Conference Transcript - AMN 2026-06-03

Trevor Romeo, Analyst — William Blair

All right. I think we can go ahead and get started. I think we're at time. Hi everyone. My name is Trevor Romeo. I'm the analyst here that covers the staffing and human capital services sector at Blair. Before we begin, I'm required to inform you we have a full list of research disclosures and conflicts of interest on our website at williamblair.com. So today we're very excited to welcome AMN Healthcare Services back to the Grow Stock Conference. AMN is a leader in comprehensive workforce management solutions to the healthcare sector. And I'm very happy to introduce AMN CEO, Carrie Grace, CFO and Chief Operating Officer, Brian Scott, the dual threat. And Randy Reese is out there as well from Investor Relations. So we will start here with a presentation and some fireside Q&A. And then there's a breakout session in the Burnham B room upstairs after this for anyone who would like to ask some more questions. So thanks for being here. And Carrie, I'll turn it over to you.

Caroline Sullivan Grace, CEO

Yeah, good morning, everyone. and a very big thank you to Trevor and to William Blair for having us at this conference. Trevor mentioned this, but AMN is the leader and innovator in total talent solutions for healthcare organizations across the United States. We provide healthcare organizations with technology, solutions, and a national talent network to ensure they can achieve their workforce goals we are fueled by long-term macro trends around increasing patient utilization amidst a constrained supply of clinicians to be able to support that demand we've been in business for over 40 years most of those years as a public company and we are a purpose-driven organization with a deeply experienced management team as brian will talk about just in some brief overview remarks will give we are well positioned to deliver long-term revenue growth and our ebitda growth targets importantly we have a strong balance sheet to position us very well both for organic growth as well as for opportunities for m a i'm trying to figure out if i have this slide

Brian Scott, CFO

here we go here you go here i might have needed that there you go okay there you go now you can

Caroline Sullivan Grace, CEO

see what i was talking about okay a bit about a bit about our company um think of us as the connector between serving and supporting the workforce needs of health care clients and the clinical labor so we support clinical and leadership roles as well as non-clinical for over 2 000 clients across diverse settings from hospitals ambulatory settings physicians offices retail urgent care home health schools and virtual care we operate a 40 billion tam with trailing 12 months revenue of 3.4 billion dollars and we operate in three segments that you can see on the slide nurse and allies our biggest all specialties of nurse as well as most specialties and allied travel nurse is our biggest segment we have international per diem as well as labor disruption. And in Allied, we support Medical Allied as well as schools and Revenue Cycle Solutions. Physicians and Leadership Solutions, we provide both permanent physician support as well as contract labor in the form of locums. And we are the largest healthcare leadership and search provider. We do both permanent management and leadership search as well as interim and in technology and workforce solutions we have the enabling technology to help organizations predict manage and be able to support their labor needs our two biggest businesses are our language services business which provides video and voice interpretation and translation through over 200 medically trained professionals as well as our vendor management solutions business which helps enable through technology the ability to predict, manage, and do analytics around your labor needs. We have three primary drivers of our growth. The first is expanding growth across the entirety of the market, supporting both MSP service models, vendor-neutral service models, as well as direct. Once we have those clients in, we want to do more with them. Right now, on average, with our strategic clients, we have over 10 of our 20 solutions in. we have significant expansion opportunity underneath that and then accelerating and faster-growing markets like acute care, PT, schools, and areas that we see disproportionate growth in. Our second growth pillar is around accelerating and getting more of our share of the growth as the industry returns to increases in demand. Over the past three years, we have made significant strides in automating all of our processes around recruiting and 24-7 enabling them predominantly through a global workforce to support that. We have an ability now from a speed standpoint to be able to grow even if market demand conditions are not growing. And we saw that performance very strongly in the first quarter when we were supporting both our business usual and we had a surge in demand from labor disruption. And then finally, we have an opportunity to grow by driving our fixed cost base and have more earnings growth coming from the revenue growth that we have. Brian will talk in a minute about our long-term growth framework and model, but we have done a lot around automation and really scaling the core of our business so we can get that accelerated earnings growth. So with that, I will turn it over to Brian.

Brian Scott, CFO

Thanks, Carrie. Yeah, we're going to jump through a bunch of these here just so we have more time for Q&A. So as Kira mentioned, as we're kind of transitioning out of the COVID pandemic and the impacts it had on our industry and getting back to a normalized environment here, we see a few opportunities to really resume growth and improve both the top line sustainability, but also expand our margins as well. So part of that strategy is getting growth back in some of our higher margin businesses. Our international business was impacted for several years with visa retrogression, where the visa days from back first quarter, we got back to positive growth. And we have talked about getting having about mid to high teens, top line growth in 2026 and have tremendous demand and supply available to continue to grow that international business long term. It's a much higher margin staffing business for us. Also, higher margin businesses around our search, both physician perm placement and executive search turned back to positive in the first quarter. and with our strategy and leadership in place we see a lot of opportunity to accelerate that growth going forward again a higher margin business and then our vendor management technologies which were impacted like most of our staffing businesses through this cycle are getting close to kind of turning the corner and again with a high margin profile it'll be very creative to our margins both EBITDA and gross margins. Our core staffing businesses which make up the bulk of our revenue we see tremendous opportunity to get back to growth across the board here our allied business including our schools business again you got back to positive growth in the first quarter and we expect that to continue going forward our nurse business was actually up in the first quarter as well right on the cusp of having that turn back to positive consistently our locals business started the year a little bit weaker than we'd like we've got several initiatives in place but that market is strong and continue to grow and we see opportunity to get that back on track as well and I'll talk in a couple slides about the impact of all of that we're still running at historically low average hours worked, particularly in our nurse and ally businesses, as that picks back up again in any way, that's margin accretive as well. And so some early signs there, but we think that will longer term be one of the drivers of margin expansion in our staffing businesses. And then as we invest more in our infrastructure, consolidate on fewer systems, invest more in processes and technology, we see a tremendous opportunity to leverage our SG&A base to drive higher incremental margins as we grow our revenue as well we've been very focused on debt reduction and strengthening your balance sheet we're in a very enviable position in our industry now and i'll talk about that in a second here but that allows us to pay down debt reduce interest expense and grow earnings as well so just real quickly in the financials i think what i just want to point out here a couple of things is one again you've seen the revenue tick up quite a bit during the pandemic on the other side of that cycle has come down we really started to hit an inflection point last year of more stabilization. And that we looked at our Q4 run rate as being more indicative of kind of the floor that we're going to build off of. Our LTM was favorably impacted by two very large strike events that we supported in the first quarter very successfully. But if you kind of pick out some of that event, you can look underneath that, you're looking at very stable revenue that we're looking to build on. Same on our gross margins now in that 27%, 27 to 28 percent, we feel like that's a very stable place to be in an area that we can grow from. And AMN's hallmark has always been able to have a very flexible cost structure so that we can convert that revenue and gross profit into strong, sustainable EBITDA, which is reflected there. And then cash flow, I'll make a point on the next slide as well, but again, consistent, strong cash, free cash flow generation in any type of cycle. And then real quick on the balance sheet, you can see our cash balance at 561 million. We mentioned in the last call that was in part a result of these two events where we got upfront payments from clients for those labor disruption events. And that our cash balance projected at the end of the second quarter, once we refunded those deposits, is at up at $175 million. Our debt, we refinanced one of our tranches. So now we have two unsecured notes that don't mature until 2029 and 2031. So we have $750 million in unsecured notes with, again, extended maturities, $450 million revolver, completely undrawn, so in a really strong position. Our debt, going back just to the end of 2024, was over a billion dollars, so significant improvement in our cash position and our debt, which is reflected in the leverage now at 1.6 times on an LTM basis. So this gives us a lot of opportunity to invest more in our business and our operations and also look at strategic acquisitions that would bolster our business and strategy as well. And then finally, oh, this is not the, well, I'll leave it at that. I'll just talk about our long-term algorithm that Kerry alluded to earlier. We talked earlier the year about as we get back to, again, a view towards growth, sustainable growth across all of our service lines. We see an opportunity to get everybody all of our businesses growing again during 2027 at different points And when we have that growth algorithm going across the board, we see mid single-digit Revenue growth on a sustained basis the ability to expand margins both within our staffing businesses as well as through higher growth in our higher margin service lines and That will allow and then with continued improvement in our cost structure investments in automation will be able to generate double-digit EBITDA margin or double-digit EBITDA growth off of that mid single-digit revenue growth and then historically we've converted about 60% of our EBITDA to free cash flow and we think that's a reasonable expectation going forward as well so that will flow through a really strong earnings growth for our shareholders. With that Trevor

Trevor Romeo, Analyst — William Blair

we'll give you the rest of time for Q&A. All right sounds good well thank you both I think that was a great overview so maybe we can start with kind of a demand picture probably a good good place to start usually you know I think you mentioned showing some signs of kind of either starting the bottom or moving past the bottom in terms of kind of the staffing business at least and maybe some of the other businesses if you look at some of the job postings metrics and weekly indicators see a little improvement lately there as well so So maybe you could just talk about, you know, what you're seeing in terms of the market out there, what your clients are saying. It feels like you've also maybe won back some market share in some areas. So maybe both talk about the state of the market and your relative sort of competitive performance lately.

Caroline Sullivan Grace, CEO

Yeah, if I start with what we're seeing just as the general theme around workforce with clients, you had this period coming out of COVID where they were really focused on how do I normalize my workforce? A lot of that you saw very significant increases in permanent hiring. They had lost a lot of that permanent hiring foundation during COVID. There was a lot of movement of the workforce during the pandemic. So you really saw a period of two plus years coming out of the pandemic where that was one of the core areas of focus and themes. What we've seen over the past really several quarters is clients going back and looking at more holistically. how do I build a workforce that is sustainable to meet what we know is going to be this aging population needing more health care is high quality but also cost-effective and so there's not going to be one solution that's going to solve that there's going to be several solutions that you have to do in concert with each other to be able to do it so I'd really say the biggest thing we're seeing with clients is really getting back to what is going to to be the solve for this challenge that we have of increasing patient demand against a constrained clinical supply to be able to support it. When we look underneath in some of the businesses, we've had somewhat different pictures over the past couple of years, and certainly we'll talk about the past couple months and quarter in terms of demand. You really saw locums as an example on the physician side have consistent demand increases. those those parts of the workforce are tied to revenue generation so there's been you know a simultaneous focus on both revenue generation and cost management allied our ally business returned to positive demand growth last year and we've seen more recently that happen in our nurse business and so broadly we're seeing the demand go in concert with this theme from clients of of how do I grow my workforce with the increases in patient demand that I'm seeing.

Trevor Romeo, Analyst — William Blair

And then maybe as you think about kind of the, we've had this, you know, this point three, four year down cycle, you think about the shape of a rebound curve, you know, obviously the past five, six years were different than anything we've ever really seen before. If you look back maybe to, you know, 2009 to 13 or whatever time period, it was coming out of a recession where, you know, a lot of nurses stopped traveling and then they eventually came back but here you're kind of coming off a very high unsustainable covet peak yeah so i mean what do you think the shape of a rebound curve here could look like

Caroline Sullivan Grace, CEO

so um i have this slide for anyone who's interested in in talking to us later on it but if you track our tam over the past seven or eight years and i'll pick three points In 2019, our TAM was $24 billion. In 2022, it was over $72 billion. And now it's $40 billion. So if you go point to point, and it shows you, by the way, the generational cycle that we went through with COVID. If you go point to point and say, 24 to 40, that's a great TAM, it's a great market. If you go from the 72 to the 40, that was not as much of a fun period but I think Trevor's we go back and look at what this looks like and you take out some of that cycle you would expect to start getting into growth that would mirror some of the underlying macro trends that we've been seeing around patient demand and utilization and the other trend that we didn't talk as much about but is it is very prevalent particularly when you're thinking about a labor market is from a clinician standpoint, one of the things that has continued to be very strongly desired is more flexible work arrangements. And so many cases the current work structures offered today do not provide the flexibility they want. So we would expect to start seeing us get back into growth patterns that we had seen historically in the sector, driven not just by patient demand, but also a workforce that at once increased flexibility in how they operate professionally.

Trevor Romeo, Analyst — William Blair

So I guess maybe following up on that, I think part of the reason that some travelers decide to travel is because there's a premium pay, difference for traveling versus a permanent role. And I think you're still seeing that be kind of below what it was pre-pandemic. So I'd agree, I think there is a good degree of desire for flexibility, but the bill rates aren't necessarily there yet. so what do you think you know really makes hospitals want to increase those and then kind of

Caroline Sullivan Grace, CEO

get the cycle all moving in the right direction yeah so let me give you some numbers about what has happened over this cycle too we look at the premium of a fully loaded cost of a permanent position to a contingent position so pre-covid that was somewhere in the very high teens to low 20s during covid that got to about a hundred percent premium just supply and demand and if you look at today that number is more like the high single digits and so what has happened is as you've come out of this period where you've been reestablishing the permanent base you probably had a little bit of an overcorrection back into the cost the psychology of where we are in bill rates coming down has not caught up with the reality and so we are starting to see clients who are really understanding that more and understanding that this is actually a very cost-effective way for me to do a completion strategy to meet my workforce needs. Interestingly, there is a front page Wall Street Journal article, I want to say last week, on travel nurses and the lifestyle, and I'm getting head nods from people who read it, and it really focused in on the psychology of why a lot of clinicians want this type of lifestyle. It's not necessarily for everybody a permanent lifestyle it could be episodic periods of your of your career yeah

Brian Scott, CFO

trevor i'd add i mean obviously during the pandemic that pay was a big driver we had more nurses that may maybe weren't going to consider travel coming in because of the pay opportunity but historically that's just one element of motivation that article is a good reflection of that the opportunity to to travel different places and have different experiences for many of them even to work in different settings and decide where you know kind of where they want to settle For our clients, it can be a chance to try out a clinician for both sides before they go into a permanent hire. So we look at it more, again, there's a lot of drivers for clinicians, and that's true for nursing, for allied, and more and more so for locals as well. We have early career physicians looking at contingent as an option for them. Pay is important, and I think what we're seeing with the bill rates is that if the bill rate isn't priced right and that pay doesn't meet that floor, it's very hard to get somebody to fill those orders and so when we work with clients we educate them we have more transparency than ever on kind of what's going on in the market where they how they compare and what it's going to take to to fill their orders and when they have more urgency and they move on the bill rates to get to that level we can fill the jobs immediately so we know the supply is there there's still a high level of interest it's kind of back to that core supply that in their in their career journey this is this is something they're very interested in doing and when it's priced appropriately we are faster than ever at filling those jobs as well and so I think this the cycle that Kerry mentioned where you know there's a lot of permanent hiring over a three-year period is that starting to slow down you're still seeing pretty low attrition rates but if you start to see attrition pick up more in the hospitals they're still running a positive patient volumes overall in 26 even though it's decelerated still it's still growing the acuity of patients is increasing when you start to hit that pinch point where maybe they haven't hired as much or they're looking at the economics of continuing to hire then and that usually will drive more demand and as demand increases, then the bill rates typically follow as well. So we're seeing the demand improve. It's modest, but it's definitely picking back up. Our bill rates have been stable for the better part of the last year now, and so with that last leg of, as you see again, more competition for talent, that would really be the biggest catalyst for further bill rate increases.

Trevor Romeo, Analyst — William Blair

Yep, okay, great. Well, maybe we move over to the international business, which you mentioned is starting to rebound. Like the visa dates have progressed pretty nicely the last several months. you also have the visa pause on 75 countries that's out there it's maybe a little bit of a headwind but it sounds like you're still confident in kind of high teens growth for this year but that business did lose I guess about 100 million of revenue over the two-year period so maybe you could help us think about what that business could look like over kind of a multi-year horizon and when you can maybe get back to the old peak or a new peak or something like that

Caroline Sullivan Grace, CEO

yeah and so the international business is a very important way to bring clinical supply in I'd say that broadly for health systems across the country, it's especially important for rural health systems where they have a hard time attracting talent. And so these clinicians come over typically on two to three year assignments. As you can imagine, the visa process to come over is multi, multi, multi year. and what happened in concert totally separate from the cycle we went through during the pandemic but what happened is you go through periodically periods of what's called visa retrogression this is really tied to just the state department and from administration standpoint getting caught up in processing those visas so they move the dates backward everyone has a time stamp on their application they're literally in line to come over and so what happens is and why we track these dates is we know by month everyone who has a time stamp for a certain date when they move that date forward we have been working for in some cases up to ten years to have those clinicians ready identified ready trained to come over and so the opportunity for us is we've already spent all the dollars to attract and and educate those clinicians so every time we move forward in these dates that started at the end of 2022 going into regression it is a very high margin opportunity for us to then place them with clients who have had long-standing orders to get them in so what we've seen happen separate from that visa retrogression is obviously a lot of focus on immigration and immigration policies we bring our clinicians over vast vast vast majority on visas not h1bs so that is really aimed at a different population but there has been a general stance around tightening immigration of workers into into the u.s that that business as we have seen retrogression improve last year has started to return to year-over-year growth it actually started the tail end of last year we had 11 year-over-year growth in the first quarter we would expect that growth for the full year to be in the mid to high teens and then continue to see growth from a year-over-year standpoint next year great and then maybe labor disruptions you mentioned

Trevor Romeo, Analyst — William Blair

that earlier you had the the two i just say huge events uh in the first quarter of this year uh strikingly large events to no i like the pun pun intended i like it very very well intended so So maybe you could talk about some of the changes you've made to your offering in that business that have helped kind of improve your win rates and your fill rates. And then, you know, just thoughts on the overall, the incidence rate of strikes, is that increasing as well? And if so, you know, what are the drivers of that?

Caroline Sullivan Grace, CEO

Let me give a high level overview and then I'll turn it over to Brian. Labor disruption for clients that unites populations is unbelievably important. It is by far the hardest solution that we execute on because we are literally in 10 days, 10 days, finding the clinicians, getting them to travel, getting them credentialed, getting them educated, and getting them on the floor on day 10. And so it requires just, you know, perfection across the number of factors. Incredibly important for them to be able to operate and to be able to go to the bargaining table. And so we made a decision three years ago to get significantly better at this because some of our largest clients were among that group that needed our support. We built specialized technology that helps us, including AI recruiting. When you have that short of a time period, you need to be able to recruit fast. So we have an AI recruiter on the front end that cut down in these strikes that we did 20,000 woman and man hours to be able to get fill rates that were 70 plus percent on both of these indefinite strikes so we were able to with both this technology that we built as well as the automation of our processes that i mentioned earlier and the speed and scale in which we can do things including 24 by 7 workforces that we can scale up and credentialing we were able to deliver on our bau in the first quarter and support two very large indefinite strikes that has never happened in the industry simultaneously the demand on an hours adjusted basis was within percentage points of the peak of COVID demand and we were able to do it at significantly higher fill rates than we had done historically i'll let brian talk a little bit about what we're seeing in terms

Brian Scott, CFO

of just strike behavior yeah there's i mean if you look at the third party data there's been a perpetual increase over the last three years from 23 to 24 higher again in 25 and and obviously the start of this year two large events kind of skewing that but every indication is that there's more contention between the unions there's more focus from different union organizations on health care specifically with some you know some more recent unionization efforts and so there it would show you really don't know until they happen if they're going to but every indication is that there's there's gonna likely be more of that and so again the capabilities we built out one to support our clients we want to be that total workforce partner and they need us to step up at the right time so that's why we made the decision that we wanted to lean in it but if you're gonna do it you have to do with excellence but it's also given us the capability now to you know offer this to other strategic either existing clients or strategic opportunities and we can we can serve more than one client at the same time where historically we kind of did it on a serial basis we now can offer it more comprehensively to multiple clients and so we'll uh you know we're we are very proud and and you know very confident in our ability to execute again it's always hard to predict the timing and magnitude of those events But again, I think from a strategic point of view, it's really important because clients want us to be able to serve them in this way. And we've got now a leading reputation with our operations and technology.

Caroline Sullivan Grace, CEO

The other part that I'd say is it gives us a really huge surge in demand opportunity to put some of the technology that we built in. So this was the first time we used our AI recruiter to the depth that we did, and it was unbelievable. We've been using AI quite aggressively in all parts of our organization and some of our client-facing technology, but to use it and be able to put it in a really high-demand scenario like this, we bring that back into the core business, and so there's a continuous virtuous circle of development that we use in Strike going back to the core business and vice versa.

Trevor Romeo, Analyst — William Blair

Let me see. Hopefully, time for one more. So, speaking of AI, I think there was a lot of noise earlier this year, sort of around the language services business. There was some noise around potential disruption fears around that business. I think that kind of doesn't consider the fact that machine translation does still need to be reviewed by a human under the regulations out there. But the language services business was kind of a consistent double-digit growing business at a very high margin. and it's run into some competitive headwinds in the last maybe year or so so maybe you could talk about what you're seeing from behavior that the tiered pricing strategy you put in if you've seen

Brian Scott, CFO

results thus far and how that business is doing yeah i thank you and to the first point um yeah ai has not really been uh a threat in any way at this point um it's understandable it's the right question but there are regulatory protections uh when you're in that patient encounter that interpretation that we provide either audio or video is required to be done by human and and there's been no discussion that we've seen in any way about changing those regulations the risk is just too great and our clients have not been asking for it either so the yeah the headwinds that we face in the business are unrelated to that and we're investing in AI around kind of the services that are that are adjacent to that patient encounter we think you can extend the way we serve our clients using AI but that core patient encounter which drives our revenue has not changed that the two bigger factors that have impacted the industry industry including us has been one some of the immigration enforcement policies where you actually saw net negative migration last year so just the utilization along with some of the pretty heavy-handed tactics um you know uh with immigrants i think that's starting to level out and then just this pricing competition as well so we've quickly adapted our model um and and we're seeing positive returns on that our new sales in the first quarter exceeded the all of the back half of last year and so it's still a very competitive environment we feel like we've got our footing and a strategy to continue to improve our operations there what do you think is a realistic

Trevor Romeo, Analyst — William Blair

long-term growth rate for that business kind of this new if it is a new pair yeah

Brian Scott, CFO

it's a we'd look at it more as a single-digit growth rating going forward but it's again that that kind of ties into our consolidated growth algorithm and again with a much higher margin profile and really good free cash flow conversion it's still going to be a very important part of our of our long-term

Caroline Sullivan Grace, CEO

growth strategy and if you if you look at it there's two really important populations that that business is supporting one is patients that are coming in with limited English proficiency it's typically one in five patients coming in and the other part is hearing impaired and so there's almost 12 million hearing impaired in every single market our ASL American Sign language is one of the top five requested languages for interpretation and so both of those markets have the same demographics broadly as some of the macro drivers that we talked about earlier okay excellent I think we're out

Trevor Romeo, Analyst — William Blair

of time I wish we had a room for a couple more but there is a breakout session for anyone who'd like to join and Gary Bryan thanks so much thank you

Caroline Sullivan Grace, CEO

Appreciate it. Of course.