Q4 2023 InfuSystem Holdings Inc Earnings Call

Participants

Joe Dorame; Investor Relations; InfuSystem Holdings Inc

Richard DiIorio; CEO; InfuSystem Holdings Inc

Barry Steele; Chief Financial Officer, Executive Vice President; InfuSystem Holdings Inc

Carrie Lachance; President & COO; InfuSystem Holdings Inc

Alex Nowak; Analyst; Craig-Hallum

Jim Sidoti; Analyst; Sidoti & Co.

Presentation

Operator

Good day, and welcome to the InfuSystem Holdings, Inc, reports fourth-quarter and fiscal year 2023 financial results conference call. (Operator Instructions) Please note this event is being recorded.
I would now like to turn the conference over to Mr. Joe Dorame. Please go ahead, sir.

Joe Dorame

Good morning, and thank you for joining us today to review a InfuSystem's Fourth Quarter and Year End 2023. With us today on the call are Richard DiIorio, Chief Executive Officer; Barry Steele, Chief Financial Officer; and Carrie Lachance, Chairman, President and Chief Operating Officer.
After the conclusion of today's prepared remarks, we'll open the call for questions. Before we begin with prepared remarks, I would like to remind everyone certain statements made by the management team of InfuSystem during this conference call constitute forward-looking statements within the meaning of the Private Securities Litigation Reform Act of 1995. Except for statements of historical fact, this conference call may contain forward looking statements that involve risks and uncertainties, some of which are detailed under risk factors in documents filed by the Company with the Securities and Exchange Commission, including the annual report on Form 10 K for the year ended December 31st, 2022.
Forward-looking statements speak only as of the date. The statements were made made. The company can give no assurance that such forward-looking statements will prove to be correct if you system does not undertake and specifically disclaims any obligation to update any forward-looking statement, except as required by law.
Now I'd like to turn the call over to Rich DiIorio, Chief Executive Officer of InfuSystem. Rich?

Richard DiIorio

Thank you, Joe, and good morning, everyone. Welcome InfuSystem's Fourth Quarter 2023 earnings call. Thank y ou all for joining us today.
I'll get things started this morning with an overview of the past year, 2023 was a great year for InfuSystem. We delivered strong organic growth of more than 14%, finishing the year with revenue of $125.8 million. It was our fifth consecutive year of record revenue and easily beat our guidance. We said at the start of the year that it would be an execution year, and I couldn't be more proud of what the team accomplished in 2023 to sustain momentum reflects our ability to focus and successfully execute on our strategic priorities while providing our patients and partners at the highest levels of service.
With our 2023 results, I believe we validated both the continuing strength of our core businesses and the potential of the two big growth initiatives we announced or launched in 2022. First on our core business, oncology had another record year in 2023, with its success coming from market share gains and continued improvements in our revenue cycle execution. These factors combined to grow the therapy by 8%.
Our core equipment rental business continues to do what it has always been good at doing while beginning to take advantage of new opportunities emerging for us in acute care. The solid strong performance and cash flows from our two core businesses support continued execution against our current two major growth initiatives, which are biomed, and we'll hear.
First, BioMed, specifically around the master services agreement with GE, delivered approximately $10 million of revenue in '23 and ended the year on a run rate of approximately $11.3 million. With the initial rollout narrow we complete, our focus will now turn to driving efficiencies, a topic Carrie will address in a few minutes.
Our second major growth initiative relates to the developing and care opportunities under our joint venture with scenario. Wound care revenue was up materially coming at $3.9 million in 2023, our expectations for the year and providing a nice ramp for the larger contributions we expect to see moving forward.
Most of the revenue and care to date has been related to our negative pressure device leases, but in the second half of the last year, we started distributing, albeit a very small amount scenarios advanced wound care products into the market. We expect a gradual but steady ramp of this in our products is facilities convert to NT system as they wound care DME provider and begin ordering third party payer products and supplies through the JV.
I'll talk to that more later on in the call, and I'd like to turn it over to Barry to discuss our Q4 in 2023 year-end results.

Barry Steele

Thank you, Rich, and thank you, everyone, on the call for joining us today. I'm going to focus on four topics.
First, I'll talk about a change we made in the classification of some expenses on our income statement. Second, I want to share a general observation regarding our financial trends driven by additional biomedical services revenue. Third, I'll review the main drivers for the fourth quarter's results. And finally, I'll update you on our current financial position and how it changed during the quarter.
During fiscal year 2023, we reviewed our cost classifications primarily related to pump service parts, accessories, and outside maintenance costs that were previously classified within general and administrative expenses. I find this review, we concluded that certain of these costs were direct costs that are more appropriately classified as cost of revenues. As a result, we have reclassified these costs within the income statement beginning in fiscal year 2021.
These costs are now presented within cost of revenues as opposed to general and administrative expenses. The reclassification did not impact revenues, operating income, net income, or earnings per share. Additionally, the reclassification to not change any amount in our balance sheet or statement of cash flows.
In conjunction with our annual audit, we are also reviewing our footnote disclosures relating to the application of accounting standards, update No. 2016-2 leases or topic 842, also known as ASC 842. We expect that this review will lead us to changing some of our revenue recognition disclosures for the years 2021 through the current year, but is not expected to result in any changes to our previously released financial results. Due to the review, along with the reclassification of expenses I previously mentioned, we have requested additional time to file our annual report.
Now let me touch on our financial results for the period. Before I get into my normal line-by-line review, I'd like to touch on some general trend related observations. During 2023, our revenue growth consisted largely of new revenue and biomedical services and in particular pain. As we ramped up the volume of devices are covered under our service agreement with GE Healthcare.
This business is different than our other businesses, some important ways, including having a lower gross margin than the average of our other businesses, which is more than mitigated by a much lower amount of SG&A expenses. In other words, the business dilute our gross margin percentage, but as accretive to our operating margin and our operating margin percentage or at least it will be, let's say, fully absorbed before we currently have as costs related to the ramp-up phase.
More other than incremental working capital amount of biomedical services business does not require additional capital investment as it grows. That is we did not have to purchase medical devices and other. Our other long lived asset. Investment we made in this business came when we acquired two small biomedical companies back in 2021. And then we ramped our biomed teams in 2022 and 2023.
Accordingly, as we increased our biomedical revenue, we also increased the overall capital efficiency of our business. Whereas our core business in oncology and pump rental are quite capital intensive, biomed is very capital light. As we look at the current year and quarterly results, we will see these impacts.
Let me go on now to focus on the actual results. We finished the year strong with net revenues for the fourth quarter of 2023 totaling $31 million and representing a $2.9 million or 10% increase from the prior year. There are two primary drivers for this increase, higher revenue from the GE Healthcare contract of $1.9 million and higher revenue in oncology of $1.6 million. On December 31, the annualized revenue run rate for devices onboard into the GE contract stood for approximately $11.3 million.
Lower equipment sales of $800,000, which was mainly due to an especially strong prior year comparison, partially offset the oncology and GE increases. Gross profit for the fourth quarter of 2023 was $16.7 million, which was $1.2 million or 8% higher than the prior year fourth quarter. This was mainly driven by the higher sales, but partially offset by a lower gross margin percentage, which was 52.6% during the fourth quarter of 2023, down from 53.9% from the prior year.
The year-over-year decrease was mainly due to the higher proportion of biomedical services revenue, which has a lower average gross margin and then related additional startup costs for the GE Healthcare biomedical services contract. GE Healthcare start-up costs are estimated to have been about $900,000 for the 2023 fourth quarter. Our startup cost has been higher than we originally planned, we expect these elevated amounts to dissipate over the next several quarters and that our margin will approach our original estimates once we reach full ramp and circle past the first year of coverage but onboarded devices.
Selling, general and administrative expenses for the fourth quarter of 2023 totaled $15.5 million, representing an increase of $1 million or 6.6% as compared to the prior year. Much of the increase represented additional commissions paid in relation to the higher revenue amounts during the quarter and higher short-term management incentive related to improve operating performance in 2023 as compared to 2022.
By the increase in dollar amount, the ratio of selling, general, and administrative expenses to net revenue was 1.6% lower during 2023 as compared to the fourth quarter of 2022. A s a result of these impacts, o ur adjusted EBITDA was $6.2 million for 19.4% of net revenue during the 2023 fourth quarter, which represented a $700,000 increase in amount for the prior year when adjusted EBITDA was $5.5 million or 19%.
Turning to a few points on our financial position and capital reserves. As we indicated during our previous quarterly calls, our operating cash flow for the fourth quarter totaling $4.7 million increased sequentially for the third straight quarter and was slightly better than the prior year fourth quarter. This was due to a slower amount of growth in our working capital levels.
Additionally, our net capital expenditures were a relatively low $1 million during the fourth quarter. This lower amount is partly related to much of our revenue growth coming from the less capital-intensive revenue sources such as biomedical services, as I already mentioned, and also from initiatives that we have been pursuing to increase the pump utilization, including reducing the number of lost pumps.
We expect similar increased capital efficiency going forward, with most of the gains related to diversifying our revenue streams. Because of these factors, we continue to be positioned well to fund continued net revenue growth within the growth -- growing cash flow from operations backed by significant liquidity reserves available from our work from Rwanda environment.
Our net debt decreased by $3.6 million to $28.9 million during the 2023 fourth quarter, marking the third straight quarterly reduction. Our available liquidity totaled $45.4 million at the end of the quarter. The decrease in total debt and higher trailing four quarter adjusted EBITDA caused our ratio of total debt to adjusted EBITDA to decrease to 1.3 times at the end of the quarter as compared to 1.59 times at the end of the 2022 fourth quarter.
Our debt consists of borrowings on our revolving line of credit with no term payment requirements, nearly five years and remaining term, and with $20 million of the outstanding balance protected from increasing interest rates for interest rate swap.
Having some having the same term, I'd like to turn the call over to Carrie to share some color on operations.

Carrie Lachance

Thanks, Barry, and good morning, everyone. I would like to cover two topics today. First, an update on our long running initiatives and revenue cycle management. Second, I'll catch everyone up on the work under GE.
Starting on revenue cycle. I hope there are someone today's call that remember back four or five years ago when revenue cycle was a regular and important part of almost every earnings call. This is because of within our patient services business units, most of the revenue with third-party payer, that is we provide our equipment and services through a hospital or clinic and estimate for payment from the patient's insurance payer.
Third-party payer or TPP billing is not as straightforward as it sounds. First, before you can build a payer, you need a contract. To date, we have more than 800 contracts ranging from national big-name insurers to small regional players, operating in remote parts of the country . Each payer requires compliance not only with the terms of the contract, but also with their unique and particular billing procedures.
Profession is not always possible, particularly since the payers will work to find reasons why they don't have to pay. However, we have been working consistently on that in our years of investing in an effort are really paying off making a material difference during 2023 full to revenue and improved profitability and our oncology business. These improvements will reap benefits for years to come, not just in oncology, but in all areas of third-party billing we dom whether for products the entry use ourselves or for those where we partner with others such as wound care under our JV with Sonora.
Turning to BioMed, we expect to complete the initial onboarding of devices under the GE MSA in the current quarter. The total number of devices covered by the contract is always changing as GE adds or dropped facility and at the inventories within each facility change. But the current number of devices under the contract is approximately 220,000 devices.
The original term of the MSA was three years, but we've already agreed to an extension. That said, both parties have the ability to opt out unreasonable notice at the contract stops working for them as expected or desired. From our perspective, GE seems very satisfied with our work and appears eager to expand the MSA to more devices and service. We are open to that. But our goal has never been to create and especially big biomedical services operation. The third-party BioMed initiative we started after an internal review confirmed it was an area of high return on investment.
This due in part to BioMed requiring very little CapEx as the RA had significant biomedical resources for servicing our own equipment, we decided to leverage that and at a revenue stream that complemented our oncology and rental business that by being less CapEx dependent.
Reviewing the progress of the GE biomed business since 2022 provides a great example of the three-part growth cycle we regularly describe. The nature of our business is such that in most cases, in order to drive material revenue growth, we must first invest. This is true whether the new business in rental where we have to buy a pump before we can rent it; or in biomed, where we have to hire and train technician before they can begin working and generating service revenue.
That three-stage cycle in our business is where we invest first; grow, second; and then harvest the value of the new business, third. In 2022, in Biomed, we began the material investments involved in standing up the network of BioMed technicians that we needed to do the work awarded under the MSA. In 2023, we continued investing and also experienced a surge of revenue growth as our bio teams onboarded facility and pumps.
And in 2024, we expect to be focused on harvesting the value of the new business.
The third stage, that profit optimization stage is the most important part of the cycle. Unlike the initial enabling investment, which generally occurs only one, the harvest stays repeated year after year. Three are incentivized to get it right to focus on process improvements that will maximize the returns and value creation from the business.
When we are satisfied with our BioMed operations, we will look to begin leveraging the national network and any reference account to resume growing the business. Our model was and still is to focus on high value work that justifies concierge level pricing. The GE MSA changed our thinking on this scale about that opportunity, but did not change the basis of our strategy. GE has allowed us to build a national biomedical services network. This, together with a reference accounts, stood elevate the opportunities we see.
In the first half of '24, we will focus on efficiencies and profitability. And in the second half of the year, we will determine what next steps are best for long-term value creation.
Back to you, Rich.

Richard DiIorio

Thanks, Carrie. Before going into the Q&A, I'd like to specifically call out how InfuSystem is leveraging the skills we developed within our core businesses to empower new business opportunities. This evolution, diversification of our business, starting with the Cardona relationship.
What it was Cardinal that approached us decide our help because they do not have the systems enabling the transition of wound care patients from the hospital to home. So they came to InfuSystem with an opportunity to partner and trying to win share and we're very large business opportunity while cargoes blended it achieved a level of success that they needed. It was our work with them that led directly to the current opportunity with scenario.
And again, it was scenario that came to us. I saw that we have the payer contracts, clinical team, national presence, TPP billing capabilities they required to execute on their own care strategies. But even more than with Cardinal, scenario is looking to leverage a whole platform services and fees system can provide.
The JV is a win for both partners. Scenario provides the advanced wound care products and business model in InfuSystem provides its platform of specialty healthcare services that will handle much of the distribution in each of those products.
I've shared before that InfuSystem is regularly approached by other healthcare companies. What opportunities to partner and ways like Cardinal and scenario. They hope to leverage our existing platform services could involve our existing distribution channels into oncology for our expertise in infusion, it could be utilizing our 24/7 patient hotline. Our payer call contracts are highly skilled revenue cycle teams. It can be about leveraging our ISO-certified BioMed services for logistics capabilities.
We continue to see and review and are reviewing in developing some of these opportunities. But as we said last year, there is currently more than enough for us to do focusing on our current two major growth initiatives. Our focus right now is on advancing these existing opportunities by improving the profitability of the work we are doing under the GE MSA and by growing our wound care revenue via the steady expansion of activities under the JV with Celera.
Now I'd like to shift to our guidance portion of the call. In 2024, we expect to see our core businesses, oncology and traditional DME sales and rentals contributing low single digit revenue growth and continued steady earnings and cash flow.
In biomedical services, after a strong year of growth, focus will be on harvesting and preparing the new national network for its next round of growth, which might start in the second half but is more likely to have impact next year. And in wound care, we expect to slow and steady build of products distributed into the third party channel. We are now starting to scale with incremental opportunities under the JV emerging over the course of the year.
As we look to 2024, we have built conservative assumptions into our full-year guidance, with revenue growth estimated to be in the high single digit range, and our adjusted EBITDA margin estimated to be in the high teens, exceeding the full year margin of 17.8% we started 2023.
We will look to update and refine our guidance as we move through the year. We expect such updates will include and integrate some important technology upgrades we're looking to initiate later this year. One of InfuSystem strengths is partnering with companies such as GE and scenario is our technology integrations. These systems improve efficiencies, reduce costs, and increase the stickiness of our services.
These integrations tie back into so much older systems we run internally systems that we are developing plans to upgrade to modern standards, which will, of course, provides significant efficiency benefits to our internal processes. When we commence with the upgrade, it will be a multiyear program will include at converting over to new financial and ERP backbones. When our planning identifies an appropriate start date, we will be able to share what the expected cost will be for this year and next year.
So in summary, the plan is simple. With our unwavering commitment to help people live longer healthier lives, we will successfully enhance our market share within acute care and wound care while remaining focused on operational excellence, which will lead to execution and expanded adjusted EBITDA margins, both leading to solid long-term returns to our shareholders.
Operator, we are now ready to begin the Q&A portion of the call.

Question and Answer Session

Operator

(Operator Instructions) Alex Nowak, Craig-Hallum.

Alex Nowak

Good morning, everyone. A lot of great commentary there in the prepared remarks. But one piece that's been the core franchise for InfuSystem for years of being calls you franchise. And when I look through the numbers, it looks like the core oncology business actually grew the most from a dollar term. Big assumption be too much of a surprise, but it still seems like there there's a fair amount of growth. Still wondering about courage of this year next year. How much further can that go?

Richard DiIorio

Yes, good morning, Alex. Great question. So last year was down. I would almost call it an exceptional year for that business. Right? It was a good perfect storm. As Carrie mentioned, on the revenue cycle side, that team just continues to to kind of overperform every year and especially in 2023 with their efficiencies and how quick they are able to collect the dollars. And in the team went out and added a bunch of new accounts too.
So it was a nice combination that drove that number. But I think it was about 8% for the year, the combination of the twos. So do I expect to see that every year now, do I still kind of expected to be be more like 2% to 5% on an average year? Probably that's more realistic if we open up a few big accounts this year and next year or maybe that pushes back up to that number.
But it's tough to squeeze that kind of efficiency like we saw in '23 kind of every year out of that business. But it's not impossible. I guess I wouldn't expect that every year. But it's obviously nice wanted every percent in that business is a big contributor for the company, obviously.

Alex Nowak

Absolutely. Makes sense. And then it's going back to the guidance candidly, it has been choppy last couple of years and the guided, the variety of factors that led to that, just the confidence in the guide. And maybe the question is really more of what is not included in the guidance. If by the end of the year, if XYZ gets added to it, we're going to reach a different level of growth performance.

Richard DiIorio

Well, we're just not -- we're kind of not being aggressive in any one spot or any spot at all. I think whether it's oncology, our core businesses in oncology or device sales and rentals or even the new businesses, we're not looking down that go into the future and the next few quarters and saying, okay, we think that's going to happen. We're going to stick that in our guidance. We're just not putting that in there.
So it's not any one specific thing, Alex. It's more like, hey, if really takes off and we're going to come from our big customers and it's a couple of million more that will obviously push the guidance up and we'll go on raise at some point. If we continue with the efficiencies in oncology, we could raise.
We didn't really mention on the call, but they're going to add a good amount of growth this year, probably solid double digits. They hit everything in their forecasts that will help us grow the business faster. So all those factors are kind of on the back burner. We just want to -- and we've talked about this a lot over the last couple of years, right? We overextended expectations in '21 and '22. We're not going to make that mistake again.
My hope is you see more of a '23 year from now on, which is where conservative upfront. As the year ago, we get more and more visibility and more runway behind us, we can get more specific and we hit our every year.
So I'd rather be a little more conservative coming out of the gate. It's only the middle of March. We only have January numbers. And so it's not like we have a lot to look at yet. But we're just being kind of conservative across the board. It doesn't mean that we're going to go in -- we don't have to get up and we'll work hard every day to get to the high single digits in revenue numbers.
But there is a there's always going to be upside there. But I'm certainly not going to put it in the guidance anymore because if it doesn't happen, I want to make sure you guys have the right expectations and we can go execute on what we tell you.

Alex Nowak

Makes total sense. A question on PainX. Actually, that's a good segue there, and we didn't talk about it much in the prepared remarks. But the PainX that goes into effect in 2025 expands access the non opioids for pain care. How do you think about that benefiting the business maybe in 2025, certainly. But is there going to be in earlier effect because people need to get new devices essentially and need to be ready for when that bill goes into effect?

Richard DiIorio

Yes, that's a great question. So having been around the reimbursement world collectively for probably 100 years as a leadership team, we're going to see two effects. We will see that we will see some people that are going to get ahead of the reimbursement and want to kind of opened up a new account sooner. That doesn't mean we'll see kind of significant revenue that are going to call us today. They'll call us at the end of the year and say, hey, we want to prepare for the new reimbursement.
The other side of that coin is that when the reimbursement comes, the floodgates don't necessarily open. It takes accounts a while to get you to the billing process to understand what they have to bill, how they have to bill, and what the reimbursement looks like. The actual dollar value of the reimbursement is and how we get faster. That will be a driver too.
So you have some -- it's like any other bulker, right? We're going to have some early adopters at the end of this year. We'll have some late adopters that might wait till mid to end of 2025 or even '26, right? Until they see the reimbursement not just to the number, but actually see the dollars come in.
So obviously, it's great news for the marke. Great news for patients and families, right? The government's finally putting something behind eliminating opioid users upfront. So that's all great news. That will definitely help InfuSystem. It will help all of us in the market from.
Our hope is we see something at the end of the year and people start to get ahead of this because they should not just because of reimbursement. But obviously that will drive behavior. So it's good news. As we get towards the end of the year, if we start to see that come in and we'll obviously give you guys line of sight into that if we see it.

Alex Nowak

Okay. Makes sense. And then just last question is the kind of a clarification around the 10-K delay. So is there going to be -- I got a couple of questions in here, but is there going to be a restatement of prior periods? Is there going to be material weakness? Notice that shows up once the 10-K as filed? And is there any issues with debt covenants with this delay?

Barry Steele

There should not be any issues with the covenants there will be able to go. All of our product requirements are meeting our financial covenants for sure. As far as the other point, until we actually had the audit done, I don't really have the ability to say anything. Obviously the reclassification has that changed we already made and share with, but we still have the best the audit to no clarity on the other issues.

Operator

Jim Sidoti, Sidoti & Co.

Jim Sidoti

Good morning and thanks for taking the questions. With respect to you, ma'am, you have sufficient staff now to implement that the contract full year for you still bringing people on?

Richard DiIorio

I think we're pretty much staffed up from there is always ebbs and flows of the team, but we're in pretty good shape. I mean care, we're probably 90% plus of the way they are?

Carrie Lachance

Yes, that's correct.

Jim Sidoti

Okay. And can you give us a little more color on how you think the revenue build would be with severe? Or do you think this is something that starts in the second third quarter? And how fast do you think that ratio?

Richard DiIorio

So we're going to see -- we're already seeing some revenue come in for their products. I think the challenge will be the comps last year, kind of in wound care specifically had the leases in last year, right, which was almost $4 million -- stock for $4 million or so.
The scenario products are going out the door today, that ramp will happen probably in a very, very steady kind of gradual pace. By the end of this year, we should really be now you should really be kicking in as it starts to build on itself. It will just be-- will give you guys clarity on future calls because it will be hard from a comp standpoint with the leases in there for '23 because those aren't going to repeat to the level that we saw last year.
So the ramp is coming in starting here. It will accelerate as we come out of this year and certainly into 2025.

Jim Sidoti

But if you're forecasting high single digit growth, I assume you knew or should I assume you are thinking that you'll get some leases and full year '24 as well?

Richard DiIorio

Yes. Leases will always be part of that business. We had one really big customer last year that drove the majority of the lease revenue. So we don't expect I expect that to repeat, but they'll always be some growth and some revenue coming in from leases every year. That hopefully is always the case. Replacing that one big customer makes a little bit tough from a comp standpoint. But we do expect the business to grow year over year versus '23. So even with the leases in the comp, we still expect growth in that business.

Jim Sidoti

And that includes beyond June and September quarters, we were particularly strong if you think you are year over year growth in those quarters as well?

Richard DiIorio

I haven't looked at it quarter to quarter. It would be hard to say right now, Jim, if that's the case. And if I go back and look at home and how many. I know the leases were heavy in those two quarters, right, second, third quarter. So I don't off the year over year comparison look great, but there should be sequential growth and kind of that core scenario of business every quarter. It's going to be hard when you look when you lump the leases in '23.

Barry Steele

When you look at our equipment sale and lease, as you've really got to look at our trailing 12 basis because we've always traditionally had large delivery that that made that quarter's lumpy. So that won't change.

Operator

(Operator Instructions) This concludes our question-and-answer session. I would like to turn the conference back over to Mr. Richard DiIorio for any closing remarks. Please go ahead, sir.

Richard DiIorio

Thanks, Chuck. I want to thank everyone for participating on today's call, and we look forward to our first quarter call when we will update on our results and the progress with this year's strategic priorities. Have a great day.

Operator

The conference has now concluded. Thank you for attending today's presentation. You may now disconnect.