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CONSOLIDATED STATEMENTS OF CASH FLOWS - USD ($)
$ in Thousands
12 Months Ended
Dec. 31, 2018
Dec. 31, 2017
Dec. 31, 2016
Cash flows from operating activities:      
Net income $ 24,181 $ 110,141 $ 75,789
Adjustments to reconcile net income to net cash from operating activities:      
Depreciation and amortization 132,660 115,706 106,046
Non-cash impairment of intangible assets     4,800
Non-cash interest expense 1,221 4,757 565
Non-cash stock compensation expense 29,472 39,116 37,422
Non-cash income tax provision (benefit) (1,725) (30,981) 4,710
Non-cash amortization on investments 1,344 3,924 5,238
Changes in assets and liabilities, net of effects from acquisitions of businesses:      
Accounts receivable, net (99,295) (40,910) (134,089)
Pharmaceutical inventory 127 17,605 (8,246)
Other assets (25,774) (4,565) (13,900)
Accounts payable and accrued liabilities 9,139 (84,445) 52,470
Medical claims payable and other medical liabilities 72,347 26,235 (8,042)
Contingent consideration 1,307 696 (51,205)
Tax contingencies 1,803 1,681 673
Deferred credits and other long-term liabilities 18,020 3,218 (5,584)
Other 17 95 52
Net cash provided by operating activities 164,844 162,273 66,699
Cash flows from investing activities:      
Capital expenditures (68,275) (57,232) (60,881)
Acquisitions and investments in businesses, net of cash acquired (958) (232,403) (199,237)
Purchases of investments (557,232) (449,873) (478,477)
Proceeds from maturities and sales of investments 498,032 423,118 494,256
Net cash used in investing activities (128,433) (316,390) (244,339)
Cash flows from financing activities:      
Proceeds from issuance of debt   1,041,736 375,000
Payments to acquire treasury stock (62,640) (21,765) (106,806)
Proceeds from exercise of stock options 23,064 44,355 25,145
Payments on debt, capital lease and deferred financing obligations (122,239) (803,393) (20,891)
Payments on contingent consideration   (3,032) (40,559)
Other (1,020) (9,560) 1,230
Net cash provided by (used in) financing activities (162,835) 248,341 233,119
Net increase (decrease) in cash and cash equivalents (126,424) 94,224 55,479
Cash and cash equivalents at beginning of period 398,732 304,508 249,029
Cash and cash equivalents at end of period $ 272,308 $ 398,732 $ 304,508