Good morning, everyone, and welcome to Encompass Health second quarter 2020 earnings conference call. At this time, I would like to inform all participants that their lines will be in a listen-only mode. After the speaker's remarks, there will be a question and answer period. If you would like to ask a question during this time, please press star one on your telephone keypad. You will be limited to one question and one follow-up question. Today's conference call is being recorded. If you have any objections, you may disconnect at this time. I will now turn the call over to Crissy Carlisle, Encompass Health Chief Investor Relations Officer. Please go ahead.
Thank you, operator, good morning, everyone. Thank you for joining Encompass Health second quarter 2020 earnings call. With me on the call today are Mark Tarr, President and Chief Executive Officer, Doug Coltharp, Chief Financial Officer, Barb Jacobsmeyer, President, Inpatient Rehabilitation Hospitals, Patrick Darby General Counsel and Corporate Secretar y, and April Anthony, Chief Executive Officer of Encompass Home Health and Hospice. Before we begin, if you do not already have a copy, the second quarter earnings release, supplemental information and related Form 8-K filed with the SEC are available on our website at encompasshealth.com. On page two of the supplemental information, you will find the safe harbor statement, which are also set forth in greater detail on the last page of the earnings release. During the call, we will make forward-looking statements, which are subject to risks and uncertainties, many of which are beyond our control.
Certain risks and uncertainties, like the magnitude and impact of the COVID-19 pandemic, that could cause our actual results to differ materially from our projections, estimates, and expectations are discussed in the company's SEC filings, including the earnings release and related Form 8-K, the Form 10-K for the year ended December 31st, 2019, and the Form 10-Q for the quarters ended March 31st, 2020, and June 30th, 2020, when filed. We encourage you to read them. You are cautioned not to place undue reliance on the estimates, projections, guidance, and other forward-looking information presented, which are based on current estimates of future events and speak only as of today. We do not undertake a duty to update these forward-looking statements. Our supplemental information and discussion on this call will include certain non-GAAP financial measures.
For such measures, reconciliations to the most directly comparable GAAP measure is available at the end of the supplemental information, at the end of the earnings release, and as part of the Form 8-K filed yesterday with the SEC, all of which are available on our website. Before I turn it over to Mark, I would like to remind everyone that we will adhere to the one question, one follow-up question rule to allow everyone to submit a question. If you have additional questions, please feel free to put yourself back in the queue. With that, I'll turn the call over to Mark.
Thank you, Crissy, good morning, everyone. The challenges presented by the ongoing COVID-19 pandemic have been and continue to be significant. Thanks to the amazing efforts of our talented and devoted team members throughout the organization, we believe we have implemented plans across our organization that will allow us to continue to succeed in the face of the ongoing challenges. Let's first talk about our volumes. Our patient volumes in both business segments have substantially rebounded from the low point experienced in April. At the end of June, inpatient rehabilitation census had rebounded to 95% of pre-pandemic levels, and home health starts of care had rebounded to pre-pandemic levels. These positive volume trends have continued in July. Volume disruptions caused by the pandemic vary by market. Most of our markets have seen a meaningful level of recovery.
Factors that have impacted our volumes include the number of COVID-19 cases in a community, the status of operations at acute care hospitals, the number of exposed or positive staff in quarantine, delays in obtaining COVID-19 test results for patients and employees, and capacity limitations created by semi-private rooms in some of our hospitals. While COVID patients do not comprise a large percentage of our patients, many of our hospitals, home health agencies, and hospice agencies treat patients recovering from the virus. These patients, many of whom have spent time on ventilators, have endured extended stays at an acute care hospital. They are extremely weak and require intense rehabilitation to regain both their strength and cognitive abilities. Unfortunately, some facilities in the post-acute space have faced significant challenges with COVID-19.
In contrast, our rehabilitation hospitals and home health agencies have been able to help recovering patients return to their independence and pre-COVID lives. These resurging markets also are where we are seeing Medicare Advantage plans once again relax pre-authorization requirements. When the pre-authorization requirements were relaxed in May, we experienced a higher conversion rate of these patients. Let's move now to pricing, where the COVID-19 pandemic is impacting each of our segments differently. Net revenue per discharge is being positively impacted in our inpatient rehabilitation segment by a higher acuity patient mix resulting from the pandemic and the suspension of sequestration that began May 1st.
The acuity of our patients increased in the second quarter of 2020 due to the deferral of elective procedures and patient anxiety causing only the most acute patients to seek medical treatment. While revenue per episode in our home health business is also benefiting from the suspension of sequestration, the COVID-19 pandemic is exacerbating the expected negative effects of implementing PDGM. LUPAs remain higher than we'd like, but they have significantly improved as of the end of the second quarter. Some patients, families, and senior living facilities remain cautious about allowing our clinicians into their homes and buildings, but the treatment refusals have decreased. To further reduce patient anxiety, we have improved communication with patients and families regarding our infection control procedures and adapted our visits to ensure proper social distancing during periods where hands-on treatment is not required.
In addition, as acute care hospital census declined and visitation restrictions were implemented, our admission source mix shifted from institutional to more community-based, which carries a lower reimbursement under PDGM. Additionally, the declines in admissions, coupled with the need to maintain proper COVID risk monitoring of patients in later stages of their care plan, resulted in the patient mix shifting from early payment periods to late payment periods, which also carry a lower reimbursement level. The COVID-19 pandemic related impact on patient volumes, staff productivity, and medical supplies also is increasing our operating expenses. Safety of our patients and employees is of paramount importance to us, making the availability of personal protective equipment a priority for our supply chain management teams. Increased PPE utilization and increased unit cost has been a significant challenge to the healthcare industry. PPE costs have increased eight times on average.
In our Inpatient Rehabilitation segment, utilization of PPE has increased approximately 12x for masks and 4x for gowns. This type of PPE was not widely used historically in our Home Health and Hospice segment, so these costs are predominantly new for that segment. We've taken a number of actions to address ongoing PPE issues. This includes identifying and contracting with secondary supply sources, as well as securing additional warehouse space and logistical support from our primary distributors so we can have larger levels of inventory on hand. We are confident we now have adequate inventories of PPE, and we have secured supply sources to meet our immediate foreseeable needs. While these challenges remain in the near term, they will eventually abate. As the population ages, the demand for high-quality care we provide across our three service lines will increase.
Throughout this pandemic, we've continued to expand our national footprint. We've opened three new hospitals in 2020, including two added in the second quarter in two states that are new for us, Iowa and South Dakota. We expect to open a new 40-bed hospital in Toledo, Ohio in the fourth quarter. In addition, we expect to add at least 120 beds to existing hospitals in 2020, with 53 of these beds already operational. Recall that at our Investor Day earlier this year, we discussed a growth target of 6- 10 de novos per year starting in 2021. For 2021, we've already announced plans to build eight new hospitals, and we've announced five new hospitals planned for 2022. Specifically, at our Investor Day, we announced we had identified 15 high-potential de novo markets in Florida.
As of today, our expected 2021 and 2022 hospital openings include five new Encompass Health IRFs in Florida, and we're not done in Florida or in other under-bedded markets across the country. You can expect more announcements in the coming months. All of this demonstrates our commitment to and confidence in our future. We also continue to seek opportunities to expand our national presence in home health and hospice. While we continue to believe PDGM will result in consolidation of the home health industry, current M&A activity is minimal, as even small agencies are focused solely on their response to COVID-19 pandemic and are being supported by the PPP and CARES Act funds. Thus far in 2020, we've opened or acquired two new home health locations and one new hospice location.
We remain diligent in assessing opportunities and keeping our ear to the ground in local markets. We believe depressed volumes, the inability to easily flex cost, and the expanding of all government support may bring small agencies to the forefront soon. We are hopeful there also will be opportunities of scale that will choose to come to market later this year or early next year. No healthcare earnings call would be complete without a regulatory update. In the second quarter, CMS released the fiscal year 2021 proposed rule for inpatient rehabilitation facilities and calendar year 2021 proposed rule for home health agencies. Both rules were largely in line with our expectations and contained minimal changes to the 2020 rules. The IRF proposed rule includes a net market basket update of 2.5%. The home health proposed rule includes a net market basket update of 2.7%.
For home health, it is also important to note that CMS acknowledged in the proposal that it had insufficient information to determine if the -4.36 behavioral adjustment was an accurate assumption for 2020. CMS indicated they will revisit it in future years. Also, on the regulatory front, CMS announced plans to extend the RCD program into North Carolina and Florida, effective August 31st, 2020. We, and many in the industry, believe the timing of such a rollout is ill-advised given the amount of added interaction the RCD process requires with physicians in already taxed environments like Florida. However, we have proven our ability to meet the standard in Texas, Ohio, and Illinois, and we are equally confident we can do so in Florida and North Carolina if necessary.
In summary, our business fundamentals aren't changing, and we believe the pandemic has created an even stronger awareness of the level we provide in our hospitals and the value of our home care service lines. While our operating environment continues to change rapidly, along with the COVID-19 pandemic and each market's response to it, we remain confident in the prospects of both of our business segments based on the increasing demands for the services we provide to an aging population. This confidence is further supported by our strong financial foundation and the substantial investments we have made in our businesses. We have a proven track record of working through difficult situations, and I believe in our ability to overcome current and future challenges. With that, I'll turn it over to Doug.
Thanks, Mark, and good morning, everyone. I'm going to summarize some of the key metrics and trends for the quarter, and then we'll move into the Q&A. Mark stated volumes rebounded across all three service lines as the quarter progressed. In the IRF segment, discharges declined 10% in quarter of 2020 as compared to the second quarter of 2019. We experienced a steep drop at the outset of the pandemic, but 0.3% for the month of June. The recovery of discharge volume was bolstered by strong growth in Medicare Advantage, which increased 66% in Q2, climbing to 20.1% of our payer mix as compared to 11.1% in the same period last year. This shift in our payer mix impacted our year-to-date clinical collaboration rate. The all-payer clinical collaboration rate for the first half of 2020 of 33.9% declined 150 basis points as compared to the first half.
This decline was attributable to the accelerated growth in our Medicare Advantage discharges, on which we have a lower clinical collaboration rate than on Medicare fee-for-service. Going a layer deeper reveals that our Medicare fee-for-service clinical collaboration rate for the first half of 2020 increased 110 basis points over the first half of 2019 to 43.9%, and our Medicare Advantage clinical collaboration rate increased 390 basis points over the first half of 2019 to 16.7%. We believe our clinical collaboration protocols continue to enhance our value proposition and serve as a competitive advantage. Home health volumes followed a similar trajectory to the IRF segment, with admissions declining 7.9% in the second quarter as compared to the prior year period, but rising to an increase of 8.4% in June after having dropped 23.5% in April. As a reminder, the anniversary of the Alacare acquisition was July 1st.
The initial decline in hospice admissions was much less severe and recovered very quickly. The effects of lower volumes were partially offset by better than expected pricing for both our IRF and home health service lines. IRF revenue per discharge increased 6.2% in the second quarter, driven by higher acuity and the suspension of sequestration beginning May 1st. Home health revenue per episode decreased 1.3% as the negative impact of PDGM, the effects of which have been exacerbated by the pandemic, were partially offset by the sequestration suspension, as well as the increase in episode starts late in the quarter. Our operating expenses in both segments were elevated by our response to the pandemic. Labor productivity was adversely impacted by revised clinical protocols and operating procedures required for infectious disease management.
Along with all other healthcare providers, we incurred higher costs related to increased utilization and pricing of PPE and cleaning supplies. In addition, we elected to reward our frontline employees with extra PTO, resulting in a $43 million incremental expense in the second quarter. Our labor productivity metrics improved over the course of the quarter. We expect a continuing impact from the pandemic for at least the balance of this year. We assume that utilization and pricing of PPE and cleaning supplies will remain elevated. Putting this all together, our consolidated adjusted EBITDA for the second quarter of $2.2 million, declined 35.7%. Excepting the $43 million extra PTO benefit, the decline would have been, with the trend line improving throughout the quarter.
As a further reminder, we returned 100% of the CARES Act relief funds we received from HHS, so our adjusted EBITDA does not include any benefit related to those distributions. Our free cash flow generation for the first half of 2020 remains strong as the decline in adjusted EBITDA was largely offset by a decrease in working capital expenses. Adjusted free cash flow for the first six months, $1 million. To bolster our liquidity in Q2, we amended our $1 billion revolving credit facility to provide financial covenant relief through the end of 2021 in order to accommodate the effects of the pandemic, and issued $600 million of new senior notes as add-ons, split equally between our 2028 and 2030 maturities. A portion of the proceeds from these notes offerings were used to repay the outstanding principal under our revolving credit facility.
As a result of these actions, and with our free cash flow generation, we ended the quarter with approximately $419 million of cash on hand and $964 million available under our revolving credit facility. Liquidity and cash flow, and the confidence we have in our business model, continued to vigorously pursue our business development opportunities and to augment the returns we generate from our operating investments. Now operator, we'll open the line for questions.
Thank you. The floor is now open for questions. To ask a question at this time, press star, then the number one on your telephone keypad. As a reminder, we ask that you please limit yourself to one question and one follow-up. Your first question is from Whit Mayo of UBS.
Morning, Whit.
Hey, thanks. Good morning, guys. By my math, it looks like you were able to offset perhaps 70% of the revenue shortfall versus what I would guess you had in your original plan, give or take a few percent. Can you maybe elaborate and talk about some of the cost and productivity initiatives that you implemented to align your clinical staff with the reduction in volume and just how sustainable you think that is as the volume begins to build back?
Whit, let me just make a couple of comments. Both operating segments looked at their provision of the clinical teams. When you factor in the pandemic, you had a number of things that concerned you about staffing. One is the amount of staff that we had quarantined at any given time. You had other staff when the pandemic first started that were concerned about treating these patients to begin with. You had the whole PPE issue that required a fair amount of education, just in terms of how to wear it and just being able to treat patients in this different environment. The home health sector looked at additional productivity opportunities and the structure of their compensation package, and I'll ask April to give additional details on that.
Barb and her team also looked at how to offset those vacancies that were created by the quarantined staff that needed to be out there, particularly as we started to see volumes come back. With that, let me turn it over to April first to talk about her productivity.
Hi, Whit. One of the things that we did was, as you can imagine, one of the areas that we saw one of the most significant declines in volume was in the physical therapy discipline. As elective surgeries ended, as assisted living facilities started locking people out of the building, they would often let our nurses in, but not our therapists. We found ourselves in a situation where we had a significant excess of therapist capacity relative to our needs. In early May, we made a shift in our reimbursement structure for therapists, lowering each therapist's base pay by 20%, and in turn, lowering their productivity expectations for the pay period by the same 20% factor. That proved to be a really successful strategy for us, both in the near term and I think ultimately in the long term.
We gave our employees the ability to earn back their extra work if they could actually complete it, if their region wasn't as heavily affected by paying them overproductivity points. We found that as a result, if you look at the periods of March and April, since that May 2nd change, we've seen about a $20 per visit improvement in our cost per visit. Obviously, in April and May, we were right in the thick of COVID, and that was a high-cost period. That structure allowed us to really lower our cost per visit, but it also gave us the opportunity to maintain 100% of our therapy staff. We didn't have to furlough anyone with that approach. We were able to keep them benefit eligible and keep them available to us and allow them to use flex capacity to get back to their full compensation.
It's really proven to be a good strategy, and we have announced that we intend to maintain that with our physical therapy team, for the foreseeable future, that we don't intend to go back to the 100% pay. That was probably the biggest single structure change we've made.
We also made changes in the hospitals too, relative to just staying on top of this every day. I'll ask Barb just to give a couple of comments on that.
Right. As you're aware, we're pretty data rich and have daily information that our leaders in the field look at as they manage their labor. Historically, when there's been any sort of volume impact, that's been handled by flexing. What we did was we started having daily calls with our operators in the field to look at what markets were the flexing not going to help us hit our labor targets. In late March, early April, about half of our markets needed to implement a furlough to align their staffing with their volumes. Substantially all those furloughed employees are now back to work with our volume recovery. That daily information as it relates to labor productivity really helps our team flex appropriately so that their staffing match the needs for the hospital census each day.
With those same These are the management reports of which you've seen some of these, that we used in managing labor, in a normal course of business, were even more important during the pandemic in terms of us just being able to make sure that we knew where staffing was given the volume levels and provide our management teams on the local level an opportunity to use that data that Barb alluded to make the necessary adjustments.
Maybe to pull some of this together to how you might think about the back half of the year. As you suggested in your question, we don't anticipate that we'll have another item like the $43 million PTO. Beyond that, even as we are very pleased with the improvements that we made in labor productivity in both business segments coming into July, and even as we are now better positioned than we were at the outset of the pandemic to flex our labor costs with the volume fluctuations, we do not anticipate returning to pre-COVID-19 labor productivity standards in the second half of the year. The incremental protocols and procedures that we've had to put in place to deal with an infectious population are going to remain in place.
I also want to remind you that, from a margin perspective, we benefited significantly in the second quarter from higher pricing in the IRF segment than we had anticipated, much of that due to the acuity that Mark discussed. We just don't know what that patient mix is going to look like on a more stabilized basis. Some portion, at least, of that pricing increase may not be sustainable in the second half. It's also the case that during the first half, we benefited from lower self-insurance costs in all three of our programs, in group medical, in GP&L, and in workers' comp. At a minimum, in the Group Medical program, to the extent things begin to open up again, we would expect that there's some pent-up demand, and so those expenses will be higher in the second half.
Finally, we've said it a couple of times, Mark mentioned it in his script, I mentioned it in mine, but we have every anticipation that the increased utilization and the increased cost of PPE and supplies are going to be with us at least for the balance of this year.
Maybe just one quick follow-up, Doug, just to follow up on your comment about the composition of the volume and the inability to roughly forecast that. I'd just be curious to see what changes you saw in the quarter. I'm going to presume stroke, ortho's still down a good bit in inpatient rehab. For home health, I'm not sure how things are that different. I think April mentioned PT's down a good bit. Just any color around the trends that you saw in the composition of the volume mix.
We're actually pretty pleased that in the higher acuity care categories like stroke, and you would expect this because those are by nature less discretionary in nature, our volumes hung in there really pretty well. It was across the ortho categories that we saw our largest decrease, and that's likely to persist into the second half. I'll let April comment on any changes that we saw on the patient mix within home health.
Yeah. We definitely saw kind of a strong pullback in the therapy-related diagnoses, joint replacements in particular during the April and May timeframe, and late March as well. We began to see those really recover kind of late May, and June actually got up to a pretty similar level to our pre-COVID experience. I would say we've kind of topped out now at about 90%-95% of the pre-COVID level as we see different markets sort of come in and out of different stages of COVID. For example, Florida has remained a hotspot, and as a result, we have not seen a recovery of our volumes in Florida. Texas recovered, and now it's drawn back a little bit as it turns into a hotspot. Other markets are actually well above their pre-COVID level. Idaho, a pretty significant market for us, has been performing above its pre-COVID level.
It's really regionally focused, and I think at this point, we see our balance of patients kind of being back, for the most part, at pre-COVID level as far as the mix. It's still just a little bit behind in MS rehab.
Bid in the hospitals, one of the things that drove up the acuity was the continued growth of our stroke program. If you look at it just in terms of percentage of discharges, we had 19.4% of our total cases were stroke, and that was the highest we've seen going back for three years. That also helped drive the Case Mix Index, just to put this acuity in perspective for you. We've been running 1.37 on a Case Mix Index now very consistently for the past two and a half, three years. We were at 1.44 this last quarter, so that's a pretty steep jump in acuity, and a lot of it's driven with the increase in stroke and more complicated cases. In the hospitals, that reduction in any of the lower acuity cases, like the elective procedures with joint replacements.
Both of those were pretty major factors on pushing that acuity up.
Whit, at the risk of piling on, because I know we've given you a very long-winded response to your question and your follow-up. The other thing we're keeping an eye on within the IRF segment is that we did see an increase in our average length of stay second quarter. Some of that is attendant to the increase in acuity. As you would expect, we tend to see a longer length of stay with a more acute patient.
The other thing that we're seeing, and it's too early to call it a trend, is for that portion of our patients that came to us from either a skilled nursing facility or an assisted living facility and are getting ready for discharge back into that environment, sometimes the testing requirements and the turnaround time on the testing required for patients before they can return to their homes is causing us to delay the discharge of the patient, which has a number of repercussions for us. In many cases, that doesn't result in a higher reimbursement for us, but we continue to have the cost of servicing that patient for the additional time that they're in our facility.
Way too early to call a trend around that one, but that is something that adds to a little bit of the uncertainty that we have regarding trends in the second half.
Thank you. Your next question is from Kevin Fischbeck of Bank of America.
Morning, Kevin.
Kevin.
Just a little bit of another question on the payer mix here. You're talking about the MA mix being up in the quarter on the IRF side, but kind of as an offset, you saw fee-for-service revenue come down as a percentage. Would you say that that's kind of a sign that you might be seeing some increase in the fee-for-service patients coming back in the back half of the year as a kind of pent-up volumes there?
We definitely saw that in June. For the quarter, our MA discharges were up 66%, fee-for-service were down a little over 26%. That had a lot to do with the suspension of the Medicare Advantage pre-authorization requirements beginning the second half of April and extending through May. Those pre-authorization requirements in most markets were reinstated towards the end of May, and yet we saw, in aggregate, a 1.3% discharge volume increase in the IRF segment for the month of June, and so that happened on the basis of a significant rebound in fee-for-service. As we moved into July and more hotspots have developed in markets like Florida and Texas, we've seen the pre-authorization suspension come back in for MA plans, but we're now seeing much more moderation between the volume impacts on fee-for-service and Medicare Advantage.
I think some of the increase in Medicare Advantage, fortunately, because we've been riding this trend line, even pre-COVID, is here to stay, and that's a good thing. We've been pretty effective in selling our value proposition to those plans, but there are still good growth opportunities in fee-for-service as well.
Got it. As a quick follow-up here, is there any talk of these prior auth changes kind of changing for the long term, or is this the type of thing that you think will be coming in and out as markets go in and out of being like a hotspot?
I think it's the latter.
Okay. Got it. Appreciate the color. Thank you.
Thank you. Your next question is from Matt Larew of William Blair.
Morning, Matt.
Morning, Matt.
Hi, good morning. Doug, on the first quarter call, you alluded to the potential for the 2021 outlook not being materially different than when you entered the year. That was caveated with all the uncertainty at the time, and obviously, a lot of that uncertainty has continued. Mark, you also mentioned today the progress you've made towards the IRF de novo goals for next year, as well as the progress to expand the bed count this year. Doug, maybe again, there may be a number of caveats, but just some thoughts on the 2021 outlook at this point, given your long-term confidence obviously remains very strong?
Matt, I think it really depends on the status of the pandemic during the first half of 2021 and around the development of vaccines and therapeutics. To the extent that, I think the more optimistic time frames we're seeing out there is the development and availability of a vaccine by the end of this year. If that's able to change the trajectory of the pandemic in the first half of next year, that's going to put us back on a footing that would have resembled our original 2020 plan, not later than the second half of 2021, we're back to business as normal, and that optimistically, it could be sooner than that. Our confidence in that being the case is evidenced in these development pipelines.
Matt, the fact that our volumes rebounded as the initial phase of the pandemic flattened out in the growth, and we saw that come back. It is testament to the resiliency of the services that we provide and the ongoing demand that's out there. To the point of our future development and opportunities we see going forward, this pandemic and the fluctuations have only proven our case as we move forward.
Matt, I think it's not a question of do we get back to that kind of trajectory, it's just a matter of when. The wild card remains around the status of the pandemic at the end of the third.
Yep, makes sense. April, I wanted to follow up on your comment about the mix of it. Maybe get a sense for how that trended throughout the quarter. In the past, you've mentioned that elective procedures were about 20% of that mix looked like in the second quarter, and whether you've now started to see a recovery on the elective.
We've definitely seen a recovery. That percentage that we presented in the Investor Day, handy for the second quarter, but it obviously dropped down dramatically in the May timeframe and then began recovering as markets began to reopen and alternate surgery centers came back online. We began to see that recover in that mid-May timeframe. We also, as it relates to the early, late situation, declined significantly in that sort of an out-of-balance situation. If you remember, in home health, early episodes are only the first. As we saw admissions decline and patients continuing into the second 30-day periods, and some of those patients then in turn recertifying, it obviously tilted the balance of patients to the late segment. In turn, similarly, as we saw admissions decline, those were primarily institutional discharges that we were no longer getting during that April through mid-May timeframe.
We also saw the proportions shift from institutional to community. We're beginning to see recovery in all those things. If you remember, as you think about a 60-day episode period, and again, recertification weighting into that as well, we're going to have to get and stay at that new run rate for at least a 60- 90 day period before we'll actually see a complete rebalancing of our patient mix back to pre-COVID-19 levels.
Thank you.
Thank you. Your next question is from Pito Chickering of Deutsche Bank.
Pito. Morning, Pito.
Good morning, guys. Thanks for taking my questions. I just want to say, you guys did a pretty incredible job managing through this quarter.
Thank you.
April, going back to Whit's question on home health, historically, you run a much higher percentage of salary employees versus per visit payments like many of your peers. With the success that you've seen with the change of therapist comp in the quarter, are there any other changes that you're considering to your non-therapists? Can you remind us what percentage of your visits are therapists versus nurses in 2Q, and does that change as we think about the back half of the year?
We're not looking at any further changes at this point in time. At the same time that we made the change to the therapy, we did change our weekly productivity goals for our RN personnel from an average of about 28. We had some employees at 30, some at 27. We moved them all to the 30-point range for their productivity goals. We have seen some ability to elevate production for our salaried staff on the RN discipline, but we don't intend to make that same adjustment that we made to therapists to the nursing staff, one, because of the available supply and demand dynamics, but also just because the relative base salaries between therapists and nursing are pretty materially different. We just don't feel like that strategy for the nurses would be a workable strategy for our RN staff.
Okay. Sorry, go ahead.
Oh, I was going to say, relative to the ratios, I don't have those percentages right in front of me. I would tell you that as we moved into June, we began to see a return to the normal balance and split, and remain just ever so slightly behind with therapy compared to others. Our therapy volume is back to about 94% of its pre-COVID level, as far as our therapy visit volume. We're just about back to our normal balance.
Okay. Then for a follow-up, either for Mark or for Doug, obviously the markets were extremely dynamic, an understatement during 2Q. Have one market share is able to deal with the volatility. As you guys have leveraged your IT systems and your processes, do you think that the success of managing through COVID during 2Q has gained market share from your hospitals over the last few months?
I think that'll play out in the longer-term statistics. I tell you, I am very proud of the way our teams have managed through this. I do think that it is superior to a lot of the providers that are in our marketplaces, and it has provided us an opportunity to show the outcomes and the quality that we provide. We are caring for a number of these COVID-19 patients that other post-acute providers would not accept, and getting great outcomes for them. Pito, to answer your question, I am going to be surprised if we don't see this as having longer-term opportunities to gain market share for us, and it has certainly provided our reputation in the communities as an outstanding post-acute provider.
Yeah, just to echo what Mark said, I think we have embellished our reputation with two key constituencies based on how we've responded to the pandemic. Those are the acute care providers who are such an important referral source for us, and the Medicare Advantage plan.
There will certainly be some stickiness to both of those.
Thank you. Your next question is from Frank Morgan of RBC Capital.
Hello, Frank.
Good morning, Frank.
Good morning. This one may be a little bit difficult to answer. It's on home healthcare and trying to isolate PDGM from the effects of COVID. Obviously, that's a complicating factor. If you could do that, if you could exclude the impact of COVID, how would you characterize PDGM? What is your sense of maybe smaller operators or handling that out in the marketplace? Any thoughts around when we may actually see the M&A activity that a lot of us are hoping for? Thanks.
It is a very muddled picture a little bit as you try to break down the PDGM implications and try to call out what's PDGM versus what is COVID related. I would tell you that we've been on balance, in spite of some of the noise in the quarter with LUPA percentage being up and the early late being out of balance and the institutional versus communities all being out of balance. We feel like in spite of those things, we're pretty encouraged with what we're seeing on a revenue per period basis. We feel like that's actually come in pretty close to our estimations, even with all of that noise in the quarter.
We think as those things begin to settle out, as we get back to a normal ratio of institutional admissions, a normal volume of new admissions, and we see our LUPA percentages coming down, which has continued to happen since they sort of hit their peak in the 14%-15% range in mid-April. We get fully through this COVID period that our PDGM Of our initial expectations, and that we're really being able to get back to some of our strategies. A lot of the strategies that we had for mitigation of the remaining implications with PDGM have been pretty hard to implement during this time of what Medicare believes would be the assumed behavior changes has been particularly difficult. One of those things as an example, was the LUPA percentage.
They believed we would lower LUPAs, but as you know, we've seen LUPAs expand dramatically during this COVID period. It's noisy, but I feel like I'm pretty encouraged, and I feel like things are going pretty well. As we look out at some of our smaller competitors, we do feel like they have really been bolstered by some of the federal programs, those PPP loans, as well as the CARES Act fund for those smaller providers have really hidden the realities of PDGM for them. We believe that as those dollars begin to be fully expended and they're left to their own accord, that it won't take them very long to realize that they're in a bit of a pickle relative to their financial situation.
We're hopeful that some of that acquisition opportunity, particularly in the mid and small end of the market, will return as we move into the fall, that they will have extended all the reality of what PDGM will mean to them. We're hopeful that the late third and early fourth quarter will return to some normal level of M&A activity for the small to mid-size transactions.
Just to clarify, you said that to be at or above, what you'd initially thought of, is that predicated just on the decline in the LUPAs, or is there anything else that might be driving that? Is that a requirement to get at or above what you had expected? Is there any other factor there?
I'm not sure I'm fully following your question. We had a number of mitigation strategies that were going to help us offset some of our PDGM implications. Managing productivity, optimizing the use of LPNs, all those things have been particularly difficult in a COVID market where employees are quarantined. There's just, again, a lot of noise, not only in the revenue side, but also in our cost mitigation side. There's been a lot of noise as a result of COVID. As we get volumes back in place, we're seeing some of that noise is beginning to abate, and we're able to really get back to some of the strategies that we were planning to put in place in the early part of the year before COVID hit.
Thank you. Your next question is from Matthew Gillmor of Baird.
Morning, Matt.
Hey.
Morning, Matt.
Thanks for the question. Good morning, everybody. Mark had mentioned that the higher COVID cases in certain markets, Florida, Texas, and Arizona may inhibit growth, and April provided some commentary on the home health side in terms of the impacts you're seeing. I was curious if Mark or Barb could give us a sense for what you're seeing in those markets with the rise in COVID cases on the IRF side.
Let me take a stab at the broader answer, and I'll let Barb weigh in on some more details. If you look at Texas, Arizona, and Florida, and I'll start with Texas. Texas has been extremely resilient. We've not seen, in spite of clearly the acute care has been full of COVID cases in their ICUs. We've not seen much of an impact, if at all, on our hospitals in the state of Texas. State of Florida is very market specific. There, if you start thinking about South Florida, which has certainly been identified as a hotspot, probably seeing a little bit more of an impact there. As I put in my comments, it is a very market by market driven situation. It's tough to look at an entire state and say, "Okay, that's a hot state," so to speak.
There are certainly some markets that have been impacted disproportionately more than others.
I guess to go just in a little bit into the weeds on that, there's several things that impact us when you have markets like Florida. First, when you look back really towards the end of May, markets were starting to open, elective surgeries were starting back up. They were allowing our clinical liaisons back into the hospitals. As some of the surges have occurred in some of these markets, those things have started to go back to the way they were in March and April. Elective surgeries are now back on hold. Our liaisons are not now back allowed in the hospital. Those impact us in each market.
I would say the other impact, and this is more at a hospital level, we don't have a lot of them, but we do have some hospitals that because of community exposures, we have employees out on quarantine, and in a few of our hospitals, that has impacted the capacity at those hospitals, because at a certain point, if we have nurses and therapists in large numbers out on quarantine, it creates a cap for how high our census can go. When you're looking at markets like Florida, those are some of the impacts that we're feeling this go around.
Matt, the testing has been an influence here, too, relative to quarantine staff and our ability to get staff back in. It's taking longer to get the test results than what it was even 60 days ago. As we see that start to improve, I think that will improve some of the staffing challenges that both April and Barb have pointed out.
One thing that's going to actually help on the staffing front is that the CDC did come out with new recommendations of moving away from a test strategy to a time strategy of when a employee or patient could come off of transmission precautions. CDC is saying that some people can test positive for up to three months, actually that's been a good thing for us that they've moved to this time strategy. It's allowing us to bring some of these employees back sooner than what maybe we were able to bring back before they changed their recommendation. We do think that will have a positive impact on getting employees back and removing some of these census caps.
Got it. Let me try one follow-up on it. Are these influences and impacts you're calling out, is that enough to interrupt the momentum in the recovery you've seen on the IRF volumes, or are these small enough where it doesn't impact the whole portfolio and the positive momentum you've seen in June?
I think the impact it's had is more of kind of, you've seen things, we had a great rebound and then things have been kind of flattened a little bit, and that's because market by market, we're feeling this. I don't think it's something that's going to impact as a whole, but it does, I think, prevent us getting to that next level right now, because as one market recovers, we're seeing this occur in another market.
Matt, it's very temporary, too. You may have two weeks that become a challenge in the marketplace, and then it kind of goes off your radar screen, the volumes come back, and some other market pops up on your radar screen. Overall, from a portfolio standpoint, I don't think it's going to impact us for the long term.
We have definitely plateaued here recently for volume gains in both the IRF segment and in home health. We would expect that that may be an issue that's with us for the next couple of months. On the IRF side, with a portfolio of 135+ hospitals, unfortunately, we're playing a little bit of game of whack-a-mole, which is, as soon as we get staffing or other issues resolved in one particular market, it pops up in another market, and it just feels like based on the course of the pandemic, that's going to be with us for a while. Whereas we don't necessarily believe that we'll see a reduction in volumes like we saw in April, gaining that next foot up over the next couple of months may be a challenge.
Thank you. Your next question is from Brian Tanquilut of Jefferies.
Brian.
Hey, good morning, guys. Good morning. I guess I'll go back to one of the earlier questions. Doug, I get the lack of visibility into some of the COVID stuff, but if we think about the de novos that you've already lined up, is there a sort of growth goal? You've already announced almost 5% bed growth for next year and then another 3.5% for 2022. Is that sort of the right level to be thinking about, kind of like the M&A department's goal, or is it the development team's goal, kind of like 5%-6% bed adds? I guess to layer onto that, how should we be thinking about the track record of your de novo beds over the last two years in terms of getting it up to capacity, as we think about filling the beds that you're adding?
I think, as Mark stated during his comments, we remain committed to the goals that we put out at the investor day regarding the number of new IRFs to be opened on an annual basis. Certainly, we've got a very solid number with eight new hospitals lined up for 2021, and already commitments to five, and this is pretty early on, we're going to add more to it, for 2022. From a capacity addition perspective, we feel very good about that. The track record, one of the reasons that we're accelerating the development of these is because our track record on building census and achieving very favorable financial returns on de novos is really solid, not just for the last two years, but really for the last 10 years, which has been when we started this program.
Gotcha
In terms of growth percentages.
Yeah.
We need a base. We don't know what the base is right now.
Right. Okay, got you. I guess shifting gears to home health, my follow-up for April. Obviously, we're hearing a lot of anecdotal discussions about how the SNFs are losing share or they're turning patients away or patients not going there. What are you seeing, and what are those discussions with the hospitals in terms of the referral flows? I guess I can ask the same thing of Barb, because last quarter, you guys talked about how some of the hospitals are keeping their patients instead of discharging them. What are we seeing in terms of discharge patterns and how sustainable, especially in the home health side, do you think this is post-COVID?
Well, I think it's hard to say when your overall volume is down, whether or not we just have trades going on that are kind of getting us back to our pre-COVID levels. When we look at some of the statistics, specifically, we see a pretty significant decline in patients that are coming to us from assisted living, independent living, and SNF environments, and yet, even though that's only recovered to about 70% of its pre-COVID level in the last few weeks, we actually are getting back to about 98% of our pre-COVID level on Medicare admissions in other areas. We think that inherently suggests that there is a new cohort of patients that are coming our way.
The area where we've seen growth over our pre-COVID levels have been in our physician-based referrals and in our short-term acute care hospitals, as we've now gotten those kind of back online. Those are actually growing above their historic levels. All of that would lead us to believe that we're getting some SNF patients that we wouldn't have otherwise gotten, particularly directly from physicians. It's a hard thing to prove what could've, might've, should've happened or would've happened in the prior world. It's hard for us to really nail it down specifically, but we do feel encouraged that even with a significant drop in our AL, IL, and SNF discharge base volumes, that we're seeing overall return to volume, and we think that's because of displacement.
We certainly heard on the IRF side, I would say our referral sources at the acute care hospitals have kind of dealt with the patients that they could get home, as April just alluded to, and then there are the patients that may need a facility level, and yet they found that many of the skilled facilities in the markets were hesitant to take them, especially if they were a recovering COVID or what we call a patient under investigation, meaning they had some sort of exposure to COVID. Our ability to take those patients and our outcomes have been really strong with those patients, has been something that I think has been a huge help to the acute care referral sources so that they could get those patients out of their hospital and into our facilities.
Thank you. Your next question is from A.J. Rice of Credit Suisse.
Hi, A.J.
Hey, how are you guys?
Good.
First of all, obviously, there's been a lot of discussion around telemedicine and the opportunities maybe to apply that in home health. I would first ask, what are you guys seeing? Are you taking advantage of all the opportunities or is some of that still to come, and is there anything in particular you're advocating to CMS to try to get further clarification or change related to telemedicine and home health?
Yeah. I would say for us, in home health, the main thing we've seen is the ability for physicians to complete their face-to-face requirements using telehealth, and certainly, we're leaning into that.
As we gather documentation from physicians to support that face-to-face. When it comes to our ability to actually use telehealth, as you know, in home health, even with the waivers, we still are not being paid, and visits aren't being recognized as billable visits that are being done via telehealth. We are utilizing some telephonic visits and even some two-way audio-video communication-based visits with patients who have the capacity, both technologically and mental capacity to do that. We're finding that to still be a fairly small percentage. We think there remains a lot of opportunity there, but until Medicare really treats those as billable services, and until we move to a kind of a point in time where our advanced aged patients are capable of navigation, we think it'll remain a fairly small percentage.
A.J., it's been an-.
Okay.
Immaterial impact so far, but we are keeping an eye on it, and like we've done in other areas of technology, if we see. This is going to be around. CMS has a big push for telemedicine, as you know. We'll be very committed to it and make the necessary investments in it once it's clear in terms of what platform is needed in either of our segments, because our IRFs, they dipped their toe in the water in it this last quarter as well.
Okay. Maybe a follow-up would be another sort of emerging area. In the CARES Act, on the IRF side, it allowed for certification by non-physician practitioners. Now I guess in the proposed rule for 2021, they've talked about making that permanent. How significant is that for you guys, and are you positioned to make meaningful use of NPs and PAs as doing the certifications for you? Does that move the needle on margin or anything else?
Let me ask Barb to weigh in on that, A.J.
We certainly already have NPs and PAs that support our physicians. We actually, at this point, actually prefer that it remain like it is now because we feel it does really differentiate us from a skilled level when we have the regular physician oversight of our patients. We actually would continue to prefer that the NPs and the PAs support the physicians as they have been doing for a long time.
Thank you. Your final question is coming from John Ransom of Raymond James.
Hey, John.
Hey, good morning. Hey, we saw Nava Health get traded again, and they've expanded to 20 markets. You have the probability maybe of a Biden presidency and a revival of some of the post-acute management strategies in BPCI and CJR. Just at a high level, you being kind of a relatively high-cost but effective post-acute provider, how do you navigate the pencil pushers on the other side trying to push volume into the lowest cost place?
John, as we've talked about relative just to our value proposition, you have to look beyond the cost per day and look at it from a longer-term perspective, including an episode. What we have the opportunity to do is to move a patient between our IRFs in the home setting and the opportunity to work with the IT investments that we've made, have the clinical collaboration. We've proven that we can get more patients back home to the home setting and fewer readmissions back to the acute care, which increases cost. I guess I would counter the implications that you said that we are a high-cost provider. I would say we're actually a high-value provider when you look at it more from a longer-term perspective.
John, specifically, those initiatives that you're talking about, those theories from a post-acute perspective, the patients that we're treating in our IRF really cannot go directly home from the hospital. They require an inpatient stay. Those patients, it becomes a choice between an IRF and SNF in almost all cases. I would ask you for your opinion as to how the skilled nursing facilities have distinguished themselves during this pandemic?
That's a pretty easy one. My follow-up would be, if we look a year down the road, two years down the road, what permanent changes do you think will be the result of this pandemic? In what ways have you changed workflows, gotten smarter, become more efficient? We've talked about the market share gains, which I don't think there'll be any doubt about that, but what other kind of permanent changes do you think would have not happened otherwise?
I think a longer-term impact, John, just going to be in market by market, where we have developed a willingness or had the willingness to take these COVID patients. Other words, we exercised our skills at taking the higher acuity patient in both our home health as well as our hospitals. We have put ourselves in even more enviable position with our relationship with the acute care hospitals. I think that's going to have long-term implications for us moving forward versus other post-acute providers that have tried or were unwilling to participate in a productive manner during this pandemic episode.
I think you're going to see a real formalization of either call them contingency plans or operational plans for dealing with another breakout of an infectious disease. I think it's going to be the identification of critical care beds throughout a market in all kinds of facilities, well-defined and documented protocols for how caregivers are going to don and doff PPE. I think you're going to see a real shift, and you're already seeing the shift in supply sources for critical medical equipment and PPE from overseas to the U.S. I think there's just going to be a real efficiency that's created in the supply chain as well. I think there are a lot of things that relate to how we deal with the next pandemic that are going to be formalized in a very significant way.
There's the potential that you will see some regulatory changes designed to make more efficient flows for patients from setting to setting, and anytime that happens, we generally believe it's in our favor.
Thank you. With that, I will turn the floor back over to Crissy Carlisle for any additional or closing remarks. Anyone has additional questions, please call me at 205-970-5860
Thank you, everyone. This does conclude today's conference call. You may now disconnect.