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Consolidated Statements of Cash Flows - USD ($)
$ in Thousands
 12 Months Ended
Dec. 31, 2019
Dec. 31, 2018
Dec. 31, 2017
Cash flows from operating activities:      
Net (loss) income $ (1,497,702) $ 268,629 $ 320,372
Loss (income) from discontinued operations 347,608 (10,018) (14,930)
Adjustments to reconcile net income to net cash provided from operating activities:      
Depreciation and amortization 78,860 83,832 78,856
Goodwill impairment 1,449,215 0 0
Amortization of premiums, discounts and issuance costs 5,672 4,572 5,514
Stock-based compensation expense 35,351 37,910 28,778
Deferred income taxes (177,000) (25,647) (61,233)
Other 389 (10,903) (3,782)
Changes in assets and liabilities:      
Accounts receivable 7,854 (43,408) 10,784
Prepaid expenses and other current assets (9,998) (6,074) (3,015)
Other long-term assets 37,989 68 (2,950)
Accounts payable and accrued expenses 104,161 45,943 34,882
Income taxes payable (24,119) (61,256) 73,050
Payments of contingent consideration liabilities (1,170) (1,093) (750)
Long-term professional liabilities 9,844 (4,490) 18,478
Other liabilities (28,487) (3,957) (687)
Net cash provided by operating activities—continuing operations 338,467 274,108 483,367
Net cash provided by operating activities—discontinued operations 8,170 15,817 28,011
Net cash provided by operating activities 346,637 289,925 511,378
Cash flows from investing activities:      
Acquisition payments, net of cash acquired (111,975) (114,491) (531,232)
Purchases of investments (35,101) (15,884) (27,723)
Proceeds from maturities or sales of investments 51,105 13,710 25,410
Purchases of property and equipment (31,881) (30,479) (26,150)
Proceeds from sales of businesses 249,730 22,764 0
Other 0 0 6,705
Net cash provided by (used in) investing activities—continuing operations 121,878 (124,380) (552,990)
Net cash used in investing activities—discontinued operations (19,423) (18,389) (23,623)
Net cash provided by (used in) investing activities 102,455 (142,769) (576,613)
Cash flows from financing activities:      
Borrowings on credit agreement 1,247,300 1,723,500 2,846,000
Payments on credit agreement (1,986,800) (2,094,500) (2,699,000)
Proceeds from issuance of senior notes 500,000 500,000 0
Payments for financing costs (9,194) (7,090) (3,525)
Payments of contingent consideration liabilities (10,120) (5,263) (5,449)
Payments on finance lease obligations (234) (1,339) (1,659)
Proceeds from issuance of common stock 11,258 16,258 23,276
Contribution from noncontrolling interests 0 0 894
Repurchases of common stock (145,280) (302,160) (70,192)
Net cash (used in) provided by financing activities—continuing operations (393,070) (170,594) 90,345
Net cash used in financing activities—discontinued operations 0 (17) (608)
Net cash (used in) provided by financing activities (393,070) (170,611) 89,737
Net increase (decrease) in cash and cash equivalents 56,022 (23,455) 24,502
Cash, cash equivalents and restricted cash at beginning of year 56,745 80,200 55,698
Less cash and cash equivalents of discontinued operations at end of year 0 (11,254) (13,843)
Cash and cash equivalents and restricted cash at end of year 112,767 45,491 66,357
Supplemental disclosure of cash flow information:      
Interest 95,444 82,540 73,837
Income taxes 86,268 185,416 75,427
Non-cash investing and financing activities:      
Value of common stock issued for acquisitions 0 0 2,657
Equipment financed through finance leases 0 0 684
Property and equipment included in accounts payable $ 2,400 $ 2,415 $ 1,918