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Summary of Significant Accounting Policies - Concentration of Business (Details) - USD ($)
$ in Thousands
3 Months Ended 12 Months Ended
Dec. 31, 2017
Sep. 30, 2017
Jun. 30, 2017
Mar. 31, 2017
Dec. 31, 2016
Sep. 30, 2016
Jun. 30, 2016
Mar. 31, 2016
Dec. 31, 2017
Dec. 31, 2016
Dec. 31, 2015
Concentration of Business                      
Net revenue $ 1,694,415 $ 1,419,406 $ 1,419,139 $ 1,305,623 $ 1,263,385 $ 1,292,132 $ 1,164,345 $ 1,117,022 $ 5,838,583 $ 4,836,884 $ 4,597,400
Minimum                      
Concentration of Business                      
Term of contracts with customers                 1 year    
Term of renewal contracts                 1 year    
Notice period for termination of contract                 60 days    
Maximum                      
Concentration of Business                      
Term of contracts with customers                 3 years    
Term of renewal contracts                 2 years    
Notice period for termination of contract                 180 days    
Pennsylvania Counties                      
Concentration of Business                      
Net revenue                 $ 490,000 461,600 395,700
Agencies and departments of the United States federal government                      
Concentration of Business                      
Net revenue                 341,500 252,500 $ 164,300
CMS | Pennsylvania Counties                      
Concentration of Business                      
Net revenue                 $ 511,000 $ 272,800