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Hello, and welcome to the AMN Healthcare Third Quarter 2021 Earnings Call. My name is Emma, and I will be your operator today. [Operator Instructions]
It's now my pleasure to hand the call over to Randy Reece, Senior Director of Investor Relations, to begin. Please go ahead.
Good afternoon, everyone. Welcome to AMN Healthcare's Third Quarter 2021 Earnings Call. A replay of this webcast will be available at ir.amnhealthcare.com, following the conclusion of this call. Details for the audio replay of the conference call are in our earnings release issued this afternoon.
Various remarks we make during this call about future expectations, projections, trends, plans, events or circumstances constitute forward-looking statements. These statements reflect the company's current beliefs based upon information currently available to it. Our actual results may differ materially from those indicated by these forward-looking statements because of various factors and cautionary statements, including those identified in our most recently filed forms 10-K and 10-Q, our earnings release and subsequent filings with the SEC. The company does not intend to update guidance or any forward-looking statements provided today prior to its next earnings release.
The call contains certain non-GAAP financial information. Information regarding and reconciliations of these non-GAAP measures to the most directly comparable GAAP measures are included in our earnings release and on our financial reports page at ir.amnhealthcare.com.
On the call today are Susan Salka, Chief Executive Officer; Jeff Knudson, our incoming Chief Financial Officer; Kelly Rakowski, Group President and COO of Strategic Talent Solutions; Landry Seedig, Group President and COO of Nursing and Allied Solutions; and James Taylor, Group President and COO of Physician and Leadership Solutions. Also joining are Chris Schwartz, AMN Controller, who has served as our Interim Principal Financial Officer for the third quarter; and Vice President of Finance, Santhi Gullapalli. I will now turn the call over to Susan.
Thank you so much, Randy, and welcome, everyone, to our earnings call. It's hard to believe that this month is the 20th anniversary of AMN becoming a public company. Over the past 2 decades, we have strategically evolved and built AMN into the largest, most diverse and consistently high-performing company in our industry. More importantly, we have created a culture that puts people and values first.
At every opportunity, we take action to ensure that we are living up to our commitment to diversity, equity, equality and inclusion. Over the past 2 decades, we have dramatically increased our impact in our communities by dedicating resources to important social issues and helping others to achieve their goals in a sustainable way. I'm reminded every day how deeply our team members care about what we do, and making a difference in this world.
Our culture is truly special and unique. And so I want to start by thanking my incredible colleagues for all that you do and who you are. Just like our clients and health care professionals, our team members are working extraordinarily hard to do our part in this environment.
Over the last 2 decades, I have also spoken frequently on these calls about the demographic changes that were likely to unfold. As the Baby Boomers began to reach retirement age, we expected to see pressure intensifying on the demand for and access to health care in this country.
Amplifying this trend, the number of people entering the health care workforce may not be enough to offset those who are exiting. We expected these workforce changes to come slowly and be most significant around 2025. However, the COVID-19 pandemic has accelerated the rate of change in ways no one foresaw. Virtually every day, we see headlines about health systems losing workers faster than they can hire them. Staffing shortages are impacting access to and timeliness of care. The clinical workforce on average is getting younger, which means they are less experienced at a time when patient care is growing more complex. Acuity levels are higher than ever before at first, because of COVID-19, but now because many millions delayed their care during the height of the pandemic amidst an aging population.
According to a recent poll, 30% of health care workers had quit or been laid off during the pandemic. Of those still employed, nearly 1/5 were considering leaving the health care profession.
This immense pressure on the health care workforce has sparked labor activism and for the next several years, the number and magnitude of strike events could exceed anything we've seen in the past. AMN and our entire industry are working harder than ever to help health care providers cope with a record labor shortage. We believe our role will be important and essential for years to come, providing workers where they're needed most.
We can also enable many of those now on the sidelines to find work that meets their needs and flexibility in the future. As the leader in total talent solutions for health care, AMN takes our responsibility very seriously to strategically support our clients as they adjust their near- and long-term plans.
Our telehealth and other workforce technology solutions are also more critical than ever to provide innovative approaches to alleviate the labor shortages. And so we are investing heavily to ensure that they can meet the changing health care delivery models and the needs of our communities.
Demand for our services is much stronger than we had anticipated, which is reflected in the better-than-expected third quarter results and our fourth quarter outlook. However, because there is significantly higher demand than supply of clinicians, we believe that even with half of the demand that we are seeing today that we would have likely seen similar volume growth.
Consolidated revenue in the third quarter was $878 million, 59% higher year-over-year, enabled by strong performance from all revenue segments. Nurse and Allied Solutions reported revenue of $627 million, up 64% year-over-year. Travel Nurse Staffing revenue grew 56% year-over-year. Volume growth was the greatest contributor, although we also had higher bill rates.
As we mentioned on our last call, we started to see demand rise during the summer even before the Delta variant hit. Due to staffing shortages, demand has sustained the same record-high levels since September even though COVID-19 hospitalizations have steadily declined.
With the clinician shortage and high demand persisting, pay rates have also increased and correspondingly, bill rates have risen. As typical, we are passing on a greater percentage of these bill rates to our clinicians.
Our Allied Staffing team hit another record high with $136 million in the third quarter revenue, up 62% year-over-year. Allied volume grew more than 50% year-over-year. Demand in the third quarter grew 72% over the second quarter level, and October orders were more than 20% above third quarter average. Demand is very strong across all Allied disciplines, including therapy, imaging, respiratory labs, case managers, and medical assistants. In the fourth quarter of 2021, for the entire Nurse and Allied segment, we expect revenue to be 96% to 100% higher year-over-year.
Physician and Leadership Solutions segment revenue for the third quarter was $151 million, 38% higher year-over-year. That is the best organic growth rate this segment has recorded in company history, but this is actually the case for all of our segments.
Locum Tenens revenue was $89 million, up 31% over prior year. Locum's providers on assignment reached their highest level since 2018, and demand increased 36% from the second quarter. Revenue growth was consistently good across specialty, and just like our other businesses, this team is executing very well. Interim leadership revenue grew 59% year-over-year as the business delivered another consecutive quarter of revenue growth. Physician and executive search is rebounding much faster than we expected and delivered revenue growth of 33% year-over-year. For the fourth quarter, we expect Physician and Leadership Solutions revenue to be approximately 35% higher year-over-year.
Third quarter revenue for the Technology and Workforce Solutions segment reached a record $100 million. The revenue increased an impressive 67% year-over-year. Language services continued its strong growth pattern with revenue of $47 million, which is 33% higher than a year ago. Revenue for our VMS business was $33 million in the quarter, growing a remarkable 113% year-over-year.
Our RPO solution, which as a reminder, assists clients with recruitment and hiring of permanent staff, grew significantly year-over-year. We're delighted to support many new clients, though market-wide demand for RPO is much greater than the available industry capacity.
In the fourth quarter, we expect revenue for the Technology and Workforce Solutions segment to be up approximately 50% compared with prior year. Enabling consolidated revenue growth of nearly 60% in the third quarter and even greater growth in the fourth quarter would be difficult at any time, and it is especially hard in the labor market of 2021. Across the company, we have added more team members than in any other year, and we continue recruiting to support our growth.
We also have made important additions to our leadership team, improving our ability to foster our culture, develop and care for our team members manage our long-term growth, and serve our health care professionals and clients always with the greatest integrity and transparency. One great example of a leadership addition that makes us stronger is Jeff Knudson, who has joined the AMN family as our Chief Financial Officer. Jeff brings very valuable health care and other sector expertise that will help us continue to build and execute on our mission and financial goals. As importantly, Jeff is a perfect match for the value-based, highly engaged, and fast-paced culture at AMN.
At this time, I'd like to invite you, Jeff, to share a little bit about yourself.
Thanks so much, Susan. My family and I are thrilled about joining AMN at such a fascinating time. I live here in Dallas with my wife, [ Selena ], and the youngest of our 3 children, while our older 2 are very much enjoying the first and second years in college.
Personally, I'm extremely excited to return to health care and join an organization with such diverse workforce and staffing solutions. I'm especially looking forward to working with Susan and the entire management team at AMN to maintain and extend the company's history of industry leadership while delivering long-term value to our team members, health care professionals, clients, communities we serve, and shareholders.
I would also like to thank Chris, Santhi, and the entire financial organization for their leadership over the past several months. I very much look forward to meeting and working with many of you on this call in the near future.
Thank you so much, Jeff. We're so glad to have you here. And since Jeff is day 3 on the job, he won't necessarily be participating in the Q&A. We're super fortunate to, of course, have Chris and Santhi here to help us out with any of those questions.
Continuing on the people front, we recently also announced that Nishan Sivathasan will be stepping into the role of Chief People Officer effective January 1. Nishan joined the AMN family over 2 years ago as our Head of Strategy and M&A. His people and culture leadership during this pandemic has been extremely valuable, which made this an obvious choice for me and the team, and we are deeply grateful Nishan is going to be at the forefront of our people strategies for the future.
I also want to take this moment to recognize Landry Seedig, who is celebrating his 20th anniversary with the AMN team this week. Time flies when you're having fun, right, Landry? Landry is a great example of how AMN obtained great talent in our acquisitions, and Landry has certainly made the most of this opportunity, first in leading and growing our Allied division, then as President of our Nurse Staffing division. And as you know, now, earlier this year, he became Group President and COO -- actually, that was last year, Landry, right? Time does fly. He's now Group President and COO of our largest revenue segment.
Landry is truly an outstanding role model of AMN's commitment to our ethics and values every single day. As a servant leader, he's been a mentor to many developing tremendous leaders along the way. So a huge thanks to you, Landry, and your amazing wife [ Jamie ] for all that you do to support the AMN mission and the team.
In a few minutes, Kelly Landry, James, and Santhi will join us for the Q&A session. But first, I'd like to tag on to Jeff's comments and thank our entire finance tax and accounting leadership team for their great work enabling a seamless transition as we searched for our new CFO. At one of the busiest times we have ever seen, it's especially comforting to have such a strong and capable team, so thank you, everyone.
And now I will turn the call over to our colleague, Chris, who will provide more insight on our financial results.
Thank you, Susan, and good afternoon, everyone. Third quarter revenue of $878 million was 11% above the upper end of our guidance, with all 3 segments showing outperformance. Consolidated revenue grew 59% year-over-year and 2% sequentially. Gross margin for the quarter was 34.8%, which was 130 basis points higher than prior year and up 210 basis points sequentially.
The year-over-year improvement was driven primarily by a favorable workers' compensation actuarial adjustment this year compared with an unfavorable one a year ago as well as an increase in high-margin labor disruption revenue. Consolidated SG&A expenses were $174 million or 19.8% of revenue compared with $111 million or 20.2% of revenue in the year-ago quarter and $157 million or 18.3% of revenue in the previous quarter. Year-over-year and sequentially, operating leverage on the higher revenue was tempered by investments in growing and supporting our team members, communities, and health care professionals.
In the third quarter, Nurse and Allied revenue was $627 million, 64% higher than the prior year and up slightly sequentially. For Travel Nurse, our largest business, revenue grew 56% over prior year with volume up 27% and the average bill rate up about 23%. Average bill rate was flat from second quarter levels.
We expect bill rates and volumes to be sequentially higher in the fourth quarter, driven by continued strength in demand. Allied revenue was $136 million, up 62% from the prior year and up 1% sequentially. Allied volume was up more than 50% over prior year with the average bill rate higher by 7%. Nurse and Allied gross margin of 29.3% was 190 basis points higher than prior year and up 270 basis points sequentially. The favorable swing in the workers' compensation accrual and the $23 million of labor disruption revenue added 300 basis points to gross margin compared with a year ago.
Segment EBITDA margin of 14.8% was 100 basis points higher than prior year due to the factors that lifted gross margins, partially offset by hiring of new team members, support of labor disruption activities, and other people-related expenses. Physician and Leadership Solutions revenue in the third quarter was $151 million, which was 38% higher year-over-year and up 8% sequentially. Gross margin for this segment was 34.8%, 190 basis points lower than the prior year and down 180 basis points sequentially. The declines were primarily due to a mix shift toward lower margin specialties.
Segment EBITDA margin was 12.8%, down 140 basis points from last year and down 290 basis points sequentially. The year-over-year and sequential decline stemmed from lower gross margin, higher team member expenses, and favorable professional liability expenses in the prior quarter. The Technology and Workforce Solutions segment had a record revenue of $100 million in the third quarter, growing 67% year-over-year and 7% sequentially, with strong growth across all service lines.
Segment gross margin was 69.4%, higher by 330 basis points year-over-year and up 170 basis points sequentially. The increases were due to a favorable revenue mix shift. Segment EBITDA margin of 47.2% was up 430 basis points year-over-year and was 180 basis points higher sequentially.
Consolidated third quarter adjusted EBITDA of $138 million was 80% higher year-over-year. Adjusted EBITDA margin of 15.8% was 190 basis points higher year-over-year and up 20 basis points sequentially. We reported net income of $74 million and diluted earnings per share of $1.54 in the third quarter. Adjusted earnings per share was $1.73 compared with $0.82 in the year ago quarter.
Days sales outstanding increased to 60 days, 10 days higher than last quarter due to a surge in revenue and accounts receivable late in the quarter. Operating cash flow for the quarter was $17 million and $227 million year-to-date. Capital expenditures, $16 million. As of September 30, we had cash and equivalents of $137 million, long-term debt of $850 million, and a leverage ratio of 1.5x to 1.
Now turning to fourth quarter guidance. We are projecting consolidated revenue to be in a range of $1.13 billion to $1.15 billion, approximately 80% higher than the prior year. Fourth quarter gross margin is projected to be 31.8% to 32.3%. Reported SG&A expenses are projected to be 17.5% to 17.9% of revenue. Operating margin is expected to be 11.8% to 12.3%, and adjusted EBITDA margin is expected to be 15.3% to 15.8%.
Other fourth quarter estimates include the following: depreciation expense of $10.5 million, noncash amortization expense of $16 million, stock-based compensation expense of $7 million, interest expense of $10 million, integration and other expenses of $7 million, an adjusted tax rate of 27%. Revenue guidance includes $14 million related to labor disruption activities.
And now I'll pass the call back to Susan for some concluding comments.
Thank you so much, Chris. We are so proud of how our entire team has responded in this environment, helping our health care professionals and clients during a very critical time. Some influences driving nursing and allied demand and order levels will certainly subside a bit over time. However, we believe the largest driver of labor shortages will endure and that the long-term growth opportunities for AMN are stronger now than they ever were before. The need for health care organizations to have a total talent solutions partner has been escalated to a higher level, and we are very energized about the future.
While we are not giving formal guidance for 2022, I have a few comments about our expectations. Health care labor shortages that we had expected to play out over many years have clearly been accelerated. This will have a long-term impact on workforce management and patient care delivery model. Looking specifically at 2022, we believe volumes will grow year-over-year across all of our businesses. Nurse demand is at record high levels and expected to decline somewhat in 2022 but remain well above pre-pandemic levels. As a result, we expect our volumes to be on a positive trajectory for the year.
Allied is doing exceptionally well with growth being driven primarily by strong volume. We expect to enter 2022 with Allied demand remaining at these record levels and volumes continuing to grow. Locum tenens demand is nearly 1.5x higher than pre-pandemic, which we expect will continue our upward trend in placements. Interim leadership, search and RPO have strong and growing demand. The need for virtual language services continues to grow each quarter, and our other technology businesses are seeing increased interest as clients seek broader solutions to address the workforce shortage long term.
Due to the strains on the workforce, retirements, and vacancies, health care wage inflation has moved much higher. The staffing paradigm for all health care services appears to have taken on lasting changes. We all want nursing bill rates to decline, which will happen when pay rates come down. Our best guess is that exiting 2022, nursing bill rates will be lower than today, though still 20% to 30% higher than pre-pandemic pricing level.
We have high confidence that the future environment will be favorable for demand across all of our businesses. As importantly, the AMN team will continue pouring our talent and our hearts into making a positive impact for our health care professionals, our clients, patients and our communities.
Now Emma, let's begin with the Q&A session. Thank you.
[Operator Instructions] Our first question comes from Tobey Sommer from Truist Securities. Our next question today comes from Jeff Silber from BMO.
Sounds like we may be having some technical difficulties because I know Tobey and Jeff are very experienced at this.
So we have Tobey who's reregistered a question. [Operator Instructions]
Emma, the callers are telling us that they can hear each other, but we can't hear them.
So you...
The other people who are on the call can hear each other, but we, in this room, can't hear them.
So there might be a setting that needs to be changed so that we are all together and can hear them, would be my guess.
Yes. The analysts are telling me that they can hear Tobey.
Okay. Is there a way for them to type in their questions or for somebody to share with us in another manner? Thank you for your patience, everyone. We appreciate it. We will figure this out. This is a new one. This is my 80th earnings call, and we have never had this happen before. So that is the environment in which we live today.
Analysts, if you could e-mail questions to me, I would be happy to read them.
Well, while we're waiting for those questions, I'm sure we have some things that we can share proactively, maybe knowing what questions might be on people's minds. So as we wait for those questions, James, perhaps I'll ask you to first share a little bit more detail about the great performance in Physician and Leadership Solutions. And some of the drivers of both the revenue growth, but also the lower gross margins in that mix change that we referred to.
Thanks, Susan. And just to add to the great success that we've had, all practices are contributing a very strong performance in quarter 3. Overall, as you heard, our revenue was $151 million, up sequentially 8% and the highest revenue quarter since quarter 3 of 2018 performing versus prior year, so a very strong recovery of revenues, up 38% as was prior mentioned. Also, we have sequential growth of core revenue that is up as well. I will say that our margin and capital margin question -- quarter-over-quarter, our gross margin and operating margins are down. There really are 3 main contributors to driving that impact. First of all, we have the higher remit of Locums business. Locums is a lower-margin practice with -- inside of the PLS division. And in quarter 3, it represented a large portion of our segment revenue.
Second point is our business specialty mix. CRNA is our largest growing specialty that's growing. And it also is one of our low-margin specialties that we have with -- inside of our portfolio. Because of its fast-growing and, of course, low margin, it represented, significantly, a portion of Locums that drove our margins down.
And then last but not least, in quarter 2, we had a favorable impact of our provider liability insurance reserves, and we did not have that in quarter 3. So those are the 3 causes that drove the margin down.
Great. That's super helpful. And I think we were able to get some questions e-mailed to us. We'll take those now, Randy.
Jeff Silber of BMO asks Susan, you called out labor disruption as a long-term driver. How do you go to market with this without upsetting unions and other groups? Or is there another way it affects us?
Yes. Whenever we originally got into the labor disruption business, it was actually because our clients were asking us to get into it. So it's a difficult business, as you can imagine, kind of helping our clients out in some of their most difficult times.
There are quite a few labor negotiations happening, right now, across the country. We mentioned that in Q3, we had $23 million worth of labor disruption or strike revenue. And we've actually included about $14 million that's in our Q4 guidance. These things are very unpredictable. It could really happen at any time. There's a few events that are actually currently going on out in the marketplace today that we're not involved in. And then there's also some events that we're trying to help our clients prepare for. So overall, as you would imagine, the potential for some larger labor events is in our pipeline.
Operator, I'm told that the people on the call cannot hear us now.
We just experiencing a little bit of technical difficulty. We're just having a member of the team sort this now.
Okay. Great. I am being told that now that folks can hear us. So maybe we'll try another question from another analyst.
Yes. This is from Tobey Sommer of Truist. Susan, could you put together your segment comments for 2022. [Technical Difficulty]
Okay. We apologize. Clearly, something has happened with the conference call technology. So we will continue on with some comments and try to get it fixed. Otherwise, we may have to set up another call so that we can answer questions later. But Landry, why don't you share a little bit more about Nurse and Allied and some of the trends.
I do have a bunch of questions.
You do, okay. I just don't think anyone can hear us.
I got one message saying they could hear us.
Okay. Let's do it.
Okay. Looking at the revenue trajectory for 2022, will revenue grow? Or what should we think of early in '22 sequentially for modeling?
So I laid out the trends and the sort of the demand drivers for 2022. And of course, the big variable is the demand environment, mostly the pay rate environment and the result of result [indiscernible] for us. Sounds like they're working on that tech stuff. So I understand that they can hear us through the webcast, but perhaps not the phone. So that's -- if folks can move over to the webcast, I think that would be helpful. And no one in here is on the webcast, correct? Okay. We got this.
So thinking about next year, obviously, going into the first quarter we'll be stronger, and we -- because we've seen very strong demand now and, honestly, haven't seen it subside for the last couple of months, we expect to come into the first quarter relatively similar-ish to the third and the fourth quarter. And I'd say something in terms of the overall consolidated revenue between the third and the fourth quarter, something in the middle is probably close to what you'd expect.
North of $1 billion is very reasonable. We're not giving that as guidance, but if you just do the math, and based on the demand today, that certainly is a very possible target for us to hit as a starting point. And then if we expect volumes to grow throughout the year, some seasonality in there across some of the businesses, and we have the offsetting headwinds. Then that's the big question of how much will those headwinds offset the volume growth.
And so whether we are down next year because the bill rates come down faster, and quite honestly, that would be a good thing because it means that things are coming back to a semi- more normalized state and a more sustainable state, even though well above pandemic levels, then it could offset the volume and we could have a decline year-over-year. But that would set us up very well going into 2023.
So I know it's not an exact answer, which is why we're also not giving guidance for next year because there's still relatively a lot of uncertainty around bill rates and pay rates in particular. But I'd have to say the, kind of, other underlying drivers of our core business are exceptionally strong, and we expect that we'll continue to see growth across most of our businesses with the exception of, again, this headwind in Nurse and a little bit of Allied in the bill rates.
Santhi, is there anything that you would add in there?
Yes. I would like to say that the same trends that are affecting us in Allied would impact the MS business also in Technology Workforce Solutions; otherwise, you've covered everything else, Susan.
That's an excellent point, Santhi. Our VMS business, which as you might recall, provides a vendor-neutral technology solutions for clients that don't want or need a staffing-led MSP. It provides them a solution to manage their contingent staff. And that business has done exceptionally well throughout the pandemic.
The team is executing exceptionally well. We have many new clients, as you can expect. And -- but they also have some of the same influences of the higher demand, driving higher pay rates, higher -- and then higher bill rates. So as that comes down, there's still a headwind there as well. And that shows up in that technology and Other Workforce Solutions segment. Thank you, Santhi.
We have the next question from A.J. Rice of Credit Suisse. Says you are seeing some strength in areas that were adversely impacted or did not participate in the COVID surge. So is the strength in VMS, interim RPO and so on a normalized run rate? Or is this reflective of some pent-up demand being worked through?
Well, I just addressed the VMS component, which certainly has had some uplift from the higher bill rates, I'd say. The underlying shortage, however, will continue -- we believe, continue to drive strong demand and good volume within VMS, but we'll just have that offset of the bill rates coming down. As you might recall, the revenue in VMS comes from a percentage of the overall gross billings that we manage for our clients. And just to put it in perspective, today, we have a run rate of over $6 billion of gross spend under management across our VMS system and our MSP, so that's a significant increase from what we had seen over the last few years. Volume is part of the story, additional clients, but also those bill rates. But the other parts of the business, our language services business is growing exceptionally well. I talked about the 33% growth. That has been the story since we acquired that company at the beginning of 2020. Early days, we had a little bit of COVID-related activity and projects, but today, it's more business as usual.
And I'll actually ask Kelly Rakowski to jump in on some of the other businesses since they report to her.
Yes. And thank you for the question, A.J., and we're really delighted to see the balance of our businesses really come back strong and strong performance by the teams and really speaks to the need some of these services. That while they might not have been as directly impacted by COVID, certainly the needs of our client base, as they work through a multitude of strategies to address the shortages, that's impacting health care services across the board.
So Susan mentioned our virtual language services. So as volume has increased in our patient care areas, our team has just performed very well across all of our modalities in language services. You mentioned RPO, A.J., which certainly was suppressed for a good portion of the COVID surges. And now as we're seeing these significantly high and growing vacancy rates in most organizations, a much higher demand for our RPO services. Our team has mobilized and grown very quickly. We're there to support our most strategic clients as they look to fill those permanent vacancies, and have those longer-term solutions.
I think Susan said in her script, though, there's a -- the market demand is so significant, we're being very selective about and really prioritizing, as we have all along, our most strategic clients to help them with that capacity on the perm side. Same goes for other things like our workforce technology, predictive analytics, where our clients are really turning to us to help them look to other solutions to help them optimize their workforce as well. So we're going to continue to see that the macro factors are actually supporting the need for these services going forward as well.
[Operator Instructions]
Emma, let's return to those questions.
The first question comes from A.J. Rice from Credit Suisse.
Can you guys hear me?
Yes, sir. We can, yahoo.
That quiet there for a moment made me nervous. I guess I'm wondering, given the demand surge, are a greater percent of your fills, revenues being fulfilled by your MSP customers versus other clients? How are you managing that push-pull of keeping clients across the spectrum happy? And assuming there is a little prioritization of MSP accounts, has that made those who aren't MSP accounts consider shifting in that direction?
A.J., this is Kelly again. I think we've been sharing all along that it's been very important for us to honor our long-term commitments to our MSP clients. and we continue to do so. We're seeing about the same percentage of fill, although our total fills have gone up. We've been really fortunate to turn to other solutions like our vendor-neutral solutions that Susan mentioned, our open talent marketplace to really support our new clients that weren't able to implement an MSP during this time.
We've also seen some growth. So while we have been selective, we have certainly had some very strong wins for not only hospital-based and health system-based MSPs, but also in some newer sectors. We had a global cruise line who signed a large MSP with us this past quarter. We've had a couple of home health organizations start new MSPs. So I think the market has really seen the value of having a strategic partner and they know the need is going to persist. So we've been really pleased with the business that we have been able to add and looking to find other ways to support organizations.
And it's not just about our capacity. It's also about their capacity to manage a change at this time. So other solutions have helped them alleviate and meet some of their needs. And we continue to work with them so that as volume starts to moderate, we'll be able to bring additional clients on board.
Okay. Maybe one more. I think I heard you say that beyond the demand for temporary staff, that you were seeing upward wage pressure in the permanent staff of the health systems you serve. Can you give us any perspective? I know pre-pandemic, we were sort of plugging at 3% every year for SWB growth. What are you seeing in the market now?
Yes, A.J. It's Kelly. I'll keep going. It really, of course, varies by market, but we are seeing not only base wage inflation, and I don't have a consistent percentage for you, A.J. But in addition to that, premium pay strategies have also been very dynamic and have gone up during this time period. So we're seeing increase in shift differentials, bonuses paid for additional shifts, additional overtime. We're seeing sign-on bonuses for nursing, which we haven't traditionally seen nationally at any other time. So it's a very competitive marketplace. And so we're seeing those rates play out in many different ways in perm core staffing as well as contingent staffing.
[Operator Instructions]
The following question comes from Brian Tanquilut from Jefferies.
I have my first question, apologies if we missed this stat, but can you share with us how much hiring you've been able to do for recruiters or revenue-generating roles and what productivity has looked like in those roles?
Sure, Brian. Well, I'll start -- this is Susan. I'll start at an enterprise level. I mentioned in my prepared remarks that we have been adding significant staff across the organization, and we have growth of about 30% in our FTEs year-over-year across the enterprise, and we are also still adding many, many more as we enter into 2022.
And I'll ask Landry to share a bit about the recruiters and sales team within Nurse and Allied, which is probably one of the areas you're most interested in.
Brian, it's Landry. So we have been, certainly, as you can imagine, increasing our producer count. We actually have increased our counts now for 5 consecutive quarters, and we're continuing to do that. So probably maybe even more what you're looking at is what we're thinking even going into next year. And so I would expect that we will continue -- or we will be continuing to grow that number.
You also asked about the productivity number. I would say it's a good story that, that's actually flat. So you think about the number of people that we've been bringing in and to get them ramped up and just still be able to maintain our consistent productivity level per person is actually a good story.
Got you. Appreciate that. And then, Susan, you talked about how you think, as we exit the pandemic, things would still be pretty robust, but maybe any comments you can share with us in terms of what your thoughts are in terms of, like, the long-term growth rate that we should be thinking about post-pandemic for your different business lines?
Sure, Brian. As I mentioned, and I think most believe in the industry, our growth prospects have certainly increased. Whereas previously, we might have looked to some of our staffing businesses and said, well, maybe 3% to 4% to 5%, 6% growth, I think that has turned into more like double-digit growth opportunity.
Once we get through any headwinds in bill rates coming down, we see this shortage persisting. It's not even just us, it's our clients and it speaks to the conversations that we're having with them today about their desire to work with us on longer-term staffing plans, whether it be ability to continue to add perm staff through utilization of RPO, international staffing and having a better visibility into what their planning needs are going to be down the road.
So it's -- I say that because it's really important that it's not just wishful thinking on our part but it is quite real. And when we talk with our clients, they're very concerned about the protracted nature of this shortage. And the numbers alone would support that in terms of vacancies being at such a high level. You look at the number of quits in health care right now, and we just hit another record month in quits across the country. The number of job openings, the hires is 2.3 openings to every 1 hire.
And so there's really a difficult, difficult time that is not going to end anywhere in the near future. And so we think that certainly accelerates our growth opportunity and probably takes our volume growth up into the higher single digits, if not double digits.
And then, of course, we have these other solutions that are either smaller or technology-related, things like Stratus, our language interpretation service, which grew this quarter at 33% and has been. Now we may not expect it to grow at 33% every quarter for the future, but if it can just continue to grow in the teens, that will be nice significant growth. And businesses like that, of course, have strong margins, strong recurring revenue, et cetera. So hopefully, that's helpful.
One target I'll throw out there for you, Brian, is, we've talked a lot about our EBITDA margin target being 14%. And clearly, we've blown through that. This quarter, we reported high 15s; the next quarter, kind of reporting 15.5% to high 15s. We think that a next sustainable target is around 15%. Now, just like now, we may have quarters where we're above that, maybe even in 16s, and we may have somewhere we're below based on investments that we're making. But we do think, in the next few years, 15% EBITDA margin is a realistic, sustainable target for us to aim for.
If I may throw one last quick one.
Sure.
Oh, yes. One last question. Since you mentioned Stratus, do you think the penetration there -- in the past, cross-selling was part of the thesis, right? And it seems like we're starting to see a slight slowdown now in the growth rate or more of a normalization. So do you think that we're getting close to the penetration rate within the existing book of business and the traditional business lines where we need to start thinking about selling beyond your existing client base?
Brian, it's Kelly. Our growth rates -- I will say our growth rates are still strong in Stratus and have been. I think we saw in prior quarters, higher sequential growth rates just as they were recovering back to normal patient care volumes.
The good news for us is a lot of our more recent growth has been from existing Stratus customers. There's still a lot of fragmentation in this market, need for more integrated solutions and full-scale solutions across the health enterprises. And we still have an opportunity to further penetrate into our existing clients, our existing AMN clients. So we've -- due to just how the market has been, the ability to add on or change services at this time, much more of our growth has been through expansion and utilization of existing customers. So we see a lot of runway for us to continue to add language services to our portfolio of services with our strategic clients. So we do expect more growth in new business going forward.
And Brian, you just think about the macro drivers of this business. You look at 67 million residents in the U.S. or 22% of the population now speak a language other than English at home. That's equal to the entire population of France, and it's growing. And in 9 states, more than 1 in 4 residents now speak a language other than English at home. And so these statistics will continue to drive the need for adoption.
I think, actually, the pandemic helped to put a spotlight on the fact that translation and interpretation is an essential part of quality patient care as well as driving a good patient experience. So we see opportunities to continue to expand and evolve not just what we're doing today in language interpretation, but actually add on other services. We have iPads and thousands of facilities around the country. We can add on other capabilities and services.
So it's a great question. As you can tell, we're very bullish, and it's a very, very important service to patients that might otherwise be in a vulnerable situation. So it really helps add to the health care equity and access of this country.
Next question comes from Tobey Sommer from Truist Securities.
Over time, throughout all of staffing, companies have tried to automate the front-end system as well as the back end, the credentialing, onboarding and payroll. How are your efforts in that regard? And how do they stack up against others who are focused on it in the marketplace?
Thanks, Tobey. And as you know, it's been a huge focus of ours for several years, and I'm really proud to say I do think we're leading the industry in digital transformation and the use of mobile apps, and I'm going to let Landry tell that story because I think it's best told in the Nurse and Allied business where we've had the greatest impact.
Yes, Tobey, it's Landry. So I know we've talked about AMN Passport before. That's our mobile app. And there's, of course, a lot of benefits from the investments that we've been making there. We've been going at that for nearly 2 years now.
And it's a good place for clinicians. They can go and they can find themselves and match the jobs easier. They can ultimately kind of take themselves all the way through the process. So they can apply for a job, they can get submitted to a job, It supports them in their onboarding, they can submit their credentials. And just recently, we have created it to where they can enter time and they can see all their pay information. So we continue, monthly, to roll out new enhancements there.
One good stat on it, just to kind of show the adoption of it as well as some of the efficiencies that it's creating within the organization, is that since inception, there's actually been over 330,000 credentialing documents that have been uploaded through the application itself. So a lot of -- automation has really allowed our teams to focus on more high-touch areas and just overall making the experience better for the clinician and just making us more efficient.
The next question comes from Tim Mulrooney from William Blair.
This is Sam filling in for Tim. We'll keep it 1 as well, just to give others a shot as well. Starting out, like, do you have an estimate for the percentage of your nursing staff and talent pool that remains unvaccinated still? And could you help quantify us for maybe what type of revenue headwind this might represent for you over the next several quarters here?
Tim, it's Landry. I can take that. So nationally, it's stated that about 96% of physicians are currently vaccinated, and about 88% of nurses are vaccinated. There's not any, really, great stat that we can find for Allied that matches our same skill set. But from what we can tell internally, it looks to be about the same as what we see on the nursing side.
So far, we have been requiring our health care professionals to follow the standards that health systems and states have put in place for their mandate. As of today, there's 19 states that require some sort of mandate. And then of course, we've got a lot of large health systems out in the marketplace that have a mandate in place.
As of right now, we -- from our experience from everybody that's already put a mandate in place, it's had an impact on 1%, approximately 1% of our clinicians just due to their vaccination status. So a very low percentage. Of course, we're getting ready to head toward the rest of our population.
Of course, we're anticipating there might be changes federally. And so we'll be working on the rest of our population here pretty soon. But we really don't anticipate any major negative impact from that. There will be some puts and takes in there. And just based on what we've seen already so far, a very, very small percentage of our population has been negatively impacted.
The next question comes from Bill Sutherland from the Benchmark Company.
My one question -- I'm glad we're all telecommunicated together here now. When I'm on conference calls, Susan, with health care providers of various types, one of the things that they're always kind of putting out there for investors is, yes, our labor costs are up, and we're not happy. And one of the initiatives we're going to take is to somehow get the contract labor number down from -- it's now up to 4%, and we're going to get that back down to maybe not where it was in the past, but we're going to get it down. Is that just wishful thinking on their part? Yes, I guess that's the main question.
Yes. So I think there's absolutely a desire for health care organizations and for us, and, I think, our industry to get the overall current cost of contract labor down primarily because of the very high pay rates that are driving the higher bill rates. And I think we're all anxious for that to subside. It is being driven by the shortage. And so that is going to continue to be a challenge with such high demand levels, but we believe that we can do our part and that over time, things will start to subside. That alone will bring the cost of contract labor down.
But when it comes to the mix of permanent and flexible staff, so I'm actually hearing the opposite from the health care executives I speak. They're talking about the staffing paradigm changing forever. Things like we will never go back to the way we used to staff for 2 reasons: one, the extreme shortage that is expected to persist for many, many, many years to come. Second, the preference of the younger workforce and this desire to have more flexibility not to commit long term and to participate in what's referred to as the gig economy. And that is absolutely, we think driving some of the behavior along with just the frustrations of the pandemic and people being burned out. So that will likely increase the mix of flexible staff over time if we truly see this staffing paradigm shift that we expect.
They'll stop complaining when the rates get back to wherever they settle in is what you're in.
Yes. I think that will help a lot. Yes. I totally agree. That will help a lot for everybody and be more sustainable.
The next question comes from Kevin Fischbeck from Bank of America.
This is Courtney on for Kevin. So I guess, just a few follow-ups on what we've talked about today. So I guess, the color you guys gave on Stratus has been especially helpful, and it definitely seems like you're pivoting towards growing out the tech business, Tech and Workforce Solutions. So I was just wondering, with the focus right now in that segment kind of be looking at new assets or more so really just on integration and ramping up and really just trying to get higher penetration in the cross-selling opportunity.
So the latter is definitely the first priority, investing in our current tech and tech-enabled solutions. So things like language interpretation, Synzi, which we recently acquired, our telehealth platform and Education, Silversheet, which is our credentialing platform and Avantas, which is our workforce optimization, predictive analytics.
So we have a lot of opportunities there to continue to invest, expand the capability so that we can penetrate in different ways with the clients that we have as well as perhaps address new markets. Avantas is a great example. They're doing a wonderful job in acute care, but there's a whole other opportunity in the nonacute, post-acute industry. And so we could continue to expand upon those opportunities just within the technologies that we currently have in place.
But we are also looking at new capabilities in the tech and tech-enabled space. They are relatively high valuations. So as you expect, we are being very disciplined about what we pursue. But when the right opportunity comes along, I think you've seen, we are willing to pay and even pay a premium for those things that really make sense. So hopefully, that's helpful, Courtney.
Yes. No, that's super helpful. And then I guess, one last quick one, I guess. You guys have been recording some labor disruption revenues and strike-related revenues for the past few quarters. So just curious, are these coming from 1 singular client? Are these coming from multiple different orders? And then just how has that trended over the past few quarters?
Courtney, it's Landry. So first off, on the revenue, Q3 of this year, we had $23 million included in our guidance for Q4, we've included $14 million, So we have a very robust pipeline, as you can imagine, of potential labor disruption event. There's a lot of negotiations that are taking place out in the market.
Primarily, we focused that to support our MSP customers. So a lot of our prioritization that we think internally has to do with making sure that they're taken care of. But it doesn't mean that we don't have contracts to support other potential disruptions that are out in the marketplace with some other clients that we do business with. But that just kind of gives you an idea of that profile.
There are some labor events that are actually active today, that we are not supporting that are out in the marketplace that have been going on for quite some time, but we are helping our clients today help prepare for some potential labor events that could happen.
Final question we have in the queue comes from Mark Marcon from Baird Capital.
Glad we all got connected. So just a follow-up with regards to disruption. Susan, in your early comments, you talked about the level of activism. So I have a broad question and a specific question. The broad question is just, how do you think that the level of labor activism is going to end up impacting the space over the next few years from a broad perspective?
And then I just wanted to make sure I understood what you were saying with regards to -- I was assuming that you were going to be helping one of your largest clients in the elements that are currently in the news. Is that an incorrect assumption?
That -- so, I'll take them in reverse order. That's not an incorrect assumption. We have, as you know, some wonderful large strategic clients that we've assisted with strike activity in the past. And, and we're always first focused on them. And so we have been planning and working with this particular client for several months now, and we're very well prepared should we be needed to step in. It's still an uncertain situation. And so we're...
So you're not building that in.
No, no, we have -- whenever we're planning and in preparing, there are fees that are collected to cover expenses that we're incurring and to recruit the clinicians to be at the ready and do a certain amount of credentialing and perhaps preorientation, So that's the $14 million in fees that Landry referred to, not all from 1 client, but a decent portion of them are. And then if a strike event would occur, then that would be on top of our guidance. We're not including any expectation of that right now.
And then getting back to your other question on the longer-term effect, I really believe and based on what we've even seen, not just guessing, that these labor disruption events will be more intense. They'll likely be larger. They'll be longer and just in order of magnitude, have a greater impact, certainly, in the profession itself for our clients. We heard of 1 health care organization that said they were going to actually just close the hospital because they didn't want to have to try to deal with labor disruption during this environment.
Now that's not practical in every community, and it's not practical on a sustainable level, but that's the kind of challenges that they're dealing with, knowing how hard it's going to be to recruit staff in an already critical time of deep shortages. So -- well, what will be the results of some of that besides it's highly disruptive? Yes, for us, an opportunity to assist and add value. Possibly for us, it'll create some lumpiness in our results going forward, although quite honestly, at our size now, $14 million just doesn't really move the needle as much. But if there are large events, it might be a little bit more impactful or a little bit more noise in our earnings.
For the industry, for the nursing profession, I think it will likely put more pressure on wage increases. That question was asked earlier. And the study came out in August indicating that frontline health care workers saw, on average, wage increase of 8%. And talking with our clients, we've heard 10% and 12% baseline wage increases. And they're saying -- or their nurses are saying, that still is not nearly enough. So it's hard to say where it will settle in, but clearly, wages and benefits for nurses will increase. And quite honestly, they should.
And it's hard to say what that will ultimately settle at, but I think it will be nothing like we saw before with the 2%, 3% increases. I also believe that health care organizations, going back to my prior comment, will have a different staffing paradigm mix, and we'll be utilizing more flexible staff rather than core staff. A, because that will be what the workforce prefers, but it will also, for them, probably be more economical in some ways to have that flexibility of having travelers and staff when they need them. So hopefully, that's helpful, Mark.
That is. Do you think that -- is this -- I've seen different periods where there's been activism with regards to health care workers. Do you think that this is the most intense period that you've ever seen?
Yes. Definitely.
Great. And then how are you thinking about the glide path in terms of the bill rates? You kind of gave us an expectation for where it should end up being by the end of the year. Do you think that's a relatively smooth path? Or -- and then can you also talk a little bit about Allied? Because it seems like there's probably room for further expansion on the bill rates there, just given the overall level of demand?
Yes. I'll talk about the glide path and then maybe Landry, you could chime in on Allied. So we think that the first quarter will continue to be relatively more elevated and that we would see the more significant decreases come in the second and third quarter, and then fourth quarter would probably just glide through. But if we're to sort of look at the sequential changes, second and third quarter would be our best guess right now. So Landry, you want to talk about Allied?
Yes. Overall, I mean, the demand in Allied is significantly ripe now. And it's across a lot of their different specialties. So therapy, I know we've talked about it a lot in the past. It's a 10x what we had seen even a year ago. And even in respiratory, you would expect that, that might have already come down. Respiratory is at 5x from what it was a year ago.
So they already have some elevated rates or higher rates due to the strong demand that's there. Yes, you could expect with where the demand is today that we would expect some bill rate increases. Due to different puts and takes in that business, we actually would expect it maybe to be a little bit more flat as we go into next year and throughout the year.
If you went back a year ago therapy -- maybe 2 years ago, therapy made up a very large percentage of that overall business, and now that's kind of flipped. And imaging, respiratory, and lab makes up a larger percentage of the business and so -- which typically carries a higher bill rate. So we think that there's a big upside in therapy. So it would be more of a mixed story that might keep that bill rate flat as we go into next year.
There are no further questions, so I'll hand back to the team for closing remarks.
Great. Thank you so much. And I thank everybody for your patience today. We're really looking forward to, as you can tell, our ability to continue to make an important impact at this time. And now is a time when we need to be laser-focused on delivery. We need to be and are investing in our clients, our businesses, our people, our communities. It's a time when we're incredibly proud of the essential positive impact we're making. We're very grateful for our amazing colleagues and partners, and we're humbled, humbled by the extraordinary efforts of health care professionals and organizations during this difficult time.
So we appreciate you all and look forward to chatting again when we give our fourth quarter results in February. Thank you, all.
Ladies and gentlemen, this concludes today's call. Thank you all for joining. You may now disconnect your lines.