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Condensed Consolidated Statements of Cash Flows (Unaudited) - USD ($)
$ in Thousands
 9 Months Ended
Sep. 30, 2018
Sep. 30, 2017
Cash flows from operating activities:    
Net income $ 208,415 $ 184,269
Adjustments to reconcile net income to net cash from operating activities:    
Depreciation and amortization 81,390 76,465
Amortization of premiums, discounts and issuance costs 3,314 4,078
Stock-based compensation expense 29,344 22,533
Deferred income taxes (16,928) 16,731
Other (3,030) (2,480)
Changes in assets and liabilities:    
Accounts receivable (18,827) (9,085)
Prepaid expenses and other current assets (5,351) 247
Other long-term assets (1,954) (1,650)
Accounts payable and accrued expenses (38,135) (9,798)
Income taxes payable (70,186) 25,422
Payments of contingent consideration liabilities (686) (574)
Long-term professional liabilities (2,608) 8,801
Other liabilities (2,427) 784
Net cash provided from operating activities 162,331 315,743
Cash flows from investing activities:    
Acquisition payments, net of cash acquired (27,035) (355,084)
Purchases of investments (15,884) (24,741)
Proceeds from maturities of investments 10,510 20,515
Purchases of property and equipment (38,135) (31,976)
Proceeds from sale of controlling interest in assets 22,764  
Other   3,809
Net cash used in investing activities (47,780) (387,477)
Cash flows from financing activities:    
Borrowings on credit agreement 1,364,500 1,256,000
Payments on credit agreement (1,211,000) (1,135,500)
Payments of contingent consideration liabilities (3,869) (3,825)
Payments on capital lease obligations (1,013) (1,622)
Proceeds from issuance of common stock 13,252 18,684
Repurchases of common stock (302,160) (70,192)
Contribution from noncontrolling interests   894
Net cash (used in) provided from financing activities (140,290) 64,439
Net decrease in cash and cash equivalents (25,739) (7,295)
Cash, cash equivalents and restricted cash at beginning of period 80,200 55,698
Cash, cash equivalents and restricted cash at end of period $ 54,461 $ 48,403