Well, good morning, everyone. My name is Jonathan Leon. I'm the Corporate Treasurer and Head of Investor Relations for Owens & Minor. It is my pleasure to welcome those of you here in the room with us in Boston, as well as those of you who's joining us via webcast, to the Owens & Minor 2023 Investor Day. Before we open our presentation, I wanna remind everyone of our safe harbor and forward-looking statement language. During the day, we will be making forward-looking statements. Owens & Minor can give no assurance that any forward-looking statements will, in fact, transpire, and therefore, we caution investors not to place undue reliance on them. Please see our SEC filings on Forms 10-Q and 10-K for a description of risks and uncertainties.
Also of note, our presentation today does contain financial measures that are not calculated in accordance with U.S. GAAP. You can find reconciliations of our non-GAAP to GAAP figures, as well as modeling assumptions in the back of this presentation that's been posted to our IR website and filed with the SEC earlier today. We have a full morning planned, during which we'll hear members of our leadership team outline our strategy, our long-term operational objectives, and our financial targets. Ed Pesicka, our President and CEO, is gonna lead us off. Then you'll hear from Tammy Gomez, our Chief Human Resources Officer, followed by Perry Bernocchi, CEO of the Patient Direct segment. After a short break, we'll start again with Andy Long, CEO of our Products and Healthcare Services segment. We'll then turn it over to Alex Bruni, our CFO.
After that, we'll bring the whole team together for a Q&A session. Before I turn it over to Ed, I want to begin with a short video that helps explain what motivates our more than 20,000 teammates every day.
When it comes to healthcare, no detail is too small. What happens behind the scenes ensures a future full of potential and helps make each day a little bit better. For over a century, we have provided essential products and solutions that have touched countless lives, working alongside the Patients, providers, and communities we serve to meet each challenge. Equipping the hands that heal, delivering peace of mind, and connecting with compassion, so healthcare stays at the forefront. From hospitals to homes, hope takes a human touch, and every day, everywhere, Life takes Care.
So good morning, everyone. Thanks for joining us in person, and again, those who are on live stream, thanks for joining us, live stream. You know, I'm really excited to be here. You know, really what I wanna discuss today is what is our vision for the next five years? Excuse me. In addition to that, what is the outlook for the next five years? You know, it's gonna consist of our strategy, and our strategy, we're not waiting to execute. We are already starting to execute upon that strategy. So quick introduction: I'm Ed Pesicka. I'm the President and CEO of Owens & Minor. I've been here for five years, and I'm extremely proud of what we've been able to accomplish over the last five years. But I'm even more excited about what the future holds for us in the next five years and beyond.
A little bit about my history. I spent 15 years at Thermo Fisher Scientific, you know, running the Fisher Scientific side of the business, responsible for distribution, had experience in manufacturing, healthcare, and other areas. Let's move on today, and what I want to start with is: What are the key takeaways? Why am I excited about the next 5 years of Owens & Minor? I'll start with the left side of the slide here. First of all, Owens & Minor is a 140-year-old company, but we've evolved, and we continue to evolve. We're not the same company today that we were 5 years ago. Our profit mix is drastically different, with 80% of our profit now coming from our Patient Direct, that at-home business, more of a recurring revenue type business.
In addition to that, our operating performance has evolved and gotten so much better over the last five years in all of our businesses. And really, we've repositioned our company to set the stage for the next five years. It's clear that we have a strategy of what we want to execute on over the next five years, and you're gonna hear about that today. Let me now talk about the next step on this slide, which is our Patient Direct. And look, our Patient Direct, our Patient Direct segment is one of the leaders in the fastest-growing area of healthcare, or one of the fastest-growing of healthcare, that being the home. In that segment, we have a proven model, we have the right footprint, and we have the right product portfolio to continue to drive growth.
It's our expectation that that growth continues at above-market levels, and we're gonna continue to outpace the market and build on the momentum we have today. You're gonna hear about this from Perry later on this morning, and give you a little more detail on that. Next, our Products and Healthcare Services segment. We've made incredible progress over the last five years with our Products and Healthcare Services. We went from a business in 2016, 2017, 2018, 2019, that was losing between $700 million and $1 billion of business a year. We've drastically improved the service, we've changed the offering to the customer, we provide flexibility, and we've made significant improvement. In addition to that, we did that in light of a pandemic, right in the middle of the last five years.
On the right side of the page, I wanna talk a little bit about how we think about the business. The Patient Direct segment, that's gonna be drive margin expansion, that's gonna drive growth, and that's gonna drive additional mix shift within the total company. Again, this segment has a higher margin and a higher margin profile within the business. Our P&HS segment, we expect to continue to improve the profitability of that business and continue to advance that. Ultimately, we're gonna think through and explain how we're gonna time out and pace our investments, so that way we can get the right return as well as success overall. Next, our balance sheet. You know, our balance sheet right now has improved drastically from where it was five years ago.
We were able to deleverage the business, we leveraged back up with the acquisition of Apria, and we've done a really good job over the last nine months of paying down nearly $500 million, or $500 million of net debt paid down in the last nine months. That's because of the continued progress in our Patient Direct business, as well as improvement in P&HS, and the layering on of our Operating model Realignment program. Let me move to the last point, and that's really around capital deployment. Here's the way we think about capital deployment: We're gonna make sure we deploy capital in a very disciplined manner, similar to what we've done over the last five years. We're gonna continue to invest that to position us to provide the best returns that are possible.
So those are the 6 key takeaways you're gonna hear today, and we're gonna talk through. Let me now move on and start with a macro level, a little bit about our company. Who are we? We're a global healthcare solutions company. We supply healthcare products to the home. In addition to that, we produce and manufacture a broad portfolio of products. We've got an incredible medical distribution business that has the ability to scale and lever in a strong channel. We're a 140-year-old company that has continued to evolve over time. You don't last 140 years unless you continue to change and continue to evolve, and we're in that continuing process right now. You look at our footprint. We have over 400 facilities, all in varying sizes through the US and around the world.
But in addition to that, we have 20,000+ teammates that come to work every day, that are driving our mission, our vision, and our purpose. Next, let's talk about scale. In our Patient Direct business, we serve over 3 million patients in the home every year. And in our medical distribution business, we have relationships with over 4,000 healthcare providers. I wanna cover one last thing here, as I talked about the 3 million patients we address within our Patient Direct business every year. With the opportunity, though, for us, is 85% of insured Americans we have access to because of our contractual relationships with payers, whether it's public or private. So that helps set the scale of what Owens & Minor is and where we are today.
Let me take a little step in a deeper dive into our two segments, and I'll start with our Patient Direct segment, and then I'll go on to our Products and Healthcare Services segment. So our Patient Direct segment, it started with the acquisition of Byram in 2017, and in 2017, that business was roughly $450 million. From 2017 to 2021, we grew that business to over $1 billion in revenue. That was all organic. It wasn't acquisitions. We grew the business from $450 million to north of $1 billion in revenue. In that space, then we layered on an acquisition of Apria, which added additional product portfolio.
And what we've been able to do with that acquisition of Apria, combined with our Byram business to create the Patient Direct segment, we now have some of the best positioning in our categories. So what this business focuses on is chronic condition, providing products for those with chronic conditions in the home, in categories like diabetes, sleep apnea, ostomy, incontinence, wound care, advanced wound care. And in the majority of those categories, we're a leader. We're a leader in this space. And our expectation is we stay a leader. But here's what else gets me excited, not just about the great proven model we have, but the entire demographics of that industry, of the industry. We've got an aging population. It's a space where patients, payers, and providers prefer to be treated in the home than in an acute or non-acute setting.
In addition to that, we continue to see that aging population increase demand for the products. You layer that on top of the fact that we've got a proven model that shows we can grow that business, not only grow the business, but expand margins while we do it, is really the model for the future for continued growth within this segment. You know, in addition to that, you know, I'll talk a little bit about this before I close out on this slide, look, within 2021, you know, going into 2022, we doubled down in this space. We made the decision that we wanted to do one of the major acquisitions. We did lever up, but in the same sense, over the last 9 months, we've delevered the business significantly.
You know, in addition to that, you can see from the time of the acquisition to now, we've grown from about $2 billion-$2.5 billion in that segment. Look, the future of this segment continues to have a lot of positivity. We have the ability to leverage our leadership, we have the ability to leverage our proven model, and we have the ability to continue to reimagine how you take care of the patient in the home. And you're gonna hear more about this today from Perry, within the strategy, that he's already beginning to execute and how he's gonna continue to provide that over the next five years. Let me now move on to our other segment, our Products and Healthcare Services segment. This segment has some of the leading brands in industry.
It has the Halyard brand, one of the leading brands in surgical infection prevention products. It has the legacy Owens & Minor distribution business that everyone knows about, that provides great level of service. It's a segment that's about $8 billion, with a little over $6 billion being in medical distribution, and roughly $1.5 billion-$2 billion being in the products part of the business. So here's what gets me excited, and why are we winning in this space today? You know, customers are looking for really three things. They're looking for service, they're looking for value, and they're looking for flexibility and customization to some extent, to help them solve their needs. And that's what this business has been able to do... The other thing you'll hear about is, from Andy today, is really the expansion of our proprietary product portfolio.
I have to be open on this. As a company, we've been talking about expansion of proprietary product portfolio for probably 30 years. We haven't put the investment into it that we need, and what you're gonna hear today is the investment we're gonna put into proprietary product portfolio expansion that can let that be successful. Investment in a commercial organization that has the technical skills to sell the product, investment in category management teams to identify where we need to expand our proprietary brand portfolio, investment in working capital and inventory, so we have the product ready when it's out, ready to be launched. So we're thinking about it very differently than we have in the past, and we're putting the resources there. The other thing you'll hear from Andy, and I really get excited about this: we're thinking different about make-buy analysis.
You know, we don't have to make everything. We're thinking about: how do we become a lower cost to serve? And really, Andy's gonna get into much deeper detail on this this morning. He's actually gonna talk about it after the break, and you'll really understand what we're doing in this space. So let me take a walk through history here a little bit, and then we'll get into the future after this. So I joined the company, as I said, in, in really March of 2019. And when I joined the company and had an opportunity to sit back and look and, and assess the company, there were really five key things we needed to do. And I think about strategies in kind of five-year blocks. We're through the five years, we're on the next five years.
But when I joined, first thing we had to do, we had to fix the medical distribution business. Our service was not where it needed to be. You know, we were not focused on the customer. We were losing significant business. And I'm extremely pleased to say that our service levels now are some of the leading in the industry. We invested in the right technology, we invested in the right approach, we trained our teammates to actually drastically improve that service. The other thing we had to do is, we had to get out and be visible. You know, we as leaders had to get out and be visible, and that's another thing that we did. And I'm really proud of what the team has done over the last five years to really fix that business. But now it's time to build on that momentum.
We even did that in light of a pandemic that's once in a century or maybe once in a lifetime type issue. Second thing we had to do, we had to delever the business. We were at a 7x multiple at one point in time in 2019, so we had to drastically deleverage the business. We did a really good job of that in through 2022, and yes, we levered back up, but again, we're in that next phase of delevering again. We did a really good job of looking at our assets. We did divest some things. We were working on our working capital management, improving the profitability, and we were able to be successful. The next, we had to expand our proprietary product portfolio, was one of the key points we had to do 5 years ago.
Look, you know, I think part of it is being accountable. We didn't achieve that goal. When we had pandemic that happened in the middle of it, where we took resources and redeployed them all to sourcing and manufacturing, expanding our manufacturing, and we didn't focus on this. I think now it gives us an opportunity to step back and look at it and put the right resources into it. You know, that also ties to some of the things we didn't do in that period of time with the Operating Model Realignment and why we launched it post-COVID to continue to take cost out of the business. The fourth thing we had to do from 2019 to now was we had to, I'll call it, insulate and invest in our Byram business.
You know, because of service issues and other things, we wanted to make sure Byram, the Byram division, had the opportunity to grow. We put investments into that. We continued to leverage the proven model that had worked, and again, the results are the results, from $450 million to over $1 billion from the time we acquired it to 2020, end of 2021. And the last thing we had to do during this period of time was change the culture. We had to make sure that we had a focus on, "Hey, we're gonna win. We're gonna be competitive," you know, and we launched two things. We launched our mission, and we launched our values. And there's probably not an event that I go to with internal or people I talk to, where I don't discuss our mission and our values.
Today, you're gonna hear our expansion on that into our vision and purpose from Tammy and how that ties in. So if I think about where we were in 2019, we had a pandemic that really hit us in 2020 and 2021. We acquired Apria, which pandemic actually helped us deleverage the balance sheet. It helped the strategy of repositioning the company. It helped the strategy of adjusting where the profit profile comes from. You know, and then we have industry normalization, I would say, this year, kind of post-pandemic, so that was the perfect time for us in 2023 to launch the Operating Model Realignment. So with that path, let's talk a little bit about some of the strengths we have today and how we're gonna leverage those going forward, as well as some of the channels or challenges, excuse me.
Starting with strengths, I'm gonna start with the first two bullet points on the left-hand side of the page. You know, this slide, the first two are really focused on Products and Healthcare Services segment. You know, Products and Healthcare Services segment has industry-leading service today, as I talked about. We have the scale to leverage. $6.5 billion of revenue in our distribution centers give us the opportunity to continue to grow and continue to leverage in that space. We have the ability to be flexible in our offering because we're not confined or constrained. You know, the other thing that we hear from our customers is really the transparency and being recognized as a strong partner to them. You know, we're gonna continue because of that flexibility, because of the service, help them solve problems.
But again, there's really three things in the acute care space or in the medical distribution they're looking for: it's value, it's service, and it's some level of flexibility. You know, the last two bullet points on the left side of this slide here are some of our strengths is, you know, our Patient Direct business. Again, look at the growth. You can see the growth on here from the acquisition to where we are, and you can see the opportunities we've created with the acquisition of Apria and continuing to grow from pro forma pre-acquisition was $2 billion, and now we're gonna be at $2.5 billion already in less than approximately 2 years. So again, you know, a lot, a lot of strengths we have in the business.
You know, let's talk about the right side of the slide, or some of the challenges. You know, and the reality is, if you take a look at our P&HS segment, there's still a lot of work to do. We still have a lot of operational things we can do that can drive profit improvement and a better customer service profile. Those things are gonna be focused on lowering our cost to serve, in addition to that, expanding our proprietary portfolio. And again, you're gonna hear a lot about this from Andy. In addition to that, the other thing we have to think about, and we're excited about, is, again, we're not thinking about our operations the same way we did in the past. We're looking at our manufacturing facilities, and we wanna run our manufacturing facilities as close to capacity as possible.
If that means consolidating so we can run at capacity, we'll do that. If that means adding technology to move them closer to capacity, we'll do that. And again, we don't have to make every single product that has our brand on it. So we really are thinking about that differently. You know, and then, really, the last couple points here is in the Patient Direct segment. That's a fragmented business, industry, excuse me. You're gonna hear Perry talk about today that roughly the business at a macro level, or the opportunity, is called close to $70 billion. And yeah, that narrows down as you get into our categories, but it's still a very fragmented business throughout the United States.
Perry's gonna talk about our national footprint that we have, but with our local presence, and an opportunity in our Patient-direct business to continue to grow. You know, and lastly, our teammates. You know, we can't get away from our teammates. We want them. They're great teammates, and we have to make sure we continue to focus on them, so we're winning the war on talent, so we can execute upon our strategy. So with that, let me talk about 2028. So there's three key pillars that we're gonna talk about today, and we have them organized by the industry or by the segment, I should say. The first one is our Patient Direct segment. And our Patient Pirect segment is simple. We're gonna continue to outpace the market. We expect to outpace the market by at least 200 basis points.
In addition to that, we're gonna continue to expand profitability by leveraging, but more importantly, we're gonna reinvest back in that business, add additional resources, so we can continue to grow. And then you'll hear Perry talk about some adjacencies and potentially inorganic growth as we de-lever the business going forward. In our Products & Healthcare Services, the number two, the middle one here, it's really focused on, you know, how do we continue to leverage the scale of our Products & Healthcare Services business? How do we continue to drive rapid growth of our proprietary portfolio? How do we make sure we're putting the right resources in so we can accomplish that? And then lastly, really expand into other areas within the hospital and outside of the hospital. And lastly, you know, Alex is gonna talk about our investment.
The way we think about investment is, really, how do we drive value through the deployment of capital? We're gonna have tremendous opportunity. We're going to make the selections on where we're gonna make those capital investments, but we're also gonna pace them right, because if you try to do too much, too fast, it can create issues. We're gonna make sure we're pacing our investment and capital deployment. Our deployment is gonna be focused on growth and profitability expansion, and really in the other order. Our growth, our deployment should be focused on profitability, expansion, and growth. Then lastly, you know, continue to focus on how we can work in other adjacencies.
So these are the 3 key talking points you're gonna hear about today from Perry, from Andy, as well as from Alex, and then Tammy will talk about how our people tie to all 3 of these. So with that, let me cover the OMR, Operating Model Realignment, because I think this is important, because this is critical for us to be able to execute our strategy and reinvest. There were 4 areas. I'll cover the left side of the slide first. There were 4 key areas. 1 was some sourcing and demand management. We didn't have centralized sourcing. We didn't have a process to put RFPs out on all of our products, whether it's commodity items or whether it's actual products we're gonna resell. We spent a tremendous amount of time putting the organization together.
We now have new leadership in this, and we're seeing significant savings by consolidating and executing on our sourcing strategy. We're through wave one, obviously, some of the bigger categories, but now we have wave two, wave three, and wave four ready to go. Design of our organizational structure. So let me talk to this one. This is important. Design of our organization, or organizational structure, isn't about just reducing and cutting heads. It's about creating the organization and putting the headcount and putting the resources in the areas that provide the highest growth. You're gonna hear that we did do some design this year, and that's freeing up additional operating dollars, so that way, we can spend on Patient Direct by adding additional commercial resources, by spending it on some technology in Patient Direct.
Within Products and Healthcare Services segment, being able to invest in that category management, portfolio expansion, those are the ways we think about that. Next one, number 3, this is the one that takes time. It's network rationalization and operational excellence. So what does that mean? That means we're looking at our distribution centers and looking, where can we put technology in that can drive cost out and continue to improve service? In our manufacturing footprints, where can we add technology or consolidate to be the right solution? And here's what I'm proud about the team: we're thinking about this differently. We don't, we don't have blinders on. We're opening up and saying, "What's the art of the possible within our distribution facilities, as well as in our manufacturing footprint?" And, and this is gonna take longer.
This is through 2024 and into 2025, getting this in place and in process. It's gonna, it's just stuff like this has to be planned out, and it takes time. Lastly, commercial excellence and product profitability. You know, you could argue this is two different ones. This is really around focusing on serving the customer, but the product profitability is really around that proprietary product expansion that I talked about. That proprietary product expansion, making sure we're making the investments for that. On the right side of the slide, these are the results. You know, this is the expectation and the results. $30 million, we're on track to meet or exceed that this year. In 2023, you know, that has played out as we had expected. It started very slow, and it's ramped sequentially, quarter over quarter over quarter.
You would think about that. If you do sourcing, you start to gain the benefit, and then as products work their way through the system, that benefit accelerates. We plan to exit the year at $100 million. So here's what's different also. We're going from just take the simple math on this page, from 30 to $100 million. That's $70 million in improvement year-over-year. We're not gonna do what we've done for years and just take that to the bottom line. We're gonna reinvest that for long-term returns. We're gonna reinvest that in our Patient Direct business by adding technology, headcount to continue to grow, whether it's in geographic regions or add additional facilities. Within our Products and Healthcare Services business, we're gonna invest in those category management leadership teams.
We're gonna invest in some of the operational effectiveness within our facilities. So we're gonna take that and reinvest that in our business to provide those long-term returns. In addition to that, we expect in 2025 to come out around $200 million, and over time, working capital management between $250 million and $400 million. I will say that through this year, we've already achieved the over $250 million in working capital improvement. A lot of it has to do with the Operating Model Realignment. I don't want anyone to get real excited about that and expect that, "Well, that should just continue as we go forward." Because if you think about what we're talking about here, we're growing in our medical distribution business, large customer we just won. We're gonna have to add significant inventory for that customer when we launch that customer in 2024.
In addition to that, as we expand our proprietary product portfolio, we're gonna have to spend some working capital dollars on making sure we have the stock in place. But we're extremely confident, obviously, to hit the $250-$400 over the life of the program. We're already there above the minimum range. You know, we know it's gonna move up and down, but we'll continue to accelerate as we move out. So, you know, I wanna leave you with one last thing on this. So why has this been successful? We talk about this as a management team. It's not because we brought in outside help, and we did, but they helped us organize, they helped us with data and analytics, but our leadership team led these programs.
All four of those key topics have a leader within the business, and we're moving this from the Operating Model Realignment in the Products and Healthcare Services business to just the operating model, that this is stuff we're gonna continue to do for the next, for the next years to come. But we did make drastic changes in our thinking, and that's helping us think through the future much better. With that, let me talk a little bit more about each of the segments, and you're gonna hear a great deal about this from Perry and Andy later about our vision for 2028. How do we optimize? How do we invest? How do we grow? So in a Patient Direct business, you know, the reality is we've got this strong brand. You know, we, we have the ability to leverage our footprint and leverage our brand.
We have the ability for geographic expansion. You're gonna see from Perry's slide, there's geographies where our footprint isn't as dense as others. There's an opportunity to leverage the existing footprint we have in areas where we don't believe we have a fair market share within that space. There's the ability to leverage our fixed cost as we continue to grow the business, and there's the opportunity in this space to grow into adjacencies. Next, we've got a proven model. That commercial model is proven. You know, we continue to prove that with the acquisition of Apria and being able to change the growth trajectory of the categories that was historically in Apria. We've got leadership, and look, the track record of execution is phenomenal in our Patient Direct segment, and we have strong leadership, so we expect that to continue. Not only that, we're positioned well in the key categories.
So you think about home health. It's one of the fastest-growing spaces. Where's our leadership? Our leadership in that is in diabetes and sleep. They're two areas where we're leaders, and you'll see some new information today of the share of our revenue and how they break out by category. Those two subcategories in the home are some of the fastest-growing categories, not only in the home, but across everywhere. So our positioning in these categories is really, really strong. And then lastly, investments. We plan on investing for organic growth, and we plan on investing for inorganic growth when the opportunity is right. On the right side of the slide, Products and Healthcare Services segment, you know, we're gonna continue to invest in high, high payback opportunities.
It's not just the second or second and third point, but we're gonna invest in areas like OR, commercial, and in tech in the warehouse to continue to drive and expand. We're gonna continue to optimize our cost structure. We're clear that what we have to do, we have to continue to lower our cost to serve in the medical distribution. We have to continue to lower our cost to serve and compete in our products business, and then we have to expand our product portfolio, which is the third one. I've talked about that a lot already, but it's, it's important, and it's critical. And we're gonna put the resources in to make sure that this is successful. And then lastly, expand into adjacencies, whether that's non-acute, ambulatory surgery centers, or others.
Those are the core areas of how we're gonna grow and, and achieve our vision of 2028. Here's the long-term financials. Here's the way we think about this: We believe, and this is organic on the revenue side, we're gonna be greater than or north of $12 billion by 2028. We're gonna have adjusted annual EBITDA of roughly $750 million. In addition to that, we're gonna have a 20%... we-- a 20% adjusted EPS CAGR and north of $350 by 2028. So again, 20% CAGR over this period of time. And lastly, you know, greater than $1.3 billion of free cash flow. Again, enabling us to delever, enabling us to then work on the right investments going forward.
So, you know, Alex will go through some of the financial targets a little more detail at the end, but this is where we expect ourselves to be.... From that, there's three things I wanna cover, and really, Patient Direct, Products and Healthcare Services, and balance sheet. Look, Patient Direct, I love that segment, that, that part of the industry. I like the fact that we have a model that's been proven, whether that's our operational model or our commercial model. I balance that with our track record. It's great to have a model, but if you don't have the right track record to support it, it's not worth it, and we have that track record. I enjoy, and I'm happy that we're in one of the fastest-growing parts of healthcare, that being the home.
If you think about what happened, Byram, which was the division alone within there, did an incredible job from 2017 all the way through to when we acquired Apria in 2022. With the acquisition of Apria, we integrated it quickly, we achieved our synergies, you know, we expanded our categories as well as our leadership, and frankly, I believe it gives us the right to continue to reinvest and grow inorganically in that space when the opportunity is right, based, again, on the proven track record. What does the future look like in this first space? We're gonna remain leaders. Our expectation is we remain leaders in this space. The second thing is we're gonna continue to invest. The third and most important is we're gonna grow above market. That's our expectation. And then expand profit. As this segment grows, it expands profit for the total company.
On Products and Healthcare Services, I think what's interesting and great about this, we're winning business today. It's because our service, our offering, our flexibility, and the value we provide. We're fixing the right issues. We fixed a lot of the right issues from 2019 through now. We're continuing to drive that. And one of those issues really is our ability now to think differently, both on a make-buy analysis and assessment, as well as think differently in how we manage our distribution centers and how we lower our cost to serve. And then lastly, our balance sheet. I can't say enough about what the team's done over the last 9 months. The expectation is that we continue to strengthen our balance sheet.
I think as P&HS continues to improve the profitability, and Andy's gonna talk today about what dollar amount he's gonna improve the profitability over that period of time, you know, that's gonna help strengthen the balance sheet, our management of cash flow and working capital, and then the strong growth and profit improvement of our Patient Direct business will help drive the balance sheet. And lastly, our investments, we're thinking about it two ways: organic, to continue to make sure we have the resources we need, and then lastly, inorganic, to make sure that when there's opportunities, we've thought through those, and we're consistent with our execution on that. With that, I'm gonna walk you through one last slide, and I'll stop talking, I promise, and then I will hand it over to Tammy to walk through our purpose, as well as our vision.
So I talk about this all the time. You know, we look at the roadmap we have, and we look at this. We clearly have a mission. When I joined the company in 2019, you'd walk into a distribution center or a call center or any other office, and there's different words on every wall. There was really no clear values, no clear mission, and we had, at the time, probably 15,000 teammates, all doing what they thought was best, but not all working and rowing in the same direction. You know, so we launched our mission, and our mission is what we do. It's humble. It's: We empower our customers to advance healthcare. They're doing the healthcare treatment. We just need to empower them and make sure they have what they need.
Then we have values, and we needed values, and we had to have values that were memorable, and we didn't have to have a thousand words on the page. So we came up with the ideal values, with each letter of our values standing for the word ideal. First is integrity. We gotta honor our commitments. We gotta hold ourself to those commitments. We gotta make sure we're focused on that. Development. We have to continue to develop ourselves, our solutions, and support our customer. You'll see the development that's gonna continue to happen today in Perry's business, in Patient Direct, and in Andy's business, in Products and Healthcare Services. We have to have excellence. Look, excellence, the standard's the standard, right? We expect excellence regardless of the circumstance. When COVID hit and it disrupted everything, we didn't whine, we didn't complain.
We just said, "This is the expectation. Let's go out and do it." You know, now we're post-COVID, and now we're continuing, we're looking to grow our Patient Direct business, continue and continue to strengthen our Products and Healthcare Services. The standard is the standard in that. Accountability. We have to hold ourselves accountable. I think I was pretty open on the fact that on our portfolio expansion over the last five years, we didn't accomplish what we wanted to. I think we stepped back and assessed why, and partially, that was the lack of the resourcing and the lack of the investment in that. I think we recognize the timeline that's gonna take. It's a little longer timeline than when most people, you know, than I think we originally would have expected.
You know, but that's, that's the accountability, that you look at it, and you assess, and you make decisions going forward. Accountability. We knew we needed to reduce our cost of the operating of the P&HS segment, so that's why we launched the Operating Model Realignment. So accountability is really critical. And the last one is listening. I think it's a value that's missed, and I know I've been talking for the last 30 minutes here, but you know, there's, it's really the opportunity to step back and listen. Listen to the customers, listen to your teammates, listen to your supplier partners of what they need and how do you figure out a way to fix that and work that into the strategy? Next is the strategy. You'll hear a clear strategy.
It really links the mission and the vision and how we're gonna execute that. You know, and then you're gonna hear from Tammy, our vision, and you know, I don't wanna spoil it, but our vision is really, we wanna be bold. You know, we wanna, we wanna win in the marketplace. And our purpose, it's why we exist. It's that North Star, and Tammy's gonna cover that in a little more detail. So with that, I'm excited to turn it over to Tammy Gomez, our Executive Vice President and Chief Human Resources Officer. So thank you, and you're up, Tammy.
... Good morning, everyone. My name is Tammy Gomez, and I am the Chief Human Resources Officer here at Owens & Minor. As Ed mentioned, our vision for the future is really rooted in three core areas. It's to grow our Patient Direct business, it's to optimize our Products and Healthcare Services segment, and then it's to invest to drive value for growth longer term. I'd like to talk today about how we're investing in our people and our processes to actually drive this growth as we move forward. So first, let me start by talking about just the strength of our teammates, who deliver for our patients and our providers every day. As Ed mentioned, we have 22,000 teammates across the globe.
40% of our management roles are led by female leaders, 27% are ethnically diverse, and we're keenly focused on ensuring we drive the highest levels of engagement, and our teammates feel that purpose. This will ultimately allow us to retain and motivate our best team as we move forward. 45% of our employees have 5+ years of service at Owens & Minor, and I think this is a testament about what I just said. And then lastly, the diversity on our board is also reflective of our commitment. I joined Owens & Minor about 18 months ago, which is hard to believe, and saw a tremendous opportunity for us to help the organization reduce its or refocus its purpose beyond just the top and bottom line.
While there are countless theories on how to get your employees to get the best out of your employees, the reality is, it's pretty simple. They wanna be paid well, they wanna be appreciated, and they wanna be recognized for a job well done, and they also wanna work for a company that is contributing to the well-being of others with purpose. There's concrete data that also shows companies benefit from having a shared purpose and values. They tend to have lower turnover, and employees are three times more likely to stay with their employer for over a decade. Companies have better annualized total shareholder return and revenue growth, and purposeful organizations willing to transform generally perform better over the long term. As we kicked off the Operating Model Realignment work, we took this opportunity to really focus on: what is our purpose? What is our...
What is the broader role that we play within the healthcare industry, and then how do we make that really clear and rally our teams around it? As we got started this morning, John started off with a short clip introducing you to Owens & Minor and our purpose, Life Takes Care. I wanna share with you another video on how this actually came to life for us and how it was actually reflected in the many conversations that we've had along the way.
Every day when I come to work, my main goal is to get the job done so that we are able to help save another person's life. My name is Kathy Harris, and I am a picker-packer in the clean room.
Kathy has always been that teammate that I go to. She's just fabulous that way.
We build all kits: open heart surgery, eye surgery, hip surgery, knee surgery, all kinds.
Kathy is the teammate that you want every teammate to be like.
Each kit represents, to me, a human being that might be in distress. The reason I'm so compassionate about picking and packing accurately is because my son, when he was 16 years old, he was diagnosed with juvenile diabetes. When he was diagnosed with the diabetes, he had to stay in the hospital for, like, 10 days, and during those 10 days, I was taught how to care for him, how to administer his insulin, how to check his sugar level. I had to be accurate in everything that I did because it was either life or death. It was just devastating.
So many different things have happened health-wise. A lot of them stemmed from me being a Type 1 diabetic, as a young adult.
We found out that Dennis' kidneys were failing and that he needed a kidney transplant. His sisters and I, we said that, that we would be tested to see if we could be an organ donor. But at that time, his wife, Darlene, said, "No, Mother, I'm gonna give my husband a kidney." We found out on Easter Sunday that she was the perfect match, and the doctor said that it would probably be better for Dennis to hit the lottery than for his spouse to be a perfect match.
Making the call to Kathy, you know, with Dennis and I together, it was just great 'cause it's like, you know, you don't want... You don't want your husband to get any sicker. It was really hard.
I went to work, and I picked the instruments and packed it, so I could see what the doctor needed to perform the surgery. The day of the surgery, I went to the hospital to be with him and Darlene, and I was in the operating room where they had prepped him, and I looked on the shelf, the supplies, Owens & Minor. I said, "Oh, my God, I work for Owens & Minor!" And at that point, I knew that he would be in good hands because whoever picked and packed the instruments for that surgery, I knew they were the correct instruments, and I knew they hadn't been expired. So I knew that he was in good hands with, and with his doctor.
You get through it all, and you're just like, "Wow, look what happened!" I'm just grateful that he's alive, because a lot of people don't make it. What I wanted most for Dennis was to have a life full with love, joy, and happiness.
I would say that the sense of purpose for me, being able to help others, definitely came from my mom, and everybody feels that, you know, when they're around.
I love people, and I care for people, and I'll do anything. I go above and beyond to help someone.
I think my mom is the perfect person for the role that she plays at Owens & Minor because she's a helper. She wants to help everybody humanly possible.
That's my calling, I think, just to take care of others, and let God take care of me. I just love to see people have smiles on their faces, and that makes my day.
At Owens & Minor, Life Takes Care. I'm actually really excited about this work. I think it truly captures the heart of our organization, and really captures why we exist, and lays a path for us in terms of where we're going. Life captures the size of our impact. We show how we support our customers to do their best work, helps our patients get back to enjoying their lives, and actually, on a larger scale, moving healthcare and society forward. At its best, Owens & Minor's dedication and empathy has remained valued and vital to our customers. You hear it all the time, the conversational phrase, "Take care." The word care is actually bold on purpose. It is clear that our teammates go the extra mile to make sure that we are delivering on our commitments to our customers.
And Kathy was actually on stage with Ed as we rolled this out to our teammates, and at the end of her presentation, she said, "When people ask me what I do for Owens & Minor," she said, "I save people's lives." Think about how impactful that is, when you rally 22,000 teammates around it. It's pretty powerful. So that's really the catalyst to the work that we've done over the last several months to get us to this point. Now that we've articulated our purpose, how are we going to bring that into action with our teammates every day, and drive value for our organization? We are embedding key, key behaviors. We want our teammates to act like owners, and encourage them to take smart risk.
We want them to advance with speed, and eliminate any unnecessary red tape that we have within our processes. We want to reward impact. We want to make sure that we're celebrating our wins for our company, for our customers, and obviously, our teams at the end of the day as well. And at the end of the day, we want to play to win. We want to be the unstoppable and dynamic leader that connects patients and providers to trusted healthcare products and solutions. So "Life Takes Care" isn't just another phrase. It has to be embedded into the way that, that we do things moving forward. And under this house structure, we're really focused on our vision, which is to be that unstoppable and dynamic leader. Our mission, like Ed had mentioned, hasn't changed. We're gonna empower our customers to advance healthcare.
Our values are who we are at our best, and our ideal values guide the way in terms of the decision-making and the things that we do as we move forward. Our strategy, as we mentioned, is hyper-focused on accelerating Patient Direct growth, optimizing Products & Healthcare Services, and then driving profitable growth at the end of the day. At the base of all of this is our commitment to growing the business, making sure that we have the best talent, and then obviously, driving excellence in everything we do each and every day. As Ed mentioned, we were at an inflection point that was really poised for change. We did take a two-level approach in terms of evaluating our organizational structure and our teammate culture. We really looked at it in two ways.
We wanted to raise the bar. We adapted to workforce trends around work from home. We identified gaps in our talent pool, we expanded automation to drive efficiency, and we upgraded talent where we needed to. But at the same time, we also wanted to retain and invest in our current teammates. Yes, we had to consolidate some roles, and we had to make some difficult decisions along the way, but we promoted from within, and we implemented training programs that invested in our teammates and built out new skill sets. And at the same time, our segments are very different, so we also took the time to reflect on the different needs that were gonna be important for us as we were gonna continue to grow as we move forward.
So we must continue to raise the bar without actually sacrificing our culture of Life Takes Care. We know that these core tenets on the left are not only important to our customers, but enrich our business in engaging in diverse hiring practices, in getting involved in the community, in our supplier diversity initiatives, and obviously, our external partnerships and our networks along the way. And if we're going to attract the best team, we need to continue to raise the bar. And I always say you have to embed and live your purpose in everything that we do. We have to build a strong culture, where our team is highly engaged, and our teammates can grow and develop their careers here at Owens & Minor, and we win the war on talent.
So as you'll hear from my peers today, we're going to drive profitable growth through 2028. Our talent is gonna be at the front and center in terms of how we actually get this done. We're gonna have bold goals and behaviors that are embedded within our organization. Our teammates are gonna have goals that are aligned in terms of how we operate, and we're gonna drive accountability. We're gonna have clear goals and metrics so that we can measure our progress along the way, but we can also course correct as needed. I'm incredibly excited about our future and the potential of our teammates to actually deliver on our bold goals that we have out there. I think this also lays a great foundation for us as we get into more details around our segments.
So with that, I'm gonna ask Perry to come on stage.
Thank you, Tammy. Good morning. I'm Perry Bernocchi, and I'm the Chief Executive Officer of the Patient Direct segment, which is Apria and Byram business. As Ed mentioned, and he's very excited about Patient Direct, I'm even more excited about our business. You can- you hear it through his theme, this is all about growth. We have a proven track record of a growth engine in Apria and in Byram, and our mission over the next five years is to accelerate our growth, optimize the business, and then continue to invest in the business. We'll continue to build off a strong foundation of growing above the market in our core therapies, investing in our technology, and then we're gonna invest in adjacent markets that are comorbidities related to our core therapies. Before we go into our business, let's talk about the industry a little.
Demand for home-based care is growing, and it comes down to two key macro drivers. The business that we compete in is a $70 billion business or market growing at 6% a year. The population is growing, and it's aging. We have 65 million Americans on Medicare today, and that's growing at 8%. And the key fact here is 50% of those Medicare-eligible patients are choosing Medicare Advantage plans. And so this is an opportunity not just with government programs, but with commercial payers as well, especially for us, and I'll touch on that. So what does it mean for home-based care? Clearly, the demand for home-based care is going up.
Payers want more sustainability in their providers, and they want value-based care, and technology is gonna play a key role in how home care is, how home care will be transacted, and we are well positioned as Patient Direct in that triangular relationship between the patient, the prescriber, and the payer. Let's talk about the benefits of home-based care. For the patient, they prefer receiving their care at home. It's a better environment for them to return to normalcy and improve their health. Patients living with chronic conditions have to adapt to the challenges of performing self-care, and achieving this independence is critical to the recovery of the products and services and the technology that we provide to make it happen faster. Tammy spoke about Life Takes Care, and life really takes care within Patient Direct.
I've been in this business for over 35 years, and I've talked to our patients, I've talked to customers for 35 years. But recently, when I talk to our customers, I ask them: "What can we do for you?" And what the customer says is, "You can provide the best care so that I am not reminded that I live with a chronic condition every day." And that means we, we provide the best possible service, the right products at the right time, and we transact their healthcare insurance needs. We take the hassle factor out of people living with chronic conditions at home, and that provides tremendous stickiness with the patients, and that's really what helps us accelerate our growth.
Patient Direct is either number one or a leader in the majority of the categories that we compete in, including diabetes, ostomy, urology, wound care, sleep, and respiratory. We have one of the broadest product portfolios today, and to the right is just a sample of the products that we serve. Many of these products came through our Apria acquisition. Let's talk about that acquisition. What a winning combination! This is awesome. Together, or individually, both organizations have 50-year history in the business and have had success, and our accomplishments together have already proved this to be true. We've executed on what we said we would do when we set out for this transaction.
We've broadened our product portfolio, we've leveraged our payer relationships, we've grown in higher-margin product categories, we're growing in a highly fragmented market, and we're taking share, and it's been accretive on the financial indicators that we spoke about. The proof of winning combination is really in the chart on the right. If we look back five years on a pro forma basis, we're growing our revenue above the market, but more importantly, we're growing our earnings at an accelerated rate, which is exciting. So let's take a few minutes to look at the combined businesses as they are today. Patient Direct is a leader in home-based care with annual revenue of $2.6 billion.
As Ed spoke about, when we acquired, when Byram was acquired, it was about a $450 million company, and it grew to over $1 billion by the time we made the Apria acquisition. We knew at that point in time we needed to expand our therapy portfolio, and we went out and acquired Apria. And what this did was essentially expanded our portfolio, and we doubled down in the industry. You can see from the chart on the right, or on the left, our revenue distribution. So if you think through it, it's diabetes, and in diabetes, primarily, our patients are either type 1 or type 2 insulin dependent. So that's top in our portfolio, followed by sleep, respiratory, ostomy, wound care, and urology.
It's also important to understand that we convert our revenue to cash through our best in revenue cycle process. Together, we service over 3 million patients. You can see again from the chart on the left, that this follows the revenue. So our density of patients are in sleep, respiratory, diabetes, wound, urology, and ostomy. The most important piece about this is the high recurring revenue stream. 80% of our business is a recurring revenue stream from the therapies that we serve. It is possible that 60% of our patients have one chronic condition, and over 40% of the patients in the population have multiple chronic conditions.
Some of the patients stay with us for many years, and others stay with us for a lifetime to manage their condition, and that is why we have such a strong focus on service, retention, while we simultaneously go out and grow the business above the market through our sales team. One of the ways we access new patients is through our significant commercial payer contract portfolio, as well as being a national Medicare provider. Patient Direct can serve 85% of the population today in-network. What does this mean? Typically, it means lower out-of-pocket for our patients. Our payer mix is 80% commercial, 20% government plans. This positions us well to serve the Medicare Advantage population. Why? Because Medicare Advantage is contracted, acts like, and works as a commercial plan, and we are well represented across the commercial plans and with Medicare Advantage.
This also makes us very attractive to our provider customers, as well as patients and manufacturer partners, and additionally, the majority of the contracts are evergreen contracts on an annual renewal basis. If we talk about retention and look at customer satisfaction, our strong NPS scores are two to three times the industry average for healthcare. We've also received industry recognition from an organization called Verywell Health. They voted Byram the best diabetes supplier four years in a row. That's like going to the Super Bowl. Who goes to the Super Bowl four years in a row? So we've gone to the Super Bowl of being the best diabetes provider four years in a row.
I think it's a testament to say that our patients appreciate what we do, we're recognized in the industry, and it solidifies our standing in the marketplace. It also means that we're contractually well-positioned to access the population, we're attractive to our payers and prescribers, and the customers value what we do through our customer service scores. Along with that, a key aspect is: who do we do business with from a manufacturer perspective? So we have relationships with 1,200 branded manufacturers across our network, and below is a few of those that are illustrated below. And it's very important that we have these relationships because it gives patients and providers the opportunity to choose. How do we service this network? So today, we have 300 sites across the U.S. We have a national footprint with local presence, so we are where the patients need us to be.
We are within 2-4 hours of the major population, and you'll see that—you'll see that—you can see that from the map. Healthcare is delivered locally, and we achieve this local presence through our sales professionals, our customer service and our customer service teams, as well as our skilled clinicians that operate in the local community. We optimize the footprint through our centralized centers of excellence, our enterprise services group, as well as the 275 branches to respond with speed to our customers. And again, we are within 80% of that population in the markets where they are, so we can respond within that 2-4-hour period.
Our platform is scalable, and we can expand that footprint, footprint, both in density, if you think about how we're gonna grow, we're gonna continue to grow in the markets where we're in through, through sales, so we can grow through density, and we can add more locations as we need to, as we continue to grow. So with that, let's look at the next chapter for Patient Direct. Let's reimagine patient care in the home. So our goal is to be the leading provider of medical equipment and supplies for people living with chronic conditions. If you think about this, we want to focus on the disease states that we can help manage and heal, promote better health, and improve the quality of life. And the best way for us to convey this is to hear from patients and the patients themselves.
My name is Kirk Martin. I've been a Byram client for about two years. We love travel, and we like the South Pacific culture, the tropical-ness, and we've invited many Tikis to stay with us and brought a lot of the culture to life in our backyard.
My name is Jim O'Brien.
My name is Linda O'Brien, and we have been with Apria since 2004.
I grew up here in Kansas City. I taught school for 30 years.
We met on a teaching assignment.
Was it love, love at first sight?
Yeah
... that bond?
Yeah, it pretty much was, wasn't it?
Yeah.
Yeah.
... I was diagnosed with diabetes in 1969. Being a diabetic, you have to worry about so many things, and one thing you don't want to worry about is getting your supplies. So Byram helps me not worry about getting my supplies. I use an insulin infusion pump, and I also use a continuous glucose monitor, and there are many incremental parts that go with those. So Byram helps me get all those incremental parts. They help navigate my insurance, so they know what they can and can't provide and how we need to get those to me. They clarify a lot of the steps that I don't know. They've made my life much, much better.
When he originally got sick back in 2004 with respiratory failure-
They told me that I had decreased lung capacity.
The pulmonologist has always told Jim-
You got no room for error.
... If you get a cold, if you get a cold, it can kill you.
So that's when I had to go on oxygen. They don't-
Apria supplies us with the oxygen-
Right
... with the concentrators, with the Trilogy. Right now, we get the oxygen tanks delivered every week.
Everything I have to do, I have to have the oxygen.
It has given him freedom. I mean, we, we are not hooked to a 50-foot cord. It, it- he can go out, he can... We can go to restaurants, we can go to the movies. That's one of the things we like to do, is go to the movies.
Yeah.
So, yeah.
If I were to describe Byram in one word, I would say committed. When I do speak to Byram, no matter whom I get on the phone, they call me by name, they say they're going to follow up with me, and they do. They do seem to care, unlike a lot of companies today, and that makes my life much less painful.
We were in Virginia several years ago, and we were at a campground. It was over Memorial Day weekend, and we ran out of oxygen. So we called Apria, and they came, took care of it that day, I mean, within hours.
They've been wonderful.
I can't say enough about them.
Apria has been wonderful.
They ask us at the hospital, "Are they taking care of you?" I says, "Absolutely.
The respiratory therapists, I feel like we're friends with them, and they're just wonderful, so we don't have... It's been life-saving.
Very positive.
Yeah.
I would recommend Byram to a friend or a family member, because as I have identified, it gives you less to worry about and more to count on.
I would highly recommend Apria. I mean, they've been very good to us. You've been not only professional in terms of delivering the services, but your personalities, you've treated us with respect, kindness. Very happy.
If I could speak to you at Byram today, I would like to tell you that, first off, I thank you for being there and for doing what you say you're going to do and making my life easier. Thank you.
You've just heard from a few of our patients, and really, if you think about what I said before, Life Takes Care. This resonates with our teammates. This is what we do every day, and this is why patients stay with us, and this is why 80% of our business has a recurring revenue base, because those patients choose us, and they stay with us. It's a key part of what makes us successful and a market leader. Let's pivot over to our commercial strategies to drive success. It's in a couple of areas. One is competitive positioning. We're a leader in top three in our key categories through strong brand awareness, recognition, footprint, and in-network access.
We've got an extensive portfolio of both products as well as strategic partnerships, and we have our customer-centric approach, and I think we've just touched on that. Let's talk about our ambition over the next 5 years to be a $5 billion organization, and this is exciting. If we start back, it started with the Byram acquisition in 2017. $450 million going to in excess of $1 billion, all organic. We knew we needed to expand, add the Apria acquisition, sprinkle on organic growth of the two organizations, and we're at $2.6 billion at the end of 2023. What's our plan over the next 5 years?
It's to continue the organic expansion, so that's invest in our commercial operations, invest in, in digital marketing, and then on top of that, invest in M&A within our core and outside of our core to look at adjacent markets to achieve our ambition of being a $5 billion provider over the next five years. Let's talk about the strategies, three key areas that we're going to focus on. One, expand our market leadership, and really, that's all about growth. Two, leverage our technology, and I'll touch on that. And three, enter adjacent markets. Expanding our leadership, where is this gonna come from? And this really is gonna come from our today commercial excellence, as well as investing in our sales and marketing resources over the coming five years to create a best experience, both from a commercial team as well as from a marketing team.
Today, our selling efforts are centered around 450 go-to-market, forward-facing salespeople, and we'll continue to do that and grow on that. But we're also shifting our priorities to look at acquiring larger patient bases. And what does that really mean? That really is focusing on payers and contractual relationships that are different. Expanding our alliances through strategic partners, looking at health plan carve-outs, going after home health agencies, as well as large hospital system contracts. And finally, we'll continue to improve and use technology to lower the cost to serve through improving and increasing our patient portals. Interesting, I've been doing this a long time, and when we first launched our first app, and we launched a reorder portal.
Everybody said: "The Medicare population will not do it." We launched the portal, and we launched the app, and we watched the Medicare population come through. It was absolutely amazing, 'cause if you think about it, the Medicare population today of the baby boomers have all grown up with an Apple phone or an iPad or a computer, and it's really revolutionized and supported how we deliver and transition healthcare. Second area is to look at our technology path, and we wanna do this to improve the patient outcomes and really to build a better opportunity and technology for value-based solutions. I'll talk about the patient management platform in a second.
We're also going to rebuild a data warehouse, and primarily, this is gonna be used to get a 360 view of the patient: what they do, what their diagnoses are, comorbidities, how they order, what their insurances are, so we can best respond to the patient and continue to provide value and that stickiness. We'll continue to invest in digital marketing as a patient acquisition. Consumers are moving and choosing themselves beyond what their providers recommend, and they're out shopping on the internet for companies like us. Today, we have a traction of that, and we'll continue to invest to accelerate that. The last piece is that we'll work on our ERP system, improve our back-end capabilities, and really leverage our revenue cycle, service, and fulfillment. I wanna spotlight what we talk about our PMP, our patient management platform.
It's an agnostic tool that allows data to flow in and out and will help the care provider better manage care. So as you can see from the diagram in the middle, all the stakeholders are in here. It's the patient, the payer, the supplier, and the provider. And the technology is really built to advance adherence to treatment, to provide and push education to the patient, to develop the information for value-based care, to enhance remote monitoring, and ultimately, to optimize patient outcomes, as well as providing the information from a supply chain perspective for our team to make sure we've got the appropriate products at the right time. And the last part of our journey is entering adjacent markets, and this means expanding beyond what we do from a core perspective and leveraging our operational capabilities to do that.
Again, we're gonna look and focus on comorbidities when we go through this M&A process. And so we've looked at the most attractive areas to do this in, that are close to our core, and that's O&P, complex rehab, dialysis, heart disease, and wearable cardio vests. So for each of these adjacent markets, you can see where they fall, either closer to our core or further from our core. The market size are also highly attractive, and we'll continue to, we'll continue to assess these as we continue to look through our M&A opportunities. So in the last 2 slides, let's just recap where we've been and where we're going. So Byram and Apria together, $2.6 billion patient Direct organization. Continue the expansion organically, $3.7 billion. Growth through acquisition, get us to $5 billion in our ambition.
We have, we have done this, 1, by growing Byram, 2, by layering on Apria and creating a great Patient Direct platform. So we've earned the right to do this again. I'm very excited about what we have accomplished and more excited about we're in a space with compounded growth rates, high retention rates of a recurring revenue stream. We'll leverage our national footprint as we do this. We'll leverage our best-in-class commercial selling operation. That's how we got through organic growth, to organic growth. We have a mature and scalable platform, so we'll continue to layer on our opportunities and continue to, to grow, and we'll invest in our talent. So as you heard, I'm excited about where we have been, but more excited about where we're headed, and we are well-positioned for the next chapter of growth for Patient Direct to achieve our $5 billion ambition.
Thank you. With that, we're gonna take a short break, and Andy Long, our Chief Executive Officer of our Products and Healthcare Services Division, will be up next on the stage. Thanks.
The break will start promptly again at 5 of the hour. Thank you.
Welcome back, everyone. Just find your seats, please. We're gonna get started in a second. And before Andy takes the stage, we have a brief video on the Products and Healthcare Services segment.
Owens & Minor's medical distribution business delivers a thoughtful combination of technology and touch centered around your needs, with automation in our distribution centers where it makes sense. Simply put, our technology solutions will never interfere with our ability to serve our customers. Our operation strategy enables us to be flexible to deploy changes in customer preferences in hours, not weeks or months, and to scale quickly when faced with demand increases or supply chain disruption. We operate strategically located distribution centers throughout the country. At Owens & Minor, we will deliver a unique vision and customized solutions for our customers. At our foundation lies the dedicated teammates at Owens & Minor. Our Owens & Minor teammates are ready to serve our customers. We are Owens & Minor. We empower our customers to advance healthcare.
All right. Good morning, everyone, and welcome back from the break. I hope you enjoyed our short video. My name is Andy, my name is Andy Long, and I am the leader of the Products and Healthcare Services segment here at Owens & Minor. I've been in the role for just over a year now, and I've been with the company just over four years. I started in November 2019. And in those three years prior to being in this role, I served as the company's chief financial officer. And in that role, it gave me a great viewpoint and visibility into the profit levers, the profit drivers, the strengths, the weaknesses, and the opportunities and challenges that this business faces.
So I, you know, I feel like with that grounding, I was able to jump right in, into this role and hit the ground running from day one. So I'm excited to share with you what, my team and I have been doing over the past year as we are charting the path to, to build the foundation, to, take the actions that we need to take in order to play to win. So, today, I'm, very excited to also share with you our strategy for the Products and Healthcare Services segment and our vision and our road to 2028, and, you know, really to share with you kind of our plans going forward. So I thought I would start the presentation with just an overview of the Products and Healthcare Services segment, right?
I'll refer to it as P&HS in our presentation. And I know many of you are familiar with the business, so this will just be a quick refresher, but there's a lot of people I know that are new to the business, and I wanna make sure you get a good overview of our business. The Products and Healthcare Services business goes to market in three divisions. Start with medical distribution. Medical distribution provides medical products in the acute care space, and we serve as really that critical link between the manufacturer and the healthcare provider. We've also got a products division, and that products division has our proprietary products, our private label products, and we play primarily in the Surgical and Infection Prevention categories. That's where we mainly play in.
We have the capability to design, to source, and to manufacture product as needed. Because we control that overall supply chain, that overall value chain, we believe that we can bring a high level of supply resiliency to our customers. Then our third division is our services division, where we offer everything from technology services to help our customers with inventory management, all the way through outsourced logistics capabilities. I thought I'd also spend a moment just going over our brands. We've got a really strong collection of brands that are known for quality and excellence. As you see on the left-hand side, we've got a set of brands that are associated with products, and I'll start with our Halyard brand. Halyard is associated with our clinically differentiated high-quality products. We also have a MediChoice brand that's associated with non-clinical value products.
We've also got a collection of brands that we go to market with our kitting and custom procedure trays. Those brands have been acquired over the years as we've purchased companies. Moving to the right-hand side is our services business, and I'll start with distribution, where we go to market under the Owens & Minor brand, of course, with a 140-year legacy of quality and excellence in serving this market. And then rounding out the brands and services are brands like QSight, and Pandac, and SurgiTrack, that round out the services that we offer to our customers.
So as we look at the strategy for the business, I thought it would be a good starting point just to share with you the journey that we've been on over the past couple of years, starting with the pandemic to where we are today, and I think that'll set up our strategy nicely. So, as you know, in the time period of about mid-2020 to early 2022, in the pandemic period, the pandemic provided a tailwind for this business. And during that time period, our teammates were laser-focused on ramping up production, on ramping up sourcing, in order to supply our customers and help them meet their almost insatiable need for PPE during that time period.
But in the aftermath of the pandemic, we've navigated a very challenging landscape, and that challenging landscape includes market conditions like oversupply of PPE in the market, tight labor markets, inflationary pressures, right? And those factors have all come together to create profit headwinds, not only for our customers, but also for us. And so in order to succeed, we're gonna have to come up with ways to adapt to these changing market conditions. We're gonna have to find solutions for our customers that drive value for our customers, but also drive value for Owens & Minor. And so as we look at what that strategy will be, right, there's three elements. It's leveraging the scale of the Products & Healthcare Services business, it's expanding our proprietary product portfolio, and it's expanding into new markets beyond the acute care market we play in today.
At the end of that, at the end of that journey, at the end of that road, we believe this strategy will lead us to more than double our profitability over the next couple of years. Let's go into a little bit more detail on the three strategies. This page, I'll touch on and introduce the three strategies, and then I'll go a little bit deeper on each of them after this. Starting with leveraging the scale of the Products and Healthcare Services business, you know, what does that mean? Right. So it means as we look at the services that we provide to our customers, we've got to look at them on the scale of, at one end, there's services that we provide that customers see as just table stakes, right?
They don't see differentiation, and in those areas, we have to work extremely hard to drive costs down and become more efficient. But at the other end of the spectrum, there are services that we provide that our customers find high value, and they're willing to pay for that value. Those are the areas that we need to continue to invest deeply in. Also, in terms of leveraging scale, we need to evaluate our footprint, and that's both of our distribution centers as well as our manufacturing footprint, as Ed said, to evaluate, to make sure we're best cost, and where we're not, we'll be looking at that, the opportunity to look at the make-buy decisions. Second strategy is to rapidly grow the O&M product portfolio, our branded portfolio. In Ed's opening remarks, he was very candid, right?
This is a strategy that we've had for a number of years, and we have failed to meet our expectations in this. So this is an area where, you know, we are truly gonna put additional effort into it. And we've got a multi-pronged approach to enacting this strategy, right? So we're expanding our sourcing infrastructure to make sure that we've got the right teams in place to source products, 'cause many of the products that you'll hear that we'll be launching won't be manufactured by us. We'll be creating category teams that are responsible for the creation from the inception, identification, and all the way through the market and commercial activation of this product launch. They'll own the entire process. And then finally, we'll be expanding into looking at our branding strategy, right?
It's an opportunity for us to look at the brands that we go to market in, that I just walked through, and make sure that those brands truly represent the value that we bring. And then the third strategy is to expand into adjacent markets, right? Markets that are growing faster and have a higher rate of return than what we play in today. So let's go a little bit deeper into the first strategy, leveraging P&HS. So what do I mean by this? So this slide is really intended to give you an example of just some of the things that we're doing in this area. So I'll start with the organization, and we've looked at the organization structure, and one example of an opportunity that we identified is in our procurement, our purchasing organization.
And we saw that there were multiple procurement organizations and pockets operating independently across the business. So what we did is we've consolidated those organizations under one leader, under a chief procurement officer, and we've been able to accomplish a number of things with that. Now we are leveraging data so that we can aggregate our spend when we work with suppliers to get best cost, and we're also utilizing best practices across the organization to drive common practices and get the best outcome. We're also looking at the way we solve customer problems. So oftentimes, we will create complex and detailed solutions for customers that are very complicated to enact and to solve the problem with.
And what we're looking at is trying to find common approaches to solving problems, where we realize that we may have a customer problem in one area, and instead of finding a new, unique, custom solution, we can draw upon other areas of the organization where maybe we've already solved that problem. And by standardizing our approach, we can drive value to the customer by being faster to implement. We can drive value to the customer by increasing our ability to be assured that that solution will be successful because it's a solution that we've tested and tried in the past and found it successful. But there's also benefit to Owens & Minor because we, we will no longer have to create a custom solution and maintain a complex solution long term. So it'll drive efficiencies internally...
prioritization, regardless of value, really, it's just a reiteration of what I said on the previous page. Where our customers find value, we're gonna invest, and where our customers don't see differentiation, where they see the service as table stakes, we're gonna need to drive costs down. And then finally, the legacy footprint. Right, so what do I mean by this? So we've got distribution, and we've got manufacturing, and I'll start with distribution as an example of what we're doing in this area. So when we acquired the Halyard business back in 2018, we acquired a set of distribution centers that managed the Halyard inventory. We refer to those as upstream distribution. And of course, we've got our downstream distribution that we all know that services our traditional distribution customers.
So in 2023, we're starting to run those distribution centers as one cohesive, functional group, right? We're not running it as two separate operations. And obviously, there's costs to take out, which are savings by eliminating redundancies, but we're also taking that Halyard products & pushing it out closer to the customer, and by doing that, we're also finding a benefit of improving customer service levels as well. On the manufacturing side, look, we've got an incredibly strong manufacturing asset, set of assets, but we have to make sure those assets are producing at the level of quality that the market demands and the level of at a cost that's competitive with the market as well.
Where we're not, look, we've got incredibly talented teams that are working to find ways to improve that, and whether that's through implementing technology, whether that is through the improving utilization, fixed cost utilization, or whether that's through our classic continuous improvement lean activities. Whatever it takes, we're trying to bring those costs down. As Ed said earlier, if we can't become competitive in those areas, we will absolutely revisit our make versus buy strategy. All right, so what I wanna communicate here is that this strategy isn't just something that we're thinking about implementing at some point in time, maybe in the future, right? This is something we're implementing now. We've put points on the board in 2023, and we're starting to see real results as we speak.
So on the previous slide, I talked to you about what we did with the purchasing organization. By putting that organization together, we have driven millions of dollars of bottom-line results. So when Ed and Alex talk to you about the $30 million of Operating Model Realignment savings, a big piece of those savings are coming from this activity. And it's nice because we've got that run rate, and that gets annualized into 2024, and that's part of that $30 million going to a $100 million. So a nice win here. Another thing that's really we found as a benefit by consolidating our sourcing is that now we've got a streamlined way of launching new products. We won't. When we launch our portfolio expansion, we won't go with 10 different ways of launching a product.
We'll have one common way of doing that. We've also launched new technology. This new organization has introduced software technology that will help us manage our spend from the time we get quotes to from suppliers all the way through, execution and management of that spend. So it'll be a nice opportunity for us to control costs. Delivering value through lean. You know, the first two bullets in this section I think are very straightforward. You can read those, but I wanna focus on the third one, right, where we've instituted integrated business planning.
This is an opportunity for us to take input from customers, demand forecasts, input from our commercial team, and link that through to our sourcing and manufacturing groups so that we can be assured that we have the right product in inventory at the right time in order to maximize our service levels. So a really nice opportunity for us here that we've been implementing. In terms of technology, technology will play an incredibly important role in our strategy, and that technology can range across the spectrum from purely internal, inward-facing, where we're automating some routine activities in our back office. And as you move closer to the customer, right, we're implementing technology to perform automation in our distribution centers. Again, we try and balance that technology versus flexibility in order to be responsive to our customers.
Even closer to the customers, where we've implemented artificial intelligence software to help us with our demand planning and forecasting, again, to improve service levels. And then finally, on the spectrum, purely customer-facing is where we continue to invest in our QSight software, right? So that is a software platform that helps our customers manage their inventory from their supplier all the way through to making sure it gets billed correctly to the patient. And then finally, establishing an end-to-end value chain in our supply chain in our operations. So you look at the functions of planning, sourcing, manufacturing, and delivering. Historically, those were siloed organizations, right? They were run by four different leaders within our organization. Today, we've put those and rolled those up under one leader.
And if you step back and think about a couple of things I've just said on this page, right, we've changed the organization, we've changed our ways of working by implementing integrated business planning, and then we've introduced technology to help us forecast and demand plan better. That combination of activities has allowed us to drive $hundreds of millions of improvement in working capital to translate the cash that we've been able to then deploy to reduce debt or to reinvest in the business. So it's a nice success story of what we've been able to achieve in this calendar year. So switching to our second strategy, which is expanding our product portfolio of proprietary products. I like this page because it's a nice visual of what we're trying to accomplish.
On the left-hand side, you see the categories of products that we currently play in with our Halyard and MediChoice brands. That's where we are today. This is where when we talk about portfolio expansion historically, these are the categories that we have been investing in to expand the portfolio. But if you look to the right-hand side, these are... It's an example of some of the categories that we will be looking to expand into going forward. All right? So we're looking outside our existing categories and moving into new categories. So I think that's really exciting.... So what does that mean? 90%, 90% of the SKUs that we will launch in 2024 will come from categories that were on the right-hand side of that previous page. 4-5 times.
We will be launching 4-5 times more SKUs in 2024 than we have launched in any previous year historically. How are we doing that? We are moving from a very passive, supplier-centric method of kind of managing our products, to a customer-centric, actively managed category view of our portfolio. Right, so if you think back to that previous page, we will be hiring, as I talked about, whereas we expand category leadership, we'll be hiring leaders for each of those categories, and their purpose in life will be to identify SKUs to expand. They'll be chartered with launching the products, getting it to market, and activating our sales force. So really a start-to-finish holistic view of how we're expanding our product portfolio.
That engine that we're creating with that team should enable us to do what we're doing in 2024, that should be repeatable year after year after year. Keep in mind that the products that we're launching can have up to 5 times the profitability of the products that they'll be replacing when we launch them. So a really, really nice opportunity to expand margins. Then turning to our third strategy, right? This is where we're looking to enter adjacent markets outside of the acute care space. On the left-hand side, just a couple of examples of areas or markets of interest to us. I'll start with ambulatory surgical centers, right? It's a very attractive market to us. It has higher growth rates. The portfolio of products needed to serve this market are aligned completely with what the portfolio that we have today.
And, and what I like about this too, is that many of our current IDN customers have captive IDNs. So it makes it a logical extension for us to go into the leadership at that IDN and say, "Look, we service your acute care today. We'd like to work with you to kind of be one-stop shopping to also support you on the ASC side of the business." Clean rooms. So when I say clean rooms, think semiconductor manufacturing, right? We like this space 'cause it too has a high growth rate. The customer base is very centralized, so it gives us an easier opportunity commercially to get in and talk to these customers. The portfolio of products that are required in this space overlap very nicely with our own PPE product line.
And in fact, entering the clean room market is a great example of where we've been able to leverage all three of our strategies together. Right, we've taken our internal design manufacturing capabilities and designed new products internally, gloves in particular. We've then taken that design and we've been able to leverage the scale of Products & Healthcare Services by producing those new gloves in our own manufacturing facilities. And then we've been able to use both of those, those steps then to enter a new market. So it's a nice example of where all three strategies kinda combine. Consumer is a newer business for us. It's a small business, but it's growing fast. Again, it has nice overlap with our portfolio of PPE products, and as we expand into new categories, we'll certainly take this this category into consideration.
We've made nice input, nice progress in retail and on Amazon in 2023. Then finally, the lab space. Again, nice overlap with our product portfolio in some areas, and again, labs are captive to existing IDNs that we serve, so it's again a logical extension for us to serve this market. On the right-hand side is not necessarily entering a new market, but it's actually going a little bit deeper into an area of the hospitals that we serve today, and that's expanding our presence in the operating room. And we think we can have a bigger presence in that space by expanding our product portfolio.
We've got a very strong kitting franchise, and we've also got the, services like SurgiTrack, Pandac, and QSight, that are all really focused on this perioperative space, so we think we can play to win here. And this market is, or this area of the hospital is really attractive for us, because if we can win in this area, it creates stickiness, and it also provides a base from which, from which we can grow to expand into other... our, our products into other areas of the hospital. And to, to win in this area, we've done some really big organizational changes as well to align our organization to support the strategy. Historically, we had three commercial teams calling on the operating room: a products team, a services team, and a kitting team, right? We've collapsed that into one team this year.
Now we have one person that can represent everything we sell into the OR, and it simplifies it. It makes us easier to do business with because the customer's only dealing with one person. Operationally, you saw on a previous slide when I talked about our kitting brands, you saw all those kitting brands, right? So we have multiple kitting operations that were run by multiple people. So we've taken all the kitting, and we've put that under one person, so we now have one operational leader. And then, category-wise, right? So I've talked about the category expansion. Now we have category leaders. We have one category leader that's focused on all of the products and services that are needed to win and succeed in the operating room. So we now have complete organizational alignment to win in the operating room.
So those are our three strategies, but as you've heard me talk about, organizational structure alignment is really critical to making sure we're successful in executing the strategy, and a lot on this slide ties back nicely to some of the things Tammy introduced earlier in her presentation. So this is kind of like the real-life example of what Tammy talked about earlier. And it's really the three-step process of making sure that we've got the right organizational structure, and it's designed to support the strategy. We staff that organization with the right people, and then once that's established, let's determine the best ways of working in order to meet the strategy. So you've heard a couple examples of that, right? So the purchasing organization, create the organization, staff it, implement software, drive millions of dollars of savings.
Operations, align the planning, sourcing, making, and delivery under one person, get the organization established. New ways of working, integrated business planning, introduced software, and we've driven $hundreds of millions to the bottom line. So there's a couple of examples, categories, and other that we're following this model in order to execute the strategy. And so in closing, you know, there's two things I want you to take away from this. One is that we have a clear strategy and a clear path to execute on that strategy. And again, the strategy itself is to leverage the scale of our P&HS business, investing where customers find differentiation, and taking costs out where they don't. And looking at our footprint to make sure our distribution and manufacturing costs are optimized.
Expand our product portfolio into new products that have higher margins, expand into new markets, into areas that are growing faster than where we play today, that have higher margins. And then finally, to expand our presence in the operating room, where we can create stickiness and where we can determine or build a base from which to grow from in the rest of the hospital. And to do that, investing in talent to make that happen. The second thing I want you to leave or walk away with is that that strategy will enable us to double our profitability over the next several years. And I think as kind of a proof point in that, in the progress that we've made, if you look at our Q3 results for our segment, you'll see that sequentially from Q2 to Q3, significant improvement in profitability in third quarter.
When we talk about our $30 million of Operating Model Realignment savings, you've heard Ed and Alex say that we are on track to meet or exceed those. So I think those are two examples of where you can see that we are demonstrating real concrete progress in achieving the strategy in 2023. So with that, I will wrap up. I'm very excited to see, you know, with the future of Products & Healthcare Services. I think we're off to a good start, and I want to thank you for your time. And at this point, I will turn it over to Alex Bruni, our Chief Financial Officer.
Thank you, Andy. Good morning, everyone. It's great to be with you here today. I hope by now you've got a really good sense of our strategy, our growth potential, our culture, and the important role that both Patient Direct and Products and Healthcare Services play in impacting the lives and well-being of millions of people every day. As we look ahead to 2028, my presentation today is gonna focus on an overview of our financial strategy and expectations. You've seen this slide across my colleagues' presentations, but what I want to emphasize here is the final step in our process, which is investing to drive value. Driving value in the short term and in the long term. We have a disciplined approach to capital deployment, and we're gonna make smart investments in the business to drive value across the organization.
We're putting our dollars into supporting expansion into adjacencies across both segments. We're strengthening our balance sheet and using our cash to support growth. And ultimately, these combined efforts will position us to drive long-term shareholder value. Before we look ahead, I do wanna take a moment to talk about where we were five years ago and where we are today. Five years ago, we had significant service issues, and those service issues were causing customer losses and driving significant revenue and Adjusted EBITDA declines in our legacy business. We had challenges with cash flow and our cash balance. We had unsustainable debt levels and had been downgraded to as low as a triple C plus credit rating, and our net leverage was as high as seven times. Today, you can see on the right, that we're in a much better spot.
We're delivering on our 2023 commitments, as we outlined at the beginning of the year in our guidance, including those for the Operating Model Realignment. We're retaining and winning new business across both segments. We've returned to our normal business trajectory post-COVID. We're improving our Adjusted EBITDA and our Patient Direct segment. Our high-margin business is now making up about 80% of Adjusted EBITDA. We've delivered about $600 million of operating cash flow year to date, and through the end of Q3, we've reduced net debt by about $500 million. And our Net Leverage Ratio at the end of the quarter was just below 4x. So we're pleased with the improvement here, but we've still got more work to do. And as part of that, we're gonna continue to focus on the Operating Model Realignment.
Ed's talked about this, so I'm just gonna provide a refresher. In summary, the Operating Model Realignment is delivering as expected. It's driving improved profitability, it's positioning us for growth, and it's generating cash to invest. We're on track to meet our goals. We're gonna hit the $30 million in savings for this year. We'll exit the year with a $100 million run rate, as Ed talked about. We're generating cash to invest in the future, and we're on a run rate to hit the $200 million by the end of 2025. We're also on track to achieve the $250 million-$400 million of working capital benefit over the life of the program.
As we go forward, we will continue the work streams officially, but as we've talked about, these are becoming more and more just the way that we operate our business from a day-to-day standpoint. So to recap, we're delivering on our goals, we've got a clear line of sight to savings, and with those savings, we're gonna reinvest to drive organic growth. As you've heard throughout today's presentation from all the speakers, from my teammates, our future growth will be driven by investments across all areas of the business, starting with Patient Direct, but also including products and healthcare services. And we're keenly focused on the following four drivers: So one, we're gonna sustain good revenue growth with investments in commercial teams in both segments, and we're gonna expand our product offerings. We're gonna continue to focus on attracting and retaining the best talent, as Tammy talked about.
We're gonna expand into adjacencies and comorbidities as patients in Patient Direct, as Perry mentioned, and we're gonna invest in technology that's gonna improve the experience for patients, providers, and payers. This will go all the way from back office automation to our patient management platform. With these 4 key drivers, we're confident that we will sustain our top line growth. If we look back to 2019, the majority of our revenue growth has been driven by Patient Direct. And now, with the powerful combination of Apria and Byram, which we created in 2022, and as we look ahead to investing even more in this business in Patient Direct, we're very confident in sustaining our top line momentum, and we expect organic revenue to reach $12 billion by 2028.
Note that this does not include any potential M&A that Perry talked about as part of his $5 billion ambition. So while we expect Patient Direct to be at the heart of our top line growth, we do expect products and healthcare services to continue to post modest upticks in revenue, and that has been a historically lower revenue growth business. As part of that revenue growth, it's important to note that there will be mix changes, as Andy's talked about, with our new products. Now, turning to the bottom line. We believe that 2023 is the post-pandemic earnings inflection point for us. Coming out of a tough Q1 this year, which we expected, we've delivered significant sequential improvements in Adjusted EPS over the past couple of quarters.
The execution of our strategy is resulting in higher quality, higher margin revenue across the company, and as we move forward, we should expect operating income margin expansion in both segments. It'll be driven by top line growth and operating leverage. It will also be aided by additional efficiencies and savings from the Operating Model Realignment program, as well as reduced interest expense from delevering. Long term, our investment in new proprietary products and P&HS should also drive incremental margin improvement. So organically, we expect an adjusted EPS CAGR of over 20% through 2028, so calculated off of 2023 for the next five years, a 20% CAGR on adjusted EPS, and we expect to reach $3.50 by 2028, as shown by the diamond here on the upper right-hand side.
We also expect to generate strong free cash flow, driven by operating profit growth, as well as our disciplined approach to working capital and capital expenditures. As we've talked about today, our cash generation will support reinvestment in the business organically, as well as other potential strategic initiatives in the future. We expect to generate over $1.3 billion of free cash flow between 2024 and 2028, and we're excited about the opportunities to invest with the cash that we're gonna generate. So as we go forward, and as we've consistently mentioned, we will use a portion of that cash flow to continue to pay down debt. We're committed to delivering our target of 2-3x net leverage, and as we delever, we gain optionality with regards to capital deployment.
So if we look at our balance sheet, what we've done over the last five years, and in particular, what we've done over the last three quarters, where we've paid down over $500 million of debt year to date, it gives us great confidence that we're going to continue to enhance the financial strength of the company as we move forward. By increasing the cash flow generating components of the business as a whole, we'll both strengthen the balance sheet and be able to reinvest in our business. From the right-hand side of this slide, you can see that we do expect to drop below our target leverage ratio range, and strategically, we would not expect to spend much time there, which brings us to capital allocation. To put it simply, we've got three priority areas for capital allocation. The first is organic reinvestment.
You heard from both Perry and Andy today that we've got attractive opportunities to build our presence in both segments. We'll also continue to explore additional M&A, and we'll maintain a disciplined approach to expand and scale our business. And third, we would evaluate opportunistic share buybacks under the right circumstances. So before I recap our financial targets through 2028, I'm just gonna touch on M&A. We believe we've established a strong track record of identifying targets, bringing them into the Owens & Minor family, and growing the combined businesses. As you heard from Perry today, the combination of Apria and Byram has been a winning combination for us, and while our current focus remains on ensuring a strong balance sheet, we're not going to let the right deals pass us by, and we have the financial flexibility to do them.
In terms of our criteria, Patient Direct is where we see the greatest opportunity to acquire. It's a target-rich market with high-quality names that would fit nicely into our platform. We'll continue to evaluate deals holistically, looking at the optimal profit growth as well as integration fit profile, and we're going to continue to maintain discipline and rigor around target identification as well as due diligence. We're very comfortable passing on opportunities that don't check the right boxes. And finally, and this is critical for every deal size, but especially for one as transformational as Apria, we have to consider every factor, including what's best for our business and our shareholders long term. So with that, let's recap our financial targets. Our first objective through 2028 is to deliver more than $12 billion in annual revenue.
We believe we can do this with a combination of reinvestment to drive organic growth and with even more upside possible through M&A. Second, we aim to deliver over $750 million of adjusted EBITDA.
... We're going to do this through driving margin expansion as a result of greater operating efficiencies, as well as a keen focus on providing services and products that drive the highest value. Third, we expect to deliver over 20% adjusted compound annual growth, or compound annual growth on Adjusted EPS, and to get to north of $3.50 by 2028. This will be driven by operating income margin expansion in both segments. And finally, we expect to deliver over $1.3 billion in cumulative free cash flow. We have a healthy business, we have a thoughtful approach to managing costs, and we believe that this cash flow is absolutely achievable, and we plan to use it to generate and unlock shareholder value for years to come.
So with that, I'd first like to say, you've heard from me and my teammates today about the path forward. I'm incredibly excited to be part of it, and before we turn the floor over to questions, I wanna ask Ed to come back up and add a few remarks.
Thanks, Alex. Just do a, you know, relatively quick recap. So, and I'll do this, and I'll bring the rest of the team up. But Patient Direct, here's again, the way I think about Patient Direct. The demographics are in our favor in that space with an aging population. The fact that patients, providers, payers prefer treatment in the home, that's in our advantage. The fact that we've have a proven model, that we've been able to take a business since Owens & Minor owned it, at $450 million, to grow it over $1 billion, layer on a large acquisition on top of that, and then continue to grow and take that business from $2 billion-$2.5 billion in about two years, in less than two short years.
We have the track record in that space, we have the proven model, we have the right footprint, and we have the right product portfolio to continue to be successful. In addition to that, they've earned the rights, the segments, to continue to do acquisitions as appropriate. What they've done with the acquisition of Apria, the integration, hitting the synergies, and then continuing to drive more growth, has been impressive. If we think about our Products & Healthcare Services business, and this is a business that can provide tremendous amount of scale and leverage. It's a business that we're growing, we're winning in the market, because we have a way to provide value, service, as well as flexibilities for our customers. In addition to that, there's clear strategies in both of the segments.
In the Products and Healthcare Services segment, there's the opportunity to expand our proprietary product portfolio, and we're making the investments necessary to do that. It has the ability to continue to drive and to be a lower the cost to serve, and that's critical. Lastly, on our balance sheet. You know, we continue to strengthen our balance sheet. We did a really good job over the last three quarters by paying down nearly $500 million or $500 million of net debt. The expectation is we'll continue to deploy capital to pay down debt, to get into the range we wanna be in, and continue to provide tremendous flexibility to the business.
We talk a lot about the balance sheet and capital deployment, but I think the other thing to talk about on here is the fact that with our Operating Model Realignment, as we're driving savings and operating cost out, taking and redeploying that operations cost back into the business, whether it's in, say, additional commercial people in the Patient Direct business, whether it's in technology in the Patient Direct business, or whether it's in the category leadership, commercial, support, as well as, you know, technology to take cost out of our P&HS business. So with that, I'll pause. I'll ask the leadership team to come up, and then we'll take some time to go through Q&A. I'm gonna let John make a couple comments before we get started on Q&A. So here you go, John.
So as the team assembles, we'll spend about a half hour or so on Q&A. We ask that you limit yourself to one question, one follow-up before getting back in queue. For the benefit of the webcast, when called upon, please wait for the microphone, and we've asked that you also provide your name and your firm name. And we're ready for you to take questions. Daniel?
Hi, Daniel Grosslight with Citi. Thanks for all the great details here, and appreciate all the, all the color around longer term targets. I wanna focus a little bit on Patient Direct, and really, the expectations for 2024, understanding that you're not going to be guiding specifically for 2024, and then the cadence on how to get you to that longer term guidance. And specifically, you guys mentioned this kind of on the 3Q call, there are a couple of big headwinds coming up in 2024. One, you've got the expiration of the adjustment to the Medicare fee-for-service fee schedule, and some estimates that I've seen, you know, expect 30-ish% cuts in reimbursement in that area to certain products. So that's, you know, that's gonna be a significant headwind for the non-CBA, non-rural areas.
So curious how you're factoring that into your overall growth rate. And then, I guess, more broadly speaking, as you think about the diabetes space and the shift from the medical segment to the pharmacy segment, I'm curious how you're integrating that into your longer term guidance as well.
So thanks, Dan. There's a lot of questions within that one long question. So, maybe I'll start, and I'll let both Perry and Alex, you know, talk a little bit about, you know, the, the business as well as the modeling. You know, so we'll provide 2024 guidance, you know, in when we announce our fourth quarter earnings in late February, early March. But the way we're thinking about it is, again, it's to continue to leverage in Patient Direct the strength they have. A really strong commercial model. We know there's some geographic footprint where there's opportunity for us to invest in. We know that as we add commercial resources in, you know, they don't pay back immediately. They have usually a 12-month or so till they start to pay back returns on.
You know, so as we think forward, you know, we're gonna continue to pace those expansion in for the organic growth and continue to do that. So I think that's part of the way you should think about it in the near term, and then that continues to accelerate in the longer term. You know, with that, you know, let me turn it over to either Alex or Perry. Alex, you know, if you wanna talk about some of the financials modeling, or Perry, if you wanna talk about some of the thoughts on the business.
Why don't I take the financials, and then you can layer on the business? So, so Daniel, I guess the way I would think about the revenue over the next 5 years is that we've talked that, about Patient Direct being the primary driver to get to the $12 billion. I mentioned we, we expect to see modest upticks in products and healthcare services along the way, so roughly 1% annual growth. I think you find that in the assumptions page in the back. So you can sort of back into what we expect from Patient Direct in terms of getting there. You know, we don't expect any sort of hockey stick or, you know, sort of abnormal growth. So I would say, you know, kind of looking at how you get, ratably to the $12 billion would make sense.
You know, in terms of how we think about, you know, headwinds and tailwinds as we move forward, you know, we talked on the last call about the 75-25 reimbursement from PHE. We've factored that into our projections. We've factored in, you know, the other things. But, Perry, I don't know if you wanna talk about how you think about it.
Well, I'll just I'll talk about the business when you look, think about PBMs or your question about pharmacy. First, there's probably 1 million to 1.5 million newly diagnosed diabetic patients a year, so there's a tailwind of patients coming into the funnel every year through the top. Those patients are on—it's a non-curable disease, they're on for a lifetime. Secondly, pharmacy benefit is not a new thing to the industry. It's been around for the last 5 to 7 years, and primarily, we, as employers and the community, choose our health plan benefit, and we, as employers, decide where we want that paid for, either a DME benefit, a dual benefit, or a pharmacy benefit. Probably unbeknownst to, we have 3 pharmacies within Patient Direct.
We service the, call it, diabetes CGM population today through our pharmacy business as well. So we actually become a highly attractive partner in this because we can serve the patient regardless of what payer channel they choose.
Obviously, we, you know, thank you, you know, Alex, Perry. Perry, you know, also shares that there's a lot about the Patient Direct business that creates competitive advantage for us. You talked about the pharmacy aspect, but, you know, that's what gives us that, you know, that encouragement and really the track record of what we've done. Alex, maybe you can add a little more color on the 75/25, 'cause I know we've gotten questions on that in the past.
Sure
... and how that impacts us and what the magnitude of that is.
Sure. So for those of you who aren't familiar, we had a number of questions a few weeks ago on what's called the 75-25 blended reimbursement rate for Medicare. There's some legislation going through Congress right now to potentially extend some funding that was approved during PHE. It's for a portion of Medicare. So the way to think about this in terms of our business is it really only applies to DME, which is Apria, so call that roughly $1 billion. And of that business, about 20% is Medicare. And within Medicare, there are essentially three rings: there's bid, there's rural, and there's non-bid, non-rural. And the non-bid, non-rural is the portion of the Medicare business to which this rate applies.
And so when you sort of chunk it down, we have factored into our projections for next year and going forward, scenarios that, you know, impact whether either having the legislation extended or not, but it's, it's not a material swing factor for us.
That's right. That's right.
All right.
Thanks for taking my question. It's Kevin Caliendo from UBS. The assumptions to get to $3.50, how much of that is in your control? How much of it is sort of macro, dependent on how the markets evolve? You know, you talked about this year, you had certain control over costs. And I guess as part of the assumptions, we appreciate the color on it, but one of the quick key questions is: How are GLP-1s impacting your assumptions on the market opportunity for sleep and for diabetes?
Sure. Well, we'll cover that in. So the way we think about it is, one, in the Patient Direct business, our expectation is we grow at least 2% above the market. So, you know, that's the minimum expectation, and we've got, you know. The way we see that market, you know, Perry shared, he thinks it's probably around a 6% overall market growth or more than that pace, and we should be at least at that, if not greater. You know, and I think, you know, in the GLP-1s, look, we've had a lot of conversation about GLP-1s, and here's, I think, what you gotta, we have to really drill into a little more detail. So take diabetes, for example. You know, the vast, vast, vast majority of our diabetes patients are either Type 1 or Type 2 insulin dependent.
Even with a GLP-1, it's not gonna—they're not gonna take, that's not gonna go away. In addition, with GLP-1s, whether it's sleep or whether it's diabetes, it's gotta be adherence, that the person who starts it generally may be taking that for life, and they need to keep, you know, continue to take that. But they're still gonna need the monitoring for, you know, continuous glucose, or they may still need sleep devices. You know, we've, we haven't seen a slowdown in this, and then, you know, the other- we haven't seen a slowdown in starts in either our diabetes or our sleep through this year, as that has supposedly gained momentum.
Then I think the other aspect, you look at some of the key suppliers out there, whether in diabetes or sleep, and I think they have a lot of the same views that we have on this. So Perry, if you want to add any additional color, please feel free to.
I think you've covered it well, and I think the other factors are, again, in diabetes, in both sleep, there's a large pre-diabetic, pre-OSA, and a population that's undiagnosed. So the demographics are in our favor. Patients with a chronic condition that'll continue to go forward, so.
And really, what Perry said there that is so critical is you cut through all of that, the demographics of the aging population, the demographics, you know, of what we're seeing are really on our side, and then you layer that in the proven model that, you know, Perry and the team have displayed, that's what gives us a lot of confidence moving forward.
If I can ask a follow-up-
Sure.
Different topic. More on the new SKUs that are coming. How do you expect to compete on these products? Is this quality? Is it price? I only ask because pre-COVID, Owens & Minor struggled with manufacturing efficiency. They weren't able to compete necessarily on price with products that were imported. You're launching a bunch of new SKUs. I'm just interested. Are these replacing outside products? Your margins will be higher. Can you compete price-wise? Just a little more color around that would be really helpful.
Yeah. I'll start, and then, you know, Andy, you can cover the bulk of it. But I think the first assumption you have to have is, we don't necessarily have to make those products as we expand. I mean, it's a make-buy analysis, you know. So we're thinking about it very differently in the past when before our blinders, as you saw the list Andy showed, was primarily on S&IP, surgical infection prevention products, and primarily made within our own facilities. There's opportunities to make other and newer products within our facilities, like Andy talked about the expansion with gloves, for example. We'll do that. But in the same sense, we're open to both the make and buy analysis. And with that, I'll turn it over to Andy to add a little more.
Yeah, if you think back to the page I presented, where the left-hand side was the existing portfolio, where we have our proprietary products, that's where our manufacturing lies today. And on the right-hand side, these new categories that we're going into, we really don't have manufacturing capabilities. So we will primarily be sourcing products on that side. So we'll have the opportunity to go out into the market and truly, you know, test a number of suppliers in order to make sure we're getting the best cost in order to be competitive. And as we select SKUs, I think another dimension to our success in being able to launch these is that, one of the criteria we're looking at in terms of SKU selection is, you know, are these SKUs that have high or what's the degree of physician preference, right?
So if there's something that's got a high degree of physician preference that's harder to convert, you know, that's probably a less attractive market for us, right? So we'd be looking for things that we would be able to get more traction earlier on as we launch these products.
You know, and I'll add one last thing is, as we launch those products, those aren't necessarily going to drive top-line growth. It's a, an in-channel swap out from one brand A to brand B or brand C. So it'll drive margin expansion, but not necessarily top-line growth.
Allen Lutz, B of A. Perry, on the Patient Direct business, you mentioned that 80% of revenue there is recurring, and then commercial is 80% of the business, and Medicare or government is 20%. Is there any way that you could follow a patient from commercial as they graduate into the Medicare Advantage bucket? And then also, can you talk a little bit about how you're growing within Medicare Advantage?
We do follow the patient in their journey, so as they are commercially insured, become Medicare eligible. We do this because we talk to the patient on a more frequent basis than their care provider. So if you start out as a commercial patient, you reach age 65, you then move over to Medicare, we gravitate you into Medicare. If you go from Medicare to Medicare Advantage, we do that. I think the key thing about that is, we have such a high contract portfolio, and we're contracted with all the major providers that cover Med Advantage, and so we're well positioned, regardless of if you start in a commercial, you go to traditional Medicare, or you go to Med Advantage, we can follow your journey.
We go to market with the 450 salespeople, and we've got a carve-out team that just works on managed care, contracting, and pull-through. So again, I think all those indices are what really keeps the 80% of the recurring patient base with us. We don't let them slip through the cracks.
Thanks. Am I live?
Yep.
Good?
Yeah, you are.
Okay. Eric Coldwell with Baird. A couple of questions on growth, and then, sorry, Ed, maybe a couple of follow-ups. I'll avoid the 27 questions I actually have. So on Patient Direct, $2.6 billion of revenue roughly this year, getting to $5 billion, getting to $3.7 billion organic. So $1.3 billion of M&A, that's hard to model on the sell side, right? Projecting timing, size, outflows, margins, et cetera. Hoping we can get some color on your thoughts on timing, how many opportunities are in the pipeline?
Sure.
Are we, are we waking up to a press release in the next few months of a bigger deal? Is this a combination of small, mid-sized deals or a couple of chunkier deals, more, and not much out there like Apria, but something chunkier over time? Just some color on-
Sure
... the thought process there. Yeah.
Here's the way we think about M&A and as well as timing of it. So, you know, I think we've been pretty clear. We wanna get into that 2-3 range. It doesn't mean we wouldn't do something if it was very advantageous, you know, for us going forward, but our key goal right now is to continue to pay down debt, continue to delever, to have that flexibility. If we think about acquisitions in the Patient Direct space, I think you gotta think about it in a couple different factors. You know, we wanna grow organically and expand our geographic footprint, as well as leverage our existing geographic footprint. If there's the right opportunity to do a bolt-on or a tuck-in that helps us expand that geographic footprint quicker, we would consider that in doing that. But those are generally smaller.
You know, and then I think as we move forward, you know, we're gonna look at varying opportunities, and I know I'm not gonna give you the answer, "This is when we expected, Eric, and this is it," but it's, it's gotta be to the right leverage. We gotta get deleveraged to the right point. It's gotta be the right to create a value, and if we would do a larger one, you know, that has to be available, and we would time that out appropriately. So, you know, the reality is on it is, first thing is deleveraging, getting us to the area we want, but it doesn't mean we would walk away from the right deal if we had to do a leverage up a little bit earlier.
But our preference is to continue to delever into that 2-3 range, very similar to what we did as a company in 2020, 2021 before we did the Apria deal to lever back up and now paying that debt down. I think we could think of some smaller tuck-ins, you know, that could fit in if it helps offset organic investments with an inorganic investment that gives us a geographic expansion. And then on those bigger ones, we're not just looking in the categories or the space we're at, we're looking at, you know, you know, where we can... Here's the way that we think about it: where we can take our proven model and overlay it, if it's a bigger one, either in the same categories or in new areas and adjacencies. So that's how we're thinking about that.
Okay, on PHS growth, you've implied, you know, decent traction in the market, onboarding a new larger customer in 2024, new products, some of which will just cannibalize existing-
That's right
... lines, so not necessarily all of those driving growth. You've talked about expansion into adjacencies, et cetera, but yet only 1% CAGR in revenue for five years. What are the underlying market assumptions in terms of market growth, patient volumes, pricing, share loss, share gain? I mean, we need more in terms of the buildup to get to just a 1% growth rate over five years.
Andy, you wanna... Maybe you can start with that one?
Yeah. No, absolutely, Eric. So, you know, as we look at it, you know, I think the one point to make is that, you know, the strategy that we've put together is definitely bottom-line focused, right? We wanna demonstrate that we can get that doubling of profitability without counting on, you know, you know, kind of go-get-volume-type gains, right? So I think a lot of the things that we are doing and to strengthen P&HS will actually lead to additional revenue and will make us more attractive to customers. We're just not counting on it in these forecasts, in these projections. But I think if we were to achieve the, you know, additional wins beyond what we forecasted, that leverage we would get, that pull-through on that incremental volume as we improve the profitability will be meaningful.
You know, I think in terms of volume projections, I think in terms of medical distribution, you know, we've talked a fair amount about the wins and that we're winning in the marketplace, but look, over a five-year period, we're expecting there's gonna be churn, all right? And so we are not counting on big share gains, as I said, but I think we're well positioned to take advantage of that, should it happen. Because-
I'll add one last thing to that, Eric, is, you know, all revenue's not the same, and I think we recognize that. So, you know, there may be times where we walk away from some things to focus on other areas. So that's the other thing that's been factored in there with some of the churn.
I'll be very transparent. I hear a large win for OMI. I think $several hundred million, maybe even up to mid-single-digit $hundreds of millions a year for a very large client. Obviously, that would get you the entirety of the five-year growth plan next year if all else were flat. So there has to be an assumption here that you're letting some business walk away, or you've lost some offsetting business, because otherwise, we get all of the growth in one year.
And I think that's part of that comment. There's, you know, again, all revenue's not the same. There's gonna be some ebbing and flowing, we think, in the next several years as we continue to adjust. And we've done that in the last couple of years, and that's not gonna change.
Okay.
Nice.
Usually when we talk, it's Kevin Caliendo from UBS. Usually when we talk, we always talk about what's going on with PPE and inventory levels and volumes and the like, and we haven't really spoken about the fourth quarter or anything else. Maybe you can just provide a little bit, what's going on? What are you seeing in terms of inventory levels with PPE, demand? You know, after, I think after you spoke, HCA talked about wanting to take down their inventory levels across their channel by, like, 25%, which made people nervous, broadly speaking. Can you just talk to sort of the environment right now?
Yeah, and, and I'll use an anecdote of a customer I was at last week, meeting with them, too, is... So here's what we're seeing. Within the customers that are our customers, where they use our Halyard brand, S&IP product, or specifically PPE, and they're our distribution channel, you know, we've seen, you know, that level off, and we've seen the demand be back to slightly above where it was in 2019. I think, I think if I look at a specific example of a customer where we took over their distribution centers for them, and they had a lot of product bought, there's some categories where they're already back to—they've utilized their entire safety stock, and this is at the customer level. I'll come back to the distributor level. They've used their entire safety stock in facial protection.
They've used their entire safety stock in gowns. They're completely out. But yet gloves, they still have several months' worth of gloves out there. But they're conflicted a little bit because the fact that they're just a basic glove versus their preferences are gloves, which are chemo-rated, so that way, they don't have to worry about where they are utilized in the hospital. So, you know, we see some of that. So you look at the categories, and that's just one example. And other customers are completely... You know, if they have their own distribution, they're out of them. What's still difficult for us-...
To put a pin in, as I've said in the past, is the fact that other distributors, whether that's within healthcare or within non-healthcare space, have bought so much product during that period of time, and when we go to them and try to understand how much they have left, they're not gonna share that with us, you know. But we can continue to see from the customer. So if I think about the trend, we were at a set point in 2019. It skyrocketed and probably hit its peak in the first two quarters of 2022. Those were our large-- 'cause people were still trying to build safety stock, as well as they were still trying to prepare for the triple-demic.
Then all of a sudden, as we talked last year, we kinda saw that thing start to cliff and really hit, you know, as the last 12 months have progressed. So you think about that as a slope. It's come down drastically, but that slope has leveled. It's not continuing. So, you know, it feels like, you know, we're kinda at that point where it's gonna ebb and flow a little bit more, but it's not gonna be that continued decline that it was. And again, on utilization, because of protocols, what we're seeing it from our customers, where we have complete visibility, is we're continuing to see utilization levels above where they were in 2019. Not drastically, but that kinda is a good proxy for us. So hopefully that helps.
Yeah, that's helpful. I wanna go to Patient Direct and follow up on Eric's question. You talked about expanding your geographic footprint. Is that organic, or is that via acquisition? First question.
Our intent is to do organic, as we've done in the past.
Okay.
That's our intent. But again, we gotta be smart when we're doing our analysis. If there's a specific geographic region, and we look at the cost to put in our own facility and expand it there, versus, you know, buying a small facility with people already there, we're gonna make that trade-off, and we're gonna look at that at the same time. But primarily, we think there's tremendous opportunity to expand within the geographic footprint we're already in, continuing to grow that space, like we've done in the past. But then look at the map and find out... You know, we've looked at the map and identified certain geographic areas where we're underrepresented, and either add our facilities there or else look at another option. But our intent is to do... You know, what Perry's done is pretty impressive.
I mean, again, to take a business from $450 million back when we acquired it in late 2017 or mid-2017, to grow it before we did the Apria acquisition to north of $1 billion, that, that's, that's just a model that works.
To that end, now that you have Apria, and you know, you talked about over $1 billion of M&A acquired revenues, is there a third leg besides diabetes and sleep? Like, is there something that's that meaningful that you would add on, or are we talking about smaller bolt-on small products that we probably would never know or you would never specifically call out as a category?
I mean, like, maybe I can start, Perry, and then you can add a lot more color on it. But I think, you know, the bolt-ons are more in the current space we're in today. You know, that's the way we think about it, is you bolt it on and move it. You know, if there's something in other areas, and Perry alluded to a couple of adjacencies, those would be some of the things, you know, we could both look at it growing organically or bolt in organically. I don't know, Perry, if you want to add.
I think Ed's absolutely correct. 45 days ago, I was in front of one of the largest payers in the country, and we were talking about Patient Direct, the services that we provide, and the payer looked at me across the table and said: "Are you looking to expand into areas like complex rehab or O&P?" I just smiled, because at that point, our strategy was in the development, and we couldn't talk about it. But as I said before, our payers are looking for providers who are sustainable and those that can serve larger populations because it's in their favor to contract with companies like entities like us that almost can do a one-stop shop for their constituency base. So, to Ed's point, we'll continue to organically.
As we have grown the business, we'll continue to do that in our footprint, and we'll look outside of that to enter adjacencies.
Thank you. You have Toshi Phillips from Jefferies, here representing Brian today. Back to Patient Direct, this is a follow-up to Allen's question. Can you maybe comment on the current appetite you're seeing in the market for value-based arrangements with the large payers, and how do you think about that opportunity within the context of your organic growth target in Patient Direct?
Sure. Why don't you?
Sure. So again, go back to my last comment. What is a payer looking for? Looking for sustainability and providers who can provide a large, broad portfolio of coverage of therapies, and we clearly fit that bill. If you look at our space, what does value-based care mean to them? Again, it means sustainability. We've got the ability to transact across the U.S. if you're a national or a large regional, and you've got the services to do that. And what it really means is cost predictability and outcomes. And so think about that through capitated-type contractual relationships. And Patient Direct has the ability and the know-how to do capitated arrangements, and collectively, Patient Direct owns the largest capitated arrangement with a payer, one of the top five payers in the country.
We've had it for many years, and it's been renewed multiple times. So we've got the capability to do it, we execute on it, and we'll continue to look for those opportunities with payers. Actually, one of the beauties of bringing Byram and Apria together is, we've brought in the portfolio, and it's made it far more attractive to the payers to do that with us.
... Hi, Daniel Grosslight with Citi again. I wanna stick with or go back to the question around PPE, everyone's favorite topic. I guess for 2024 and beyond, in that 1% growth rate assumption, I know there's a lot of moving parts, but I was wondering if you could just break out what you're assuming for PPE stabilization, particularly in the third-party distributor channel in 2024 and beyond.
We have not talked about that, that publicly yet. You know, maybe Andy, we can give some general color on it. I think that may be, that may help.
Yeah, I think it would be safe to say that, you know, as we exited, you know, Q3, you know, we're starting to see, as Ed said, with consumption and purchasing patterns starting to get more linked together, there's not that big disconnect. So I think that's probably... That stabilization, I think, is probably a good jumping off point for the outer years.
The way to think about it is, you know, we saw, if you think about dollars, we saw that, a drastic decline over the last four quarters. You know, now we've seen somewhat leveling out. So we still got some comps back to. If you look, just look at the trends, some comps last year, while it was declining drastically from 2022 to 2023, you know, it declined during the year as the year progressed. So you still got a little bit of that on the comps that are left.
Got it, okay. And then on the doubling of profit, excuse me, doubling of profit, in P&HS, over the next several years, is that 2028 that you expect it to double? And maybe if you can help us think through the cadence of that improvement.
Sure. Yeah, so, you know, I don't think, I wouldn't expect, you know, in terms of the cadence addressing that first, I wouldn't expect a linear cadence, but I think what we're building today will certainly continue to see nice increases. I think the achievements that we've had in the current year, and you'll see some nice annualization next year. Things like the category build-out, for example, that takes time, right? And so, while we're launching 4-5 more SKUs than we have historically, you know, it's gonna take time for that to get out into the market, to get these SKUs on GPO contracts, and then there's a conversion time within the hospital, right? And then, as we continue to build out that team, you know, that acceleration of SKUs should continue into the out years.
So that might take a little bit more traction. On the shorter duration ones, it's think of the sourcing savings, right? Minimal investment required. It's things that we can act on quickly and get a benefit. Really, the longest lead time is just the bidding process, and then getting that product to work its way through inventory, and then once it's, you know, through inventory, you start to see the P&L benefit immediately. That one, though, on the other hand, is that over, over time, those, those savings will start to decrease, right? As you pick off the low-hanging fruit initially, your opportunities shrink over time, which is the opposite of portfolio expansion, right? It starts slow, but it should accelerate over time. So we should be exiting that 2028 time horizon, accelerating out of that for, for portfolio expansion.
Let me add just a little more color on it, too, from Andy's comments. So if you think about the talking points we covered today is Operating Model Realignment, network rationalization, network optimization. And I think it's pretty clear that 2024 is gonna take time to rationalize the warehousing, rationalize manufacturing, optimize those with technology. That's not something that happens overnight, and then there's the payback on those. I think very consistent with that is what Andy talked about in, in portfolio expansion. You add the commercial people, you add the inventory, you add the category management, you start to gain that traction. You know, then once you have those products placed, you know, they keep reselling every year after that, and then you can continue to grow, and you get the leverage on that. And I think Andy's right, though.
Up front, though, you do have some benefit next year, really in one area in sourcing. I think hopefully, that helps think about, you know, the investments that are made, and then the paybacks that come from those.
Hi, it's Eric Caldwell, Baird again. So the Operating Model Realignment program run rate, $100 million exiting this year, you'll capture $30 million plus this year. So if you did nothing else, you'd have $70 million next year. You've talked, Ed, about reinvesting. Are you reinvesting $70 million, $50 million, $150 million, but picking up savings elsewhere? I'm just-
I would say, Eric, we're investing the vast majority of that.
Vast, vast majority?
Yeah. Yeah.
And, um-
Yep
... and then in terms of CapEx versus OpEx on investments?
Primarily, it'll be OpEx.
Primarily OpEx.
You know, think about the expansion we're doing in footprint to, to grow the Patient Direct business, some of the technology we wanna put in there, the category leadership within Andy's, within the P&HS segment business, the commercial leaders out there on those. You know, and then some of the cost to continue to drive some of those longer-term benefits going forward.
Okay, and then just, last one for me. When you, when you started this year, you changed some of your reporting methodology, what went into adjustments, EBITDA versus EPS. And if I understand correctly, still trying to get my head around all of this, there was originally expected to be a $30 million optical benefit to 2023 adjusted EBITDA due to these changes. And based on what's happened year-to-date, we believe that the implication is the fourth quarter has roughly $17.5 million of LIFO charges that will be added back in stock comp, a combination of the two. Is that still on pace? Is that still the expectation, that original guidance for $30 million of optical benefit?
Yep.
Then, as we go into 2024, can you help us at all understand what your thought process is for LIFO charges? Which I believe the implication is there are LIFO charges next year. Because high level outlook for 2024, EBITDA and earnings growth, EBITDA was in line with the street looked fine, earnings was below street. So I'm assuming there are charges being added back to EBITDA next year that would have to, and, and/or stock comp, that would have to be fairly substantial to allow the EBITDA to be in line, but the earnings are, are lower because you're not doing the add backs there. I'm sorry, that's a really complicated question, two parts, but would just help us with the modeling thoughts. Thank you.
Sure. Yeah. So, I'll try to kinda repeat some of the things we talked about on some of the calls following the Q3 earnings, and then to clarify. So in Q1 of this year, we changed our Adjusted EBITDA definition to add backs for stock comp and LIFO. And at that time, we said we thought that those add backs together would be roughly $30 million in 2023, and in 2022, they would have been about $25 million. So that was what was factored into our original Adjusted EBITDA guidance for the year coming out of that definitional change. At the end of Q3, we see some more uncertainty there because of the radical reduction in working capital benefit—the working capital benefit we got from the Operating Model Realignment, the reduction in inventory.
And so with that, we would expect less of a LIFO add back in 2023, and as we normalize next year, we would expect more of a LIFO add back in 2024.
Any time for another question or so? Any, any other questions?
Go ahead, Kevin.
Oh, Kevin, we'll go one last question unless somebody has a burning one they wanna get out after.
I appreciate that. Market share gains and losses in the products business, it's always been a debate, you know, are you guys taking share or losing share? Are there contracts that you've walked away from that weren't as profitable in the past? Or when we think about net business wins from a gross perspective and maybe from a margin perspective, any color you can provide in what, you know, for 2024 at least, or and beyond, how that shapes up?
I can start, analyst.
Mm-hmm.
I mean, if I - Go ahead. Why don't you start?
Yeah, I would say, not speaking to 2024 in particular-
Exactly
... but over the five-year period, I think you can tell by our, you know, assumption of 1% kind of compound growth rate that you're gonna see some lift from some of the activities that we're doing outside of medical products the division. But I think, again, we have taken and will continue to take a very disciplined approach to how we go after new business. And again, being a very competitive segment, I think the assumption is that we will roughly stay whole on share. But the important thing is that, you know, the doubling of the profitability can be achieved without significant gains, and the investments we're making to improve the business should make us more attractive to win new business.
Maybe I can explain kinda how the process we go through internally to assess this. So we've created a business development team that's done a great job going out, attracting new business, attracting business that fits what we can provide and provide value to them, value to us, you know, high level of service. But we have a detailed review internally of existing customers and renewals and where are the optionality within those for us as a business, as well as the same with pursuits that we're going after. So we do have a robust, you know, pipeline to try to match up, you know, where we can provide value to them, the right level of service and flexibility, in the same sense, the fair returns back for us. That's how we think about it and manage it, at least internally.
Super helpful.
Thank you. Well, with that, let me just make a couple of closing comments. You know, one, I, you know, appreciate everybody spending the time here today. You know, we'll close on this slide with Life Takes Care because we've really launched our purpose and where we're going as a company, but we continue to accelerate that. We had our mission, we had our values, now we got a vision and a purpose, and Life Takes Care. I'll also make one other comment, and I'll close on summaries and takeaways. The reality is, you heard today from Perry's business. You can tell from my excitement how much I love that business, where we've invested the business and made the right bets.
The fact that we have a proven model that works, the fact that we have the right portfolio, the fact that we have the right footprint, and the fact that we've been able to deliver on strong execution and grow that business at incredible rates over the last 5-6 years. Post-acquisition of Apria, we were able to then take that model and overlay it. So you can clearly see in Perry's strategy is to continue to execute on that, add the incremental resources for that organic growth, you know, continue to look at adjacencies, invest in some technology, and then when appropriate, you know, look at the other aspect, which is inorganic. Take a look at Andy's business, P&HS segment. It's drastically different today than it was in 2019. Service levels are some of the industry-leading service levels, drastically have improved that business.
And we really get excited about this space, is we're thinking about the business different. We understand what the customer wants. The customers want quality, they want service, they want value, and they want some level of flexibility. You know, but we're thinking about it differently is that with our product portfolio, we're gonna expand all that product portfolio, but we're gonna put the resources in it that we haven't put in it for the last 30 years to make sure we do that, knowing it's gonna have a longer-term payback, but ultimately, will provide tremendous value for us. You know, in addition to that, you know, we're gonna continue to focus on how to lower our cost to serve. If we're gonna provide value to our customers, we gotta continue to drive cost out of the business and lower the cost to serve. And how do you do that?
You do that by thinking differently. We're thinking differently, and that's in that business, and the fact that everything doesn't have to be made in our facilities, everything. You know, so how do we take and look at, can we run our facilities at capacity? Can we consolidate them down so we can be extremely efficient? Where's the right point to make versus buy? And that goes, too, in the portfolio expansion. Our portfolio, as we expand, it doesn't have to be in our factories. It can be partnered with others, or it can be in our factories. We're gonna make those decisions. Then lastly, the balance sheet. You know, we've done a really good job, you know, from where we were in 2019, taking the balance sheet down.
We leveraged up with the acquisition of Apria, and we're starting to delever now, and that balance sheet gives us flexibility. When I talk about capital deployment, I also like to talk about operating expense deployment or operating investments. You know, as we take our Operating Model Realignment, we take costs out, we're gonna redeploy those dollars back into the business to provide growth. And just because the dollars may have come out of Products & Healthcare Services segment, doesn't mean that's where they go back in. We're gonna take and deploy those dollars where it will provide the most benefit. So with that, I appreciate the time today. You know, I'm sure we'll talk to a lot of you after we do our fourth quarter earnings release, which will be in late February, early March.
Again, appreciate the time, appreciate the questions, and look forward to talking to everybody again soon. Thank you.