General - Stock Compensation (Details) $ / shares in Units, $ in Thousands	3 Months Ended
Mar. 31, 2019 USD ($) company $ / shares shares	Mar. 31, 2018 USD ($)
Stock options, Non vested restricted stock awards and nonvested restricted stock units
Stock compensation expense \| $	$ 9,607	$ 7,646
Benefits of tax deductions (tax on deficiencies) in excess of recognized stock compensation expense \| $	$ (800)	$ 4,100
Minimum
Stock options, Non vested restricted stock awards and nonvested restricted stock units
Estimated forfeitures (as a percent)	0.00%	0.00%
Maximum
Stock options, Non vested restricted stock awards and nonvested restricted stock units
Estimated forfeitures (as a percent)	4.00%	4.00%
Stock options
Stock options, Non vested restricted stock awards and nonvested restricted stock units
Grants in period, weighted average grant date fair value (in dollars per share)	$ 20.61
Expected volatility (as a percent)	35.07%
Stock option activity
Outstanding, beginning of period (in shares) \| shares	2,352,609
Granted (in shares) \| shares	409,124
Forfeited (in shares) \| shares	(30,835)
Exercised (in shares) \| shares	(41,496)
Outstanding, end of period (in shares) \| shares	2,689,402
Vested and expected to vest end of period (in shares) \| shares	2,666,529
Exercisable, end of period (in shares) \| shares	1,828,120
Weighted average exercise price of stock options
Outstanding, beginning of period (in dollars per share)	$ 68.10
Granted (in dollars per share)	66.03
Forfeited (in dollars per share)	84.51
Exercised (in dollars per share)	49.28
Outstanding, end of period (in dollars per share)	67.89
Vested and expected to vest end of period (in dollars per share)	67.84
Exercisable, end of period (in dollars per share)	$ 63.73
Assumptions used for estimating value of awards granted
Vesting period	3 years
Life of options (Expiration period)	10 years
Restricted stock awards
Nonvested restricted stock awards and units
Outstanding, beginning of period (in shares) \| shares	11,795
Outstanding, end of period (in shares) \| shares	11,795
Weighted average exercise price of nonvested restricted stock award and units
Outstanding, beginning of period (in dollars per share)	$ 89.05
Outstanding, end of period (in dollars per share)	$ 89.05
Restricted Stock Units (RSUs)
Nonvested restricted stock awards and units
Outstanding, beginning of period (in shares) \| shares	156,750
Awarded (in shares) \| shares	184,074
Vested (in shares) \| shares	(67,308)
Forfeited (in shares) \| shares	(4,759)
Outstanding, end of period (in shares) \| shares	268,757
Weighted average exercise price of nonvested restricted stock award and units
Outstanding, beginning of period (in dollars per share)	$ 86.68
Awarded (in dollars per share)	66.57
Vested (in dollars per share)	81.77
Forfeited (in dollars per share)	92.34
Outstanding, end of period (in dollars per share)	$ 74.03
Assumptions used for estimating value of awards granted
Vesting period	3 years
Performance Based Restricted Stock Units (“PSUs”)
Nonvested restricted stock awards and units
Outstanding, beginning of period (in shares) \| shares	209,019
Awarded (in shares) \| shares	83,087
Vested (in shares) \| shares	(43,109)
Forfeited (in shares) \| shares	(12,157)
Outstanding, end of period (in shares) \| shares	236,840
Weighted average exercise price of nonvested restricted stock award and units
Outstanding, beginning of period (in dollars per share)	$ 103.38
Awarded (in dollars per share)	100.31
Vested (in dollars per share)	97.12
Forfeited (in dollars per share)	97.12
Outstanding, end of period (in dollars per share)	$ 103.76
Assumptions used for estimating value of awards granted
Vesting period	3 years
Expected dividend yield (as a percent)	0.00%
Risk-free interest rate (as a percent)	2.51%
Expected volatility, minimum (as a percent)	19.00%
Expected volatility, maximum (as a percent)	82.00%
Expected volatility, average (as a percent)	36.00%
Number of trading days considered for average share value	30 days
Number of companies in peer group \| company	48
Performance Based Restricted Stock Units (“PSUs”) \| Minimum
Assumptions used for estimating value of awards granted
Percentage of shares to be settled	0.00%
Performance Based Restricted Stock Units (“PSUs”) \| Maximum
Assumptions used for estimating value of awards granted
Percentage of shares to be settled	200.00%

Represents the number of companies in peer group considered for S&P Health Care Services Industry Index.

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Represents the estimated percentage of forfeitures considered for reduction in stock compensation expense recognized during the period.

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Threshold number of specified trading days that common stock price to be considered for average share value for share based compensation during the performance period.

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Represents the expense recognized during the period arising from equity-based compensation arrangements (for example, shares of stock, unit, stock options or other equity instruments) with employees, directors and certain consultants qualifying for treatment as employees.

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The total recognized tax benefit related to compensation cost for equity-based payment arrangements recognized in income during the period.

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The number of grants made during the period on other than stock (or unit) option plans (for example, phantom stock or unit plan, stock or unit appreciation rights plan, performance target plan).

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The weighted average fair value at grant date for nonvested equity-based awards issued during the period on other than stock (or unit) option plans (for example, phantom stock or unit plan, stock or unit appreciation rights plan, performance target plan).

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The number of non-vested equity-based payment instruments, excluding stock (or unit) options, that validly exist and are outstanding as of the balance sheet date.

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The weighted average fair value of nonvested awards on equity-based plans excluding option plans (for example, phantom stock or unit plan, stock or unit appreciation rights plan, revenue or profit achievement stock award plan) for which the employer is contingently obligated to issue equity instruments or transfer assets to an employee who has not yet satisfied service or performance criteria necessary to gain title to proceeds from the sale of the award or underlying shares or units.

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The estimated dividend rate (a percentage of the share price) to be paid (expected dividends) to holders of the underlying shares over the option's term.

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The estimated measure of the percentage by which a share price is expected to fluctuate during a period. Volatility also may be defined as a probability-weighted measure of the dispersion of returns about the mean. The volatility of a share price is the standard deviation of the continuously compounded rates of return on the share over a specified period. That is the same as the standard deviation of the differences in the natural logarithms of the stock prices plus dividends, if any, over the period.

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The estimated measure of the maximum percentage by which a share price is expected to fluctuate during a period. Volatility also may be defined as a probability-weighted measure of the dispersion of returns about the mean. The volatility of a share price is the standard deviation of the continuously compounded rates of return on the share over a specified period. That is the same as the standard deviation of the differences in the natural logarithms of the stock prices plus dividends, if any, over the period.

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The estimated measure of the minimum percentage by which a share price is expected to fluctuate during a period. Volatility also may be defined as a probability-weighted measure of the dispersion of returns about the mean. The volatility of a share price is the standard deviation of the continuously compounded rates of return on the share over a specified period. That is the same as the standard deviation of the differences in the natural logarithms of the stock prices plus dividends, if any, over the period.

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The risk-free interest rate assumption that is used in valuing an option on its own shares.

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Weighted average expected volatility rate of share-based compensation awards.

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Line items represent financial concepts included in a table. These concepts are used to disclose reportable information associated with domain members defined in one or many axes to the table.

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Number of options or other stock instruments for which the right to exercise has lapsed under the terms of the plan agreements.

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The number of shares under options that were cancelled during the reporting period as a result of occurrence of a terminating event specified in contractual agreements pertaining to the stock option plan.

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Net number of share options (or share units) granted during the period.

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The weighted average grant-date fair value of options granted during the reporting period as calculated by applying the disclosed option pricing methodology.

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Number of options outstanding, including both vested and non-vested options.

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Weighted average price at which grantees can acquire the shares reserved for issuance under the stock option plan.

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Number of fully vested and expected to vest exercisable options that may be converted into shares under option plan. Includes, but is not limited to, unvested options for which requisite service period has not been rendered but that are expected to vest based on achievement of performance condition, if forfeitures are recognized when they occur.

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Weighted-average exercise price, at which grantee can acquire shares reserved for issuance, for fully vested and expected to vest exercisable or convertible options. Includes, but is not limited to, unvested options for which requisite service period has not been rendered but that are expected to vest based on achievement of performance condition, if forfeitures are recognized when they occur.

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Number of fully vested and expected to vest options outstanding that can be converted into shares under option plan. Includes, but is not limited to, unvested options for which requisite service period has not been rendered but that are expected to vest based on achievement of performance condition, if forfeitures are recognized when they occur.

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Weighted-average exercise price, at which grantee can acquire shares reserved for issuance, for fully vested and expected to vest options outstanding. Includes, but is not limited to, unvested options for which requisite service period has not been rendered but that are expected to vest based on achievement of performance condition, if forfeitures are recognized when they occur.

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Weighted average price at which option holders acquired shares when converting their stock options into shares.

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Weighted average price at which grantees could have acquired the underlying shares with respect to stock options of the plan that expired.

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Weighted average per share amount at which grantees can acquire shares of common stock by exercise of options.

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Period from grant date that an equity-based award expires, in 'PnYnMnDTnHnMnS' format, for example, 'P1Y5M13D' represents the reported fact of one year, five months, and thirteen days.

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