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NATIONAL HEALTHCARE CORP - Quarter Report: 2019 June (Form 10-Q)

nhc20190630_10q.htm
 

 

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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 June 30, 2019

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 number    001-13489

 

 

(Exact name of registrant as specified in its Charter)

 

 

Delaware

52-2057472

(State or other jurisdiction of

(I.R.S. Employer

incorporation or organization

Identification No.)

 

 

100 E. Vine Street

Murfreesboro, TN

37130

(Address of principal executive offices)

(Zip Code)

 

 

(615) 890–2020

Registrant's telephone number, including area code

 

 

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 [  ]

 
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 (§232.405 of this chapter) during the preceding 12 months (or for such period that the registrant was required to submit such files).    Yes [x]      No [  ]

 

Indicate by check mark whether the registrant is a large accelerated filer, an accelerated filer, a non-accelerated filer, 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 filer [X]

Accelerated filer  [  ]

 

 

Non–accelerated filer [  ]

Smaller reporting company [  ]

 

 

 

Emerging 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. [  ]

 

Indicate by check mark whether the registrant is a shell company (as is defined in Rule 12b–2 of the Exchange Act). Yes [  ]   No [x]

 

15,318,790 shares of common stock of the registrant were outstanding as of August 7, 2019.

 

Securities registered pursuant to Section 12(b) of the Exchange Act:

 

Title of each class

Trading Symbol(s)

Name of each exchange on which registered

Common, $0.1 par value

NHC

NYSE American

 



 

 

 

 

TABLE OF CONTENTS

 

 

 

 

PART I. FINANCIAL INFORMATION

 

Page

Item 1.

Financial Statement

3

 

 

 

Item 2.

Management's Discussion and Analysis of Financial Condition and Results of Operations

23

 

 

 

Item 3.

Quantitative and Qualitative Disclosures About Market Risk

32

 

 

 

Item 4.

Controls and Procedures

32

 

PART II. OTHER INFORMATION

 

Item 1.

Legal Proceedings

33

 

 

 

Item 1A

Risk Factors

33

 

 

 

Item 2.

Unregistered Sales of Equity Securities and Use of Proceeds

33

 

 

 

Item 3.

Defaults Upon Senior Securities

33

 

 

 

Item 4.

Mine Safety Disclosures

33

 

 

 

Item 5.

Other Information

33

 

 

 

Item 6.

Exhibits

34

 

2

 

 

PART I. FINANCIAL INFORMATION

 

Item 1.

Financial Statements.

 

 

NATIONAL HEALTHCARE CORPORATION

Interim Condensed Consolidated Statements of Operations

(in thousands, except share and per share amounts)

(unaudited)

 

 

   

Three Months Ended

June 30

   

Six Months Ended

June 30

 
   

2019

   

2018

   

2019

   

2018

 
                                 

Revenues:

                               

Net patient revenues

  $ 235,264     $ 230,654     $ 471,375     $ 462,346  

Other revenues

    11,887       11,488       24,061       22,757  

Net operating revenues

    247,151       242,142       495,436       485,103  
                                 

Cost and expenses:

                               

Salaries, wages and benefits

    147,878       145,466       289,266       285,561  

Other operating

    67,598       62,589       137,030       127,761  

Facility rent

    10,197       10,272       20,435       20,501  

Depreciation and amortization

    10,335       10,397       20,852       20,739  

Interest

    954       1,253       1,880       2,493  

Total costs and expenses

    236,962       229,977       469,463       457,055  
                                 

Income from operations

    10,189       12,165       25,973       28,048  
                                 

Other income:

                               

Non–operating income

    8,272       5,654       14,273       2,589  

Unrealized gains (losses) on marketable equity securities

    (54 )     12,448       6,784       (3,069 )
                                 

Income before income taxes

    18,407       30,267       47,030       27,568  

Income tax provision

    (4,725 )     (7,892 )     (12,117 )     (8,092 )

Net income

    13,682       22,375       34,913       19,476  

Net loss attributable to noncontrolling interest

    29       86       67       194  
                                 

Net income attributable to National HealthCare Corporation

  $ 13,711     $ 22,461     $ 34,980     $ 19,670  
                                 

Earnings per share attributable to National HealthCare Corporation stockholders:

                               

Basic

  $ 0.90     $ 1.48     $ 2.29     $ 1.29  

Diluted

  $ 0.89     $ 1.47     $ 2.28     $ 1.29  
                                 

Weighted average common shares outstanding:

                         

Basic

    15,269,637       15,221,262       15,262,950       15,218,962  

Diluted

    15,352,702       15,228,305       15,338,520       15,224,958  
                                 

Dividends declared per common share

  $ 0.52     $ 0.50     $ 1.02     $ 0.98  

 

 

 The accompanying notes to interim condensed consolidated financial statements are an integral part of these consolidated statements.

 

3

Table of Contents

 

 

 

NATIONAL HEALTHCARE CORPORATION

Interim Condensed Consolidated Statements of Comprehensive Income

(unaudited – in thousands)

 

 

   

Three Months Ended

June 30

   

Six Months Ended

June 30

 
   

2019

   

2018

   

2019

   

2018

 
                                 

Net income

  $ 13,682     $ 22,375     $ 34,913     $ 19,476  
                                 

Other comprehensive income (loss):

                               

Unrealized gains (losses) on investments in restricted marketable debt securities

    2,969       (794 )     6,194       (3,592 )

Reclassification adjustment for realized gains on sale of securities

    -       (14 )     -       (25 )

Income tax benefit (expense) related to items of other comprehensive income

    (624 )     169       (1,301 )     759  

Other comprehensive income (loss), net of tax

    2,345       (639 )     4,893       (2,858 )
                                 

Net loss attributable to noncontrolling interest

    29       86       67       194  
                                 

Comprehensive income attributable to National HealthCare Corporation

  $ 16,056     $ 21,822     $ 39,873     $ 16,812  

 

 

The accompanying notes to interim condensed consolidated financial statements are an integral part of these consolidated statements.

 

4

Table of Contents

 

 

 

NATIONAL HEALTHCARE CORPORATION

Interim Condensed Consolidated Balance Sheets

(in thousands)

 

 

   

June 30,

2019

   

December 31,

2018

 
   

unaudited

         

Assets

               

Current Assets:

               

Cash and cash equivalents

  $ 29,746     $ 43,247  

Restricted cash and cash equivalents, current portion

    34,436       9,967  

Marketable equity securities

    147,007       140,223  

Restricted marketable debt securities, current portion

    -       18,676  

Accounts receivable

    97,448       97,274  

Inventories

    7,317       7,470  

Prepaid expenses and other assets

    4,192       3,863  

Notes receivable, current portion

    1,431       1,289  

Total current assets

    321,577       322,009  
                 

Property and Equipment:

               

Property and equipment, at cost

    1,009,842       979,088  

Accumulated depreciation and amortization

    (465,256 )     (444,438 )

Net property and equipment

    544,586       534,650  
                 

Other Assets:

               

Restricted cash and cash equivalents, less current portion

    1,724       1,706  

Restricted marketable securities, less current portion

    155,571       153,917  

Deposits and other assets

    5,903       5,602  

Operating lease right-of-use assets

    214,367       -  

Goodwill

    20,995       20,995  

Notes receivable, less current portion

    14,217       9,707  

Investments in unconsolidated companies

    35,675       32,362  

Total other assets

    448,452       224,289  

Total assets

  $ 1,314,615     $ 1,080,948  

  

 

The accompanying notes to interim condensed consolidated financial statements are an integral part of these consolidated statements.

 

5

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NATIONAL HEALTHCARE CORPORATION

Interim Condensed Consolidated Balance Sheets (continued)

(in thousands, except share and per share amounts)

 

 

   

June 30,

2019

   

December 31,

2018

 
   

unaudited

         

Liabilities and Stockholders’ Equity

               

Current Liabilities:

               

Trade accounts payable

  $ 15,737     $ 19,759  

Finance lease obligations, current portion

    4,043       3,924  

Operating lease liabilities, current portion

    23,625       -  

Accrued payroll

    56,691       67,618  

Amounts due to third party payors

    16,799       16,108  

Accrued risk reserves, current portion

    28,496       28,643  

Other current liabilities

    18,330       14,249  

Dividends payable

    7,966       7,623  

Total current liabilities

    171,687       157,924  
                 

Long–term debt

    55,000       55,000  

Finance lease obligations, less current portion

    17,077       19,128  

Operating lease liabilities, less current portion

    190,742       -  

Accrued risk reserves, less current portion

    68,795       67,381  

Refundable entrance fees

    7,975       8,078  

Obligation to provide future services

    2,172       2,172  

Deferred income taxes

    21,145       18,550  

Other noncurrent liabilities

    15,395       15,204  

Deferred revenue

    4,380       3,054  

Total liabilities

    554,368       346,491  
                 

Equity:

               

Common stock, $.01 par value; 45,000,000 shares authorized; 15,318,790 and 15,255,002 shares, respectively, issued and outstanding

    153       153  

Capital in excess of par value

    221,054       219,435  

Retained earnings

    535,797       516,435  

Accumulated other comprehensive income (loss)

    2,148       (2,745 )

Total National HealthCare Corporation stockholders’ equity

    759,152       733,278  

Noncontrolling interest

    1,095       1,179  

Total equity

    760,247       734,457  

Total liabilities and equity

  $ 1,314,615     $ 1,080,948  

 

 

The accompanying notes to interim condensed consolidated financial statements are an integral part of these consolidated statements.

 

6

Table of Contents

 

 

 

NATIONAL HEALTHCARE CORPORATION

Interim Condensed Consolidated Statements of Cash Flows

(unaudited – in thousands)

 

 

   

Six Months Ended

June 30

 
   

2019

   

2018

 

Cash Flows From Operating Activities:

               

Net income

  $ 34,913     $ 19,476  

Adjustments to reconcile net income to net cash provided by operating activities:

               

Depreciation and amortization

    20,852       20,739  

Equity in (earnings) losses of unconsolidated investments

    (4,801 )     4,584  

Distributions from unconsolidated investments

    2,609       3,741  

Unrealized (gains) losses on marketable equity securities

    (6,784 )     3,069  

Gains on sale of restricted marketable debt securities

    -       (25 )

Gain on acquisition of equity method investment

    (1,975 )     -  

Deferred income taxes

    1,294       (2,376 )

Stock–based compensation

    1,108       1,177  

Changes in operating assets and liabilities:

               

Accounts receivable

    (174 )     4,537  

Income tax receivable

    -       5,465  

Inventories

    153       (153 )

Prepaid expenses and other assets

    (590 )     (1,551 )

Trade accounts payable

    (4,022 )     188  

Accrued payroll

    (10,927 )     (11,414 )

Amounts due to third party payors

    691       (171 )

Accrued risk reserves

    1,227       1,538  

Other current liabilities

    4,081       (1,386 )

Other noncurrent liabilities

    191       540  

Deferred revenue

    1,326       1,395  

Net cash provided by operating activities

    39,172       49,373  

Cash Flows From Investing Activities:

               

Additions to property and equipment

    (13,989 )     (15,456 )

Acquisition of equity method investment

    (15,589 )     -  

Investments in unconsolidated companies

    (356 )     -  

Investments in notes receivable

    (5,312 )     -  

Collections of notes receivable

    660       800  

Purchase of restricted marketable debt securities

    (6,887 )     (6,545 )

Sale of restricted marketable debt securities

    30,103       4,399  

Net cash used in investing activities

    (11,370 )     (16,802 )

Cash Flows From Financing Activities:

               

Principal payments on debt

    -       (15,000 )

Principal payments under finance lease obligations

    (1,932 )     (1,820 )

Dividends paid to common stockholders

    (15,275 )     (14,602 )

Distributions attributable to noncontrolling interest

    (17 )     -  

Issuance of common shares

    1,383       1,327  

Repurchase of common shares

    (872 )     (867 )

Entrance fee refunds

    (103 )     (159 )

Net cash used in financing activities

    (16,816 )     (31,121 )

Net Increase in Cash, Cash Equivalents, Restricted Cash, and Restricted Cash Equivalents

    10,986       1,450  

Cash, Cash Equivalents, Restricted Cash, and Restricted Cash Equivalents, Beginning of Period

    54,920       67,421  

Cash, Cash Equivalents, Restricted Cash, and Restricted Cash Equivalents, End of Period

  $ 65,906     $ 68,871  
                 

Balance Sheet Classifications:

               

Cash and cash equivalents

  $ 29,746     $ 59,322  

Restricted cash and cash equivalents

    36,160       9,549  

Total Cash, Cash Equivalents, Restricted Cash, and Restricted Cash Equivalents

  $ 65,906     $ 68,871  

 

 

   

The accompanying notes to interim condensed consolidated financial statements are an integral part of these consolidated statements.

 

 

7

Table of Contents

 

 

 

NATIONAL HEALTHCARE CORPORATION

Interim Condensed Consolidated Statements of Stockholders’ Equity

(in thousands, except share and per share amounts)

(unaudited)

 

 

   

Common Stock

   

Capital in

Excess of

   

Retained

   

Accumulated

Other

Comprehensive

   

Non-

controlling

   

Total

Stockholders’

 
   

Shares

   

Amount

   

Par Value

   

Earnings

   

Income

   

Interest

   

Equity

 

Balance at January 1, 2019

    15,255,002     $ 153     $ 219,435     $ 516,435     $ (2,745

)

  $ 1,179     $ 734,457  

Net income attributable to National HealthCare Corporation

                      21,269                   21,269  

Net loss attributable to noncontrolling interest

                                  (38

)

    (38

)

Other comprehensive income

                            2,548             2,548  

Stock–based compensation

                424                         424  

Shares sold – options exercised

    59,384             579                         579  

Repurchase of common shares

    (10,396

)

          (872

)

                      (872

)

Dividends declared to common stockholders ($0.50 per share)

                      (7,652

)

                (7,652

)

Balance at March 31, 2019

    15,303,990     $ 153     $ 219,566     $ 530,052     $ (197

)

  $ 1,141       750,715  
                                                         

Net income attributable to National HealthCare Corporation

                      13,711                   13,711  

Net loss attributable to noncontrolling interest

                                  (29

)

    (29

)

Distributions attributable to noncontrolling interest

                                  (17

)

    (17

)

Other comprehensive income

                            2,345             2,345  

Stock–based compensation

                684                         684  

Shares sold – options exercised

    14,800             804                         804  

Dividends declared to common stockholders ($0.52 per share)

                      (7,966

)

                (7,966

)

Balance at June 30, 2019

    15,318,790     $ 153     $ 221,054     $ 535,797     $ 2,148     $ 1,095     $ 760,247  

 

 

   

Common Stock

   

Capital in

Excess of

   

Retained

   

Accumulated

Other

Comprehensive

   

Non-

controlling

   

Total

Stockholders’

 
   

Shares

   

Amount

   

Par Value

   

Earnings

   

Income

   

Interest

   

Equity

 

Balance at January 1, 2018

    15,212,133     $ 152     $ 215,659     $ 419,423     $ 67,504     $ 694     $ 703,432  

Reclassification due to new accounting standards

                      68,201       (68,201

)

           

Net loss attributable to National HealthCare Corporation

                      (2,791

)

                (2,791

)

Net loss attributable to noncontrolling interest

                                  (108

)

    (108

)

Other comprehensive loss

                            (2,219

)

          (2,219

)

Stock–based compensation

                428                         428  

Shares sold – options exercised

    21,906             1,067                         1,067  

Repurchase of common shares

    (14,506

)

          (867

)

                      (867

)

Dividends declared to common stockholders ($0.48 per share)

                      (7,305

)

                (7,305

)

Balance at March 31, 2018

    15,219,533     $ 152     $ 216,287     $ 477,528     $ (2,916

)

  $ 586       691,637  
                                                         

Net income attributable to National HealthCare Corporation

                      22,461                   22,461  

Net loss attributable to noncontrolling interest

                                  (86

)

    (86

)

Other comprehensive loss

                            (639

)

          (639

)

Stock–based compensation

                749                         749  

Shares sold – options exercised

    6,121             260                         260  

Dividends declared to common stockholders ($0.50 per share)

                      (7,612

)

                (7,612

)

Balance at June 30, 2018

    15,225,654     $ 152     $ 217,296     $ 492,377     $ (3,555

)

  $ 500     $ 706,770  

 

 

The accompanying notes to interim condensed consolidated financial statements are an integral part of these consolidated statements.

 

8

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NATIONAL HEALTHCARE CORPORATION

Notes to Interim Condensed Consolidated Financial Statements

June 30, 2019

(unaudited)

 

 

 

 

Note 1 – Description of Business

 

National HealthCare Corporation (“NHC” or the “Company”) is a leading provider of senior health care services. As of June 30, 2019, we operate or manage, through certain affiliates, 75 skilled nursing facilities with a total of 9,510 licensed beds, 26 assisted living facilities, five independent living facilities, one behavioral health hospital, and 36 homecare programs. We operate specialized care units within certain of our healthcare centers such as Alzheimer's disease care units and sub-acute nursing units. We also have a noncontrolling ownership interest in a hospice care business that services NHC owned skilled nursing facilities and others. In addition, we provide insurance services, management and accounting services, and we lease properties to operators of skilled nursing and assisted living facilities. We operate in 10 states and are located primarily in the southeastern United States.

 

 

 

Note 2 – Summary of Significant Accounting Policies

 

The listing below is not intended to be a comprehensive list of all our significant accounting policies. In many cases, the accounting treatment of a particular transaction is specifically dictated by generally accepted accounting principles (“GAAP”), with limited need for management’s judgment in their application. There are also areas in which management’s judgment in selecting any available alternative would not produce a materially different result. See our audited December 31, 2018 consolidated financial statements and notes thereto which contain accounting policies and other disclosures required by GAAP. Our audited December 31, 2018 consolidated financial statements are available at our web site: www.nhccare.com.

 

Basis of Presentation

 

The unaudited interim condensed consolidated financial statements to which these notes are attached include all normal, recurring adjustments which are necessary to fairly present the financial position, results of operations and cash flows of NHC. All significant intercompany transactions and balances have been eliminated in consolidation. The consolidated financial statements include the accounts of all entities controlled by NHC. The Company presents noncontrolling interest within the equity section of its consolidated balance sheets. The Company presents the amount of consolidated net income that is attributable to NHC and the noncontrolling interest in its consolidated statements of operations.

 

We assume that users of these interim financial statements have read or have access to the audited December 31, 2018 consolidated financial statements and Management’s Discussion and Analysis of Financial Condition and Results of Operations and that the adequacy of additional disclosure needed for a fair presentation, except in regard to material contingencies, may be determined in that context. Accordingly, footnotes and other disclosures which would substantially duplicate the disclosure contained in our most recent annual report to stockholders have been omitted. This interim financial information is not necessarily indicative of the results that may be expected for a full year for a variety of reasons.

 

Estimates and Assumptions

 

The preparation of financial statements in conformity with U.S. GAAP requires us to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosure of contingent assets and liabilities at the date of the financial statements and the reported amounts of revenues and expenses during the reporting period. Actual results could differ from those estimates and could cause our reported net income to vary significantly from period to period.

 

Recently Adopted Accounting Guidance

 

In February 2016, the Financial Accounting Standards Board (“FASB”) issued Accounting Standards Update (“ASU”) No. 2016-02, "Leases (Topic 842)." The objective of this update is to increase transparency and comparability among organizations by recognizing lease assets and lease liabilities on the balance sheet and disclosing key information about leasing arrangements. This ASU is effective for fiscal years beginning after December 15, 2018, including interim periods within those annual periods and is to be applied either retrospectively to each prior reporting period presented in the financial statements or retrospectively at the beginning of the period of adoption.

 

The Company adopted the standard as of January 1, 2019, electing the transition method that allows us to apply the standard as of the adoption date and record a cumulative adjustment in retained earnings, if applicable. We did not have a cumulative adjustment to retained earnings. The interim condensed consolidated financial statements for the period ending June 30, 2019, are presented under the new standard, while comparative years presented are not adjusted and continue to be reported in accordance with our historical accounting policy.

 

On June 20, 2018, the FASB issued ASU No. 2018-07, “Compensation – Stock Compensation (Topic 718): Improvements to Nonemployee Share-based Payment Accounting.” ASU No. 2018-07 simplifies the accounting for share-based payments granted to nonemployees for goods and services. Under the ASU, most of the guidance on such payments to nonemployees is aligned with the requirements for share-based payments granted to employees. On January 1, 2019, the Company early adopted the provisions of ASU No. 2018-07 and this standard did not have an impact on our consolidated financial statements.

 

On August 28, 2018, the FASB issued ASU No. 2018-13, “Fair Value Measurement (Topic 820): Disclosure Framework – Changes to the Disclosure Requirements for Fair Value Measurement.” ASU No. 2018-13 changes the fair value measurement disclosure requirements of Accounting Standards Codification (“ASC”) 820. Entities are no longer required to disclose the amount of and reasons for transfers between Level 1 and Level 2 of the fair value hierarchy, but they will be required to disclose the range and weighted average used to develop significant unobservable inputs for Level 3 fair value measurements. On January 1, 2019, the Company early adopted the provisions of ASU No. 2018-13 and this standard did not have a material impact on our consolidated financial statements as we do not have any Level 3 investments.

 

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Recent Accounting Guidance Not Yet Adopted 

     

In June 2016, the FASB issued ASU No. 2016-13, “Financial Instruments – Credit Losses: Measurement of Credit Losses on Financial Instruments.” ASU No. 2016-13 adds to U.S GAAP an impairment model that is based on expected losses rather than incurred losses. Under the new guidance, an entity recognizes as an allowance its estimate of expected credit losses, which the FASB believes will result in more timely recognition of such losses. The ASU is also intended to reduce the complexity of U.S. GAAP by decreasing the number of credit impairment models that entities use to account for debt instruments. This ASU is effective for fiscal years beginning after December 15, 2019, including interim periods within those annual periods, with early adoption permitted for fiscal years beginning after December 15, 2018. We are currently evaluating the impact this standard will have on our policies and procedures and internal control framework.

 

Net Patient Revenues and Accounts Receivable

 

Net patient revenues are derived from services rendered to patients for skilled and intermediate nursing, rehabilitation therapy, assisted living and independent living, and home health care services. Net patient revenue is reported at the amount that reflects the consideration to which the Company expects to be entitled in exchange for providing patient services. These amounts are due from patients, governmental programs, and other third-party payors, and include variable consideration for retroactive revenue adjustments due to settlement of audits, reviews, and investigations.

 

The Company recognizes revenue as its performance obligations are completed. Routine services are treated as a single performance obligation satisfied over time as services are rendered. These routine services represent a bundle of services that are not capable of being distinct. The performance obligations are satisfied over time as the patient simultaneously receives and consumes the benefits of the healthcare services provided. Additionally, there may be ancillary services which are not included in the daily rates for routine services, but instead are treated as separate performance obligations satisfied at a point in time when those services are rendered.

 

The Company determines the transaction price based on established billing rates reduced by contractual adjustments provided to third party payors. Contractual adjustments are based on contractual agreements and historical experience. The Company considers the patient's ability and intent to pay the amount of consideration upon admission. Subsequent changes resulting from a patient’s ability to pay are recorded as bad debt expense, which is included as a component of other operating expenses in the interim condensed consolidated statements of operations. For the three months and six months ended June 30, 2019, bad debt expense was $992,000 and $2,039,000, respectively. For the three months and six months ended June 30, 2018, bad debt expense was $1,064,000 and $2,023,000, respectively. As of June 30, 2019, and December 31, 2018, the Company has recorded allowance for doubtful accounts of $5,541,000 and $4,610,000, respectively, as our best estimate of probable losses inherent in the accounts receivable balance.

 

Other Revenues

 

Other revenues include revenues from the provision of insurance services, management and accounting services to other long–term care providers, and rental income. Our insurance revenues consist of premiums that are generally paid in advance and then amortized into income over the policy period. We charge for management services based on a percentage of net revenues. We charge for accounting services based on a monthly fee or a fixed fee per bed of the healthcare facility under contract. We record other revenues as the performance obligations are satisfied based on the terms of our contractual arrangements.

 

Segment Reporting

 

In accordance with the provisions of ASC 280, “Segment Reporting”, the Company is required to report financial and descriptive information about its reportable operating segments. The Company has two reportable operating segments: (1) inpatient services, which includes the operation of skilled nursing facilities, assisted and independent living facilities, and one behavioral health hospital, and (2) homecare services. The Company also reports an “all other” category that includes revenues from rental income, management and accounting services fees, insurance services, and costs of the corporate office. See Note 6 for further disclosure of the Company’s operating segments.

 

Other Operating Expenses

 

Other operating expenses include the costs of care and services that we provide to the residents of our facilities and the costs of maintaining our facilities. Our primary patient care costs include drugs, medical supplies, purchased professional services, food, and professional liability insurance and licensing fees. The primary facility costs include utilities and property insurance.

 

General and Administrative Costs

 

With the Company being a healthcare provider, the majority of our expenses are "cost of revenue" items. Costs that could be classified as "general and administrative" by the Company would include its corporate office costs, excluding stock-based compensation, which were $6,677,000 and $11,821,000 for the three months and six months ended June 30, 2019, respectively. General and administrative costs were $6,573,000 and $13,250,000 for the three months and six months ended June 30, 2018, respectively.

 

Property and Equipment

 

Property and equipment are recorded at cost. Depreciation is provided by the straight-line method over the expected useful lives of the assets estimated as follows: buildings and improvements, 20-40 years and equipment and furniture, 3-15 years. Leasehold improvements are amortized over periods that do not exceed the non-cancelable respective lease terms using the straight-line method.

 

Finance leases are recorded at cost. Finance leases are amortized in accordance with the provision codified within ASC 842, Leases. Amortization of finance lease assets is included in depreciation and amortization expense.

 

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Accrued Risk Reserves  

 

We are self–insured for risks related to health insurance and have wholly–owned limited purpose insurance companies that insure risks related to workers’ compensation and general and professional liability insurance claims. The accrued risk reserves include a liability for reported claims and estimates for incurred but unreported claims. Our policy is to engage an external, independent actuary to assist in estimating our exposure for claims obligations (for both asserted and unasserted claims). We reassess our accrued risk reserves on a quarterly basis.

 

Professional liability remains an area of particular concern to us. The long-term care industry has seen an increase in personal injury/wrongful death claims based on alleged negligence by skilled nursing facilities and their employees in providing care to residents. As of June 30, 2019, we and/or our managed centers are defendants in 65 such claims. It remains possible that those pending matters plus potential unasserted claims could exceed our reserves, which could have a material adverse effect on our consolidated financial position, results of operations and cash flows. It is also possible that future events could cause us to make significant adjustments or revisions to these reserve estimates and cause our reported net income to vary significantly from period to period.

 

We are principally self-insured for incidents occurring in all centers owned or leased by us. The coverages include both primary policies and excess policies. In all years, settlements, if any, in excess of available insurance policy limits and our own reserves would be expensed by us.

 

Continuing Care Contracts and Refundable Entrance Fee

 

We have one continuing care retirement center (“CCRC”) within our operations. Residents at this retirement center may enter into continuing care contracts with us. The contracts provide that 10% of the resident entry fee becomes non-refundable upon occupancy, and the remaining refundable portion of the entry fee is calculated using the lessor of the price at which the apartment is re-assigned or 90% of the original entry fee, plus 40% of any appreciation if the apartment exceeds the original resident’s entry fee.

 

Non-refundable fees are included as a component of the transaction price and are amortized into revenue over the actuarily determined remaining life of the resident, which is the expected period of occupancy by the resident. We pay the refundable portion of our entry fees to residents when they relocate from our community and the apartment is re-occupied. Refundable entrance fees are not included as part of the transaction price and are classified as non-current liabilities in our consolidated balance sheets. As of June 30, 2019, and December 31, 2018, we have recorded a refundable entrance fee in the amount of $7,975,000 and $8,078,000, respectively.

 

Obligation to Provide Future Services

 

We annually estimate the present value of the cost of future services and the use of facilities to be provided to the current CCRC residents and compare that amount with the balance of non-refundable deferred revenue from entrance fees received. If the present value of the cost of future services exceeds the related anticipated revenues, a liability is recorded (obligation to provide future services) with a corresponding charge to income. As of June 30, 2019, and December 31, 2018, we have recorded a future service obligation in the amount of $2,172,000.

 

Other Noncurrent Liabilities

 

Other noncurrent liabilities include reserves primarily related to various uncertain income tax positions.

 

Deferred Revenue

 

Deferred revenue includes the deferred gain on the sale of assets to National Health Corporation (“National”), the non-refundable portion (10%) of CCRC entrance fees being amortized over the remaining life expectancies of the residents, and premiums received within our workers’ compensation and professional liability companies in which the performance obligations have not been satisfied.

 

Noncontrolling Interest

 

The noncontrolling interest in a subsidiary is presented within total equity in the Company's interim condensed consolidated balance sheets. The Company presents the noncontrolling interest and the amount of consolidated net income attributable to NHC in its interim condensed consolidated statements of operations. The Company’s earnings per share is calculated based on net income attributable to NHC’s stockholders. The carrying amount of the noncontrolling interest is adjusted based on an allocation of subsidiary earnings based on ownership interest.

 

Variable Interest Entities

 

We have equity interests in unconsolidated limited liability companies that operate various post-acute and senior healthcare businesses. We analyze our investments in these limited liability companies to determine if the company is considered a variable interest entity (“VIE”) and would require consolidation. To the extent that we own interests in a VIE and we (i) are the sole entity that has the power to direct the activities of the VIE and (ii) have the obligation or rights to absorb the VIE's losses or receive its benefits, then we would be determined to be the primary beneficiary and would consolidate the VIE. To the extent we own interests in a VIE, then at each reporting period, we re-assess our conclusions as to which, if any, party within the VIE is considered the primary beneficiary.

 

The Company's maximum exposure to losses in its investments in unconsolidated VIEs cannot be quantified and may or may not be limited to its investment in the unconsolidated VIE. The investments in unconsolidated VIEs are classified as “investments in limited liability companies” in the consolidated balance sheets.

 

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Note 3 – Net Patient Revenues

 

The Company disaggregates revenue from contracts with customers by service type and by payor.

 

Revenue by Service Type

 

The Company’s net patient services can generally be classified into the following two categories: (1) inpatient services, which includes the operation of skilled nursing facilities, assisted and independent living facilities, and a behavioral health hospital, and (2) homecare services.

 

   

Three Months Ended

June 30

   

Six Months Ended

June 30

 

(in thousands)

 

2019

   

2018

   

2019

   

2018

 

Net patient revenues:

                               

Inpatient services

  $ 220,887     $ 215,617     $ 442,521     $ 431,968  

Homecare

    14,377       15,037       28,854       30,378  

Total net patient revenue

  $ 235,264     $ 230,654     $ 471,375     $ 462,346  

 

For inpatient services, revenue is recognized on a daily basis as each day represents a separate contract and performance obligation. For homecare, revenue is recognized when services are provided based on the number of days of service rendered in the episode or on a per-visit basis. Typically, patients and third-party payors are billed monthly after services are performed or the patient is discharged, and payments are due based on contract terms.

 

As our performance obligations relate to contracts with a duration of one year or less, the Company is not required to disclose the aggregate amount of the transaction price allocated to performance obligations that are unsatisfied or partially unsatisfied at the end of the reporting period. The Company has minimal unsatisfied performance obligations at the end of the reporting period as our patients are typically under no obligation to remain admitted in our facilities or under our care. As the period between the time of service and time of payment is typically one year or less, the Company did not adjust for the effects of a significant financing component.

 

Revenue by Payor

 

Certain groups of patients receive funds to pay the cost of their care from a common source. The following table sets forth sources of net patient revenues for the periods indicated:

 

   

Three Months Ended

June 30

   

Six Months Ended

June 30

 

Source

 

2019

   

2018

   

2019

   

2018

 

Medicare

    33 %     35 %     34 %     36 %

Managed Care

    11 %     12 %     11 %     12 %

Medicaid

    29 %     26 %     28 %     26 %

Private Pay and Other

    27 %     27 %     27 %     26 %

Total

    100 %     100 %     100 %     100 %

 

Medicare covers skilled nursing services for beneficiaries who require nursing care and/or rehabilitation services following a hospitalization of at least three consecutive days. For each eligible day a Medicare beneficiary is in a skilled nursing facility, Medicare pays the facility a daily payment, subject to adjustment for certain factors such as a wage index in the geographic area. The payment covers all services provided by the skilled nursing facility for the beneficiary that day, including room and board, nursing, therapy and drugs, as well as an estimate of capital–related costs to deliver those services.

 

For homecare services, Medicare pays based on the acuity level of the patient for each episode of care. An episode of care is defined as a length of care up to 60 days with multiple continuous episodes allowed. The services covered by the episode payment include all disciplines of care, in addition to medical supplies, within the scope of the home health benefit. We are allowed to make a request for anticipated payment at the start of care equal to 60% of the expected payment for the initial episode. The remaining balance due is paid following the submission of the final claim at the end of the episode. Deferred revenue is recorded for payments received for which the related services have not yet been provided.

 

Medicaid is operated by individual states with the financial participation of the federal government. The states in which we operate currently use prospective cost–based reimbursement systems. Under cost–based reimbursement systems, the skilled nursing facility is reimbursed for the reasonable direct and indirect allowable costs it incurred in a base year in providing routine resident care services as defined by the program.

 

Private pay, managed care, and other payment sources include commercial insurance, individual patient funds, managed care plans and the Veterans Administration. Private paying patients, private insurance carriers and the Veterans Administration generally pay based on the healthcare center's charges or specifically negotiated contracts. For private pay patients in skilled nursing, assisted living and independent living facilities, the Company bills for room and board charges, with the remittance being due on receipt of the statement and generally by the 10th day of the month the services are performed.

 

Certain managed care payors for homecare services pay on a per-visit basis. This non-episodic based revenue is recorded on an accrual basis based upon the date of services at amounts equal to its established or estimated per-visit rates.

 

Third Party Payors

 

Laws and regulations governing the Medicare and Medicaid programs are complex and subject to interpretation. Noncompliance with such laws and regulations can be subject to regulatory actions including fines, penalties, and exclusion from the Medicare and Medicaid programs. We believe that we are following all applicable laws and regulations.

 

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Medicare and Medicaid program revenues, as well as certain Managed Care program revenues, are subject to audit and retroactive adjustment by government representatives or their agents. The Medicare PPS methodology requires that patients be assigned to Resource Utilization Groups ("RUGs") based on the acuity level of the patient to determine the amount paid to us for patient services. The assignment of patients to the various RUG categories is subject to post–payment review by Medicare intermediaries or their agents. Settlements with third-party payors for retroactive adjustments due to audits, reviews or investigations are considered variable consideration and are included in the determination of the estimated transaction price for providing patient care. These settlements are estimated based on the terms of the payment agreement with the payor, correspondence from the payor and the Company’s historical settlement activity, including an assessment to ensure that it is probable that a significant reversal in the amount of cumulative revenue recognized will not occur when the uncertainty associated with the retroactive adjustment is subsequently resolved. Estimated settlements are adjusted in future periods as adjustments become known, or as years are settled or are no longer subject to such audits, reviews, and investigations. We believe that any differences between the net revenues recorded and final determination will not materially affect the consolidated financial statements. We have made provisions of approximately $16,799,000 and $16,108,000 as of June 30, 2019 and December 31, 2018, respectively, for various Medicare, Medicaid, and Managed Care claims reviews and current and prior year cost reports.

 

 

Note 4 – Other Revenues

 

Other revenues are outlined in the table below. Revenues from insurance services include premiums for workers’ compensation and professional liability insurance policies that our wholly owned insurance subsidiaries have written for certain healthcare operators to which we provide management or accounting services. Revenues from management and accounting services include fees provided to manage and provide accounting services to other healthcare operators. Revenues from rental income include health care real estate properties owned by us and leased to third party operators. "Other" revenues include miscellaneous health care related earnings.

 

   

Three Months Ended

June 30

   

Six Months Ended

June 30

 

(in thousands)

 

2019

   

2018

   

2019

   

2018

 

Insurance services

  $ 1,615     $ 1,955     $ 3,139     $ 3,646  

Management and accounting services fees

    4,297       3,738       9,047       7,446  

Rental income

    5,677       5,553       11,285       11,086  

Other

    298       242       590       579  

Total other revenues

  $ 11,887     $ 11,488     $ 24,061     $ 22,757  

 

 Insurance Services

 

For workers’ compensation insurance services, the premium revenues reflected in the interim condensed consolidated statements of operations for the three and six months ended June 30, 2019 were $943,000 and $1,791,000, respectively. For the three and six months ended June 30, 2018, the workers’ compensation premium revenues reflected in the interim condensed consolidated statements of operations were $1,282,000 and $2,300,000, respectively. Associated losses and expenses are reflected in the interim condensed consolidated statements of operations as "Salaries, wages and benefits."

 

For professional liability insurance services, the premium revenues reflected in the interim condensed consolidated statements of operations for the three and six months ended June 30, 2019 were $672,000 and $1,348,000, respectively. For professional liability insurance services, the premium revenues reflected in the interim condensed consolidated statements of operations for the three months and six months ended June 30, 2018 were $673,000 and $1,346,000, respectively. Associated losses and expenses including those for self–insurance claims are included in the interim condensed consolidated statements of operations as "Other operating costs and expenses".

 

Management Fees from National

 

We manage five skilled nursing facilities owned by National. For the three months and six months ended June 30, 2019, we recognized management fees and interest on management fees of $1,351,000 and $3,206,000 from these centers, respectively. For the three months and six months ended June 30, 2018, we recognized management fees and interest on management fees of $1,038,000 and $2,053,000 from these centers, respectively.

 

Rental Income

 

The Company leases real estate assets consisting of skilled nursing facilities and assisted living facilities to third party operators. Additionally, we sublease four Florida skilled nursing facilities included in our lease from National Health Investors (“NHI”) as noted in Note 7 – Long Term Leases.

 

The following table sets forth the undiscounted cash flows for future minimum lease payments receivable for leases in effect at June 30, 2019 (in thousands):

 

 

2020

  $ 21,938  

2021

    22,474  

2022

    22,923  

2023

    22,816  

2024

    22,730  

Thereafter

    34,316  

Total future minimum lease payments

  $ 147,197  

 

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Note 5 – Non–Operating Income

 

Non–operating income includes equity in earnings of unconsolidated investments, dividends and other realized gains and losses on sales of marketable securities, and interest income.

 

Our most significant equity method investment is a 75.1% non–controlling ownership interest in Caris HealthCare L.P. (“Caris”), a business that specializes in hospice care services. For the three months and six months ended June 30, 2018, Caris’ equity in earnings were negatively impacted by $136,000 and $8,364,000 for the settlement of a Qui Tam legal matter and legal fees related to the settlement.

 

   

Three Months Ended

June 30

   

Six Months Ended

June 30

 

(in thousands)

 

2019

   

2018

   

2019

   

2018

 

Equity in earnings (losses) of unconsolidated investments

  $ 2,480     $ 2,001     $ 4,801     $ (4,584 )

Dividends and net realized gains on sales of securities

    1,931       1,795       3,862       3,597  

Interest income

    1,886       1,858       3,635       3,576  

Gain on acquisition of equity method investment

    1,975       -       1,975       -  

Total non-operating income

  $ 8,272     $ 5,654     $ 14,273     $ 2,589  

 

Gain on Acquisition of Equity Method Investment

 

Effective June 1, 2019, the Company expanded its controlled operations through an acquisition of the remaining ownership interest of a 60-bed memory care facility in St. Peters, Missouri. We previously held a noncontrolling interest in the facility and accounted for the investment as an equity method investment. The operating results of the business have been included in the accompanying interim condensed consolidated financial statements since the remaining ownership interest acquisition date.

 

Upon acquiring the remaining ownership interest, the Company recorded and increased its previously held equity interest up to fair value as of the acquisition date. This remeasurement of our equity interest at fair value resulted in a gain of $1,975,000 during the second quarter of 2019. The gain was recorded in "Non-operating income" in the interim condensed consolidated statement of operations.

 

 

Note 6 – Business Segments

 

The Company has two reportable operating segments: (1) inpatient services, which includes the operation of skilled nursing facilities, assisted and independent living facilities, and our behavioral health hospital; and (2) homecare services. These reportable operating segments are consistent with information used by the Company’s Chief Executive Officer, as chief operating decision maker (“CODM”), to assess performance and allocate resources.

 

The Company also reports an “all other” category that includes revenues from rental income, management and accounting services fees, insurance services, and costs of the corporate office. For additional information on these reportable segments see Note 2Summary of Significant Accounting Policies.

 

The Company’s CODM evaluates performance and allocates capital resources to each segment based on an operating model that is designed to improve the quality of patient care and profitability of the Company while enhancing long-term shareholder value. The CODM does not review assets by segment in his resource allocation and therefore, assets by segment are not disclosed below.

 

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The following table sets forth the Company’s unaudited interim condensed consolidated statements of operations by business segment (in thousands): 

 

   

Three Months Ended June 30, 2019

 
   

Inpatient

Services

   

Homecare

   

All Other

   

Total

 

Revenues:

                               

Net patient revenues

  $ 220,887     $ 14,377     $ -     $ 235,264  

Other revenues

    242       -       11,645       11,887  

Net operating revenues

    221,129       14,377       11,645       247,151  
                                 

Costs and expenses:

                               

Salaries, wages and benefits

    130,720       8,480       8,678       147,878  

Other operating

    60,172       4,674       2,752       67,598  

Rent

    8,229       489       1,479       10,197  

Depreciation and amortization

    9,471       61       803       10,335  

Interest

    319       -       635       954  

Total costs and expenses

    208,911       13,704       14,347       236,962  
                                 

Income (loss) from operations

    12,218       673       (2,702 )     10,189  

Non-operating income

    -       -       8,272       8,272  

Unrealized losses on marketable equity securities

    -       -       (54 )     (54 )
                                 

Income before income taxes

  $ 12,218     $ 673     $ 5,516     $ 18,407  

 

 

   

Three Months Ended June 30, 2018

 
   

Inpatient

Services

   

Homecare

   

All Other

   

Total

 

Revenues:

                               

Net patient revenues

  $ 215,617     $ 15,037     $ -     $ 230,654  

Other revenues

    181       -       11,307       11,488  

Net operating revenues

    215,798       15,037       11,307       242,142  
                                 

Costs and expenses:

                               

Salaries, wages and benefits

    128,115       8,611       8,740       145,466  

Other operating

    56,069       4,740       1,780       62,589  

Rent

    8,267       485       1,520       10,272  

Depreciation and amortization

    9,571       44       782       10,397  

Interest

    383       -       870       1,253  

Total costs and expenses

    202,405       13,880       13,692       229,977  
                                 

Income (loss) from operations

    13,393       1,157       (2,385 )     12,165  

Non-operating income

    -       -       5,654       5,654  

Unrealized gains on marketable equity securities

    -       -       12,448       12,448  
                                 

Income before income taxes

  $ 13,393     $ 1,157     $ 15,717     $ 30,267  

 

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Six Months Ended June 30, 2019

 
   

Inpatient

Services

   

Homecare

   

All Other

   

Total

 

Revenues:

                               

Net patient revenues

  $ 442,521     $ 28,854     $ -     $ 471,375  

Other revenues

    473       -       23,588       24,061  

Net operating revenues

    442,994       28,854       23,588       495,436  
                                 

Costs and expenses:

                               

Salaries, wages and benefits

    256,821       16,506       15,939       289,266  

Other operating

    122,801       8,926       5,303       137,030  

Rent

    16,520       951       2,964       20,435  

Depreciation and amortization

    19,124       122       1,606       20,852  

Interest

    668       -       1,212       1,880  

Total costs and expenses

    415,934       26,505       27,024       469,463  
                                 

Income (loss) from operations

    27,060       2,349       (3,436 )     25,973  

Non-operating income

    -       -       14,273       14,273  

Unrealized gains on marketable equity securities

    -       -       6,784       6,784  
                                 

Income before income taxes

  $ 27,060     $ 2,349     $ 17,621     $ 47,030  

 

 

   

Six Months Ended June 30, 2018

 
   

Inpatient

Services

   

Homecare

   

All Other

   

Total

 

Revenues:

                               

Net patient revenues

  $ 431,968     $ 30,378     $ -     $ 462,346  

Other revenues

    451       -       22,306       22,757  

Net operating revenues

    432,419       30,378       22,306       485,103  
                                 

Costs and expenses:

                               

Salaries, wages and benefits

    251,495       16,642       17,424       285,561  

Other operating

    113,904       10,019       3,838       127,761  

Rent

    16,524       973       3,004       20,501  

Depreciation and amortization

    19,032       82       1,625       20,739  

Interest

    780       -       1,713       2,493  

Total costs and expenses

    401,735       27,716       27,604       457,055  
                                 

Income (loss) from operations

    30,684       2,662       (5,298 )     28,048  

Non-operating income

    -       -       2,589       2,589  

Unrealized losses on marketable equity securities

    -       -       (3,069 )     (3,069 )
                                 

Income (loss) before income taxes

  $ 30,684     $ 2,662     $ (5,778 )   $ 27,568  

 

 

 

Note 7 – Long-Term Leases

 

The Company’s lease portfolio primarily consists of finance and operating real estate leases for certain skilled nursing facilities, assisted and independent living facilities, homecare offices, and pharmacy warehouses. The original terms of the leases typically range from 2 to 15 years. Several of the real estate leases include renewal options which vary in length and may not include specific rent renewal amounts. We determine if an arrangement is a lease at the inception of a contract. We determine the lease term by assuming exercise of renewal options that are reasonably certain.

 

On January 1, 2019, the Company recorded right-of-use assets and liabilities on the condensed consolidated balance sheets for non-cancelable real estate operating leases with original or remaining lease terms in excess of one year. Leases with a lease term of 12 months or less at inception are not recorded on our condensed consolidated balance sheets and are expensed on a straight-line basis over the lease term in our condensed consolidated statement of operations. Finance leases remain on the condensed consolidated balance sheets as required by previous accounting guidance.

 

Operating lease right-of-use assets and liabilities are recorded at the present value of the lease payments over the lease term. The present values of the lease payments are discounted using the incremental borrowing rate associated with each lease. As most of our leases do not provide implicit rates, we have used incremental borrowing rates that were calculated based on information available at the later of the lease commencement date or the adoption date, January 1, 2019. The variable components of the lease payment that fluctuate with the operations of a healthcare facility are not included in determining the right-of-use assets and lease liabilities. Rather, these variable components are expensed as incurred.

 

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Accounting Policy Elections

 

The Company has elected the package of practical expedients offered in the transition guidance which allows management not to reassess lease identification, lease classification, and initial direct costs. The Company has elected the accounting policy practical expedient to exclude recording short-term leases, for all asset classes, as right-of-use assets and lease liabilities on the condensed consolidated balance sheets. Finally, the Company has elected the accounting policy practical expedient to recognize lease components and non-lease components together and not as separate parts of a lease for real estate leases.

 

Operating Leases with NHI

 

At June 30, 2019, we leased from NHI the real property of 35 skilled nursing facilities, seven assisted living centers and three independent living centers under two separate lease agreements. As part of the first lease agreement, we sublease four Florida skilled nursing facilities to a third-party operator.

 

On January 1, 2007, a 15-year lease extension began which included three additional five–year renewal options. In December 2012, NHC extended the lease agreement through the first of the three additional 5–year renewal options, which extended the lease date through 2026. The two additional five–year renewal options on the lease still remain. Under the terms of the lease, base rent totals $30,750,000 annually with rent thereafter escalating by 4% of the increase in facility revenue over a 2007 base year.

 

In September 2013 and under the second lease agreement, NHC began operating seven skilled nursing facilities in New Hampshire and Massachusetts. The 15-year lease term consists of base rent of $3,450,000 annually with rent escalating by 4% of the increase in facility revenue over a 2014 base year. Additionally, NHC has the option to purchase the seven facilities from NHI in the 13th year of the lease for a purchase price of $49,000,000.

 

Base rent expense under both NHI lease agreements totals $34,200,000 annually. Percentage rent under the leases is based on a quarterly calculation of revenue increases and is payable on a quarterly basis. Percentage rent expense under both leases was $965,000 and $928,000 for the three months ended June 30, 2019 and 2018, respectively. Percentage rent expense under both leases was $1,930,000 and $1,856,000 for the six months ended June 30, 2019 and 2018, respectively.

  

We have a right of first refusal with NHI to purchase any of the properties should NHI receive an offer from an unrelated party during the term of the lease or up to 180 days after termination of the related lease.

 

Finance Leases

 

Effective June 1, 2014, NHC began leasing and operating three senior healthcare facilities in the state of Missouri under three separate lease agreements. Two of the healthcare facilities are skilled nursing facilities that also include assisted living facilities and the third healthcare facility is a memory care facility. Each of the leases is a 10-year lease with two 5–year renewal options. Under the terms of the leases, base rent totals $5,200,000 annually with rent thereafter escalating by 4% of the increase in facility revenue over the 2014 base year.

 

Lease Classification

 

At June 30, 2019, the Company recorded the following on the condensed consolidated balance sheets (in thousands):

 

 

Right-of-Use Assets

 

Balance Sheet Classification

 

June 30,

2019

 

Finance lease assets

 

Net property and equipment

  $ 18,114  

Operating lease right-of-use assets

 

Operating lease right-of-use assets

    214,367  

Total

  $ 232,481  

 

 

 

Lease Liabilities

 

 

Balance Sheet Classification

 

June 30,

2019

 

Current:

           

Finance lease liabilities

 

Finance lease obligations, current portion

  $ 4,043  

Operating lease liabilities

 

Operating lease liabilities, current portion

    23,625  

Noncurrent:

           

Finance lease liabilities

 

Finance lease obligations, less current portion

    17,077  

Operating lease liabilities

 

Operating lease liabilities, less current portion

    190,742  

Total

  $ 235,487  

 

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Weighted-average remaining lease terms and discount rates at June 30, 2019 were as follows:

 

Weighted-average remaining lease terms (in years)

       

Finance

    4.7  

Operating

    7.6  
         

Weighted-average discount rate

       

Finance

    6.0

%

Operating

    6.0

%

 

Lease Costs

 

For the three and six months ended June 30, 2019, the lease costs recorded in the condensed consolidated statement of operations are as follows (in thousands):

 

   

Three Months Ended

June 30, 2019

   

Six Months Ended

June 30, 2019

 

Finance lease costs:

               

Depreciation of leased assets

  $ 968     $ 1,949  

Interest of lease liabilities

    334       682  

Total finance lease costs

    1,302       2,631  
                 

Operating lease costs:

               

Operating lease costs

    9,004       18,090  

Variable lease costs

    965       1,930  

Short-term lease costs

    228       415  

Total operating lease costs

    10,197       20,435  
                 

Total lease costs

  $ 11,499     $ 23,066  

 

Minimum Lease Payments

 

The following table summarizes the maturity of our finance and operating lease liabilities as of June 30, 2019 (in thousands):

 

   

Finance

Leases

   

Operating

Leases

 

2020

  $ 5,200     $ 35,658  

2021

    5,200       35,351  

2022

    5,200       35,047  

2023

    5,200       34,564  

2024

    3,467       34,369  

Thereafter

    -       91,294  

Total minimum lease payments

  $ 24,267     $ 266,283  

Less: amounts representing interest

    (3,147

)

    (51,916

)

Present value of future minimum lease payments

    21,120       214,367  

Less: current portion

    (4,043

)

    (23,625

)

Noncurrent lease liabilities

  $ 17,077     $ 190,742  

 

Other

 

Supplemental cash flow data for the six months ended June 30, 2019 was as follows (in thousands):

 

Cash paid for amounts included in the measurement of lease liabilities:

       

Operating cash flows for operating leases

  $ 18,090  

Operating cash flows for finance leases

    682  

Financing cash flows for finance leases

    1,932  

 

 

 

Note 8 – Earnings per Share

 

Basic net income per share is computed based on the weighted average number of common shares outstanding for each period presented. Diluted net income per share reflects the potential dilution that would have occurred if securities to issue common stock were exercised, converted, or resulted in the issuance of common stock that would have then shared in our earnings.

 

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The following table summarizes the earnings and the weighted average number of common shares used in the calculation of basic and diluted earnings per share (in thousands, except for share and per share amounts):

 

   

Three Months Ended June 30

   

Six Months Ended June 30

 
   

2019

   

2018

   

2019

   

2018

 

Basic:

                               

Weighted average common shares outstanding

    15,269,637       15,221,262       15,262,950       15,218,962  

Net income attributable to National HealthCare Corporation

  $ 13,711     $ 22,461     $ 34,980     $ 19,670  

Earnings per common share, basic

  $ 0.90     $ 1.48     $ 2.29     $ 1.29  
                                 

Diluted:

                               

Weighted average common shares outstanding

    15,269,637       15,221,262       15,262,950       15,218,962  

Effects of dilutive instruments

    83,065       7,043       75,570       5,996  

Weighted average common shares outstanding

    15,352,702       15,228,305       15,338,520       15,224,958  
                                 

Net income attributable to National HealthCare Corporation

  $ 13,711     $ 22,461     $ 34,980     $ 19,670  

Earnings per common share, diluted

  $ 0.89     $ 1.47     $ 2.28     $ 1.29  

 

In the above table, options to purchase 8,796 and 1,137,015 shares of our common stock have been excluded for the six months ended June 30, 2019 and 2018, respectively, due to their anti–dilutive impact.

 

 

Note 9 – Investments in Marketable Securities

 

Our investments in marketable equity securities are carried at fair value with the changes in unrealized gains and losses recognized in our results of operations at each measurement date. Our investments in marketable debt securities are classified as available for sale securities and carried at fair value with the unrealized gains and losses recognized through accumulated other comprehensive income at each measurement date. Realized gains and losses from securities sales are recognized in results of operations upon disposition of the securities using the specific identification method on a trade date basis. Refer to Note 10 for a description of the Company's methodology for determining the fair value of marketable securities.

 

Marketable securities and restricted marketable securities consist of the following (in thousands):

 

   

June 30, 2019

   

December 31, 2018

 
   

Amortized

Cost

   

Fair

Value

   

Amortized

Cost

   

Fair

Value

 

Investments available for sale:

                               

Marketable equity securities

  $ 30,176     $ 147,007     $ 30,176     $ 140,223  

Restricted investments available for sale:

                               

Corporate debt securities

    61,747       63,326       69,439       67,632  

Asset-based securities

    59,632       60,358       62,772       62,068  

U.S. Treasury securities

    9,866       9,974       22,038       21,457  

State and municipal securities

    21,606       21,913       21,818       21,436  
    $ 183,027     $ 302,578     $ 206,243     $ 312,816  

 

Included in the marketable equity securities are the following (in thousands, except share amounts):

 

   

June 30, 2019

   

December 31, 2018

 
   

Shares

   

Cost

   

Fair

Value

   

Shares

   

Cost

   

Fair

Value

 

NHI Common Stock

    1,630,642     $ 24,734     $ 127,239       1,630,642     $ 24,734     $ 123,179  

 

The amortized cost and estimated fair value of debt securities classified as available for sale, by contractual maturity, are as follows (in thousands):

 

   

June 30, 2019

   

December 31, 2018

 
   

Cost

   

Fair

Value

   

Cost

   

Fair

Value

 

Maturities:

                               

Within 1 year

  $ 9,573     $ 9,588     $ 11,448     $ 11,401  

1 to 5 years

    92,116       93,733       98,487       97,430  

6 to 10 years

    51,162       52,250       64,932       62,527  

Over 10 years

    -       -       1,200       1,235  
    $ 152,851     $ 155,571     $ 176,067     $ 172,593  

 

Gross unrealized gains related to marketable equity securities are $116,851,000 and $110,081,000 as of June 30, 2019 and December 31, 2018, respectively. Gross unrealized losses related to marketable equity securities are $20,000 and $34,000 as of June 30, 2019 and December 31, 2018, respectively. For the three months and six months ended June 30, 2019, the Company recognized net unrealized losses of $54,000 and net unrealized gains of $6,784,000, respectively, for the changes in fair market value of the marketable equity securities in the interim condensed consolidated statement of operations. For the three and six months ended June 30, 2018, the Company recognized net unrealized gains of $12,448,000 and net unrealized losses of $3,069,000, respectively, for the change in market value of the marketable equity securities in the interim condensed consolidated statements of operations.

 

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Gross unrealized gains related to available for sale debt securities are $2,907,000 and $335,000 as of June 30, 2019 and December 31, 2018, respectively. Gross unrealized losses related to available for sale debt securities are $187,000 and $3,809,000 as of June 30, 2019 and December 31, 2018, respectively.

 

For the marketable securities in gross unrealized loss positions, (a) it is more likely than not that the Company will not be required to sell the investment securities before recovery of the unrealized losses, and (b) the Company expects that the contractual principal and interest will be received on the investment securities. As a result, the Company recognized no other-than-temporary impairment during the six months ended June 30, 2019 or for the year ended December 31, 2018.

 

Proceeds from the sale of available for sale debt securities during the six months ended June 30, 2019 and 2018 were $30,103,000 and $4,399,000, respectively. Investment gains of $0 and $25,000 were realized on these sales during the six months ended June 30, 2019 and 2018, respectively. No sales were reported for marketable equity securities for the six months ended June 30, 2019 and 2018, respectively.

 

 

 

Note 10 – Fair Value Measurements

 

The accounting standard for fair value measurements provides a framework for measuring fair value and requires expanded disclosures regarding fair value measurements. Fair value is defined as the price that would be received for an asset or the exit price that would be paid to transfer a liability in the principal or most advantageous market in an orderly transaction between market participants on the measurement date. This accounting standard establishes a fair value hierarchy, which requires an entity to maximize the use of observable inputs, where available. The following summarizes the three levels of inputs that may be used to measure fair value:

 

Level 1 – The valuation is based on quoted prices in active markets for identical instruments.

Level 2 – The valuation is based on observable inputs such as quoted prices for similar instruments in active markets, quoted prices for identical or similar instruments in markets that are not active, and model–based valuation techniques for which all significant assumptions are observable in the market.

Level 3 – The valuation is based on unobservable inputs that are supported by minimal or no market activity and that are significant to the fair value of the instrument. Level 3 valuations are typically performed using pricing models, discounted cash flow methodologies, or similar techniques that incorporate management’s own estimates of assumptions that market participants would use in pricing the instrument, or valuations that require significant management judgment or estimation.

 

A financial instrument’s level within the fair value hierarchy is based on the lowest level of input that is significant to the fair value measurement.

 

The following table summarizes fair value measurements by level at June 30, 2019 and December 31, 2018 for assets and liabilities measured at fair value on a recurring basis (in thousands):

 

   

Fair Value Measurements Using

 

June 30, 2019

 

Fair

Value

   

Quoted Prices in

Active Markets

For Identical

Assets

(Level 1)

   

Significant

Other

Observable

Inputs

(Level 2)

   

Significant

Unobservable

Inputs

(Level 3)

 

Cash and cash equivalents

  $ 29,746     $ 29,746     $     $  

Restricted cash and cash equivalents

    36,160       36,160              

Marketable equity securities

    147,007       147,007              

Corporate debt securities

    63,326       48,759       14,567        

Mortgage–backed securities

    60,358             60,358        

U.S. Treasury securities

    9,974       9,974              

State and municipal securities

    21,913             21,913        

Total financial assets

  $ 368,484     $ 271,646     $ 96,838     $  

 

   

Fair Value Measurements Using

 

December 31, 2018

 

Fair

Value

   

Quoted Prices in

Active Markets

For Identical

Assets

(Level 1)

   

Significant

Other

Observable

Inputs

(Level 2)

   

Significant

Unobservable

Inputs

(Level 3)

 

Cash and cash equivalents

  $ 43,247     $ 43,247     $     $  

Restricted cash and cash equivalents

    11,673       11,673              

Marketable equity securities

    140,223       140,223              

Corporate debt securities

    67,632       47,921       19,711        

Asset - backed securities

    62,068             62,068        

U.S. Treasury securities

    21,457       21,457              

State and municipal securities

    21,436             21,436        

Total financial assets

  $ 367,736     $ 264,521     $ 103,215     $  

 

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Note 11 – Long–Term Debt

 

Long–term debt consists of the following:

 

   

Weighted Average

Interest Rate

   

Maturity

   

June 30,

2019

   

December 31,

2018

 
   

Variable

           

(dollars in thousands)

 

Credit facility, interest payable monthly

    3.8%       2020     $ 55,000     $ 55,000  

Less current portion

                           

Total long-term debt

                  $ 55,000     $ 55,000  

 

The available borrowing capacity of the credit facility is $110,000,000. The credit facility has a maturity date of October 2020. Loans bear interest at either (i) LIBOR plus 1.40% or (ii) the base rate plus 0.40%.

 

 

 

Note 12 - Stock Repurchase Program

 

In August 2018, the Board of Directors authorized a common stock purchase program. The program will allow for repurchases of up to $25 million of its common stock. During the six months ended June 30, 2019, the Company repurchased 10,396 shares of its common stock for a total cost of $872,000.

 

 

 

Note 13 – Stock–Based Compensation

 

NHC recognizes stock–based compensation expense for all stock options granted over the requisite service period using the fair value at the date of grant using the Black–Scholes pricing model. Stock–based compensation totaled $684,000 and $749,000 for the three months ended June 30, 2019 and 2018, respectively. Stock-based compensation totaled $1,108,000 and $1,177,000 for the six months ended June 30, 2019 and 2018, respectively. Stock–based compensation is included in “Salaries, wages and benefits” in the interim condensed consolidated statements of operations.

 

At June 30, 2019, the Company had $4,520,000 of unrecognized compensation cost related to unvested stock–based compensation awards. This unrecognized compensation cost will be amortized over an approximate 3-year period.

 

Stock Options

 

The following table summarizes the significant assumptions used to value the options granted for the six months ended June 30, 2019 and for the year ended December 31, 2018.

 

   

June 30,

2019

   

December 31,

2018

 

Risk–free interest rate

  2.30%     2.46%  

Expected volatility

  17.4%     16.1%  

Expected life, in years

  2.3%     3.0%  

Expected dividend yield

  2.73%     3.29%  

 

The following table summarizes our outstanding stock options for the six months ended June 30, 2019 and for the year ended December 31, 2018.

 

   

Number of

Shares

   

Weighted

Average

Exercise Price

   

Aggregate

Intrinsic

Value

 

Options outstanding at January 1, 2018

    1,239,407     $ 71.19     $  

Options granted

    110,265       61.39        

Options exercised

    (68,291

)

    54.31        

Options cancelled

    (118,000

)

    72.11        

Options outstanding at December 31, 2018

    1,163,381       71.16        

Options granted

    53,796       77.89        

Options exercised

    (332,852

)

    71.56        

Options cancelled

    (60,000 )     72.94       --  

Options outstanding at June 30, 2019

    824,325     $ 71.31     $ 8,115,000  
                         

Options exercisable at June 30, 2019

    209,029     $ 68.05     $ 2,739,000  

 

Options

Outstanding

June 30, 2019

   

Exercise Prices

   

Weighted

Average

Exercise Price

   

Weighted

Average

Remaining

Contractual

Life in Years

 
144,968       60.73 - 62.78       61.81       2.5  
679,357       72.94 - 77.92       73.33       2.8  
824,325               71.31       2.8  

 

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Note 14 – Income Taxes

 

The income tax provision for the three months ended June 30, 2019 is $4,725,000 (an effective income tax rate of 25.7%). The income tax provision and effective tax rate for the three months ended June 30, 2019 were unfavorably impacted by adjustments to unrecognized tax benefits of $95,000 but were favorably impacted by a tax benefit of $47,000 relating to the exercise of stock options. The income tax provision for the three months ended June 30, 2018 was $7,892,000 (an effective income tax rate of 26.1%). The income tax provision and effective tax rate for the three months ended June 30, 2018 were unfavorably impacted by adjustments to unrecognized tax benefits of $112,000 but was favorably impacted by a tax benefit of $22,000 relating to the exercise of stock options.

 

The income tax provision for the six months ended June 30, 2019 is $12,117,000 (an effective tax rate of 25.8%). The income tax provision and effective tax rate for the six months ended June 30, 2019 were unfavorably impacted by nondeductible expenses of $105,000 and adjustments to unrecognized tax benefits of $295,000 but were favorably impacted by a tax benefit of $275,000 relating to the exercise of stock options. The income tax provision for the six months ended June 30, 2018 was $8,092,000 (an effective tax rate of 29.4%). The income tax provision and effective tax rate for the six months ended June 30, 2018 were unfavorably impacted by nondeductible expenses of $881,000 (primarily the non-deductible portion of the estimated potential settlement of the Caris HealthCare, L.P. Qui Tam legal matter) or 3.2% of income before taxes for the six months.

 

Interest and penalties expense related to U.S. federal and state income tax returns are included within income tax expense.

 

The Company is no longer subject to U.S. federal and state examinations by tax authorities for years before 2015 (with certain state exceptions).

 

 

 

Note 15 – Contingencies and Commitments

 

Accrued Risk Reserves

 

We are self–insured for risks related to health insurance and have wholly–owned limited purpose insurance companies that insure risks related to workers’ compensation and general and professional liability insurance claims both for our owned and leased entities and certain of the entities to which we provide management or accounting services. The liability we have recognized for reported claims and estimates for incurred but unreported claims totals $97,291,000 and $96,024,000 at June 30, 2019 and December 31, 2018, respectively. The liability is included in accrued risk reserves in the interim condensed consolidated balance sheets and is subject to adjustment for actual claims incurred. It is possible that these claims plus unasserted claims could exceed our insurance coverages and our reserves, which could have a material adverse effect on our consolidated financial position, results of operations and cash flows.

 

As a result of the terms of our insurance policies and our use of wholly owned limited purpose insurance companies, we have retained significant insurance risk with respect to workers’ compensation and general and professional liability. We consider the professional services of independent actuaries to assist us in estimating our exposures for claims obligations (for both asserted and unasserted claims) related to deductibles and exposures in excess of coverage limits, and we maintain reserves for these obligations. Such estimates are based on many variables including historical and statistical information and other factors.

 

Workers’ Compensation

 

For workers’ compensation, we utilize a wholly owned Tennessee domiciled property/casualty insurance company to write coverage for NHC affiliates and for third–party customers. Policies are written for a duration of twelve months and cover only risks related to workers’ compensation losses. All customers are companies which operate in the senior care industry. Business is written on a direct basis. Direct business coverage is written for statutory limits and the insurance company’s losses in excess of $1,000,000 per claim are covered by reinsurance.

 

General and Professional Liability Lawsuits and Insurance

 

The senior care industry has experienced increases in both the number of personal injury/wrongful death claims and in the severity of awards based upon alleged negligence by nursing facilities and their employees in providing care to residents. As of June 30, 2019, we and/or our managed centers are currently defendants in 65 such claims.

 

Insurance coverage for both periods includes both primary policies and excess policies. The primary coverage is in the amount of $1.0 million per incident, $3.0 million per location with an annual primary policy aggregate limit that is adjusted on an annual basis. For 2018 and 2019, the excess coverage is $9.0 million per occurrence. Additional insurance is purchased through third party providers that serve to supplement the coverage provided through our wholly owned captive insurance company.

 

Financing Commitments

 

In conjunction with our management contract with National, we have entered into a line of credit arrangement whereby we may have amounts due from National from time to time. The maximum loan commitment under the line of credit is $2,000,000. At June 30, 2019, National did not have an outstanding balance on the line of credit.

 

Nutritional Support Services, L.P., Qui Tam Litigation

 

On June 19, 2018, a First Amended Complaint was filed naming Nutritional Support Services, L.P. (“NSS”), a wholly owned subsidiary of the Company, as a defendant in the action captioned U.S. ex rel. McClain v. Nutritional Support Services, L.P., No. 6:17-cv-2608-AMQ (D.S.C.), which was filed in the United States District Court for the District of South Carolina. The action alleges that NSS violated the False Claims Act by reporting a National Drug Code (“NDC”) number that did not correspond to the NDC for dispensed prescriptions. On April 16, 2018, the United States filed a Notice of Election to Decline Intervention with respect to the allegations asserted in this action. NSS intends to vigorously defend itself with respect to this action.

 

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Governmental Regulations

 

Laws and regulations governing the Medicare, Medicaid and other federal healthcare programs are complex and subject to interpretation. Management believes that it is following all applicable laws and regulations in all material respects. However, compliance with such laws and regulations can be subject to future government review and interpretation as well as significant regulatory action including fines, penalties, and exclusions from the Medicare, Medicaid and other federal healthcare programs.

 

Item 2.

Management's Discussion and Analysis of Financial Condition and Results of Operations.

 

 

Forward–Looking Statements

 

References throughout this document to the Company include National HealthCare Corporation and its wholly owned subsidiaries. In accordance with the Securities and Exchange Commissions “Plain English” guidelines, this Quarterly Report on Form 10–Q has been written in the first person. In this document, the words “we”, “our”, “ours” and “us” refer only to National HealthCare Corporation and its wholly–owned subsidiaries and not any other person.

 

This Quarterly Report on Form 10–Q and other information we provide from time to time, contains certain “forward–looking” statements as that term is defined by the Private Securities Litigation Reform Act of 1995. All statements regarding our expected future financial position, results of operations or cash flows, continued performance improvements, ability to service and refinance our debt obligations, ability to finance growth opportunities, ability to control our patient care liability costs, ability to respond to changes in government regulations, ability to execute our three–year strategic plan, and similar statements including, without limitations, those containing words such as “believes”, “anticipates”, “expects”, “intends”, “estimates”, “plans”, and other similar expressions are forward–looking statements.

 

Forward–looking statements involve known and unknown risks and uncertainties that may cause our actual results in future periods to differ materially from those projected or contemplated in the forward–looking statements as a result of, but not limited to, the following factors:

 

 

national and local economic conditions, including their effect on the availability and cost of labor, utilities and materials;

     
 

the effect of government regulations and changes in regulations governing the healthcare industry, including our compliance with such regulations;

     
 

changes in Medicare and Medicaid payment levels and methodologies and the application of such methodologies by the government and its fiscal intermediaries;

     
 

liabilities and other claims asserted against us, including patient care liabilities, as well as the resolution of current litigation (see Note 15: Contingencies and Commitments);

     
 

the ability of third parties for whom we have guaranteed debt, if any, to refinance certain short-term debt obligations;

     
 

the ability to attract and retain qualified personnel;

     
 

the availability and terms of capital to fund acquisitions and capital improvements;

     
 

the ability to refinance existing debt on favorable terms;

     
 

the competitive environment in which we operate;

     
 

the ability to maintain and increase census levels; and

     
 

demographic changes.

 

See the notes to the quarterly financial statements, and “Item 1. Business” in our 2018 Annual Report on Form 10–K for a discussion of various governmental regulations and other operating factors relating to the healthcare industry and the risk factors inherent in them. This may be found on our web site at www.nhccare.com. You should carefully consider these risks before making any investment in the Company. These risks and uncertainties are not the only ones facing us. There may be additional risks that we do not presently know of or that we currently deem immaterial. If any of the risks actually occur, our business, financial condition or results of operations could be materially adversely affected. In that case, the trading price of our shares of stock could decline, and you may lose all or part of your investment. Given these risks and uncertainties, we can give no assurances that these forward–looking statements will, in fact, transpire and, therefore, caution investors not to place undue reliance on them.

 

Overview

 

National HealthCare Corporation (“NHC” or the “Company”) is a leading provider of senior health care services. We operate or manage, through certain affiliates, 75 skilled nursing facilities with a total of 9,510 licensed beds, 26 assisted living facilities, five independent living facilities, one behavioral health hospital and 36 homecare programs. We operate specialized care units within certain of our healthcare centers such as Alzheimer's disease care units and sub-acute nursing units. We also have a non-controlling ownership interest in a hospice care business that services NHC owned health care centers and others. In addition, we provide insurance services, management and accounting services, and we lease properties to operators of skilled nursing and assisted living facilities. We operate in 10 states and are located primarily in the southeastern United States.

 

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Summary of Goals and Areas of Focus

 

Occupancy

 

A primary area of management focus continues to be the rates of occupancy within our skilled nursing facilities. The overall census in owned and leased skilled nursing facilities for the six months ending June 30, 2019 was 90.4% compared to 89.5% for the same period a year ago. With the average length of stay decreasing for a skilled nursing patient across the industry, as well as the increased availability of assisted living facilities and home and community-based services, the challenge of maintaining desirable patient census levels has been amplified. Management has undertaken a number of steps in order to best position our current and future health care facilities. This includes working internally to examine and improve systems to be most responsive to referral sources and payors. Additionally, NHC is in various stages of partnerships with hospital systems, payors, and other post–acute alliances to better position ourselves so we are an active participant in the delivery of post-acute healthcare services.

 

Quality of Patient Care

 

CMS introduced the Five-Star Quality Rating System to help consumers, their families and caregivers compare skilled nursing facilities more easily. The Five-Star Quality Rating System gives each skilled nursing operation a rating ranging between one and five stars in various categories (five stars being the best). The Company has always strived for patient-centered care and quality outcomes as precursors to outstanding financial performance.

 

On April 24, 2019, CMS announced several changes to the Five-Star Quality Rating System which included updating thresholds for both the staffing and quality components of the system. The new changes include separate ratings for short-stay and long-stay quality of resident care in addition to an overall quality of resident care rating. The measures of long-stay hospitalizations and long-stay emergency department visits were added to the quality component of the rating, and the long-stay physical restraints measure was dropped from the quality component of the rating. The scoring rules for the quality measures changed to give more weight to measures with greater opportunity for improvement. Further, the staffing rating thresholds were changed with CMS placing a strong emphasis on registered nurse (“RN”) staffing. 

 

CMS estimated the changes will cause 47% of all nursing centers to lose stars in their "Quality" ratings and 33% are expected to lose stars in their "Staffing" ratings.  Therefore,  approximately 36% of all nursing centers are expected to lose stars in their "Overall" ratings. As anticipated, the implementation of these changes impacted our overall ratings, as well as everyone in the industry.

 

The tables below summarize NHC's overall performance in these Five-Star ratings versus the skilled nursing industry:

 

NHC Ratings  

June 30, 2019

 

Total number of skilled nursing facilities, end of period

  75  

Number of 4 and 5-star rated skilled nursing facilities

  54  

Percentage of 4 and 5-star rated skilled nursing facilities

  72%

 

NHC average rating for all skilled nursing facilities, end of period   3.99  

 

 

Industry Ratings  

June 30, 2019

 
Industry percentage of 4 and 5-star rated skilled nursing facilities   44%  

Industry average rating for skilled nursing facilities, end of period

  3.05  


Development and Growth

 

We are undertaking to expand our senior care operations while protecting our existing operations and markets. The following table lists our recent development activities.

 

Type of

Operation

 

Description

 

Size

 

Location

 

Placed in Service

SNF

 

Bed Addition

 

30 beds

 

Springfield, MO

 

April, 2018

Behavioral Health Hospital

 

Acquisition

 

14 beds

 

Osage Beach, MO

 

August, 2018

Memory Care

 

New Facility

 

60 beds

 

Farragut, TN

 

January, 2019

Memory Care

 

Acquisition

 

60 beds

 

St. Peters, MO

 

June 2019

 

Accrued Risk Reserves

 

Our accrued professional liability and workers’ compensation reserves totaled $97,291,000 at June 30, 2019 and are a primary area of management focus. We have set aside restricted cash and cash equivalents and marketable securities to fund our estimated professional liability and workers’ compensation liabilities.

 

As to exposure for professional liability claims, we have developed performance certification criteria to measure and bring focus to the patient care issues most likely to produce professional liability exposure, including in–house acquired pressure ulcers, significant weight loss and numbers of falls. These programs for certification, which we regularly modify and improve, have produced measurable improvements in reducing these incidents. Our experience is that achieving goals in these patient care areas improves both patient and employee satisfaction.

 

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Government Program Financial Changes

 

Medicare – Skilled Nursing Facilities

 

On August 8, 2018, CMS issued a final rule outlining fiscal year 2019 Medicare payments and quality changes for skilled nursing facilities. The 2019 final rule, which began October 1, 2018, provided for an approximate 2.4% market basket update that was included in the Bipartisan Budget Act of 2018. The market basket increase is expected to increase overall payments to skilled nursing facilities in fiscal year 2019 by $820 million compared to fiscal year 2018 levels.

 

For the first six months of 2019, our average Medicare per diem rate for skilled nursing facilities decreased 0.6% as compared to the same period in 2018.

 

As part of the final rule and effective October 1, 2019, CMS plans to start using a new case-mix model, called the Patient-Driven Payment Model (“PDPM”), which focuses on a resident’s condition and care needs, rather than the amount of care provided to determine reimbursement levels. The PDPM utilizes clinically relevant factors for determining Medicare payment by using ICD-10 diagnosis codes and other patient characteristics as the basis for patient classification. PDPM utilizes five case-mix adjusted payment components: physical therapy (“PT”), occupational therapy (“OT”), speech language pathology (“SLP”), nursing and social services and non-therapy ancillary services (“NTA”). It also uses a sixth non-case mix component to cover utilization of skilled nursing facility (“SNF”) resources that do not vary depending on resident characteristics.

 

PDPM will replace the existing case-mix classification methodology, Resource Utilization Groups, Version IV. The structure of the PDPM moves Medicare towards a more value-based, unified post-acute care payment system. PDPM also removes therapy minutes as the basis for therapy payment and adjusts the SNF per diem payments to reflect varying costs throughout the stay, through the PT, OT and NTA components. In addition, PDPM is intended to reduce paperwork requirements for performing patient assessments. Under the new PDPM system, the payment to skilled nursing facilities will be based heavily on the patient’s condition rather than the specific services provided by each skilled nursing facility.

 

In July 2019, CMS released its final rule outlining fiscal year 2020 Medicare payment rates and policy changes for skilled nursing facilities, which will begin October 1, 2019. The fiscal year 2020 final rule provided for an approximate net 2.4% increase, or $851 million, compared to fiscal year 2019 levels. This includes a 2.8% market-basket update, offset by a statutorily required 0.4% productivity reduction.  In addition to the pay raise, the fiscal year 2020 final rule includes new guidance on the components of PDPM.  It institutes an expected sub-regulatory process for classification of diseases and corresponding ICD-10 codes, such as when a prior code is split into two new codes.  Also, group therapy was defined and will cover therapy sessions with groups of two to six patients.  The rule also institutes two new quality reporting measures designed to improve interoperability.  Those require providers to document the transfer of health information to other healthcare providers and to document the transfer of health information to the patient.  The agency’s goal is to improve medication management among subsequent providers and discharged patients, especially through the use of electronic medication records.

 

Medicaid – Skilled Nursing Facilities

 

Effective July 1, 2019 and for the fiscal year 2020, the state of Tennessee implemented specific individual nursing facility rate increases. We estimate the resulting increase in revenue for the 2020 fiscal year will be approximately $1,680,000 annually, or $420,000 per quarter. Effective July 1, 2018 and for the fiscal year 2019, the state of Tennessee implemented specific individual nursing facility rate increases. The resulting increase in revenue beginning July 1, 2018 was approximately $2,100,000 annually, or $525,000 per quarter.

 

Effective October 1, 2018 and for the fiscal year 2019, South Carolina implemented specific individual nursing facility rate changes. The resulting increase in revenue beginning October 1, 2018 was approximately $2,200,000 annually, or $550,000 per quarter.

 

Effective July 1, 2019 and for the fiscal year 2020, the state of Missouri approved a Medicaid rate increase of $.07 per patient day to Missouri skilled nursing providers. The increase per patient day will result in an insignificant increase to revenue for 2020. Effective July 1, 2018 and for the fiscal year 2019, the state of Missouri approved a Medicaid rate increase of $7.76 per patient day to Missouri skilled nursing providers. The resulting increase in revenue beginning July 1, 2018 was approximately $2,000,000 annually, or $500,000 per quarter.

 

For the first six months of 2019, our average Medicaid per diem increased 3.6% compared to the same period in 2018.

 

We face challenges with respect to states’ Medicaid payments, because many currently do not cover the total costs incurred in providing care to those patients. States will continue to control Medicaid expenditures and also look for adequate funding sources, including provider assessments. There are several pieces of legislation that include provisions designed to reduce Medicaid spending. These provisions include, among others, provisions strengthening the Medicaid asset transfer restrictions for persons seeking to qualify for Medicaid long-term care coverage, which could, due to the timing of the penalty period, increase facilities’ exposure to uncompensated care. Other provisions could increase state funding for home and community-based services, potentially having an impact on funding for nursing facilities.

 

Medicare – Homecare Programs

 

On November 13, 2018, CMS published a final rule which updates the Medicare HH PPS rates, including the conversion factor and case-mix weights for calendar years 2019 and 2020. Effective January 1, 2019, CMS estimates the net impact of the PPS rule results in a 2.2% increase ($420 million) in Medicare payments for agencies in 2019. The increase reflects the effects of a 2.2% home health payment update percentage; a 0.1% increase in payments due to decreasing the fixed-dollar-loss ratio in order to pay no more than 2.5% of total payments as outlier payments; and a 0.1% decrease in payments due to the new rural add-on policy mandated by the Bipartisan Budget Act of 2018.

 

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Also published in the final rule and effective January 1, 2020, there will be an elimination of therapy thresholds for payment, implementation of the Patient-Driven Group Model (“PDGM”) case-mix methodology refinements and a change in the unit of payment from a sixty (60) day episode to a thirty (30) day episode period. These changes focus on providing value over volume of services to patients. Once the changes are implemented, home health payments will no longer be based on the number of visits provided, but rather the patient’s medical condition and care needs.

 

On July 11, 2019, CMS released a proposed rule that would set forth the implementation of the PDGM and a 30-day unit of payment as mandated by the Bipartisan Budget Act of 2018 (“BBA”). CMS projects payments to home health agencies in fiscal year 2020 will increase in aggregate by 1.3%, or $250 million, based on proposed policies. The increase reflects the effects of the 1.5% home health payment update percentage as mandated by the BBA and a 0.2% decrease in aggregate payments due to reductions made by the new rural add-on policy, also mandated by the BBA.

 

Segment Reporting

 

The Company has two reportable operating segments: (1) inpatient services, which includes the operation of skilled nursing facilities, assisted and independent living facilities, and our behavioral health hospital; and (2) homecare services. These reportable operating segments are consistent with information used by the Company’s Chief Executive Officer, as chief operating decision maker (“CODM”), to assess performance and allocate resources.

 

The Company also reports an “all other” category that includes revenues from rental income, management and accounting services fees, insurance services, and costs of the corporate office. For additional information on these reportable segments see Note 2 – Summary of Significant Accounting Policies.   

 

The Company’s CODM evaluates performance and allocates capital resources to each segment based on an operating model that is designed to improve the quality of patient care and profitability of the Company while enhancing long-term shareholder value. The CODM does not review assets by segment in his resource allocation and therefore, assets by segment are not disclosed below.

 

The following table sets forth the Company’s unaudited interim condensed consolidated statements of operations by business segment (in thousands): 

 

   

Three Months Ended June 30, 2019

 
   

Inpatient

Services

   

Homecare

   

All Other

   

Total

 

Revenues:

                               

Net patient revenues

  $ 220,887     $ 14,377     $ -     $ 235,264  

Other revenues

    242       -       11,645       11,887  

Net operating revenues

    221,129       14,377       11,645       247,151  
                                 

Costs and expenses:

                               

Salaries, wages and benefits

    130,720       8,480       8,678       147,878  

Other operating

    60,172       4,674       2,752       67,598  

Rent

    8,229       489       1,479       10,197  

Depreciation and amortization

    9,471       61       803       10,335  

Interest

    319       -       635       954  

Total costs and expenses

    208,911       13,704       14,347       236,962  
                                 

Income (loss) from operations

    12,218       673       (2,702 )     10,189  

Non-operating income

    -       -       8,272       8,272  

Unrealized losses on marketable equity securities

    -       -       (54 )     (54 )
                                 

Income before income taxes

  $ 12,218     $ 673     $ 5,516     $ 18,407  

 

 

   

Three Months Ended June 30, 2018

 
   

Inpatient

Services

   

Homecare

   

All Other

   

Total

 

Revenues:

                               

Net patient revenues

  $ 215,617     $ 15,037     $ -     $ 230,654  

Other revenues

    181       -       11,307       11,488  

Net operating revenues

    215,798       15,037       11,307       242,142  
                                 

Costs and expenses:

                               

Salaries, wages and benefits

    128,115       8,611       8,740       145,466  

Other operating

    56,069       4,740       1,780       62,589  

Rent

    8,267       485       1,520       10,272  

Depreciation and amortization

    9,571       44       782       10,397  

Interest

    383       -       870       1,253  

Total costs and expenses

    202,405       13,880       13,692       229,977  
                                 

Income (loss) from operations

    13,393       1,157       (2,385 )     12,165  

Non-operating income

    -       -       5,654       5,654  

Unrealized gains on marketable equity securities

    -       -       12,448       12,448  
                                 

Income before income taxes

  $ 13,393     $ 1,157     $ 15,717     $ 30,267  

 

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Six Months Ended June 30, 2019

 
   

Inpatient

Services

   

Homecare

   

All Other

   

Total

 

Revenues:

                               

Net patient revenues

  $ 442,521     $ 28,854     $ -     $ 471,375  

Other revenues

    473       -       23,588       24,061  

Net operating revenues

    442,994       28,854       23,588       495,436  
                                 

Costs and expenses:

                               

Salaries, wages and benefits

    256,821       16,506       15,939       289,266  

Other operating

    122,801       8,926       5,303       137,030  

Rent

    16,520       951       2,964       20,435  

Depreciation and amortization

    19,124       122       1,606       20,852  

Interest

    668       -       1,212       1,880  

Total costs and expenses

    415,934       26,505       27,024       469,463  
                                 

Income (loss) from operations

    27,060       2,349       (3,436 )     25,973  

Non-operating income

    -       -       14,273       14,273  

Unrealized gains on marketable equity securities

    -       -       6,784       6,784  
                                 

Income before income taxes

  $ 27,060     $ 2,349     $ 17,621     $ 47,030  

 

 

   

Six Months Ended June 30, 2018

 
   

Inpatient

Services

   

Homecare

   

All Other

   

Total

 

Revenues:

                               

Net patient revenues

  $ 431,968     $ 30,378     $ -     $ 462,346  

Other revenues

    451       -       22,306       22,757  

Net operating revenues

    432,419       30,378       22,306       485,103  
                                 

Costs and expenses:

                               

Salaries, wages and benefits

    251,495       16,642       17,424       285,561  

Other operating

    113,904       10,019       3,838       127,761  

Rent

    16,524       973       3,004       20,501  

Depreciation and amortization

    19,032       82       1,625       20,739  

Interest

    780       -       1,713       2,493  

Total costs and expenses

    401,735       27,716       27,604       457,055  
                                 

Income (loss) from operations

    30,684       2,662       (5,298 )     28,048  

Non-operating income

    -       -       2,589       2,589  

Unrealized losses on marketable equity securities

    -       -       (3,069 )     (3,069 )
                                 

Income (loss) before income taxes

  $ 30,684     $ 2,662     $ (5,778 )   $ 27,568  

 

 

Non-GAAP Financial Presentation

 

The Company is providing certain non-GAAP financial measures as the Company believes that these figures are helpful in allowing investors to more accurately assess the ongoing nature of the Company’s operations and measure the Company’s performance more consistently across periods. Therefore, the Company believes this information is meaningful in addition to the information contained in the GAAP presentation of financial information. The presentation of this additional non-GAAP financial information is not intended to be considered in isolation or as a substitute for the financial information prepared and presented in accordance with GAAP.

 

Specifically, the Company believes the presentation of non-GAAP financial information that excludes the unrealized gains or losses on our marketable equity securities, operating results for the newly constructed healthcare facilities not at full capacity, share-based compensation expense, any gains on the acquisition of equity method investments, and the legal costs and charges related to the settlement of a Qui Tam investigation within our Caris hospice partnership is helpful in allowing investors to more accurately access the Company’s operations.

 

The operating results for the newly constructed healthcare facilities not at full capacity for the six months ended June 30, 2019 include facilities that began operations from 2017 to 2019 (one skilled nursing facility, two assisted living facilities, and one memory care facility). For the six months ended June 30, 2018, included are facilities that began operations from 2016 to 2018 (two skilled nursing facilities and three assisted living facilities).

 

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The tables below provide reconciliations of GAAP to non-GAAP items (dollars in thousands, except per share data):

 

   

Three Months Ended

June 30

   

Six Months Ended

June 30

 
   

2019

   

2018

   

2019

   

2018

 
                                 

Net income attributable to National Healthcare Corporation

  $ 13,711     $ 22,461     $ 34,980     $ 19,670  

Non-GAAP adjustments

                               

Unrealized (gains)/losses on marketable equity securities

    54       (12,448 )     (6,784 )     3,069  

Gain on acquisition of equity method investment

    (1,975 )     -       (1,975 )     -  

Operating results for newly opened facilities not at full capacity

    137       500       731       1,056  

Share-based compensation expense

    684       749       1,108       1,177  

Legal costs and charges related to Caris’ legal investigation

    -       136       -       8,364  

Provision of income taxes on non-GAAP adjustments

    284       2,861       1,785       (2,714 )

Non-GAAP Net income

  $ 12,895     $ 14,259     $ 29,845     $ 30,622  
                                 
                                 

GAAP diluted earnings per share

  $ 0.89     $ 1.47     $ 2.28     $ 1.29  

Non-GAAP adjustments

                               

Unrealized (gains)/losses on marketable equity securities

    -       (0.61 )     (0.34 )     0.15  

Gain on acquisition of equity method investment

    (0.09 )     -       (0.09 )     -  

Operating results for newly opened facilities not at full capacity

    0.01       0.02       0.04       0.05  

Share-based compensation expense

    0.03       0.04       0.05       0.06  

Legal costs and charges related to Caris’ legal investigation

    -       0.01       -       0.46  

Non-GAAP diluted earnings per share

  $ 0.84     $ 0.93     $ 1.94     $ 2.01  

 

 

Results of Operations

 

The following table and discussion set forth items from the interim condensed consolidated statements of income as a percentage of net operating revenues for the three months and six months ended June 30, 2019 and 2018.

 

Percentage of Net Operating Revenues

 

   

Three Months Ended

June 30

   

Six Months Ended

June 30

 
   

2019

   

2018

   

2019

   

2018

 

Net operating revenues:

    100.0 %     100.0 %     100 %     100 %

Costs and expenses:

                               

Salaries, wages and benefits

    59.8       60.1       58.4       58.9  

Other operating

    27.4       25.9       27.7       26.3  

Facility rent

    4.1       4.2       4.1       4.2  

Depreciation and amortization

    4.2       4.3       4.2       4.3  

Interest

    0.4       0.5       0.4       0.5  

Total costs and expenses

    95.9       95.0       94.8       94.2  

Income from operations

    4.1       5.0       5.2       5.8  

Non–operating income

    3.3       2.3       2.9       0.6  

Unrealized gains/losses on marketable equity securities

    0.0       5.2       1.4       (0.6 )

Income before income taxes

    7.4       12.5       9.5       5.8  

Income tax provision

    (1.9 )     (3.3 )     (2.4 )     (1.7 )

Net income

    5.5       9.2       7.1       4.1  

Net loss attributable to noncontrolling interest

    0.0       0.0       0.0       0.0  

Net income attributable to stockholders of NHC

    5.5       9.2       7.1       4.1  

 

Three Months Ended June 30, 2019 Compared to Three Months Ended June 30, 2018

 

Results for the quarter ended June 30, 2019 compared to the second quarter of 2018 include a 2.1% increase in net operating revenues and a 39.0% decrease in net income attributable to NHC, in which the decrease was primarily driven by the unrealized gains and losses in our marketable equity securities portfolio. Excluding the unrealized gains in our marketable equity securities portfolio, income before income taxes for the quarter ended June 30, 2019 increased 3.3% compared to the second quarter of 2018.  Also, non-GAAP net income for the three months ended June 30, 2019 was $12,895,000 compared to $14,259,000 for the second quarter of 2018.

 

Net operating revenues

 

Net patient revenues increased $4,610,000, or 2.0%, compared to the same period last year.

 

The total census at owned and leased skilled nursing facilities for the quarter averaged 90.5% compared to an average of 89.3% for the same quarter a year ago. Medicare per diem rates decreased 1.2% and managed care per diem rates decreased 2.2% compared to the same quarter a year ago. Medicaid and private pay per diem rates increased 4.1% and 3.6%, respectively, compared to the same quarter a year ago. Overall, the composite skilled nursing facility per diem at our owned and leased skilled nursing facilities increased 0.3% compared to the same quarter a year ago.

 

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Beginning January 1, 2019, the Company’s Institutional Special Needs Plan (“I-SNP”) began offering and providing insurance and healthcare services in the state of Tennessee. Our I-SNP, which is called NHC Advantage, is a managed care insurance company that enrolls Medicare Advantage eligible individuals who are patients in our skilled nursing facilities. We believe the I-SNP will benefit our patients by providing nurse practitioners and care-coordination teams that will continue to enhance the patient-centered experience and our quality of care. We also believe our progressive improvement to patient care will continue to drive positive financial results for the Company. For the three months ended June 30, 2019, the I-SNP increased net patient revenues approximately $3,072,000 compared to the same quarter a year ago.

 

In August 2018, the Company acquired a controlling ownership interest in a 14-bed behavioral health hospital. For the three months ending June 30, 2019, this hospital increased net patient revenues approximately $1,738,000 compared to the same quarter of a year ago. The Company has opened four assisted living and memory care facilities from the years 2016 to 2019.  These four assisted living and memory care facilities continue to stabilize and increased net patient revenues approximately $1,347,000 for the three months ended June 30, 2019 compared to the same quarter a year ago.  In October 2018, we sold a skilled nursing facility in Madisonville, Kentucky. The sale of this facility decreased net patient revenues for the second quarter of 2019 by $1,612,000 compared to the same quarter of 2018.

 

Other revenues increased $399,000, or 3.5%, compared to the same quarter last year, as further detailed in Note 4 to our interim condensed consolidated financial statements. The increase in management fee revenue for the three months ended June 30, 2019 compared to the same quarter of 2018 is the primary reason for the increase in other revenues.

 

Total costs and expenses

 

Total costs and expenses for the three months ended June 30, 2019 compared to the same quarter of 2018 increased $6,985,000 or 3.0%, to $236,962,000 from $229,977,000.

 

Salaries, wages and benefits increased $2,412,000, or 1.7%, to $147,878,000 from $145,466,000. Salaries, wages and benefits as a percentage of net operating revenues was 59.8% compared to 60.1% for the three months ended June 30, 2019 and 2018, respectively. The primary reason for salaries, wages and benefits being down as a percentage of net operating revenues is due to the October 2018 sale of the skilled nursing facility in Madisonville, Kentucky.

 

Other operating expenses increased $5,009,000, or 8.0%, to $67,598,000 for the 2019 period compared to $62,589,000 for the 2018 period. Other operating expenses as a percentage of net operating revenue was 27.4% and 25.9% for the three months ended June 30, 2019 and 2018, respectively. The majority of the increase in other operating expenses for the second quarter of 2019 compared to the second quarter of 2018 is due to the January 1, 2019 start of our I-SNP insurance plan, NHC Advantage. For the three months ended June 30, 2019, the I-SNP increased other operating expenses approximately $2,487,000 compared to the second quarter a year ago. We also experienced unfavorable results within our self-insured accrued risk reserve programs for the three months ended June 30, 2019.  Our self-insured accrued risk reserve programs increased other operating expenses by approximately $1,114,000 for the three months ended June 30, 2019 compared to the second quarter a year ago.  The acquisition of the 14-bed behavioral health hospital in August 2018 contributed $614,000 of the increase in other operating expenses.   

 

The decrease in interest expense is due from our long-term debt being paid down during 2018. At June 30, 2019, we have $55 million outstanding on our credit facility.

 

Other income (expense)

 

Non–operating income increased by $2,618,000 compared to the same period last year, as further detailed in Note 5 to our interim condensed consolidated financial statements. The increase in non-operating income is primarily due to the gain of $1,975,000 recorded on the acquisition of the remaining ownership interest in a 60-bed memory care facility in St. Peters, Missouri. We previously held a 25% noncontrolling ownership interest in this memory care facility. Upon acquiring the remaining ownership interest, we properly fair valued the business and our previously held equity position based upon the facility’s fair value.

 

Income taxes

 

The income tax provision for the three months ended June 30, 2019 is $4,725,000 (an effective income tax rate of 25.7%). Excluding nondeductible expenses, we expect our corporate income tax rate for 2019 to be approximately 26.0%.

 

Noncontrolling interest

 

The noncontrolling interest in subsidiaries is presented within total equity of the Company’s consolidated balance sheets. The company presents the noncontrolling interest and the amount of consolidated net income attributable to NHC in its consolidated statements of operations. The Company’s earnings per share is calculated based on net income attributable to NHC’s stockholders. The carrying amount of the noncontrolling interest is adjusted based on an allocation of subsidiary earnings based on ownership interest.

 

Six Months Ended June 30, 2019 Compared to Six Months Ended June 30, 2018

 

Results for the six months ended June 30, 2019 compared to the first six month of 2018 include a 2.1% increase in net operating revenues and a 77.8% increase in net income attributable to NHC. Excluding the unrealized gains in our marketable equity securities portfolio and the 2018 Caris Qui Tam settlement, income before income taxes for the six months ended June 30, 2019 increased 2.9% compared to the same six-month period in 2018.  Also, non-GAAP net income for the six months ended June 30, 2019 was $29,845,000 compared to $30,622,000 for the six months of 2018.

 

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Net operating revenues

 

Net patient revenues increased $9,029,000, or 2.0%, compared to the same period last year.

 

The total census at owned and leased skilled nursing facilities for the six months ended June 30, 2019 averaged 90.4% compared to an average of 89.5% for the same period a year ago. Medicare per diem rates decreased 0.6%, and managed care per diem rates decreased 1.9% compared to the same six-month period a year ago. Medicaid and private pay per diem rates increased 3.6% and 3.2%, respectively, compared to the same period a year ago. Overall, the composite skilled nursing facility per diem at our owned and leased skilled nursing facilities decreased 3 basis points, or 0.03%, compared to the six months a year ago.

 

Beginning January 1, 2019, the Company’s Institutional Special Needs Plan (“I-SNP”) began offering and providing insurance and healthcare services in the state of Tennessee. Our I-SNP, which is called NHC Advantage, is a managed care insurance company that enrolls Medicare Advantage eligible individuals who are patients in our skilled nursing facilities. We believe the I-SNP will benefit our patients by providing nurse practitioners and care-coordination teams that will continue to enhance the patient-centered experience and our quality of care. We also believe our progressive improvement to patient care will continue to drive positive financial results for the Company. For the six months ended June 30, 2019, the I-SNP increased net patient revenues approximately $6,740,000 compared to the same period a year ago.

 

In August 2018, the Company acquired a controlling ownership interest in a 14-bed behavioral health hospital. For the six months ending June 30, 2019, this hospital increased net patient revenues approximately $3,328,000 compared to the same six-month period a year ago. The Company has opened four assisted living and memory care facilities from the years 2016 to 2019.  These four assisted living and memory care facilities continue to stabilize and increased net patient revenues approximately $2,302,000 for the six months ended June 30, 2019 compared to the same period a year ago.  In October 2018, we sold a skilled nursing facility in Madisonville, Kentucky. The sale of this facility decreased net patient revenues for the first six months of 2019 by $3,195,000 compared to the same period of 2018.

 

Other revenues increased $1,304,000, or 5.7%, compared to the first six months last year, as further detailed in Note 4 to our interim condensed consolidated financial statements. The increase in management fee revenue for the six months ended June 30, 2019 compared to the same period of 2018 is the primary reason for the increase in other revenues.

 

Total costs and expenses

 

Total costs and expenses for the first six months of 2019 compared to the first six months of 2018 increased $12,408,000 or 2.7%, to $469,463,000 from $457,055,000.

 

Salaries, wages and benefits increased $3,705,000, or 1.3%, to $289,266,000 from $285,561,000. Salaries, wages and benefits as a percentage of net operating revenues was 58.4% compared to 58.9% for the six months ended June 30, 2019 and 2018, respectively. The primary reason for salaries, wages and benefits being down as a percentage of net operating revenues is due to the October 2018 sale of the skilled nursing facility in Madisonville, Kentucky.

 

Other operating expenses increased $9,269,000, or 7.3%, to $137,030,000 for the 2019 period compared to $127,761,000 for the 2018 period. Other operating expenses as a percentage of net operating revenue was 27.7% compared to 26.3% for the six months ended June 30, 2019 and 2018, respectively. The increase in other operating expenses for the first six months of 2019 compared to the first six months of 2018 is due to the January 1, 2019 start of our I-SNP insurance plan, NHC Advantage. For the six months ended June 30, 2019, the I-SNP increased other operating expenses approximately $5,440,000 compared to the same period a year ago. We also experienced unfavorable results within our self-insured accrued risk reserve programs for the six months ended June 30, 2019.  Our self-insured accrued risk reserve programs increased other operating expenses by approximately $1,476,000 for the six months ended June 30, 2019 compared to the same period a year ago.  The acquisition of the 14-bed behavioral health hospital in August 2018 contributed $1,221,000 of the increase in other operating expenses.

 

The decrease in interest expense is due from our long-term debt being paid down during 2018. At June 30, 2019, we have $55 million outstanding on our credit facility.

 

Other income (expense)

 

Non–operating income increased by $11,684,000 compared to the same period last year, as further detailed in Note 5 to our interim condensed consolidated financial statements. The increase in non-operating income is due from our equity in earnings investment in our Caris hospice operations. During the first quarter of 2018, Caris recorded a charge to earnings of $8,500,000 for the settlement of a Qui Tam investigation, of which 75.1% is included in the Company’s earnings. In total, with the $8.5 million settlement and legal expenses, Caris’ earnings negatively impacted NHC’s non-operating income by $8,364,000 for the first six months of 2018.

 

Additionally, the increase in non-operating income for the six months ended June 30, 2019 is partly due to the gain of $1,975,000 on the acquisition of the remaining ownership interest in a 60-bed memory care facility in St. Peters, Missouri. We previously held a 25% noncontrolling ownership interest in this memory care facility. Upon acquiring the remaining ownership interest, we properly fair valued the business and our previously held equity position based upon the facility’s fair value.

 

Income taxes

 

The income tax provision for the six months ended June 30, 2019 is $12,117,000 (an effective income tax rate of 25.8%). Excluding nondeductible expenses, we expect our corporate income tax rate for 2019 to be approximately 26.0%.

 

Noncontrolling interest

 

The noncontrolling interest in subsidiaries is presented within total equity of the Company’s consolidated balance sheets. The company presents the noncontrolling interest and the amount of consolidated net income attributable to NHC in its consolidated statements of operations. The Company’s earnings per share is calculated based on net income attributable to NHC’s stockholders. The carrying amount of the noncontrolling interest is adjusted based on an allocation of subsidiary earnings based on ownership interest.

 

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Liquidity, Capital Resources, and Financial Condition

 

Our primary sources of cash include revenues from the operations of our healthcare and senior living facilities, management and accounting services, rental income, and investment income. Our primary uses of cash include salaries, wages and other operating costs of our healthcare and senior living facilities, the cost of additions to and acquisitions of real property, facility rent expenses, and dividend distributions. These sources and uses of cash are reflected in our interim condensed consolidated statements of cash flows and are discussed in further detail below.

 

The following is a summary of our sources and uses of cash flows (dollars in thousands):

 

   

Six Months Ended

June 30

   

Six Month Change

 
   

2019

   

2018

    $    

%

 

Cash, cash equivalents, restricted cash and restricted cash equivalents, at beginning of period

  $ 54,920     $ 67,421     $ (12,501

)

    (18.5

)

                                 

Cash provided by operating activities

    39,172       49,373       (10,201

)

    (20.7

)

                                 

Cash used in investing activities

    (11,370

)

    (16,802

)

    5,432       32.3  
                                 

Cash used in financing activities

    (16,816

)

    (31,121

)

    14,305       46.0  
                                 

Cash, cash equivalents, restricted cash and restricted cash equivalents, at end of period

  $ 65,906     $ 68,871     $ (2,965

)

    (4.3

)

 

Operating Activities

 

Net cash provided by operating activities for the six months ended June 30, 2019 was $39,172,000 as compared to $49,373,000 in the same period last year. Cash provided by operating activities consisted of net income of $34,913,000 and adjustments for non–cash items of $9,694,000. There was cash used for working capital needs in the amount of $8,044,000 for the six months ended June 30, 2019 compared to $1,012,000 for the same period a year ago. We also received cash distributions from our unconsolidated investments of $2,609,000 during the six months ended June 30, 2019 compared to $3,741,000 for the same period a year ago. 

 

Investing Activities

 

Net cash used in investing activities totaled $11,370,000 for the six months ended June 30, 2019 compared to $16,802,000 for the six months ended June 30, 2018. Cash used for property and equipment additions was $13,989,000 and $15,456,000 for the six months ended June 30, 2019 and 2018, respectively. Cash was also used in the acquisition of an equity method investment (St. Peters Memory Care) for the six months ended June 30, 2019 of $15,589,000.  Investments in notes receivable were $5,312,000 and $0 for the six months ended June 30, 2019 and 2018, respectively.  Additionally, the Company collected notes receivable of $660,000 and $800,000 for the six months ended June 30, 2019 and 2018, respectively. Sales of restricted marketable securities, net of purchases, resulted in cash of $23,216,000 for the six months ended June 30, 2019 compared to purchases of restricted marketable securities, net of sales, of $2,146,000 for the six months ended June 30, 2018.

 

Financing Activities 

 

Net cash used in financing activities totaled $16,816,000 and $31,121,000 for the six months ending June 30, 2019 and 2018, respectively. Cash used for dividend payments to common stockholders totaled $15,275,000 in the current year period compared to $14,602,000 for the same period a year ago. In the current period, $1,383,000 was provided by the issuance of common stock compared to $1,327,000 in the prior year period. In the current period, repurchases of common stock totaled $872,000 compared to $867,000 in the prior period. In the prior year period, cash of $15,000,000 was used for principal payments on the Company’s credit facility.

 

Short–term liquidity

 

We expect to meet our short-term liquidity requirements primarily from our cash flows from operating activities. In addition to cash flows from operations, our current cash on hand of $29,746,000, marketable equity securities of $147,007,000, and as needed, our borrowing capacity on the credit facility, are expected to be adequate to meet our contractual obligations, operating liquidity, and our growth and development plans in the next twelve months.

 

Long–term liquidity

 

We expect to meet our long-term liquidity requirements primarily from our cash flows from operating activities, our current cash on hand of $29,746,000, marketable equity securities of $147,007,000 and our borrowing capacity on the credit facility. At June 30, 2019, the outstanding balance on the credit facility is $55,000,000; therefore, leaving $55,000,000 available for future borrowings. The maturity date on the credit facility is October 7, 2020. The credit facility is available for general corporate purposes, including working capital and acquisitions.

 

Our ability to refinance the credit agreement, to meet our long–term contractual obligations and to finance our operating requirements, and growth and development plans will depend upon our future performance, which will be affected by business, economic, financial and other factors, including potential changes in state and federal government payment rates for healthcare, customer demand, success of our marketing efforts, pressures from competitors, and the state of the economy, including the state of financial and credit markets.

 

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Commitment and Contingencies

 

Nutritional Support Services, L.P., Qui Tam Litigation

 

On June 19, 2018, a First Amended Complaint was filed naming Nutritional Support Services, L.P. (“NSS”), a wholly owned subsidiary of the Company, as a defendant in the action captioned U.S. ex rel. McClain v. Nutritional Support Services, L.P., No. 6:17-cv-2608-AMQ (D.S.C.), which was filed in the United States District Court for the District of South Carolina. The action alleges that NSS violated the False Claims Act by reporting a National Drug Code (“NDC”) number that did not correspond to the NDC for dispensed prescriptions. The plaintiffs are seeking unspecified damages. On April 16, 2018, the United States filed a Notice of Election to Decline Intervention with respect to the allegations asserted in this action. NSS intends to vigorously defend itself with respect to this action.

 

Governmental Regulations

 

Laws and regulations governing the Medicare, Medicaid and other federal healthcare programs are complex and subject to interpretation. Management believes that it is following all applicable laws and regulations in all material respects. However, compliance with such laws and regulations can be subject to future government review and interpretation as well as significant regulatory action including fines, penalties, and exclusions from the Medicare, Medicaid and other federal healthcare programs.

 

New Accounting Pronouncements

 

See Note 2 to the interim condensed consolidated financial statements for the impact of new accounting standards.

 

 

Item 3.

Quantitative and Qualitative Disclosures About Market Risk.

 

Market risk represents the potential economic loss arising from adverse changes in the fair value of financial instruments. Currently, our exposure to market risk relates primarily to our fixed–income and equity portfolios. These investment portfolios are exposed primarily to, but not limited to, interest rate risk, credit risk, equity price risk, and concentration risk. We also have exposure to market risk that includes our cash and cash equivalents, notes receivable, revolving credit facility, and long–term debt. The Company's senior management has established comprehensive risk management policies and procedures to manage these market risks.

 

Interest Rate Risk

 

The fair values of our fixed–income investments fluctuate in response to changes in market interest rates. Increases and decreases in prevailing interest rates generally translate into decreases and increases, respectively, in the fair values of those instruments. Additionally, the fair values of interest rate sensitive instruments may be affected by the creditworthiness of the issuer, prepayment options, the liquidity of the instrument and other general market conditions. At June 30, 2019, we have available for sale marketable debt securities in the amount of $155,571,000. The fixed maturity portfolio is comprised of investments with primarily short–term and intermediate–term maturities. The portfolio composition allows flexibility in reacting to fluctuations of interest rates. The fixed maturity portfolio allows our insurance company subsidiaries to achieve an adequate risk–adjusted return while maintaining sufficient liquidity to meet obligations.

 

As of June 30, 2019, the Company has $55,000,000 of long–term debt that bears interest at variable interest rates. Based on our outstanding long–term debt, a 1% change in interest rates would change our annual interest cost by approximately $550,000.

 

Our cash and cash equivalents consist of highly liquid investments with a maturity of less than three months when purchased. As a result of the short–term nature of our cash instruments, a hypothetical 1% change in interest rates would have minimal impact on our future earnings and cash flows related to these instruments.

 

We do not currently use any derivative instruments to hedge our interest rate exposure. We have not used derivative instruments for trading purposes and the use of such instruments in the future would be subject to approvals by the Investment Committee of the Board of Directors.

 

Credit Risk

 

Credit risk is managed by diversifying the fixed maturity portfolio to avoid concentrations in any single industry group or issuer and by limiting investments in securities with lower credit ratings.

 

Equity Price and Concentration Risk

 

Our marketable equity securities are recorded at their fair market value based on quoted market prices. Thus, there is exposure to equity price risk, which is the potential change in fair value due to a change in quoted market prices. At June 30, 2019, the fair value of our marketable equity securities is approximately $147,007,000. Of the $147.0 million equity securities portfolio, our investment in NHI comprises approximately $127.2 million, or 87%, of the total fair value. We manage our exposure to NHI by closely monitoring the financial condition, performance, and outlook of the company. Hypothetically, a 10% change in quoted market prices would result in a related increase or decrease in the fair value of our equity investments of approximately $14.7 million. At June 30, 2019, our equity securities had unrealized gains of $116.8 million. Of the $116.8 million of unrealized gains, $102.5 million is related to our investment in NHI.

 

 

Item 4.

Controls and Procedures.

 

As of June 30, 2019, an evaluation was performed under the supervision and with the participation of the Company’s management, including the Chief Executive Officer (“CEO”) and Principal Accounting Officer (“PAO”), of the effectiveness of the design and operation of the Company’s disclosure controls and procedures. Based on that evaluation, the Company’s management, including the CEO and PAO, concluded that the Company’s disclosure controls and procedures were effective as of June 30, 2019. There have been no changes in the Company’s internal control over financial reporting during the quarter ended June 30, 2019 that have materially affected, or are reasonably likely to materially affect, the Company’s internal control over financial reporting.

 

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PART II. OTHER INFORMATION

 

 

Item 1.

Legal Proceedings.

 

For a discussion of prior, current and pending litigation of material significance to NHC, please see Note 15 of this Form 10–Q.

 

 

Item 1A.

Risk Factors.

 

During the six months ended June 30, 2019, there were no material changes to the risk factors that were disclosed in Item 1A of National HealthCare Corporation’s Annual Report on Form 10–K for the year ended December 31, 2018.

 

 

Item 2.

Unregistered Sales of Equity Securities and Use of Proceeds.

 

Not applicable

 

 

Item 3.

Defaults Upon Senior Securities.

 

None

 

 

Item 4.

Mine Safety Disclosures.

 

Not applicable

 

 

Item 5.

Other Information.

 

None

 

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Table of Contents

 

Item 6.

Exhibits.

 

 

(a)

List of exhibits

 

EXHIBIT INDEX

 

Exhibit No.

 

Description

 

 

 

 

 

 

 

3.1

 

Certificate of Incorporation of National HealthCare Corporation (Incorporated by reference to Exhibit 3.1 to the Registrant’s registration statement on Form S-4 (File No. 333-37185) dated October 3, 1997.)

 

 

 

 

 

3.2

 

Certificate of Amendment to the Certificate of Incorporation of National HealthCare Corporation (Incorporated by reference to Exhibit 3.5 to the quarterly report on Form 10-Q filed on August 3, 2017.)

 

 

 

 

 

3.3

 

Certificate of Designation Series B Junior Participating Preferred Stock (Incorporated by reference to Exhibit 3.1 to the Registrant’s registration statement on Form 8-A, dated August 3, 2007.)

 

 

 

 

 

3.4

 

Restated Bylaws as amended February 14, 2013 (Incorporated by reference to Exhibit 3.5 to the quarterly report on Form 10-Q filed on May 8, 2013.)

 

 

 

 

 

4.1

 

Form of Common Stock (Incorporated by reference to Exhibit 4.1 to the quarterly report on Form 10-Q filed on August 3, 2017.)

 

 

 

 

 

31.1

 

Rule 13a-14(a)/15d-14(a) Certification of Chief Executive Officer

 

 

 

 

 

31.2

 

Rule 13a-14(a)/15d-14(a) Certification of Principal Accounting Officer

 

 

 

 

 

32

 

Certification pursuant to 18 U.S.C. Section 1350 by Chief Executive Officer and Principal Accounting Officer

 
 

 

 

 

 

 

101.SCH

 

XBRL Taxonomy Extension Schema Document

 

 

 

 

 

101.CAL

 

XBRL Taxonomy Extension Calculation Linkbase Document

 

 

 

 

 

101.DEF

 

XBRL Taxonomy Extension Definition Linkbase Document

 

 

 

 

 

101.LAB

 

XBRL Taxonomy Extension Label Linkbase Document

 

 

 

 

 

101.PRE

 

XBRL Taxonomy Extension Presentation Linkbase Document

  

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Table of Contents

 

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.

 

 

NATIONAL HEALTHCARE CORPORATION

 

(Registrant)

 

 

Date: August 8, 2019

/s/ Stephen F. Flatt                   

 

Stephen F. Flatt

 

Chief Executive Officer

 

 

 

 

Date: August 8, 2019

/s/ Brian F. Kidd                     

 

Brian F. Kidd

 

Senior Vice President and Controller

 

(Principal Accounting Officer)

 

35