Good morning and welcome to the AOTI half-year results investor presentation. This call is being recorded. The investor presentation will be in listen-only mode. Questions are encouraged, and they can be submitted at any time by the Q&A tab situated in the right corner of your screen. Simply type in your questions and press send. The company may not be in a position to answer every question received in the meeting itself. However, the company can view the questions submitted today, and publish responses where it's appropriate to do so. Before we begin, I'd like to launch the following poll. I'd now like to hand over to Mike Griffiths. Good morning to you, sir.
Good morning. Welcome to speak to everybody again. I'm Mike Griffiths. I'm the CEO and President of AOTI, and we'd like to be presenting our half-year results. Just wanna remind people initially that, you know, we are a unique company creating a new topical oxygen category in the Medicare space that's focused specifically on delivering what we call sustained wound healing and value-based care. So long-term outcomes in an area of high cost in the Medicare space. So here are disclosures, which I won't read, but you can all read them. As myself presenting and also our CFO here, Jayesh Pankhania , and I'll say one highlight is we've had a robust half-year performance despite what clearly has been a challenging market, particularly in the U.S., and we'll elaborate more on that. We're on track to deliver our revised guidance.
You know, as you can see, grew in the first half of the year 21%, which, considering some of the market conditions that we're dealing with, I think it is quite commendable. What we're doing, as I mentioned at the beginning, is we're establishing a new category, topical oxygen, in the chronic wound space, not dissimilar to KCI did back in the 1990s in establishing negative pressure wound therapy. So I think that's a precedent of the big picture of where we're going. As I say, our revenue growth was strong across all segments despite unprecedented external upheaval created, you know, by the efficiency directives in the U.S. and obviously the Big Beautiful Bill. We'll touch on more of that in the later slides, which obviously impacted certainly aggressively our performance across the two quarters.
But as a company, we've been pivoting and adapting proactively, and targeting where we can drive revenue in the short term while not forgetting our bigger strategic growth opportunities. I think some very encouraging news was we had three validation milestones of the longer-term clinical outcomes, you know, delivered by a therapy from various segments around the world. The first being, we were able to gain our California Medicaid provider ID, and California not only being the most populous state in America, but also the most populous Medicaid state with over 15 million or close to 15 million Medicaid enrollees. Separately, we gained coverage recommendation from G-BA in Germany, and this is the national agency in Germany similar to CMS in the U.S.
This is an evidence-based assessment of our therapy, which obviously is very complementary endorsement to what we're trying to achieve in the U.S. Likewise, we received in the U.K. a NICE treatment recommendation for our therapy, which again is based purely on the quality and the quantity of the clinical evidence. We believe these all set nice strong precedents for what we believe will be a positive recommendation in the future from CMS. If I want to then highlight the sort of framework behind what we believe will give us long-term profitable scalable growth, the first thing is the sector that we're playing in. Chronic care consumes about 90% of all healthcare spending in the U.S. and somewhere around 70% of European countries.
And we are creating a new category which is gonna allow us then to drive our more durable healthcare benefits to the different stakeholders. This market is large and expanding. You know, chronic disease and certainly, you know, diabetes and obesity are expanding at epidemic proportions. So again, it's an opportunity that we can take on. And we clearly are the market leader in the topical oxygen space, but also in delivering long-term clinical efficacy. How have we established that? That's 'cause we've a product offering that's differentiated by all other topical wound oxygen therapy because it not only has significant clinical benefits, but because of the more durable healing results in less resource utilization and significant cost savings to the payers.
We focus on hard-to-heal wounds and particularly diabetic foot ulcers 'cause they are the highest spend area in healthcare, and we'll touch on that more in a minute. And I said we are uniquely positioned because we are not only just a manufacturer, we're actually a provider. We go into the patient's home, we deliver the therapy, and engage with the patients in value-based care to address the clear objectives of the U.S. administration, which is to reduce cost and deliver patient-centered, outcome-based care. We continue to make strategic investments in the growth drivers for the business. So even though we have obviously, you know, one eye on delivering the short-term performance, we want to make sure we invest in the future. And the future is expanding access to our therapy to more providers and payers.
We see through our Medicaid strategy, which is gonna give us a springboard then to drive forward the broader national reimbursement that will come with CMS approval, which is clearly transformational. We believe we have good confidence. The predicates we have seen in Germany and the U.K. really align well with what expectations on what will come from CMS in the near future. Now I'm gonna pass it over to our CFO to walk you through some of the financials.
Thanks, Mike. So the first thing to note is revenue grew across all of our business segments. Q1 growth was really strong at 26%. However, by Q2, that growth had reduced to 16%, and that's a direct result of the disruption caused by the efficiency measures in the U.S. and the Big Beautiful Bill. Overall, we grew 21% on revenues, and I'll come on to these other areas in subsequent slides. So just sticking with revenue, as I mentioned, 21% year-on-year growth. The biggest contributor to that was Medicaid, which grew 57%, and a contribution of $5.1 million, and the biggest item within that category was New York City, New York State. The VA grew 2.4%, and the other segment grew 0.7%, which was mainly improvements in the Gulf Region. Taking a longer-term view of revenue, you know, revenue has primarily been driven by the VA and New York Medicaid.
Looking at the VA, firstly, we've had consistent long-term growth. However, the impact in Q2 actually showed us declining between H2 2024 and H1 2021. However, near-term, it remains our main source of revenue, with increased penetration. Medicaid has grown strongly over the longer term, and remains robust. It's underpinned by New York Medicaid, which uniquely has mandated coverage policy, and Mike will get into some detail around what that means later on. We also expect New York Medicaid to be another main source of revenue going forward in the near term, again, through expanded penetration. Our other segment is more early stage, and it encompasses sort of international and distribution.
It's gonna be a marginal revenue contributor in the near term, but this is where we're making validation and progress of our therapy in places like Germany and the U.K., which we hope will be a good reference for things like CMS. Mike will give a bit more color about that later on as well. From an Adjusted EBITDA perspective, you know, longer term, we expect to achieve operational leverage. In the period, our Adjusted EBITDA declined from $3.4 million last year to $3.1 million. That's as a result of the headwinds in the U.S. healthcare system. We have invested in growth through investing in sales and sales support headcount, which will drive sales in future periods. And some cost includes an increase in the non-cash CECL provision, which should unwind once the Arizona debt situation resolves itself and receivables reduce.
Again, Mike will provide some color later on what that means. On a cash and debt position, we increased our debt facility judiciously to help us with, you know, our cash needs in the near term. Our SWK facility has increased by $11 million to a total available facility of $19.5 million. We achieved that at a lower interest rate and longer amortization period. Our modeling shows we've got headroom against all our government tests. Our operating cash flow was negative to about $4.7 million, and that's mainly due to an increase in the Arizona debtors. CapEx investment was around $1.2 million, which is a combination of our Eyes on the Wound investment, which is an app under development that reinforces home-based care, and the remainder is our controllers and concentrators, which we use to deliver our therapy.
Finally, just to say that, you know, we're on track to deliver our revised FY25 guidance with revenue expected to be in the mid-teens and Adjusted EBITDA margin to be low double digit. I'm happy to say that trading post-period in July and August has been consistent with this guidance. I'll pass back to Mike now to do the business overview.
Thank you, Jayesh. So I just wanna remind people about, you know, our product and what differentiates us from others in the wound care space. We have a unique multimodality therapy that combines oxygen compression and humidification. It's that combination that gives us very consistent outcomes in all types of chronic wounds, and our evidence then that supports that is second to none. We have state-of-the-art award-winning double-blinded placebo-controlled trials, RCTs, that show we're six times more likely to heal diabetic foot ulcers at 12 weeks, but probably most importantly, that the quality of healing, the durability results in a sixfold lower reoccurrence over 12 months. So that great, great quick clinical evidence then results to real-world evidence that says if we keep these wounds healed longer, do we have less resource utilization?
We're able to demonstrate over an 80% reduction in hospitalizations and 71% reduction in amputations in these patients over 12 months, which, yeah, you can imagine, results in a significant cost saving. The two segments we're focused on most, even though we are regulatory approved for any acute and chronic wound, are the lower extremity wounds and diabetic foot ulcers being the prominent one here. Diabetic foot ulcers can consume a disproportionate amount of healthcare resources, but sadly will affect about a third of all diabetics in their lifetime. Many diabetics, about 50% of these ulcers become infected, and the leading cause of hospitalization for a diabetic is an infected diabetic foot ulcer. Sadly, as many as 20% end up being amputated.
Looking at the cost of diabetic foot in the U.S., they spend about $230 billion a year managing diabetes, and one third, nearly $80 billion of that goes towards managing the diabetic foot. It's an enormous burden, nearly as much as we spend on cancer in its entirety. In the U.K., that actually represents 1% of the NHS budget, of $192 billion, is spent on managing diabetic foot, so enormous burden additional to suffering for patients.
Now, if we look at the quality of life for patients, not only does it affect their ability, their morbidity, their ability to live their lives, but also if you look at the study below where they compared the five-year mortality of diabetic foot ulcers and resultant complications and amputations to that of various cancers, you can see that you have mortality as bad as the worst cancers. So it has enormous impact on quality and quantity of life and suffering and cost for the system. Venous leg ulcers, by contrast, are ulcers on the leg, less on the foot of patients with venous insufficiency and are characterized by a lot of swelling and edema, and 60% of these are chronic. You know, they don't correct themselves and they become refractory. Only 60% ever get healed in 12 weeks.
Out of those, three quarters reoccur within three years. These are the most refractory and cost-consuming wounds over longer term seen on the leg. We have equal efficacy demonstrated there, and we are commencing or have commenced, and I'll be working through a randomized trial of similar quality as what we have in the DFU space, to prove the efficacy to payers in a similar manner. If we talk about how we've taken the product to market, most companies wait until they have what they call Traditional CMS, Medicare coverage and codes to enter the market. We, because we had had good progress prior to the IPO in both the Veterans Administration in the U.S. nationwide, but also had clear coverage policy in place, and New York State Medicaid was able to start marketing into these sectors prior to that Traditional CMS coverage.
As you know, historically, we've been growing for six years at over 30% revenue, even prior to having CMS in place, predominantly coming from these sectors. Where we are at the moment then is in phase II, where we decided we would take this cost-saving, health utility story to state Medicaid, where you have managed care insurers that can make their own decisions on what they wanna cover. We, the first step in that is you have to get the ability to get provider IDs to do business in each state Medicaid. We've now been actively pursuing this in more states. Now 13 Medicaid states where we can do business. You'll see in a moment Arizona being one of the first, which grew quite significantly early on.
And as you can see, this allows us then to build infrastructure, but also to have relationships with payers and providers in more and more sites so that when we get to phase III, where most people would only start their business, marketing, which is full CMS coverage, which allows us access not just to Medicare, but will cascade down to improve traction and access into Medicaid and to other payers, we'll be able to hit the ground running more effectively. Today, as I said already, 75% of our revenue has come predominantly from our contract in the Veterans Administration nationwide and New York State Medicaid, with clear coverage policy that exists for our therapy. However, the VA is the first area we started seeing some headwinds from the efficiency exercises being done, you know, by the U.S. government.
And that resulted predominantly in significant headcount cost and upheaval in the VA, which slowed down the processing of our purchase orders and certainly, you know, ended up with more cost scrutiny, where obviously when we're able to present our science and data, we have good outcomes. What that's done then is it obviously been short-term disruption in the VA that we're beginning to see subside, and we expect, you know, continues to subside progressively across the rest of the year. But it's also spurred the focus on more Community Care, which is where the VA allows veterans to seek care outside of their facility system in the home care environment from other prescribers.
As we're able now to navigate to those prescribers, it allows us then to create advocacy with prescribers for the therapy for not just Community Care patients, but also for Medicaid and managed Medicare down the line when it comes down the pike. On the New York Medicaid, where the therapy is mandated and we've not seen, you know, issues with insurers paying, there has been a slight knock-on we've seen in timing, but certainly not significant compared to that in other states. That's driven by the overall challenges that U.S. health insurers have faced with regards to miscalculating, you know, their expected medical loss runs this year, resulting, as you've seen in the press, most large U.S. health insurers either retracting completely their guidance or at least reducing it significantly for 2025.
So our commercial strategy then is to continue to invest in the channels to grow the business, but also allowing us to pivot and execute in these paying areas more effectively. And that involves driving key opinion leader awareness, working with academic centers that have residency programs across the VA and the private sector, and then driving this market awareness of the therapy in general, and better focusing of our sales force to then execute on that. If we look at every other Medicaid state outside of New York, currently there's not coverage determinations for our therapy. So we rely to do business on our prescribers, on the physicians to write orders for the therapy saying this is clinically necessary.
Then we work, and we've been successful historically with the payers in that state to pay for the therapy based on the clinical and the cost saving outcomes. Before the BBB Act, you know, the Big Beautiful Bill, which was an attempt for the federal government to cut back their support of Medicaid, their contribution back to more historical levels, we were finding good progress. An example of that was in Arizona and the growth we saw there and growth we were beginning to see in some other states where we have provider IDs.
However, since the Big Beautiful Bill, it's thrown a lot of focus with both state agencies and insurers on trying to work out how they're gonna cover the shortfalls of Medicaid as a whole, such that their focus on us and working, you know, through our claims has become more secondary and certainly has slowed our short-term ability to drive revenue from this sector. Hence, we expect the majority of our revenue and growth will continue to come from New York Medicaid, Arizona Medicaid, and of course the Veterans Administration in the near term. But what we've done by setting in place all of the infrastructure and momentum with other payers in other states is we've driven our ability to lever for the future our growth.
Now, specifically talking about Arizona, Arizona has been, you know, hit with all the same problems under managed care insurers with regards, as I mentioned earlier, their medical loss runs, which has caused all of them to do anything they can to slow down payment and exposure in this calendar year. However, it's also been the epicenter of another, a number of other events, and you know, the first one being about a year ago, the Change Healthcare cybersecurity breach, which is the main processing entity for all claims for all insurers, which definitely threw up the ability to process claims into upheaval. In parallel, the state went through its seven-year recontracting of its contracts with managed Medicaid insurers, with all of the current insurers losing out to the new awardees, which then was challenged and subsequently was temporarily reinstated.
There's a whole degree of uncertainty in these payers of whether they long-term will be managing these patients. On top of that, this was sadly the epicenter for the cellular tissue-based product fraud and abuse issues, which the DOJ and Department of Health in the U.S. has focused heavily on, to you know, a lot of them, sadly, of the abusees being there in Arizona as well and in Medicaid. Last but not least, the Medicaid director resigned over half a year ago. Because of the structure, they haven't been able to yet appoint a new director. It's a state that has split, you know, control being the legislature Republican control, and a governor being a Democrat. It seems to be neither of the two can meet these days.
So what we're finding is the effect of this has been, you know, significant reduction in time of payment of our, sorry, extension and time of payment of our claims. And all of our claims where we have provided service with prior authorization are taking longer to get paid, although some of the longer ones have now begun to be paid. And we're seeing movement there. We continue actively to engage with the Medicaid insurers directly and with the agency to resolve the issues. And obviously with the work that we're touched on in the moment regarding CMS and the activities regarding getting national coverage, which will cascade through to all of these payer groups, particularly the state Medicaid agencies that tend to use that as a predicate for coverage determinations.
The board believes it's prudent to continue to service patients in the short term here until our resolutions come into play, and likewise, you know, as we said earlier, you know, Arizona is a material contributor to our financial success, being about 50% of our business overall. What, where are we on CMS? Firstly, CMS is transformational for the company when it happens, 'cause it will not only open up the whole Medicare sector, which is fee for service and managed care, but it also would transcend through the fee codes will be transmitted down to the states and to private insurers. In most cases, as I mentioned earlier, most of these insurers, including the state agencies, make their coverage determinations to mimic what CMS makes. They use them as the gatekeepers.
So we will see not only uptick and momentum in Medicare, but we will see it also accelerate our ability to do business in all other areas as well. You know, how confident are we of where CMS will make a decision? Well, obviously we believe in the quality of our evidence, the second to none, and we've had some really good milestones that reinforce those beliefs with provision of our California Provider ID that have given us access, as I mentioned earlier, to as many as 15 million Medicaid enrollees in California. As we announced recently, our positive treatment recommendation from G-BA in Germany, which is the equivalent of CMS in the German market, and the positive NICE recommendation in the U.K., which likewise is an evidence-based assessment like G-BA, which is exactly the process that CMS followed.
You know, we cannot, you know, obviously, you know, determine exactly the timing of this, but we know it's under review and we know these are good predicates that should help and influence a positive decision. As I mentioned earlier, though, the work that we've done in building out market access and investing in our channels in the managed Medicaid and also in the Community Care VA space has allowed us to build a large infrastructure that we can then take advantage of. Now, just to clarify the process in a little bit more detail that CMS goes through, because there are a number of steps. CMS are mandated by law to make a reasonable and necessary determination as to whether to cover the therapy in that space purely on evidence, randomized controlled trial evidence that demonstrates efficacy.
As you know, we have second to none quality of evidence. We, on our behalf, a team of key opinion leaders submitted a coverage request back in the summer of 2023 for coverage of topical oxygen therapy. The DME MAC, which are the body under CMS required to review this because we are a therapy that goes into homes, so it's classified as durable medical equipment. These are the people that are mandated to make that decision, accepted that as a valid request, meeting all the statutory requirements for them to review in July of 2023. It was not until December of 2024 that we know they actively started reviewing the request for coverage determination with a coverage advisory committee meeting towards the end of the year.
Since then, this is where we sit today. They are considering then completing their review and coming up with what their coverage determination and policy will be. The next step will be when they publish a proposed or draft Local Coverage Determination, which will cover the whole country. At that point, there will be a 45-day public comment period, after which they can complete their analysis and input to come up with a final rule, which when published after 60 days becomes a rule and law. It will then cascade out through the fee schedule to all payers. So again, it will not only allow the code to be accessed, but it will set a predicate that's commonly used by all payers to make their own coverage determination on state Medicaid and in commercial care as well.
So when that happens, this will allow us to then take that market access that we've done and the leverage, the infrastructure. And here you can see on the map the 90-odd direct reps we have, and we have equally that many support structures in place as well in the U.S. across the different states. The light blue states are the states where we already have either Medicaid provider IDs or we're in the process of gaining when we believe we'll gain over the next year. And it accounts for about 86% of the U.S. population.
So we believe we're uniquely positioned that not only we're to expand market access through the VA into Community Care, but also to expand where we can work with dual eligible plans within Medicaid in the short term to gain business and traction, but also uniquely positioned that when Medicare coverage comes down the pike, that we can hit the road running and have a faster ramp than we would most companies waiting just for Medicare to happen. So to summarize, we're a company that's focused on delivering durable wound healing and value-based care. We saw in the first half year growth across all sectors of the business, delivering over 20% growth in unprecedented U.S. market conditions, you know, which I think, you know, is quite exemplary considering everything that we're challenged to deal with, like our peers.
We've continued to establish topical oxygen as a new category and clearly are the market leader, not dissimilar to what KCI did in the early days. In the near term, we expect predominantly our revenue will come from the VA, New York Medicaid, and Arizona Medicaid. We believe that the continued efforts we're doing with state Medicaid payers and insurers will not only gain dividends progressively in the Medicaid sector, but will give us a framework and a structure of providers, 'cause all of the providers that are seeing Medicaid patients or Community Care patients in the VA are all seeing Medicare patients. So we'll be able to hit the road running as soon as that comes down the pike.
The recent news, both in Europe with NICE and G-BA in Germany, of evidence-based decisions to cover our therapy, I think sets great precedents for CMS. We said CMS will be transformational 'cause it won't only just drive Medicare, but it will drive all these other sectors that we're in. Additionally, we're on track to deliver the revised guidance for 2025 with good supporting performances in July and August consistent with that. We do believe then as we open up more of these higher paying sectors, that we will start seeing, you know, the leverage come through and that we will return to much higher margins. We see these headwinds today that we're facing as transitional.
We are uniquely positioned to deliver effective outcome-based care to patients at home, which tie in perfectly with the administration's focus to reduce costs and deliver patient-centered value-based care. So our belief is these headwinds, which is really transitory, you know, disruption to business today, will turn into tailwinds in the future and, and prepare us to faster and higher growth, as, as time progresses. Okay, well, thank you very much for listening. And I think we'll take a look then at the Q& A.
That's great. Well, Mike, Jayesh, thank you very much for your presentation. Ladies and gentlemen, please do continue to submit your questions. You can do so just by using the Q&A tab that's situated on the right corner of your screen.
But just while the company take a few moments through the questions that have been submitted today, I'd like to remind you the recording of this presentation, along with a copy of the slides and the published Q& A, can be accessed via your investor dashboards. What I'll do now is I'll hand back to the team to run through the question, and then I'll pick up from you both at the end.
Okay, thank you. So our first question we have is, how do you plan to balance margin discipline with continued investment in sales execution and international expansion?
Do you want me to, when you first double up, do you want it?
Yeah. So, we invest in expansion across states, and make sure that we earn a good return on each of our investments.
So if you look at our gross margins, they're very, very high at almost 90%. Executing in those, in expanding into each of the states, it's becoming a bit of a cookie cutter. As long as we get reimbursement, we should be able to drive that return to the bottom line. On the international side of things, we're developing a market that will likely in U.K. and Germany be similar to the U.S. model, and we're in the Gulf S tates, we're likely to be a distributor-based models. Again, but all three contributing to good, strong returns on investment. We have a process to analyze that and make sure we deliver that over the medium term.
Okay. Next question is, you have 13 Medicaid provider IDs, and New York is driving most of the growth so far.
When do you expect other states to start contributing in a more meaningful way?
So yeah, before the sort of more recent, you know, headwinds, you know, driven predominantly in this case by the, you know, the BBB legislation and the Medicaid reduction of federal support of Medicaid. And I think to put that, you know, in the framework that what they're trying to do is bring it back to what the program was meant to be, where it's meant to be 50/50 state and federal support. And since the expansion of Medicaid has become predominantly federal support of it, so it's not like they're trying to think to do too radical, but any change creates temporary disruption.
Before that, we were seeing that if we, once we got Medicaid IDs, we would work then, obviously we, with advocacy, with prescribers in the state, they would, you know, prescribe patients, and we would then work individually with the insurance to get paid. And we were getting consistent traction and the growth that we saw in Arizona, I think is a good example of the trajectory we can achieve there. Obviously with this bill, the these state agencies and providers are all distracted with, for want of a better, bigger problems in their own house. And they're focused on dealing with those issues. So us to be able to get that traction with them is slowed down. Hence, you know, we're doubling down a little bit of our resources on the areas where we can predict consistent revenue, you know, moving forward.
What happens though, by opening up a new state and putting in place resources that we have on the ground, because of our VA nationwide infrastructure, we have headcount in all of those states we identified. So what we're able to do and some of the changes we've done is pivot those sales teams to not just deal with VA business, but also to deal where appropriate with Community Care VA out with prescribers, also see other patients like Workman's Comp, where we get paid well for at the moment and manage Medicaid.
So by doing that and doing sort of a parallel strategy, not just having dedicated sales teams, we can utilize and get the best return on investment, but also we create those prescriber relationships so that as we move past this year and we believe these transitory headwinds settle down, even prior to CMS, we can start driving more of that Traditional Medicaid revenue. And then hence, once we get national coverage, it will cascade down and we'll have an infrastructure ready and prescribers knowledgeable and adopters of our therapy to drive that business forward.
Thanks, Mike. So we've had a number of questions around Arizona and the debt position and our views on collectibility of debt in Arizona.
So, you know, we're assuming that in our sort of internal models, we're assuming that there's gonna be minimal collection from Arizona this year. Okay. But we're expecting Arizona to start to unwind and start to collect over the course of next year with the majority of it being collected by the end of next year. That gives us quite a long runway to collect all of that debt. We have got, as I mentioned, in the presentation, we've got a facility with SWK Funding of $19.5 million. Although, we've drawn down all that, our cash balance is at $14 million at the half year. We've got quite a long runway to help us weather these debt stops.
One thing to add is, you know, we believe it's prudent for us to keep focusing. We are delivering service. We are delivering it based on prior authorization from the insurers. So, you know, like us and auditors, we all believe that this debt, you know, is recoupable and will be paid. And at the moment, you know, we believe as a company and as a board that we, because of where we are with the direction, you know, looking positive towards national coverage determinations, we really want to make sure we're prudent in not, you know, shutting down the market, that then we would have to ramp back up and potentially have a knock-on effects in bigger picture things going on.
So, you know, we believe at the moment the correct thing is to continue to service those patients, making sure we have adequate headroom, you know, to weather the debt in the short term.
Thanks, Mike. So what role does innovation or pipeline development play in supporting AOTI's medium to long-term growth strategy?
I think most of the projections that we have at the moment are based around what we have today. So we've based it on the product range we have for extremity wounds. So we have different versions of the chamber for smaller wounds, larger wounds, you know, venous leg ulcers, DFUs. But we've, what we've been doing, expanding that product line, and we have versions of the product that can be used on the body, you know, for pressure ulcers.
And we're just releasing actually this month a version of the product that allows us to go after surgical incisions and other areas, you know, which haven't been a focus point. So our predominant view is that these line extensions are opening up new sectors and they're not yet built into our financial modeling, you know, so they're all upside should they, and when they come down the pike.
Thanks, Mike. So just looking at the questions, the next question is, there's a question on, do you believe we have sufficient capital to see the headwinds? And I think answered that previously, we do. How is the therapy actually delivered? What is AOTI's practical involvement with the patient?
So depending on the market, but where we are direct, for instance, the U.S. and the U.K., what happens there is a prescriber orders the therapy.
We then take the therapy. We have, you know, representatives that go and set up the patients, that train them how to use it in the home. Then we engage with the patients with our Eyes on the Wound, the apps and stuff, because the key is when you deliver therapy at home is that patients use it. That allows us to engage and encourage and make sure they use it adequately, but it also allows us to capture information and feed this back to the prescribers and the payers, which closes the loop on value-based care, which is also usually very difficult to do. We're directly involved with the patients. We're not doing, providing anything clinically. We're training them. They're applying the therapy themselves. It's very simple, but our job is to make sure they utilize it at an adequate rate.
And if they don't, to work with the prescribers to encourage them to do so, which is very, very important, you know. And we are uniquely positioned that that beachhead we have as not just being a manufacturer selling to a channel, but being the actual provider to the patient at home, allows us then the ability to, you know, believably and provability-wise, deliver value-based care, something that everybody wants to deliver, but it's hard when you don't have control of that part of the channel. It also opens us up for the future to deliver more than what we're doing today. So we wanna walk before we can run, of course. But obviously, you know, these patients are co-morbid with lots of chronic disease. So in the future, we have the ability potentially to do more holistic care should we so choose to.
Thanks, Mike.
So we've got a question on employee headcount, and questions around, you know, where do we think we can get the margins to in the longer term. I sort of answer that in two ways. So right now we've got about 150 employees, about two thirds of which are in either sales or sales support slash operations type activity. So delivering, you know, for the customer. So the way we think about operating leverage is that the sort of the cost of the business, the headcount won't rise in proportion to revenue. And that in the longer term, you know, we we'd expect margins into the sort of 20%-30%, you know, EBITDA margin in the longer term. So that's kind of where we, how we think about it.
There's a question on adjusting commission terms, how it will help with data buildup, but I think it means on operating efficiency. I think it would mean. What we've done is we've introduced as part of helping to drive growth and productivity and again then get to higher Adjusted EBITDA margins is we've introduced a new commission scheme. We will be introducing it in Q4 onwards. What we found was that we had, you know, a fair number of stars in our sales population, but there's also a fair chunk of people who could be more productive. We've devised a sales commission scheme, which incentivizes the, shall we say, bottom third of performers to perform more towards the middle ground and to the top ground.
It really incentivizes overperformance, more than it previously did. And we think that will drive productivity and enhance the margins going forward. So just looking for new. I've got new questions, but they're very similar to what I've already answered. Talked about innovation. Do we know how far through the drafting process of the LCD, DME MAC medical directors are?
So, I mean, the fact that they've considered. They've conducted a Coverage Advisory Committee review back in December and that since then, you know, had discussions with other stakeholders, which we're aware of. We believe that they're well along, but we obviously have no direct insight as to timing and when they will come through.
You know, obviously there's a lot of activity in the wound care space with CTPs and you know, resolving you know, the release of the Local Coverage Determination, which is you know, January 1st should become active, but also in reimbursement and pricing. So, you know, our best guess is you know, that that's the focus of the administration at the moment and this may be will be sometime after that, but you know, that's just a guess at this point. We know they're actively working on it, but that's what we can say.
Okay. Thank you.
There's a question on, given the poor share price performance, are you considering going private? I think the short answer to that is no, we're not.
You know, we believe in keeping the company public and, you know, we chose AIM for the positive reasons of being a smaller company and having that focus, you know, on AIM and appreciate the price has come down, but we are expecting that, as we continue to deliver the results and as the operating leverage is delivered, the share price will go up. Any, anything?
Yeah. No, and I think, you know, obviously we are all disappointed in where the share price is. We think we've had great momentum in the strategic direction of the company and the big value drivers.
Obviously we faced headwinds like everybody else in the short term, but still delivered 21% growth, which I think when you look at our peers is superior to many of them, all of which are dealing with the same headwinds, which are transitory. So I think if you take, you know, an opportunistic look at it, I think the opportunity of where we're going and where the value should be to where we are today, I think there's a great, you know, investment, you know, proposition for people who are so inclined.
Yeah. Absolutely. Then, just one more question around the revenue impact in 2026 of California, Germany, and the U.K. So I think, should I have a crack and then you can jump in if you want to, Mike.
In terms of California, you know, we have our provider ID and we'll look to get insurance coverage in that state. It is our home state, so we would expect some traction to be made there. But I think, you know, with Big Beautiful Bill, there are some headwinds as well. I think we will start to see some modest revenues in California, but it's really too early to say how fast that could ramp until we have a bit more experience of that. With Germany and the U.K., I'll take Germany first. We've got a G-BA approval, which is a clinical approval. The next process is with a subcommittee of the G-BA and IQWiG process, which is more around pricing.
And then a final process called the GKV process, which is to actually get a reimbursement code and reimbursement in Germany. That's still a little bit more longer term. However, just having G-BA approval does mean we can talk to insurers to get coverage without that, you know, mandated at the state level. So that should help traction. But again, we're being a little bit cautious at the moment. So we should see some growth there the next period. And similarly in the U.K. with a NICE approval, we should start seeing some better traction there. But again, being a bit cautious there.
Yeah.
And I think the big thing in the U.K. is that in parallel, we are also as of September 1st on the NHS framework and we've seen, started seeing actually our first orders come through 'cause now we're in the system, should we say. So, you know, we do believe we'll see some sort of gradual increase in the U.K. 'cause it, you know, it doesn't happen overnight. But I think both of those should contribute progressively more next year and as time goes on. Yeah. Thank you.
Okay. Any more questions?
Okay. Okay. Well, Mike, Mike, Jayesh, well, thank you very much for answering those questions from investors. Of course, the company can view all the questions that have been submitted today and we will publish the responses on the Investor Meet Company platform.
But just before redirecting investors, provide you with their feedback, which is particularly important to you both. Mike, could I just ask you for a few closing comments?
Yeah. I think firstly, we, we are doing something different. We, we are out in the market prior to traditional Medicare coverage in the U.S., and we've been successfully growing the company at over 30% compound growth for six years, and why? Because we have a differentiated product offering that now that CMS, one of the better words is catching up, 'cause that process just takes its time, will allow us to cascade with the normal momentum seen with, with other companies in the market, and, you know, to deliver, you know, you know, for the first half year, over 20% growth in the current unprecedented external, you know, environment in the U.S.
And obviously with these big value drivers, you know, we believe somewhat imminent, we believe this company is an excellent opportunity for future growth, and, and profitability.
That's great. Well, thank you once again for updating investors today. Gonna please ask investors not to close the session as you now be automatically redirected to provide your feedback and the management team can better understand your views and expectations of the management team. AOTI. We'd like to thank you for attending today's presentation and good afternoon to you all. Good afternoon.
Thank you everyone. Thank you. Bye-bye.