All right, we're here at the top of the hour. Welcome, everyone, to day one of the Stephens 2025 Annual Investment Conference. We're live and in person here in Nashville. I'm Raj Kumar, Healthcare Services Analyst with Stephens. To initiate our conference, we have Addus HomeCare, a leading provider of home-based care and support services focused on personal care, hospice, and home health. Joining us from Addus today are Dirk Allison, Chairman and CEO; Brian Poff, Executive Vice President and CFO; and Heather Dixon, newly named President and COO. I want to thank you all for joining us here today. Always a pleasure having the Addus team. I think we'll just jump right into Q&A if it's all good with you all.
Yep.
All right. Maybe, Heather, you know, kind of want to start off with kind of your new role as COO and kind of as you enter the role and look at the operational groundwork that's kind of been set and continues to be executed upon. Where do you see some of the incremental opportunities and kind of how would you frame the operational priorities for 2026 across the different lines of businesses?
Sure. I'll answer that in a couple of parts. First, what do I see as the opportunities from the framework that's been put in place? First, I would point to the caregiver app that we have. We've seen an opportunity there that we're liking what we see in Illinois, where we have rolled that out. It's now rolled out to all the caregivers in the state. While it's not mandatory, we are seeing very high utilization percentages, and those are improving each month. The caregivers are using it. They're enjoying using it, I think, for their own personal benefit. They are also seeing the benefits of managing their own schedule. That is creating an increase in our service utilization percentage. As we start to think about rolling that out next in New Mexico and then quickly followed by Texas, that'll be our three largest states.
I see an opportunity to increase the hours utilization and that service percentage. The second is in terms of Illinois. It was the last state of hours to go through redeterminations. We are starting to see sort of cycling through the end of that and seeing admissions increase while discharges decrease. That will lead to, I should set us up nicely for 2026 as we think about census growth there. On the skilled side of the business, we have seen a lot of success this year by some of the programs that we are driving, looking at putting together business development plans on a local market basis and using community liaisons there. That is another opportunity that I see in the near term.
Longer term, of course, the strategy has been, and I continue to believe, the opportunity is to connect PCS into the skilled side of our business with home health and hospice to just follow that seamless route of care or different levels of care as the clients and the patients need it. In terms of 2026 priorities, you can imagine they're closely aligned to that. Drive census. We've been driving hours, but to drive census with the hours, now that we have an app that we can use to really drive the utilization of the hours, the community-based focus will continue, not just for skilled, but also on the personal care side as well. The Bridge programs to continue to focus on those.
Got it. Yeah, great overview. I think maybe starting off with personal care, the largest segment, yeah, same-store census has been a kind of key metric for investors of focus this year, kind of the sustainability of that against the backdrop of an uncertain Medicaid reimbursement environment as we go on ahead. Long-term, 3%-5% revenue growth, split evenly between volume and rate, kind of how we think about it from a modeling perspective. Yeah, you spoke to Illinois kind of curtailing now the Medicaid redeterminations process where you're seeing admissions more so than discharges. Maybe trying to frame that comment quantitatively. Is there a ratio of kind of rat admits to discharges and kind of how that's been trending so far quarter to date and whether those trends are kind of expected to result in kind of year-over-year growth in the fourth quarter?
Yeah, I think I can talk to that one, Raj. I think I wouldn't say there's necessarily a threshold or ratio if you think about it in the context of what we've been talking about as far as just overall targeted kind of volume growth in hours. And there's a couple of different components to that. Census is going to be one. Hours per census, obviously, the other. But we're targeting to be consistently in that 2%-2.5% range. I think we've been right around there. We were over that number in Q3, right at it in Q1, a little under in Q2. But we want to get consistently into that range. So just think about it just from a logistics perspective.
If admits are turning into the same ratio of starts of care and then outpacing discharges by kind of that same ratio of 2%, 2.5%, 3%, then you should get additional census from that that could kind of feed into that goal that we've kind of set for ourselves.
Yep. Got it. Maybe trying to further understand that census story. I think you called out New Mexico and Texas had already kind of finished their process kind of by the middle of the year. Maybe since those are kind of two of also larger states kind of behind Illinois, what kind of level of improvement in kind of census growth have you seen there from an admits to discharge kind of basis?
Yeah, I think I can start, and Dirk, want to add any color to it. I think specifically New Mexico, which I think has been a little ahead of that curve, but we've been seeing, I think, over the last couple of quarters, probably 3% plus growth in New Mexico. They've kind of come out of that redetermination phase. I think Texas is probably a little bit behind them, but we're starting to see them start to have positive quarter-over-quarter growth as well. Not quite to that same kind of 3% level there, but it's trending in the right direction. I think to Heather's point earlier, Illinois, probably the latest of those. We've seen admissions start to outpace discharges the last quarter or two.
That should take a little bit of time to kind of turn into starts, and that hopefully will start to follow the same trajectory. We are hopeful we will see that into 2026.
Got it. Got it. Maybe kind of now focusing on our side, that's been progressing pretty well. You talked about the app kind of filling that authorized hours to fill the filled hours gap. How would you kind of frame that remaining yield in terms of kind of being able to readily close that hiring gap? How much of that function is just kind of getting more caregivers into the Addus kind of environment or ecosystem, or is it just more so that some of those gaps are just structurally hard to kind of fill in like Sunday A.M. shifts, right? That's kind of a lot of people are probably going to be hesitant to fill those. Maybe just any color on that.
Yeah, I think I can start. I think where we are today is we're probably right around 83%-83.5%, kind of what we call fill rate, which is the number of hours that we're actually serving to the authorization. I think we've said, I think in the past, we're hopeful we can get that on a consolidated basis up in more into the mid-80s%. We'll see where we can go from there. It probably becomes difficult to really think about pressing toward 90% due to some of the logistics issues that you kind of reference. You're always going to have those issues. I think it's really a factor of two things. I think hiring is important, having enough caregivers and having those folks be able to be there to serve some of those unfilled shifts.
I think some of the things that we're doing on the technology side through our app and other initiatives to actually utilize our own existing caregiver base where maybe they're looking for more hours, how can we match them up with someone that has an unfilled shift today and take advantage of that opportunity as well? I think it's a combination of those two.
If you think about it, you would think if you're authorized for 70 hours of care, you'll get 70 hours of care because there's no risk of the state not paying you until you go over 70 hours. The problem is these are elderly patients. They're consumers. They're in their home. They're going to end up having family come visit them, and the family's going to say, "We don't need the caregiver this week because family's here to take care of them." You're going to lose those hours. They're going to go in the hospital. It just happens at that age. They'll go in the hospital, and you can't serve while they're in the hospital. Structurally in the industry itself, there's a limit as to how much of that, 100% of those hours you can get.
We believe right now, as Brian said, we're about just under 83%. If we can get that to the mid-80s, that really is quite a movement for us because we got down into the mid-to-high 70s during the pandemic. It has been really nice to see that growth back up after certainly the last couple of years.
Yep. And yeah, clearly, caregivers are an important part of the equation. I think some states kind of have programs where family members directly get reimbursed as part of the caregiver hours. Maybe just how much of Addus's base is kind of based on that as we think about the beneficiary profile of your services.
It's like, so how many are kind of just getting directly taken care of by the family members and getting reimbursed through kind of Addus to that regard versus these are kind of dedicated caregivers that are serving multiple patients in a given week?
Yeah. You know, if you think in terms of the states we serve, really our bigger states with family caregivers are Illinois and Texas. Probably before we did the Gentiva transaction and brought Texas in, I think we were at 30, a little over 30% of our caregivers were qualified as "family caregivers." Texas is an interesting market because it's a pretty large family caregiver market, which is really a benefit if you think in terms of it, because if you get a consumer needing care, you get a caregiver. So it's really kind of an exciting thing.
It probably took our number from 30% + right up to between 35% and 40%. That is what we run today.
Okay. Got it. Now switching over to the reimbursement framework, which has been very favorable post-pandemic, and especially kind of you had the ARPA funds in New Mexico, and that has been able to drive not only growth, but also kind of better caregiver hiring and retention. There are a few states that kind of remain on the sideline just given all the OB3 uncertainty around what the Medicaid landscape looks like from a budgetary perspective. I think New Mexico and Pennsylvania come to mind, especially kind of the latter since there has been a deal done there in the recent year. Kind of how are those processes progressing in those states?
Kind of any framing around expectations on potential rate updates kind of in the first half of next year? What is the magnitude that the kind of industry is asking for from a rate standpoint?
Yeah, I mean, I think, Raj, on those two specifically, obviously with Pennsylvania finalizing their budget recently, I know it was maybe a little contentious as they kind of went through that process. I think we had indicated that we were hopeful that maybe we would see something. I think kind of when that got more down the road and we kind of saw what was happening, I think we probably got in a position where we didn't really expect to see something come through in that cycle. We didn't expect a cut, and I think that's kind of where it landed, so we're kind of status quo with them. We'll wait and see what happens with them next year. I think the one we're really watching is New Mexico. We've talked about that.
They had talked about a rate increase this year, but I think at the time they were in session was around the time that OB3 was also kind of in flux. I think they made the decision to kind of hold status quo and see what it looks like next year. We are hopeful for that, but that cycle will happen early into kind of the spring of next year. I do not have a lot of context to provide today, but obviously the industry and our lobbyists there will be working on that, kind of putting up our position. I think trying to quantify what that would be, I think, is probably difficult. It is always going to be a factor every year of kind of the state budgets process and the legislature and those conversations.
We'll always advocate for something that we think will be helpful to us and the industry. I think the main key is every time we can get a reimbursement increase, we're able to give our caregivers a corresponding wage increase, which should allow more access to more caregivers and more folks into the program, which we believe is a good value to the state. That's always the conversation we'll have with them. I think Texas coming off of almost a 10% increase that went into effect September 1 of this year. We've got just under 4% coming from Illinois again on January 1. We'll continue to talk to Illinois again next year when they go into session. Texas only meets every two years, so we got a little bit of a reprieve there, but we'll keep watching some of the smaller states as well.
Yeah.
Maybe focusing on kind of some of the in-state dynamics. There are some nuances. New Mexico seems like they've kind of handled their Medicaid budget pretty well since they're kind of looking to fund the ACA-enhanced subsidies next year through kind of internal state funds. And Addus is a low-cost care provider, but does that create any contention with kind of where the dollars go in 2026 around kind of rate increases for personal caregivers?
You know, I think one of the things we benefit from, as you say, we're a low-cost provider. If you think in terms of the consumers we take care of on the non-clinical side, if those individuals do not have care such as we can give, remember they have multiple activities of daily living that they need help with.
If we are not able to keep them in their home, we being a provider, they're going to have to either have non-compensated care from a family member or they're going into a SNF. They're going into a nursing facility. Just by the nature of the industry, skilled nursing facilities are much more expensive than keeping them at home. We've been in this business a long time, and I think we've done a fairly good job with our states of sharing that story with them. I think the states realize that and support it. When you talk about a state like New Mexico that may be considering using some of their dollars to fund some things that they haven't in the past in their Medicaid program, I think our opportunity is to go into them and show them how we save them money.
If you continue to support our industry, we'll continue to keep these people at home. We'll keep them out of the nursing home, which will help your overall budget. Now, it's always a challenge. Anytime states have Medicaid pressures, you got to reemphasize the story. But we think we're in a good position to do that.
And then kind of from a market-by-market standpoint, I know sometimes you call out nuances around kind of minimum wage updates in some of those, particularly in the Chicago market, which kind of sometimes misaligns with kind of when the state rate update kind of comes to fruition. So anything to call out from that perspective in any of your markets where you're kind of seeing minimum wage increases, but not kind of corresponding rate updates for caregivers?
Yeah, nothing material in our radar for 2026.
We have a couple of small minimum wage increases in a couple of our smaller states, but they're fairly immaterial. One of them is partially funded. The other, I think we only have two locations in that state, so it's not much of an impact for us. Just on Chicago, I think just to kind of talk about that for a second, I think obviously when they get to $15 an hour, a couple of years ago, they've been doing kind of annual CPI. The rate increases we've gotten from the state of Illinois the last couple of years have put us in a position to be well outpaced from there. Even with a CPI increase in minimum wage, there's no impact to us in Illinois today because we're well ahead of that schedule. Nothing on our radar today.
You're looking at 2026 that looks like it's going to be anything for us to be concerned about.
Great. Now kind of focusing on the scale aspect, right? Dirk, I think when kind of this whole Medicaid uncertainty started, the strategic mantra was gaining scale in markets that in PCS markets where you want to be kind of number one, number two type of player. You divested your New York-based assets since that was just a kind of very kind of contentious back and forth and CDPAP.
As we think about how you drive the scale and the margin opportunity for that segment, given the maturation that you are about to come upon with at least a year now post-Gentiva here entering into 2026, how would you frame some of the key milestones to achieving the targeted margin profile for the Gentiva book of business relative to your sustained mature book and the horizon around that?
I will start with that, and then you guys jump in. I think the key in most of our markets, all of our markets except for New Mexico, the state sets the rate no matter whether it is outsourced through a Medicaid outsourced provider payer.
For us, the gross margins are going to be fairly consistent year to year because what happens when we get a rate increase, either by agreement in states where we have unions or in non-union states, what we do is we pass along as much of that increase as we can to keep our caregivers competitive so that we can make it easier to hire. Because if you think in terms of the 3%-5% target we talk about in our organic growth, the real key to that growth, yes, rates have been really nice the last few years, and we think we'll continue to get rate support. We need to get back to where about half of that 3%-5% is volume growth. What dictates volume growth is do you have the caregiver available to provide that care?
Because almost without fail, if you look at our 23 states in which we operate, there are very few markets where we have caregivers, but we do not have clients. The elderly population, the baby boomers that started turning 65, that has been out there now for 10 years or 15 years, and those folks are getting up into their high 70s. That is where our personal care consumer is. For us, we are in an industry where it is not a demand issue. It is a supply issue. Can we supply care? That is why it is so critical that we continue to work with our states to drive rate increases. It is not just for us because, yeah, sure, we need those too to hit our growth targets.
At the end of the day, it also allows us to pass through enough wage increases to make caregivers, at least compared to a lot of the jobs in that range, it allows them to believe they're being compensated at a rate comparatively that works. We'd always like to get more from the states. We'd always like to pass along more. For us, it's never been a gross margin story. If we can maintain that mid-low 30 margin that we do, that's really key. That's great. If you look historically, we've done a really good job. We get our margin growth on two aspects. We get it through overhead as we grow. We don't have to put as much overhead onto it, so we get some margin improvement there.
The fact is when we moved into some clinical aspects, we get a little greater margin in the clinical aspect. For us, it all works well, but you got to focus on being able to pay the caregivers so that we can hit these targets we talk about growing.
On that kind of last point about kind of combining the non-clinical and the clinical, that's kind of been an ongoing initiative, especially kind of New Mexico piloted with Presbyterian. Maybe just kind of focusing on that opportunity, has that kind of expanded to other payers in New Mexico around value-based care and joining the personal care and the home health kind of bundling or services together?
What's kind of the kind of rollout strategy when we think about other markets where you kind of have density around the clinical side of, we think, Tennessee, where there's a healthy home health and hospice presence and some personal care, and then, of course, Illinois, where you're trying to replicate the New Mexico model. Any kind of color on that front?
Yeah, you want to?
I'll take it. When we started in value-based care, it was based in New Mexico. That's where we started. It was with Presbyterian, which is our largest payer out there.
It's been a good relationship because what we've been able to prove to them, because they have all risk at all aspects of care, Medicaid, hospitalization, emergency room visits, and whatnot, we've been able to show a large decrease if we can take a high-cost population and use some clinical services on top of our personal care base, which is a little bit different from some of our competitors. We start with personal care because we believe they're in the home much more often, and they can see things early and can get clinicians involved. We do other contracts too. The other payers in New Mexico, we have value-based contracts with. It's spread to other markets.
What we've seen with value-based care, I think some people, when we first started in this, we thought, well, if we can generate savings, we can share with that savings, and that's great. When you're a company at our size now and you start these contracts, that's not going to be a material amount of revenue. What do you get out of value-based care? What we have found is it makes our relationship stronger with the payers. Remember, if you're in a state that's not outsourced, you're not doing value-based care. If we're working with the big Medicaid outsource payers, they're interested in saving money, but doing it right from a clinical standpoint. If we're able to work with them and show them we can reduce costs, our real upside is them sending us more referrals. That's really the key.
It's helping our growth rates in those states as opposed to value-based care itself being a material profit maker for us. That's not the way we view it today.
Gotcha. Maybe before we kind of switch over to hospice, if anyone has questions in the audience. All right. Yeah, I mean, shifting over to now the clinical side of the business, hospice, clearly an outperformer this year as we kind of get this post-pandemic recovery track. Year-to-date organic growth revenue-wise is low teens, well above that targeted 5%-7% for the clinical asset base. While operating margin still some way to get to pre-pandemic levels, but directionally going towards that high 20s type of framework. Maybe looking at the third quarter and kind of even kind of discounting, I think there was a softer comp last year from a growth standpoint.
There's still low double digits type of growth, but even believe between volume and rate. I want to maybe talk about the investments you've made on that front. I think you hired some key talent, some business development, local level liaison work. Maybe kind of flushing that out so we can kind of better appreciate what's kind of underlying this type of outsized kind of volume growth relative to what we're seeing on the peers.
Sure. I'm happy to talk about that. Building on what I said earlier, there's a couple of things that we did to really focus the efforts there. The first is, you're right, we did hire some key leaders. We made some leadership changes to really focus on driving that business.
The second is we put in place sort of a centralized business development team that works on sort of the broader scale marketing efforts, but also looking at local market business development plans and then leading those through the community liaisons who are in the local market and present. That has been a big driver of what we've seen to date within hospice for the initiatives we're running. Finally, I would say the Bridge program that we've talked about, where you have looking at the home health business. While it's a very small part of our business, it's an important business to hospice, especially because it's getting people on the right level of care. We have seen success with that program, certainly in New Mexico and in Tennessee now, where we've had it for a while.
We see a quarter of our referrals that go into the hospice business in those markets are coming from the Bridge program. That is really what I would point to from an operational perspective.
I think Raj just added that real quick. I mean, I think Heather mentioned New Mexico and Tennessee. I think Illinois is a focus for ours going forward as well. We have a nice size hospice business there along with, obviously, personal care and some home health. We can see some progression there. I think that hopefully will be helpful just for on the ADC side in hospice growth. I think we have obviously done very well this year on some of the initiatives that we talked about.
I think still longer term, I think we would probably say we would expect to probably see a little moderation in that percentage to get back into that probably more upper single digit range. I think we've got a couple more quarters where we start to see some of those comps and probably start to see that moderate and level out.
I think from a volume perspective, right, LOS kind of went down as your referral mix kind of changed more to the acute side relative to SNFs. Kind of what's the opportunity on that front without pushing on the kind of hospice cap, right, kind of balancing that framework? How should we, I think, I guess, organic revenue growth next year, I think you framed kind of upper single digits.
Kind of what's that from a perspective of looking at LOS versus kind of census?
Yeah. Yeah. I mean, I think we've seen a return. I think referral patterns are probably back. We're probably getting around 40% of our referrals today out of SNFs or ALFs, which I think is probably back to consistent with what we saw kind of pre-pandemic. It's taken a little bit of time to get there. Obviously, there was some impact with some of the rule changes that were made during the pandemic, but I think that's gotten back into a pretty normal cadence. I think for us, I know some folks out there have had some issues with cap. I think we've managed it very well on our end. We're pretty used to it. To us, it's just part of the normal course of doing business in hospice.
I think there's always pockets or areas of opportunity, but I think maintaining a good consistent referral mix is just very important. I wouldn't say there necessarily are large levers for us to pull to really think about length of stay. I think we just want to be consistent, making sure we're having a good mix to stay in a healthy position to be as growth-oriented as we can be, but also managing our cap reasonably and not letting that get into a bad position.
Got it. Kind of M&A, right? This is kind of an area where essentially the company's talked about that capital deployment via M&A is essentially priced out since you got these mid-to-high teens valuation, I guess, makes sense in the broader aspects of kind of clinical healthcare because of how well hospice businesses have been just doing industry-wide.
Clearly, the fundamental backdrop is very supported and relatively favorable to, say, home health and likely an attractive end market since you kind of have this referral mix channel where you're getting a quarter of your hospice business from home health in New Mexico and Tennessee. Thinking about the company's strong balance sheet positioning and operational capabilities, is kind of de novo is kind of out of the picture. Is that something that the company's willing to kind of flesh out since it's just M&A seems like not the strategic priority at the moment given valuations?
You want to talk a little about de novos?
We're not against de novos. We've never had a big de novo program like some have.
If you think in terms of personal care, I know we're talking hospice, but just bringing personal care because of our history, it's really not been a big de novo market because you generally could go out and you could acquire so inexpensively very small operations. It was a better use of funds than taking two or three years to profitability with the de novo. We've done a de novo in the clinical side that after a period of time does well. We are always looking. One of the things we talk to our operations team about, and they certainly, if they want to recommend that we do a de novo in a location because of reach or other things that we want to extend, we're always open to that. It's just we've never, as a company, probably by our background, had a systematic de novo program.
It just hadn't made sense for us. From a clinical standpoint, from a hospice standpoint, we can look at that. Certainly today, with the multiples you have to pay to get into hospice, that is a way to expand a bit. It is awfully hard to do a de novo program to move them, except to just extend your reach where you are today.
Got it. Addus has done kind of hospice acquisitions that are kind of what we think non-traditional types of assets, with JourneyCare, right? Flipping a not-for-profit to now a profit business. Thinking about that asset environment or what is up for sale, what are you kind of seeing in terms of the asset base in the market today?
I mean, there were a couple of really sizable large hospice organizations that traded this year for pretty high multiples.
I think for us, we've had to be a little creative over the last couple of years. You're right, JourneyCare was a little different type scenario. We've also done a couple of acquisitions, one in Tennessee, the one we just announced this year in Pennsylvania, that were mixed assets. Where they had some personal care, maybe a little home health, but also had some hospice. I think those are probably more likely for us just because you see a blended multiple there. You're not having to pay mid-to-upper teens. I think we're always open to adding additional hospice assets, even on the smaller side in markets where we have strong personal care or maybe some home health. I think we're going to be disciplined in kind of probably what we'll look to pay.
If we need to be a little creative and find some opportunities to add some hospice, but in kind of, to your phrase, a little more non-traditional type opportunities, then those are things that we're definitely open to looking at.
Got it. Spending maybe just contextualizing that kind of amongst the long-term revenue framework, 10% +, half organic, half M&A driven, maybe just kind of thinking about the acquisition pipeline. I know prior to COVID or in the early stages of COVID, there was a revenue target of $100 million + acquired revenue on an annual basis. Is that still a good framework to think about as we kind of move forward? Or do you think there's still more legroom on the organic side that maybe you just do not need that much M&A to push towards 10%?
Yeah.
I think our probably frame of mind on that isn't any different depending on what's happening on the organic side. I think we want to be consistently growing, like I said, on the volume side in personal care and that 2%-2.5% + rate. We've kind of talked about hospice and kind of our expectation there. I think we keep those separate. We don't trade one for the other per se. I think we still believe there should be opportunity. This industry is still very fragmented to be able to go out there. When we've kind of set a target for ourselves as can we get $100 million in annualized revenue through M&A every year, I think we'd still like to shoot for that. I think some years, depending upon availability of targets or market conditions, it's been a little bit softer.
Then you have years like last year where we closed Gentiva that was $280 million in revenue. We will continue to focus on that. I think what we are hearing from folks is I think there is some level of optimism maybe that next year with rates starting to come down and maybe that should maybe loosen up some things. Maybe there will be more opportunities. I think we are very well capitalized and I think are in a great position to be able to be aggressive if the right opportunities and targets are out there. I think we are looking forward to that as something we will be focused on.
Great. Now kind of moving on to home health, a much smaller part of the business, but I think investors appreciate kind of the bundling of all the home-based assets, whether it be non-clinical or clinical.
But I think there's been a different operational focus there. It's not growth, but more margin and kind of given the constraint reimbursement backdrop. Maybe kind of any color on deciphering the underlying margin improvement year over year. Kind of do you see more room for expansion kind of on the episodic side, which kind of seems to be the main focus? Then maybe just as a follow-up, fee-for-service mix did kind of drop significantly kind of on a sequential basis. Anything to kind of call out there from a mix perspective?
Yeah. I think first just on the margin, I think some of the improvement we've seen since last year, I think we've talked about. We looked at our processes. We've done a few acquisitions in home health, but I think had probably not standardized some of our processes across all three.
We did some work last year to really try to be as efficient as we can. That business is not a big business for us. It does not take a lot to kind of see some volatility in the margin profile with cost. I think we have done a good job of getting that back to the level that we would expect. I think on the growth side and thinking about just episodic mix, I think we, like several others, saw some shift into M&A out of Medicare fee-for-service. I think we think that has been pretty stable for several quarters, not really expecting to see further push there. Our focus in our business is to try to see if we can get more episodic contracts through our M&A business. We are always having those conversations. Hopefully we will continue to see some improvement there.
I think just thinking about the shift that we saw in Q3, we did get a new case rate agreement in Tennessee that was in M&A. I think we saw a little bit of a shift in business there, probably what drove kind of that little shift quarter to quarter. I think if we can continue to do better, we're kind of, I think like several others, we're chipping around the edges. I think everybody would say when we come to the table, you're not necessarily walking away with the rate you would love to have, but it's better than maybe that we've seen in the past. I think we used to be 40%-ish discounts on Medicare fee-for-service. I think we feel in our business, again, it's small. We're probably more 20% discount today.
You'd love to get to the fee-for-service, but at least it is progress from our perspective.
Yeah, kind of speaking about that discount, I guess if they pay at parity, then there might be something kind of going on there. Is it more like they close that gap if you give them more scale or more capacity to serve their patient base or beneficiary base? Or is it just more of a function that it's just blocking and tackling and you kind of have to, they still think of it more as a commoditized type of business on their end from a home health, given how fragmented the home health market is?
I can start there. I think for us, it's probably a little bit of both.
I think, to be honest, I think in the industry, I think some of the M&A plans started to see they were literally having an access to care issue. I think that's kind of pressed them a little bit to be a little more open in those negotiations. I think a lot of the folks in the industry really started to kind of toe the line. I think we were similar. I think we talked about it on prior calls where we would look at business and say, "This doesn't make sense for us.
We're not going to take those referrals. I think in the old days, folks would say, "If I don't do that, my competitors will take them and I'll be at a disadvantage or I won't get some of the other referrals." I think a lot of folks started to really kind of more hold the line in uniformity. I think it's pressed them to be able to come back to the table to a certain extent. I think it's been a little bit of both.
Now, thinking about 2026, if we think about the same-store revenue growth in hospice, it's kind of been on decline.
Given the margin recovery aspects and the case rate optimization aspects, how should we be thinking about 2026 in that segment? Is that kind of still a year of further rationalization on the margin side? I guess do we kind of expect kind of growth off of this kind of base of 2025?
Yeah. I think we'd be hopeful we get back to, I mean, I can't really speak to the rate component of the same-store. We don't control a pretty decent portion of that. I think we all know where that stands. I think our focus is can we get to where we start to see some positive volume growth? I think we've been still a little upside down in our home health business for a bit. I think we'd like to see that get back into positive territory.
We will all wait and see kind of what happens with the rate, which I know we are all anxiously waiting to see when that is going to come in.
I think we look at it just a little different than maybe some of the others in the industry because when we look at home health, sure, we do want the rate to come out and we want to grow the business. We really also look at it as support to our hospice because of our Bridge program. From that standpoint, that is why we are very careful where we go into home health.
We want it to overlap preferably with personal care and hospice because as we continue to work towards getting into one EMR system across all three levels of care, we believe there's some opportunity to do from personal care to hospice what we're seeing from home health to hospice. Again, we do look at what Brian's talking about with home health. We kind of look at it bifurcated as a business by itself, but also as a strong support for our hospice program.
Yeah. Taking that comment and maybe contextualizing that from an organic standpoint, right? Texas is a prime opportunity for Addus to grow that clinical asset base, which solely started as a hospice state. With Gentiva now, it's much more larger personal care presence.
As we think about kind of the M&A market, it seems like there's a bit of a standstill given the uncertainty around rate, which we would usually have by now and be able to talk about. Are you kind of seeing people in your pipeline just kind of teetering across the line where it's like once that rate comes out, it's like, "All right, the deal book's going to open up," or it's just they're not even kind of thinking about the conversation at the moment?
Yeah. I think we've always kind of seen this dynamic the last couple of years between kind of that time period between the proposed home health rate and then the final. If you're having a conversation with anybody of any decent size, obviously, if you're a buyer, you need to kind of bake that into your projection model, your pro forma.
I think if you're a seller, you're like, "Oh, it's going to come out better." You really actually get some credit there. It kind of creates a situation during that kind of window that you probably see a little less deal flow. We've looked at it. I think the things we've been doing are typically on the smaller side. To be honest, we always make some assumptions of what we think the rate outlook looks like for the next couple of years. We can be conservative with that, but it doesn't move the needle a lot for us. I think on our end, we're just a little different because it is going to be smaller opportunities.
I think we'd still like to do some home health in the right markets because to Dirk's point, there's some definite benefit that we see in how it feeds to some of our other businesses. To be honest, when you're doing things on the smaller side of home health, they're really good multiples, I think, for us as well. They're not necessarily expensive either. We'll wait and see. I think after the final rule comes out, I would suspect that people can have a little more educated conversations, at least about this year. I think a big piece of that too is when the rule comes out, what do they indicate for what might be coming in the future? I think we've all talked about the clawback and things like that.
We have said pretty openly, we'd love to see there be some resolution so the overhang goes away. They have kind of been kicking that can down the road the last few years. We will wait and see what they say.
Great. I guess we are kind of now in the last five minutes here, but maybe just kind of polling around 2026, just kind of general qualitative comments. Maybe starting off with the clinical labor backdrop, personal care has seen broader improvement. You have called out pressures or pockets of pressure in the clinical business around some of your urban geographies. How should we think about on the clinical side, just the persistence of that pressure heading into 2026?
Do you kind of expect the general improvement in that pressure as we kind of go through and the clinical asset base kind of continues to grow?
Yeah. I think you're always probably going to have certain markets and pockets where you maybe need to do a little more than you probably do on a standard basis. I think we're kind of back to the environment where we think around 3% just overall on the clinical side is probably pretty standard across the board. There might be some pockets where it might need to be slightly higher than that. I think that's probably never going to completely subside. You're always going to have that from place to place, market to market. That's our expectation going into next year.
Just keep in mind on the caregiver side on PCS, which is the bulk of ours, those are not year-to-year CPI inflation-type employees. It is all kind of tied into what we talked about earlier with states and reimbursement updates, etc.
Maybe just kind of thinking about the consolidated EBITDA margin framework, clearly years of margin expansion now and kind of in this 12% type of range. How should we think about the additional leverage opportunity, especially when we think about Gentiva and you still have the kind of the tech investments still to kind of integrate on that front? How much kind of incremental synergies does that drive to the overall book of business? Is that kind of expected to be realized completely in 2026, or is that like kind of multi-year type of rollout?
I don't think on the Gentiva side specifically around, we talked about kind of redundant EMR system. They're on their legacy platform. We moved them into HomeCare Homebase sometime probably later next year, to be honest. And so we've talked about that in context of being probably right at or just under $1 million in kind of annualized spend. It's not redundant today. If we see them moving over late next year, I think obviously you're going to realize that more in 2027, maybe a little bit in 2026 because it'll be probably late 2026 before we see that transition. I think just more broadly on consolidated, I think our thesis has been, Dirk talked earlier about gross margins and consistency. Assuming similar mix of business and M&A could always kind of impact that.
Outside of that, really seeing top-line growth allow us to get leverage on our G&A, specifically a lot of our corporate and overhead, a little bit out in the field probably as well. That is where we think maybe there is some opportunity for additional bottom-line EBITDA percentage growth.
Got it. Maybe just capping it off with just kind of broader conversation around headwinds and tailwinds to consider heading into 2026. I know we have covered a lot, but maybe some items that you foresee or are planning as part of your budgeting process for 2026 that will be helpful to consider from our viewpoint.
Yeah. I mean, I think the thing for us may not necessarily tie into our budgeting. We are looking at our business and existing today.
I think some of the things that we're doing that we referenced on just trying to be more efficient and using our own workforce and increasing hours and volume, I think is a big focus. We're probably early in thinking about ways to utilize AI today. How can we? We've talked about this for the last couple of years, even back to when Medicaid access rule was proposed and came out. I think we said we're always looking for ways to be more efficient and use technology in our business to leverage costs. I think that's something that we're continuing to work through. I think just otherwise looking at next year, what's really going to happen with states and their legislative sessions? What do we see from rates? Are those potential opportunities kind of on the tailwind side? We'll wait and see kind of what happens there.
Everything else, I think we got a good trajectory coming out of 2025, and hopefully we can continue that into next year.
Great. I think that wraps that up. Thank you very much for joining us today.
Thanks, Raj. Appreciate it.