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Consolidated Statements of Cash Flows - USD ($) $ in Thousands | 12 Months Ended
--- | ---
Dec. 31, 2016 | Dec. 31, 2015 | Dec. 31, 2014
Cash flows from operating activities: |  |  |
Net income | $ 324,596 | $ 335,691 | $ 317,203
Adjustments to reconcile net income to net cash provided from operating activities: |  |  |
Depreciation and amortization | 89,264 | 64,228 | 45,990
Amortization of premiums, discounts and issuance costs | 4,816 | 1,541 | 1,230
Net change in fair value of contingent consideration liabilities | 772 | 13 | (417)
Stock-based compensation expense | 34,000 | 32,129 | 31,719
Equity in earnings of unconsolidated affiliate | (3,185) | (3,127) | (1,780)
Distribution of earnings from unconsolidated affiliate | 2,625 | 2,062 |
Deferred income taxes | 18,149 | 14,494 | 2,559
Changes in assets and liabilities: |  |  |
Accounts receivable | (34,000) | (55,391) | (57,018)
Prepaid expenses and other current assets | (783) | (4,905) | 1,506
Other long-term assets | 10,035 | 98 | 907
Accounts payable and accrued expenses | 11,617 | (7,874) | 66,039
Income taxes payable | (2,234) | (4,101) | 6,998
Payments of contingent consideration liabilities | (1,037) | (1,439) | (4,071)
Long-term professional liabilities | (3,452) | (2,064) | 9,284
Other liabilities | (7,405) | (2,654) | 2,492
Net cash provided from operating activities | 443,778 | 368,701 | 422,641
Cash flows from investing activities: |  |  |
Acquisition payments, net of cash acquired | (762,302) | (818,903) | (479,394)
Purchases of investments | (60,976) | (33,980) | (26,884)
Proceeds from maturities of investments | 41,325 | 31,956 | 20,735
Purchases of property and equipment | (39,264) | (27,073) | (18,061)
Net cash used in investing activities | (821,217) | (848,000) | (503,604)
Cash flows from financing activities: |  |  |
Borrowings on credit agreement | 1,940,000 | 2,121,500 | 1,754,500
Payments on credit agreement | (1,510,000) | (2,156,000) | (1,213,500)
Proceeds from issuance of senior notes |  | 750,000 |
Payments for financing costs |  | (14,190) | (4,281)
Payments of contingent consideration liabilities | (10,740) | (12,856) | (11,740)
Payments on capital lease obligations | (2,130) | (2,171) | (159)
Excess tax benefit from exercises of stock options and vesting of restricted and deferred stock | 4,241 | 11,583 | 17,462
Proceeds from issuance of common stock | 22,022 | 20,128 | 42,876
Contribution from noncontrolling interests |  |  | 1,025
Repurchases of common stock | (61,828) | (235,051) | (488,429)
Net cash provided from financing activities | 381,565 | 482,943 | 97,754
Net increase in cash and cash equivalents | 4,126 | 3,644 | 16,791
Cash and cash equivalents at beginning of year | 51,572 | 47,928 | 31,137
Cash and cash equivalents at end of year | 55,698 | 51,572 | 47,928
Supplemental disclosure of cash flow information: |  |  |
Interest | 60,453 | 20,367 | 7,323
Income taxes | 175,962 | 181,005 | 161,841
Non-cash investing and financing activities: |  |  |
Value of common stock issued for an acquisition |  | 7,800 |
Equipment financed through capital leases | 1,619 | 3,135 | $ 1,244
Property and equipment included in accounts payable | $ 2,673 | $ 1,800 |

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- Definition The cash outflow for loan and debt issuance costs. + References Reference 1: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 230 -SubTopic 10 -Section 45 -Paragraph 15 -URI http://asc.fasb.org/extlink&oid=66902209&loc=d3e3291-108585 Reference 2: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Glossary Financing Activities -URI http://asc.fasb.org/extlink&oid=6513228 + Details
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- Definition The cash outflow associated with the acquisition of a business, net of the cash acquired from the purchase. + References Reference 1: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 230 -SubTopic 10 -Section 45 -Paragraph 13 -Subparagraph (b) -URI http://asc.fasb.org/extlink&oid=66902209&loc=d3e3213-108585 Reference 2: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Glossary Investing Activities -URI http://asc.fasb.org/extlink&oid=6516133 + Details
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- Definition The cash outflow associated with the purchase of all investments (debt, security, other) during the period. + References Reference 1: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Glossary Investing Activities -URI http://asc.fasb.org/extlink&oid=6516133 Reference 2: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 230 -SubTopic 10 -Section 45 -Paragraph 13 -URI http://asc.fasb.org/extlink&oid=66902209&loc=d3e3213-108585 + Details
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- Definition Amount of cash outflow from the acquisition of or improvements to long-lived, physical assets used to produce goods and services and not intended for resale, classified as other. + References Reference 1: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 230 -SubTopic 10 -Section 45 -Paragraph 13 -Subparagraph (c) -URI http://asc.fasb.org/extlink&oid=66902209&loc=d3e3213-108585 Reference 2: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Glossary Investing Activities -URI http://asc.fasb.org/extlink&oid=6516133 + Details
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- Definition The cash inflow from the additional capital contribution to the entity. + References Reference 1: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Glossary Financing Activities -URI http://asc.fasb.org/extlink&oid=6513228 Reference 2: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 230 -SubTopic 10 -Section 45 -Paragraph 14 -Subparagraph (a) -URI http://asc.fasb.org/extlink&oid=66902209&loc=d3e3255-108585 + Details
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- Definition The cash inflow from a borrowing with the highest claim on the assets of the entity in case of bankruptcy or liquidation (with maturities initially due after one year or beyond the operating cycle, if longer). + References Reference 1: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Glossary Financing Activities -URI http://asc.fasb.org/extlink&oid=6513228 Reference 2: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 230 -SubTopic 10 -Section 45 -Paragraph 14 -Subparagraph (b) -URI http://asc.fasb.org/extlink&oid=66902209&loc=d3e3255-108585 + Details
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- Definition Amount of cash inflow from contractual arrangement with the lender, including but not limited to, letter of credit, standby letter of credit and revolving credit arrangements. + References Reference 1: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Glossary Financing Activities -URI http://asc.fasb.org/extlink&oid=6513228 Reference 2: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 230 -SubTopic 10 -Section 45 -Paragraph 14 -Subparagraph (b) -URI http://asc.fasb.org/extlink&oid=66902209&loc=d3e3255-108585 Reference 3: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 235 -SubTopic 10 -Section S99 -Paragraph 1 -Subparagraph (SX 210.4-08.(f)) -URI http://asc.fasb.org/extlink&oid=26873400&loc=d3e23780-122690 + Details
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- Definition Amount of cash inflow from a noncontrolling interest. Includes, but is not limited to, purchase of additional shares or other increase in noncontrolling interest ownership. + References Reference 1: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Glossary Financing Activities -URI http://asc.fasb.org/extlink&oid=6513228 Reference 2: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 230 -SubTopic 10 -Section 45 -Paragraph 14 -URI http://asc.fasb.org/extlink&oid=66902209&loc=d3e3255-108585 + Details
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- Definition The cash inflow associated with the sale, maturity and collection of all investments such as debt, security and so forth during the period. + References Reference 1: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Glossary Investing Activities -URI http://asc.fasb.org/extlink&oid=6516133 Reference 2: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 230 -SubTopic 10 -Section 45 -Paragraph 12 -URI http://asc.fasb.org/extlink&oid=66902209&loc=d3e3179-108585 + Details
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- Definition The consolidated profit or loss for the period, net of income taxes, including the portion attributable to the noncontrolling interest. + References Reference 1: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 810 -SubTopic 10 -Section 55 -Paragraph 4K -URI http://asc.fasb.org/extlink&oid=65897068&loc=SL4591552-111686 Reference 2: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 810 -SubTopic 10 -Section 45 -Paragraph 19 -URI http://asc.fasb.org/extlink&oid=68079674&loc=SL4569616-111683 Reference 3: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 810 -SubTopic 10 -Section 50 -Paragraph 1A -Subparagraph (c)(1) -URI http://asc.fasb.org/extlink&oid=64809438&loc=SL4573702-111684 Reference 4: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 810 -SubTopic 10 -Section 55 -Paragraph 4J -URI http://asc.fasb.org/extlink&oid=65897068&loc=SL4591551-111686 Reference 5: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 810 -SubTopic 10 -Section 50 -Paragraph 1A -Subparagraph (a)(2) -URI http://asc.fasb.org/extlink&oid=64809438&loc=SL4573702-111684 + Details
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- Definition Amount of cash outflow for payment of an obligation from a lender, including but not limited to, letter of credit, standby letter of credit and revolving credit arrangements. + References Reference 1: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 230 -SubTopic 10 -Section 45 -Paragraph 15 -Subparagraph (b) -URI http://asc.fasb.org/extlink&oid=66902209&loc=d3e3291-108585 Reference 2: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Glossary Financing Activities -URI http://asc.fasb.org/extlink&oid=6513228 Reference 3: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 235 -SubTopic 10 -Section S99 -Paragraph 1 -Subparagraph (SX 210.4-08.(f)) -URI http://asc.fasb.org/extlink&oid=26873400&loc=d3e23780-122690 + Details
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- Definition The cash outflow for the obligation for a lease meeting the criteria for capitalization (with maturities exceeding one year or beyond the operating cycle of the entity, if longer). + References Reference 1: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 230 -SubTopic 10 -Section 45 -Paragraph 15 -Subparagraph (b) -URI http://asc.fasb.org/extlink&oid=66902209&loc=d3e3291-108585 + Details
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- Definition The aggregate amount of noncash, equity-based employee remuneration. This may include the value of stock or unit options, amortization of restricted stock or units, and adjustment for officers' compensation. As noncash, this element is an add back when calculating net cash generated by operating activities using the indirect method. + References Reference 1: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 230 -SubTopic 10 -Section 45 -Paragraph 28 -Subparagraph (a) -URI http://asc.fasb.org/extlink&oid=66902209&loc=d3e3602-108585 + Details
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- Definition The fair value of stock issued in noncash financing activities. + References Reference 1: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 230 -SubTopic 10 -Section 50 -Paragraph 5 -URI http://asc.fasb.org/extlink&oid=6367179&loc=d3e4332-108586 Reference 2: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 230 -SubTopic 10 -Section 50 -Paragraph 3 -URI http://asc.fasb.org/extlink&oid=6367179&loc=d3e4304-108586 Reference 3: http://www.xbrl.org/2003/role/presentationRef -Publisher FASB -Name Accounting Standards Codification -Topic 230 -SubTopic 10 -Section 50 -Paragraph 4 -URI http://asc.fasb.org/extlink&oid=6367179&loc=d3e4313-108586 + Details
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