly over 75,000 additional psychiatric beds, and we really believe that we are meeting this need. So over the last couple of years, we've worked to significantly accelerate our pace of bed expansion, and this is translated into 2024 being the largest capacity expansion year in the history of Acadia. Can't overstate, as we've grown to 776 beds that we delivered last year, the impact that these facilities continue to have on the lives of our patients and their communities. Also, you can see in our 2025 guide, 800-1,000 beds, and we've already opened 300 thus far this year.
Over the next couple of slides, I'm just going to share a little bit more detail on some of the facilities that we've just constructed and several that are in progress. I'm just going to go through these very quickly. These are just example facilities. Again, the two most recent joint venture facilities, the one in Denver you can see in the upper left with Intermountain, the one on the right that we just opened just outside of Detroit with Henry Ford, and then you can see a few de novos that we opened earlier last year in Arizona and Indio, California. So these are 2024 facilities, and Henry Ford just opened in 2025. This also demonstrates a number of facilities that we have that are currently under construction.
I'm not going to spend a lot of time on this page, but I would draw your attention in the upper right to Geisinger. This is the second facility that we have underway that we're building with Geisinger, a 96-bed facility in their headquarters of Danville, Pennsylvania. We opened our first facility with them in the second half of 2023 in Moosic, Pennsylvania, right outside of Scranton. You can also see the joint venture hospital that we have underway on the left with ECU Health in Greenville, North Carolina, as well as the JV underway with Tufts Medicine just outside of Boston in Malden, Massachusetts. Don't want to spend a lot of time on this slide either, but just wanted to reinforce just the elegance of the design of these facilities.
Many people are surprised by the degree of natural light, the high ceilings, and just the architectural rendering of these. These are truly state-of-the-art facilities. And then the last slide that I would just reference here for everyone is that you can see the specific facilities here that are in the ramping phase by year, and you can see the acceleration over the last several years. One thing that I think this page makes clear is just the degree of acceleration that we have underway at Acadia right now. And I don't have time to go into a significant amount of detail, but I would just reference that we do select these locations with a tremendous amount of thought when we build a de novo facility.
We go through a sophisticated analytical process spanning the degree of unmet need that we see in a local market, the competitive landscape, reimbursement, labor, regulatory considerations, and a diverse mix of other factors. But you can see the facilities that we have, the five that we build in 2024, and then the future cohorts that we have that are currently underway, including several of those that were photographed earlier. So this is the last slide. I would just say in closing, we continue to execute on our strategy to serve the highest acuity patients in behavioral health. And with these new facilities we're building and the IT and quality investments that we continue to make, believe that we have positioned the company for significant growth while also addressing a major societal need in high-quality behavioral healthcare.
So John, that's it on the slides, and we can go to Q&A.
All right, so the company had its first Analyst Day at the end of 2022 and laid out this 10% EBITDA growth. We're kind of taking our medicine this year on that target. But maybe it'd be helpful, I think, just to take a step back and say, okay, what went off the rails a little bit in terms of hitting that target? And then as we look forward, 2026 and beyond, what are some of the items that are going to be more temporary in nature, and what are some of the items that look to be maybe a structural bad guy in the outlook?
I'll jump in and answer that. So I would call out a few things, actually, John. The first is the professional liability expense. We have experienced costs across the industry running hotter over the last few years than what we would have anticipated. In the guidance that was formed in 2022, we've absorbed around a 75 basis point headwind as a result of that from the last few years. And while it's really difficult to predict what will happen in the future related to these professional liability costs, what I can say is that we have made some significant investments in our facilities. That's investments in the facilities as well as investments around the supervision of the facilities. And that should really help us moderate any potential future increases for those professional liability costs.
The second thing I would point to is, obviously, we've been subject to some external scrutiny recently, including a government investigation, and we've talked about for the last couple of quarters quite a bit the impact that that has had, so I'm not going to go back into a lot of detail here, but obviously, that's been an impact to the performance of the business recently, and then finally, kind of to your question about going forward and what's the future look like, I would just point to the bed additions and the difference in the pace of how we're adding beds, so as Chris just mentioned, we've added a significant number of beds over the past few years. We added 776 beds in 2024, and we would expect to add 800-1,000 more in 2025.
That's a really healthy rate of growth, but it's still around 25% lower than what we would have anticipated and what underpinned the guidance back in 2022. And then on a go forward basis, we have said that we'll plan to add 600-800 beds. And that is really us focusing on a balance between growth and the generation of free cash flow. So again, very, very healthy growth rates when you think about adding that many beds, but certainly different than what underpinned the 2022 guidance. So I think those are the main things I would point to, John.
And then this year, elevated startup losses. So as we add all this up, you've got $25 million of additional startup losses. You've got $20 million from the underperforming facilities, and you've got $25 million from liability. So those would be kind of the three. And so I would think the startup losses should be in the rearview mirror, and then we'll see about the underperforming facilities. So just going back to, I don't want to devolve into an accounting discussion of med mal because my head hurts. But there's obviously the claims you're paying out, but then there's the reserve on the prior stuff. Is this mostly related to older claims and just reestablishing reserve? Is there any forward-looking indicator that says the pace or the payouts of these claims are starting to slow? In other words, is this a catch-up, or was it just too early to say?
Yeah, I'll take that one. I mean, the increase that you're talking about in professional liability costs has been a function of these higher settlement payouts projected for the entire industry that are based on third-party actuarial analysis. So I think the point I would make is that we've, just as I went through a few slides, we've been investing heavily in technology and processes and just generally the way that we run the business over the last several years in a way to mitigate that. And we feel strongly that the remote patient monitoring, the EMRs, the patient safety devices, the Joint Commission's licensed software that we have in place on the quality side will continue to help us mitigate those here going forward.
Great. The second question is, let's delve in a little more if we could into the $20 million drag from the underperforming facilities. I know you've said in the past you can kind of trace local media to the performance, but just maybe a little more, what's the blend of specialty versus acute? And I know you guys have done a ton of work with your referral sources on the acute care side, but again, where do you see maybe that being something you can put in the rearview mirror over time? And where do you think maybe that's some structural damage?
Yeah, I'll jump in on that one. So to your first question of what's the mix in the facilities, we've called out a handful of facilities. We talked about those back in January and that's the facility group that we were focused on largely as a result of some of the headwinds that we saw in Q4. Those are split across the two lines that you mentioned, acute and specialty. They include a bit of both. When we look at the referral patterns and what we've been looking at recently, we feel like that larger referral pattern issue is largely behind us. And we understand that what we're doing to mitigate it as appropriate seems to be working. So when you look across the entire book of business, we feel like that's largely behind us.
But to your point, we do still have a small handful of facilities where we are continuing to work through some issues there. As with any portfolio of this size, you're going to have facilities that overperform and facilities that underperform. And these are a few that are in that underperforming bucket. We are working with those. We are effectively operating them at a subscale level right now with, in some instances, a self-imposed census cap while we work through the issues and we have some time to retool. From the perspective of 2025 and the $20 million headwind that you call out, we have not assumed upside coming from those facilities. We have assumed in our guide that those remain sort of at the same level throughout the year.
Of course, we are seeing things that lead us to believe that there will be favorable outcomes here, but at this point, we feel like it's more prudent to just take a conservative approach. So in the instance that those have a material change and start to develop faster, that's clearly a positive swing factor for us.
Somebody asked me a question. I didn't know the answer. Are these collectively EBITDA positive still, these facilities, just down from where they were? Are they collectively EBITDA negative or something in between?
No, there are facilities that are running at an EBITDA negative stance right now. As I mentioned, some of them are at subscale. We are effectively putting in some census caps there so that we can go in, do the work that we need to do to retool, and so, yeah, some of them are running at a loss.
What would be some of the work needed there? Is it maybe some new leadership? Is it staffing? Is it process? What are you doing there before you feel like you can get back to playing offense?
Sure. I'll take that. I mean, I think it starts with just doing a diagnostic on the individual facility. I mean, healthcare is local, so we'll dig in and really look at the competitive landscape and look at referral sources, look at the labor market very specifically. But we'll also then look at the leadership of that individual facility. Are there gaps with respect to key leadership roles that we need in place? We'll look at the programs that we have in place at the individual facility. And there's just a litany of things from even reviewing the physical plant that we'll go through in extensive detail. I think one of the things that also I always like to look at right out of the gate. We've invested so much in technology and quality initiatives.
We want to make sure that these facilities are leveraging those because we think that that's always a leading indicator of strong operational performance as well as financial strength. So those are just some of the things that we look at, John.
Thanks. So second big topic, I think, is, look, I remember the legacy management team at this conference in 2021 laid out this, let's go add a bunch of beds. And we've written a couple of papers, a lot of the credible complicated notes, trying to look at all that. So the last time we looked at this back in December, our conclusion and challenges on this is that when we looked at pure De Novos, we were getting to about a 10%-12% payback, meaning just a simple calculation of EBITDA at maturity over investment. And that was down some from our original analysis, mostly because the construction costs have gone up probably by a third since we looked at it in 2021.
So when you look at the, I mean, we don't see into your cohorts, but when you start looking into these cohorts, what kind of return are you targeting for the, because I think there is a concern that, gosh, we love the bed adds, but these de Novos look like the returns maybe weren't what we thought they were going to be. So please challenge us on that assertion and bring some actual facts to our speculation if needed.
Yeah, maybe I'll start and Heather can add in. But I mean, we have been very focused on, as I just went through in the presentation, adding new facilities. But 85% of the time that we add a new facility, we're going to expand beds. These were unique opportunities for us to partner with some of the most premier names in healthcare, and we continue to think a pipeline there makes a significant amount of sense. The returns on bed additions to existing facilities are going to be higher because it's obviously a shorter ramp time. You have visibility on the demand in the marketplace. You can get those. You already have staff in place, referrals, et cetera. But we also believe that the returns on the De Novo facilities have been and will continue to be very strong.
And so we feel like we need to be able to balance both. What else would you add, Heather?
Maybe just to your point of what the returns look like. We are seeing the returns that we anticipated. So when you look at the process that we follow, of course, upfront, before we make a decision of where to invest capital, we look across the options. We have obviously many different growth pathways that we've talked about before, but then in each one of those, there are multiple options. So we take a very structured approach to ensure that we're choosing the right option. And if one of them looks like it's a substandard return, then we'll move on to the next. When we're actually in the process of putting the plans together and moving forward with an investment, we check in multiple times and we ensure that we're factoring in any of the changes in the landscape.
From a construction perspective, we have a very disciplined approach to how we construct our facilities, and we take advantage of all of the different pieces that are available to us to lower the cost of construction. Then, of course, we check back in throughout the way to make sure that we're still getting the returns that we anticipated upfront. Maybe just the last point in sort of bringing those two comments together, Chris talked about how lucrative those bed additions to existing facilities are and that we build the facilities as new de Novos with room or potential for expansion in the future. When we approve the returns and when we move forward as a decision with a project, it is based on the returns of the initial opening beds alone.
And so it has to pass our internal thresholds for an investment approval without those extra beds. And then that's upside in the future to the beds.
And just as a corollary point, I would assume too that you, by taking the brand name of a Geisinger and also by capturing referrals from that system, I would assume that those are two factors that differentiate those projects versus maybe some of your legacy unbranded facilities.
Yeah, absolutely. And to your point on the cohorts, when you go back and you look at the cohort from 2023, we had two JVs that we opened with Bronson and with Geisinger. You fast forward a year later, those were right on pace for breaking even in the second half of the year, actually a little bit ahead of schedule relative to what we've seen historically. And those have just continued not only on a clinical and quality standpoint, but just the financial expectations that we had with those have continued to deliver right on pace. So we obviously opened a lot of facilities at the very back end of last year, and it's too early to track those.
And we've obviously opened 300 beds this year, but I would say all of these projects more recently just continue to go according to our expectations, if not a little bit better.
And just lastly, we're at time, but just to comment on the CTC business, as we mentioned on the call. I mean, growth is kind of back to CPI, kind of a single digit. Heather, I think you said that's kind of the outlook you see for the business. Does this also imply that you're going to be investing less in M&A or new CTC facilities or how are we thinking about that business today? And did you see any fallout from the negative press late last year?
I would say we did not see fallout from the press. Right now, only 10% of people that have an opioid use disorder are actually in treatment. And we continue to believe that methadone is the gold standard for treatment. The acuity of those that are presenting with an opioid use disorder, the intensity of their addiction gets greater and greater, which we think plays well into the counseling and the facilities that we're offering. So we still think that there's significant opportunity with that business overall. And we do think that there are some very attractive tuck-in acquisitions that we see across the landscape. I referenced earlier being able to make some investments that clearly in a fragmented market with a number of subscale players, they have not been able to.
So we've been able to find some very attractive assets that can be very accretive and will continue to deliver on that on the CTC side.
All right. Thank you. Go to breakout.
Thank you.