Q3 2023 Computer Programs and Systems Inc Earnings Call

Participants

Christopher L. Fowler; CEO, President & Director; Computer Programs and Systems, Inc.

Matt J. Chambless; CFO, Secretary & Treasurer; Computer Programs and Systems, Inc.

George Robert Hill; MD & Equity Research Analyst; Deutsche Bank AG, Research Division

Jeffrey Robert Garro; MD & Analyst; Stephens Inc., Research Division

Dru L. Anderson; SVP and Principal; Corporate Communications, Inc.

Presentation

Operator

Greetings, and welcome to the CPSI Third Quarter Earnings Conference Call. (Operator Instructions). As a reminder, this conference is being recorded. It is now my pleasure to introduce your host, Dru Anderson, Investor Relations. Thank you. You may begin.

Dru L. Anderson

Good afternoon, and welcome to the CPSI Third Quarter 2023 Earnings Conference Call. Leading today's call are Chris Fowler, President and Chief Executive Officer; Matt Chambless, Chief Financial Officer.
This call may include statements regarding future operating plans, expectations and performance that constitute forward-looking statements made pursuant to the safe harbor provisions of the Private Securities Litigation Reform Act of 1995. The company cautions you that any such forward-looking statements only reflect management expectations and predictions based upon currently available information and are not guarantees of future results or performance. Actual results may differ materially from those expressed or implied by such forward-looking statements as a result of known and unknown risks, uncertainties and other factors including those described in public releases and reports filed with the Securities and Exchange Commission, including, but not limited to, the most recent annual report on Form 10-K.
The company also cautions investors that the forward-looking information provided on this call represents their outlook only as of this date and they undertake no obligation to update or revise any forward-looking statements to reflect events or developments after the date of this call. At this time, I will turn the call over to Mr. Chris Fowler, President and Chief Executive Officer. Please go ahead, sir.

Christopher L. Fowler

Thanks, Dru, and thank you to everyone for joining us this afternoon. Unfortunately, this was another tough quarter for CPSI with metrics around the top line, bottom line and growth-oriented bookings all underperforming our expectations and surely those of our shareholders. Three months ago, we acknowledged the reality of our historical tendency of allowing optimism to trump realism, and we told you those days were behind us.
While our mindset and outlook have definitely shifted, it's taking time for that to flow through to our operations. Pulling this all down, what it means for the third quarter is that our results came in below our expectations on the top and bottom line as well as soft on bookings. Our revenue of $84.7 million was about $2 million short of our plan. Adjusted EBITDA of $9.7 million was light as a result of revenue mix as well as some unexpected out-of-period vendor expenses of around $0.5 million. And bookings in the third quarter came in at $16.2 million, also well below our target. Finally, the growth of our RCM business continues to be sluggish.
However, our -- however, our EHR business performed slightly better than expected, and we saw continued strength in our existing customer base with retention coming in above our expectations for the quarter. This gives us optimism around our right to win in those cross-sell opportunities for RCM.
Let me start by saying that, over the course of this year, revenue has come in slower than we anticipated. And at the same time, as we discussed last quarter, we did not scale back the additional investments we have been making in our future. With that backdrop, we have increased our vigor in making the operational adjustments in the core business that will serve to increase profitability once sales emerge from what has been a more elongated cycle than originally expected. I'll get into more of the operational initiatives in a moment, but I also want to comment on some external pressures we're facing as an organization as we continue to shepherd our sales opportunities to close.
Externally, hospitals, especially the smaller ones with less than 100 beds where we have identified cross-sell opportunities, are under tremendous cost pressure related to labor and many of them have simply paused making decisions on nonclinical spending like new technology solutions and RCM services. While this is not a new pressure on our end market, we did experience an uptick in prospective deals where no decision was made this quarter.
As we strategically move upstream to large hospitals with 100 to 400 beds, the decision-making process in those institutions just takes longer due to the greater complexity and the involvement of multiple decision makers. We're managing the challenging environment and staying in front of these opportunities. I have spent the last few weeks meeting with existing customers and new targets. These meetings have reinforced our belief that eventually all providers will move to an outsourced model. As I have met with dozens of CEOs, what I have found is that they tend to fall into one of 2 camps: either their hospitals are underperforming and they know they need help now; or they're performing okay, but could be doing a little bit better and they typically have employees, key employees that they just aren't ready to outsource yet.
But the headline here is that they all agree that it's a foregone conclusion, they will ultimately need to outsource and in time will become prospects for us. As all this unfolds, we will be laser-focused internally, improving the efficiency of our operations, which will also ensure that we'll be in a position to take advantage of future opportunities.
Operationally, we're actively working to fine-tune or accelerate the following initiatives that we laid out for ourselves in the beginning of the year. First, availability of domestic and global resources have put pressure on timely deliveries and performance in our RCM business. This isn't really anything new to us as the scarcity of domestic resources was essential motivation behind our global workforce strategy. What's incremental, however, over the last 90 days has been the inconsistent resourcing from our global partners, which has led to some delayed go-lives for RCM services.
Global partners will continue to be an important contributor to our workforce strategy. However, they are now part of a broader solution for us. Our sole reliance on partners put us at a disadvantage as we were working to scale our global workforce. With the acquisition of Viewgol, I am confident that we are on a better path to eliminate this bottleneck.
For context, we expect to have 400 global resources by the end of this year and a total of 800 global resources by the end of 2024. And we anticipate 30% at a minimum of these global resources to be CPSI employees, thanks to this acquisition. This deal also provides some wow factor margin expansion potential by bringing these efforts in-house. Initially, our offshore partners helped us lower our labor expense by 41% for each FTE but the Viewgol transaction will enable us to bring offshore capabilities in-house, bringing the savings opportunity closer to 75% per FTE.
Lastly, beyond the improved access to global resources and the margin expansion that comes with Viewgol, it's also opening up a new market for us in ambulatory RCM services. Second, as noted in our 8-K last week, we made another push towards the ramping of our enterprise-wide offshoring initiatives by shifting 2% of our current domestic workforce to the global or outsourced model. This is an additional $2 million in cost savings to the voluntary retirement program that kickstarted our efforts to streamline our organization, leading to the roughly $3 million in savings this year and $6 million on an annualized basis.
Third, while the quarter's bookings results are disappointing, the visibility we have in the pipeline gives me confidence that this team is curating an impressive set of opportunities. There's good reason to believe that our deal flow will likely pick up and, longer term, we can achieve the consistency in sales performance needed to take advantage of this finite window for RCM market share gains.
Our total 3-month weighted pipeline has increased 20% from the third quarter of 2022, and we have also closed several significant deals in the first month of the fourth quarter, which are both promising indicators. Make no mistake, we are bullish on the RCM opportunity ahead of us. However, there is a real nuance in how we must manage the current fluctuation in market demand.
Our recently reorganized sales team must balance being assertive with a stronger consultative, even educational approach with buyers. Motivating hospitals that are performing okay, but could be doing better, takes time and comes with a variety of complexities, especially when people's jobs are potentially impacted.
We've been aggressively deploying a successful land-and-expand strategy of pursuing short-term contracts and AR work-down opportunities. While we are -- while we continue to see this as an effective foot-in-the-door strategy, these opportunities have greater risk compared to our long-term, full-service model where we manage the hospital's entire net patient revenue. While we're very motivated to perform well against short-term contracts and, in turn, convert them to long-term deals, it is never a guarantee and therefore, creates risk of lumpy revenue recognition due to the potential onetime nature of these project-based arrangements.
Lastly, while overall bookings for our encoder solution came in near expected levels, these wins were heavily weighted toward the last week of the quarter with a high mix of SaaS and roughly half of the win is not expected to go live until 2025, creating real challenges versus historical bookings to revenue conversion time frames.
And finally, as our business has evolved, our pace of acquisition has picked up. Our workforce has become more global, and our financial infrastructure needs to be modernized. We've obviously struggled with our cost structure and budgeting. We've been operating with dated financial software and some mismatch skill sets that haven't served us well during our dynamic transformation over the last 12 months.
To address the former issue, we will be updating our financial operating system to Microsoft Dynamics with a planned go-live of September in 2024. And on the latter point, recognizing that the skill set of our financial team needs to evolve over time, we're pleased to announce that Vinay Bassi will be assuming the role of CFO effective January 1. Vinay brings much-needed maturity to our FP&A function including the experience from his tenure at Nielsen that will benefit our own transformation journey and his deep experience in offshore operations that has become a key need with our acquisition of Viewgol.
We're confident Vinay's background and pedigree will bring our budgeting and financial operations to the next level, holding us accountable, not allowing us to get ahead of ourselves and ensuring that there is a business case to support us and not work against us.
As you'd expect, our third quarter financial results and our booking performance is going to have an impact on our outlook for the year. We're lowering our 2023 guidance to account for these factors and now expect revenue of between $337 million and $342 million and adjusted EBITDA to be between $47 million and $49 million.
Before turning things back over to Matt, I want to reiterate that there's a lot for us to be excited about. But we're also realistic about the frustrations from the shareholder community around the lack of growth and what seems like a terrific RCM opportunity and the need for greater scrutiny on the cost side of the P&L. We believe that patience is a virtue as the RCM opportunity market for community hospitals continues to develop. And we're pursuing cost strategies that are both intentional and surgical, ensuring that we have the organizational health necessary to deliver on the needs of our loyal customer base.
The continued execution of our voluntary early retirement program, the continued transition to a global and outsourced workforce and the recent acquisition of Viewgol have all been with a keen focus on improving profitability in advance of any revenue gains. We're evolving and adapting our leadership team to the changing needs of the organization as we continue down this path of transformation.
We look forward to showing you what this team of now more than 3,000 people across multiple countries can accomplish, and we thank everyone for their willingness to endure this bumpy road to success. We believe in the future of community health care and remain convicted that community hospitals need a robust and healthy CPSI to help them thrive in delivering care to their communities. And we're dedicated to returning to operational excellence and making the tough decisions necessary to ensure that a vibrant, healthy CPSI is here to shepherd community healthcare into a bright future. And with that, I'll turn it over to Matt for a bit more color on the financials.

Matt J. Chambless

Thanks, Chris, and thanks to everyone for joining the call. I'm going to quickly cover the Viewgol transaction and then dive into the third quarter's results. The purchase price for view include upfront cash consideration of $36 million using amounts available under our $160 million revolver. The purchase agreement includes additional earn-out incentives of up to $31.5 million based on a combination of a minimum 2024 EBITDA contribution threshold and Viewgol's ability to provide offshore employees dedicated to our existing RCM services within TruBridge. For the full year 2023, Viewgol should ride a roughly 45% annual revenue increase to generate a top line of about $17 million and roughly $3 million in adjusted EBITDA. With the acquisition taking place in the fourth quarter, we expect our financials to see incremental revenues of around $3.9 million and $1 million of EBITDA for 2023 as a result of the acquisition.
Looking forward to 2024, we believe stand-alone Viewgol should deliver at least $4.5 million of EBITDA, and that's without the synergies of transitioning our offshore workforce to the combined business.
Moving on to the quarter's results. Net patient revenue, which represents our total NPR of just our end-to-end RCM customers was just shy of $3.5 billion, an increase of 17% year-over-year. Total bookings in the quarter were $16.2 million. RCM bookings of $9.1 million comprised 56% of total bookings but underperformed versus internal expectations and year-over-year as the cross-sell decision pace which Chris touched on earlier.
Total revenue of $82.7 million was effectively flat compared to last year. For the quarter, RCM represented 56% of total revenue. EHR was 42% and patient engagement rounded out the remaining 2%. While revenues were flat, our cost of revenues increased by $600,000 as the RCM margin headwinds we discussed on the last call offset most of the cost reductions we've achieved within our EHR business through our scaled agile implementation and the voluntary early retirement program we announced last -- on the last call.
Outside of cost of revenues, we saw operating expenses increased by $9.5 million to 53.3% of total revenues compared to only 41.7% in the third quarter of last year. Roughly 70% of that increase came from EBITDA-neutral nonrecurring acquisition costs and severance costs associated with cost-cutting efforts like the voluntary early retirement program. Other major cost increases were seen in product development as costs associated with our Microsoft Azure cloud migration and other workplace modernization efforts increased $1.4 million while G&A costs on a combined $1.3 million increase in benefits costs and bad debt expense. These all resulted in adjusted EBITDA of $9.7 million compared to $13.3 million a year ago.
Adjusted EBITDA margin of 11.8% was down 440 basis points due to growth in operating costs. Wrapping up the financials. Operating cash flow for the third quarter was $3.1 million.
Turning to guidance. While we certainly didn't want to be in a position to adjust guidance again following the third quarter, the top line challenges that have unfolded in the back half of the year have us adjusting guidance yet again with the details as follows: we're reducing our expected revenue range to a range of $337 million to $342 million from the previous expectation of $340 million to $350 million. Reducing adjusted EBITDA expectations to a range of $47 million to $49 million from the previous expectation of $52.5 million to $54.5 million.
And reducing our non-GAAP net income to a range of $24.5 million to $26.5 million from the previous expectation of $25.6 million to $27.6 million. These new guidance ranges are inclusive of Viewgol's contribution to the fourth quarter. And with that, I'll turn the things back over to the operator for questions.

Question and Answer Session

Operator

(Operator Instructions) Our first question comes from George Hill with Deutsche Bank.

George Robert Hill

I guess Chris, I'll probably start off with the one that's on the top of everybody's mind right now. I know you guys are not in a position to talk about 2024 guidance yet. But I missed -- I guess, maybe can you talk about given how you guys see the market environment right now, what might be the big puts and takes or the big moving pieces as we think about 2024? And I know you talked about some of the new wins not going on until 2025. So there's clearly some push out. But kind of any early color you can give, I think, would be super helpful.

Christopher L. Fowler

And obviously, we want to be really mindful as we continue to sharpen our pencil a little bit here, George, and thinking about 2024. Again, also not falling into some of the tracks that we have up to this point. But with that said, as I said in the prepared remarks, we're thinking about this from a "Let's make sure that we've got the business healthy as we prepare for the revenue to unlock."
We have been very intentional about the moves that we've made to prepare the business to be ready to take on these opportunities and to address the margin compression that we've seen happen over the last 24 to 18 months. And I think that we're going to see those come through nicely in 2024.
On the revenue side, on the bookings opportunity, as I said, I've been on the road the last couple of weeks, I intend to continue to be on the road in front of these opportunities, where I think that I can be helpful from the CEO level, the CEO at the facility to help push them a little bit over the edge of understanding that this is an eventuality.
I had 5 one-on-one meetings over the last week with CEOs where, again, the posture, the position is that this is going to happen. Whether they're operating well today or whether they're not, is really kind of the throttle on how that's going to shake out. Again, we continue to look for opportunities for us to show them ease of the strain of managing this operation by themselves and also areas of opportunity where we can bring along new revenues for them through either better efficiencies, better processes, whether it's through programs that we can bring in.
And so what I continue to hear more and more from these hospitals and the CEOs is that the cash collections, while it's vital to their operation, it's not their mission and it's not their focus. And it is ours. And so where we're going and where they are as well lines up nicely. And so as we continue to work over the last part of this year, as we onboard Vinay in January, we'll look forward to providing what 2024 looks like then.

Matt J. Chambless

Yes. And then George, I'll just hop in -- George, I'll just hop in quickly. Yes, tack on to that just a little bit. We've been decisioning items throughout the year really to make sure the cost structure is in order and the decisions are being made in 2023, so that in 2024, we're not as reliant on growth to drive margin expansion. So trying to do what we can now, make the smart decisions, get lean, get fit, get in shape so we can grow margins next year and not be so dependent on top line trajectory.

George Robert Hill

Okay. That's helpful. I have a couple more, I'll hop in real quick. On the core RCM business, I know that you guys are disappointed by kind of the pace of new business wins. Can you talk about what's going on in that business from a same-store sales basis? And kind of how should we think about what same-store billings volume looks like and kind of your ability to achieve operating leverage there?

Matt J. Chambless

Yes. So we do typically see some changes from time-to-time in what happens in the same-store sales side of things. Sometimes what we see in the same-store sales part of the business is a function of kind of pending attrition which does happen from time-to-time. We do see real actual, like, volume changes from period-to-period that hit us as well. We can also have same-store declines or same-store changes depending on the nature of contracts, so if it's a short-term contract or project related.
Those can obviously have a long tail on them. But as time goes on, the revenue opportunity and revenue profile decreases. It is same-store change. It's one of the dynamics that has impacted us here in the past couple of quarters. And we do think that part of the reason for that and the lack of visibility that we've had in that has been the prevalence of these kind of project-oriented, short-term major contracts that aren't quite CPSI taking over the entire book of business for the hospital. We're focusing on only a small slice, and that certainly increases forecast risk for us.

George Robert Hill

Okay. Two more and then I'll stop being selfish and can get off the line. Any change in the competitive environment in RCM? And I guess, are you seeing any new competitors show up that you guys think could be elongating the sales cycle or impacting your win rate?

Christopher L. Fowler

No. Again, George, the dynamic here is super fascinating from that respect in that the competition still widely remains to be the hospital themselves. And the analogy for good or for bad is we're moving through 2 different phases here of sales cycles.
We're doing the education and selling the benefit of outsourcing in the first place. And then we're selling TruBridge by itself. And the beauty of having this captive audience of customers on the EHR is that we have an open door into them to have these conversations. And so while it may be middle to bottom of their list of priorities, we have the ability through our conversations through our continued education of what we can deliver for them, moving that up the priority list. But from a competitive landscape standpoint, I would say by and large, we're still more fighting against the hospital themselves than we are competition, especially in the 400 beds and under in the space that we play.

George Robert Hill

Helpful. And my last one is on the Viewgol deal. And I'll say I get the outsourcing aspect of the deal, but I was a little confused as to why you guys would target a company with such a strong ambulatory footprint as opposed to your legacy hospital footprint. So I guess, could you kind of talk about the ability to achieve synergies and whether or not there's a cross-sell opportunity as a result of that transaction? And then I'll hop back in the queue.

Christopher L. Fowler

Yes. I don't know if I look at it as so much of a cross-sell opportunity. I think there is that, but it's really opening up a whole new market. I mean we have been very much focused in the acute space for 40-plus years. We've dabbled in ambulatory we made -- through the acquisition of Healthland. We bought our way into post-acute. But the nature of health care seems to be moving in the direction towards outside the four walls of the hospital. So this was an opportunity for us to marry up two things that we were looking to solve for, one, creating our own workforce globally and also how do we break into that ambulatory market, where we see opportunities going forward.
Where we think that there is a cross-sell opportunity is some of the analytics, the analytics platform that Viewgol developed and really started as a tech company, bringing some of those tech services opportunities into either our TruBridge-only business line or even some of our hospitals, where they may have disparate PMs for their providers that are connected to their network. And so that's where those 2 things start to marry up.
But again, really as over the last 18, 24 months, as we've gone down this journey of the expansion of the global workforce, we very quickly realized that we needed to have our own operation, where we could create the opportunity and have the rigor around the delivery of the service for our customers. And that was really at the forefront of this. The ambulatory market was a very nice secondary component to how we thought about the deal.

Operator

Our next question comes from Jeff Garro with Stephens.

Jeffrey Robert Garro

I'll start on the demand side of things. Just want to get any further color from you guys on what might catalyze customer prospect decisions from here. And then the second part of it is while you're trying to create some urgency with these prospects, how do you simultaneously set the appropriate expectations on the cash collection performance as one metric and your ability to deliver the resources necessary to improve their financial outlook? So you just don't want to overpromise while trying to get them over the line, and you've talked about some of the operational hiccups that you've seen over the last 6 to 9 months.

Christopher L. Fowler

Yes. Let's see where to start with that. Let's see, I guess, on the hand, if I look at it from the operational standpoint. Obviously, we've got the Viewgol team in here this week talking through what the integration plan looks like and how we can rapidly onboard staff inside of their operation and start delivering to the TruBridge operations. We've also expanded our partner set from the outsourced model to where we're not reliant on not a single, but not being quite a single-threaded on where that delivery comes from and, again, continuing to push hard on exactly what our expectations there are.
And I think the interest of our own operation is going to create some urgency from those organizations as well to deliver to make sure that they're still partners with us going forward. So that's one part of it. I guess the catalyst -- again, I'll go back to, Jeff, from my perspective. There's a couple of pieces of this. One, you've got the hospitals that probably their house is, I would say, a little bit on fire from the perspective of they're not collecting the cash that's available to go get.
They're in the high 80% of net cash collections, maybe low 90s. And there is plenty of meat on the bone for us to jump in and immediately be able to deliver that return for them. I think the other thing really is just the distraction of things. When I think about specifically at our hospitals, 400 beds and under, if I'm the CEO there and I've got 400 priorities on my desk, very few of those am I able to do outsource or give to somebody else. There are things that have to be dealt with inside the facility, whether it's new providers, new nurses, new facilities, new services, upgrades of facilities, going on and on and on, on negotiation of contracts. A lot of that has to be done internally.
This piece of work, this RCM work on the back end is something that can be given away and can be very metric-driven to make sure that we're delivering on what it is. And now with this component of us being able to -- be able to get the cost structure even better related to our own workforce offshore, where it's not -- maybe it's not quite so cost-prohibitive for them to go forward with it.
So I think those are the catalysts as we think about going forward is driving home for our providers and our facilities, what is your mission, give yourself more bandwidth to be able to focus there, let us focus on the things that we are great at as well, and we continue to expand our partnership.

Jeffrey Robert Garro

Makes sense. I appreciate those comments. One more for me. I want to ask about the revised guidance. And just want to get a sense of your visibility into the rest of the year. Q4, usually a seasonally strong quarter and would expect quarter-over-quarter increases in revenue and profitability. But if you talk about specific drivers that would lead to those typical seasonal trends this year, I think it would be helpful.

Matt J. Chambless

Yes. So the visibility into the next 90 days is generally going to be fairly strong from a bookings to revenue conversion time frame. We don't have a lot of bookings that we expect to convert to revenues in that sort of a period of time. So it's really the expectations with the existing book of business for the top line revenue. So that visibility, we feel like is there.
And the cost side of the P&L where we do see some subjectivity and some seasonality, Jeff, most of that's going to be seen down in the benefits area where the seasonality of people taking vacations can throw some noise into the P&L, but it's usually to the benefit. So I'd say that from a seasonality standpoint, benefits primarily in G&A is where we expect to see the most movement.

Operator

There are no further questions at this time. I would now like to turn the floor back over to Chris Fowler for closing comments.

Christopher L. Fowler

Thank you, Maria, and thank you, everyone, for your time this afternoon. And real quickly in closing, I'd like to acknowledge the hard work and passion that the people of CPSI bring each day to our company, our clients and the communities we serve. Clearly, the way for care is not always a straight line nor an easy path. But we are driven to overcome challenges so that, together, we can make a difference. Thanks again, and I hope everyone has a wonderful weekend.

Operator

This concludes today's teleconference. You may disconnect your lines at this time. Thank you for your participation.