Earnings Call Transcript - CCRN Q1 2024

Operator, Operator

Good afternoon, everyone. Welcome to Cross Country Healthcare's Earnings Conference Call for the First Quarter 2024. Please be advised that this call is being recorded, and a replay of this webcast will be available on the company's website. Details for accessing the audio replay can be found in the company's earnings release issued this afternoon.

Joshua Vogel, Vice President of Investor Relations

Thank you, and good afternoon, everyone. I'm joined today by our President and Chief Executive Officer, John Martins; as well as Bill Burns, our Chief Financial Officer; and Marc Krug, Group President of Delivery. Today's call will include a discussion of our financial results for the first quarter of 2024 as well as our outlook for the second quarter. A copy of our earnings press release is available on our website at crosscountry.com. Please note that certain statements made on this call may constitute forward-looking statements. These statements reflect the company's beliefs based upon information currently available to it. As noted in our press release, forward-looking statements can vary materially from actual results and are subject to known and unknown risks, uncertainties and other factors, including those contained in the company's 2023 annual report on Form 10-K and quarterly reports on Form 10-Q as well as in other filings with the SEC. The company does not intend to update guidance or any of its forward-looking statements prior to the next earnings release. Additionally, we reference non-GAAP financial measures such as adjusted EBITDA or adjusted earnings per share. Such non-GAAP financial measures are provided as additional information and should not be considered substitutes for or superior to those calculated in accordance with U.S. GAAP. More information related to these non-GAAP financial measures is contained in our press release. Also during this call, we may refer to pro forma when normalized numbers pertain to our most recent acquisitions as though the results were included or excluded from the periods presented. With that, I will now turn the call over to our Chief Executive Officer, John Martins.

John Martins, CEO

Thanks, Josh, and thank you, everyone, for joining us this afternoon. As you can see in today's press release, our first quarter 2024 revenue and adjusted EBITDA were in line with expectations. I am pleased that our team continues to perform well in this difficult environment as demand for travel assignments softened further since the end of last year. And while the market for Nurse and Allied remains challenging, our focus is on growth opportunities across all of our portfolio, including our locums, education, home care staffing, search and recruitment process outsourcing businesses. With our pipeline for new business and continued investments in technology as well as our strong balance sheet, I believe that Cross Country is well positioned for future growth. Looking more closely at our travel business, while demand is down across the market in the high double digits since we exited 2023, our weekly production is only down in the mid- to high single digits, indicating our ability to execute. Open order rates for travel have been fairly stable for several quarters, although average bill rates continue to decline as we blend down towards the current market rates. Accordingly, travel rates in the first quarter were down roughly 2% sequentially and are expected to decline in the low single digits for the next couple of quarters as the market finds its floor. Similar to travel, our local or per diem business has faced market headwinds. In the first quarter, we saw a double-digit sequential decline in volume and a mid- to high single-digit decline in REITs. We are focused on expanding our local services deeper into non-acute care settings, including within our own offerings. The local business remains a key part of our value proposition, and we will continue to offer these services in the markets where it makes sense based on client needs and opportunities. Shifting gears, we continue to see strong performance in several of our other lines of business. Physician Staffing, for example, reported first quarter revenue up double digits year-over-year. Driving this was a combination of higher billable days and revenue per day filled tied to a growing mix of higher bill rate specialties. Contribution income increased both year-over-year and sequentially. And as a percent of revenue, was up more than 250 basis points, reflecting the improved mix and our efforts to proactively manage costs. Our Homecare business was up mid-single digits, both sequentially and year-over-year in the first quarter on the heels of the recent wins and program implementations that we highlighted on the February call. I'm pleased to note that this division now staffs over 1,700 FTEs, up high single digits year-over-year. We believe that this business is poised for robust growth in 2024. Lastly, our Education business continued to perform well, up low double digits sequentially. This business continued to expand nationwide as we are now in more than 20 states. I'd like to take a moment to talk about what we are seeing in the market. And more importantly, what we are doing to remain competitive while also being mindful of preserving shareholder value and profitability. It is clear that health systems have reduced their reliance on contracted labor, yet there remains structural staffing shortages and high turnover within these settings. Accordingly, we believe that a stronger travel environment could emerge sometime in the back half of this year. Having said that, given the current market headwinds, we have taken actions to better align our cost structure to the demand environment. As of today, our U.S. head count is now down more than 20% since the beginning of the year. While these decisions are never easy, I am confident that we have sufficient capacity to capitalize when the market rebounds. It's also important to note that part of the catalyst behind these reductions is the fact that we've been able to further leverage our operations in India, which will yield millions of dollars in annualized cost savings. Additionally, we expect to drive further efficiencies company-wide by leveraging our technology, such as artificial intelligence and robotic process automation. Lastly, we will see additional savings as the remainder of our legacy clients are migrated on to Intellify, our vendor-neutral technology platform. Looking forward, we will continue to make targeted investments in technology and businesses that serve to enhance our competitive positioning and operational excellence. As we discussed on our last earnings call, the line between MSP and VMS continues to blur as clients seemingly want to have the best of both worlds. This is where Intellify has become a critical component of our value proposition since it can be utilized both as a VMS and MSP. Overall, we continue to see strong interest in the market for this technology, and we are confident that Intellify's value proposition will drive additional business opportunities at Cross Country. In fact, we are excited to share that yet another Intellify client was signed last month. Now turning to our outlook for the second quarter. Given the current demand backdrop in travel, we anticipate that second quarter revenue will be between $330 million and $340 million, with adjusted EBITDA coming in at $10 million to $15 million. Our goal remains to achieve a high single-digit adjusted EBITDA margin. And as we navigate the headwinds from the pullback in Nurse and Allied demand, we expect to see mid-single-digit adjusted EBITDA margins near term, while maintaining capacity when the market rebounds. We remain confident in our ability to capture market share by leveraging both our leading client and candidate-facing technologies as well as our expertise in delivering high-quality clinical and nonclinical professionals. Coupled with our diversified platform that includes locums, home care and education, we expect to emerge a stronger, more agile and profitable organization once the current travel market pressures dissipate. We're also focused on putting our healthy balance sheet to work through ongoing strategic technology investments, share repurchases and potential M&A. On the M&A front, in particular, our goal has not changed. We look to close on several accretive acquisitions that we believe will further diversify our platform, enhance our value proposition and improve our margin profile. In closing, I'm encouraged by our prospects for growth and improved profitability. As we execute our strategy as a tech-enabled workforce solutions provider, we are seeing strong momentum in many of our business lines outside of travel, and we continue to execute on our initiatives across the organization. I am impressed by the dedication and hard work of all of our employees, and I am very proud to announce that we were recently named as one of Newsweek's Greatest Workplaces for Diversity in 2024. A recognition like this is a testament to our workplace culture and the reason why we have such a deep pool of talent that has made Cross Country their employer destination of choice. I want to thank all of our employees and our healthcare professionals for your continued hard work and contributions, as well as our shareholders for believing in the company.

William Burns, CFO

Thanks, John, and good afternoon, everyone. As highlighted in our press release, performance for the first quarter was largely in line with expectations with revenue near the high end of guidance and adjusted EBITDA towards the midpoint of our range. Consolidated revenue for the first quarter of $379 million was down 8% sequentially and 39% over the prior year, driven primarily by declines in travel and local assignments in large acute care settings. I'll get into more details on the segments in just a few minutes. Gross profit for the quarter was $77 million, which represented a gross margin of 20.4%. Gross margin was down 150 basis points sequentially and 200 basis points over the prior year. The sequential decline was primarily due to the annual reset in payroll taxes as well as a rise in certain burdens such as health insurance and workers' comp and an adjustment for professional liability insurance costs that is not expected to recur. Relative to the prior year, the decline in gross margin was principally due to the tightening of the bill-pay spreads for travel and local assignments, as well as the burdens that impacted the sequential change. Moving down the income statement, selling, general and administrative expense was $63 million, down 6% sequentially and 25% over the prior year. The majority of the decrease relates to lower salary and benefit costs associated with our reductions in headcount, as well as lower incentive compensation over the last 2 years. We have proactively managed our costs to align with the broader market while seeking to preserve adequate capacity for future growth and to maintain the cadence of investments in longer-term projects. In the first quarter, US headcount was down 9% from the start of the year, and we have taken actions in the second quarter to reduce headcount by an additional 15%. Over the last 18 months, we have reduced total headcount in the U.S. by 40%. While these reductions reflect the headwinds experienced across both our travel and local businesses, it's important to note that a good portion were the result of enhanced productivity and offshoring to our center of excellence in India. As of the end of the first quarter, we grew headcount in India by 45% since the start of the year, and we will continue identifying future opportunities to capture incremental savings. While we are keenly focused on managing our total cost structure to the most efficient level possible, we will continue to make investments in those businesses where we see opportunity for growth, like education and home care staffing. Our SG&A for the first quarter includes more than $1 million of costs pertaining to the implementation of our ERP system. The costs were higher than prior quarters as we have been working simultaneously on two phases of the project. I'm proud to share that as of today, we've successfully completed the first phase of the project, which is the foundation that will allow us to realize significant efficiencies once the second phase is completed in mid-2025. Excluding these implementation costs for our ERP system, SG&A was down more than 7% sequentially and 26% from the prior year. We reported adjusted EBITDA of $15 million for the quarter, representing an adjusted EBITDA margin of 4%. Though revenue was at the high end of our expectations, our adjusted EBITDA was impacted by a lower-than-expected gross margin, which was partly offset by lower SG&A through tighter cost management. Interest expense in the first quarter was $500,000, which was down 21% sequentially and 87% from the prior year. The decline was entirely driven by lower average borrowings throughout the quarter. The majority of the interest expense reported for the first quarter was related to the carrying costs for the ABL and fees related to outstanding letters of credit. The effective interest rate on amounts drawn under our ABL was 7% as of March 31. As a result of our strong cash flows, we ended the quarter once again with no debt outstanding. And finally, on the income statement, income tax expense was $1 million, representing an effective tax rate of 27%, which was slightly lower than our expectations due to the impact from discrete items recognized in the quarter. Our overall performance resulted in an adjusted earnings per share of $0.19 via the midpoint of guidance. Turning to the segments. Nurse and Allied reported revenue of $332 million, down 10% sequentially and 43% from the prior year. Our largest business, travel nurse in Allied was down 11% sequentially and 48% from the prior year. Billable hours were down 9% sequentially on the softer demand, while bill rates were down 2%. Given the continued softness in travel demand, we expect to see a further sequential decline for revenue with the second quarter in the mid-teens. Similar to Travel, our local business has also been impacted by the softness in demand for continued clinical labor. First quarter revenue was down 36% from the prior year and 19% sequentially. The majority of the decline came from fewer billable hours and to a lesser extent, lower bill rates. Though core Nurse and Allied staffing is facing headwinds, several other businesses continue to experience organic growth. Homecare Staffing was up 4% sequentially, while Education was up 11%. And given the growth prospects of both of these businesses, they remain focus areas for further investments. Specific to the Homecare Staffing business, we continue to win new PACE clients across the nation and have 7 programs currently being implemented, with another 2 contracts likely to sign in the coming quarter that should be catalysts for continued growth. Finally, Physician Staffing once again delivered a strong top line reporting $47 million in revenue, which was up 16% over the prior year and flat sequentially. Year-over-year growth was evenly split between price and volume, with the number of days filled increasing across specialties such as anesthesiologists, primary care, physicians, CRNAs, and nurse practitioners. Turning to the balance sheet. We ended the first quarter with $5 million in cash and no outstanding debt. With the health of our balance sheet and strong cash flow, we remain well-positioned to make further investments in technology and accretive acquisitions, as well as to continue purchasing shares under our $100 million share repurchase plan. From a cash flow perspective, we generated $6 million in cash from operations in the first quarter, which was impacted by the timing of payments for annual incentives as well as payroll taxes. Collections were largely in line with expectations, though our days filled outstanding increased to 74 days as a result of a single client which added 5 days to this metric. Specific to that client, we did see collections resume this quarter and expect that trend to continue. Our goal remains to operate with a DSO of 60 days, which is more in line with our historic performance, and we expect to make progress towards that in the coming quarters. Cash used in investing activities was $2 million, primarily reflecting continued technology investments, predominantly for Intellify and our new ERP system. From a financing perspective, we repurchased an additional 300,000 shares during the quarter under both our 10b5-1 trading plan and our 10b-18 one. This brings me to our outlook for the first quarter. We are guiding to revenue of between $330 million and $340 million, representing a sequential decline of 10% to 13%, driven predominantly by the expected decline in both billable hours and rates for travel. We're guiding to an adjusted EBITDA range of between $10 million and $15 million, representing an adjusted EBITDA margin of approximately 4% at the midpoint of guidance. Adjusted earnings per share is expected to be between $0.10 and $0.20 based on an average share count of approximately 34 million shares. Also assumed in this guidance is a gross margin of between 21% and 21.5%, interest expense of $500,000 and depreciation and amortization of $5 million, stock-based compensation of $2 million and an effective tax rate of between 30% and 32%.

John Martins, CEO

And that concludes our prepared remarks, and we'd now like to open the lines for questions.

Operator, Operator

Thank you. Ladies and gentlemen, before we open the lines for questions, I want to turn the call back over to John Martins for another word.

John Martins, CEO

Thank you, operator. I want to recognize that today is the start of National Nurses Month. This month serves not only as a celebration of nurses' unwavering dedication and tireless efforts but also as a poignant reminder of the invaluable role they play in healthcare and our society. Nurses are the compassionate and steadfast pillars of patient care. Their contributions extend far beyond the confines of hospital walls, touching the lives of countless individuals and families around the world. Nurses are truly the heroes and the lifeline of the healthcare system. I want to personally thank every nurse out there for your hard work and dedication. And now I'd like to turn it back to the operator for Q&A.

Trevor Romeo, Analyst

The first one is if you look at the Q2 guide, I think historically, you haven't seen as big of a drop is what you're guiding to in terms of revenue. It looks like maybe it's a little more than 10% below Q1. Consolidated, I think Bill had said maybe down mid-teens for travel. So I was just kind of wondering if you could talk about demand trends for the first 4 months of the year this year and maybe what's different versus years in the past? And I guess further, do you believe the entire industry is experiencing a similar level of decline? Or are there additional competitive headwinds you're facing? Or anything more you could say on that front would be really helpful.

William Burns, CFO

Sure. Thanks for the question, Trevor. This is Bill Burns. You're spot on. When you look at our second quarter, it is not following historic patterns, and it's entirely driven off of travel. As we progress through the first quarter, demand remained soft and still has not yet rebounded. We do think there's some opportunity there and programs that we've won are still ramping, but that's putting the drag on the second quarter. Bill rates for travel are projected to be kind of in the same range of a low single-digit, 1% to 2% sequential decline going into Q2 and possibly into Q3, and we don't guide out that far. But rates are trending exactly where we expected them to be. This has really been a volume story across travel nurse. And John, I mean, if you want to comment on the market.

John Martins, CEO

Yes, Trevor, I would just add, this is definitely the market conditions. And when we look at the different information that's out there, we can see that demand has fallen off pretty sharply over this first quarter and into the second quarter. Now I would say, over the last 6 weeks, we've seen demand level off. While I think it's too early to say that this is a trend, we are cautiously optimistic that we are seeing a flattening of demand, but it's still too early to call it.

Trevor Romeo, Analyst

And then I guess on the locum side of the house, what are you seeing in terms of the supply side with the willingness among physicians and advanced practice providers to take those assignments? I guess, where are we longer term in that adoption curve of the clinicians wanting to take more of the temporary flexible assignments? And how much room is there for that to increase going forward?

John Martins, CEO

Sure. In the U.S., there are around 800,000 physicians, and locum positions make up a small portion of this total. However, similar to trends observed in travel nursing and other staffing sectors, we are noticing that physicians are increasingly seeking more flexible work options, which makes the locum space more appealing. We believe there is still significant potential for more physicians to enter this field. For hospital systems, having enough physicians is critical for driving revenue, so as long as this need persists, we remain very optimistic about the locum market.

Brian Tanquilut, Analyst

Maybe John, I'll go back to the demand question. I mean, in your prepared remarks, you mentioned it sounds like you have an optimistic or more optimistic view in the back half of the year. But what's the feedback? When you talk to hospital CEOs or chief nursing officers, how much more cutting is there? I mean given the strength in demand for volumes at the hospitals, like how does this all blend in, right? And so curious what those conversations are and where your optimism is going from.

John Martins, CEO

Yes, that's an interesting question. You're correct that hospitals are still assessing where demand levels will stabilize. However, based on recent statements from publicly traded hospitals, they seem to be at ease with the current state of contingent labor. Additionally, with rising census numbers and an increase in surgeries, the demand for nurses is likely to persist. We just launched our annual nurse survey in partnership with Florida Atlantic University's Christine E. Lynn College of Nursing, surveying over 1,100 nurses and nursing students. Notably, 43% of nurses report struggling with understaffing at their facilities, and 37% are experiencing a stressful work environment. While these figures are slightly improved from the pandemic era, they remain concerningly high. Therefore, my optimism stems from the possibility of a stabilization in demand trends, supported by the successful programs we've implemented and the ongoing nurse shortage. I believe we can leverage these factors to achieve month-over-month volume growth in the latter half of the year, particularly through effective execution of our initiatives, such as the Intellify platform, which is resonating well in the market.

Brian Tanquilut, Analyst

That makes sense. And then maybe just shifting gears to the Locums business, obviously strong during the quarter. So how do you think about the sustainability of that strength? Maybe number one. And then second, what do you need to do to continue driving that growth, right? I mean in terms of recruiting and things like that. So just curious what that looks like that you try to strategize around locums.

John Martins, CEO

We've experienced several years of growth in locums, outpacing the industry. I don't expect that growth rate to continue this year, but I believe we can achieve a more stable pace. Staffing industry analysts are predicting around a 12% year-over-year increase, which seems to be more in line with future growth. I don't anticipate seeing the 30% growth we had in the previous years, but we are still in a period of sustainable growth. To ensure we continue to grow, we need to focus on attracting the right candidates and providing quality jobs. There is demand for both travel nurses and allied professionals, as well as physicians, but it's crucial to offer quality jobs that come with appropriate compensation packages and flexibility. When we can provide a quality job, it becomes easier to match candidates to those positions.

Albert Rice, Analyst

On the gross margin for the quarter, I think at 20.4%, it was a little below the guidance of 21%, 21.5%; usually have pretty good visibility on the quarter ahead. I know in the prepared remarks, you said the gross margin pressure in general was because of the bill-pay spread. Did anything happen as the quarter progressed toward the end of the quarter that put incremental pressure? Is that just maybe the mix of Locums business being strong or relatively speaking or something else? Any comments there?

William Burns, CFO

Yes, this is Bill. Thank you for the question. In my prepared remarks, I mentioned some burden charges, which were likely one of the larger surprises that only became clear at the end of the quarter. The main contributors were rising health insurance costs and increased visits to doctors. Additionally, the actuarial-driven adjustments for workers' compensation and professional liability were unexpected quarter-end changes. However, I don't foresee much of that happening again, although health insurance costs will continue. Most of the burden we experienced in this quarter, particularly related to professional liability, is not expected to reoccur. Therefore, I anticipate a slight improvement moving forward, which is why we adjusted our guidance upwards. The recent guidance reflects a change that exceeds just the reset of the payroll tax. This quarter, the payroll tax reset was about 65 basis points, which is also higher than we typically see. Some regions, especially California, experienced a greater payroll tax burden this year than we had anticipated. Overall, we were somewhat surprised by the payroll tax and the burdens, but I believe these burdens will normalize as we enter the second quarter.

Albert Rice, Analyst

And the longer-term issue on the whole bill-pay spread seems to be, in some ways, competitor behavior, the people that grab some share in the pandemic were trying to still hold on to. And I know you've talked about it, your biggest peers talked about that. Are you seeing some easing of that competitive pressure? Or is that still pretty prevalent out there?

William Burns, CFO

The pressure continues to be significant. There is a constant competition for talent and on the client side regarding bill rates. We do not anticipate a substantial increase in bill rates, although it's worth noting that the open order rate has shown a slight improvement compared to the previous quarter and year-over-year. While not a major difference, this is a positive indication for us regarding the open order bill rate. On the compensation front, the market remains competitive, and nurse pay packages are quite transparent. Sequentially, we faced some challenges with payroll taxes and burdens. However, the bill-pay housing spread improved slightly from the fourth quarter to the first quarter, gaining around 20 to 30 basis points, which is a step in the right direction. Yet, year-over-year, we still face significant pressure in this area, and I don't expect that to change soon. As I mentioned in the last earnings call, while most pay rates are decreasing at a pace that matches or exceeds bill rates, the housing component has been persistently problematic.

John Martins, CEO

Sure. Thanks, A.J. This is John. And I'd say, much different than a year ago. A year ago, the nurses' expectations were not in line with where the bill rates were coming down and probably even 6 months ago. And now as we've had a sustained period of deceleration of bill rates and pay rates, I think nurses are more apt to accept that they are at a lower rate than they had 2 years ago. But I think there's also another dynamic, and we've called this out before, is that in the height of COVID, we had a lot of core nurses who became travelers. And the travel market had expanded much larger. That travel market, as we will acknowledge as an industry has now shrunk a little bit, still much larger than we were pre-COVID but definitely down. So some of those nurses have left to go back to core. And potentially, those are the ones that were seeking the high pay packages, what drove them to leave their core jobs. But I think the nurses that we have left are the ones that want to travel, want the flexibility, want to enjoy this gig lifestyle, and they are fine with the pay package. Marc, do you want to add anything to that?

Marc Krug, Group President of Delivery

Sure. It's Marc. To John's point, I think expectations have been reset, and many travelers who were pursuing higher pay have returned to their core positions, resulting in the return of traditional travelers to the market. There is a significant level of pay transparency, and everyone is quite aware of the current market conditions in various locations.

William Sutherland, Analyst

I wanted to focus on Allied briefly. Could you remind us of its proportion within the travel business or the Nurse and Allied business? Also, could you elaborate on what's happening with some of those allied positions?

John Martins, CEO

Sure. So it's about 40% of our total travel. And I'll hand it over to Marc, if you want to talk about some of the specialties and what's going on in the Allied world, what you're seeing?

Marc Krug, Group President of Delivery

Sure. And demand is very strong in physical therapy. Imaging continues to have very strong demand. I don't foresee that slowing down anytime soon. Increased reliance on imaging for diagnosis and efficient patient care with the higher volume and the shortage of imaging professionals, and the shortage of people going into the profession is really going to drive demand.

John Martins, CEO

This is John. I would like to add that when we examine allied demand, it closely correlates with the number of surgeries. As we observe an increase in surgeries, there is a corresponding need for ancillary services, the majority of which are allied services. We are seeing a rise in demand for these services, similar to the heightened demand for CRNAs and anesthesiologists. The allied sector tends to follow the trend of increasing surgeries.

William Burns, CFO

We don't usually separate out travel allied. We consider it as total travel, as mentioned earlier. When we look at the second quarter, most of the decline in volume is coming from the nursing side. Based on the mix of specialties within Allied, if you're not seeing demand in respiratory, you're likely compensating for it in imaging and lab. There are many different modalities that make up Allied, which means that segment has been somewhat more resistant to the decline we have observed across the rest of travel.

John Martins, CEO

No. I think assignment lengths have been fairly consistent. Over the past two quarters, specifically the third and fourth quarters, we noticed a slight decrease in our renewal rates, which was expected due to declining demand. However, we are now observing an increase in renewal rates, which is quite significant in comparison to the third, fourth, and first quarters. This indicates that hospitals are in greater need of these nurses as renewal rates rise. I expect that our renewal rate will continue to grow throughout the rest of the year as hospitals increasingly require these clinicians.

Constantine Davides, Analyst

Can you expand a little bit on the challenges specific to the per diem portion of the Nurse and Allied business? It sounds like the first quarter decline was almost twice as large sequentially as what the segment experienced as a whole, if I heard you correctly. And then I guess a follow-up to that is what are you sort of contemplating in your second quarter outlook as far as that business goes?

John Martins, CEO

I'll begin by discussing the per diem market and our observations there. This market closely aligns with travel nursing, and we're noticing a similar decrease in the utilization of those nurses daily. Moreover, a significant portion of our per diem nursing business takes place in skilled nursing facilities, which experienced an increase in clinicians during COVID due to funding from federal, state, and local sources aimed at supporting contingency labor in these facilities. As that funding has diminished over the past year, we've observed a decline in the utilization of contingent labor in skilled nursing facilities, a trend that affects not only us but the entire market. This is the current situation in that marketplace.

William Burns, CFO

And Constantine, this is Bill. I want to mention that the local business differs from travel, which has a longer assignment term and more predictability. When I examine the weekly billings for the first quarter compared to how we ended the fourth quarter, there wasn’t much deterioration. It looked more stable when compared to the beginning of the fourth quarter. Therefore, the first quarter showed consistent performance throughout. Regarding the guidance for the second quarter, it essentially indicates flat sequentially. We do not anticipate significant deterioration or improvement. The local business tends to fluctuate more quickly in response to market conditions than the travel sector does.

Tobey Sommer, Analyst

Last year, there were some competitive pressures impacting market share. Have the effects of that percolated through the P&L? Or is there anything lingering that could provide a headwind of sorts moving forward?

John Martins, CEO

Tobey, over the past six months, we've certainly secured more than our fair share of deals, and we're in the process of ramping them up. As you mentioned, we reported last year that we experienced a higher-than-average number of losses about 18 months ago to a year ago. Most of those have mostly cleared out of the system. Even among the deals we lost, we've managed to keep a significant number of those travelers on assignment. So to answer your question, I believe the situation is mostly resolved. While there are still some strong and weak competitors, the strong ones significantly outnumber the weak ones at this point.

Tobey Sommer, Analyst

Okay. And then with the visibility you have, you said demand has kind of been stable for a handful of weeks, 6 weeks, I think you said. Would you think at this point that TOA in Q3 would grow sequentially, be flat or stable?

William Burns, CFO

Yes. I don't know if I'm calling out the full quarter. I think we would expect to be growing TLA across the third quarter and whether that averages to a full increase over the second quarter, I think, remains to be seen.

John Martins, CEO

Yes, it's complex, Tobey, regarding when we expect that lift to show up in the volume. We do believe that in the third and fourth quarters, particularly with some optimism for the third quarter, we could see month-over-month volume growth during that period.

Tobey Sommer, Analyst

What are the KPIs or demand signals that you used to sort of inform that? Or is it predicated on the survey work and overworking of nurses? So I'm kind of trying to get at how tangible that is.

John Martins, CEO

Sure. If the demand remains stable as it has over the last six weeks, and if there is a slight increase in demand, that boosts our confidence level. This should help answer your question. Regarding demand, I would note the quality of the...

William Burns, CFO

We anticipate that the majority of order improvements in the second quarter will come from our own programs, which tend to yield higher quality orders compared to market orders where we are competing with other companies. We have a clear understanding of the programs we've secured and what is currently being implemented or ramped up. This information will guide our outlook for the third quarter. Although I can’t provide a specific number of orders or details on what that might look like, we expect the order quality to enhance. Additionally, as demand has decreased significantly, it is still falling more than our production levels. We are effectively managing our internal key performance indicators for net weeks booked, and our production levels have remained steady even as orders have reduced considerably.

John Martins, CEO

Yes. Thank you, operator. Before I sign off, I want to relate one last time how truly optimistic I am for the long-term prospects of Cross Country, given that the underlying fundamentals for the industry are intact. We really have a great team and we have a great brand, and we are well-positioned to come out ahead once the market rebounds. In closing, I'd like to thank everyone for participating in today's call, and we look forward to updating you on the progress of the company on the next call.

Operator, Operator

Ladies and gentlemen, this does conclude today's conference call. Thank you for your participation. You may disconnect now.