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Edited Transcript of INGN.OQ earnings conference call or presentation 24-Feb-21 9:30pm GMT

·36 min read

Q4 2020 Inogen Inc Earnings Call GOLETA Feb 25, 2021 (Thomson StreetEvents) -- Edited Transcript of Inogen Inc earnings conference call or presentation Wednesday, February 24, 2021 at 9:30:00pm GMT TEXT version of Transcript ================================================================================ Corporate Participants ================================================================================ * Alison Perry Bauerlein Inogen, Inc. - Co-Founder, Executive VP of Finance, CFO, Corporate Secretary & Corporate Treasurer * Matthew Pigeon Inogen, Inc. - IR Officer * Nabil Shabshab Inogen, Inc. - President, CEO & Director ================================================================================ Conference Call Participants ================================================================================ * Brandon Vazquez William Blair & Company L.L.C., Research Division - Associate * Fan Wang SVB Leerink LLC, Research Division - Associate * Matthew Ian Mishan KeyBanc Capital Markets Inc., Research Division - VP and Senior Equity Research Analyst * Robert Justin Marcus JPMorgan Chase & Co, Research Division - Analyst ================================================================================ Presentation -------------------------------------------------------------------------------- Operator [1] -------------------------------------------------------------------------------- Greetings, and welcome to the Inogen Fourth Quarter and Year-end 2020 Earnings Conference Call. (Operator Instructions) As a reminder, this conference is being recorded. I would now like to turn the conference over to your host, Matt Pigeon, Investor Relations. Please go ahead. -------------------------------------------------------------------------------- Matthew Pigeon, Inogen, Inc. - IR Officer [2] -------------------------------------------------------------------------------- Thank you for participating in today's call. Joining me from Inogen, our newly appointed CEO, Nabil Shabshab; and CFO and Co-Founder, Ali Bauerlein. Earlier today, Inogen released financial results for the fourth quarter and full year 2020. This earnings release and Inogen's corporate presentation are currently available in the Investor Relations section of the company's website. As a reminder, the information presented today will include forward-looking statements, including, without limitations, statements about our growth prospects and strategy for 2021 and beyond; expectations related to our operating results for 2021, including directional revenue commentary for the first quarter of 2021; our ability to create shareholder value by driving awareness of our products; expectations regarding our international and domestic sales channels; expectations related to our rental channel; expectations related to our physician sales force; hiring expectations and expectations regarding our sales and marketing roles and related investments; product development expectations; expectations regarding reimbursement and regulatory changes; and our expectations regarding the market for our products; and the impact of the COVID-19 pandemic on our business and demand for our products in both the short and long term. The forward-looking statements in this call are based on information currently available to us as of today's date. These forward-looking statements are only predictions and involve risks and uncertainties that are set forth in more detail in our most recent periodic reports filed with the Securities and Exchange Commission. Actual results may vary, and we disclaim any obligations to update these forward-looking statements, except as may be required by law. We have posted historical financial statements and our investor presentation in the Investor Relations section of the company's website. Please refer to these files for more detailed information. During the call, we will also present certain financial information on a non-GAAP basis. Management believes that non-GAAP financial measures taken in conjunction with U.S. GAAP financial measures provide useful information for both management and investors by excluding certain noncash items and other expenses that are not indicative of Inogen's core operating results. Management uses non-GAAP measures internally to understand, manage and evaluate our business and make operating decisions. Reconciliations between U.S. GAAP and non-GAAP results are presented in tables within our earnings release. For future periods, we are unable to provide a reconciliation of our non-GAAP guidance to the most directly comparable GAAP measures without unreasonable effort as discussed in more detail in our earnings release. With that, I will now turn the call over to Inogen's President and CEO, Nabil Shabshab. Nabil? -------------------------------------------------------------------------------- Nabil Shabshab, Inogen, Inc. - President, CEO & Director [3] -------------------------------------------------------------------------------- Thank you, Matt. Good afternoon, and thank you for joining our fourth quarter 2020 conference call. Before I discuss our recent performance for the fourth quarter of 2020, I would like to say that I'm really excited to have joined the Inogen team as I believe that this company has a real opportunity to impact the quality of patients' lives by providing them increased freedom and independence of their oxygen therapy needs. Also, I believe that Inogen is in a great position to continue to be a leader in the oxygen therapy market while driving patient access to portable oxygen concentrators, or POCs, in what I believe is a large and currently underpenetrated market. With that, I would like to turn to the review of our fourth quarter 2020 performance. While the COVID-19 pandemic continued to have a significant effect on our business in the fourth quarter of 2020, primarily in the direct-to-consumer and international business-to-business sales channels, we are pleased with the rebound in performance in our domestic business-to-business channel, which exhibited double-digit growth over the comparable period of the prior year. Additionally, our recent focus on the rental channel produced strong operating performance with rental revenue growing significantly in the fourth quarter of 2020 versus the comparable period in the prior year. With that, I will now provide details of our fourth quarter 2020 revenue by channel. For the fourth quarter, we generated total revenue of $74 million compared to $78.9 million in the fourth quarter of 2019, a decline of 6.3% from the comparative period in 2019. Domestic business-to-business sales in the fourth quarter of 2020 increased 17.9% to $24.2 million compared to $20.6 million in the fourth quarter of 2019. We believe this increase was primarily a result of the unfulfilled orders in the fourth quarter of 2019, which set an easier comparable period in the fourth quarter of 2020, and increased demand of POC as hospital systems and stationary oxygen concentrator supplies were strained to keep up with the rapid increase in COVID-19 cases. In addition, we believe the resolution of the competitive bidding uncertainty back in October 2020 also contributed to increased demand in the quarter, which was partially offset by lower reseller customer demand in the comparative period. International business-to-business sales in the fourth quarter of 2020 decreased by 20.4%, a 23.8% decrease on a constant currency basis to $13.6 million compared to $17.1 million in the fourth quarter of 2019. We believe the decrease was primarily driven by the resurgence of the COVID-19 pandemic in the quarter causing additional lockdowns in many European countries, along with reduced operational capacity of certain European respiratory assessment centers. However, I would like to mention that during the fourth quarter of 2020, the Inogen One G5 POC was cleared for reimbursement in Germany, and we are excited for our German customers to begin purchasing our latest and highest-output POC. Direct-to-consumer sales decreased 25.2% to $26.8 million in the fourth quarter of 2020 from $35.8 million in the fourth quarter of 2019. We believe the decrease was primarily driven by the impact of COVID-19 PHE on consumer travel, mobility and consumer confidence, as well as an approximately 6% reduction in average inside sales representative headcount. Given the impact of COVID-19 PHE on our direct-to-consumer sales, we have continued to review our hiring and retention practices and ended the year with 300 inside sales representatives, down from 329 at the end of 2019. We plan to continue inside sales representative hiring at a measured pace in the first half of 2021, while we monitor the impact of the COVID-19 PHE on our business. Rental revenue in the fourth quarter of 2020 increased to $9.4 million from $5.4 million in the same period in 2019, an increase of 71.7%, primarily due to increased patients on service, higher billable patients as a percent of total patients on service, higher Medicare reimbursement rates and lower rental revenue adjustment. As of December 31, 2020, we had approximately 32,200 patients on service, which was up 9.2% sequentially compared to September 30, 2020, and up 27.3% compared to December 31, 2019. The increase in patients on service was driven by both greater utilization of leads for rental opportunities and initiatives to increase physician awareness by our own sales force. As of December 31, 2020, we had a total of 24 physician sales representatives, up from 17 as of December 31, 2019. Looking ahead, and as I previously mentioned, I believe we are leaders in the POC technology and that the markets for our technology remain underpenetrated with only an estimated 18% of patients using POCs of the total long-term oxygen therapy market in 2019 based on Medicare data. Furthermore, we are committed to our vision of making our POC technology the standard of care for oxygen therapy patients. To do so, we believe we need to increase patient access to our technology at the onset of care, which requires driving physician awareness of our products and services and expanding our insurance contract coverage. As part of this strategic initiative, we plan to invest to expand our physician sales force with the intent to have a national presence within the next 3 to 5 years. Also, as part of this strategic initiative, we plan to make further investments to build out our rental infrastructure to offer physicians the necessary solutions to better serve their patients' needs. In addition, over time, we plan to increase investments in R&D to broaden our portfolio with innovative product offerings while gradually expanding the clinical evidence in support of those products. We are excited about our initiatives to drive new oxygen patient rentals as we continue to see meaningful patient interest in our products. We expect these planned investments for this strategic initiative will impact our operating expenses in the near term. However, we believe that such investments will provide a more predictable revenue stream while enhancing our growth and margin profiles in the future. With that, I will now turn the call over to our CFO, Ali Bauerlein. Ali? -------------------------------------------------------------------------------- Alison Perry Bauerlein, Inogen, Inc. - Co-Founder, Executive VP of Finance, CFO, Corporate Secretary & Corporate Treasurer [4] -------------------------------------------------------------------------------- Thanks, Nabil, and good afternoon, everyone. As Nabil noted, total revenue for the fourth quarter of 2020 was $74 million, representing a decline of 6.3% from the comparative period in 2019. Turning to gross margin. For the fourth quarter of 2020, total gross margin was 46% compared to 43% in the fourth quarter of 2019. Our sales revenue gross margin increased to 44.5% in the fourth quarter of 2020 versus 43% in the same period of 2019. This increase was primarily due to lower manufacturing cost per unit versus certain manufacturing inefficiencies we experienced in the comparable period of 2019 and lower warranty cost per unit. These increases were partially offset by higher labor and overhead costs per unit and lower average selling prices due to an increased mix of domestic business-to-business sales, which have a lower gross margin versus our direct-to-consumer sales. Rental revenue gross margin increased to 56.5% in the fourth quarter of 2020 versus 43.3% in the fourth quarter of 2019, primarily due to higher billable patients as a percent of total patients on service, higher Medicare reimbursement rates, lower rental revenue adjustments and lower depreciation expense per patient on service. As for operating expense, total operating expense increased to $39.6 million in the fourth quarter of 2020 versus $39.2 million in the fourth quarter of 2019, primarily due to an increase in the fair value of the New Aera earnout liability and higher personnel-related expenses, partially offset by lower legal and consulting expense and a reduction in product incentives and advertising expense. Research and development expense increased to $3.7 million in the fourth quarter of 2020 compared to $3.6 million in the fourth quarter of 2019, primarily associated with increased product development-related expenses. Sales and marketing expense decreased to $25.4 million in the fourth quarter of 2020 versus $25.5 million in the comparative period of 2019, primarily due to decreased product incentives and advertising expenditures, partially offset by increased personnel-related expenses. Advertising expenditures were $9.3 million in the fourth quarter of 2020 compared to $9.5 million in the fourth quarter of 2019. General and administrative expense increased to $10.5 million in the fourth quarter of 2020 versus $10.1 million in the fourth quarter of 2019, primarily due to a $0.4 million increase in the fair value of the New Aera earnout liability and increased recruiting costs, partially offset by lower legal and consulting expense. In the fourth quarter of 2020, we reported an operating loss of $5.5 million, adjusted EBITDA of $3 million, a net loss of $5.1 million and loss per diluted common share of $0.23. Finally, we ended the year with cash, cash equivalents and marketable securities of $231.2 million with no debt outstanding. Regarding reimbursement rates, the recent stimulus bill that passed in December 2020 included 2 provisions related to oxygen therapy. The bill extended the temporary elimination of the 2% Medicare sequester reduction that went into effect in 2013. It previously was expected to go back into effect on January 1, 2021, and this extends this benefit until March 31, 2021. The bill also waives the budget-neutrality provision for oxygen therapy, thereby, increasing payments for certain oxygen equipment in rural areas. We see both of these changes as incrementally positive for our industry and POC adoption. Now turning to guidance. Because of the unprecedented market uncertainties, we are still unable to provide guidance for the full year 2021. Given the uncertain scope and duration of the COVID-19 pandemic, we are unable to estimate the impact on our financial results, including our revenue, revenue mix, net income or loss and adjusted EBITDA estimates for such periods. While we expect the COVID-19 pandemic and any potential for further prolonged lockdowns would have a negative impact on our sales revenue in the period, as Nabil mentioned, we believe it is prudent to continue to make investments to build the necessary infrastructure to support our strategy to focus on rentals at the onset of care. As part of this strategic initiative, we plan to invest to expand our physician sales force and to build up the infrastructure to enable us to offer physicians the necessary solutions to better serve their patients' needs. In addition, over time, we plan to increase investments to broaden our portfolio with innovative products and to support those products by gradually expanding clinical evidence. Given such investment initiatives, we expect increased operating expenses for 2021 that we believe will support future revenue growth and margin expansion while also increasing the predictability of our revenue. Also, while we incurred minimal expenses related to bonus and performance-based stock compensation in 2020, we expect such costs to increase in 2021, along with certain expenses related to the recent CEO transition. As we saw in the fourth quarter of 2020, demand has increased so far in the first quarter of 2021 compared to the first quarter of 2020 from our domestic HME partners, primarily due to increased demand for POCs as hospital systems and stationary oxygen concentrator supply has been strained to keep up with the rapid increase in COVID-19 cases. While we do not know how long this increased demand for POCs will continue, we expect our domestic business-to-business sales to increase in the first quarter of 2021 versus the comparative period in the prior year. Furthermore, we expect rental revenue to grow in the first quarter of 2021 compared to the same period in the prior year, primarily due to increased patients on service, higher billable patients as a percent of total patients on service and higher average reimbursement rates. However, we expect our international business-to-business and direct-to-consumer sales channels in the first quarter of 2021 to be down compared to the same period in the prior year as a result of the continued COVID-19 impact on these channels. With that, we'll be happy to take your questions. ================================================================================ Questions and Answers -------------------------------------------------------------------------------- Operator [1] -------------------------------------------------------------------------------- (Operator Instructions) The first question is from Robbie Marcus from JPMorgan. -------------------------------------------------------------------------------- Robert Justin Marcus, JPMorgan Chase & Co, Research Division - Analyst [2] -------------------------------------------------------------------------------- Nice quarter. Nabil, I thought I'd start off, 2 questions: one maybe higher level, one maybe more focused on the business here. But for a lot of us, this is the first time we get to hear from you. And it'd be great if you just gave us your thoughts on what attracted you to the role, what you think you can achieve in the next 6 to 12 months here with Inogen, and what you think you might be doing differently versus the prior CEO. -------------------------------------------------------------------------------- Nabil Shabshab, Inogen, Inc. - President, CEO & Director [3] -------------------------------------------------------------------------------- Robbie, thank you for the question. So let me go through the first part of the question to address what attracted me to Inogen and the role. So a few things stand out in my mind, specifically how underpenetrated POC oxygen therapy market remains, not only in the U.S. but around the world, and the opportunity for a company like Inogen that has truly a best-in-class portfolio of products to meet the needs of patients that require such therapy. Also, what attracted me is the fact that Inogen has -- is a company with the purpose, basically, focused on really improving respiratory therapy around the world. But that, coupled with, as I mentioned, the portfolio strength, the commitment of the team that I saw during the discussions we were having provide for a unique opportunity to serve patients in need and deliver on their expectations as well as expectations of shareholders. So -- but with that said, there's a lot of work ahead of us. The division is real, and the capabilities are strong, and the portfolio is good. And I look forward on working with the team on improving that. Now to the second part of your question, Robbie, in terms of what can we do in the short and in the medium term. Like any incoming CEO into the organization, I'm spending a lot of time doing deep dives with the team, specifically around 2 things: the strength of the portfolio, both existing as well what's in the innovation pipeline in terms of what's coming next; as well as the strength of the go-to-market model and its durability and how we can continue to build on that and leverage the strength that we have there. So the market itself is, as I said, not penetrated that much and leaves a lot of room for us to grow as well as our partners in the channel. So we'll be looking as part of that into what areas can we double down and strengthening some of the investments or where we're placing our bets, including some of the capabilities we have, some of the underlying technology systems that we need to look at, looking at the business model as well as revisiting the strategic imperatives and tweaking them for us to get to that aspired growth rate. -------------------------------------------------------------------------------- Robert Justin Marcus, JPMorgan Chase & Co, Research Division - Analyst [4] -------------------------------------------------------------------------------- And maybe just as a follow-up, you talked about underpenetrated market. How are you thinking about the business strategically? Because on the one hand, DTC is the most profitable on a net income dollar basis for the company, yet a lot of patients like to get it through their HME suppliers, and you've done well in that bucket over the past several years. And it's -- the company, at one point, was moving away from rental, now coming back to rental. So where do you think the market is in terms of penetration, in terms of available units for patients? And where do you think the key focus for Inogen will be in the next 12, 24 months? Is it returning to DTC? Is it building a big, aggressive B2B presence? Is it getting more aggressive on rental? How do you think about balancing the 3 because they don't always work perfectly well together? -------------------------------------------------------------------------------- Nabil Shabshab, Inogen, Inc. - President, CEO & Director [5] -------------------------------------------------------------------------------- Yes. So I'm going to take a first pass. And since I've only been here 3 weeks or 2.5 weeks, I'll let Ali chime in after I give you my thoughts. So I think in terms of the balance between the 3 channels, let me start with the penetration of the market. Based on the CMS data that we have, and it's difficult to put all the data sets together, but we believe that the penetration is around 18%. So there's still a lot of room left in the market in terms of how do you tackle that upside based on the channel and the field of play that you go into. So on the -- let me start with the smaller side, the business-to-business. So of course, it remains a focus, but we need to balance it with a direct-to-patient or direct-to-consumer as well as the rental market. The rental market that we have started focusing on again recently has shown some positive signs in terms of how it responded to our efforts and us increasing the exposure and the attention of the patients within that space. We will continue to double down on that because we've seen good growth rates there as well as continue to refund our model for the direct-to-consumer and see how we can leverage some of our strengths and optimize our performance and spend in that space. So the answer is, we're not going to take our eye off any of them, but we're going to be placing bets a little bit differently after I have a little bit more time with the team to look at the return in terms of the investment in 1 of the 3 channels as well as what tweaks are required in each one of them. Ali, you want to weigh in a little bit? -------------------------------------------------------------------------------- Alison Perry Bauerlein, Inogen, Inc. - Co-Founder, Executive VP of Finance, CFO, Corporate Secretary & Corporate Treasurer [6] -------------------------------------------------------------------------------- Yes. Sure. So Robbie, as you know, our vision of the future is really to make POCs the standard of care for ambulatory oxygen therapy patients. And certainly, it's been difficult the last couple of years to really see improvements, significant improvements in the penetration there. And we're really about trying to drive that patient access to the product. And we think the combination efforts of creating patient awareness that we've done through our D2C efforts, creating physician awareness that we do with our rental efforts, as well as our physician-facing sales team and then also through our partners who are also creating that awareness, we believe that's the best way to get to POCs becoming the standard of care. So we're about trying to drive that access. Certainly, we're proud of what we've been able to accomplish in the rental business. And it shows the true patient interest in POCs and the high demand that's there, if they can get access using their insurance benefits. And as you rightly said, a large portion of patients can't afford to buy a POC out of pocket. So the more we can give patients access to using their rental benefits as a way to get POCs, the higher conversion rates that we would expect in our business and the pathway to achieving our vision for the company. -------------------------------------------------------------------------------- Nabil Shabshab, Inogen, Inc. - President, CEO & Director [7] -------------------------------------------------------------------------------- So maybe I'll just add something that Ali mentioned, which is getting to those prescriptions at the onset of care. So the efforts we're putting behind our direct-to-physician sales force is part of the strategy that Ali and I covered in terms of making sure that we give the patients the options, we give the physicians the awareness required, and we are capable of either serving it through their insurance and/or through cash sales. -------------------------------------------------------------------------------- Operator [8] -------------------------------------------------------------------------------- The next question is from Matthew Mishan from KeyBanc. -------------------------------------------------------------------------------- Matthew Ian Mishan, KeyBanc Capital Markets Inc., Research Division - VP and Senior Equity Research Analyst [9] -------------------------------------------------------------------------------- And Nabil, congratulations on the new role. Before I ask a longer-term question, I just wanted to ask around, just what are some of the early signals of activity you're seeing from your DTC customers at this point? Now that the vaccines are rolling through, have you seen call volumes or inquiries start to improve? -------------------------------------------------------------------------------- Alison Perry Bauerlein, Inogen, Inc. - Co-Founder, Executive VP of Finance, CFO, Corporate Secretary & Corporate Treasurer [10] -------------------------------------------------------------------------------- Yes. I'd say it's a little early to say that still. We're just now getting into what would be our typical higher seasonality period. Usually, that starts in March or April for us where we would see consumers increasing, both seeing our cost per lead decline as well as our conversion rates increase. But we certainly have sensed a significant amount of optimism from the patient population that they do plan to get vaccinated and they plan to resume traveling once they do receive those vaccinations. So I think that we've seen some hopeful signs there. But still, it's a little too early to say that we've seen a trend in our business that would immediately drive an impact to our results. -------------------------------------------------------------------------------- Matthew Ian Mishan, KeyBanc Capital Markets Inc., Research Division - VP and Senior Equity Research Analyst [11] -------------------------------------------------------------------------------- And then on the international side, it would seem as if there are several potential catalysts for some improvement into 2021. Can you talk about what the U.K. tender timing and some of the launches in France and reimbursement in Germany and what that could mean? -------------------------------------------------------------------------------- Alison Perry Bauerlein, Inogen, Inc. - Co-Founder, Executive VP of Finance, CFO, Corporate Secretary & Corporate Treasurer [12] -------------------------------------------------------------------------------- Sure. Yes, I'm happy to take that question. And the tenders have been resolved in the U.K. There has been a little bit of delay in the implementation of those given the pandemic and the impacts that, that has. But the contracts have been awarded. We have visibility on the winners. And we believe that, that should be a tailwind to growth as those markets start returning to normalcy. We have seen in the past that when we launch new products and get reimbursement approval in markets like Germany and France, that does lead to heightened interest in the product and conversions of that product, so we are excited about those 2 markets. Of course, COVID still has an overall impact on the business in the short term. But we know giving our partners access to the best product on the market with the G5 certainly will help enable them to provide POCs and provide that patient-preferred product. So we do expect those customers in those markets to convert to the G5 since it is better than the G3 in any way, and that's the standard product that has been used across most of Europe. And we have already seen that in other accounts where that product was available. So we would expect that, and we do think that, that will continue to strengthen our competitive position and market position in those markets. -------------------------------------------------------------------------------- Nabil Shabshab, Inogen, Inc. - President, CEO & Director [13] -------------------------------------------------------------------------------- And maybe, Matthew, the other thing is, hopefully, with the assessment centers starting to reopen again as people get vaccinated, that will definitely be a little bit of a help in terms of the demand that we expect. -------------------------------------------------------------------------------- Matthew Ian Mishan, KeyBanc Capital Markets Inc., Research Division - VP and Senior Equity Research Analyst [14] -------------------------------------------------------------------------------- Okay. Excellent. And then last question is just, Nabil, can you just give us a sense of what you're going to be trying to prove out with clinical evidence and what you think you're going to be able to show? -------------------------------------------------------------------------------- Nabil Shabshab, Inogen, Inc. - President, CEO & Director [15] -------------------------------------------------------------------------------- Yes. I think this is to be determined, but I'll frame it at a high level that people actually get to better clinical outcomes and lower hospital admissions. Hopefully, if we can get to that level, if they are on oxygen therapy, especially if they're on a POC that allows them to get to a higher level of compliance and adherence to the required therapy versus using it intermittently because they are tied to a unit or to a tank, we'd like to be able to do some by clinical studies to prove the value of POCs and its superiority over other modalities of therapy. It's established that oxygen therapy is definitely very helpful and beneficial. We believe that there is an added cluster adherence and compliance, which I think is at the core of the offering that we have. So we're having a discussion as a team in terms of how do we go about getting to that evidence because it will definitely be some of the help that we require in terms of tailwinds. -------------------------------------------------------------------------------- Alison Perry Bauerlein, Inogen, Inc. - Co-Founder, Executive VP of Finance, CFO, Corporate Secretary & Corporate Treasurer [16] -------------------------------------------------------------------------------- Yes. And just to add on to that, all of that is certainly true, and we also want to do more clinical work with the combination product that we've talked about of the POC with the TAV technology and really showing the differences between that product and a traditional POC. So that will be another leg to this clinical evidence approach. -------------------------------------------------------------------------------- Operator [17] -------------------------------------------------------------------------------- The next question is from Mike Matson from Needham. -------------------------------------------------------------------------------- Unidentified Analyst, [18] -------------------------------------------------------------------------------- This is [Joseph] on for Mike. The first question, maybe frame it around COVID. Just curious how -- why it took so long to get a benefit from COVID-related demand. Like what changed? And why wasn't this seen earlier? And maybe going back to the POCs as well, any information on how long these COVID patients need to use the POCs? And specifically, what happens to the units after they're no longer needed? -------------------------------------------------------------------------------- Alison Perry Bauerlein, Inogen, Inc. - Co-Founder, Executive VP of Finance, CFO, Corporate Secretary & Corporate Treasurer [19] -------------------------------------------------------------------------------- Yes. Sure. Great question. And we did actually see this early in the pandemic as well. Back in March and April, there was a heightened interest in POCs. And of course, there was just a lot of unknowns at that moment about what the best treatment was for COVID patients. But we have seen oxygen therapy emerge as a common treatment for patients who need -- who have COVID-19. And particularly, as we saw hospital systems trying to increase discharges of patients because they have limited capacity, we saw more patients going home with oxygen therapy versus staying in the hospitals. And we've seen a shortage of what would traditionally these patients would be treated with stationary concentrators because if they're still recovering from COVID, ambulation is not their biggest priority. It typically would be a higher-flow unit and a unit that doesn't have that ambulation. But as that supply got more constrained in the fourth quarter, we did see a pull-through into POC demand for that use since they couldn't get access to more traditional oxygen therapy. So that is -- that's the main driver of why we didn't see this earlier and kind of what we are currently seeing, that is a little different than historical trends. We don't have good data on how long these patients do stay on oxygen therapy, if they are prescribed oxygen therapy. Obviously, a large percentage of COVID patients do not need oxygen therapy. They recover on their own. But for those who do have severe cases, there is a portion who needs oxygen therapy, it does appear to be short term in nature, thus far. But it's really hard to tell any long-term impacts at this point. -------------------------------------------------------------------------------- Unidentified Analyst, [20] -------------------------------------------------------------------------------- Okay. That's very helpful. And then maybe one more. I know you guys aren't giving guidance, but if you could give maybe a sense of the magnitude of the increase of operating expenses in 2021? That would be very helpful. -------------------------------------------------------------------------------- Alison Perry Bauerlein, Inogen, Inc. - Co-Founder, Executive VP of Finance, CFO, Corporate Secretary & Corporate Treasurer [21] -------------------------------------------------------------------------------- Yes. Thanks. And we aren't giving guidance today, so we're not going to quantify the exact level of investments, but it is a step-up from the operating expenses that we saw in 2020. And we do hope at some point during the year, we will be able to give more details, give more guidance, but this is something that will grow over time as we continue to make those investments on both the R&D side as well as the physician sales forces. You'll see incremental costs growing as we make those investments. -------------------------------------------------------------------------------- Operator [22] -------------------------------------------------------------------------------- The next question is from Margaret Kaczor from William Blair. -------------------------------------------------------------------------------- Brandon Vazquez, William Blair & Company L.L.C., Research Division - Associate [23] -------------------------------------------------------------------------------- This is Brandon, on for Margaret. First just, in the fourth quarter, can you just talk a little bit about what lead generation looks like and maybe even going into so far into the first quarter? And part of what I'm trying to think about is, are you able to -- even as we move through COVID, are you able to kind of keep a solid pipeline of patients? Maybe this is more applicable to DTC. And so as we move past COVID are -- is the sales team kind of hitting the floor running with a strong pipeline? Do they have good leads? Or do we kind of need to rebuild that once we move past COVID? -------------------------------------------------------------------------------- Alison Perry Bauerlein, Inogen, Inc. - Co-Founder, Executive VP of Finance, CFO, Corporate Secretary & Corporate Treasurer [24] -------------------------------------------------------------------------------- Yes. So the lead flow was still strong in the fourth quarter and going into 2021. Of course, with the election that occurred in the fourth quarter, during those periods, we tend to see higher cost per lead, particularly with TV campaigns. But outside of that anomaly, media was performing as expected in the period. Again, as I said earlier, there is seasonality to cost per lead and kind of conversion rates of those sales. And we're a little early in that cycle. We usually see that pick up in the March-April time frame. But we do still see strong patient interest in the product, high conversions and high interest in the product from our direct-to-consumer side. And of course, as you would expect, the rental conversion rate for those who qualify to use their rental benefits is significantly higher than a cash sale conversion rate where somebody needs to pay out of pocket. So that is certainly a factor in looking at the lead pool as well. -------------------------------------------------------------------------------- Brandon Vazquez, William Blair & Company L.L.C., Research Division - Associate [25] -------------------------------------------------------------------------------- Got it. And we spent a little bit of time today talking about kind of reducing the friction points for market access for patients. I was just curious if you could kind of go over what specifically are some of the friction points that you'll be focused on that you hope to lower those barriers over the next few years. Like what are you going to be focusing those -- your reps on or your reimbursement teams in order to help patients get this in their hands easier? -------------------------------------------------------------------------------- Alison Perry Bauerlein, Inogen, Inc. - Co-Founder, Executive VP of Finance, CFO, Corporate Secretary & Corporate Treasurer [26] -------------------------------------------------------------------------------- Yes. So at a high level, what we're looking to do is really make physicians aware that POCs are available for their patients. Right now, in our rental business, we are heavily Medicare-focused. So our ability to expand contracting coverage is another way to expand access to the products. And expanding the clinical evidence to also show those things that physicians care about and their patients' outcomes, that will also be important as we look to interact more with the physician community around the benefits of POCs versus standard oxygen and really help them see also the quality-of-life improvements that the patients experience and really enjoy about POCs. So all of those things are things that we will be focused on interacting with the physicians. And this is one thing that we think that -- physician awareness should help both us and our partners, just like when we drove patient awareness for our products that also helped our partners to create more awareness for POCs and drive that interest in the product and create that retail sale. We think driving more physician awareness of POCs and the options that patients have and why the technology really does work for the mass majority of the ambulatory long-term oxygen therapy patients, that's something that we think will help supplement the work that the provider community is already doing on physician education. -------------------------------------------------------------------------------- Nabil Shabshab, Inogen, Inc. - President, CEO & Director [27] -------------------------------------------------------------------------------- So Brandon, let me just weigh in and bring it to life with an example. So today, like you refer to the frictions or the experience that the patients go through. And today, instead of me going to a physician, and I have to advocate for what unit do I want. Do I want a POC or what modality? The hypothesis and the investment thesis behind the direct-to-physicians, like Ali said, is to increase that awareness of the benefit of this modality and of the Inogen product and brand to be able to remove that friction, so the patients don't have to advocate for themselves. Of course, it will still happen. And then we referred to as that friction is removed from the process, can I really get it covered either if I'm on a private insurance or I'm on Medicare, as an example? But we're focused on both in terms of contracting as well as the awareness upstream at the point of prescription. -------------------------------------------------------------------------------- Operator [28] -------------------------------------------------------------------------------- The next question is from Danielle Antalffy from SVB Leerink. -------------------------------------------------------------------------------- Fan Wang, SVB Leerink LLC, Research Division - Associate [29] -------------------------------------------------------------------------------- This is actually Rebecca on for Danielle. I want to touch base on the New Aera product. When can we actually expect New Aera to become a revenue contributor? And what are the barriers to adoption for this technology, if we want to think about the next few years when you start to ramp adoption? -------------------------------------------------------------------------------- Alison Perry Bauerlein, Inogen, Inc. - Co-Founder, Executive VP of Finance, CFO, Corporate Secretary & Corporate Treasurer [30] -------------------------------------------------------------------------------- Yes, Rebecca, thanks for the question. And certainly, we're still in the early stages of the benefits of the New Aera technology. The TAV product today that we sell, either B2B or through our D2C channel, only works with tanks and certain stationary concentrators. So it doesn't provide the full freedom and independence that POCs provide. So we really see the benefit of the TAV technology to be when we can integrate that into the POC product. And that still is ongoing in development. It will require an additional FDA clearance. So we haven't given specific timing there, both given the uncertainty there as well as for competitive reasons. But that is something that we are focused on in terms of really utilizing that technology to its fullest is the integrated product, not the stand-alone product. -------------------------------------------------------------------------------- Fan Wang, SVB Leerink LLC, Research Division - Associate [31] -------------------------------------------------------------------------------- All right. Next question, I know you guys don't want to give guidance for 2021. But comparables will become very -- quite easy next -- this year. So what are the key headwinds and tailwinds we need to consider when we think about 2021 and maybe into 2022? If you can touch this, yes. -------------------------------------------------------------------------------- Alison Perry Bauerlein, Inogen, Inc. - Co-Founder, Executive VP of Finance, CFO, Corporate Secretary & Corporate Treasurer [32] -------------------------------------------------------------------------------- Great question, Rebecca. And certainly, the comps get significantly easier when you get into the second quarter and onward throughout 2021. So we would expect that to be a tailwind once you kind of lap the COVID-19 impacts in the business. Of course, on the rental side of the business, we've been able to continue to grow that business in spite of the COVID-19 pandemic and the impacts of that because we've really been able to continue to grow our patients on service. So we would expect that business to continue to grow. There is some reimbursement uncertainty of what the rates will be after the public health emergency is over. But given the growth in patients, that's an area that we see as a true opportunity in our business going forward. Looking at the other channels, D2C, we'll be watching the leading indicators there of how patients return to travel, the vaccine rollouts broadly across the U.S. and just the consumer confidence there. But as you said, comps get easier in the second quarter. And typically, we see seasonality that was very different than last year. So we would normally see second quarter being the high, followed by the third and then the fourth, and the first being the low, which is, of course, not what we saw in 2020. So that can create some tailwinds to growth in the D2C side, of course, assuming patients do return to travel, which is a big assumption and uncertainty at the moment. On the B2B side, we certainly have looked at our partners, and we see great partner opportunities to continue to convert their businesses from the traditional delivery-based models to nondelivery models both here in the U.S. and internationally. And being able to go back into patients' homes and feel comfortable converting out equipment is a critical part of that. So vaccinations of their staff and their ability to want to proactively go into homes is a critical component of returning to growth in those channels. -------------------------------------------------------------------------------- Operator [33] -------------------------------------------------------------------------------- Ladies and gentlemen, this concludes the question-and-answer session. And I would like to turn the call back to Nabil Shabshab for closing remarks. -------------------------------------------------------------------------------- Nabil Shabshab, Inogen, Inc. - President, CEO & Director [34] -------------------------------------------------------------------------------- Thank you. So while the COVID-19 pandemic has and will continue to have a significant effect on our business, we as a company are excited about the future as the leader in POCs and the focus we are placing to drive rentals and expand patient access to our oxygen solutions. We believe this strategic initiative will help us ensure that we continue to be a leader in improving freedom and independence of patients with respiratory disorders. Thank you for the time today, and I look forward to many engaging conversations with our investors about Inogen's future. -------------------------------------------------------------------------------- Operator [35] -------------------------------------------------------------------------------- This concludes today's conference. You may disconnect your lines at this time. Thank you for your participation.