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Revenue | 12 Months Ended
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Dec. 31, 2019
Revenue From Contract With Customer [Abstract] |
Revenue | 3. Revenue In May 2014, the FASB and the International Accounting Standards Board issued ASU 2014-09, “Revenue from Contracts with Customers (Topic 606)” (“ASU 2014-09”). ASU 2014-09 requires companies to exercise more judgment and recognize revenue using a five-step process. The Company adopted ASU 2014-09 using the modified retrospective method for all contracts effective January 1, 2018 and is using a portfolio approach to group contracts with similar characteristics and analyze historical cash collections trends. Modified retrospective adoption requires entities to apply the standard retrospectively to the most current period presented in the financial statements, requiring the cumulative effect of the retrospective application as an adjustment to the opening balance of retained earnings at the date of initial application. Prior periods have not been adjusted. No cumulative-effect adjustment in retained earnings was recorded as the adoption of ASU 2014-09 did not significantly impact the Company’s reported historical revenue. As a result of certain changes required by ASU 2014-09, the majority of the Company’s provision for doubtful accounts are recorded as a direct reduction to revenue instead of being presented as a separate line item on the consolidated statements of operations. The adoption of ASU 2014-09 has no impact on the Company’s accounts receivable as it was historically recorded net of allowance for doubtful accounts and contractual adjustments, and the Company has eliminated the presentation of allowance for doubtful accounts on the consolidated balance sheets. At December 31, 2019 and 2018, estimated implicit price concessions of $47.4 million and $47.0 million, respectively, had been recorded as reductions to our accounts receivable balances to enable us to record our revenues and accounts receivable at the estimated amounts we expected to collect. The adoption of ASU 2014-09 did not have a significant impact on the Company’s consolidated statements of operations. The Company evaluated the nature, amount, timing and uncertainty of revenue and cash flows using the five-step process provided within ASU 2014-09. Revenue is primarily derived from services rendered to patients for inpatient psychiatric and substance abuse care, outpatient psychiatric care and residential treatment. The services provided by the Company have no fixed duration and can be terminated by the patient or the facility at any time, and therefore, each treatment is its own stand-alone contract. Services ordered by a healthcare provider in an episode of care are not separately identifiable and therefore have been combined into a single performance obligation for each contract. The Company recognizes revenue as its performance obligations are completed. The performance obligation is satisfied over time as the customer simultaneously receives and consumes the benefits of the healthcare services provided. For inpatient services, the Company recognizes revenue equally over the patient stay on a daily basis. For outpatient services, the Company recognizes revenue equally over the number of treatments provided in a single episode of care. Typically, patients and third-party payors are billed within several days of the service being performed or the patient being discharged, and payments are due based on contract terms. As our performance obligations relate to contracts with a duration of one year or less, the Company elected the optional exemption in ASC 606-10-50-14(a). Therefore, the Company is not required to disclose the transaction price for the remaining performance obligations at the end of the reporting period or when the Company expects to recognize the revenue. The Company has minimal unsatisfied performance obligations at the end of the reporting period as our patients typically are under no obligation to remain admitted in our facilities. The Company disaggregates revenue from contracts with customers by service type and by payor within each of the Company’s segments. U.S. Facilities The Company’s U.S. Facilities and services provided by the U.S. Facilities can generally be classified into the following categories: acute inpatient psychiatric facilities; specialty treatment facilities; residential treatment centers; and outpatient community-based facilities. Acute inpatient psychiatric facilities. Acute inpatient psychiatric facilities provide a high level of care in order to stabilize patients that are either a threat to themselves or to others. The acute setting provides 24-hour observation, daily intervention and monitoring by psychiatrists. Specialty treatment facilities. Specialty treatment facilities include residential recovery facilities, eating disorder facilities and comprehensive treatment centers. The Company provides a comprehensive continuum of care for adults with addictive disorders and co-occurring mental disorders. Inpatient, including detoxification and rehabilitation, partial hospitalization and outpatient treatment programs give patients access to the least restrictive level of care. Residential treatment centers. Residential treatment centers treat patients with behavioral disorders in a non-hospital setting, including outdoor programs. The facilities balance therapy activities with social, academic and other activities. Outpatient community-based facilities. Outpatient community-based programs are designed to provide therapeutic treatment to children and adolescents who have a clinically-defined emotional, psychiatric or chemical dependency disorder while enabling the youth to remain at home and within their community. The table below presents total U.S. revenue attributed to each category (in thousands):
|  | Year Ended December 31, |
|  | 2019 |  |  | 2018 |  |  | 2017 |
Acute inpatient psychiatric facilities |  | $ | 912,097 |  |  | $ | 814,124 |  |  | $ | 757,211 |
Specialty treatment facilities |  |  | 788,232 |  |  |  | 761,017 |  |  |  | 725,151 |
Residential treatment centers |  |  | 286,959 |  |  |  | 293,053 |  |  |  | 284,637 |
Outpatient community-based facilities |  |  | 21,093 |  |  |  | 36,501 |  |  |  | 42,845 |
Revenue |  | $ | 2,008,381 |  |  | $ | 1,904,695 |  |  | $ | 1,809,844 |
The Company receives payments from the following sources for services rendered in our U.S. Facilities: (i) state governments under their respective Medicaid and other programs; (ii) commercial insurers; (iii) the federal government under the Medicare program administered by the Centers for Medicare and Medicaid Services (“CMS”); and (iv) individual patients and clients. As the period between the time of service and time of payment is typically one year or less, the Company elected the practical expedient under ASC 606-10-32-18 and did not adjust for the effects of a significant financing component. The Company determines the transaction price based on established billing rates reduced by contractual adjustments provided to third-party payors, discounts provided to uninsured patients and implicit price concessions. Contractual adjustments and discounts are based on contractual agreements, discount policies and historical experience. Implicit price concessions are based on historical collection experience. Most of our U.S. Facilities have contracts containing variable consideration. However, it is unlikely a significant reversal of revenue will occur when the uncertainty is resolved, and therefore, the Company has included the variable consideration in the estimated transaction price. Subsequent changes resulting from a patient’s ability to pay are recorded as bad debt expense, which is included as a component of other operating expenses in the consolidated statements of operations. Bad debt expense for the years ended December 31, 2019 and 2018 was not significant. The Company derives a significant portion of its revenue from Medicare, Medicaid and other payors that receive discounts from established billing rates. The Medicare and Medicaid regulations and various managed care contracts under which these discounts must be estimated are complex, subject to interpretation and adjustment, and may include multiple reimbursement mechanisms for different types of services provided in the Company’s facilities and cost settlement provisions. Management estimates the transaction price on a payor-specific basis given its interpretation of the applicable regulations or contract terms. The services authorized and provided and related reimbursement are often subject to interpretation that could result in payments that differ from the Company’s estimates. Additionally, updated regulations and contract renegotiations occur frequently, necessitating regular review and assessment of the estimation process by management. Settlements under cost reimbursement agreements with third-party payors are estimated and recorded in the period in which the related services are rendered and are adjusted in future periods as final settlements are determined. Final determination of amounts earned under the Medicare and Medicaid programs often occurs in subsequent years because of audits by such programs, rights of appeal and the application of numerous technical provisions. In the opinion of management, adequate provision has been made for any adjustments and final settlements. However, there can be no assurance that any such adjustments and final settlements will not have a material effect on the Company’s financial condition or results of operations. The Company’s cost report receivables were $13.7 million and $10.3 million for the years ended December 31, 2019 and 2018, respectively, and were included in other current assets in the consolidated balance sheets. Management believes that these receivables are properly stated and are not likely to be settled for a significantly different amount. The net adjustments to estimated cost report settlements resulted in a decreases to revenue of $0.4 million for the year ended December 31, 2019 and increases to revenue of $0.5 million and $0.2 million for the years ended December 31, 2018 and 2017, respectively. The Company provides care without charge to patients who are financially unable to pay for the healthcare services they receive based on Company policies and federal and state poverty thresholds. Such amounts determined to qualify as charity care are not reported as revenue. The cost of providing charity care services were $4.3 million, $4.7 million and $5.3 million for the years ended December 31, 2019, 2018 and 2017, respectively. The estimated cost of charity care services was determined using a ratio of cost to gross charges determined from our most recently filed Medicare cost reports and applying that ratio to the gross charges associated with providing charity care for the period. The following table presents revenue by payor type and as a percentage of revenue in our U.S. Facilities for the years ended December 31, 2019, 2018 and 2017 (in thousands):
|  | Year Ended December 31, |
|  | 2019 |  |  | 2018 |  |  | 2017 |
|  | Amount |  |  | % |  |  | Amount |  |  | % |  |  | Amount |  |  | % |
Commercial |  | $ | 565,350 |  |  |  | 28.2 | % |  | $ | 573,089 |  |  |  | 30.1 | % |  | $ | 569,242 |  |  |  | 30.8 | %
Medicare |  |  | 294,691 |  |  |  | 14.7 | % |  |  | 280,340 |  |  |  | 14.7 | % |  |  | 281,270 |  |  |  | 15.2 | %
Medicaid |  |  | 1,007,102 |  |  |  | 50.1 | % |  |  | 893,644 |  |  |  | 46.9 | % |  |  | 796,375 |  |  |  | 43.0 | %
Self-Pay |  |  | 118,716 |  |  |  | 5.9 | % |  |  | 134,054 |  |  |  | 7.1 | % |  |  | 169,727 |  |  |  | 9.2 | %
Other |  |  | 22,522 |  |  |  | 1.1 | % |  |  | 23,568 |  |  |  | 1.2 | % |  |  | 33,942 |  |  |  | 1.8 | %
Revenue before provision for doubtful accounts |  |  | 2,008,381 |  |  |  | 100.0 | % |  |  | 1,904,695 |  |  |  | 100.0 | % |  |  | 1,850,556 |  |  |  | 100.0 | %
Provision for doubtful accounts |  |  | — |  |  |  |  |  |  |  | — |  |  |  |  |  |  |  | (40,712 | ) |  |  |  |
Revenue |  | $ | 2,008,381 |  |  |  |  |  |  | $ | 1,904,695 |  |  |  |  |  |  | $ | 1,809,844 |  |  |  |  |
U.K. Facilities The Company’s U.K. Facilities and services provided by the U.K. Facilities can generally be classified into the following categories: healthcare facilities, education and children’s services; and adult care facilities. Healthcare facilities. Healthcare facilities provide psychiatric treatment and nursing for sufferers of mental disorders, including for patients whose risk of harm to others and risk of escape from hospitals cannot be managed safely within other mental health settings. In order to manage the risks involved with treating patients, the facility is managed through the application of a range of security measures depending on the level of dependency and risk exhibited by the patient. Education and children’s services. Education and children’s services provide specialist education for children and young people with special educational needs, including autism, Asperger’s Syndrome, social, emotional and mental health, and specific learning difficulties, such as dyslexia. The division also offers standalone children’s homes for children that require 52-week residential care to support complex and challenging behavior and fostering services. Adult care facilities. Adult care focuses on care of individuals with a variety of learning difficulties, mental health illnesses and adult autism spectrum disorders. It also includes long-term, short-term and respite nursing care to high-dependency elderly individuals who are physically frail or suffering from dementia. Care is provided in a number of settings, including in residential care homes and through supported living. The table below presents total U.K. revenue attributed to each category (in thousands):
|  | Year Ended December 31, |
|  | 2019 |  |  | 2018 |  |  | 2017 |
Healthcare facilities |  | $ | 607,053 |  |  | $ | 614,994 |  |  | $ | 566,482 |
Education and Children’s Services |  |  | 183,195 |  |  |  | 187,306 |  |  |  | 165,874 |
Adult Care facilities |  |  | 308,833 |  |  |  | 305,447 |  |  |  | 294,116 |
Revenue |  | $ | 1,099,081 |  |  | $ | 1,107,747 |  |  | $ | 1,026,472 |
The Company receives payments from approximately 500 public funded sources in the U.K. (including the National Health Service (“NHS”), Clinical Commissioning Groups (“CCGs”) and local authorities in England, Scotland and Wales) and individual patients and clients. The Company determines the transaction price based on established billing rates by payor and is reduced by implicit price concessions. Implicit price concessions are insignificant in our U.K. Facilities. There is no significant variable consideration in our U.K. Facilities’ contracts. As the period between the time of service and time of payment is typically one year or less, the Company elected the practical expedient under ASC 606-10-32-18 and did not adjust for the effects of a significant financing component. The following table presents revenue by payor type and as a percentage of revenue in our U.K. Facilities for the years ended December 31, 2019, 2018 and 2017 (in thousands):
|  | Year Ended December 31, |
|  | 2019 |  |  | 2018 |  |  | 2017 |
|  | Amount |  |  | % |  |  | Amount |  |  | % |  |  | Amount |  |  | % |
U.K. public funded sources |  | $ | 991,353 |  |  |  | 90.2 | % |  | $ | 1,000,828 |  |  |  | 90.3 | % |  | $ | 922,159 |  |  |  | 89.8 | %
Self-Pay |  |  | 105,430 |  |  |  | 9.6 | % |  |  | 104,824 |  |  |  | 9.5 | % |  |  | 95,687 |  |  |  | 9.3 | %
Other |  |  | 2,298 |  |  |  | 0.2 | % |  |  | 2,095 |  |  |  | 0.2 | % |  |  | 8,832 |  |  |  | 0.9 | %
Revenue before provision for doubtful accounts |  |  | 1,099,081 |  |  |  | 100.0 | % |  |  | 1,107,747 |  |  |  | 100.0 | % |  |  | 1,026,678 |  |  |  | 100.0 | %
Provision for doubtful accounts |  |  | — |  |  |  |  |  |  |  | — |  |  |  |  |  |  |  | (206 | ) |  |  |  |
Revenue |  | $ | 1,099,081 |  |  |  |  |  |  | $ | 1,107,747 |  |  |  |  |  |  | $ | 1,026,472 |  |  |  |  |
The Company’s contract liabilities primarily consist of unearned revenue in our U.K. Facilities due to the timing of payments received mainly in our education and children’s services and healthcare facilities. Contract liabilities are included in other accrued liabilities on the consolidated balance sheets. A summary of the activity in unearned revenue in the U.K. Facilities is as follows (in thousands):
Balance at December 31, 2018 |  | $ | 31,239 |
Payments received |  |  | 172,666 |
Revenue recognized |  |  | (167,811 | )
Foreign currency translation loss |  |  | 485 |
Balance at December 31, 2019 |  | $ | 36,579 |

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- Definition The entire disclosure of revenue from contract with customer to transfer good or service and to transfer nonfinancial asset. Includes, but is not limited to, disaggregation of revenue, credit loss recognized from contract with customer, judgment and change in judgment related to contract with customer, and asset recognized from cost incurred to obtain or fulfill contract with customer. Excludes insurance and lease contracts. + References Reference 1: http://www.xbrl.org/2003/role/disclosureRef -Publisher FASB -Name Accounting Standards Codification -Topic 606 -URI http://asc.fasb.org/topic&trid=49130388 + Details
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