Good morning, everyone. Thanks for joining us today. My pleasure to have Jon Rousseau, the Chief Executive Officer of BrightSpring Health Services. Jon, thanks for joining us today. Maybe it'd just be helpful for those in the room that don't have a full, you know, understanding of the platform that you've assembled and all the unique capabilities, if we could just maybe spend a minute talking about the strengths and of the organization and, you know, what you guys have put together, that might be a good starting place.
Sure. Thanks, Whit. Thanks for having us.
Yeah.
Good morning, everybody. So at our organization, BrightSpring, you know, through our pharmacy and our provider businesses, you know, we are serving specialty and chronic senior populations in a home and community setting where they are. We're doing that with really high-quality services that very clearly and dramatically reduce costs and provide ROI to the healthcare system and to payers, and provide a better experience to patients and their families as well. So we have the ability to deliver a holistic set of services to people where they reside. We've really focused on addressing these very large markets we're in by growing our volume significantly over time and at rates greater than our competitors.
We've done that through our quality and our operational strength, and our sales and marketing focus. And then ultimately, with the scale that we've built out, you know, we really do leverage a lot of benefits from that, you know, on the purchasing side, on acquisition synergies, driving best practices through the organization as well, and having a lot of payer diversification. So, you know, we're serving really big markets in healthcare that have dramatic need. We're doing that with a high ROI, and we continue to scale and leverage the benefits of our platform as we do so.
Yeah. Maybe drill down into the core competencies in the pharmacy segment that may be different than the legacy PharMerica business that people may be familiar with and other pharmacy platforms that, you know, we're all maybe more accustomed to studying.
Sure, sure. On the pharmacy side of our business, everybody we serve, you know, needs their pharmacy. You know, they have a need for eight or nine or more medications, and so we can be anywhere in the United States to somebody's door within three hours. So this is not retail. This is the polar opposite of retail. You know, what our pharmacy does is really we operate in three segments, which are all really attractive, and we're excited about the long-term prospects for. The first one is the specialty oncology industry. We're one of the two biggest independent specialty oncology pharmacies in the U.S. The second one is home infusion, increasingly infusion in suites and clinics, but infusion is a very local pharmacy model as well. It's a tough business where service delivery metrics are everything.
We like tough businesses that you have to lean into. The third is our home and community pharmacy, where we take medications to wherever people are across a myriad of settings, whether that's assisted living facilities, senior living communities, whether that's skilled nursing facilities, people in their home on home health or hospice, people with behavioral conditions in their home, hospital customers, addiction treatment centers. There are just a myriad of settings and millions of people every day who require very white-glove pharmacy services where they are outside of you or me going into CVS or Walgreens, and that's what we do in those three segments. Quality is critical. We have customized programs for all of our patients, and scale is really critical.
It's very difficult to compete and be successful in pharmacy without tremendous scale that we've built over the last 25 or 30 years. And so, you sort of mentioned PharMerica even going back 7 or 8 years ago, that company would probably have about a 10% resemblance to who we are today-
Yeah
... just given the markets that we've further built out and penetrated.
If I take all the businesses in the pharmacy today and think over the long term, as you guys sort of define in any given year, this isn't like guidance, but how do we think about the growth rate of the segment and, you know, margins and the growth in margins over time?
Yeah, we've been able to grow the pharmacy side of our business well into the double digits, you know, over the past 6, 7 years from a CAGR standpoint. Q1 was obviously a great quarter. All of pharmacy grew at about 35%. But we've seen broad-based growth. Our specialty oncology business has been the fastest grower for us. We have a tremendous franchise and position in that market, given our standing as a leading independent. Oncology is defined by limited distribution drug networks, and we've got about 117 of those limited distribution drugs. There is a deep pipeline of drugs at the FDA that just continue to come to market. And so, you know, we continue to service, you know, drugs on the oncology side that continue to ramp into the market. New drugs are coming.
We focus on generics as well, high-value generics, and those are all driving growth in that specialty, oncology business. Infusion we see is a, is a business growing more, as a market, grows more at about 7%-9%. You know, different therapies grow at different rates, but it averages out to about 7% or 9%. You know, over the long term, you know, we see that business growing into the double digits as well, like it has been. And home and community pharmacy, that third pharmacy business that we have, I mean, it grew 14% in Q1 year-over-year, and we expect that business to at least grow in the, in the high single digits and, and hopefully better in the future.
So, you know, I don't know that we will continue to grow at sort of a 35% clip every quarter, but certainly, well into the double digits, over the long term within pharmacy is what we imagine. And as we look out to the future, you know, we see far more, far more tailwinds, and opportunities to even accelerate that growth.
Great. And now, you sort of alluded to this, but I just wanna... I think it's a really important point, that just the level of the outperformance that you had within specialty, you ended up raising your top line by about $1 billion. I mean, it was a pretty meaningful raise. What contributed to the outperformance versus your internal plan? Maybe we'll just start there.
Yeah. So we ended up growing on the specialty side, our volume at about four times the rate of the industry in Q1. And so, you know, I think we've just continued to see the results from a lot of the initiatives that were put in place and were executed upon in 2020, 2023. You know, in particular, some of the new drugs that we've been servicing that have launched into the market on the oncology side, are just ramping faster than we've seen in the past. You know, classes of drugs that we've started servicing on oncology in 2022 and 2023, are just penetrating the market and gaining market share faster than the 2019 and 2020 drugs. That, combined with some noteworthy generic conversions-
Mm-hmm
... brand to generic conversions, that converted even faster than we thought as well, you know, contributed to that. And we've just continued to invest in our sales force as well. We have the biggest sales force in the oncology pharmacy space, and these individuals are out there every day working with doctors, patients, and their families, to advocate for our pharmacy services for them. And we continue to see more and more pull-through and market share gains due to our sales force as well.
Right.
It's a positive market dynamic, for sure, within oncology. At the same time, you know, we've been continuing to, you know, to grow our market share within that space.
Do you think you're growing your market share within the LDD market in terms of the pipeline? And you commented around the sales and marketing, what's unique about that and the service. Maybe talk about, like, the differentiation you have with the pharma companies, and how you're able to, you know, win more than your fair share of these drugs.
Yeah, you know, that's—those relationships have built, have been built over the last 10 or 15 years, with bio-pharma. It really just starts with our quality. We have a 93-94 Net Promoter Score-
Mm-hmm
... from physicians and, and from patients and their families. So really outstanding quality levels. And, you know, because these drugs are, are life-sustaining, life-saving drugs, a lot of the time, you know, manufacturers care very, very deeply about the experience of their patients. And so, you know, starting at the very beginning, with benefits verification, helping patients get funding, all the prior auths, the patient education, making sure the drugs are there quickly, reliably on time. You know, we, we really focus on, on all of those key elements of the patient journey, and I think the manufacturers appreciate that. And, you know, they've, they've trusted us with, you know, more and more of their, of their products in these limited pharmacy networks over time. We have seen more and more exclusive and ultra-narrow networks-
Mm-hmm
... that we're, that we're a part of over time, and, and those have been beneficial as well. But, and we've got 117 of those LDDs today, and as we look out over the next 16 months, we think we'll, we'll probably have another 18-20. So about one new drug launching in a limited network every month is about what we're seeing right now. And, you know, certainly, that makes us very positive about, you know, the ongoing growth prospects.
Right. Looking at the home infusion business, maybe size, like the number centers you have today, where you think that business can go in the next two, three, four, five years in terms of growth-
Yeah
... or number of centers, and how do you prioritize the markets and geographies that you would like to enter into, and, you know, where you may have other assets to complement it?
Yeah. We're at about 35. We've got about 35 pharmacies in about 30 states today.
Yeah.
So we've really come a long way in the last several years. You know, having some national scale like that is really important to be able to have national contracts with payers. You know, that's really what they require, so it's been helpful in that regard. You know, there's probably another 5, or 6, or 7 states we'd like to be in, so I could see us adding another 5 to 10 pharmacies over the coming years. I think we'll continue to also to lean into AICs and AISs. So, you know, as opposed to infusing somebody in their own home, people can come to a center or a suite to be infused.
Right.
That's a good experience. A lot of people like that. You know, we will continue to deepen in that area. We've only got about 15 of those today, and I could see that number ramping materially into the future. We're very focused in our infusion business right now on some operational initiatives, leveraging some of the best practices we have on our specialty oncology business, which drove that very high Net Promoter Score over there. We're trying to bring some of those practices to infusion as well, centralizing some of the processes to try to make the experience as fast and consistent as possible for the referral source and for the patient. You know, I think some of our operational initiatives are gonna take through the remainder of this year.
And then, I would say into next year and beyond is where we have greater growth expectations for that business, and I think we'll be in a really good position going forward.
Right. One of the headwinds that you have this year, that you have more than fully absorbed, is the quality incentive payment that you may or may not get, you probably will get. You've pulled it out of your guidance, fully raised your guidance anyway. Do you have visibility into when you may know whether or not you're entitled to those funds?
Yeah.
Or whether it's-
So that quality incentive payment we received from a PBM based on our performance. We pulled that out of all of our numbers in our guidance this year, so it could be crystal clear. That was a four-year program, and this is the last year of it. And that'll be a binary outcome, you know, and if we do receive it, you know, somewhere around probably $30 million, we'll know probably within the next month or so-
Right
By the end of Q2. You know, it'll be, it'll be very positive, obviously, if we receive that again for the fourth year based on our quality. Helpful to debt, helpful to any tuck-in acquisitions, but we pulled it out, given the non-recurring nature of it.
Got it. Okay. Last one on sort of pharmacy, and I want to shift gears, but just thinking the, kind of the margin profile of business specialty growing faster, that has lower margins, that has an optical impact right now. I, I know that there's some opportunities, I think, to begin to bring that margin back up over time. What are some of the drivers of that over the next few years?
Yeah, as you say, in Q1, we did have some mixed impact on EBITDA margin, really, as our specialty oncology business just continued to ramp as quickly as it did. I mean, growing into the 40% range in Q1. And, you know, that is a business characteristic of the specialty pharmacy industry that has a lower margin. So as that business continues to grow within our organization, there is some mixed impact on EBITDA margin. I think we're in a very stable place here in Q1, and for the rest of the year, we see the margin ticking up a little bit as a company as we go forward. I mentioned some of the operational initiatives we're focused on in Infusion, and I think home and community, we're very focused on a number of procurement and operational initiatives as well.
You know, we see about at least 1%-2% margin opportunity in those businesses over the next year or two. Then, even though we had, you know, a really 25% growth on the EBITDA side and the provider side of our business in Q1, very healthy margin in that business, about 15% overall on the provider side. You know, we do see a little bit of opportunity in home health and hospice as well from a margin perspective.
Right.
And then, you know, if we're able to ultimately scale, home-based primary care, that's a higher margin business, too. And so, you know, those would be some of the drivers that give us confidence as we move throughout this year and into next year. You know, we would see a very stable to upticking margin from this point on.
All right, on the provider business, just thinking headwinds and tailwinds, I mean, the overall segment's growing very nicely, but anything you'd call out in terms of one business growing faster than the other right now?
Yeah, provider has also been a double-digit growth, you know, segment for us. You know, really characteristic of the broad-based growth in the organization. Home Health and Hospice grew near 10% in Q1. Rehab grew well into the double digits. And, you know, community living and personal care, those are more Medicaid businesses-
Mm-hmm
Which have just been very steady for us. Really good cash flow businesses as well. So, you know, a very nice mix of businesses serving people in the home on the provider side. I would say going forward, where we really expect more outsized growth in provider is on home health and hospice and rehab-
Right
On the very skilled parts of that business, and we're very optimistic that those businesses will continue to grow into the double digits for the long term.
What are some of the synergies that exist between the pharmacy and the provider business? I guess I'm thinking more home health right now-
Yeah
And hospice.
Yeah, most of our provider patients all get their pharmacy from our organization, so that's a very, very meaningful, synergy, synergy right there. There was a JAMDA study in terms of better clinical outcomes as well. JAMDA put out a study of ours, peer-reviewed in November, that showed a 73%-
Wow
Reduction in hospitalization for people in their home receiving both home health from us and us managing their medications in the home, which is called our Continue Care program. Just a 73% reduction result, which even you know surprised us with how dramatic that was. I think that just shows the benefit of when people can address both their home health needs and their pharmacy needs. Because pharmacy, medication issues are one of the top two reasons why people go to the hospital. A lot of people don't talk about that a lot. So addressing the pharmacy side of a patient who is high risk is one of the number one ways you can keep them out of the hospital and drive savings.
You know, all of our provider patients, most of them getting their pharmacy from us, and then it goes the opposite direction as well. When you think about our pharmacy patients, we'll have several hundred thousand people a year leave and go home from skilled nursing facilities where we're the pharmacy. Most of those people will go home and need home health, will need rehab, will need palliative care. All of them should keep a house calls, should stay with our house calls and have a doctor in the home. All of them should stay on our Continue Care in the Home Meds Management program. And then you look at ALS, and you look at hospital customers.
You know, the ability to drive home health referrals from your pharmacy customer base as well, you know, those are the things that we see as a much bigger opportunity-
Right
In the future. And we're putting care management resources to that. And really, the build-out of our third pillar of home-based primary care was focused on driving more coordinated care and driving more of these integrated care cross-referrals.
Conversations with payers today, what does the economic model look like when you implement a medication management program such as Continue Care?
So, med-
Continue Care
Yeah, Continue Care, our med management program in the home. You know, that is typically gonna be historically funded, similar to any pharmacy services through the Part D. Now, we are talking to several payers about directly funding that because of the benefit it has in terms of reducing costs by keeping people out of the hospital. And so, there is an interest in trying to really grow that business by direct contracting with the payers.
Mm-hmm.
That would be them either just paying for the service because they see the dramatic benefit of keeping members out of the hospital, you know, or there can be models where you step into where you get a share of that savings, if you can come to an agreement on what that construct would look like.
Right.
You know, when we go to payers because of the holistic nature, the unique holistic nature of our services, that's how we're talking to them. You know, we're not a home health company saying: "How can we structure a home health contract with you?" We are going to them saying: "We can do your home-based primary care longitudinally for your members. We can better manage their medications in the home. We have clinical hub services." And those are the three things which really keep people out of the hospital. Can you have a primary care house calls doc going to the home? That reduces hospitalizations by 50%. Can you address medication issues in the home with our med management program? And then number three, do you have nurses who are checking in with them and triaging them?
That's what we've built, sort of our care management program of the future around, and that is what we talk to payers about. So we're talking to several right now. We would be really optimistic that this year we would strike our first payer arrangement around something that probably looks like shared savings to start, and then you would potentially evolve that in the future from there around risk-taking.
Recently you announced a couple of acquisitions. You want to spend a minute talking about each one of them, the strategic nature of, maybe the I-SNP platform, which I think is really fascinating as well?
Sure, sure. Yeah, I think these acquisitions that we announced a couple of weeks ago that we closed here recently are really indicative and a good example of the acquisitions and our philosophy that we've always had in place and have done. You know, it's either to expand geographically and penetrate more markets with our core services, it's to continue to drive broad-based growth throughout our organization, and then third, ultimately, you know, working to enhance our integrated care capabilities. So we did a little tuck-in of a home and community pharmacy down in Texas. We were able to take in their customer base across several of our pharmacies.
And so, you know, this is very characteristic of a lot of our pharmacy acquisitions, where we integrate them on day one in terms of all of our contracts. Within day 30, they're fully integrated, and we drive a very significant amount of acquisition synergies and a really attractive pro forma EBITDA multiple. We will continue to do those as we have. We also did an add-on to our home-based primary care, a growing little third pillar that we have in our company in Arkansas. So an adjacent state for home-based primary care, added about another 30 NPs and doctors in that practice in Arkansas. Arkansas is a state where we have a deep hospice presence as well, so that was very synergistic to us. There's always a reason why we do these deals, where we do them.
That was also a pretty attractive pro forma multiple as well. And then third, we entered into the managed care world by buying a little I-SNP. That's an institutional special needs plan. That is a managed care plan serving long-term care residents in skilled nursing facilities and in assisted living facilities. MA, it is an MA plan, and so that was really our first attempt to have our own MA plan. We can partner with payers and work with them to try to help them better manage their members in their homes every day, but then we can also have our own managed care plans-
Right
For our patients who are under our own home-based primary care clinicians. So we wanna have both an internal payer model and then externally partner with people on the payer side as well. And so that was in two states of Kentucky and Tennessee. In managed care, you have to get approvals county by county, state by state. So over the next five years, we look to enter into about 20 more states with that internal managed care plan, and that was a way to, you know, start to get going with our integrated care and our value-based care strategy, and continue to progress there.
Yeah. Maybe just spend a minute on. You talked a little bit about the pipeline, but, like, the pipeline over the rest of the year and, if we also work backwards and think about the acquisitions you've made, any details, metrics, returns, anything you'd care to share on valuation, just to look at the success of your historical M&A strategy.
Yeah, yeah. We continue to have a very deep and robust M&A pipeline, like we always do. Most of our deals are proprietary, you know, across all of our people and our businesses. We're very deep in our markets. We know a lot of people and companies. A lot of people look to us as a long-term home for their business and a place that, you know, they wanna sell to and be a part of long term. They're excited about our strategy. When you look historically across our 60 acquisitions over 5+ years, 5.5 years now, most of them are tuck-ins. The average revenue we've acquired is about $4 million. The average EBITDA is about $700,000. Our pro forma EBITDA multiple is averaged at about 4x.
So we are able to leverage our operational capability and our acquisition synergy to drive-
Right
Very accretive acquisitions, historically. And, you know, that will just continue to be the playbook that we use going forward on, on the M&A side. I think, you know, I think if you look at our typical cadence of deals, you know, we were very heads down last year and in Q1 on the IPO. We're very focused on balance sheet and our long-term leverage target or, or 3x or below. So we're very focused on, on being very intentional about which deals we do and why, and balancing our, our leverage with our ability to do very accretive acquisitions. And we would expect to do probably several more this year. And, you know, all of them are gonna make sense geographically, strategically, and, and typically be very, very attractive from a pro forma EBITDA multiple standpoint.
Okay, and then maybe just last one here, let's talk about the balance sheet. I know your target's 3 times to get to that today, and, I think you're right around maybe, maybe 4, so correct me if I'm wrong. And then, thinking about, like, a normalized free cash flow, amount for, you know, the next year or two, what, what's kind of a normalized level that we should think about?
Yeah. Certainly in Q1, we had a bunch of IPO expenses, and then in Q2, you know, we've got some legacy expenses and, you know, some management fee termination, you know, which is ultimately good, but, you know, paying some additional expenses out, one-timers in Q1 and Q2. As we get past that, you know, we see our operating cash flow on a normalized basis of about $275 million. You know, we were able to. The IPO was all about, you know, working towards our target leverage level. We reduced over $100 million of interest expense through that process. We have about a little under $50 million of quarterly interest expense today, and, and...
But $275 for operating cash flow is a number we're really comfortable with, and hopefully, we grow off of this year and into next year in 2025.
Great. Any questions in the audience? All right, we'll finish with a couple minutes to go. Well, John, thanks for taking the time today.
Yeah, thank you, Whit.
Thanks.
Really enjoyed it. Thank you.