ATI Physical Therapy, Inc. (NYSE:ATIP) Q3 2022 Earnings Conference Call November 7, 2022 5:00 PM ET
Company Participants
Joanne Fong – Senior Vice President, Treasurer and Head of Investor Relations
Sharon Vitti – Chief Executive Officer
Eimile Tansey – Chief People Officer
Ray Wahl – Chief Operating Officer
Joseph Jordan – Chief Financial Officer
Conference Call Participants
Brian Tanquilit – Jefferies
Jason Cassorla – Citi
Operator
Good afternoon, and welcome to ATI Physical Therapy’s Third Quarter 2022 Earnings Conference Call and Webcast. All participants will be in a listen-only mode. After today’s presentation, there will be an opportunity to ask questions. [Operator Instructions] Please note, this event is being recorded.
On the call today is Sharon Vitti, Chief Executive Officer; Eimile Tansey, Chief People Officer; Ray Wahl, Chief Operating Officer; Joseph Jordan, Chief Financial Officer; and Joanne Fong, Senior Vice President, Treasurer and Head of Investor Relations.
I would like to now turn the call over to Ms. Fong to read the Safe Harbor and forward-looking statements.
Joanne Fong
Thank you Abby. Good afternoon, everyone, and thank you for joining us for today’s call. Before we begin, we’d like to remind you that certain statements made during this call will be forward-looking statements that are subject to various risks and uncertainties and reflect our current expectations based on our beliefs, assumptions and information currently available to us.
Although, we believe these expectations are reasonable, we undertake no obligation to revise any statements to reflect changes that occur after this call. Descriptions of some of the factors that cause actual results to be materially different from these forward-looking statements can be found in the Risk Factors section in the company’s filings with the Securities and Exchange Commissions.
In addition, please note that the company will be discussing certain non-GAAP financial measures that we believe are important in evaluating performance. Details and the relationship between these non-GAAP measures to the most comparable GAAP measures and a reconciliation of historical non-GAAP financial measures can be found in the earnings press release that’s posted on ATI’s website and filed with the SEC.
And with that, I’d like to turn the call over to Sharon.
Sharon Vitti
Thank you, Joanne. Welcome everyone to our third quarter earning call. I am joined today by Eimile Tansey, our Chief People Officer, Ray Wahl, our Chief Operating Officer and Joseph Jordan, our Chief Financial Officer.
But since our last call I continue to learn about the ATI business and the physical therapy ecosystem and have far more definitive views on what the business needs. I’ve enjoyed meeting with many of our therapists, patients and stakeholders across the country and we’ll begin by sharing some observations.
Next I will provide highlights of Q3 results with a focus on our most impactful operational levers, the 3Ps of our practice; pipeline, provider base, and provider productivity. These are critical drivers to achieving our near term growth targets. Eimile will discuss the labor environment and key activities around our provider base. Ray will walk through operational performance during the quarter and Joe will take us through a detailed review of financial results. Finally, I will wrap up with closing remarks before we open the call to Q&A
To start I want to thank ATI’s talented and dedicated team of clinicians who later than emotionally invest and are passionate about enriching the lives of the patients and communities they serve. Over the last few months, I’ve had the pleasure of visiting clinics and hosting in person townhall meetings across the footprints. Altogether I’ve probably met and spoken with close to 1000 team members and my reaction to what we offer we made strong and proud.
The passion of the teams and the commitment to helping patients get back to their lives it’s consistent and visible. I observed firsthand the dedication of our teams to help patients on their healthcare journey and ensure that everyone feels like a member of our ATI family. From our patients, new hires, established colleagues and corporate teams when I asked them why they love ATI, it’s the people.
ATI was built on a solid foundation and the company is poised for success with the work ahead. While demand for physical therapy remains strong, the healthcare provider labor market and economic environment continue to present challenges. We are eager to demonstrate to our investors, board and employees our ability to define, execute and deliver on the right actions for both short and long term success.
Regarding our first operational team pipeline, sustained demand for physical therapy care reiterates the value of this offering and then the third quarter the pipeline for ATI services continues to be strong. Referrals grew quarter-over-quarter and are just shy of pre-COVID levels. Our business development team is focused on local relationship building alongside our clinicians with targeted referral sources and employer customers. The second P; provider base, the headwinds we discussed previously with recruitment and hiring persisted through the third quarter.
Despite the tough labor market, our ATI employee attrition rate excluding our clinician contractors, has improved since the beginning of this year, and it’s currently in the mid 20s. Moreover, in the third quarter, the clinical FTE count remains stable. The labor challenges affecting ATI and the broader PT market will take some time to dissipate. In the meantime, we are not standing still, and are making investments and executing on tactics both short and long term to accelerate the way we grow our provider teams.
One of my first priorities in this regard was to fill the Chief People Officer role. I’m delighted to introduce Eimile Tansey on this call. She joined us CPO just over two months ago. Eimile is a strong and seasoned leader with more than 20 years experience in human resources and operations in healthcare and provider organizations. Eimile will share some perspective shortly on the labor market, and discuss new approaches and talent acquisition and people development to advance the business. We are delighted to have her.
For the third P; provider productivity our teams across our national footprint saw an average of 8.7 visits per day per clinical FTE in the third quarter, and 8.8 visits per day per clinical FTE in the year-to-date period. And when we break this down, we rank our clinics based on productivity in Q3. The providers in the top 80% of our clinic saw on average of 9.5 VPD per clinical FTE, compared to the bottom 20% of our clinics that are at a 6.5 VPD. So the top 80% of clinics are doing well, seeing patients and achieving or exceeding our productivity targets. We believe there’s room for incremental improvement in both groups and we’ll discuss our roadmap later in the cost.
We completed a first pass and reviewing our clinic footprint and observed a similar clustering related to financial and operational performance. We see the top 80% of our clinics meeting were exceeding performance targets while 20% are under performing. We are currently pursuing different approaches to optimize half of the underperforming clinics including consolidation, closure and divestiture. We will also continue to closely monitor the remaining lag in clinics. In addition to boosting financial returns rethinking select clinic locations will strengthen operations and facilitate redeployment of displaced providers to clinics with more demand.
Now historically, ATI has increased the number of clinics every quarter since the company’s inception in 1996. While we plan to continue opening De Novos. in attractive geographies and markets, we’re taking a hard look at the existing fleet and will exercise discipline and pruning underperforming locations. Looking ahead in 2023, we may have a decline in total number of clinics year-over-year as we prioritize same clinic growth over expanding clinics.
We continue to gain insight into the past for near and long term earnings and cash potential of this business. In the third quarter, we have identified and developed work plans on a portfolio of initiatives with the deliberate aim to strengthen our financial position, including execution of several quick sprint efficiency and improvement projects in 2022. The priority areas for review, organizational change, and/or process transformation includes streamlining the corporate SG&A function, redesigning our referral and patient intake structures and leveraging technology to improve revenue cycle performance. We are moving with speed and are focused on being prudent with our spend and conserving cash. I’m pleased with the focus, the intensity and the progress that our teams have made.
Finally, we need to celebrate our exceptional rating under the Medicare Merit Based Incentive Payment System otherwise known as MIPS, and our outstanding NPS in Google star rating customer satisfaction scores. Both are testaments to our purpose driven culture.
As I said before ATI has solid foundation and talented team of leaders. I am confident we will continue to make progress toward our goals.
With that, I will turn the call over to Eimile for a discussion of talent acquisition and people development.
Eimile Tansey
Thanks, Sharon. I’d like to provide perspective on the current labor market and discuss some of our activities aimed at our provider base. Through the pandemic, the overall health care industry has seen the number of providers decline. This is also true in the outpatient physical therapy sector.
The American Physical Therapy Association recently issued a benchmark survey showing most PT practices reported hiring challenges and significant vacancy rates. With this backdrop, I am focused on developing programs that will further advance ATI as an outstanding place for providers to start, build and accelerate their careers. In the short time I’ve been here at ATI, I’ve had the distinct pleasure of joining several listening tours, and getting on the road out to clinics to personally connect with the frontline and understand our care delivery model. It has been great to meet with providers and hear their questions, concerns and goals. Being a large national operator has certain advantages that allow us to offer unique talent programs for providers to gain a wide range of medical experiences and stay in the ATI family.
One new program I’m really excited about is called Explore ATI. This program is geared towards our providers who are mobile and want to accelerate their learning. Explore ATI is an opportunity to spend one year at a clinic and then rotate each year to a different clinic while the person remains in the program. Participants can travel and live in potentially any of the 25 states where we currently operate while gaining experience, treating different patient populations and all of this while building relationships and tenure with the company. If a clinician is interested in the business side of physical therapy, we have the pathways program that is an opportunity for career progression through managing a clinic, a district and even a region. In the third quarter, we also began refining our hiring tactics.
We are testing and iterating with various forms of digital outreach, including social media, geo-framing and programmatic media to better engage passive candidates with onpoint messaging. The aim is to garner more than our fair share of candidates in this competitive environment as we look to grow. The key performance metrics I’m tracking at the macro level are clinician turnover, and clinician hiring right, with a business goal to grow and balance the provider base in line with referrals at the local market level. My focus areas are workforce development, performance management, and team member engagement. ATI has an amazing culture and I’m excited to do my part to locate, attract, acquire, engage and develop the next generation of skilled therapists for future leaders.
Now I’d like to turn the call over to Ray for discussion of clinic operations.
Ray Wahl
Thanks, Eimile. I would like to provide a review of operational performance and discuss some of our activities in the field during the third quarter. So before [Indiscernible] since we just finished National Physical Therapy month in October, I’d like to take a quick moment to say thanks and to appreciate all of our PTs and PTAs, along with our clinic support staff for what they’re doing day in and day out and the impact they’re having on our patients lives.
We had a lot of fun in October celebrating the profession, and each other’s accomplishments and it was great to see. As Sharon mentioned, demand for physical therapy continues to be strong, with ATI referrals continuing to increase quarter-over-quarter. Our business development team alongside our clinical directors are doing a great job and getting out to the communities they serve and building meaningful relationships with the medical community. As Eimile and her team work to grow the ATI provider base in the clinics we are continuing to be focused on optimizing patient intake and scheduling, coordinating handoffs, advancing accountability and on-boarding new team members to the ATI way. From the work done during this past year I feel good we have improved the amount of support in the clinics and our team is growing and can focus on providing excellent care to our patients.
In the third quarter, our provider team averaged 8.7 visits per day. While this was lower than the second quarter this pattern is consistent with seasonal trends considering summer PTO. As previously discussed we are in the process of assessing our national footprint and clinics at the local market level. As Sharon mentioned earlier, when looking at individual clinics during the third quarter in 2022 80% of our clinics are at the 9.5 visits per day or greater.
This is encouraging as it shows when providers, referrals and support staff are at the right levels, the team is then able to execute the playbook. And this results in excellent patient experiences in high functioning clinic operations. As we progress in assessing the real estate footprint, there will be opportunities to consolidate locations with the dual benefit of adding much needed providers to these busy locations, and offering a vibrant work environment, which is what we’re all striving for. Each of our clinics is unique with their own local market considerations.
So balancing the right level of staff and productivity expectations is always a work in progress. With the work we’re doing to ensure the foundation is in place and with many of our providers already achieving productivity targets I feel we are positioned for further growth not only in these clinics, but across the entire platform. Q3 has shown our ability to exceed performance expectations in many clinics. I think our Northwest region is a great example of a market where referral support has been solid. We’ve made some leadership changes that are having a real impact.
Staffing is starting to take hold and we’re seeing high patient volumes and great clinical outcomes because of it. We look forward to replicating these types of results as we move forward. So I just want to say I’m really proud of the entire ATI team. This group continues to work hard every single day towards our overarching mission that’s helping patients reach their full potential. I’m excited as we finish the year and I look forward to delivering on our commitments to our investors and our stakeholders as well.
With that said, I’d like to turn the call over to Joe for a financial review.
Joseph Jordan
Thank you, Ray. And thanks to everyone for joining the call today. I’ll jump right into the third quarter 2022 financial results. Net operating revenue in the third quarter was $156.8 million down 1% from $159 million in Q3 of the prior year. Net patient revenue was $142.3 million, which is essentially flat with the prior year. Other revenue was $14.5 million decreasing 16% year-over-year primarily due to the sale of our home health service line in the fourth quarter of 2021.
Visits per day per clinic during the quarter were 23.2 sequentially decreasing one visit from 24.2 in the second quarter with the quarter-over-quarter decrease following normal seasonality trends. Visits per day per clinic increased 0.1 from 23.1 in the third quarter of 2021 as we increase the number of clinicians’ year-over-year to see more patients. Our rate per visit was $103.46 essentially flat from the second quarter of 2022 and decreasing 2% year-over-year from 105.56 from the third quarter of the prior year.
The year-over-year decrease was primarily due to lower Medicare rates on account of the 2022 Medicare Physician Fee Schedule changes and sequestration as well unfavorable mix shift in both payers and states. Salaries and related costs in the third quarter of 2022 were $90.3 million a 4% increase year-over-year from $86.8 million in the third quarter of the prior year due to more clinical FTE and wage inflation. PT salaries and related costs per visit during the quarter were $56.20 a 5% increase quarter-over-quarter compared to $53.64 in the second quarter driven by lower labor productivity and continuing wage inflation. Comparing year-over-year we saw a similar 5% increase from $53.70 in the third quarter the prior year, primarily due to wage inflation and added clinic support.
Rent, clinic supplies, contract labor and other in the third quarter of 2022 was $51.4 million a 12% increase year-over-year from 45.8 million in Q3 of the prior year due to more clinics and greater use of contract labor. PT rent and other costs per clinic during the quarter was 54,000 sequentially increasing 2% from 53,000 in the second quarter, and 9% year-over-year from 49,000 driven by greater contract labor use. Provision for doubtful accounts during the second quarter was $2.8 million or 2% of net patient revenue, which is consistent with the third quarter 2021 at 2% of net patient revenue, or $3.5 million.
SG&A during the quarter was 25.3 million, an 18% decrease year-over-year from 30.8 million primarily due to lower severance and transaction costs. Non-cash, goodwill and intangible asset impairment charge in the third quarter of 2022 was 106.7 million. The impairment was primarily due to increase in market interest rates. Operating loss in the third quarter was 119.7 million decreasing year-over-year from 516.9 million, the third quarter of 2022 including an impairment charge of 106.7 million, while the third quarter of 2021 included an impairment charge of 509 million.
When excluding these non-cash impairment charges the remaining $5 million increase in operating loss year-over-year was primarily due to lower revenue and the continuing tight labor market which resulted in wage inflation and a greater use of contract labor as previously discussed. And these costs were partially offset by SG&A cost containment. Notable below the line items during the quarter included a decrease in the fair value of certain warrant and contingent common share liabilities totaling $7.7 million. The mark to market to fair value was based on a valuation analysis as of September 30, 2022.
Interest expense during the quarter was $11.8 million, compared to 7.4 million in the third quarter of the prior year consistent with the reduced outstanding debt balance pursuant to the business combination 2021 and then the subsequent refinancing of our debt earlier this year. Income tax benefit for the quarter was 7.2 million, compared to 35.3 million in the third quarter of 2021. Net loss during the quarter was 116.7 million compared to 326 million in third quarter the prior year. Adjusted EBITDA during the quarter was a loss of 0.4 million or 0% margin, decreasing year-over-year from 8.5 million or 5% margin.
Similar to the year-over-year change in operating loss, the year-over-year decrease in adjusted EBITDA was primarily driven by lower revenue and the continuing impact from the tight labor market, partially offset by lower SG&A. Cash flow year-to-date 2022 was essentially breakeven with 59 million use to fund operations, 22 million used in investing activities, offset by 81 million provided by financing activities. Cash used in operations included 12 million repaid in connection with the Medicare accelerated advanced payment program or the MAP program under the Cares Act. All MAP funds had been repaid as of September 30, 2022.
During the third quarter cash use was $31 million. Of that amount 26 million was used in operations, which included 2 million repaid in connection with MAP, 4 million was used in investing activities, and 1 million was used in financing activities. As of September 30, available liquidity was approximately $97 million which was comprised of 49 million in cash and cash equivalents and 48 million and available revolver capacity. While cash use and operating and investing activities and 2022 year-to-date was approximately $80 million we are focused on driving operational performance as Sharon talked about controlling costs, and making investment decisions to improve cash flows over the next 12 months as compared to the last 12 months. As we move forward as a company, we’ll continue to closely monitor the business performance, and our financial covenants under a credit agreement.
Finally, when considering financial performance through September, along with October results and early November trends, we’re tracking to deliver against the low end of our full year 2022 guided ranges. And those ranges are for revenue 635 million to 655 million and adjusted EBITDA of 5 million to 15 million.
With that, I’d like to turn the call back over to Sharon.
Sharon Vitti
Thanks, Joe. As you can see, ATI has a strong commitment to all its stakeholders. We have a plan, and are continuing to make progress on multiple fronts to ensure the company continues to improve operational and financial performance. We are aggressively working to implement plan changes. And I’m confident that our talented team will fulfill our mission to provide the highest quality of care to our patients while delivering on our financial targets.
Operator, let’s open the call for Q&A please.
Question-and-Answer Session
Operator
[Operator Instructions] Your first question comes from the line of Larry Solow from CJS Securities. Your line is open.
Unidentified Analyst
Hi, this is Chris calling in for Larry. Thanks for taking our questions. I think you mentioned lower clinics next year. Can you talk about that just in terms of additions and closures is that you’re going to continue to add while closing or mostly closures?
Sharon Vitti
Thanks for the question. So we will finish out the year with de novo that we have on the docket that’s in the…
Joseph Jordan
Roughly 35 for the year, a couple that are opening in the fourth quarter.
Sharon Vitti
And then we as you know, there’s a long lead time to pulling together the de novo. So we will continue with a lower rate of de novos in 2020 probably in the mid teens. So that’s on the growth side. And then in parallel, as I mentioned, we have done a full review of our real estate and we’ve looked at it at a clinic level, we’ve looked at profitability, prospects, local operational, synergies, etc.
And so we’re focused on all of our clinics. The ones that we are taking action on are the 20% that are not, don’t have sufficient market demand or for one other one reason or another, they’re not achieving our target unit economics. And so with that there’s obviously a lot of things that go into consideration here. So I’d say, half of that 20% is on a watch list. Some of them are newer clinics, some of them have seen growth, but not necessarily up to the levels that we need. So we call that our watch list. And then the other half of that 20%, we’ve developed a plan for each of those clinics, and we will be taking actions starting now and over the next three to five years obviously, the lease terms are one of the factors that plays into the decision we’re moving on those that we can relative to a lease term or those that we have made a decision on closing or divesting.
Unidentified Analyst
That was great color. Thank you so much. Just a follow up, can you just give a little more color on PT availability? If that’s improved over the last few months, and maybe talk about turnover specifically at ATI?
Sharon Vitti
Sure. Why don’t I let Eimile jump in?
Eimile Tansey
Yes, absolutely, I think that the market has remained extremely competitive. And we’re working to a variety of different channels to make sure that we can continue to attract and retain talent. And we’ve experienced reduction and attrition as we’ve gone through quarter-over-quarter, year-over-year. So we’re really encouraged by that. And so, we think that through the programs that we put together, we continue to listen to our employees and we think that internal friction in the mid 20s is pretty good.
We think we can continue to drive it down several more points. But we probably think that the industry has changed since the pandemic not just with PT, but healthcare broadly. So we believe we can continue to maintain levels, drive them down a little bit more with our programs and focusing on our culture, which is fantastic. And making sure that we’re putting programs together with development. Development is a big focus of ours. So we feel pretty good about it. But it takes time and we’re actively creating mechanism for open and frequent communication with our providers.
Sharon Vitti
And just clarify that attrition rate is without our contractors, obviously we know, the contractors turn. So we’re measuring it without our contractors in it to make an apples to apples comparison.
Operator
Your next question comes from the line of Brian Tanquilit from Jefferies. Your line is open.
Brian Tanquilit
I guess just to follow up on some other questions there. As I think about it, I know we’ve been talking about turnover, but as I think about lead generation for new hires, and what does that look like right now in terms of new applicants coming in?
Eimile Tansey
Absolutely. Thanks for the question — outreach, increasing our sourcing capability. And focusing on recruiter capability through additional digital channels. So we’re looking at being able to pull in, not just new grads, but with a heavy focus on outreach for passive candidates out in the market. So I think that all of these tactics are widening the top of our funnel. And we’re really focused on converting all those people to be ATI employees.
Sharon Vitti
And I would just add, so under Eimile’s short tenure, she has brought on a new VP of talent acquisition, to complement the existing team and to add a level of those experiences in and quite honestly, a new way of thinking about our go to market tactics. And I will say some of the activities that we put in place, August and September, we have seen an increase in the top of the funnel, obviously, we need to convert those. But we’ve been pleased with some of the activities that have generated a higher number of candidates, quality candidates, and those were good learnings for the types of tactics that Eimile referred to. And then the last would be we’ve also increased our spent in the area to support those tactics.
Brian Tanquilit
Got it. And then I think about the clinic closures coming up. Is there a way to or do you retain some of those clinicians and redeploy them? And how does that work? Just curious.
Sharon Vitti
Yes. No, great question, Brian. Thank you. Absolutely that is our goal. And when you look, I mean there’s a bunch of different things that we see out there. One relates to just dense markets that have a lot of duplication or a lot of capacity and so those are obvious where we might do a consolidation there. There’s some other markets where we have staffing challenges. And so closing clinics and consolidating makes it a way for us to move the staff and then also that makes it a more vibrant clinic setting when you have more than a single provider. So our intentions would be to maintain or to keep those the staff. If there’s a divestiture that we’ll have to see how that plays out. That was a little bit harder.
Brian Tanquilit
Last question for you, Joe. I think about free cash flow, as we think about clinic closures I mean, is that something that we should be thinking about as a potential contributor to driving improvement next year and kind of pull them back into the de novo?
Joseph Jordan
Yes, certainly, certainly can Brian drive improvement next year. To Sharon’s point, it depends on how the closure happens, divesture that’s one way to get an improvement in free cash flow. But closing money losing clinics is another way. Plus, there’s the resources that are allocated to those clinics too on top of it. So the other important thing for us to do as a business is make sure that as we close clinics, we’re scaling our corporate cost structure appropriately with those clinics.
Sharon Vitti
I think there will be some, there’s some action we’re taking right now. There will be some action we’ll be taking in ‘23, I would say the majority of the action is going to happen over the next three years. But again, it’s all predicated on the both the action we’re going to take and then the lease.
Operator
Your next question comes from the line Jason Cassorla from Citi. Your line is open.
Jason Cassorla
Hey, great. Thanks, guys. Just as we think about, just thinking about mix, payer mix the staff up, you’ve talked about referrals, but maybe could you when do you think you’ll get back to sort of a pre-pandemic level of payer mix. And then just maybe, broadly, how you’re thinking about the puts and takes on the revenue per clinic, Ryan for next year, just given your new hires, the focuses of referral channels and the like, but also in context of this final Medicare rates that came out? So anything just on, one, payer mix if you think you can get back to pre-pandemic levels, and then two, how you’re thinking about revenue, kind of per visit next year, and the puts and takes there?
Sharon Vitti
Sure, Jason. Do you want to take us through those Joe?
Joseph Jordan
Hey, Jason, it’s Joe. So I’ll unpack that because you asked kind of a lot there. And maybe I’ll start at the highest level on rate. From a rate perspective, we’re monitoring what’s happened with Medicare pretty closely. They’ve come out and said 4.5% cut and in the past last couple of years the Medicare rate cut that’s originally been “final” has not equaled where, where it landed at the end of the year. Congress has stepped in. And often that’s been coming down. So we’re monitoring because there’s a chance that that happens again, like it has the last couple of years. If it stays as is that 4.5% would impact roughly 20% of our volume.
Now, we do have, as Sharon mentioned, when she was speaking, during the scripted part of the call, we do have our exceptional rating under the MESS program, which would give us a bonus, which would help to offset the 4.% rate reduction. So I think overall on our volume, it will have some impact, but it gets pretty diluted quickly. And then we think about rate as being flat if we can have some wins elsewhere. From a payer mix perspective, as it relates to getting workers comp and auto personal injury back to where it once was we are focused on driving mix and we’re rolling out through states, Illinois, one where we built up our workers comp ATI historically, and it’s not back to where it once was. So we’re trying to drive that business back. So far, the mix has stayed pretty flat. We haven’t seen the improvement which as a result, we’re not prepared to make a prediction on where the mix is in 2023.
Jason Cassorla
Understood. Yes, no, that was very helpful. Thank you. And then just quickly as a follow up, and we’ve talked about divestitures on this call, and apologies, I missed this are you thinking about it more broad based? Is it regionally focused or concentrated? And then just thinking about, I think back a couple years ago, you’re talking about your growth in the areas of white space. The way that you’ve seen kind of regional development play out, do you still think a lot of that construct around white space and growth opportunities still exist in this framework? Or do you think you’d have to be more choosy as you think about growth off of this kind of revised baseline of clinics and just try to understand the right size, the business what where you could think growth will ultimately be achieved in the white space that’s available to you on the go forward. Thanks.
Sharon Vitti
So, on divestitures, from a divestiture perspective, I’d say the actions we’re taking are across the footprint, but as it relates to the divestitures, it’s definitely clusters with clinics, and predominantly within a market. So a little bit of that is TBD. But I would say we’re being pretty selective on where that is, both from what makes sense to us. And what would make sense to a buyer. On the growth in the white space, we’re slowing down our growth for the right reasons because we’ve gone through such a large growth, kind of pausing and taking a look at where we are, but absolutely see the white space and the opportunities going forward and anticipate getting back to that after we finish this internal sort of review.
And I would say obviously, how we look at things now, maybe different than we looked at them before, because things are pretty different post-COVID and the whole landscape has changed. And I would say we’re also smarter. We have a lot of experiences, the review of our fleet tells us it gives us great insight onto where we made a bet and it came through and where we made a bet, and maybe it wasn’t what we thought it would be. So I think we’re positioned nicely. We haven’t shut that off. We’re still active in that area, but because you need to keep a seat at the table. But we will. I think there’s plenty of opportunity going forth.
Joseph Jordan
Yes, and maybe, Jason, this is Joe, just a add to Sharon’s point. She mentioned earlier that de novo next years, probably somewhere in the mid teens, the white space, certainly to Sharon’s point still exists. But the two challenges that we have, which causes us to pause and slow down. One is labor, labor availability, and where we are adding de novo those are areas where we generally believe we can add labor, but we want to add people across our platform and if you do a lot of de novos you’re stressing a talent acquisition team that already has a requirement to add. So we certainly recognize that and the second is the CapEx need.
There is a investment to open these de novos even though they pay back pretty quickly we do see the cash burn of the business and we need to, to Sharon’s point, get the underlying fleet running how we want it to run. Be pretty diligent with the capital spend that we have in 2023. Obviously we have plans in place to drive the business forward and make improvements to our cash burn. But it’s another reason why it makes sense to slow down.
Operator
[Operator Instructions] Your next question comes from the line of Mike Petusky from Barrington. Your line is open.
Mike Petusky
So I guess I want to understand the commentary around the guidance. It looks to me like the guidance was pulled out of the release itself versus Q2 unless I missed it somehow. And then it sounded like Joe maybe said, well, the guidance that we gave previously, we’re sort of reaffirming, but maybe at the lower end. I mean, is that essentially what you’re communicating? I get that that’s what you’re communicating? Why was it pulled out on the release? Thanks.
Joseph Jordan
Hey, Mike. I mean, we didn’t pull it out of the so yes, your understanding is correct, that we are reaffirming the guidance, maybe I’ll just state that we do think that we’re going to be at the low end of the guidance. I guess we just didn’t put it back in the release to say that we’re reaffirming the guidance. And say, in practice, we’ve seen companies do both. If you’re still in line with guidance, then sometimes there’s just no need to update because it’s assumed unless you go out and say something different. So but you’re correct. You heard me right on the call, and we’re tracking towards the low end of guidance.
You might recall that when we talked about that 5 million to 15 million adjusted EBITDA the low end of that range, assume that our clinical FTE stayed pretty flat, our headcount stayed pretty flat. And we tracked that way, in the third quarter. the rest of the operating KPIs followed seasonal trends, based on what we’ve seen here in October with an uptick, early trends in November. It gives us some comfort that we’re moving towards the low end of the range within the low end of the range.
Mike Petusky
Q4 was the worst quarter last year for adjusted EBITDA and typically, it’s one of the two weaker quarters for most PT companies. So you’re saying in October and moving November, gives you confidence that this is going to come in as your second best quarter for EBITDA or maybe even close to your best quarter?
Joseph Jordan
That’s an unpack Q4 of last year. But last year, in Q4 you may recall, we had a couple of things going on. We had some relatively significant severance. We revamped our sales team brought in a consultant to help us do that, which was some spend, and Omicron picked up pretty heavily in December, and then into January.
Mike Petusky
So then, I guess Sharon going back to this idea of optimizing the bottom 20% it sounded I think I heard you say that a lot of this will be accomplished over three years. I mean, is it likely on some of the divestitures that we’ll see that action more than the front end of the three years in order to give you guys a little extra liquidity, etc.
Sharon Vitti
So yes, Mike a lot of this, we were able to, say process, and they work with our board on the plans. We had our board meeting last week. So I would say we are actively taking, pursuing the activities that we’ve laid out per clinic. And I would say the divestiture work is actively in progress. So I would say those who knows, but I think we have a few different clusters that we take half of the clusters we already have at real meaningful activity and the other half. We’re not sure. But all of them are out there. All of them are out and being actively pursued at this point. It’s just been very recent, in the last few days.
Mike Petusky
Can I just ask — maybe I missed this earlier when you’re talking about the bottom 20% you were talking about closure consolidation, divestiture, I mean, is it roughly a third, a third a third when you think about that, or the more facilities to hopefully divesture? Can you give some sense of that?
Sharon Vitti
Well, first of all the 20% the bottom 20% we are acting on 10%. The other 10% I can pacified as underperforming but on a watch list because there’s still, we look at holistically at the clinic. We look at every the demand, the competitors, the staffing levels, etc. So on the 10% that we have, that are not on the watch list that we’ve identified, we’re going to take an action on. I’d say yes, I’d say it’s about a third, a third, a third, off the top of my head, in regards to closures than in regards to some other activity, like maybe a closure with a sublease, depending on the lease terms. And then on the divestiture.
Joseph Jordan
And Mike, maybe just the one thing that I’d add on to that is, you shouldn’t walk away thinking that 10% of our clinics are going to be closed in 2022. Because there is lease lives are hanging on these clinics, they are open, they are seeing volume, for the most part, there’s a handful of dark clinics, they’re just they’re underperforming, so over, over some period of time, they will be closed, most likely, certainly some of them can turn around. But that’s kind of how to think about it.
Sharon Vitti
So I might say the thing is, we’re actively — and we’re actively working with all of them, to take an action. And if that action doesn’t pan out, we may look at a different action. So I think I don’t know, maybe, what do we think about 80% of the actions will happen in the next three years based on the action we’re taking and based on the timing of clinic that has a longer lease, or it wouldn’t make sense. So we’ve done a full analysis and have the standard of clinic level, and then it gets we’ll see how our actions, how fruitful we are with the actions, if we’re being pretty, not trying to be coy here more, we have a plan, and we have a commitment to take an action and we’re going to see how the market responds, and then we may modify the action, but the taking these 10% off the Grid is really important, because we spend a lot of time on this 10% and they obviously weigh down the performance of the other 80%.
Mike Petusky
So of the 10% above that bottom 10% that are sort of watch list are those situations where finding an extra therapist or a therapist assistant could make a difference or those mostly staffed appropriately, they’re underperformers?
Sharon Vitti
No, I think there’s definitely could be a de novo where we just haven’t been able to get it fully ramped from a staffing perspective. We could have had a lot of fun. Some certain geographies we’re really just hit with a higher amount of attrition. And so we’re building that fast, there typically also markets that have less available staff. I’d say some of them, they’re just not ramping as quickly as we thought and so they’re questionable whether they will get there or not. So there’s not enough here to say, oh, these need to go on the close list. But we are watching it. So now we know what that list is. We are TA group is hyper focused on trying to recover from a staffing perspective on these. They could be referral starved areas. Our business development group is working hard to see if we can accelerate the referral. So it’s typically one of those three levers, the staffing, the referrals, or it’s just hasn’t been long enough to kind of write this one off.
Operator
There are no further questions at this time. Ms. Sharon Vitti, I turn the call back over to you.
Sharon Vitti
I thank everyone for their participation in the call today. Thank my team for joining me and helping share where we are, and we look forward to seeing everyone Q4. Thank you.
Operator
This concludes today’s conference call. You may now disconnect.
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