Greetings, and welcome to Adapt Health's Third Quarter 2022 Financial Results Conference Call. At this time, all participants are in a listen only mode. A question and answer session will follow the formal presentation. As a reminder, this conference is being recorded. It is now my pleasure to introduce your host, Chris Joyce, General Counsel.
Thank you. You may begin.
Thank you, operator. I'd like to welcome everyone to today's AdaptHealth Corp. Conference call for the Q3 ended September 30, 2022. Everyone should have received a copy of our earnings release earlier this morning. If not, I'd like to highlight that the earnings release as well as a supplemental slide presentation regarding Q3 2022 results is posted on the Investor Relations section of our website.
In a moment, we'll have some prepared comments from Steve Griggs, Chief Executive Officer of Adaptel Josh Porns, President of Adaptel and Jason Clemens, Chief Financial Officer of Adaptel. We will then open the call for questions. Before we begin, I'd like to remind everyone that statements included in this conference call and in our press release may constitute forward looking statements within the meaning of the Private Securities Litigation Reform Act. These statements include, but are not limited to, comments regarding our financial results for 2022 and beyond. Actual results could differ materially from those projected in forward looking statements because of a number of risk factors and uncertainties, which are discussed at length in our annual and quarterly SEC filings.
AdaptHealth Corp. Shall have no obligation to update the information provided on this call to reflect such subsequent events. Additionally, on this morning's call, we'll reference certain financial measures Such as EBITDA, adjusted EBITDA and free cash flow, all of which are non GAAP financial measures. This morning's call is being recorded And a replay of the call will be available later today. I'm now pleased to introduce our Chief Executive Officer, Steve Grieks.
Good morning and thank you for joining our call. AdaptHealth is a full service nationwide provider of products and services for our patients at home and in the community, empowering them to live their healthiest lives. I'd like to express my appreciation to our 11,033 employees, including more than 1,000 healthcare professionals who work daily to serve our 3,900,000 patients. I'm very pleased that Adapt Health today reported record net revenues of $756,000,000 for the Q3 of 2022. Our performance reflects our revenue growth of 15.8% over the Q3 of 2021, With non acquired growth of 6.1% for the same period.
This reflects strong sequential improvement from the Q2 and supports our full year non acquired growth expectation of approximately 4%. The highlights for the quarter were the much better than expected performance in our sleep business, continued strong growth in diabetes and the increase in the supply center. In our sleep category, we continue to regain the ground we had previously lost due to the Phillips recall. During the Q3, we had 34% more starts than in the Q1 of the year, resulting in a record number of setups for the company. In addition, our PAP census, also a record, has grown 27% over the lowest point in February 2022.
The increased census bodes well for the future revenue as the patients continue to use their PAP machines and will need supplies on an ongoing basis. Our performance in PAP setups has continued in October and based on supply and demand, we expect strong PAP setups to continue for the balance of the year. Our Q3 performance of PAP setups was driven by our ability to source more units. This allowed us to quickly ramp up Our PAP setups to serve our patients, especially those who have been waiting. As a result, we have incurred some additional costs, Especially in commissions and expedited delivery and setup, which pressures the bottom line but will benefit us going forward as we believe that our efforts are resulting in a growth in our share of the sleep market.
I'm also pleased to report that we resumed mid teens Growth in diabetes and this reflects a notable increase from our 2nd quarter growth rate. We continue to be confident in the sustained growth potential in diabetes Given the expanding acceptance of CGM as a critical component in managing diabetes and related comorbidities and further reflected in CMS's proposed expansion of coverage for CGM. Our Supplies to the Home product lines also Due to the commencement of an exclusive supply arrangement with a payer that we hope will lead to a broader value based arrangement across more supply lines of business. These revenue increases give us confidence in the continued strength of our business and are a solid foundation To build upon to reach our 2025 net revenue target of $4,000,000,000 While we are very pleased with our Q3 results and confident in the strength of AdaptHealth's business heading into the Q4 and into next year. We aren't immune from the general inflationary pressures facing all healthcare providers today, and we continue to deal with disruptions to our supply chain from manufacturing delays and product recalls.
In addition to the increased costs incurred to expedite PAP setups, the quarter's results were pressured by the unexpected recall Of Phillips Pap bask related to deficient safety labeling in August. While we were able to quickly mitigate the recall disruption, We did see a loss of past supply revenue in Q3, while those mitigation plans were gaining traction. In a few minutes, Jason will provide more color on our financial results. And I can say that we are pleased to see sequential improvement in our adjusted EBITDA margins for the Q3. Although the improvement was not as much as we would have liked, I'm confident in the initiatives our team has in place for the Q4 will result in further improved margins.
Finally, before I turn the call over to our President, Josh Parnas, I'd like to provide an update on the supply of PAPS as a result of the ongoing Phillips recall. As expected, our PAP partners have continued to expand their manufacturing capacity. And beginning in August 2022, we saw our supply of PAP units begin to exceed pre recall levels. This has allowed us to begin to work through our backlog of PAP patients impacted by the equipment shortages over the past 15 months. Assuming this level of supply for manufacturers continues past November, December and current indications suggest that they will, We expect to substantially address our backlog in early 2023.
Now, I'd like to turn the call over to Josh to provide further details and an update on strategic developments.
Thank you, Steve. As we discussed during our Capital Markets Day in mid September, Our ongoing conversations with payers make it clear that there is a growing amount of interest in value based care and what Adapt Health can bring to the marketplace Through its national presence, patient data and broad product offering combined with an efficient operating model. Our recent value based agreements with 2 payers in large metropolitan markets have grown very nicely in a short amount of time And initial results are very promising with high level technology integration resulting in greater care transparency and higher levels of patient satisfaction. For example, in connection with one of these opportunities, Adapt Health's application design team developed an integrated portal allowing the payers care and claims management teams to seamlessly order and monitor patient services. These integrations have allowed both parties to reduce the administrative expense associated with providing care for more than 20,000 patients.
This technology is scalable and proprietary and available to deploy on behalf of additional payers. Accordingly, Adapt is increasing its focus on additional opportunities of innovative care models in the home. Consistent with the technology roadmap we shared at Capital Markets Day, Adapt Health recently rolled out MyApp, which is a comprehensive patient app enabling channel of choice communication with the patient, as well as the ability to place and track orders And facilitate clinical coaching. MyApp will allow patients and physicians to access their data on their connected medical devices, which will help improve clinical outcomes at lower costs for our 3,900,000 patients. Initial data is showing strong adoptions by our patients With close to 5,000 downloads from the Apple and Android App Stores and hundreds of digital orders processed in the initial 30 day launch with our diabetes patients.
These investments are part of Adapt Health's strategic plan to facilitate a complete digital path for all our constituents. By expanding the use of e prescribing as well as our payer portal technology and the AdaptHealth MyApp, We will provide full transparency with respect to what's being ordered, when and where it's being delivered and access to healthcare data on connected devices. This information will allow physicians, patients and payers to collaborate to drive better clinical outcomes, while allowing Adapt Health to reduce the administrative costs of maintaining service to the patient. These efforts are part of the initiatives underway To continue to increase productivity across all work streams and part of the reason that our revenue per employee today Approximately $262,000 per employee is at its highest level ever and we expect to Even more efficient as we head into the New Year. As cost pressures continue, Adapt will benefit from its scale as we will
be able to leverage our technology to take market share from less efficient competitors. With that, I'll pass the call over to our CFO, Jason Clemens To review our financial results. Thanks, Josh. Good morning and thank you for joining our call. I'll discuss the Q3 operating results, our cash flow performance and capital allocation and conclude with a discussion of our 2022 outlook.
For the Q3 ending September 30, 2022, Adapt Health reported net revenue of $756,500,000 representing year over year growth of 15.8%. Non acquired net revenue growth was 6.1% for the quarter. We were pleased to see continued improvement in trends within our largest product category, sleep, where the non acquired growth continues to exceed our previous forecasts. At the end of September 2022, our PAP rental census was 27% higher than the PAP rental census in February 2022, Our lowest census month following the June 2021 Respironics recall. Our PAP rental census growth and the compounding nature of the PAP resupply business Gives us confidence in increasing our revenue guidance for 2022.
Our diabetes category delivered mid double digit non acquired growth, reflecting sequential improvement relative to last quarter. While our respiratory category experienced an expected decline in non acquired growth, The Q3 2021 census was elevated due to COVID cases. We were encouraged to see modest sequential growth from Q2 2022 levels. Accordingly, we are raising our guidance for net revenue. Turning to profitability, while modest inflationary headwinds Negatively impacted adjusted EBITDA margins in the quarter, we were pleased that we were able to sequentially expand Q3 2022 adjusted EBITDA margin to 21.2% versus 20.6% in the 2nd quarter.
As Steve mentioned earlier, adjusted EBITDA was negatively impacted by lost revenue from delays in PAP resupply shipping related to the Respironics recall in August 2022 of certain PAP resupply products due to deficient warning labeling. This recall and related supply chain disruption Negatively impacted results by several $1,000,000 but we do not expect this to impact our operations in the 4th quarter. Within cost of goods sold, distribution expense remained elevated, specifically fuel cost incurred by our vehicle fleet and by some of our suppliers and couriers. On the labor side, expenses associated with our over performance in PAP setups increased costs for the quarter, But this added cost will be offset over the next few quarters by the increased rental revenue related to our record setups. Additionally, We believe that the continued decline in the impact of the COVID pandemic has resulted in an increase in our employee benefit utilization over prior year, And we expect this trend to continue through the Q4, resulting in the guidance update we announced this morning.
For Q3 2022, Cash flow from operations was $107,000,000 Free cash flow for the quarter, defined as cash flow from operations less capital expenditures, was $12,900,000 Capital expenditures of $94,200,000 reflected considerable CPAP procurement activity. We're very pleased with CPAP availability in the quarter. Turning to working capital. We had cash on hand of $110,700,000 And an undrawn revolver at quarter end with trailing 12 months leverage of 3.5 times consistent with the 2nd quarter. At the end of the Q3, 78% of our debt was on fixed rates.
DSO was 44 days for the 3rd quarter, Down from 51 days in the Q3 of 2021. The technology and workflow investments we made over the past year are driving these results. We continue to increase adoption of ePrescribe and we made additional investments in hardening our claims editor engines. These changes are resulting in cleaner claims, Lower denial rates and more cash. Additionally, our patient pay collection rates continue to improve as we deploy Our e ordering and e delivery workflow to get more accounts on AutoPay.
Inventory was up $22,700,000 from the 2nd quarter And we prepare for the typical reordering demand that occurs in the Q4. During the Q3, we completed $10,600,000 in share repurchases $2,950,000,000 to $3,010,000,000 versus our previous range of $2,840,000,000 to $3,040,000,000 And adjusted EBITDA of $620,000,000 to $650,000,000 versus our previous range of $615,000,000 to $675,000,000 This revised guidance translates to a Q4 2022 revenue range of $760,000,000 to $820,000,000 And adjusted EBITDA of $172,000,000 to $202,000,000 Consistent with previous periods, Our guidance does not include contribution from acquisitions that have not yet closed. I'll now pass the call back over to Steve for some final thoughts before we open it up for
Q and A. Thanks, Jason. Over the past 2 years, Adapt Health has undergone a significant transformation, starting with the impact of the COVID-nineteen pandemic in We would like to once again thank our tremendous employees for their patience and persistence as we have overcome these and other challenges. As we look forward to the Q4 of this year and to 2023, we have high expectations for the company as these challenges recede. We expect our sleep business to return to normalized growth with continued opportunities for us and the diabetes business to continue to benefit from greater adoption and regulatory acknowledgment of this important therapy.
We also expect our respiratory business to return to pre COVID growth levels, but with a greater appreciation from clinicians and regulators as an important role HME suppliers play in the critical care of Respiratory Patients. We are also optimistic that our supplies of the home business will benefit from the fact that we are a full service HME provider and its ability to meet the broad HME needs of our referral partners and payers will ensure Sustainable growth for AdaptHealth. Operator, please open the line for questions.
Ladies and gentlemen, we apologize for the delay. We'll now begin our question and answer session. Our first question is coming from the line of Brian Tanquilut with Jefferies. Please proceed with your question. Hi, good morning.
You have Taji Phillips on for Brian. So just thinking back to your diabetes segment, happy to see that growth is picking back up into that mid double digit range. Just Curious, if you can discuss what has changed from Q2 to Q3 to kind of allow that growth to pick up again in Q3 And how that's tracking towards your annual growth guidance, if that's uplifting it, how you expect it to round out for the year given that Q3 was Solid number. Thank you.
Thanks for the question and sorry for the delay folks out there. This is Steve. Yes, so the diabetes, we think Q2 was an anomaly and just a Confluence of a bunch of things that happened that reduced the rates both for us and for other people within the marketplace. And seemingly, everybody has come back nicely and we expect that same growth rate in the Q4.
Yes, and this is Jason. To round that out, We had I'll remind everyone, we had 18% projected for the diabetes Product line in terms of non acquired growth for the full year will likely come in a touch shy of that, but we're making it up on the PAP side as we discussed
Thank you. We'll move on to our next question, which
It sounds like there are a lot of one time costs incurred during This relates to our CPAP coming back online. Can you sort of help break out these one time costs associated with the expedited setups and the Phillips recall? I was trying to or is there anything else we should be aware of? I'm just trying to understand the 3Q margin bridge into 4Q margin guidance better.
Sure, Pito. This is Jason. So I'd really call out, I guess, three areas. We About labor and benefits, PEG debt about a $6,000,000 surprise for us, about half of that was increased benefits utilization. I don't know that we'll get relief there in Q4, but we don't think it will get worse based on what we're seeing.
The other was very associated with We set up more than we thought. We got more than we thought. We spent every dollar that we could to ensure Folks are out there late night over weekends and getting product on our patients. So we were obviously glad to spend it. The second bucket, we talked about the Phillips recall on PAP resupply.
In our prepared remarks, We spoke about several $1,000,000 of impact bottom line, so peg that
at 2,000,000 to
3,000,000 We don't believe it will disrupt operations in Q4. We believe we're over the hump operationally there. And then finally, distribution costs, led by fuel for us and for our couriers and suppliers. We think that trend will continue In Q4, but bigger picture kind of next year, we think that these costs will abate as a percent of revenue.
Okay, great. And then actually just quantify, how much was the expedited cost the CPAP set up this quarter? I mean, said $6,000,000 for labor and benefits, half labor, dollars 2,500,000 on the Phillips recall. What was the CPAP sort of one time cost for the segments? Yes.
So Yes. So 2.5 for Phillips and then when it comes to overall labor, it was $6,000,000 So half of that benefits utilization, half of that Labor associated with PAP setup.
Okay, perfect.
All right.
And then on the CapEx guidance increase that you talked about, Can you just give us details why it spikes so much in 3Q and your guidance assumes more of a normalization in the 4th quarter? So not only I guess question is what happened in 3Q and why should it not continue? And how should we think about sort of CapEx as a percent of revenue in 'twenty three? It's always going down with diabetes going faster, which is a better sort of EBITDA to CapEx conversion?
Yes, yes. Good question, Peter. So I'd say that firstly, We were thrilled and a bit surprised at how many PAPs were available to DAP Health. And so that's what we're seeing is A huge increase in CapEx related to PAPS, which we'll be glad to spend that money all day long. So for $94,000,000 of CapEx during the quarter, more normalized, it probably would have been about $80,000,000 maybe $82,000,000 something like that.
So that's what you're seeing is the increase. We expect that will continue in Q4 based on what we're seeing in the supply chain. I would expect that would continue in the first half of 2023. Now, as we get to second half 'twenty three, we think that CapEx spend will come back down to normal levels. Certainly, we'll guide CapEx as part of our guidance release in the coming weeks, but that's the way to think about the roll off of CapEx,
Ben. Great. Thanks
so much.
Thank you. Our next question is coming from the line of Kevin Caliendo with UBS.
You've talked about your script backlog And size for devices in the past, I think it was $1,000,000 or $900,000 or some numbers that have been thrown around. Has that number changed at all? And how should we think about now that we're maybe a couple of months closer to 'twenty three, how should we think about The way that backlog is fulfilled through the course of 'twenty three and the impact of maybe how the year progresses?
Yes. So that backlog, when we mentioned that has industry backlog of $900,000 and that was assuming That continued operations from the beginning of the year to the end of the year, those obviously have changed dramatically. So Really, the not getting enough to the market pretty much ended mid this year, Probably August ish. And so you could probably cut that backlog back by a third maybe for the industry. So we are eating into our backlog as we speak today and suspect that we'll be out of it early 2023.
Depending on where other suppliers, depending on where you are at with your backlog, how much you're able to Mitigate along the way, we were pretty successful at minimizing ours. Some other people may have may take a little bit longer to get through theirs.
That's helpful. In the context of thinking about that against your normalized Sort of 8 ish percent enterprise growth that you've outlined in the past, how does this impact how we should think about and I'm not asking for guidance for 'twenty three, but just how The way this backlog has progressed and played out, how that might impact the sort of 8% enterprise growth environment?
Kevin, are you still with us?
Yes. Could you hear me? I'm sorry.
Operator, did we lose Kevin?
No. Kevin is still on the line. Just to confirm, are you able hear me as well?
Yes, I can hear you. Can you hear me?
Yes, Kevin, I can hear you. Yes, it seems like maybe we're having some issues with the speaker line. Just one moment please.
Operator, did we lose Kevin there?
Can you hear me now?
Yes, we can hear you.
Yes.
Okay, sorry. So the question was, as we think about The way you've just described the backlog and how that's played out, how does that impact what is typically a more normalized than what you've talked about 8% enterprise I'm not asking for 'twenty three guidance. I'm just trying to think about how the way this backlog has progressed versus What would traditionally be your enterprise your normal enterprise growth that you would normally expect? Sure.
Sure, Kevin. Great question. So I'd start with, as we outlined the 4% non acquired growth target in our Guidance for the year, that assumed PAP would be down. So sleep overall would be down about 5% or 6% for the full year. Well, for Q3, I mean, we were up high single digits.
I mean, we were just thrilled with the performance. And so the way I would Think about it is our typical 7% to 9% growth in sleep, that will likely outperform Next several quarters as we're working through backlog and then come down to more of a normalized range. So I mean, again, we'll give specifics when we guide, but that's the right way
Okay, great. Thank you.
Thank you. Our next question is coming from the line of Richard Close with Canaccord Genuity.
Esma, maybe you could talk a little bit about the CMS proposed coverage expansion in diabetes And just thoughts on how that's going to potentially impact growth?
Sure, Richard. This is Steve. Yes. And so They're expanding the coverage for Type 2 diabetics and are proposed assuming that it passes. So then that just opens up a whole new avenue of patients that are available on Medicare basis.
And we suspect that many of the commercial plans will follow suit. So I think everybody believes that The growth rates that we've seen in the past 2 or 3 years on the CGMs will continue, maybe not quite as high, but they'll still continue Throughout the next 2 or 3 years.
Okay. And then can you go into a little bit more detail Back to the exclusive payer relationship that you highlighted, I think that was in HME and just How that came about and other opportunities maybe like that?
Sure, Kevin. This is Josh. Thanks for the question. Yes, I mean, these are actually 2 payer contracts with fairly large providers on both coasts that Really, we're interested in doing something less traditional than fee for service in terms of value and looking at Trying something, getting a foot in the water, seeing how we could connect with them through our payer portal. Really what they were looking for more than anything was A better experience on the customer side and on the payer side, better claims utilization, better management of the patient, Better case management.
So really a lot of the discussion started around what we could do for them from a technology perspective. And really it's evolved into That typically happens between a provider and a payer. There were some savings to be had there. And really, Like I mentioned in the prepared remarks, it's gone very well and they're looking to expand that with us and we feel this could be A good base case and we're having discussions with other payers around the similar structure.
Is there any opportunity to Share in those savings?
Sure. Yes, this is a shared savings model where Essentially, we're taking out admin expense by integrating directly with the payer, and then we're sharing the savings with the payer, But also getting a broader share of
their wallet. Okay. Thank you.
Thank you. Our next question is coming from the line of Joanna Gajuk with Bank of America. Please proceed with your question.
Thank you. Good morning. So thanks. A couple of follow ups. So I guess on the guidance, I understand you raised revenues and lowered the margins.
You talked about the items Sir, what about the PHE expansion, the public health emergency? Does that change anything in your guidance?
Hey, Johnny, it's Jason. Yes, so similar to last quarter, we had mentioned about a $3,000,000 to $4,000,000 improvement from PHE, so that is that's rolled forward for this quarter. So that's how to think about PHE.
Okay. And second part of the guidance, so you've raised your CapEx. Obviously, you have a lot of Supply over the machine is always good. But how should we think about the free cash flow? I guess, previously you've got about 5% to 6% of revenue.
So I guess that's Coming down, but does things change when you think about your 7% to 8% long term package for free cash flow?
No, certainly nothing changes in the long term. In the short term, right, bigger CapEx obviously results in $1,000,000,000 of accelerated CapEx spending due to PAPS. And so when you kind of take those numbers net, you're looking at about a 4 Maybe a touch on over 4% free cash as a percent of revenue for the quarter. I'd remind you, Q3 is one of Our cash interest quarters, much like Q1, and so it's typically a lower quarter. Throw out the mixture and we're feeling good about Q4.
It's typically a strong cash quarter. And big picture, there nothing to change our overall view.
Okay, great. And I guess to that end, Previously, we also talked about with the sleep supply improving, that at some point, there would be more Deals to be done because the visibility would improve, so any commentary around that?
Yes. I mean, I think what we're seeing from what we saw so far in Q3 and what we're looking forward to in Q4 is a normalizing, Somewhat normalizing, we hope, of the sleep market. Again, we're probably a quarter or 2 before sellers Start feeling really good about supply and putting their businesses back on the market. I think what just in terms of market dynamics on M and A, Obviously, not just us, but there's a lot less deals that are going on with rising interest rates. We are actively Pursuing pipeline deals, so we're still working pipeline deals in terms of M and A opportunities.
From an ability to integrate, I think we're Positioned very well and we're looking for the right opportunities both regionally and also what could drive good synergies in terms of product lines. So we're out there on the market. We're involved in a lot of kind of deal just looking around and seeing what's available on the market now. But I think from Some of the PAP sellers you probably see come back online mid next year.
Great. Thank you so much.
Thank you. Our next question is coming from the line of Eric Coldwell with Robert W. Baird. I
was hoping to hit on your expectations for the CPIU Medicare update coming in December and maybe on a gross basis as well as a net basis after the adjustment factors, What you're expecting? And then looking at the slides, 26.3% of sales are government, how much of that is tied to CPIU directly or also indirectly? And what are your Thoughts on commercial payers following CMS' lead next year? Thank you very much. I have one more follow-up after that too.
Thanks.
Yes. Thanks. This is Steve. From our data that we see that our calculation for the DME space Expect that to get some sort of adjustment to that to bring that down less than that. So I think the common Agreement amongst both is we're looking around 8.7.
But again, we're going to wait for that data. That's Consistent with what we've seen in like providers that get similar calculations to us. So I suspect it's going to be within 10 to the point one way or the other of that. And then Jason, you want to comment on the Yes.
I mean, just based on that, Matt, We caution everyone on it's this is our view, but I mean who knows how this will play out. We'll know in another Right. That could trend upwards of $80,000,000 top line in 2023, Your question on the kind of the flow through?
Yes. And then just it was more on the flow through because I've had some of your compatriots The market have suggested maybe a bigger PECO adjustment or other adjustments this year that could bring the net benefit down to maybe a couple of 3 points or So I'm just curious if you have that similar thought process?
Well, the PHE, when that ends, There's some benefits that the industry has had, particularly in what we'll call the non bid, non rural areas. That is about $30,000,000 $35,000,000 for us. And so that would go away unless that is there's some legislation proposed that extends it, but That doesn't go through. And then the whole healthcare industry is working on the sequester going from 2% to 6 That's a law that happens. People generally expect that to go away or be delayed.
But as of now, there's nothing that says that and that would be another $30 plus 1,000,000 for us. So it still ended up being a net benefit, but it'd be much smaller depending on those three factors. Those are the three factors that Make up the differences in the Medicare adjustment. As far as commercial payers, we're getting some increases and some adjustments It's more on a line by line product basis. There's no wholesale increases that we've seen yet.
We continue to negotiate with them, but it's more been about other things that Josh has already mentioned. I think that's kind of the more of the topic now And just better improvements and making efficiencies in the system. I think they're more committed to that than given price increases or increases, today.
Yes. I've been I've probably been a little more constructive on the reimbursement and regulatory environment than some, but Despite my better judgment, I have to bring this one up because I'm still getting questions on it. Love to get an updated thought on competitive bidding. I mean, 7 weeks Now we'll be in 'twenty three looking at 'twenty four. I'm not aware that the government really has a framework for competitive bidding in 'twenty four, but Maybe you've seen something more recently that would give you some thoughts.
Yes. I would say I wouldn't say Close to logistically impossible for it to happen in 2024 beginning in 2024. So I think once Out of the pandemic and the pandemic is over, we'll know at the end of this month whether it gets extended or not. The administration is committed The healthcare industry to give them 60 days notice, they're still committed to that. But I think once post pandemic happens and they have Transition of patients from post pandemic to from pandemic to post pandemic, then they might be able to start looking at that kind of stuff.
So I guess they start looking at it in mid-twenty 24 or 'twenty 3, excuse me. And so because possibly something happened In 'twenty five, I guess so. But right now, it's on in our discussions with CMS, it's pretty far our back burners. They have so many other things that they need to work on. Predominantly, this what happens post pandemic, I think is mainly on their mind right now.
All right. Thanks very much, guys.
Yes. Kevin, just to add on the competitive bidding thing, just one other thought that I think it's important for people to know is that The reality is with price inflation that's happened over the last year, we even saw when CMS came out in 2021 with competitive bidding that They basically pulled it back because prices went up. I don't see how that dynamic potentially doesn't happen again. If they theoretically were to roll out competitive bidding, like Steve says, in 2024 or 2025, the reality is With price pressures, inflation, gas prices, product prices up, I don't know that there is suppliers are not coming in now. I don't see that and really bidding much lower than what the current rates are.
So like our general sense is that there's a floor to the rates and There's really not that much more room for people to go in terms of giving back. But again, we'll see, but that's something else to consider there.
Yes, I entirely agree on that too. Thanks guys. I appreciate the comments.
Thank you. Our next question is coming from the line of Whit Mayo with SVB Securities. Please proceed with your question.
Hey, thanks. Jason, last year, I think you sized what you thought the PAP headwind was around the $30,000,000 range, I think coming into this year, Maybe it was in the $30,000,000 $40,000,000 range. What is the number that you're circling today for either the headwind or the tailwind from PAP earnings.
Yes. So, Whit, if I recall, we had pegged it in about $5,000,000 headwind in 2022. We think that, That will be we'll probably beat that by a touch, but I mean, I'd still peg it at 55 to 65 for the full year.
And as you think about working through the backlog at this point in time, I wouldn't anticipate that you could You know, get 100% of that back over the next 12 months or so, but how do you think about Working through that $60,000,000 headwind over time?
Yes. So I want to be careful just as it starts I'm linking into formal guidance discussion, but if it's 55 to 65 This year of a headwind, I think it's safe to assume 50% to 75%. That feels very conservative to me. Steve or Josh, I have a different view there, but that's how I think about it.
No, I think that's right. As It takes time as it took time for the effect of the Filtree call to hit us. It will take time for the ramp back up, but The ramp of continuous CPAP setups at this level and then the resupply adding on top It's pretty powerful. So I think Jason's that's pretty good range that he's given you.
Jason, looking on balance sheet, the inventories was up a lot over 20,000,000 I mean, it's a little bit higher than the $10,000,000 increase that you framed for, I think, Pito, on CapEx for the increased Pat purchases, anything else that's influencing that number?
Yes, sure. I mean, if you look in our history, We do typically run hot on inventory Q3. So we're up over prior year, I think it was up $12,000,000 $13,000,000 In terms of cash usage, really that's planning for the typically large reorder activity across Tap resupply, diabetes and supplies to the home that occurs in the Q4. And so we expect to liquidate Most or all of that into sales for the Q4.
Okay. And one last one for me is I've been trying to think about Kind of the PAP market and the impact on sort of the replacement cycle. Do you have a view on the percentage of Your patients today on census that have sort of hit that 4 or 5 year mark where they're due for replacement Pat, but haven't been able to obtain one given how the reprioritization efforts have been focused on new starts. I'm just trying to sort of size, kind Thinking about like the current census today and how we might start to see an upgrade play out over the next 12 months or so? Well,
I don't think we're prepared to give a percentage, but certainly we were prioritizing For 12 months, new patients over, 5 year patients, but we were able to start giving some 5 year replacement machines out this quarter and a little bit last quarter. So I mean, I think that part of our backlog will start Decreasing also fairly rapidly over the next 3 to 9 months.
Okay. All right. Thanks, guys.
Thank you.
Thank you. Our next question is coming from the line of Tito Chickering with Deutsche Bank. Please proceed with your question.
Hey guys, thanks a lot. Let me back in. So couple of quick ones at this point. 4Q EBITDA range is pretty wide. So I understand what it takes to hit the bottom of the range, the high end of the range and where you think we should be modeling?
Yes. Good question, Peter. So I'd start with at that mid, to hit that implied 187, I believe is the Q4 Number, so on the top line, we put the mid at $790,000,000 We believe we'll land $790,000,000 to $800,000,000 feels comfortable to us. There's a flow through to gross margin bottom line of about 5% on that is our assumption. So that kind of bridges you out from 160 printed in Q3 to 180 and change In Q4, despite the kind of utilization of benefits and kind of other costs that we expect to continue From Q3, we did, in the 1st week of October, make some pretty big Changes are countermeasures to both labor and operating expense.
And so we expect a pickup there For the rest of the year getting to the 187 mid. So that's our base case, if you will. To the down Could we incur further costs than what we're seeing in Q3? Possible. But We feel that fuel, benefits utilization, kind of incremental PAP setup cost, we think that's pretty low risk, But it's a risk to the downside.
I'd say to the upside, it's really top line. I mean, if If we continue to outperform, if we get really on the respiratory side, kind of a clean exit from the kind of prior year COVID spike and we grow sequentially in respiratory more than we did in Q3 3 over Q2. Those I think are levers on the top side in terms of a beat.
Okay, great. And then it's great news that ResMed is able to sort of crank through this Backlog is fast. I'm just curious, can you help us quantify what the pricing is for these new CPAP machines sort of today versus say Q1
So our contract is not up till January of next year. So for the base unit, it's main the same thing. They've had some surcharges for Freight, which is still in there, which were I believe were $7,000,000 $8,000,000 $12 or something like that, I can't remember exact number. They've had those. We've also had some freight costs that we've incurred to try to move products around faster that's now discontinued that will improve our CapEx numbers next year To a pretty significant tune, dollars 15,000,000 to $20,000,000 So that's all beneficial for us.
But I think we're anxiously looking forward to our contract negotiations coming up in a few months.
I guess, just any color on sort of how much of a headwind you think that the pricing can be for next year, if you get a ballpark?
Well, it's an interesting conversation, so I'd hate to give my friends any hints.
I guess, so last question here, again, I know you're not giving 'twenty three guidance, just curious how would you think about the PEG headwinds next year versus where the tailwinds the new CCAP starts? I mean PEG in theory is there to help out when things Just trying to figure out if we should be viewing them as a headwind as you bridge to 2023 or if it's irrelevant with all the ramp up of the new seab starts? Thanks so much.
Yes. And so the PHE, I think it affects different products different ways. I think on the CPAPs, I don't think that PHE is playing much of a factor. I think it's more than supply, obviously. And so now that comes out.
So We have ample supply and return to normal growth rates. Sleep should be fantastic. I think post PHE for oxygen respiratory, I think it kind of peaked at the end of last year, beginning of this year. It's come down since then. We've had some Sequential improvement from Q2 to Q3.
So I think that gets back to normality in 2023. And diabetes, I think PHE helped diabetes a little bit, but this regulation that's proposed right now should help it too going forward. So that should be good. Basic DME, I think hospital discharges are constrained right now because they're having a hard time discharging people. So I think that's going to get resolved.
DME should come back. Supplies to the home, we feel we're making great headwinds with our partners and payers. So I think all of our product categories have positive outlooks for 2023 As opposed to they're up both ups and downs in 2022 2021. So I think it's back to more normality. And so that's For us, because we do have the ability, we're operators, we do have the ability to control cost and be able to get things Operating more much more efficiently.
We haven't been able to control some of our external stuff from supply chain, and that appears to be going away. So it It should be back to business as usual in 2023. So we're looking forward to it.
You know what I think is, as you all are thinking about the jump off point Coming out of 2022, top line, I mean, I would probably throw it all in the mixer and say It's a wash, right? There's likely upside on Demipo's fee schedule. There's PAT headwind. There's theoretically, there's Sequestration headwind, I mean, there's a lot of ins and outs, but if you assume high level, that's a wash. And then you add in top and bottom line, the range I gave Whit on PAB, whether you think that's $25,000,000 to $40,000,000 or so based on the numbers I provided him.
That's a decent way to think about a jump off point. And then from there, as you said, we think it's normal operations When it comes to non acquired growth and just margin improvement across the business and We're looking forward to a good 2023 and certainly will be specific here in the coming weeks.
Great. Thanks so much guys.
And with that, ladies and gentlemen, we have reached the end of our time for the question and answer session. I would like to turn the floor back over to management for concluding comments.
Yes. Thanks everybody for attending our call this morning. We appreciate the support. And once again, we'd like to thank our fantastic employees out They've been through a lot over the past couple of years, and we're all looking for a more normal environment, where we Do the good great things for our patients, our referral sources and our payers. Thanks again and appreciate everybody.
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