Ladies and gentlemen, the program is about to begin. At this time, it is my pleasure to turn the program over to your host, Joanna Gajuk. Please go ahead.
Hello, everyone. Thanks so much for joining. My name is Joanna Gajuk. I'm the Equity Research Analyst at Bank of America, covering healthcare facilities and managed care. And thank you so much for joining the Home Care Conference. So this is our second day, and it's my pleasure to now host this session with Chemed, one of the largest hospice providers, but also a provider of other services, non-healthcare related services. So we'll talk about that briefly too as well, I think.
But with us today, we have Chemed's team here: Kevin McNamara, President and CEO, Mike Witzeman, who's the CFO, and also Nick Westfall, who's the CEO of VITAS. So thanks so much, gentlemen, for joining us again this year. And before we go into the Q&A, I just want to make a note to the audience. You can see the Ask Question window in the webcast panel, so please feel free to send your questions my way, and I'll be happy to ask on your behalf. So with that, I figured, you know, this is a Home Care Conference, so we're going to start with VITAS.
And the results that have been coming in are much better than expected. Census is growing organically, more than 10% so far this year. And on the call, you said you expect a VITAS census to grow high single to low double digits next year. So can you talk through the main assumptions for that and kind of what gives you confidence in that kind of level of growth continuing?
Yeah, so to reaffirm some of the comments that we made, so if you just take the third quarter run rate, which is about 15.5% volume, with 2.5% of that being accretive to the acquisition earlier in the year, what we think our new run rate will be and how it gets comprised ultimately, and obviously we'll finalize it when we finalize our 2025 guidance and release that in February, is our new normal is something that is probably in the high single digit range, where pre-pandemic we would have talked about volume growth somewhere between 4%-6%, and so, you know, for illustrative purposes, we talk about something in the 8%-10% volume range.
How we get confidence and comfort there is not just in '24 results, which have outpaced that, but to effectively illustrate, right, over when we ended the third quarter, we had nine quarters of continuous demonstration of our ability to add net clinical capacity, which is the best leading indicator as long as demand, which it has, continues to be strong for our services, of the result of the fact that with nine quarters of net sequential growth in clinical capacity, we've had eight quarters of sequential growth from an ADC standpoint, and so that's what's brought us from, you know, the low 17,000s at the low of the pandemic north of 22,000 as we entered the third quarter.
And so everything that goes into our ability to not only continue to attract, but more importantly, retain all of our team members and our balanced approach, not only from community access, but really just continuing to service all four of our pre-admit segments in every market in which we operate, is what gives us the confidence that our new normal, you know, organic volume growth rate will be somewhere between, you know, 8% and 10% for 2025, and that that becomes a sustainable approach on a go-forward basis.
And when you combine that with an anticipated price increase October 1 of next year, it gets us to low double digit top line growth.
I think the other thing, Joanna, that's important to mention is the baby boomer generation. There's a bubble of demographics for the entire hospice industry that are just about to hit the age range where they're going to need to access hospice more. We think, and we've seen studies that overall, over the next 10 years, the hospice industry itself is going to grow 8%-10% a year over those 10 years. There's going to be a rising tide for the whole industry as well. We think we're in a great position to take that and maybe a little more than that, given that 60% of our business is in Florida.
If 8%-10% is the national average, you know, Florida's probably going to be a little higher than that. So we're pretty confident that the industry is a sustainable high single digits, and we'll take our share of that, if not even a little more.
Yeah, and the other variable really gets to the continued education and awareness that the pandemic helped elevate to, you know, build better awareness and openness towards, you know, advanced care planning, goals of care conversation that over time should lead towards earlier access and earlier adoption of the hospice benefit, which things like the NORC study and others have proven to be not only beneficial to higher quality outcomes for patients and their families, but just as importantly, you know, elevates the return of dollars and cost savings back to the Medicare Trust Fund, which is important for the overall country, right? It completes the triple aim, which we've talked about for a decade or so, right, inside of the healthcare system.
I guess with that kind of census growth you're talking about, very high single digits, do you need to grow your staff at the same pace to kind of meet that demand?
Short answer is yes, and so that same methodical pace that we have grown it at over the last, I would say, more six quarters than the nine quarters that we're talking about. We've proven, you know, a methodical, predictable way to say with days of care growth, and there's a lot of variables embedded inside of that. We will grow thoughtfully, mindfully, and selectively clinical capacity on a site-by-site level based upon what those needs are, and so, you know, we've disclosed the net growth rates of the five disciplines that were assimilated with our retention program that expired well over a year and a half ago, but it's not only those five clinical disciplines, but others to make sure we continue to have high quality care at the bedside.
I guess talking about that bonus program and retention success that you have had, so can you talk about, you know, what's driving really the clinicians to VITAS, right, even after the expiration of this bonus program? And maybe, you know, talk about, you know, where these people are coming from. Are you just essentially hiring them away from your competition, or is it that they're coming from other settings?
So, you know, we'd probably throw it into three categories. I'll answer the second question first, which is we absolutely see some of our newest team members coming from competition, and I'll get to why we believe they're coming to us in those circumstances. Similarly, I think you have a natural reentry of some clinicians reentering the workforce from the pandemic and really thinking about the settings of care and the type of care that may have been their initial motivator for becoming a nurse or becoming, you know, whatever clinical discipline in which they have.
And then the other aspect to it, particularly inside of the home care and specifically hospice industry, we're seeing younger and younger applicants than we would have pre-pandemic. I find that to be the most encouraging of all three because we're trying to break down maybe some of the social stigmas and educational stigmas that would have occurred inside of nursing schools and other places that would only think about, you know, working in hospice late stage of your career, so that they now begin thinking about all the benefit, all the outcome pieces.
Obviously, my opinion is biased, but they can really impact patients and families' lives in a dramatic way. Why not do that for your entire career, just as opposed to the last, you know, 10 years of your career? And so, I think just based on average age of some of our new clinicians, which we don't disclose, it's very encouraging that we are getting people earlier in their career, and hopefully we continue to keep them because we have a lot of career path options and career growth depending on what that individual wants.
Joanna, I think also implicit in your question, at least, is we've always, even during the height of the pandemic, been able to hire people. Really, what's improved more dramatically, I believe, is our retention of people. Our turnover has really, really improved over the past three years due to a lot of the things Nick talked about. And so during the pandemic, we might have had to hire 700 new people in a quarter to add a net 200 headcount. Well, now we only have to hire maybe 300 people to add a net 200 headcount. And so it's really just. So we can be more selective.
Yeah, so we can be more selective in who we hire, but we also have to hire so many fewer people now than we did to add the same number of headcount in a given quarter.
Yeah, and to answer the first part of the question as to why is retention improving, there are a lot, a lot, a lot of reasons. I think at the crux of it, right, we're always paying prevailing market wages. We're always looking for ways to improve, you know, benefit packages and everything else. That sort of table stakes, I think, being any type of healthcare provider at this point, what we really have is leaned into and tried to elevate our culture, not only our VITAS culture, which we think is a differentiator, but use that to elevate why, if you're thinking about why coming to hospice that has a lot of cultural benefits, right?
You're out in the community, you're able to spend time with patients and their families and see the significant impact it has. But at VITAS, we're really trying to celebrate some of that unique cultural pieces and elevate every location that has their own culture that comes along with it. While we have a foundational mission and value, we're allowing all of our local leadership to sort of create their own fun team culture and the things they want to celebrate and recognize and celebrate one another. And while that sounds very, it is a high level simplification of everything.
It's proven to have an impact, and we'll measure it, call it scientifically, but at the end of the day, where the rubber meets the road is retention levels continuing to elevate and stabilize and us continuing to keep that top of mind because that is the leading indicator around our future success, and every member of the team knows it.
And switching a little bit onto other areas of growth. So we talk about the organic growth, but also, you know, recently the company did its first hospice acquisition in many, many years, right? So I guess the question, obvious question here is like, should we expect more, right? Is there increased appetite for deals and what types of assets you're looking at? And I guess with that, you know, would you consider something bigger? You know, should we expect, you know, more like a Covenant-sized acquisitions, or is there, you know, capacity and interest to do something maybe bigger than that?
To simplify all answers, the answer is yes to every question you ask there. With all that being said, though, we're not going to stray from what I think we've been pretty consistent of through all of 2024. We think there's an opportunity for us to enter into not only, you know, additional counties and states in which we operate in that we'd like to be in, like the state of Florida, which we've done through CON or acquisition, as you pointed out with Covenant earlier in the year.
But there's other states that we think are particularly attractive for a variety of reasons and align with our service and operating model that we're also being very intentional around how we approach much more proactively than maybe we would have in the past. As you guys and as everybody, I think, on this call knows with our balance sheet, in no way, shape, or form are we capitally constrained, but that does not mean we're just out, you know, looking to acquire things blindly for the sake of adding census.
It's very intentional, methodical, and we want to enter into locations where we think we can, you know, really have a differentiated offering and grow with the same growth expectation that the shareholders have for us and the same expectation we have internally. There's nothing I would say we would shy away from, but it has to meet our strategic thesis first and foremost. Like-minded, longstanding, mission-focused hospice providers are the key underbelly because that cultural integration is so, so critical when we start talking about, you know, M&A activity inside of the space.
I'd just like to add, you know, everyone likes, you know, in business, baseball analogies, but, you know, it's been observed that, you know, if in baseball, they didn't call balls as strikes and you just waited for a ball right in the middle of the play, everyone would be in the Hall of Fame. That's kind of, we could reduce our strategy pretty much over the last several years to that, and we're not straying too much from that because we have limitations in our organization as far as the type of program we have experience managing. You know, we recognize our limits in that regard.
We don't rule out in the future as far as expanding our vistas, but that's a reference to VistaCare that we didn't buy. But that certainly adequately summarized where we are on that. We just, you know, at Chemed, we have a long history of buying and selling companies prior to getting to a stable situation with VITAS. But we've learned that, you know, some of the pitfalls. We were almost every acquisition we made, you know, going back to our history was a positive one. If we exited it, it exited it as a capital gain. But at the same time, that doesn't move the needle.
Capital gains don't move the needle. And, you know, there are risks. I mean, I always like to say when you evaluate Chemed's stock performance, you have to risk-adjust it. You know, up to this point, we've been swinging at the pitches right down the middle of the plate, not taking much risk, and they haven't changed too much, you know, recently on that approach.
No, thank you. Thank you for that. But I guess coming back to the fundamentals a little bit more, so the margins in VITAS in this segment, let's focus on that. You know, for 2024, right, this is 19.2%-19%, called 19.5%, right? And then this is above where margins were in this segment in 2019. So how much, I guess, is from the higher volumes you just talked about versus maybe some efficiencies or maybe also the Medicare rebasing, right, that took effect in the last quarter of 2019? So we haven't really seen this flowing through the full year, which is more a normalized year. So can you kind of help us understand, like, these margins being that much higher than 2019?
Sure. So there's a few levers, and the fourth quarter, as you suggest, will always be our highest because our price increase goes through on October 1st. And so obviously our cost structure on September 30th is the same as it is on October 1st. And so a significant amount of that price increase, particularly in the fourth quarter, will drop to the EBITDA line fairly directly. The second thing that Nick has talked about a lot that has helped expand our margins in an outsized way over the last 15 months or so is the Community Access Program and expanding length of stay.
When we expand length of stay, that has an outsized impact on margins as well as revenue because our first 30 and last 30 days are the most expensive days of care for us. And so to the extent you can expand those days in the middle, that will help us on a marginal basis. And then the third thing I would say is we've always had sort of an internal benchmark that we will grow back office costs, call it SG&A, at half the rate of our revenue increase. And so there are some years we've hit that and some years we haven't, but that's sort of our benchmark.
But when we're growing top line by 15% or 16%, it's less likely that we're going to grow back office SG&A costs by, you know, 7%-8%. And so we've gotten some leverage on the back office because of our higher than average growth rate. Having said that, there's going to be going forward puts and takes and some headwinds and some tailwinds to that margin rate. So I would say where we're headed in or where we've projected 2024 is probably going to be the stable number to use for the foreseeable future as to where margins will wind up.
It'll be a good predictable range. And just to remind everybody too, right, when you take not the VITAS specifically, but the overall industry price increase that just went into effect October 1st, you're talking 2.9%. And if you try to hold all things constant, 2.9% is not going to, well, we're not complaining about it. It's more than some of the other segments, right, inside of healthcare. It's not going to keep up with overall cost of doing business and inflation.
And so it's up to us and the rest of the providers to continue to find ways to be more efficient so that on all the other various puts and takes, we're making sure we're not, you know, we're paying prevailing market wages, we're able to provide appropriate and sufficient ancillary services to all of our team members. And that's what each of us as providers gets tasked with doing as we're, you know, deploying funds that we're being paid for by the federal government.
I guess staying on the margin discussion, right? So you made some comments about next year. Obviously, you don't have the guidance, the full guidance just yet, but you kind of alluded to, you know, margins, I guess, should be expanding with that kind of, you know, rate growth to your point and census, but maybe not to the degree that it did in 2024. Because when I look at this guidance for 2024, you know, it's kind of implying like a 200 basis points improvement in the margin year- over- year, right? And obviously, this was coming off a very depressed level in 2023, I guess, in terms of the margins.
But if you grow, you know, that fast, right? If you grow your top line double digits, sounds like there should be some margin expansion, right? So is that the way to think about it for 2025, that some margin expansion would, you know, should be happening still?
I think you'd be safer saying that our margins will be consistent year to year. I don't see a significant amount of expansion, and again, there's pluses and minuses. The leverage is certainly an improvement to margin. As Nick mentioned, while the gap between wages and our reimbursement has certainly, you know, narrowed, it's still, they're still not equivalent.
So that's a headwind, and then the third thing that we've talked about a little bit is we have a few programs that are, you know, because of the expanded length of stay and the community access program, we have a few programs that are starting to get uncomfortably close to the Medicare cap limitation, and so in those few handful of programs, we're going to have to slow down growth and expansion of length of stay.
It's not going to be material, and we'll still be growing. We'll be growing dollars for sure, but I would think margins will be fairly stable.
And not even that, like, from a long-term perspective, I think realistically it's spot on. But the growth in admissions is the wild card there. I mean, to the extent that growth of admissions through the, you know, hospital admissions, if that exceeds our expectations, the limit of growth even in those markets would disappear. Yeah. And like to Kevin's point, nothing's changed in that regard. It always becomes a balancing act related, but there's no.
Not a hard-to-pass limitation.
There's no limitation, but it's one every hospice provider is, you know, constantly evaluating. And as everyone knows, it's very market-specific given the fact, you know, the Medicare cap rate just raises universally over the last few years with some of the statutory changes irrespective of what the individual CBSA does. So it creates its own county and state-specific dynamics each and every year with the rate update.
Right. Exactly. And just talking about reimbursement here, so it's been relatively stable, right, and some changes here and there and such. But I guess I want to ask you your thoughts about this proposal that's been out there, I guess, now for a little bit. But the Hospice Care Act from Congressman Blumenauer, right, includes a bunch of different things in there, right? There's the integrity reforms, but there are also changes to payment structure, which was surprising. So can you give us your sense of, you know, the likelihood of either the entire bill getting picked up somewhere there or maybe the pieces? And, you know, and if so, I guess what, you know, how you would think about the impact from those pieces to your business?
Yeah, sure. So Representative Earl Blumenauer , first and foremost, you know, was always a champion for hospice, and we appreciated that as an overall industry. And so, you know, what you're alluding to, that bill was really, we saw it, and I think everybody else in the industry and from direct dialogue related to it as a discussionary piece that wanted to throw out, you know, some topics or some things for consideration over the coming years as he looks for, you know, new champions inside the legislation to continue to advocate for hospice.
And I think that's the key theme underneath it, which is, you know, Representative Earl Blumenauer very much saw the positive impact of hospice and was looking to elevate and expand those things. And so there's a lot of different ways. One could argue you go about it, but I think first and foremost, it is rebaselining everyone's understanding that earlier access to hospice and longer stays in hospice increase quality outcomes for patients and families.
That's been proven by every study, and more importantly, in the last few years, it reduces total cost of care to the Medicare Trust Fund, and when you take those two combinations, it's a really powerful thing.
Right.
So there are a lot of items that we individually and collectively as an industry agree with, don't agree with, and I think it's a good reference point going forward for a collaborative approach with our new, you know, consolidated trade association to be working, you know, both directly with CMS and with the new administration to help accomplish. But you don't think it's something that's necessarily, you know, it's going to be passed or has a good likelihood of being passed, correct?
That's exactly right.
It's a talking point.
They're talking points, not actionable.
Right. And since you mentioned incoming administration, I guess I'll ask you the question I'm asking everyone, but obviously we don't know any details and such, but kind of, you know, any high-level thoughts of anything that might come out from the new administration or the new head of CMS that, you know, might be impactful for your industry at all?
No one has a crystal ball. I'm sure everyone's given you that same answer, but I think universally, you know, hospice has, and I'll just use the past year, has been very universally supported and understood in a bipartisan way. With the new administration, we're very encouraged about some of the key themes that could come out of it and what it may mean for the hospice industry. If I'll go back to what I referenced in the studies, we believe we're one of the solutions for helping, you know, root out maybe unnecessary spending and other pieces and replace it with high quality of care for some of the most vulnerable population in the country.
And so we're looking forward to continuing to work with, you know, the new administration to slowly and incrementally pass any type of, you know, legislative updates, reforms that could help elevate awareness and access to the hospice benefit throughout the country because it's going to be needed and it's going to be needed for decades to come.
Exactly, so I guess we'll be on the lookout for that, and maybe we have, I guess, 15 minutes or so left, so maybe even though this is a hospice conference, but I guess the other business gets a lot of attention since, you know, the results at the Roto-Rooter have been, you know, disappointing. So maybe we can talk a little bit about that business, and, you know, commercial revenues show some stabilization there in third quarter because they were actually up sequentially, but still down year- over- year, right? So what needs to happen really for this part of the business to grow again?
So we've talked a lot about it over the last three quarters. There were a number of management initiatives that were put in place that we think are showing some grassroots, you know, efforts that are starting to pay some fruit. I would tell you, ultimately, they all center around the idea of blocking and tackling boots on the ground sales efforts at the local branch level. And when I say that, people get the maybe misconception that our commercial business is centered around like the Targets and Walmarts of the world, but that's really not the bread and butter of our Roto-Rooter commercial business.
The real key customers we have are on the location-by-location basis, large apartment complexes, or maybe someone who owns a few McDonald's franchises in the territory. And those are local sales relationships that need to be established. We've put a lot of effort into a number of things to get those relationships, you know, kickstarted.
Right. So I guess it's taking some time there. And on the call, you alluded to this idea of the segment, which is commercial, but the Roto-Rooter segment revenue may be flattish year- over- year next year. So what are the biggest swing factors there? And what do you assume when you think about it as being flatish? What do you assume for the commercial, which is talk about, and then residential?
Sure. So we, like I said, we see some definite momentum for commercial going into 2025. How much that'll be up is yet to be determined. We're still working and finalizing our budgets and things. But we see, you know, some level of growth in the commercial business in 2025. We believe residential has hit a bottom for the most part, but we aren't, we're less confident or we have a little, we're a little more cautious on the residential side that we're going to see any substantial growth in that segment. Residential, 75% of the business.
So, you know, like I said, we're putting pen to paper now and finalizing budgets and things, but a little bit of growth in commercial, you know, call it down a little to up a little in residential. And we can, you know, eke out a little bit of growth in 2025 for Roto-Rooter.
So when talking about this residential piece of the Roto-Rooter business, kind of, yeah, what are some of the indicators that you're looking at to kind of, you know, tell you that, hey, you know, you said you think this is pretty much bottom, but you're kind of, what we should be looking out for to kind of assess that from the outside as well, that this is the bottom?
Let me just start by saying, you know, with Roto-Rooter, you know, what we're looking at is call volume. I mean, when we talk about market share, you know, but, you know, we're talking about something we track is calls that we're getting, you know, and the calls that we're getting come as a result of kind of legacy customers who know us or they're responding to sales efforts, you know, and hopefully they're calling us directly. You know, those are calls we get. 80% right now, approximately, of our jobs come up with some reference to Google, whether it's natural or paid search.
You know, we really feel that, you know, even though there's been increased competition, increased bidding for placement, you know, we think that despite having the preeminent service mark by far in the sector, you know, we're getting, you know, kind of lost in the shuffle. Google has created a bit of a shuffle. As I said, you know, the LSA, there's more aggressive paid search. They've changed, you know, a couple of times in the last 18 months, the algorithm determining where you show up on the kind of the natural search maps section that has adversely affected us.
Roto-Rooter has, you know, been dealing with that. We've gotten some new help in that regard. We've changed internet marketing for them. I think we have a deeper understanding of what we're facing. The net effect, what gives to answer your question, what gives us a good feeling with regard to the improvement is the fact that by doing a better job analyzing the bidding market, we're bidding less and getting the same number of phone calls. You might say, well, bid more and get even more phone calls. And we tried that.
You know, the market and that kind of the overbidding that's occurring by, you know, competing private equity firms has suggested that, and we tried that. We tried that in really two different times last year. We didn't get more calls as a result of that. So we think we're confident that right-sizing our bidding strategy will get us the optimum number of calls. I shouldn't really say the maximum number. The optimum is always more. But the maximum number of calls, we're able to save money on the marketing.
We're expanding our efforts to the non-Google, you know, resources to get calls. The fact of the matter is, as we've indicated, I mean, we're now coming into the time of year on a seasonality basis where Roto-Rooter historically has done well. As we cover more fixed expenses with the increased, you know, number of calls, we're, you know, it's easier to assume that we're going to, that we are doing better and we expect to do better.
So, you know, we're seeing that. We think that, you know, most of the strategies that we've talked about, you know, over the last couple of months that are the grand strategies, that is things like adding an app, you know, to customers' phones, to starting a program where we're getting maintenance contracts going among our customers. We obviously, those are programs that are going to take some time to bear fruit.
But on the other hand, we're going in with some real advantages, you know, the real advantages being, you know, the number one service mark, the fact that when you accumulate over a long period of time, the fact that, you know, at this point, the number of residents in the United States that have used Roto-Rooter at some point over the last 40 years is, you know, approaching almost total market dominance in that respect. We have that going for us. We have a very solid service force. We have, in regard to that, they're operating at peak efficiencies.
We have almost historically high close rates at the call center level. At the service tech level, we have historically high close rates. The ancillary services that they are selling to customers, that is the water restoration, the excavation, are beyond historic and previous historic levels. I mean, they're approaching 50% of our sales at this point. I mean, we have a lot of things going for us. You know, a big win will be, you know, somehow have those programs take hold and/or increase the number of share, the number of calls through Google, which we're going to get by bidding smarter, not higher. Would you agree with that, Mike? That's what I've seen.
Yes, absolutely. The only thing I would add to what Kevin said is, you know, we aren't economists and we don't pretend to be. There have been some studies we've seen, you know, in the Wall Street Journal and other publications that would say that they believe some of the economic factors that have led to the softness, some of the softness in a lot of home service industries are starting to get better and maybe some improved conditions for operating in those industries, you know, maybe mid-2025 and beyond, and so we're cautious.
We think the first quarter, first two quarters at Roto-Rooter are still going to be some tough sledding, but sequentially, we think that just the overall operating environment is going to start to improve for us from a demand standpoint.
Right. Because, like you mentioned, seasonally, you know, Q4 is a strong quarter, but I guess Q1, probably Q2. So is it the idea we would need to wait to kind of see things really, you know, in a year, essentially in the Q4 of 2025 to kind of say, hey, like things are improving? Or I guess we could also maybe see it through like the better than seasonal trends, quarter over quarter through the year.
I think you'll start, you know, to see it even in the second quarter of 2025 is improving sequentially. As we sit today, the first quarter last year of 2024, first quarter of 2024 was by far Roto-Rooter's best quarter. There were some weather impacts that happened there and things like that that, you know, we can't budget for that sort of thing.
We can hope for them.
We can hope for them, but we can't budget for them. And so as we sit today, we think that, you know, there's a pretty good chance that Roto-Rooter might still show some level of revenue decline in the first quarter, but then start to really improve starting the second quarter and beyond.
I guess on margins very quickly in Roto-Rooter, year to date, I guess it's averaging like 26% or so. Is this a way to think about next year, the starting point?
I would think about it and again, we're still working on our budget. So this is just off the top of my head sort of. I would say somewhere between 26 and 27 is probably a fairly good way to think about it. We have some plans that are going to maybe cause a little margin pressure for us to try and drive some top-line demand. At the same time, if we do drive top-line demand, there's some leverage that we'll get over fixed costs. So there's, I think, you know, where we're at currently is probably a pretty good indicator for the next year or so.
The last question, I guess on the corporate level, the company has really no leverage, no debt really, right? So how to think about that? You know, is there any goal for the leverage? And also with that, you know, capital deployment priorities, should we think about, you know, hospice acquisitions or is there something maybe in the Roto-Rooter segment that you might be considering as well? And any additional, I guess, you know, priorities that you want to discuss now for cash flow?
Sure. We aren't scared of leverage. That's the first thing. We haven't had any need for leverage in the last few years. We can, you know, we generate free cash flow of roughly $300 million a year. So we can use that for stock buybacks. We obviously cover any capital needs we have internally. But because of our strong balance sheet, we can continue to do our stock buyback program and take fairly significant opportunistic swings at stock buyback when it's advantageous. And that in no way would impede any M&A that we really want to do.
That's the advantage of having the balance sheet that we have. On an M&A front, we wouldn't shy away from anything. I think we would buy anything at Roto-Rooter in the right location that comes available. Those opportunities are probably not from a pure dollar standpoint as large as some of the opportunities we could potentially have at VITAS. But again, VITAS acquisitions would be well thought out within our current strategic thought process on location, valuation, and those sorts of things. So we're not going to do M&A just to grow the company at any cost.
So M&A is going to be thoughtful. The Covenant deal has went very, very well for us. And we would love to do more transactions in that, you know, in that neighborhood.
And if I may just to follow up on that, any thoughts on, I guess, the de novo in hospice? I mean, I guess maybe they are just low capital outlay. So you might have been doing those, but we just don't really talk about it. But maybe any thoughts on that?
Yeah, no, we have been doing them. We just don't. Sometimes we'll reference it. I think I referenced it at the end of the third quarter. We just lifted up and began servicing Pasco County in Florida October 1st. We have two new locations in California that are up and running, so there has been de novo activity that has always occurred. But Joanna, as you point out, from time to time, maybe we'll call it out, but it's not large capital, nor is it immediately material to the overall, you know, financials and outlook, so it's one that we may talk about happenstance, but it's part of the growth formula as well.
It's expected in the future that de novo would occur where they're either in California or more likely in a CON state.
Yep. We have a pipeline of anticipated CONs that we're already with feet on the street preparing for. So yeah, de novos will be part of the strategy as well.
Great. This is all the time we have today. So.