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What changed in AMN HEALTHCARE SERVICES INC's 10-K — 2023 vs 2024

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Paragraph-level year-over-year comparison of AMN HEALTHCARE SERVICES INC's 2023 and 2024 10-K annual filings, covering the Business, Risk Factors, Legal Proceedings, Cybersecurity, MD&A and Market Risk sections. Every new, removed and edited paragraph is highlighted side-by-side so you can see exactly what management changed in the 2024 report.

+287 added−268 removedSource: 10-K (2025-02-21) vs 10-K (2024-02-22)

Top changes in AMN HEALTHCARE SERVICES INC's 2024 10-K

287 paragraphs added · 268 removed · 218 edited across 7 sections

Item 1. Business

Business — how the company describes what it does

68 edited+7 added−17 removed38 unchanged
Biggest changeWe believe the nursing shortage has been exacerbated by the COVID-19 pandemic through nurse burnout, attrition, and retirements. Demand for our services is positively correlated with activity in the permanent labor market. When nurse vacancy rates increase, temporary nurse staffing orders typically increase as well. • General Demand for Healthcare Services .
Biggest changeWhen nurse vacancy rates increase, temporary nurse staffing orders typically increase as well. • General Demand for Healthcare Services . Changes in demand for healthcare services, particularly at acute healthcare hospitals and other inpatient facilities, like skilled nursing facilities, affect the demand for our services. According to the U.S.
We provide technology and data intelligence that enable sustainable, long-term improvement and offer flexible solution options, agile, scalable processes in our pay-for-performance model. Technology (9) Language Interpretation .
We provide technology and data intelligence that enable sustainable, long-term improvement and offer flexible solution options and agile, scalable processes in our pay-for-performance model. Technology (9) Language Interpretation .
We also believe we have a market-leading share in managed services solutions, including VMS and MSP, and healthcare language interpretation services. With the stronger competitive market, we believe AMN Healthcare is well-positioned as a tech-centric total talent solutions partner to capitalize on the larger, addressable market through our comprehensive set of workforce and tech-enabled solutions.
We also believe we have a market-leading share in vendor neutral and managed services solutions, including VMS and MSP, and healthcare language interpretation services. With the stronger competitive market, we believe AMN Healthcare is well-positioned as a tech-centric total talent solutions partner to capitalize on the larger, addressable market through our comprehensive set of workforce and tech-enabled solutions.
Item 1. Business Overview of Our Company and Business Strategy AMN Healthcare empowers the future of care through the nation’s broadest network of highly-qualified healthcare professionals.
Item 1. Business Overview of Our Company and Business Strategy AMN Healthcare empowers the future of care through one of the nation’s broadest network of highly-qualified healthcare professionals.
Continuous improvement of our operations and business technology is a core component of our growth strategy and profitability goals. We have accelerated the integration of technology-based solutions in our core recruitment processes through investment in digital capabilities, mobile applications and data analytics.
Continuous improvement of our operations and business technology is a core component of our growth strategy and profitability goals. We have accelerated the integration of technology-based solutions in our core recruitment processes through investment in digital capabilities, mobile applications, brand consolidation and data analytics.
Development of a broad base of healthcare professionals and corporate team members who feel valued, respected and supported is essential to driving shareholder value and achieving our long-term growth objectives. To support these objectives, our human capital management strategy focuses on talent acquisition, engagement, retention, diversity, equity, inclusion, and employee well-being and belonging.
Development of a broad base of healthcare professionals and corporate team members who feel valued, respected and supported is essential to driving shareholder value and achieving our long-term growth objectives. To support these objectives, our human capital management strategy focuses on talent acquisition, engagement, retention, employee well-being and belonging.
Nurse staffing solutions that we offer include (a) travel nurse staffing which are typically for a 13-week assignment but can support a wide range of assignment lengths, (b) international nurse staffing for which we recruit registered nurses from outside of the United States on long-term contracts ranging from 24 to 36 months (or for direct placement with our clients), (c) crisis nurse staffing (commonly referred to as critical staffing and rapid response nursing) for which we quickly coordinate and deploy registered nurses to provide temporary assistance during critical periods such as unexpected specialty gaps and urgent needs, including pandemic surges, natural disasters and other emergency situations, (d) labor disruption staffing for which we provide crucial support for clients involved in strikes of nurses and allied professional staff, and (e) local staffing of all nursing specialties, covering short-term assignments with same-day shifts that potentially last for several weeks.
Nurse staffing solutions that we offer include (a) travel nurse staffing which are typically for a 13-week assignment but can support a wide range of assignment lengths, (b) international nurse staffing for which we recruit registered nurses from outside of the United States on long-term contracts ranging from 24 to 36 months, (c) international nurse permanent placement which provides our clients with direct placement of nurses from outside of the United States, (d) crisis nurse staffing (commonly referred to as critical staffing and rapid response nursing) for which we quickly deploy registered nurses on assignment during critical periods such as unexpected specialty gaps and urgent needs, including pandemic surges, natural disasters and other emergency situations, (e) labor disruption staffing for which we provide crucial support for clients involved in strikes of nurses and allied professional staff, and (f) local staffing of all nursing specialties, covering short-term assignments with same-day shifts that potentially last for several weeks.
This business line provides us greater access to the “C-suite” of our clients and prospective clients, which we believe helps improve our visibility as a strategic partner to them and helps provide us with cross-selling opportunities. Talent Planning & Acquisition (7) Managed Services Programs .
This business line provides us greater access to the “C-suite” of our clients and prospective clients, which we believe helps improve our visibility as a strategic partner to them and helps provide us with cross-selling opportunities. Talent Planning & Acquisition 4 Table of Contents (7) Managed Services Programs .
We expect this will enable us to expand our strategic customer relationships, while driving more recurring revenue, with an improved margin mix that will be less sensitive to economic cycles. 1 Table of Contents Over the past decade, our business has evolved beyond traditional healthcare staffing and recruitment services; we have become a strategic total talent solutions partner with our clients.
We expect this will enable us to expand our strategic customer relationships, while driving more recurring revenue, improve margin mix, and be less sensitive to economic cycles. 1 Table of Contents Over the past decade, our business has evolved beyond traditional healthcare staffing and recruitment services; we have become a strategic total talent solutions partner with our clients.
We have provided our healthcare professionals with additional support through access to employee assistance programs, on demand mental health resources through nonprofit partners and third-party vendors, sick pay while quarantined, wellness products and services to care for them while they are caring for our communities.
We have provided our healthcare professionals with additional support through access to employee assistance programs, on demand mental health resources through nonprofit partners and third-party vendors, wellness products and services to care for them while they are caring for our communities.
Such reports, proxy statements and other information are also available on the 8 Table of Contents SEC’s website, http://www.sec.gov. The information found on our website and the SEC’s website is not part of this Annual Report on Form 10-K or any other report we file with or furnish to the SEC.
Such reports, proxy statements and other information are also available on the SEC’s website, http://www.sec.gov. The information found on our website and the SEC’s website is not part of this Annual Report on Form 10-K or any other report we file with or furnish to the SEC.
We also provide a variety of other voluntary programs to support the health and well-being of our team members and their families, such as health and flexible spending accounts, family leave, adoption assistance, education assistance, retirement plans, employee assistance programs, and financial wellness programs.
We also provide a variety of other voluntary programs to support 2 Table of Contents the health and well-being of our team members and their families, such as health and flexible spending accounts, family leave, adoption assistance, education assistance, retirement plans, employee assistance programs, and financial wellness programs.
If clients use other staffing companies (associate vendors), our software as a service (“SaaS”)-based VMS technologies help them track and efficiently organize their staffing process. Our leading VMS products, which collectively serve clients of all sizes and complexity, are ShiftWise, including the recent release of ShiftWise Flex, Medefis and b4health.
If clients use other staffing companies (associate vendors), our software as a service (“SaaS”)-based VMS technologies help them track and efficiently organize their staffing process. Our leading VMS products, which collectively serve clients of all sizes and complexity, are ShiftWise Flex, Medefis and b4health.
Our solutions enable our clients to build a sustainable workforce, increase efficiency, and elevate the patient experience. Our comprehensive suite of talent solutions provides management, staffing, recruitment, language services, technology, predictive and market analytics, and related services to build and manage all or part of our clients’ healthcare workforce needs.
Our solutions enable our clients to build a quality, cost effective workforce, increase efficiency, and elevate the patient experience. Our comprehensive suite of talent solutions provides management, staffing, recruitment, language services, technology, predictive and market analytics, and related services to build and manage all or part of our clients’ healthcare workforce needs.
Our commitment to supporting the mental, physical, and economic well-being of our team members and healthcare professionals continued throughout 2023. The care, support and safety of our frontline healthcare professionals remains at the forefront for us.
Employee Well-being Our commitment to supporting the mental, physical, and economic well-being of our team members and healthcare professionals continued throughout 2024. The care, support and safety of our frontline healthcare professionals remains at the forefront for us.
We also operate within the interim leadership, executive search, physician permanent placement, RPO, VMS, and workforce optimization and consulting services markets. Industry Demand Drivers 6 Table of Contents Many factors affect the demand for contingent and permanent healthcare talent, which, accordingly, affects the size of the markets in which we primarily operate.
We also operate within the interim leadership, executive search, physician permanent placement, RPO, and workforce optimization and consulting services markets. Industry Demand Drivers Many factors affect the demand for contingent and permanent healthcare talent, which, accordingly, affects the size of the markets in which we primarily operate.
We are passionate about all aspects of our mission to: • Deliver the right talent and insights to help healthcare organizations optimize their workforce. • Provide healthcare professionals opportunities to do their best work toward high-quality patient care. • Create a values-based culture of innovation and inclusion in which our team members can achieve their goals.
We are passionate about all aspects of our mission to: • Deliver the right talent and insights to help healthcare organizations optimize their workforce. • Provide healthcare professionals opportunities to do their best work toward high-quality patient care. • Create an innovative and values-based culture in which our team members can achieve their goals.
Our solutions for schools feature an advanced teletherapy platform, Televate, and qualified school speech-language pathologists, psychologists, nurses, 4 Table of Contents social workers, and other care providers who provide customized care and interactive learning plans to engage students. (3) Revenue Cycle Solutions .
Our solutions for schools feature an advanced teletherapy platform, Televate, and qualified school speech-language pathologists, psychologists, nurses, social workers, and other care providers who provide customized care and interactive learning plans to engage students. (3) Revenue Cycle Solutions .
AMN Language Services provides healthcare interpretation services via proprietary platforms that enable video remote interpretation, over the phone interpretation, onsite interpretation, and telehealth interoperability, with more than 350 health systems, more than 2,300 hospitals, and thousands of clinics using our solutions.
AMN Language Services provides healthcare interpretation services via proprietary platforms that enable video remote interpretation, over the phone interpretation, onsite interpretation, and telehealth interoperability, with more than 375 health systems, more than 2,600 hospitals, and thousands of clinics using our solutions.
We believe an MSP increases efficiencies and often provides cost savings while enhancing provider experiences. We often use our own VMS technology as part of our MSPs, which we believe further enhances the value of our service offering.
We believe an MSP increases efficiencies and often provides cost savings while enhancing provider experiences. We often use our own VMS technology as part of our staffing-led and vendor-neutral MSPs, which we believe further enhances the value of our service offering.
No other client healthcare system or single client facility comprised more than 5% of our consolidated revenue for the fiscal year ended December 31, 2023. Our Industry The primary healthcare service markets in which we compete are U.S. temporary and contract healthcare staffing, workforce managed service programs, locum tenens, and language services.
No other client healthcare system or single client facility comprised more than 5% of our consolidated revenue for the fiscal year ended December 31, 2024. Our Industry The primary healthcare service markets in which we compete are U.S. temporary and contract healthcare staffing, workforce vendor neutral (i.e., VMS) and managed service programs, locum tenens, and language services.
Larger firms, such as us, also generally have a deeper, more comprehensive infrastructure with a more established operating model and processes that provide the long-term stability and foundation for quality standards recognition, such as the Joint Commission staffing agency certification and National Committee for Quality Assurance Credentials Verification Organization certification.
Larger firms, such as us, also generally have a deeper, more comprehensive infrastructure with a more established operating model and processes that provide the long-term stability and foundation for quality standards recognition, such as the Joint Commission staffing agency certification.
ShiftWise Flex is also integrated with AMN Passport, our top clinician-rated mobile application with more than 225,000 registered users as of January 2024.
ShiftWise Flex is also integrated with AMN Passport, our top clinician-rated mobile application with more than 270,000 registered users as of January 2025.
We believe the prevalence of workforce solutions, such as MSP, VMS, RPO and workforce optimization tools, in the healthcare industry is still underpenetrated in comparison with non-healthcare sectors. During 2023, approximately 54% of our consolidated revenues were generated through MSP relationships. 7 Table of Contents Industry Competition The healthcare staffing and workforce solutions industry is highly competitive.
We believe the prevalence of workforce solutions, such as MSP, VMS, RPO and workforce optimization tools, in the healthcare industry is still underpenetrated in comparison with non-healthcare sectors. During 2024, approximately 45% of our consolidated revenues were generated through MSP relationships. Industry Competition The healthcare staffing and workforce solutions industry is highly competitive.
For example, during 2023, we launched ShiftWise Flex, AMN Healthcare’s next-generation VMS that leverages the power of automation to increase efficiency of talent matching, credentialing, and candidate self-service, enabling our clients to develop sustainable workforces to deliver better outcomes for patients and caregivers alike.
We added capabilities and functionalities for ShiftWise Flex, AMN Healthcare’s next-generation VMS that leverages the power of automation to increase efficiency of talent matching, credentialing, and candidate self-service, enabling our clients to develop sustainable workforces to deliver better outcomes for patients and caregivers alike.
Our VMS technologies provide, among other things, control over a wide variety of tasks via a single system and consolidated reporting. 5 Table of Contents In 2023, we had approximately $4.2 billion in gross spend flow through our VMS programs, for which we typically earn a fee as a percentage of spend. (11) Scheduling and Staff Planning .
Our VMS technologies provide, among other things, control over a wide variety of tasks via a single system and consolidated reporting. In 2024, we had approximately $2.0 billion in spend flow through our VMS programs, for which we typically earn a fee as a percentage of spend. (11) Scheduling and Staff Planning .
Additionally, our mentorship program allows team members the opportunity to connect with colleagues across the company to support their development, strengthen their skills, and deepen relationships. Nearly 20% of our team members were enrolled in the mentoring program during 2023, which resulted in approximately 300 mentoring connections.
Additionally, our mentorship program allows team members the opportunity to connect with colleagues across the company to support their development, strengthen their skills, and deepen relationships. Approximately 10% of our team members were enrolled in the mentoring program during 2024, which resulted in approximately 100 mentoring connections.
During the fourth quarter of 2023, we had an average of (1) 11,869 nurses, allied and other healthcare professionals, (2) 293 executive and clinical leadership interim staff, and (3) 2,479 medically qualified interpreters working for us. This does not include independent contractors, such as our locum tenens and contract interpreters, who were not our employees in 2023.
During the fourth quarter of 2024, we had an average of (1) 9,206 nurses, allied and other healthcare professionals, (2) 257 executive and clinical leadership interim staff, and (3) 2,819 medically qualified interpreters working for us. This does not include independent contractors, such as our locum tenens and contract interpreters, who were not our employees in 2024.
We now have fully embraced a hybrid work environment, with team members working a combination of in the office and virtually to fully support our clients and healthcare professionals with the highest level of service, regardless of their location and without disruption to our business operations.
We embrace a flexible work environment, with team members working a combination of in office and virtually to fully support our clients and healthcare professionals with the highest level of service, regardless of location and without disruption to our business operations.
Our Geographic Markets and Client Base During each of the past three years, (1) we generated substantially all our revenue in the United States and (2) substantially all our long-lived assets were located in the United States. We typically generate revenue in all 50 states. During 2023, the largest percentages of our revenue were concentrated in California, Texas and Georgia.
Our Geographic Markets and Client Base During each of the past three years, (1) we generated substantially all our revenue in the United States and (2) substantially all our long-lived assets were located in the United States. We typically generate revenue in all 50 states.
Throughout 2023, more than 700 team members were promoted or transferred internally into new positions, representing approximately 20% of our corporate team members. Our professional development education assistance program provides reimbursement to our corporate team members to advance their knowledge and skills through certificate and degree programs.
Throughout 2024, nearly 500 team members were promoted or transferred internally into new positions, representing approximately 17% of our corporate team members. Our professional development education assistance program provides reimbursement to our corporate team members to advance their knowledge and skills through certificate and degree programs.
In 2023, we had approximately $3.4 billion in spend under management through our MSPs and approximately 54% of our consolidated revenue flowed through MSP relationships. Together with the vendor-neutral spend through our VMS programs (as discussed below), we had approximately $7.6 billion of spend under management during 2023. (8) Recruitment Solutions .
In 2024, we had approximately $2.0 billion in spend under management through our MSPs and approximately 45% of our consolidated revenue flowed through MSP relationships. Together with the vendor-neutral spend through our VMS programs (as discussed below), we had approximately $4.0 billion of spend under management during 2024. (8) Recruitment Solutions .
As our corporate team members have returned to our offices, health and safety remains paramount. We believe it is important to bring our teams together to instill and reinforce our values-based culture, provide an opportunity to build meaningful connections with each other and the communities we serve as well as provide ongoing professional development and advancement opportunities.
We believe it is important to bring our teams together to instill and reinforce our values-based culture, provide an opportunity to build meaningful connections with each other and the communities we serve as well as provide ongoing professional development and advancement opportunities.
Our process to attract and retain healthcare professionals for temporary assignments and permanent placement depends on (1) offering a large selection of assignments and placements in a variety of geographies and settings with opportunities for career development, (2) creating competitive compensation packages, (3) developing passionate, knowledgeable recruiters and service professionals who understand the needs of our healthcare professionals and provide a personalized approach, and (4) maintaining a reputation for service excellence.
Word-of-mouth referrals from the thousands of current and former healthcare professionals we have placed enhance our effectiveness at reaching healthcare professionals. 5 Table of Contents Our process to attract and retain healthcare professionals for temporary assignments and permanent placement depends on (1) offering a large selection of assignments and placements in a variety of geographies and settings with opportunities for career development, (2) creating competitive compensation packages, (3) developing passionate, knowledgeable recruiters and service professionals who understand the needs of our healthcare professionals and provide a personalized approach, and (4) maintaining a reputation for service excellence.
While reports differ on the existence and extent of current and future healthcare professional shortages, many regions of the United States are experiencing a shortage of physicians and nurses that we believe will persist in the future. According to the Association of American Medical Colleges, the physician shortage is projected to be between 38,000 and 124,000 physicians by 2034.
While reports differ on the existence and extent of current and future healthcare professional shortages, many regions of the United States are experiencing a shortage of physicians and nurses that we believe will persist in the future. The Association of American Medical Colleges estimates a nationwide physician shortage up to 86,000 by 2036.
Driving increased adoption of our numerous talent solutions through cross-selling will deepen and broaden our customer relationships. We will continue to innovate, develop and invest in new, complementary service and technology solutions that optimize and manage our clients’ workforce, enhance the patient experience, better engage our talent network and expand into different healthcare delivery settings.
We will continue to innovate, develop and invest in new, complementary service and technology solutions that optimize and manage our clients’ workforce, enhance the patient experience, better engage our talent network and expand into different healthcare delivery settings.
These programs are supplemented with professional development resources from third-party vendors and our corporate memberships in large industry associations, to which every team member has access. Our training and development programs include curriculum that promotes and nurtures our values-based culture and commitment to ethics, compliance and diversity, equity and inclusion (as detailed more specifically below).
These programs are supplemented with resources from our corporate memberships in large industry associations, to which every team member has access. Our training and development programs include curriculum that promotes our values-based culture and commitment to ethics and compliance.
A pronounced shift in U.S. age demographics is expected to boost growth of health expenditures, projected by the Centers for Medicare & Medicaid Services to grow 5.0% in 2024 and at a 5.6% annual rate on average from 2025-2031, while annual growth in healthcare spend is projected to increase 7.4% and at an annual rate on average of 5.6% for the same time periods, respectively.
A pronounced shift in U.S. age demographics is expected to boost growth of national health spending, projected by the Centers for Medicare & Medicaid Services to grow at average annual rates of 4.9% and 5.6% from 2025-2026 and 2027-2032, respectively, while Medicare spending growth is projected to increase to average annual rates of 7.1% and 7.6% for the same time periods, respectively.
Additionally, individual states often have regulations governing healthcare staffing agencies and technology platforms, requiring registration and various types of certifications and reporting. Compliance with these laws, rules and regulation has not had, and is not expected to have, a material effect on our capital expenditures, results of operations, or competitive position. Additional Information We maintain a corporate website at www.amnhealthcare.com.
Compliance with these laws, rules and regulations has not had, and is not expected to have, a material effect on our capital expenditures, results of operations, or competitive position. Additional Information We maintain a corporate website at www.amnhealthcare.com.
More than half of our temporary and contract healthcare professional assignments occur at acute-care hospitals. In addition to acute-care hospitals, we provide services to sub-acute healthcare facilities, physician groups, rehabilitation centers, schools, home health service providers and ambulatory surgery centers. Our clients include many of the largest and most prestigious and progressive health care systems in the country.
During 2024, the largest percentages of our revenue were concentrated in California, New York and Texas. More than half of our temporary and contract healthcare professional assignments occur at acute-care hospitals. In addition to acute-care hospitals, we provide services to sub-acute healthcare facilities, physician groups, rehabilitation centers, schools, home health service providers and ambulatory surgery centers.
(5) Interim Leadership Staffing . We provide executive and clinical leadership interim staffing. Practice areas include senior healthcare executives, physician executives, chief nursing officers and other clinical and operational leaders. Interim leaders provide strategic guidance and assist in setting short and long-term goals to offer immediate support, maintain momentum, and contribute leading practices and perspectives.
Practice areas include senior healthcare executives, physician executives, chief nursing officers and other clinical and operational leaders. Interim leaders provide strategic guidance and assist in setting short and long-term goals to offer immediate support, maintain momentum, and contribute leading practices and perspectives. Our interim leaders enjoy the flexibility of a consulting role with the stability of full-time employment.
To reward our employees for their extraordinary efforts and dedication to advancing AMN Healthcare and supporting our clients and healthcare professionals during 2023, we launched the first offering period for our employee stock purchase plan (“ESPP”) to attract, motivate and retain employees and to provide a way for our employees to acquire an equity interest in our company.
To reward our employees for their efforts and dedication to advancing AMN Healthcare and supporting our clients and healthcare professionals and to further align their interests with that of our shareholders, we continued to offer an employee stock purchase plan (“ESPP”) to attract, motivate and retain employees and to provide a way for our employees to acquire an equity interest in our company.
Team Member Communication and Engagement Team member engagement and wellness is of critical importance to our success. In 2023, we continued to prioritize engaging with our team members through monthly town halls and an enterprise-wide company meeting with our chief executive officer and other senior executives.
In 2024, we continued to prioritize engaging with our team members through quarterly town halls and an enterprise-wide company meeting with our chief executive officer and other senior executives.
We believe our investments in technology systems will help us realize greater scale, agility, and cost efficiencies and will improve the experience for our healthcare professionals. Human Capital Management The strength of our human capital management strategy is foundational as we invest resources to address talent shortages, including the healthcare labor shortages faced by our clients.
We believe our investments in technology systems will help us realize greater scale, agility, speed, and cost efficiencies and will improve the experience for our healthcare professionals and clients. Human Capital Management Our human capital management strategy is a foundation of our business strategy as we strive to address the short- and long-term talent needs of our clients.
We believe we are currently licensed in all states that require such licenses and take measures to ensure compliance with all state licensure requirements. In addition, the healthcare professionals who we employ or independently contract with are required to be individually licensed or certified under applicable state laws.
In addition, the healthcare professionals who we employ or independently contract with are required to be individually licensed or certified under applicable state laws. We believe we take appropriate and reasonable steps to validate that our healthcare professionals possess all necessary licenses and certifications.
Kaiser Foundation Hospitals (and its affiliates), to whom we provide clinical managed services, comprised approximately 17% of our consolidated revenue and 22% of our nurse and allied solutions segment revenue for the fiscal year ended December 31, 2023.
Our clients include many of the largest and most prestigious and progressive health care systems in the country. Kaiser Foundation Hospitals (and its affiliates), to whom we provide clinical managed services, comprised approximately 16% of our consolidated revenue and 23% of our nurse and allied solutions segment revenue for the fiscal year ended December 31, 2024.
While the diverse backgrounds and experiences we seek are broad, here is a snapshot of the diversity of our corporate team members as of December 31, 2023: 69% of our team members are women; 63% of our supervisor through senior manager 3 Table of Contents roles are held by women; 56% of our board of directors are women; 43% of our team members are from historically underrepresented groups; our team is 57% Millennials, 32% Generation X, 6% Baby Boomers, and 5% Generation Z; and team members self-identified as veterans, disabled, and LGBTQ+, each representing approximately 3% of our team.
While our team members’ backgrounds and experiences are broad, here is a snapshot of the demographics of our corporate team members as of December 31, 2024: 68% of our team members are women; 73% of our supervisor through senior manager roles are held by women; 44% of our board of directors are women; 37% of our team members identify as black, indigenous, or people of color (“BIPOC”); our team is 57% Millennials, 32% Generation X, 6% Baby Boomers, and 5% Generation Z; and team members self-identified as veterans, disabled, and LGBTQ+, each representing approximately 3% of our team.
We believe we take appropriate and reasonable steps to validate that our healthcare professionals possess all necessary licenses and certifications. We design our internal processes to ensure that the healthcare professionals that we directly place with clients have the appropriate experience, credentials and skills. Our nurse, allied healthcare and locum tenens staffing divisions have received Joint Commission certification.
We design our internal processes to ensure that the healthcare professionals that we directly place with clients have the appropriate experience, credentials and skills. Our nurse, allied healthcare and locum tenens staffing divisions have received Joint Commission certification. We have also obtained our Credentials Verification Organization certification from the National Committee for Quality Assurance.
Substantially all of our people leaders completed our inclusive leaders curriculum and, in 2023, we had a 97% completion rate for our ethics and compliance training program, which includes, but is not limited to, training on our Code of Conduct, harassment prevention and cybersecurity.
In 2024, we had a 98% completion rate for our ethics and compliance training program, which includes, but is not limited to, training on our Code of Conduct, harassment prevention and cybersecurity. Team Member Communication and Engagement Team member engagement is of critical importance to our success.
Our interim leaders enjoy the flexibility of a consulting role with the stability of full-time employment. (6) Executive Search and Academic Leadership . We provide executive leadership search services across the healthcare industry with areas of focus including academic medical centers and children’s hospitals nationwide.
(6) Executive Search and Academic Leadership . Augmenting our permanent placement service offerings, we provide executive leadership search services across the healthcare industry with areas of focus including academic medical centers and children’s hospitals nationwide.
In addition, in 2023, we continued our focus on creating opportunities for team members to build connections with colleagues through our ten employee resource groups (“ERG”). Best practice research indicates that team member engagement and retention is positively impacted if team members are connected to peers who share their viewpoints and backgrounds and leaders who are invested in their success.
Best practice research indicates that team member engagement and retention is positively impacted if team members are connected to peers who share their viewpoints and backgrounds and leaders who are invested in their success. These resource groups continue to foster engagement through their close alignment with the interests and backgrounds of our team members.
We offer temporary and permanent career opportunities to our healthcare professionals, from nurses, doctors, and allied health professionals to healthcare leaders and executives in a variety of settings across the nation. Our strategy is designed to support growth in the number and size of customer relationships and expansion of the markets we serve as care delivery settings continue to expand.
We offer temporary and permanent career opportunities to our healthcare professionals, from nurses, physicians, and allied health professionals to healthcare leaders and executives in a variety of settings across the nation.
Growth of the insured population contributed to a relatively sharp increase in national healthcare expenditures beginning in 2014. Additionally, the U.S. population continues to age, and medical technology advances are contributing to longer life expectancy.
Additionally, the U.S. population continues to age, and medical technology advances are contributing to longer life expectancy.
Through these funds, corporate team members and healthcare professionals can receive financial support for qualifying events such as life-threatening or serious illnesses, natural disasters, funeral costs, or other events causing financial strain. This support is in addition to the insurance and other benefits and employee assistance programs available to support our team members and healthcare professionals.
We also continued our AMN Healthcare Hardship Fund and our AMN Caring for Caregivers Fund, through which corporate team members and healthcare professionals, respectively, can receive financial support for qualifying events such as life-threatening or serious illnesses, natural disasters, funeral costs, or other events causing financial strain.
We recruit our healthcare professionals, depending on the particular service line, under the following brands: AMN Healthcare, Nursefinders, HealthSource Global Staffing, O’Grady Peyton International, Connetics, Medical Search International, DRW Healthcare Staffing, and B.E. Smith.
We recruit our healthcare professionals, depending on the particular service line, under the following brands: AMN Healthcare, Nursefinders, O’Grady Peyton International, Connetics, Medical Search International, DRW Healthcare Staffing, and B.E. Smith. Our recruiting strategy is supported by innovative and effective digital-first marketing programs that focus on lead management, including our digital presence on websites, social media, and mobile applications.
Each ERG is sponsored by one or more members of our executive team, and in 2023, AMN’s collective ERGs hosted more than 100 member events and meetings. Board Oversight Our Board of Directors plays an active role in overseeing our human capital management strategy and programs.
As of December 31, 2024, more than 45% of our corporate team members participate in one or more ERG. Each ERG is sponsored by one or more members of our executive team, and in 2024, AMN’s collective ERGs hosted more than 150 member events and meetings.
When recruiting for healthcare professionals, in addition to other executive search and staffing firms, we also compete with hospital systems that have developed their own recruitment departments and internal travel agencies. Licensure For Our Business Some states require state licensure for businesses that employ, assign and/or place healthcare professionals.
Our leading competitors vary by segment and include Amergis, Aya Healthcare, CHG Healthcare Services, Cross Country Healthcare, HealthTrust Workforce Solutions, Ingenovis Health, Jackson Healthcare, LanguageLine Solutions, and Medical Solutions. When recruiting for healthcare professionals, in addition to other executive search and staffing firms, we also compete with hospital systems that have developed their own recruitment departments and internal travel agencies.
These dynamics could place upward pressure on demand for the services we provide in the coming years. Not only does the age-demographic shift affect healthcare services demand, it also complicates the supply of skilled labor, as an increasing number of clinicians are aging out of the workforce.
Not only does the age-demographic shift affect healthcare services demand, it also complicates the supply of skilled labor, as an increasing number of clinicians are aging out of the workforce. • Adoption of Workforce Solutions . We believe healthcare organizations increasingly seek sophisticated, innovative and economically beneficial total talent solutions that improve patient experience and outcomes.
Changes in demand for healthcare services, particularly at acute healthcare hospitals and other inpatient facilities, like skilled nursing facilities, affect the demand for our services. According to the U.S. Department of Health and Human Services, with the passage of the Affordable Care Act, the uninsured population declined by more than 18 million people between 2010 and 2018.
Department of Health and Human Services, with the passage of the Affordable Care Act, the uninsured population declined by more than 18 million people between 2010 and 2018. Growth of the insured population contributed to a relatively sharp increase in national healthcare expenditures beginning in 2014.
We have also obtained our Credentials Verification Organization certification from the National Committee for Quality Assurance. Government Regulation We are subject to the laws of the United States and certain foreign jurisdictions in which we operate and the rules and regulations of various governing bodies, which may differ among jurisdictions.
Government Regulation 7 Table of Contents We are subject to the laws of the United States and certain foreign jurisdictions in which we operate and the rules and regulations of various governing bodies, which may differ among jurisdictions. Additionally, individual states often have regulations governing healthcare staffing agencies and technology platforms, requiring registration and various types of certifications and reporting.
Our Talent and Compensation Committee provides oversight of our human capital management programs, including talent strategies, diversity, equity and inclusion initiatives, compensation plans and policies, and talent acquisition, development, and retention. Our Services In 2023, we conducted our business through three reportable segments: (1) nurse and allied solutions, (2) physician and leadership solutions, and (3) technology and workforce solutions.
Our Services In 2024, we conducted our business through three reportable segments: (1) nurse and allied solutions, (2) physician and leadership solutions, and (3) technology and workforce solutions.
In nursing, McKinsey & Company estimates a nationwide shortage of between 200,000 and 450,000 nurses available for direct patient care by 2025. Additionally, according to the National Council of State Boards of Nursing, approximately 900,000 registered nurses are anticipated to leave the workforce by the end of 2027.
In nursing, the World Health Organization estimates a worldwide shortage of 4.5 million by 2030. According to the National Council of State Boards of Nursing, approximately 900,000 registered nurses are anticipated to leave the workforce by the end of 2027. Demand for our services is positively correlated with activity in the permanent labor market.
Our team members are located across the country, and we have offices in Dallas, TX; San Diego, CA; Omaha, NE; Boca Raton, FL; Florham Park, NJ; and Atlanta and Savannah, GA. Learning and Professional Development AMN’s purpose is to help our team members and healthcare professionals achieve their personal and professional goals.
Our team members are located across the country, and we have offices in Dallas, TX; San Diego, CA; Boca Raton, FL; Florham Park, NJ; and Atlanta, GA. As of December 31, 2024, we had 2,968 corporate team members, which includes both full-time and part-time employees.
According to the U.S. Census Bureau, the number of adults age 65 or older is on pace to grow an estimated 31% between 2022 and 2035. People over 65 are three times more likely to have a hospital stay and twice as likely to visit a physician office compared with the rest of the population.
People over 65 are three times more likely to have a hospital stay and twice as likely to visit a physician office compared with the rest of the population. These dynamics could place upward pressure on demand for the services we provide in the coming years.
In its 2023 ratings for total workforce solutions, HRO Today recognized AMN Healthcare as the top-ranking healthcare workforce provider based on overall capabilities; we also were honored in the Baker’s Dozen for quality of services, breadth of services and size of deals for both MSPs and total workforce solutions.
As compared to many private firms, we also offer transparency and financial and operational controls, which we believe further enhance the value of our service offering. In its 2024 ratings for MSPs, HRO Today recognized AMN Healthcare in the Baker’s Dozen for overall quality of services, breadth of services and size of deals.
Our recent acquisition of MSI Systems Corp. and DrWanted.com LLC (together, “MSDR”) expands our portfolio of physician solutions and provides clients with a larger and more diverse candidate pool. We also offer full-service, permanent physician search across many specialties and modalities, specializing in recruiting and placing top physicians and advanced practitioner talent in jobs across the country.
We also offer full-service, permanent physician search (also referred to as physician permanent placement) across many specialties and modalities, specializing in recruiting and placing top physicians and advanced practitioner talent in jobs across the country. (5) Interim Leadership Staffing . We provide executive and clinical leadership interim staffing.
In 2 Table of Contents addition to our team members and independent contractors, we also leverage global partners to support our 24/7 client service model. Health and Safety AMN is committed to providing comprehensive benefit options, including health insurance, a prescription drug benefit, life and disability insurance, and paid time off.
For our corporate team members, we provide comprehensive benefit options, including health insurance, a prescription drug benefit, life and disability insurance, and paid time off.
These technology investments provide a more seamless and efficient workflow for our team members, our healthcare professionals and our clients.
These technology investments provide a more seamless and efficient workflow for our team members, our healthcare professionals and our clients. For example, during 2024, we launched WorkWise, a healthcare technology solution that quantifies staffing demand with predictive scheduling, automates workforce and vendor management in one solution, and seeks to improve the clinician experience.
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We also continued our AMN Healthcare Hardship Fund, providing financial support for team members experiencing extreme financial hardship, as well as launched our AMN Caring for Caregivers Fund to provide similar support to our healthcare professionals.
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Our strategy is designed to support growth in the number and size of customer relationships and expansion of the markets we serve as care delivery settings continue to evolve and expand. Driving increased adoption of our numerous talent solutions through cross-selling will deepen and broaden our customer relationships.
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We also invested in the long-term financial well-being of our corporate team members by adding a Roth 401(k) option to our existing 401(k) program beginning January 1, 2024. As of December 31, 2023, we had 3,585 corporate team members, which includes both full-time and part-time employees.
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This support is in addition to the insurance and other benefits and employee assistance programs available to support our team members and healthcare professionals.
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In June 2022, as the pandemic subsided and workplace safety improved with the availability of vaccines, we carefully returned to the office in phases.
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In addition to our team members and independent contractors, we also leverage global partners to support our 24/7 client service model. Learning and Professional Development To help our team members and healthcare professionals achieve their personal and professional goals, we continue to make significant investments in our multi-faceted professional development programs.
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To fulfill this purpose, we continue to make significant investments in our multi-faceted professional development programs.
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To assess the engagement of our team members and take action to mitigate risks associated with workforce engagement, development and retention, we conducted our annual survey to assess team member engagement, with 79% enterprise participation. In 2024, we continued our focus on creating opportunities for team members to build connections with colleagues through our ten employee resource groups (“ERG”).
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Diversity, Equity and Inclusion At AMN our diversity, equity and inclusion (“DEI”) philosophy is grounded in the belief that creating an inclusive workplace that captures diverse perspectives and backgrounds is instrumental in fueling innovation and driving better outcomes for our clients and clinicians, making us the leader in total talent solutions.
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Board Oversight 3 Table of Contents Our Board of Directors plays an active role in overseeing our human capital management strategy and programs. Our Talent and Compensation Committee provides oversight of our human capital management programs, including talent strategies, compensation plans and policies, and talent acquisition, development, engagement and retention.
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We are committed to driving DEI at AMN and throughout our value chain and industry. The DEI Excellence Council sponsored by our executive leadership team, ensures we advance enterprise inclusion efforts.
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According to the U.S. Census Bureau, the number of adults age 65 or older grew by 9.4% from 6 Table of Contents 2020 to 2023 and is projected to grow an estimated 31% between 2022 and 2035.

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Item 1A. Risk Factors

Risk Factors — what could go wrong, per management

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Biggest changeAny such access, disclosure or other loss of information could (1) result in legal claims or proceedings, liability under laws that protect the privacy of personal information and regulatory penalties, (2) disrupt our operations and the services we provide to our clients and (3) damage our reputation, any of which could adversely affect our profitability, revenue and competitive position. 15 Table of Contents The inability to quickly and properly credential and match quality healthcare professionals with suitable placements may negatively affect demand for our services.
Biggest changeThe Company’s use of AI may also lead to novel and urgent cybersecurity risks, including access to or the misuse of personal data. 14 Table of Contents Any such access, disclosure or other loss of information could (1) result in legal claims or proceedings, liability under laws that protect the privacy of personal information and regulatory penalties, (2) disrupt our operations and the services we provide to our clients and (3) damage our reputation, any of which could adversely affect our profitability, revenue and competitive position.
The COVID-19 pandemic has disrupted, and any other future outbreak of illness or other public health crises or reemergence or future strain of COVID-19 may also disrupt, our operations due to the unavailability of our corporate team members or healthcare professionals due to illness, risk of illness, quarantines, travel restrictions, vaccine mandates or other factors that limit our existing or potential workforce and pool of candidates.
The COVID-19 pandemic disrupted, and any other future outbreak of illness or other public health crises or reemergence or future strain of COVID-19 may also disrupt, our operations due to the unavailability of our corporate team members or healthcare professionals due to illness, risk of illness, quarantines, travel restrictions, vaccine mandates or other factors that limit our existing or potential workforce and pool of candidates.
If our clients are able to increase the effectiveness of their staffing and recruitment functions through analytics, automation, machine learning, artificial intelligence or other advanced technologies or otherwise increase the effectiveness of their permanent hiring or retention of permanent employees, their need for our services may decline.
If our clients are able to increase the effectiveness of their staffing and recruitment functions through analytics, automation, machine learning, artificial intelligence (“AI”) or other advanced technologies or otherwise increase the effectiveness of their permanent hiring or retention of permanent employees, their need for our services may decline.
Like all employers, we must also comply with various laws and regulations relating to employment and pay practices and from time to time may be subject to individual and class action lawsuits related to alleged wage and hour violations under California and Federal law.
Like all employers, we must also comply with various laws and regulations relating to employment and pay practices and from time to time may be subject to individual, representative and class action lawsuits related to alleged wage and hour violations under California and Federal law.
Patient delivery settings continue to evolve, giving rise to alternative modes of healthcare delivery, such as retail medicine, telemedicine and home health. In addition, changes in reimbursement models and government mandates are also impacting the healthcare environments.
Patient delivery settings continue to evolve, giving rise to alternative modes of healthcare delivery, such as retail medicine, telemedicine and home health. In addition, changes in reimbursement models and government mandates are also impacting healthcare environments.
The repeal or significant erosion of the Patient Protection and Affordable Care Act (“ACA”) without a corresponding replacement may negatively affect the demand for our services. 11 Table of Contents In 2010, the adoption of the ACA brought significant reforms to the health care system that included, among other things, a requirement that all individuals have health insurance (with limited exceptions).
The repeal or significant erosion of the Patient Protection and Affordable Care Act (“ACA”) without a corresponding replacement may negatively affect the demand for our services. 10 Table of Contents In 2010, the adoption of the ACA brought significant reforms to the health care system that included, among other things, a requirement that all individuals have health insurance (with limited exceptions).
If that were to occur, we may further increase our allowance for expected credit losses and our days sales outstanding would be negatively affected. 10 Table of Contents If we are unable to anticipate and quickly respond to changing marketplace conditions, such as alternative modes of healthcare delivery, reimbursement and client needs, we may not remain competitive.
If that were to occur, we may further increase our allowance for expected credit losses and our days sales outstanding would be negatively affected. 9 Table of Contents If we are unable to anticipate and quickly respond to changing marketplace conditions, such as alternative modes of healthcare delivery, reimbursement and client needs, we may not remain competitive.
These covenants limit our ability to, among other things: • incur or guarantee additional indebtedness or issue certain preferred equity, • pay dividends on, redeem, repurchase, or make distributions in respect of our capital stock, prepay, redeem, or repurchase certain debt or make other restricted payments, • make certain investments, • create, or permit to exist, certain liens, • sell assets, • enter into sale/leaseback transactions, • enter into agreements restricting restricted subsidiaries’ ability to pay dividends or make other payments, • consolidate, merge, sell, or otherwise dispose of all or substantially all of our assets, • enter into certain transactions with affiliates, and • designate restricted subsidiaries as unrestricted subsidiaries.
These covenants limit our ability to, among other things: 17 Table of Contents • incur or guarantee additional indebtedness or issue certain preferred equity, • pay dividends on, redeem, repurchase, or make distributions in respect of our capital stock, prepay, redeem, or repurchase certain debt or make other restricted payments, • make certain investments, • create, or permit to exist, certain liens, • sell assets, • enter into sale/leaseback transactions, • enter into agreements restricting restricted subsidiaries’ ability to pay dividends or make other payments, • consolidate, merge, sell, or otherwise dispose of all or substantially all of our assets, • enter into certain transactions with affiliates, and • designate restricted subsidiaries as unrestricted subsidiaries.
If new or additional caps or other price limitations were imposed that prevented us from passing these increased costs on or if the amount that we were able to pass on to our clients, it would likely have an adverse impact on our financial performance and profitability.
If new or additional caps or other price limitations were imposed that prevented us from passing these increased costs on or if the amount that we were able to pass on to our clients is limited, it would likely have an adverse impact on our financial performance and profitability.
If we are unable to design, develop, acquire, implement and utilize, in a cost-effective manner, technology and information systems that provide the capabilities necessary for us to compete effectively, or for any 14 Table of Contents reason any interruption or loss of our information processing capabilities occurs, this could harm our business, results of operations and financial condition.
If we are unable to design, develop, acquire, implement and utilize, in a cost-effective manner, technology and information systems that provide the capabilities necessary for us to compete effectively, or for any reason any interruption or loss of our information processing capabilities occurs, this could harm our business, results of operations and financial condition.
We could be negatively affected by the widespread outbreak of an illness or any other public health crisis. The COVID-19 pandemic negatively impacted the global economy and created significant volatility and disruption of financial markets. 9 Table of Contents Demand for our staffing services and workforce technology solutions fluctuated over the course of the COVID-19 pandemic.
We could be negatively affected by the widespread outbreak of an illness or any other public health crisis. The COVID-19 pandemic negatively impacted the global economy and created significant volatility and disruption of financial markets. Demand for our staffing services and workforce technology solutions fluctuated over the course of the COVID-19 pandemic.
These dynamics each separately or together could negatively affect pricing for our services and our ability to maintain certain clients. Hospital concentration coupled with our success in winning managed services contracts means our revenues from some larger health systems have grown and may continue to grow substantially relative to our other revenue sources.
These dynamics each separately or together could negatively affect pricing for our services and our ability to maintain certain clients. Hospital concentration coupled with our managed services contracts means our revenues from some larger health systems have grown and may continue to grow substantially relative to our other revenue sources.
A reclassification of our locum tenens to employees from independent contractors could result in liability that would have a significant negative impact on our profitability for the period in which such reclassification was implemented, and would require changes to our payroll and related business processes, which could be costly.
A reclassification of our locum tenens to employees from independent contractors could result in liability that would have a significant negative impact on our profitability for the period in which such reclassification was implemented, and would require changes to our payroll and 12 Table of Contents related business processes, which could be costly.
We maintain various types of insurance coverage for many types of claims, including professional liability, errors and omissions, employment practices and cyber, through commercial insurance carriers and a wholly-owned captive insurance company and for other claims such as wage and hour practices and competition actions, we are uninsured.
We maintain various types of insurance coverage for many types of claims, including professional liability, errors and omissions, employment practices and cyber, through commercial insurance carriers and a wholly-owned captive insurance 11 Table of Contents company and for other claims such as wage and hour practices and competition actions, we are uninsured.
Our inability to consummate and effectively incorporate acquisitions into our business operations may adversely affect our long-term growth and our results of operations. 16 Table of Contents We invest time and resources in carefully assessing opportunities for acquisitions, and acquisitions are a key component of our growth strategy.
Our inability to consummate and effectively incorporate acquisitions into our business operations may adversely affect our long-term growth and our results of operations. We invest time and resources in carefully assessing opportunities for acquisitions, and acquisitions are a key component of our growth strategy.
We may also experience increased insurance premiums and retention and deductible accruals that we may not be able to pass on to our clients, thereby 12 Table of Contents reducing our profitability. Moreover, our insurance coverage and reserve accruals may not be sufficient to cover all claims against us.
We may also experience increased insurance premiums and retention and deductible accruals that we may not be able to pass on to our clients, thereby reducing our profitability. Moreover, our insurance coverage and reserve accruals may not be sufficient to cover all claims against us.
With the advent of technology and more sophisticated staffing management and recruitment processes, including internal “travel,” other healthcare staffing models, and the increasing adoption of artificial intelligence technologies, clients may be able to successfully increase the efficiency and effectiveness of their internal staffing management and recruiting efforts, through more effective planning and analytic tools, internet- or social media-based recruiting or otherwise.
With the 8 Table of Contents advent of technology and more sophisticated staffing management and recruitment processes, including internal “travel,” other healthcare staffing models, and the increasing adoption of AI technologies, clients may be able to successfully increase the efficiency and effectiveness of their internal staffing management and recruiting efforts, through more effective planning and analytic tools, internet- or social media-based recruiting or otherwise.
In addition, as technology continues to evolve, more tasks currently performed by people may continue to be replaced by automation, robotics, machine learning, artificial intelligence and other technological advances outside of our control.
In addition, as technology continues to evolve, more tasks currently performed by people may continue to be replaced by automation, robotics, machine learning, AI and other technological advances that may be outside of our control.
In addition, we have and may in the future experience negative financial effects related to the COVID-19 pandemic due to higher workers’ compensation and health insurance costs, for which we are largely self-insured, and payroll costs associated with quarantine of our healthcare professionals.
In addition, we have and may in the future experience negative financial effects related a pandemic or other future outbreaks of illness due to higher workers’ compensation and health insurance costs, for which we are largely self-insured, and payroll costs associated with quarantine of our healthcare professionals.
For example, Kaiser Foundation Hospitals (and its affiliates) (collectively, “Kaiser”) comprised approximately 17% of our consolidated revenue in 2023.
For example, Kaiser Foundation Hospitals (and its affiliates) (collectively, “Kaiser”) comprised approximately 16% of our consolidated revenue in 2024.
The loss of key officers and management personnel could adversely affect our business and operating results. We believe that the success of our business strategy and our ability to maintain our recent levels of profitability depends on the continued employment of our senior executive team. All of our executive officers are employees at will with standard severance agreements.
The loss of key officers and management personnel could adversely affect our business and operating results. We believe that the success of our business strategy and our ability to maintain our recent levels of profitability depends on the continued employment of our senior executive team.
The performance, reliability and security of our technology-enabled services, including our language interpretation services and SaaS-based technologies, such as AMN Language Services, ShiftWise, including the recent release of ShiftWise Flex, Medefis, b4health, and Avantas Smart Square are critical to such offerings’ operations, reputation and ability to attract new clients.
The performance, reliability and security of our technology-enabled services, including our language interpretation services and SaaS-based technologies, such as AMN Language Services, ShiftWise Flex, Medefis, b4health, and Avantas Smart Square are critical to such offerings’ operations, reputation and ability to attract new clients. Some of our clients rely on our SaaS-based technologies to perform certain of their operational functions.
We are subject to federal and state healthcare industry regulation including conduct of operations, costs and payment for services and payment for referrals as well as laws regarding government contracting. The healthcare industry is subject to extensive and complex federal and state laws and regulations related to conduct of operations, costs and payment for services and payment for referrals.
We are subject to federal and state healthcare industry regulation including conduct of operations, costs and payment for services and payment for referrals as well as laws regarding immigration and government contracting.
The costs and speed with which we provide these credentialing services impact the revenue and profitability of our business. Our operations may deteriorate if we are unable to continue to attract, develop and retain our sales and operations team members.
The costs and speed with which we provide these credentialing services, which in part is dependent on the availability of our third-party vendors, impact the revenue and profitability of our business. Our operations may deteriorate if we are unable to continue to attract, develop and retain our sales and operations team members.
Our clients are facing cost pressures and in turn are looking to decrease expenses, including for contingent labor and other services. Demand for our services may be impacted by these cost pressures and we may be subject to claims from these clients relating to the ability to provide services under terms and conditions that they believe are fair and reasonable.
Demand for our services may be impacted by these cost pressures and we may be subject to claims from these clients relating to the ability to provide services under terms and conditions that they believe are fair and reasonable.
Although we were in compliance with the financial ratios and financial condition tests set forth in our credit agreement on December 31, 2023, we cannot provide assurance that we will continue to be.
In addition, the restrictive covenants in our credit agreement require us to maintain specified financial ratios and satisfy other financial condition tests. Although we were in compliance with the financial ratios and financial condition tests set forth in our credit agreement on December 31, 2024, we cannot provide assurance that we will continue to be.
If members of our executive team become unable or unwilling to continue in their present positions, our business and financial results could be adversely affected. Our inability to maintain our positive brand awareness and identity may adversely affect our results of operations.
All of our executive officers are employees at will with standard 15 Table of Contents severance agreements. If members of our executive team become unable or unwilling to continue in their present positions, our business and financial results could be adversely affected. Our inability to maintain our positive brand awareness and identity may adversely affect our results of operations.
As of December 31, 2023, our total indebtedness, net of unamortized fees and premium, equaled $1,304.7 million.
As of December 31, 2024, our total indebtedness, net of unamortized fees and premium, equaled $1,055.9 million.
Our ability to ensure the quality of our healthcare professionals also relies heavily on the effectiveness of our data and communication systems as well as properly trained and competent team members that credential and match healthcare professionals in suitable placements and third-party vendors that provide ancillary services.
Our ability to ensure the quality of our healthcare professionals also relies heavily on the effectiveness of our data and communication systems as well as properly trained and competent team members and third-party vendors that credential and match healthcare professionals in suitable placements. We also rely on the accuracy and credibility of information provided by licensing bodies and educational institutions.
If our current or planned systems do not adequately support our operations, are damaged or disrupted or if we are unable to replace, repair, maintain or expand them, it may adversely affect our business operations and our profitability. Our business could be harmed if we fail to further develop and evolve our current talent solutions technology offerings and capabilities.
If our current or planned systems do not adequately support our operations, are damaged or disrupted or if we are unable to replace, repair, maintain or expand them, it may adversely affect our business operations and our profitability.
Conversely, when hospital admissions decrease in economic downturns or periods of high inflation, due to reduced consumer spending, the demand for our temporary healthcare professionals typically declines.
Demand for staffing services is sensitive to changes in economic activity. Many healthcare facilities utilize temporary healthcare professionals to accommodate an increase in hospital admissions. Conversely, when hospital admissions decrease in economic downturns or periods of high inflation, due to reduced consumer spending, the demand for our temporary healthcare professionals typically declines.
If there were an event of default under any of our debt instruments, holders of such defaulted debt could cause all amounts borrowed under the applicable instrument to be due and payable immediately.
If there were an event of default under any of our debt instruments, holders of such defaulted debt could cause all amounts borrowed under the applicable instrument to be due and payable immediately. Our assets or cash flow may not be sufficient to repay borrowings under our outstanding debt instruments in the event of a default thereunder.
In addition, many states have laws that prohibit non-physician owned companies from employing physicians, referred to as the “corporate practice of medicine.” If our independent contractor physicians were classified as employees in states that prohibit the corporate practice of medicine, we may be prohibited from conducting our locum tenens staffing business in those states under our current business model, which may have a substantial negative effect on our revenue, results of operations and profitability. 13 Table of Contents Risk Factors Related to Our Operations, Personnel and Information Systems If we do not continue to recruit and retain sufficient quality healthcare professionals at reasonable costs, it could increase our operating costs and negatively affect our business and our profitability.
In addition, many states have laws that prohibit non-physician owned companies from employing physicians, referred to as the “corporate practice of medicine.” If our independent contractor physicians were classified as employees in states that prohibit the corporate practice of medicine, we may be prohibited from conducting our locum tenens staffing business in those states under our current business model, which may have a substantial negative effect on our revenue, results of operations and profitability.
As our business continues to evolve and we provide a wider range of services, we will become increasingly dependent upon our employees, particularly those operating in business environments less familiar to us. Failure to identify, hire, train and retain talented employees who share our values could have a negative effect on our reputation and our business.
As our business continues to evolve and we provide a wider range of services, we will become increasingly dependent upon our employees, particularly those operating in business environments less familiar to us.
Initially, in 2020, demand for some temporary healthcare professionals and services decreased as the demand for non-essential and elective healthcare was initially negatively impacted by the COVID-19 pandemic.
Initially, in 2020, demand for some temporary healthcare professionals and services decreased as the demand for non-essential and elective healthcare was initially negatively impacted by the COVID-19 pandemic. As the pandemic subsided, demand and bill rates, especially in our nurse and allied solutions businesses, decreased from the levels seen during the pandemic.
If any of these problems occur, our clients may, among other things, terminate their agreements with us or make indemnification or other claims against us, which may also negatively affect us.
Accordingly, any degradation, errors, defects, disruptions or other performance problems with our SaaS-based technologies could damage our or our clients’ operations and reputations and negatively affect our business. If any of these problems occur, our clients may, among other things, terminate their agreements with us or make indemnification or other claims against us, which may also negatively affect us.
With continuing clinician burnout rates resulting from the COVID-19 pandemic, an ongoing shortage of certain qualified nurses and physicians in many areas of the United States and low unemployment rates for nurses and physicians, competition for the hiring of these professionals remains intense.
With continuing clinician burnout rates, an ongoing shortage of certain qualified nurses and physicians in many areas of the United States and low unemployment rates for nurses and physicians, competition for the hiring of these professionals remains intense. Our ability to recruit temporary and permanent healthcare professionals may be exacerbated by continued low levels of unemployment.
The demands that our current and future growth place on our people and systems, controls, compliance efforts, policies and procedures may exceed the benefits of such growth, and our operating results may suffer, at least in the short-term, and perhaps in the long-term.
Failure to identify, hire, train and retain talented employees who share our values could have a negative effect on our reputation and our business. 16 Table of Contents The demands that our current and future growth place on our people and systems, controls, compliance efforts, policies and procedures may exceed the benefits of such growth, and our operating results may suffer, at least in the short-term, and perhaps in the long-term.
We may also be subject to claims regarding the health and safety of our healthcare professionals and our corporate team members. The economic impact of the COVID-19 pandemic has negatively impacted the financial condition of many hospitals and healthcare systems.
We may also be subject to claims regarding the health and safety of our healthcare professionals and our corporate team members.
To achieve our strategic objectives and to remain competitive, we must continue to develop and enhance our talent solutions technology offerings and capabilities. This may require the acquisition of equipment and software and the development of new proprietary software and capabilities, either internally or through independent consultants, which may require significant investment of capital.
This may require the acquisition of equipment and software and the development of new proprietary software and capabilities, either internally or through independent consultants, which may require significant investment of capital.
In a situation such as ransomware attack, our access to critical business information and ability to conduct business may be interrupted or impaired.
In a situation such as ransomware attack, our access to critical business information and ability to conduct business may be interrupted or impaired. Further, unauthorized use or misuse of AI by the Company’s employees, vendors or others may result in disclosure of confidential Company and customer data.
As we grow and increase our leadership position, we are at greater risk for anti-competitive conduct claims and investigations, such as violation of federal and state antitrust laws, unfair business practices and “price-gouging.” An environment of high-demand for healthcare staffing support coupled with the healthcare labor shortage, especially with respect to nurse and allied healthcare professionals, has led and may continue to lead to higher wages for healthcare professionals and higher costs to our clients for healthcare staffing.
An environment of high-demand for healthcare staffing support coupled with the healthcare labor shortage, especially with respect to nurse and allied healthcare professionals, has led and may continue to lead to higher wages for healthcare professionals and higher costs to our clients for healthcare staffing.
We provide talent solutions and technologies on a contract basis to our clients, who pay us directly. Accordingly, Medicare, Medicaid and insurance reimbursement policy changes generally do not directly impact us. Nevertheless, reimbursement changes in government programs, particularly Medicare and Medicaid, can and do indirectly affect the demand and the prices paid for our services.
The healthcare industry is subject to extensive and complex federal and state laws and regulations related to conduct of operations, costs and payment for services and payment for referrals. We provide talent solutions and technologies on a contract basis to our clients, who pay us directly. Accordingly, Medicare, Medicaid and insurance reimbursement policy changes generally do not directly impact us.
The extent of the impact of COVID-19 on our operational and financial performance will depend on future developments, including the duration and spread of COVID-19. Additionally, outbreaks of illness or public health crises other than COVID-19 could occur and may have similar or even more significant impact on our business.
Additionally, outbreaks of illness, public health crises or reemergence or future strain of COVID-19 could occur and may have similar or even more significant impact on our business. Economic downturns, inflation and slow recoveries could result in less demand from clients and pricing pressure that could negatively impact our financial condition.
However, we are unable to predict the duration and extent to which demand for our services could be negatively impacted by the COVID-19 pandemic or could be negatively impacted as the pandemic subsides.
This decrease in demand has had a negative impact on our revenue, financial condition, and results of operations. However, we are unable to predict the duration and extent to which demand for our services or bill rates will be negatively impacted.
However, the failure or inability to perform or adhere to law, regulation and our policies on the part of one or more of these critical suppliers or perform the services in a timely manner could cause significant disruptions and increased costs to our business as well as reputational damage.
However, the failure or inability to perform on the part of one or more of these critical partners has caused and could in the future cause disruptions and increased costs. We are also dependent on security measures that some of our third-party vendors and customers are taking to protect their own systems and infrastructures.
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During 2021, demand for nurse and allied healthcare professionals reached record highs and throughout 2021 and 2022 demand for most other types of healthcare professionals we work with returned to and remained above pre-pandemic levels.
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The economic impact of the COVID-19 pandemic negatively impacted the financial condition of many hospitals and healthcare systems, and our clients continue to face cost pressures and in turn are looking to decrease expenses, including for contingent labor and other services.
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As the pandemic has subsided, demand and bill rates, especially in our nurse and allied solutions businesses, have fluctuated from the levels seen during the pandemic. We expect this decrease in demand will have a negative impact on our revenue, financial condition, and results of operations.
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As we grow and increase our leadership position, we are at greater risk for anti-competitive conduct claims and investigations, such as violation of federal and state antitrust laws and unfair business practices.
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In addition, the significant level of individuals who left the workforce, changed jobs and/or entered the “gig workforce” over the last two years may cause an increase in under- and uninsured patients, which generally results in a reduction in overall healthcare utilization and a decrease in demand for our services.
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As we incorporate AI and machine learning into our business there are uncertainties in the legal regulatory regime relating to AI that may require significant resources to modify and maintain our business practices to comply with U.S. and non-U.S. laws, the nature of which cannot be determined at this time.
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We are unable to predict the duration and extent to which our businesses could be negatively impacted by this shift in the labor market.
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If the jurisdictions in which we operate decide to adopt laws governing AI, such legislation may render the use of such technologies challenging, impossible or financially prohibitive.
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Economic downturns, inflation and slow recoveries could result in less demand from clients and pricing pressure that could negatively impact our financial condition. Demand for staffing services is sensitive to changes in economic activity. Many healthcare facilities utilize temporary healthcare professionals to accommodate an increase in hospital admissions.
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Nevertheless, reimbursement changes in government programs, particularly Medicare and Medicaid, can and do indirectly affect the demand and the prices paid for our services.
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Our ability to recruit temporary and permanent healthcare professionals may be exacerbated by continued low levels of unemployment.
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In our international nurse business, we recruit registered nurses from outside of the United States who rely on visas to be eligible to be placed or hired directly with healthcare facilities.
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Some of our clients rely on our SaaS-based technologies to perform certain of their operational functions. Accordingly, any degradation, errors, defects, disruptions or other performance problems with our SaaS-based technologies could damage our or our clients’ operations and reputations and negatively affect our business.
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Visa retrogression, where the date(s) that determine availability for applying for a visa are moved to a later date, has had and may in the future have a negative impact on our international nursing volumes. Additionally, other changes in immigration policy, laws and processes could negatively impact our financial performance.
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We also rely on the accuracy and credibility of information provided by licensing bodies and educational institutions.
Added
Risk Factors Related to Our Operations, Personnel and Information Systems If we do not continue to recruit and retain sufficient quality healthcare professionals at reasonable costs, it could increase our operating costs and negatively affect our business and our profitability.
Removed
If we identify an impairment, we record a 17 Table of Contents charge to earnings. An impairment charge to goodwill or intangible assets would decrease our earnings or increase our losses, as the case may be.
Added
Our business could be harmed if we fail to further develop and evolve our current talent solutions technology offerings and capabilities. 13 Table of Contents To achieve our strategic objectives and to remain competitive, we must continue to develop and enhance our talent solutions technology offerings and capabilities.
Removed
Our assets or cash flow may not be sufficient to repay borrowings under our outstanding debt instruments in the event of a default thereunder. 18 Table of Contents In addition, the restrictive covenants in our credit agreement require us to maintain specified financial ratios and satisfy other financial condition tests.
Added
Use of AI may result in operational challenges or issues, liability, and reputational concerns. Our business uses and intends to further rely on AI technology, which introduces certain risks including dependency on accurate AI performance, potential data privacy and security breaches, challenges in regulatory compliance, ethical considerations, potential workforce disruption, the risk of intellectual property infringement, and emerging technology risks.
Added
While we have established policies governing the use of AI technology, we cannot ensure that our employees, contractors or other agents will adhere to those policies. Failure to address these risks adequately may negatively impact our operations, reputation and financial performance.
Added
Additionally, other unforeseen risks stemming from our use and development of AI tools and technology may arise in the future that could adversely affect our business, financial condition and results of operations. The inability to quickly and properly credential and match quality healthcare professionals with suitable placements may negatively affect demand for our services.
Added
If our third-party vendors do not maintain adequate security measures, do not require their sub-contractors to maintain adequate security measures, do not perform as anticipated and in accordance with contractual requirements, or become targets of cyber-attacks, we may experience operational difficulties and increased costs, as well as reputational damage, which could materially and adversely affect our business.
Added
If we identify an impairment, we record a non-cash charge to earnings. During the year ended December 31, 2024, we recognized goodwill impairment losses totaling $222.5 million. See additional information in “Item 8.
Added
Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements— Note ( 4 ) , Goodwill and Identifiable Intangible Assets.” We may have additional impairment losses in connection with our periodic evaluation of our goodwill and intangible assets.
Added
In the event of further impairment, a non-cash impairment charge could have a material adverse effect on our results of operations and balance sheet.

Item 1C. Cybersecurity

Cybersecurity — threats and controls disclosure

13 edited+1 added−1 removed4 unchanged
Biggest changeOur CIO has over 25 years of experience serving as Chief Information Officer, Senior Vice President of IT, and Director of IT at various healthcare services and technology companies. AMN’s Senior Director, Information Security has over 20 years of experience in various roles in information technology and information security.
Biggest changeOur CIO and Vice President, Information & Cyber Security have proven experience as technology leaders establishing and overseeing enterprise information security programs in the healthcare industry. Our CIO has over 25 years of experience serving as Chief Information Officer, Senior Vice President of IT, and Director of IT at various healthcare services and technology companies.
AMN’s information security program has adopted policies, standards, processes, and practices that follow recognized frameworks established by the National Institute of Standards and Technology (“NIST”), the International Organization for Standardization, and other relevant standards. AMN Healthcare has also implemented certain controls and procedures that allow its management to assess, identify, and manage material risks from cybersecurity threats.
AMN’s information and cybersecurity program has adopted policies, standards, processes, and practices that follow recognized frameworks established by the National Institute of Standards and Technology (“NIST”), the International Organization for Standardization, and other relevant standards. AMN Healthcare has also implemented certain controls and procedures that allow its management to assess, identify, and manage material risks from cybersecurity threats.
Item 1C. Cybersecurity AMN Healthcare’s board of directors (the “Board”) is responsible for overseeing our enterprise-wide risk management program. The audit committee of the Board (the “Audit Committee”) has primary oversight responsibility for information security and cybersecurity, including internal controls designed to mitigate risks related to these topics.
Item 1C. Cybersecurity AMN Healthcare’s board of directors (the “Board”) is responsible for overseeing our enterprise-wide risk management program. The audit committee of the Board (the “Audit Committee”) has primary oversight responsibility for information and cybersecurity, including internal controls designed to mitigate risks related to these topics.
To identify and assess material risks from cybersecurity threats, we engage in regular network and endpoint monitoring, vulnerability assessments, penetration testing, and tabletop exercises. We have developed an incident response plan to manage identified vulnerabilities and further improve our cybersecurity preparedness and response infrastructure.
To identify and assess material risks from cybersecurity threats, we engage in regular network and endpoint monitoring, vulnerability assessments, penetration testing, and periodic tabletop exercises. We have developed an incident response plan to manage identified vulnerabilities and further improve our cybersecurity preparedness and response infrastructure.
The Company has experienced cyber threats resulting in immaterial cyber incidents and expects cyber threats to continue with varying levels of sophistication.
The Company has experienced cyber threats resulting in immaterial cyber incidents and expects cyber threats to continue with varying levels of sophistication. 19 Table of Contents
AMN’s information security program reports up to our Chief Information & Digital Officer (“CIO”) and is managed by our Senior Director, Information Security, whose team is responsible for leading our enterprise-wide cybersecurity strategy.
AMN’s information and cybersecurity program reports up to our Chief Information & Digital Officer (“CIO”) and is managed by our Vice President, Information & Cyber Security, whose team is responsible for leading our enterprise-wide cybersecurity strategy.
Through ongoing communications with the team, the CIO and the Senior Director, Information Security, are informed about and monitor the prevention, detection, mitigation and remediation of cybersecurity incidents and progress on cybersecurity infrastructure initiatives.
Through ongoing communications with the team, the CIO and the Vice President, Information & Cyber Security, are informed about and monitor the prevention, detection, mitigation and remediation of cybersecurity incidents and progress on cybersecurity infrastructure initiatives.
In addition to updating the Audit Committee, the CIO and Senior Director, Information Security, and Privacy team provide regular updates to our Chief Executive Officer and other members of our senior management as appropriate.
In addition to updating the Audit Committee, the CIO and Vice President, Information & Security, and Privacy team provide regular updates to the Corporate Governance and Compliance Committee, as well as our Chief Executive Officer and other members of our senior management as appropriate.
We have also implemented processes to identify, monitor and address material risks from cybersecurity threats associated with our use of third-party vendors, including those in our supply chain or who have access to our systems, data or facilities that house such systems or data.
We maintain and operate a proactive threat intelligence program to identify and assess risk. We have implemented processes to identify, monitor and address material risks from cybersecurity threats associated with our use of third-party vendors, including those in our supply chain or who have access to our systems, data or facilities that house such systems or data.
Material breaches, if any, and any disclosure obligations arising from any such breach are also discussed during separate Audit Committee meetings as part of the Boards’ risk oversight generally.
Material breaches, if any, and any disclosure obligations arising from any such breach are also discussed separately with the Audit Committee as part of the Board’s risk oversight generally.
In addition to our in-house capabilities, we engage with key security and technology vendors, industry participants and intelligence communities to assess our program and test our technical capabilities and enhance the effectiveness of our information security policies and procedures.
In addition to our in-house capabilities, we engage with key security and technology vendors, industry participants and intelligence communities to assess our program and test our technical capabilities and enhance the effectiveness of our information and cybersecurity policies and procedures. We use a combination of tools and technologies to protect AMN Healthcare’s assets and information.
In the event of a material cybersecurity incident, the CIO will escalate to the Audit Committee and the Board is made aware as appropriate and in accordance with AMN’s incident response plan. Our CIO and Senior Director, Information Security have proven experience as technology leaders establishing and overseeing enterprise information security programs in the healthcare industry.
In the event of a material cybersecurity incident, the CIO, in coordination with AMN’s Chief Legal Officer, will escalate to the Audit Committee and the Board is made aware as appropriate and in accordance with AMN’s incident response plan.
He holds a M.Sc. in Computer Information Systems and holds several relevant certifications, including Certified Information Security Manager and Zero Trust Certified Architect. 19 Table of Contents AMN’s Privacy function, which reports up through our Chief Legal Officer, works collaboratively with the Information Security function and to create and review policies, standards and processes.
AMN’s Privacy function, which reports up through our Chief Legal Officer, works collaboratively with the Information Security function to create and review policies, standards and processes.
Removed
We use a combination of tools and technologies to protect AMN Healthcare and the personal information we maintain and operate a proactive threat intelligence program to identify and assess risk.
Added
AMN’s Vice President, Information & Cyber Security has over 20 years of experience in various roles in information technology and information security. He holds a M.Sc. in Computer Information Systems and holds several relevant certifications, including Certified Information Security Manager and Zero Trust Certified Architect.

Item 2. Properties

Properties — owned and leased real estate

1 edited+0 added−0 removed1 unchanged
Biggest changeWe set forth below our principal leased office spaces as of December 31, 2023 together with our business segments that utilize them: Location Square Feet Dallas, Texas (all segments) 92,420 San Diego, California (all segments) 51,002 See additional information in “Item 8. Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements— Note (5) , Leases.”
Biggest changeWe set forth below our principal leased office spaces as of December 31, 2024 together with our business segments that utilize them: Location Square Feet Dallas, Texas (all segments) 92,420 San Diego, California (all segments) 50,519 See additional information in “Item 8. Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements— Note (5) , Leases.”

Item 5. Market for Registrant's Common Equity

Market for Common Equity — stock, dividends, buybacks

9 edited+0 added−5 removed9 unchanged
Biggest changeOn November 10, 2021, February 17, 2022 and June 15, 2022, we announced increases to the repurchase program totaling $700.0 million. Additionally, on February 16, 2023, we announced an increase of $500.0 million for a total of $1,350.0 million of repurchase authorization, of which $226.7 million remained on the repurchase program as of December 31, 2023.
Biggest changeOn November 10, 2021, February 17, 2022, June 15, 2022, and February 16, 2023, we announced increases to the repurchase program totaling $1,200.0 million. These increases brought the total authorization of the repurchase program to $1,350.0 million, of which $226.7 million remained as of December 31, 2024.
Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements— Note (8) , Notes Payable and Credit Agreement.” The information required by Item 201(d) of Regulation S-K is incorporated by reference to the table set forth in Item 12 of this Annual Report on Form 10-K. 22 Table of Contents Performance Graph This performance graph shall not be deemed “filed” with the SEC or subject to Section 18 of the Exchange Act, nor shall it be deemed incorporated by reference in any of our filings under the Exchange Act or the Securities Act.
Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements— Note (8) , Notes Payable and Credit Agreement.” The information required by Item 201(d) of Regulation S-K is incorporated by reference to the table set forth in Item 12 of this Annual Report on Form 10-K. 21 Table of Contents Performance Graph This performance graph shall not be deemed “filed” with the SEC or subject to Section 18 of the Exchange Act, nor shall it be deemed incorporated by reference in any of our filings under the Exchange Act or the Securities Act.
As of December 31, 2023, we have repurchased 12.6 million shares of our common stock at an average price of $89.04 per share excluding broker’s fees under the Company Repurchase Program, resulting in an aggregate purchase price of $1,123.3 million excluding the effect of excise taxes, since 2016. See “Item 8.
As of December 31, 2024, we have repurchased 12.6 million shares of our common stock at an average price of $89.04 per share excluding broker’s fees under the Company Repurchase Program, resulting in an aggregate purchase price of $1,123.3 million, excluding the effect of excise taxes, since 2016. See “Item 8.
During the fiscal year ended December 31, 2023, we did not sell any equity securities that were not registered under the Securities Act. From time to time, we may repurchase our common stock in the open market pursuant to programs approved by our board of directors (the “Board”).
During the fiscal year ended December 31, 2024, we did not sell any equity securities that were not registered under the Securities Act. From time to time, we may repurchase our common stock in the open market pursuant to programs approved by our board of directors (the “Board”).
Item 5. Market For Registrant’s Common Equity, Related Stockholder Matters and Issuer Purchases of Equity Securities Our common stock trades on the New York Stock Exchange under the symbol “AMN.” As of February 20, 2024, there were 20 stockholders of record of our common stock, one of which was Cede & Co., a nominee for The Depository Trust Company.
Item 5. Market For Registrant’s Common Equity, Related Stockholder Matters and Issuer Purchases of Equity Securities Our common stock trades on the New York Stock Exchange under the symbol “AMN.” As of February 18, 2025, there were 17 stockholders of record of our common stock, one of which was Cede & Co., a nominee for The Depository Trust Company.
Such repurchases or exchanges, if any, will be upon such terms and at such prices as we may determine, and will depend on prevailing market conditions, our liquidity requirements, contractual restrictions and other factors. The amounts involved may be material.
Such repurchases or exchanges, if any, will be upon such terms and at such prices as we may determine, and will depend on prevailing market conditions, our liquidity requirements, contractual restrictions and other factors. The amounts involved may be material. During 2024, we did not repurchase any shares of our common stock.
The total number of shares received and average price paid per share pursuant to the ASR agreement were approximately 2.0 million shares and $98.97, respectively. We have not paid any dividends on our common stock in the past and currently do not expect to pay cash dividends or make any other distributions on common stock in the future.
We have not paid any dividends on our common stock in the past and currently do not expect to pay cash dividends or make any other distributions on common stock in the future.
The graph below compares the total return on our common stock with the total return of (i) the Russell 2000 Index, and (ii) the S&P Healthcare Services Select Industry Index (“SPSIHP”), assuming an investment of $100 on December 31, 2018 in our common stock and the stocks comprising the Russell 2000 Index and the SPSIHP, respectively. 12/31/18 12/31/19 12/31/20 12/31/21 12/31/22 12/31/23 AMN Healthcare Services, Inc. 100.00 109.97 120.46 215.90 181.47 132.16 Russell 2000 100.00 125.52 150.58 172.90 137.56 160.85 SPSIHP 100.00 119.18 159.48 175.42 140.90 148.19
The graph below compares the total return on our common stock with the total return of (i) the Russell 2000 Index, and (ii) the S&P Healthcare Services Select Industry Index (“SPSIHP”), assuming an investment of $100 on December 31, 2019 in our common stock and the stocks comprising the Russell 2000 Index and the SPSIHP, respectively. 12/31/19 12/31/20 12/31/21 12/31/22 12/31/23 12/31/24 AMN Healthcare Services, Inc. 100.00 109.53 196.32 165.01 120.17 38.39 Russell 2000 100.00 119.96 137.74 109.59 128.14 142.93 SPSIHP 100.00 133.81 147.19 118.22 124.34 126.92
Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements— Note (10)(b) , Capital Stock—Treasury Stock.” The following table presents the detail of shares repurchased, excluding the effect of excise taxes, during 2023.
Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements— Note (10)(b) , Capital Stock—Treasury Stock.” All share repurchases to date were made under the Company Repurchase Program, which is the only repurchase program of the Company currently in effect.
Removed
On May 8, 2023, we entered into an accelerated share repurchase (“ASR”) agreement with a counterparty whereupon we prepaid $200.0 million and received an initial delivery of 1.8 million shares of our common stock, which was 80% of the prepayment amount based on a price of $90.89 per share.
Removed
In August 2023, upon settlement of the ASR agreement, we received an additional 0.3 million shares of our common stock. The total number of shares delivered and average price per share of $98.97 was based on the volume-weighted average price over the term of the ASR agreement, less an agreed upon discount.
Removed
During 2023, exclusive of the shares delivered pursuant to the ASR, we repurchased 2.4 million shares of common stock at an average price of $95.13 per share excluding broker’s fees, resulting in an aggregate purchase price of $224.7 million excluding the effect of excise taxes.
Removed
All share repurchases to date were made under the Company Repurchase Program, which is the only repurchase program of the Company currently in effect. 21 Table of Contents Period Total Number of Shares (or Units) Purchased Average Price Paid per Share (or Unit) Total Number of Shares (or Units) Purchased as Part of Publicly Announced Program Maximum Dollar Value of Shares (or Units) that May Yet Be Purchased Under the Program January 1 - 31, 2023 922,516 $108.40 922,516 $ 51,374,511 February 1 - 28, 2023 187,031 $93.83 187,031 $ 533,820,512 March 1 - 31, 2023 658,402 $86.79 658,402 $ 476,658,438 April 1 - 30, 2023 550,245 $84.02 550,245 $ 430,412,324 May 1 - 31, 2023 (a) 1,803,863 $90.78 1,803,863 $ 226,658,470 June 1 - 30, 2023 — $— — $ 226,658,470 July 1 - 31, 2023 — $— — $ 226,658,470 August 1 - 31, 2023 260,360 (b) 260,360 $ 226,658,470 September 1 - 30, 2023 — $— — $ 226,658,470 October 1 - 31, 2023 — $— — $ 226,658,470 November 1 - 30, 2023 — $— — $ 226,658,470 December 1 - 31, 2023 — $— — $ 226,658,470 Total 4,382,417 $96.90 4,382,417 $ 226,658,470 (a) The number of shares repurchased during May 1 - 31, 2023 includes the initial delivery of 1.8 million shares under the ASR agreement, and the average price paid per share reflects the ASR prepayment’s $90.89 per share basis.
Removed
Additionally, the remaining $226.7 million that may yet be repurchased under the Company Repurchase Program reflects the full effect of the $200.0 million ASR prepayment. (b) The number of shares repurchased during the August 1 - 31, 2023 represents the additional shares received upon final settlement of the ASR agreement.

Item 7. Management's Discussion & Analysis

Management's Discussion & Analysis (MD&A) — revenue / margin commentary

77 edited+45 added−17 removed38 unchanged
Biggest changeThe overall decrease in net cash provided by operating activities was partially offset by (1) a decrease in accounts receivable and subcontractor receivables between periods of $192.1 million primarily due to a larger decrease in the receivables balance in the current year as compared to the prior year, which was due to decreases in revenue and associate vendor usage along with timing of collections, (2) an increase in other liabilities between periods of $116.3 million primarily due to lower cash paid for income taxes, and (3) a decrease in income taxes receivable between periods of $12.7 million primarily due to an overpayment of estimated taxes during 2022.
Biggest changeThe overall decrease in net cash provided by operating activities was partially offset by (1) an increase in accrued compensation and benefits between periods of $68.8 million primarily due to bonuses and commissions that were paid during the first quarter of 2023, (2) an increase in other liabilities between periods of $54.7 million primarily due to client deposits related to labor disruption services in the current year, and (3) an increase in accounts payable and accrued expenses between periods of $28.6 million primarily due to (a) a larger decrease in the subcontractor payable balance in the prior year as compared to the current year primarily attributable to declines in associate vendor usage and (b) a decrease in the accrued expenses balance in the current year as a result of a decrease in operating expenses associated with our revenue decline and timing of payments, partially offset by a payment of the legal settlement amount for the Clarke matter in the current year.
We believe this information is useful in understanding our operational performance and trends affecting our businesses. • Average travelers on assignment represents the average number of nurse and allied healthcare professionals on assignment during the period, which is used by management as a measure of volume in our nurse and allied solutions segment; • Bill rates represent the hourly straight-time rates that we bill to clients, which are an indicator of labor market trends and costs within our nurse and allied solutions segment; • Billable hours represent hours worked by our healthcare professionals that we are able to bill on client engagements, which are used by management as a measure of volume in our nurse and allied solutions segment; • Days filled is calculated by dividing total locum tenens hours filled during the period by eight hours, which is used by management as a measure of volume in our locum tenens business within our physician and leadership solutions segment; and • Revenue per day filled is calculated by dividing revenue of our locum tenens business by days filled for the period, which is an indicator of labor market trends and costs in our locum tenens business within our physician and leadership solutions segment. • Minutes represent the time-based utilization of interpretation services that we are able to bill our clients, which are used by management as a measure of volume in our language services business within our technology and workforce solutions segment.
We believe this information is useful in understanding our operational performance and trends affecting our businesses. • Average travelers on assignment represents the average number of nurse and allied healthcare professionals on assignment during the period, which is used by management as a measure of volume in our nurse and allied solutions segment; • Bill rates represent the hourly straight-time rates that we bill to clients, which are an indicator of labor market trends and costs within our nurse and allied solutions segment; • Billable hours represent the number of hours worked by our healthcare professionals that we are able to bill on client engagements, which are used by management as a measure of volume in our nurse and allied solutions segment; • Days filled is calculated by dividing total locum tenens hours filled during the period by eight hours, which is used by management as a measure of volume in our locum tenens business within our physician and leadership solutions segment; • Revenue per day filled is calculated by dividing revenue of our locum tenens business by days filled for the period, which is an indicator of labor market trends and costs in our locum tenens business within our physician and leadership solutions segment; and • Minutes represent the time-based utilization of interpretation services that we are able to bill our clients, which are used by management as a measure of volume in our language services business within our technology and workforce solutions segment.
If, after assessing the totality of events and circumstances, we determine that it is more likely than not that the fair value of the reporting unit is greater than its carrying amount, the quantitative impairment test is unnecessary. If the reporting unit does not pass the qualitative assessment, then the reporting unit’s carrying value is compared to its fair value.
If, after assessing the totality of events and circumstances, we determine that it is more likely than not that the fair value of the reporting unit is greater than its carrying amount, the quantitative impairment test is unnecessary. If the reporting unit does not pass the qualitative assessment, then the reporting unit’s carrying amount is compared to its fair value.
We determine ultimate losses through the use of several actuarial methods, including (but not limited to) loss development methods and Bornhuetter Ferguson methods. These methods use our specific historical claims data related to paid losses and loss adjustment expenses, historical and current case reserves, reported and closed claim counts, and industry and other data.
We determine ultimate losses through the use of several actuarial methods, including (but not limited to) loss development methods and Bornhuetter-Ferguson method. These methods use our specific historical claims data related to paid losses and loss adjustment expenses, historical and current case reserves, reported and closed claim counts, and industry and other data.
We review these provisions at least quarterly and adjust these provisions accordingly to reflect the impact of negotiations, settlements, rulings, advice of legal counsel, and updated information. We generally record changes in accruals related to legal matters in selling, general and administrative expenses in the consolidated statements of comprehensive income.
We review these provisions at least quarterly and adjust these provisions accordingly to reflect the impact of negotiations, settlements, rulings, advice of legal counsel, and updated information. We generally record changes in accruals related to legal matters in selling, general and administrative expenses in the consolidated statements of comprehensive income (loss).
Net cash provided by financing activities for 2023 was primarily due to borrowings of $815.0 million under the Senior Credit Facility (as defined below), partially offset by (1) $424.7 million paid in connection with the repurchase of our common stock, (2) repayments of $355.0 million under the Senior Credit Facility, and (3) $13.1 million in cash paid for shares withheld for payroll taxes resulting from the vesting of employee equity awards.
Net cash provided by financing activities for 2023 was primarily due to borrowings of $815.0 million under the Senior Credit Facility, partially offset by (1) $424.7 million paid in connection with the repurchase of our common stock, (2) repayments of $355.0 million under the Senior Credit Facility, and (3) $13.1 million in cash paid for shares withheld for payroll taxes resulting from the vesting of employee equity awards.
Significant judgments are required to estimate the fair value of reporting units including estimating future cash flows, and determining appropriate discount rates, growth rates, company control premium and other assumptions. Changes in these estimates and assumptions could materially affect the determination of fair value for each reporting unit. We perform our annual impairment test on October 31 of each year.
Significant judgments are required to estimate the fair value of reporting units including estimating future cash flows, and determining appropriate discount rates, growth rates, and other assumptions. Changes in these estimates and assumptions could materially affect the determination of fair value for each reporting unit. We perform our annual impairment test on October 31 of each year.
We assess the impairment of goodwill of our reporting units and indefinite-lived intangible assets annually, or more often if events or changes in circumstances indicate that the carrying value may not be recoverable.
We assess the impairment of goodwill of our reporting units and indefinite-lived intangible assets annually, or more often if events or changes in circumstances indicate that the carrying amount may not be recoverable.
Additionally, some of our clients may also become subject to claims, governmental inquiries and investigations and legal actions relating to services provided by our healthcare 32 Table of Contents professionals. From time to time, and depending upon the particular facts and circumstances, we may be subject to indemnification obligations under our contracts with such clients relating to these matters.
Additionally, some of our clients may also become subject to claims, governmental inquiries and investigations and legal actions relating to services provided by our healthcare professionals. From time to time, and depending upon the particular facts and circumstances, we may be subject to indemnification obligations under our contracts with such clients relating to these matters.
A 10% change in the expected frequency is within a reasonable range of possibilities and would increase or reduce the accrual estimate by approximately $2.0 million. A 10% change in the expected claim severity is within a reasonable range of possibilities and would increase or reduce the accrual estimate by approximately $4.0 million.
A 10% change in the expected frequency is within a reasonable range of possibilities and would increase or reduce the accrual estimate by approximately $2.0 million. A 10% change in the expected claim severity is within a reasonable range of possibilities and would increase or reduce the accrual estimate by approximately $5.0 million.
Our market growth strategy continues to focus on broadening and investing, both organically and through strategic acquisitions, in service and technology offerings beyond our traditional temporary staffing and permanent placement services, to include more strategic and recurring revenue sources from innovative talent solutions offerings such as MSP, VMS, workforce optimization service, and other technology-enabled services.
Our 23 Table of Contents market growth strategy continues to focus on broadening and investing, both organically and through strategic acquisitions, in service and technology offerings beyond our traditional temporary staffing and permanent placement services, to include more strategic and recurring revenue sources from innovative talent solutions offerings such as MSP, VMS, workforce optimization service, and other technology-enabled services.
We believe that the amount or estimable range of reasonably possible loss beyond the accruals that we have established, will not, either individually or in the aggregate, have a material adverse effect on our business, consolidated financial position, results of operations, or cash flows with respect to loss contingencies for legal and other contingencies as of December 31, 2023.
We believe that the amount or estimable range of reasonably possible loss beyond the accruals that we have established, will not, either individually or in the aggregate, have a material adverse effect on our business, consolidated financial position, 33 Table of Contents results of operations, or cash flows with respect to loss contingencies for legal and other contingencies as of December 31, 2024.
The following sections comprise this MD&A: • Overview of Our Business • Operating Metrics • Recent Trends • Results of Operations • Liquidity and Capital Resources • Critical Accounting Policies and Estimates • Recent Accounting Pronouncements Overview of Our Business We provide healthcare workforce solutions and staffing services to healthcare facilities across the nation.
The following sections comprise this MD&A: • Overview of Our Business • Operating Metrics • Recent Trends • Results of Operations • Liquidity and Capital Resources • Critical Accounting Policies and Estimates • Recent Accounting Pronouncements Overview of Our Business We provide technology-enabled healthcare workforce solutions and staffing services to healthcare organizations across the nation.
Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements— Note (8) , Notes Payable and Credit Agreement.” As of December 31, 2023, the total of our contractual obligations under operating leases with initial terms in excess of one year was $55.1 million. We describe in further detail our operating lease arrangements in “Item 8.
Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements— Note (8) , Notes Payable and Credit Agreement.” As of December 31, 2024, the total of our contractual obligations under operating leases with initial terms in excess of one year was $50.2 million. We describe in further detail our operating lease arrangements in “Item 8.
We have funded these requirements through internally generated cash flow and funds borrowed under our credit facilities and senior notes. 27 Table of Contents As of December 31, 2023, (1) $460.0 million was drawn with $269.2 million of available credit under the Senior Credit Facility (as defined below), (2) the aggregate principal amount of our 2027 Notes (as defined below) outstanding was $500.0 million, and (3) the aggregate principal amount of our 2029 Notes (as defined below) outstanding was $350.0 million.
We have funded these requirements through internally generated cash flow and funds borrowed under our credit facilities and senior notes. 27 Table of Contents As of December 31, 2024, (1) $210.0 million was drawn with $519.6 million of available credit under the Senior Credit Facility (as defined below), (2) the aggregate principal amount of our 2027 Notes (as defined below) outstanding was $500.0 million, and (3) the aggregate principal amount of our 2029 Notes (as defined below) outstanding was $350.0 million.
Our Days Sales Outstanding (“DSO”) was 70 and 55 days at December 31, 2023 and December 31, 2022, respectively. Our consolidated results for the year ended December 31, 2023 include only one month of MSDR’s revenue, but our consolidated balance sheet includes the full amount of MSDR’s accounts receivable.
Our Days Sales Outstanding (“DSO”) was 55 and 70 days at December 31, 2024 and December 31, 2023, respectively. Our consolidated results for the year ended December 31, 2023 included only one month of MSDR’s revenue, but our consolidated balance sheet included the full amount of MSDR’s accounts receivable.
Management’s Discussion and Analysis of Financial Condition and Results of Operations—Results of Operations—Comparison of Results for the Year Ended December 31, 2022 to the Year Ended December 31, 2021” of our 2022 Annual Report on Form 10-K.
Management’s Discussion and Analysis of Financial Condition and Results of Operations—Results of Operations—Comparison of Results for the Year Ended December 31, 2023 to the Year Ended December 31, 2022” of our 2023 Annual Report on Form 10-K.
The indenture governing the 2029 Notes contains covenants that, among other things, restricts our ability to: • sell assets; • pay dividends or make other distributions on capital stock, make payments in respect of subordinated indebtedness or make other restricted payments; • make certain investments; • incur or guarantee additional indebtedness or issue preferred stock; • create certain liens; • enter into agreements that restrict dividends or other payments from our restricted subsidiaries to us; • consolidate, merge or transfer all or substantially all of their assets; • enter into transactions with affiliates; and • create unrestricted subsidiaries. 30 Table of Contents These covenants are subject to a number of important exceptions and qualifications.
The indenture governing the 2029 Notes contains covenants that, among other things, restricts our ability to: • sell assets; • pay dividends or make other distributions on capital stock, make payments in respect of subordinated indebtedness or make other restricted payments; • make certain investments; • incur or guarantee additional indebtedness or issue preferred stock; • create certain liens; • enter into agreements that restrict dividends or other payments from our restricted subsidiaries to us; • consolidate, merge or transfer all or substantially all of their assets; • enter into transactions with affiliates; and • create unrestricted subsidiaries.
Excluding the acquisition of MSDR, our DSO was 66 days at December 31, 2023. Investing Activities Net cash used in investing activities for 2023, 2022 and 2021 was $412.5 million, $170.7 million and $107.4 million, respectively.
Excluding the acquisition of MSDR, our DSO was 66 days at December 31, 2023. Investing Activities Net cash used in investing activities for 2024, 2023 and 2022 was $79.9 million, $412.5 million and $170.7 million, respectively.
Years Ended December 31, 2023 2022 2021 Consolidated Statements of Operations: Revenue 100.0 % 100.0 % 100.0 % Cost of revenue 67.0 67.3 67.1 Gross profit 33.0 32.7 32.9 Selling, general and administrative 20.0 17.9 18.3 Depreciation and amortization 4.1 2.5 2.6 Income from operations 8.9 12.3 12.0 Interest expense, net, and other 1.4 0.7 0.9 Income before income taxes 7.5 11.6 11.1 Income tax expense 1.9 3.1 2.9 Net income 5.6 % 8.5 % 8.2 % Comparison of Results for the Year Ended December 31, 2023 to the Year Ended December 31, 2022 Revenue .
Years Ended December 31, 2024 2023 2022 Consolidated Statements of Operations: Revenue 100.0 % 100.0 % 100.0 % Cost of revenue 69.2 67.0 67.3 Gross profit 30.8 33.0 32.7 Selling, general and administrative 21.2 20.0 17.9 Depreciation and amortization 5.5 4.1 2.5 Goodwill impairment losses 7.5 — — Income (loss) from operations (3.4) 8.9 12.3 Interest expense, net, and other 2.4 1.4 0.7 Income (loss) before income taxes (5.8) 7.5 11.6 Income tax expense (benefit) (0.9) 1.9 3.1 Net income (loss) (4.9) % 5.6 % 8.5 % Comparison of Results for the Year Ended December 31, 2024 to the Year Ended December 31, 2023 Revenue .
The indenture governing the 2029 Notes contains affirmative covenants and events of default that are customary for indentures governing high yield securities. The 2029 Notes and the guarantees are not subject to any registration rights agreement.
These covenants are subject to a number of important exceptions and qualifications. The indenture governing the 2029 Notes contains affirmative covenants and events of default that are customary for indentures governing high yield securities. The 2029 Notes and the guarantees are not subject to any registration rights agreement.
Operating Activities Net cash provided by operating activities for 2023, 2022 and 2021 was $372.2 million, $653.7 million and $305.4 million, respectively.
Operating Activities Net cash provided by operating activities for 2024, 2023 and 2022 was $320.4 million, $372.2 million and $653.7 million, respectively.
Letters of Credit As of December 31, 2023, we maintained outstanding standby letters of credit totaling $21.3 million as collateral in relation to our workers’ compensation insurance agreements and a corporate office lease agreement.
Letters of Credit As of December 31, 2024, we maintained outstanding standby letters of credit totaling $20.9 million as collateral in relation to our workers’ compensation insurance agreements and a corporate office lease agreement.
The fair values of the reporting units are estimated using market and discounted cash flow approaches. Goodwill is considered impaired if the carrying value of the reporting unit exceeds its fair value.
The fair values of the reporting units are estimated using market and income approaches. Goodwill is considered impaired if the carrying amount of the reporting unit exceeds its fair value.
Depreciation expense (exclusive of depreciation included in cost of revenue) increased 31% to $65.2 million for 2023 from $49.9 million for 2022, primarily attributable to an increase in purchased and developed hardware and software placed in service for our ongoing information technology investments to support our total talent solutions initiatives and to optimize our internal front and back-office systems.
Depreciation expense (exclusive of depreciation included in cost of revenue) increased 14% to $74.3 million for 2024 from $65.2 million for 2023, primarily attributable to an increase in purchased and developed hardware and software placed in service for our ongoing technology investments to support our tech-centric total talent solutions initiatives and to optimize our internal front and back-office systems.
We assess potential impairments to intangible assets when there is evidence that events or changes in circumstances indicate that the carrying amount of an asset or asset group may not be recovered.
An impairment is recognized if the carrying amount of the asset group exceeds the fair value of the asset group. We assess potential impairments to long-lived assets when there is evidence that events or changes in circumstances indicate that the carrying amount of an asset or asset group may not be recovered.
We are currently evaluating the impact of adopting this standard on our disclosures. There have been no other new accounting pronouncements issued but not yet adopted that are expected to materially affect our consolidated financial condition or results of operations.
There have been no other new accounting pronouncements issued but not yet adopted that are expected to materially affect our consolidated financial condition or results of operations.
Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements— Note (7) , Income Taxes, and Note (1) , Summary of Significant Accounting Policies.” Comparison of Results for the Year Ended December 31, 2022 to the Year Ended December 31, 2021 We describe in detail the comparison of results for the years ended December 31, 2022 and 2021 in “Item 7.
Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements— Note (7) , Income Taxes, and Note ( 4 ) , Goodwill and Identifiable Assets.” Comparison of Results for the Year Ended December 31, 2023 to the Year Ended December 31, 2022 We describe in detail the comparison of results for the years ended December 31, 2023 and 2022 in “Item 7.
The following table presents the case reserves, IBNR losses and excess liability as estimated by the most recently obtained actuarial study that make up our accrual for professional liability as of December 31, 2023 and 2022: (In Thousands) December 31, 2023 2022 Case reserves (1) $ 8,503 $ 8,450 IBNR losses (1) 24,893 25,176 Excess liability (2) 11,256 10,344 Total accrual $ 44,652 $ 43,970 (1) The provisions for case reserves and estimated IBNR losses are presented net of excess liability.
The following table 32 Table of Contents presents the case reserves, IBNR losses and excess liability as estimated by the most recently obtained actuarial study that make up our accrual for professional liability as of December 31, 2024 and 2023: (In Thousands) December 31, 2024 2023 Case reserves (1) $ 11,590 $ 8,503 IBNR losses (1) 21,823 24,893 Excess liability (2) 13,289 11,256 Total accrual $ 46,702 $ 44,652 (1) The provisions for case reserves and estimated IBNR losses are presented net of excess liability.
Critical Accounting Policies and Estimates Our critical accounting policies are those that we believe are both important to the portrayal of our financial condition and results and require our most difficult, subjective or complex judgments, often as a result of the need to make estimates about the effect of matters that are inherently uncertain.
Outstanding standby letters of credit at December 31, 2023 totaled $21.3 million. 30 Table of Contents Critical Accounting Policies and Estimates Our critical accounting policies are those that we believe are both important to the portrayal of our financial condition and results and require our most difficult, subjective or complex judgments, often as a result of the need to make estimates about the effect of matters that are inherently uncertain.
At any time and from time to time on and after April 15, 2024, we will be entitled at our option to redeem all or a portion of the 2029 Notes upon not less than 10 nor more than 60 days’ notice, at the redemption prices (expressed in percentages of principal amount on the redemption date) set forth below, plus accrued and unpaid interest, if any, to (but excluding) the redemption date (subject to the right of holders of record of the 2029 Notes on the relevant record date to receive interest due on the relevant interest payment date), if redeemed during the twelve month period commencing on April 15 of the years set forth below: Period Redemption Price 2024 102.000 % 2025 101.000 % 2026 and thereafter 100.000 % At any time and from time to time prior to April 15, 2024, we may also redeem 2029 Notes with the net cash proceeds of certain equity offerings in an aggregate principal amount not to exceed 40% of the aggregate principal amount of the 2029 Notes issued, at a redemption price (expressed as a percentage of principal amount) of 104.000% of the principal amount thereof plus accrued and unpaid interest, if any, to (but excluding) the applicable redemption date.
At any time and from time to time on and after April 15, 2024, we will be entitled at our option to redeem all or a portion of the 2029 Notes upon not less than 10 nor more than 60 days’ notice, at the redemption prices (expressed in percentages of principal amount on the redemption date) set forth below, plus accrued and unpaid interest, if any, to (but excluding) the redemption date (subject to the right of holders of record of the 2029 Notes on the relevant record date to receive interest due on the relevant interest payment date), if redeemed during the twelve month period commencing on April 15 of the years set forth below: Period Redemption Price 2024 102.000 % 2025 101.000 % 2026 and thereafter 100.000 % Upon the occurrence of specified change of control events as defined in the indenture governing the 2029 Notes, we must offer to repurchase the 2029 Notes at 101% of the principal amount, plus accrued and unpaid interest, if any, to (but excluding) the purchase date.
Over the past five years, these quarterly fluctuations have been muted in our consolidated results. Operating Metrics In addition to our consolidated and segment financial results, we monitor the following key metrics to help us evaluate our results of operations and financial condition and make strategic decisions.
Operating Metrics In addition to our consolidated and segment financial results, we monitor the following key metrics to help us evaluate our results of operations and financial condition and make strategic decisions.
The terms of the Amended Credit Agreement, including maturity dates, payment and interest terms, are described in further detail in “Item 8.
Our obligations under the Amended Credit Agreement are secured by substantially all of our assets. The terms of the Amended Credit Agreement, including maturity dates, payment and interest terms, are described in further detail in “Item 8.
We describe in further detail our Amended Credit Agreement (as defined below), under which our Senior Credit Facility is governed, the 2027 Notes, and the 2029 Notes in “Item 8.
As of December 31, 2024, we were in compliance with the various covenants under our debt instruments. We describe in further detail our Amended Credit Agreement (as defined below), under which our Senior Credit Facility is governed, the 2027 Notes, and the 2029 Notes in “Item 8.
Liquidity and Capital Resources In summary, our cash flows were: (In Thousands) Years Ended December 31, 2023 2022 2021 Net cash provided by operating activities $ 372,165 $ 653,733 $ 305,356 Net cash used in investing activities (412,493) (170,710) (107,402) Net cash provided by (used in) financing activities 10,729 (591,865) (34,895) Historically, our primary liquidity requirements have been for acquisitions, working capital requirements, and debt service under our credit facilities and senior notes.
Liquidity and Capital Resources In summary, our cash flows were: (In Thousands) Years Ended December 31, 2024 2023 2022 Net cash provided by operating activities $ 320,418 $ 372,165 $ 653,733 Net cash used in investing activities (79,938) (412,493) (170,710) Net cash provided by (used in) financing activities (259,448) 10,729 (591,865) Net decrease in cash, cash equivalents and restricted cash (18,968) $ (29,599) $ (108,842) Historically, our primary liquidity requirements have been for acquisitions, working capital requirements, and debt service under our credit facilities and senior notes.
An impairment evaluation is based on an undiscounted cash flow analysis at the lowest level at which cash flows of the long-lived assets are largely independent of other groups of assets and liabilities.
An impairment evaluation is based on an undiscounted cash flow analysis of the asset group, which is the lowest level at which cash flows of the long-lived assets are largely independent of other groups of assets and liabilities. If the asset group’s undiscounted cash flows are less than its carrying amount, the asset group’s fair value is measured.
We seek to advance our market-leading position through a number of strategies that focus on market penetration, expansion of our talent solutions, increasing operational efficiency and scalability and increasing our supply of qualified healthcare professionals.
Business—Our Services.” We believe we are recognized as a market-leading innovator in providing healthcare talent solutions in the United States. We seek to advance our position through a number of strategies that focus on market penetration, expansion of our talent solutions, increasing operational efficiency and scalability and increasing our supply of qualified healthcare professionals.
Revenue in our locum tenens business grew 9% during 2023 primarily due to a 10% increase in the revenue per day filled on an organic basis and additional revenue of $13.2 million in connection with the MSDR acquisition, partially offset by a 4% decrease in the number of days filled on an organic basis.
Revenue in our locum tenens business grew $101.6 million (or 22%) during 2024 primarily due to the favorable impact of $23.9 million as a result of a 6% increase in the revenue per day filled on an organic basis and additional revenue of $121.2 million in connection with the MSDR acquisition, partially offset by a $43.5 million decline driven by a 10% decrease in the number of days filled on an organic basis.
For 2023 and 2022, revenue under our MSP arrangements comprised approximately 54% and 64% of our consolidated revenue, 72% and 81% for nurse and allied solutions segment revenue, 20% and 18% for physician and leadership solutions segment revenue, and 2% and 2% of our technology and workforce solutions segment revenue, respectively. Gross Profit .
For 2024 and 2023, revenue under our MSP arrangements comprised approximately 45% and 54% of our consolidated revenue, 67% and 72% for nurse and allied solutions segment revenue, 15% and 20% for physician and leadership solutions segment revenue, and 3% and 2% of our technology and workforce solutions segment revenue, respectively. Cost of Revenue .
We are currently evaluating the impact of adopting this standard on our disclosures. In December 2023, the FASB issued ASU 2023-09, “Income Taxes (Topic 740): Improvements to Income Tax Disclosures,” which is intended to enhance the transparency and decision-usefulness of income tax disclosures.
Recent Accounting Pronouncements In December 2023, the FASB issued ASU 2023-09, “Income Taxes (Topic 740): Improvements to Income Tax Disclosures,” which is intended to enhance the transparency and decision-usefulness of income tax disclosures.
Revenue decreased 28% to $3,789.3 million for 2023 from $5,243.2 million for 2022, attributable to a decline in revenue across our segments with the greatest decline in our nurse and allied solutions segment. Nurse and allied solutions segment revenue decreased 34% to $2,624.5 million for 2023 from $3,982.5 million for 2022.
Revenue decreased 21% to $2,983.8 million for 2024 from $3,789.3 million for 2023, attributable to a decline in organic revenue across our segments with the greatest decline in our nurse and allied solutions segment. Nurse and allied solutions segment revenue decreased 31% to $1,815.7 million for 2024 from $2,624.5 million for 2023.
Physician and leadership solutions segment revenue comprised 18% and 13% of total consolidated revenue for the years ended December 31, 2023 and 2022, respectively. Technology and workforce solutions segment revenue comprised 13% and 11% of total consolidated revenue for the years ended December 31, 2023 and 2022, respectively.
Nurse and allied solutions segment revenue comprised 61% and 69% of total consolidated revenue for the years ended December 31, 2024 and 2023, respectively. Physician and leadership solutions segment revenue comprised 24% and 18% of total consolidated revenue for the years ended December 31, 2024 and 2023, respectively.
SG&A expenses broken down among the reportable segments, unallocated corporate overhead, and share-based compensation are as follows: (In Thousands) Years Ended December 31, 2023 2022 Nurse and allied solutions $ 330,252 $ 471,489 Physician and leadership solutions 134,505 148,619 Technology and workforce solutions 118,977 132,733 Unallocated corporate overhead 154,484 153,669 Share-based compensation 18,020 30,066 $ 756,238 $ 936,576 Depreciation and Amortization Expenses .
SG&A expenses broken down among the reportable segments, unallocated corporate overhead, and share-based 26 Table of Contents compensation are as follows: (In Thousands) Years Ended December 31, 2024 2023 Nurse and allied solutions $ 270,467 $ 330,252 Physician and leadership solutions 137,600 134,505 Technology and workforce solutions 91,590 118,977 Unallocated corporate overhead 109,515 154,484 Share-based compensation 23,317 18,020 $ 632,489 $ 756,238 Depreciation and Amortization Expenses .
Physician and leadership solutions segment revenue decreased 4% to $669.7 million for 2023 from $697.9 million for 2022. The $28.2 million decrease was attributable to lower revenue in our interim leadership, physician permanent placement and executive search businesses, which was partially offset by higher revenue in our locum tenens business.
The $58.9 million increase was attributable to higher revenue in our locum tenens business, which was partially offset by lower revenue in our interim leadership, physician permanent placement and executive search businesses.
Gross profit decreased 27% to $1,249.6 million for 2023 from $1,716.7 million for 2022, representing gross margins of 33.0% and 32.7%, respectively.
Gross profit decreased 26% to $919.4 million for 2024 from $1,249.6 million for 2023, representing gross margins of 30.8% and 33.0%, respectively.
Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements— Note (2) , Acquisitions.” Our historical results are not necessarily indicative of our results of operations to be expected in the future.
The acquisitions during the three years ended December 31, 2024 impact the comparability of the results between the years presented. See additional information in “Item 8. Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements— Note (2) , Acquisitions.” Our historical results are not necessarily indicative of our results of operations to be expected in the future.
Of the $21.3 million of outstanding letters of credit, we have collateralized $0.6 million in cash and cash equivalents and the remaining $20.8 million is collateralized by the Senior Credit Facility. Outstanding standby letters of credit at December 31, 2022 totaled $22.0 million.
Of the $20.9 million of outstanding letters of credit, we have collateralized approximately $0.6 million in cash and cash equivalents and the remaining approximately $20.4 million is collateralized by the Senior Credit Facility.
Our judgments regarding the existence of impairment indicators and future cash flows related to intangible assets are based on operational performance of our businesses, market conditions and other factors. 31 Table of Contents Although there are inherent uncertainties in this assessment process, the estimates and assumptions we use, including estimates of future cash flows, volumes, market penetration and discount rates, are consistent with our internal planning.
Although there are inherent uncertainties in this assessment process, the estimates and assumptions we use, including estimates of future cash flows, volumes, market penetration and discount rates, are consistent with our internal planning.
The increase in consolidated gross margin for the year ended December 31, 2023 was primarily due to (1) a change in sales mix resulting from lower revenue in our nurse and allied solutions segment and (2) a higher margin in our nurse and allied solutions segment driven by a revenue mix shift within the segment.
The decline in consolidated gross margin for the year ended December 31, 2024 was primarily due to (1) lower margins in our nurse and allied solutions and physician and leadership solutions segments driven by higher provider pay packages, including housing, travel and allowances and (2) a lower margin in our technology and workforce solution segment primarily due to a change in sales mix resulting from lower revenue in our higher-margin VMS business and higher revenue in our lower-margin language services business.
If these estimates or their related assumptions change in the future, we may be required to record an impairment charge on all or a portion of our long-lived intangible assets. Furthermore, we cannot predict the occurrence of future impairment-triggering events nor the impact such events might have on our reported asset values.
Therefore, no impairment loss on our long-lived assets was recognized. If these estimates or their related assumptions change in the future, we may be required to record an impairment loss on all or a portion of our long-lived assets.
The $1,357.9 million decrease was primarily attributable to a 17% decrease in the average number of travelers on assignment, an approximately 15% decrease in the average bill rate, a 3% decrease in billable hours during the year ended December 31, 2023, and an approximately $99.0 million decrease in labor disruption revenue.
The $808.8 million decrease was primarily attributable to a $592.1 million decline driven by a 24% decrease in the average number of travelers on assignment, a $257.0 million decline driven by an approximately 10% decrease in the average bill rate, and a $41.1 million decline driven by a 2% decrease in average billable hours during the year ended December 31, 2024.
Expense recognized for accruals (inclusive of actuarial-based decreases) was $5.5 million, $7.2 million and $7.2 million for the years ended December 31, 2023, 2022 and 2021, respectively. Our accrual for professional liability includes provisions for estimated incurred but not yet reported (“IBNR”) losses and known claims (“case reserves”), as well as losses covered by excess insurance carriers (“excess liability”).
Our accrual for professional liability includes provisions for estimated incurred but not yet reported (“IBNR”) losses and known claims (“case reserves”), as well as losses covered by excess insurance carriers (“excess liability”).
Over the past five years, we have grown our business both organically and as a result of a number of acquisitions. 24 Table of Contents We typically experience modest seasonal fluctuations during our fiscal year and they tend to vary among our business segments. These fluctuations can vary slightly in intensity from year to year.
Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements— Note (2) , Acquisitions.” We typically experience modest seasonal fluctuations during our fiscal year and they tend to vary among our business segments. These fluctuations can vary slightly in intensity from year to year. Over the past five years, these quarterly fluctuations have been muted in our consolidated results.
Our interim leadership business experienced an approximately 26% decline, while our physician permanent placement and executive search businesses declined 20% during 2023. Technology and workforce solutions segment revenue decreased 12% to $495.0 million for 2023 from $562.8 million for 2022.
As a result of a decline in demand, revenue in our interim leadership business experienced a decline of $21.3 million (or 16%), while our physician permanent placement and executive search businesses declined $21.4 million (or 31%) during 2024. Technology and workforce solutions segment revenue decreased 11% to $439.5 million for 2024 from $495.0 million for 2023.
Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements— Note (10)(b) , Capital Stock—Treasury Stock.” We believe that cash generated from operations and available borrowings under our Senior Credit Facility will be sufficient to fund our operations and liquidity requirements, including expected capital expenditures, for the next 12 months and beyond.
See additional information in “Item 5. Market For Registrant’s Common Equity, Related Stockholder Matters and Issuer Purchases of Equity Securities.” We believe that cash generated from operations and available borrowings under our Senior Credit Facility will be sufficient to fund our operations and liquidity requirements, including expected capital expenditures, for the next 12 months and beyond.
Additionally, $6.0 million and $4.1 million of depreciation expense for our language services business is included in cost of revenue for 2023 and 2022, respectively. Interest Expense, Net, and Other . Interest expense, net, and other, was $54.1 million for 2023 as compared to $40.4 million for 2022.
Additionally, $6.7 million and $6.0 million of depreciation expense for our language services business is included in cost of revenue for 2024 and 2023, respectively. Goodwill Impairment Losses .
Future events could cause us to conclude that impairment indicators exist and that long-lived intangible assets associated with our acquired businesses are impaired. Professional Liability Reserve We determine the adequacy of our accrual for professional liability by evaluating our historical experience and trends, loss reserves established by our insurance carriers, management and third-party administrators, and our independent actuarial studies.
Professional Liability Reserve We determine the adequacy of our accrual for professional liability by evaluating our historical experience and trends, loss reserves established by our insurance carriers, management and third-party administrators, and our independent actuarial studies. We obtain actuarial studies on a semi-annual basis to assist us in determining the adequacy of our accrual.
The increase was primarily due to a higher average debt outstanding balance during 2023. Income Tax Expense . Income tax expense was $73.6 million for 2023 as compared to $162.7 million for 2022, reflecting effective income tax rates of 26% and 27% for these periods, respectively.
Income tax benefit was $25.6 million for 2024 as compared to income tax expense of $73.6 million for 2023, reflecting effective income tax rates of 15% and 26% for these periods, respectively.
Our 28 Table of Contents capital expenditures in recent years were primarily related to ongoing information technology investments to support our total talent solutions initiatives and to optimize our internal front and back-office systems. Financing Activities Net cash provided by (used in) financing activities for 2023, 2022 and 2021 was $10.7 million, $(591.9) million and $(34.9) million, respectively.
In addition, capital expenditures were $80.9 million, $103.7 million and $75.8 million for the years ended December 31, 2024, 2023 and 2022, respectively. Our capital expenditures in recent years were primarily related to ongoing technology investments to support our tech-centric total talent solutions initiatives and to optimize our internal front and back-office systems.
Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements— Note (2) , Acquisitions.” Operationally, our strategic initiatives focus on investing in digitizing and further developing our processes and systems to achieve market leading efficiency and scalability, which we believe will provide operating leverage as our revenue grows.
We also seek strategic opportunities to expand into complementary service offerings to our staffing businesses that leverage our core capabilities of recruiting and credentialing healthcare professionals. Operationally, our strategic initiatives focus on investing in digitizing and further developing our processes and systems to achieve market leading efficiency and scalability, which we believe will provide operating leverage as our revenue grows.
For the year ended December 31, 2023, we recorded revenue of $3,789.3 million, as compared to $5,243.2 million for 2022. We recorded net income of $210.7 million for 2023, as compared to $444.1 million for 2022. Nurse and allied solutions segment revenue comprised 69% and 76% of total consolidated revenue for the years ended December 31, 2023 and 2022, respectively.
For the year ended December 31, 2024, we recorded revenue of $2,983.8 million, as compared to $3,789.3 million for 2023. We recorded net income (loss) of $(147.0) million for 2024, as compared to $210.7 million for 2023.
The $67.8 million decrease was primarily attributable to a decline within our VMS business, partially offset by growth within our language services business. Revenue for our VMS business declined 36% for similar reasons as nurse and allied solutions segment revenue, while our language services business grew 20% primarily due to a 24% increase in minutes during 2023.
Revenue for our VMS business declined $65.1 million (or 38%) for similar reasons as nurse and allied solutions segment revenue and our outsourced solutions business 25 Table of Contents declined $25.5 million (or 62%) primarily due to a decline in demand, while our language services business grew $38.1 million (or 15%) primarily due to growth of $43.2 million as a result of a 17% increase in minutes during 2024.
We last performed a quantitative impairment test of our goodwill in the first quarter of 2020 and the estimated fair value of each reporting unit exceeded the respective carrying value by more than 100 percent. As of December 31, 2023, we do not have any indefinite-lived intangible assets.
As of December 31, 2024, we do not have any indefinite-lived intangible assets. We performed a quantitative impairment test of our goodwill as of October 31, 2024 and determined that the estimated fair values of the nurse and allied solutions and physician and leadership solutions reporting units were below their respective carrying amounts.
Gross margin by reportable segment for 2023 and 2022 was 26.4% and 26.3% for nurse and allied solutions, 34.3% and 34.5% for physician and leadership solutions, and 66.2% and 76.0% for technology and workforce solutions, respectively. Selling, General and Administrative Expenses .
The overall decline was partially offset by a change in sales mix resulting from lower revenue in our nurse and allied solutions segment. Gross margin by reportable segment for 2024 and 2023 was 24.5% and 26.4% for nurse and allied solutions, 29.7% and 34.3% for physician and leadership solutions, and 58.9% and 66.2% for technology and workforce solutions, respectively.
Additionally, public entities will be required to provide in interim periods all disclosures about a reportable segment’s profit or loss that are currently required annually by Topic 280. This standard is effective on a retrospective basis for fiscal years beginning after December 15, 2023 and interim periods within fiscal years beginning after December 15, 2024, with early adoption permitted.
This standard is effective on either a prospective or retrospective basis for fiscal years beginning after December 15, 2026 and interim periods within fiscal years beginning after December 15, 2027, with early adoption permitted. We are currently evaluating the impact of adopting this standard on our disclosures.
We have seen several years of growth in certified registered nurse anesthetists (CRNAs), the specialty that represents the largest percentage of revenue in this business. Elevated demand levels for locum tenens staffing drove a double digit increase to revenue per day filled in 2023 as compared to the prior year.
Certified registered nurse anesthetists (CRNAs) continue to be the largest specialty for our locum tenens staffing business. Revenue per day filled increased in the 24 Table of Contents fourth quarter as compared to both the prior year and prior quarter.
We obtain actuarial studies on a semi-annual basis to assist us in determining the adequacy of our accrual. For periods between the actuarial studies, we record accruals based on loss rates provided in the most recent actuarial study and management’s review of loss history.
For periods between the actuarial studies, we record accruals based on loss rates provided in the most recent actuarial study and management’s review of loss history. Expense recognized for accruals (inclusive of actuarial-based adjustments) was $7.8 million, $5.5 million and $7.2 million for the years ended December 31, 2024, 2023 and 2022, respectively.
The year-over-year increase from 2022 to 2023 in net cash used in investing activities was primarily attributable to $292.2 million used for acquisitions in 2023 as compared to $69.6 million in 2022. In addition, capital expenditures were $103.7 million, $75.8 million and $53.6 million for the years ended December 31, 2023, 2022 and 2021, respectively.
The year-over-year decrease from 2023 to 2024 in net cash used in investing activities was primarily attributable to (1) no cash paid for acquisitions in 2024 as compared to $292.2 million in 2023 and (2) $8.4 million of payments to fund the deferred compensation plan in 2024 as compared to $24.9 million in 2023.
Net cash used in financing activities for 2022 was due to $576.8 million paid in connection with the repurchase of our common stock and $15.1 million in cash paid for shares withheld for payroll taxes resulting from the vesting of employee equity awards.
Net cash used in financing activities for 2024 was primarily due to (1) repayments of $375.0 million under the Senior Credit Facility (as defined below), (2) $4.8 million in cash paid for shares withheld for payroll taxes resulting from the vesting of employee equity awards, and (3) $3.7 million in cash paid for excise tax on prior year share repurchases, partially offset by borrowings of $125.0 million under the Senior Credit Facility.
In our technology and workforce solutions segment, our language services business continued to experience increased utilization and shift to more virtual interpretation. Bill rates and volumes in our VMS business followed similar trends, although to a greater extent, as our nurse and allied solutions segment, declining from historic highs.
In our technology and workforce solutions segment, our language services business continued to experience an increase in minutes from our existing clients and growth from new clients. Volumes in our VMS business followed similar trends as our travel nurse business as compared to the prior year and prior quarter.
Selling, general and administrative (“SG&A”) expenses were $756.2 million, representing 20.0% of revenue, for 2023, as compared to $936.6 million, representing 17.9% of revenue, for 2022. The decrease in SG&A expenses was primarily due to $164.5 million of lower employee compensation and benefits (inclusive of share-based compensation) and a $22.1 million decrease in the provision for expected credit losses.
Selling, General and Administrative Expenses . Selling, general and administrative (“SG&A”) expenses consist predominantly of compensation and benefits costs for corporate employees, in addition to professional service fees, legal matter accruals and other overhead costs. SG&A expenses were $632.5 million, representing 21.2% of revenue, for 2024, as compared to $756.2 million, representing 20.0% of revenue, for 2023.
Our results of operations include three reportable segments: (1) nurse and allied solutions, (2) physician and leadership solutions, and (3) technology and workforce solutions. The acquisitions during the three years ended December 31, 2023 impact the comparability of the results between the years presented. See additional information in “Item 8.
Goodwill impairment losses of $123.3 million and $99.2 million were recognized in the nurse and allied solutions segment and physician and leadership solutions segment, respectively, during the year ended December 31, 2024. See additional information in “Item 8.
Amortization expense increased 8% to $89.8 million for 2023 from $83.1 million for 2022, primarily attributable to (1) the reduction of useful lives of certain staffing database assets and (2) additional amortization expense related to the intangible assets acquired in the MSDR and Connetics acquisitions.
Amortization expense increased 3% to $92.8 million for 2024 from $89.8 million for 2023, primarily attributable to additional amortization expense related to the intangible assets acquired in the MSDR acquisition, partially offset by having more intangible assets fully amortized during the year ended December 31, 2024.
Bill rates continued to decrease in the fourth quarter but are expected to remain above pre-pandemic levels. 25 Table of Contents Results of Operations The following table sets forth, for the periods indicated, certain statements of operations data as a percentage of revenue.
VMS bill rates in the fourth quarter were down sequentially and year over year. Results of Operations The following table sets forth, for the periods indicated, certain statements of operations data as a percentage of revenue. Our results of operations include three reportable segments: (1) nurse and allied solutions, (2) physician and leadership solutions, and (3) technology and workforce solutions.
The decrease in net cash provided by operating activities for 2023 from 2022 was primarily attributable to (1) a decrease in net income excluding non-cash expenses of $232.0 million primarily due to a decline in operating results in our nurse and allied solutions and technology and workforce solutions segments, (2) a decrease in accounts payable and accrued expenses between periods of $232.3 million primarily due to decreased associate vendor usage, and (3) a decrease in accrued compensation and benefits between periods of $69.6 million primarily due to prior year increases in pay rates and the average number of travelers on assignment in our nurse and allied solutions segment and increased employee compensation and benefits in 2022, including accrued bonuses and commissions that were paid during the first quarter of 2023, and (4) increases in prepaid expenses and other current assets between periods of $55.3 million and $13.6 million, respectively, primarily due to prepayments and deposits that were made in 2021 and refunded by third-party vendors in 2022 related to labor disruption services.
The decrease in net cash provided by operating activities for 2024 from 2023 was primarily attributable to (1) a decrease in net income (loss) excluding non-cash expenses of $187.8 million primarily due to a decline in segment operating income in each of our segments, (2) an increase in other current assets between periods of $12.7 million primarily due to subcontractor deposits related to labor disruption services in the current year, and (3) an increase in income taxes receivable between periods of $7.8 million primarily due to a larger overpayment of estimated taxes during the current year as compared to 2023.
The Senior Credit Facility includes a $125.0 million sublimit for the issuance of letters of credit and a $75.0 million sublimit for swingline loans. Our obligations under the Amended Credit Agreement are secured by substantially all of our assets.
The Senior Credit Facility includes a $125.0 million sublimit for the issuance of letters of credit and a $75.0 million sublimit for swingline loans. On November 5, 2024, we entered into the fourth amendment to our credit agreement (the “Fourth Amendment”) which increased our consolidated net leverage ratio covenant for the year ending December 31, 2025.
For a description of the services we provide under each of our business segments, please see, “Item 1. Business—Our Services.” We believe we are recognized as the market-leading innovator in providing healthcare talent solutions in the United States.
Technology and workforce solutions segment revenue comprised 15% and 13% of total consolidated revenue for the years ended December 31, 2024 and 2023, respectively. For a description of the services we provide under each of our business segments, please see, “Item 1.
Removed
As a tech-centric total talent solutions partner, our managed services programs, or “MSP,” vendor management systems, or “VMS,” workforce consulting services, predictive modeling, staff scheduling, revenue cycle solutions, language interpretation services and the placement of physicians, nurses, allied healthcare professionals and healthcare leaders into temporary and permanent positions enable our clients to successfully reduce staffing complexity, increase efficiency and lead their organizations within the rapidly evolving healthcare environment.
Added
The Company provides access to a comprehensive network of healthcare professionals through its recruitment strategies and breadth of career opportunities. We help providers optimize their workforce to reduce complexity and increase efficiency.
Removed
We also seek strategic opportunities to expand into complementary service offerings to our staffing businesses that leverage our core capabilities of recruiting and credentialing healthcare professionals.

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Item 7A. Quantitative and Qualitative Disclosures About Market Risk

Market Risk — interest-rate, FX, commodity exposure

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Biggest changeSuch unrealized gains or losses would be realized only if we sell the investments prior to maturity. 33 Table of Contents During 2023, we generated substantially all of our revenue in the United States. Accordingly, we believe that our foreign currency risk is immaterial. 34 Table of Contents
Biggest changeDuring 2024, we generated substantially all of our revenue in the United States. Accordingly, we believe that our foreign currency risk is immaterial. 34 Table of Contents
Item 7A. Quantitative and Qualitative Disclosures about Market Risk Market risk is the risk of loss arising from adverse changes in market rates and prices, such as interest rates, foreign currency exchange rates and commodity prices. During 2023, our primary exposure to market risk was interest rate risk associated with our variable interest debt instruments and our investment portfolio.
Item 7A. Quantitative and Qualitative Disclosures about Market Risk Market risk is the risk of loss arising from adverse changes in market rates and prices, such as interest rates, foreign currency exchange rates and commodity prices. During 2024, our primary exposure to market risk was interest rate risk associated with our variable interest debt instruments and our investment portfolio.
A 100 basis point increase in interest rates on our variable rate debt would not have resulted in a material effect on our consolidated financial statements for 2023. A 100 basis point change in interest rates as of December 31, 2023 would not have resulted in a material effect on the fair value of our investment portfolio.
A 100 basis point increase in interest rates on our variable rate debt would not have resulted in a material effect on our consolidated financial statements for 2024. A 100 basis point change in interest rates as of December 31, 2024 would not have resulted in a material effect on the fair value of our investment portfolio.
For our investments that are classified as available-for-sale, unrealized gains or losses related to fluctuations in market volatility and interest rates are reflected within stockholders’ equity in accumulated other comprehensive income (loss) in the consolidated balance sheets.
For our investments that are classified as available-for-sale, unrealized gains or losses related to fluctuations in market volatility and interest rates are reflected within stockholders’ equity in accumulated other comprehensive income (loss) in the consolidated balance sheets. Such unrealized gains or losses would be realized only if we sell the investments prior to maturity.

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