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Consolidated Statements of Cash Flows - USD ($)
$ in Thousands
 12 Months Ended
Dec. 31, 2022
Dec. 31, 2021
Dec. 31, 2020
Cash flows from operating activities:      
Net Income (loss) $ 66,335 $ 130,964 $ (796,488)
(Income) loss from discontinued operations (3,767) (22,950) 786,908
Adjustments to reconcile net income (loss) to net cash provided from operating activities:      
Depreciation and amortization 35,636 32,147 28,441
Amortization of premiums, discounts and issuance costs 1,765 4,335 7,163
Loss on early extinguishment of debt 57,016 14,532 0
Stock-based compensation expense 16,127 18,968 39,042
Deferred income taxes (22,771) (31,239) 36,292
Gain on sale of building 0 (7,280) 0
Other 144 (2,350) (198)
Changes in assets and liabilities:      
Accounts receivable (5,543) (72,731) 37,937
Prepaid expenses and other current assets 15,928 41,530 (47,956)
Other long-term assets 17,196 9,799 13,916
Accounts payable and accrued expenses 420 21,326 47,908
Income taxes receivable (payable) 18,225 (2,285) (6,931)
Payment of contingent consideration liabilities 0 (11) 0
Long-term professional liabilities 5,600 1,523 4,336
Other liabilities (19,999) (22,518) 3,518
Net cash provided by operating activities – continuing operations 182,312 113,760 153,888
Net cash (used in) provided by operating activities - discontinued operations (15,371) (37,023) 50,732
Net cash provided by operating activities 166,941 76,737 204,620
Cash flows from investing activities:      
Acquisition payments, net of cash acquired (28,167) (29,930) (2,225)
Purchases of investments (17,346) (15,052) (61,845)
Proceeds from maturities or sales of investments 16,889 16,496 33,432
Purchases of property and equipment (29,708) (32,249) (28,788)
Proceeds from sale of buildings 0 24,728 0
Strategic investments 0 (20,000) 0
Other 1,378 584 1,080
Net cash (used in) provided by investing activities – continuing operations (56,954) (55,423) (58,346)
Net cash provided by investing activities - discontinued operations 0 2,350 873,857
Net cash (used in) provided by investing activities (56,954) (53,073) 815,511
Cash flows from financing activities:      
Borrowings on credit agreement 830,000 0 527,500
Payments on credit agreement (826,000) 0 (527,500)
Redemption of senior notes, including call premium (1,046,880) (759,848) 0
Proceeds from issuance of senior notes 650,000 0 0
Payments on term loan (9,375) 0 0
Payments for credit facility amendment and financing costs (8,621) 0 (510)
Payments of contingent consideration liabilities 0 (189) 0
Payments on finance lease obligations (2,916) (2,809) (1,161)
Proceeds from issuance of common stock 5,396 6,853 7,009
Repurchases of common stock (88,511) (4,719) (8,493)
Contribution from noncontrolling interests 0 0 245
Other 9,353 596 0
Net cash used in financing activities – continuing operations (487,554) (760,116) (2,910)
Net cash used in financing activities – discontinued operations 0 0 (1,248)
Net cash used in financing activities (487,554) (760,116) (4,158)
Net (decrease) increase in cash and cash equivalents (377,567) (736,452) 1,015,973
Cash, cash equivalents at beginning of year 387,391 1,123,843 107,870
Cash and cash equivalents at end of year 9,824 387,391 1,123,843
Supplemental disclosure of cash flow information:      
Interest 116,235 86,537 110,488
Income taxes 26,908 54,728 (27,775)
Non-cash investing and financing activities:      
Equipment financed through finance leases 282 6,762 12,507
Property and equipment included in accounts payable $ 2,589 $ 2,300 $ 2,305