InfuSystem Holdings, Inc. (AMEX:INFU) Q4 2022 Earnings Call Transcript

InfuSystem Holdings, Inc. (AMEX:INFU) Q4 2022 Earnings Call Transcript March 17, 2023

Operator: Good day, and welcome to the InfuSystem Holdings, Inc. Reports Fourth Quarter and Full Year 2022 Financial Results Conference Call. Please note this event is being recorded. I would now like to turn the conference over to Mr. Joe Dorame. Please go ahead, sir.

Joe Dorame: Good morning, and thanks for joining us today to review InfuSystem Holdings’ financial results for the fourth quarter and full year 2022 ended December 31, 2022. With us today on the call are Rich 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, 2021.

Forward-looking statements speak only as of the date 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?

Richard DiIorio: Thank you, Joe. Good morning, everyone, and welcome to InfuSystem’s Fourth Quarter and Year-end 2022 Earnings Call. Thank you all for joining us today. Our press release announcing results for the fourth quarter and for our fiscal year 2022 was distributed earlier this morning. As you can see from the summary of financials in the release, we underperformed against our expectations for the end of the year. This was a result of a few material deals that did not develop as expected at year-end. It should be noted, however, that in the fourth quarter, we did deliver 8.7% top line growth versus the prior year. Our core oncology, pump sales and rental businesses remain very sound, and we delivered another year of strong operating cash flows.

Our core business remains strong, but we did struggle in 2022 to advance certain growth initiatives. Case in point is our negative pressure wound therapy business. We expected to close on some material new pump placements during the fourth quarter. In December, we had the orders but found ourselves unable to ship devices and book the revenue when our manufacturer could not get us the devices before the end of the year. This time, the supplier problem was not with Cardinal, but instead the new supplier that we have selected to replace Cardinal. Our new partner identified a circuit board problem related to 1 of its components. The faulty circuit board made the equipment unreliable and unsafe for patients, and this made it impossible for the manufacturer to release the devices.

In response to the supply chain problem, we have expedited our efforts to identify and onboard multiple, reliable negative pressure device suppliers. In the meantime, I can report that the supply chain issue did not hurt us with respect to the affected customer. The circuit board problem is being resolved, and we have begun making the planned deliveries in the first quarter of 2023. At this point, I would like to turn the call over to our CFO, Barry Steele, who will discuss in more detail our fourth quarter and fiscal 2022 financial results.

Barry Steele: Thank you, Rich, and good morning, everyone. Let me start with an explanation of why we are reporting results much later than we have over the past few years. As many of you are aware, InfuSystem reached a key milestone in 2021 by exceeding the $100 million revenue threshold. While exciting for our team and also brought new reporting responsibilities, namely a requirement for an integrated independent audit that included an audit of our internal control environment in accordance with 404B, the Sarbanes-Oxley Act of 2002. Like many companies addressing such a challenge, the amount of effort put forth to complete the controls audit for the first time slowed our reporting process time line. To prepare for this eventuality, we’ve begun putting resources towards making ourselves ready for the controls audit in the summer of 2021.

This readiness project included expanding our internal audit resources, documenting our financial processes and controls, and identifying and enhancing key control activities. These efforts were not completely successful and like many companies experiencing their first integrated audit, we identified several material control deficiencies that we were unable to crack prior to the end of the year. These will be outlined in detail, along with our plans to correct them, when we file our 2022 annual report. In summary, the deficiencies fall into 3 categories that first include control surrounding information and reports that we create and use to support our control activities or so-called IPE. Second, controls over access rights of our team members within certain software applications used in financial reporting to establish adequate segregation of duties over certain financial reporting processes.

And third, management review controls covering both customer prices and contract terms in certain of our revenue cycles. While these deficiencies are important and correcting them will be a high priority for 2023, it is an important fact that the deficiencies were not identified in conjunction with any specific error in or restatement of our financial statements for any period. In fact, our audit firm has not identified any necessary adjustments to our financial statements in conjunction with our sustained audit process procedures. This has been the case for 2022 and for several prior years. Furthermore, as the audit has proceeded, we have already begun to plan and implement improvements to our control activities and add additional controls that we believe will mediate each of these control deficiency areas without significant additional administrative process.

Turning to the actual results themselves. I want to share with you some insights into the financial performance of the fourth quarter. For 2022, fourth quarter revenue was $28.8 million, which topped the prior year fourth quarter by 8.7% and represented a 5.7% improvement sequentially from the third quarter. This amount establishes a new quarterly revenue record, our fifth in a row. The year-over-year quarterly revenue growth of $2.3 million included improvements in oncology, pain management, biomedical services, equipment sales and equipment rentals. Three of these categories, Oncology, Biomedical Services and Equipment Sales, all grew by just over $700,000 each. The increases for Biomedical Services and Pain Management represented a growth rate of 50% and 45%, respectively.

Negative Pressure Wound Therapy revenue partially offset these increases with a decrease of $302,000, mainly due to a difficult comparison to 2021, which included equipment sales that were not repeated in 2022 due to the supply chain issue previously mentioned by Rich. The Biomedical Services revenue included over $600,000 in revenue from the GE Master Services agreement, which was launched in April 2022. During the fourth quarter, we continued to process — continued the process of onboarding covered devices as part of a ramp-up period originally expected to span the first 15 months of the contract and achieve a run rate totaling $10 million to $12 million annually. The actual onboarding pace realized during 2022 was slower than originally expected.

However, during 2023, the monthly onboarding rate is expected to accelerate. We now anticipate reaching an annualized run rate of $10 million by September 2023, 18 months after the initial launch and $12 million by December 2023. Onboarding activities are expected to level off during the first quarter of 2024 to bring total annualized revenue under the contract to an amount slightly above the original expected range. The strong fourth quarter revenue led us to an annual revenue for 2022 of $110 million, which is our fourth straight annual revenue record and an improvement of 7.4% from 2021. Higher amounts of revenue led to an increase in gross profit of nearly $800,000 during the fourth quarter of 2022, despite a 2% decline in our gross margin percentage.

The decline in gross profit margin percentage was attributable to a different mix of product volume favoring lower margin revenue such as medical equipment sales and the Biomedical Services revenue, a change in the impact from adjustments in our missing pump reserve, which was a benefit in the prior year and higher pump maintenance expense on our pump rental fleet. The lower Biomedical Services gross margin was partially attributable to temporary expenses associated with building a larger team such as training costs and other start-up expenses for the project. Selling, general and administrative expenses were higher in the fourth quarter of 2022 by about $2 million as compared to the prior year. This increase included a higher expense accrual for our short-term incentive bonus totaling approximately $1.5 million, and severance and other termination costs associated with reorganization of certain management positions totaling approximately $600,000.

Other increases were offset by a decrease in stock-based compensation expense of $900,000 and include investments in business applications for the Biomedical Services revenue, additional head count to support higher sales volumes and inflationary increases in wages and salaries. Adjusted EBITDA for the fourth quarter was $5.5 million or 19% of revenue, representing an approximate $1.1 million decrease from the fourth quarter of 2021. However, adjusted EBITDA for the fourth quarter of 2021 included a $2.2 million benefit related to the fourth quarter adjustment and our short-term incentive accrual in that year. Turning to a few points on our financial position and capital reserves. We continue to be positioned well 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 part.

Our net debt increased by — decreased by $1.1 million to $33 million and our available liquidity totaled $41 million at the end of the quarter. Our net debt to adjusted EBITDA continues to be a modest 1.59x. Our debt consists of borrowings on our revolving line of credit with no term payment requirements, just under 3 years remaining on its term and $20 million of which is protected from increasing interest rates through an interest rate swap in the same time. And with that, I’d like to turn it back over to Mr. DiIorio.

Richard DiIorio: Thanks, Barry. Despite some challenges, 2022 was a year filled with significant strategic accomplishments. In the first half, we signed and were able to announce our master services agreement with GE Healthcare. We believe that relationship will serve as a springboard for significant growth in our biomedical business and more broadly, our entry into acute care. In the second half, we signed and announced what we believe will be a material joint venture with Sanara Medtech to distribute its advanced wound care products. I am absolute in my belief that InfuSystem’s long-term prospects are stronger than ever. The shift in timing of the negative pressure pump deliveries to this quarter, coupled with our improving GE ramp, gives us confidence that we will be ahead of our internal budget for the first quarter, giving us a strong start for the year.

That said, I fully appreciate that the delays we have experienced in delivering on some of our major growth initiatives warrant appropriate adjustments going forward. This presents in 2 ways. First, as discussed last year, we’re going to be very conservative around our longer-term guidance. We are only going to talk about business we can clearly see, predict and deliver. Second, respecting the length of time it is taking for some of our growth initiatives to launch, our plan is to trim some investments and hold back on some spending to more closely align our growth-related cash outflows with more cautious expectations around the timing for our revenue ramp. In Wound Care, this means being conservative with some planned investments as we take into account the need to find a secondary supplier of negative pressure devices and the time it will take to get all of the regulatory approvals necessary to begin distributing and billing Sanara products under the new joint venture.

Photo by Luis Melendez on Unsplash

We believe we will be going at full strength in our expanded Wound Care initiative as we enter the second half of the year. We will be making similar adjustments to reduce our spending and investments related to some lower priority growth initiatives. Pain management is 1 area of focus here. We have a great offering in Pain and there’s always been a lot of interest in the program. While it is growing, it is behind our expectations as it has been confronted by 1 challenge after another, including supply chain shortages and the impact of COVID. Given the much larger opportunities that we have — that have emerged in recent years, particularly our new growth initiatives with GE and Sanara, we have taken steps to retool that initiative. And at least for 2023, there will be less of a growth focus and more of a focus on ROI in this Pain business.

That leads us nicely into a higher level of review of our business and strategic priorities for 2023. As an introduction, it has been a couple of years since we first launched what we called our InfuSystem 2.0 initiatives. Recall that just a few years ago, InfuSystem was generally understood to be an oncology pump rental business with strong operating cash flows, but limited growth prospects. We’ve been very busy changing that. And this results from the recognition that over its 3-plus decades of operations, InfuSystem has developed some very significant capabilities. And a few years back when we began looking outside the scope of our core business, we quickly discovered that there is a lot of demand within the healthcare community for the unique and powerful solutions that we can deliver.

Today, it takes time to review all the opportunities that are or could be pursued under each of our 2 operating units. In our Integrated Therapy Services or ITS business, the strategic objective is to leverage the platform we’ve built for Oncology into additional therapies, Pain Management and Wound Care currently being the 2 primary examples. Our second business unit, DME Services, has historically operated primarily in a support function to ITS. But that changed when we did an ROI study and identified that the incredible — potential inherent within our Biomed Services group. In addition to servicing our own pump fleet, our highly skilled Biomed teams can be deployed to service customer-owned devices. While Biomed starts with lower gross margins, it has minimal CapEx requirements and leverages the capabilities we have spent decades perfecting.

The new Biomed revenue opportunities balance our ITS and pump rental efforts by delivering growth with a low CapEx model. The emphasis on biomedical services is relatively new. But I’ve said before that I expect Biomed to be the first of our various growth initiatives to scale to the point of exceeding the size of our core oncology business. And as we increase the reach of our Biomed Services, this will create new opportunities in acute care for our core DME service business, which includes pump rentals and the sales of both medical equipment and consumables. Over the last couple of years, we’ve made substantial progress in repositioning the company. InfuSystem is now a multifaceted business with significant growth opportunities. And as word gets out within the healthcare marketplace, these opportunities keep expanding.

Here are the highlights. In 2019, we worked with McKesson to onboard their oncology patients. In 2020, Cardinal approached us to help provide a last-mile solution for their negative pressure wound therapy pumps. In 2021, our new Biomed offerings captured the attention of GE Healthcare, which led to the multiyear master services agreement. And in 2022, our partnership with Sanara was formed through a joint venture relating to wound care, and the opportunity to combine their best-in-class products with our industry-leading services and payor network to change the way wounds are treated. InfuSystem is increasingly well known for its exceptional levels of service and our culture that is committed to exceptional patient care. We solve problems for device manufacturers, hospitals, clinics, patients and payors.

We are experts in the last mile and every year handle the logistics for hundreds of thousands of pumps and the paperwork and revenue cycle for even more medical procedures and service calls. We’ve seen that these capabilities are sought after by many leading healthcare companies and that there is no shortage of opportunities for expanding the business and delivering significant long-term growth. Going into 2023, it is clear that to effectively execute against our potential, it is necessary to apply focus to the most important of the current opportunities and those with the greatest long-term potential. What this means in our DME Services unit is easy. Focus on executing and ramping the relationship under the GE agreement. To give additional color to this, I’d like to have Carrie Lachance, our President and COO, discuss our partnership with GE and the progress we have made at the end of 2022 and the acceleration of our ramp-up as we start the year.

Carrie Lachance: Thanks, Rich, and good morning, everyone. When we announced the GE master services agreement in April of 2022, we were very excited to get things rolling. We had several ones to prepare and then hired and trained the appropriate number of biomedical technicians to begin the onboarding process. As we reported later in the year, however, the onboarding was slower than expected during the early stages. I think it’s important to explain that the delays were not caused by problems with the early rollout, just the reverse. Our white-glove approach and services were received very favorably. However, we needed to slow down in an effort to align expectations and gain efficiencies. Since then, we have worked hard with our partner to better align the communication channels, further streamlining onboarding processes and to develop and implement software tools shared between our companies.

As intended, these process improvements are paying dividends now, allowing us to significantly accelerate the onboarding process. I am confident that the careful and measured approach we took in 2022 will greatly enhance the long-term success of the strategic relationship. Our visibility to the work ahead continues to improve every month, and we now have a clear schedule of upcoming locations, number of devices to be serviced and appropriate staffing needs. Our pace with the GE contract is accelerating. Each month, we are onboarding more devices than the prior month and we will have already onboarded more devices in the first quarter of this year than we did in all of 2022. At our current pace, we will be well ahead of our Q1 forecasted ramp up.

As Barry mentioned earlier, these initial indicators should allow us to get to the $12 million run rate by the end of this year. We are extremely proud of the quality of work our teams are performing. We will continue to onboard more technicians as we scale into larger hospital systems throughout the U.S. I’m happy to report that the feedback coming from GE customers on the work we have completed has been phenomenal. This is further proof of what we believed early on, which is that our biomedical services capabilities are a core competency that we have perfected over the last couple of decades. At this point, I would like to turn the call back over to Rich.

Richard DiIorio: Thanks, Carrie. So in 2023, focus and execution in our DME Services business means: one, protecting and expanding our core pump rentals and sales and consumable business; and two, absolute obsessive attention to executing above and beyond under the GE Master Services Agreement as the planned rollout continues and opportunities emerge to expand the relationship and services, thereby deepening our move into the acute care setting. In our ITS business unit, we are moving to apply a similar focus that will result in improved execution against the potential demonstrated in our business. In 2023, this means our priorities will be, first, on our core business in oncology, providing excellent patient and customer service, and continued expansion of our already dominant market position, generating more revenue and continuing our strong and steady cash flows.

And second, our most important incremental therapy this year will be the new Sanara joint venture. This doesn’t mean we’ve lost interest in our other ITS therapies, including pain and lymphedema. Instead, it means that current circumstances warrant that we prioritize and focus on executing against our largest and most compelling current growth opportunities. Our Lymphedema opportunity is still present. It was, of course, sidelined when we shifted attention to the more urgent and compelling GE opportunity when it emerged in 2021. And Pain in 2023, we’ll have an increased focus on improving ROI and less on the pursuit of growth as we shift resources to the more urgent and compelling Sanara opportunities. As we discussed during our last earnings call, the Sanara opportunity incorporates and greatly expands upon our prior negative pressure efforts with Cardinal.

Our Sanara Wound Care initiative gives us a complete product portfolio and is more compelling — is a more compelling offering to take to healthcare providers. It also targets a much broader addressable market. Our relationship with Cardinal excluded us from the largest segment of the wound care market located in long-term care and skilled nursing facilities, and this is our initial focus in our joint venture with Sanara. So our key objectives in 2023 in our ITS business are: one, to develop a more robust device agnostic supply of negative pressure manufacturer and suppliers. Two, obtain all necessary accreditations and approval for devices and products. Three, as devices and approvals come through, work with Sanara to continue to develop best practices and build our pipeline.

And four, ramp business into 2024 in an effective and efficient way. And stepping back, the strategy for all of InfuSystem in 2023 is focus on execution. In DME services, this means our core business and successful ramping of GE through the year. And in ITS, it means advancing the core business and launching the Sanara Wound Care joint venture, getting all the pieces in place during the first half and then gaining momentum in the second half in order to be able to deliver in 2024 the kind of growth we are seeing in ’23 from GE. Before commenting on guidance, I want to announce some branding changes that you will be seeing as we refresh our IR deck. Over the last few years, we’ve been referring to our 2 operating units, most often by their acronyms, ITS and DME.

Moving forward, what was ITS will now be known as Patient Services and what was DME services will now be known as Device Solutions. In short, Patient Services focuses directly on improving the quality of life for our patients by enabling continuity of care, while Device Solutions focuses on allowing our customers to do the same, utilizing the devices we support. Now moving to our 2023 guidance. I would like to first reiterate the point I emphasized earlier, that InfuSystem is a company surrounded by opportunities creating truly significant growth potential. I believe we have so much opportunity that the key to our success in ’23 will be to prioritize and focus on executing against our most significant opportunities. The first of these is our master services agreement with GE Healthcare and the adjacent projects that are already beginning to develop for us in acute care.

As Barry and Carrie mentioned earlier, our Biomedical Services business with GE is now ramping and will have a material impact on our results in ’23. Our second priority this year will be developing the Sanara Wound Care joint venture and preparing it to begin building momentum later this year to deliver significant revenue next year. As discussed last year, we intend to be much more conservative with our guidance going forward. This acknowledges the difficulties we’ve had in accurately predicting when material events will occur. I hope everyone will agree that we’ve generally been pretty good in describing where our business is going. For example, the strategic initiative in Biomed that began with a couple of small acquisitions in 2021 and led directly into the current master services agreement with GE.

The difficulties have been in accurately predicting the timing of things. For example, we were very confident in closing on some material negative pressure wound therapy placements in December of ’22, only to see that, that business push unexpectedly into ’23 due to an unpredictable circuit board problem with our device supplier. Turning to our outlook for ’23. We are taking a conservative approach to our guidance. We are estimating full year 2023 revenue growth to be in the range of 8% to 10% or approximately $118 million to $121 million in net revenue. We are forecasting adjusted EBITDA margin to be greater than 19% or more than $22 million for the year. It’s important to note that guidance for 2023 does not include any material revenue from the Sanara Wound Care initiative and reflects a modest growth forecast for Pain Management, making this outlook more achievable.

And now we are happy to answer any questions.

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Q&A Session

Operator: And the first question will come from Brooks O’Neil with Lake Street Capital Markets.

Brooks O’Neil : I have a few questions. I guess I’ll start on the DME side. Could — I appreciate the comments, particularly that Carrie made, but can you talk about how satisfied GE is with your performance and the execution with them?

Richard DiIorio : I think I don’t want to speak too much for them, but between GE and the customers, I think they’re very satisfied. I think that that’s why we’re — the governor kind of came off the program and the ramp up kind of late in the fourth quarter and certainly into this year, and we’re starting to see the ramp really accelerate. I think it’s a combination of GE just kind of getting to know us and seeing our performance and also them getting feedback from their customers, not just us. So if I’d speak for them, I’d say they’re very pleased with the performance so far.

Brooks O’Neil : Right, Rich. Could you just amplify a little bit on what you mean when you speak about the broadening opportunity in acute care? And is that arrangement similar to what you do with GE? Or do you anticipate different but related opportunities?

Richard DiIorio : Yes, that’s a great question. So historically, as a company, we’ve been in acute care a little bit on the Oncology side when our customers are hospital based. But for the most part, we’ve been more in the alternate side market. So private practices, ambulatory surgery centers and pain, even the home infusion space on our DME side. It was — it’s really tough to kind of break into the acute care space and what’s going to broaden for us and change for us is with GE and us, all of their business is in the hospital space. So once we’re in the hospital, we have a presence and the customer is happy with our performance on the Biomed side, does that open up opportunities for us to rent pumps to bring our negative pressure program and to do some other things within the acute care space that we didn’t have entree into before.

So this kind of opens up a whole new world. Some of that, hopefully, will be with GE and other programs beyond just repairing and servicing devices. But some of that will just be our sales team having an opportunity to now call on a customer that they didn’t have access to before. There’s no number to put on it, but having access to the biggest space in healthcare that we didn’t have before, certainly will create opportunities over time for us.

Brooks O’Neil : Right. And then just a third question on that side of the business. Could you just say whether you see opportunities with other clients beyond GE on the DME Services business?

Richard DiIorio : Yes. So we don’t see anything the size or scale with GE kind of that’s imminent, but there’s certainly at the customer level hospitals that we’re doing service with today. We’re trying to focus mostly on the GE piece and in some cases, even walking away from kind of one-off deals just to focus and get the GE contract up and running. But there’s definitely one-off hospital deals, and there’s manufacturers that approach us all the time to help them with service in the field, recalls, issues that they have. So over time, that’s why I think it’s going to be the first program to catch Oncology. GE is not going to do that on its own, right? It’s going to be a nice cornerstone for us to launch off of. But the opportunities outside of GE are all over the place. It’s just we want to get this contract and execute on it and then move on to the other opportunities.