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Consolidated Statements of Cash Flows - USD ($)
$ in Thousands
 12 Months Ended
Dec. 31, 2017
Dec. 31, 2016
Dec. 31, 2015
Cash flows from operating activities:      
Net income $ 320,372 $ 324,596 $ 335,691
Adjustments to reconcile net income to net cash provided from operating activities:      
Depreciation and amortization 102,879 89,264 64,228
Amortization of premiums, discounts and issuance costs 5,514 4,816 1,541
Stock-based compensation expense 29,573 34,000 32,129
Deferred income taxes (60,073) 18,149 14,494
Other (3,783) 212 (1,052)
Changes in assets and liabilities:      
Accounts receivable 7,803 (34,000) (55,391)
Prepaid expenses and other current assets (2,792) (783) (4,905)
Other long-term assets (2,709) 10,035 98
Accounts payable and accrued expenses 24,551 11,617 (7,874)
Income taxes payable 73,050 (2,234) (4,101)
Payments of contingent consideration liabilities (750) (1,037) (1,439)
Long-term professional liabilities 18,478 (3,452) (2,064)
Other liabilities (735) (7,405) (2,654)
Net cash provided from operating activities 511,378 443,778 368,701
Cash flows from investing activities:      
Acquisition payments, net of cash acquired (531,696) (762,302) (818,903)
Purchases of investments (27,723) (60,976) (33,980)
Proceeds from maturities of investments 25,410 41,325 31,956
Purchases of property and equipment (49,309) (39,264) (27,073)
Other 6,705    
Net cash used in investing activities (576,613) (821,217) (848,000)
Cash flows from financing activities:      
Borrowings on credit agreement 2,846,000 1,940,000 2,121,500
Payments on credit agreement (2,699,000) (1,510,000) (2,156,000)
Proceeds from issuance of senior notes     750,000
Payments for financing costs (3,525)   (14,190)
Payments of contingent consideration liabilities (5,449) (10,740) (12,856)
Payments on capital lease obligations (2,267) (2,130) (2,171)
Excess tax benefit from exercises of stock options and vesting of restricted and deferred stock   4,241 11,583
Proceeds from issuance of common stock 23,276 22,022 20,128
Contribution from noncontrolling interests 894    
Repurchases of common stock (70,192) (61,828) (235,051)
Net cash provided from financing activities 89,737 381,565 482,943
Net increase in cash and cash equivalents 24,502 4,126 3,644
Cash, cash equivalents and restricted cash at beginning of year 55,698 51,572 47,928
Cash, cash equivalents and restricted cash at end of year 80,200 55,698 51,572
Supplemental disclosure of cash flow information:      
Interest 73,837 60,453 20,367
Income taxes 75,427 175,962 181,005
Non-cash investing and financing activities:      
Value of common stock issued for acquisitions 2,657   7,800
Equipment financed through capital leases 684 1,619 3,135
Property and equipment included in accounts payable $ 2,700 $ 2,673 $ 1,800