Participants

Patrick Feeley; IR; Acadia Healthcare Company Inc

Christopher Hunter; Chief Executive Officer, Director; Acadia Healthcare Company Inc

Heather Dixon; Chief Financial Officer; Acadia Healthcare Company Inc

Whit Mayo; Analyst; Leerink Partners

Brian Tanquilut; Analyst; Jefferies

AJ Rice; Analyst; UBS

Ben Hendrix; Analyst; RBC Capital Markets

John Ransom; Analyst; Raymond James

Matthew Gilmore; Analyst; KeyBanc

Scott Fidel; Analyst; Stephens

Andrew Mok; Analyst; Barclays

Presentation

Operator

Hello and welcome to the Acadia Healthcare fourth quarter 2024 earnings conference calls. (Operator Instructions) As a reminder, this conference is being recorded. I would now like to hand the call to Patrick Feeley. Please go ahead.

Patrick Feeley

Thank you, and good morning. Yesterday after the market closed, we issued a press release announcing our fourth quarter 2024 financial results. This press release can be found in the investor relations section of the acadiahealthcare.com website. Here with me today to discuss the results are Chris Hunter, Chief Executive Officer; and Heather Dixon, Chief Financial Officer.
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 in the press release that is posted on our website.
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 2024 and beyond.
These statements may be affected by the important factors, among others set forth in the Acadia 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, I would like to turn the conference call over to Chris.

Christopher Hunter

Thank you, Patrick, and good morning everyone. Thank you for being with us for Acadia's fourth quarter 2024 conference call. For the fourth quarter, we reported solid financial and operating results, capping off another year of growth and progress for Acadia. Total revenue increased 4.2% over the prior year's fourth quarter to $774 million. For the full year we delivered over $3.1 billion in revenue, a 7.7% increase over 2023.
Same facility patient days grew 3.2% in the fourth quarter and remained stable between 3% and 4% in each month throughout the quarter, excluding the impact of a handful of underperforming facilities, same facility growth would have been above 5% in the quarter.
We also benefited from a more stable labor environment in 2024 supported by our initiatives centered around recruitment, retention, and employee engagement and a strong focus on training in our local markets. Working together with our facility operators has helped us attract and maintain talent in a competitive market.
I'd like to now take a moment to reflect on what drives us forward as an organization and why I remain as confident as ever in our strategy. At our core, we are a company dedicated to transforming the lives of patients, families, and those in the communities we serve for the better.
Our facilities treat many of the most complex high acuity cases and fill a critical GAAP in the continuum of care for evidence-based specialized behavioral healthcare.
What sets us apart is our unwavering commitment to putting patient needs first, setting a high bar for care standards and compliance and prioritizing quality. We back up this commitment by investing heavily in technologies to enhance safety and people and processes to support effective patient care delivery.
We believe we have led the industry in adopting the latest technology and evidence-based practices and attracting the most skilled practitioners in the field.
Helping us to deliver safe quality care with positive clinical outcomes and patient satisfaction scores, for example, We are going above and beyond what's required of behavioral health care facilities by investing in electronic medical records which reduce medication errors, improve care coordination, support quality, and ensure the consistent delivery of evidence-based care.
We have added patient monitoring devices across Acadia's acute facilities which enhance patient safety and mitigate incident risk. We believe we lead the industry in performance metrics and the use of this technology, underscoring our confidence that the care delivered at Acadia sets the standard for other providers. We have also implemented wearable safety devices for staff that enables improved response times in mitigation of potential risk.
Our ability to use data has continued to advance significantly. Our integrated quality dashboard now provides real-time visibility into over 50 distinct safety, patient experience, and regulatory compliance related key performance indicators. This gives facility leadership real-time insight into performance across our hospitals, creating a culture of accountability for quality.
As CEO of Acadia, I continue to remain highly focused on these initiatives, and we will continue to prioritize them and expand them when necessary. I strongly believe this patient-centered approach is driving superior outcomes and patient experience and also unlocking operational effectiveness across the organization.
Before I turn it over to Heather to dive deeper into the financial discussion, I'd like to provide a progress update on our growth strategy. We completed construction on approximately 1,300 beds in 2024, including approximately 1,100 completed during the fourth quarter. 776 of these new beds became operational during 2024, including the opening of four new acute inpatient hospitals.
In the fourth quarter, 577 newly constructed beds became operational, including 233 beds to existing facilities and 344 beds from new facilities. In the first two months of 2025, we have added an additional 313 license beds. Joint venture partnerships continue to be an important part of our growth strategy.
We are fortunate that a growing number of well respected health systems are choosing to partner with Acadia to better serve patients by bridging the GAAP between physical and behavioral healthcare. During the fourth quarter, we opened our 144 bed joint venture hospital with Intermountain Health in Denver, Colorado.
We also recently opened our 192 bed joint venture hospital in partnership with Henry Ford Health in Detroit. Looking forward, we have a solid pipeline of potential opportunities to work with other leading providers and attractive markets and expect to add between 800 and 1,000 total beds this year.
We are proud of this progress, which would not have been possible without the efforts of the over 25,000 dedicated employees, clinicians, and healthcare professionals who work at Acadia.
As communities across the United States continue to face an unprecedented mental health and addiction crisis with rising rates of depression, anxiety, substance use disorders, and suicide, Acadia continues to be committed to expanding access and providing the specialized care and treatment that's so desperately needed. As we look to 2025 and beyond, we remain confident in our strategy and goals we have set for ourselves.
At this time, I will now turn the call over to Heather to discuss our financial results for the quarter.

Heather Dixon

Thanks, Chris, and good morning everyone. Our fourth quarter of financial performance reflects consistent growth trends across our diversified portfolio of behavioral health service lines. We reported $774 million in revenue for the quarter, representing an increase of 4.2% over the fourth quarter of last year.
Same facility revenue grew 4.7% compared with the fourth quarter of 2023, which included patient day growth of 3.2% and an increase in revenue per patient day of 1.4%. As Chris mentioned, same facility patient day growth stabilized in the 3% to 4% range for each month in the quarter.
Our revenue per patient day growth moderated versus the 3rd quarter primarily due to the timing of supplemental payments. Absent the impact of timing, pricing trends remained stable as payers continued to place a high degree of emphasis on the behavioral health needs of their members.
Adjusted EBITDA for the fourth quarter of 2024 was $153.1 million. Adjusted EBITDA margin was 19.8% compared with 22.8% for the same quarter last year. On the same facility basis, adjusted EBITDA was $196.4 million and adjusted EBITDA margin was 25.7% in the fourth quarter of this year and 28.4% for the prior year's fourth quarter.
During the fourth quarter of 2024, we recorded a $14 million dollar increase to our reserves for self-insured professional and general liability claims.
This adjustment is related to years prior to 2024 and is largely a result of the unfavorable trends experienced by the broader industry in recent years.
Startup losses related to new facilities were $11.2 million in the fourth quarter of 2024, a $6 million year over year increase relative to the fourth quarter of 2023, and a $4 million dollar increase sequentially over the third quarter, a reflection of the step up in the number of newly-constructed facilities.
These quarterly results also reflect a $7 million revenue impact and a $5 million EBITDA impact due to the decision to close the facility in the fourth quarter as a part of our ongoing portfolio management efforts.
Adjusted income attributable to Acadia stockholders per diluted share was $0.64 for the fourth quarter of 2024 and $0.85 for the prior year period, excluding the income from the provider relief fund in the fourth quarter of 2023.
Consistent with previous periods, adjustments to income for the fourth quarter of 2024 include transaction, legal, and other costs, loss on impairment, and provision for income taxes.
We continued to maintain a strong financial position throughout 2024, providing us with the ability to make the right strategic investments to enhance our operations and support our growth strategy. As of December 31, 2024, we had $76.3 million in cash and cash equivalents and $226.5 million available under our $600 million dollar revolving credit facility with a net leverage ratio of approximately 2.7.
Moving on to our outlook for 2025, as noted in our press release, we are providing full year guidance as follows. Revenue is expected to be in the range of $3.3 billion to $3.4 billion. Adjusted EBITDA is expected to be in the range of $675 million to $725 million. Adjusted earnings per share is expected to be in the range of $2.50 to $2.80. We expect operating cash flows to be in the range of $460 million to $510 million. We expect capital spending to be in the range of $630 million to $690 million. This includes approximately $525 million to $575 million in expansion spending related to the construction of new beds.
Our full year guidance includes same facility patient day growth and the low to mid single digits, as Chris mentioned, we continue to focus on improving volume at a handful of underperforming facilities. However, our outlook does not assume a material improvement in the performance of this group. Were we to see a more material improvement sooner, that would represent potential upside to our guidance range.
As a result, full year guidance therefore assumes an approximate $20 million EBITDA headwind from this small group of facilities. Our full year guidance assumes same facility revenue per patient day growth and the low single digits.
This includes a net year over year change in Medicaid supplemental payments in the range of flat to a $15 million dollar increase. This contemplates a range of outcomes related to the new Tennessee program which the company expects to recognize subsequent to the first quarter of 2025.
I would also remind you that as called out throughout the last year, 2024 EBITDA included approximately $10 million in non-recurring supplemental payments.
Full-year guidance includes $50 million to $55 million in total startup losses related to newly opened facilities. This represents a year over year increase in startup costs of approximately $25 million as compared to 2024, a reflection of the significant increase in the pace of bed growth, as well as the timing of new facility openings.
Full year guidance also includes a year over year increase in professional liability expense of approximately $10 million. This increase is related to recent trends experienced across the industry, including higher reinsurance costs, and we believe reflects a more conservative position.
I would also point out that 2024 consolidated results included approximately $60 million of revenue and $5 million of EBITDA from facilities that were subsequently exited, or a 200 basis point and 70-basis point headwind to 2025 revenue and EBITDA growth respectively.
We also issued financial guidance for the first quarter of 2025 as follows. Revenue in the range of $765 million to $775 million and adjusted EBITDA in the range of $130 million to $135 million.
First quarter guidance includes the following assumptions. Given the large number of beds open towards the end of 2024 and anticipated in early 2025, startup losses are expected to be disproportionately weighted towards the first half of the year.
First quarter startup losses are expected to be approximately $20 million representing an increase of approximately $15 million over the first quarter of 2024.
First quarter guidance assumes a net decrease in Medicaid supplemental payments of approximately $10 million to $15 million.
As a reminder, 2024 first quarter results included $7 million in non-recurring supplemental payments.
I would also note that first quarter 2024 consolidated results included approximately $25 million of revenue from facilities that were subsequently closed, representing a 300-basis-point headwind to first quarter growth. Facility closures are expected to be a headwind to year over year EBITDA growth of approximately $5 million in the first quarter.
Finally, for modeling purposes, I would remind you that last year's first quarter had one extra day compared to this year's first quarter. As always, the company's guidance does not reflect the impact of any future acquisitions, divestitures, transaction, legal, and other costs, or non-recurring settlements expense.
Before we move on to Q&A, I would like to talk briefly about the outlook beyond 2025 and the significant tailwinds for this business over the next few years. We materially accelerated the pace of new bed growth in 2024, and we expect to add another 800 to 1,000 beds in 2025.
This means we will have roughly 1,600 to 1,800 new beds that we expect to go from generating startup losses to a positive EBITDA contribution over the course of 2026 and beyond. At the same time, startup losses from new facilities are expected to decline beyond 2025.
Therefore, we see an inflection point in earnings growth in 2026 and expect 2026 EBITDA growth to be towards the high end of the long-term outlook range provided with our press release yesterday.
We anticipate the benefit of accelerating EBITDA growth combined with the decline in capital spending will drive the company towards meaningful free cash flow generation.
As a reminder, a little over $100 million of our annual CapEx is related to maintenance and IT spending, or about 2% to 3% of revenue, with the remainder going towards the construction of new beds and CTC facilities. As such, we anticipate a material reduction in capital expenditures relative to our current quarterly run rate later this year and again in 2026 as the pace of bed construction moderates from the recent highs.
Over the three years beginning 2026, we expect revenue growth of 7% to 9% and EBITDA growth of 8% to 10%. We have excellent visibility into this level of growth as we moderate the pace of our bed additions to 600 to 800 beds per year, still well above our historical pace of annual bed growth.
Moderating the pace of bed growth will allow us to unlock more of the embedded EBITDA and free cash flow generating power of the record setting beds added throughout 2024 and 2025. Going forward, we believe the pace of investment and new bed growth strikes the right balance between investment and the growth of the business and the generation of free cash flow.
In summary, we believe we can continue to invest to meet growing demand and drive a healthy pace of top and bottom line growth while returning to free cash flow positive by the end of 2026.
We believe this more balanced approach to growth and free cash flow generation will also provide the company increased flexibility going forward when it comes to capital deployment.
Finally, as noted in our press release, our board of directors has authorized a new $300 million share repurchase program. Repurchases will be made in accordance with applicable securities laws and are subject to market conditions and other factors.
With that operator, we are ready to open the call for questions.

Question and Answer Session

Operator

Thank you. We will now begin the question and answer session.
(Operator Instructions) Whit Mayo, Leerink Partners.

Whit Mayo

Hey, thanks. Maybe Heather to follow up on that last comment. Obviously you have a lot of capital commitment this year. Guidance implies that you're burning maybe $180 million of cash. The interest expenses up presumably might include some incremental debt. To fund the growth. So one of their financing plans this year, and can you give us an idea on preliminary sources and uses of cash next year? Like how much exactly will the growth CapEx and IT spending be down in 2026?

Heather Dixon

Hi, thanks for the question. Yeah, just to give you a little bit of information in regards to the financing option that you mentioned, if you look in our 10-K, you will see a disclosure included regarding the refinancing that we are just about to wrap up it it.
Mentions that we have refinanced the existing bank facilities and also that we will be upsizing our revolver to about a billion dollars. So that is contemplated in in what's disclosed in the 10-K and there should be more coming about that shortly.
In terms of free cash flow and how we think about that, we have Messaged and you would have seen in our disclosures that came out in the press release that we expect to see cash flow be back to cash flow positive by the end of 2026, and that is largely a result of a couple of things.
The first would be the EBITDA contribution that we expect to see beginning in 2026. And that is as the result with a couple of things. One, the contribution from the new beds that we have been adding, those should start to really generate nice EBITDA in 2026. And two, the cessation of the elevated level of costs associated with the pre-opening of those facilities. So those two things in confluence should generate operating cash flows at a nice rate.
In addition, you'll see that CapEx will come down as well. The high water mark for CapEx sort of came to the end of '24 and will continue with that rate in the beginning of '25 as we continue to have that high pace of beds opening, but that should moderate and then start to decline in the back half of '25 and then continue to decline in 2026.

Whit Mayo

Is there a number that you can share within a range for how much the CapEx is going to decline next year.

Heather Dixon

It's -- I don't want to provide guidance on 2026 at this point, but we would expect the run rate of CapEx to come down materially over '25 and then again in 2026. I mean, maybe ballpark around $100 million.

Whit Mayo

Okay. And then the follow up here, just the first quarter guide implies that you're going to earn, I think, like 18% of the full year, which is certainly a question that we're getting. Can you just maybe help us think through a bridge from the from the first quarter to the full year? I mean, there should be more supplemental dollars in the back half, fewer startup losses, maybe an expectation the growth is better. Just any numbers around that to frame kind of the walk forward would be helpful. Thanks.

Heather Dixon

Yeah, let me take that and hopefully I'll hit all the pieces that you were looking at. So you can see in the first quarter and certainly the full year guidance that the first quarter is expected to contribute less to the full year than what we would see in a typical year, but we would also anticipate the second quarter is likely to be less than typical as the percentage of the full year as well due to similar timing factors looking year over year.
That's largely driven by a couple of things, the first, the startup costs that we've been talking about, and then also the timing of supplemental payments.
Yeah, we expect the first quarter to be the high water mark for startup losses, with about $20 million in total startup losses for the quarter out of the $50 million to $55 million that we're guiding to for the full year. So think about roughly 35% to 40% of the full year startup costs landing in the first quarter alone. And startup costs are expected to taper down over the course of the year. So the second quarter is also likely to be elevated.
But again, that depends on the timing of, several factors which are hard to predict with any precision. The other swing factor I would mention is related to the quarterly cadence for supplemental payments, the net supplemental payments, including the associated taxes, and those can be lumpy and, as hard to predict with precision. But what our guidance assumes is that first quarter supplemental payments will be down about $10 million to $15 million year over year, but they will be up for the full year. So I would suggest for modeling purposes, you assume second quarter net supplemental payments are down year over year as well.

Whit Mayo

Yeah thanks.

Operator

Brian Tankila, Jefferies.

Brian Tanquilut

Hey, good morning. Maybe Heather, just to drill down into some of the comments you made on the long, longer term growth algorithm or growth outlook. Just curious, I mean, as we think about 10% bet ads the past few years in a soft comp in 2025. And I know you said high end of the range, in '26. So shouldn't that be higher than that 8% to 10% range, number one, and how should we be thinking about the margin and pricing assumptions that you have, post 2025?

Heather Dixon

Yeah, hi, thanks for the question. I'll just maybe start by reiterating a couple of things, the revenue growth at 7% to 9% for those several years beginning and, beginning after this year. And EBITDA growth of 8% to 10%. So to your question about How should we feel about margin and margin expansion just to point out the delta and those two numbers that we've headlined and I'll just point out one more thing.
We would expect 2026 to be at the high end of that range, based on all the things that I just talked to in response to Whit's question a little bit more granularity. We'd expect volume growth to be in the mid-single digit range on average, and that pulls in the beds that we're adding, of course. And to answer that question that you asked. But as we said in the past, we'd expect average rates to normalize back towards the historical low to mid-single digit range at some point in the future, and our long-term outlook assumes we see rate growth in that area.
That doesn't mean that we won't have years when we outperform, as I mentioned, 2026, we're going to be at the high end of that range, but our base case assumes that we see a more normalized growth rate and, that's a prudent approach and leaves room, for conservatism and for us to outpace that.
Maybe just stepping back a little bit higher level, that was a lot of granular detail. I just want to say a couple of things about the long term guide. Nothing has changed with how we're thinking about the opportunity here, the strategy that we have in terms of, meeting that significant unmet demand is the same. We'll continue to expand capacity and we'll we'll continue to meet that need, but.
What we're doing today is taking a more balanced approach, and that's balancing CapEx bed growth, and free cash flow. We can still add beds at a much faster rate than the company has historically done and drive top and bottom bottom line growth at the same time.
To be clear, our growth strategy remains primarily focused on deploying capital efficiently towards growth and expanding the footprint of the business to meet those needs. And I'm not suggesting any sort of shift away from that with this long-term guide.
But we also recognize the opportunity to moderate the pace of spending, smooth out the bed growth a bit, and then unlock more of the free cash flow power embedded in the business as these beds continue to ramp, as we've been talking about, and that's going to give us the ability to be more opportunistic from a capital allocation perspective.
So that, that's a reflection, this refreshed look is a reflection, as we look back and look forward and making sure that we are being appropriately prudent when we're building our assumptions and putting targets in the market. So maybe just to summarize, I've said a lot, it's really a combination of those two things. I would add that we have a high level of confidence in this growth outlook and our visibility is supported by the significant embedded EBITDA power from the thousands of beds that we've been adding.

Brian Tanquilut

I appreciate that. And my follow up as I think about Q1, there's a lot of chatter about whether it's the fire fire issues in California or snowstorms.
Just curious what you're seeing in terms of that and then kind of like if you can share the same sort of assumptions that you've made into the Q1 guide just out of curiosity. Thanks.

Heather Dixon

Why don't I just maybe give you a little bit of the color on the bridge in general just to address that and then any sort of knock-on questions here just for clarity. So for Q1, I'll start with startup costs. I mentioned this, but I'll just reiterate in terms of Q1 specifically here to be complete, we expect about $15 million in higher startup costs versus the first quarter of 2024, and we expect that to be to the high water mark for the year.
In terms of supplemental payment, the first quarter will be down around $10 million to $15 million year over year due to timing, and recall that we had $7 million in out of period payments in the first quarter last year.
We mentioned in our press release that we had a facility closure right at the beginning of Q1, that's about a $5 million dollar drag to Q1 for 2025, and then, come to your point on on volume, our '25 outlook does not assume a material improvement on those handful of facilities that we've previously talked about. It's difficult for us to put an estimate on the timing for the turnaround of a small group of facilities. And so we believe it's more prudent just to take a conservative approach when we're setting guidance.
So 2025, as a result of that assumes roughly a $20 million dollar EEA headwind for the full year from that handful of underperforming facilities.
And just directly to your question, that's not specifically related to, fires or or any of the other, events.
There, there's, normal seasonality with weather, of course, always in Q1, but nothing that I would call out here. It's just focused on those few facilities. One point on that, the year over year headwind would be spread over the first three quarters of the year, just as a reminder because the fourth quarter would already have been impacted in 2024. And so, we should see a tailwind as we comp over the fourth quarter of 24 results. So that's a total of 20 in the year, but really, distributed to the first three quarters and then, starting in Q1.
One last thing that that we haven't talked about that I'll just mention for completeness as I'm going through the bridge for Q1 is professional liability expense. We -- you would have seen that we took a charge in Q4 and we're also assuming in the guidance for 2025 an incremental $10 million year over year for the full year so obviously there's going to be a piece of that in one as well that's that's just a reflection of what we believe is a more conservative approach to reserve claims this year.

Brian Tanquilut

Awesome thank you.

Operator

AJ Rice, UBS.

AJ Rice

Thanks. Hi everyone. So in Q4, I think the revenue, per day moderated, growth to 1.7% and then 3.6% in Q3, which is more like what it was for the full year and you're calling out low single digit pricing, growth for 25. I'm just trying to understand. I know there's some moving parts and maybe that's impacting it more than is a parent, but.
Is that something you're seeing rates come down on the Medicaid side, on the commercial side, or otherwise or rate growth rather moderate, or are you just giving yourself the leeway that it could moderate?

Heather Dixon

Yeah, hi AJ, thanks for the question. Maybe I'll just go through a little bit of detail on the rate and what we're thinking about when we go through guidance.
First, I just want to, I know I've said it a couple of times, but I think it bears saying again, the 25 guidance assumes supplemental payments will be flat to up $15 million for this year. So the '25 guidance essentially assumes we'll get a little less of a tailwind relative to the years past.
The timing and the magnitude of those payments, can be very difficult to predict, and if that improves then we have more visibility or timing shifts then we will see upside and that could be, it's a positive swing factor for us in the reported revenue per day.
And the second thing I would say is, given the noise on the policy front, we just believe it's prudent at this early point in the year, incorporate a more conservative approach in our thinking about rate updates given the broader environment.
There's nothing specific on the horizon that we're seeing is concerning, but we have taken a slightly more cautious approach as we think about 2025, given the level of uncertainty on the policy front.
If this level of conservatism proves unnecessary, then great growth could wind up closer to the mid single digit range. And it may finally just to round it out from an overall rate perspective, we're assuming the commercial rate environment remains stable.

AJ Rice

Okay and then for my follow up. Looking at the different margin dynamics, I know again there's a lot of moving parts. I think fourth quarter you're 19.8%. that gave you the full year even down margin about 22.5%. I think for the last five years prior to that you've been more like 23.3%. If I look at.
Peel away what you're saying about liability and those cluster of facilities that are underperforming. What are you assuming in '25 that your core portfolio does in margin stable? Is it down? And if I look at the implied growth, going out a couple years, I think you you sort of back of the envelope get to about 21.5% for '28, which is below the five year prior. Are you thinking?
That you can't can't that the margin of the last five years is probably higher than you're going to see for quite a while. So essence of it, what's the assumption for the underlying portfolio actually the call out for '25 and is the assumption that that the margin of the last five years is a couple 100 basis points higher than what you're likely to get to even a couple of years from now.

Heather Dixon

Okay, AJ, let me try to answer that. So, I would point to a couple of things at a very high level. Let me just talk about a couple of things. You talk about Q4 '24, and the impact full year and then moving into '25. What do we expect and and pointing to specifically that margin compression. Q4 margin compression was, very specifically a result of two things. That was the additional reserve for the professional liability reserve and the closure of liability in the quarter. So that's what drove that and obviously it impacted the full year as well.
As we think about '25, I would just point out to a couple of things I won't belabor these. But we've got the startup costs and we have the continuation of the professional liability expense that we are assuming a higher rate for 2025. That's about $10 million over 2024. And then when we look at at volume, we, we're not expecting a material improvement, as I said, in those few facilities. And we're just trying to be prudent and take a conservative approach when we set the guidance, and that is giving us about a $20 million dollar headwind toe it off for 2025.
If those items that I'm calling out improve, then we will have upside and we will have a tailwind as we move through. The year, but we just felt it was better to be more cautious at this point to your question of what's the underlying business look like from a margin perspective, we see that as stable. It's just these few things that we're calling out specifically on top. But the underlying business we see is continuing to be stable in the range that we've seen historically.

AJ Rice

Okay, alright, thank you.

Operator

Ben Hendrix, RBC Capital Markets.

Ben Hendrix

Hey, thank you very much. Last quarter, you talked a lot about depressed referral activity on the back of some difficult press headlines last year.
Can you give us an update on how your referral activity has progressed across your various service lines into 2025 and then how should that impact the pacing we should expect through the year of your low to mid single digit, same sort of volume growth that you've you've put into guidance. Thanks.

Christopher Hunter

Hey, thanks, Ben. This is Chris. Why don't I start and maybe Heather can add some commentary as well, I would say just on the referral source front that we just continue to be very engaged with outreach to our external stakeholders, including all these key referral sources and other important partners. We have been very intentional about consistent outreach.
Really to correct any of the misunderstandings that were created from the media reporting and as we've consistently emphasized for them the quality of the care that we provide, the substantial investments that we're making, and safety and compliance and quality over the last two years that we continue to make, we think that that is resonating. We have put particular focus on ensuring that our most important referral sources do understand. The facts and we've, clearly put some commentary on our website that I think has a lot of detail that has been very well received.
And so when you just look across our entire facility base, the referral issue continues to be less and less of a challenge, and it allows us to focus on the smaller number of facilities that Heather referenced are still performing below our expectation, right now. So Heather, anything you would add? .

Heather Dixon

Just maybe to double down on a couple of things there, Chris, we talked about, back in January that the majority of the headwinds were coming from a handful of facilities and that began in Q4, as Chris mentioned, we are just continuing to work through the process and turning around the small group of facilities.
But you know, I would just note as well that, in the portfolio portfolio of this size in any period we're going to have some that overperform and some that underperform and we spent the last several months just really getting to understand the referral pattern issue and mitigate it where appropriate. And we're at a point now where if you look across our entire book of business, we feel good that referrals are not a widespread issue.
But as I noticed, we're focused on, the small number of facilities that are performing below our expectations.

Ben Hendrix

Thank you.

Operator

John Ransom, Raymond James.

John Ransom

Hey good morning, if we look out to '26 and beyond the mix of bed ads, it's crept up in terms of de novos versus facility ads. What does that look like in the out years?

Heather Dixon

Hi, John, good morning. As we look out in the out years, I think we'll con we'll continue to be focused on denovos, some of those JV partners just based on the pipeline that we have as well, but I would say de novo facilities heavily focused in the acute space.

John Ransom

So our math is that, the construction costs have gone up probably a third or so since the plan was laid out by the old management team in '21. So, unless the returns have improved, it looks like to us like thee of returns are in the maybe 10% range, but I just didn't know is there a rethinking of the de novo math and do all these projects still make sense in kind of light of the current environment.

Heather Dixon

So no, I don't think there's anything there to talk about in terms of the profitability or sort of the returns expectations for those facilities. I mean, it's clear that we have multiple options of how to deploy capital and we apply a very rigorous approach that that we've talked about many times before. We are, constantly looking at.
Those returns we're making sure that we have our models updated for the right information and we continue to see, the benefit from those those hospitals, those de novos that we're adding and, we have seen nice returns over the last several years. We've seen rate improvement and we've seen that really contribute to volume and I think we will we'll see that in a big way in 2026 whenever we see that happening so.
Whenever we see the cost of construction, the construction rates going up in some pockets, that's what we feel confident about the rate growth that has kept up with that construction cost at the same time. So from a returns perspective, we still feel good about those returns.

John Ransom

Okay, thank you. And just two more quick ones for me, the MIT business slowed a bit in the quarter, we're, seeing mid single digit, growth. Number one, and then number two, just going back to the question on referral patterns and underperforming facilities are the ones that are left are these mostly in the markets that were the subject of the media scrutiny or are there other markets? Thank you.

Heather Dixon

So, that business, as you will recall, has grown substantially over the past 12, 18 months, maybe even 24 months, and that is that experienced great growth. The growth rates we have expected would come down just as a comp over the prior years because of that significant growth, there is.
A lot of strength in that business. We continue to see record volumes associated with that business. So there's nothing I would point to apart from just the normal, growth pattern as we talk over some periods of significant growth. We still see that as a strong business and we think about it as a mid single digit grower for future periods.

John Ransom

Okay, thank you.

Operator

Matthew Gilmore, KeyBanc.

Matthew Gilmore

Hey, thanks for the question. So for the underperforming facilities that you've called out, can you maybe just give us a sense for, what you're doing on the ground to to improve the results there?

Christopher Hunter

Yeah, thanks, Matt. I would start with health care is local, so for us it really starts with a comprehensive review of the competitive landscape. We look really closely at the programming at that individual facility. And then you know as we really dig in and make an assessment on you know a specific facility we're going to look at a number of very specific factors.
So one would be -- we'll look at the business development function we'll look at the current funnel, we'll look at the referral sources, identify any gaps in coverage, and, clearly work with the team, on a plan there. We're going to look really closely at admissions and that can include.
Inquiries it can you know look at deflections and what's going on there we're going to do an assessment of the leadership team, not only the quality of the team but also any staffing needs and gaps related to that team.
We'll look at technology. We've obviously invested heavily, but we want to ensure that there's, adherence and, really strong adoption. Of the platforms that we've put in place from the remote monitoring technology to the EMR to the patient safety and specifically the comprehensive quality dashboards that we've put in place as well.
So we want to make sure that that is also in place. And then the final thing I would say is maybe just the Physical plant we would even look at, are there any facility improvements that, would be an impediment. So it's a comprehensive suite of things that we're looking at working very closely with our operational leadership and getting very granular on the ground level.

Matthew Gilmore

Got it. And then as a follow up, should we think about the drag from those facilities assuming there's no improvement over the over the near term, but that'd be a 2% drag kind of consistent with what you saw in the fourth quarter?

Heather Dixon

Yeah, that's about the right ballpark now. Okay, thank you.

Operator

Scott Fidel, Stephens.

Scott Fidel

Oh hi, thanks. Good morning. First question, just, wanted to, get your update around. I know that you had talked about, in the last few quarters that it, ultimately you saw sort of the volumes, start to moderate a bit that, you would have flexibility to potentially flex down, some of the the labor you know staffing related costs.
The full year guidance does assume a bit lower of a volume frame, around it, so just curious sort of how are you guys thinking about, that option, or lever, doesn't seem like you have, much, embedded into the guidance, around that, but, was hoping to get your sort of breakdown of some of the, options you have around, flexing down cost potentially.

Heather Dixon

Yeah, hi, thanks for the question. That that's a good question. If you recall in Q4 when we brought the guide down related to, the pressure that we were seeing, we brought the EBITDA guide down disproportionately higher than the revenue guide, and that implied about a $15 million EBITDA headwind for Q4 of '24. As we think about 2025, we are anticipating for that same small group of facilities about $20 million of a headwind built into $25 million. So to your question of have we started to focus on cost levers and right sizing the cost structure? Yes. Because $15 million for for one quarter alone versus $20 million for the full year is factoring in the cost measures that we are taking and the things that we're doing in relation to those facilities.
Just as a reminder, we have not built in any upside expectations from a volume perspective for that handful of facilities for the year, but if those facilities were to begin to turn around and and the volume.
Improves, that would of course be upside and a tailwind for us as we move throughout the year. But at this point, because the timing is hard to predict on those facilities or any facility that we're working on, we thought it was more prudent to take a cautious approach.

Scott Fidel

Okay. And then as my follow up, I wanted to know whether, as you've announced, or the board announced that the $300 million dollar expansion of the buyback program, whether there's any type of, methodical, inputs or sort of framing that you're going to be approaching this around. In terms of sort of, like a maximum leverage, target that you'd be willing to go to fund buybacks, as compared to comparing against sort of, the current valuation and pressure, in the stock and then on that front, maybe if you want to just, give us some. Some clarity around. What you're thinking would be the maximum leverage, given the increase in the revolver. You know that you have, accessible to to fund, some of the negative free cash flow in the projects that you have, until you get to '26 where FTF is expected to improve.

Christopher Hunter

Thanks Scott. This is Chris. I'll go ahead and start and see if Heather wants to add anything, I would just start by saying, I mean, we have this authorization that's been approved by the board in place and it was clearly deliberately put in place to utilize and we're planning to do so. We're not going to comment on any specific timeline, but I think right now from a leverage standpoint and Heather can chime in. We would expect to naturally de-lever as dog grows over the next few years, and we talked about anticipating, an inflection point with respect to free cash flow in '26. And so what would you add from there?

Heather Dixon

I mean that's the exact point that I would add, if we think about, to your point of effectively when and how would we fund. And think about actually being in the market in terms of leverage. We have a comfortable leverage ratio, and we are expecting that to come down naturally to Chris's point, we've talked about '26 being a significant growth year for us from an EBITDA perspective, and that will naturally bring that leverage back down.
And then we think even beyond that if you think about the CapEx reductions that's going to bring that leverage down as well. And so given that we would be comfortable looking at, taking up leverage in order to to fund what we need to do from a share repurchase perspective just given the cash flow power in the business, we'd see comfort there.

Scott Fidel

Okay, thank you.

Operator

Andrew Mok, Barclays.

Andrew Mok

Hi, good morning. Obviously a lot of attention on state directed payments lately. I think you can appreciate that investors want to understand the risk to get comfortable, around that area of concern. So can you disclose your total exposure to state directed payments for us for 2024?

Heather Dixon

Yeah, sure. Hi Andrew, good morning, would be happy to. So the total gross supplemental payments, would be less than $200 million, and that's of course before the provider taxes that we pay into those programs.

Andrew Mok

Okay, so about 2/3 of that is a good ballpark to think about in terms of net benefit.

Heather Dixon

I just wouldn't, I wouldn't expect ours to be any different than that for the rest of the industry. That's a pretty good ballpark.

Andrew Mok

Understood. And then I'm still struggling to understand how there could be such a significant drop off in revenue per patient day from mid to low single digits, mid single digits to low single digits. Especially when I think about fiscal year '25 rates carrying into the first half of calendar year '25 and state supplementals being up overall, it seems like you're kind of pointing to state supplementals being the area of conservatism.
But that seems to go against the philosophy of booking six quarters of Tennessee. So if state directed payments are up overall, it feels like there's a moderation on either core rate or CTC revenue. Is there anything you can share that might help reconcile these comments?

Heather Dixon

Yeah, let me head on a couple of things. The first we've talked about, supplemental payments that in prior years they've been a nice tailwind for us and that it will be less of a tailwind certainly compared to the relative, recent years.
The second thing that I will just reiterate is that we feel that there is that it's the right thing to do to just be prudent at this point in the year just just given.
Everything that, the noise that we're seeing, we feel like it's better to take a conservative approach and, certainly there will be upside there if our conservative approach is is sort of proven wrong. And then just directly to your question regarding CPC, that's service line delivered. Above trend growth obviously in '23 and early '24, and that was a tailwind of about 100 basis points to our growth in the early part of 2024 from a rate perspective, and that's just naturally is the growth rate moderate over the prior year comp, we would see that become less of a tailwind.
In '25, we wouldn't expect that service line to be a material swing factor in either direction. It's just not the tailwind that we had early in 2024.

Operator

Thank you. This concludes our question and answer session. I would now like to turn the call back over to Mr. Hunter for closing remarks.

Christopher Hunter

Thank you. In closing, I want to again thank our committed facility leaders, clinicians, and over 25,000 dedicated employees across the country who have continued to work tirelessly to meet the needs of patients in a safe and effective manner. We have a strong foundation and a proven strategy for driving growth and delivering greater value to both the patients we serve and our shareholders.
Thank you for being with us this morning and for your interest in Acadia. Have a great day.

Operator

The conference has now concluded. Thank you for your participation. You may now disconnect your lines.