Aveanna Healthcare Holdings Inc. (NASDAQ:AVAH) Q3 2022 Earnings Conference Call November 10, 2022 10:00 AM ET
Company Participants
Shannon Drake – Chief Legal Officer and Corporate Secretary
Tony Strange – President and Chief Executive Officer
Jeff Shaner – Chief Operating Officer
David Afshar – Chief Financial Officer
Conference Call Participants
Taji Phillips – Jefferies
Joanna Gajuk – Bank of America
Pito Chickering – Deutsche Bank
Ben Hendrix – RBC
Operator
Good morning, and welcome to Aveanna Healthcare Holdings Third Quarter 2022 Earnings Conference Call. Today’s call is being recorded and we have allocated one hour for prepared remarks and Q&A.
At this time, I would like to turn the call over to Shannon Drake, Aveanna’s Chief Legal Officer and Corporate Secretary. Thank you. You may begin.
Shannon Drake
Thank you, operator. Good morning, everyone, and thank you for joining us today. Speaking on today’s call are Rod Windley, Aveanna’s Executive Chairman; Tony Strange, Aveanna’s Chief Executive Officer and President; David Afshar, Aveanna’s Chief Financial Officer; and Jeff Shaner, Aveanna’s Chief Operating Officer.
We issued our earnings press release and filed our 10-Q yesterday. These documents are available on the Investor Relations section of our website at www.aveanna.com as well as on the SEC’s website at www.sec.gov. A replay of this call will be available until November 17, 2022. We want to remind anyone who may be listening to a replay of this call that all statements made are as of today, November 10, 2022. Today’s call may contain forward-looking statements, which may be identified by the use of words such as plan, could and other similar words and expressions.
All forward-looking statements made today are based on management’s current beliefs and assumptions about our business and the environment in which we operate. These statements are subject to risks and uncertainties that could cause our actual results to materially differ from those expressed or implied on today’s call. Except as required by federal securities laws, Aveanna will not publicly update or revise any forward-looking statements subsequent to the date made as a result of new information, future events or changing circumstances.
Also, we supplement our financial results reported in accordance with GAAP with certain non-GAAP financial measures. The reconciliation of any non-GAAP measure mentioned during our call to the most comparable GAAP measure is available in our earnings press release and Form 10-Q, both of which are available on our website at the SEC’s website at www.sec.gov or is otherwise available separately on our website. Following today’s prepared remarks, we will open the call to questions. Please limit your initial comments to one question and one follow-up so that we can accommodate as many callers as possible in the allotted time.
With that, I will turn the call over to Aveanna’s Chief Executive Officer, Tony Strange. Tony?
Tony Strange
Thank you, Shannon, and good morning, everyone. We appreciate you investing your time to better understanding our results as well as the factors that are affecting our industry. On the call today, we’ll update you on our third quarter results, we’ll provide some insight into the labor markets and our ongoing efforts with payers to create additional capacity.
And finally, we’ll provide some insight into our expectations for Q4 as well as a preliminary look at 2023. As you’ve seen in our press release last night, our Q3 results clearly fall below our expectations with net revenues of $443 million and adjusted EBITDA of approximately $25 million. Despite the ongoing disruptions in the labor market, we’re seeing progress in staffing specifically as it relates to our preferred payer relationships within PDS. We now have seven preferred payer relationships, all showing signs of growth compared to the two that we discussed on our last call.
Additionally, our medical solutions business is benefiting from the market consolidation after two providers left the market in late Q2. Finally, both our private duty services and our medical solutions produced sequential volume growth in Q3, which is typically the lower quarter of the year, both posting their best results of the year. As referenced in the release, our biggest issues in the quarter were driven by Home Health and Hospice. Earlier this year, we consolidated four separate and unique operating systems into Homecare Homebase.
In addition, we implemented Metalogix to provide predictive data analytics. Both will play a significant role in our ability to position Aveanna as a leader in value-based care. And while we’re confident that these decisions are the right long-term strategy for the company, we can see a short-term effect within Home Health and Hospice in Q3. Our results were driven primarily by the following three factors, lower-than-expected volumes as Homecare Homebase was rolled out to all 91 branches, we could feel the effect on volume during the integration phase, while we completed the install in Q2 with little disruption as we began to implement the disciplined policies associated with Homecare Homebase, we saw a decline both in new admissions and recertifications.
And while this impact was across our platform, it was most acute in the state of Florida within our legacy Doctor’s Choice acquisition. With the benefits of Homecare Homebase securely in place, we are experiencing an improvement in volumes across the board and particularly in Florida going into Q4, notwithstanding the impact of Hurricane Ian in the first two weeks of October.
Number two, higher-than-expected adjustments in revenue reserves, we took adjustments and additional reserves to revenue above our normal rate of about $6.5 million during the quarter. These adjustments include provisions for uncollectible AR on legacy systems, increased reserves for documentation issues that occurred during the system conversion and additional adjustments for configuration issues that have since been addressed.
Dave will provide additional details in his remarks. The fourth quarter will continue to have a slightly elevated reserve rate before returning to normal levels in Q1 of 2023, with the rest of the adjustments that we discussed being more one-time in nature. And number three, higher costs associated with lower revenues. As a result of the lower revenue as well as the efficiencies gained through Homecare Homebase, the operating team has identified about $6.5 million of costs that we took out in late Q3, with the full benefit being realized in Q4.
Jeff will provide some additional commentary on all of the Home Health and Hospice results during his remarks. While we’re on the topic of home health on Monday of last week, CMS issued its final rule for home health payments for 2023. As you’ll recall, CMS proposed a net reduction of approximately 4.2%, up for the 23 rule. CMS increased the market basket update as well as reduce the behavioral adjustment, resulting in a rate increase for 23 of 0.7%.
In full disclosure, CMS indicated that while it would be implementing half of the behavioral adjustment in 2023, it would implement the remaining 50% at some point in the future. Clearly, this is a better outcome for the industry because it allows companies to continue to invest in caregivers and technology to better position themselves for what CMS views as the end game, where all providers are paid based on the value that they deliver.
We believe that with the investments that we’ve made into Homecare Homebase and Metalogix, we are well positioned to be a winner in the value-based care system. With that said, we strongly urge CMS not to proceed with the additional behavioral adjustment in future years as it contradicts the shift in behavior that they’re trying to encourage. In summary, we feel good about the future of our Home Health and Hospice business. There are 10,000 Americans turning 65 every day.
Home Health and Hospice provides a cost-effective alternative to rising healthcare costs and most importantly, it’s preferred by the patient. We expect this business to grow in the high single-digits year-after-year and continue to produce gross margins in the high 40%s to 50%. On our last call, we spent a fair amount of time talking about the preferred payer relationships as well as value-based pricing. While it still represents a small portion of our overall revenue, we have continued to see momentum in moving our capacity toward payers that value the role that home care can play in reducing overall healthcare costs.
Within these preferred payer agreements, we can see early signs of success with PDS growth rates in the mid to high single digits as well as the potential for gross margin expansion. The indicators demonstrate that an all-in commitment to this strategy in states where value-based pricing is currently a possibility is a clear path forward for Aveanna.
Before we get into Q4 and 2023, I’d like to make a few comments about cash flow and liquidity. First and foremost, despite the discussion related to the adjustments that we took in Home Health and Hospice, the revenue cycle teams have produced extraordinary results in Q3. Our collections were $470 million against a goal of $445 million or 106% to plan. DSOs for the quarter dropped to 48 days.
These results give us confidence that our revenues are collectible and that we will be able to convert revenue and growth into improved cash flow. In the meantime, we have flexible covenants within our loan agreements in addition to substantially all of our debt being hedged in one form or another. At the end of Q3, we had nearly $280 million in liquidity. This represents more than enough access to capital to operate the business and to continue to make the necessary investments into clinical systems, payer and government relations to further enhance our efforts related to the value-based pricing and preferred payer relationships. Dave will provide some additional detail in his remarks related to liquidity and cash flow.
Let’s turn our focus towards Q4 and an early look into our expectations for 2023. We expect Q4 revenues of $445 million to $450 million and adjusted EBITDA of approximately $28 million to $30 million. These estimates include the benefit of a hospice rate increase effective October 1, the ongoing benefit of the 2022 rate improvements and improved volumes in PDS partially offset by continued reserve pressure in home health during the quarter as well as the impact that we experienced during the Hurricane Ian across our private duty and Home Health segments.
Looking forward to 2023, we will issue specific guidance in early next year once the 2023 budget has been finalized and approved by our Board of Directors. We’re targeting revenues greater than $1.8 billion in adjusted EBITDA in the mid $140 million range. These estimates include ongoing labor market disruption and shortage of skilled caregivers. The full impact of the CMS rule that we discussed earlier. It includes Home Health and Hospice returning to mid to high single-digit growth with gross margins in the high 40% to 50% and normalized base rate improvements that we received through private duty services as well as ongoing improvements from value-based pricing and preferred relationship.
What those estimates do not include because any material rate improvements were one or more significant states within our service area. It doesn’t include provisions for further disruptions from COVID-19 or other pandemics or provisions for catastrophic weather-related events or fires.
Again, we’ll provide precise guidance once the 2023 budget has been finalized, but we believe that this provides a broad framework to begin thinking about the full year 2023 and beyond. Before I turn the call over to Jeff, I wanted to summarize my thoughts on Aveanna and the home care industry.
In the eyes of our patients, payers, state and federal governments as well as our physician and hospital partners, home and community-based care is a solution, not a problem – with higher demand for services and fewer available resources, we must be innovative and nimble in our response. Companies that have size and scale and breadth and service levels are positioned to be successful.
We are not satisfied with our results in Q3 and for that, we take full responsibility. We will not be defined by a single moment in time. We expect Q4 to be better than Q3, and we expect 2023 to be better than 2022. We have seen progress in both Medical Solutions and private-duty services. We’ve seen preferred payer models drive growth in skilled nursing care. We’ve seen innovation related to alternative caregiver models produced increased capacity.
We recognize that we have work to do in order to bring our Home Health and Hospice business back to our level of expectation. We anticipate having all this work finalized by the end of Q1 of 2023. I’m confident that Aveanna can and will position itself as a leader in the industry through these trying times. In today’s environment, our employees can work wherever they choose. Our employees have continually demonstrated a willingness to work hard even when times are tough. It’s the same resiliency and our culture that will define our success. I thank each of our employees and caregivers for what you do and for calling Aveanna your home.
With that, Jeff will provide you with some additional insight into our segment results. Jeff?
Jeff Shaner
Thank you, Tony. Our Aveanna leaders remain focused on the task at hand, bringing medically fragile pediatric, adult and geriatric patients home and staffing their cases with highly skilled caregivers. We continue to develop our preferred payer strategy and are actively shifting caregiver capacity to those payers that value our services. Aveanna preferred payers are identified as those payers that are willing to partner with Aveanna at value-based rates in return for preferred staffing, enhanced clinical outcomes and reduced unplanned hospitalizations.
In our Private Duty Services segment, we have seven preferred payer agreements, up from two at the end of 2021. We continue to work on our robust payer pipeline to shift payers from a fee-for-service rate to a market premium rate, including value-based payment for performance as the long-term effects of the pandemic inflation and the nursing shortage settle in, we have become steadfast in our commitment to partner with those payers who value our services and outcomes. I look forward to continuing to update you in subsequent quarters on our progress with our preferred payer strategy. Now on to our Q3 operating indicators, starting with our Private Duty Services segment.
We produced $355.6 million of revenue during the quarter. Revenue was driven by approximately 9.65 million hours of care, which was up slightly from Q2. While volumes did improve, we continue to be constrained by the turbulent labor markets, primarily driven by the shortage of nurses. We experienced improvement in our preferred payer volumes with select payers year-to-date organic growth rates reaching the high single digits. Although still early, these positive growth trends show us a path forward for our private duty services business.
Our Q3 revenue per hour of $36.84 was up $0.49 sequentially from Q2 or 1.4%. We continue to experience rate improvements in the back half of 2022, with the PDS year-to-date rate increases totaling 28. These rate wins include state Medicaid PDS rates as well as MCO-specific Aveanna rate increases. All of our state legislatures have completed their 2022 legislative sessions, and we have now turned our focus to the 2023 legislative process for future rate improvements and program expansion opportunities. We have a full slate of 2023 legislative and MCO preferred payer initiatives to execute on.
We also have an update on our Medicaid program expansion efforts, such as the family caregiver model or a licensed health aid model. As you may recall, Arizona’s Medicaid system launched its licensed health aid program recently. I am proud to report that we have admitted over a dozen Arizona LHA families to our service and have many more families currently being credentialed. I expect this important program to continue to expand across numerous states, including Washington and New Jersey, both of which have recently endorsed similar programs.
Turning to our cost of labor and gross margin metrics. We achieved $100.9 million of gross margin or 28.4%. Our wage rate of $26.39 per hour reflects the commitment we’ve made to passing through our rate wins to our caregivers. Our Q3 spread per hour was $10.45 in line with our expectations. Q3 experienced higher PTO usage with our summer holidays. As such, I expect gross margins to bounce back to approximately 29% in Q4. Lastly, in September, we rationalized approximately $4 million of annualized overhead to better align our PDS business with our current volume trends.
This was a necessary step in our PDS stabilization and will help us be more efficient as we move forward into 2023. Now moving on to our Home Health and Hospice segment for Q3 where the impact of higher inflation has increased caregiver wages, mileage and applied pressure on our gross margins. We stand united with the National Association for Home Care and Hospice and our industry peers and our support for the 2023 final home health rule. While CMS recognized the unprecedented times we’re facing the issue of the PDGM behavioral adjustment still looms large for the industry. We will continue to advocate for a thoughtful solution for the behavioral adjustments while recognizing the value home health brings to the healthcare system.
As Tony previewed, while we’re excited to be fully converted to the Homecare Homebase operating system, we’ve experienced some business disruptions that significantly impacted Q3’s Home Health and Hospice results. First, while we expected some seasonality in our Q3 volume trends, we felt the distraction of our system integration and our mission trends for both Home Health and Hospice. At our lowest point in mid-summer, we were admitting in the low 800 home health admissions per week.
On a comparable basis, this trend improved to just over 900 home health admissions per week post-Labor day. With the exception of Hurricane Ian’s temporary impact on Southwest Florida, I expect us to remain in approximately 900 emissions per week range in Q4.
As I look forward to Q1, I see a path back to 1,000 home health admissions per week while maintaining our episodic mix in the low 60% range. Approximately 1,000 home health admissions per week equates to Aveanna sustaining organic growth rates in the 7% to 8% range year-over-year. Our Home Health and Hospice leadership team is dedicated to driving sustained episodic growth.
Second, the higher-than-expected revenue adjustments and revenue reserves totaling approximately $6.5 million in Q3. During the quarter, we made the strategic decision to direct 100% of our Home Health and Hospice teams focus towards Homecare Homebase and the process improvements driven by the system.
This necessary change was made to align our teams with our go-forward systems, processes and protocols. Over the last 90 days, our operating clinical billing cutting teams have improved their performance materially, which gives us confidence in our Q4 results. Although I expect some revenue adjustments to bleed through to Q4, our Home Health and Hospice revenue should rebound back into the $54 million to $56 million range with our Home Health and Hospice collections significantly improving and our revenue reserve getting back down below 5%, our Q4 gross margin should normalize in the 45% to 47% range. Lastly, with all Home Health and Hospice locations fully operational on Homecare Homebase, we adjusted our SG&A in line with expectations. In September, we eliminated approximately $6.5 million of annualized overhead.
This important outcome was achieved in large part to the long-term benefit of Homecare Homebase and establishing one set of standard practices and policies. It’s been two years in two acquisitions since we reentered the Home Health and Hospice business, and I’m pleased to have all the company integrations and system implementations now behind us. The commitment to establishing a Home Health and Hospice division was one we made with a long-term focus in mind. Now back to the quarter where we produced $49.9 million in revenue, a $2.9 million increase over the prior year period.
The biggest impact of revenue was the Comfort Care acquisition, offset by the revenue adjustments detailed just above. Q3 revenue was driven by 11,300 total admissions, approximately 62% being episodic and 11,400 total episodes of care. We were negatively impacted by Hurricane Ian in our Florida business in late September and into early Q4. However, our Florida business has rebounded from the storm and continues to pick up momentum as the market recovers from the devastating event. I want to personally thank our Aveanna team for your resilience, commitment to patient safety and compassion display for one another during this tragic event.
Now on to revenue per episode for the quarter, which was $3,023 up slightly from Q2. This increase was driven by better episodic management and demonstrates the value of being fully transitioned to Homecare Homebase. From a cost and margin perspective, Q3 gross margins were 33.9%. This impact was primarily driven by the revenue adjustment factors detailed above.
As mentioned, I expect Q4 gross margins to settle back into the 45% to 47% range. Home health visits per episode have trended down to just under 14 visits and overall cost per visit are in line with our expectations. Although Q3 was a difficult quarter for our Home Health and Hospice segment, we firmly believe in this business and its long-term value proposition. We have an established Home Health and Hospice platform poised for growth, focused on delivering value through sound operational management and delivering excellence in patient care.
Now on to our Aveanna Medical Solutions segment results for Q3. During the quarter, we produced $37.5 million of revenue. Revenue was driven by approximately 81,000 unique patients served and revenue per UPS of $463.41. Volumes were up 3.8% from Q2 and demonstrates our Medical Solutions team’s commitment to growth. Aveanna has emerged from this year’s national supply chain event as the leading provider of interim nutrition for clinically complex patients. We see our medical solutions business back on track to achieve high single-digit organic volume growth trends.
Turning to our cost of goods and gross margin metrics. We achieved $16.8 million in gross margin dollars or 44.8%. Gross margins have stabilized and our growth rate is improving, leading to additional leverage in medical solutions.
We continue to evaluate ways to be more efficient and effective in our back office to leverage our overhead as we continue to grow. While other intro providers decided to exit the market, we see this opportunity to expand our national intra-presence and to further our payer partnerships.
Long-term, we remain confident in the value proposition our medical solutions business generates for patients, payers and referral sources. In summary, we continue to fight through a difficult labor and inflationary environment while keeping our patients care at the center of everything we do. It is clear to us that shifting caregiver capacity to those preferred payers that value our partnership is the path forward at Aveanna.
We will continue to pass through wage improvements and other benefits to our caregivers and the ongoing effort to better improve volumes. While we expected Q3 volumes to have improved more, we eliminated $10.5 million in total overhead to be more in line with our current trends. These necessary changes will improve our bottom line results while still giving us the operational platform and flexibility we need to deliver on our mission.
And finally, although disappointed with our Q3 Home Health and Hospice results, we firmly believe in the fundamentals of both businesses and our Home Health and Hospice leadership team’s ability to generate sustained growth, positive clinical outcomes, improved profitability and cash collections moving forward. I look forward to updating you on our improved Home Health and Hospice results after the first of the new year.
With that, I’d like to turn the call over to Dave for additional color on the quarter. Dave?
David Afshar
Thanks, Jeff. Tony and Jeff provided color around our consolidated and segment results, and I’m sure topics such as cash collections, cash flow, liquidity and credit-related items are top of mind with our equity holders and lenders. So I’ll jump right in with these items. With respect to cash collections, we had a great cash collections quarter, particularly within our HHH business. We collected $470 million of cash and reduced our overall receivables from $246 million at the end of the second quarter to $219 million at the end of the third quarter, which is about where we began the year.
In addition to strong HHH collections, we also saw strong collections in our PDS businesses, including a number of successes on particularly aged accounts. I want to thank all our revenue cycle team members and operators in the field who contributed to our great cash collections in Q3. And while it was a great cash collections quarter, we did have a number of revenue-related items that affected the HHH business. As we’ve transitioned our HHH businesses into the Homecare Homebase system, we’ve been working down accounts receivable and multiple legacy systems from four different acquisitions. As Jeff mentioned, during the third quarter, we turned our HHH team’s focus fully towards the HCHB system and away from legacy systems.
As a result, we took additional allowances against legacy system receivables during the quarter. The incremental legacy system allowances are not something I expect to recur in the future. In addition, as we’ve integrated our operations into the HCHB system, we’ve encountered implementation and configuration challenges, which have impacted not only volumes, but also resulted in higher allowances against our HCHB revenues.
We believe the configuration issues are now, I think, in the past. And as we further align our operations with the disciplined processes of the system, we fully expect to capture all the benefits that HCHB has to offer and put our implementation challenges behind us. I know we’re all excited to now be focused on one HHH EMR system that we can leverage to the fullest extent possible.
I want to say a big thank you to all our teams from operations to revenue cycle to accounting and finance for hanging in there over the past year during this transition. And now turning to cash flow, we improved free cash flow in Q3 and on a year-to-date basis from where we were at the end of Q2. Free cash flow was negative $45 million for the nine months ended October 1, which is a $12 million improvement from where we were on a year-to-date Q2 basis. Bear in mind, though, that this included one-time cash usages of $11.7 million to purchase an interest rate cap in Q1 and $3.5 million of repayments of CMS advances received by certain of our acquired companies.
The free cash deficit for the nine months ended October 1 was funded by $20 million of net borrowings on our securitization facility and with cash from the balance sheet. We also drew $60 million on our delayed draw term loan to replace cash used in Q4 2021 in connection with the accredited Comfort Care acquisitions.
At the end of Q3, we had $64 million of cash on the balance sheet compared to $17 million at the end of the second quarter. Thinking about the fourth quarter, we have the remaining $25 million of deferred payroll taxes that we will repay the IRS at the end of December, and we will fund that with cash from the balance sheet. And looking forward to 2023, we expect to make significant progress towards breaking even from a free cash flow perspective.
We’ll continue to focus on doing the things we need to do to improve our cash flow, including growing our volumes, reducing costs where possible and optimizing our collections. In a more limited M&A environment, integration and system transition costs should also be significantly lower in 2023 than 2022. And our 2023 cash flow will also not be negatively impacted by the repayment of CMS Advances deferred payroll taxes or the purchase of interest rate caps, all of which will be $40 million for 2022.
On the debt service front, we had approximately $1.47 billion of variable rate debt at the end of Q2. Of this amount, $520 million is hedged with fixed rate swaps and $880 million is subject to an interest rate cap, which limits further exposure to increases in LIBOR above 3%.
Accordingly, substantially all of our variable rate debt was hedged at the end of Q3. Our interest rate swaps extend through June 2026 and our interest rate caps extend through February 2027. One last item I’d mention related to our debt is that we have no material term loan maturities until July 2028.
Turning to liquidity. We have ample liquidity to fund our operations as needed. At the end of the third quarter, we had close to $280 million of total liquidity, considering cash balances and availability under our securitization facility and revolver.
As a reminder, the leverage covenants under our revolver are not applicable unless more than one-third of the total availability under the revolving credit facility has been utilized, subject to a $15 million carve-out for letters of credit. Should the leverage covenant become applicable, maximum allowable first lien leverage would be 7.6 turns, which we were well below at the end of Q3.
In summary, as I wrap up, I’ll say once again that we’re pleased with our third quarter cash collections as our operations and revenue cycle teams executed on reducing our accounts receivable balances. As Jeff mentioned, we firmly believe in the HHH business and its long-term value proposition. We look forward to all the HHH initiatives that we have underway, including optimizing our performance within HCHB.
And with that, I’d like to turn it over to the operator for questions.
Question-and-Answer Session
Operator
Thank you. We will now be conducting a question-and-answer session. [Operator Instructions] Your first question comes from Brian Tanquilut with Jefferies. Please go ahead.
Taji Phillips
Hi, good morning and thank you for taking my question. This is Taji on for Brian. So my first question has to do with the labor environment. Can you kind of provide some insights on what nurse recruitment looks like?
Jeff Shaner
Taji, good morning. This is Jeff. And thanks for your question. It’s difficult as a year as 2022 has been for us. I think you’ll hear optimism in our voice over the last few months related to our – primarily our nursing, hiring and retention in our PDS segment in our Home Health and Hospice segment. What’s been a very difficult year and really following a difficult 2021. So almost six quarters in a row of a very, very choppy environment. Over the last 90 days, we have finally seen some positive both hiring and retention metrics in our core nursing trends, specifically in our Private Duty Services segment.
I think as both Tony and I pointed out, we really see the positive momentum directly related to our preferred payers, those payers that are partnering with us to be able to offer higher market reimbursement rates to us and ultimately, higher wage rates to our employees. So I think through our seven preferred partnerships we talked about in our PDS segment, we’re finally seeing some movement, albeit it’s very small at this point because the preferred payer relations touch a very small percentage of our PDS business. But I think it truly shows us a path forward with our nursing hires and retention.
Taji Phillips
Great. And then just…
Tony Strange
Go ahead, I’m sorry.
Taji Phillips
Sorry, go ahead.
Tony Strange
No, I was just going to say that to follow on what Jeff said. That Jeff and Mike and the whole government relations and payer relations team have really done an outstanding job in moving this idea of preferred payer relationships down the field. And I like our plan that these guys have developed related to government relations. And what Jeff just talked about is, I think from a macro perspective, I think what we’re feeling is that when we adjust rate in such a way that we can pay clinicians market wages that we can move the ball in volume. We can hire people. People like our job. They like our mission.
They want to come to work. We’ve just got to position ourselves in a way that we can pay them competitive wages. And if we can do that, we can get the nurses. And I think that’s what Jeff just said. I think I’d take it a step further and just really brag on our team a little bit. I think the government relations team and the payer relations team have just done an outstanding job. And I can see a runway from here where we can get those nurses engaged. One of the things that we may begin sharing in 2023 is a number of caregivers that we’re hiring. And that is a leading indicator for us as to where volume is going to go.
Taji Phillips
Great. Thank for that, Tony and Jeff. Just one follow-up question. Just thinking about admissions for Home Health and Hospice, you had mentioned that they’re lower year-over-year, quarter-over-quarter. And I’m just curious, can you break out what percentage of that was from HCHB rollout versus lower demand that you’re seeing or any other factors that contributed to that decline?
Jeff Shaner
Yes. Maybe I’ll answer it a little bit differently than you ask me. But at the end of the day, I think we saw – it’s not a demand is. I’ll start with that. It’s not a demand issue. I think it’s really just a focus issue. And by the way, I don’t blame our lack of admissions on the summer on Homecare Homebase. It was just a distraction of moving four companies to one. And as you know, we’ve been heads down on the Homecare Homebase invitation for almost a year. It’s been – this will be almost a year at the end of Q3.
But the big movement was the last, I’ll call it, the last five months ending really in September. And I think it’s just a distraction both for the clinicians, for the branch teams, the sales teams, as you ultimately sunset the practices of four different companies and now have the operating standards and practices of Aveanna. Clearly, Homecare Homebase is an important support of that as is Metalogix as SHP and different tools we use, I think most importantly, our Home Health and Hospice division President Rob would tell you, we now have one company. We have one operating division, one focus.
And it’s just been two years, barely two years since we acquired our first company five points in Q4 of 2020. And so getting that team to now be on one set of – one focus, one strategy, one set of systems has been a big deal to us. And so I think at the end of day, we feel confident we’ve had great trends going into Q4. Obviously, Hurricane Ian hit us right in Southwest Florida. That was a pretty big part of our Florida business. But really proud of that Florida team. They bounce, Taji back from that event faster than we ever would have thought. They were back blown to go and within about three weeks.
All employees accounted for all patients accounted for and really seeing that. I think as you’re hearing from us, we’re looking into Q1 to really get back to about 1,000 emissions a week. And to us, maintaining that episodic mix at north of 60% is a big deal, not lowering that and staying committed to that and getting back to 1,000 missions a week really gets us back to growing that business, and that’s what our focus is. But thanks for your question.
Taji Phillips
Thank you.
Operator
Next question, Joanna Gajuk with Bank of America. Please go ahead.
Joanna Gajuk
Good morning. Thanks so much for taking the question. Maybe just first a follow-up on the Home Health and Hospice segment disruption. So the comment around rebounding to 54%, 56% revenue range. That was a comment about Q4. Is that correct?
Jeff Shaner
That is correct, Joanna. That getting back just to our normalized quarter, we see that $54 million to $56 million, just getting back to normal business. We have a pretty clear lot of sight at this point into what Q4 will be in both that revenue run rate as well as gross margins normalizing back in that 45%, 46%, 47% is where we see Q4 directionally heading.
Joanna Gajuk
Because I guess when I was looking at Q2 revenue for that segment, it was closer to 60%. So it doesn’t mean that there’s something else that I guess. No, I think being low in the Q3, so it’s like a lower, I guess, run rate? Or is there some more ramp-up, I guess, you expect asset before into Q1 of next year?
Jeff Shaner
Yes. No. I think, Joanna, we talked about a little bit of the bleed over into Q4 from some of the additional reserve noise. And we see that tailing off in the quarter. Sequestration is fully baked into our run rate now, certainly from July forward. But no, I think we see this stabilizing back in that mid- to high 50s. If I jumped into 2023, our budget process is still working out, I’d be disappointed if our Q1 wasn’t north of $60 million for Home Health and Hospice out of the gate. And so I think we can see ourselves back to being in the 60s and growing from there. But I think as some of these reserves bleeds off into Q4, we feel like we’ll be in the high 50s.
Tony Strange
And so Jeff, you said it well. Joanna the sequestration comment. If you recall, sequestration was phased in overtime in the last phase of sequestration being put back in or taken back out rather, is July 1. So we had the full impact of sequestration in Q3, and then we’ll still be there in Q4.
Joanna Gajuk
Exactly. Thank you for the clarification there. And I guess a question here on the PDN segment, but which are the done relative to you well. So you’re still talking about some labor shortages and whatnot, but at the same time, rate, I guess, you’re still saying that even for next year, your comment around the EBITDA in the $140 million rate, does not assume any meaningful rate updates for these states. So can you give us any flavor for anything new in terms of progress of getting additional updates? Have there been specific have you received any rate increases in Q3? Or can you tell us the magnitude of things, how you’re tracking? And also with that $140 million EBITDA, what PDN bill rate or average pricing you assume for next year?
Tony Strange
Well, so that was a lot. And first of all, thank you for pointing that out. So you are correct. In the numbers that we’ve said for preliminary look at 2023, that number in the mid-140s of EBITDA did not include any material rate changes in any of our large states. What it does include is just the normalized cost of living updates that we have in many of our operating states. But it doesn’t include any material change from a large state like maybe like the change we saw in Virginia this past year.
As it relates to your question about Q3, from a legislative perspective, and Jeff made this in his comments that all of our states have put through whatever rate increases we’re going to see in 2023, I mean, in 2022, those are all done.
Now many states go through a legislative process every year to address rates some every other year. Obviously, we’ve talked about our large states being California, Florida, Texas, Colorado, Pennsylvania, and we’ll be paying a lot of attention to all of those states during the legislative process to make sure that people understand what’s going on within private duty and as well as the negative impact that’s having on their overall Medicaid budget because these patients are sitting in hospitals in higher cost settings waiting to come home.
And so we’re going to – some of the – I talked about our government relations team, we were actually making additional investments into government relations in 2023 to go out and tell those stories. Now we will provide updates for that as we go through the year. We’ll provide updates as they become public information as to what the process. Keep in mind that different states have different legislative cycles. Some cycles are have fiscal years that ended June, others have fiscal years that ended the end of September. So any rate changes for – any material rate changes for 2023 would be phased in over some period of time-based on the state and when it happened.
So from that standpoint, I think we have no new information to give you, and we’ll update you as we go. To the last part of your question about private duty, and Jeff made the comment when he was in his prepared remarks. We have been very disciplined about as we’ve received rate changes, we’ve been aggressive about pushing those rate increases through to additional wages to caregivers. And I think that’s where some of Jeff’s optimism comes from is that we’ve seen some improvement in the number of caregivers that were paid based on those rates.
But I made the comment earlier, where we see increased rates when people – when states and payers invest in rates, we then can grow caregivers and as a result, grow home care. And when we do that, we save the state or the payer money. And that’s why I think we’ve gotten such good traction and good reception from some of these value-based pricing discussions that we’ve been having. Jeff, anything you want to add to that?
Jeff Shaner
That’s right. Thanks, Joanna.
Operator
[Operator Instructions] Your next question comes from Pito Chickering with Deutsche Bank. Please go ahead.
Pito Chickering
Hey, good morning, guys. Thanks for taking my questions. Just back on PDS labor sort of, I guess, rates are high note versus other parts of the business. What was the third quarter turn rate? How has that changed looking at 1Q versus 2Q? And then as you’re hiring new nurses, what are the wages of new hires? And as they compare versus legacy people that they work for you?
Jeff Shaner
Yes, Pito. I’m going to stick with the same theme of preferred payers. Because the momentum we’re feeling in new nurse hires, also the slowdown of turnover of same-store nurses are really tying around our seven preferred payers, MCO payers and the states that have passed through material rate increases over the last, I’ll call it, the last 18 months. That’s where we – when we look market by market, state by state, we see the greatest improvement in both nurse hires and nurse retention and overall nurse employment. We – so that’s the good news. The flip side of that is we still have markets that have not passed through, states have not passed through market increases that have kept up with the cost of living change over the last two years.
Those are the states that Tony just talked about that were dialed in on 2023. So in one way or another, it’s the haves and have-nots are starting to play through the business on the PDS side. And I think what makes us feel the optimism you’re hearing is our MCO payers absolutely understand this. They understand the pressure. They understand the issue of children being backed up in the hospital. They understand the issue of low fill rates, and that’s a problem for them, and they’re wanting to partner with us. And I think that, that conversation we’ve been talking now for 18 months, it’s playing better and better and better at the state legislative process as well.
So we had a – what we can see – consider to be a very good legislative year in 2022. We’re expecting 2023 to be even a better year. And probably more important, we’re expecting to move the states in 2023 that didn’t move in 2021 or 2022 on a material basis. And again, that gives us confidence in those markets where today we still can’t be competitive in nurse wages in those specific markets on being able to raise wages and retain those nurses and hire new ones.
Tony Strange
And Pito, we’ve talked about this openly in the past. If you look back a year ago, going back to your question about how we’re paying nurses, if you look back a year ago, on average across different states, we were probably paying LPNs $22 to $24 an hour. In today’s market, you’ve got to be in the high 20s to even upwards to $30 an hour to be competitive for that LPN because that LPN can now go to get a job at a hospital that they couldn’t have gotten a year ago. So with that, that’s the magnitude that we’ve got to move rates in order to be competitive and pay LPNs in that high 20s to $30 an hour. And in markets where Jeff and the team have negotiated great rates for people that recognize the value that we provide, we have been able to move those wages into those high 20s, and that’s where we’re seeing the growth come from.
To Jeff’s point, in states or payers that are lagging behind, until those rate changes that we’re not going to be able to move that metric. Now I will point out in Jeff’s comments, he made, I think you referenced $10.49 spread, which is right in the wheelhouse of where we expect them to be. If Jeff wanted to move volume in a hurry, he could take that spread number down to $8 or $9 an hour, and we could hire nurses at $28 an hour, and we can grow the business. However, we just give it all the way in margin. And once we give it away in margin, we’ll never get it back. So sequentially, we’ve got to drive rate and then follow that with wage.
Pito Chickering
Okay. Fair enough. Because of all these really good rate caps you guys did, – just curious how we should think about interest costs for 2023? Should we just take the third quarter to annualize that? Like any color that you can give us there?
David Afshar
Yes, Pito, I think you’d see it bump up a little bit in Q4 as LIBOR rates continue to increase, but now that they’re over 3% were essentially capped. So we’ll see incremental interest costs in 2023 as compared to the Q3 run rate. But bear in mind that our – the payments that we receive under our swaps and caps will also increase. So you could – as you think about interest expense, think about the margin that we pay on our first and second lien and then think about the LIBOR component being capped at 3% if you wanted to forecast the net, call it, interest expense in 2023.
Pito Chickering
So is this the one when all said together, is this more the 130, 140 range? Is that the right level?
David Afshar
That’s probably a fair estimate.
Pito Chickering
Okay. Fair enough. And then which leads to the next question from a free cash flow breakeven standpoint, what EBITDA do you -think that you have to achieve in order to get to free cash flow breakeven?
David Afshar
I think we’ll make a lot of progress towards that in 2023. We expect our EBITDA to grow from where we are in 2022. I can’t give you a specific estimate on what that would be because there’s a lot of moving parts. But what I can say is that without $40 million in one-time usages of cash this year, including the social deferred social security payments. The growth in EBITDA, as I mentioned, in a lower M&A environment, we’re going to have lower integration and systems-related costs. So we’ll make significant progress in 2023 towards breakeven.
Pito Chickering
And sorry, go ahead.
David Afshar
Thank you.
Pito Chickering
And then last question for me here. Just you talked about a lot of volatility within Doctor’s choice because the rollout of Homecare Homebase and Metalogix. Just curious if you can give more details on what you saw specifically in Doctor’s choice. Thanks so much.
Jeff Shaner
I just think at the end of the day, it was 4. So I’m going to step up a second and just say all four companies we acquired had four different operating practices. They were on three different systems or three different versions of systems. They all had different standards. They were different markets. The Florida market is very different than Minnesota, Iowa recover and Alabama.
I think at the end of the day, each company had its own path inside of Aveanna and through Homecare Homebase. And for whatever reason, the Florida business was a little bit choppier in the process. We had a little bit more turnover and maybe just was a little bit slower to come around to be a part of the Aveanna family. And so we had a decent amount of leadership turnover there.
And I think at the end of the day, I would tell you fast forwarding, Hurricane Ian showed us how great the Florida team is as part of Aveanna – they not only handle the hurricane event, but how they treated each other, how they got back to business, got back to treating their patients, I think, really showed us – they’re part of the Aveanna family now. And so each integration takes on a different life of its own. That’s the nature of the beast in M&A. And I would tell you sitting here today, all of us are on the table. Not one of us wouldn’t have done the doctor storage integration. We should be in Florida. These are great markets, great Medicare markets. And long term, we’re still very excited about being in that business in that state.
Tony Strange
That’s well said, Jeff. And I’ll echo what you said about our employees down there. Those guys did an unbelievable job in responding and recovering from Hurricane Ian, and I’ll echo what Jeff said as well, the Doctor’s Choice acquisition will be a great acquisition for us. And one of the things that we will benefit from the implementation of Homecare Homebase is – and I’m going to say this in a positive way, Homecare Homebase is a rigid system.
And it forces you to do things right the first time every time. And I’ll use an example, if you don’t have the face-to-face requirement for a patient or you don’t do the notification of admission process with them, there is a hard stop in the system and says, you’ve got to go do this right in order to move forward. And I think over – while it’s been a little bit painful in Q3, I think over the long term, Homecare Homebase will make us a better company, giving us a disciplined infrastructure to build that business around. So I’m pretty excited about it going forward.
Jeff Shaner
Thanks Pito.
Operator
Next question, Ben Hendrix with RBC. Please go ahead.
Ben Hendrix
Thanks guys. I just want to follow up on your comments around the home health final rule and your comments about how the behavioral assumptions kind of negate the value-based efforts more broadly. I just wanted to know if your government relations folks have had conversations with CMS around this – and we’re able to gauge the receptivity discussion argument. And then secondly, how the better-than-proposed rule impact momentum in the year-end with trying to stay some of these behavioral cuts over the intermediate term? Thanks.
Tony Strange
I think the first questions were yes and then no. So yes, our folks, our teams are well engaged. Rod sits on the board of NOC as well. NOC is extremely engaged in this process. And I think share – we share the same position that NOC has that while we are very appreciative and we think CMS did the right thing in the short term, we’re going to continue with the pressure going forward that we don’t believe that the behavioral adjustment is warranted. As a matter of fact, to your question about my comment, CMS is actually trying to incentivize behavior through value-based pricing, they’re incentivizing companies to do the right thing for the patient to help the patient get better, stay out of the hospital, get rehabilitated, return to activities of data living – and at the same time, when they cut those behavioral adjustments, they’re basically taking away the incentive of the behavior they’re trying to create.
And so for those reasons, we believe that they really want to move the industry to a value-based pricing arrangement that they’ve got to leave enough dollars in there to incentivize companies to want to do the right things and provide more care if necessary. And that’s the piece that we don’t think the behavioral adjustment takes into account is that CMS is really trying to encourage doing more for patients, keeping them out of the hospital and then rewarding people for their outcomes. And that’s why we don’t think the behavioral adjustment is the right thing to be doing. And we’ll continue these pressures in the years to come to make sure that we get the outcome we need.
Ben Hendrix
Thank you.
Tony Strange
Thanks Ben.
Operator
We’ve come to the end of the Q&A session. I would like to turn the floor over to Tony Strange for closing remarks.
Tony Strange
Well, I just want to say thank you again for your interest in our business and joining our call. We look forward to updating you on our progress at the end of the year, and I look forward to catching up with everybody soon. Thank you.
Operator
Thank you. This concludes today’s teleconference. You may disconnect your lines at this time and thank you for your participation.
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