TOI - NASDAQ

Greetings, and welcome to The Oncology Institute Third Quarter 2025 Earnings Call. [Operator Instructions] As a reminder, this conference is being recorded. It is now my pleasure to introduce Mark Hueppelsheuser. Thank you. You may begin.

The press release announcing The Oncology Institute's results for the third quarter of 2025 are available at the Investors section of the company's website, theoncologyinstitute.com. A replay of this call will also be available at the company's website after the conclusion of this call. Before we get started, I would like to remind you of the company's safe harbor language included within the company's press release for the third quarter of 2025. Management may make forward-looking statements, including guidance and underlying assumptions. Forward-looking statements are based on expectations that involve risks and uncertainties that could cause actual results to differ materially. For a further discussion of risks related to our business, see our filings with the SEC. This call will also discuss non-GAAP financial measures, such as adjusted EBITDA and free cash flow. Reconciliation of these non-GAAP measures to the most comparable GAAP measures are included in the earnings release furnished to the SEC and available on our website. Joining me on the call today are our CEO, Dan Virnich; and our CFO, Rob Carter. Following our prepared remarks, we'll open the call for your questions. With that, I'll turn the call over to Dan.

Thank you, Mark. Good afternoon, everyone, and thank you for joining our third quarter 2025 earnings call. During the third quarter, we were able to build on momentum from the first half of this year, delivering strong results across all areas of the business, including proving out MLR performance on our expanding delegated capitation model in Florida in addition to other significant pipeline wins, continuing to set records in our Pharmacy business and hitting a big milestone as we achieved adjusted EBITDA profitability for our first month as a public company in September. The combination of these factors provides us with the confidence required to increase our outlook for 2025. Our third quarter revenue of $137 million increased 23% compared to a year ago and was driven by 42% growth in our Pharmacy business as well as 13% year-over-year growth in our fee-for-service business which outperformed expectations. Adjusted EBITDA loss of $3.5 million in Q3 represents a $4.7 million improvement compared to the same quarter last year. We are reinforcing our expectation to achieve profitability in the fourth quarter and become free cash flow positive in 2026. Turning to our operations. During the quarter, we saw material progress on integration of care and MLR performance in the initial 40,000 delegated capitated lives with our partnership in Florida with Elevance Health. We are expanding this relationship with Elevance in Q4 through additional Medicare Advantage lives in Central Florida, which more than doubles our relationship with this payer in less than a year as measured by MA lives under capitation to TOI. Other key milestones achieved in Q3 were expansion of our MSO network in Florida to over 200 providers and growing as well as the official opening of our TOI Florida pharmacy location, which will serve network providers requiring delivery of Part B drugs as well as a fast and convenient option for Part B specialty medications for patients and providers alike. We view the Florida Pharmacy as incremental growth to our core Part D dispensing strategy as well as meaningful to our capitated MLR where we can provide Part B drugs to practice that deliver at our cost. On a full year basis, the new capitation contracts that we had signed across markets over the course of 2025 will contribute an estimated $19 million of full year revenue, a 29% increase to capitated revenue versus full year 2024. We expect margins on these contracts to continue to mature to target over the next few quarters as we see these new patients transition their care and pharmacy needs to our in-network providers and as we focus on adherence to our care pathways and increased script attachment. Last quarter, I mentioned that we were launching three AI enablement efforts in the coming months to make meaningful changes in performance and costs, specifically in revenue cycle management, prior authorization services, and our patient call center. As an example of how this is now benefiting patients and delivering OpEx efficiencies, we expect our offices and authorizations to be fully transitioned to our agentic AI model in Q4, which will take submission time from 18 minutes to approximately 5 seconds and deliver savings per auth of over 80%. This will expand to other authorization functions in 2026, and our early estimate of savings from authorization efficiencies alone could yield up to $2 million of operating expense efficiencies. This frees up hundreds of hours a week for our staff, which can be directed to patient care and yield a more efficient operating model for our organization. I also want to address an 8-K that we filed last week related to a cybersecurity incident at one of our key vendors that we utilize for billing and practice management. Due to the incident, we experienced a period where we were unable to bill for fee-for-service claims while we transition to a new platform. Thanks to the quick response of our team, we were able to pivot and manage schedules through our EHR and develop an interim billing process, minimizing the impact on our day-to-day operations. Importantly, despite this incident, our patient treatment plans remain intact, and we've seen no significant disruption to volume. From a timing perspective, this event will influence collections in late Q4 and early Q1 as we catch up on submitted claims, but we project ample cash on our balance sheet to manage through this and meet our operating goals for Q4 and 2026. Heading into the last few months of 2025, I'm excited about the momentum we have built over the last year. We continue to prove that our model is profitable across markets and have proven our ability to manage full delegation with health plan partners, which opens a massive new TAM of value-based contract growth in upcoming years. Now I'll turn the call over to Rob to review the financials. Rob?

Thanks, Dan, and good afternoon, everyone. I want to echo Dan's comments on what was another strong quarter for TOI. In the third quarter, we continued to build momentum across our fee-for-service and capitation businesses as well as dispensing while moving toward achieving adjusted EBITDA profitability. On the call today, I'll provide an overview of our different value-based care contract methodologies, review our third quarter results, touch on our balance sheet and liquidity, and conclude by reviewing our increased outlook for 2025. Regarding our primary value-based care contracting methods, I want to take a step back to provide an overview of each and describe some of the nuances to give you a better understanding of how they all flow through our P&L. Let me start with our narrow network capitation contracts, which represent approximately $50 million of revenue for us this year, where we act as the exclusive oncology provider for a risk-bearing organization, typically a risk-bearing primary care group or IPA that takes global risk for health plan partners. This is a product that we have used in California since 2007. In these arrangements, we are required to build clinics to achieve network adequacy but due to their exclusivity, we can optimize utilization, experience very low leakage and drive high Part D script attachments. From a financial standpoint, these narrow network capitation contracts typically produce medical loss ratios in the mid-60%. More recently, we've been focused on growing our delegated model, first in Florida, although we believe this will eventually become our most prominent model across all markets. In these arrangements, our partner is the health plan, and we manage the entire oncology benefit from designing the provider network to managing claims and preauthorizations, allowing real-time views into utilization trends and the ability to include non-employee providers in care. The provider network is a combination of our employed oncologists and clinics and are affiliated with contracted or MSO oncologists and the health plan partners network. Leveraging the health plan partners network allows us to more quickly scale and address the TAM in a more capital-effective manner. We can also steer complex patients to our clinics to more closely monitor their treatment. There are also ancillary opportunities to drive revenue and margin through engagement with our MSO partners in our pharmacy business, decentralized clinical trials and other long-term value creation initiatives. Our mature MLR in the delegated model is typically in the mid-80s, although it yields a higher gross profit dollar compared to our legacy network model because we're addressing a larger TAM and typically driving savings against higher benchmark utilization. Our results highlight the strength of our diversified capitation portfolio. Turning to financial performance. Total revenue for the third quarter was $136.6 million compared to $99.9 million in the prior year period, representing 36.7% year-over-year growth. Patient services revenue, which includes both capitation and fee-for-service arrangements totaled $60.2 million or 44.1% of total revenue and increased 21% year-over-year. Within this segment, fee-for-service contributed roughly 66% of total revenue and capitation accounted for 34%, reflecting our strong mix of recurring revenue and steady patient volumes. Patient service growth was driven by our capitated revenue, which increased 38.9% year-over-year. Pharmacy revenue was $75.9 million, representing 55.6% of total revenue and increased 57.4% year-over-year driven by higher prescription volumes and greater pharmacy attachment within our network, which is a key operational focus for us. Turning to gross profit. We reported $18.9 million for the quarter compared to $14.4 million in the third quarter of 2024. Gross margin was 13.9% versus 14.4% in the prior period. With our fee-for-service revenue exceeding expectations and following the input from our new Chief Administrative Officer, we elected out of an abundance of caution to begin reserving for potential future bad debt as fee-for-service revenue is recognized. As a onetime catch-up adjustment, we recorded a $1.8 million reserve against fee-for-service revenue in the third quarter. Normalized for this reserve, gross profit for the quarter would have been $20.7 million, with a gross margin of 15.2%. Looking ahead, we do not expect any material impact to fee-for-service revenue recognition on a go-forward basis. Patient services gross profit was $5.6 million, up from $4.6 million a year ago, representing a 21% year-over-year increase with a gross margin of 9.3%, consistent with the prior year period. Within patient services, capitation margin declined modestly year-over-year due to the ramp of new delegated contracts with typical MLRs beginning at low margins. In contrast, fee-for-service margin improved driven by higher provider utilization and continued improvement in Part D purchasing as we scale. Pharmacy gross profit totaled $12.8 million compared to $8.1 million in the third quarter of 2024, a 58% year-over-year increase driven by higher dispensing volumes. The gross margin of 16.9% remained essentially flat compared to prior year. Turning to SG&A. Excluding depreciation and amortization, it was $25.3 million or 18.5% of revenue compared to 26.7% of revenue, a reduction of approximately 820 basis points versus a year ago. The decrease reflects continued cost discipline operating leverage inherent in our model and technology efficiencies realized across our administrative and support functions. Adjusted EBITDA was negative $3.5 million, improving from negative $8.2 million in the third quarter of 2024. This is in the range of our prior guidance for Q3, and we remain on track to achieve adjusted EBITDA positivity in the fourth quarter, a key milestone as we exit 2025. As mentioned earlier, we saw our first adjusted EBITDA positive month in September. Turning to the balance sheet and cash flow. We ended the quarter with $27.7 million in cash and cash equivalents and $86 million of convertible debt outstanding maturing in 2027. Cash flow from operations was negative $27.8 million, improving 9.5% from prior year reflecting investments in drug inventory and working capital to support our scaling dispensing activity. I want to remind you that operating cash flow will fluctuate as we scale and become more active in drug buy-ins with our partners at the end of periods. During the quarter and immediately subsequent, we efficiently utilized our aftermarket equity program to generate growth capital consisting of $14.4 million of gross proceeds and $4.1 million of common shares. The transaction provided additional operational flexibility and allowed us to participate in end-of-quarter drug buy-ins, which contributed roughly $3 million to incremental profitability year-to-date. Finally, turning to guidance. We are raising our guidance ranges for the full year of 2025 because of the strength of our year-to-date financials and providing our initial outlook for the fourth quarter. For the full year revenue, we are raising outlook from $460 million to $480 million to a range of $495 million to $505 million. For adjusted EBITDA, we are raising the lower end of our range from our previous guidance of a loss of negative $17 million to negative $8 million to a range of a loss of negative $13 million to negative $11 million. This implies adjusted EBITDA between breakeven and positive $2 million for the fourth quarter. We remain focused on executing against our strategic plan and delivering continued progress towards sustained profitability. The third quarter reflected clear momentum in the business. Notably, September marked the first month of profitability in our business and demonstrated the inherent leverage in our model. With that, I'll turn the call over to Dan for closing remarks.

Thanks, Rob. In closing, in the third quarter, we saw very strong top line growth in all lines of our business and have now shown two full quarters of strong MLR performance on our delegated model which we believe will give confidence to investors in our ability to manage risk and lead the world in oncology value-based care. We also continue to set records in our Pharmacy business, and look forward to the next wave of growth as we expand our use cases over our rapidly growing network of non-employee providers. Finally, we saw some amazing results from integration at agentic AI into our central business office functions and are in a position to fully scale these efforts through the course of 2026 as we grow. I'm excited that we can increase our guidance on 2025 full year revenue and reaffirm Q4 adjusted EBITDA positivity. We look forward to continuing to update you in future earnings calls. Operator, at this point, let's open the call to questions.

[Operator Instructions] First question comes from David Larsen with BTIG.

Congratulations on a very good quarter. Rob, you mentioned an impact to the cost of goods, I think, for a reserve. Can you just describe what that was again, please? What was the amount? And was that unfavorable impact included in your reported adjusted EBITDA for the quarter?

Dave, yes. So it was a $1.8 million reserve to fee-for-service revenue, right? So that flows directly to adjusted EBITDA and was included in the adjusted EBITDA figures that we gave. And so we normalized for that in the script to show what sort of the normalized performance was, which was obviously significantly better than what we reported.

So it would have been obviously not a $3.5 million loss. It would have been close to...

Yes, $1.7 million.

$1.7 million. Okay. Great. And then -- and I think you said that you had your first month of profitability in September. I guess, how sustainable do you think that is? Was there anything unusual in September? And it sounds like you're on track for at least breakeven EBITDA in the fourth quarter?

Yes. No, that's exactly right. So we're fully expecting breakeven for the quarter. Obviously, we haven't put out full year guidance for next year yet. But as we've talked about before, are expecting full year positive adjusted EBITDA in 2026.

And then will you have a positive free cash flow in 4Q of '25 as well?

In 4Q, we will, yes. Yes. In terms of free cash flow, it will be positive in Q4. Not from a run rate basis, we expect free cash flow positivity, mid-2026.

Okay. Great. And then can you talk a little bit about the delegated contract? And I think you mentioned like a very good MLR actually. Just any more color there? What was that MLR? I think I heard mid-60%. Is that correct? Just any more thoughts there would be very helpful.

Yes. So thanks, Dave. So we will be filing an updated investor deck after hours today, which will kind of go into great detail on the MLRs between different contract types. But yes, the rough way to think about it is kind of an overall MLR for TOI across all markets and contract types in the high 60s with the delegated model being slightly higher. So typically, we would be kind of mid-70s and then the narrow network model being slightly better. And again, that's due the differences in engaging with non-employee providers in the delegated model but a much greater TAM in that model. So we expect long term, both the growth rate and total gross profit contribution to that model to be much greater.

Okay. And then there's a lot of, we'll call them, generalist health care investors. Watching the managed care plans just come under enormous pressure because of pressure on their MLRs. Can you maybe just remind us why you're able to manage trends so much better than some of these other like MA plans and the value that you bring to them?

Yes, absolutely. I think really, the core of our value proposition is the fact that we have a very unique care delivery model because we've got a backbone of employee clinics and providers with a wrap network of nonemployee providers in select markets where we work with health plans which just gives us a much greater degree of control over consistency of care and NCCN guideline adherence and prescribing patterns across all encounter types. So that gives us a differential ability to drive better value for patients and payers.

Okay. And then just one more, and I'll hop in the queue. The dispensing revenue was fantastic, up almost 60% year-over-year. Was there anything unusual driving that?

Not unusual. As we've talked about before, we've done quite a bit of work around minimizing leakage in our script attachment. And so I think that we've gotten that to a level that, quite frankly, we weren't expecting to get to. So it's been fantastic to see. I think there's a little bit of juice to be squeezed from here, but I wouldn't expect that level of growth, at least sequentially into Q4.

Next question Yuan

Congratulations on a strong top line. Maybe just a follow-up there on the reserve for the receivables. What was the past performance of that reserve or receivables? Why suddenly we need to change the reserve for this revenue part, our receivable parts?

Yuan, thanks for the question. So this is fairly standard across provider practices. We're at a point now with fee-for-service revenue being as substantial as it is, that we thought was prudent. And so we don't think of this as something that's sort of out of the ordinary. We think of this as something that we should be doing proactively and we're in a position to do so. And so we made that choice to take that reserve in Q3.

Got it. And then what will be the impact for 4Q? And whether if we can recover most of the receivables from this reserve?

Yes. No impact to Q4 specifically. We want to keep it on the books obviously, out of conservatism. So no impact forecasted at this point.

Got it. So the other question I have is on the payer part. So payers are changing their behavior. Cigna is eliminating drug rebates. And then CMS in the process of removing many or most prior authorization, how will that impact your business? Great to see your AI initiative already in the prior authorization? I know this is a big question. So perhaps you can break it down into smaller pieces.

Yes, I would say that at the highest level, I mean, the overall sort of macro landscape when it comes to drugs, which were obviously firmly believers in is to lower the cost of drugs for patients and to simplify the drug reimbursement process. As it relates to specific changes that we see coming through the IRA and some of the other policies are being enacted, those -- as we talked about on prior earnings calls, we believe are still net positive for The Oncology Institute because they're, again, overall lowering the unit cost of drugs for the most part and enhancing accessibility. So the health plan specific changes like the Cigna prior auth change, again, that wouldn't really impact us that much directly. If anything, we think it would help accelerate kind of the care delivery process, but sort of at a very high level, we think the general trend towards lower-cost drugs and then also kind of easing the kind of reimbursement model is net favorable for TOI.

Got it. Now we have a very high medical utilization across the board in the industry, especially in oncology. Can you please comment on the current PMPM trend on your new contracts? And how does that compare to versus, let's say, 1 year ago? And then for your existing contract are you able to get the same level of upward adjustment based on this current utilization trends?

Yes. So as we've talked about before, PMPM is dependent on where the population is located. Ultimately, the benchmark spend of that market. And so if we're doing deals in markets like Florida, the MA PMPM there is going to be significantly higher than it is in California. The majority of our contracts at this point have PMPM escalators in them. And so it's contractual. We'll take an increase every year going forward contract by contract.

And I would just also add to that, as we called out in our earnings call, we've had phenomenal success growing our capitated business. We expect that growth rate to continue, if not accelerate, as you go forward. So the key question on many investors' minds is as you're growing so quickly, how is the MLR trending? And again, we've got a pretty crisp update in our new investor deck, but it's been basically stable despite the rapid growth, which is what we want to see.

Yes. Got it. Maybe my last question, Novartis reported strong adoption of Pluvicto in their community setting. I'm curious about your observation so far in California clinics? And any plans for you to offer that in your Florida clinics?

Yes, absolutely. We achieved certification on Pluvicto a little bit after this time last year. We have seen increased request patients for the therapy. And generally, I would say, strong adoption from a payer and risk-bearing medical group perspective. Given the fact that we can do it in the community as opposed to an acute care setting. At this point, the use cases are still fairly limited. So it's not massive numbers when you look at our overall encounters versus the number of patients that have enrolled in Pluvicto, but we expect as the use cases to expand over time, kind of the community-based ability to provide radiopharmaceuticals will be a distinct advantage for us.

Next question Robert LeBoyer with NOBLE Capital Markets.

Congratulations on a great quarter. You had mentioned that it's probably too early to give guidance for 2026. There were some things that you mentioned in terms of free cash flow. But in terms of what's in the pipeline for new contracts, new covered lives, margin goals or ballpark figures for revenue or anything else. Is there anything that you can tell us along those lines in addition to what's been mentioned already?

Yes. Robert. Yes, we are looking at top line growth that mirrors what we've seen in the last couple of years, so 20% plus, subtle improvement to gross margin and an SG&A percent of revenue that stays relatively flat.

Okay. Great. And anything in terms of pipeline prospects or addition to the covered lives or territories?

Yes. Robert, I would say at a very high level, again, we continue to see ramp and interest in our model. I think we're working with, obviously, very high-quality payers like Elevance, and we think that our relationships are going to continue to grow with plans across markets as we kind of prove our ability to provide great care and high-quality care in the community. So no slowdown at this point in terms of what we're seeing in terms of opportunities to do value-based contracting across markets.

Next question, David Larsen with BTIG.

Just a quick follow-up. In terms of like the new contracts that you won that are being deployed in 2025, just any thoughts on how much of that has been recognized. I think the annualized value was like $50 million. And of that, like how much has been deployed? And just any thoughts on what we could expect for '26?

Yes. So I think Dan mentioned this in the script. So deals that have launched this year have generated about $19 million in revenue. That's got a good $10 million to $15 million left in it. So that's again deals signed within the year not contemplating deals that are in the pipeline that are going to be launching over the course of the next 3 months and into 2026.

Congrats on a good quarter.

Next question, Yuan

Maybe a quick follow-up here. So now we have this ACA debate, as the ACA change debate, we are not sure whether we will get credit for that. How will that impact your patient population or the broad business?

Sorry, Yuan. Can you clarify a bit more like what aspects of the ACA specifically?

So for the ACA, if the patient cannot get their credit or cannot pay the insurance themselves, how will that impact your patient population?

Yes. I don't think there will be much impact in our model broadly speaking. I think most of the patients that would qualify under that new rule are already in capitated arrangements to us. So they would have access regardless. I don't really foresee it as a major shift in volume or sort of patient mix for TOI at this point.