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Condensed Consolidated Statements of Cash Flows (Unaudited) - USD ($)
$ in Thousands
 6 Months Ended
Jun. 30, 2017
Jun. 30, 2016
Cash flows from operating activities:    
Net income $ 118,389 $ 150,096
Adjustments to reconcile net income to net cash from operating activities:    
Depreciation and amortization 51,349 39,825
Amortization of premiums, discounts and issuance costs 2,740 2,693
Stock-based compensation expense 14,781 17,240
Deferred income taxes 18,454 18,081
Other (3,407) (1,089)
Changes in assets and liabilities:    
Accounts receivable 18,361 (16,228)
Prepaid expenses and other current assets (666) (2,225)
Other assets (3,425) 795
Accounts payable and accrued expenses (87,862) (91,836)
Income taxes payable (15,900) (6,136)
Payments of contingent consideration liabilities (299) (501)
Long-term professional liabilities 1,016 3,522
Other liabilities 2,282 2,467
Net cash provided from operating activities 115,813 116,704
Cash flows from investing activities:    
Acquisition payments, net of cash acquired (113,746) (195,715)
Purchases of investments (15,324) (38,679)
Proceeds from maturities of investments 7,290 25,020
Purchases of property and equipment (21,909) (19,171)
Other 3,868  
Net cash used in investing activities (139,821) (228,545)
Cash flows from financing activities:    
Borrowings on credit agreement 821,000 902,000
Payments on credit agreement (754,000) (737,500)
Payments of contingent consideration liabilities (1,961) (4,393)
Payments on capital lease obligations (998) (927)
Excess tax benefit from vesting of restricted stock and exercises of stock options   3,354
Proceeds from issuance of common stock 13,990 11,455
Repurchases of common stock (70,192) (61,828)
Contribution from noncontrolling interests 894  
Net cash provided from financing activities 8,733 112,161
Net (decrease) increase in cash and cash equivalents (15,275) 320
Cash and cash equivalents at beginning of period 55,698 51,572
Cash and cash equivalents at end of period $ 40,423 $ 51,892