Earnings Call Transcript - ACHC Q4 2022

Operator, Operator

Good morning and welcome to Acadia Healthcare's Fourth Quarter and Full Year 2022 Earnings Call. All participants will be in a listen-only mode. After today's presentation, there will be an opportunity to ask questions. Please note that this event is being recorded today. I would now like to turn the conference over to Gretchen Hommrich. Please go ahead ma'am.

Gretchen Hommrich, Vice President of Investor Relations

Good morning and welcome to Acadia's fourth quarter 2022 conference call. I'm Gretchen Hommrich, Vice President of Investor Relations for Acadia. I'll first provide you with our Safe Harbor before turning the call over to our Chief Executive Officer, Chris Hunter. To the extent any non-GAAP financial measure is discussed in today's call, you will also find a reconciliation of that measure to the most directly comparable financial measure calculated according to GAAP on our website by viewing yesterday's news release under the Investors link. This conference call may contain forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995 including statements among others regarding Acadia's expected quarterly and annual financial performance for 2022 and beyond. You are hereby cautioned that these statements may be affected by the important factors among others set forth in Acadia's filings with the Securities and Exchange Commission and in the company's fourth quarter news release. And consequently, actual operations and results may differ materially from the results discussed in the forward-looking statements. At this time for opening remarks, I would like to turn the conference call over to our Chief Executive Officer, Chris Hunter.

Chris Hunter, CEO

Thank you, Gretchen. Good morning everyone and thank you for being with us today for our fourth quarter 2022 conference call. I'm here today with Chief Financial Officer, David Duckworth; and other members of our executive management team. David and I will provide some remarks about our financial and operating performance for the fourth quarter of 2022 and guidance for 2023. Following our comments, we'll open the line for your questions. In December, we held our first ever Investor Day at Carnegie Hall in New York and we're appreciative that so many of you joined us in person and through our webcast. It was a great event and we appreciate your support. I'm pleased to say that our fourth quarter results and start to 2023 demonstrate that we're executing on the strategy we presented with favorable results across our key performance metrics. Throughout the past year, we continued to see strong momentum in our business, reflecting robust demand for our behavioral healthcare services. We continue to commend our dedicated team of employees and clinicians across our operations who have worked tirelessly to meet the needs of those seeking treatment for mental health and substance use issues. Our strong results reflect our ability to effectively operate our 250 facilities across Acadia's network and serve our patients with safe, quality care. During the fourth quarter, we continued to see positive trends in our business with an increase in our same facility revenue of 9.4% compared with the fourth quarter of 2021 including an increase in revenue per patient day of 5.2% and an increase in patient days of 4.0%. Our fourth quarter results marked a strong finish to 2022 and we believe set us up well for 2023. We are proud of our vitally important work to support expanding patient populations in order to make a positive difference in more communities. Acadia has created a strong foundation to build upon during a time of unprecedented demand for behavioral healthcare services. A recent 2022 study from Indiana University found that approximately 45% of patients who visit the emergency department for physical injuries and ailments also have mental health and substance use problems that are frequently overlooked. Acadia has established strong relationships with med-surg hospitals across the country, bringing our experience and expertise to markets where they are desperately needed. Fortunately, a greater social awareness of mental health issues and broader acceptance of treatment have made behavioral healthcare a priority with medical professionals and government healthcare officials. Acadia is well-positioned to address this critical societal need as a leader in providing behavioral healthcare services across the care continuum. During the fourth quarter of 2022, we continued to advance our growth objectives across each of our service lines. As we've previously shared, we believe our five distinct growth pathways will enable the company to meet this demand and extend our market reach. I'll briefly update you on our accomplishments related to these five pathways during the fourth quarter. On the first pathway, facility expansions remain a primary driver of our growth as this pathway allows us to efficiently expand services in established markets by utilizing our existing infrastructure and experienced staff. We added 80 beds to our existing facilities during the fourth quarter, finishing the year with a strong second half performance with 212 bed additions and bringing our total number of bed additions to 290 for the year. Looking ahead, we expect to add approximately 300 beds through facility expansions in 2023. Importantly, many of the bed additions in 2023 will open in the first half of the year and are expected to contribute to an accelerating volume growth outlook for the company. A second important growth pathway is to identify underserved markets for behavioral healthcare services and develop wholly owned de novo facilities that bridge this gap and help meet the critical community need. In 2022, we opened a 60-bed children's hospital, the first stage of our Montrose Behavioral Health Hospital operations in Chicago. We look forward to increasing the pace of our de novos from opening one per year to two per year in 2023, as we're on track to open our 101-bed Montrose adult hospital and an outpatient facility in our 80-bed facility Coachella Valley Behavioral Health in Indio, California later this year. We're excited to announce a new de novo facility that is slated to open in 2024. This 100-bed acute care behavioral health hospital will serve the residents of Mesa, Arizona and surrounding communities. Agave Ridge Behavioral Hospital will offer a full continuum of inpatient behavioral healthcare services for adult, older adult, adolescent, and child patients. Our groundbreaking is scheduled for next week. We will continue to pursue additional de novo opportunities in other underserved markets with a goal to develop and open acute and specialty facilities in 2024 and beyond. We also continued to expand our network of comprehensive treatment center facilities or CTCs, specifically designed to meet the growing and critical need for addiction treatment, especially for patients dealing with opioid use disorder. During the fourth quarter, we opened three new de novo CTCs in Florida and Delaware, bringing our total to seven new CTCs for the year, which exceeded our goal of at least six CTCs. As the opioid crisis has continued to escalate across the country, we believe Acadia's CTC facilities play a vital role in the communities they serve with programs that combine behavioral therapy and medication to treat opioid use disorders. Each CTC provides a range of comprehensive substance use treatment support services that include medical, counseling, vocational, educational, and other treatment services to help our patients progress. We will continue to expand our CTC network and service offerings to meet this essential need with an objective of adding six CTCs in the year ahead. Our third attractive growth pathway is forming strategic partnerships with leading health systems across the country. We've been fortunate to establish strong relationships with leading national healthcare providers and premier healthcare systems, who want to expand behavioral healthcare treatment options in their respective communities. We bring the clinical expertise and experience they need to deliver high-quality care while we have an opportunity to leverage the provider's market presence and establish relationships in the community. In the second half of 2022, we were pleased to open two new facilities. The first facility was a 90-bed facility with our joint venture partner Covenant Health in Knoxville, Tennessee in August; and the second facility was Maple Heights Behavioral Health, a 120-bed facility, which was opened in December with our partner Lutheran Health Network in Fort Wayne, Indiana. Acadia now has 19 joint venture facilities in various stages of development, with nine facilities opened, and 10 facilities expected to open over the next several years, including two in 2023. We remain encouraged by the strong continued interest from potential partners in our joint venture pipeline. For our fourth growth pathway, we have maintained a very disciplined focus on M&A opportunities and continue to look for selective acquisitions that complement our growth strategy, and are incremental to our financial objectives. During the fourth quarter, we acquired four CTCs from Georgia-based brand-new start treatment centers located in separate suburbs of the Atlanta metropolitan area extending Acadia's CTC network to 151 locations at the end of 2022. We remain focused on selectively identifying attractive M&A opportunities that are complementary to our existing geographic footprint and portfolio of service offerings. We are fortunate to have a strong balance sheet that provides the flexibility to pursue acquisitions, as well as make the necessary investments to support our other strategic growth pathways. For our fifth and final growth pathway, we remain focused on extending the continuum of care across our facilities and identifying additional ways to support patients. For example, we are continuing to strengthen our mid-level acuity programming, which we most often use to step down our patients after residential treatment. Since 2019, we have added over 50 PHP and IOP programs, including five in Q4 2022 alone. We are also continuing to advance our cross-referral program, including by launching system improvements in Q4, which make it easier for our nurses and clinicians to identify cross-referral opportunities and facilitate the referral process itself. Finally, we continue to fill in service line gaps in our markets. Our previously mentioned acquisition of four CTCs in the Atlanta area, for example, complements our existing acute specialty PHP and IOP service lines in that market. In conclusion, we are well-positioned to maintain our strong growth trajectory and meet our development targets for the year, which are adding approximately 670 beds in 2023 through approximately 300-bed additions to existing facilities, opening two inpatient de novo facilities, two facilities with joint venture partners, with more JV announcements to come, and opening at least six CTC locations. We're working hard to deliver on our 2024 and 2025 growth targets, as well as strengthening the foundation that these new facilities will become a part of. As Acadia continues to lead and grow, we are committed to creating and implementing best-in-class IT solutions that will further enhance the delivery of care and support the patients we serve. As we discussed at our Investor Day, investments in technology will be a key area of focus for Acadia in 2023 and beyond. We are accelerating investments where we can strengthen our capabilities and lead the industry forward by leveraging technology to increase access to care, improve the delivery of care and ultimately support clinical integration and operational efficiencies. Initially, the areas where we expect to make short-term investments include enhancing our infrastructure, which involves improving all of Acadia's technology capabilities across our network. A top priority is centered around electronic medical records. Today, we have manual paper-based processes across most of the company, and the potential for electronic medical records is a significant opportunity for not only Acadia, but also the industry. As we migrate to electronic records, there are significant benefits from both a clinical and financial perspective. We are focused on technology investments across five main categories. The first is that we'll be able to better support our medical teams, with respect to patient safety and compliance. Second, we believe these investments will enhance the overall patient experience. Third, we expect improvement in employee satisfaction, which will support recruiting and retention. Fourth, the additional data and analytics capabilities will also help us engage with payers, as we are better able to support value-based care and identify operational efficiencies. And finally, we believe these disciplined investments will drive revenue and margin improvement opportunities for the company over time. As we communicated in December at our Investor Day, we expect to allocate approximately $35 million to $45 million in IT investments in the coming year, of which $15 million to $25 million is incremental to our historical investment. We will continue to evaluate the value derived from these investments and believe that over the four-year period from 2023 to 2026, that we could see a total of $75 million to $125 million in dedicated IT incremental capital expenditures. We are highly encouraged by the value that this will provide for Acadia, as we lead the industry forward in leveraging technology to improve the delivery of care. As we also noted in December, we had planned to add key leadership for this important initiative. And we're pleased to add that Laura Groschen joined Acadia as the company's new Chief Information Officer in early January. Laura joins Acadia with over 25 years of experience, driving strategic transformation at large healthcare and consumer-focused IT organizations. She most recently served as the business unit CIO of Medtronic, the $30 billion global healthcare solutions company, where she led a team supporting information and technology for 20 operating units in global business functions across Medtronic's locations in 150 countries. As Acadia CIO, Laura will shape and advance our IT strategy as an integral part of our digital transformation and she will drive continued digital transformation across Acadia's scaled behavioral health capabilities. I also want to reinforce our commitment to quality across our operations. As we continue to extend our market reach, safe and quality care remains the top priority for the patients who seek our help. I'm pleased to announce that we recently added Dr. Navdeep Kang to our management team as our new Chief Quality Officer for inpatient services. In this role, Nav will work closely with our Chief Medical Officer, Dr. Mike Genovese and will be responsible for ensuring patient safety and superior quality of care by improving delivery of clinical services in our inpatient facilities. Nav will lead our initiative to provide a robust proactive culture of quality and excellence, supported by processes and systems designed to prevent any issue and when necessary, quickly respond to any adverse events. Nav is a clinical psychologist and brings extensive experience in addiction treatment and behavioral health. As we look to the year ahead, we remain focused on increasing our pace of growth and capitalizing on expansion across our service lines. At the same time, we'll look for ways to improve upon the delivery of care we provide and strengthen our capabilities with the right technology investments in differentiated services that drive improved clinical outcomes. Across our network of 250 facilities, we have a shared mission to provide high-quality behavioral healthcare services and we look forward to the opportunities ahead for Acadia in 2023 and beyond. At this time, I will now turn the call over to David Duckworth to discuss our financial results for the quarter and 2023 guidance.

David Duckworth, CFO

Thanks, Chris, and good morning. In the fourth quarter, we achieved strong financial and operational results, successfully meeting our key performance metrics and demonstrating consistent execution of our strategy. Revenue for the fourth quarter of 2022 rose 13.8% to $675.3 million compared to $593.5 million in the fourth quarter of 2021. This growth includes a 9.4% increase in same facility revenue. For the quarter, our adjusted EBITDA was $150.9 million, and adjusted income per diluted share for Acadia stockholders was $0.74, which includes $5.2 million related to the provider relief fund from the American Rescue Plan payments. Adjustments to our income for the quarter include transaction-related expenses and their associated tax effects. The company also recorded an unfavorable adjustment of $5.9 million, or $0.05 per diluted share, to its self-insured professional and general liability reserves regarding the settlement or expected settlement of certain claims from the 2017 to 2018 period. The estimated accrual for these liabilities is based on historical claims, prior settlements, judgments, and other factors as well as actuarial assumptions. Although we may experience volatility in this reserve due to our self-insured retention level of $5 million, we consider this fourth quarter adjustment a non-recurring item related to unique facts and circumstances of the claims from that period. From a cost management perspective, we were satisfied with our performance throughout 2022. Despite experiencing higher wage inflation in 2022, including around 8% base wage inflation for the fourth quarter, we believe it is crucial to stay proactive with our compensation. Our volume and reimbursement growth have remained robust. While base wage inflation is expected to stay elevated in the 7% to 8% range during the first half of 2023, we are noticing positive hiring trends and we recorded an 8% sequential decrease in premium pay from the third quarter to the fourth quarter of 2022. Maintaining a strong financial position will continue to be a top priority in 2023, providing us with the flexibility and capital necessary to support our growth strategy and future investments. As of December 31, 2022, the company held $97.6 million in cash and cash equivalents and had $525 million available from its $600 million revolving credit facility, with a net leverage ratio of approximately 2.1 times. During the fourth quarter, the company completed its repayments for amounts received under the Medicare Accelerated and Advanced Payment Program as part of the CARES Act. From the $45.2 million in advanced payments received in 2020, the company repaid $25.1 million in 2021 and $20.1 million in 2022, including $1.2 million in the fourth quarter of 2022. Regarding our guidance, as highlighted in our press release, we refined our previously issued guidance for 2023 as follows: revenue expected to be between $2.82 billion and $2.88 billion, adjusted EBITDA between $635 million and $675 million, adjusted earnings per diluted share between $3.10 and $3.40, interest expense between $80 million and $85 million, a tax rate between 25% and 26%, depreciation and amortization expense between $125 million and $135 million, stock compensation expense between $30 million and $35 million, operating cash flow between $450 million and $500 million, expansion capital expenditures between $350 million and $400 million, maintenance capital expenditures between $40 million and $50 million, and IT capital expenditures between $35 million and $45 million. We also set financial guidance for the first quarter of 2023, anticipating revenue between $690 million and $700 million, adjusted EBITDA between $145 million and $150 million, and adjusted earnings per diluted share between $0.70 and $0.74. The company's guidance does not account for the impact of any future acquisitions, divestitures, transaction-related expenses, or the recognition of additional provider relief fund income. With that, Joe, we are ready to open the call for questions.

Operator, Operator

We will now begin the question-and-answer session. And our first question will come from A.J. Rice with Credit Suisse. Please go ahead.

A.J. Rice, Analyst

Thanks. Hi, everyone. I know at the Investor Day and then in your comments today you've talked about a little bit about the potential acquisition pipeline that's out there for you. I wondered if you'd expand a little more on what you're seeing. It seems like there's a lot of JV and potential acquisition opportunities coming out of the pandemic. Is that still there? And then is there any opportunity you think this year as you look out for larger deals are there any of those potentially out there?

Chris Hunter, CEO

Yes. Thanks, A.J. This is Chris and I'll start. We continue to feel very optimistic about the M&A pipeline, which is clearly one of our important growth levers for 2023. I would say that we have done extensive work in looking at the under-bedded markets and really targeting the MSAs where we believe we have the most upside potential over time. So we are always looking to find ways to optimally deploy capital whether that is doing more JVs, doing de novos, or clearly looking at M&A. And right now we feel very good about the pipeline that we have on the M&A front. I feel also that we have some confidence that valuations are slightly softening as we're heading here into the new year. I would say to your question on the JV front, we also feel very strong about the pipeline there. Our existing JV announcements are expected to take us from our current acute states of 21 plus Puerto Rico into three additional states; Colorado, Minnesota and North Carolina. And then the pipeline of near-term deals on the JV front are expected to take us into two additional states. I think really just strengthen our geographic footprint overall. So we feel very good about the pipeline that's building in these MSAs on the JV front certainly with de novos and definitely with M&A as well.

A.J. Rice, Analyst

Okay. Great. And maybe my follow-up. The 9.4% revenue increase is impressive. Could you provide some insight into the individual segments? Was the growth rate consistent across your main business lines, or was there significant variation?

David Duckworth, CFO

Yes, A.J. we were pleased with the same-facility revenue performance in the quarter, which included another strong quarter of revenue per day growth and our strongest quarter of the year from a volume perspective. As we look at that by service line we saw incredibly strong performance demand, volume pricing really across all of the service lines but we would highlight acute specialty and the CTC business all saw a very strong quarter. RTC also performed well very stable. Of course, there are fewer investments going into that service line, but the facilities we have had a very good 2022 and fourth quarter, but acute specialty and CTC really led the charge in terms of revenue growth for the quarter.

Chris Hunter, CEO

For 2023, we continue to anticipate strong patient day growth of 4% to 6% for the year. This volume is driven by three factors. First, we have strong ongoing demand. Second, there are significant capacity additions that we discussed for the second half of 2022, which will carry into early 2023. Third, we are seeing improved performance from optimizing our marketing and admissions processes. While it's still early in the year, we are currently experiencing record census and patient day growth, leading us to believe we will achieve the higher end of the 4% to 6% projection for the year.

A.J. Rice, Analyst

Okay, great. Thanks so much.

Operator, Operator

And our next question will come from Whit Mayo with SVB Securities. Please go ahead.

Whit Mayo, Analyst

Hey. Thanks. Maybe for David or actually more for Chris. When you guys look at the capital that you're deploying have you changed at all or refined how you measure returns on capital? I'm just wondering how the returns have changed on these deals and what your minimum hurdle rates are today? And it might just be more helpful to frame from like a cohort perspective how capital returns are tracking?

David Duckworth, CFO

We always refine how we think about allocating capital across our growth pathways, across our service lines and haven't necessarily changed how we think about our targets. Certainly, like a lot of companies would say our weighted average cost of capital and the cost of debt have increased slightly. But from our perspective, we've always built in a higher threshold that we target in our transactions such that we haven't had to significantly change how we think about that capital allocation. We continue to think that our existing facility expansions are our most attractive opportunity. And then as we think about de novos and as we think about joint ventures and even M&A opportunities, we have a deal-specific analysis that we look at. But across those growth pathways, we're still seeing good opportunities that exceed the hurdles that we have in place across a number of different metrics, IRR. We look at ROIC. We look at our EBITDA multiple not only at the time that we make an investment, but over the course of the investment as we hope to grow earnings whether that's an M&A deal or a de novo or a joint venture facility. So no major changes, of course, as we projected out in December. There are many joint venture projects that we think will be tremendous for the company that we're working hard to bring online and bring good EBITDA growth for the company at strong returns. But we think all pathways will have activity that is going to be attractive.

Whit Mayo, Analyst

We get the question a lot around redeterminations, and I presume that most of your Medicaid is in the adolescent population and many of those that would lose traditional Medicaid coverage may just flip into CHIP. It might just be helpful to hear some of the work that you guys have done internally and how you might be thinking about how that plays out over the course of 2023? Thanks.

David Duckworth, CFO

Yeah, Whit we've been focused on this topic as it's certainly been out there and now is I guess closer to being implemented across the different states than it was as we thought about the potential of it happening over the course of last year. But we've had a lot of time to plan. As we've talked about previously, we really view mental health coverage as essential and think that many states and payers would intend to continue to provide coverage. But, of course, we want to help all of our Medicaid patients navigate what that means for them whether it's an administrative process that they go through to reenroll in their Medicaid plans or find some other product. Our focus has been on educating our patients, our facilities, our operations leaders, our revenue cycle leaders have done a tremendous job just planning for that and communicating what to expect as we move into the second quarter. We'll continue to monitor the potential impact. Of course there are patient populations as you mentioned, the child and adolescent population that I think is less likely to have a disruption and will have a longer period of time where they can stay enrolled in Medicaid. But we want to help all of our patients just navigate what it means for their coverage through the year and the team has done a nice job preparing.

Whit Mayo, Analyst

Okay. Thanks guys.

Operator, Operator

Our next question will come from Kevin Fischbeck with Bank of America. Please go ahead.

Kevin Fischbeck, Analyst

Okay, Great. Thanks. I just wanted to follow-up on some of your labor comments because I think last quarter you had talked about kind of 5% to 7% wage growth and it seems a little bit optimistic that you see some moderation in that number over time back to the 3% to 4% number. So I just want to get a little more color on kind of why it was so much higher in Q4 when most of the companies seem to be saying that they're seeing some progress on labor?

David Duckworth, CFO

Yeah, Kevin, we did see 5% to 7% over the first three quarters of the year. The third quarter was around that 7% level. The fourth quarter as we isolate just base wage inflation, we were around 8% which we view as pretty similar to the 7% that we saw in the third quarter. We do want to remain proactive with our pay. So we're seeing an improved environment as we look at just our recruiting metrics, as we look at our net new hires which improved throughout the fourth quarter and in January and the weekly data that we have for February. And so we're seeing some positive signs of improvement. We do have for the company our annual merit increase process that happens either in January for two-thirds of the company or in April for the other one-third of the company. And we want to remain committed to that and stay in the right place from a pay perspective across our markets. So we have moved forward with that. And partially because of that expect wage inflation to stay in that 7% to 8% range through the first half of this year. But with some of those positive metrics that we're seeing with the improvement that we mentioned in premium pay that we saw in the fourth quarter, we're seeing some positive signs. And I think as we look out at the second half of the year, we would see wage inflation and our outlook reflects wage inflation dropping back down below the 5% level. We'll ultimately see if it returns to more of the 3% to 4% that the company saw for a number of years and the industry saw for a number of years. But for now, second half of the year, we think we would moderate at that point to less than 5% on a base wage inflation. And then premium pay, we think continues to improve throughout the year.

Kevin Fischbeck, Analyst

Okay. I think last quarter you kind of broke out some of the labor pressure from things like CenterPoint. Is there anything like that kind of skewing the metrics at all from ramp-up of newly opened facilities? And I guess has labor sourcing had all been a headwind to volume growth? Are you having a hard time staffing, or is it just you can staff you just have to pay up for it? Thanks.

David Duckworth, CFO

I appreciate the question on the metrics. We would say as you look at our labor metrics including salaries, wages and benefits as a percentage of revenue, we did have a $4 million pickup that we recorded and highlighted in the fourth quarter of last year relating to the direct payment program in the state of Florida. And so that did lower our SWB metric by 30 basis points. And then of course, depending on what metric you're looking at here in the fourth quarter of this year, if it's margin, it's impacted by the reserve adjustment that we highlighted. So we do have some adjustments that need to be made as you think about the year-over-year metrics given that. And within that, we would say our same facility group is performing very well. It's stable year-over-year and is seeing margin improvement year-over-year. But there are three new facilities that we've opened in the second half of 2022 that do carry a much higher labor load as their volume and revenue ramps. So that did have an impact on both the SWB metric as well as our margin. CenterPoint performed well in the fourth quarter. We saw that just the team overseeing their integration, do a fantastic job throughout the year, bringing improvements to the performance of that acquisition. But it did also have an impact on our margin as from the acquired date, and even in the fourth quarter that business has a lower margin than the company average. So there's a few items like that that did impact our labor metrics and some investments we've made at the corporate level, which are having a positive impact on the company as we move into 2023 also are reflected in that SWB and in the margin.

Kevin Fischbeck, Analyst

Great. Thanks.

Operator, Operator

Our next question will come from Andrew Mok with UBS. Please go ahead.

Andrew Mok, Analyst

Hi, good morning. Chris, you mentioned some new investments and facility openings in your prepared remarks, but it wasn't entirely clear to me what changed versus the previous outlook. Can you help us better understand what specifically is driving the higher revenue outlook for 2023? And why that's causing a narrowing of the EBITDA range at this stage? Thanks.

Chris Hunter, CEO

So Andrew, just to clarify, you're looking for more detail on the IT investments?

Andrew Mok, Analyst

Just the 2023 revenue outlook versus the previous outlook you gave at the Investor Day. And why that's causing a narrowing of the EBITDA range at this stage?

David Duckworth, CFO

Yes, we did provide initial guidance earlier than usual back in December. When we updated that guidance in February, we saw it as a tightening of what we had shared in December. Since then, as we've finalized our budgeting and observed trends through the fourth quarter and the beginning of Q1, we have raised our revenue outlook. The main factor for this is our accelerating volume. For the fourth quarter, we reported a 4% same facility volume growth, and we're now projecting that to accelerate to a range of 4% to 6% for 2023, starting Q1 at the high end of that range. We're very pleased with our volume outlook, which is slightly stronger than we anticipated in December due to some positive trends early in the year. We also believe that the increased volume will lead to higher EBITDA; however, since it's still early in the year, we only tightened our EBITDA range while keeping the midpoint the same. Factors like wage inflation have also been incorporated based on our updated views since December.

Andrew Mok, Analyst

Got it. That's helpful. And then on the CapEx, I think it's been about two years in a row now where you've cut the growth CapEx about $85 million lower versus initial expectations with the step-up in growth CapEx $375 million this year. What's your confidence level in getting that completed this year? Thanks.

David Duckworth, CFO

Well it's a good question because as we talked about throughout 2022, we have been looking forward to breaking ground across all of those new facilities that we've had in the pipeline just ready to start construction and work towards the opening of those new joint ventures and other facilities and didn't have as much visibility a year ago, as we talked about our CapEx guidance as we feel like we have today. There are a number of projects that have now broken ground. And at that point, we do have higher visibility and have a higher confidence level. And so we're expecting for that step-up to occur and that's reflected in our guidance. And we'll continue to provide an update as to the timing of those projects. But we're glad to be at this moment where we feel like we have higher visibility because the opportunity we have to get those facilities open and bring them into the company, we think is a key driver for our results, two, three years from now. So I'm not going to give you a percentage confidence level but we do have much higher visibility today, given that we've broken ground across many of those projects.

Andrew Mok, Analyst

Great. Thanks for the color.

David Duckworth, CFO

Yes, thanks, Andrew.

Operator, Operator

Our next question will come from Gary Taylor with Cowen. Please go ahead.

Gary Taylor, Analyst

Hey, good morning. I had a question. I noticed in the release and you talked about this at Investor Day, a little bit about the opportunity to add the intense outpatient programs at some of your IPF. So the question was how many of your IPFs have all three or also include partial hospitalization and the intense outpatient programs? And is there a way to sort of size the remaining revenue opportunity, either per facility or just for the total company to build out those step-down programs across all the acute hospitals?

Chris Hunter, CEO

Thank you for the question, Gary. This is Chris. I would say that most of our acute facilities definitely have the potential for step-down programs, although we haven't shared the specific numbers. This is a key focus for our clinical team, which is led by our Chief Medical Officer, Mike Genovese, as we continue to develop our fifth growth pathway around PHP and IOP, while also aiming to improve cross-referral opportunities within the company. David, would you like to add anything regarding step-down programs?

David Duckworth, CFO

No. We have seen a number of new programs opened over the years. And our team has done a nice job really looking at where our patients are coming from, where we might be deflecting patients based on the level of care that's appropriate for them and where they might be stepping down and really using that to open new programs. It also informs our de novo strategy, just as we think about where we might have a service gap. So happy to bring on a number of new programs at our existing facilities, but it's also really being informed and useful as we think about the de novo growth and other opportunities where the company might need to add capacity.

Gary Taylor, Analyst

Could I just do a quick follow? Could you give us a sense of you have an IPF that doesn't have those two step-down programs? You have an IPF that has kind of mature step-down programs, is the revenue differential, is it 10% higher 20% higher? Can you give us any sort of sense on what those step-down programs add to the facility profile?

David Duckworth, CFO

We would probably be ballparking it right now. But I think that 10% range is probably about right, depending on the size of their program. In some cases the facility could have a strong program that's not only stepped down. It's also capturing other patients in that market that may just need a different level of care. So it does vary by facility, but 10% may be the right estimate.

Gary Taylor, Analyst

Thank you.

David Duckworth, CFO

Thanks, Gary.

Operator, Operator

Our next question will come from Pito Chickering with Deutsche Bank. Please, go ahead.

Kieran Ryan, Analyst

Hi, there. You've got Kieran Ryan on here for Pito. Thanks for taking the question. I was just wondering if you could maybe break out the SMB impact in 4Q from the one-time reserve adjustment. And then I have a quick follow-up after that.

David Duckworth, CFO

Yes. As we think about the SWB impact from the reserve adjustment, where that adjustment went on our P&L was actually in other operating expenses, which is where we have our interest expense. And so, just thinking about it more from a margin perspective and other operating expenses, that metric as a percentage of revenue for the fourth quarter was 13.9%. And without that reserve adjustment, would have been 13.0%. So that's the impact that it had on that line item and had about a 0.9% impact on margin as well.

Kieran Ryan, Analyst

That's helpful. Thank you. Regarding the 2023 EBITDA outlook, could you break out how much of the change is due to discretionary investments and facility openings versus the wage pressure, which appears to remain high in the fourth quarter in the high single digits? Thank you.

David Duckworth, CFO

Yes. I mean, our expectation continues to be for those new facilities which do carry some startup losses in the near-term, but are an important driver of longer-term value creation and earnings growth for the company. But our expectation for 2023 is that those new facilities would still be in the $15 million to $20 million range in terms of where their start-up losses should run. That always depends on just the timing and number of new facilities that we have. But that $15 million to $20 million continues to be our estimate for annual startup losses of our new facilities.

Kieran Ryan, Analyst

Thank you.

David Duckworth, CFO

Thank you.

Operator, Operator

And our next question will come from John Ransom with Raymond James. Please go ahead.

John Ransom, Analyst

Hi. Good morning. Just a couple on the reimbursement side, I have one and then a follow-up. So, if we're looking at apples-to-apples just pure rate, 2023 over 2022, how should we think about just the pure rate updates affecting your revenue per day percentage growth? Thanks.

David Duckworth, CFO

Yes. Compared to December, we have a more positive outlook regarding reimbursement. We typically anticipate rate increases in the mid-single-digit range, as we have noted throughout 2022. Considering inflation and other factors, I expect this trend to continue with most of our payers moving forward. However, I want to be cautious since we work with a variety of payers. Lately, as we have assessed what the year may look like from a revenue per day perspective, we are projecting an average increase of 3% to 5%. At the beginning of the year, we have higher visibility, which suggests we should achieve growth closer to the 5% mark. This expectation is largely due to our contracts with Medicaid plans, as more than 75% of our Medicaid revenue is contracted for the latter half of the year. This means that in the early part of the year, we will benefit from the rate increases secured in the latter half of the previous year. Our focus will be on renegotiating with these payers ahead of next year's contract dates. Overall, we have greater visibility now and saw considerable success across our facilities and payers in 2022. We hope this trend continues within the mid-single-digit range, and we believe that visibility will hold through the first part of the year. However, I am incorporating some caution for the latter half of the year where we might see performance at the lower end, but we will remain attentive to this. I also see opportunities, though I am being cautious in our outlook for the later part of the year.

Chris Hunter, CEO

And John, I would just add that, to David's point, we have a very strong corporate managed care team that I think has continued to just build and enhance really good relationships with payers across the board and has for a number of years. We've chosen to invest in that team, and I think that really factors into some of the comments that David made. But we do want to be cautious about how all of this comes together and just the overall impact for the company in total.

John Ransom, Analyst

And my follow-up is, in theory as you talk to your commercial and Medicaid partners about value-based kickers use the baseball analogy kind of where are you? And then just in theory, what would that look like for behavioral because we're not used to being very common in your world. Thanks.

Chris Hunter, CEO

Yes. To use your baseball analogy, I would say we are just getting started. We want to strategically position ourselves, and we are making IT investments that will allow us to keep pace with the industry's developments in behavioral health. This is a key reason we are focused on building our infrastructure to effectively capture data and compete based on the quality of our clinical outcomes compared to our competitors. However, regarding value-based programs, it varies by payer. We are currently observing some initial interest from payers who are willing to offer incentives, typically focused on reducing readmissions, although other criteria may be added in the future. At this moment, the contracts we are encountering are primarily upside-only agreements; we are not seeing any interest in downside risk or a shift towards full capitation. Thus, I would emphasize that we are still at the beginning stages. If we ramp up our efforts towards further stages, we will be ready thanks to our ongoing investments, and that's how we intend to position ourselves for growth.

John Ransom, Analyst

So, Chris to be clear baseball you're supposed to talk about innings you know, on that basis, but that's okay. I get a second inning then, right?

Chris Hunter, CEO

Sure. I tried to give you both.

John Ransom, Analyst

That’s good. All right. Thanks so much.

Operator, Operator

This concludes our question-and-answer session. I'd like to turn the conference back over to Chris Hunter for closing remarks.

Chris Hunter, CEO

Well, thank you. Before we end the call, I just want to thank again our committed facility leaders, clinicians, and approximately 23,000 dedicated employees across the country, who have just continued to work tirelessly to meet the needs of patients in a safe and effective manner. I want to thank you all for being with us this morning and for your interest in Acadia. If you have any additional questions today, please don't hesitate to contact us directly. Have a great day everyone.

Operator, Operator

The conference has now concluded. Thank you for attending today's presentation. You may now disconnect your lines.