InfuSystem Holdings, Inc. (INFU) Q4 2021 Earnings Report, Transcript and Summary

Good day, and welcome to the InfuSystem Preliminary Fourth Quarter and Full Year 2021 Financial Results Conference Call. [Operator Instructions] Please also note this event is being recorded. I would now like to turn the conference over to Joe Dorame, Managing Partner. Please go ahead.

Thanks, Tom. Good morning, and thank you all for joining us today to review the preliminary financial results of InfuSystem Holdings, Inc. for the fourth quarter and year-end 2021, ended December 31, 2021. 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. If anyone participating on today's call does not have a full text copy of the press release, you can retrieve it from the company's website at www.infusystem.com or numerous other financial websites. Before we begin our prepared remarks, I'd 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, 2020. 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?

Thanks, Joe. Good morning, everyone, and welcome to our preliminary fourth quarter and year-end 2021 earnings call. Thank you all for taking the time to join us today, and I hope you and your families are staying safe. This morning, we will review our preliminary financial results for the fourth quarter and year-end of 2021, provide an update on developments in our business and talk about our priorities and outlook for 2022 and beyond. To start, the team delivered a record year in 2021 with revenue of $102.4 million. While that number is certainly not what we expected for the year, we remain very confident in the continued strong growth potential of the business. We are transforming the company for long-term success in facilitating the clinic-to-home last mile solution and biomedical services for hospitals in North America. As I will discuss shortly, some major initiatives that were expected to contribute to our fourth quarter have slipped into 2022. This was largely, but not entirely, due to the impact of steeply rising COVID cases starting in November. While most of America largely avoided a repeat of the 2020 shutdowns, the health care sector was impacted by Omicron in a way similar to that seen with earlier waves of the virus. Before continuing further, I would like to take a moment to thank the members of the InfuSystem team, who once again showed their professionalism and dedication to our patients and providers that we serve. What we do is important, and I'm proud to be a part of it. So we know going into the fourth quarter that we had to get a lot done to deliver against our guidance. We started the quarter confident as we had some very good momentum going into year-end. There was the exclusive agreement with a leading West Coast health care provider for our pain management solution and we expected to close some larger deals for negative pressure wound care equipment before year-end. On top of this, it was normal to see the number of elective surgeries rise at the end of the year due to people taking advantage of the annual cycle with their health care insurance deductibles. Instead of the expected increase in activity during the fourth quarter, our business experienced a rapid deceleration as Omicron cases exploded. Although not to the extent seen when COVID first appeared in early 2020, the health care community took actions they thought necessary to focus on the potential emergency. This included reducing access to facilities, curbing elective surgeries, and deferring contract signings and the onboarding of new products and services. We felt the impact of these effects in almost every product and therapy across both platforms. In oncology, new patient starts dropped off after Thanksgiving, pain procedures did not scale at the end of the year and wound care contracts, we thought would be signed in December, slipped into 2022. These unforeseen headwinds negatively affected our ability to gain the expected business traction, causing us to fall short of the expected combined year-end run rate for pain and wound care. As you can see from reading the management discussion section of this morning's press release, despite the year-end slowdown, our revenue did still come in materially above last year's levels. Our fourth quarter revenue was actually up 7.3% versus the prior year. Our business is perfectly sound. We just experienced a temporary break in our growth momentum, which, much of this due, is due to the unexpected impact of Omicron in the fourth quarter. As I'll discuss shortly, after Barry has finished with his discussion, we see our revenue momentum coming back strongly in '22 and into '23. InfuSystem is very well positioned in the marketplace as a solutions provider, and we continue to see many attractive opportunities. Our business grew by approximately 20% in 2019, and again in 2020. And we see the business returning to 20% growth in 2022, and we are very well positioned to make that happen. We feel like we're a runner at the starting line, ready and eager for the signal to sound so we can get going, and execute on our plan and the opportunities in front of us. Now I'd like to turn it over to our CFO, Barry Steele, who will provide a review of our preliminary financial results.

Thank you, Rich, and thank you, everyone, on the call for joining us today. I'm going to focus on 2 areas: The main drivers for the current quarter's results; and advance our financial resource reserves. First, let me touch on our financial results for the fourth quarter. Net revenues for the fourth quarter of 2021 totaled $26.5 million, representing a 7% increase from the prior year fourth quarter. This amount was nearly tied with our highest quarterly revenue ever, a record freshly minted during the 2021 third quarter, and also beating our best quarterly revenue amount in 2020 when the panic of COVID-19 significantly accelerated market demand for infusion pumps. Growth drivers included revenue from the acquisitions, increases in pain management and negative pressure wound therapy revenues, and strong treatment volumes of patient collections in oncology. Preparations for the new large biomedical services agreement continued to create additional costs during the quarter, totaling $700,000 in both cost of sales and general and administrative expenses that slightly diminish our gross profit and adjusted EBITDA margins and increase our G&A expenses. Other factors unfavorably impacting profit margins included: Unfavorable gross margin mix related to the increased DME revenue from the 2 acquisitions; and $800,000 in costs related to the increased sales team for negative pressure wound therapy and pain management, which started during the second quarter. A portion of this increase totaling $600,000 was included in selling expense with the remaining amount included in G&A expenses. Partially offsetting these were a decrease in our lost pump reserve in the ITS segment, and a decrease to our management bonus expense totaling $2.2 million compared to the prior year. Turning to a few points on our capital reserves. We continue to be positioned well to fund our growth with strong cash flow from operations backed by significant liquidity reserves available from our revolving line of credit. Notwithstanding the strong position, our growth capital needs are expected to be markedly lower as compared to historical growth periods. This is because our biomedical services revenue growth does not require us to purchase medical equipment or other capital items as compared to our ITS business. At the end of -- excuse me, 2021, our total debt stood at $33.1 million, an increase of $2.2 million since the end of the third quarter, and our ratio of total debt to adjusted EBITDA for the last 12 months is [ 1.38x ]. A portion of this increase was due to $500,000 in purchases of our own common stock under our $20 million stock repurchase program. We continue to be enthusiastic buyers of our stock at the current market prices. Our total available liquidity at the end of the quarter was $41.6 million and consisted of $41.4 million in available borrowing capacity under the revolving line and cash on hand. And with that, I'd like to turn it back over to Mr. DiIorio.

Thanks, Barry. Notwithstanding the negative impact of Omicron in our business at year-end, 2021 was a strategically productive year, with several developments that we believe will drive top and bottom line growth in '22 and beyond. We started the year by expanding our capabilities with 2 biomedical services company acquisitions, FilAMed and OB Health in February and April, respectively. We took advantage of a onetime situation and expanded our pain and wound care sales forces midyear. In early November, we announced an exclusive 3-year agreement for our pain management solution with a leading West Coast health care provider. And later in November, we were down selected by a leading global medical technology and diagnostic equipment company to provide biomedical services to 800 hospital systems in the U.S. and Canada. It would be difficult to overstate how material the emerging opportunity in acute care hospitals is for InfuSystem. Our business has historically been almost exclusively related to the home health care sector, and that is where we've spent the last several decades developing a number of skills that are increasingly providing InfuSystem with competitive advantages in a rapidly involving (sic) [ evolving ] marketplace. As a company, we are now big enough that our skills, and in particular, our high service levels have started to be noticed outside of the home health care market. Of course, this is no accident. Our acquisitions in the first half of 2021 of 2 biomed companies were specifically designed to increase our capabilities and our profile in acute care. Almost immediately after integrating these 2 companies, we began to uncover opportunities to scale our legacy skill sets, and our new capabilities, into our opportunities far larger than the business we acquired. Take, for example, the opportunity we disclosed in November. We expect $8 million to $12 million in new business during the first 12 months, with the potential of the work scaling up to $14 million to $15 million per year. This is obviously very material for a company of our current size, and the revenue ramps very quickly. This is different than the slower burn we see in our ITS business segment where the opportunity may be just as big, but the revenue ramp comes more slowly, typically at least 6 to 9 months. Because of the materiality of the pending contract, we believe we had to disclose it in November and that we have to update investors today. We are at the ready to formally sign this agreement and begin the work, not just because of the significant contributions of this contract and what will happen to our top and bottom lines, but also because of the further opportunities we believe this contract will create. Our team and our services will gain exposure within 800 hospital systems in the U.S. and Canada. I've talked about cross-selling opportunities before. Well those opportunities are going to be a lot more significant as soon as our partner is ready and we get to work in all those facilities. InfuSystem's unique skill sets relate to managing mobile devices used in health care. To support our existing operations, we manage a fleet of more than 110,000 medical devices. As we move into the acute care hospital environment, we are going to be exposed to millions of devices with us creating constant opportunities to leverage the skills we have developed over the last 30 years. We will see large new opportunities to rent equipment, buy and sell equipment, provide annual maintenance, repairs and upgrades to equipment, and provide consumables. I should take a moment and emphasize that this is not a change in our business. This is a new opportunity relating to our second business unit, our DME services business. The services I listed above, including rental, sales, and equipment services, are things that our DME business has always done, but almost entirely to just the home health care market. Now we can target home health and acute care, and acute care has many more devices and a much larger total addressable market for us. Going forward, we believe that our DME business segment will have growth potential on par with our ITS business segment. And there's one more thing: new business in DME often has a defined value. By that, I mean that we agree at the onset to rent a certain number of pumps for a defined period and a defined price, or that we agree to provide biomed services with an agreed fee per device for labor and parts. This means when we sign a new contract to provide DME services, we will know before the contract has even signed how much revenue we can expect from the new relationship. This also means that the timing of a material new contract will have the potential to affect our results for a particular quarter. In InfuSystem, our culture has and will continue to manage the business for the long-term creation of value. We will resist the urge to manage our results by pulling business forward. We will manage the potential of periodic lumpiness in our business by disclosing, to the extent we can, the status and timing of large new contracts. We thought the 800-hospital contract will be signed before year-end. The delays are not completely related to COVID, although I'm sure that has contributed. We believe the delays are the result of working on a complex agreement with a very large and complex organization. This is a very big deal for us, but a very small deal for them. Although it hasn't worked on our time frame, it certainly will be worth the wait. We are ready and anxious to start and plan to provide updates and disclosures as we make progress. And I should note, the big contract is not the only opportunity we are pursuing in biomed services and DME. We are currently doing work related to 3 agreements recently signed with GE Healthcare. We expect approximately $3 million in annual revenue under these contracts, and the work includes device maintenance, inventory management, and repair services for some of their hospitals. As we continue to grow our capabilities, we continue to see rising demand for our expertise and high levels of service from some of the largest health care companies in the world. Our motto is safe, smart and trusted, and we are increasingly seen as a company with the skills to solve problems and facilitate quality care, whether that involves our ITS turnkey solutions or our DME suite of products and services. Before opening the line to questions, I think it's important to emphasize that while I've spent significant time this morning talking about material developments in our DME business, none of it is intended to take away from our continued opportunities in the ITS business segment. Omicron stole some of our momentum last year, but we see '22 as being a very good year for ITS with pain management, expected to take the lead in delivering solid top line growth. This is, in part, due to the 3-year exclusive agreement with a large West Coast health care provider. For the year, we currently believe ITS will match the strong growth forecast in our DME segment. Together, our 2 business units are currently expected to drive an aggregate of 20% top line growth in '22, with equal top line contributions coming from the ITS and DME segments. Pain management is expected to be the largest contributor to growth in ITS and the large new biomedical contract is expected to contribute a lot of the growth in DME. This aggregate outlook is, of course, contingent on the execution and timing of the large biomed contract and the return to somewhat normal operations in the health care sector post-Omicron. Once we have the necessary visibility on these matters, we'll host an investor call to share guidance for the remainder of the fiscal year and give an update on our progress. We are working hard not only to regain our momentum in '22, but to grow and extend the potential of our 2 business platforms. We are well positioned to successfully drive operational performance and create shareholder value. And now we're happy to answer any questions.

[Operator Instructions] And the first question comes from Alex Nowak with Craig-Hallum.

I haven't listened to a variety of health care earnings calls so far this earnings season. I think we all get the COVID impacts that we're seeing in Q4. But I think the biggest question here is just besides Omicron, what has changed from November's Q3 earnings call through the end of this quarter? You made it seem like Omicron was the big piece of it, but you said it's not only Omicron. So I'm curious what else changed?

Yes. So Omicron is definitely the biggest piece of it, right? That slowed down elective surgeries, which impacted our pain management business. And it definitely impacted our wound care business in a little bit different way in that when nurses are kind of struggling and there are 7 instead of 20 nurses in a facility, they're just not making decisions, and executing on agreements, and bringing in new devices. And that was a big deal for us because we were relying quite a bit on some big wound care device leases that we expected to come in December. Part of the slippage was because of Omicron, people out, not available to sign, and part of it is just a timing thing, right? It just didn't happen to fit with our quarterly target, but we expect those to come in very shortly, actually here in the first quarter of this year. So it's just something that got pushed to the right a little bit. So a big part of it is definitely Omicron, and some of it is just timing of working with big facilities, and big leases, and big deals similar to the contract, the big biomed contract. It was kind of out of our control, but it's still a deal we're working on and we expect to get. But Omicron is definitely a big piece of it, especially in pain and wound care.

Okay. Understood. And actually on that big DME biomedical deal, I mean I think last quarter, I think we all thought that the deal was pretty much done. I guess I'm trying to figure out why it seems that, that agreement is a little bit further off than originally expected in November? Was this a pushback from the big device company that ultimately led to delays? Do you combine that with COVID, and that's why it's being pushed out a little bit? And then when you take that 20% growth guidance, is that deal included in that number? Or what is included there?

So that is, let me go kind of in reverse. So it is included in the number. If for some reason, it fell apart, we have the team in place to go out and work on other agreements we could bring in. So it's not the only agreement we're working on. To answer your question about why did it slip and why is it pushed out that far, nothing has really changed. All the terms and conditions are agreed to. It's literally just a matter of getting their legal teams' time and focus. I think when you guys see the name, you'll know why it's taking so long. So part of it, we are into the holidays. Part of it is COVID, and part of it is just dealing with a big company. But our confidence in getting it hasn't wavered at all since November. So we're still in the same position. It's just taking longer than kind of we would hope. It's just not on our time frame.

Yes, understood. And then what did the pain and the wound business run rate end at the end of 2021? The original target, I think, was $12 million to $15 million, so when do you expect to get to that number during 2022?

Yes, I think it was closer to $6 million for -- on an annual basis.

Yes. And a lot of what was in that run rate was those leases. So to answer the second part of that question, Alex, I think -- I don't know if I want to put a date on when we're going to be at that run rate, but it will be pretty soon. It will really be contingent on -- for pain at least, for the kind of post-Omicron surge, we expect to see patients still have torn rotator cuffs and torn ACLs and they need their surgery. So we expect those cases to show up. It's just when do people feel confident to come back to a hospital and when does the hospital turn those surgeries back on. That's a huge piece of it. On the wound care side, a lot of it is tied to the leasing strategy we have to get into the inpatient side of the business, not just outpatient. You kind of need both sides to be successful. And some of those contracts are well over $1 million. So as those hit, we'll start to see the run rate really, really pick up. But most of the growth in ITS this year is combined between pain and wound care, with pain driving most of it. So that run rate should pick up pretty significantly, probably fairly quickly. It's just hard to tell with Omicron.

Okay. Got it. And then just last question for me. This one is a housekeeping clarification item. The press release says the results are preliminary, but it looks like these are full financial statements. So I just want to clarify, are these financial statements subject to change? Or just clarify what is preliminary here.

Yes. We're not fully complete with our audit, so that's the main thing. I would not expect them to change, but we're only about halfway through. So we don't typically have audit adjustments, but after March.

I see. But you want to get the results out or at least the commentary out there now.

That's correct.

Yes. As soon as we -- as soon as we felt we had solid numbers, we have the call. So they'll be finalized in the next few weeks.

The next question comes from Brooks O'Neil with Lake Street Capital Markets.

Appreciate all the color and the answers to Alex's questions. I'm just curious, you mentioned, I think, in the press release, in the preliminary remarks that you also saw a bit of a slowdown in the cancer business, and I was kind of surprised by that. I kind of view cancer as one of those things that doesn't stop for much. So can you just give us some color on what you're seeing in kind of that big business?

Sure, Brooks. That's a great question. So the slowdown there is because people aren't going in and getting preventative care. So there's just less colonoscopies happening. It's kind of like what we're seeing with heart disease and other types of things in health care. People just aren't going to get their checkups. So you see less new patients because there's less diagnoses, right? There's nothing fundamentally wrong with the business at all. What -- we saw this at the end of '19 -- or the end of '20 a little bit, with kind of that second surge. And then early in '21, we saw them all come back. All those patients end up showing up once they go get their colonoscopies and reschedule it. The good news is, in that business, you'll see an announcement, I think it's 2 weeks from today. We signed up one of the biggest private practices in oncology, and we also just signed one of the biggest -- I think, one of the top 3 cancer centers in the country as well. So the oncology business is as strong as ever. It's just we can't control the patients and their colonoscopies and diagnosis. But that will happen. It's just -- it's a timing issue. Again, as Omicron kind of loosens its grip, we should see those new patients start to come back in.

Yes, I just want to add -- we actually grew in oncology quarter 4 versus quarter 4, it just wasn't where our expectations were.

Okay. That's good. I'm always torn in the health care business, whether I should root for more patients to get serious diseases or whether I should be happy that -- I don't think this is a slowdown, but at least you're not seeing it in your business, right, this second. So on the DME side, would you say any of the delays will create pent-up demand here in 2022? Or would you say the delay simply results in lost business that we don't get in 2021 or 2022?

You talking about on the biomed side on the services?

Yes.

So I would say it's pent-up demand. If a pump needs to be maintained this year, it has to be maintained this year, right, based on FDA guidelines and manufacturer regulations. It just means we're going to have to work a little quicker to kind of catch up as these facilities need their devices repaired and maintained. So if a device is broken, it's still broken, we still have to repair it. If it has to be maintained, it still has to be maintained. If we have to take inventory, we still have to do that. So I wouldn't say it's gone forever. I think the timing of the contract does impact things, right? We can only catch up so much per day -- but I think we're fine. I think we're still in the $8 million to $12 million in the first 12 months. And the hope is we get the most -- as much of that as possible this year, just to tie in.

That's great. And then I think you mentioned the potential for some other contracts out there? And would you say your pacing there is related to your ability to scale that DME services business? Or is it more sort of the same kind of phenomenon that you're seeing with the current big contract that's pending?

It's a little bit of both. So I mentioned the 3 GE contracts. So our guys are out working with a good, right, great relationship with a phenomenal huge company. There are other contracts to get. Part of it is when the big one comes in, it's going to take a lot of resources, right? The good news is we're ready, right? We have the guys ready to go and the day of that contract, we put pen on paper. They're going to be booking flights and flying all over the U.S. to repair devices. That's good news. So we're a little cautious of bringing on anything significant before that comes in. But there'll be -- there's some big contracts out there that we're looking to sign. They're not all $15 million a year, but there's some big numbers out there. This is one $15 million contract. There's a lot to be had out there. I mentioned earlier in the call that there's millions of devices in the acute care setting. And with the bunch of hospitals are feeling financially, they're not going to necessarily go and replace them and spend the capital. They want to repair them and maintain what they have. So the opportunity is just growing for us, which is nice. So DME, the biomed side, yes, one contract is going to be fantastic, but that's just a piece of the puzzle here. It's going to be much bigger than that.

Great. And then let me ask you one more question. Obviously, the delays are impacting your growth really on both sides of the business. But the platform you have in ITS, we've always sort of thought there might be more devices, more categories that you can target. Would you say the current environment is such that you're going to be perhaps more cautious in adding another leg to that ITS stool in 2022? Or do you think you'll continue to push the envelope and expand that platform for the future.

Yes. So I don't think we're going to turn a blind eye to new therapies, but at the same time, I think our mantra this year is going to be to focus on executing on what we have in front of us, right? So between biomed services, wound care, and pain, those are 3 huge opportunities for us that are ready to go. I think the focus for this team and this company this year is to go execute on those 3. Now if something really nice comes up and it's the right time, the right product, the right partner, all that stuff, then great, right? We'll think about it. But right now, we have 3 tremendous growth opportunities, like right in our hands, right, within our reach. So that's where we're going to focus in 2022. And as things progress, we'll see what happens.

Great. And I don't mean to belabor this, but Lymphedema, you're still working on, you're still enthusiastic about? This might not be a big contributor in 2022?

Yes, I think that's fair. We're still working behind the scenes to kind of perfect the model and iron out some of the, kind of, go-to-market strategies. So that's still all in the works. It's just not where we're going to focus the team's efforts. We're doing that kind of behind the scenes. So that's really a '23, '24 thing. It's not '22. I think the 3 we're working on today have -- could all be transformative for the company. I think we're going to execute on all 3. And if we do, that's where we start to double the revenue of the business. So we have some great opportunities in front of us. Lymphedema is in that -- on that list. It's just staged differently than the rest of them.

And our next question comes from Jim Sidoti with Sidoti & Company.

Can you just quickly -- you said you have 3 big opportunities. I know one is this big contract on the service side. What were the other 2?

So the other 2 were just the growth in pain and the growth in wound care. So wound care is ready to go. It's just a matter of getting the health care world to be properly staffed, so they can start to make decisions and bring in new products. And on the pain side, they're ready to go as soon as elective surgeries kind of comeback fully online. We've added a bunch of market share in the last 6 months. And as soon as the patients come back in, it's going to really, really accelerate in the next few months. So between pain, wound care, and biomed, all of those can be transformative if they hit.

And how many sales folks have you added for the pain and wound care business in 2021?

So in pain, we went from 3 to 8. So we added 5. And in wound care, we went from 3 to 15 or 16. I forget the exact number. So effectively, we doubled the sales team of almost the entire company, even including well, we didn't add it in oncology, but if you add the totals up, it almost doubled.

Okay. And then one of the things about Omicron is it ramped up very quickly, but it also seems to be ramping down fairly quickly. I know it's very early in February, but are you seeing any indications that things are improving?

So I agree with you, at least the perception is it's ramping down, right? I mean I think we all kind of feel that difference, where in December and January, we all knew a bunch of people that were sick, and now it seems to be kind of phasing out a little bit. I think the fact is in the hospital environment, at least in January, they still felt it. For them, it's more a reality than our perception, right? So I think the health care market is going to take a little longer to recover, but we definitely are starting to see signs of it. We just don't know how fast it will be. So my hope is we still felt the pain in January for sure. But as we're into February here, 1.5 weeks in, it's starting to feel a little better to us. And that's the hope as we move through this month and into March. So it's -- no one can predict Omicron, but the expectation is over the next few weeks, we should start to see the Omicron impact really lessen for us.

And then the last question. You didn't provide formal guidance, but you kind of gave an outlook including the contract, but why not give us guidance without this contract, and then you could always take it up later on when you get it.

We could. I just don't -- I don't want to bounce the number around too much. And I feel like it's close enough time wise that it's worth the wait. We're confident in 20% growth with the contract. And even if we didn't get it, I still think we'll be in the mid- to high teens, because there's enough opportunities out there. We just have to wait until this contract comes in. It's not even the -- well, the contract coming in is important, but it's the timing of it that's as important as anything, right? It's a $15 million a year on a run rate. It's about $1 million a month. So the faster we get it, obviously, the more it's going to contribute. But we want to be conservative and cautious to make sure we have as good of a number for you guys as possible. And we'll give you top and bottom line numbers as soon as we can.

And do you think you'll get this contract in the first half of 2022? Is that the expectation?

Absolutely.

This concludes our question-and-answer session. I'll turn the conference back over to Joe Dorame for any closing remarks. I'm sorry, Rich DiIorio for any closing remarks.

Thanks, Tom. I want to thank everyone for participating in today's call. I hope everyone has a good day, and I look forward to talking with you again when we host our 2022 full year guidance call. Please stay safe, and thank you.

The conference has now concluded. Thank you for attending today's presentation. You may now disconnect.