All right, thank you. Good afternoon. I'm Jamie Perse, the healthcare provider analyst here at Goldman Sachs. We're gonna get started with our next session. We have Option Care Health, and, from the company, we've got John Rademacher, President and CEO, and Mike Shapiro, CFO. I think, John, you were gonna make a few opening comments?
Yeah. Thanks, Jamie. Thank you for everyone for joining us today. Yeah, just wanted to reaffirm, you know, some of the commentary that we've been making really since the first quarter earnings call, and that is, really proud of the response that the team had given some of the circumstances around the Change Healthcare issue. Team responded extremely well. We had a very strong quarter that, you know, I think just shows the resilience of the enterprise, the diversity of our portfolio, and the ability for us to respond to situations that are happening around us and making the most of it. You know, as we sit here today, you know, continuing to make progress on the Change Healthcare, you know, cleanup that exists there.
We had talked about some of the challenges that were in the first quarter and our expectations that we'll be moving towards, you know, clearing things up on the Change Healthcare side by the end of the year, and certainly making some progress on some of the procurement disruptions, and we're on plan for both of those. We continue to make really good progress, to really drive the results of the organization. And as we sit here today, just feel really good about where we are in the platform and stability that it provides, and more importantly, the progress that the team has been making, in achieving our goals that we had provided for the full year.
Okay, great. Well, what I wanted to start with was just the market backdrop. It feels like it's been a really strong market over the last couple of years. You guys have, you know, certainly done well in the last three years in terms of top-line growth. So starting with the overall market, how would you frame the drivers of growth? And maybe in particular, I know there's a lot of infusions still done in upstream, in hospitals and physicians offices. To what extent is there migration into the home and into alternate sites like you guys are building capacity for, that's driving the business?
Yeah, the backdrop remains strong for some of the characteristics that you've talked about. So, first and foremost, you know, we are a home-centered business, so that ability to provide care in the home is highly sought after, especially for those patients that are immunocompromised or have some form of medical complexity. They're ambulatory constrained. That ability to reach into the home and with the network of nursing as well as the pharmacy infrastructure we have continues to be a very high value on that, and especially in some of those acute therapies. You know, being local, having national scale, but that local responsiveness is something that we've worked hard to put in position, but I think positions us well as we're moving ahead.
You also see a continued move in the chronic conditions and the products and therapies that support that, whether it's moving out of a hospital outpatient department into one of our infusion centers or ultimately into the home or out of physician practices. Again, being able to offer high-quality care at an appropriate cost in the setting in which the patients wanna receive, we think positions us extremely well, and that backdrop will continue to be there. We also see the opportunity as, you know, the focus around medical loss ratio and continued pressures for payers in that scenario that are focused around that total cost of care and thinking about holistically how to drive value to their members, but really manage the cost on a total cost of care.
We're well positioned to support those needs for the payer community as they're kind of realigning and refocusing around those key areas.
Now, how much has the broader utilization tailwinds that, you know, many of us have been talking about and, you know, companies at the conference here, been helping the broader business? I imagine that shows up more on the acute side, but generally, there seems to be a normalization in healthcare activity, patients going back to the doctor or, you know, whatever it might be. How much do you think that's been a tailwind to the business over the last, you know, 1-2 years?
You know, I think exiting COVID, certainly there were some disruptive moves happening there. You know, first, at the first blush, there was that need to get patients out of the hospital and kinda free up facilities in order to take COVID patients on. And so we saw kind of a broader acceptance of transitioning patients to the home and seeing that they weren't returning, right? That we could manage them effectively, I think, continued that process. You then saw kind of that next tranche of patients that were going to community settings, but maybe immunocompromised or, you know, physically challenged, and the ability for them to be, again, managed effectively in the home. You saw kind of a broader acceptance of home and alternate site infusion capabilities as is moving down that path.
So I think as you kinda fast-forward to today, there's probably a broader acceptance of home and infusion suite capabilities. I think that with some of the constraints that exist, both from a cost structure, but also in some of the nursing capabilities and capacity, that ability to help move those patients into these settings that are efficient and effective, I think, is a positive aspect. We as a team focus really on two things. One is there's still an opportunity to take share. When you look at the way that the industry is organized, there's over 800 home infusion providers that are kinda registered with the Home Infusion Association that are providing those services. Our expectations is with that national footprint, but with that local reach, our ability to take share remains there.
And it's competitive, and you gotta hustle, but, you know, I think as an organization, we feel really well-positioned to continue with reach and frequency to capture that market demand. On top of that, we focus also on making share, and that is that introduction of new products entering into the channel and the ability to service those patients. And we highlighted that in the first quarter around some of the novel new drugs that are part of our portfolio with limited distribution products. That again, given the clinical complexities, given the infrastructure we have, given the competencies of our team, we're a really great platform for some of those rare and orphan or those unique products that have that clinical touch that's required to be able to utilize that.
So we think there's opportunity to make share with those new product launches and continue to manage and monitor the product pipeline. But we still think even with the existing portfolio of products that we have, before you have that, an opportunity to take share, given the capability set that we have.
Well, it's a good segue to I want to think about innovation in the market next. And one way I've framed the business in the past, many provider businesses, it's some function of volume and price, simplistically. For you guys, there's this added layer of innovation and new therapies coming to the market that you can augment growth with. So I guess just broadly, where are we in the innovation cycle upstream? I think you guys have talked about in the past, you have very good visibility to what's in clinical trials and what's being developed. And so where are we in the context of the last few years? What does the next few years look like in terms of new therapies coming to market that can support?
Yeah, I think it's a similar setup as we're looking at that pipeline of products, as well as, you know, other impacts on the maturity of our existing formulary and kinda where they are in their life cycle. You know, I think there are a couple of really interesting therapeutic categories that we're keeping a very close eye on. You know, one, I think you and I have talked about, you know, multiple times, and that is around Alzheimer's products. We've been very conservative in our approach, knowing that it was gonna take time for that therapeutic category to kinda develop and for path to payment as well as medical policy to be building that out.
But we think there are some unique opportunities there, especially when you look at our platform and the needs of those therapeutic therapies as we're looking down the path. There's a robust pipeline of infused drugs that are in different order of, you know, phase two, phase three, that are moving through that process as well. So, you know, I think it's as robust as it has been. You know, you can't kinda count your chickens until they're hatched in getting FDA approval through that process, but we feel like it's a strong pipeline.
We think the platform that we've created of having that licensed in all 50 states, access to about 96% of the U.S. population, national consistency in our presence, but very local in our ability to execute, puts us in a really strong position to be a partner of choice and a channel partner as the innovative new products are entering into the marketplace.
Well, maybe let's go to Alzheimer's since you brought it up. I mean, there's been positive news just this week on donanemab. What are you seeing in terms of adoption of Alzheimer's and just the progress that needs to be made over time to build this market?
Yeah, I think with any of these products, right, they start at the academic medical centers, and I think that's where you're seeing, you know, some of the activity right now, especially with the products that are available. You know, I think as additional products come in, and certainly there becomes a level of confidence in the way that the patients respond to the therapy, maybe potentially some relaxing on the monitoring and some of the scanning that's required as part of that. All that starts to set up well for expanding into these other sites, as opposed to just being primarily at academic medical centers. How that develops and grows, again, I think we'll be on the conservative side of seeing how that develops.
But, you know, when you're thinking of products that require, you know, a oversight and distribute the product in a very efficient way... Oversight, in a well-equipped... Like, we've got all... Well, within that is it starts to move from academic medical center to clinic to, you know, home or alternate site infusion, providers within that environment.
You mentioned other categories you're excited about. Anything else that comes to mind in terms of what could be a big opportunity over the next-
Yeah. Y ou know, I think the product portfolio we have has still a lot of runway left within that. But we're also looking at areas in oncology. You know, some of the products that are within that, and especially the adoption of things like the PD-1s, the Keytrudas, Opdivos, Yervoys, they have a lot of the characteristics that we've seen within the chronic inflammatory disease. Again, those patients where they're served, a lot of them are in oncology practices today. But you know, as that kind of expands and as economics starts to within that, again, we think there might be opportunities for broader participation in those type of products as they become a little more mainstream and start to move out from just the clinic setting in which those patients are served.
Maybe just talk about the oncology opportunity a little bit more. I think you guys are— There's a couple big players there that have, you know, high share. I think you guys have, you know, been under-indexed on a relative basis. I mean, what's the strategy in oncology? Is this a new, you know, growth driver for the company over the next few years? How are you thinking about it?
It's aligning certainly resources, you know, to think about that commercial go-to-market on that. It certainly is working upstream with the pharma partners to make certain that, you know, the value of our channel is fairly, you know, represented within that. It is, you know, thinking more holistically around the full suite of products that we have. You know, we do everything from nutrition support and antibiotics, right? That many patients that are struggling with cancer diagnosis have broader needs just beyond oncolytics. More broadly, around the categories that we have and how to think about aligning those in the needs of those prescribers and their patients. So, that opportunity that we have...
Again, I think the clinical competencies that are already embedded in the organization set up well for it. There will be some tension in the system, the things necessary to capitalize on the capacity that we have and the infrastructure that we've built.
Okay. Let's go to the existing portfolio. You've mentioned there's a couple, you know, categories within your existing, you know, portfolio of drugs that have runway. Talk about that a little bit. Where are you seeing, you know, really good traction and continued, you know, driving a disproportionate amount of your growth today and over the next 12 to 18 months or so?
Yeah, I mean, we've called out just the progress that we made in chronic inflammatory disease and some of the products associated with that. That has been, you know, a part of the growth algorithm that we've had over the last few years, and we think there's still opportunities to continue to grow there. IG, you know, as much as people have called that as the... You know, that product is, you know, at the end of its life cycle, it continues to be one that continues to grow. The utility that exists there is broad. And, you know, I think as you look at some of the data from the fractionators, et cetera, they still see a path to growth for the products.
You know, we expect to fully participate in that growth. You know, antibiotics are gonna grow slower. Nutrition support will grow slower than kind of the fleet average, but they're very important products, and especially as that discharge planner, case manager, being able to manage those patients and as they're focusing around bed day management and total cost of care, all those kinda fit well within that. You know, where we're investing our time and investment dollars into our facilities, our people, our process, our technology really makes that full spectrum of products and the clinical competencies that are required to service those patients in a very efficient and effective way position us to continue to grow really across that portfolio.
Part of managing this business over time is you, you've got headwinds, you've got tailwinds, and you've described the collection of drugs that you're serving has changed over the last, you know, 5-10 years. You know, pick a time horizon. I think there's some concern around what the next leg of that looks like. There's, you know, drugs like Stelara coming off patent. There's a range of headwinds, things coming off patent over the next, you know, 5 years. How are you thinking about the risks to growth and some of the specific therapy categories that are, you know, coming off IP protection?
Yeah. You know, biosimilars kind of operate a little bit unique, based on the therapy and, and kinda how the, you know, the market participants kind of enter in and move forward. You know, I think we're always looking at that pipeline. We're always understanding where biosimilars are gonna enter within our portfolio, where we understand where subcutaneous or other forms of administration may have some impact on that. That's why we've focused a lot around that pipeline of new products. I mean, when Mike and I started in the business back in 2015, hemophilia was a big part of home infusion and a significant part of our portfolio at that point in time.
With introduction of products like Hemlibra and others, that's kinda moved in more of a specialty pharmacy direction than a home infusion. Find other products and utilize our infrastructure with those new products that have entered in. So you know, that's just a constant aspect of what we manage as part of the business, is there's gonna be products that go through different forms of their life cycle. And we also know that, you know, as a pharma manufacturer, the easiest form of administration is a little white pill that you take with water.
Yeah.
Right? But some of the molecules that are utilized to treat these disease states just, you know, need to be injected or need to be intravenously administered, or have some complexities from a clinical standpoint that require healthcare professional oversight, even on a sub-Q administration. And so everything we're doing is to align and make certain that we're utilizing our resources efficiently and effectively in support of therapies that have those characteristics, and where we can drive value in managing those patients and managing those disease states.
Jamie, the only, the only thing I'd add on that is, look, over the last five years, and it's amazing, it's been five years since we merged with BioScrip to create Option Care Health in its current form. Over that five years, we've delivered revenue growth on average of more than 12%. And one of the things we preach internally and externally is just the diversification and the balance. I think that's something that's really unique about this platform. When you look at the diversification of our revenue base, which has grown, again, double digits over the last five years, whether it's with payers, whether it's with geographies, whether it's with individual therapies or therapy categories, we've really driven a very balanced and, you know, the ballast isn't skewed towards one area or another.
And, you know, we get the question quite often around, "Well, drug X is going sub-Q, or drug Y is going biosimilar." Nothing evolves in the portfolio that catches our trade relations and our business development teams off guard, and we anticipate each of these. And that's part of the calculus, as John said, as we think about the portfolio today relative to what it was five years ago, relative to what it is five years from now, it will continue to evolve. But as we look at all those macro trends, incorporating biosimilar and subcutaneous events, our conviction in this being a high single-digit growth enterprise, again, maintaining that balance and diversification remains very high.
Okay. And just to be very specific on this point, you don't think we are entering a phase over the next several years where there are greater headwinds that need to be offset, due to either biosimilars, sub-Q?
Yeah, I mean, look-
You know,
This has been the, you know, the tour of duty over the last five years. You know, Remicade, which is a phenomenal treatment, and infliximab, five years ago, it was really the only infused treatment for chronic inflammatory conditions. Today, it's a very diversified base. Over that time, the ASP and the reference prices of Remicade has truncated considerably. We exited, and these are all things we've talked about openly, we exited Radicava and Makena, which both were meaningful therapies for us. Cubicin, which was the most broadly prescribed intravenous antibiotic, went generic and is now known by its generic name, daptomycin. And as John said, hemophilia factor has been de-emphasized and been declining year-over-year. Short-winded answer to a very simple question is, we're not entering a different phase that we haven't...
This is a playing field we've been playing on for years.
Okay, very clear. Thank you. I wanna move competitively. We've got a, you know, new public comp that gives us a little more visibility in what's going on in the market. We've seen some M&A activity by some of the managed care players in the space. Just what are you observing broadly from a competitive standpoint? And you mentioned earlier, smaller players and your aim to take share over time. What are you seeing competitively?
Yeah, it's a competitive marketplace. You know, we know that we've got to bring our best every single day through that. I mean, we're also, you know, clear in... When you look at the portfolio of the products that we have and the way that we have to go and really win market demand and be able to take that on, a lot of our acute patients that we'll have in the fourth quarter, we haven't even met yet. You know, they're shorter duration. So, you know, there is that process that we know it's a very competitive environment, and we have to work through that. You know, do we see the moves of some of the payers getting captive capabilities or expanding capabilities in that? Yeah.
Does that create some form of competitive threat? It does. But we also know that, when we're having our conversations with the payer, the folks that are designing those networks that are so important for their members, they focus on four key things, and we have to make certain that we're driving value across those. First and foremost, we know we have to be cost competitive, and we think we can use our scale and the efficiencies to, you know, be efficient and cost effective for those therapies. The second thing they need is they need access for their members. You can design the most high-performance network, but if your members can't get in to receive the care in those settings, it doesn't really matter.
The third thing is they're focused around quality, making certain that things like hospital readmissions, line infection rates, like, you're doing the things that you promise, and more importantly, you're driving better clinical outcomes. We spend a lot of time collecting the data and sharing that back with the payers to show the value and the performance. The fourth thing they're focused on is member satisfaction, or in our instance, you know, patient satisfaction, because they too need to recruit members through open enrollment and other aspects, and the providers, and the provider network that they have available is part of that decision point around that.
So we do a lot to make certain we are communicating clearly with the payers around the value that we bring across those four dimensions, as well as working with them around things like site of care initiatives and other things that help them reduce that total cost of care. The fact that we're independent, the fact that we have reach to be able to be in all 10 of the top 10 national payers, we have over 800 payer relationships, over 1,400 contracts. That makes us easier to do business with the referral sources, knowing that, you know, the vast amount of times that we can take the patient on the service because we're in-network through that process. So that all fits kind of within that dimension, and again, we expect that those create fishing licenses, right?
For us to be in-network, and then it's a matter of making certain our people are being extremely responsive to the referral sources and extremely responsive to the patients in order to keep them on service, if they're a chronic patient, and to take more of that referrals in capturing the market demand, as we're looking ahead.
Well, it's a good segue. I feel like, the nursing, just clinical resources and being able to be responsive to referral sources is, has been especially critical the last couple years. You guys have done a couple acquisitions on the nursing network front. Can you give us an update on what those acquisitions have done, you know, for in terms of your ability to meet the referral sources and just more broadly, how you think you're differentiated from a kind of access to clinical labor perspective?
Yeah, it's really, glad you asked. It's really transformed our clinical capabilities. Again, over the last couple of years, we've made three acquisitions of infusion nursing enterprises, Specialty Pharmacy Nursing Network, Infinity Infusion Nursing, and Revitalize Nursing. These were contract agencies with whom we had relationships when we wanted to augment some of our own employed nursing team, when we had surge needs in certain markets. So having acquired these three and integrated what were three competing entities into one, per diem nursing platform, has really changed our clinical capabilities. Again, just to level set, we employ approximately 1,000 full-time and part-time nurses on the Option Care Health side. In addition to that, we operate Naven Health, which is the rebranded, integrated, flex nursing enterprise.
That nursing enterprise supports both Option Care Health as well as others in need of infusion nursing capabilities. That allows us to aggregate demand, engage, employ, and retain a broader cohort of infusion nurses. And it's really been a game changer for us because, you know, as we think about growing our patient census and expanding the scope of therapies that we can support, having access to vital clinical labor, which frankly is challenging, to say the least, is critical to executing on our strategy. And Naven has been invaluable. It's growing, it's profitable, and it's, you know, strategically integral to the overall growth strategy.
Okay, that's really helpful. The National Home Infusion Association, of which you guys are a part, one of their top advocacy priorities for their 23-25 strategic plan is around Medicare reimbursement and having fair reimbursement there. It's not been a big part of the industry historically. What's the latest in terms of a legislative fix to improve reimbursement in the Medicare segment of the market?
Yeah, the association, as well as we independently, continue to do the work behind that, getting bipartisan support and trying to move it forward. We have been working. The association has been working with the CBO. Any of these pieces of legislation need to be scored in that process. We've gotten some informal feedback that NHIA has around the initial view is that it was gonna be a cost on that. And so trying to work through around some of the levers that can be pulled to try to get it closer to neutral or a savings, as you would expect. Right now, there's not a lot of legislation moving forward in Washington for obvious reasons.
You know, the expectations are that trying to fine-tune that legislative fix to be more in alignment with the CBO scoring methodology and have that correct, and then try to get this as part of either an omnibus bill at the end of the year or those types of things, is kind of the goal. There is, at least from, you know, what we're hearing, low expectations that anything is really gonna pass between now and the elections in November. So everything that is being aligned is to try to be in a position where those omnibus bill, kinda end-of-year wrap-up, trying to get something in at that point in time. But even with that, setting expectations, if that were to pass, it's not kind of a watershed event. It will be a positive.
We think it's a great stepping stone to broadening access, even farther, but a lot of that is more tied up in the Part B DMEPOS type of benefit that requires pump and the administration. You know, as we're looking at opportunities to think more broadly around how to serve that population, there's kind of steps that go behind that that could expand access even more broadly to replicate what you have in the commercial vein, both in Medicare Advantage as well as with the commercial population.
... Okay, let's go to financials. I'm gonna actually skip top line, 'cause I think we touched on it a little bit, and focus on gross profit dollars-
Mm-hmm.
which I think is a, you know, important way to look at the business. It's grown, I think, 11% CAGR over the last three years, a little bit slower growth in the first quarter. But you've talked about gross profit dollars growing slightly below revenue over time. I think you essentially reiterated the high single-digit revenue growth, you know, here in this conversation. So can you get back to, you know, high single digit-ish type gross profit growth? What's the path? Just any comments on that?
Yeah, I think we can. Again, we've tried to be as transparent and as competitively possible. There were obviously some extenuating circumstances with prior year procurement benefits, some supply chain challenges. As John mentioned, naturally, the Change Healthcare challenges of the first quarter were a little bit of a headwind for us, as well as the fact that, you know, there was a little bit of a divergence between top line and gross margin dollar growth in the first quarter, really because of some of the traction on some of the newer rare, orphan, and limited distribution therapies that, you know, we've launched over the last 12-18 months, which initially carry a lower gross margin rate. These are typically mid-single digit gross margin rate therapies out of the gate. The dollars are attractive.
And again, just as to level set, as you know, Jamie, some of our gross margin rate is out of our control because the denominator is a reference price over which we have little to no control, whether it's the ASP or an AWP of a therapy. And make no mistake, the way that we manage this enterprise is to focus on gross profit dollar growth. And so there will be quarters where the revenue and the gross margin dollars diverge a little bit. There might be times when they converge and have similar growth profiles. But the growth algorithm of this enterprise, make no mistake, is focused on maximizing those gross margin dollars at a growth line. And that's absolutely... We fight for every basis point, but it's really around what's that margin dollar growth.
Okay. And maybe layer on to that just the infusion suite strategy. How much do you think that can contribute to gross margin improvement over time and just your-
Yeah, the suite strategy's been incredible. You know, we've opened over 80 over the last couple of years. Today, we operate a network of 170 infusion suites, over 600 chairs nationally. About 30% of our nursing events are occurring in one of our conveniently located infusion centers. This helps us drive cost of service leverage. For some of our more mature centers, we're seeing 20% or more in nurse productivity, which is great from our perspective, because it helps our margins, but it's also as if we're saving 20% more nurse capacity, which helps, again, fuel the top-line growth by having that confidence to take additional patients. And that'll be part of our growth strategy for years to come.
Okay. We've got about a minute left here. Two quick topics, maybe. First, just you, you've got your guidance out there for the year. Any comments broadly on, you know, how, how, the year's progressed relative to your expectations, the momentum in the business or, or, you know, things that can, you know, move you across the range?
Yeah, look, we take our credibility very seriously, and we're proud of the fact that we've built a track record of delivering on what we've laid out for The Street, so to speak. We typically start out conservatively, and we were encouraged and pleased that in the first quarter we were able to bring up the bottom end of our range, despite a couple of unexpected curveballs in the first quarter.
Okay. Maybe on that point, real quick, the Change cleanup, as you referenced, where are we on that?
Yeah, I mean, the team's made really good progress. As we said at the end of the first quarter, like, our expectation is that cash will be back in line by the end of the year. You know, we're working aggressively to bring that forward. There is some inefficiencies, as you would expect, even as we're going through that cleanup, that will be in the second quarter, and a little bit will straddle into the third quarter. But we feel as if we're in a really good position. The team has done extraordinary work to make certain that it was not a revenue event, that we could take those patients on. And now there's just kind of the cleanup of being able to take cash that we're receiving and applying it and those aspects.
So some continued manual process that's just gonna, you know, take us a little bit longer to get through, given the complexity of the situation with the initial, you know, cyber stopping and utilizing that system. But things are coming back online, and we feel very confident and really good about the progress that's being made.
Okay. You guys have $300 million in operating cash flow.
Mm-hmm.
$30 million-$40 million of CapEx. That leaves a lot of, you know, capital flexibility, clean balance sheet, under 2x levered. What's your priority for use of cash?
Yeah, we're thrilled that... Look, this is a very strong enterprise in terms of cash flow generation, and we've established a multifaceted capital deployment strategy that centers around M&A and share repurchase. We did say that, you know, we reaffirmed our confidence in generating at least $300 million of cash flow from ops, and we did touch pause on capital deployment, as we were in liquidity preservation mode on the outside of the Change challenges. But, as our cash position improves, I think our shareholders should expect to see us re-engage on capital deployment on both of those fronts.
Okay, great. Well, with that, thank you, John and Mike. Appreciate it.
Thank you.
Thank you, everyone.