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Condensed Consolidated Statements of Cash Flows (Unaudited) - USD ($)
$ in Thousands
 3 Months Ended
Mar. 31, 2017
Mar. 31, 2016
Cash flows from operating activities:    
Net income $ 54,691 $ 67,771
Adjustments to reconcile net income to net cash from operating activities:    
Depreciation and amortization 25,614 19,584
Amortization of premiums, discounts and issuance costs 1,383 1,296
Stock-based compensation expense 7,536 8,913
Deferred income taxes 2,184 2,595
Other (2,756) (520)
Changes in assets and liabilities:    
Accounts receivable 11,078 (21,089)
Prepaid expenses and other current assets 3,142 1,273
Other assets (2,357) 1,164
Accounts payable and accrued expenses (151,867) (135,356)
Income taxes payable 28,979 19,429
Payments of contingent consideration liabilities (44) (29)
Long-term professional liabilities (1,505) 1,601
Other liabilities 2,159 329
Net cash used in operating activities (21,763) (33,039)
Cash flows from investing activities:    
Acquisition payments, net of cash acquired (110,945) (59,540)
Purchases of investments (12,405) (18,291)
Proceeds from maturities of investments 3,870 12,130
Purchases of property and equipment (11,730) (10,443)
Other 3,750  
Net cash used in investing activities (127,460) (76,144)
Cash flows from financing activities:    
Borrowings on credit agreement 536,500 550,000
Payments on credit agreement (340,000) (382,000)
Payments of contingent consideration liabilities (416) (432)
Payments on capital lease obligations (577) (536)
Excess tax benefit from exercises of stock options and vesting of restricted stock   319
Proceeds from issuance of common stock 7,077 4,397
Repurchases of common stock (68,114) (58,646)
Contribution from noncontrolling interests 894  
Net cash provided from financing activities 135,364 113,102
Net (decrease) increase in cash and cash equivalents (13,859) 3,919
Cash and cash equivalents at beginning of period 55,698 51,572
Cash and cash equivalents at end of period $ 41,839 $ 55,491