Uncovering the Outlook for Healthcare Staffing

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1 OCT 24 8:30 AM INTERNATIONAL KEYNOTE Uncovering the Outlook for Healthcare Staffing Barry Asin, President, Staffing Industry Analysts

2 Agenda The Big Picture Where We ve Been Key Trends and Issues The Outlook Ahead Questions

3 US Healthcare Spending Growing at Historically Slow Rates, But Outlook Improving Source: National Health Expenditure Projections, Health Affairs, October 2013

4 Healthcare Industry Job Growth Healthcare Industry Monthly Job Growth (000) Recession Monthly Job Growth 6 month average 0 Source: U.S. Bureau of Labor Statistics (September 2013) and Staffing Industry Analysts

5 Most Growth not in a Hospital Setting Source: U.S. Bureau of Labor Statistics (September 2013) and Staffing Industry Analysts

6 Good News: Healthcare Quits Rising Again Y/Y % Change in Healthcare Quits - Healthcare & Social Assistance 40% 30% 20% 10% 0% -10% -20% -30% -40% Recession Y/Y change in healthcare quits 3-month moving average Source: U.S. Bureau of Labor Statistics

7 Agenda The Big Picture Where We ve Been Key Trends and Issues The Outlook Ahead Questions

8 Historical Growth of Healthcare Staffing % indicates annual growth rate vs. prior year Source: SIA U.S. Staffing Industry Forecast (September 2013)

9 Pulse Survey Suggests Deceleration in Healthcare Revenue Growth Source: SIA Staffing Industry Pulse Survey (September 2013)

10 2013 a Low Growth Year in Healthcare Staffing Source: SIA U.S. Staffing Industry Forecast (September 2013)

11 Healthcare Staffing Market Share Leaders Top 5 Market Share 2005 = 25% 2012 = 30% Largest healthcare staffing firms in the U.S. Ranked by estimated 2012 U.S. temporary staffing revenue 2012 U.S. Staffing Revenue ($million) Market Share Rank Company 1 AMN Healthcare Services $912 10% 2 CHG Healthcare Services $721 8% 3 Jackson Healthcare $467 5% 4 Cross Country Healthcare $400 4% 5 Maxim Healthcare Services $279 3% 6 Medical Staffing Network $244 3% 7 On Assignment $208 2% 8 Supplemental Healthcare $199 2% 9 Team Health $190 2% 10 Aureus Medical Group (C&A Industries) $178 2% 11 Parallon Workforce Management Solutions (HCA Holding) $173 2% 12 Soliant Health (Adecco) $157 2% 13 Reliant Healthcare $100 1% Total $4,228 46% Source: SIA 2013 Staffing Firm Market Share Landscape and Book of Lists

12 Public Company Revenue Growth Slowing Healthcare Staffing* Revenue (Y/Y Growth) 28% *Includes nurse/allied/physician business only 13% 12% 11% 11% 6% -2% 3% 7% 2% 2% 6% 3Q12 4Q12 1Q13 2Q13 AMN Cross Country On Assignment Source: Company Reports and Staffing Industry Analysts

13 Public Company Gross Margins Relatively Stable Since 2012 Healthcare Staffing* Public Company Gross Margin % 29.7% 29.6% 29.2% 29.8% 30.0% 27.1% 27.0% 27.0% 27.6% 27.7% 26.2% 24.9% 24.6% 25.0% 25.1% *Includes nurse/ allied/physician business only, except Cross Country margin is company-wide 2Q12 3Q12 4Q12 1Q13 2Q13 Source: Company Reports and Staffing Industry Analysts AMN Cross Country On Assignment

14 Allied and Locum Tenens About Half of the US Healthcare Staffing Market 2012 US Healthcare Staffing by Segment Source: SIA U.S. Staffing Industry Forecast (September 2013)

15 Travel Nurse Growth Forecast Slower in 2013 Source: SIA U.S. Staffing Industry Forecast (September 2013)

16 Pulse Deceleration in Travel Nurse Growth 50% 40% 30% Y/Y Revenue Growth 20% 10% 0% -10% -20% J A S OND J FMAM J J A S OND J FMAM J J A S OND J FMAM J J A S OND J FMAM J J A % -40% Source: SIA Staffing Industry Pulse Survey (September 2013)

17 SIA NATHO Benchmark Survey Shows Travel Nursing Gross Margins Tightly Clustered Source: SIA 2013 NATHO Benchmarking Analysis

18 SIA NATHO Benchmark Survey: A Profitable Travel Nurse Industry Aggregated across travel nurse survey respondents Source: SIA 2013 NATHO Benchmarking Analysis

19 Per Diem Nurse Growth Forecast Improving in % Growth in Per Diem Temp. Staffing Market 15% 10% 5% 5% 0% 0% P Source: SIA U.S. Staffing Industry Forecast (September 2013)

20 Allied Health Growth Forecast Down in 2013 Source: SIA U.S. Staffing Industry Forecast (September 2013)

21 Allied Health Pulse Shows Recent Deceleration in Growth Source: SIA Staffing Industry Pulse Survey (September 2013)

22 SIA Allied Benchmark Survey Revenue Mix $416M in Annualized Revenue (15% of the market) Source: SIA 2013 Allied Health and Advanced Practice Benchmarking Survey

23 Allied Benchmark Survey Highlights Weakness in Key Allied Segments Allied Health Revenue Growth 1H13/1H12 Total Allied health -3% Respiratory therapists 20% Speech therapists/speech pathologists Medical technologists/mlt Pharmacists 9% 9% 12% Physical therapists (PT) Occupational therapists (OT) -7% -9% OT assistants/cota -19% PT assistants -30% Other allied health 10% Source: SIA 2013 Allied Health and Advanced Practice Benchmarking Survey

24 Locum Tenens Growth Estimate & Projection Source: SIA U.S. Staffing Industry Forecast (September 2013)

25 Locum Tenens Revenue from SIA NALTO Survey (2012) Other Locum Tenens 21% Hospitalists, 19% $1.2B in Revenue (58% of the market) Source: SIA NALTO Benchmarking Survey Radiology, 3% Pediatrics 4% Anesthesiology, 5% OBGYN, 5% Psychiatry, 7% Family/Internal Medicine 9% Surgery, 11% Emergency Medicine, 16%

26 Locums Results by Segment in 2012 Locum Tenens Revenue Growth 2012/2011 Total Locum Tenens Urgent Care Pediatrics Surgery Emergency Medicine Hospitalists OBGYN Psychiatry Family/Internal Medicine Anesthesiology Radiology Other Locum Tenens -33% -9% 1% 4% 4% 10% 28% 19% 19% 18% 15% 17% Total Locums=10% Source: SIA NALTO Benchmarking Survey

27 st Half Shows More Mixed Results Locum Tenens Revenue Growth 1H13/1H12 Total Locum Tenens 5% Urgent Care 33% Emergency Medicine Hospitalists 16% 19% Family/Internal Medicine Psychiatry Pediatrics 4% 3% 5% OBGYN Radiology -19% -5% Total Locums=5% Surgery -20% Anesthesiology -22% Other Locum Tenens -10% Source: SIA NALTO Benchmarking Survey

28 Healthcare Staffing Firms on SIA s Fastest Growing Staffing Firm List 2012 U.S. Staffing Revenue ($mil) Compound Annual Growth Rate (Organic, ) Rank Company Top Staffing Segment(s) Served 2 InGenesis Allied healthcare, Clinical/scientific $ % 14 A-Line Staffing Solutions Allied healthcare $ % 44 AB Staffing Solutions Travel nursing $ % 51 Clinical Resources LLC Travel nursing $ % 60 Therapy Source Inc. Allied healthcare, Industrial $ % 70 CEO Inc. Office/clerical, Allied healthcare $ % 78 Mitchell Martin Inc. IT staffing, Allied healthcare $ % Source: SIA 2013 Staffing Firm Market Share Landscape and Book of Lists

29 Agenda The Big Picture Where We ve Been Key Trends and Issues The Outlook Ahead Questions

30 ACA Projected to Deliver Significant Growth in Healthcare Spending in 2014 Source: National Health Expenditure Projections, Health Affairs, October 2013

31 Buyers and staffing firms disagree on which side will bear the cost of ACA compliance Staffing companies median expected cost increase for ACA compliance is $1.50 per temp hour Source: SIA 2012 Contingent Buyers Survey, 2013 Staffing Company Survey

32 Cost/Benefit Analysis of ACA Compliance Options Suggest Fully Compliant Insurance the Answer for Most Healthcare Staffing Firms Pay the $2,000 penalty Buy Skinny Med Insurance Buy Fully- Compliant Insurance Annual Cost $2,000 x (FT-30) $585 x FT -and/or- $3,000 x?? $2,600 x FT x 60% Risk None Some None Benefits to Employees None Partial Insurance Full Insurance Cost-Example 1 55 FT Employees Cost-Example FT Employees $2,000 x (55-30) = $50,000 $2,000 x (300-30) = $540,000 $585 x 55 = $32,175 $3,000 x?? = up to $50,000 $585 x 300 = $175,500 $3,000 x?? = up to $540K Source: Affordable Care Act The Play-or-Pay Employer Penalties and How to Avoid Them $2,600 x 55 x 60% = $85,800 $2,600 x 300 x 60% = $468,000 Rarely Sometimes Most Likely

33 The Growth of VMS, MSP and RPO

34 Significant Growth in Healthcare VMS and MSP Spend Under Management +24% +27% Source: SIA 2013 VMS/MSP Supplier Competitive Landscape Report

35 High Interest in MSP, VMS, Master Supplier and RPO as Offerings of Healthcare Staffing Firms Source: SIA 2013 Staffing Company Survey

36 Health IT Deadlines Driving Growth Opportunities EHR Implementation: To avoid a penalty in 2015: - Hospital must begin 90 day EHR reporting period no later than April 1, 2014 (if hospital has not yet demonstrated meaningful use) - Eligible Professional must begin 90 day EHR reporting period no later than July 1, 2014 (if EP has not yet demonstrated meaningful use) - Hardship exceptions U.S. ICD-10 Conversion - October 1, 2014 deadline - Late compared to other developed nations (Canada is laughing at us) AHIMA is in the house at HCSS!!

37 Younger and Older Nurses Growing as Part of the Mix of the Nurse Workforce Source: U.S. Census Bureau

38 Nurse Shortages: The Gift That Keeps on Giving Source: United States Registered Nurse Workforce Report Card and Shortage Forecast, American Journal of Medical Quality, 2012

39 Agenda The Big Picture Where We ve Been Key Trends and Issues The Outlook Ahead Questions

40 US Health Spending to Rise Significantly in 2014 and Beyond Source: National Health Expenditure Projections, Health Affairs, October 2013

41 US Health Spending in 2014 and 2015 Source: National Health Expenditure Projections, Health Affairs, October 2013

42 Our 2014 Forecast Shows Improvement Source: SIA U.S. Staffing Industry Forecast (September 2013)

43 The Future of Healthcare? The Walmart Way Big volumes Lowest prices Efficient operations Heavy IT focus

44 Questions?

45 The Long Term Outlook

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