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Consolidated Statements of Cash Flows - USD ($)
$ in Thousands
 12 Months Ended
Dec. 31, 2021
Dec. 31, 2020
Dec. 31, 2019
Cash flows from operating activities:      
Net Income (loss) $ 130,964 $ (796,488) $ (1,497,702)
(Income) loss from discontinued operations (22,950) 786,908 1,539,910
Adjustments to reconcile net income to net cash provided from operating activities:      
Depreciation and amortization 32,147 28,441 25,931
Amortization of premiums, discounts and issuance costs 4,335 7,163 5,672
Loss on early extinguishment of debt (14,532)
Stock-based compensation expense 18,968 39,042 33,410
Deferred income taxes (31,239) 36,292 (55,715)
Gain on sale of building (7,280)
Other (2,350) (198) 6,553
Changes in assets and liabilities:      
Accounts receivable (72,731) 37,937 6,512
Prepaid expenses and other current assets 41,530 (47,956) (24,621)
Other long-term assets 9,799 13,916 32,121
Accounts payable and accrued expenses 21,326 47,908 46,196
Income taxes receivable (payable) (2,285) (6,931) (24,120)
Payment of contingent consideration liabilities (11)
Long-term professional liabilities 1,523 4,336 5,413
Other liabilities (22,518) 3,518 (25,469)
Net cash provided by operating activities – continuing operations 113,760 153,888 74,091
Net cash (used in) provided by operating activities - discontinued operations (37,023) 50,732 283,620
Net cash provided by operating activities 76,737 204,620 357,711
Cash flows from investing activities:      
Acquisition payments, net of cash acquired 29,930 2,225 46,975
Purchases of investments (15,052) (61,845) (35,101)
Proceeds from maturities or sales of investments 16,496 33,432 51,105
Purchases of property and equipment (32,249) (28,788) (19,269)
Proceeds from sale of buildings 24,728
Strategic investments (20,000)
Other 584 1,080 0
Net cash (used in) provided by investing activities – continuing operations (55,423) (58,346) (50,240)
Net cash provided by investing activities - discontinued operations 2,350 873,857 152,695
Net cash (used in) provided by investing activities (53,073) 815,511 102,455
Cash flows from financing activities:      
Borrowings on credit agreement 527,500 1,247,300
Payments on credit agreement (527,500) (1,986,800)
Redemption of senior notes, including call premium 759,848
Proceeds from issuance of senior notes 500,000
Payments for credit facility amendment and financing costs (510) (9,194)
Payments of contingent consideration liabilities (189) (1,394)
Payments on finance lease obligations (2,809) (1,161)
Proceeds from issuance of common stock 6,853 7,009 11,258
Repurchases of common stock (4,719) (8,493) (145,280)
Contribution from noncontrolling interests 245
Other 596
Net cash used in financing activities – continuing operations (760,116) (2,910) (384,110)
Net cash used in financing activities – discontinued operations (1,248) (8,960)
Net cash used in financing activities (760,116) (4,158) (393,070)
Net (decrease) increase in cash and cash equivalents (736,452) 1,015,973 67,096
Cash, cash equivalents at beginning of year 1,123,843 107,870 40,774
Cash and cash equivalents at end of year 387,391 1,123,843 107,870
Supplemental disclosure of cash flow information:      
Interest 86,537 110,488 95,444
Income taxes 54,728 (27,775) 86,268
Non-cash investing and financing activities:      
Equipment financed through finance leases 6,762 12,507
Property and equipment included in accounts payable $ 2,300 $ 2,305 $ 2,400