Ensign Group Inc
NASDAQ:ENSG
Earnings Call Analysis
Q4-2023 Analysis
Ensign Group Inc
An investor would find it promising that a company not only sets but exceeds goals consistently, delivering substantial returns. The company has seen adjusted EPS grow by an impressive 168% since 2019, which translates to a compound annual growth rate of 28%. This steady climb in earnings per share showcases the company's ability to maintain growth momentum, an indicator that it follows proven operational principles which generate results over time.
Looking ahead, the company has set its guidance for 2024, aiming for $5.29 to $5.47 per diluted share in earnings and projecting annual revenue between $4.13 billion to $4.17 billion. This guidance reflects the company's confidence in its growth trajectory and operational efficiency. For investors, such figures provide a measure of the company's expectations and a benchmark against which to assess future performance.
The company expanded its operational bed count by 528 with the addition of three new healthcare operations and one real estate asset. These additions bring the total number of operations acquired since 2022 to 54, and are selected based on ample clinical and financial potential. This strategic growth suggests that the company is not merely expanding for the sake of it, but is doing so with careful consideration for value and future performance.
In addition to expansion, there's a clear focus on optimizing current operations. The occupancy and skilled mix days for newly acquired skilled nursing operations stand at 77.6% and 27.5% respectively, compared to a 79.9% occupancy and 30.9% skilled mix for same-store operations. This indicates room for substantial organic growth within the newly added facilities. Success stories from existing operations, such as the Healthcare Resort of Topeka and the Grove Healthcare and Wellness Center, demonstrate significant EBIT growth and high occupancy, underlining strong operational capabilities and the application of successful, locally-driven healthcare models to sustain high performance levels.
The organization touts over $1 billion in 'dry powder' earmarked for future investments and assures that it possesses a strong pipeline for new deals. More importantly, the company emphasizes its disciplined approach to acquisition, only pursuing growth when the proper leadership is in place and the pricing is favorable. This cautious yet poised approach to expansion reflects a strategic patience that is often rewarded in the market.
A glance at the company's financials reveals robust health and performance, with year-end cash and equivalents standing at over $509.6 million and a cash flow from operations of $376.7 million. The company managed to deleverage its portfolio, achieving a lease-adjusted net debt-to-EBITDA ratio of 1.98x, a commendable feat given the scope of growth taken on over the past year.
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Thank you for standing by. My name is Jessica, and I will be your conference operator today. At this time, I would like to welcome everyone to the Ensign Q4 2023 Earnings Call. [Operator Instructions] After the speakers' remarks, there will be a question-and-answer session.
[Operator Instructions]
I would now like to turn the call over to Mr. Keetch. Please go ahead.
Thank you, operator, and welcome, everyone. We filed our earnings press release yesterday, and it is available on the Investor Relations section of our website at ensigngroup.net. A replay of this call will also be available on our website until 5:00 p.m. Pacific on Friday, March 1, 2024. We want to remind anyone that may be listening to a replay of this call that all statements made are as of today, February 2, 2024, and these statements have not been nor will be updated subsequent to today's call. Also, any forward-looking statements made today are based on management's current expectations, assumptions and beliefs 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. Listeners should not place undue reliance on forward-looking statements and are encouraged to review our SEC filings for a more complete discussion of factors that could impact our results. Except as required by federal securities laws, Ensign and its independent subsidiaries do not undertake to publicly update or revise any forward-looking statements where changes arise as a result of new information, future events, changing circumstances or for any other reason. In addition, the Ensign Group, Inc. is a holding company with no direct operating assets, employees or revenues. Certain of our independent subsidiaries, collectively referred to as the service center, provide accounting, payroll, human resources, information technology, legal, risk management and other services to the other independent subsidiaries through contractual relationships with such subsidiaries. In addition, our captive insurance subsidiary, which we refer to as the insurance captive, provides certain claims made coverage to our operating companies for general and professional liability as well as for workers' compensation insurance liabilities. Ensign also owns Standard Bearer Healthcare REIT Inc., which is a captive real estate investment trust that invest in healthcare properties and enters into lease arrangements with certain independent subsidiaries of Ensign as well as third-party tenants that are unaffiliated with the Ensign Group. The words Ensign, company, we, our and us refer to the Ensign Group, Inc. and its consolidated subsidiaries. All of our independent subsidiaries, the Service Center, Standard Bearer Healthcare REIT and the insurance captive are operated by separate independent companies that have their own management, employees and assets. References herein to the consolidated company and its assets and activities as well as the use of words we, us and our and similar terms are not meant to imply nor should it be construed as meaning that the Ensign Group has direct operating assets, employees or revenue or that any of the subsidiaries are operated by the Ensign Group. Also, we supplement our GAAP reporting with non-GAAP metrics. When viewed together with our GAAP results, we believe that these measures can provide a more complete understanding of our business, but they should not be relied upon to the exclusion of GAAP reports. A GAAP to non-GAAP reconciliation is available in yesterday's press release and is available in our Form 10-K. And with that, I'll turn the call over to Barry Port, our CEO. Barry?
Thank you, Chad, and thank you, everyone, for joining us today. Our local teams have once again posted impressive clinical and financial results and continue to build remarkable momentum in each market across our portfolio. Our success is entirely due to the efforts and commitment of those leadership teams, caregivers, field resources and service center partners. One of our most important priorities is to support those that care for our patients every day. After another record quarter, we're excited about the many opportunities to continue to capture the enormous potential inherent in our portfolio as we relentlessly focus on our operational fundamentals both in existing operations and the growing number of new acquisitions. We are pleased to see same-store occupancy of 79.9%, which grew by 240 basis points over the prior year quarter. In addition, we saw an improvement in occupancy on a sequential basis of 40 basis points over the third quarter. We saw increased volume in our combined same-store and transitioning managed care revenue and managed care census which increased during the quarter by 12.3% and 3.5%, respectively, over the prior year quarter as a result of strengthened relationships with our managed care partners and quality outcomes. As expected, we saw an increase in our skilled mix during the quarter as our same-store days for the quarter increased by 110 basis points sequentially over the Third Quarter. We are encouraged by the continued strength in our skilled mix as it demonstrates the continuously increasing demand for skilled post-acute services. By applying proven cultural and operational principles, our local leaders continue to retain and recruit high-caliber individuals which they want to achieve tremendous success across our growing footprint. We continue to be encouraged by the reduction in our use of third-party nursing agencies, which improved again for the Fourth Quarter in a row representing a reduction in agency usage of 58% since its peak in December 2022. We're also thrilled to see lower turnover for the third year in a row which is a result of our local leaders focused on our customer second philosophy, which has and will continue to result in better patient care and outcomes. Likewise, we are also encouraged to see the pace of wage inflation continue to slow, along with improvement in our ability to successfully recruit new talent. As of the end of the quarter, we saw net new hires increased by approximately 6,000 employees over the course of the year, which is particularly impressive given that from the start of the pandemic in 2020 until December 2023, there has been a 9% reduction in employment for the skilled nursing sector. We are confident that by being true to our cultural values strong clinical results and proven operating principles that the near and long-term future is bright. We are humbled by what we were able to accomplish in 2023 and but we are eager to continue to drive improvements in our existing portfolio and take advantage of the acquisition opportunities that we see on the horizon. We are issuing our 2024 earnings guidance of $5.29 to $5.47 per diluted share and annual revenue guidance of $4.13 billion to $4.17 billion. The midpoint of this 2024 earnings guidance represents an increase of 13% over our 2023 results and is 30% higher than our 2022 results. The annual guidance comes on top of the extraordinary growth we experienced in the last few years. To put this performance in perspective, since we spun out the Pennant Group in 2019, we have seen adjusted EPS grow by 168% with a compound annual growth rate of 28%. The performance is not due to some large event or single transformative transaction, but instead, is the result of consistent growth and performance quarter after quarter, which comes from following the proven insight principles. We are excited about the upcoming year and confident that our partners will continue to apply our proven locally driven healthcare model. As we evaluate our expanding portfolio, we continue to see enormous organic growth potential within our existing portfolio and are very excited about the continued growth in occupancies that we experienced during the fourth quarter and that continued so far in the First Quarter of this year. There are so many opportunities in front of us to improve in expense management and drive occupancy and skilled mix as we continue to successfully unlock value in the dozens of recently acquired operations. We are poised to again showcase our ability to find, acquire and transition performing and underperforming operations by applying proven enzyme principles developed over 2 decades. When we consider the health of our organization, combined with our culture and proven local leadership strategy, we are well positioned to have another outstanding year in 2024. Next, I'll ask Chad to provide some additional insights regarding our recent growth. Chad?
Thank you, Barry. We are very excited about the 3 new operations and one real estate asset we added during the quarter and since. Bringing the number of operations acquired since 2022 to 54. These new operations include a healthcare campus in Houston, Texas, which included the real estate assets that were required by Standard Bearer, one operation in Kansas, one operation in Nevada and our first campus in Tennessee, totaling an additional 528 new operational beds. These additions were all carefully selected amongst the many opportunities available to us and were chosen because of the huge clinical and financial potential. Following our recent SNF growth in 2023, occupancy and skilled mix days for the skilled nursing operations in the recently acquired bucket were 77.6% and 27.5%, respectively, for the quarter. When compared to our same-store occupancy and skilled mix days of 79.9% and 30.9%, respectively, there is enormous upside in each of these new operations as they continue to transform into same-store caliber operations. We also remind you that there is nothing about the designation of same-store within our 3 buckets that should be seen as a cap on the occupancies that our more mature operations can achieve. Our leaders consistently drive remarkable improvement in our most mature assets. many of which achieve and maintain occupancies well into the 90-plus percent range as they seek and deliver on opportunities to expand their clinical capabilities into new functional areas and provide alternatives to long hospital days. We are very optimistic about the organic growth potential within our existing portfolio, including our new acquisitions. Because Tennessee is our first new state in several years, I thought I would just briefly highlight our new market program. As most of you know, the foundational principle of our entire strategy is the recognition that post-acute care is a locally driven business and the success or failure of any operation is largely determined by the quality of the leadership and the vision of the team leading each unique multimillion-dollar business. Because we believe that so deeply we take entering into a new state very seriously. Long before we acquired our first asset in Tennessee, one of the most trusted and tenured leaders in our organization, Tyler Albrechtsen, identified that market as one with extraordinary potential. For years, Tyler successfully operated one of our flagship operations in California and later led one of our most dynamic markets in Southern California, developed the business plan for Ensign's growth in Tennessee and presented it to his partners. That business plan was debated and discussed and ultimately approved by his peers. Tyler carefully prepared to replace himself in his existing role as a market leader in Southern California and only after it was clear that he was leaving his old role in better hands than he found it, Tyler moved his family to Tennessee to begin the process of learning the dynamics of the market, meeting new talent and evaluating acquisition opportunities. After many months of preparation and after evaluating dozens of opportunities, Tyler and partners from other supporting geographies agreed to acquire our first building as of January 1. So far, the transition has gone well, and we fully expect all his hard work in preparation to pay off. Over the next several months, as Tyler and his team of resources transitioned the initial acquisition, we anticipate that they will acquire additional operations to build a cluster of facilities over the next few quarters. As we have seen recently in South Carolina, eventually, this will grow into multiple clusters, which will eventually comprise a sizable market. We can't wait to watch Tyler and his team of leaders and caregivers apply Ensign's operating principles in this new market, and look forward to Tennessee becoming another reflection of the template of growth and development we've seen across our footprint over the last 25 years. We also remind you that we are now in 14 states and have significant bandwidth to grow in the other 36 states. The pipeline for new deals remains strong. We are lining up several exciting opportunities and expect to announce several deals over the coming months, and we remain poised to grow with over $1 billion in dry powder for future investments. Our local leaders continue to recruit future CEOs of Ensign affiliated operations, and we have a deep bench of CEOs and training that are eagerly preparing for their opportunity to lead. We continue to see evidence that many operators in this industry are struggling, and we expect that the operating environment will translate into many near- and long-term opportunities to both lease and acquire post-acute care assets. However, we do not set arbitrary growth goals and will remain true to our disciplined acquisition strategy, only growing when we have the right leaders in place and the pricing is right. We continue to provide additional disclosure on Standard Bearer, which is comprised of 108 properties owned by the company and leased to 79 affiliated skilled nursing and senior living operations and 30 operations that are leased to third-party operators. Each of these properties are subject to triple-net long-term leases and together generated rental revenue of $21.9 million for the quarter, of which $17.7 million was derived from Ensign affiliated operations. Also for the quarter, we reported $14.2 million in FFO. And as of the end of the quarter, had an EBITDAR to rent coverage ratio of 2.2x. And with that, I'll turn the call over to Spencer, our COO, to add more color around operations. Spencer?
Thank you, Chad, and hello, everyone. As was mentioned earlier, the continued success we experienced during the Fourth Quarter was a result of continued improvements in occupancy and staffing combined with hundreds of small but meaningful innovations by facility leaders and clusters. Today, I'd like to share 2 examples that demonstrate how diverse geographies and business lines are maturing and in turn, providing more and more opportunities for growth and expansion as we enter 2024. The first facility to highlight is the Healthcare Resort of Topeka, Kansas. This 94 bed skilled nursing and senior living campus has consistently grown since opening in 2016. While the facility has maintained a high census and been successful for many years, going into 2023, CEO, Ben Leiker and Director of Nursing, Amanda [ Paran ], together with their interdisciplinary team, developed a strategy to take performance to the next level. By leveraging the reputation and the stability in nurse staffing to improve skilled mix in the SNF and improved revenue quality in their senior living. The strategy involves concerted efforts to develop clinical programs that met their local hospitals discharge needs, as well as strengthening partnerships with key managed care plans and conveners. As a result, the Senior Living section of the campus maintained 100% occupancy for all of 2023, and the campus grew revenues by 13.4% over prior year quarter. During that same period, skilled mix days improved by 17%, and driven specifically by an increase in managed care days of more than 40%. This growth in acuity was accompanied by an equal focus on recruiting and retention, which led to one of the lowest turnover rates in the market, and 0 agency staffing during all of 2023. The stability in staffing resulted in great regulatory performance, including no survey deficiencies and allowed the facility to avoid much of the costs associated with orienting and training new staff. As a result, HCR Topeka accomplished its best-ever EBIT performance for 2023. And including 70% EBIT growth in Q4 over the prior year quarter. The second example comes from Riverside, California. The Grove Healthcare and Wellness Center is a thriving campus, which includes 38 skilled nursing beds and 90 senior living units. Led by Executive Director, Michelle Mora. The skilled nursing portion has been operated as an Ensign affiliate since 2009. However, in April 2022, the growth Senior Living portion was acquired from Pennant Group. And over the past 18 months, the unified campus has been enjoying exceptional growth. As they have operated more as a healthcare campus DON, Maria Manalo and her team are able to provide integrated and comprehensive care to more and more acute residents within the senior living. At the same time, the SNF portion of the campus has been able to utilize the senior living to safely discharge residents to lower levels of care, which has allowed for more skilled admissions and has increased the skilled mix by 14%. And revenues by 23% in Q4 2023 compared to the same quarter for 2022. Over the past year, community partners, including managed care plans have taken note, and occupancy has frequently hit 100%, in large part due to an 88% increase in managed care census over prior year quarter. Perhaps the most important aspect of the Grove's success story is the incredibly supportive culture that the team has developed. For example, 100% of the Groves employees voluntarily contribute a portion of their paycheck to elevate charities, our charitable fund that provides emergency assistance for employees and crisis. These same employees have also bound together to eliminate agency staffing and reduce turnover, which, in turn, have contributed to a 103% increase in EBIT over prior year quarter at the skilled nursing and to an all-time record EBIT for the campus as a whole. These examples demonstrate the strength of our operating model and how frontline leaders and their local teams are innovating and providing healthcare solutions to their communities and to the residents they serve. With that, I'll turn the time over to Suzanne to provide more detail on the company's financial performance and our guidance, and then we'll open up for some questions. Suzanne?
Thanks, Spencer, and good morning, everyone. Detailed financials for the year and the quarter are contained in our 10-K and press release filed yesterday. Some additional highlights for the year include: Consolidated GAAP revenues and adjusted revenues were both $3.73 billion, an increase of 23%. GAAP diluted earnings per share was $3.65 and GAAP net income was $209.4 million, adjusted diluted earnings per share was $4.77, an increase of 15.2% and adjusted net income was $273.5 million, an increase of 16%. Highlights for the quarter include consolidated GAAP revenues and adjusted revenues were both $980.4 million, an increase of 21%. GAAP diluted earnings per share was $0.38, and GAAP income was $21.7 million. Adjusted diluted earnings per share was $1.28, an increase of 16.4%, and adjusted net income was $73.7 million, an increase of 17.5%. Other key metrics as of December 31, 2023, include cash and cash equivalents of $509.6 million and cash flow from operations of $376.7 million. We continue to delever our portfolio, achieving a lease adjusted net debt-to-EBITDA ratio of 1.98x, which is particularly noteworthy given the amount of growth we have taken on over the last year. In addition, we currently have over $593 million of available capacity on our line of credit, which when combined with our cash on our balance sheet, give us over $1 billion of dry cutter and future investments. We also own 113 assets, of which 108 are held by Standard Bearer and 89 of which are owned completely debt-free and continue to gain significant value return adding even more liquidity to help our future growth. During the quarter, we increased our cash -- quarterly cash dividend to $0.06 per share, marking the 21st consecutive annual dividend increase. Given our strengths, we plan to continue our 22-year history of paying dividends in the future. CMS continues to review the thousands of comments they have received as they look to finalize a federal minimum staffing rule. However, if the rule is implemented, we do not expect the rule to impact us in 2024. Also, during the quarter, we settled a litigation matter that we previously disclosed. We are pleased to put this matter behind us and look forward to focusing solely on our mission of providing compassionate care to patients and achieving our goal of setting the standard for high-quality healthcare services throughout the industry. As Barry mentioned, we are providing our annual guidance of $5.29 to $5.47 per diluted share and annual revenue guidance of $4.13 billion to $4.17 billion. We have evaluated multiple scenarios and based on the strength in our performance and positive momentum we've seen in occupancy and skilled mix as well as some additional strength in Medicaid and managed care programs, we have confidence that we can achieve these results. Our 2024 guidance is based on diluted weighted average common shares outstanding of 58.5 million, a tax rate of 25% and the inclusion of acquisitions closed in the first half of 2024. The inclusion of management's expectations for Medicare and Medicaid reimbursement net of provider tax; with the primary exclusions coming from stock-based compensation and certain expenses related to specific litigation matters arising outside the normal course of business. Additionally, other factors that could impact quarterly performance include variations in reimbursement systems, delays and changes in state budgets, seasonality in occupancy and skilled mix, the influence of the general economy on census and staffing, the short-term impact of our acquisition activities, variations in insurance pools and other factors. And with that, I'll turn it back over to Barry. Barry?
Thanks, Suzanne. As we wrap up, I can't emphasize enough how incredibly honored and grateful we are to work alongside our facility leaders, field resources, clinical partners, and service center team that are behind these record-setting results. We never cease to be amazed by their impressive resiliency as they focus on supporting one another in new and innovative ways. Their commitment has blessed the lives of so many, including our own. We're excited about our future because of our amazing partners, and we have complete faith in them and the culture that they have collectively built. We'll now turn over to the Q&A portion of our call. Operator, can you please instruct the audience on the Q&A procedure?
[Operator Instructions] Our first question comes from the line of Ben Hendrix with RBC Capital Markets.
Suzanne, I was hoping you follow up on some of your comments on the top line guidance, really good revenue outlook there. I was just wondering if we could kind of break down a little bit more of the drivers there. For example, what you're thinking about in terms of how occupancy faces through the year? Also, you mentioned the rate backdrop and strong Medicaid reimbursement. Just wanted to see what you're seeing there and how that -- how sustainable that is in the next couple of years? And then just any commentary on contribution from recent acquisitions that we could see ramp up this year.
Yes. Thanks, Ben, for a great question. As we look at the guidance for this year, a couple of things that would took into consideration. As you know, we have historically given you guys some visibility into the revenue by breaking it out into the 3 buckets, same-store, transitioning and recently acquired. And as we kind of look at those 3 different buckets, what we're kind of projecting for rate growth -- overall growth in each one of the bucket is mid-single digits, kind of in that same-store bucket and that transitioning bucket kind of high single digits and then in the recently acquired low double digits. As we stated in the remarks, the acquisitions were including through the first half of the year. So not a ton of acquisitions. And as we stated in the previous years, when we bring those acquisitions in, we're really bringing in that revenue and it's going to kind of hit on that margin line as we don't expect a lot from in those first years. For occupancy, continued growth is what we are anticipating in 2024 with that seasonality all built into that. So overall, we're really excited about where we're positioned on rates. One of the strongest rate years that we've had was in 2023. As you know, a lot of that comes in the late Third Quarter, early Fourth Quarter. So most of that rate growth will then push into 2024 and then really looking at some continued nice growth in the kind of late Q3, Q4 of 2024 as well. Not as probably as strong as what we saw in late 2023, but relatively strong compared to historical.
You asked about contribution from acquisitions. Obviously, the ones that we obviously have some visibility and some deals that we'll do this year and we don't expect much, if any, contribution from those. The ones that we acquired last year overall are ahead of schedule, largely due to the North American transition that went extremely well. So some of our optimism in our guidance comes from the kind of accelerated growth that we saw from those buildings that will continue throughout this year as they mature.
And just one quickly. We are also getting questions. I know the legal settlement kind of has brought into the spotlight, some of the typical kind of legal activity that happens in the healthcare industry, but also getting questions on. We noticed that there was another kind of or DOJ CID issue that might have been raised earlier this month regarding Medicare and Texas Medicaid. Just wondering to see if that's kind of a similar situation, if that's something that's related to this issue that you just settled or if it's separate, just your take on that.
Yes. I mean, so the settlement from earlier that we've been disclosing for years now was related to its resolution on a case from 2018 that began as a related initiated DOJ inquiry. And when the DOJ declined intervene, that turned into a civil case that just stretched and stretched over many years. We brought in a mediator earlier this year to find a suitable resolution. And we found one and this saves us from additional defense costs, which was significant time and distraction as well because there's a large breadth to the scope of it. And it allows us to move forward without any overpaying of liability. So we just felt like the cost and the timing of distraction made it important for us to just get that one behind us. So that's that one. And like I said, we've disclosed that over the course of many years in our filings. This new one is unrelated. And while there are some references to some Texas Medicaid issues, it's a fairly general inquiry. This is healthcare. When you're dealing with government payers, there's always the chance that they're going to ask questions and do audits. We don't know what kind of -- what's driving it necessarily. We don't have a whole lot of details on it. And we've retained really, really good outside counsel to help represent us on it and get to the bottom of what they're asking for. But yes, it is totally unrelated to the prior settlement.
Your next question comes from the line of Scott Fidel with Stephens.
Actually, just wanted to start just double-click on Ben's question just on the Medicaid rates and one state and specifically, you had an important California rebasing process that was underway for a while. And I think at this point, you should have pretty strong visibility into that. So maybe if you could give us an update on sort of how that is playing out and how you expect that to impact revenue costs and margins in '24?
Yes. Great question, Scott. Obviously, California was one of the few stages to refresh everyone's memory that continue to pay out the additional 10% [indiscernible] In 2023. What the state has done is really gone and said, "Hey, how do we continue to make sure that we make operators in a great position." And so they went through a process of instituting a rebate program that starts January 1, 2024. At the same time as that, they also went and re-upped their supplemental program that they haven't had in place for a couple of years now. And so really, how we're looking at those and how the state is really looking at this, it's a combination of those to really make up the overall state rate. And so we'll have some folks that will enter into the rebasing program where their rates will be raised and based upon kind of the costs that are there and the increase in costs that we've seen. And then as a part of that program, they will also have to do some additional cost for benefits and other things. But overall, we're really, really happy with that. On top of that, will also be having a supplemental program that allows us to earn additional funds for quality improvement. So all of that goes into effect in January. So January 1, it went into effect. The state where it's at right now is it actually is with the CMS for their state approval because every state has to get all of their Medicaid rates approved. And so overall, we're really excited about combination of those 2 programs together. There might be a little bit of a hit on margin because there is some cost associated with getting some of that revenue, but overall feel really great about the additional revenue that's going to come through and the cost that we pay for it.
Okay. Great. And then next question, just want to ask you just on EBITDA margin and on cost of services. First, in the Fourth Quarter, I know that you have the deferred comp program that can affect that I think your slide deck literally just came out, so we haven't had a chance to review that yet. But maybe just walk through the interplay for us of the deferred comp program on the 4Q margin. And then talk about in your outlook for 2024, how you sort of see core EBITDA margins trending between the low and the high end of the ranges?
Starting with the 2023, the best kind of clarity that we try to give to you is in -- like we mentioned -- like you mentioned in the investor deck, Slides 46 and 47, actually, one slide gives you on a quarterly basis, and the other slide gives it to you on a year-to-date basis. Looking at Q4 specifically, when we go back and look at this. If you take Q3 relative to Q4, we had a 50 basis input increase in cost of services. When you break down that 50 basis points, 30 of those basis points are related to the DCP. And remember that the amount with those earnings really is just offset below the line. So this isn't -- it's an accounting thing, not necessarily an earnings thing. And so when you look at it, it's neutralized below the line. So those 30 basis points are in net income. Those are neutralized. So that's just a P&L placement. And then the other 20 basis points really are what we've been talking about all year long. This recently acquired operations, when they make up a more significant portion of the overall cost you're going to have the margin impacted by that. And you can see that our recently acquired operations continue to make up a significant portion of our cost. And again, quarter-over-quarter over quarter-over-quarter increase were a higher percentage of our overall revenue. A couple of other things with Q3 to Q4. You always have a little bit higher cost associated with benefits and GLPL and we did have some [indiscernible]. So you've got some -- a little bit of noise to make up that additional 20 basis points up there, but that kind of rounds out 2023. Pushing into 2024, what we try to get you guys to do is neutralize that deferred comp impact, kind of getting that out of there because again, that it's below the line and above the line. And so kind of making that all neutralized, I really think that the overall neutralized effect will have really consistent margins what we saw in 2023 and before. And so overall consistent to slightly improved on the top end.
Okay. Great. Very helpful. Then just last question. In 2023, you had really significant growth in both operating cash flow and free cash flow as well. And we're just trying to think about how to model off of that, given, again, a very sort of sharp uplift in operating cash flow. So any guidance you can give us on thinking about operating cash flow, any sort of working capital or other items that we should be contemplating or trying to trend out our cash flow forecast for 2024.
Yes. As you kind of think through, obviously, in Q1, we always have a significant hit in cash for a couple of different reasons, right? That's when you see the outflow of our incentives go out all the year-end incentives get paid out in Q1. So you'd anticipate that outflow going into Q1. It will be a little bit different pattern that we saw in 2023. Remember in 2023, we were able to differ a lot of our taxes all the way to Q4. And so you're going to see those taxes really be spread out throughout the year in 2024. Other than that, we just don't have as much lumpiness other than the timing of when we'll pay out the settlement of the litigation matter that we disclosed that's -- there's a little unclarity there. So that will -- my best guess would be maybe late Q2, early Q3, but that will be in there. But other than that, I think we'll have nice, more steady cash flow, but those are some of the things that will make it a little bumpy in Q1 and then kind of steadied out throughout the rest of the year.
Got it. So overall, probably fair to think about operating cash flows generally consistent with the earnings 2024.
Correct. With the exception of Q1, that little bit of hit I talked about and then the other things being that the DOJ.
And that is currently all the questions that we have in our Q. At this point, I would like to hand the call back over to Barry for some closing remarks.
Thanks, operator, and thanks, everyone, for joining us today. We appreciate your support, as always, and look forward to an amazing 2024.
Thank you. And ladies and gentlemen, that does conclude today's call. Thanks again for joining. You may now disconnect.