HealthStream, Inc. (HSTM) Q2 2022 Earnings Report, Transcript and Summary

Good morning, and welcome to HealthStream's Second Quarter 2022 Earnings Conference Call. At this time, I would like to inform you that this conference is being recorded [Operator Instructions]. I will now turn the conference over to Scotty Roberts, CFO and Senior Vice President. Please go ahead, Mr. Robert.

Thank you. Good morning, and thank you for joining us today to discuss our second quarter 2022 results. I'll be filling in this morning for Mollie Condra. Also in the conference call with me is Robert A. Frist Jr., CEO and Chairman of HealthStream. I would also like to remind you that this conference call may contain forward-looking statements regarding future events and the future performance of HealthStream that involve risks and uncertainties that could cause the actual results to differ materially from those projected in the forward-looking statements. Information concerning these risks and other factors that could cause the results to differ materially from those forward-looking statements are contained in the company's filings with the SEC, including Forms 10-K, 10-Q and our earnings release. Additionally, we may reference measures such as adjusted EBITDA, which is a non-GAAP financial measure. A table providing supplemental information on adjusted EBITDA and reconciling to net income attributable to HealthStream is included in the earnings release that we issued yesterday and may refer to in this call. I'll now turn the call over to our CEO, Bobby Frist.

Thank you, Scotty. Good morning, everyone. Welcome to our second quarter 2022 earnings call. At a time when so many things in the world are up in the air, pandemic, recessionary trends or there's just so many unpredictable things and they continue shifting. I think it's important to kind of pause a little bit and double down on who we are and where we're going. And for that reason, I'm going to take the opportunity here to open to reground everyone in the basics of our business and our business focus. First and foremost, HealthStream is a healthcare technology company dedicated to developing, credentialing and scheduling the healthcare workforce through SaaS based applications. We sell these applications on a subscription basis under contracts, which average three to five years on link. That means our revenues are recurring and highly predictable. We are profitable and we have little to no debt. We're also fortunate to be solely focused on one of the more recession resistant markets around, healthcare. And as we define our target customers within healthcare, we see it's a rather large audience of about 10.4 million healthcare professionals. Those healthcare professionals are the end users of our SaaS applications. We are led by a seasoned team of executives who have proven track record generating earnings and cash flows through both organic and inorganic means. We have internally developed innovative patented solutions such as Jane, robust enterprise class market leading applications, again, developed internally, such as our HealthStream Learning Center, and we have created new application suites such as CredentialStream through acquiring and integrating other companies. When markets have been appropriate for repurchasing our shares, we have done that as well. Since March of 2020, we have repurchased approximately $48 million of shares at an average price of $21.75, retiring approximately 6.5% of our shares outstanding in the process. Keeping sight of these fundamentals have allowed us to reliably deliver even in unreliable times, and we expect to continue doing so. With that framework in place, I want to share three key takeaways for the remainder of this year. First, we believe we are positioned to deliver an improved top line growth rate of generally around 6%, inclusive of our acquisition of CloudCME in the second half of the year. This rate, which will be more than double our growth rate of the first half. Second, our gross margin is 66% in the second quarter, representing a 700 basis point improvement from the 2019 gross margin of 59%. That improvement occurred sequentially over time due to our improving mix of higher margin products. Third, we believe sales bookings indicate that customer purchasing decisions are beginning to pick up based on our sales teams reporting higher levels of engagement with customers and an increased level of virtual and in person meetings when compared to the height of the pandemic. We take each of these three items to be positive indicators as we move into the second half of the year. In fact, as we reflect on the last few years, the management team is excited to feel that we're now more on offense or maybe a slightly more defensive posture in the prior three years. It's exciting to be on offense. Later in the call, I'll talk about important developments with our single platform strategy as well as areas that we believe will drive future growth and expansion. But first, I'll turn it over to Scotty Roberts, our CFO, to provide details on our financial results for the second quarter.

Thank you, Bobby. I'll jump into the financials, beginning with a recap of our key financial metrics for the quarter. Revenues were $65.6 million, which were up 1%. Operating income was $3 million, down 14%. Net income was $3.1 million, up 26%. Earnings per share was $0.10 per share, which is up 25%. And adjusted EBITDA was $13.1 million and down 10%. Workforce Solutions revenues were $52.5 million and were up 1% and revenues from Provider Solutions were $13.2 million and were up 4%. We continue to see positive product adoption and sales momentum in areas such as our market leading learning application, the HealthStream Learning Center, clinical competency solutions like Jane, the Credential Stream application, the ShiftWizard scheduling application, and new contributions from the Rievent and CloudCME acquisitions. We are pleased with the growth of these solutions, although the year-over-year comparison, particularly in the workforce segment was impacted by two products that experienced lower revenues this quarter. The first was the expected revenue runoff from the legacy resuscitation products of approximately $0.9 million and the second was a decline in the legacy ANSOS scheduling product of $1 million. ANSOS along with NurseGrid and ShiftWizard was acquired in 2020, and collectively, they comprise our scheduling and capacity management application suite. Unlike the other two products we acquired, ANSOS features an installed software application sold under nonrecurring perpetual software licenses. During the quarter, ANSOS experienced lower new sales and a higher rate of churn of its legacy installed software. Our focus is now on upgrading legacy ANSOS customers to our recurring revenue SaaS scheduling applications, including ShiftWizard, which by the way, demonstrated 28% revenue growth compared to the same period last year. Our gross margin was 66.1% compared to 65.1% last year. As Bobby mentioned just a minute ago, our shift in product mix to higher margin solutions continues to improve our gross margin. Looking at operating expenses. Excluding cost of revenues, [sales] were up 4% or $1.7 million. As our business has grown over the past year, staffing levels, in particular, have increased and were the primary driver for expense growth over last year. Investing in sales, marketing and product development have been our primary focus to drive sales and revenue growth, and create new products and enhancements for our customers. Sales and marketing expenses increased by 15% and included a combination of increased staffing levels, sales commissions, travel and marketing spend. It's good to see the pickup in sales activity even though it brings some increased levels of expense. Product development increased by 2%, which is net of labor costs that were capitalized for software development. Capitalized labor costs increased approximately $800,000 over the prior year quarter. This increase was mainly associated with investments in the scheduling and capacity management application fleet as well as the development of courseware to create more higher margin products. As anticipated, our business travel began to pick up during the second quarter. We spent about $400,000 this quarter compared to less than $60,000 in the second quarter of last year. While $400,000 in the quarter is well below our pre-COVID travel spend, this amount exceeded what we spent for the full year of 2021. We expect that travel will continue to increase during the second half of the year, although it will likely remain below the pre-COVID levels. General and administrative expenses declined by 2%. The reduction in office lease costs and transition service costs associated with the ANSOS staff scheduling acquisition, both generated cost savings versus last year. Partially offsetting lease savings, though, were higher bad debt, software expenses, insurance premiums and costs associated with employee recruiting and onboarding. Our adjusted EBITDA was $13.1 million, which was down 10% from the record high that was set in last year's second quarter. We ended the quarter with cash and investment balances of $39.2 million, which is down by $6.2 million since last quarter. During the quarter, we deployed $3.1 million of cash for share repurchases, $6.1 million for capital expenditures and $4 million to acquire CloudCME. DSO was 45 days compared to 43 days last year. On a year-to-date basis, our cash flows from operations were $28 million compared to $24.3 million last year and free cash flows were $15 million compared to $11.6 million last year. For our share repurchase program, as I said, we spent $3.1 million under the program this quarter and we have approximately $1.9 million remaining under the program. Over this past two and half years, we've deployed over $48 million of capital towards share buybacks, retiring approximately 6.5% of our outstanding common stock in the process. The average price at which we repurchased shares over the last two and half years was $21.75 per share. We've also had a long history of deploying capital towards mergers and acquisitions. And on May 18th, we completed the acquisition of the remaining ownership interest we had in CloudCME for approximately $4 million in cash and $4.1 million in shares of our common stock. We also recognized a $0.9 million gain associated with the change in the fair value of our previously held minority interest in CloudCME. The acquisition of CloudCME complements the Rievent acquisition that we completed in December of last year. Both companies provide software solutions for CME management to accredited healthcare organizations. Now let's discuss guidance. We are reaffirming our previously issued guidance, which is as follows. Consolidated revenues are forecasted to range between $267.5 million and $273 million. Adjusted EBITDA is forecasted to range between $50 million and $53.5 million and capital expenditures are forecasted to range between $26 million and $29 million. With the first half of the year behind us and some of the year-over-year declines on the top line mostly flushed out during the first and second quarters, we expect revenues will begin showing improvement during the second half of the year. That said, as I mentioned earlier, there will be a reduced focus on selling ANSOS nonrecurring perpetual software, which will result in some drag on the top line growth. As a reminder, even the low end of our range would still result in an approximate 6% revenue growth rate for the second half of the year, which is more than double our top line growth rate for the first half of the year. From a hiring and retention perspective, through the first half of the year, our headcount increased by 4.5% through filling new positions and the addition of CloudCME employees. Our plan remains to increase staffing levels by 5% to 7% during the year. We've been able to recruit and hire effectively while our employee turnover rates remain similar to what we've experienced the past several quarters. Looking to adjusted EBITDA guidance, we expect the second half of the year will be lower than the first half, attributed in part to the expected lower sales of ANSOS nonrecurring perpetual software, and as expenses such as travel, trade shows and compensation expenses will be higher than they were in the first half of the year. Thanks for your time this morning. Bobby, I'll turn the call back over to you now.

Thank you, Scotty. Whether it's the HealthStream Learning Center application for learning, the CredentialStream application for credentialing or the ShiftWizard application for scheduling, we firmly believe that HealthStream offers the best SaaS applications for the healthcare workforce. What we want to do now is make those applications even better and that's why we never stopped asking ourselves what is next. One clear answer to what is next is we believe is interoperability. The best application should leverage each other and they should work together. And of course, that's easy to say, but not as easy to do. That's where our hStream platform comes in. Our emerging hStream platform is designed to deliver interoperability. With the expected launch of our developer portal in the third quarter of this year, our first API services will become commercially available to customers and partners. The number of APIs available in the December launch of the developer portal will start small and grow over time. That said, the learning APIs, for example, that will be included in the developer portal at its launch, are already being used by some of our largest customers. With our learning APIs, for example, one large customer has plugged into the hStream platform to establish interoperability between their HRIS system and the HealthStream Learning Center application. Now as soon as a new nurse is hired, they are automatically enrolled in the appropriate training programs in the HealthStream Learning Center application. This happens automatically to the learning APIs, saving the customer time and resources. This is just one example of how interoperability extends the reach of our network, makes our applications more deeply integrated with customer workflows and improves our value propositions. With the emergence of our developer portal and the APIs it will] contain, the opportunities created through interoperability will continue to expand. We look forward to updating you on that journey. Before we go to questions, I want to tell you about something new that is happening at HealthStream. There's a new way for individuals -- individual healthcare professionals to enter and participate in our network. For the first time, people are arriving on our platform directly through a business-to-professional model. Let me describe a couple of the applications that are making this possible. I'll start with NurseGrid, which is the top-rated app for nurses in the Apple's App Store with 4.9 star rating, and now over 84,000 ratings. Nurses love it and over 395,000 of them actively use it every month. That means one in eight nurses in the United States logged on to the NurseGrid application in the past 30 days to socialize and switch shifts with their colleagues. The number of monthly average users has increased by 135,000 since we acquired NurseGrid in March of 2020. I believe that's about 52% organic growth. And just last week, we added 5,000 new subscribers during the course of the week. That's 5,000 people choosing to subscribe in the last seven days. I find that level of compounding network effect, fantastic. Another business-to-professional application is myClinicalExchange. We estimate that approximately 20% of all nursing students in the United States enroll in their first clinical rotation using myClinicalExchange. The constant influx of new nursing students ensure a steady flow of new users for myClinicalExchange, and they are signing up in their capacity as individuals. Not only that but they're signing up as students before their professional careers even begin. This allow us -- allowing us to go upstream and form a relationship between individuals on our platform earlier than before. Through these examples, you start to see why we're excited about this development. For over 25 years, we were strictly a business-to-business company. Every healthcare professional that interacted with our applications did so because their employer purchased a subscription for them to use, to now begin welcoming users directly to our platform through business to professional applications like NurseGrid and myClinicalExchange unlocks a great deal of potential. It creates the opportunity for us to reimagine our customer base. In the future, we hope that the millions of healthcare professionals who use HealthStream on the job will become customers and consumers in their individual capacity as well. With that, we'll go to questions, but not before I say a sincere thank you to all HealthStreamers who are making this progress that I'm reporting on possible. Whether it's launching the developer portal in this quarter, while creating our new business to professional experience, while making our leading workforce applications even better, our success is due to our amazing employees. Please note that we are all excited now, management and employees to be on offense, launching new products and solutions and growing HealthStream. I'll turn it back over to the operator for Q&A from our analysts.

[Operator Instructions] Our first question comes from the line of Jared Hasse from William Blair & Company.

I wanted to circle back on that comment from the prepared remarks about just feeling like you can play on office a little bit more at this point, and just to put a little more context around that. Should we really just think about that as more -- just sort of feeling better about having some of these transitions that you've been going through in the last few years, kind of were behind you now, combined with just the general sort of favorable end market trends or is there something else that you're seeing in the market that maybe gives you confidence that you could perhaps invest a little bit more aggressively to drive an even faster growth profile over the next couple of years?

Well, it's definitely the combination of those things. As you know, we've spent many quarters explaining some of these business transitions we've been going through and the risks involved in them. And so it's exciting to have a prepared script that I didn't feel the need to address any of them. In other words, we've kind of gotten back to normal course. And normal course for us is launching new products, finding out new ways to grow, like we talked about here at the very end and acquiring companies that tuck into our strategy. So it just -- generally, as you pointed out, it feels different. The tone and the attitude of our executives and our employees. And then second is through the market conditions, too, because as I, in my opening comments, talked about the great uncertainties. I mean, certainly, the pandemic -- if your customers were hospitals predominantly, and skilled nursing facilities and long term care facilities, this is one of the hardest times they've been through in my lifetime, the pandemic adjusting their strategy. So it affected our customer base in many ways. And to watch them fight their way through all this, figure out a new normal continue to improve their delivery of care to patients. It's generally encouraging to watch [some] market conditions for our customers change. And I think some of that's reflected in some of their announcements, the public company announcements over the last few quarters as they continue to show growth as well, many of them. So I think it's both the macro environment conditions. We still have plenty of overhangs with recessionary fillers and things like that, but that's why we also mentioned that healthcare seems to always be in demand and the need for quality care is always in demand. And so we feel that our products and solutions are well positioned in the market as well. So it is both the internal change in tone and the condition of our target customers changing to deposit that leads me to say, it feels good to be back on offense instead of on defense.

And I think this is a related follow-up. But just in regards to the positive comments on the velocity of booking activities in some of the pipeline, things that you're seeing just as it gives you confidence for the rest of this year. Is there anything sort of competitively to call out or is it more of just starting to see these macro trends that have been really impacting the health system end market for the last couple of years, maybe just starting to alleviate and that's what giving you a little bit more comfort, just specifically as it relates to that comment on the pipeline.

It's definitely a little bit of both. So during the pandemic, I described things -- I call them air bubbles kind of like if you know how it breaks system works in the cars get air bubbles, it creates kind of less effective braking. I think in the sales process, there are times where certain parts of the country, they are so busy with the pandemic, they really weren't in a purchasing mode or if they had purchased something, they didn't have the capacity to deal with implementation. And the way I've characterized that is, I think a lot of those air bubbles have kind of worked their way out of the system and we see a return to those patterns. But in addition, I think quietly and sometimes not so quietly, we were building new products and capacity during the pandemic. For example, our CredentialStream application suite I now believe has a clear competitive advantage. It's the most comprehensive suite for onboarding physicians, getting them credential privilege and enrolled and ready for work, time to billing. We believe we're best positioned as an organization through our CredentialStream application to shorten the time to productivity and billing for newly onboarded physicians. We think that has huge economic -- positive economic impact for our customers. And we think our application suite for CredentialStream is the best in the industry. So I would say, as with my prior answer, it's a little bit of both. We're really excited about the positioning of some of our products as much as we are, the conditions of our customers to be able to purchase and implement them.

Our next question comes from the line of Richard Close from Canaccord Genuity.

[Technical Difficulty] with respect to the previous question. So Bobby or Scotty, with respect to the confidence in the second half growth, I know a couple over the last couple of years, you had some softness in bookings, and because you're a SaaS company that takes a while to flow through the model, so to speak. So does the confidence in the accelerated growth in the second half, does that -- all of a sudden, you have a lot of new contracts that are going live here, as we speak. I'm just trying to gauge that level of confidence and then is that in the provider or the workforce area?

So the confidence stems from all the things we've already mentioned, and you reiterated that some of these purchase processes seem to be getting back on track. We're having more meetings both in person and virtually. Our sales model is accommodating customers to meet them in person and virtually. So I feel like the environment for us right now and our products are aligned with needs is good. And we do have some operational challenges, we did have a little bit of a drag on growth. So we try to factor those in as well. And we talked a little bit about the -- what I guess we now refer to as the installed products and scheduling that we acquired struggling a little bit more than we had expected. That said -- and we have some backlog issues that we're getting through as fast as we can to get to revenue but they're not really issues. There are opportunities because we did have some good contract wins like on the CredentialStream platform, we've got a nice backlog that we're trying to normalize and get the revenue on those. So it's really -- as always, it's a blend of all those things. But the net effect of all that is we think our growth rate will more than double. In fact, we provided that a little additional detail that we're looking at 6% inclusive of our CloudCME acquisition, which is in the range that we provided. So we were able to reiterate our range and provide a little more clarity at using the 6% inclusive of the CloudCME for a growth target.

With respect to CredentialStream, you've talked -- and I guess you're referring to that with respect to backlog. Has there been any clear improvement on the implementations over the last quarter, any thoughts on that?

The processes and tools and teams we've been hiring and the teams to increase the rate of implementation of processes or better the tools to help customers migrate the strategies for migration or even enhance, we actually preselling now, provide some tools to allow people to experiment and prepare for implementation. So we're getting better but we're also selling a lot. So we're adding to that backlog by winning deals. So it's a healthy dynamic and we don't exactly know the normal. We might always go faster. But generally all the tool sets and processes have matured considerably in the last 36 months to help us implement our CredentialStream customers.

And my final question would be, Scotty, on ANSOS. I think you said there was $1 million headwind in the second quarter. Was there any headwind in the first quarter from that as well?

Richard, looking back to last year, we saw some benefits come through in the first half, both Q1 and Q2 for that product, in particular, and a combination of sales of perpetual licenses, which have kind of an upfront revenue recognition and then just higher professional services and then just some other items as well. But those kind of normalized. And saw some reductions as they played out in the first half of this year. So I think it's combined both Q1 and Q2, we see both of those quarters reductions related to that product.

Our next question comes from the line of Vincent Colicchio from Barrington.

Just wanted to ask you about the labor market. It sounds like you're able to hire the people you're looking for. Just curious, is there any tempering of wage inflation?

No, but we're doing better at our strategies for hiring or hiring pools of people for different types of roles. We've kind of -- shifting our strategies and being successful hiring at the rate we need. I think in general, we're probably backfilling positions at fairly consistent pay grades as before, but maybe getting a little less experienced people. We have to train more in those positions as the churn and employees continues to remain high for really our company and all the colleagues I talked to across industries. And so we may be getting -- we've been able to manage costs but we're probably bringing in slightly less experienced people that we're training up more in order to manage the costs of inflationary pressures on pay scales.

And it seems like increased travel for your sales force is helping out the sales process. Just curious have your thoughts changed on how much you may spend on sales when things normalize versus pre-COVID levels.

Well, right now, we're just still watching the patterns return. And so we're allowing our managers to encourage travel when it facilitates a customer relationship or a sale. We're still encouraging generally our internal meetings, with some exceptions to be done virtually to manage costs. And so we're trying to establish the new rate. And what I would say is we've seen it pick up in each of the first quarter and pick up again in the second quarter. We, in our budget, planned to have it pick up again in the third and again in the fourth. But even after all that, the total travel budget for the year would probably still be less than half of pre-pandemic levels. And so -- because we've insisted on kind of prioritizing travel for customer-facing instead of assuming five people at trade show, we try to send three, things like that. So we're making adjustments to our style but encouraging our teams to get out with customers when it can make a difference in closing the deal or building a relationship.

And then last question for me, the resuscitation business. Does that meet your expectations in the quarter, and has there been any change in the competitive behavior?

It's tracking expectations through the middle of the year. Competitive dynamic is steep but the implementations, utilization rates, all seem to be holding up right now. So we've got a long way to go, though. We're up against a really strong -- we represent both partners as options for customers and both products are improving. And so there's quite a battle for market share going on there. And we're kind of facilitating the delivery of the products for both and continue to invest in the development of the Red Cross solution as well.

Our next question comes from the line of Richard Close from Canaccord Genuity.

Bobby, I was curious with respect to myClinicalExchange and the NurseGrid. In terms of how you monetize that and as you think about that longer term with people, providers, clinicians, what not accessing the platform. What is the long term benefit with respect to the, I guess, the ecosystem?

Well, we're working that out now. It's kind of -- as we've mentioned, a new phenomenon in our 30-year history. This is the last 18 months. But what it does represent is higher levels of engagement at different points in their career. It makes us more of a longitudinal service provider, meaning instead of just engaging with these individuals when they're employed at an institution, they can now reach out, log in and increasingly participate in activities, in this case, finding a rotation to hospital if you're a student. And so we hope that as other tools come online like our portfolio concept we've been working on for a few years, it will create a longitudinal history for each person that they can carry with them throughout their lifetime. We think that by the end of the year, we'll be testing some commerce solutions directly to the professionals. And so hopefully, in the fourth quarter, we'll have our first attempts to provide some value to them directly as professionals through some offerings, through e-commerce. So kind of a different selling model. And so I don't really know the answer, but just conceptually the idea is, can we maintain contact through our applications and suites over their lifetime as healthcare professionals instead of only during their employment through a B2B application. And we think increasingly based on the some of the numbers I was showing you at NurseGrid and myClinicalExchange, we think the answer is going to be yes. And we do have a fairly robust road map of tools that like the ePortfolio we're working on, that will service the needs of the individuals and service their further ends of their career development and career opportunities. So you have to kind of watch for that. We wanted to plant and seed with these two examples and talk about their growth. I mean a 50% growth organically in NurseGrid monthly active users of nurses, we're pretty excited about that. But you're right, we're new to -- I call it B2P, business to professional. So we're new to the business-to-professional world, but we do have millions of professionals in our network, but not as individual consumers. And so in the next 18 months, I hope to be able to announce that some of our pilots were successful and we've got some strategies to provide them value and also generate revenue. So kind of have to hold on for the next couple of quarters while we roll out some of these tools.

And my final question is, last quarter, in 1Q, you talked about strength in the -- renewed strength in the learning center. You talked about some softness on maybe some of the clinical programs. I think this morning, you mentioned Jane, or Scotty did, as being an area of strength as well as Learning Center. Have the softness in the clinical programs, has that reversed and you're seeing strength there or just any update on that would be helpful?

I think first, what was really exciting in the second quarter was surprisingly strong new additions to the HealthStream Learning Center. I believe that the number added in the quarter and largely due to a couple of big renewals that extended their contracts to cover more people, but also new market share was, over -- I'm trying to find the number. I believe there's over 100,000 new subscribers, which if you think back even five or seven years ago, that would have been a big number then. And so we're selling into these niche markets. We have other people reselling the application as part of a bundle. We're direct selling it ourselves. And then some of our hospital systems expanded and added users. So it was exceptional. But it is fun to see that one of our oldest products was still grabbing some market share, which is really fantastic. 100,000 or more subscribers in the second quarter. I believe it's right around there. I guess I'll put a range around it just because I'm not 100% sure, but let's put between 80,000 and 110,000 in the quarter. But even if you think back five years ago, I used to say 20,000 to 50,000 net new subscribers was good on the learning platform, and we did add close to 100,000 this quarter. And then Jane and Checklist and CE Center and our EBSCO products have all done well. And so we -- those are all clinical products. And so we see a bit of a pickup, particularly in what we call CE Center, which is almost a Netflix like subscription to a large library for continuing education. We see more institutions buying the subscription for their employees in bulk and provisioning -- hopefully, the benefit and maybe as a strategy to retain them showing their investing in their education and development. So we're encouraged by Jane, Checklist, CE Center and EBSCO, all performed pretty well now in the first half of this year.

Thank you. I would now like to turn the conference back to the executives for closing remarks.

Thank you, everyone, for your participation in the earnings call. Congratulations to our employees for our progress. And we look forward to reporting our third quarter as time permits and as the schedules come off. Thank you all, everyone, we'll see you on the next earnings call.

This concludes today's conference call. Thank you for participating. You may now disconnect.