CFO. We'll get right into some questions here. If anybody has any of their own questions, raise your hand. We can keep this very informal. Maybe just to start for a minute on the core business, you sort of have three categories now that you've communicated that you plan to invest in. You've got predominantly your sleep business, respiratory, and then let's just call it diabetes. You've announced some divestiture activity of some non-core assets. How would you characterize sort of the end markets around sleep today? I mean, we've had some challenges with supplies and getting product over the last few years. Has that all normalized and calmed down? On the demand side of it, how do you think about just the growth in the end markets?
Yeah, sure, Whit. First, I guess I'd start with on the new start or the new setup side of things. I think despite a lot of questions we still get on GLP-1s, we're just not seeing an impact, really good or bad, we'd say. I mean, I think we're listening to the same KOLs that you all are. We think that sleep demand is as healthy as it's ever been. Our starts are very steady. We continue to report the percentage of those patients that are on a GLP-1. It's actually proven to be a tailwind so far for our business. New start activity is healthy and growing. On the resupply side of things, we continue to outperform there. Adherence continues to break records, frankly, every quarter, as does retention. Our census now stands at 1.66 million patients.
I'd say big picture, we do think that this is a mid-single-digit market, potentially an upper single-digit marketplace. I think when you run the math on our full-year guide, we're not necessarily guiding for that for 2025. Frankly, there's nothing in that other than it's early in the year, and we wanted to put out something that we felt good about.
Any of the—you've had a ton of operational internal initiatives around technology and things around that adherence and resupply. Maybe anything new or in the last year that's contributing to that improved performance?
A couple of things. In mid-202—I guess it was early 2024, we rolled out what we call a best-in-class sleep setup. It got very specific on the type of products as well as the process for setting patients up market by market. That has yielded additional supply when we put out that first CPAP. The mask, the tubes, the cushions, humidifiers, things like that that come with it. There has been an uptick there, and that has driven our adherence a bit, which is a big deal. I mean, every patient that you start across the industry, you typically lose three out of ten. For us, we do better than that. I mean, we're at more of a 75% retention through that first 90 days. We do think there's opportunity there to push that up a point or two. Those are the kind of things we're working on.
Okay. Apple announced last year that new sleep apnea app or whatever it is. What's the update on that? I mean, the obvious reaction to that is like, wow, that's got to drive additional awareness and that could drive additional growth for the industry. Where do we stand on that as an industry development?
On that news, I mean, we got the new version and we tried it out. We in the company refer to that a little bit more as sleep apnea detection. We think that anything wearable or otherwise that indicates to someone that they might have a problem with sleep or particularly OSA, it can only be a good thing. I can't say that I can draw any specific numbers or benefit to you other than more awareness is a good thing for the industry.
Okay. All right. Respiratory, same thing. Product, any challenges with availability of product in the marketplace?
Oh, none. Yeah, extraordinarily stable. Respiratory over time, given the years, is typically a 2%-4% grower. For us, in our guidance, we said, "Look, expect about a point." I mean, we had a big year in respiratory for 2024 on account of a full year of the Humana contract. There was a lot of respiratory in that. I mean, we feel confident in hitting that 1%, particularly with an elevated flu season that we're going through right now here in Q1. Full availability of product, we expect that respiratory to add $ 1 million up to $2 million a quarter, every quarter sequentially over the balance of the year. Frankly, it should look like that for the coming couple of years based on what we're seeing today. Very steady.
Yeah. And long term, as you think about the revenue?
We think it's a 2%-4%.
2%-4%. Okay.
Again, depending on the year, depending on the flu season spikes and troughs, things like that will carry you closer to two than to four. Straight down the fairway, 3%.
Okay. Okay. Sleep, you said, mid-single digit?
Correct.
Okay. All right. Diabetes, been a journey?
Sure has.
Yeah. Certainly a list of cross currents that have impacted that business for sure. Maybe just it'd be helpful to get an update. You've changed out a lot of the team. You've made that very public. That's nothing that I can't share. You've identified a lot of issues and put into place correction plans to fix it. We've had the pharmacy, DME sort of channel fight, which is very well documented. Where are we in terms of right-sizing that, fixing the issues, identifying all the problems that we identified, all the problems? I'll shut up and just let you.
Okay. Fair enough. In terms of diagnosis, I mean, I don't know if this is overly complicated. I do think we're through the diagnosis period. That period started with Suzanne Foster, our new CEO that joined in May of last year, coming most recently from Danaher. One of the first discussions that I had with Suzanne, she said, "Okay, all this diabetes and the channel mix and all these things that we've talked about, if we step back for a minute, Jason, what do you think this market's growing at? Forget all the pharmacy and medical benefit." I said, "I think it's a 15%-20% growth market right now. If you just look at Dexcom and Abbott, you average those.
I mean, that gets you a ballpark. She says, "Okay, well, then what about our competitors, particularly in the medical benefit channel or DMEs? What do you think they're growing at?" I said, "Well, if you look at our public competitor, I mean, they have reported for some time now what we believe to be upper single-digit, potentially low double-digit growth. That's continued. We know the privates, just kind of ear to the ground. We know that they have grown lower double-digit revenue for the last three years." She just simply said, "Well, it seems that the market's growing, our competitors are growing, and we're not growing." Again, it's just fresh eyes. It's so simple. Okay, well, there's probably more internal problems here than we really realize. Yeah, by mid-September, we made a lot of changes.
Essentially, all of the leadership in that business unit within the company are no longer with the company. The first thing that burst significant move was all of the resupply in that business. For context, that represents in any given quarter, 85%-90% of the revenue in that quarter was produced by patients set up in previous quarters. We picked up that business and we moved it to our team in Nashville that runs our sleep center of excellence for resupply. Again, the team that manages that 1.66 million patient population. We asked them to take on diabetes. Some of the first things they found, I mean, even just in the first week or two, our calls were just very disappointing.
I mean, we heard things like certain patients in certain markets, we had autodialers turned on that were calling them 10-12 times a day for someone to pick up and talk about a new CGM order. What do you think is going to happen if, I mean, what happens to each of you when someone calls you three times a day or twice a day, let alone 10-12? They get blocked and you lose contact with that patient. Just some simple things like turning off those autodialers, having the—I mean, we have a big team. We have about 1,000 people that work some offshore, but mostly onshore there in Nashville. Taking on those same workflows, it is very similar to the sleep workflow. That has changed some things.
Even dropping postcards, which it sounds also silly, but you'd be amazed when we drop postcards, how many inbound calls that generates. It's actually pretty incredible. That happened as well. Some of these CGM patients that were gone and dropped off of our census and no longer ordering, they came back on. What all that created was a Q4 with the greatest retention in diabetes resupply that we've had in two years now. We feel like, look, it's only one quarter. We got a ways to go, but that team is moving the ball. That then helps on the new sales because the problem is when you're frustrating patients with that kind of call volume or you're not setting them up soon enough, they're never going to complain to you, but they will complain to their physician next time they go in.
That obviously hurts your sales funnel as you're working for referrals from those physicians that are now also frustrated with you. That repair, we've said, is going to take a little time. Gary Sheehan, who's a well-known name in the DME industry, I mean, look, Gary, his sales team, I mean, they're literally out apologizing and asking for a second chance. That's starting. We set up sequentially more new starts in Q4 than we did in Q3. It's been some time since that's happened. Again, no one's claiming victory here, but it was a very solid, stable quarter. We have guided diabetes down for 2025. Certainly, that's not our goal, but we think we've taken an appropriate approach with the business for 2025 as we continue to press the levers to stabilize and get back to growth mode.
Yeah. Long-term thesis. How do you feel about the long-term thesis around diabetes?
Someone asked me this earlier today, and I said, "If you think very long-term, like five years, seven years out, if you unpack the TAM that we've got today, at a minimum, it's about 7 million patients today. Who knows if in the future, patients that are not using insulin, but they are type 2 diabetics, if that market opens up, there could be accelerated growth coming again. We'll see. If you just take the 7 million patients today, the type 1s, type 1 diabetics, a little under 2 million patients in the U.S., those penetration rates are pretty deep. I mean, upwards of 70%, 60%-70% of those patients are on a CGM. You'll get a little growth in the TAM on the top line, just patient population and the diagnosis of the disease. Penetration rates are really slowing down.
Type 2s, there's a little more penetration runway to go. And then certainly with the basals, there's one way. If you fast forward to five years, you'll get a little bit of growth in that top line and underdiagnosed nature of the disease state. Could it be 3%, 5%, somewhere in that area? Again, in the future, once CGMs are really fully penetrated, we think that makes sense. Now, again, between here and there, we think the growth rates are more of an upper single digit. Our competitors are still putting out lower double digits. We think over time it will continue to glide down. There's a lot of growth there. I mean, there's a lot of growth for us to chase right now.
Maybe back on some of the internal initiatives. I think you guys have framed like four or five, maybe five, like key areas of focus right now. There's the One Adapt. Just maybe an update on what those primary internal initiatives are. Where are you? Where do you hope to be by the end of the year?
Sure. On One Adapt, I mean, it's really about standard work, creating an environment of continuous improvement. Even the way we go to market and we represent ourselves as one company as opposed to a collection of 100 acquisitions over the years with those local names operating. That work has a long way to go. I mean, it takes time to consolidate entities and there are tax implications. I mean, there is this blocking and tackling back office work. That will go on for some time. In terms of the continuous improvement, Kaizen initiatives, you have heard Suzanne talk about this on our calls. She will continue to talk about this. We have made a new hire that starts in two weeks that is a direct report to Suzanne that will run all of these programs programmatically as opposed to just kind of one-off projects.
This person worked very closely with her also at Danaher over the years. If you think of that old—I shouldn't say old. If you think of the DBS model or Danaher Business System, I mean, over here at Adapt, we're not copying and pasting here. I mean, we are taking some of these principles and we're making it our own. Projects do continue to get identified. We haven't yet committed to margin improvement, but there will be margin improvement coming from these programs. That's exciting. Organic growth is one of these five key initiatives or pillars. We hired a new Chief Commercial Officer, started in December, named Russ Schuster. I mean, we've invested big in commercial. I mean, he's got five direct reports. Four of them are brand new to the company. They've come from big med tech primarily.
These are trusted people in Suzanne's network and Russ's network that have worked over time with them. We have reinstated quotas at AdaptHealth for the first time in a couple of years, which probably sounds surprising. I mean, different management teams have different views. One of the previous ones was a longtime DME leader that did not think quotas made sense in DME. I mean, med tech, as you all know, runs very differently. I have been thrilled with this initiative. I mean, the new quotas, the new territories got recut, and all that got put in place January 1 of this year. Hopeful that we will start seeing benefit from that here in the very near term. Balance sheet, I mean, just in general, delivering. I mean, we have set a target of two and a half times.
We reported that we're just under 2.8x as of the fourth quarter. We're on path for that. I mean, as we generate more free cash flow and we'll do a couple of deals here and there, a little bit of M&A. We did a small deal in November that we reported. Expect more of the same in 2025. We'll continue driving leverage to two and a half or below. The other areas of investment are really in we're experimenting in AI, particularly in our intake function. This stat, every time I say it, it's still astounding. I mean, we receive and ingest over 5 million pages a month of faxes. Not much is a eFax, but still, I mean, these are oftentimes handwritten notes, sometimes not, but this data all comes in. It's unstructured in nature.
We have a lot of humans, onshore, mostly offshore, but there's a lot of humans with a dual screen reading the eFax that came in and creating a sales order on the other screen, copying, pasting, kind of creating that order, and then QAing it downstream. There is tremendous opportunity here by turning that unstructured data with AI into structured data and lifting this out. Certainly, you will continue to QA that and making sure that the machines are doing their jobs. I mean, there's a lot of opportunity there. Again, we haven't committed to margin improvement on these initiatives either for 2025. However, we're working very hard on these investments. We think that's going to bear fruit, certainly, as we look towards 2026.
Back on the implementation, the quotas. Oftentimes in your restructuring sales initiatives and incentives, there can be some turnover changes. Any unusual turnover versus your expectations or anything that we should be aware of?
No, it's a good question. I think like many, I've been around a couple of these over the years, and most go as planned. Some don't. I am acutely aware of the risk to that. No, turnover has been very stable. We had our national sales meeting, actually the week of earnings, right after earnings. Folks then turned around and flew to Vegas for a sales meeting. It's been very welcomed. The amount of questions that comes into our sales analytics team is definitely up. I mean, people are very focused. Our salespeople are very focused, particularly on the conversion side of orders because it's not unusual to get an order that never converts. If it doesn't convert, you don't get paid. These sales folks are incentivized to be part of the solution of higher conversion rates.
We view that as a very good thing. People are definitely paying attention and watching the purse strings. I mean, that's the behavior that we wanted to incentivize. I mean, there's been just, I think, huge respect for the people that have come in. I mean, we've hired several very, very talented sales leaders that have run huge commercial operations. We are hopeful.
I saw the pictures on LinkedIn. It looked like a good Vegas party. Oracle investment. That was a conversion that you did two years ago, three years ago?
Boy, yeah. It feels like a lifetime ago, but it went live in everything early 2022.
Okay.
Yes.
No Oracle 2.0, no other?
I wouldn't call it 2.0. Maybe 1.1 is turning on our perpetual inventory system. I mean, you can think of that program as just kind of the right plumbing and electrical that you want in the house. There is investment going into it. However, what we are seeing through inventory and CapEx reduction has been well worth that effort. We do think that that'll continue over the next couple of years as we continue to roll that out at more and more locations.
Let's spend a second and transition to the Humana contract and maybe just frame for those that are less familiar with what you're doing, the number of lives, where you are, revenue size, contribution margin, anything that you care to share.
Most of that, not all of it. I don't know if we'll get into contribution margin, but I've got some perspective. For those that haven't followed the company, we were awarded the biggest contract in the history of the industry with Humana. We are coming up on the end of our second year of the contract. It'll roll up here at the end of June. That's been underway now for two years. It's all of the Humana Medicare Advantage HMO business for DME in 33 different states plus the District of Columbia. If you're a member across those states, at the time we announced the contract, we showed it as over 1.2 million lives, covered lives or members, that we get paid a per member per month fee that we priced and Humana agreed to.
We will take risk on the utilization and put all of the DME products on those patients that are needed, whether it's respiratory or DME or sleep. We announced in our recent earnings call a multi-year extension on that contract. We essentially just rolled forward the date. I mean, we've been thrilled with the performance of the contract, the pricing of the contract. Even our SLAs, we've continued to bring forth more commitments, holding ourselves to a higher standard with Humana, which we know that they've appreciated. With that comes our infrastructure and our ability to rinse and repeat and do this again. We've said about margins that that contract operates at or better enterprise EBITDA margins. We did make key investment in 2024.
I mean, we have individuals now in the company that their full-time job, all they do every day is either price capitated arrangements or pitch capitated arrangements to payers or operate the capitated arrangements. We have full teams that are very focused on this. We are running a very healthy pipeline. We did make two conversions in the fourth quarter for new capitated agreements. We are working very hard on that. With a little luck, we will see more in the future.
Any additional details around those two plans?
Not other than.
Regional Blues, like anything that.
Regional West Coast.
Yeah.
Yeah, yeah. Smaller players, but good contracts, multi-year contracts. You'll see that reported in our capitated revenue. We expect capitated to continue to inch up over time as membership grows. Certainly if we're able to convert more capitated agreements in the future.
This isn't like a new concept for the plans, right? I mean, we've seen the delegation of post-acute in general down to all these conveners. So it doesn't seem like it would be that challenging for the plans to understand.
It's interesting. It's nuanced. I mean, capitated arrangements have been part of the DME industry for arguably 15 years now. I mean, there were big capitated arrangements built up over time. Depending on the payer, I mean, they're, I guess, more advanced in being able to adjudicate those type of arrangements. West Coast, as normal in managed care, is a little ahead of the curve. Depending on the blue and depending on the market, there's maybe bigger appetite versus smaller appetite. At the end of the day, the value to the payer of having a single operator in a single state is huge. I mean, there's hundreds of DMEs in every state in the country.
The ability to wrap all of that into a single contract, sign up for SLAs, I mean, when a patient has a stat order for either oxygen or ventilation, I mean, it's critical that patient gets that order in two hours after being discharged from the hospital, up to four hours. It's got to be fast. With our network of 670 locations, I mean, we got vehicles all over the country zipping around every day meeting those commitments. I mean, that's a huge part of this, that essentially grouping all this together in a single contract, it just simplifies things. We're more than willing to do that at a reduced rate in exchange for a lot more volume. Really, it's a win-win, I think, for the payers, for us, and most importantly, for patients.
Just got me thinking about just the AdaptHealth brand in general and One Adapt. Do all these vans that are shooting around the country, do they say AdaptHealth on them now, or is it still?
We're getting there. I mean, there was a big effort to repaint the fleet. We didn't get to all of it, but we did that about two years ago. Each year, we bring about 500 new vehicles into the fleet. They're brand new, freshly painted. I mean, they're fantastic. I mean, we're on schedule to continue to turn that fleet over every six years or so. We've got about 3,000 of these vehicles.
Yeah. Okay. Can you spend just a second? Cash flow, I can't remember if you guided specifically to cash flow from ops.
We guided free cash flow.
You guided free cash flow.
Of $175 million-$225 million.
Okay. The growth in cash flow from ops is in line with EBITDA and like?
Yes. Yeah. Expect the same relative conversion of adjusted EBITDA to cash flow from operations in 2025 as what we saw in 2024.
Okay.
Really the big difference is we have a lower midpoint guide, $35 million, than what we reported last year. Frankly, some of the big manufacturing partners of ours, I mean, we extended payment terms in 2024. We're thrilled to have the extra cash. We paid down more debt. I mean, those events won't be repeated. We made that adjustment as we thought about $200 million at the mid for free cash flow in 2025.
Okay. All right. $200 million.
$200 million at the mid. Yep.
All right. You're going to end the year with $200 million more of cash than you started.
Plus proceeds if we're able to move these disposition processes forward.
Yeah.
The proceeds will all get pushed to the balance sheet. We're going to push to debt. In terms of free cash, I mean, Suzanne and I have said that we've earmarked $30 million-$35 million for M&A that we expect to do over the course of the year. We have a pipeline. We have a couple of small deals under LOI. That'll continue. For now, any unused cash on M&A, it's going to go also to debt and continue to delever to get us towards that 2.5 target sooner rather than later.
I feel like you've kind of developed some new muscles around development and how you kind of approach M&A. How's the process different today versus a few years ago before Suzanne joined?
Yeah, it's quite different. I'd say the biggest changes are within the managed care landscape. I mean, depending on the deal size, it doesn't make a lot of sense to chase these things. Oftentimes when you're buying a DME company from a hospital, that hospital's rates, the managed care rates, it's all kind of bundled into the DRG, into the overall contracting structure of the hospital. When you buy that company, your rates oftentimes won't be as generous. That is very meticulously accounted for and you clean rooms and everything that comes with that to do it compliantly. That's a big change in how we've looked at deals. We require a 15% ROIC, even for us to spend a minute looking at it out of the gate. I mean, there's just some new governance controls that we've laid in place.
For every deal, I mean, we need operators pounding tables on the deal. I'd say that M&A was driven a little more top-down in our past. Going forward with Suzanne, new leadership, just new ways of doing things. I mean, it's more of a bottoms-up. Those deals are vetted very tightly, even the small ones. I mean, we're taking our ROIC delivery very seriously.
Yeah. All right. One last one for me. I get this question a lot. I haven't asked it to you in a long time. I didn't give Jason any questions. I didn't realize that until this morning. I was like, "I never sent him any questions." So he's done a fantastic job. How do you value your business? Is it EBITDA, EBITDA less, patient equipment, CapEx?
I have free cash flow, free cash flow yield. Right? I mean, I look at our aggregate valuation. I'm looking at we just put up $236 million of free cash, and we're planning a minimum of, at the mid anyway, $200 million. I look at it that way. I think for others, look, whether you look at EBITDA less depreciation amortization, so EBIT essentially, or you bring in a CapEx measure, that makes probably more sense from a comparable perspective to other companies. At the end of the day, I mean, we guide and report adjusted EBITDA. I mean, healthcare services is obviously adjusted EBITDA-driven. We have provided new disclosures around patient depreciation amortization by segment. I think we've now given the visibility to investors to look at it really any way you wish. Again, at the end of the day, for me, it's all about free cash flow. And we're bonused on that. It's an important metric for management, and we're all driving towards it.
Cool. With that, we can conclude. Thank you, Jason.
Thanks for having us.
That was great. Thank you.