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Condensed Consolidated Statements of Cash Flows (Unaudited) - USD ($)
$ in Thousands
 3 Months Ended
Mar. 31, 2018
Mar. 31, 2017
Cash flows from operating activities:    
Net income $ 63,428 $ 54,691
Adjustments to reconcile net income to net cash from operating activities:    
Depreciation and amortization 26,163 25,614
Amortization of premiums, discounts and issuance costs 1,089 1,383
Stock-based compensation expense 9,875 7,536
Deferred income taxes 45 2,184
Other (1,216) (2,756)
Changes in assets and liabilities:    
Accounts receivable (38,610) 11,078
Prepaid expenses and other current assets 961 3,142
Other long-term assets (517) (2,357)
Accounts payable and accrued expenses (136,308) (151,867)
Income taxes payable (38,785) 28,979
Payments of contingent consideration liabilities (65) (44)
Long-term professional liabilities (643) (1,505)
Other liabilities 949 2,159
Net cash used in operating activities (113,634) (21,763)
Cash flows from investing activities:    
Acquisition payments, net of cash acquired (21,975) (110,945)
Purchases of investments (14,039) (12,405)
Proceeds from maturities of investments 3,500 3,870
Purchases of property and equipment (12,426) (11,730)
Proceeds from sale of controlling interest in assets 22,764  
Other   3,750
Net cash used in investing activities (22,176) (127,460)
Cash flows from financing activities:    
Borrowings on credit agreement 506,000 536,500
Payments on credit agreement (392,500) (340,000)
Payments of contingent consideration liabilities (367) (416)
Payments on capital lease obligations (315) (577)
Proceeds from issuance of common stock 3,731 7,077
Contribution from noncontrolling interest   894
Repurchases of common stock   (68,114)
Net cash provided from financing activities 116,549 135,364
Net decrease in cash and cash equivalents (19,261) (13,859)
Cash, cash equivalents and restricted cash at beginning of period 80,200 55,698
Cash, cash equivalents and restricted cash at end of period $ 60,939 $ 41,839