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Summary of Significant Accounting Policies - Concentration Risk (Details) - USD ($)
$ in Thousands
3 Months Ended 12 Months Ended
Dec. 31, 2016
Sep. 30, 2016
Jun. 30, 2016
Mar. 31, 2016
Dec. 31, 2015
Sep. 30, 2015
Jun. 30, 2015
Mar. 31, 2015
Dec. 31, 2016
Dec. 31, 2015
Dec. 31, 2014
Concentration of Business                      
Net revenue $ 1,263,385 $ 1,292,132 $ 1,164,345 $ 1,117,022 $ 1,268,743 $ 1,190,082 $ 1,157,607 $ 980,968 $ 4,836,884 $ 4,597,400 $ 3,760,118
Minimum                      
Concentration of Business                      
Term of Contract                 1 year    
Term of renewed contract                 1 year    
Notice period for termination of contract                 60 days    
Maximum                      
Concentration of Business                      
Term of Contract                 3 years    
Term of renewed contract                 2 years    
Notice period for termination of contract                 180 days    
Pennsylvania Counties                      
Concentration of Business                      
Net revenue                 $ 461,600 395,700 369,900
Agencies and department of United States federal government                      
Concentration of Business                      
Net revenue                 252,500 $ 164,300 $ 139,500
CMS | Pennsylvania Counties                      
Concentration of Business                      
Net revenue                 $ 272,800