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Consolidated Statements of Cash Flows - USD ($)
$ in Thousands
 12 Months Ended
Dec. 31, 2024
Dec. 31, 2023
Dec. 31, 2022
Cash flows from operating activities:      
Net Income (Loss) $ (99,069) $ (60,408) $ 66,335
Income from discontinued operations 0 0 (3,767)
Adjustments to reconcile net (loss) income to net cash provided from operating activities:      
Depreciation and amortization 32,226 36,171 35,636
Amortization of premiums, discounts and issuance costs 954 1,239 1,765
Impairment losses 178,435 168,312 0
Loss on disposal of businesses 9,699 0 0
Loss on early extinguishment of debt 0 0 57,016
Stock-based compensation expense 11,868 12,323 16,127
Deferred income taxes (2,130) 3,239 (22,771)
Other (2,972) (3,167) 144
Changes in assets and liabilities:      
Accounts receivable 10,292 26,276 (5,543)
Prepaid expenses and other current assets 3,497 514 15,928
Other long-term assets 33,728 22,851 17,196
Accounts payable and accrued expenses 51,140 (11,921) 420
Income taxes (payable) receivable (5,037) (21,677) 18,225
Long-term professional liabilities 17,303 837 5,600
Other liabilities (22,684) (28,508) (19,999)
Net cash provided by operating activities - continuing operations 217,250 146,081 182,312
Net cash used in operating activities - discontinued operations (10,677) (8,756) (15,371)
Net cash provided by operating activities 206,573 137,325 166,941
Cash flows from investing activities:      
Acquisition payments, net of cash acquired (8,167) (6,667) (28,167)
Purchases of investments (64,546) (31,893) (17,346)
Proceeds from maturities or sales of investments 52,494 22,905 16,889
Purchases of property and equipment (22,022) (33,328) (29,708)
Other 6,835 807 1,378
Net cash used in investing activities (35,406) (48,176) (56,954)
Cash flows from financing activities:      
Borrowings on credit agreement 235,500 470,000 830,000
Payments on credit agreement (235,500) (474,000) (826,000)
Redemption of senior notes, including call premium 0 0 (1,046,880)
Proceeds from issuance of senior notes and term loan 0 0 650,000
Payments on term loan (12,500) (12,500) (9,375)
Payments for credit facility amendment and financing costs 0 0 (8,621)
Payments of contingent consideration liabilities (1,167) (1,817) 0
Payments on finance lease obligations (2,888) (2,618) (2,916)
Proceeds from issuance of common stock 3,638 4,912 5,396
Repurchases of common stock (1,703) (919) (88,511)
Other 135 (8,773) 9,353
Net cash used in financing activities (14,485) (25,715) (487,554)
Net increase (decrease) in cash and cash equivalents 156,682 63,434 (377,567)
Cash, cash equivalents at beginning of year 73,258 9,824 387,391
Cash and cash equivalents at end of year 229,940 73,258 9,824
Supplemental disclosure of cash flow information:      
Interest 40,003 42,278 116,235
Income taxes 4,673 30,835 26,908
Non-cash investing and financing activities:      
Equipment financed through finance leases 0 132 282
Property and equipment included in accounts payable $ 1,400 $ 2,874 $ 2,589