Welcome, ladies and gentlemen to the Fourth Quarter and Fiscal Year 2022 Earnings Conference Call for Tactile Medical. At this time, all participants have been placed in a listen-only mode. At the end of the company's prepared remarks, we will conduct a question-and-answer session.
Please note that this conference call is being recorded and will be available on the company’s website for replay shortly.
Before we begin, I would like to remind everyone that our remarks and responses to your questions today may contain forward-looking statements that are based on the current expectations of management and involve inherent risks and uncertainties which could cause actual results to differ materially from those indicated, including those identified in the Risk Factors section of our Annual Report on Form 10-K to be filed with the Securities and Exchange Commission.
Such factors may be updated from time-to-time in our filings with the SEC, which are available on our website. We undertake no obligation to publicly update or revise our forward-looking statements as a result of new information, future events or otherwise.
This call will also include references to certain financial measures that are not calculated in accordance with Generally Accepted Accounting Principles or GAAP. We generally refer to these as non-GAAP financial measures.
Reconciliations of those non-GAAP financial measures to the most comparable measures calculated and presented in accordance with GAAP are available in the earnings press release on the Investor Relations portion of our website. I would now like to turn the call over to Mr. Dan Reuvers, Tactile Medical’s President and Chief Executive Officer.
Please go ahead sir..
Thank you, operator and welcome everyone to our fourth quarter and full year 2022 earnings call. I'm joined on the line by our Chief Financial Officer Brent Moen. I'll start off today's remarks with a high level of review of our financial performance in the fourth quarter and the factors that drove our better than expected performance.
Then I'll share an update on some of the important operational highlights during the quarter and in recent months. Brent will review our financial results in greater detail along with financial guidance for 2023, which we introduced in our earnings press release today.
And then I'll conclude by sharing some additional thoughts on our strategic priorities for 2023 and our outlook for this year and the years to come before we begin the Q&A session. With that, let's begin with a review of our Q4 financial performance. In the fourth quarter, we grew our total revenue by 20%, year-over-year to $73.9 million.
Our total revenue performance was well above our expectations for the quarter, enabling us to exceed the high end of the updated fiscal year guidance range that we shared in our third quarter earnings press release.
Looking at the composition of our total revenue growth for the quarter, we were especially pleased to see significant contributions from sales of both our lymphedema and airway clearance products.
Revenue from our lymphedema products increased 14% year-over-year to $65.8 million and sales of our airway clearance products increased 90% year-over-year to $8.1 million.
We complimented our revenue performance in the fourth quarter with strong year-over-year improvements in our profitability with several 100 basis points of GAAP and non-GAAP operating margin expansion, generating $5 million and $6 million of net income on a GAAP and non-GAAP basis respectively compared to net losses in their prior year periods and delivering a 100 basis points of adjusted EBITDA expansion year-over-year.
From a cash perspective, we generated $3.8 million of free cash flow, which helped fund our $5 million milestone payment in the period related to the AffloVest acquisition.
In terms of the factors that contributed to our fourth quarter revenue performance, with respect to our lymphedema product line, we ended 2022 with 250 sales representatives consistent with our headcount at the beginning of the fourth quarter, which speaks to the improved level of retention and engagement we've seen in comparison to some of the challenging quarters we experienced in the second half of 2021.
Our fourth quarter lymphedema revenue performance reflects the productivity of our sales team during the quarters, as the bolus of reps that we hired and trained since late 2021 continued to contribute more meaningfully. From a macro level, clinic throughput continued to stabilize and we saw pockets of VA centers resume seeing patients.
At the same time our reps made notable progress during the quarter in engaging with accounts, including those accounts that were previously unrepresented in 2021..
Additionally, we were pleased to see that CMS discontinued their policy that required suppliers to include certificates of medical necessity for all pneumatic compression device claims beginning January 1st, 2023. The upcoming change provided our reps with another reason to engage with and educate prescribers during the fourth quarter.
Turning to our airway clearance product line, our team of respiratory specialists continued to work with our existing base of DME channel partners, helping to educate and support their reps. We continued to experience solid demand for our AffloVest airway clearance therapy from the DME distributors.
The DME distributors continued to expand the availability of AffloVest to additional branches, and their reps have been successful in identifying patients eligible for airway clearance therapy among their existing customers that they serve.
We believe that the demand we're seeing continues to reflect the increasing awareness and adoption by previously underserved patients who would have otherwise been left unidentified and untreated.
For these patients, our AffloVest airway clearance therapy provides them with an at-home solution that's clinically proven to reduce the risk of recurring pulmonary infections and pneumonias.
While we were pleased to see nearly double our airway clearance revenue on a year-over-year basis in the first full quarter following the anniversary of our AffloVest acquisition, our sales performance continued to be paced by the supply constraints that we've discussed on our recent earnings calls.
With that said, our operations team has made notable progress in working to expand AffloVest production capacity by establishing our second supplier and securing our supply chain.
Our sales performance in 2022 has us excited about the future prospects for this product line, and as we enter 2023, we're now squarely focused on developing and supporting demand. Shifting to a review of our operational progress in the fourth quarter.
From a new product standpoint, we continue to be pleased with the response we've seen from prescribers, trainers, and patients following the full market release of our ComfortEase lower extremity garments, and our Kylee Mobile Application.
The feedback we've received on ComfortEase garments from trainers and patients continues to underscore that the product's design features improving ease of use, comfort and fit have substantially enhanced the patient experience, especially for the large portion of our patients with bilateral lymphedema in the lower extremities with limited mobility.
Feedback from our patients highlights an appreciation for the flexible and breathable materials used in the ComfortEase garments, which are designed to make the garment more comfortable to wear and easier to apply while continuing to deliver best-in-class treatment.
These features are indicative of the improving patient experience our product development priorities will continue to focus on.
Our team also made steady progress in expanding the adoption of our first generation Kylee Mobile Application, which is available on both the iOS and Android platforms by educating clinician prescribers and making the app available to patients in their doctor's offices through our in-clinic patient product demos en via social media platforms.
As a reminder, our Kylee Mobile App represents a new resource for patients with tools to engage with them earlier in their disease progression, educate them about lymphedema and their treatment options, and help them assemble the requisite data to obtain a definitive diagnosis and qualify for treatment.
Once a patient qualifies to receive our Flexitouch or Entre systems, they can use the app to track their order and review our training to tutorials, helping to further enhance our industry leading customer support and training effort. During the fourth quarter, our team also worked to expand the app's capabilities beyond these initial features.
Most notably, we began incorporating Bluetooth functionality into our Flexitouch Plus systems shipped late last year. Flexitouch Plus with Bluetooth allows patients with the latest version of Kylee, which we recently rolled out in February to synchronize their flexi touch with the app, enabling them to automatically track and log their treatments.
The latest version of our Kylee app also allows users to easily summarize their recent treatment activity in an auto-generated activity report, which they can share with their doctor.
While we're still in the initial days of this rollout, we believe the addition of Bluetooth connectivity between Flexitouch Plus and Kylee represents a significant milestone in bringing more personalized care to the treatment of lymphedema.
In short, we're pleased with the initial success of both ComfortEase lower extremity garments and Kylee Mobile Application. As I'll discuss later in my remarks, they represent the beginning of a more consistent cadence of product innovation from Tactile Medical in 2023 and the years to come.
Turning our efforts to raise awareness for lymphedema and educate the medical community on its effective treatment. On November 16th, a new clinical publication was featured in the European Journal of Vascular and Endovascular Surgery discussing the role of obesity in lymphedema.
The publication was authored by five researchers, including our Chief Medical Officer, Dr. Tom O’Donnell, and described the results of an observational cohort study that included de-identified patient data from over 60,000 lymphedema patients.
The researchers separated these patients into two groups, depending on whether they were also diagnosed with severe obesity. The researchers then compared the demographics, health related characteristics, treatment plans, and outcomes of the two respective groups.
The study demonstrated that patients with both lymphedema and severe obesity were more than two and a half times as likely to suffer from cellulitis, a deep and painful bacterial infection of the skin with potentially serious consequences. These patients had higher medical costs as a result.
Importantly, the researchers also found that these patients with lymphedema and severe obesity received fewer targeted treatments for their lymphedema, including treatments that are proven to reduce the incidence of cellulitis.
This underscores the importance of recognizing often overlooked lymphedema among those with obesity and the importance of early and accurate diagnosis, as well as effective treatment to reduce both the health and economic burden for these patients.
With this in mind, during the fourth quarter, our clinical services and medical education team continued their efforts to raise awareness of lymphedema and its effective treatment through educational events, including programming that featured the results of this study.
In December, our team launched the first continuing education unit course for obesity related lymphedema, which drew participation from 266 attendees. During the fourth quarter as a whole, we hosted 43 educational programs that were attended by approximately 1300 clinician participants.
Our in-person and virtual programming for the full year trained nearly 6,500 participants, demonstrating the significant role we continue to play in expanding awareness.
Stepping back, we were pleased with our conclusion to 2022 from both a financial and operational standpoint and looking back over the year as a whole, we recovered from the turnover in our sales force that we experienced in late 2021, and our lymphedema product line returned to double digit revenue growth on a year-over-year basis in the fourth quarter.
We achieved exceptionally strong growth throughout 2022 in sales of our airway clearance product line following the acquisition of the AffloVest. On a standalone basis this product line achieved annual growth of 109% in 2022.
As a result of the performance in each of these product lines, we were able to raise our annual total revenue guidance in the second and third quarter earnings press releases, which we ultimately exceeded the fourth quarter.
And lastly, we successfully introduced the first new products Tactile Medical has released for lymphedema patients in over three years, reflecting our renewed multi-year commitment to new product innovation. Now before I turn the call over to Brent, I'd like to discuss an important announcement we made via press release earlier this morning.
Today we announced that Brent has communicated his intention to retire as Chief financial Officer in 2023.
Since joining Tactile Medical in September of 2018, Brent has been an important contributor to our growth as an organization, helping develop a strong financial and accounting team, improve our analytical and reporting processes, and achieve multiple milestones, including our largest acquisition as a public company.
And as we announced in today's press release, we've initiated a process to identify a successor. In the interim, we appreciate Brent's commitment to continued leadership in his role through the end of the first quarter or until such time as his successor is named.
Brent has been a close and trusted colleague over the last three years since I joined tactile. On behalf of the broader team, I'd like to take the opportunity on today's call to thank him for the important contributions he has made while at Tactile, and I look forward to his continued support amid a smooth transition.
Brent will now review our fourth quarter financial results in more detail along with our financial guidance for 2023.
Brent?.
Additionally, we were pleased to see that CMS discontinued their policy that required suppliers to include certificates of medical necessity for all pneumatic compression device claims beginning January 1st, 2023. The upcoming change provided our reps with another reason to engage with and educate prescribers during the fourth quarter.
Turning to our airway clearance product line, our team of respiratory specialists continued to work with our existing base of DME channel partners, helping to educate and support their reps. We continued to experience solid demand for our AffloVest airway clearance therapy from the DME distributors.
The DME distributors continued to expand the availability of AffloVest to additional branches, and their reps have been successful in identifying patients eligible for airway clearance therapy among their existing customers that they serve.
We believe that the demand we're seeing continues to reflect the increasing awareness and adoption by previously underserved patients who would have otherwise been left unidentified and untreated.
For these patients, our AffloVest airway clearance therapy provides them with an at-home solution that's clinically proven to reduce the risk of recurring pulmonary infections and pneumonias.
While we were pleased to see nearly double our airway clearance revenue on a year-over-year basis in the first full quarter following the anniversary of our AffloVest acquisition, our sales performance continued to be paced by the supply constraints that we've discussed on our recent earnings calls.
With that said, our operations team has made notable progress in working to expand AffloVest production capacity by establishing our second supplier and securing our supply chain.
Our sales performance in 2022 has us excited about the future prospects for this product line, and as we enter 2023, we're now squarely focused on developing and supporting demand. Shifting to a review of our operational progress in the fourth quarter.
From a new product standpoint, we continue to be pleased with the response we've seen from prescribers, trainers, and patients following the full market release of our ComfortEase lower extremity garments, and our Kylee Mobile Application.
The feedback we've received on ComfortEase garments from trainers and patients continues to underscore that the product's design features improving ease of use, comfort and fit have substantially enhanced the patient experience, especially for the large portion of our patients with bilateral lymphedema in the lower extremities with limited mobility.
Feedback from our patients highlights an appreciation for the flexible and breathable materials used in the ComfortEase garments, which are designed to make the garment more comfortable to wear and easier to apply while continuing to deliver best-in-class treatment.
These features are indicative of the improving patient experience our product development priorities will continue to focus on.
Our team also made steady progress in expanding the adoption of our first generation Kylee Mobile Application, which is available on both the iOS and Android platforms by educating clinician prescribers and making the app available to patients in their doctor's offices through our in-clinic patient product demos en via social media platforms.
As a reminder, our Kylee Mobile App represents a new resource for patients with tools to engage with them earlier in their disease progression, educate them about lymphedema and their treatment options, and help them assemble the requisite data to obtain a definitive diagnosis and qualify for treatment.
Once a patient qualifies to receive our Flexitouch or Entre systems, they can use the app to track their order and review our training to tutorials, helping to further enhance our industry leading customer support and training effort. During the fourth quarter, our team also worked to expand the app's capabilities beyond these initial features.
Most notably, we began incorporating Bluetooth functionality into our Flexitouch Plus systems shipped late last year. Flexitouch Plus with Bluetooth allows patients with the latest version of Kylee, which we recently rolled out in February to synchronize their flexi touch with the app, enabling them to automatically track and log their treatments.
The latest version of our Kylee app also allows users to easily summarize their recent treatment activity in an auto-generated activity report, which they can share with their doctor.
While we're still in the initial days of this rollout, we believe the addition of Bluetooth connectivity between Flexitouch Plus and Kylee represents a significant milestone in bringing more personalized care to the treatment of lymphedema.
In short, we're pleased with the initial success of both ComfortEase lower extremity garments and Kylee Mobile Application. As I'll discuss later in my remarks, they represent the beginning of a more consistent cadence of product innovation from Tactile Medical in 2023 and the years to come.
Turning our efforts to raise awareness for lymphedema and educate the medical community on its effective treatment. On November 16th, a new clinical publication was featured in the European Journal of Vascular and Endovascular Surgery discussing the role of obesity in lymphedema.
The publication was authored by five researchers, including our Chief Medical Officer, Dr. Tom O’Donnell, and described the results of an observational cohort study that included de-identified patient data from over 60,000 lymphedema patients.
The researchers separated these patients into two groups, depending on whether they were also diagnosed with severe obesity. The researchers then compared the demographics, health related characteristics, treatment plans, and outcomes of the two respective groups.
The study demonstrated that patients with both lymphedema and severe obesity were more than two and a half times as likely to suffer from cellulitis, a deep and painful bacterial infection of the skin with potentially serious consequences. These patients had higher medical costs as a result.
Importantly, the researchers also found that these patients with lymphedema and severe obesity received fewer targeted treatments for their lymphedema, including treatments that are proven to reduce the incidence of cellulitis.
This underscores the importance of recognizing often overlooked lymphedema among those with obesity and the importance of early and accurate diagnosis, as well as effective treatment to reduce both the health and economic burden for these patients.
With this in mind, during the fourth quarter, our clinical services and medical education team continued their efforts to raise awareness of lymphedema and its effective treatment through educational events, including programming that featured the results of this study.
In December, our team launched the first continuing education unit course for obesity related lymphedema, which drew participation from 266 attendees. During the fourth quarter as a whole, we hosted 43 educational programs that were attended by approximately 1300 clinician participants.
Our in-person and virtual programming for the full year trained nearly 6,500 participants, demonstrating the significant role we continue to play in expanding awareness.
Stepping back, we were pleased with our conclusion to 2022 from both a financial and operational standpoint and looking back over the year as a whole, we recovered from the turnover in our sales force that we experienced in late 2021, and our lymphedema product line returned to double digit revenue growth on a year-over-year basis in the fourth quarter.
We achieved exceptionally strong growth throughout 2022 in sales of our airway clearance product line following the acquisition of the AffloVest. On a standalone basis this product line achieved annual growth of 109% in 2022.
As a result of the performance in each of these product lines, we were able to raise our annual total revenue guidance in the second and third quarter earnings press releases, which we ultimately exceeded the fourth quarter.
And lastly, we successfully introduced the first new products Tactile Medical has released for lymphedema patients in over three years, reflecting our renewed multi-year commitment to new product innovation. Now before I turn the call over to Brent, I'd like to discuss an important announcement we made via press release earlier this morning.
Today we announced that Brent has communicated his intention to retire as Chief financial Officer in 2023.
Since joining Tactile Medical in September of 2018, Brent has been an important contributor to our growth as an organization, helping develop a strong financial and accounting team, improve our analytical and reporting processes, and achieve multiple milestones, including our largest acquisition as a public company.
And as we announced in today's press release, we've initiated a process to identify a successor. In the interim, we appreciate Brent's commitment to continued leadership in his role through the end of the first quarter or until such time as his successor is named.
Brent has been a close and trusted colleague over the last three years since I joined tactile. On behalf of the broader team, I'd like to take the opportunity on today's call to thank him for the important contributions he has made while at Tactile, and I look forward to his continued support amid a smooth transition.
Brent will now review our fourth quarter financial results in more detail along with our financial guidance for 2023.
Brent?.
Thanks, Dan. It has been a privilege to serve as a member of Tactile's executive leadership team and work with an excellent group of colleagues to develop and grow the organization as we bring life-changing therapies to patients.
Given the strength and the depth of our team and the financial and operational progress made over the course of the last year, I believe this is the right time for me to begin my transition to retiring from CFO role at Tactile.
I'd like to thank everyone on our team for their support over the last five years, and I look forward to supporting a smooth transition. Turning to review of our financial performance, total revenue in the fourth quarter increased 20% year-over-year to $73.9 million compared to $61.7 million in the fourth quarter of 2021.
Looking at our total revenue by product line, sales and rentals of our lymphedema products, which includes our Flexitouch Plus and Entre systems increased $8.3 million or 14% year-over-year to $65.8 million and sales of our airway clearance products, which includes our AffloVest product line increased $3.9 million or 90% year-over-year to $8.1 million.
Total revenue by channel was comprised of $41.4 million from sales to commercial payers, $18 million from Medicare, $8.1 million from Durable Medical Equipment distributors, and $6.4 million from the VA. As a reminder, Durable Medical Equipment distributors is comprised of revenue from our acquisition of the airway clearance therapy business.
These figures compared to our total revenue by channel in the fourth quarter of 2021, in which Commercial, Medicare, DME distributors and the VA represented approximately $41.7 million, $10 million, $4.3 million and $5.7 million respectively.
Continuing down the P&L, unless noted, all references to fourth quarter results are on a GAAP and year-over-year basis. Gross margin was 70.5% of revenue compared to 72.6%. Non-GAAP gross margin was 71.2% compared to 73.3%.
The decrease in non-GAAP gross margin was attributable to higher direct labor and freight expense, as well as spot buys on select components. Non-GAAP gross margin excludes non-cash intangible amortization in both periods.
Non-GAAP gross margin also excludes inventory write-offs in the fourth quarter of 2022 and non-cash purchase price adjustments related to the acquisition of AffloVest in the fourth quarter of 2021. As a reminder, we have provided reconciliations of certain GAAP to non-GAAP measures in our earnings press release.
Fourth quarter operating expenses were $44.2 million, an increase of $3.2 million or 8%.
The increase in operating expenses year-over-year was primarily driven by a $2.3 million increase in sales and marketing expenses due to new hires added to our lymphedema sales team, along with increased travel related expenses as we returned to normalized business activities.
The year-over-year increase in operating expenses was also driven by a $1.2 million increase in non-cash intangible asset amortization and non-cash earnout expense related to the acquisition of the airway clearance therapy business and a $365,000 increase in research and development expenses offset partially by a $567,000 decrease in reimbursement general and administrative expenses.
Operating income in the fourth quarter was $7.9 million compared to $3.8 million in the prior year. Non-GAAP operating income was $9.5 million or 13% of sales compared to $6.4 million or 10% of sales.
Other expense was $950,000 compared to $377,000 due to a year-over-year increase in interest expense driven by higher interest rates on outstanding borrowings compared to the prior year. Income tax expense was $2.3 million compared to $10.9 million.
Income tax expense in the fourth quarter of 2022 relates to valuation allowance being recorded against our current year deferred tax assets, while income tax expense in the prior year period was a result of establishing a full valuation allowance against our deferred tax assets.
Net income was $4.6 million or $0.23 per diluted share compared to a net loss of $7.5 million or $0.38 per diluted share. Non-GAAP net income was $5.9 million compared to non-GAAP net loss of $5.5 million. Adjusted EBITDA increased 27% year-over-year to $12.1 million or 16% of sales compared to $9.5 million or 15% of sales.
As of December 31, 2022, we had $21.9 million in cash and $49 million of outstanding borrowings. This compares to $28.2 million in cash and $55 million of outstanding borrowings as of December 31, 2021. In addition, during the fourth quarter of 2022, we made the $5 million earnout payment to the former owner of AffloVest.
Turning to review of our 2023 outlook, which we introduced in our earnings press release this morning, we expect full year 2023 total revenue in the range of $269 million to $273 million, representing growth of 9% to 11% year-over-year.
Our 2023 total revenue guidance range assumes sales and rentals of our lymphedema products increased approximately 8% to 9% year-over-year, and sales of our airway clearance products increased approximately 18% to 22% year-over-year.
For modeling purposes, for the full year 2023, we expect our GAAP gross margins to be in the low 70% range, our GAAP operating expenses to increase in the low single digits year-over-year, interest expense of approximately$ 4.2 million, a tax rate of 25%, and a fully diluted weighted average share count of approximately $20 million shares.
We also expect to generate adjusted EBITDA of approximately $23 million to $25 million in 2023.
Our adjusted EBITDA expectation assumes certain non-cash items including stock compensation expense of approximately $12 million, intangible amortization and changes in fair value of contingent consideration of approximately $5.8 million and depreciation expense of approximately $2.5 million.
Lastly, in the first quarter of 2023, we expect our total revenue to increase in the range of 10% to 15% year-over-year. With that, I'll turn the call back to Dan for some closing remarks.
Dan?.
Thanks, Brent. Our 2023 guidance reflects our belief in the ability to return to double digit organic revenue growth on an annual basis while driving year-over-year improvements in our profitability profile. This view is based in part on the financial and operational progress we made in 2022.
With an increasingly established lymphedema field sales team, traction emerging within our DME channel partners and the momentum created by our new product introductions, we believe we're well positioned as we enter 2023 to drive strong, sustainable, profitable growth going forward.
In 2023, we're also focused on pursuing the following strategic priorities for the year to support our continued financial and operational progress, improve the productivity of our lymphedema sales team. Number two, expand and deepen relationships with DME providers and their reps for our airway clearance product line.
Three, develop and introduce new products and innovations focused on addressing the lifestyle needs of our patients in improving digital functionality and therapy optimization, and finally, enhancing our operational efficiency to continue to reduce our overall cost to serve.
We believe that driving execution with respect to each of these four priorities will enable us to achieve our revenue and profitability guidance for 2023 while progressing towards our longer term financial goals as introduced in our investor presentation last December.
Specifically for the full year of 2025, we continue to expect to deliver at least $350 million in total revenue and at least $50 million of adjusted EBITDA. Additionally, we expect to generate at least $75 million in cumulative free cash flow during the three-year period from 2023 to 2025.
As we progress towards these goals, we believe significant runway lies ahead for us in the end markets we serve, and we look forward to extending our leadership position as we continue to reveal and treat patients with underserved chronic conditions.
I'd just like to close by thanking the entire team at Tactile Medical for their efforts this past year and congratulating our team on a job well done in 2022. A special thanks as well to our customers, our supply partners, our shareholders, and everyone on this morning's call. And with that operator, we'll now open the call for questions..
Thank you. [Operator Instructions] Our first question comes from the line of Adam Maeder with Piper Sandler. Please proceed with your question..
Hi, good morning, Dan and Brent. Congrats on the quarter and nice finish to the year, and Brent, congrats on the upcoming retirement. Maybe just to start, I wanted to ask for a little bit more color on the 2023 outlook as it relates to the top line, the 9% to 11%. I think I heard lymphedema growth of 8% to 9%, airway clearance of 18% to 22%.
Maybe just talk a little bit about kind of what's assumed from a procedure environment standpoint, you know, AffloVest, are there supply chain headwinds that are lingering in into 2023? How do we think about those? Any revenue contribution from new product launches? And then, just I guess is there some general conservatism baked into the guide as we look to kind of square your outlook versus where you exited the year? And then I'd had a followup, thanks..
Yes, thanks for the question, Adam. Yes, let me give you a little bit of color on how we arrived at 2023 guidance and then if Brent has anything he wants to add, I'll turn it over to him.
First of all, I think it's worth pointing out that we're really trying to demonstrate balanced growth here, both in revenue and operating margin and getting back to double digits is a step in the direction that we've wanted to make.
The lymphedema growth assumes a growth for the full year doubling what we did in 2022, so we're certainly moving in the direction that we want to go and getting back to double digit roughly overall. It also reflects cautious and I think leverage in the profitability side demonstrating over 30% of adjusted EBITDA growth in in the guidance as well.
I think with the AffloVest question about supply chain, we think that we're beyond most of this as we enter the year now, so I think that we can focus more on continuing to develop that business, but I think at the end of the day, yes, there's a bit of cautiousness in our stance.
I think some of the assumptions that we had on the low end or things that probably created a little bit of caution on our part was a little bit of uncertainty on what a recession could look like in the back half of the year.
If we find that you know, we don't find the soft landing that so many of us, I think hope for, and you see an increase in things like unemployment and more pressure on consumer spending, those things can certainly affect co-pays and they probably could have even a bigger impact on the AffloVest just because the price point is much higher than some of our lymphedema products.
So I think those were some of the cautions that we felt. The other is, we're continuing to put increased energy into making sure that we're trying to grow in both lymphedema categories, and while we expect to serve even more patients, the growth in the E0651 category obviously comes at a slightly lower ASP.
And I think the last one is just thinking about what kind of impact the removal of the public health exemption waiver with CMS has on the AffloVest business, so we're just a little bit cautious there. I think on the flip side we certainly see opportunities from tailwinds that could emerge.
So if we can continue to demonstrate expansion in sales productivity, I think if the reception to some of our new products, not only those that we introduced in 2022, but some of the things we have in mind for 2023 get a bit more traction, and there's always opportunities, I think for some payer policy improvement.
So those are kind of the bookends that framed some of our thinking..
That's really helpful, Dan. I appreciate the color there. And then I guess I'll just ask one kind of housekeeping question and then a followup.
But on housekeeping, AffloVest, did you see any impact to your Q4 result there from supply chain? It was another nice quarter, but revenue did step down sequentially, so just wondering if you can quantify any potential impact from supply chain? And then for the followup, just help us kind of think through the commercial organization on the lymphedema side.
I think you said you exited with 250 heads. Is that the right number for this business going forward? And may be just kind of talk about the levers there to drive increased productivity in 2023? Thanks so much for taking the question..
Sure. So on the AffloVest, yes, we did have a bit of supply chain constraints that's still lingered into Q4. I think Brent even mentioned some of the spot by impact on gross margin. But again, I think that we expect that we've kind of managed our way through those. So I think that we expect less of a headwind related to those in 2023.
It's always going to be a little bit naturally lumpier than our direct lymphedema business but with a 90% growth that we still saw in Q4, I think a solid result overall. I think as it relates to sales head count, Adam, yes we finished up with 250, which is pretty much spot on where we had intended to be.
And I think that we feel like we're in a pretty good spot as far as the staff that we want on the street certainly through the first half and perhaps deeper into the second half.
If we continue to see some expansion in productivity we think that, the growth in headcount certainly is not going to be the ramp that we've seen in historical years, but the 250 we think is a good target for us at least through the first half and potentially a bit deeper into the year..
Thanks again..
Thank you. Our next question comes from line of Margaret Kaczor with William Blair. Please proceed with your question..
Hey, good morning everyone. Thanks for taking the questions. I wanted to maybe go a little further just like Adam did in, in terms of sales guidance for lymphedema. And just to know what we're assuming, what you're assuming basically in retroactivity versus what we saw in the fourth quarter.
And then also touching maybe a little bit on your comments of the VA reopening, being able to see those patients again, can that help drive results in 2023? And then since you mentioned the potential kind of macro impact, are you seeing any of that at this point or that was just what was contemplated in guidance?.
Yes, let me take a shot at those. I think from a Q4 rep productivity we were really pleased with the productivity we saw on a per rep headcount. You know, it's always worth reminding that Q4 is just a different dynamic with co-pays have mostly been addressed earlier in the year on kind of a broad basis, we always see a step up.
So it's always our kind of our best quarter from a productivity standpoint. We're hopeful that we can continue to demonstrate expanded productivity in 2023, but that's one of the reasons that we always see a bit of an expansion there.
From the VA question, we did see some anecdotal return to some of the VA centers, but I think it's a little early to declare victory there. They seem to behave in an inconsistent manner or such that, if the old adage, if you've seen one VA, you've seen one VA.
We haven't heard about a broad return to the VA centers, but certainly on an anecdotal basis it was helpful. So I think we're going to continue to monitor that and see if that becomes a trend as we get a little deeper into 2023.
And I think on the macro question, yes we haven't seen much in the face of headwinds as it relates to some of the things that have created voice of caution, I think, for us in 2023. But we also do know that co-pays do have an impact on patient adoption and their ability to advance with their therapies.
If we see some change in that posture, I think as the year progresses that was probably a bit of a voice of caution in how we established our guidance..
Okay. And then I wanted to walk through the adjusted EBITDA improvement expected this year, impressive in terms of operating expenses only going up. I think I heard those single digits versus kind of the guidance on the top line.
So I guess what would get you to the high and low end of the range? How hard are you kind of pushing the operating levers? And then how should we think about free cash flow exchange for the year as well? Thanks..
Oh, yes. No. Hey, Margaret, it's Brent. Good questions. So as we look at kind of the operating expense profile, certainly and I think Dan has probably mentioned and if not on this call, previous calls, but certainly our focus is on the cost to serve.
So how much, how expensive is it to serve a patient and how do we actually bring that cost down? And so we've got dedicated focus in 2023 to delivering profitable growth.
So, one of the things Dan mentioned in his previous answer to Adam was certainly about headcount and to the extent we can reduce or at least normalize the turnover in our sales force that certainly provides both productivity and upside in terms of leverage there.
So and then on top of that, the reimbursement and G&A category is going to be a bit moderated from a GAAP perspective as we won't have the same legal expense that we had in 2022, recurring in 2023. So, all of those things certainly are positive contributions to overall EBITDA margin improvement in 2023..
And then the free cash flow?.
Oh, free cash flow, yes, right. So we finished the year at $22 million of cash, just short of $22 million. As we look into 2023, we'll generate a pretty significant amount of cash flow, but we've got some commitments in 2023 that we've got to focus on.
They particularly include the remainder of the earnout to AffloVest, so we've got a $15 million commitment provided that AffloVest continues to drive an increase in revenue. We've got some CapEx obligations, albeit minor to the tune of about $2 million. We've got debt service that we've got out there.
All of those things, our commitments that we have, but one thing to keep in mind, Margaret, is that, if we even at the midpoint, if we generate $24 million of adjusted EBITDA, we certainly believe that we've got enough cash to continue to support the growth of this organization and make the necessary investments for the future as well..
Great, thank you, guys..
You bet..
Thank you. Our next question comes from the line of Ryan Zimmerman with BTIG. Please proceed with your question..
Good morning. Thanks for taking the questions. Congrats on a good end of the year and Brent congrats on your retirement. I don't know if this is like a Tom Brady type retirement, you might come back in a year, but we do appreciate working with you over the years through this company and others.
I want to ask about the long-term guidance that you're putting out there Dan, if I do the math, it looks like I've got a 12%, 13% CAGR over the next few years.
Just help us understand kind of the cadence of your expectations, how to think about that CAGR and kind of as we get out to 2025 and so forth?.
Yes, I think first of all, the reason that we put out, let me take a step back, the reason we put out the 2025 numbers was, I think as we've emerged from the post-COVID environment, there's been an interest in what does the future look like.
And while we wanted to clearly give 2023 guidance today, I think the question continues to be kind of what's on the other side of the horizon. That's why we established those 25 numbers. We're -- we'll give, as we did today 2023 guidance. We're not going to break out 2024 and 2025 at this point.
And if we found ourselves there a bit early, we'd be delighted. But I think the point we were trying to make was, from an investor's standpoint we think that there's consistent double-digit growth in front of us. We think the opportunity to establish an expanded adjusted EBITDA profile to the tune of 50 million by 2025.
And then the free cash flow piece, I think is an important one that we tried to establish as well.
To Brent's point, he kind of walked through cash needs and cash generation for 2023, but when we get to 2024 and 2025 beyond the earn out payments we think that we become a really healthy cash flow generator and that's an important part of the profile, that we hope to express is people kind of contemplate us..
Okay. That's very helpful. And then, Dan, you kind of hinted at, the pipeline getting more robust and just a steady stream of updates.
Maybe I don't want to steal the thunder here, but can you expand a little bit on kind of what you're thinking and where you go over the next few years from a new product standpoint?.
Sure. Yes, new product development continues to be an important one for us. We want to make sure that we continue to demonstrate ourselves as a leader and making sure that the patient experience increasingly becomes more consumer-like as part of that journey.
I can certainly add specifically in 2023 in the first half, we're going to introduce just a line extension on AffloVest. We have a size gap on some of the larger patients that we couldn't accommodate, and we'll be introducing that in the first half.
We're also going to refresh our entree device in the first half of the year with some feature enhancements. As I mentioned earlier, competing in the 651 or entry level pump space is going to be important for us, we believe to serve all the patients. So, we're not going to neglect that space.
And then in the second half Ryan, we're going to, we're looking forward to introducing the balance of our ComfortEase portfolio, so in the upper extremity garments.
Those are devices that help patients that are oncology survivors, typically with head and neck cancer survivors or breast cancer survivors that can treat the head and neck, the arm and the chest. That we think is going to invite us into an opportunity to go revisit the oncology space with a really good new solution.
And then there's a series of new Kylee drops that we'll have over the course of the year. Kylee today now enables a patient to track their order. That's something we couldn't have allowed or enabled not very long ago.
It allows them to get some training assistance, which can reduce our cost to serve, when they can self-serve in some of those areas and then sharing stats with their physicians. In the second half, we're looking forward to some additional features on Kylee. Patients will be able to track measurements.
They'll be able to get reminders and encouragement prompts to make sure they have the best kind of outcome as possible. And some order processing engagement, which again comes back to cost to serve. So those are some of the things I think that, you can expect in 2023.
And then we have some longer term things, which I'll just suggest continue to focus on treating the therapy like a daily consumer experience and those will likely demonstrate themselves in the outer windows..
I appreciate all the color and congrats again, solid, great end to the year..
Thanks Ryan..
Thanks Ryan..
Thank you. [Operator Instructions] Our next question comes from line of Suraj Kalia with Oppenheimer and Company. Please proceed with your question..
Good morning, Dan, Brent, can you hear me all right?.
We can. Good morning, Suraj..
First and foremost, let me echo the sentiments. Brent, it's been a pleasure working with you through the years and wish you all the success in your next endeavor. So Dan, a few questions at least from my side, maybe, Brent can also jump in.
Dan, when we look at the number of tenured reps, how many would you say are, “Tenured”, how many would you say currently have, let's say 1 million, 1.5 million annual productivity? You know, which is usually sort of what the target you'll have talked to in the past?.
Yes, Suraj, it's Brent. I'll take a shot and then Dan can chime in. But, I think as we exited 2021 we saw larger than normal turnover in our sales rep category and I think that led to some of the things we communicated back, in the back half of 2021.
Throughout 2022, we've seen good success in being able to get our sales force back to where we believe we can sustain growth in 2023. So in terms of the turnover, our turnover on an average basis, we expected it to be roughly 20% range, and it was outsized in 2021.
So you can imagine that the ability to become productive certainly started to show itself in the latter half of 2022 and will continue to provide benefit into 2023. But we we're going to talk a little -- talk much about the number of reps that are at that point, so but good progress..
Fair enough. And last couple of questions, I'll ask both of them. One for you, Brent, one for Dan, and I'll hop back in the queue.
So Brent, first in terms of the FY 2023 guide, forgive me if I missed it, I know you'll give the overall lymphedema growth, but I'm more interested in the commercial component of it, if you could give some additional color there? Also, what was the impact of ASPs with ComfortEase and others to the guide? And then specifically for you in terms of Kylee, maybe I'm just looking at it from a purely engineering perspective, right? It's a great step up in terms of data gathering and presumably it's passive in nature.
Could it become more assistive in the future, i.e. improving compliance and functionality? Gentlemen, thank you for taking my question and Brent congrats again..
Thanks, Suraj. I appreciate that. So I'll provide a little bit of color on commercial. I think your first question was what we should expect from commercial? And I'll just be honest with you, Suraj, we don't forecast by payer in terms of expectations over the course of the year.
Our focus is identifying patients and making sure that we can provide the therapies necessary to those patients. And whether it's a Commercial patient or a Medicare patient or a VA patient, all of them are, we look at equally. So we don't provide much color relative to where the commercial expectation is relative to that..
Yes, I think just to add to that Suraj, we did have a particularly good quarter as it relates to the, the Medicare mix in Q4, which you, I suspect recognized and I think that it's less about focusing on a payer and more about a prescriber source.
So the vascular call point has continued to be an important one to us, the fact that we have bilateral solutions including trunk, which serves the entire need of those patients..
And I think your question's a good one on Kylee. So Kylee has in my mind two different identities.
One is it can continue to reduce our cost to serve, being able to track their order, schedule a training, manage the order process, all of those things have historically been done in a very manual basis with a lot of people in our office doing personal outreach on the telephone.
And we all know that that's not the most efficient way in 2023 and nor the way most businesses operate. So I think Kylee is a vehicle that will continue to help reduce cost to serve.
On the flip side, I think the other component of its identity is exactly what you described, which is the ability to increase compliance and also to ensure that the patient has the best therapeutic outcome.
So the mention I had about being able to share their progress with their physician doing reminders and encouraging prompts on their handheld as it relates to celebrating when they've been consistent in their therapy or encouraging them when they haven't are both components that I think can help as well..
Thank you. We are currently seeing no remaining questions at this time. That does conclude our conference today. Thank you for your participation. You may now disconnect your lines..