Relations in the room. Thank you guys very much for joining us.
Thanks for having us, man.
Yeah, I just wanted to kind of recap some of the dynamics that are going on in the quarter. Diabetes revenue declined 8%, but it's largely as expected. We're doing an overhaul of that segment, but you noticed some better-than-expected sequential developments and setups. Maybe you can kind of walk us through what you're seeing and kind of how we are framing the diabetes backdrop as we get through the quarter here.
Sure, sure. Yeah, we were planning for down about 10%. We did a little better than we thought. You know, the two metrics we're really watching, I think investors should be watching, are our retention, which, you know, our resupply represents about 85% of the diabetes revenue in any given quarter, is coming from patients that were set up in previous quarters. That number is a big deal. I'll talk about that in a moment. Second is certainly the new starts, new patient starts. Those are, you know, that's our field force that's out every day, knocking on doors with referral partners, working to earn business. All that comes into the resupply funnel. The idea is to compound that over time and then continue to resupply those patients as long as they need CGMs or pumps and related supplies.
Mid-Q3 last year, we had a significant changeover in management of the division or of the segment. You know, we've brought in several new leaders, a new President for the segment, a new SVP of sales, various operators at a kind of a Vice President level. The second thing we did was we lifted the resupply unit in diabetes and we shifted it to our sleep resupply center in Nashville. Our center of excellence, frankly, it's the crown jewel of AdaptHealth. I mean, we do over $1 billion a year of business on resupply for sleep products. The mechanics and the process for a diabetes resupply is largely the same. You know, we've brought that team together. Just a quarter later, in the fourth quarter, they had achieved the best retention we've seen in over two years. That happened again in Q1.
Q1 retention typically drops off a touch from Q4 as, you know, deductibles reset and, you know, insurance plans change. Again, they achieved the best Q1 retention that we've seen in over two years. If we string together a couple of those, we're going to be in very good shape. While on the new start side, we've now had two consecutive quarters of sequential new start growth, so new patients coming into the funnel. I think it's easy to see if you're able to retain what you have at a steady state and you're bringing in more patients each month, pretty soon that segment's going to be back to growth mode. It's absolutely the top priority in the company right now. So far, so good.
Great. Can you tell us what's involved with, you know, you mentioned the overhaul and bringing the diabetes into your sleep platform. What was involved there? Are there any headwinds that you had to manage through? And kind of how much room do we have to run on the further integration there?
I'll start with the second part, you know, in terms of how much more we have to run. In terms of process, we're there. We're fully integrated. We're running the same process in diabetes now that we run in sleep. We do have some room to run on the technology front. That has to be developed. We're hard at work developing that. That'll likely take a little time for us to build out, but it's not holding us back. It is something that should drive further efficiency going forward. In terms of the processes and getting them lined up, I'd qualify this as simple, but not easy. I'll give you some examples. They'll probably sound certainly simple and maybe silly.
You would be shocked at the number of dials that we get, inbound calls from patients seeking resupply when we send them a postcard reminding them that they're eligible. I mean, it's really amazing this day and age with all the technology and everything else, like how much business that really drives. Similarly, you know, processes like if we call a patient and they don't answer, they're on a do not call list for 48 hours, because the last thing we want to do is, you know, just, you know, excessively contact patients seeking resupply. You know, it's a balance. You know, you want to take good care of those patients, not excessively call them, but also make sure they're getting what they need.
We have turned on various processes as it relates to text messaging, the My App, which has had great success within the diabetes business unit, as well as just email and other modes, kind of other channels of communication. I think a lot of this sounds simple, but I mean, these changes have made big impacts quickly.
How about on the personnel side for diabetes? You've made some changes there as well. Do you have the people you need in the seats, or are we still hiring, or?
No, we've got a built-out team. We're really happy with Gary Sheehan. So if you follow DME or you know DME, he's very well known. He and his brothers and the family, they're well known in New England DME. We bought a big business from that family back in 2021. And so Gary came back with us to run the diabetes unit. So he doesn't have a diabetes background, but he's been a DME guy for 40 years. He knows how to resupply. He knows what it takes to win business from referral partners. And so he's now leading the charge in that business segment. You know, he said he's having the most fun he's had in his career. So that's, I think, a good sign. Graham Ward, I mean, he's our head of sales for diabetes. He was with Suzanne back in Medtronic.
Later, when Suzanne was running Edgepark for Cardinal, Graham was her leader of sales and ops for the diabetes business. He knows the business well. He's got a military background. He's a very hard charger, but he's an inspirational sales leader as well. Just the energy that he's brought and the best practices from training and, you know, monitoring and coaching, he's doing an excellent job, and it's showing in those sales numbers.
Great. If we could turn over to the sleep side a little bit, I know we had a little bit of a headwind in the first quarter. It looks like we're a little slow off the line on some startups. Maybe you can kind of talk about what drove that and kind of your strategy to turn that around.
Sure. To put it in perspective, there were a handful of states that were too slow at the moment. I mean, we're getting beat out on speed to set up. You know, to put it in perspective, we're talking about a couple million dollars. Now, the reason we called it out was that it's obviously our largest business. It's our largest segment. If you continuously miss on setups, it just compounds. We did not want to be in a position that if we do not get our arms around this, it could catch up to us later in the year. That is the reason we called it out. There are two things that we're really focused on getting after there. The first is operationally and speed to set up, time to set up. We have spoken about AI and automation.
I mean, this is our first big bet is on the front end of the documentation and the prescriptions coming in from referral partners. I mean, we've said that it's amazing. We actually ingest over 5 million pages of fax every month. You can think about how many humans that takes to pull up that eight, nine-page script. On a dual screen, they're looking for the key fields, the patient name, address, the ICD-10 code for the diagnoses that the physician determined, you know, what's been prescribed specifically. You know, there's about, call it 40 or 50 fields that need to be used to generate the sales order. These are humans with eyeballs. I mean, that takes five minutes to do that, even if you're efficient. We're testing three different AI organizations right now, one starting to edge out, it seems.
We're not yet scaling this, but we do intend to. We're getting 90% of the fields pre-populated now in the sales order. There's still human in that loop with the AI. However, we're reducing the time to lift that data out to under a minute. You know, that can be fantastic from a cost perspective. We'll comment further on that later in the year. I mean, I would think of that as a 2026 opportunity. However, the speed to cycle through, it just increases dramatically. That's what we're working on operationally. It's going to take a little time. In the meantime, to close the gap, a separate procedure we have is related to what we call REPAP. It's pretty typical for a patient, depending on their managed care provider, to be eligible for a new CPAP machine every five years.
Historically, we would determine that the patient's eligible, and then that would be handled at the branch level. The branch would be responsible for scheduling the patient, having them come in and get set up on the new CPAP, and then we earn that revenue. We've changed that. We've centralized that just in the last couple of weeks since the earnings call, actually. What we're doing out of our resupply center of excellence in Nashville is there we're identifying the patient's eligible for REPAP because it is a sale. I mean, you need the patient to confirm that they actually want the new machine and that they're going to pay for it, their insurance company and through their copay that they're going to pay for it. Rather than sending that to the branch, these are patients that know how to use a CPAP.
They've been on it for five years. They don't need fitted for the mask. They don't need to go through training. They don't need to go through the standard setup process. They don't need to be in our location. We can drop ship that. I mean, the settings have to be, you know, updated properly. And we've got respiratory therapists that do that. We're now centralizing that function. That machine's starting to turn. We're showing a little bit of progress. It's early, but we're showing some progress. We hope to close up that gap. We'll update everybody, I think, on the next call.
Great. Lastly, just the respiratory oxygen record census. It sounds like in the first quarter, maybe you can kind of talk about, you know, where that's going and what's kind of driving that strength.
Two things are driving the strength. First and foremost, I mean, record flu season. I mean, it started late, which is why Q4 for respiratory was a little lighter than we anticipated, but it came back in full force in Q1. What happens when there's a record flu season or COVID is that patients will present in the emergency room with, you know, a respiratory problem. The physician, the ED doc, will get that patient into a stable, steady state is what it's called. They'll test for underlying respiratory condition like COPD. When these things happen, like a big flu season, what it does is it drives more diagnosis of the disease state because it's about 25% underdiagnosed in the U.S. There's 20 million folks with COPD. Only 15 million or so are getting treated for the disease state.
It helps bring more patients into the funnel. It's just kind of a natural tailwind for us. That happened. Secondly, we did install new quotas at the beginning of the year. You know, we're turning those dials as we're going into Q2 a bit. You know, certainly we saw a little more, particularly out of ventilation. We saw a little more out of respiratory and vent in the first quarter because of how we've incentivized the field force.
Gotcha. And then maybe you could kind of talk about your capitated business.
Sure.
How that's going. I know that, you know, there was a little bit slower initially getting that off the ground, but it seems like it's up and running now. How's that fairing for similar types of arrangements as we go forward?
Yeah, sure. I'd say firstly that, I mean, we learned a lot in starting up the Humana agreement. For those that don't know, a couple of years ago, we won an RFP for 33 states plus the District of Columbia. If you're a Humana Medicare Advantage patient with an HMO plan, AdaptHealth is your only DME provider for sleep, respiratory, and DME. I mean, it was a fantastic win for us. State by state, we had to swap out respiratory products or sleep products or hospital beds, patients that had been serviced by a competitor. Per state, you're talking about hundreds of competitors in each state. There was considerable startup costs with that. There were some penalties for not transitioning fast enough that we wouldn't structure a contract that way again. We learned that lesson.
However, now that we're up and running, we've been online now with Humana for almost two years. We reported that we extended that agreement for multiple years. We reported that earlier in the year. I mean, the relationship is fantastic. We're very pleased to serve Humana. We want to do more with Humana. We are getting the benefit on the PPO side of the business of a halo effect. Some of our public competitors have actually talked about that as a headwind to their business. We're seeing that very clearly because it's just an easier transition of the administrative office. You know, Adapt is the only game in town for HMO. You have to think HMO versus PPO and does this plan, how does it map? Just send it to Adapt. That's absolutely happening. We're seeing that in the numbers.
For that reason, and many reasons, we think that the capitated business is such a good solution for payers and/or large hospital systems. You know, the reason is that, I mean, we're happy to take a little bit of reimbursement cut in exchange for a lot of volume at once. I mean, we'll do that all day. For the payer, it's much less about the money than it is about those hundreds of DME providers I talked about. I mean, managing all that and the administrative, you know, headache. And, you know, you got patients complaining about all these different things from all these different companies. You can have one throat to choke. I mean, we're happy to be that throat here at AdaptHealth. I mean, you know, we've signed up for SLAs that, I mean, that doesn't exist in fee-for-service contracts, you know.
We're happy to sign up for one-time delivery of oxygen and other products. We're happy to sign up for patient satisfaction improvement and, over time, continuous improvement so we get better together. Like, that value prop to a payer is meaningful. We've invested meaningfully in dedicated resources that we've got folks that all they do is they'll price these contracts. They'll pitch these types of arrangements with payers and large hospital systems. You know, they operate the utilization, manage the utilization, and run these contracts. You know, Suzanne was very purposeful answering a question on the last earnings call that our pipeline for capitated arrangements, it has grown since our last earnings call. Deals within that pipeline have advanced since the last earnings call. We reported that we won two new capitated arrangements in the fourth quarter. It started January first. Not huge, but great business.
We've got, you know, we've got a lot of things we're working on, large, small, somewhere in between. We think that rather than 4% of our revenue today capitated, we think that's going to grow pretty significantly over time. We could see that at 10% just in the next couple of years.
As you increasingly become that one-stop shop underneath these capitated arrangements, are there competitive pressures that could drive more roll-up in some of your markets of mom-and-pops?
Sure. I mean, we think we're at another new pivot point of consolidation within the HME industry. If you look back at 2016, the CMS reported there were over 10,000 operators in the United States. More recently, just a couple of years ago, they showed that number was now under 5,500. You know, we believe that there won't be more than 2,000 DME operators in the next three to five years, maybe sooner. The reasons are several-fold. First, again, back to that Humana arrangement, like hundreds of DME operators, like they have all their fixed costs they got to worry about. I mean, all of that margin got ripped out at once, and they can't do anything about it. They got to find more business somehow. That's point one. I think point two is the $7,525 reimbursement cut last year.
I mean, for us, that was $25 million, top and bottom line. And we absorbed that and grew through it. Not so easy if you're the little guy. I mean, inflation's ripping. You got just, I mean, you've got Medicare Advantage growing. I mean, there's a lot of factors to battle in this industry. And so scale matters. Like size and scale really, really matters in managing through that. So those pressures are very real. M&A is still happening. I mean, we did a nice little deal in November, about $10 million of revenue. Great hospital DME business, bolts right on, easy integration. And, you know, you're bringing on resources that are tied into that hospital system. Oftentimes, they work in the four walls of the hospital with the discharge coordinators and planners. And so that's all getting, you know, brought into our network.
We said in the last earnings call, we got a couple of deals under LOI. We will continue that. We have earmarked $30-$35 million. Suzanne and I have earmarked for M&A this year. You will continue to see these hospital-based DMEs tucking in, rolling up, fantastic multiples. If we make progress, we will report that and update guidance next quarter or the following. Others, there is M&A in other places that is also forcing that consolidation. Finally, the conveners. I mean, there are various companies out there that are convening. They are performing somewhat of a similar business model that we are doing with Humana, except they are capitating with the payer and taking the risk, and they are outsourcing the operations. We are happy to take that. We get paid there too.
You know, as long as we maintain the relationship with a patient and maintain the clinical data and outcomes of that patient, we'll accept that type of model. It is different than our core business model. By accepting that, that does force rapid consolidation as well because those folks managing risk, they're going to make more money if they're doing it with big operators that can do it at lower rates. Again, that's another natural consolidation point that's happening in the industry.
We do have a deal announcement. Quipt takeout DME provider, $250 million revenue. Can you talk about your thoughts on that and kind of what it means for your landscape?
Sure. Quipt, QIPT, publicly traded, you know, significantly smaller DME than us. Yeah, it was reported yesterday of an investor offer to take out the company. We understand the multiple from an EBITDA less patient equipment CapEx perspective to be 10.6. You know, not long ago, Cardinal took out ADS, Advanced Diabetes Supply. You know, again, we understand that EBITDA less patient equipment CapEx multiple to be at 11 times even. You know, I won't get into valuation. That's your job. You know, we look different than that. You know, we think that was interesting. We also think it's interesting that, you know, there does seem to be more appetite for M&A in the industry. We, on our end, are seeing more activity. We are looking at more opportunities than we were, call it six months ago.
I mean, the landscape's just shifting a little bit. Again, we're not, I mean, if we stay on path doing exactly what we're doing, we think we're in very, very good shape. There is nothing to chase. We'll continue to be extraordinarily disciplined. You know, it's something certainly that we're keeping an eye on.
Then sticking on the capital front, guidance adjusted for a couple of divestitures that are coming down the pike. Maybe you can kind of talk about the strategic focus you're putting in place and kind of how you think of the go-forward portfolio.
Sure. So, you know, we conducted a thorough portfolio review. Started almost two years ago, actually. We looked at several kind of subcategories underneath the segments. Where we landed was there were three businesses specifically as part of our wellness at home segment that we did not have scale. They were anchors to our top line growth. They were anchors to our margins. And frankly, we just were not the right owner. We just were not great operators in the space. That first asset, we sold in the third quarter last year. That was a custom rehab business. Think of like motorized wheelchairs. Labor-intensive, capital-intensive, negative margins for us. We sold that to the leader in custom rehab. We think they are going to do great with that business.
A little bit of proceeds, but frankly, that was one we were moving pretty quickly just to move along. We were pleased with that. Last quarter, we reported the sale of ActiveStyle. This was a business that we bought five years ago. It's incontinence business, but it was focused on the direct-to-consumer, which that doesn't really fit our business model. It was a lot of late-night television ads finding Medicaid patients that could be eligible for incontinence products and then working that lead and turning it into a revenue stream. We sold that business on May 1. You'll see in our subsequent events in the first quarter, we did report the proceeds from that sale of $68.8 million. We paid off another $70 million of our term loan A since the first quarter ended.
We were very pleased to report that, you know, with that, you know, gross debt down from $1.975 billion to $1.905 billion based on that subsequent event. That same day, we announced a definitive agreement to sell our home infusion business. Think of like an Option Care Health type model. That's what it is. Again, subscale. You know, we're working to sell that asset. With a little luck, we'll close it at the end of the second quarter. All of the proceeds of that are earmarked to further debt reduction on our term loan A. You know, with that, I think any company, you're always potentially evaluating your portfolio. You know, we feel very good that these three assets that we're almost done. We're focused on our three core segments, which are sleep, respiratory, and diabetes. Then the wellness category, which is there to support.
Oftentimes, those patients need products in our wellness segment and where it drives ancillary revenue into the core. That's really where our focus is.
Great. I guess we'll close just a quick commentary on expectations for cash flow ramp through the back of the year.
Oh, sure. I mean, just like last year, a third of our free cash flow will deliver in the first half. The second, thi rd will come in the second half of the year. Some of that's just timing of when payments are sent for debt servicing and bonus payments early in the year and things like that. You know, we're very, very confident in our free cash flow guidance that we put out for the year.
Great. Thank you very much. Really appreciate you being with us today.
Thanks for having us.