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Consolidated Statements of Cash Flows - USD ($)
$ in Thousands
 12 Months Ended
Dec. 31, 2018
Dec. 31, 2017
Dec. 31, 2016
Cash flows from operating activities:      
Net income $ 268,629 $ 320,372 $ 324,596
Adjustments to reconcile net income to net cash provided from operating activities:      
Depreciation and amortization 111,281 102,879 89,264
Amortization of premiums, discounts and issuance costs 4,572 5,514 4,816
Stock-based compensation expense 38,703 29,573 34,000
Deferred income taxes (24,149) (60,073) 18,149
Other (10,903) (3,783) 212
Changes in assets and liabilities:      
Accounts receivable (36,598) 7,803 (34,000)
Prepaid expenses and other current assets (5,472) (2,792) (783)
Other long-term assets (395) (2,709) 10,035
Accounts payable and accrued expenses 15,390 24,551 11,617
Income taxes payable (61,256) 73,050 (2,234)
Payments of contingent consideration liabilities (1,093) (750) (1,037)
Long-term professional liabilities (4,490) 18,478 (3,452)
Other liabilities (4,294) (735) (7,405)
Net cash provided from operating activities 289,925 511,378 443,778
Cash flows from investing activities:      
Acquisition payments, net of cash acquired (114,491) (531,696) (762,302)
Purchases of investments (15,884) (27,723) (60,976)
Proceeds from maturities of investments 13,710 25,410 41,325
Purchases of property and equipment (48,868) (49,309) (39,264)
Proceeds from sale of controlling interest in assets 22,764    
Other   6,705  
Net cash used in investing activities (142,769) (576,613) (821,217)
Cash flows from financing activities:      
Borrowings on credit agreement 1,723,500 2,846,000 1,940,000
Payments on credit agreement (2,094,500) (2,699,000) (1,510,000)
Proceeds from issuance of senior notes 500,000    
Payments for financing costs (7,090) (3,525)  
Payments of contingent consideration liabilities (5,263) (5,449) (10,740)
Payments on capital lease obligations (1,356) (2,267) (2,130)
Excess tax benefit from exercises of stock options and vesting of restricted stock     4,241
Proceeds from issuance of common stock 16,258 23,276 22,022
Contribution from noncontrolling interests   894  
Repurchases of common stock (302,160) (70,192) (61,828)
Net cash (used in) provided from financing activities (170,611) 89,737 381,565
Net (decrease) increase in cash and cash equivalents (23,455) 24,502 4,126
Cash, cash equivalents and restricted cash at beginning of year 80,200 55,698 51,572
Cash, cash equivalents and restricted cash at end of year 56,745 80,200 55,698
Supplemental disclosure of cash flow information:      
Interest 82,540 73,837 60,453
Income taxes 185,416 75,427 175,962
Non-cash investing and financing activities:      
Value of common stock issued for acquisitions   2,657  
Equipment financed through capital leases   684 1,619
Property and equipment included in accounts payable $ 2,927 $ 2,700 $ 2,673