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Condensed Consolidated Statements of Cash Flows (Unaudited) - USD ($)
$ in Thousands
 9 Months Ended
Sep. 30, 2017
Sep. 30, 2016
Cash flows from operating activities:    
Net income $ 184,269 $ 246,517
Adjustments to reconcile net income to net cash from operating activities:    
Depreciation and amortization 76,465 64,010
Amortization of premiums, discounts and issuance costs 4,078 4,077
Stock-based compensation expense 22,533 25,889
Deferred income taxes 16,731 16,276
Other (2,480) 838
Changes in assets and liabilities:    
Accounts receivable (9,085) (24,812)
Prepaid expenses and other current assets 247 (1,121)
Other assets (1,650) 10,279
Accounts payable and accrued expenses (9,798) (32,628)
Income taxes payable 25,422 8,930
Payments of contingent consideration liabilities (574) (735)
Long-term professional liabilities 8,801 3,453
Other liabilities 784 (8,143)
Net cash provided from operating activities 315,743 312,830
Cash flows from investing activities:    
Acquisition payments, net of cash acquired (355,084) (724,861)
Purchases of investments (24,741) (50,868)
Proceeds from maturities of investments 20,515 32,240
Purchases of property and equipment (31,976) (28,420)
Other 3,809  
Net cash used in investing activities (387,477) (771,909)
Cash flows from financing activities:    
Borrowings on credit agreement 1,256,000 1,661,000
Payments on credit agreement (1,135,500) (1,148,000)
Payments of contingent consideration liabilities (3,825) (8,282)
Payments on capital lease obligations (1,622) (1,601)
Excess tax benefit from vesting of restricted stock and exercises of stock options   3,424
Proceeds from issuance of common stock 18,684 15,599
Repurchases of common stock (70,192) (61,828)
Contribution from noncontrolling interests 894  
Net cash provided from financing activities 64,439 460,312
Net (decrease) increase in cash and cash equivalents (7,295) 1,233
Cash and cash equivalents at beginning of period 55,698 51,572
Cash and cash equivalents at end of period $ 48,403 $ 52,805