All right, we're going to get started here. I'm Scott Fidel, the Healthcare Services Analyst with Stephens. It's a pleasure to see you all here for our first fireside chat for the 2024 Stephens Annual Investment Conference. Delighted to kick it off once again with Addus HomeCare. Here from the company to my left, we've got Dirk Allison, Chairman and CEO, and to my right, Brad Bickham, President and COO, and Brian Poff, who's the Chief Financial Officer. Addus focuses on three primary areas in the home health market: personal care, home health, and hospice. And Dirk, I thought maybe what we would do just to start out here, I always like to ask you, like, just for a sort of lead-in, you know, type, you know, sort of, I guess, state of the union type update. And I do want to do that.
But even before we get to that, obviously, one thing I do want to try to ask all the companies that will be participating is just, as we're coming right off the heels of the elections, how each of the companies really is interpreting. Obviously, we've all had a lot of, you know, our own commentary and thoughts around impacts to the different parts of the businesses, but definitely curious on your take. So maybe if you could start, you know, with the elections and obviously with Trump, we've had him as, you know, president before, so you have had a Trump administration to interface with previously. So maybe walk us through your thoughts around that for the overall business, and then, you know, maybe thinking about each of the three business lines as well.
Sure. And then from the perspective of Scott, you know, we said before the election, and I think we truly believed it, we really didn't care so much who won the election because we have done well historically, whether it's a Democratic or Republican administration. There were some things, you know, the Harris administration were talking about expanding services that might have been something that made sense for the company. On the other hand, one of our biggest challenges over the last couple of years has been the Medicaid Access Rule. And while we were very pleased with when the final rule came out, there was an extension of time to six years. There were some definitional changes that made sense. But it's still, I think, to some of our shareholders, it still is a question they have.
What we understand now, our government relations folks have been working with our various associations. As we've talked to the Trump administration, what we understand now is that during the first year of the administration, we believe that he will do away with the Medicaid Access Rule, which is what we expected to have happen if he won. That is definitely, I think, a tailwind for us once we get that passed. Not that we, from an Addus standpoint, we were moving forward with our strategy, whether or not it stayed or went, it was going to work for us. It really won't change what we do.
But I think it might change some perception, especially maybe of some new shareholders that have come in over the last year or so compared to some of the folks who have been with us a long time who have had time to talk to us and understand our feelings. So overall, I think Medicaid Access Rule potentially going away is very solid. I think the one question we do have, to be fair, on if there's any kind of tailwind out there. It seems that the Trump administration has talked more favorably towards the Medicare Advantage players, which could affect home health a little bit. Managed care, Medicare Advantage, they don't pay quite what fee-for-service does. And so as we've seen that shift in home health, it's affected profitability in some.
Now, for us, it's only 6% of our business, so it's not a huge issue today, but that is something we'll have to look at. I think the fact if Medicare Advantage continues their growth under him, that could be a little bit of a disadvantage. At the same time, we're hoping maybe he looks at what CMS has been doing the last two or three years, reducing costs and maybe increase that, so I think from three levels of care, hospice is fine. It's worked well in both administrations. We're pretty comfortable that PCS will be beneficial from the Medicaid Access Rule, Medicare access going away, and then home health is still kind of puts some clouds, and we'll see how that works out.
Okay. All right. Great. Yeah. One element I wanted to follow up was just if, you know, if we do just have a full reversal of the 80/20 Rule and appreciate that comment on what you've been hearing around that. Like you said, it won't change the strategy. With that said, you know, you have talked about making sort of, obviously, you guys had to do a lot of analysis around sort of, you know, thinking about the personal care business in that construct, and ultimately, you decided that sort of it seemed like the best strategy would be sort of to go on offense around it, right, and build out more scale in the markets where you're going to compete, but then also considering, particularly in markets where, you know, the different reimbursements, you know, at the state level are going to be different.
That's where obviously there's a lot of pushback on the 80/20 Rule, not really appreciating how much different the economics are in each of the states. Obviously, you've got the big acquisition, which we're going to obviously touch on. But I guess to that sort of element, you said that you're going to sort of still feel comfortable with your current strategy. So maybe just walk us through sort of how, if there's any evolution in the thinking around that, like, do you still feel that sort of need, if you're going to be in the business, to have sort of increased scale is still, you know, going to be a critical sort of area of focus?
Or does this, I guess, sort of, to sort of back to the future a little bit around some of the other types of, you know, approaches that you guys would do? We're thinking about personal care, perhaps, you know, alongside the three legs of the stool, you know, where maybe you would do some smaller sort of tuck-ins on personal care because it was complementary with some things you were doing on the clinical side.
Yeah. I think if you look at our locations, realistically, everything's built around personal care. Personal care is our base of business. It's our focus for years. It's still our, if you look at 75% of our business, it'll be 80% of our business once we close the Gentiva transaction. So it's still the driver of what we do. And then we put clinical service around it. Now, I think with the change of administration and the Medicaid Access Rule potentially going away, I think what it does, it opens up a couple of things for us. When we agreed to buy the Gentiva business, Texas being their largest market, Texas did an increase last year, about a 20% increase in their rates. At the same time, they didn't give all of the payroll tax burden through on that rate increase that the industry was hoping.
So what it actually did, it made it where it fit into the 80/20 really well. If the 80/20 goes away, now all of a sudden we still have a tremendous opportunity in Texas to continue lobbying the state to try to get back some of that margin. That's one area that we will really be focusing on, knowing that the rule will go away. That's very important. But also now, you know, we open up Texas completely. You're thinking Texas, not only can you backfill with additional personal care locations in the market, although we do cover the state with this acquisition, but quite frankly, it opens up home health and hospice. We have a small, I'll say, we're in the central part of the state with hospice.
It allows us to look at expanding that elsewhere, but it also allows us to come in with some smaller home health opportunities back behind us so we can continue to work with these payers. Since it's a managed Medicaid market, it really opens that up. So we're really excited, not just about Texas. There's other markets we're excited about, but that is a big focus of ours going forward in trying to really develop the Texas market. It's a state that has a huge budget surplus. It has a huge rainy day fund. It has the funds to invest in this type of service. And so we'll be working with the state to see if we can't get that done.
Okay. And then just as we think about capital allocation over the long term and for you guys, capital allocation means a lot of allocation towards growth capital on the M&A side. I guess with the red wave, you know, and sort of thinking ahead, are there any nuances that you'd want to highlight around how you think about capital allocation, let's say, over the next four years, right? Let's sort of think about it in that frame, I guess, at this point.
Yeah. I mean, I think it's going to be consistent for us. I think personal care is going to be our lead to Dirk's point. I think adding complementary clinical services, probably more opportunities for us around skilled home health in Texas, like Dirk mentioned, and some other markets where we don't have any clinical services today. But I don't think we really see with the election as a result, really a change in our overall strategy on deployment. It'll be primarily M&A and mostly personal care and home health. I think hospice, you know, at the right price and the right markets, I think that's something we'd still be open to, but probably, you know, a step behind personal care and home health as a priority.
Okay. And it was a question I was going to ask a little later, but I think it actually folds in well with the elections and some of the second derivative effects that can play out. And, Brad, maybe get your take on this too, is, you know, just when we think about some of the dynamics that have played out in the labor market over the last four years with the huge influx of undocumented migrants and particularly thinking clearly about the unskilled business, so with personal care, maybe just sort of walk us through the backdrop of that in terms of, you know, to what extent, what types of impacts has that had on the labor market, positive or negative, the last three to four years?
And if we do see a more aggressive movement by the Trump administration to try to, well, we'll see ultimately what happens here, right, in terms of how many, how these deportations and things like that practically end up working out. But if they move forward with what they're saying they're going to try to do, how do you think that may affect the labor environment and any, I guess, sort of any operational sort of thinking that you have around trying to get in front of any of this?
Yeah, I don't think, you know, from a labor standpoint, I don't think they'll have a direct impact on us. I mean, our workforce is, you know, all documented, you know, [inaudible] and everything else. So it won't have a direct impact on us. Now, could it potentially have indirect consequences by resulting in some inflation, some wage inflation, possibly, you know, but in a lot of cases where you start having an inflationary environment, we've done pretty well from a workforce standpoint because people are looking for additional work. And what we found in that kind of, you know, in the last year where we had relatively high inflation is we actually saw candidate flow increase, hiring increase, because our workforce and the type of work that we do allows a lot of flexibility.
So if somebody needs extra money, they want to work on the weekends, want to work at night, we're a perfect employer for that. So I could see it's not going to, I don't think, have a direct effect, but there could be some kind of tangential effect from a little bit of inflation, maybe some wage inflation. We've been pretty successful, though, getting rate increases to offset that, but that's actually helped on the hiring front too.
Okay. Okay. Sounds good. Thanks. Let's move on and talk a little bit about just the overall sort of long-term growth outlook and how we think about it as you guys are now sort of scaling up, you know, in terms of what you're doing. You have reaffirmed the long-term target for driving at least 10% revenue growth. Obviously, you're going to have, you know, some of the mixed effects from the Gentiva acquisition. Maybe from the big picture, let's sort of start about thinking about sort of walk us through the, when you think about that 10% plus algo, sort of how, you know, intuitively that breaks down between organic and inorganic. I mean, obviously, we do know the, you know, you guys give us the different pieces of organic growth across the businesses.
But I'm just curious if that, excuse me, if that sort of mix you think sort of evolves at all from the big picture, and then we could get into a few inputs to that.
Yeah. I think our organic growth targets, I think kind of by segment still remain pretty consistent, so 3%-5%, I think long-term in personal care, we obviously have been nicely at or above the top end of that recently with some of the rate support we've gotten. We've got the Illinois rate increase coming on January 1, 2025. That'll be very helpful, we think, keeping us kind of toward the top end of that range into next year. But long-term, still 3%-5% overall. I think on the clinical side, home health and hospice, you know, we probably see that long-term being more mid-single digit, so blended basis of that 10%, you know, probably half or slightly over half is going to be organic, and the rest will come through M&A.
So we're, you know, been pretty active, as you guys know, since, you know, back in 2017, we've done 16, 17 deals. So we still want to be opportunistic in M&A, and we think there's going to be opportunities to be able to continue to achieve that 10% plus through that.
And then, thinking about the pipeline on the M&A side and your stance recently has been emphasis on personal care and home health have really been the two that you've sort of highlighted. I guess sort of one, you know, sort of how would you break out the pipeline across those two, you know, those two areas? And then from that election perspective, you know, I wanted to ask you about, you know, sort of what the environment's like from, you know, a seller sort of valuation type expectations. And markets have been, you know, on a nice run here too. So I think there's this expectation, you know, of animal spirits potentially being reignited to some degree. I'm curious how that may just actually flow down at sort of real time into some of these ongoing discussions you're always having.
Yeah. I think multiples have remained pretty consistent. So I think, you know, personal care for us are going to be, you know, low to mid to upper single digit, depending on the size and scale. I think home health is going to be, you know, smaller side, still single digit, larger, more sophisticated. Maybe it creeps up above, you know, 10, 11 times. We think hospice is probably still, you know, looking for a higher multiple from sellers these days. We know there's some larger assets that will come to market or expected to in 2025. So not a lot of movement there from a multiple perspective, but you're right on our priorities of personal care and home health. But I think our view, you know, with the pipeline right now, I think we have opportunities across, you know, multiple segments today that we're evaluating.
You guys know we're pretty conservative on our approach to M&A. We want to make sure that strategically they're a good fit, they're in the right markets, and also at the right price. And we've been pretty successful with that over the years, but a little slower the last couple of years with the way the markets have been. I think the expectation going into 2025 is that hopefully it would open up some. You know, we'll wait and see kind of if that develops. We kind of have heard similar kind of, you know, conversations going into the last two years from brokers that, hey, next year is going to be the year. We're hopeful 2025 will provide, you know, more opportunities for us. But in absence of that, I think we've been pretty diligent on, you know, going out and finding our own deals and sourcing things.
And we're willing to be creative. I think Gentiva is a great example of that. So a carve-out of a larger organization. And I think we'll still be focused on that even if the market, you know, doesn't improve as a lot of people think it might next year.
You know, one thing to comment on Brad's statement is we have seen recently one or two deals come into the market, kind of larger deals that we look at, but we have to be careful because we have, we want to put it around our personal care network. So if it's not a personal care transaction, it needs to fit into our, you know, our network in which we already have. If it is a personal care transaction, then it needs to be in the states in which we believe we can operate successfully. You know, some of the transactions we've seen in the last year or two have New York presence. That's difficult for us because we just stepped out of New York.
So, it's one of the things that we have to be aware of as we look at, but we certainly have our capital structure set up to be able to do the things that are out there if they make sense for the company.
Okay. Yeah. Because my next question around that was going to be around when we think about scaled assets, and you made it clear that you have an interest and will take action on the personal care side, you know, on home health. Obviously, you know, there's been a dynamic environment around M&A and larger-sized assets out there. I guess to be sort of clear, right, how do you? So that's helpful. I think that you just gave us sort of one clue already there that thinking about the alignment with your personal care footprint is sort of key, right, to thinking about strategically whether any of those assets would work.
And then sort of, I guess, separately, how closely do you look at, you know, I guess, and this is clearly where the election's come into play again, you know, just given the more activist, aggressive stance that we've seen from DOJ and now formally trying to block the Amedisys acquisition with United. I guess, would you want to just, if you were going to even consider, if you found an asset that, you know, did make sense from a strategic perspective in terms of how it aligns with personal care, would you also prefer from a timing perspective to sort of let the dust settle on the elections, let a new DOJ come in, see how that's going to get staffed, the, you know, FTC, et cetera?
Or is that something that, you know, because of your sizing and home health being, you know, very small overall, would not really be as much of a consideration?
You look at what the Gentiva transaction, because it was an acquisition of personal care, and we have sizable personal care. We have to go to the FTC, and we got cleared immediately. Even the Biden administration cleared us immediately. We're excited about that. The fact of the matter is, though, in home health, we have very little footprint. If you look at our business with only the revenue we have, I think we could look at anything if it made sense. I think that's the key. It has to make financial sense. It has to make strategic sense. If there was something a little larger that would qualify for a look for the FTC, I don't think we would be concerned about it because any remedy, if there was any, would be immaterial to us.
So I don't think that keeps us from looking at a deal. I think what keeps us focused is something in our personal care network so that we have three levels of care in these markets so that we are important to the payer, to the state, to our clients, and gives us a seat at the table when we negotiate with them.
Okay. And then just rounding out the M&A on the hospice side, you know, you guys have in the short term sort of de-emphasized that as a sort of major target area. And just wanted to, I guess, sort of frame that a little bit more. I mean, part of it, I suspect, could be that we look back in the last sort of two and a half to five-year frame, you guys were sort of allocating a lot of capital to hospice. So clearly, when you look at your clinical mix, it's four-fifths, you know, hospice. So you've already sort of built that up more than home health. And still, your core focus is personal care.
So is it some sort of sequencing dynamic that relates just to the timing of that, or is it a little more relative to the current environment, whether there's sort of, you know, valuations did rise, you know, more in hospice when there was a lot of M&A a few years ago? Or is there anything from the regulatory perspective as well that you would think about? I mean, you know, knock on wood, hospice has been, you know, a lot more, I think, you know, uncomplicated, right, from the regulatory dynamics. But whenever we say that, right, then the shoe always drops. It feels like the way things go in healthcare services. So just curious if there's anything. And we have, you know, heard some buzz out, you know, in the market.
Definitely, there seems to be a lot more sort of just focus on evaluating, you know, truly evaluating the quality of assets, how they do clinically, how they do in terms of quality performance, scrutiny around that. So no threat, a bunch out there, but basically hospice would be the update there.
Start, and you guys jump in. You know, I think when we were active in hospice a few years back, it fit well with our market where we wanted to be. We found deals that, while they were double digits, were on the lower double digits compared to some of the others we saw. We saw some above 15, 16, 17, 18. We didn't play in that realm. We were down in the 12-12.5 range. We like hospice. All three of us came from the hospice industry back in our background. We think it fits very well with the elderly clients we have in personal care. The problem we have today is most of the assets that we know that are coming out in the next year or two are going to want those very high multiples.
There doesn't seem to be the adjustment downwards of valuation expectations that maybe we've seen in personal care and home health. So that's the issue we have is even if it's a very strategic asset, if it gets too high from a cost standpoint, it's hard to make it work long term. And so we're very aware of that. So we'll continue to look, obviously. And if we can find something that fits all of our strategic needs yet is one that gives us the return that our shareholders expect, it'd be something we'd look at, but we're not going to chase a deal.
Yeah. I mean, I agree with that. I think first and foremost is the pricing aspect of it. But secondly, it's probably sequencing to a certain extent. I mean, as you pointed out, our hospice platform is certainly significantly larger than our home health platform. We have found that home health does a good job of feeding hospice in the markets where we do have that overlap. So I think some of it is sequencing. It'd be good to essentially kind of catch up our home health platform with the hospice side. And certainly, it's a cheaper valuation.
Brad, maybe can you bring us up to speed a little bit, maybe just on that sort of from the operational side, just some of this dynamic maybe around, you know, sort of the focus on quality and some of the scrutiny, I guess, that buyers are having. Is there, you know, what's driving that from? Are there some deals that, you know, didn't go well? Is there certain sort of expectations around sort of a regulatory shift, you know, towards areas of focus? It would be great if, I mean, definitely have sort of caught more of that through the channel. So want to figure that out.
Yeah. I mean, certainly star ratings matter. And I think, you know, they'll start mattering more. Probably the bigger piece, though, is just kind of just regulatory compliance from the standpoint of, you know, is the documentation up to snuff? You know, we are in a highly regulated industry. Hospice, probably, even though it has a favorable reimbursement environment right now, it's kind of going through probably heavier on the audit side. You know, we've lived through that in our previous life with Odyssey. You know, there was a timeframe for over a two or three-year period where it was under a lot of scrutiny. You're seeing a lot of that now, focus on long length of stay. So really making sure that that documentation is solid.
And I think some of the smaller deals that people look at tend to collapse under that piece of it, is maybe there's just, you know, the documentation where it needs to be.
Okay. That's helpful. So that audit cycle seems to be a tie in here. Okay. That's helpful. Thank you. Why don't we sort of shift over just to the Gentiva deal and sort of maybe just even bring us up to speed on sort of specific timings here in terms of what we're looking at, you know, around close and around, let's say, sort of that initial sort of phase of integration that you'll be looking to do sort of that day, let's say the 90-day plan, I guess they always talk about, right, or 100-day plan, right, in elections. Maybe you can walk us through your 100-day plan with Gentiva integration.
Yeah. I mean, you know, we still feel like we'll get it closed before the end of the year. So we think we'll get it done in Q4. You know, from an integration standpoint, this one will be a little different than some of that we've done in the past where we'll take over payroll and benefits day one. But we've been testing systems agnostic for quite some time to make sure we've got all the everything ties in and flows well. So day one, just like normally, we'll take over the financial side of it. We'll take over, we'll roll them into our payroll system and onboarding system, roll them into our benefits plan. The one aspect that's going to be a little different is we won't move them immediately to our kind of billing and scheduling system. They just went through a transition back in October.
So they're, you know, not anxious to kind of get back on that bus. And it was October of last year. So, you know, we're in the process with Homecare Homebase, which is our clinical EMR and billing and scheduling system. We're in the process of developing a personal care system with them, with Homecare Homebase. We've rolled that out to, I think we've got in three states, three smaller markets for us. Still have a lot of work to do on that system. So we won't move Gentiva until that probably kind of the tail end of our enterprise rollout when we do that probably in the next 12 to 18 months.
Okay. And yeah, just curious on that sort of, that's obviously been a very interesting operational initiative in terms of that customized personal care instance for Homecare Homebase. Can you maybe walk us through in terms of, you know, it looks like you're sort of in that beta type phase right now, but testing it real time in the market, maybe some of the, you know, the key, ultimately the key, you know, positive returns that you're expecting. And then from the just sort of practical reality of implementing a whole brand new system, some of the key areas of focus right now.
Yeah, you know, it's interesting. We started talking to Homecare Homebase, I guess it's probably about three years ago. You know, they approached us that they wanted to develop a personal care module if they had clients that are on the clinical side that wanted, that had personal care assets that wanted to have something. And, you know, we actually had gone through a process of evaluating different systems and spent about a year doing that and really couldn't find one that met all our needs. Some of them were really good on the front end on the scheduling, but not very good on the back end collecting revenue. Others were kind of vice versa.
And so when Homecare Homebase approached us and basically said, we'll develop it for you, just, you know, you can kind of customize it to the needs that you need on both the front end and the back end, it was a great opportunity for us to basically work with somebody to build something that would suit our needs, you know, with really no skin in the game until it's time to go, until we actually get a product that we want that'll work for us. So we've rolled it out in three markets. It's gone well. There's still, you know, there's always challenges when you roll out a new system and you're still developing it. And some of the rollout is, you know, let's get it into a market and kind of figure out, find out what we don't know.
The challenge with developing something for personal care is every state's different. I think Homecare Homebase three years ago when they approached us probably didn't fully appreciate how complex Medicaid environment is, billing and scheduling, you know, the regulatory environment, the coding is also dramatically different. When you've seen one state or even one program within a state, you've seen one program within a state. The customization, I think, is something that probably surprised them how challenging that is. That being said, they've made a lot of progress on that. They actually acquired our EVV vendor, CellTrak. Homecare Homebase owns the CellTrak as well, which I think really helped them kind of really take giant leaps forward getting that expertise on board to help them develop the system. Right now we've got, like I say, three states rolled out.
We're doing the kind of studies on two additional states to kind of look at what customizations do we need to happen. There's still some, you know, future releases that they're working on when it will be kind of ready for prime time. I think, you know, come April, May, I think we'll be able to say, yeah, this looks pretty good and we might be able to position to kind of map out an enterprise-wide rollout of the system. But I think the efficiencies, you know, we had made a lot of enhancements on our existing system where, you know, we had certain offices or states that were actually operating in an environment that was different from our kind of the back end that just made it a lot easier to schedule for our service coordinators. Just much more user-friendly.
So it's easier to train on, just easier to move things around. You know, that's what we're looking for on the Homecare Homebase to have it enterprise-wide, have that functionality. And then I know on the billing side, there were things that, you know, we would like to have had in our existing system that we're having developed with this that should help on the collection side. And ultimately, we should have some, you know, some synergies as well.
Yeah, yeah. There should definitely be some efficiencies both in the front end and breadth up in the field offices and also in the back office and rev cycle. So using technology, we've talked about that even back when the Medicaid Access Rule was first proposed. We talked about our approach of using technology to just become as a most efficient organization as we can.
This is a big part of that. We're pretty excited to see, you know, once we go enterprise-wide, you know, what we gain from that.
And then ultimately over time, I could see now maybe even though the sort of steps to get there were a little bit separated, the fact that you're sort of doing these more scaled acquisitions in personal care, you're building this sort of very, I guess, sort of, you know, modernized sort of stack here. Ultimately, that can drive the synergy with these larger acquisitions you're doing and being able to implement the more modern tech stack that you've been building here, I would assume.
Yeah. No, I think there's certainly some opportunities there to make the integrations actually smoother, you know, easier. We're currently operating on primarily one system on the personal care side, but we have a couple of smaller systems. It's kind of like, well, you know, this is kind of more private pay focused. It really doesn't work well with our current environment, with the Horizon environment. So having one system that can handle all of that would be great.
And then one last question here. What do you see as sort of the, I guess, the timeline and then prioritization, sort of recognizing the management time, the capital that's required to sort of focus on building out this system? You know, ultimately, it would seem like the ideal end state would be having this integrated with your Homecare Homebase on the clinical side and having this as a fully integrated system between personal care and clinical. And then that could really drive sort of, I guess, a competitive advantage for you around value-based care contracting with payers and the data that you can drive from that. Is that?
Yeah, that certainly was one of the real attractive components of this is to have everybody on one system, so to speak, even though they are certainly different. But having just that one kind of clinical record is certainly helpful, will help us be able to kind of leverage some, you know, some of that data collection and information in the value-based type of arrangements. And really, you know, as we talk through kind of value-based a little bit, you know, value-based in and of itself, the payments you're going to get from that, probably not terribly material. However, it does allow us to potentially build additional volume with payers, particularly managed care payers that are looking for a one-stop shop that can also, you know, potentially reduce hospitalizations, you know, their overall cost of care.
But then also just, you know, if you think about the transitions between the service lines. Right now, home health does a pretty good job of, you know, we've got a lot of data analytics around home health to transition patients to hospice. We're developing that on the personal care side now because that's really the big untapped piece is how do you really, right now, it's a lot of it's manual to be able to work, have workflows that identifies a personal care client that may be time to introduce hospice. Maybe they went into the hospital and so they're more likely to have a home health episode on the back end. How do you track that? And so having all that in one system, I think will help us certainly be beneficial.
But that's where I think the kind of value-based piece really plays in. It really has kind of gotten us to, you know, we've got all this data. How do we use it? How do we develop the algorithms that can identify, you know, here are the 100 clients you need to focus on on the personal care side that may need home health, that may need hospice, that we may be able to take and do something on the intervention to help out our payer that we work with.
Great. Before I move to another topic, let me just pause here. Anybody have any questions? Anyone else? All right. Well, if you do, please raise your hand. We'll definitely get you in. So let's move over just to some of the near-term sort of trends and to the extent that we can sort of talk about those. I guess sort of first, you know, sort of around, you know, you're thinking on sort of volumes and for the fourth quarter and sort of the framework. And we talked about this a bit on the third quarter call, but, you know, obviously we're sort of moving along in the quarter. You know, maybe sort of, you know, set it against, you know, sort of what your expectations are around sort of normal seasonal trends across the fourth quarter for personal care and for the clinical businesses.
And then anything that you would observe about this year's fourth quarter that, you know, you've been focused on or thinking about that could be a, you know, impact those trends either positively or negative?
Yeah, I mean, I'll start. I mean, there's, you know, from a seasonality standpoint, a little bit of seasonality on the personal care side just from the hiring, you know, around the holidays tends to be a little lower hiring. You know, as people are out, you know, celebrating or enjoying the holidays. So you see a little bit of seasonality there, but not anything that's really material. On that front, hospice can, it's interesting, you know, historically hospice was a little slower in Q4 around the holidays and then kind of picked up after the first of the year. We have seen that dynamic be a little different, you know, of late where your fourth quarter tends to be, you know, you don't see as much seasonality there.
health, you know, when you get down to, you know, kind of late November, December, and then really into January, you start seeing volumes pick up. A lot of people are trying to get those procedures in before the end of the year. So you tend to see some business from that, from the outpatient environment.
Okay. And then on the, I guess, sort of the impact on the New York side and maybe an update, you know, obviously you've got the sort of, you can account for it now on GAAP. You have the, you have the sort of the deal in place. You've disclosed that it's around $23 million, right, would be the sale sort of price for that asset and some contingents around that. You know, ultimately, I wanted to sort of get an update on that, but then lead it into a bigger picture question, which would be when thinking about just the overall margin sort of, you know, it'd be helpful because there's some moving pieces for sure, right? When we think about the Gentiva acquisition, which is going to have a huge effect on the overall business, the continued rate increases in Illinois, the New York divestiture.
Ultimately, how do you see this all sort of netting out from a margin perspective as we look out to 2025?
Yeah, I think I'll start with New York. I think coming, you know, out of Q3 into Q4, you know, we set out our call. So we met the requirements for sale consideration. So in Q4, you actually will not have any P&L activity from New York in our financials. So that comes completely out. So just thinking about that sequentially, I think we're a little over $20 million, about $21 million in revenue in Q3. That'll come out in Q4. So that won't be booked. But keep in mind through the arrangement we had in our sale agreement, we had a zero EBITDA impact the last couple of quarters from New York. So revenue will come out. It'll have an expansion impact on both gross margin and EBITDA margins just from the fact of all of the cost and revenue coming out of our P&L.
Gross margin impact will be positive by about 150 basis points. And then bottom line, EBITDA will actually be positive by about 90 basis points sequentially from Q3. That's the way you kind of think about New York. If you think about Gentiva coming on board, if it comes in as we expect and closes in Q4, you know, that's going to be $280 million in annualized revenue coming on board, you know, probably, you know, similar low double-digit bottom line EBITDA margin. So it might have a slight impact there. It's all personal care, no skilled. So our mix will go from 85% personal care down to, I'm sorry, 75% up to 80%. So the skilled businesses being a little higher, EBITDA percentage is a little bit less than the mix.
We'll have a little bit of a negative impact overall on margin, but I think New York will more than offset that. And then Illinois coming in, their rate increased January 1 of 2025, annualized revenues of about $23 million. That's going to come in at our normal kind of, you know, low 20s margin based on the 77% rule in the state.
And then any other rate increases on PCS that are worth calling out for any of the other states for 2025?
Not right now that we would say are material. I think, you know, we traditionally have seen, you know, some that come up. Every state's fiscal year is a little different. So we don't have, you know, I think a lot of long, you know, transparency into some of those. So there's possible that we could see some additional, but nothing that we'd probably flag out as being material into 2025 right now.
Okay, and then how would you sort of, I guess, sort of frame the long-term EBITDA margin sort of expectations now when, you know, we think about a few different things. I guess I'll sort of add in there. You know, so you're sort of doubling down again on the personal care side. Typically, you're going to be acquiring assets that do have a sort of relatively lower margin profile, at least initially, but gives you the synergy opportunity. You've got, you know, sort of the clinical businesses. You guys have been doing a little bit less on the hospice M&A, which tends to be a higher margin business across the three.
And then on home health, there's these different moving pieces, right, on margins, they're around MA and around ultimately if we see the Medicare fee-for-service, you know, reimbursement outlook improved or at least stabilized under the Trump administration. So, you know, like generally it's been like this 10%-12%, right, typical EBITDA margin frame. We tend to think about you guys in, you know, as we think about the longer term. Is that like the general sort of, you know, operating sort of framework you would point to, or do we think you get, we get to the higher end of that and can eclipse it for any types of reasons?
Yeah, I mean, I think we've settled pretty comfortably in like the 11%-12% range over the last year. So I think New York coming out of the mix we talked about is going to have, you know, a positive impact offset a little bit by Gentiva acquisition, but we'll probably still be somewhere in that range. I think we've always said, you know, as we continue to grow top line 10% plus, we should get additional leverage primarily off of our G&A. So we would expect to see, you know, some positive momentum there. I think, you know, keeping in that lower double-digit range though is probably a fair assessment. And I think the wild card there is just, you know, through M&A, you know, does it slant more towards skilled or personal care will be impactful into what that is.
We'll wait and see what that opportunity looks like. I think thinking about it still in that low double-digit range, I think we're probably above the old days of, you know, 10%-11%. We're probably more 11%-12%, you know, we're a little above that where we are settling today and where we're headed, I think in the short term.
And then what about just home health within that as we think about, you know, sort of margins for 2025 and some of the key headwinds and tailwinds there? Clearly still a very tough, you know, sort of reimbursement backdrop for fee-for-service. Medicare Advantage is going to grow. We're still waiting to see to what extent relative to last few years. We probably have possibly some slower level of growth, you know, compared to that, let's call it sort of 7-8%, you know, frame. But who knows? You know, we'll be getting that data. And obviously we track that data closely. And then just sort of your efforts from internally to improve your rates with MA players through your preferred payer strategy.
So maybe just, you know, sort of within the preferred payer strategy, an update on sort of any new contracts that are notable for 2025 and then sort of your thinking around overall home health margins given the different inputs.
Yeah, I mean, I can start on the contracting side. You know, we've had some, you know, near-term kind of wins where, you know, we're in discussions with payers about trying to move more to an episodic type reimbursement environment, having those ongoing discussions. In the meantime, we have continued to work on, let's just try to increase our rates, the per-visit rates. And we've had some success there. You know, I think there's a pretty well-documented concerns and issues around access to care, particularly for Medicare Advantage beneficiaries. I think the payers are seeing that, are feeling it. So you're starting to see them, you know, loosen up the purse strings a little bit. Even though MA under the, you know, current administration has been under pressure, we've seen some wins there. So there's still room to go.
We're still at a discount, but it's not the 40% discount that you were seeing to Medicare fee-for-service. You know, we've probably closed that gap, you know, probably, you know, is now more of a 20%-30% discount in some cases, much better than that. Still work to do there. I think there's still opportunity there to be able to increase our margins. Then just from, you know, again, home health is a very small piece of our business, you know, around 6% of our revenue. We've spent some time really kind of going through and working with an outside consultant to say, you know, how can we, you know, let's look at standardizing processes, centralizing certain functions. So we've largely wrapped that up.
We're still kind of have one market that we're still working through there that I think will, you know, will provide some additional margin opportunities there just from reduced headcount and greater efficiencies there. So I think home health is one area that we have probably the most opportunity on a gross margin basis and, you know, for us to improve and also from just a bottom line operating margin as well. But it's only 6% of our business right now.
Sure. That makes sense just given definitely the most pressurized end market of the three from sort of market level perspective the last couple of years. I've got question time for probably one more quick one here. First, just want to check anybody want to take us out or else I will.
Sorry, it's kind of a basic question. Not as close to your company, but would you mind just rehashing the M&A value creation logic of your business where you see, obviously it's a big part of your growth plan. Where do you create value?
Yeah, I mean, I think if you think about the three segments that we operate in, I think first and foremost, if you're working in personal care or home health, just the multiples that we're paying for those acquisitions being where they are, I think there's just kind of automatic accretion value just from a financial perspective. But I think that the larger part of our overall strategy being leading with personal care and then having home health and hospice, there's a lot of revenue synergies between those three segments of being all in the home. Think about the demographics of the patients that are in personal care being largely dual eligible, but older individuals that, you know, would qualify for a home health and/or potentially hospice at some point.
Brad talked about, you know, in the markets where we have mature home health and hospice today. We see, you know, a pretty large portion of our referrals into our own hospice coming from our own home health. So we just see a lot of opportunity in those three segments to operate together through revenue synergies. But then also just the overall, just like I said, the pricing on expectation as we do these deals based on where we're priced today and the multiples that we're paying is a high value. And then you can put on top of that the things that we're able to do and the value we're able to demonstrate to manage Medicaid particularly in the markets where, you know, they have, you know, at-risk populations. I think has also been very helpful for us.
All right. Well, I think we're out of time here. So I want to thank the Addus team for joining us again and hope you have a great conference. Thanks.