Good morning, everybody. This is John Ransom. I'm here with David and Fred from Guardian Pharmacy. Just a minute of background: the company is newly in the public market as of late September 2024. They made some news this morning with a strong quarter, about $5 million above our model, and an outlook about 4% above our model. Institutional pharmacy an N of 1 in the public market. Yeah, so far, so good. We are going to do a hybrid format followed by Q&A. Take it away.
Super. Thank you, John. I'll start. I'm Fred Burke, and I just wanted to take a minute and thank you first for coming, for your interest in the company, and provide a 30,000-foot overview. If you step way back, what Guardian Pharmacy Services does is focus on an underserved segment of long-term care, which is assisted living, that requires a completely different type of service than skilled nursing. Recognize that a lot of pharmacies are engineered to serve skilled nursing. There's a different requirement needed for assisted living, and that's what we've done as engineers at our pharmacy from the ground up to provide the special services they require. Those services produce two important outcomes. Firstly, we get the resident on the proper drug regimen. That means clinically and also in accordance with their Part D plan formulary.
We provide a tech-enabled platform to the facility to allow for the meds to be administered safely and effectively and achieve adherence. When we are in a great place in healthcare, we get the resident on the proper drug regimen, and we make sure they adhere to it. Both of those things improve outcomes and bend the cost curve. A great place to be in healthcare. We have grown with a multi-pronged strategy that includes, very importantly, organic growth, but also M&A. David will talk in more detail about that as we move through. We are very proud of our management teams. One of the key elements of our success are the teams that run the pharmacies. These are quite complex, little smaller businesses, $20 million, $30 million, $50 million in size.
We have helped a clinician, typically a clinician, go to the Guardian Business School, if you will, to become a general manager and run this business, not only to provide the outstanding clinical services needed that our customers need, but also to make it be, in and of itself, an ongoing self-sustaining business enterprise. We are very proud of those people. We also have invested heavily in a corporate support group, subject matter experts that help these local operators leverage the scale. David.
Talk a minute about the market that we operate in. As Fred mentioned, we're in the long-term care pharmacy market. When you include Al Smith and Behavioral Health, the market's about $25 billion. We're focused on the assisted living market, and it's more $7 billion. We currently enjoy about 12% of U.S. market share. The assisted living market, in and of itself, is about 800-plus residents. We're fortunate it has a nice tailwind of about 5% growth a year. The market serving these communities is very fragmented. I mentioned we have 12% market share, and the majority of the rest of the market is served by 1,200 independent pharmacies, which is a nice opportunity to continue to enhance our growth. You can see from this map that, you know, we've achieved national scale, yet we've got a great opportunity to continue to execute and continue to grow.
We've got 51 pharmacies serve about 186,000 residents, and we did 25 million scripts last year. Our growth is something we're really proud of. You can see the strong CAGR we've enjoyed from a revenue standpoint, ended up with a strong 2024. One thing that we've done from our beginning 20 years ago has been a very judicious steward of capital. We built this business pre-IPO with around $68 million of capital. As we sit today, we have little to no leverage.
Let me take a minute and talk about the residents that we serve, because one might think of assisted living historically as a real estate play with hospitality, and your mother is going to go in and mix doubles this morning, lunch by the pool, movies this afternoon, that kind of a thing. The reality is starkly different. These residents have a high level of acuity. You can see the percentages that need assistance in these various ADLs, which is the way CMS defines acuity level. The average resident is 87 years of age, takes more than a dozen prescriptions daily. Importantly, they're private pay. They've chosen to live in these newer, nicer facilities because they're paying for it themselves. Our customer, the resident, is a private pay individual. Just a quick word on why we think it's different for a pharmacy to service assisted living versus skill.
It all revolves around the level of skill set in the facility. In a skilled nursing facility, you've got a medical director, a physician. The caregivers are nurses. The pharmacy is providing healthcare to healthcare professional to healthcare professional service. You get the right drugs at the right time, and the nurses can take it from there. Whereas in assisted living, there is no medical director. There are very few healthcare professionals. In many ways, we are serving, we the pharmacy, as that coordinating element with the multiple physicians in the community that are prescribing for each of these residents. We are providing the tech-enabled platform to make sure that a non-healthcare professional can safely and effectively administer the drugs. Very proud of the assisted living groups that we serve.
The industry is very fragmented, but it is consolidating with sophisticated operators like this that prefer our more sophisticated level of service.
70% of Guardian's revenue comes from Medicare Part D versus, you know, the retail setting. It's probably 25-30%. And we enjoy higher MedD reimbursement because when MedD was rolled out 20 years ago, CMS had rules of participation for long-term care pharmacies. And if you participate, you know, the MedD rates, you're reimbursed is higher than retail. You know, what this has yielded for us over the years is stability. You know, frankly, people, you know, see this chart and wonder, you know, how you manage through this, whether there's a lot going on, a lot of puts and takes as we manage this business over the years. But we've got, you know, nice, stable, you know, gross margin percentages. Our SG&A is trending, you know, down as percent of revenue. And you can see, you know, our adjusted EBITDA margin trending upward slightly.
Stable margins with this business. You know, how do we grow the business? We've had a track record of very strong organic growth over the years. We do that two ways. One, we bring on new facilities and new homes in existing markets. Once we bring on new facilities, we work hard with, say, a Brookdale of the world to increase adoption. It's typically around 50% of the residents are using the preferred pharmacy when we bring on a new community in a pharmacy market. Over a period of time, we grow that substantially. On average, we're at 90% for the overall company. The third way we grow organically is through contiguous expansion with existing partners. We've been very successful in that arena.
Supplementing our organic growth is our M&A activity, where we find like-minded operators where we can put new pins on the map and continue to grow the business. As you saw in that earlier map, we've got a lot of geography to continue that. We put out a release this morning with some flash numbers. I don't know if you guys had a chance to see that, but strong, you know, revenue growth for Q4, up 21% with adjusted EBITDA up around 30%. A couple of things I'm going to touch in more detail, but Q4 had, you know, a seasonal benefit from our flu and COVID vaccine clinics. You know, had some impact, positive impact on the quarter. The other thing I'll point out that this 30% growth on adjusted EBITDA includes our first quarter of Pubco cost, which was about $1 million.
We also closed an acquisition on November 1 in Morristown, New Jersey. Talking more about COVID and flu, you know, when COVID hit, you know, it was very, you know, traumatic on our business and because it was traumatic on the customers and the residents we serve. Coming out of that, these COVID and flu vaccine clinics became very prevalent. We were looked to to do that. In the past, probably three years, we've been working to somewhat normalize how we do that, how we meet the customer's demands. You know, it's extremely complex operationally, financially, reimbursement-wise. In the past two years, we've had a task force working on this to optimize how we serve the residents with COVID and flu vaccines during this, you know, Q4 seasonality bump and move it to, you know, a position where it's marginally profitable.
You know, areas we worked on are supply chain from acquiring the product, logistics, how we distribute it to all the residents and where they are, all the way to reimbursement. You know, things really have come together for us on this, you know, the last six months. You know, and if you just look at the quarter, we had $2 million of incremental revenue related to flu and COVID vaccine clinics that we did in Q4 of 2024. The bigger impact, this business had a drag on Q4 of 2023. We lost money on it, and it became slightly profitable in Q4 of 2024. A nice transition there with that piece of our business. Here's our full year revenue, up 17% and adjusted EBITDA, you know, up 19.
We also included our 2025 guidance in the release this morning, $1.33 billion-$1.35 billion on revenue and adjusted EBITDA $97 million-$101 million. That growth rate on adjusted EBITDA of 9% includes full Pubco cost. We have three quarters of Pubco in 2025 and only one in 2024 for the comparable numbers.
In summary, our secret sauce, we serve a target market that is growing and greatly benefits from our service. We have provided a tech-enabled suite of services that bend the cost curve and improve clinical outcomes. We have a very, very strong management team and corporate culture of service and impressive track record of growth. We are good stewards of capital. We have an M&A platform that is capable of delivering accretive growth through leverage. Very importantly, we just rolled out, and are very excited about this, a new LTIP program to our employee owners.
We have 35% of our company is employee-owned among 235 individuals. This has been a very exciting event that has really, really excited our team.
All right. We have a little time for questions. We have a few here, and then if we have time, we'll take some. Let me first take some risks because we have two SEC grads talking about numbers. Just kind of take this at face value. If we look at the revenue upside in your 2025 guide versus the EBITDA upside, there's a lot more EBITDA drop through than we would have thought from the revenue. What's just at a high level, what's going on with the 2024 to 2025 margin comparison? I know you got the Pubco cost as a bad guy, but what are some of the good guys, maybe Heartland and some other things we should think about on the margin journey to 2025?
I'll start. Fred can add in. I think when the business is strong, I mean, we ended the year, you know, with strong resident growth and strong operating margins. Obviously, we've got businesses like Heartland going through the maturation process, and that's adding to it. You know, if you look at our guidance, that is the midpoint. You know, I think, you know, we've got nice opportunities ahead of us in 2025.
Okay. I'll add one thing, John. We audaciously stepped on the gas a bit in 2023, 2024. If you look at that map that David showed earlier, 9 of 51 pharmacies are new and still coming up to scale. Part of our guidance is capitalizing on that as we bring those up. The integration is going very nicely for Heartland and the others, and we're really excited about that as those cohorts of pharmacies come up.
Heartland, you know, we're nine months into that. As the maturation process, you know, takes two to three years, this time next year, I think Heartland will really be, you know, contributing.
Great. Kind of a fascinating, in our opinion, IPO because it was unusual. The company did not take down a lot of primary capital. You turned, memory serves, 230 employees into owners of the stock. Just that process of unwinding the old structure and putting in the new structure, what do you think that does for external growth and then just kind of internal operations? Have you noticed any difference kind of post-IPO in sort of the rhythm and pace of the company from that process?
Many of these shareholders, employee shareholders, had carried equity. So in an LLC format, similar to options, they really didn't have the ability to look this up anywhere and understand what this meant to them. I believe the IPO has just really kick-charged our employees to realize, gee, this stuff is real. This is tangible. This is meaningful. That's been one outcome. Of course, we're building on that with the new LTIP program as well.
You just have to keep them from checking the stock every day, don't you?
Absolutely.
I think it's given us a point of focus. You think about we had 50, you know, separate businesses, and the majority of those were converted. And now, you know, everybody's unified and focused on executing and, you know, driving more synergies out of the business. So it's a great milestone, and I think the organization's energized.
One of the other things that's, I think, notable about the company is the competitive moat here is unusually wide, in our opinion. Just talk a little bit about you've got some upstream competitors, Omnicare, PharMerica, and then you've got a bunch of downstream competitors. Just talk a little bit about your competitive moat, both upstream and downstream, as you see it.
If you look, Omnicare and PharMerica historically and today are focused on the skilled market. Alpha is harder to serve, and it's difficult to pivot. What that yields is our competitors who we see out in the market every day are these 1,200 independents. Great clinicians. They provide excellent service, but it's even more difficult than ever over our 20-year history to make these businesses profitable. You know, that's where, you know, we come in with the tools, services, and the team we built over the last 15 years to add the synergies, be it on the revenue cycle side or purchasing or, you know, 20 other areas where we bring synergy. We think that that's a nice moat. We're fortunate that we built this business from day one when we started in Phoenix, focused on serving the Alpha community.
You'll remember we have a 12% share of the market. We're the market leader nationally, even though we don't cover the entire geographic footprint. The way we look at it is there's 88% left to go. We're running in the open field and doing that.
I like that expression. Just looking at the obvious dot on the map, there's only one dot in Texas. A lot of our services companies kind of over-index in Florida and Texas. Has that been a particularly challenging market to find a good entry point? Or is that all upside?
It's upside.
I would say the majority is upside.
Right.
Okay. All right. That was a little off-script question.
Just keep them going.
Just testing you a little bit to see if you're on your toes over there. Medicare Part D, 70% of revenue. CMS did a premium stabilization pilot that most people are entering, but there's a lot of chop. A lot of the Medicare plans are calling out Part D this year as a margin bad guy. Just talk about, and we would expect, I don't think we've got the stats yet, but we would expect that the 57% of Part D plans, Parker's going to be impressed. I remember that number. 57% probably goes up that more and more get embedded in regular Medicare Advantage to get the cross-subsidy. How do you see that evolution in your contracting cycle this year? How do you think about how that does or doesn't play to Guardian's strengths?
I think our contracting process has been sort of steady as it goes. There's not been anything dramatic from our engagement. What we're dealing with, we're engaged, we're talking about IRA, they recognize the problem. So I would say steady as we go. We've seen slight reduction in some of the PDP plans because of the churn and, you know, the med advantage. You know, I think they're trying to reduce some costs because of the shift, but it's pretty much steady as we go.
Currently, the company's formula is a dispensing fee and an AWP spread. Do you think two years from now we're sitting here looking at maybe a third leg of the stool, which might be some incentive payments and some cost reduction sharing programs with the plants?
That would be our hope and plan. With our newfound direct relationships with the PBMs, we're already starting to talk about strategic opportunities such as that.
They're tough though, right? They don't move too quickly when we're talking about downstream economics.
Given all of the issues that you referenced earlier, you can understand why.
Yeah, Fred and I have had some interesting conversations about PBMs.
I'm going to try to be nice.
You've been wonderful. Another thing that's kind of interesting to us when we went to see the local pharmacy in Tampa, just the process of, we understand like your market share gains happen over the move-in cycle. So what happens when, you know, usually it's the older daughter or son is sitting there with their mom and she's moving in? Who delivers the missionary sale and how do you follow up with that resident? Because, you know, it's a pretty obvious reason why you'd want to switch away from a retail pharmacy to an institutional pharmacy, but how do you deliver that message? Who delivers it? How does the company support the local administrator in making that happen?
There are two elements. David can talk how we have leveraged the home themselves, the facilities at that transition of care to sell the responsible parties on why they should use the pharmacy. What we've realized is that we need to augment that with B2C type systems, which we are in the process of developing and launching. You know, what you're speaking about for the audience is adoption rate. Very important in assisted living. It's needed. The homes desire it. We do too. It's the safe and effective way that we can serve a resident, but we have to sell them. First, we have systems with the home itself, which David can describe.
Five plus years ago, we rolled out an adoption toolkit, which many of you may have seen the video on one of our, you know, roadshow presentations. As Fred said, that's used to equip the home to educate the family and the responsible party why their loved one needs to use the primary pharmacy, i.e., Guardian. While that's been effective and we've driven the adoption, as I mentioned, you know, typically 50% goes up to 85% or 90%. We've talked, you know, we've moved even further into B2C and working with the resident when they come on board with Guardian. We're educating with our teams why they need to use the pharmacy for safety, for convenience, and all the other reasons. We've even rolled out additional programs in the last year.
I mean, do you all go into the home with your own people and say, "Coffee and learn about Guardian at 10:00 down at the rec room" kind of thing? Is that part of the plan?
We have family nights and, you know, we'll set up and be there with the home, meeting with all the families and educating them on the services.
Okay. Believe it or not, I've run out of my prepared questions and I'm not so good at improvising and we have five minutes. I am hoping one of you guys will bail me out here and ask a couple of questions. There we go. Thank you, sir. Former Raymond James alumni here coming to the rescue of his old teammate.
Talk a little bit about M&A, just kind of targets, returns, leverage.
For sure.
The question is just M&A.
That's near and dear to David.
M&A, returns, targets, leverage.
He sleeps, drinks, breathes it. Let's let him talk about it.
Thank you, Fred. You see what I have to put up with between Ransom and Fred? I'm in trouble. No, M&A is core to our growth. We talked about the 1,200 independents. These are businesses that are, you know, $15 million, $20 million in revenue, serving a couple of thousand residents in communities all across the country. These businesses are great operators, great clinicians, but typically are struggling on the business side because of all the external pressure over the last 10 or 15 years from reimbursement with the PBMs to dealing with the wholesalers. What we strive to do is find like-minded operators in markets where we have rich national account concentration and we don't have bricks and mortar there. We bring this operator together. We're looking for people that want to embrace the platform we've built and want to continue to grow.
We have done that very successfully around the country. We find good operators in national account rich territory, grow with them, new pins on the map. The other way we grow, I mentioned, is through geographic expansion and contiguous locations with existing partners. We find, you know, good partners who can grow in a market and then they are able to expand in other areas. That is more of an organic type expansion versus the M&A.
I'll start with the investment for both. The capital outlay is very similar. One, when we expand contiguously, we have the systems and the people that understand how to, you know, grow the business effectively, but we don't have the volume. When we partner with a new pin, we have the volume, but we don't have the systems. These businesses, you know, normally would trade on a multiple of residents if they don't have, you know, an EBITDA to multiply. Over a period of two, three, four years, we're able to get them up on our platform, implement the systems, and achieve operating margins that are similar to others throughout the system. I'll say it's a very attractive return on the capital deployed in the initial investment.
I mean, just for example, in our report, Guardian was $60 million in revenue, purchased for $15 million. If it were to get to company margins, that's like a three times multiple over four years. So the returns are very, very attractive. One more for me, again, dangerous when I do math on the fly, but if we just looked at Q4 run rate times four, you know, that's above your mid-point of your 2025 guide is $99 million of EBITDA. You take Q4 run rate, it's above that. How much in the Q4 should investors think about that would come out on a more normalized basis due to some of the things you're talking about with vaccines and other seasonal factors?
We talked about in the release, there's incremental $2 million of flu and COVID revenue on top of the business, you know, performing strongly. And then, you know, with the flu COVID being unprofitable in Q4 2023, flipping to profitability. There is a pretty big flip there that's not, you can't bake in to, you know, the run rate for 2025.
Now, we had heard like some of the manufacturers were offering some pretty good buy-side incentives for COVID. Did you guys see that in your purchasing?
We did.
Was that part of the deal? Like one in particular? Okay. All right. We made it till 9:20 here. Excuse me, 10:20. Head to the breakout, everybody. Thank you.
Thanks, everybody.