Jeffrey S. Shaner; CEO & Director; Aveanna Healthcare Holdings Inc.
Matt Buckhalter; Interim CFO & Principal Financial Officer; Aveanna Healthcare Holdings Inc.
Shannon L. Drake; Chief Legal Officer & Secretary; Aveanna Healthcare Holdings Inc.
Benjamin Hendrix; Assistant VP; RBC Capital Markets, Research Division
Brian Gil Tanquilut; Senior Equity/Stock Analyst; Jefferies LLC, Research Division
Joanna Sylvia Gajuk; VP; BofA Securities, Research Division
Philip Chickering; Research Analyst; Deutsche Bank AG, Research Division
Greetings. Welcome to the Aveanna Healthcare Holdings, Inc. Second Quarter 2023 Earnings Call. (Operator Instructions) Please note, this conference is being recorded. I'll now turn the conference over to your host, Shannon Drake. You may begin.
Shannon L. Drake
Thanks, Shamali. Good morning, everyone, and welcome to Aveanna Second Quarter 2023 Earnings Call. My name is Shannon Drake. I'm the company's Chief Legal Officer and Corporate Secretary. With me today is Jeff Shaner, our Chief Executive Officer; Matt Buckhalter, our Interim Chief Financial Officer; and Debbie Stewart, our Chief Accounting Officer. During this call, we will make forward-looking statements. Risk factors that may impact those statements and can cause actual future results to differ materially from currently projected results are described in this morning's press release and the reports we file with the SEC. The company does not undertake any duty to update such forward-looking statements.
Additionally, during today's call, we will discuss certain non-GAAP measures, which we believe can be useful in evaluating our performance. The presentation of this additional information should not be considered in isolation or as a substitute for results prepared in accordance with GAAP. A reconciliation of these measures can be found in this morning's press release, which is posted on our website at www.aveanna.com and in our most recent quarterly report on Form 10-Q filed with the SEC. With that, I will turn the call over to Aveanna's Chief Executive Officer, Jeff Shaner. Jeff?
Jeffrey S. Shaner
Thank you, Shannon. Good morning, and thank you for joining us today. We appreciate each of you investing your time this morning to better understand our second quarter results and how we are continuing to progress against our near- and longer-term objectives for 2023 and beyond. My initial comments will briefly highlight our second quarter results, along with the progress we are making in addressing the labor markets and our ongoing efforts with government and managed care payers to create additional capacity. I will then provide some thoughts regarding our liquidity and refreshed outlook for 2023 prior to turning the call over to Matt to provide further details into the quarter and full year guidance.
Starting with some highlights for the quarter. Revenue was approximately $471.9 million, representing a 6.5% increase over the prior year period and a 1.2% sequential improvement. Gross margins was $155.3 million or 32.9%, which is essentially flat when compared to the comparable prior year period, but a 7.5% sequential improvement. And finally, adjusted EBITDA was $35.8 million, representing a 3.2% decrease when compared to the prior year period, primarily due to the costs associated with the current labor environment. However, a 25.6% sequential improvement, reflecting the improved payer rating environment as well as cost reduction efforts taking hold.
As we have previously discussed, the labor environment remains the primary challenge that we are aggressively addressing in 2023 to see Aveanna resume the growth trajectory that we believe our company can achieve. As a reminder, we do not have a demand problem. Demand for home and community-based care has never been higher with both state and federal governments and managed care organizations asking for solutions that can create more clinical capacity. As communicated in our previous quarter, our ability to recruit and retain the best talent is a function of rate. Our business model offers a preferred work setting that is mission-driven, providing a deep sense of purpose for our teammates. However, our caregivers need to be able to provide for themselves and their families in this inflationary environment, and we must offer a competitive wage.
Since our first quarter earnings call, I am pleased with the progress we have made on several of our rate improvement initiatives with both government and managed care payers. Specifically, as it relates to our private duty services business, our goal for 2023 was to execute a legislative strategy that would increase rates by double-digit percentages across our various states with particular emphasis on California, Texas and Oklahoma, which represent approximately 25% of our total PDS revenue. Year-to-date 2023, we obtained double-digit PDS rate increases in 6 key states, including Oklahoma. We have also achieved rate wins in an additional 11 states that were either in line or slightly better than our expectations. These combined 17 states represent approximately 50% of our PDS footprint. And we should continue to see positive progress throughout 2023 and into 2024 as we continue to focus on the remaining states.
As a point of reference, the majority of the rate increases are effective in the second half of 2023, so we will get a full year benefit as we head into 2024. Finally, we were successful in expanding the family caregiver benefit in 2 additional states, which should help ease caregiver capacity constraints. While we're pleased with our PDS legislative messaging is being well received by state legislators, we still have much work to do. As an example of the work ahead, we received a modest increase in Texas effective September 1 and do not anticipate being included in the California budget until mid-2024. While we believe we have made significant strides with both Texas and California legislature, demonstrating the importance of rate increases and how they support an overall lower health care costs, improve patient satisfaction and quality outcomes, it is clear that we need to further accelerate our preferred payer strategy and continue to focus on opportunities within our current infrastructure to allow us to pass meaningful wages through to our caregivers. This allows us to become a solution for overcrowded children's hospitals and to straw parents who want their children to be cared for in the comfort of their home.
Moving on to our progress with preferred payers. Our goal for 2023 was to double our PDS preferred payer volumes from approximately 10% to 20% by year-end 2023. In the second quarter, we added one additional preferred pay agreement in a key market. Our preferred payer volumes increased to approximately 16% of total PDS volumes as compared to 13% at the end of Q1. We have since signed an additional preferred pay agreement in early July and are optimistic we will continue to execute this strategic initiative throughout 2023. While we are taking a national approach to our PDS preferred payer strategy, we are placing particular focus on the state of Texas due to the moderate rate increase and intensifying our ability to shift capacity to our preferred payers.
As of June 30, we now have over 50% of our Texas PDN volumes with preferred payers and believe we have an opportunity to further improve this trend to approximately 70% by the end of the year. Finally, we discussed the need to shift our current labor capacity to those payers that value our services and appropriately reimburse us for the care we provide. We continued several initiatives to shift caregiver capacity in our -- to our preferred payers to optimize staffing rates while minimizing days in an acute care facility. In the second quarter, our preferred payer relationships benefited from accelerated caregiver hires up 2.5 to 3x more than our other payers. And we continue to experience staffing rates approximately 20% greater with significantly higher patient admissions.
The value proposition is straightforward. Preferred payers reimburse us a fair rate, and we pay market competitive wage rates while also earning value-based payments for achieving positive clinical outcomes and improved staff dollars. We are encouraged by our 2023 rate increases and the subsequent recruiting results and believe our business can rebound quickly as we achieve our rate goals previously discussed. Home and community-based care will continue to grow and Aveanna is a comprehensive platform with a diverse payer base, providing a cost-effective, high-quality alternative to higher cost care settings. And most importantly, we provide this care in the most desirable setting the comfort of the patient's home.
Before I turn the call over to Matt, let me briefly comment on our liquidity and refreshed outlook for 2023. We recently renewed and extended our AR securitization facility for an additional 3-year term effective July 31, 2023, maintaining our ability to access up to $175 million in cash proceeds associated with our ongoing reoccurring receivable balances. I am pleased with the work of the entire team in finalizing this agreement and allowing us to maintain our focus on running the business. On the liquidity front, more broadly, we continue to make progress on improving our cash flow by focusing on obtaining adequate reimbursement rates and growing our volumes. We have also implemented several initiatives to rightsize our corporate cost structure while optimizing our collections.
As Matt will discuss further, we have ample liquidity to operate our business while we work with government and payers to improve the reimbursement rates to reflect the inflationary environment. As it relates to our refreshed outlook for the year, based on the strength of our first 6 months results and the rate increases that will impact the back half of the year, we are comfortable raising our full year revenue guidance to a range of $1.85 billion to $1.86 billion and an adjusted EBITDA guidance range of $132 million to $135 million, respectively. We believe it is important to continue to set expectations that acknowledge the environment that we are operating in and the time it will take to transform our company and return to sustainable growth. We believe our revised outlook provides a prudent view considering the challenges we face with the current inflationary labor environment. And hopefully, it proves to be conservative as we execute throughout the remainder of the year.
Finally, I am proud of our Aveanna team as we continue to execute on our 2023 strategic objectives, the power and efficiency of the home as a health care setting remains critical to our patients, families, payers, referral sources and government partners. The value of our clinical workforce continues to be recognized through various rate increases across the country and through our expanding preferred payer relationships. I look forward to updating you on our results at the end of Q3. With that, let me turn the call over to Matt to provide further details on the quarter and our 2023 outlook. Matt?
Thanks, Jeff, and good morning. I will first talk about our second quarter financial results and liquidity before providing additional details on our refreshed outlook for 2023. Starting with the top line. We saw revenues rise 6.5% over the prior year period to $471.9 million. We experienced revenue growth in both our private duty Services and Medical Solutions segments, which grew by 8.5% and 15.9%, respectively, while our home health and hospice segment declined by 9.7% as compared to the prior year quarter. Consolidated adjusted EBITDA was $35.8 million, a 3.2% decrease as compared to the prior year, but a 25.6% sequential improvement, reflecting the improved payer rating environment as well as cost reduction efforts taking hold.
Now taking a deeper look into each of our segments. Starting with private duty services. Revenue for the quarter was approximately $378 million, an 8.5% increase and was driven by approximately 9.9 million hours of care, a volume increase of 2.7% over the prior year, while volume on a sequential basis. Our Q2 spread per hour was $11.30, representing a 7.3% year-over-year improvement. Our Q2 spread did benefit from some timing-related items and should normalize in the $10 to $10.50 range in the back half of the year.
Moving on to our home health and hospice segment. Revenue for the quarter was approximately $55.4 million, a 9.7% decrease over the prior year. Revenue was driven by 9,900 total admissions with approximately 69% being episodic and 11,100 total episodes of care. Medicare revenue per episode for the quarter was $3,051, up 2.8% sequentially from Q1. We have intentionally focused on rightsizing our approach to growth in the near term by focusing on preferred payers that reimburse us on an episodic basis. This episodic focus has accelerated our margin expansion and improved our clinical outcomes. With episodic admissions approaching 70%, we have achieved our goals of rightsizing our margin profile and enhancing our clinical offerings.
As we think about Q3, we expect relatively flat admission growth with improvements in growth coming in Q4. We are committed to a disciplined approach to growth while shifting our capacity to those payers that value our clinical resources. We were pleased with the gross margin improvement from 44.6% in Q1 of 2023 to 48.6% in Q2, demonstrating our continued focus on cost initiatives to achieve our targeted gross margins. Despite the challenging challenges faced by our HHH segment in 2022, we hold a strong belief in this business and its lasting value proposition. Our home health and hospice platform, which is prime for growth is dedicated to creating value through effective operational management and delivery of exceptional patient care. We'd expect to see improvements throughout 2023 as our direct and indirect cost initiatives continue to take hold.
Now to our Medical Solutions segment results for Q2. During the quarter, we produced revenue of $38.9 million, a 15.9% increase over the prior year. Revenue was driven by approximately 85,000 unique patients served and revenue per EPS of $457.26. Gross margins were $16.8 million, a $2.8 million or 19.7% improvement over the prior year period. Gross margins, which were 43.3% in the quarter, represented a 1.4% increase as compared to the prior year period. We continue to evaluate ways to be more effective and efficient in our back office to leverage our overhead as we continue to grow. While other intra providers decided to exit the market, we see this as an opportunity to expand our national intra presence and to further our payer partnerships.
In summary, we continue to fight through a difficult labor and inflationary environment while keeping our patients care at the center of everything we do. It is clear to us that shifting caregiver capacity to those preferred payers who value our partnership is the path forward at Aveanna. As Jeff stated, our primary challenge is reimbursement rates. With the positive momentum we saw in Q2, we're optimistic that such trends will continue into the second half of 2023. As we make progress in 2023 with the rate environment, we will pass through wage improvements and other benefits to our caregivers and the ongoing efforts to better improve volumes.
Now moving to our balance sheet and liquidity. At the end of the second quarter, we have liquidity in excess of $205 million, representing cash on hand of approximately $28 million, $15 million of availability under our securitization facility and approximately $162 million of availability on our revolver, which was undrawn as of the end of the quarter. Lastly, we had $38 million of outstanding letters of credit at the end of Q2. While we analyze the 2023 earnings timetable and their related cash flows, there's a possibility of utilizing the revolver for the short term due to timing-related needs. However, our primary goals are to have the revolver undrawn as of the end of the year and achieve positive operating cash flows during the latter half of 2023.
On the debt service front, we had approximately $1.48 billion of variable rate debt at the end of Q2. Of this amount, $520 million is hedged with fixed rate swaps and $880 million is subject to interest rate cap, which further limits our exposure to increases in SOFR above 2.96%. Accordingly, substantially all of our variable rate debt is hedged. Our interest rate swaps extend through June 2026 and our interest rate caps extend tough February 2027. One last item I will mention related to our debt is that we have no material term loan maturities until July 2028. Looking at cash flow. Cash provided by operating activities was negative $3 million for the quarter as a result of certain onetime working capital items.
Free cash flow was approximately negative $9.5 million. We also expect to see cash flow benefits throughout 2023 as our top line and cost management initiatives come to fruition. Before I hand the call over to the operator for Q&A, let me take a moment to address our refreshed outlook for 2023. As Jeff mentioned, we are comfortable raising our full year revenue guidance to a range of $1.85 billion to $1.86 billion and adjusted EBITDA guidance range of $132 million to $135 million, respectively. If the trends we saw in the second quarter continue and we are successful in obtaining our additional rate increases, along with expanded preferred pay arrangements, we would expect to further update our guidance in the back half of the year. As we think about seasonality, we expect our revenue to grow as rate increases are implemented throughout the year, which drives our volumes.
So we now have more clarity into the annual rate increases we will receive on their effective dates, we now expect approximately 25% to 26% of our full year guided adjusted EBITDA to be recognized in the third quarter. Our EBITDA is expected to further ramp in the fourth quarter as we realize the benefits of our cost savings initiatives. I'm proud of all of our Aveanna team members and their hard work achieving these results. I look forward to the continued execution of our 2023 strategic plan and updating you further at the end of Q3. With that, let me turn the call over to the operator.
Question and Answer Session
(Operator Instructions) Our first question comes from the line of Joanna Gajuk with Bank of America.
Joanna Sylvia Gajuk
This is Minas on for Joanna Gajuk. The first question we had was just about operating cash flow being negative this quarter. So I just wanted to get a sense for what your outlook was for the year, and if you still expect it to be negative in the third quarter of a positive in the fourth.
Jeffrey S. Shaner
Yes, and thanks for joining us. As we said last quarter, we expected our second quarter to be slightly negative in our operating cash flow, and it was a negative $3 million. Our goal all year has been to reach positive operating cash flow by the end of the year. And I think everything that we know today tells us we're still on that trend. We'll have some certain one timing things that will play through Q3 and Q4, but we still feel very optimistic on reaching that positive operating cash flow. And ultimately, heading into 2024 as a positive operating cash flow and free cash flow company as we really move through '24. Matt, anything you'd add to?
I think you said it well, Jeff, a couple of onetime working capital items this quarter results in that negative $3 million that we saw. But given our outlook of what we're looking at with continued rate improvements as well as our continued cost initiatives that we will continue to take. I think improvements in the business will continue. And from there, we should see positive operating cash flow going forward.
Joanna Sylvia Gajuk
Okay. Perfect. I just have one follow-up question or a separate question on PDS volumes and how I guess the 10-Q listed that it was primarily attributable to growth in demand for nonclinical services. So what was the volume change year-over-year and quarter-over-quarter for these clinical services and where do you expect the volumes to be for the rest of the year?
No, that's a great question. And yes, we saw a nice uptick in some of our lower skill than some of our less nurse-driven businesses. I would tell you that as we -- first of all, positive 2.7% year-over-year growth for us is a good thing because it's been a couple of years since we've had positive growth in our PDS business. I'll take us back to our preferred payers that at the end of the day, we see our preferred payer strategy working both in rate and and beginning to work in volume.
Obviously, we've made a strong commitment to shifting caregiver capacity to those payers that are leaning into us, both in our PDS and I think you heard it in our home health and hospice line of business as well that we're committing to those payers that are paying us either on an episodic basis, or an aligned preferred payer. But I think as we think of the back half of the year, we see continued progress in our PDS business, both in rate and volume. And we're just really proud of our PDS team and that they have recovered well in 2023 from the COVID hang around. And I think we just see a clear path forward with our preferred payers to really driving the business forward. So we're really pleased with where we're sitting today. Thank you.
Brian Gil Tanquilut
Our next question comes from the line of Brian Tanquilut with Jefferies.
Brian Gil Tanquilut
You've got Taji on for Brian. So my first one relates to the raised guidance, right? So just looking at revenue first, if we're looking at first half or second half, that implies a ramp down in the back half, but at the same time, we're hearing some strong momentum in PDS and your other segments. So maybe if you can just kind of talk through the moving pieces and what's informing the, I guess, ramp down in the back half? And then on EBITDA as well, I know that you guys have kind of called out a couple of cost savings. But as we reconcile this with like the different margin profiles for PDS, HHH and MS. Just curious if you can talk about the areas where you have more leverage to improve the margin profile across the 3 different segments, especially in PDS, I know that you guys said you expect that to normalize. But I think if I factor my model, I'm still getting to the lower end of the margin you guys had kind of loosely commented on. So just we'll start there.
Jeffrey S. Shaner
That's a lot to unpack there, but we'll do our best. So let's start with Q3. So from a seasonality standpoint, and I would say from the first time since COVID hit, we see a seasonal impact of our Q3 business. So pre-COVID Q3 for us was when schools are out, and both our PDN, our PDS business, schools being out is a little bit less value for us. And we're experiencing that in Q3. So we expect Q3 to be seasonally a little bit light on revenue and ultimately, probably relatively in line with earnings as we think of Q2, maybe a little bit softer. And I think Matt in his prepared remarks kind of led you to what we think Q3 EBITDA will ultimately be.
I think to the second half of your question, the back half of the year, the rate increases, majority of our rate increases were either effective July 1. And or September or October 1, both on the PDS as well as, obviously, the hospice rate increase coming. So we will see a lift and I'll call it the back 4 months of the year, so I'll call it September, kind of through December, we'll see a nice volume lift in all 3 of our businesses as well as continued rate lift. So I think where we sit today, Taji, it's still early in our transformation story. I think we use words like prudent, conservative on purpose that we understand that this guidance revision is prudent in nature.
I think Matt ended his comments by saying if things play out the way we think they will, that we would plan to to readdress guidance in our November earnings call as well. So I would tell you you're not missing anything other than just keep in mind, Q3 is our seasonally low period. And I think everything we know today tells us that it will play out to be that way, both in our PDS business as well as our home health and hospice business is our seasonal low point. Matt, anything you want to address on the cost side of the margin side?
No, I think, Taji, it's a great question altogether. I think there's improvements throughout all 3 business segments in there. And I'm going to say that's above gross margin and below that we're focusing on. And so I think as we continue to kind of dig into it and be transformational in nature and lean into technology in certain segments, but then also make sure that we're delivering the appropriate amount of care, the right amount of care with the right amount of overhead supporting it as well. We'll continue to be prudent in that one in all portions of our business. And I think that will lead to your a little bit of margin expansion as well.
Jeffrey S. Shaner
Anything else Taji?
Brian Gil Tanquilut
Yes. Just one more question for me, and I appreciate the detail on my first question. And then kind of getting to this conversation around labor, maybe you can provide a couple of KPIs as to how your labor force stands today in terms of recruitment, retention, turnover, things like that and how that's trended over the past year? And then one follow-up to that. I know you mentioned, Jeff, that if you -- it's not a demand issue, it's really capacity. So if you had sufficient labor, how much more volume percentage-wise do you think you can feel?
Jeffrey S. Shaner
Great one, Taji. I think we think of labor as a function of rate and a lot of people try to drive us towards what's the inflation rate of caregivers on both the PDS as well as home health and hospice. We just refused to think of it that way because we don't control inflation. We do control reimbursement rate. And we do control where what partners we ultimately put our labor capacity with. And so it just brings us back to our preferred payer and government affairs strategy, which is, as we've been crystal clear with the last 2 quarters, our job is to drive appropriate reimbursement rates, both on the government affairs side and the preferred payer strategy, and in turn, invest those caregiver wages. And in those relationships, we're demonstrating we can grow the business and be a good business partner. The flip side of though that is true Taji.
In markets or payers who are not paying us above-market preferred rates, we're not seeing incremental hires. We're not seeing better staffing rates. And so it just drives us and I'll use Texas as the example we used in this call. It just drives us to align our capacity both current and the future with those payers that want to be long-term business partners of ours. And we talked in Texas 50% of our PDN volumes in Texas are now aligned with a preferred payer. We are aggressively driving that towards the end of the year to be 70% of our Texas PDM business to be aligned with a preferred payer because the only way we can truly live out the story that we tell, which is to improve clinical outcomes, lower total cost of care and just staff more hours, which our payers want us to is to partner with those payers that will ultimately give us higher rates and include us in value-based bonus payments as we earn them.
I do want to touch lastly because you brought up the idea of home health and hospice. And I think it's important. We were pretty crystal clear in this that we have committed to also aligning our home health, clinical workforce with preferred payers. Obviously, episodic payers and home health is the way we measure preferred payers. But we're approaching 70%, some weeks, we've been in low 70s on episodic emissions. And even though our missions are down year-over-year, even quarter-over-quarter sequentially, even though our revenue was down year-over-year, we have made a commitment in home health to not give away our capacity to low-dollar, low-margin payers. And I think you'll find us firing -- terminating more contracts as we align ourselves in home health to those payers who will ultimately pay us a fair rate, market fare rate and/or an episodic grade. And I'm really, really proud of our home health team and hospice team. They have turned our business around in the last 2 quarters.
Matt talked about 48.6% gross margin that for Aveanna is as good as it's gotten in the last year. And equally important, we can now see our clinical outcomes also improve in home health and hospice because we're not chasing low dollar low-margin business. So again, I think you're hearing us just beat the same drum, which is in all 3 of our businesses, our resources are scarce in nature, and we're going to align them with the payers who want to partner with us on a long-term basis and be a good business partner, and we're going to be a good business partner to them in return. Thanks, Taji.
Our next question comes from the line of Philip Chickering with Deutsche Bank.
So looking at guidance, can you help us quantify the headwinds and tailwinds on the rate increases versus your prior guidance. I believe that you're looking for a mid- to high single-digit rate increases in California and Texas. It sounds like that's a headwind. The headwinds got rate increases from others. So can you just help us, I guess, model sort of these moving parts between what was better versus worse versus your last guidance. And on Texas. Do you assume that about 70% of those payers will be in the preferred network within guidance in Texas.
Jeffrey S. Shaner
Thanks, Pito. I think -- let me start with clearly, we're disappointed that we were not included in the fiscal year 2023 California budget because that was a big deal for us. I'm going to flip that to a positive Boleto. We're the largest provider of PDN in the state of California. We've been in California for over a decade. We're going to be in California a decade from now. So we are committed to the long-term success of California, and we're going to get a rate increase for PDN in California. It's the right thing to do. We've made really nice inroads with both the legislature and the governor staff, and we're going to continue to lead in to the governor and his key leadership as we move into '24. I think as you think about the timing of California, which as we talked about going in the year is a big mover for Aveanna.
I think of it now in the back half of '24 and potentially as late as January 1 25, that rate improvement. How it plays out in our 2023 guidance compared to the rate increases that we did get and some Pito, that we were not expecting some came in significantly higher than we expected on a per-day basis. It's roughly a wash for us in '23. So I think as we think of the back half of the year, it will be roughly a wash. Now we won't have the 7.1 of 23 California rate increase. So we didn't have that step in Q3 of '23. We didn't have that immediate step up. So it's a little bit more of a layered in approach as we move from Q3 to Q4. And then I think as Matt talked about, Pito, the nice part for us right now is we have a couple of levers we can pull. Our cost, I'll call it, tenacity has significantly ramped up. And we just found within a company, there were some areas that we really could address overall contribution margin in the businesses.
And so I think as you think about its impact on guidance, ultimately, I think we'll land in about the same place in '23. And then we're still early on '24, right? We're still probably 3 months early from really focusing on 24. We won't have the California rate increase in early '24, right? So we'll look at other measures like the continued acceleration of the preferred payer strategy to make sure that as we roll into '24, we really have good momentum on our preferred payer mixes. I think I got most of the question there.
Yes. Perfect. And then sort of sticking, I guess, on same topic. And you get that every contract is different here. But because preferred networks are becoming an increasingly important sort of 4-year growth engine, can you help quantify for us how much a preferred partner pace versus sort of a standard contract? And sticking with Texas, again, just because you brought up earlier, like you said in the script that demand remains very high. And if you -- the spaces are not being treated, are they just being stuck in acute hospitals or what's happened with patients specifically in Texas today?
Jeffrey S. Shaner
Yes. That's a fantastic question. And it goes back to -- and we've got studies to prove it, both in California and in Texas, and we've presented those studies to both the governor's offices as well as Medicaid department and many legislatures. PDN stays between $5,000 and $6,000 a day compared to acute care setting, right, holistic cost to cost. It takes time to kind of get that messaging through legislatures, it doesn't take time to get that through to MCOs. They absolutely understand that. And I'll use Texas to your question, our MCO partners in Texas understand that they have to get these kids out of the hospitals and that some studies are suggesting that medical federal children are remaining in hospitals up to 54 days on average longer than they need to be there. So you just do the math, it's $200,000 or $300,000 per stay greater or slightly more.
So yes, we feel our MCO partners understand that in the markets like Texas where we have scale and size and in true sophistication, we really are the market mover, right? So you need Aveanna to partner with you from a nursing standpoint. And so again, we've gone into this wanting to be good long-term business partners with our payer partners. We don't want to flip partners, payer partners every quarter. Our goal was to align with partners over a multiyear period to really build sustainable relationships. The fact that we already had 50% of our volume in Texas with the MCO preferred payer, I think, demonstrates that we were already well aligned there. The fact that we only got a 2% rate increase effective September 1, was almost embarrassing from the taxes.
So it just highlighted that the pay-preferred payer strategy was the path forward. And our MCO partners have graciously aligned. We talked about signing additional preferred payer. It was in Texas in July. And I think we'll sign 1 or 2 more by the end of the year and ultimately be somewhere around 70%. Lastly, Pito, you asked kind of what's the market difference when we're earning our value-based payments, most of those are established on a quarterly basis, when we're earning not only the rate -- the higher market rate but also the value-based payment. It's material in nature compared to the Medicaid rate. So it's in the range of 25% to 30% greater than the Medicaid market rate. So it's important for us not only to have the preferred rate. It's also important for us to have value-based components so that the preferred payer sees that we're aligned with them long term. Hopefully, that was helpful.
Perfect. And just one super fast cash flow question. Just a follow-up to the previous question. You're negative in 3Q or positive in 4Q. Is the difference there simply those rate increases flowing through in the last 4 months of the year? Or is there something else that we should be thinking about as you shift from cash flow negative to cash flow positive.
Jeffrey S. Shaner
No, it's just a little bit of the volume. As you think about the business itself, Pito, we're a little bit light in volumes in Q3, primarily in the core businesses of home health and PDN. That ramps kind of back up September through the end of the year. And so if you file the revenue there in earnings, it's just -- it -- we expect Q4 to be a very, very strong quarter for us and we expect to end the year on a great trajectory. But Q3 is just a little bit lighter for us and that's how we've laid out the cash flow for Q3 and Q4.
Our next question comes from the line of Ben Hendricks with RBC Capital Markets.
I definitely appreciate the commentary about your preferred payer mix in Texas. I think for overall, you had noted that you were expecting preferred payers to account for 18% to 20% of nursing hours for the year. I'm wondering if this July contract in Texas gets you there? Are there still kind of wood to chop on that front? That's my first question.
Jeffrey S. Shaner
Yes. Now, Ben it's -- as we think of the year, right, we started the year at 10%. We were about 13% by the end of Q1. I think our actual number was 16.5% by the end of Q2. Yes, that one agreement we signed in both Q2 and the one we signed in July is helpful. But no, we still have wood to chop. We will sign another 3 or 4 between now and the end of the year. I believe Matt may hedge on me a little bit, but I believe we'll comfortably be at that 20% by the end of the year. And then we'll reset -- will reset that goal for 24 to continue to push that story. So we're not done. We're not 'stopping at 20%. We want to continue to drive that to be the more and more meaningful part of our business. Matt, anything you add to be?
No, I think that's well said, Jeff. I mean, preferred payers are the answer for Aveanna to answer for our caregivers and the answers for our patients. Moving that to 20% and above is what we're focused on as an organization because it allows us to pay that higher wage rate to our caregivers, which allows us to drive more volume and provide more clinical care for them. So as we kind of check the box on that 18% to 20% in the back half of the year and say that's where we're going to be, we'll set a new goal for 2024 as well and continue to push forward.
And just a follow-up on one of your prepared comments. You mentioned Pro Texas and California that they plan to include you and stay budget next year. How much visibility does that realistically give you? Is that something that kind of the negotiation process just starts all over? Or is there kind of a real indication that at those double-digit increases will be realistically considered next year?
Jeffrey S. Shaner
That's a great question, Matt. Let me separate the 2. Texas is a biannual let's say, a process. So Texas is done for the next 2 years. And our strategy in Texas is what we just talked about, working with the MCO. So we're not waiting on any rate increase in Texas. We're driving our own destiny California, we are in active conversations continuing every day. We will spend time this fall with the governor and the governor's key leadership team as we continue to move forward the story. California is in every single year, right? So so January resets another legislative process for us. And we're 15, 16 months in California now focused on this. There's still plenty of wood to chop using your words, plenty of wood chop in California. But then I don't think of it as if I just think of it as when and how long it will have taken us to tell our full story.
We are an absolute total health care cost saver to California, and our studies show that. And I think that's resonated really about. We've gotten good feedback from the governor staff. And I think partnering with them this fall as they go into the 2024 legislative cycle is the best thing that we could do as both a company and an industry in California. It is the right thing to do. We need to be on the governor's key legislative initiatives to really see this rate increase through. As I said to Taji and Pito, that would be a late 2024. So as you think about when would that come to fruition, the earliest would be July of '24, the more likely outcome would be probably 11% of 'as most rate initiatives or rate investments from California start on the first day of the following fiscal year.
But just step back, Ben, as we talked in our prepared remarks, we've had a great year from a government affairs advocacy standpoint, 17 state rate increases, we got 33 states total. So 17 states. Slightly better than we expected, certainly would have loved California to be on that list. But I think it sets up well for us as we -- as most of those rate increases will flow into '24. And really, I'm kind of excited that California is kind of on that horizon, right? Because it gives us the next step. And as Matt reminded us, at the end of the day, the only way we can pay the caregiver is the fair rate and to truly take patients home and fulfill our mission is to have an appropriate rate. And I feel confident that we'll see that through with California here over the next 6 months. Anything else?
And we have reached the end of the question-and-answer session. I'll now turn the call back over to Jeff Shaner for closing remarks.
Jeffrey S. Shaner
Awesome. Thank you so much for joining our earnings call. And one point, thank you for your interest in our Aveanna story. We certainly look forward to updating you on our continued progress at the end of Q3 in November. Thank you, and have a great day.
This concludes today's conference, and you may disconnect your lines at this time. Thank you for your participation.