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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