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What changed in AMN HEALTHCARE SERVICES INC's 10-K — 2022 vs 2023

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Paragraph-level year-over-year comparison of AMN HEALTHCARE SERVICES INC's 2022 and 2023 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 2023 report.

+224 added−230 removedSource: 10-K (2024-02-22) vs 10-K (2023-02-22)

Top changes in AMN HEALTHCARE SERVICES INC's 2023 10-K

224 paragraphs added · 230 removed · 179 edited across 6 sections

Item 1. Business

Business — how the company describes what it does

68 edited+15 added−20 removed40 unchanged
Biggest changeWe 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. (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.
Biggest changeOur 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 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 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 a values-based culture of innovation and inclusion in which our team members can achieve their goals.
Driving increased adoption of our existing 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.
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.
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 4 Table of Contents 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, often in support of our MSP clients, 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 (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.
We expect demand for these 7 Table of Contents services to remain at higher than pre-pandemic levels due to the tight labor market and the amount of care that was deferred during the pandemic. • Adoption of Workforce Solutions . We believe healthcare organizations increasingly seek sophisticated, innovative and economically beneficial total talent solutions that improve patient experience and outcomes.
We expect demand for these services to remain at higher than pre-pandemic levels due to the tight labor market and the amount of care that was deferred during the pandemic. • Adoption of Workforce Solutions . We believe healthcare organizations increasingly seek sophisticated, innovative and economically beneficial total talent solutions that improve patient experience and outcomes.
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. Licensure For Our Business Some states require state licensure for businesses that employ, assign and/or place healthcare professionals.
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.
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.
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.
No other client healthcare system or single client facility comprised more than 6% of our consolidated revenue for the fiscal year ended December 31, 2022. 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, 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.
Item 1. Business Overview of Our Company and Business Strategy AMN Healthcare empowers the future of care through the nation’s largest network of highly-qualified healthcare professionals.
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.
In 2022, we launched a corporate fellowship program with Hiring Our Heroes, a veterans organization, and expanded our partnerships with Historically Black Colleges and Universities Career Development Marketplace and early talent platform Handshake. We track our hiring, promotion, retention and engagement rates to inform our overall progress in attainment of our workforce goals.
In 2023, we continued our corporate fellowship program with Hiring Our Heroes, a veterans organization, and expanded our partnerships with Historically Black Colleges and Universities Career Development Marketplace and early talent platform Handshake. We track our hiring, promotion, retention and engagement rates to inform our overall progress in attainment of our workforce goals.
AMN Revenue Cycle Solutions provides skilled labor solutions for remote medical coding, clinical documentation improvement, case management, and clinical data registry, and also provide auditing and advisory services. (4) Physician and Advanced Practice Staffing . We provide locum tenens staffing services through which we offer clients thousands of physicians of all specialties and advanced practice and other clinicians.
We provide skilled labor solutions for remote medical coding, clinical documentation improvement, case management, and clinical data registry, and also provide auditing and advisory services. (4) Physician and Advanced Practice Staffing . We provide locum tenens staffing services through which we offer clients thousands of physicians of all specialties and advanced practice and other clinicians.
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 2022, the largest percentages of our revenue were concentrated in California, Texas and Florida.
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 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 .
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 .
We offer leadership development curriculums led by our team of learning and talent development professionals for new leaders, called LEAD at AMN, as well as a leadership curriculum for our individual contributors who are seeking leadership positions, which we call our emerging leaders program.
We offer leadership development curriculums led by our team of learning and talent development professionals for newly hired and promoted leaders, called LEAD at AMN, as well as a leadership curriculum for our individual contributors who are seeking leadership positions, which we call our emerging leaders program.
Substantially all of our people leaders completed our inclusive leaders curriculum and, in 2022, we had a 96% 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.
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.
Kaiser Foundation Hospitals (and its affiliates), to whom we provide clinical managed services, comprised approximately 18% of our consolidated revenue and 22% of our nurse and allied solutions segment revenue for the fiscal year ended December 31, 2022.
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.
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.
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 also operate within the interim leadership, executive search, physician permanent placement, RPO, VMS, telehealth technology, 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 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 now have embraced a hybrid work environment with team members working a combination of in the office and virtually. Throughout these transitions, our team members have continued to support our clients and healthcare professionals with the highest level of service, regardless of their location and without disruption to our business operations.
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.
The attractive compensation, benefits and reimbursement package that we 6 Table of Contents provide our temporary healthcare professionals includes a competitive wage, professional development opportunities, professional liability insurance, 401(k) plan, health insurance and reimbursements for housing, meals and travel expenses.
The attractive compensation, benefits and reimbursement package that we provide our temporary healthcare professionals includes a competitive wage, professional development opportunities, professional liability insurance, 401(k) plan, ESPP, health insurance and reimbursements for housing, meals and travel expenses.
As the leader and innovator in total talent solutions for the healthcare sector in the United States, we tailor our solutions to our clients’ challenges and goals, and provide staffing, talent optimization strategies, and technology solutions aimed to support caregivers and improve patient outcomes.
As the leader and innovator in total talent solutions for the healthcare sector in the United States, we tailor our solutions to our clients’ workforce challenges and goals, and provide staffing, talent optimization strategies, and technology solutions to support caregivers and patient care.
Our VMS technologies provide, among other things, control over a wide variety of tasks via a single system and consolidated reporting. In 2022, we had approximately $6.7 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. 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 .
Census Bureau, the number of adults age 65 or older is on pace to grow an estimated 30% between 2020 and 2030. 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.
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.
Our team members are dispersed across the country, and we have offices in Dallas, TX; San Diego, CA; Omaha, NE; Boca Raton and Clearwater, FL; Savannah, GA; and Hickory, NC. 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; 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.
AMN has received a top ranking – 95 out of 100 – in the Human Rights Campaign Foundation’s Corporate Equality Index in each of the last four years.
In each of the last seven years, AMN has been named to the Bloomberg Gender-Equality Index. AMN has received a top ranking – 95 out of 100 – in the Human Rights Campaign Foundation’s Corporate Equality Index in each of the last four years.
Our commitment to equity extends to our compensation philosophy and our leadership development strategy, including identifying high-potential diverse talent within the Company.
Our commitment to equity is reflected in our compensation philosophy and programs and our leadership development strategy, including identifying high-potential diverse talent within the Company.
Our solutions enable our clients to optimize their workforce, increase efficiency, and elevate the patient experience. Our comprehensive suite of talent solutions provides management, staffing, recruitment, language services, technology, telehealth and virtual care management, 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 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.
Technology 5 Table of Contents (9) Language Interpretation . 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 250 health systems, more than 2,000 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 350 health systems, more than 2,300 hospitals, and thousands of clinics using our solutions.
We also continued our AMN Healthcare Hardship Fund which began in 2021, providing financial support for team members experiencing extreme financial hardship and launched our AMN Caring for Caregivers Fund to provide similar support to our healthcare professionals.
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.
In its ratings for both MSPs and 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. We are a leading provider of nurse, allied and locum tenens staffing in the United States.
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 our corporate team members returned to an office environment, the health and safety of our team members remained 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 our communities and provide professional development and training opportunities.
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.
While the diverse backgrounds and experiences we seek are broad, here is a snapshot of the diversity of our corporate team members as of January 2023: 69% of our team members are women; 63% of our supervisor through senior manager roles are held by women; 56% of our board of directors are women; 45% of our team members are people of color; our team is 58% Millennials, 31% Generation X, 6% Baby Boomers, and 5% Generation Z; and team members self-identified as veterans, disabled, and LGBTQ+, each representing approximately 2% to 3% of our team.
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.
AMN Passport, which has more than 170,000 registered users and approximately 40,000 average monthly active users as of January 2023, provides a centralized experience for nurses and allied professionals to find, book and manage assignments, access time and pay details, and receive instantaneous alerts and updates, while also creating operational efficiencies through the ability to customize job preferences, store and manage credentials, electronically sign important documents and contact our dedicated recruiters.
AMN Passport provides a centralized experience for nurses and allied professionals to find, book and manage assignments, access time and pay details, and receive instantaneous alerts and updates, while also creating operational efficiencies through the ability to customize job preferences, store and manage credentials, electronically sign important documents and contact our dedicated recruiters.
In addition to our traditional staffing services, our suite of healthcare workforce solutions includes managed services programs (“MSP”), vendor management systems (“VMS”), medical language interpretation services, predictive labor analytics, workforce optimization technology and consulting, clinical labor scheduling, recruitment process outsourcing (“RPO”), revenue cycle solutions, credentialing software services, and virtual care management services.
We expanded our portfolio to serve a diverse and growing set of healthcare talent-related needs. In addition to our traditional staffing services, our suite of healthcare workforce solutions includes managed services programs (“MSP”), vendor management systems (“VMS”), medical language interpretation services, predictive labor analytics, workforce optimization technology and consulting, clinical labor scheduling, recruitment process outsourcing (“RPO”), and revenue cycle solutions.
Talent Planning & Acquisition (7) Managed Services Programs . Many of our clients and prospective clients use a number of healthcare staffing agencies to fulfill their healthcare professional needs. We offer a comprehensive managed services program, in which we manage all or a portion of a client’s contingent staffing needs.
Many of our clients and prospective clients use a number of healthcare staffing agencies to fulfill their healthcare professional needs. We offer a comprehensive managed services program, in which we manage all or a portion of a client’s contingent staffing needs. Through our MSPs, we place our own healthcare professionals and utilize other staffing agencies to fulfill the client’s needs.
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 2022, approximately 64% of our consolidated revenues were generated through MSP relationships, which we estimate is higher than our competitors.
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.
In nurse and allied staffing, we compete with several national competitors together with numerous smaller, regional and local companies. The locum tenens staffing market consists of many small- to mid-sized companies with only a small number of national competitors of which we are one.
The locum tenens staffing market consists of many small- to mid-sized companies with only a small number of national competitors of which we are one.
We recruit our healthcare professionals, depending on the particular service line, under the following brands: AMN Healthcare, American Mobile, Nursefinders, NurseChoice, HealthSource Global Staffing, Onward Healthcare, O’Grady Peyton International, Connetics, Med Travelers, Club Staffing, Staff Care, B.E. Smith, and Merritt Hawkins.
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.
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. 8 Table of Contents Additional Information We maintain a corporate website at www.amnhealthcare.com.
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.
We provide executive leadership search services across the healthcare industry with areas of focus including academic medical centers and children’s hospitals nationwide. 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.
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 .
We believe that human capital management infrastructure, including our DEI commitment, is fundamental to our continued recognition as one of America’s Most Responsible Companies by Newsweek in each of the last four years. Team Member Communication and Engagement Team member engagement and wellness is of critical importance to our success.
We believe that human capital management infrastructure, including our DEI commitment, is fundamental to our continued recognition as one of America’s Most Responsible Companies by Newsweek in each of the last five years. AMN was also recognized by Newsweek as one of America’s Greatest Workplaces for Diversity for 2024.
Industry Competition The healthcare staffing and workforce solutions industry is highly competitive. We compete in national, regional and local markets for healthcare organization clients and healthcare professionals.
We compete in national, regional and local markets for healthcare organization clients and healthcare professionals.
We typically experience modest seasonal fluctuations during our fiscal year, and they tend to vary among our businesses and reportable segments. These fluctuations can vary slightly in intensity from year to year.
We also provide consulting services to our clients to evaluate their staffing spend and offer recommendations for savings by optimizing workforce and scheduling capabilities. We typically experience modest seasonal fluctuations during our fiscal year, and they tend to vary among our businesses and reportable segments. These fluctuations can vary slightly in intensity from year to year.
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. We have invested in and dedicated resources to build an inclusive infrastructure to support our ERGs.
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.
To assure the health and safety of our corporate team members, we worked primarily in a remote work environment for over two years in response to the pandemic. In June 2022, as the pandemic subsided and workplace safety improved with the availability of vaccines, we carefully returned to the office in phases.
In June 2022, as the pandemic subsided and workplace safety improved with the availability of vaccines, we carefully returned to the office in phases.
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 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.
We believe strongly that cultivating a diverse, equitable and inclusive workforce enables us to recruit and retain the best talent, and to develop that talent so that we can best address the evolving needs of our stakeholders. 3 Table of Contents To achieve a diverse workforce that reflects the communities that we serve, we are committed to sourcing candidates from historically underrepresented groups and have focused recruitment efforts to hire team members from a variety of backgrounds.
We believe strongly that cultivating a diverse, equitable and inclusive workforce enables us to recruit and retain the best talent, and to develop that talent so that we can best address the evolving needs of our stakeholders.
We also believe we have a market-leading share in managed services solutions, including VMS and MSP, and healthcare language interpretation services. Our leading competitors vary by segment and include Aya Healthcare, CHG Healthcare Services, Cross Country Healthcare, HealthTrust Workforce Solutions, Ingenovis Health, Jackson Healthcare, Loyal Source, Maxim Healthcare Services, Medical Solutions, Teleperformance, and WittKieffer.
Our leading competitors vary by segment and include Aya Healthcare, CHG Healthcare Services, Cross Country Healthcare, HealthTrust Workforce Solutions, Ingenovis Health, Jackson Healthcare, LanguageLine Solutions, Maxim Healthcare Services, and Medical Solutions.
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 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 technology investments provide a more seamless and efficient workflow for our team members, our healthcare professionals and our clients. For example, throughout 2022, we continued to add functionality to AMN Passport, our top clinician-rated mobile application.
These technology investments provide a more seamless and efficient workflow for our team members, our healthcare professionals and our clients.
In nursing, McKinsey & Company estimates a nationwide shortage of between 200,000 and 450,000 nurses available for direct patient care by 2025. We 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.
We 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 .
In 2022, 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 addition, in 2022, we continued our focus on increasing opportunities for team members to build connections with colleagues through our growing number of employee resource groups (“ERG”).
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.
Our recruitment solutions, which many refer to as RPO, are customized to the client’s particular needs, in which we recruit, hire and/or onboard permanent clinical and nonclinical positions on their behalf. 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.
We partner with clients to streamline their permanent workforce planning and recruitment process through one efficient, agile solution. Our recruitment solutions, which many refer to as RPO, are customized to the client’s particular needs, in which we recruit, hire and/or onboard permanent clinical and nonclinical positions on their behalf.
Some clients and prospective clients prefer a vendor-neutral VMS technology that allows them to self-manage the procurement of contingent clinical labor and their internal float pool. 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 current VMS products are ShiftWise, 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, including the recent release of ShiftWise Flex, Medefis and b4health.
This does not include independent contractors, such as our locum tenens and contract interpreters, who were not our employees in 2022. Health and Safety 2 Table of Contents AMN is committed to providing comprehensive benefit options, including health insurance, a prescription drug benefit, life and disability insurance, and paid time off.
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.
We believe our investments in technology systems will help us realize greater scale, agility, and cost efficiencies. Human Capital Management 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.
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.
Additionally, the U.S. population continues to age, and medical technology advances are contributing to longer life expectancy. A pronounced shift in U.S. age demographics is expected to boost growth of health expenditures, projected by the Centers for Medicare & Medicaid Services at a 5.1% annual rate on average from 2021-2030. According to the U.S.
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.
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.
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.
Our Services In 2022, 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 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.
Together with the vendor-neutral spend through our VMS programs (as discussed below), we had approximately $12.1 billion of spend under management during 2022. (8) Recruitment Solutions . We partner with clients to streamline their permanent workforce planning and recruitment process through one efficient, agile solution.
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 .
These resource groups continue to grow and foster engagement through their close alignment with the diverse interests and backgrounds of our team members. During 2022, we increased the number of ERGs from eight to ten, and 39% of our corporate team members are members of at least one ERG.
We have invested in and dedicated resources to build an inclusive infrastructure to support our ERGs. These resource groups continue to foster engagement through their close alignment with the diverse interests and backgrounds of our team members. As of December 31, 2023, approximately 40% of our corporate team members participate in one or more ERG.
As of December 31, 2022, we had 4,230 corporate team members, which includes both full-time and part-time employees. During the fourth quarter of 2022, we had an average of (1) 15,183 nurses, allied and other healthcare professionals, (2) 451 executive and clinical leadership interim staff, and (3) 1,983 medically qualified interpreters working for us.
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.
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. (6) Executive Search and Academic Leadership .
(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.
We often use our own VMS technology as part of our MSPs, which we believe further enhances the value of our service offering. In 2022, we had approximately $5.3 billion in spend under management through our MSPs and approximately 64% of our consolidated revenue flowed through MSP relationships, which has steadily increased over the past decade.
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.
In 2022, we also partnered with a university to offer a virtual certificate program for high-potential leaders and expanded access to executive coaching programs. Additionally, we provide a mentorship program to provide a larger group of our team members the opportunity to connect with others across the company to support their development, strengthen their skills, and deepen relationships.
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.
To support these objectives, our human capital management strategy focuses on talent acquisition, engagement, retention, diversity, equity, and inclusion, and employee well-being. The strength of our human capital management strategy was instrumental throughout the pandemic and continues to be foundational as we invest resources to address talent shortages, including the severe healthcare labor shortages faced by our clients.
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.
Also, for a portion of the year, we waived healthcare insurance co-premiums for our eligible corporate team members and increased our 401(k) and deferred compensation matching contribution. The care, support and safety of our frontline healthcare professionals remains at the forefront for us.
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.
To reward our employees for their extraordinary efforts and dedication to advancing AMN Healthcare and supporting our clients and healthcare professionals during 2022, we paid one-time cash bonuses to our regular full-time and part-time employees.
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.
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We expanded our portfolio to serve a diverse and growing set of healthcare talent-related needs.
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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.
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Our commitment to supporting our colleagues’ mental, physical, and economic well-being continued throughout 2022. We are working hard every day to ensure that all our team members and healthcare professionals have the resources available to help them navigate the continued challenges and stresses they face in this environment.
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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.
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Additionally, in 2022, our corporate clinician team members placed over 14,000 care calls to our healthcare professionals to assure they had the necessary support during this stressful time.
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We have also updated AMN Passport, our top clinician-rated mobile application, to allow users to see their impact on the patients they support. The app now includes an impact tracker in user profiles that shows the amount of patient care hours they provide and how many communities they serve over their career with us.
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In preparation, AMN implemented a COVID-19 prevention and response program designed to educate our team members on reporting protocols for positive cases and exposures, and outline the investigation and response protocol for identified cases in the workplace.
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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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We are committed to ensuring our offices are a safe place for our team members through continuing education and awareness, including supplemental health and safety training for team members that visit our offices and performing periodic assessments to identify and correct recognizable workplace hazards.
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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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Additionally, through our Chief Nurse Officer Academy, we provided leadership skills training to more than 100 aspiring nurse executives in 2022. Throughout 2022, approximately 1,400 team members were promoted or transferred internally into new positions, representing one third of our corporate team members.
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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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Item 1A. Risk Factors

Risk Factors — what could go wrong, per management

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Biggest changeThe inability to quickly and properly credential and match quality healthcare professionals with suitable placements may negatively affect demand for our services. Our success depends on the quality of our healthcare professionals and our ability to quickly and efficiently assist in obtaining licenses and privileges for our healthcare professionals.
Biggest changeOur success depends on the quality of our healthcare professionals and our ability to quickly and efficiently assist in obtaining licenses and privileges for our healthcare professionals. The speed with which our healthcare professionals can obtain the appropriate licenses, and we can credential them depends in part, on state licensing laws.
We are also subject to certain state laws and regulations applicable to “nursing pools” with which we must comply in order to continue to conduct business in that particular state. Increased regulation relating to healthcare staffing agencies has increased the operational and administrative requirements and increased the cost to provide various of our services in certain states.
We are also subject to certain state laws and regulations applicable to healthcare staffing and “nursing pools” with which we must comply in order to continue to conduct business in that particular state. Regulation relating to healthcare staffing agencies has increased the operational and administrative requirements and increased the cost to provide various of our services in certain states.
Our ability to deliver services to our clients and to manage our commercial technologies, internal systems and data depends largely upon our access to and the performance of our management information and communications systems, including our SaaS-based solutions, client relationship management systems and client/healthcare professional-facing self-service websites.
Our ability to deliver services to our clients and to manage our commercial technologies, internal systems and data depends largely upon our access to and the performance of our management information and communications systems, including our SaaS-based solutions, client relationship management systems and client/healthcare professional-facing self-service websites and applications.
With rising 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 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.
Our information technology and other security protocols may not provide sufficient protection, and as a result a security reach could compromise our networks and significant information about us, our employees, healthcare professionals, patients or clients may be accessed, disclosed, lost or stolen.
Our information technology and other security protocols may not provide sufficient protection, and as a result a security breach could compromise our networks and significant information about us, our employees, healthcare professionals, patients or clients may be accessed, disclosed, lost or stolen.
We maintain accruals related to legal matters, our captive insurance company and self-insured retentions for various lines of insurance coverage, including professional liability, employment practices, health insurance and workers compensation on our balance sheet.
We maintain accruals related to legal matters, our captive insurance company and self-insured retentions for various lines of insurance coverage, including professional liability, employment practices, health insurance and workers’ compensation on our balance sheet.
If that were to occur, we may further increase our allowance for expected credit losses and our days sales outstanding would be negatively affected. 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. 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.
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.
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.
The markets in which we compete are highly competitive, and our competitors may respond more quickly to new or emerging client needs and marketplace conditions. The development 10 Table of Contents of new service lines and business models requires close attention to emerging trends and proposed federal and state legislation related to the healthcare industry.
The markets in which we compete are highly competitive, and our competitors may respond more quickly to new or emerging client needs and marketplace conditions. The development of new service lines and business models requires close attention to emerging trends and proposed federal and state legislation related to the healthcare industry.
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 9 Table of Contents expect this decrease in demand will have a negative impact on our revenue, financial condition, and results of operations.
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.
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.
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 ability to meet 18 Table of Contents those financial ratios and tests will depend on our ongoing financial and operating performance, which, in turn, will be subject to economic conditions and to financial, market, and competitive factors, many of which are beyond our control.
Our ability to meet those financial ratios and tests will depend on our ongoing financial and operating performance, which, in turn, will be subject to economic conditions and to financial, market, and competitive factors, many of which are beyond our control.
We rely on our human capital intensive, relationship-oriented approach and national infrastructure to enable us to compete in all aspects of our business. We must continually evaluate and expand our healthcare professional network to serve the needs of our clients.
We rely on our tech-enabled, relationship-oriented approach and national infrastructure to enable us to compete in all aspects of our business. We must continually evaluate and expand our healthcare professional network to serve the needs of our clients.
With the advent of technology and more sophisticated staffing management and recruitment processes, including internal “travel” and other healthcare staffing models, 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 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.
For example, Kaiser Foundation Hospitals (and its affiliates) (collectively, “Kaiser”) comprised approximately 18% of our consolidated revenue in 2022.
For example, Kaiser Foundation Hospitals (and its affiliates) (collectively, “Kaiser”) comprised approximately 17% of our consolidated revenue in 2023.
We maintain goodwill on our balance sheet, which represents the excess of the total purchase price of our acquisitions over the fair value of the net assets and intangible assets we acquired. We evaluate goodwill and intangible assets for impairment annually or when evidence of potential impairment exists, respectively. If we identify an impairment, we record a charge to earnings.
We maintain goodwill on our balance sheet, which represents the excess of the total purchase price of our acquisitions over the fair value of the net assets and intangible assets we acquired. We evaluate goodwill and intangible assets for impairment annually or when evidence of potential impairment exists, respectively.
A decline or change in interstate compact laws can impact our business. 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 that credential and match healthcare professionals in suitable placements and third-party vendors that provide ancillary services.
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, Medefis, b4health, Avantas Smart Square, Silversheet and Synzi 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.
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.
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.
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. 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.
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, 2022, we cannot provide assurance that we will continue to be.
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.
If our clients are able to increase the effectiveness of their staffing and recruitment functions through analytics, automation or otherwise, 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 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 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.
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.
As of December 31, 2022, our total indebtedness, net of unamortized fees and premium, equaled $843.5 million.
As of December 31, 2023, our total indebtedness, net of unamortized fees and premium, equaled $1,304.7 million.
An impairment charge to goodwill or intangible assets would decrease our earnings or increase our losses, as the case may be. 17 Table of Contents Risk Factors Related to Our Indebtedness and Other Liabilities Our indebtedness could adversely affect our ability to raise additional capital to fund our operations, limit our ability to react to changes in the economy or our industry, and expose us to interest rate risk to the extent of any variable rate debt.
Risk Factors Related to Our Indebtedness and Other Liabilities Our indebtedness could adversely affect our ability to raise additional capital to fund our operations, limit our ability to react to changes in the economy or our industry, and expose us to interest rate risk to the extent of any variable rate debt.
If we are unable to consummate additional acquisitions, we may not achieve our long-term growth goals. 16 Table of Contents Despite diligence and integration planning, acquisitions still present certain risks, including the time and economic costs of integrating an acquisition’s technology, control and financial systems, unforeseen liabilities, and the difficulties in bringing together different work cultures and personnel.
Despite diligence and integration planning, acquisitions still present certain risks, including the time and economic costs of integrating an acquisition’s technology, control and financial systems, unforeseen liabilities, and the difficulties in bringing together different work cultures and personnel.
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 has remained above pre-pandemic levels. However, if new variants emerge or an outbreak of a different illness emerges, demand may again decrease.
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.
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.
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.
We have made acquisitions in the past several years to broaden the scope and depth of our talent solutions.
We have made acquisitions in the past several years to broaden the scope and depth of our talent solutions. If we are unable to consummate additional acquisitions, we may not achieve our long-term growth goals.
In addition, our inability to establish relationships with these intermediaries may result in us losing our ability to work with certain healthcare facilities. The ability of our clients to increase the efficiency and effectiveness of their staffing management and recruiting efforts may affect the demand for our services that could negatively affect our business.
Risk Factors that May Affect the Demand for Our Services The ability of our clients to increase the efficiency and effectiveness of their staffing management and recruiting efforts may affect the demand for our services that could negatively affect our business.
We have substantial insurance-related accruals and legal accruals on our balance sheet, and any significant adverse adjustments may decrease our earnings or increase our losses and negatively impact our cash flows.
As interest rates increase, our debt service obligations on certain of our variable rate indebtedness will increase even though the amount borrowed remains the same. We have substantial insurance-related accruals and legal accruals on our balance sheet, and any significant adverse adjustments may decrease our earnings or increase our losses and negatively impact our cash flows.
Our risk factor descriptions are intended to convey our assessment of each applicable risk and such assessments are integrated into our strategic and operational planning. Risk Factors that May Affect the Demand for Our Services The widespread outbreak of illness or other public health crisis could have an adverse effect on our business, financial condition and results of operations .
Such new technologies and processes could reduce the demand for our services, which could negatively affect our business. The widespread outbreak of illness or other public health crisis could have an adverse effect on our business, financial condition and results of operations .
The speed with which our healthcare professionals can obtain 15 Table of Contents the appropriate licenses, and we can credential them depends in part, on state licensing laws. Roughly 35 states are part of the Enhanced Nurse Compact and over 20 states are part of the Physical Therapy Licensure Compact and Interstate Medical Compact Acts.
Roughly 35 states are part of the Enhanced Nurse Compact and over 20 states are part of the Physical Therapy Licensure Compact and Interstate Medical Compact Acts. A decline or change in interstate compact laws can impact our business.
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Such new technologies and processes could reduce the demand for our services, which could negatively affect our business.
Added
Our risk factor descriptions are intended to convey our assessment of each applicable risk and such assessments are integrated into our strategic and operational planning.
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As interest rates increase, our debt service obligations on certain of our variable rate indebtedness will increase even though the amount borrowed remains the same. In addition, on March 5, 2021, the U.K.
Added
In addition, our inability to establish relationships with these intermediaries may result in us losing our ability to work with certain healthcare facilities.
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Financial Conduct Authority announced that 1-week and 2-week USD LIBOR will cease publication after December 31, 2021, and that 1-month, 3-month, 6-month and 1-year USD LIBOR will cease publication after June 30, 2023. As a result, we have transitioned to the Secured Overnight Financing Rate (“SOFR”) in the third amendment to our credit agreement.
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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.
Added
These technological changes may reduce demand for our services, enable the development of competitive products or services or enable our customers to reduce or bypass the use of our services.
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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.
Added
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.
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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.

Item 2. Properties

Properties — owned and leased real estate

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Biggest changeWe set forth below our principal leased office spaces as of December 31, 2022 together with our business segments that utilize them: Location Square Feet Dallas, Texas (all segments) 108,502 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, 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.”

Item 5. Market for Registrant's Common Equity

Market for Common Equity — stock, dividends, buybacks

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Biggest changeThe graph below compares the total return on our common stock with the total return of (i) the NYSE Composite Index, (ii) the Russell 2000 Index, (iii) the Dow Jones US Business Training & Employment Agencies Index (“BTEA”), and (iv) the S&P Healthcare Services Select Industry Index (“SPSIHP”), assuming an investment of $100 on December 31, 2017 in our common stock and the stocks comprising the NYSE Composite Index, the Russell 2000 Index, the BTEA, and the SPSIHP, respectively.
Biggest changeThe 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
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.
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.
During the fiscal year ended December 31, 2022, 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, 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”).
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, 2023, there were 18 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 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.
On November 10, 2021, February 17, 2022 and June 15, 2022, we announced increases to the repurchase program totaling $700.0 million for a total of $850.0 million of repurchase authorization as of December 31, 2022.
On November 10, 2021, February 17, 2022 and June 15, 2022, we announced increases to the repurchase program totaling $700.0 million. Additionally, on February 16, 2023, we announced an increase of $500.0 million for a total of $1,350.0 million of repurchase authorization, of which $226.7 million remained on the repurchase program as of December 31, 2023.
As of December 31, 2022, we have repurchased 8.2 million shares of our common stock at an average price of $84.85 per share excluding broker’s fees, resulting in an aggregate purchase price of $698.6 million, since 2016.
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.
During 2022, we repurchased 5.6 million shares of common stock at an average price of $102.16 per share excluding broker’s fees, resulting in an aggregate purchase price of $576.8 million. See “Item 8. 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 during 2022.
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.
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All share repurchases to date were made under the Company Repurchase Program, which is the only repurchase program of the Company currently in effect. 20 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, 2022 690,783 $97.98 690,783 $ 110,467,685 February 1 - 28, 2022 648,346 $99.67 648,346 $ 345,825,167 March 1 - 31, 2022 958,545 $99.79 958,545 $ 250,144,621 April 1 - 30, 2022 104,843 $101.59 104,843 $ 239,490,711 May 1 - 31, 2022 1,771,240 $92.12 1,771,240 $ 76,278,235 June 1 - 30, 2022 — $0.00 — $ 326,278,235 July 1 - 31, 2022 — $0.00 — $ 326,278,235 August 1 - 31, 2022 — $0.00 — $ 326,278,235 September 1 - 30, 2022 — $0.00 — $ 326,278,235 October 1 - 31, 2022 — $0.00 — $ 326,278,235 November 1 - 30, 2022 1,006,756 $119.76 1,006,756 $ 205,682,254 December 1 - 31, 2022 463,774 $117.01 463,774 $ 151,402,100 Total 5,644,287 $102.16 5,644,287 $ 151,402,100 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.
Added
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.
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The Russell 2000 Index and the SPSIHP have been added to the performance graph for the fiscal year ended December 31, 2022 and we plan to include them in future filings. The Russell 2000 Index is a widely used broad-based market index that we believe more accurately represents companies of comparable market capitalization.
Added
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
Additionally, we believe that the SPSIHP is a more accurate representation of a published industry index that includes companies engaged in businesses similar to ours.
Added
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
Accordingly, we plan to discontinue the use of the NYSE Composite Index and the BTEA in future filings. 22 Table of Contents 12/31/17 12/31/18 12/31/19 12/31/20 12/31/21 12/31/22 AMN Healthcare Services, Inc. 100.00 115.05 126.52 138.58 248.39 208.77 NYSE Composite 100.00 91.05 114.28 122.26 147.54 133.75 Russell 2000 100.00 88.99 111.70 134.00 153.85 122.41 BTEA 100.00 74.61 94.22 99.70 136.41 94.30 SPSIHP 100.00 103.02 122.78 164.29 180.72 145.15
Added
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.
Added
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.
Added
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.

Item 7. Management's Discussion & Analysis

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

67 edited+17 added−24 removed48 unchanged
Biggest changeThe overall increase in net cash provided by operating activities was partially offset by (1) a decrease in other liabilities between periods of $249.3 million primarily due to cash paid for income taxes and client deposits related to labor disruption services that were returned during the current year, which was partially offset by the payment of a lease termination fee during 2021, (2) a decrease in accounts payable and accrued expenses between periods of $207.3 million primarily due to the increase in associate vendor usage during the prior year and timing of payments, (3) a decrease in accrued compensation and benefits between periods of $139.7 million primarily due to prior year increases in pay rates, billable hours, and the average number of travelers on assignment in our nurse and allied solutions segment and increased employee compensation and benefits in 2021, and (4) an increase in income taxes receivable between periods of $15.5 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) 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.
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.
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.
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, credentialing, workforce optimization service, and other technology-enabled services.
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.
Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements—Note (2), Acquisitions.” Operationally, our strategic initiatives focus on investing in 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.
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.
The most significant matters for which the Company has established accruals in connection with loss contingencies are class actions related to wage and hour claims under California and Federal law.
The most significant matters for which the Company has established accruals in connection with loss contingencies are class and representative actions related to wage and hour claims under California and Federal law.
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, 2022.
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 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, 2022, we do not have any indefinite-lived intangible assets.
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.
The indenture governing the 2027 Notes contains covenants that, among other things, restrict 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, • consolidate, merge or transfer all or substantially all of our assets, • engage in transactions with affiliates, and • create unrestricted subsidiaries.
The indenture governing the 2027 Notes contains covenants that, among other things, restrict 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, 29 Table of Contents • create certain liens, • enter into agreements that restrict dividends or other payments from our restricted subsidiaries, • consolidate, merge or transfer all or substantially all of our assets, • engage in transactions with affiliates, and • create unrestricted subsidiaries.
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, 2021 to the Year Ended December 31, 2020 We describe in detail the comparison of results for the years ended December 31, 2021 and 2020 in “Item 7.
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.
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.
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.
Over the past five years, we have grown our business both organically and as a result of a number of 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, 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.
Years Ended December 31, 2022 2021 2020 Consolidated Statements of Operations: Revenue 100.0 % 100.0 % 100.0 % Cost of revenue 67.3 67.1 66.9 Gross profit 32.7 32.9 33.1 Selling, general and administrative 17.9 18.3 23.0 Depreciation and amortization 2.5 2.6 3.9 Income from operations 12.3 12.0 6.2 Interest expense, net, and other 0.7 0.9 2.4 Income before income taxes 11.6 11.1 3.8 Income tax expense 3.1 2.9 0.8 Net income 8.5 % 8.2 % 3.0 % Comparison of Results for the Year Ended December 31, 2022 to the Year Ended December 31, 2021 Revenue .
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 .
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.
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.
Significant judgment is required to determine both probability and the estimated amount and the final outcome may ultimately be materially different. Where a range of loss can be reasonably 33 Table of Con tents estimated with no best estimate in the range, we record the minimum estimated liability.
Significant judgment is required to determine both probability and the estimated amount and the final outcome may ultimately be materially different. Where a range of loss can be reasonably estimated with no best estimate in the range, we record the minimum estimated liability.
Interest on the 2029 Notes will be payable semi-annually in arrears on April 15 and October 15 of each year, commencing April 15, 2021. 30 Table of Con tents 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 % 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.
As an innovative total talent solutions partner, our managed services programs, or “MSP,” vendor management systems, or “VMS,” workforce consulting services, predictive modeling, staff scheduling, telehealth services, credentialing services, 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.
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.
Depreciation expense (exclusive of depreciation included in cost of revenue) increased 31% to $49.9 million for 2022 from $38.1 million for 2021, 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 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.
Financial Statements and Supplementary Data—Notes to Consolidated Financial Statements—Note (8), Notes Payable and Credit Agreement.” As of December 31, 2022, the total of our contractual obligations under operating leases with initial terms in excess of one year was $18.0 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, 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.
Recent Trends Demand for our temporary and permanent placement staffing services is driven in part by U.S. economic and labor trends, and since early 2020 through present, the COVID-19 pandemic and the “Great Resignation” have impacted demand.
Recent Trends Demand for our temporary and permanent placement staffing services is driven in part by U.S. economic and labor trends, and from early 2020 through 2022, the COVID-19 pandemic and the “Great Resignation” impacted demand.
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.
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 terms of the Amended Credit Agreement, including maturity dates, payment and interest terms, are described in further detail in “Item 29 Table of Con tents 8.
The terms of the Amended Credit Agreement, including maturity dates, payment and interest terms, are described in further detail in “Item 8.
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 2022, 2021 and 2020 impact the comparability of the results between the years presented. See additional information in “Item 8.
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.
These covenants are subject to a number of important exceptions and qualifications. The indenture governing the 2027 Notes contains affirmative covenants and events of default that are customary for indentures governing high yield securities. The 2027 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 2027 Notes contains affirmative covenants and events of default that are customary for indentures governing high yield securities.
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.
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.
Physician and leadership solutions segment revenue comprised 13% and 15% of total consolidated revenue for the years ended December 31, 2022 and 2021, respectively. Technology and workforce solutions segment revenue comprised 11% and 10% of total consolidated revenue for the years ended December 31, 2022 and 2021, respectively.
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.
The increase in the effective income tax rate was primarily attributable to the recognition of net discrete tax expense of $1.7 million during 2022 compared to $3.4 million of net discrete tax benefits recognized during 2021, in relation to income before income taxes of $606.7 million and $443.9 million for 2022 and 2021, respectively. See additional information in “Item 8.
The decrease in the effective income tax rate was primarily attributable to the recognition of net discrete tax benefit of $5.4 million during 2023 compared to $1.7 million of net discrete tax expense recognized during 2022, in relation to income before income taxes of $284.3 million and $606.7 million for 2023 and 2022, respectively. See additional information in “Item 8.
We intend to finance potential future acquisitions with cash provided from operations, borrowings under our Senior Credit Facility, or other borrowings under our Amended Credit Agreement, bank loans, debt or equity offerings, or some combination of the foregoing.
We intend to finance potential future acquisitions with cash provided from operations, borrowings under our Senior Credit Facility, or other borrowings under our Amended Credit Agreement, bank loans, debt or equity offerings, or some combination of the foregoing. The following discussion provides further details of our liquidity and capital resources.
Additionally, $4.1 million and $2.5 million of depreciation expense for our language services business is included in cost of revenue for 2022 and 2021, respectively. Interest Expense, Net, and Other . Interest expense, net, and other, was $40.4 million for 2022 as compared to $34.1 million for 2021.
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.
For the year ended December 31, 2022, we recorded revenue of $5,243.2 million, as compared to $3,984.2 million for 2021. We recorded net income of $444.1 million for 2022, as compared to $327.4 million for 2021. Nurse and allied solutions segment revenue comprised 76% and 75% of total consolidated revenue for the years ended December 31, 2022 and 2021, respectively.
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.
The overall decline was partially offset by (1) a higher margin in our technology and workforce solutions segment primarily due to a change in sales mix resulting from increased revenue in our VMS business and its higher margins as compared to our other businesses within the segment and (2) a change in sales mix resulting from higher revenue in our technology and workforce solutions segment.
The overall increase was partially offset by a lower margin in our technology and workforce solutions segment primarily due to a change in sales mix resulting from lower revenue in our VMS business and its higher margins as compared to our other businesses within the 26 Table of Contents segment.
For 2022 and 2021, revenue under our MSP arrangements comprised approximately 64% and 56% of our consolidated revenue, 81% and 71% for nurse and allied solutions segment revenue, 18% and 15% for physician and leadership solutions segment revenue, and 2% and 2% of our technology and workforce solutions segment revenue, respectively. Gross Profit .
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 .
Letters of Credit As of December 31, 2022, we maintained outstanding standby letters of credit totaling $22.0 million as collateral in relation to our workers compensation insurance agreements and a corporate office lease agreement.
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.
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, 2022 and 2021 (in thousands): December 31, 2022 2021 Case reserves (1) $ 8,450 $ 10,407 IBNR losses (1) 25,176 23,027 Excess liability (2) 10,344 8,237 Total accrual $ 43,970 $ 41,671 (1) The provisions for case reserves and estimated IBNR losses are presented net of excess liability.
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.
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.
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.
Gross margin by reportable segment for 2022 and 2021 was 26.3% 26 Table of Contents and 27.4% for nurse and allied solutions, 34.5% and 35.8% for physician and leadership solutions, and 76.0% and 69.4% for technology and workforce solutions, respectively. Selling, General and Administrative Expenses .
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 .
Of the $22.0 million of outstanding letters of credit, we have collateralized $0.6 million in cash and cash equivalents and the remaining $21.4 million is collateralized by the Senior Credit Facility.
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.
The decline in consolidated gross margin for the year ended December 31, 2022 was primarily due to (1) a lower margin in our nurse and allied solutions segment driven by higher clinician compensation, (2) a change in sales mix resulting from higher revenue in our nurse and allied solutions segment, and (3) a lower margin in our physician and leadership solutions segment driven by higher compensation and a change in specialty mix in our locum tenens and interim leadership businesses.
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.
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, 2022 2021 Nurse and allied solutions $ 471,489 $ 358,092 Physician and leadership solutions 148,619 131,228 Technology and workforce solutions 132,733 92,498 Unallocated corporate overhead 153,669 123,416 Share-based compensation 30,066 25,217 $ 936,576 $ 730,451 Depreciation and Amortization Expenses .
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 .
Net cash used in financing activities for 2021 was primarily due to (1) repayments of $70.0 million under the Senior Credit Facility (as defined below) and $21.9 million under the Additional Term Loan (as defined below), (2) $7.2 million in cash paid for shares withheld for payroll taxes resulting from the vesting of employee equity awards, and (3) $3.1 million of acquisition earn-out payments, partially offset by borrowings of $70.0 million under the Senior Credit Facility.
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.
From a healthcare professional supply perspective, we continue to invest in new candidate recruitment and engagement initiatives and technologies to access and effectively utilize our network of qualified healthcare professionals to capitalize on the demand we are experiencing due to the combined effects of healthcare reform, the aging population and labor shortages within certain regions and disciplines. 24 Table of Contents Over the last several years, we have worked to execute on our management strategies and intend to continue to do so in the future.
From a healthcare professional supply perspective, we continue to invest in new candidate recruitment and engagement initiatives and technologies to retain and grow our network of qualified healthcare professionals. Over the last several years, we have worked to execute on our management strategies and intend to continue to do so in the future.
Gross profit increased 31% to $1,716.7 million for 2022 from $1,309.6 million for 2021, representing gross margins of 32.7% and 32.9%, respectively.
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.
Management’s Discussion and Analysis of Financial Condition and Results of Operations—Results of Operations—Comparison of Results for the Year Ended December 31, 2021 to the Year Ended December 31, 2020” of our 2021 Annual Report on Form 10-K. 27 Table of Con tents Liquidity and Capital Resources In summary, our cash flows were: Years Ended December 31, 2022 2021 2020 (in thousands) Net cash provided by operating activities $ 653,733 $ 305,356 $ 256,826 Net cash used in investing activities (170,710) (107,402) (538,172) Net cash provided by (used in) financing activities (591,865) (34,895) 211,486 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, 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.
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.
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.
On February 10, 2023, we entered into the third amendment to the New Credit Agreement (the “Third Amendment”). The Third Amendment (together with the New Credit Agreement, the First Amendment and the Second Amendment, collectively, the “Amended Credit Agreement”) provides for, among other things, an increase to the Senior Credit Facility to $750.0 million.
The Third Amendment (together with the credit agreement, the first amendment and the second amendment, collectively, the “Amended Credit Agreement”) provides for, among other things, an increase to the secured revolving credit facility (the “Senior Credit Facility”) from $400.0 million to $750.0 million.
As of December 31, 2022, (1) no amount was drawn with $378.6 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.
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.
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”).
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”).
Income tax expense was $162.7 million for 2022 as compared to $116.5 million for 2021, reflecting effective income tax rates of 27% and 26% for these periods, respectively.
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.
Our Days Sales Outstanding was 55 and 53 days at December 31, 2022 and December 31, 2021, respectively. Investing Activities Net cash used in investing activities for 2022, 2021 and 2020 was $170.7 million, $107.4 million and $538.2 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 2023, 2022 and 2021 was $412.5 million, $170.7 million and $107.4 million, respectively.
The $992.4 million increase was primarily attributable to a 23% increase in the average number of travelers on assignment and an approximately 14% increase in the average bill rate, partially offset by a 2% decrease in billable hours during the year ended December 31, 2022.
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.
In addition, capital expenditures were $75.8 million, $53.6 million and $37.7 million for the years ended December 31, 2022, 2021 and 2020, respectively. Our 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.
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.
The increase in net cash provided by operating activities for 2022 from 2021 was primarily attributable to (1) an increase in net income excluding non-cash expenses of $205.4 million primarily due to improved operating results in our nurse and allied solutions and technology and workforce solutions segments, (2) a decrease in accounts receivable and subcontractor receivables between periods of $614.2 million primarily due to the significant increase in the receivables balance in the prior year, which was due to increases in revenue and associate vendor usage in the prior year along with timing of collections, and (3) decreases in prepaid expenses and other current assets between periods of $112.6 million and $39.8 million, respectively, primarily due to prepayments made in the prior year and refunds received in the current year by third-party vendors related to labor disruption services.
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.
Our interim leadership business experienced an approximately 9% growth, while our physician permanent placement and executive search businesses grew 19% during 2022. Technology and workforce solutions segment revenue increased 41% to $562.8 million for 2022 from $399.9 million for 2021. The $163.0 million increase was primarily attributable to growth within our VMS and language services businesses during 2022.
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.
We used the proceeds from the issuance of the New 2027 Notes to repay $200.0 million of our indebtedness under the Additional Term Loan during the third quarter of 2020. 4.000% Senior Notes Due 2029 On October 20, 2020, AMN Healthcare, Inc., a wholly owned subsidiary of the Company, completed the issuance of $350.0 million aggregate principal amount of 4.000% Senior Notes due 2029 (the “2029 Notes”).
The 2027 Notes and the guarantees are not subject to any registration rights agreement. 4.000% Senior Notes Due 2029 On October 20, 2020, AMN Healthcare, Inc., a wholly owned subsidiary of the Company, completed the issuance of $350.0 million aggregate principal amount of 4.000% Senior Notes due 2029 (the “2029 Notes”). The 2029 Notes will mature on April 15, 2029.
Amortization expense increased 32% to $83.1 million for 2022 from $63.0 million for 2021, primarily attributable to (1) $14.6 million of additional amortization expense from the assignment of useful lives to certain tradenames and trademarks intangible assets that were previously not subject to amortization effective December 31, 2021 and (2) $3.0 million of additional amortization expense related to the intangible assets acquired in the Connetics and Synzi acquisitions.
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.
The year-over-year increase from 2021 to 2022 in net cash used in investing activities was primarily attributable to (1) $69.6 million used for acquisitions in 2022 as compared to $41.3 million in 2021 and (2) $21.5 million of payments to fund the deferred compensation plan during 2022 as compared to $7.6 million during 2021.
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.
Professional Liability Reserve 32 Table of Con tents 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.
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.
Revenue increased 32% to $5,243.2 million for 2022 from $3,984.2 million for 2021, primarily attributable to higher organic revenue across our segments. Nurse and allied solutions segment revenue increased 33% to $3,982.5 million for 2022 from $2,990.1 million for 2021.
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.
Physician and leadership solutions segment revenue increased 17% to $697.9 million for 2022 from $594.2 million for 2021. The $103.7 million increase was attributable to growth in our core businesses across the segment, partially offset by lower COVID-19 project work.
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 following discussion provides further details of our liquidity and capital resources. 28 Table of Con tents Operating Activities Net cash provided by operating activities for 2022, 2021 and 2020 was $653.7 million, $305.4 million and $256.8 million, respectively.
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.
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 decreases) was $7.2 million, $7.2 million and $6.0 million for the years ended December 31, 2022, 2021 and 2020, respectively.
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.
We have also increased spending to support our current team members and retain talent. 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.
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.
Selling, general and administrative (“SG&A”) expenses were $936.6 million, representing 17.9% of revenue, for 2022, as compared to $730.5 million, representing 18.3% of revenue, for 2021.
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.
Revenue in our locum tenens business grew approximately 21% during 2022 primarily due to a 14% increase in the number of days filled and a 6% increase in the revenue per day filled, which was driven by growth in core demand and volume over pre-pandemic levels.
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.
As part of our long-term growth strategy to add value for our clients, healthcare professionals, and stockholders, on May 13, 2022, April 7, 2021, and February 14, 2020, we acquired Connetics, Synzi (including its wholly-owned subsidiary SnapMD), and Stratus Video (which we have since rebranded as AMN Language Services), respectively.
As part of our long-term growth strategy to add value for our clients, healthcare professionals, and stockholders, we acquired MSI Systems Corp. and DrWanted.com LLC (together “MSDR”) on November 30, 2023 and Connetics on May 13, 2022. See additional information in “Item 8.
See additional information in “Item 5. Market For Registrant’s Common Equity, Related Stockholder Matters and Issuer Purchases of Equity Securities” and “Item 8.
See additional information in “Item 5. Market For Registrant’s Common Equity, Related Stockholder Matters and Issuer Purchases of Equity Securities.” Under the repurchase program, we entered into an accelerated share repurchase (“ASR”) agreement with a counterparty on May 8, 2023 to repurchase $200.0 million of our outstanding common stock and received an initial delivery of 1.8 million shares.
This standard is effective on a prospective basis for fiscal years, and interim periods within those fiscal years, beginning after December 15, 2022, with early adoption permitted. We have adopted this standard effective January 1, 2023 and do not expect the adoption to have a material impact on our consolidated financial statements.
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.
Demand softened for that business in the second half of 2022 as some healthcare organizations streamlined leadership roles to reduce costs. In our technology and workforce solutions segment, our language services business continued to experience increased utilization due to a shift to more virtual interpretation during the pandemic and labor shortages.
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.
Removed
Connetics specializes in the direct hire recruitment and permanent placement of international nurse and allied health professionals with healthcare facilities in the United States. See additional information in “Item 8.
Added
From late 2020 through most of 2022, these conditions resulted in historically high demand for our nurses, allied healthcare professionals and vendor-neutral VMS technologies supporting the placement of these professionals. Since 2022, healthcare organizations have hired permanent staff aggressively, enabling them to reduce what had been historically high utilization of contingent labor.
Removed
Since late 2020, we have been experiencing historically high demand for nurses and allied healthcare professionals and current demand across all segments and business lines is above pre-COVID-19 levels. We continue to see demand above pre-pandemic levels across our nurse and allied solutions segment driven by vacancies resulting from burnout, attrition, and retirements.
Added
As a result, in 2023, demand in our travel nurse business declined significantly over the course of the first quarter and into the early second quarter. In the third and fourth quarter, demand for our travel nurse business was relatively stable but remained below pre-pandemic levels.
Removed
The wages for nurses and the corresponding bill rates we charge our clients peaked in the first quarter of 2022. Bill rates and clinician compensation declined during the rest of the year, but remained well above prior year and pre-pandemic levels. We expect bill rates and clinician compensation to stabilize above pre-pandemic levels entering 2023.
Added
Demand in our allied business continues to be above pre-pandemic levels, and certain specialties such as therapy and imaging are up significantly year over year, offsetting the decline in laboratory and other specialties involved in treating COVID-19 patients.
Removed
In our physician and leadership solutions segment, demand for our locum tenens business exceeded pre-pandemic levels throughout all of 2022. We expect continued strong demand for locums tenens staffing in the first quarter of 2023. Our interim leadership business saw all time high demand in the second half of 2021 and the first half of 2022.
Added
In our nurse and allied solutions segment, we have seen a decrease in overall staffing volume from prior year due to lower travel nurse demand with fourth quarter staffing volume relatively flat to the prior quarter. Overall staffing volume remains above pre-pandemic levels with favorable demand in international nurse staffing and allied staffing.
Removed
Bill rates and volumes declined in our VMS business from peak levels in the first quarter, but still remained well above pre-pandemic levels. We anticipate bill rates to follow similar trends as our nurse and allied solutions segment and stabilize well above pre-pandemic levels as we enter 2023.
Added
Bill rates decreased slightly in the fourth quarter, at a slower rate than the first three quarters of the year, and remain well above pre-pandemic levels across the nurse and allied solutions segment. In our physician and leadership solutions segment, demand for our locum tenens business is well above pre-pandemic levels.
Removed
The demand for our recruitment process outsourcing services remained strong as clients look for solutions to help address the increased labor shortages and the need to address vacancies in their permanent roles and challenges with staffing their internal recruiting teams. In the current constrained labor market, we expect an elevated level of demand as compared to pre-pandemic.
Added
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.
Removed
As our businesses have continued to grow, we have increased our sales and operations workforce to support our clients and healthcare professionals.

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Item 7A. Quantitative and Qualitative Disclosures About Market Risk

Market Risk — interest-rate, FX, commodity exposure

4 edited+0 added−0 removed0 unchanged
Biggest changeDuring 2022, we generated substantially all of our revenue in the United States. Accordingly, we believe that our foreign currency risk is immaterial. 34 Table of Con tents
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
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 2022, 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 2023, our primary exposure to market risk was interest rate risk associated with our variable interest debt instruments and our investment portfolio.
A 100 basis point increase in interest rates on our variable rate debt would not have resulted in a material effect on our consolidated financial statements for 2022. A 100 basis point change in interest rates as of December 31, 2022 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 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.
For our investments that are classified as available-for-sale, unrealized gains or losses related to fluctuations in market volatility and interest rates are reflected within stockholders’ equity in accumulated other comprehensive income (loss) in the consolidated balance sheets. Such unrealized losses would be realized only if we sell the investments prior to maturity.
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.

Other AMN 10-K year-over-year comparisons