Q3 2023 Adapthealth Corp Earnings Call
Participants
Jason A. Clemens; CFO; AdaptHealth Corp.
Richard Alan Barasch; Chairman of the Board & Interim CEO; AdaptHealth Corp.
Eric White Coldwell; Senior Research Analyst; Robert W. Baird & Co. Incorporated, Research Division
Joanna Sylvia Gajuk; VP; BofA Securities, Research Division
Mathew Justin Blackman; Analyst; Stifel, Nicolaus & Company, Incorporated, Research Division
Philip Chickering; Research Analyst; Deutsche Bank AG, Research Division
Richard Collamer Close; MD & Senior Analyst; Canaccord Genuity Corp., Research Division
Taji Milan Phillips; Equity Associate; Jefferies LLC, Research Division
Presentation
Operator
Good day, everyone, and welcome to today's AdaptHealth Third Quarter 2023 Earnings Release Call. (Operator Instructions)
It is now my pleasure to turn today's call over to Richard Barasch, Chairman and Interim CEO. Please go ahead.
Richard Alan Barasch
Good morning, everyone. Thank you for joining us today to discuss AdaptHealth's third quarter performance.
Before we begin, I'd like to remind everyone that statements included in this conference call and in the press release issued today may constitute forward-looking statements within the meaning of the Private Securities Litigation Reform Act. These statements include but are not limited to comments regarding financial results for 2023 and beyond. Actual results could differ materially from those projected in forward-looking statements because of a number of risk factors and uncertainties which are discussed at length in the company's annual and quarterly SEC filings. AdaptHealth Corp. should have no obligation to update the information provided on this call to reflect such subsequent events.
Additionally, on this call, the company will reference certain financial measures, such as EBITDA, adjusted EBITDA and free cash flow, all of which are non-GAAP financial measures.
This morning's call is being recorded, and a replay of the call will be available later today.
We are pleased with the results of the third quarter. Powered by our sleep business, we generated 6.3% growth over last year, leading to record revenues for the quarter. Equally important, we generated cash flow from operations of $98.8 million and free cash flow of $21.7 million.
Adjusted EBITDA fell short of our expectations largely as a result of unplanned delays in the implementation of the Humana contract. Jason and I will get into more detail on why this happened, but these results do not reduce our optimism that this will be a profitable contract for AdaptHealth, nor does it diminish our enthusiasm for more enterprise sales of this type. Other than this contract, we would have met our expectations for revenue, adjusted EBITDA, margins and cash flow in the quarter.
Our sleep product line continues to outperform, resulting in a 17% increase over last year. Our new PAP starts were consistent with our expectations and our PAP resupply business generated record order volumes. An important metric is that our resupply census has grown 12% over the past year and now totals over 1.5 million patients.
Among the reasons we continue to grow is that we have focused on electronic ordering, which reduces friction and enhances the patient experience. The relationship that we've established with these patients is a critical aspect of our strategy to become more than just a provider of devices and supplies.
Building on the strong trends in the first half of the year, we grew our respiratory net revenue by over 8% year-on-year. This growth was driven by increased patient census, coupled with stabilization in the length of time patients remain on oxygen and vents.
Diabetes continues to be a work in progress, as discussed last quarter. While the results in the third quarter were a bit softer than we had planned, we are encouraged by the progress we are making to improve this vital product line.
To resume growth, we are focusing our sales efforts toward the growing government business, especially in areas where diabetes is prevalent. The government market for CGMs and pumps is large and growing, and we are continuing to shift our strategy to specifically focus on the acquisition and retention of these patients. Government-sponsored payers are now 79% of our CGM census, up 200 basis points versus last quarter.
We are rapidly recruiting dedicated diabetes representatives in the areas of high diabetes prevalence, leveraging the scale and capability of the entire AdaptHealth sales team. Our objective is to double the number of diabetes sales reps over the next several months. We're also exploring strategies to participate profitably in the growing pharmacy sales channel. This will allow us to regain some of the share that we relinquished as more commercial payers move to the pharmacy channel.
Finally, and quite promising, is that we are beginning to execute a strategy to use the data generated from CGMs to create a better patient experience while generating information that is important for their providers and payers. This will enhance our value proposition to all of our constituents.
Our experience in the early days of the Humana implementation has not diminished our optimism about the value that this contract will provide to all parties to the transaction. We've established a very strong relationship with Humana, and we've been working to make the transition process as seamless as possible for Humana members who will ultimately benefit from better service for their HME needs.
Unfortunately however, we underestimated the size and complexity of the patient transition process. Onboarding members is taking longer than we had anticipated, resulted in a reduction to our expected cap revenues from Humana. Nevertheless, we remain confident that this agreement will achieve positive results for AdaptHealth.
Since AdaptHealth went public in 2019, we've increased revenue and adjusted EBITDA each year and have recently improved our cash flow and strengthened our balance sheet. However, we must take responsibility for issues, some self-inflicted, that have caused a reduction in investor confidence, including setbacks around the CEO search. The top priority for our Board is to fill the CEO job with the best candidate as soon as possible. We are currently talking to highly capable candidates with the goal of having the post filled by year-end.
In the meantime, we're not slowing down, and I'd like to describe the key initiatives and goals that our Board and management are aligned on. Further increases in cash flow from operations and free cash flow is a high priority. The company continues to focus on better collections, better inventory management and more efficient capital spending, all of which have contributed to our improved cash flow results.
We recently used some of our free cash to buy back stock, but we were also addressing our balance sheet. During 2023, we paid down our revolver and reduced our leverage from 3.66 to 3.51x. We are fortunate to have a comfortable debt structure in terms of rates and maturities, but we intend to delever further with the goal of reducing our leverage to under 3x by the end of next year.
As to the business itself, our short-term priorities are to solidify our diabetes line and resume a market rate of growth, expedite the transaction of the Humana business and expand our enterprise sales effort, continue to reduce the cost of operations through automation and better processes and implement our strategy to become even more relevant in the health care ecosystem.
Finally, I'd like to comment on the affect of GLP-1s on our sleep and diabetes product lines. Most important, we are seeing no current impact on our sleep product line. Our total sleep census, which is a combination of new starts and ongoing PAP resupply patients, continues to grow at a pace that bodes well for continued revenue growth.
Further, we have seen recent analysis that indicates that the affect of GLP-1s on PAP utilization may have been overstated in some earlier analysis and resulting market reaction. For example, one recent study indicated that only 3% of GLP-1 users with obstructive sleep apnea were able to stop using their PAP therapy. Another recent piece highlighted the lack of adherence to GLP therapy over time. Others, ourselves included, think that the sleep TAM may actually grow as a result of more awareness and increased diagnosis of OSA as a result of the publicity around GLP-1s.
Our working assumption though is that GLP-1 drugs will likely have a significant impact on obesity over time, which may cause some leakage to the current sleep TAM. How large and how soon are the subject of much speculation, but we will proactively respond to this potential pressure. If there is a net reduction in sleep TAM, we can overcome it by continuing to increase market share, decrease costs through automation and better processes and focus on patient retention. We've improved on each of these measures over the past few years and the GLP-1 conversation will accelerate our efforts in these basic areas.
There is more consensus that GLP-1 usage may accelerate growth -- more GLP usage may accelerate growth in CGM usage. We believe that diabetes patients on GLP-1s are actively engaged in their health and will be inclined to monitor their A1C levels through CGMs. We also believe that increased insurance coverage of CGM, especially in the government sector, is a strong tailwind.
AdaptHealth is at the epicenter of efforts to improve the health of people with chronic conditions like obesity, diabetes, sleep apnea and COPD. We occupy a unique position, connecting providers, patients and payers. We currently have an ongoing relationship with over 1.5 million people with sleep apnea, roughly 170,000 diabetics and 300,000 people with chronic respiratory conditions. We interact with these folks on a regular basis to help them with adherence to their therapies by supplying and resupplying needed equipment and coaching them as to better usage.
Better adherence alone will improve outcomes and reduce downstream costs, where we are just now beginning to understand how we can compliantly use the data we are generating to do even more to improve the health of our patients, especially those with comorbidities.
One early example is that we recently surveyed 10,000 people who set up on PAPs last month. Of these, 7% of those who responded -- and by the way, the response rate was over 40%, so we think this is a reasonably good sample. Of these, 7% are taking GLP-1s, which indicates that GLP-1 usage can coexist and will coexist with CPAP therapy. Further, 20% of this group has diabetes, but only 15% of the diabetics are using CGMs to monitor their results. If we extrapolate these findings to our entire population, we will find many opportunities to identify and better service patients with comorbidities.
Jason A. Clemens
Thank you, Richard, and thanks to all for joining our call today. Let me begin by reviewing our third quarter results. We achieved record revenue of $804.0 million, an increase of 6.3% over the third quarter of 2022. Other than the Humana details that Richard described, this quarter met our expectations for top line growth and adjusted EBITDA, and cash flow exceeded our expectations.
Our total sleep revenue of $315.4 million increased 17% against a year ago, driven by PAP equipment setups and increasing resupply. Our new PAP equipment starts were consistent with our expectations in the third quarter. Our PAP resupply business achieved record order volumes, our resupply census now totals over 1.5 million patients and our electronic ordering utilization broke company records.
Respiratory revenue of $151.1 million increased 8% over the third quarter of 2022.
As we continue to revamp our diabetes product category, CGM census was up 4.3% year-over-year, resulting in flat CGM revenue. As expected, pump and pump supply revenue was down $9 million year-over-year as our tube-based pump volumes remain under pressure from tubeless pumps. We expect this pressure to continue into the fourth quarter. As Richard said, we are bolstering our sales force and focusing on growth in the government sector.
Outsized growth in our sleep product category largely offset a shortfall in diabetes and a modest increase in operating expenses. So overall, except for the unexpected losses on the Humana start-up, our top line and bottom line results were in line with our expectations for the quarter. The primary reason for the shortfall in the Humana contract was a delay in patient transitions and corresponding capitation deductions, resulting in a $10 million top and bottom line miss against our expectations.
It will take longer than originally expected to transition all patients, but we believe that we will indeed get substantially transitioned by early next year. As we continue transitioning patients, we expect sequential improvement in both our top and bottom lines.
Our adjusted EBITDA was $161.2 million in the quarter, resulting in an adjusted EBITDA margin of 20.0%, down from 21.6% in the second quarter, primarily related to the patient transition backlog. Cash flow from operations in the third quarter was $98.8 million. CapEx was $77.1 million or 9.6% of revenue, resulting in free cash flow of $21.7 million. For the first 3 quarters of 2023, we generated $76.6 million of free cash flow, which was more than 2.5x the first 3 quarters of 2022. We reiterate our full year free cash flow goal of between 3% and 4% of revenue.
For the third quarter of 2023, and DSOs of 42.1 days were down over a day against 2022. And for the first 3 quarters of 2023, DSOs were 42.5 days, down from 44.8 days for the first 3 quarters of 2022. We continue to realize the benefits of our refining of revenue cycle process and investments we have made in our technology and workflow.
Our net leverage ratio at the end of the quarter was 3.51x, down slightly from the second quarter. During the third quarter, we made principal payments of $10 million. And after the end of the quarter, we repurchased approximately 2.5 million shares in the open market for a total cost of $19.4 million.
As part of our third quarter results, we recorded a $511 million impairment to goodwill as we discussed in our earnings release this morning. This noncash pretax charge was triggered by our stock price as of September 30.
Turning to guidance. We are revising our prior outlook as follows. We are narrowing our expected revenue range to $3.160 billion to $3.185 billion. We are updating our expected adjusted EBITDA range to $630 million to $650 million. And we are maintaining our expectations for total CapEx representing 10% to 12% of revenue, which should yield free cash flow of 3% to 4% of revenue.
To close our comments today, we believe we're well positioned heading into the final weeks of the year. We are turning around diabetes, we are focused on transitioning patients as part of our new relationship with Humana, and we are optimistic about our business overall.
With that, we will open the call for questions. Operator?
Question and Answer Session
Operator
(Operator Instructions) We have our first question from Brian Tanquilut with Jefferies.
Taji Milan Phillips
You've got Taji for Brian. So going back to the Humana contract, I really appreciate the color on the updated implementation time line. But as we think about the profitability ramp, maybe you could provide some detail around your expectations around that and maybe outline the levers that will drive profitability at an accelerated rate.
Richard Alan Barasch
Thank you for the question. We're delayed, we're talking about that. But we think once the transition occurs, we're going head to a more -- head to a situation where the profitability of the contract is more consistent. We are ramping up our efforts to transition this quarter. It's likely going to take us through the beginning, perhaps next quarter. But we feel very good that once that happens, we will resume the contract as we had originally planned it.
Jason A. Clemens
And Taji, this is Jason. I would say that at a unit economic or a patient level from this stage forward, profitability as a percent will ramp very rapidly. The reason for that is, a cap deduction on, let's say, an oxygen patient, the allowables, the fee schedules for that patient is around $120 a month. So for a full quarter, you got $360. You got thousands and thousands of patients on that oxygen allowable from competitors that still need to be transitioned. So as each and every one is transitioned, that entire amount is -- it comes back as cap revenue for us, and it drops 100% to our bottom line. So we do expect a good ramp from this stage forward as we continue staying focused on transitioning patients.
Taji Milan Phillips
Appreciate the detail there. Just another follow-up. As I think about your guidance, looking at the midpoint, it implies a margin step-up in Q4. Just curious, the different puts and takes that are going to help you get that margin accretion in Q4.
Jason A. Clemens
Yes, sure, Taji. So firstly, we do historically enjoy a step-up in patient demand, particularly in our resupply categories. As insurance plan changeovers that occur in January as well as deductible resets, patients are hoping to get in front of that and stock up the resupply they need to carry them through the end of the year and into the new year. So we are expecting, in our resupply lines, specifically sleep and diabetes, to be up over $20 million sequentially in Q4 from Q3. We expect that to flow at our typical purchase margin, call it about 40% of that, stepping down. So that's the first sequential step-up in profitability in Q4.
The second, Humana, as we said, kind of patient-by-patient. As we are transitioning patients, we do expect a material step-up in cap payments and that bottom line that we spoke about as we've made key investments just over the last several weeks in additional resources and capability to ensure smooth patient transition.
Operator
We have our next question from Mathew Blackman with Stifel.
Mathew Justin Blackman
I've got two 2-parters. And maybe, Jason, if I could just start with you. Just curious to frame the guide down on revenues. How much of it was diabetes versus the Humana contract delay? And then the same impact on EBITDA?
And the second part of the first question is, did the Humana contract disproportionately impact any specific franchise? Does it impact any specific franchises in 4Q as we think ahead? And then I'll wait for the follow-up.
Jason A. Clemens
Yes, sure, Mat. So the first part of that question is the vast majority as we look towards Q4 is Humana-related. Diabetes, we did expect out of CGMs a little bit more in the third quarter, so we fell a bit short of that. So certainly, we're rolling a touch of that into Q4. But again, the vast majority of this was Humana-related, just rolling the timing. And you've got the compounding effect going into the fourth quarter.
And for the second -- can you rephrase the second part of your question?
Mathew Justin Blackman
The Humana -- when we think about the revenue...
Jason A. Clemens
Of the franchise.
Mathew Justin Blackman
Yes. Does it disproportionately impact any specific franchise?
Jason A. Clemens
Well, I don't know that I'd say it impacts any franchise in terms of like earning power and the go-forward. I will say that when you think about the second quarter revenue that we earned from the 33 states and the District of Columbia, where we won the Humana HMO contract, there was substantial revenue earned within the second quarter prior to the contract going into effect.
And so much of that revenue was in the rental lines, specifically respiratory and then a little bit in PAP and -- or sleep and HME. And so starting July 1, 100% of that revenue is eliminated, right? It's no longer a fee-for-service revenue that will go into Humana. And it converts to a patient per month revenue line. Of course, you've got the new patients coming on that also generate PMPM, but it does create a timing disconnect of your dropping out top and bottom line rental revenues. And until you convert the competitor patients to bring that into the census, you're left with this gap that we're focused on today.
Mathew Justin Blackman
Got it. I appreciate that. And then second question, part one. Can we zoom in a little bit more on the diabetes franchise? And I appreciate some of the color you gave us on the pump and CGM franchises. But just what are you seeing in terms of new patient starts and attrition? Is there anything that stands out? I think specifically on the attrition side relative to historical trends, just given all the noise we're hearing with GLPs.
And then the second part to that question is, what does have to happen for you to be able to push more aggressively into the farmer -- pharmacy channel? Are you specifically horsetrading anything with payers? And to the extent that this does ultimately play out, is that patient worth a little bit less from a revenue and profitability standpoint through the pharmacy channel versus the DME? Just help us think through that opportunity and what sort of the moving parts are. Apologies for the long-winded question, but thanks.
Richard Alan Barasch
Okay. This is Richard. First off, we're not seeing any attrition and any effect in diabetes relative to any perception of GLP-1 utilization. The issue that we have been dealing with is the shift in channels more than any attrition.
What our strategy is, is to work in the pharmacy channel with payers. But the key to that will be to add value in the way that we generate data for the utilization of the payers. We believe that both manufacturers and payers will care about this and will help us to improve our margins in the pharmacy channel.
Jason A. Clemens
Yes, Mat, I'd add a little color. Certainly, at the top and bottom line financials on a unit economics of a pharmacy patient is typically less than the traditional medical benefit or DME channel.
But as Richard said, we see tremendous value in aggregating patients and covered lives within diabetes, In Richard's prepared remarks, he spoke about the first steps that we've taken this quarter in actively monitoring CGM data produced from devices of our patients. We have deployed certified diabetes coaches with that data, engaging with patients.
Initially, we really focused on sensor and overall utilization. And so what are the reasons that a patient was set up last month, and you'd expect a new sensor to be applied in the first 10 to 14 days, depending on the manufacturer. But a month later, we're not seeing the data communicated on that CGM. And so we're working hand-in-hand with those patients, and we're learning a lot about patients that are on initial setup that might not be in compliance.
So compare this to the capability we already have with over 350 sleep coaches in our business that all day, every day are monitoring data produced from equipment and these devices to help patients along their journey with resupply. We intend to do more there, additionally monitoring A1c levels, hypoglycemia levels, just the rich level of information that's produced from these CGMs. We don't think that needs to be a medical benefit channel strategy or a pharmacy channel strategy. We think it's an all-encompassing diabetes strategy.
Operator
(Operator Instructions) Our next question comes from Pito Chickering with Deutsche Bank.
Philip Chickering
So I apologize for another question on Humana. Maybe I'm just being dense here. So for that, I do apologize ahead of time. But since it's a capitated arrangement and you have to capture the patients back from the competitors in order to build PMPM, and that's where you sort of mismodeled.
So if I understand it, to get the cap payments, you have to go recap those payments back within Adapt. I'm just saying, like how are you able to shift those patients? Can you be that without patients' consent? Patient perspective, if I have a DME provider for 1 or 2 years, I guess, why would I want to change?
Jason A. Clemens
Sure, Pito. Good question. Well, firstly, if you've been the DME provider for a number of years, you absolutely will not want to change. However, as part of the mechanism of the contract, those competitors in these 33 states and the District of Columbia as we stand here today are not authorized and they're out of network, right? They're not authorized to bill fee-for-service for these patients.
On the rental lines, however, that's really where the nuance is. The lifting and shifting a patient is -- it is more complicated than we anticipated. Now we, in some cases, expected just either better or more thorough documentation maintained by competitors, that just isn't there. And so in that instance, that requires us to work directly with the patient and with the patient's provider to work backwards, if you will. Like an oxygen patient tracking down their saturation testing to support the therapy and the referral.
And so without getting into just layers and layers of detail, that is an example of what needs to happen in order to transition those patients. But we have invested in additional resource and capability just in the last several weeks, and we are already seeing ramp week-over-week in our patient transitions.
Philip Chickering
Okay, fair enough. And then shifting to diabetes, it's going to be sort of multipart, so I apologize again. What percent of revenues in diabetes are CGM versus pumps at this point? What's the breakout between commercial and Medicare sort of within the segments?
And if I look at CGM, what did Medicare CGM grow this quarter? What did commercial, MA CGM grow this quarter? I'm trying to bridge Dexcom's U.S. revenue growth with sort of what you guys saw within the Medicare book of business.
Jason A. Clemens
Sure, Pito. Yes, that's a complicated question. I'd say firstly, the delineation between pump and pump supplies versus our CGM business. We've been on record saying that pump and pump supplies was about $160 million of revenue last year, and that we believe it will be about $120 million of revenue this year. That's the $30 million to $40 million compression we've been talking about, just that headwind created by the med tech and the tubeless based pump on the market.
The rest of the business is CGM business. As Richard said in his prepared remarks, government payers made up now 79% of that census. So that's up another 2 full points sequentially from the second quarter.
I mentioned that CGM census was up 4.3% in the third quarter and resulted in about flat revenue. And so what you're seeing there is continued but less reimbursement pressure created by a movement of traditional government payers and the medical benefit channel versus commercial. So as we're taking care of fewer commercial patients in exchange for taking care of more government patients, we will continue to see a reimbursement headwind. But for this quarter, our volume was enough to offset that pressure.
Philip Chickering
Okay. Just specifically looking at CGM Medicare. I guess, how much did that grow -- that segment grow year-over-year?
Jason A. Clemens
It was up about higher single digits and then offset by lower single-digit commercial. And then you've got the rate equation to get you to about flat revenue.
Philip Chickering
Okay. So from a market share, again, only focusing on Medicare, ignore sort of your commercial and MA for a second. Do you think you're gaining or if you're losing share within the Medicare CGM market?
Jason A. Clemens
Sure. We are gaining patients, certainly. I think it's tough to delineate are we gaining share or not from that. But certainly, we're gaining patients.
We are very aggressively recruiting new sales reps for really selling CGM and other diabetes products. But we're really selling CGM in just key markets, key geographies. We spend a lot of time thinking through the data over the last 2 quarters about where we want to go strong in adding sales reps. So we do expect that government business growth to resume in the fourth quarter.
Operator
We have our next question from Richard Close with Canaccord Genuity.
Richard Collamer Close
Jason, I'm just curious if you've reaped all the benefits from the system upgrades and restructuring from the last couple of years. If you can give us an update there.
Jason A. Clemens
Sure, Richard. I would tell you that from the last year specifically, yes. During the third quarter, we have met the earnings commitment, the cost-out commitment of $25 million in year for 2023 and $40 million annualized. So that program, we put a bow on that. The final reductions were made in early September. And so those dollars will start flowing.
In terms of the overarching ability to get cost out by leveraging technology. We absolutely believe there is more to go. We've made reference in the last 90 days of, when we guide in 2024 -- or for 2024, we will expect to have a commitment on cost management. And as you said, it's a result of these technology investments that we've made as well as the heavy integration work that we've been focused on throughout the year.
Richard Collamer Close
Okay. That's helpful. And then with respect to the strategy on expanding enterprise sales. Can you just go maybe more in detail on that strategy, and potentially sizing the opportunities there?
Richard Alan Barasch
Yes, sure. This is Richard. The traditional Adapt sales model has been an individual sale generated by a referral from a provider, which results in a prescription, which results in a fulfillment of a prescription. So we're dealing with literally millions of individual transactions.
In enterprise sale, like what we are doing with Humana, aggregates patients in one place. And the issues that we've got with Humana aside, which by the way, are going to be great learnings; and just want to reemphasize that our relationship with Humana is in great shape, we're working together on all these issues. So I made that very, very clear.
But by having a large relationship with a payer or a hospital system to aggregate all of the -- in a particular category, like CGMs, like PAPs, like respiratory, that we can achieve savings for the system, the most important -- most importantly, reduce friction by having a set of parameters that are not individual prescriptions being fulfilled by individual providers.
So we think the market is large. We think every payer is a potential customer for this. We think that every health system is a potential customer for this. We're generating a pipeline, even in a very short time, that we're very happy with. And quite frankly, we expect to see a lot of good results in this category in 2024.
Operator
(Operator Instructions) Our next question comes from Joanna Gajuk with Bank of America.
Joanna Sylvia Gajuk
I guess a couple I guess different follow-ups, if I may. I guess kind of back to diabetes. So I guess this quarter sounds like slightly lower than expected, down 8% year-over-year in the quarter. And previously, you talked about kind of flat for the year, do you still expect it? Or is it more kind of down slightly for the year? And I guess for next year, how should we think about diabetes revenue? I guess, previously, you talked about a slight growth. And then I guess as it ties to your previously expressed long-term outlook for that business growth there, any changes there?
Jason A. Clemens
Joanna, thanks for the question. This is Jason. I'd say, firstly, on the pump and pump supply revenue. Again, we expect about a $9 million or $10 million year-over-year headwind in the fourth quarter.
As we think about '24 on pump and pump supplies, and I'll get back to CGM in a moment. I mean, I think we need to look towards the pump manufacturers, Insulet with their OP5 product that is continuing to take share. And we are indeed a distributor of OP5s on our pharmacy channel, so we do intend to continue to grow that. Medtronic and Tandem are continuing to come to market with upgrades to existing products. And all that in the mix, we do think that pump and pump supplies will be another headwind in '24 over '23, but not as much as it was this year, so perhaps half. So that's still our expectation.
In terms of CGMs, year-to-date, we're -- we grew about 3% year-over-year. Again, that's short of our expectation of where we want to be. We were flat in Q3, planning about the same, maybe up 1 point or 2 in Q4. But we do expect the effect of the big investment in sales force to start yielding results as we get into '24.
I think it's a little early for us to comment on specifics of what we think CGM growth will be. But I do think it's safe to say, with the large investment we're making, we do anticipate a return to growth for CGM in 2024. And that's the data that we're able to share today.
Joanna Sylvia Gajuk
Okay. That's helpful. And I guess, sleep, obviously much better, but it creates tough comps for next year. So I guess, how should we think about the sleep business into next year when it comes to growth? Because I guess this year is shaping up to be a mid-teens or maybe even better for the year.
Jason A. Clemens
Yes, absolutely, Joanna. I would say that as you think about the full year, the first half in particular, we'll have a tougher comp particularly on PAP equipment as we had record setup levels in the first quarter as well as the second quarter of 2023. Due to that 13-month reimbursement cycle, those patients will come off of the rental reimbursement. However, they will come into our resupply reimbursement, and we're continuing to grow that double digit year-over-year. So we certainly expect sequential growth in our census as we go from here until through 2024.
Joanna Sylvia Gajuk
And if I may on the sleep business, so I guess you talk about some surveys you've done on the GLP-1 use by CPAP patients. And you did say something to the effect of potentially could at some point, I guess, if the utilization of these drugs increases meaningfully, could impact that business.
But any thoughts in terms of how you think it might change your long-term growth outlook for that business versus how you were thinking about this previously? Does it change at all? Or at this point, you kind of still expect similar growth when we look out. I'm not talking next year, but longer term.
Richard Alan Barasch
I think what I tried to express is that there's a lot of speculation from a lot of people, including something that came out from Bank of America, which was the stat about the 3%, which we thought was incredibly good for thinking about the growth of our business going forward. But we just don't know. We just don't know how fast the adoption, how would the adherence of the adoption of GLP-1s is going to be.
And we do know that, if there are fewer people who are obese, there are likely to be, on the margins, some level of fewer people who are going to use PAP therapy. What we need to do is to -- even if we assume that's the case, what we need to do is take steps internally to make sure that we don't lose from any reduction in TAM that might occur.
And we've got tools. We're the largest provider of sleep equipment. So we start with a great position of great strength. We can afford to keep investing in technology to get our costs down. We've increased share every year over the past several years. The investments that we made in 2022, as painful as they were at the time, are yielding -- have yielded benefits to us.
We also are highly focused on patient adherence and retention, and there's a couple of different flavors to it. One is we want to keep these people as patients that we can keep resupplying to. But we also believe that we can, by increasing adherence, increase downstream results for these patients and reduce downstream cost.
So all of the things we're talking about are geared toward keeping our business intact and growing well, but also using our size and our data capabilities to improve outcomes for our members.
Operator
We have our next question from Eric Coldwell with Baird.
Eric White Coldwell
Okay. Just a technical on diabetes. I think you said pumps were down $9 million and CGM revenue was flat. But I'm seeing a $13.4 million year-over-year revenue decline. So I'm curious where the additional $4.5 million came from.
Jason A. Clemens
Yes, sure. Just a little bit of supply. So these are like traditional, like BGMs, test strips, wipes, things like that. That's continuing as expected to be just a smaller part of the business.
Eric White Coldwell
Okay. And then on PAP, the comments on first half '24 tough comparison on equipment. Are you indicating simply lower growth versus the tough comparison? Or actual revenue decline on the equipment side of PAP as the 13-month rentals start to phase out?
Jason A. Clemens
No, the former. We're just expecting -- the 17% growth that we achieved in this quarter, right? I mean, I don't expect we're putting up 17% growth in Q1 into next year on already very high comps. That's all we're saying, Eric.
Eric White Coldwell
Okay. And then on Humana again. I think it was 1.1 million, 1.2 million lives that you inherited with the 33 states and D.C. You had some of those patients previously, and you're not doing all of the HME-DME for those patients.
But if you'll bear with a difficult-to-ask question, I'm trying to get a sense on how many of those Humana lives that you have access to, how many of those people are actually using DME that you are going to be the exclusive on in those states? How many of those patients were you previously serving? And what is your penetration on the incremental opportunity?
I don't know what the number is. But let's say just for a baseline, if it's 100,000 lives that you picked up incrementally, what percent of that have you actually onboarded at this point, so you're fully operational on?
Jason A. Clemens
Yes. Good question, Eric. A couple of things to offer. Firstly, utilization is in line with expectations so far. So that means think of the 1.2 million patients or more we classified that as. And the number of them utilizing equipment, and then kind of the size and shape of that equipment by category, is largely in line with what we modeled with the data that was shared as part of the award, and within our expectations.
I would tell you that the number of patients is higher than anticipated. I mean, I know Humana reported, I think, last week, they're showing huge growth over 2022. So we've got some of that coming on as well, so just more patients than anticipated overall, which frankly is a very good thing. It didn't help us from a timing perspective as it just creates more and more patients that we need to push through with the capacity we've got on transition. But overall, that's a very good thing as we expect to continue to grow with Humana.
The last thing I'd say is in terms of the pace of that transition, I mean, we did expect to buy out equipment as well as the supporting records that came with that from several competitors. But frankly, some of those deals did not materialize. And so that means we need to work patient-by-patient on transition.
So again, we're very confident that we will get through the transition in the early part of 2024, but that's a little more color on what's created more patients to transition than we expected.
Operator
(Operator Instructions) And at this time, I'm currently showing no questions in the queue. I'll go ahead and turn the call back over to today's presenters for any closing remarks.
Richard Alan Barasch
This is Richard. Thanks. First of all, thanks to everyone for their very good questions that helped us articulate what we think are the very positive things that are going on in AdaptHealth. We look forward to more interaction and thank you for your time this morning.
Operator
This does conclude today's program. Thank you for your participation. You may now disconnect.
