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AMN HEALTHCARE SERVICES INC - Quarter Report: 2023 March (Form 10-Q)



UNITED STATES
SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
____________________
FORM 10-Q
____________________
QUARTERLY REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934
For the quarterly period ended March 31, 2023
OR
TRANSITION REPORT PURSUANT TO SECTION 13 OR 15(d) OF THE SECURITIES EXCHANGE ACT OF 1934
For the transition period from                       to                      
Commission File No.: 001-16753
Cover page photo.10Q.jpg
AMN HEALTHCARE SERVICES, INC.
(Exact Name of Registrant as Specified in Its Charter)
Delaware
06-1500476
(State or Other Jurisdiction of
Incorporation or Organization)
(I.R.S. Employer
Identification No.)
8840 Cypress Waters BoulevardSuite 300
DallasTexas75019
(Address of Principal Executive Offices)(Zip Code)

Registrant’s Telephone Number, Including Area Code: (866) 871-8519
____________________

Securities registered pursuant to Section 12(b) of the Act:
Title of Each ClassTrading SymbolName of each exchange on which registered
Common Stock, $0.01 par valueAMNNew York Stock Exchange
Indicate by check mark whether the registrant: (1) has filed all reports required to be filed by Section 13 or 15(d) of the Securities Exchange Act of 1934 during the preceding 12 months (or for such shorter period that the registrant was required to file such reports), and (2) has been subject to such filing requirements for the past 90 days.  Yes  x  No  o
Indicate by check mark whether the registrant has submitted electronically every Interactive Data File required to be submitted pursuant to Rule 405 of Regulation S-T during the preceding 12 months (or for such shorter period that the registrant was required to submit such files).  Yes  x No  o
Indicate by check mark whether the registrant is a large accelerated filer, an accelerated filer, a non-accelerated filer, a smaller reporting company, or an emerging growth company. See the definitions of “large accelerated filer,” “accelerated filer,” “smaller reporting company,” and “emerging growth company” in Rule 12b-2 of the Exchange Act.
Large accelerated filerAccelerated filer   Non-accelerated filer
Smaller reporting companyEmerging growth company
If an emerging growth company, indicate by check mark if the registrant has elected not to use the extended transition period for complying with any new or revised financial accounting standards provided pursuant to Section 13(a) of the Exchange Act. o
Indicate by check mark whether the registrant is a shell company (as defined in Rule 12b-2 of the Exchange
Act).  Yes  ☐  No  x
As of May 3, 2023, there were 39,645,292 shares of common stock, $0.01 par value, outstanding.

Auditor Name: KPMG LLP        Auditor Location: San Diego, California        Auditor Firm ID: 185



TABLE OF CONTENTS
 
Item Page
PART I - FINANCIAL INFORMATION
1.
2.
3.
4.
PART II - OTHER INFORMATION
1.
1A.
2.
3.
4.
5.
6.



Table of Contents
PART I - FINANCIAL INFORMATION

Item 1. Condensed Consolidated Financial Statements

AMN HEALTHCARE SERVICES, INC.
 
CONDENSED CONSOLIDATED BALANCE SHEETS
(Unaudited and in thousands, except par value)
March 31, 2023December 31, 2022
ASSETS
Current assets:
Cash and cash equivalents$28,516 $64,524 
Accounts receivable, net of allowances of $37,736 and $31,910 at March 31, 2023 and December 31, 2022, respectively
687,645 675,650 
Accounts receivable, subcontractor276,655 268,726 
Prepaid expenses26,696 18,708 
Other current assets51,552 66,037 
Total current assets1,071,064 1,093,645 
Restricted cash, cash equivalents and investments67,594 61,218 
Fixed assets, net of accumulated depreciation of $233,942 and $227,617 at March 31, 2023 and December 31, 2022, respectively
155,276 149,276 
Other assets197,325 172,016 
Goodwill935,319 935,364 
Intangible assets, net of accumulated amortization of $379,172 and $361,327 at March 31, 2023 and December 31, 2022, respectively
454,485 476,832 
Total assets$2,881,063 $2,888,351 
LIABILITIES AND STOCKHOLDERS’ EQUITY
Current liabilities:
Accounts payable and accrued expenses$473,764 $476,452 
Accrued compensation and benefits269,237 333,244 
Other current liabilities60,600 48,237 
Total current liabilities803,601 857,933 
Revolving credit facility140,000 — 
Notes payable, net of unamortized fees and premium843,801 843,505 
Deferred income taxes, net16,113 22,713 
Other long-term liabilities121,774 120,566 
Total liabilities1,925,289 1,844,717 
Commitments and contingencies
Stockholders’ equity:
Preferred stock, $0.01 par value; 10,000 shares authorized; none issued and outstanding at March 31, 2023 and December 31, 2022
— — 
Common stock, $0.01 par value; 200,000 shares authorized; 50,236 issued and 40,238 outstanding at March 31, 2023 and 50,109 issued and 41,879 outstanding at December 31, 2022
502 501 
Additional paid-in capital505,857 501,674 
Treasury stock, at cost; 9,998 and 8,230 shares at March 31, 2023 and December 31, 2022, respectively
(874,898)(698,598)
Retained earnings1,325,106 1,240,996 
Accumulated other comprehensive loss(793)(939)
Total stockholders’ equity955,774 1,043,634 
Total liabilities and stockholders’ equity$2,881,063 $2,888,351 

See accompanying notes to unaudited condensed consolidated financial statements.
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AMN HEALTHCARE SERVICES, INC.
 
CONDENSED CONSOLIDATED STATEMENTS OF COMPREHENSIVE INCOME
(Unaudited and in thousands, except per share amounts)
 
 Three Months Ended March 31,
 20232022
Revenue$1,126,223 $1,552,538 
Cost of revenue757,377 1,056,370 
Gross profit368,846 496,168 
Operating expenses:
Selling, general and administrative205,599 257,579 
Depreciation and amortization (exclusive of depreciation included in cost of revenue)37,577 30,656 
Total operating expenses243,176 288,235 
Income from operations125,670 207,933 
Interest expense, net, and other10,259 9,589 
Income before income taxes115,411 198,344 
Income tax expense31,301 52,336 
Net income$84,110 $146,008 
Other comprehensive income (loss):
Unrealized gains (losses) on available-for-sale securities, net, and other146 (907)
Other comprehensive income (loss)146 (907)
Comprehensive income$84,256 $145,101 
Net income per common share:
Basic$2.03 $3.11 
Diluted$2.02 $3.09 
Weighted average common shares outstanding:
Basic41,378 46,913 
Diluted41,570 47,208 
 
See accompanying notes to unaudited condensed consolidated financial statements.

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AMN HEALTHCARE SERVICES, INC.
 
CONDENSED CONSOLIDATED STATEMENTS OF STOCKHOLDERS’ EQUITY
(Unaudited and in thousands)
 Common StockAdditional
Paid-in
Capital
Treasury StockRetained EarningsAccumulated Other Comprehensive LossTotal
 SharesAmountSharesAmount
Balance, December 31, 202149,849 $498 $486,709 (2,586)$(121,831)$796,946 $(295)$1,162,027 
Repurchase of common stock into treasury— — — (2,298)(228,024)— — (228,024)
Equity awards vested, net of shares withheld for taxes164 (9,433)— — — — (9,431)
Share-based compensation— — 11,259 — — — — 11,259 
Comprehensive income (loss)— — — — — 146,008 (907)145,101 
Balance, March 31, 202250,013 $500 $488,535 (4,884)$(349,855)$942,954 $(1,202)$1,080,932 


 Common StockAdditional
Paid-in
Capital
Treasury StockRetained EarningsAccumulated Other Comprehensive LossTotal
 SharesAmountSharesAmount
Balance, December 31, 202250,109 $501 $501,674 (8,230)$(698,598)$1,240,996 $(939)$1,043,634 
Repurchase of common stock into treasury— — — (1,768)(176,300)— — (176,300)
Equity awards vested, net of shares withheld for taxes127 (6,135)— — — — (6,134)
Share-based compensation— — 10,318 — — — — 10,318 
Comprehensive income— — — — — 84,110 146 84,256 
Balance, March 31, 202350,236 $502 $505,857 (9,998)$(874,898)$1,325,106 $(793)$955,774 

See accompanying notes to unaudited condensed consolidated financial statements.

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AMN HEALTHCARE SERVICES, INC.
 
CONDENSED CONSOLIDATED STATEMENTS OF CASH FLOWS
(Unaudited and in thousands)
 
Three Months Ended March 31,
 
20232022
Cash flows from operating activities:
Net income$84,110 $146,008 
Adjustments to reconcile net income to net cash provided by operating activities:
Depreciation and amortization (inclusive of depreciation included in cost of revenue)38,834 31,510 
Non-cash interest expense and other505 479 
Change in fair value of contingent consideration liabilities80 — 
Increase in allowance for credit losses and sales credits25,447 3,432 
Provision for deferred income taxes(6,639)18,526 
Share-based compensation10,318 11,259 
Loss on disposal or impairment of long-lived assets1,849 241 
Net loss on investments in available-for-sale securities81 174 
Net loss (gain) on deferred compensation balances41 (570)
Non-cash lease expense(228)2,880 
Changes in assets and liabilities, net of effects from acquisitions:
Accounts receivable(37,376)(194,044)
Accounts receivable, subcontractor(7,929)(50,592)
Income taxes receivable8,875 — 
Prepaid expenses(7,988)33,373 
Other current assets(115)12,180 
Other assets221 (342)
Accounts payable and accrued expenses(9,557)70,988 
Accrued compensation and benefits(71,038)96,486 
Other liabilities11,903 18,353 
Deferred revenue2,040 (126)
Net cash provided by operating activities43,434 200,215 
Cash flows from investing activities:
Purchase and development of fixed assets(17,487)(13,590)
Purchase of investments— (4,018)
Proceeds from sale and maturity of investments2,007 6,885 
Proceeds from sale of equity investment— 68 
Payments to fund deferred compensation plan(16,951)(12,584)
Net cash used in investing activities(32,431)(23,239)
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Three Months Ended March 31,
 
20232022
Cash flows from financing activities:
Payments on revolving credit facility(70,000)— 
Proceeds from revolving credit facility210,000 — 
Repurchase of common stock (1)
(174,744)(228,024)
Payment of financing costs(3,579)— 
Cash paid for shares withheld for taxes(6,134)(9,431)
Net cash used in financing activities(44,457)(237,455)
Effect of exchange rate changes on cash— (183)
Net decrease in cash, cash equivalents and restricted cash(33,454)(60,662)
Cash, cash equivalents and restricted cash at beginning of period137,872 246,714 
Cash, cash equivalents and restricted cash at end of period$104,418 $186,052 
Supplemental disclosures of cash flow information:
Cash paid for amounts included in the measurement of operating lease liabilities$2,610 $4,230 
Cash paid for interest (net of $288 and $121 capitalized for the three months ended March 31, 2023 and 2022, respectively)
$1,053 $196 
Cash paid for income taxes$5,404 $9,824 
Supplemental disclosures of non-cash investing and financing activities:
Purchase of fixed assets recorded in accounts payable and accrued expenses$6,849 $4,771 
Excise tax payable on share repurchases$1,556 $— 
(1) The difference between the amount reported for the three months ended March 31, 2023 and the corresponding amount presented in the condensed consolidated statements of stockholders’ equity is due to accrued excise tax payable on share repurchases recorded within treasury stock.

See accompanying notes to unaudited condensed consolidated financial statements.
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AMN HEALTHCARE SERVICES, INC.
 
NOTES TO UNAUDITED CONDENSED CONSOLIDATED FINANCIAL STATEMENTS
(in thousands, except per share amounts)
 
1. BASIS OF PRESENTATION
The condensed consolidated balance sheets and related condensed consolidated statements of comprehensive income, stockholders’ equity and cash flows contained in this Quarterly Report on Form 10-Q (this “Quarterly Report”), which are unaudited, include the accounts of AMN Healthcare Services, Inc. and its wholly-owned subsidiaries (collectively, the “Company”). All significant intercompany balances and transactions have been eliminated in consolidation. In the opinion of management, all entries necessary for a fair presentation of such unaudited condensed consolidated financial statements have been included. These entries consisted of all normal recurring items. The results of operations for the interim period are not necessarily indicative of the results to be expected for any other interim period or for the entire fiscal year or for any future period.
The unaudited condensed consolidated financial statements do not include all information and notes necessary for a complete presentation of financial position, results of operations and cash flows in conformity with accounting principles generally accepted in the United States (“U.S. GAAP”). Please refer to the Company’s audited consolidated financial statements and the related notes for the fiscal year ended December 31, 2022, contained in the Company’s Annual Report on Form 10-K for the fiscal year ended December 31, 2022, filed with the Securities and Exchange Commission on February 22, 2023 (the “2022 Annual Report”).
The preparation of financial statements in conformity with U.S. GAAP requires management to make a number of estimates and assumptions relating to the reporting of assets and liabilities and the disclosure of contingent assets and liabilities at the dates of the financial statements and the reported amounts of revenue and expenses during the reporting periods. On an ongoing basis, the Company evaluates its estimates, including those related to intangible assets purchased in a business combination, asset impairments, accruals for self-insurance, compensation and related benefits, accounts receivable, contingencies and litigation, contingent consideration liabilities associated with acquisitions, and income taxes. Actual results could differ from those estimates under different assumptions or conditions.
Recently Adopted Accounting Pronouncements
In October 2021, the Financial Accounting Standards Board issued Accounting Standards Update (“ASU”) 2021-08, “Business Combinations (Topic 805): Accounting for Contract Assets and Contract Liabilities from Contracts with Customers.” The new guidance requires companies to apply the definition of a performance obligation under Accounting Standards Codification (“ASC”) Topic 606, Revenue from Contracts with Customers, to recognize and measure contract assets and contract liabilities, such as deferred revenue, relating to contracts with customers that are acquired in a business combination. Under prior guidance, an acquirer generally recognized assets acquired and liabilities assumed in a business combination, including contract assets and contract liabilities arising from revenue contracts with customers, at their acquisition-date fair values in accordance with ASC Subtopic 820-10, Fair Value Measurements—Overall. Generally, this new guidance will result in the acquirer recognizing acquired contract assets and liabilities on the same basis that would have been recorded by the acquiree prior to the acquisition under ASC Topic 606. The Company adopted this standard effective January 1, 2023 on a prospective basis, and the adoption did not have a material effect on the Company’s consolidated financial statements.
Cash, Cash Equivalents and Restricted Cash
The Company considers all highly liquid investments with an original maturity of three months or less to be cash equivalents. Cash and cash equivalents include currency on hand, deposits with financial institutions, money market funds, commercial paper and other highly liquid investments. Restricted cash and cash equivalents primarily includes cash, corporate bonds and commercial paper that serve as collateral for the Company’s captive insurance subsidiary claim payments. See Note (7), “Fair Value Measurement” for additional information.
The following table provides a reconciliation of cash, cash equivalents and restricted cash reported within the accompanying condensed consolidated balance sheets and related notes to the amounts presented in the accompanying condensed consolidated statements of cash flows.
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 March 31, 2023December 31, 2022
Cash and cash equivalents$28,516 $64,524 
Restricted cash and cash equivalents (included in other current assets)31,500 37,225 
Restricted cash, cash equivalents and investments67,594 61,218 
Total cash, cash equivalents and restricted cash and investments127,610 162,967 
Less restricted investments(23,192)(25,095)
Total cash, cash equivalents and restricted cash$104,418 $137,872 
The Company maintains its cash and restricted cash in bank deposit accounts primarily at large, national financial institutions, which typically exceed federally insured limits. The Company has not experienced any losses in such accounts.
Accounts Receivable
The Company records accounts receivable at the invoiced amount. Accounts receivable are non-interest bearing. The Company maintains an allowance for expected credit losses based on the Company’s historical write-off experience, an assessment of its customers’ financial conditions and available information that is relevant to assessing the collectability of cash flows, which includes current conditions and forecasts about future economic conditions.
The following table provides a reconciliation of activity in the allowance for credit losses for accounts receivable:
20232022
Balance as of January 1,$31,910 $6,838 
Provision for expected credit losses6,938 1,166 
Amounts written off charged against the allowance(1,112)(534)
Balance as of March 31,$37,736 $7,470 
The increase in the provision for expected credit losses for the three months ended March 31, 2023 was primarily the result of concern with a specific customer’s ability to meet its financial obligations, and uncertainty regarding the collectability of cash flows from customers due primarily to the current macroeconomic outlook.
Reclassifications
To conform to the current year presentation, certain reclassifications have been made to prior year balances in the condensed consolidated balance sheets and accompanying Note (10), “Balance Sheet Details.”
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2. ACQUISITIONS
The Company accounted for the acquisition set forth below using the acquisition method of accounting. Accordingly, the Company recorded the tangible and intangible assets acquired and liabilities assumed at their estimated fair values as of the date of acquisition. Since the date of acquisition, the Company has revised the allocation of the purchase price to the tangible and intangible assets acquired and liabilities assumed based on analysis of information that has been made available through March 31, 2023. The allocation will continue to be updated through the measurement period, if necessary. The goodwill recognized for the acquisition is attributable to expected growth as the Company leverages its brand and diversifies its services offered to clients, including potential revenue growth and margin expansion. The Company did not incur any material acquisition-related costs.
Connetics Acquisition
On May 13, 2022, the Company completed its acquisition of Connetics Communications, LLC (“Connetics”), which specializes in the direct hire recruitment and permanent placement of international nurse and allied health professionals with healthcare facilities in the United States. The initial purchase price of $78,764 included (1) $70,764 cash consideration paid upon acquisition, funded through cash on hand, and (2) contingent consideration (earn-out payment) of up to $12,500 with an estimated fair value of $8,000 as of the acquisition date. The contingent earn-out payment is based on the operating results of Connetics for the twelve months ending May 31, 2023. The results of Connetics have been included in the Company’s nurse and allied solutions segment since the date of acquisition. During the fourth quarter of 2022, $231 was returned to the Company in respect of the final working capital settlement.
The preliminary allocation of the $78,533 purchase price, which was reduced by the final working capital settlement during the fourth quarter of 2022, consisted of (1) $3,632 of fair value of tangible assets acquired, which included $963 cash received, (2) $8,244 of liabilities assumed, (3) $40,200 of identified intangible assets, and (4) $42,945 of goodwill, of which $34,944 is deductible for tax purposes. The intangible assets acquired have a weighted average useful life of approximately thirteen years. The following table summarizes the fair value and useful life of each intangible asset acquired as of the acquisition date:
Fair ValueUseful Life
(in years)
Identifiable intangible assets
Customer relationships$32,800 15
Staffing database4,200 5
Tradenames and trademarks3,200 5
$40,200 

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3. REVENUE RECOGNITION
Revenue primarily consists of fees earned from the temporary staffing and permanent placement of healthcare professionals, executives, and leaders (clinical and operational). The Company also generates revenue from technology-enabled services, including language interpretation and vendor management systems, and talent planning and acquisition services, including recruitment process outsourcing. The Company recognizes revenue when control of its services is transferred to its customers, in an amount that reflects the consideration the Company expects to be entitled to receive in exchange for those services. Revenue from temporary staffing services is recognized as the services are rendered by clinical and non-clinical healthcare professionals. Under the Company’s managed services program (“MSP”) arrangements, the Company manages all or a part of a customer’s supplemental workforce needs utilizing its own network of healthcare professionals along with those of third-party subcontractors. Revenue and the related direct costs under MSP arrangements are recorded in accordance with the accounting guidance on reporting revenue gross as a principal versus net as an agent. When the Company uses subcontractors and acts as an agent, revenue is recorded net of the related subcontractor’s expense. Revenue from permanent placement and recruitment process outsourcing services is recognized as the services are rendered. Depending on the arrangement, the Company’s technology-enabled service revenue is recognized either as the services are rendered or ratably over the applicable arrangement’s service period.
The Company’s customers are primarily billed as services are rendered. Any fees billed in advance of being earned are recorded as deferred revenue. While payment terms vary by the type of customer and the services rendered, the term between invoicing and when payment is due is not significant.
The Company has elected to apply the following practical expedients and optional exemptions related to contract costs and revenue recognition:
Recognize incremental costs of obtaining a contract with amortization periods of one year or less as expense when incurred. These costs are recorded within selling, general and administrative expenses.
Recognize revenue in the amount of consideration that the Company has a right to invoice the customer if that amount corresponds directly with the value to the customer of the Company’s services completed to date.
Exemptions from disclosing the value of unsatisfied performance obligations for (i) contracts with an original expected length of one year or less, (ii) contracts for which revenue is recognized in the amount of consideration that the Company has a right to invoice for services performed and (iii) contracts for which variable consideration is allocated entirely to a wholly unsatisfied performance obligation or to a wholly unsatisfied promise to transfer a distinct service that forms part of a single performance obligation.
See Note (5), “Segment Information,” for additional information regarding the Company’s revenue disaggregated by service type.

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4. NET INCOME PER COMMON SHARE
Basic net income per common share is calculated by dividing net income by the weighted average number of common shares outstanding during the reporting period. The following table sets forth the computation of basic and diluted net income per common share:
 Three Months Ended March 31,
 20232022
Net income$84,110 $146,008 
Net income per common share - basic $2.03 $3.11 
Net income per common share - diluted $2.02 $3.09 
Weighted average common shares outstanding - basic41,378 46,913 
Plus dilutive effect of potential common shares192 295 
Weighted average common shares outstanding - diluted41,570 47,208 
Share-based awards to purchase 243 and 160 shares of common stock were not included in the above calculation of diluted net income per common share for the three months ended March 31, 2023 and 2022, respectively, because the effect of these instruments was anti-dilutive.
Since March 31, 2023, and through May 5, 2023, the Company repurchased 594 shares of its common stock at an average price of $84.18 per share excluding broker’s fee, resulting in an aggregate purchase price of $50,000 excluding the effect of 1% of excise taxes on the repurchased amount.

5. SEGMENT INFORMATION
The Company’s operating segments are identified in the same manner as they are reported internally and used by the Company’s chief operating decision maker for the purpose of evaluating performance and allocating resources. The Company has three reportable segments: (1) nurse and allied solutions, (2) physician and leadership solutions, and (3) technology and workforce solutions. The nurse and allied solutions segment includes the Company’s travel nurse staffing (including international nurse staffing and rapid response nurse staffing), labor disruption staffing, local staffing, international nurse and allied permanent placement, allied staffing and revenue cycle solutions businesses. The physician and leadership solutions segment includes the Company’s locum tenens staffing, healthcare interim leadership staffing, executive search, and physician permanent placement businesses. The technology and workforce solutions segment includes the Company’s language services, vendor management systems, workforce optimization, virtual care, and outsourced solutions businesses.
The Company’s chief operating decision maker relies on internal management reporting processes that provide revenue and operating income by reportable segment for making financial decisions and allocating resources. Segment operating income represents income before income taxes plus depreciation, amortization of intangible assets, share-based compensation, interest expense, net, and other, and unallocated corporate overhead. The Company’s management does not evaluate, manage or measure performance of segments using asset information; accordingly, asset information by segment is not prepared or disclosed.
The following table provides a reconciliation of revenue and operating income by reportable segment to consolidated results and was derived from each segment’s internal financial information as used for corporate management purposes:
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 Three Months Ended March 31,
 20232022
Revenue
Nurse and allied solutions$824,480 $1,228,039 
Physician and leadership solutions165,757 179,506 
Technology and workforce solutions135,986 144,993 
$1,126,223 $1,552,538 
Segment operating income
Nurse and allied solutions$113,445 $195,089 
Physician and leadership solutions25,100 20,381 
Technology and workforce solutions67,010 78,880 
205,555 294,350 
Unallocated corporate overhead30,733 43,648 
Depreciation and amortization37,577 30,656 
Depreciation (included in cost of revenue)1,257 854 
Share-based compensation10,318 11,259 
Interest expense, net, and other10,259 9,589 
Income before income taxes$115,411 $198,344 

The following table summarizes the activity related to the carrying value of goodwill by reportable segment:
Nurse and Allied SolutionsPhysician and Leadership SolutionsTechnology and Workforce SolutionsTotal
Balance, January 1, 2023$382,005 $152,800 $400,559 $935,364 
Goodwill adjustment for Connetics acquisition(45)— — (45)
Balance, March 31, 2023$381,960 $152,800 $400,559 $935,319 
Accumulated impairment loss as of December 31, 2022 and March 31, 2023$154,444 $60,495 $— $214,939 

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Disaggregation of Revenue
The following tables present the Company’s revenue disaggregated by service type:
Three Months Ended March 31, 2023
Nurse and Allied SolutionsPhysician and Leadership SolutionsTechnology and Workforce SolutionsTotal
Travel nurse staffing$592,677 $— $— $592,677 
Labor disruption services5,702 — — 5,702 
Local staffing25,272 — — 25,272 
Allied staffing196,125 — — 196,125 
Locum tenens staffing— 106,703 — 106,703 
Interim leadership staffing— 40,242 — 40,242 
Temporary staffing819,776 146,945 — 966,721 
Permanent placement4,704 18,812 — 23,516 
Language services— — 61,676 61,676 
Vendor management systems— — 54,173 54,173 
Other technologies— — 7,347 7,347 
Technology-enabled services— — 123,196 123,196 
Talent planning and acquisition— — 12,790 12,790 
Total revenue$824,480 $165,757 $135,986 $1,126,223 
Three Months Ended March 31, 2022
Nurse and Allied SolutionsPhysician and Leadership SolutionsTechnology and Workforce SolutionsTotal
Travel nurse staffing$970,109 $— $— $970,109 
Local staffing44,057 — — 44,057 
Allied staffing213,873 — — 213,873 
Locum tenens staffing— 112,672 — 112,672 
Interim leadership staffing— 44,354 — 44,354 
Temporary staffing1,228,039 157,026 — 1,385,065 
Permanent placement— 22,480 — 22,480 
Language services— — 49,238 49,238 
Vendor management systems— — 75,022 75,022 
Other technologies— — 7,658 7,658 
Technology-enabled services— — 131,918 131,918 
Talent planning and acquisition— — 13,075 13,075 
Total revenue$1,228,039 $179,506 $144,993 $1,552,538 
The Company did not generate material revenue from labor disruption services during the three months ended March 31, 2022.
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6. NOTES PAYABLE AND CREDIT AGREEMENT
On February 10, 2023, the Company entered into the third amendment to its credit agreement (the “Third Amendment”). The Third Amendment provides for, among other things, the following: (i) an extension of the maturity date of the secured revolving credit facility (the “Senior Credit Facility”) to February 10, 2028, (ii) an increase of the revolving commitments to $750,000, and (iii) a transition from LIBOR to a SOFR-based interest rate. The obligations of the Company under the amended credit agreement are secured by substantially all of the assets of the Company. Additional information regarding the credit agreement, Senior Credit Facility and Third Amendment is disclosed in Part II, Item 8, “Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements—Note (8), Notes Payable and Credit Agreement” of the 2022 Annual Report.

7. FAIR VALUE MEASUREMENT
The Company’s valuation techniques and inputs used to measure fair value and the definition of the three levels (Level 1, Level 2, and Level 3) of the fair value hierarchy are disclosed in Part II, Item 8, “Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements—Note (3), Fair Value Measurement” of the 2022 Annual Report. The Company has not changed the valuation techniques or inputs it uses for its fair value measurement during the three months ended March 31, 2023.
Assets and Liabilities Measured on a Recurring Basis
The Company invests a portion of its cash and cash equivalents in non-federally insured money market funds that are measured at fair value based on quoted prices, which are Level 1 inputs.
The Company has a deferred compensation plan for certain executives and employees, which is composed of deferred compensation and all related income and losses attributable thereto. The Company’s obligation under its deferred compensation plan is measured at fair value based on quoted market prices of the participants’ elected investments, which are Level 1 inputs.
The Company’s restricted cash equivalents and investments that serve as collateral for the Company’s captive insurance company include commercial paper that is measured at observable market prices for identical securities that are traded in less active markets, which are Level 2 inputs. The Company’s cash equivalents also include commercial paper classified as Level 2 in the fair value hierarchy. Of the $37,600 commercial paper issued and outstanding as of March 31, 2023, none had original maturities greater than three months. Of the $31,536 commercial paper issued and outstanding as of December 31, 2022, none had original maturities greater than three months.
The Company’s restricted cash equivalents and investments that serve as collateral for the Company’s captive insurance company also include corporate bonds that are measured using readily available pricing sources that utilize observable market data, including the current interest rate for comparable instruments, which are Level 2 inputs. As of March 31, 2023, the Company had $23,192 corporate bonds issued and outstanding, all of which had original maturities greater than three months and were considered available-for-sale securities. As of December 31, 2022, the Company had $25,095 corporate bonds issued and outstanding, all of which had original maturities greater than three months and were considered available-for-sale securities.
The Company’s contingent consideration liabilities associated with acquisitions are measured at fair value using a probability-weighted discounted cash flow analysis or a simulation-based methodology for the acquired companies, which are Level 3 inputs. The Company recognizes changes to the fair value of its contingent consideration liabilities in selling, general and administrative expenses in the condensed consolidated statements of comprehensive income.
The following tables present information about the above-referenced assets and liabilities and indicate the fair value hierarchy of the valuation techniques utilized to determine such fair value:
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 Fair Value Measurements as of March 31, 2023Fair Value Measurements as of December 31, 2022
Assets (Liabilities)Level 1Level 2Level 3TotalLevel 1Level 2Level 3Total
Money market funds$641 $— $— $641 $36,895 $— $— $36,895 
Deferred compensation(144,349)— — (144,349)(128,465)— — (128,465)
Corporate bonds— 23,192 — 23,192 — 25,095 — 25,095 
Commercial paper— 37,600 — 37,600 — 31,536 — 31,536 
Acquisition contingent consideration liabilities— — (5,150)(5,150)— — (5,070)(5,070)
Assets Measured on a Non-Recurring Basis
The Company applies fair value techniques on a non-recurring basis associated with valuing potential impairment losses related to its goodwill, long-lived assets, and equity investments.
The Company evaluates goodwill and indefinite-lived intangible assets annually for impairment and whenever events or changes in circumstances indicate that it is more likely than not that an impairment exists. The Company determines the fair value of its reporting units based on a combination of inputs, including the market capitalization of the Company, as well as Level 3 inputs such as discounted cash flows, which are not observable from the market, directly or indirectly. The Company determines the fair value of its indefinite-lived intangible assets using the income approach (relief-from-royalty method) based on Level 3 inputs.
The Company’s equity investment represents an investment in a non-controlled corporation without a readily determinable market value. The Company has elected to measure the investment at cost minus impairment, if any, plus or minus changes resulting from observable price changes. The fair value is determined by using quoted prices for identical or similar investments of the same issuer, which are Level 2 inputs, and other information available to the Company such as the rights and obligations of the securities. The Company recognizes changes to the fair value of its equity investment in interest expense, net, and other in the condensed consolidated statements of comprehensive income. The balance of the equity investment was $19,204 as of both March 31, 2023 and December 31, 2022.
There were no material impairment charges recorded during the three months ended March 31, 2023 and 2022.
Fair Value of Financial Instruments
The Company is required to disclose the fair value of financial instruments for which it is practicable to estimate the value, even though these instruments are not recognized at fair value in the consolidated balance sheets. The fair value of the Company’s 4.625% senior notes due 2027 (the “2027 Notes”) and 4.000% senior notes due 2029 (the “2029 Notes”) was estimated using quoted market prices in active markets for identical liabilities, which are Level 1 inputs. The carrying amounts and estimated fair value of the 2027 Notes and the 2029 Notes are presented in the following table. See additional information regarding the 2027 Notes and the 2029 Notes in Part II, Item 8, “Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements—Note (8), Notes Payable and Credit Agreement” of the 2022 Annual Report.
As of March 31, 2023As of December 31, 2022
Carrying
Amount
Estimated
Fair Value
Carrying
Amount
Estimated
Fair Value
2027 Notes$500,000 $463,125 $500,000 $460,000 
2029 Notes350,000 308,875 350,000 300,125 
The fair value of the Company’s long-term self-insurance accruals cannot be estimated as the Company cannot reasonably determine the timing of future payments.

8. INCOME TAXES
The Company is subject to taxation in the U.S. and various states and foreign jurisdictions. With few exceptions, as of March 31, 2023, the Company is no longer subject to state, local or foreign examinations by tax authorities for tax years before 2011, and the Company is no longer subject to U.S. federal income or payroll tax examinations for tax years before 2019.
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The Company believes its liability for unrecognized tax benefits and contingent tax issues is adequate with respect to all open years. Notwithstanding the foregoing, the Company could adjust its provision for income taxes and contingent tax liability based on future developments.

9. COMMITMENTS AND CONTINGENCIES
Legal Proceedings
From time to time, the Company is involved in various lawsuits, claims, investigations, and proceedings that arise in the ordinary course of business. These matters typically relate to professional liability, tax, compensation, contract, competitor disputes and employee-related matters and include individual and class action lawsuits, as well as inquiries and investigations by governmental agencies regarding the Company’s employment and compensation practices. Additionally, some of the Company’s clients may also become subject to claims, governmental inquiries and investigations, and legal actions relating to services provided by the Company’s healthcare professionals. Depending upon the particular facts and circumstances, the Company may also be subject to indemnification obligations under its contracts with such clients relating to these matters. The Company accrues for contingencies and records a liability when management believes an adverse outcome from a loss contingency is both probable and the amount, or a range, can be reasonably estimated. Significant judgment is required to determine both probability of loss and the estimated amount. The Company reviews its loss contingencies at least quarterly and adjusts its accruals and/or disclosures to reflect the impact of negotiations, settlements, rulings, advice of legal counsel, or other new information, as deemed necessary. The most significant matters for which the Company has established loss contingencies are class actions related to wage and hour claims under California and Federal law. Specifically, among other claims in these lawsuits, it is alleged that certain expense reimbursements should be considered wages and included in the regular rate of pay for purposes of calculating overtime rates.
On May 26, 2016, former travel nurse Verna Maxwell Clarke filed a complaint against AMN Services, LLC, in California Superior Court in Los Angeles County. The Company removed the case to the United States District Court for the Central District of California (Case No. 2:16-cv-04132-DSF-KS) (the “Clarke Matter”). The complaint asserts that, due to the Company’s per diem adjustment practices, traveling nurses’ per diem benefits should be included in their regular rate of pay for the purposes of calculating their overtime compensation. On June 26, 2018, the district court denied the plaintiffs’ Motion for Summary Judgment in its entirety, and granted the Company’s Motion for Summary Judgment with respect to the plaintiffs’ per diem and overtime claims. The plaintiffs filed an appeal of the judgment relating to the per diem claims with the Ninth Circuit Court of Appeals (the “Ninth Circuit”). On February 8, 2021, the Ninth Circuit issued an opinion that reversed the district court’s granting of the Company’s Motion for Summary Judgment and remanded the matter to the district court instructing the district to enter partial summary judgment in favor of the plaintiffs. On August 26, 2021, the Company filed a Petition for Writ of Certiorari in the United States Supreme Court seeking review of the Ninth Circuit’s decision, which was denied on December 13, 2021. This case is proceeding in the United States District Court.
On May 2, 2019, former travel nurse Sara Woehrle filed a complaint against AMN Services, LLC, and Providence Health System – Southern California in California Superior Court in Los Angeles County. The Company removed the case to the United States District Court for the Central District of California (Case No. 2:19-cv-05282 DSF-KS). The complaint asserts that, due to the Company’s per diem adjustment practices, traveling nurses’ per diem benefits should be included in their regular rate of pay for the purposes of calculating their overtime compensation. The complaint also alleges that the putative class members were denied required meal periods, denied proper overtime compensation, were not compensated for all time worked, including reporting time and training time, and received non-compliant wage statements. The Company reached an agreement to settle this matter in its entirety and received court approval of the settlement. Payment is expected to be made in the second quarter of 2023.
Because of the inherent uncertainty of litigation, the Company is not able to reasonably predict if any matter will be resolved in a manner that is materially adverse to the Company. The Company has recorded accruals in connection with the two matters described above amounting to $46,225. The Company is currently unable to estimate the possible loss or range of loss beyond amounts already accrued. Loss contingencies accrued as of both March 31, 2023 and December 31, 2022 are included in accounts payable and accrued expenses and other long-term liabilities in the consolidated balance sheets.
Operating Leases
In the first quarter of 2022, the Company entered into a lease agreement for an office building located in Dallas, Texas, with future undiscounted lease payments of approximately $29,514, excluding lease incentives. Because the Company does not control the underlying asset during the construction period, the Company is not considered the owner of the asset under construction for accounting purposes. The lease will commence upon completion of the construction of the office building which is expected be in the second quarter of 2023. The initial term of the lease is approximately eleven years with options to renew the lease during the lease term. A right-of-use asset and lease liability will be recognized in the consolidated balance sheet in the period the lease commences.
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10. BALANCE SHEET DETAILS

The consolidated balance sheets detail is as follows:
March 31, 2023December 31, 2022
Other current assets:
Restricted cash and cash equivalents$31,500 $37,225 
Income taxes receivable— 8,875 
Other20,052 19,937 
Other current assets$51,552 $66,037 
Fixed assets:
Furniture and equipment$54,978 $51,408 
Software333,302 323,418 
Leasehold improvements938 2,067 
389,218 376,893 
Accumulated depreciation(233,942)(227,617)
Fixed assets, net$155,276 $149,276 
Other assets:
Life insurance cash surrender value$140,731 $117,139 
Operating lease right-of-use assets$14,484 16,266 
Other42,110 38,611 
Other assets$197,325 $172,016 
Accounts payable and accrued expenses:
Trade accounts payable$81,447 $78,057 
Subcontractor payable278,432 295,259 
Accrued expenses82,337 73,885 
Loss contingencies15,874 14,638 
Professional liability reserve8,091 7,756 
Other7,583 6,857 
Accounts payable and accrued expenses$473,764 $476,452 
Accrued compensation and benefits:
Accrued payroll$72,113 $63,857 
Accrued bonuses and commissions28,032 96,760 
Workers compensation reserve12,394 12,113 
Deferred compensation144,349 128,465 
Other12,349 32,049 
Accrued compensation and benefits$269,237 $333,244 
Other current liabilities:
Acquisition related liabilities$5,150 $5,070 
Income taxes payable23,395 — 
Client deposits7,463 21,466 
Operating lease liabilities7,789 8,090 
Deferred revenue13,876 11,825 
Other2,927 1,786 
Other current liabilities$60,600 $48,237 
Other long-term liabilities:
Workers compensation reserve$22,756 $23,841 
Professional liability reserve38,153 36,214 
Operating lease liabilities7,652 9,360 
Other53,213 51,151 
Other long-term liabilities$121,774 $120,566 
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Item 2. Management’s Discussion and Analysis of Financial Condition and Results of Operations
The following discussion should be read in conjunction with our consolidated financial statements and the notes thereto and other financial information included elsewhere herein and in our Annual Report on Form 10-K for the fiscal year ended December 31, 2022, filed with the Securities and Exchange Commission (“SEC”) on February 22, 2023 (“2022 Annual Report”). Certain statements in this “Management’s Discussion and Analysis of Financial Condition and Results of Operations” are “forward-looking statements.” See “Special Note Regarding Forward-Looking Statements.” We undertake no obligation to update the forward-looking statements in this Quarterly Report. References in this Quarterly Report to “AMN Healthcare,” the “Company,” “we,” “us” and “our” refer to AMN Healthcare Services, Inc. and its wholly owned subsidiaries.
Overview of Our Business
 
We provide healthcare workforce solutions and staffing services to healthcare organizations across the nation. As an innovative total talent solutions partner, our managed services programs, or “MSP,” vendor management systems, or “VMS,” workforce consulting services, predictive modeling, staff scheduling, revenue cycle solutions, language services, and the placement of physicians, nurses, allied healthcare professionals and healthcare leaders into temporary and permanent positions enable our clients to successfully reduce staffing complexity, increase efficiency and lead their organizations within the rapidly evolving healthcare environment.
We conduct business through three reportable segments: (1) nurse and allied solutions, (2) physician and leadership solutions, and (3) technology and workforce solutions. For the three months ended March 31, 2023, we recorded revenue of $1,126.2 million, as compared to $1,552.5 million for the same period last year.
Nurse and allied solutions segment revenue comprised 73% and 79% of total consolidated revenue for the three months ended March 31, 2023 and 2022, respectively. Through our nurse and allied solutions segment, we provide hospitals and other healthcare facilities with a comprehensive managed services solution in which we manage and staff all of the temporary and permanent nursing and allied staffing needs of a client. We also provide revenue cycle solutions, which include skilled labor solutions for remote medical coding, clinical documentation improvement, case management, and clinical data registry, and provide auditing and advisory services. A majority of our placements in this segment are under our managed services solution, however, we also provide traditional direct nurse and allied healthcare staffing solutions of variable assignment lengths. 
Physician and leadership solutions segment revenue comprised 15% and 12% of total consolidated revenue for the three months ended March 31, 2023 and 2022, respectively. Through our physician and leadership solutions segment, we place physicians of all specialties, as well as dentists and advanced practice providers, with clients on a temporary basis, generally as independent contractors. We also recruit physicians and healthcare leaders for permanent placement and place interim leaders and executives across all healthcare settings. The interim healthcare leaders and executives we place are typically placed on contracts with assignment lengths ranging from a few days to one year, and a growing number of these placements are under our managed services solution.
Technology and workforce solutions segment revenue comprised 12% and 9% of total consolidated revenue for both of the three months ended March 31, 2023 and 2022, respectively. Through our technology and workforce solutions segment, we provide hospitals and other healthcare facilities with a range of workforce solutions, including: (1) language services, (2) software-as-a-service (“SaaS”) VMS technologies through which our clients can manage their temporary staffing needs, (3) workforce optimization services that include consulting, data analytics, predictive modeling, and SaaS-based scheduling technology, (4) recruitment process outsourcing services that leverage our expertise and support systems to replace or complement a client’s existing internal recruitment function for permanent placement needs, and (5) virtual care services.
Operating Metrics
 
In addition to our consolidated and segment financial results, we monitor the following key metrics to help us evaluate our results of operations and financial condition and make strategic decisions. We believe this information is useful in understanding our operational performance and trends affecting our businesses.
Average travelers on assignment represents the average number of nurse and allied healthcare professionals on assignment during the period, which is used by management as a measure of volume in our nurse and allied solutions segment;
Bill rates represent the hourly straight-time rates that we bill to clients, which are an indicator of labor market trends and costs within our nurse and allied solutions segment;
Billable hours represent hours worked by our healthcare professionals that we are able to bill on client engagements, which are used by management as a measure of volume in our nurse and allied solutions segment;
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Days filled is calculated by dividing total locum tenens hours filled during the period by eight hours, which is used by management as a measure of volume in our locum tenens business within our physician and leadership solutions segment; and
Revenue per day filled is calculated by dividing revenue of our locum tenens business by days filled for the period, which is an indicator of labor market trends and costs in our locum tenens business within our physician and leadership solutions segment.
Recent Trends
Demand for our temporary and permanent placement staffing services is driven in part by U.S. economic and labor trends, and from early 2020 through 2022, the COVID-19 pandemic and the “Great Resignation” impacted demand. From late 2020 through most of 2022, these conditions resulted in historically high demand for our nurses and allied healthcare professionals. In 2023, with the pandemic-related needs subsiding, demand in our travel nurse business has declined significantly from historic highs and is currently slightly below pre-pandemic levels. Demand in our allied business continues to be above pre-pandemic levels and certain specialties such as allied therapy are up significantly year over year. Our clients are still dealing with significant labor shortages as their progress on permanent hiring and retention has not addressed the vacancies. At the same time, despite the relatively high level of hospital job openings, our clients have focused on reducing what had been historically high utilization of contingent labor.
Wages for nurses and the corresponding bill rates we charge our clients peaked in the first quarter of 2022. Bill rates in our nurse and allied solutions segment decreased year-over-year in the first quarter of 2023. We expect bill rates and clinician compensation to stabilize above pre-pandemic levels in 2023.
In our physician and leadership solutions segment, demand for our locum tenens business is well above pre-pandemic levels. Demand for certified registered nurse anesthetists (CRNAs), which represents the largest percentage of revenue in this business, continues to be strong. We expect continued strong demand for locums tenens staffing in the second quarter of 2023. Demand remained softer for our interim leadership and search businesses in the first quarter of 2023 as some healthcare organizations streamlined or deferred leadership roles to reduce costs.
In our technology and workforce solutions segment, our language services business continued to experience increased utilization reflecting a continued shift to more virtual interpretation that began during the pandemic. As anticipated, bill rates and volumes in our VMS business followed similar trends as our nurse and allied solutions segment, declining from historic highs but remaining above pre-pandemic levels. We anticipate our VMS business to continue to trend along the same lines as our nurse and allied solutions segment with bill rates stabilizing in 2023 above pre-pandemic levels.
Our clients have accelerated initiatives designed to contain costs of their spend on contingent labor, and we are experiencing a number of clients that are reevaluating their approach and seeking sustainable workforce solutions.
Critical Accounting Policies and Estimates
The preparation of our consolidated financial statements in conformity with United States generally accepted accounting principles (“U.S. GAAP”) requires us to make estimates and judgments that affect our reported amounts of assets and liabilities, revenue and expenses, and related disclosures of contingent assets and liabilities. On an ongoing basis, we evaluate our estimates, including those related to intangible assets purchased in a business combination, asset impairments, accruals for self-insurance, compensation and related benefits, accounts receivable, contingencies and litigation, contingent consideration (“earn-out”) liabilities associated with acquisitions, and income taxes. We base these estimates on the information that is currently available to us and on various other assumptions that we believe are reasonable under the circumstances. Actual results could vary from these estimates under different assumptions or conditions. If these estimates differ significantly from actual results, our consolidated financial statements and future results of operations may be materially impacted. There have been no material changes in our critical accounting policies and estimates, other than the adoption of the Accounting Standard Update (“ASU”) described in the accompanying Note (1), “Basis of Presentation,” as compared to the critical accounting policies and estimates described in our 2022 Annual Report.
 
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Results of Operations
The following table sets forth, for the periods indicated, selected unaudited condensed consolidated statements of operations data as a percentage of revenue. Our results of operations include three reportable segments: (1) nurse and allied solutions, (2) physician and leadership solutions, and (3) technology and workforce solutions. The Connetics acquisition impacts the comparability of the results between the three months ended March 31, 2023 and 2022. See additional information in the accompanying Note (2), “Acquisitions.” Our historical results are not necessarily indicative of our future results of operations.
 Three Months Ended March 31,
 20232022
Unaudited Condensed Consolidated Statements of Operations:
Revenue100.0 %100.0 %
Cost of revenue67.2 68.0 
Gross profit32.8 32.0 
Selling, general and administrative18.3 16.6 
Depreciation and amortization3.3 2.0 
Income from operations11.2 13.4 
Interest expense, net, and other1.0 0.6 
Income before income taxes10.2 12.8 
Income tax expense 2.7 3.4 
Net income7.5 %9.4 %

 
Comparison of Results for the Three Months Ended March 31, 2023 to the Three Months Ended March 31, 2022
 
RevenueRevenue decreased 27% to $1,126.2 million for the three months ended March 31, 2023 from $1,552.5 million for the same period in 2022, attributable to a decline in revenue across our segments with the greatest decline in our nurse and allied solutions segment.
Nurse and allied solutions segment revenue decreased 33% to $824.5 million for the three months ended March 31, 2023 from $1,228.0 million for the same period in 2022. The $403.5 million decrease was primarily attributable to an approximately 22% decrease in the average bill rate, an 11% decrease in the average number of travelers on assignment, and a 3% decrease in billable hours during the three months ended March 31, 2023. The overall decrease was partially offset by an approximately $6.0 million increase in labor disruption revenue and additional revenue of $4.7 million in connection with the Connetics acquisition.
Physician and leadership solutions segment revenue decreased 8% to $165.8 million for the three months ended March 31, 2023 from $179.5 million for the same period in 2022. The $13.7 million decrease was attributable to declines in revenue of our businesses across the segment driven, in part, by COVID-19 project work in the prior year. Revenue in our locum tenens business declined approximately 5% during the three months ended March 31, 2023 primarily due to a 9% decrease in the number of days filled, partially offset by a 4% increase in the revenue per day filled. Our interim leadership business experienced a 9% decline and our physician permanent placement and executive search businesses declined 16% during the three months ended March 31, 2023, primarily due to lower demand.
Technology and workforce solutions segment revenue decreased 6% to $136.0 million for the three months ended March 31, 2023 from $145.0 million for the same period in 2022. The $9.0 million decrease was primarily attributable to a decline within our VMS business, partially offset by growth within our language services business. Revenue for our VMS business declined 28% for the same reasons as nurse and allied solutions segment revenue, while our language services business grew 25% during the three months ended March 31, 2023.
For the three months ended March 31, 2023 and 2022, revenue under our MSP arrangements comprised approximately 57% and 66% of our consolidated revenue, 74% and 81% of our nurse and allied solutions segment revenue, 21% and 14% of our physician and leadership solutions segment revenue, and 2% and 2% of our technology and workforce solutions segment revenue, respectively.

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Gross Profit. Gross profit decreased 26% to $368.8 million for the three months ended March 31, 2023 from $496.2 million for the same period in 2022, representing gross margins of 32.8% and 32.0%, respectively. The increase in consolidated gross margin for the three months ended March 31, 2023, as compared to the same period in 2022, was primarily due to a change in sales mix resulting from lower revenue in our nurse and allied solutions segment. The overall increase was partially offset by (1) a lower margin in our technology and workforce solutions segment primarily due to a change in sales mix resulting from lower revenue in our VMS business and its higher margins as compared to our other businesses within the segment and (2) a lower margin in our nurse and allied solutions segment driven by a decrease in billable hours. Gross margin by reportable segment for the three months ended March 31, 2023 and 2022 was 25.9% and 26.2% for nurse and allied solutions, 35.2% and 35.0% for physician and leadership solutions, and 71.4% and 76.7% for technology and workforce solutions, respectively.
 
Selling, General and Administrative Expenses. Selling, general and administrative (“SG&A”) expenses were $205.6 million, representing 18.3% of revenue, for the three months ended March 31, 2023, as compared to $257.6 million, representing 16.6% of revenue, for the same period in 2022. The decrease in SG&A expenses was primarily due to $56.9 million of lower employee compensation and benefits (inclusive of share-based compensation), partially offset by a $5.8 million increase in the provision for expected credit losses. SG&A expenses broken down among the reportable segments, unallocated corporate overhead, and share-based compensation are as follows:
(In Thousands)
 Three Months Ended March 31,
 20232022
Nurse and allied solutions$99,997 $126,996 
Physician and leadership solutions33,208 42,489 
Technology and workforce solutions31,343 33,187 
Unallocated corporate overhead30,733 43,648 
Share-based compensation10,318 11,259 
$205,599 $257,579 
Depreciation and Amortization Expenses. Amortization expense increased 10% to $21.7 million for the three months ended March 31, 2023 from $19.6 million for the same period in 2022, primarily attributable to additional amortization expense related to the intangible assets acquired in the Connetics acquisition. Depreciation expense (exclusive of depreciation included in cost of revenue) increased 45% to $15.9 million for the three months ended March 31, 2023 from $11.0 million for the same period in 2022, primarily attributable to an increase in purchased and developed hardware and software placed in service for our ongoing information technology investments to support our total talent solutions initiatives and to optimize our internal front and back-office systems. Additionally, $1.3 million and $0.9 million of depreciation expense for our language services business is included in cost of revenue for the three months ended March 31, 2023 and 2022, respectively.
Interest Expense, Net, and OtherInterest expense, net, and other was $10.3 million during the three months ended March 31, 2023 as compared to $9.6 million for the same period in 2022. The increase was primarily due to a higher average debt outstanding balance during the three months ended March 31, 2023.

Income Tax Expense. Income tax expense was $31.3 million for the three months ended March 31, 2023 as compared to $52.3 million for the same period in 2022, reflecting effective income tax rates of 27% and 26% for these periods, respectively. The increase in the effective income tax rate was primarily attributable to the recognition of $0.8 million of net discrete tax expense during the three months ended March 31, 2023 compared to a $1.0 million net discrete tax benefits during the same period in 2022, in relation to income before income taxes of $115.4 million and $198.3 million for the three months ended March 31, 2023 and 2022, respectively. We currently estimate our annual effective tax rate to be approximately 28% for 2023. The 27% effective tax rate for the three months ended March 31, 2023 differs from our estimated annual effective tax rate of 28% primarily due to certain discrete tax benefits recognized during the three months ended March 31, 2023, in relation to income before income taxes.

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Liquidity and Capital Resources
In summary, our cash flows were:
(In Thousands)
 Three Months Ended March 31,
 20232022
Net cash provided by operating activities$43,434 $200,215 
Net cash used in investing activities(32,431)(23,239)
Net cash used in financing activities(44,457)(237,455)
Historically, our primary liquidity requirements have been for acquisitions, working capital requirements, and debt service under our credit facilities and senior notes. We have funded these requirements through internally generated cash flow and funds borrowed under our credit facilities.
As of March 31, 2023, (1) $140.0 million was drawn with $589.2 million of available credit under our $750.0 million secured revolving credit facility (the “Senior Credit Facility”), (2) the aggregate principal amount of our 4.625% senior notes due 2027 (the “2027 Notes”) outstanding was $500.0 million, and (3) the aggregate principal amount of our 4.000% senior notes due 2029 (the “2029 Notes”) outstanding was $350.0 million. We describe in further detail our Amended Credit Agreement (as defined below), under which the Senior Credit Facility is governed, the 2027 Notes, and the 2029 Notes in Part II, Item 8, “Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements—Note (8), Notes Payable and Credit Agreement” of our 2022 Annual Report.
As of March 31, 2023, the total of our contractual obligations under operating leases with initial terms in excess of one year was $16.0 million. We describe in further detail our operating lease arrangements in Part II, Item 8, “Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements—Note (5), Leases” of our 2022 Annual Report. We also have various obligations and working capital requirements, such as certain tax and legal matters, contingent consideration and other liabilities, that are recorded on our consolidated balance sheets. See additional information in the accompanying Note (7), “Fair Value Measurement,” Note (8), “Income Taxes,” Note (9), “Commitments and Contingencies,” and Note (10), “Balance Sheet Details.”
In addition to our cash requirements, we have a share repurchase program authorized by our board of directors, which does not require the purchase of any minimum number of shares and may be suspended or discontinued at any time. See additional information in the accompanying Part II, Item 2, “Unregistered Sales of Equity Securities and Use of Proceeds.” Under the repurchase program, we intend to enter into an accelerated share repurchase (“ASR”) agreement with a counterparty to repurchase approximately $200.0 million of our outstanding common stock.
We believe that cash generated from operations and available borrowings under the Senior Credit Facility will be sufficient to fund our operations and liquidity requirements, including expected capital expenditures, for the next 12 months and beyond. We intend to finance potential future acquisitions with cash provided from operations, borrowings under the Senior Credit Facility or other borrowings under our amended credit agreement, bank loans, debt or equity offerings, or some combination of the foregoing. The following discussion provides further details of our liquidity and capital resources.
Operating Activities
Net cash provided by operating activities for the three months ended March 31, 2023 was $43.4 million, compared to $200.2 million for the same period in 2022. The decrease in net cash provided by operating activities was primarily attributable to (1) a decrease in net income excluding non-cash expenses of $59.5 million primarily due to a decline in operating results in our nurse and allied solutions segment, (2) a decrease in accrued compensation and benefits between periods of $167.5 million primarily due to prior year increases in pay rates and the average number of travelers on assignment in our nurse and allied solutions segment and increased employee compensation and benefits in 2022, including accrued bonuses and commissions that were paid during the first quarter of 2023, (3) a decrease in accounts payable and accrued expenses between periods of $80.5 million primarily due to increased associate vendor usage in 2022, and (4) increases in prepaid expenses and other current assets between periods of $41.4 million and $12.3 million, respectively, primarily due to prepayments and deposits that were made in 2021 and refunded by third-party vendors in 2022 related to labor disruption services. The overall decrease in net cash provided by operating activities was partially offset by a decrease in accounts receivable and subcontractor receivables between periods of $199.3 million primarily due to a smaller increase in the receivables balance in the current year as compared to the prior year, which was due to increases in revenue and associate vendor usage in the prior year along with timing of collections during the three months ended March 31, 2023. Our Days Sales Outstanding (“DSO”) was 55 days at March 31, 2023, 55 days at December 31, 2022, and 57 days at March 31, 2022.
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Investing Activities
Net cash used in investing activities for the three months ended March 31, 2023 was $32.4 million, compared to net cash used in investing activities of $23.2 million for the same period in 2022. The increase was primarily due to $17.0 million of payments to fund the deferred compensation plan during the three months ended March 31, 2023 as compared to $12.6 million of payments during the three months ended March 31, 2022. In addition, capital expenditures were $17.5 million and $13.6 million for the three months ended March 31, 2023 and 2022, respectively.
Financing Activities
Net cash used in financing activities during the three months ended March 31, 2023 was $44.5 million, primarily due to (1) $174.7 million paid in connection with the repurchase of our common stock, (2) repayments of $70.0 million under the Senior Credit Facility, (3) $6.1 million in cash paid for shares withheld for payroll taxes resulting from the vesting of employee equity awards, and (4) $3.6 million payment of financing costs in connection with the Third Amendment (as defined below), all of which was partially offset by borrowings of $210.0 million under the Senior Credit Facility. Net cash used in financing activities during the three months ended March 31, 2022 was $237.5 million due to $228.0 million paid in connection with the repurchase of our common stock and $9.4 million in cash paid for shares withheld for payroll taxes resulting from the vesting of employee equity awards.
Amended Credit Agreement
On February 10, 2023, we entered into the third amendment to our credit agreement (the “Third Amendment”). The Third Amendment (together with the credit agreement as amended to date, collectively, the “Amended Credit Agreement”) provides for, among other things, an increase to the revolving commitments under the Senior Credit Facility to $750.0 million and an extension of the maturity date of the Amended Credit Agreement to February 10, 2028. Our obligations under the Amended Credit Agreement are secured by substantially all of our assets. We describe in further detail the terms of the Amended Credit Agreement, including maturity dates and interest terms, in Part II, Item 8, “Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements—Note (8), Notes Payable and Credit Agreement” of our 2022 Annual Report.
Letters of Credit
At March 31, 2023, we maintained outstanding standby letters of credit totaling $21.3 million as collateral in relation to our workers’ compensation insurance agreements and a corporate office lease agreement. Of the $21.3 million of outstanding letters of credit, we have collateralized $0.5 million in cash and cash equivalents and the remaining $20.8 million is collateralized by the Senior Credit Facility. Outstanding standby letters of credit at December 31, 2022 totaled $22.0 million.
Recent Accounting Pronouncements
There have been no new accounting pronouncements issued but not yet adopted that are expected to materially affect our consolidated financial condition or results of operations.
Special Note Regarding Forward-Looking Statements
This Quarterly Report contains “forward-looking statements” within the meaning of Section 27A of the Securities Act of 1933, as amended, and Section 21E of the Securities Exchange Act of 1934, as amended. We base these forward-looking statements on our expectations, estimates, forecasts, and projections about future events and about the industry in which we operate. Forward-looking statements are identified by words such as “believe,” “anticipate,” “expect,” “intend,” “plan,” “will,” “should,” “would,” “project,” “may,” variations of such words, and other similar expressions. In addition, any statements that refer to projections of demand or supply trends, financial items, anticipated growth, future growth and revenues, future economic conditions and performance, plans, objectives and strategies for future operations, expectations, or other characterizations of future events or circumstances are forward-looking statements. All forward-looking statements involve risks and uncertainties. Our actual results could differ materially from those discussed in, or implied by, these forward-looking statements. Factors that could cause actual results to differ materially from those implied by the forward-looking statements in this Quarterly Report are set forth in our 2022 Annual Report and include but are not limited to:
the effects of the COVID-19 pandemic on our business, financial condition and results of operations;
the duration and extent to which hospitals and other healthcare entities adjust their utilization of temporary nurses and allied healthcare professionals, physicians, healthcare leaders and other healthcare professionals and workforce technology applications as a result of the labor market, economic conditions or COVID-19 pandemic;
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the extent to which a spike in the COVID-19 pandemic may disrupt our operations due to the unavailability of our employees or healthcare professionals because of illness, risk of illness, quarantines, travel restrictions, mandatory vaccination requirements, desire to travel and work on temporary assignments or other factors that limit our existing or potential workforce and pool of candidates;
the severity and duration of the impact the COVID-19 pandemic, the Great Resignation, economic downturns, inflation, recession or slow recoveries have on the financial condition and cash flow of many hospitals and healthcare systems such that it impairs their ability to make payments to us, timely or otherwise, for services rendered;
the effects of economic downturns, inflation, recession or slow recoveries, which could result in less demand for our services, increased client initiatives designed to contain costs, including reevaluating their approach as it pertains to contingent labor and managed services programs;
any inability on our part to anticipate and quickly respond to changing marketplace conditions, such as alternative modes of healthcare delivery, reimbursement, or client needs and requirements, including mandatory vaccination requirements;
the negative effects that intermediary organizations may have on our ability to secure new and profitable contracts;
the level of consolidation and concentration of buyers of healthcare workforce, staffing and technology solutions, which could affect the pricing of our services and our ability to mitigate concentration risk;
the ability of our clients to increase the efficiency and effectiveness of their staffing management and recruiting efforts, through predictive analytics, online recruiting, telemedicine or otherwise, which may negatively affect our revenue, results of operations, and cash flows;
any inability on our part to recruit and retain sufficient quality healthcare professionals at reasonable costs, which could increase our operating costs and negatively affect our business and profitability;
any inability on our part to grow and operate our business profitably in compliance with federal and state regulation, including privacy laws, conduct of operations, costs and payment for services and payment for referrals as well as laws regarding employment and compensation practices and government contracting; 
any challenge to the classification of certain of our healthcare professionals as independent contractors, which could adversely affect our profitability;
the effect of investigations, claims, and legal proceedings alleging medical malpractice, anti-competitive conduct, violations of employment, privacy and wage regulations and other legal theories of liability asserted against us, which could subject us to substantial liabilities;
any technology disruptions or our inability to implement new infrastructure and technology systems effectively may adversely affect our operating results and ability to manage our business effectively;
any failure to further develop and evolve our current workforce solutions technology offerings and capabilities, which may harm our business and/or impact our ability to compete with new technologies and competitors;
disruption to or failures of our SaaS-based or technology-enabled services, or our inability to adequately protect our intellectual property rights with respect to such technologies or sufficiently protect the privacy of personal information, could reduce client satisfaction, harm our reputation and negatively affect our business;
security breaches and cybersecurity incidents, including ransomware, that could compromise our information and systems, which could adversely affect our business operations and reputation and could subject us to substantial liabilities;
any inability on our part to quickly and properly credential and match quality healthcare professionals with suitable placements, which may adversely affect demand for our services;
any inability on our part to continue to attract, develop and retain our sales and operations team members, which may deteriorate our operations;
our increasing dependence on third parties, including offshore vendors, for the execution of certain critical functions;
the loss of our key officers and management personnel, which could adversely affect our business and operating results;
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any inability to consummate and effectively incorporate acquisitions into our business operations, which may adversely affect our long-term growth and our results of operations;
businesses we acquire may have liabilities or adverse operating issues, which could harm our operating results;
any increase to our business and operating risks as we develop new services and clients, enter new lines of business, and focus more of our business on providing a full range of client solutions;
any inability on our part to maintain our positive brand awareness and identity, which may adversely affect our results of operation;
the expansion of social media platforms presents new risks and challenges, which could cause damage to our brand reputation;
any recognition of an impairment to the substantial amount of goodwill or indefinite-lived intangibles on our balance sheet;
our indebtedness, which could adversely affect our ability to raise additional capital to fund operations, limit our ability to react to changes in the economy or our industry, and expose us to interest rate risk to the extent of any variable rate debt;
the terms of our debt instruments that impose restrictions on us that may affect our ability to successfully operate our business; and
the effect of significant adverse adjustments to our insurance-related accruals on our balance sheet, which could decrease our earnings or increase our losses and negatively impact our cash flows.
Item 3. Quantitative and Qualitative Disclosures about Market Risk
Market risk is the risk of loss arising from adverse changes in market rates and prices, such as interest rates, foreign currency exchange rates, and commodity prices. During the three months ended March 31, 2023, our primary exposure to market risk was interest rate risk associated with our variable interest debt instruments and our investment portfolio. A 100 basis point increase in interest rates on our variable rate debt would not have resulted in a material effect on our unaudited condensed consolidated financial statements for the three months ended March 31, 2023. A 100 basis point change in interest rates as of March 31, 2023 would not have resulted in a material effect on the fair value of our investment portfolio. For our investments that are classified as available-for-sale, unrealized gains or losses related to fluctuations in market volatility and interest rates are reflected within stockholders’ equity in accumulated other comprehensive income (loss) in the consolidated balance sheets. Such unrealized losses would be realized only if we sell the investments prior to maturity.
During the three months ended March 31, 2023, we generated substantially all of our revenue in the United States. Accordingly, we believe that our foreign currency risk is immaterial.
Item 4. Controls and Procedures
We carried out an evaluation, under the supervision and with the participation of our management, including our Chief Executive Officer and Chief Financial Officer, of the effectiveness of our disclosure controls and procedures, as defined in Rules 13a-15(e) and 15d-15(e) of the Securities Exchange Act of 1934. Based on that evaluation, our Chief Executive Officer and Chief Financial Officer have concluded that our disclosure controls and procedures as of March 31, 2023 were effective to ensure that information required to be disclosed by us in reports that we file or submit under the Securities Exchange Act of 1934 is recorded, processed, summarized and reported within the time periods specified in the SEC’s rules and forms, and that such information is accumulated and communicated to management, including our Chief Executive Officer and Chief Financial Officer, as appropriate, to allow timely decisions regarding required disclosure.
 
There were no changes in our internal control over financial reporting that occurred during the quarter ended March 31, 2023 that have materially affected, or are reasonably likely to materially affect, our internal control over financial reporting.
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PART II - OTHER INFORMATION
 
Item 1. Legal Proceedings
Information with respect to this item may be found in the accompanying Note (9), “Commitments and Contingencies,” which is incorporated herein by reference.

Item 1A. Risk Factors
We do not believe that there have been any material changes to the risk factors disclosed in Part I, Item 1A of our 2022 Annual Report. The risk factors described in our 2022 Annual Report are not the only risks we face. Factors we currently do not know, factors that we currently consider immaterial or factors that are not specific to us, such as general economic conditions, may also materially adversely affect our business or our consolidated operating results, financial condition or cash flows.

Item 2. Unregistered Sales of Equity Securities and Use of Proceeds
From time to time, we may repurchase our common stock in the open market pursuant to programs approved by our board of directors (the “Board”). On November 1, 2016, our Board authorized us to repurchase up to $150.0 million of our outstanding common stock in the open market. On November 10, 2021, February 17, 2022 and June 15, 2022, we announced increases to the repurchase program totaling $700.0 million. Additionally, on February 16, 2023, we announced an increase of $500.0 million for a total of $1,350.0 million of repurchase authorization as of March 31, 2023. Under the repurchase program announced on November 1, 2016 and the aforementioned increases (collectively, the “Company Repurchase Program”), share repurchases may be made from time to time, depending on prevailing market conditions and other considerations. The Company Repurchase Program has no expiration date and may be discontinued or suspended at any time.
During the three months ended March 31, 2023, we repurchased 1.8 million shares of common stock at an average price of $98.81 per share excluding broker’s fees, resulting in an aggregate purchase price of $174.7 million excluding the effect of excise taxes, funded through cash on hand and borrowings under our secured revolving credit facility. We describe in further detail our repurchase program and the shares repurchased thereunder in Part II, Item 5, “Market For Registrant’s Common Equity, Related Stockholder Matters and Issuer Purchases of Equity Securities” and Item 8, “Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements—Note (10)(b), Capital Stock—Treasury Stock” set forth in our 2022 Annual Report.
The following table presents repurchases of our common stock, which excludes the effect of excise taxes, during the three months ended March 31, 2023:

Period
Total
Number of
Shares (or
Units)
Purchased
Average
Price Paid
per Share
(or Unit)
Total Number of
Shares (or Units)
Purchased as Part of
Publicly Announced
Program
Maximum Dollar
Value of Shares (or Units)
that May Yet Be
Purchased Under the Program
January 1 - 31, 2023922,516 $108.40922,516 $51,374,511 
February 1 - 28, 2023187,031 $93.83187,031 $533,820,512 
March 1 - 31, 2023658,402 $86.79658,402 $476,658,438 
Total1,767,949 $98.811,767,949 $476,658,438 

Item 3. Defaults Upon Senior Securities
None.

Item 4. Mine Safety Disclosures
Not applicable.

Item 5. Other Information
None.
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Item 6. Exhibits
 
Exhibit
Number
Description
4.1
31.1
31.2
32.1
32.2
101.INSXBRL Instance Document.*
101.SCHXBRL Taxonomy Extension Schema Document.*
101.CALXBRL Taxonomy Extension Calculation Linkbase Document.*
101.DEFXBRL Taxonomy Extension Definition Linkbase Document.*
101.LABXBRL Taxonomy Extension Label Linkbase Document.*
101.PREXBRL Taxonomy Extension Presentation Linkbase Document.*
*Filed herewith.
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SIGNATURES
 
Pursuant to the requirements of the Securities Exchange Act of 1934, the registrant has duly caused this report to be signed on its behalf by the undersigned, thereunto duly authorized.

Date: May 5, 2023
 
AMN HEALTHCARE SERVICES, INC.
/S/    CAROLINE S. GRACE
Caroline S. Grace
President and Chief Executive Officer
(Principal Executive Officer)
 
Date: May 5, 2023
 

 
/S/    JEFFREY R. KNUDSON
Jeffrey R. Knudson
Chief Financial Officer
(Principal Financial and Accounting Officer)
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