INFU - AMEX

Good day, and welcome to the InfuSystem Holdings Inc. First Quarter 2023 Financial Results Conference Call. [Operator Instructions] Please note that today's event is being recorded. At this time, I would like to turn the conference over to Joe Dorame, Managing Partner. Please go ahead.

Good morning, and thanks for joining us today to review InfuSystem's financial results for the first quarter of 2023 ended March 31, 2023. With us today on the call are Richard DiIorio, Chief Executive Officer; Barry Steele, Chief Financial Officer; and Carrie Lachance, President and Chief Operating Officer. After the conclusion of today's prepared remarks, we will 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 the 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 and documents filed by the company with the Securities and Exchange Commission, including the annual report on Form 10-K for the year ended December 31, 2022. Forward-looking statements speak only as of the date of the statements were made. The company can give no assurance that such forward-looking statements will prove to be correct. InfuSystem does not undertake and specifically disclaims any obligation to update any forward-looking statements, whether as a result of new information, future events or otherwise. Now I'd like to turn the call over to Rich DiIorio, Chief Executive Officer of InfuSystem. Rich?

Thank you, Joe. Good morning, everyone, and welcome to InfuSystem's First Quarter 2023 Earnings Call. Thank you all for joining us today. We issued our first quarter earnings press release earlier this morning, and the message I want to convey today is that we are off to a strong start in 2023. We achieved another milestone with record quarterly revenue surpassing $30 million, a first in the company's history. We see strong demand for our services, led by our core oncology and our biomedical service business with GE Healthcare. As discussed on our last call, we entered the year with a strategic focus to execute against current opportunities, most particularly our business with GE in biomed and Sanara in Wound Care, driving organic growth while seeking continuous improvement in our operational efficiencies. Our focus is paying dividends, and we are executing. The negative pressure pump orders we had expected last December started to ship in the first quarter. We recognized approximately $500,000 in revenue from leases through the end of March and have materially more in the pipeline that we expect to realize over the coming quarters. Pain Management continues to be strong, with the top line of 28% -- up 28% from the prior year quarter. I want to emphasize that our pain business is and will continue to be an important contributor to our business. But today, I want to highlight the strong performance of our biomedical services during the first quarter, particularly the onboarding of new facilities and devices under the master service agreement with GE Healthcare. Our progress with GE has been especially strong, and I am pleased to report that we are running ahead of our plan for the year. In order to do so, and as Barry will further explain, we accelerated our plans to add biomed servicing capacity and the related onetime expenses by hiring, onboarding and training additional technicians. We believe the execution on the GE agreement is important to InfuSystem today and that it will drive long-term value creation. Before handing the call over to Barry for his financial summary of the first quarter, I wanted to touch on a couple more key points. In addition to starting to ship a material number of negative pressure devices manufactured by our partner, Cork, last week, we announced our new distribution agreement with Genadyne to be our second negative pressure equipment supplier. This looks to be another strong partnership with Genadyne making available as an entire portfolio of devices and wound care products. This addresses an important initiative that will help to mitigate supply chain issues and provide our customers with multiple options. As I hope everyone is well aware, negative pressure is now only part of our wound care strategy. And as Carrie will discuss in a few minutes, another positive development is that we recently received the accreditation necessary to sell and bill for advanced wound care products under our SI Wound Care joint venture with Sanara. Finally, Oncology, it is off to a great start in 2023. We are seeing market share gains, higher patient volumes, higher collection rates and improved pricing. And with that, I'd like to have our CFO, Barry Steele, walk us through a more detailed discussion of our first quarter financial results.

Thank you, Rich, and thank you, everyone, on the call for joining us today. I'm going to focus on two topics, the main drivers for the current quarter's results and the status of our financial resource reserves. First, let me touch on our financial results for the period. Net revenues for the first quarter of 2023 totaled $30.4 million, representing a 13.5% increase from the prior year and setting a new all-time revenue record for the fifth straight quarter, also the sixth record in the last 7 quarters. The year-over-year growth came from both of our operating segments with Oncology and biomedical services leading the way in dollars with increases totaling $1.6 million for Oncology and $1.7 million for biomed. On a percentage basis, Wound Care and Pain Management were both very strong with growth of 63% for wound care and 28% for pain management. Although biomed took the percentage improvement crown by achieving a 98% increase in revenue over 2022. The improvement in Oncology resulted from the usual suspects, including improved volumes and collection yield, but also was helped by some incremental improvements in pricing. The biomedical services revenue included revenue from that new master services agreement with a leading global health care technology and diagnostic company, yes GE Healthcare, that was launched in April of last year. As we foreshadowed during our previous call, revenue under that agreement accelerated significantly during the first quarter, even faster than we had previously thought and a greater pace is expected to continue as we proceed through the next few quarters. The increase in Wound Care was driven by negative pressure equipment sales that we had previously hoped to ship in the fourth quarter, we can now safely predict that more will follow. Preparations for this large biomedical services agreement, along with other anticipated biomedical services volume, created additional costs during the quarter in both cost of sales and general and administrative expenses. These diminished the gross profit margin percentage for the DME Services segment and increase our G&A expenses. These higher expenses, which included both an increase in our biomed workforce and other expenses were partially offset by the higher biomed revenue during the quarter and are expected to decrease or get absorbed as we continue to grow these revenues. Much of this cost is attributable to building our capacity that is our workforce in both onboarding devices in the contract as well as manage higher overall service volumes. They largely include employee acquisition and development costs such as recruiting fees and hiring bonuses, training time and lower initial productivity in the field. This also included higher travel expenses for the field team. These upfront expenses were higher than we predicted, because the timing of when we needed to bring in these team members was earlier than previously planned. We anticipate that these elevated amounts will continue at some level during the onboarding phase, but should dissipate over the next several quarters and that our margin in biomed will approach our original estimates. As a result of these impacts, our adjusted EBITDA was $4.2 million or 14% of net revenue during the 2023 first quarter, which represented a slight increase in amount totaling $93,000, but a decrease in margin totaling 1.5% from 15.5% last year. Turning to a few points in our financial position and capital reserves. You may have seen from an 8-K we filed earlier this week that last week, we amended our 2021 credit agreement. The amendment changed our interest rate index to Term SOFR from LIBOR and also renewed the term to 5 years. Because of this, we continue to be well positioned to fund net revenue growth with strong cash flow from operations backed by significant liquidity reserves available from our revolving line of credit and manageable leverage and debt service requirements. Our operating cash flow significantly decreased this quarter, primarily due to the higher launch expenses for the biomed service team previously mentioned and increases in our working capital related to the higher revenue volumes. This metric is expected to recover in the coming quarters. Our net debt increased by $3.1 million to $36.1 million, and our available liquidity totaled $38.2 million at the end of the quarter. The increase in total debt offset partially by the slightly higher adjusted EBITDA, caused our ratio of total debt to adjusted EBITDA for the last 12 months to increase modestly to 1.73x at the end of the quarter as compared to 1.5x at the end of the 2022 fourth quarter. Part of this increase is attributable to the $1.9 million in stock repurchased during the trailing 4-quarter period. Our debt consists of borrowings on our revolving line of credit with no term payment requirements, a fresh 5 years in remaining term and with $20 million of the outstanding balance protected from increasing interest rates through an interest rate swap for the next 2 years. Next up is our President and Chief Operating Officer, Carrie Lachance, who will provide some additional color on development in our Wound Care business.

Thanks, Barry, and good morning, everyone. I would like to provide color on 2 recent developments in our Wound Care business, the receipt of accreditation to sell Sanara's advanced wound care products and our partnership with Genadyne as a distributor for their full line of Negative Pressure Wound Therapy products. First, the accreditation. We are very pleased to announce that we are now authorized from CMS to submit for reimbursement of Sanara's products to our broad network of private payers as well as Medicare. This authorization was a critical step in the success of the business we are pursuing with the Sanara partnership. When we entered wound care with Cardinal, our role was mostly limited to provide last mile clinic-to-home solutions that did not require us to obtain additional accreditation. In fact, we were contractually limited as distribution agreement with Cardinal prevented us from selling into the long-term care and skilled nursing facilities. Under the new joint venture, those facilities are our initial focus. We are going in offering a suite of products and services such as Negative Pressure Wound pumps, but also exclusive distribution in those channels for Sanara's advanced wound care products. InfuSystem is a great partner for Sanara, not only because we pulled together the suite of products, but also because our billing and payer expertise allowed us to acquire chat accreditation and updated CMS status in near record time. With the accreditation now in hand, we have commenced creating the tables, codes and connections necessary for our revenue cycle team to efficiently submit requests for reimbursement to all payers. This is a complex process that we expect to be completed in the second quarter, allowing our Wound Care sales force to begin third-party payer selling of Sanara products in the second half of the year. I've said a couple of times now that we are moving toward a suite of products in Wound Care. This is exemplified by the announcements related to our new relationship with Genadyne. Genadyne is based in New York and specializes in Negative Pressure systems and products. We are moving quickly into the wound care market to remain device-agnostic, offering customers multiple device options similar to our other lines of business. This is part of our concierge level of service approach, but it is also important given how supply chain and other issues can and do impact the ability of any one manufacturer to have devices and supplies available when requested. I am happy to report that we have made significant progress during the first quarter, advancing our agenda to take a retooled and far stronger wound care offering to market. We expect the SI Wound Care partnership with Sanara to commence in the second half of the year and to deliver material results starting in 2024. At this point, I would like to turn the call back over to Rich.

Thanks, Carrie. Before going into Q&A, I'd like to spend some time further developing a few strategic topics. We said that 2023 is going to be a year of focus on execution. This means our focus is driving organic growth with our existing business opportunities and especially the new partnerships with GE Healthcare and Sanara, each of which we think will be a major growth driver for years to come. After the last call, many of you have asked why we spoke of pain management differently than in the past. I want to assure you that pain is still an important part of our future growth, as can be seen from the strong first quarter results, up 28% year-over-year. What we were trying to convey on the prior call is that InfuSystem has multiple growth opportunities and that the 2 strategic opportunities we announced last year, GE and our new wound care offering through our joint venture with Sanara have breakout potential. It is our current expectation that biomedical services this year and Wound Care next year will grow quickly and easily surpass pain's contribution to our top and bottom line. Additionally, we wanted to call that out, because these opportunities are still in the early stages of development, they will be getting the bulk of our growth resources in IT and marketing. We made the appropriate investments to build our pain business, which is now in a good position. This allows us to reallocate our resources to Wound Care and GE. Material developments relating to wound care and biomed are occurring at a steady pace. We are now shipping Cork pumps and have added Genadyne as a second supplier. We also received accreditation and can begin the process of implementing the third-party billing processes that we hope will allow us to launch our Sanara products in the second half of the year. On the biomed side, I'm happy to reiterate and emphasize that the relationship with GE launches InfuSystem into the acute care space. This is a really big thing for us. We spent years focused on home health in various niche markets, all the time knowing there was a large TAM outside our reach in acute care. Each stage of the rollout plan for this year will not only add materially to our top line, but it will also advance our agenda to further build out our national service footprint. Our deployment model for biomedical services under the GE contract has 2 components: a mobile team and a local presence. The mobile team is built to go from site to site anywhere in the country. But in each major city, we are hiring regional technicians, who will be there to provide the year-round service and maintenance. When the rollout is complete, we will have regional techs adjacent to all of the most important health care centers in the country. Creating this regional presence in addition to the mobile strike teams is a potent new asset with potential beyond initial performance under the master service agreement with GE. InfuSystem will be in 1,200 facilities, solving problems on a daily basis. This will lead to additional biomedical service opportunities with GE, with the hospitals and manufacturers and involving a growing variety of devices. And then there is our depot service available at each of our 7 centers of excellence, geographically dispersed and covering the U.S. and Canada. You've heard me say before, I think biomedical services is the most likely business to catch and exceed the revenue we see from our oncology business. When I speak to this opportunity, I'm not just talking about revenue only coming from the current GE contract, I'm talking about the revenue that can result from the infrastructure and reputation that the GE relationship is helping InfuSystem to build. There's three final ideas I want to highlight before moving off the strategic discussion of our biomedical services business. First, the master service agreement with GE has really jump-started our biomedical services business, moving into a level on par with the therapies we had previously focused on in our ITS business unit. Second, this year, we are obsessively focused on the GE rollout. It is allowing us to build the infrastructure we will leverage in the future and nothing, but good can come from GE being a very pleased reference account. And lastly, our business plan is not to become the biggest biomedical services company. But instead, we expect to retain our concierge-like approach where our services are available for those willing to pay for white glove levels of service. We often use the concierge analogy to describe our desired market positions. We believe our role is to deploy our unique assets and talents to solve discrete problems. For example, our Oncology business solves problems for health care providers and facilities, making sure high-quality dependable equipment is always available. We take care of the billing and provide a 24-hour patient hotline to resolve issues that might arise anytime a day. These skills and assets are redeployed in Pain Management where we solve the problem of opioids being prescribed post surgery. The facilitating of continuous peripheral nerve blocks can reduce the need for opioids, solving problems for the patient and society and our service includes patient surveys that help providers and facilities deliver an improved quality of care. In Wound Care, InfuSystem is working with Sanara to provide patients, providers and payers, advanced technologies for healing, improving patients' lives and reducing costs. InfuSystem has a unique and valuable set of assets and skills in high demand by some of the largest health care companies, because they solve problems that regularly plague the delivery of quality health care. What InfuSystem is all about is helping to facilitate quality and efficient health care, providing solutions benefiting the patient, the health provider, payers and device manufacturers. We help with logistics. We provide last mile solutions, perform revenue cycle management, educate and answer patient questions and most especially, maintain and deploy quality dependable and safe, durable medical equipment and supplies. We are extremely pleased with the progress made during the first quarter, and we are off to a strong start in 2023, and I look forward to continuing the momentum for the rest of the year and beyond. As of today, we are reaffirming our annual guidance for the full year 2023, with estimated net revenue growth of 8% to 10% and greater than 19% adjusted EBITDA margin. We need to get further into the year to have more visibility on how events will play out and see if we will make any changes. To conclude my prepared remarks, I would like to thank our shareholders for their continued support and the entire InfuSystem team for their hard work and dedication and helping our patients live healthier and longer lives. And with that, we are happy to answer any questions.

[Operator Instructions] Today's first question comes from Brooks O'Neil with Lake Street Capital Markets.

You covered a lot of territory, but I want to start kind of with the traditional allergy business. I mean the results there this quarter were quite a bit better than we've been seeing. Do you think that kind of performance is sustainable?

I think so. I mean it's not sustainable year after year, but we're definitely going to have some good times like this. We added some -- we added one big customer after our supply chain issues late last spring, early summer. So that's given us a little bit of a lift. Our revenue cycle team is doing a phenomenal job collecting on the bill. So those are the improvements that have been going on for a while, and we're starting to see that impact our numbers. So is it -- it's never going to be a 10% grower year after year, but there'll be some times when it's a little bit higher, but it's still kind of a low mid-single-digit growth business.

Okay. Okay, good. Let me ask this. Maybe Carrie can speak to it since she was talking about the wound care opportunity. My sense is there are some pretty good reimbursement opportunities for wound care in skilled nursing facilities. Are you guys positioned? Do you think to benefit from strong reimbursement in that setting? Or how do you think about reimbursement for what you're going to do in that area?

Brooks, I hope you're well. I do think we have some opportunity. So we have a pretty large billing and collections team. They're very good at what they do, a little bit newer for us in the skilled nursing facility. But much of that is retail base from our sales team selling the products in there. And then from there, those patients to go home very similar to our DME line of business anywhere. So that billing team, we first see no problem, a little bit different, but we have no issues seeing or thinking we're going to be successful there.

Yes. Cool. And then maybe just to ask Rich, I mean, if I was listening correctly this morning, you have your traditional businesses that historically, at least in my brain, seem to focus on health care in the home and bringing your durable medical equipment and services to patients there. You talked this morning, Carrie and I just talked a little bit about the nursing home opportunity with wound care. And then you also mentioned the tremendous growth you see in biomedical services in acute care facility. So a, do you think you're spreading too broadly by focusing on all 3 of these diverse settings of care? Or maybe the flip side is you just have enormous opportunity, because all 3 of these are offer opportunities to deploy certain .

Yes. So I think there are markets we've always wanted to get into. But I think the important part -- it's a good -- it's a fair question, Brooks, just to ask if we're spreading ourselves then. I think the answer is no, because everything we're doing is still in our core competency, right? So it's still the revenue cycle piece. It's still the clinical piece. It's still built around devices. So even on the biomed side, we've been repairing devices for 30 years. So it's doing it on site or at the hospital is no different, right? It's the same skill set. So I think as long as we can stay within our core competencies, the market itself, I wouldn't say it's irrelevant, but it's less important. As long as we have the right sales team in place to go into those markets and they have the contacts and they have the ability to sell to those customers, which that's what we have to do, right? When we build out a pain team, we have to find pain reps that are specific within orthopedic surgeons and anesthesiologists. On the wound care side, we have some great reps that have experience in the LTAC and skilled nursing facilities. So that's really the only difference, but we're bringing our core competencies into those markets. So it's not something I'm worried about.

Great. Congratulations on a strong start to the year.

The next question comes from Alex Nowak with Craig-Hallum Capital.

Okay, great. Don't take this the wrong way, but it seems like in Q1, it seems like the lead weights are removed. So I'm curious, we went through 2022, and it's always been kind of maybe one step forward, 2 steps back. I think this quarter is very much 3 steps forward. What changed since Q4?

So it's a good question. I think that the performance in the first quarter was because of things we've been doing for the last 1.5 years, right? They've finally showed up. It's not one thing, Alex, right? So the leases for Wound Care in example, right? They should have come in, in the fourth quarter. We had a supply chain issue. They're showing up now, right? So nothing really changed other than the supply chain issue freed up there. On the GE side, we knew there was going to be a ramp-up period. It was just a little bit slower, and it showed up in Q1, but that's effort that was put in a year ago by our biomedical and operations team. So I don't know if anything has dramatically shifted other than it's starting to show up, right? Everything we had talked about and hoped for over the last year or so, -- and it's not all here yet either, right? Wound Care is still kind of on its way and it's more of a '24 thing. But certainly on the GE side, I think we had mentioned on the February call, it's here, right? This isn't like hopeful, we hope to get on board some devices. We have visibility into it. We know it's coming. So I think things are just starting to fall into place that we've been working on for quite a while, and we knew it would show up. We just didn't know exactly when on the calendar.

It's great to see. And given the other, call it, mega device reports that we've seen so far, this earnings cycle, it does seem a little bit of a rising tide, it's all where hospitals are back, nurses are back, staffing is back, whatever it might be, health care seems to be just getting back to normal, but also a big help as well. I've got to imagine it is.

Yes. Normal is good, right? Just don't jinx us. But I think in general, yes, I mean, we feel like we did pre-COVID, right? We don't really hear from the field that they're having trouble getting into facilities and there's some more credentialing and those sorts of things. But in general, it feels much more normal as a business, knock on wood, even from a supply chain standpoint or in decent shape. So hopefully, we're kind of through the floors there, and it's a smoother sealing.

Makes sense. When I look at the numbers from Q1 here and as we look at the full year guide, though, based on my model, you're expecting basically no sequential growth. But you talked through a number of dynamics here why we should see sequential growth, whether it be wound, GE and biomed. So maybe expand on that why we shouldn't expect a subsequent to grow at least implied in your guidance?

So there are a lot of growth opportunities, right? So we have more leases coming already in this quarter and in the next quarter. We should see oncology remain strong. We should see a little bit of wound care lift at the end of the year. It's just a little bit early for us to move the guidance, right? There's just -- what if a supply chain issue hits us next month that we don't see or something like that. So I think we're just being conservative, and we're giving ourselves a little more runway behind us before we make any changes.

And then just two final questions. On the DME costs that were higher, you discussed that, I think that all makes sense, but you're keeping the EBITDA guidance the same. So where do you see the cost gains come from? And then just the status of fixing the internal control issue that popped up last quarter.

Yes. And the extra cost for the biomed activity is really things that we can plan for. We have to build a team. We have to build a workforce. There's the step functions as you add on costs. So that will clearly improve as we get through the year and we believe that our original estimate for the margin of that business, which are lower than our other businesses, but still accretive to our EBITDA margin will play out. We won't be completely through that ramp up by the end of the year, but we'll be getting close. So that's a significant improvement. The first quarter margins are usually a little bit low just generally, higher bad debts and things like that typically. So we'll just have some natural lift as we go through the year. And so -- and there'll be other things that just timing of expenses is a little bit tougher in the first quarter, too. So we still have a good view of where our margin will end up for the year, and our guidance is still intact for that. What was your other question, I think, given...

Just the internal controls.

And then we literally finished the audit a month ago. We're obviously working hard to address the different efficiencies the auditors found where we've made some progress there, but we need more time to get through it. We're obviously planning for success to have our 10-K be clean next year, but maybe even before that, we'll be able to eliminate some of the material weaknesses.

[Operator Instructions] The next question comes from Jim Sidoti with Sidoti & Company.

Understandably, the gross margin was impacted by the start-up costs related to GE. But can you give us some sense where you think gross margin will come in for the year?

Yes, we're not giving guidance on gross margin. We do -- obviously, it will improve, because some of these costs will go away. It cost us from an EBITDA perspective of about 4%. So you can probably expect that a similar number, maybe a little bit better in terms of improvement back on the gross margin side.

Okay. And then on sales and marketing, and general and administrative costs. Were there any onetime items in the quarter? Or are those more typically your lend rates going forward?

Yes. We -- some of the expenses we have do come in the first quarter, some marketing things we do and whatnot. We also had on the audit and the internal controls audit we had an extra cost to finish up that audit was a couple of hundred thousand. So that will hopefully be a onetimer. But just generally, there's some just heavier cost typically in the first quarter as you look at the pattern from the prior years.

So is it reasonable to assume that in general, the cash flow should improve throughout the year and you should be close to free cash flow positive for the year?

Yes. The main driver for the cash flow being slightly negative was working capital. We built inventory. Some of that was parts inventories we need for the biomed contract, supplies that we need to support the higher volumes for oncology, et cetera, et cetera. So that will moderate or actually reverse is all we expect as we go through the rest of the year.

Okay. And then the last one, annual revenue from GE, do you still expect it to be in that same level that you had thought before? Maybe not 2023, but '24 and beyond.

Yes. Yes. What we said is that sometime in the first quarter next year of 2024, we'll have onboard all the devices that we expect to get under the contract, and that's maybe a little bit north of $12 million on an annual basis. From what we see in the first quarter, we might be a little bit quicker. But how does third and fourth quarter sort of shake out where it's maybe a little bit not perfectly certain, which facilities will go to, how many devices are there, we could end up a little bit sooner than we think, to get to the total level.

Okay. But you still think that $12 million of annual revenue starting 2024, that's a good number.

Yes. I think that we have a really good opportunity to start at that run rate in 2024, not just a little bit higher.

And are there price escalators built into that agreement?

I couldn't hear the question.

Well, pricing -- are there price escalators as part of that agreement will pricing increase from 2025, 2026?

Yes, pricing is flat throughout the contract.

At this time, we are showing no further questioners in the queue. And this concludes our question-and-answer session. I would now like to turn the conference back over to Rich DiIorio for any closing remarks.

Thank you, Chris. I want to thank everyone for participating on today's call. I hope everyone has a great day, and I look forward to talking with you again when we host our second quarter call. Please stay safe, and thank you.