Thank you for standing by, and welcome to the Option Care Health Q1 2022 Earnings Conference Call. At this time, all participants are in listen-only mode. After the speakers' presentations, there'll be a question-and-answer session. To ask a question at that time, please press star then one on your touch-tone telephone. As a reminder, today's conference call is being recorded. I will now turn the call over to your host, Mr. Mike Shapiro. Sir, you may begin.
Good morning. Before we begin, please note that today's discussion will include certain forward-looking statements that reflect our current assumptions and expectations, including those related to our future financial performance and industry and market conditions. These forward-looking statements are subject to risks and uncertainties that could cause actual results to differ materially from our expectations. We encourage you to review the information in today's press release as well as our Form 10-K filed with the SEC regarding the specific risks and uncertainties. We do not undertake any duty to update any forward-looking statements except as required by law. During the call, we will use non-GAAP financial measures when talking about the company's performance and financial condition. You can find additional information on these non-GAAP measures in this morning's press release posted on the investor relations portion of the website.
With that, I'll turn the call over to John Rademacher, Chief Executive Officer. Thanks, Mike, and good morning, everyone. Overall, after initial sluggishness due to the widespread impacts of Omicron variant on our team members, customers and patients, the first quarter proved to be a very productive start to the year for the Option Care Health team. We continue to invest in our future growth strategy while navigating a challenging economic environment to ensure we provide unsurpassed patient care. As Mike will review in a few minutes, our first quarter financial results were very strong, and I am pleased by our performance across the spectrum of financial and operational metrics we use to manage the enterprise.
Specific to the Q1 of this year, note that the prior year comparable period was quite soft as we were just starting to see COVID-19 vaccine distribution in the second half of the Q1 2021. We also benefited this year from a few one-time expense benefits that helped drive leverage in the P&L that we do not believe are likely to repeat. While reported growth is very strong in the Q1 , as we anticipated, we believe the comps will balance out in the back half and we anticipate our growth profile normalizing to a greater extent. Nonetheless, based on our momentum coming out of the Q1 , we are raising our financial guidance for the year accordingly, as Mike will discuss shortly. As we entered the year, we were in the midst of the COVID-19 resurgence related to the Omicron variant.
This had a very disruptive impact on our referral patterns and local pharmacy operations. Given the resilience of our teams in the field, we were able to quickly respond after the Omicron cases subsided, and we saw a return to normal operations by the end of the first quarter. While acute referral volumes continued to lag in certain geographies, we did see a gradual reopening in many of our referral sources. Our chronic revenue was especially strong in the quarter and was driven by our portfolio of chronic inflammatory therapies and newer therapies for multiple sclerosis, myasthenia gravis, muscular dystrophy and others. We also saw a few points of growth from therapies that were in short supply last year, but are now available, including therapies for thyroid eye disease.
As we discussed on our prior earnings call, we also entered the year with unprecedented inflationary pressures across the broad spectrum of goods and services we utilize. While the collective inflationary pressures was somewhat muted in the Q1 , we do see an increased impact in the balance of the year. We continue to thoroughly assess our labor competitiveness, and we adjust compensation primarily at the end of the first quarter as part of our annual cycle, so the compensation increases are not fully reflected until after Q1. We are also seeing broad cost increases in key procurement categories including transportation, medical plastics and key supplies, business services and others. As always, the team is focused on finding new sources of efficiency to mitigate the inflationary pressures to the greatest extent possible while ensuring the highest level of quality and patient care.
The labor situation remains challenging, but we continue to recruit our team members every day, and we are making investments to remain competitive both from a compensation and career development perspective. I believe we will continue to weather the storm reasonably well while maintaining focus on fielding the best clinical team in the industry. Aside from the dynamics in the Q1 , we continue to invest in future growth initiatives. The team is making good progress on integrating the Wasatch Infusion acquisition, which we believe provides a tremendous platform in the growing AIS market while also adding a unique patient infusion experience to our portfolio from which we can learn a great deal.
We recently also closed on our acquisition of Specialty Pharmacy Nursing Network, or SPNN, and we are excited about the national alternate site nursing platform we are establishing with our two recent acquisitions of Infinity Infusion Nursing and SPNN. We continue to believe this clinical platform will not only differentiate our nursing capabilities in the marketplace, but will also help enable future growth, especially among our chronic therapies. Regarding the SPNN acquisition, this is a unique team that has created a very robust clinical model to serve a broad array of customers, including infusion pharmacies, specialty pharmacies, clinics, and biopharmaceutical manufacturers. The Option Care Health team had a pre-existing and very constructive collaboration with SPNN, and it was a natural progression for us to seek a stronger integration of our capabilities.
We believe their model is distinct and highly complementary to the capabilities of our Infinity organization, and we are just beginning to write the script on our unique national clinical platform, taking the best of both. Reflecting back over the past 12 months, the team has executed on four strategic and economic acquisitions that have built upon the foundation we've established. Funded solely through free cash flow generation, these transactions have added commercial capabilities to our chronic strategy, helped establish a national infusion nursing platform, and expanded our infusion suite capability, and we're just getting started. With our capital structure and strong cash flow, we continue to focus intensely on attractive acquisitions to further accelerate our growth. With our technology foundation and clinical expertise, I'm confident in our ability to find attractive opportunities that will help further expand our presence in the ambulatory setting and post-acute space.
To wrap up my comments, while it is still early in the year, I'm quite encouraged by the momentum coming out of the first quarter, and the team is on track to deliver a very solid year. Despite a number of variables and risks that we continue to manage, we expect to perpetuate our track record of strong growth and accelerating cash flow in 2022. With that, I'll turn the call over to Mike to review the results in a bit more detail. Mike?
Thanks, John. Before jumping into the specific results for the quarter, I wanted to provide a few high-level perspectives as there are a number of dynamics in the Q1 . First, recall that we do not provide quarterly guidance, and the Q1 typically is a bit softer than subsequent quarters, given modest seasonality in the business. Additionally, as John mentioned, the prior year first quarter was especially soft due to the continued pandemic impact with flat acute revenue growth and low double-digit chronic revenue growth in that quarter. The softer prior year comp amplifies our year-over-year reported growth to an extent. We believe those considerations are key as we review the growth profile in the Q1 . Revenue growth of 20.6% was the result of solid performance across the portfolio.
The impact of our recently completed acquisitions, namely Infinity, Wasatch, and BioCure, none of which were in our prior year numbers, represented approximately 250 basis points of revenue growth. Acute revenue was up in the mid-single digits as we saw referral trends rebound throughout the Q1 , and again, due to easier comps to last year. Chronic revenue growth of mid-twenties was driven by a few factors. First, better supply chain dynamics enabled accelerated growth for certain therapies that were plagued by challenging supply chains and product shortages in the prior year, especially thyroid eye disease and immune globulin therapies. As John mentioned, we also saw very strong execution across our chronic inflammatory portfolio, as well as from our newer chronic therapies.
Gross margin dollars grew similarly at 21.4%, and gross margin rate was flat year-over-year as our continued focus on operational leverage offset the mix headwinds related to our faster-growing chronic portfolio. As we've consistently articulated, we fight for every basis point, but we do see gross margin rate pressure going forward given our revenue mix, as well as the ongoing labor and supply chain inflationary pressures. Spending was well controlled in the first quarter as we continued to aggressively manage SG&A in light of emerging inflationary pressures. Spending grew 11.6% and dropped as a percent of revenue to 14.6%. As John mentioned, we recognized approximately $5 million in one-time credits related to a variety of items, including reserve adjustments and vendor credits.
This obviously benefited the first quarter, and I do not expect those to persist into the Q2 . Adjusted EBITDA of $77.8 million represented 8.5% of revenue and grew 49% over the prior year, driven by factors previously discussed. Shifting to the capital structure, we generated $32.7 million in cash flow from operations and cash balances increased over $145 million at quarter end. Our net debt to leverage ratio declined to 3.0x, less than half our leverage profile at the time of the merger with BioScrip less than three years ago. Additionally, I want to address some recent questions regarding our exposure to rising interest rates. Recall that last fall, we opportunistically refinanced and extended our entire capital structure under very favorable terms.
As of the end of the Q1 , we had approximately $1.1 billion of total debt outstanding, $500 million consisting of fixed rate senior unsecured notes at 4 3/8% and $600 million in term loans with a floating rate of 275 basis points over LIBOR. As outlined in our most recent Form 10-K, in conjunction with the refinancing, we entered into $300 million in interest rate caps on the term loans. Effectively, $800 million of our $1.1 billion is fixed, or approximately 70%. As a result, our exposure to elevated interest rates is relatively muted. We feel really good where we're sitting from a capital structure perspective, as well as our access to capital to continue investing in the enterprise.
Finally, based on a number of factors, including our Q1 results, the momentum of the business, our views on impending inflationary pressures, as well as the impact of the SPNN acquisition, we are increasing our expectations for the full year. For the year, we now expect to generate revenue of $3.75 billion-$3.9 billion. We have increased our adjusted EBITDA expectations to $300 million-$335 million. While we do not provide quarterly expectations, given the tougher comps throughout the year, one-time spending benefits realized in the first quarter, combined with an increase in inflationary pressures, we would anticipate the quarterly trend to be relatively flatter as compared to previous years. As John mentioned, we continue to anticipate delivering a very strong year in terms of growth and cash flow generation.
With that, we'll open the call for Q&A. Operator?
Thank you. Again, ladies and gentlemen, if you'd like to ask a question, please press star then one on your touchtone telephone. Again, if you'd like to ask a question, please press star then one. Our first question comes from Matt Larew of William Blair. Your line is open.
Hi, good morning. Congrats on another impressive quarter here. Just on the growth in the quarter, I understand this is somewhat challenging, but curious if you could try to perhaps break out what was from easy comps or a return supply chain side versus just underlying growth. I guess specifically, I'm interested in do you feel like you're gaining even further traction with some of the payers you've signed agreements with in recent years? Do you sense that you're grabbing even more market share of some of these newer therapies that are launched, again, where companies are looking to de-risk launches by looking for a reliable scaled resource like yourself?
Hey, good morning, Matt. I'll start, and John can obviously provide some color. Yeah, we tried to unpack it a little bit. Obviously, we're thrilled with the 20% growth headline. Again, I would say a couple points of that were due to therapies that frankly weren't available or had compromised supply chains and led to referral sources being reluctant to put new patients on service. About 250 basis points were from the three acquisitions that were closed, going into the first quarter. Again, SPNN wasn't included since we closed on that. Again, as you know, there's a lot of moving pieces. But if you back those out, it would imply, you know, mid-teens growth. Frankly, I think a couple of factors, obviously, as we mentioned, things definitely improved throughout the Q1 .
I think you hit on a couple of the themes, which is number one. I think just our dependable presence allowed us to maintain and build upon our referral source relationships. Entering into the quarter, we had extended and renewed all of our major payer contracts. I can assure you that the team is laser focused on growing and fostering deeper relationships with our portfolio payers.
Okay. You mentioned SPNN, so I'm curious now with SPNN and Infinity under the Option Care hood, maybe just refresh us on how you envision incorporating those businesses in terms of both servicing Option Care volume as well as the broader market, and if perhaps anything has changed with that thought process over the last six-plus months as you've been stitching them together.
Hey, Matt, it's John. Yeah, look, really excited to close on SPNN and to start the process. As you would expect, it's early days and you know, we're really gonna spend time working both with the Infinity and SPNN team to make certain that we maximize you know, that platform as we move forward. A couple things, we had mentioned before, but bears repeating is, look, we think that their their similarities of the platform are fantastic. It's complementary in nature. There are some unique things that both of those organizations bring, and we're gonna capitalize on that as we move forward.
When we did the work behind, the SPNN acquisition, there wasn't a lot of overlap of the resources, so it really extends our access to, you know, a very critical clinical capability in the nursing community. S o to expand that network and the size of that network, we thought was, a competitive advantage as we're moving forward. To your broader question, look, we're gonna continue to use this platform to not only support our growth and think about how we're going to continue to have the resources necessary and the capacity to continue to grow, as we both take share and make share in the marketplace. We're also gonna continue to support, the external market on that.
We like the fact that we can use this platform as an aggregator in the marketplace. It gives us an opportunity for us to really capitalize on market demand, to be able to bring those resources forward. This is a unique, differentiated national platform that really allows us to continue to extend our leadership position.
Okay. Thank you.
Thanks, Matt.
Thank you. Our next question comes from Lisa Gill of JP Morgan. Your line is open.
Hi. Thanks very much, and good morning. Mike, I just wanted to go back to your comment around rate pressure. Was that specific to your comment on the faster-growing chronic portfolio, or is it something that relates to the renewal of the payer contracts that you talked about? Maybe if you could just talk a little bit about what you're seeing on the reimbursement side.
Sure, Lisa. Actually, the reimbursement environment has been I'd characterize as relatively stable. Again, as we entered into those collaborative relationships, especially with the national folks, they understand the value-based components of how we arrange and establish our relationships. Really, the rate pressure on gross margin that I was referring to is really around the mix shift of our revenue. Going forward, we've been pretty open that we see that acute portfolio growing in the low single digits. Obviously, the chronic portfolio, which bears a considerably lower gross margin profile, we expect to grow in the double digits. Over time, in the Q1 , we were around 72% chronic, around 28% acute.
Over time, as we shift more towards that chronic portfolio, that will have considerable gross margin rate pressure, although we view the chronic gross margin dollar growth opportunity as very favorable.
My second question would really just be around the referral trends that you saw in the first quarter. Obviously, you guys came out really well. When we think about COVID-19 having a strong impact overall in January, kind of waning as we went into February and March. Was that the same that you saw in your business, that there was some amount of impact with Omicron in January and it got better, or were you still seeing referrals throughout the early parts of the virus in January?
Yeah, Lisa, it's John Rademacher. Look, as the quarter progressed, certainly the referral patterns got stronger. T here is a constant rhythm to the business and the referral patterns that we saw, but they were constrained. Look, I think everyone was dealing in early January through probably mid-February, challenges not only with their own staff and the infection rates of the Omicron variant, but it did disrupt from that path. G iven the national scale that we have, the markets kinda act independently on that. We saw probably a bigger impact in the coast in the December timeframe, and then it started to wane by the time we got to the end of January, and some of the Midwest lagged behind that.
It got stronger and stronger and certainly we saw, as I said in my prepared remarks, by the time we got to the end of March, things had gotten back to, you know, near normal or whatever the new normal is from our perspective, both in impact on our own staffing and some of the challenges from a labor standpoint with folks being infected, as well as the referral patterns starting to come back, as we exited the quarter.
Great. That's very helpful. Thank you.
You're welcome. Thanks, Lisa.
Thank you. Our next question comes from David MacDonald of Truist. Your line is open.
Hey, good morning, guys.
Hey, Dave.
Couple questions. First, just a clarification. Mike, did you say that acute was, excuse me, and I realize that the comps were, you know, what they were, but that acute was up mid-single-digit % in the first quarter? Is that correct?
Yeah, that's right, Dave.
I assume it's fair to say that, you know, January was probably, either flattish, modestly up or modestly down. You know, again, if I look at, some of the referral disconnect that you guys were having early in the quarter, it suggests, really strong numbers in the last two months, or at least in March. I guess my question is, are you guys holding on to more volume in both businesses that may have used a different site of care pre-COVID? What are you doing on the sales side to, potentially make those referrals more sticky and keep them being driven towards a different site of care?
Yeah, Dave, I think the way you characterized the progression throughout Q1 is right. I think as John mentioned, clearly January was pretty sluggish out of the gate, just given the Omicron wave, and I think we definitely saw, you know, a rebound throughout the quarter. Again, we have a relentless focus on the acute referral sources, but again, that's a lower growth proposition. In the first quarter, again, partially due to the easier comps last year, that definitely helped us post the mid-single-digit growth, which we're thrilled with. Again, I think throughout the year, as acute rebounded last year, the comps will become a little tougher, but nonetheless, very pleased with the acute portfolio in the quarter.
Yeah. David, to your question around, the stickiness of the referrals and the patient base. Look, we've spent a lot of time as an organization focusing around the quality of the care that we deliver, certainly with our commercial resources around the reach and frequency and the reliability that we've been able to demonstrate. With those referral sources over the last two-plus years throughout that process. Our focus as an organization has always been around the patient experience and that patient satisfaction.
To the previous questions that we've received, and I think kind of to your question, we haven't seen a lot of movement back for patients that are on long-term care with us that are those chronic patients reverting back to those other sites. Now, we understand competitive dynamics, and we don't take any of that for granted. We wanna make certain that we're driving patient loyalty by the services that we're providing and the care that we're delivering. As of this time, you know, the retention rates of the patients seems to be solid and something that is a stable base from which we're building from.
Okay. Just one other question, guys. You mentioned you know ongoing investment a couple of times in the prepared remarks. I was wondering if you could give you know a couple of what you view as the key areas of investment over the next 12-18 months. I'm curious as you guys were renewing with your major payers just any conversation during those contractual updates around you know the Ambulatory Infusion Suites site of care redirection just you know anything incrementally you can add there.
Yeah, Dave. A s we've talked about previously, you know, we're continuing down the path of building out a comprehensive network of infusion suites. In the conversations that we're having kind of across the spectrum with the payer community, there is a high level of interest there. Knowing that, the ability to have high quality care at an appropriate cost in a setting in which patients wanna receive it, we're on the right side of that conversation, both in the home, but also in the infusion suite.
You know, as we're looking at, areas of investment, as we move ahead, you know, we have committed to continue to expand that out and to build out a comprehensive network in order to serve the needs of our patients and partner closely around site of care initiatives and other aspects from that standpoint. You know, the other aspect, as we said, is look, not gonna necessarily unveil our strategic playbook, but we're looking for other areas to augment what we're doing.
We know that we have a privileged position of being able to provide care in the home or in one of our infusion suites, and we're always looking for the opportunities to expand service lines or to look for additional ways to increase the value that we're delivering to our patients, to our referral sources, to the payer community, and really upstream to biopharma as well. You know, we're gonna continue to take a look, and as we've always committed, we'll be disciplined, but it's gonna be both strategic and economic in any moves that we make.
We really, feel fortunate about the position we're in from a capital structure, and we think that the opportunity is before us to continue to look for ways to enhance the role we play in ambulatory settings and post-acute care.
Okay. Thanks very much, guys.
Yeah. Thanks, Dave.
Thank you. Our next question comes from Brooks O'Neil of Lake Street Capital Markets. Your line is open.
Good morning. I just have one question. I'm hoping you could just talk a little bit about labor pressures, labor shortages, particularly as it relates to nursing availability and pharmacists, and whether you're seeing, having difficulty, filling roles or whether you're in pretty good shape in those two key areas?
Hey, Brooks. Yeah, look, we're not immune to the pressures, in the marketplace, but I would tell you that our sense is that we're faring pretty well through that standpoint. T o your specific question, part of the reasons for the acquisitions, you know, within Infinity and SPNN was to expand our nursing network. At this point in time, we really have not run into capacity constraints, or had to turn away patients, on that. The other thing is, look, we've increased our clinical team size, just naturally through Q1 based on, our recruiting and moving that forward.
On a positive basis, we've seen our time- to- fill moving downward, and we continue to be able to attract talent to the organization as opportunities arrive with open positions. From the clinical standpoint, the area I think that has got the biggest constraint is really around nursing, and we feel that our model has that flexibility of our full-time nurses, our part-time nurses, and then access to per diem and this network allows us to continue to meet market demand and continue to grow as we're looking forward.
Hey, Brooks O'Neil, this is Mike Shapiro. I'd add just to put a little more granularity around it. Look, you know, we have over 7,000 associates across the country. That's over $500 million of labor costs. As John Rademacher mentioned, just to remind and reiterate that, we take most of our merit and adjustment actions at the end of the first quarter. I would characterize, like most organizations, our adjustments are a couple points higher than they have been in previous years. That labor-related inflationary action, which again, as John Rademacher always says, you know, we need to focus on recruiting our team every single day, that's gonna start to impact us more in the second quarter.
Okay. Just to clarify, I appreciate all that color, no big problem finding pharmacists either?
No. I mean, for the most part. Look, I mean, there's market nuances as you would expect, from that standpoint. In general, our ability to recruit, and onboard teams, team members has been strong.
Great. Thank you.
You're welcome. Thanks, Brooks O'Neil.
Thank you. Our next question comes from Pito Chickering of Deutsche Bank. Your line is open.
Hi there. This is Kieran Ryan on for Pito Chickering. Thanks for taking my question. So if I add back the $5 million in credits that you called out in 1Q, it looks like EBITDA margin came in around 7.9% adjusted for that. Then taking the midpoints of revenue guidance, it looks like you see about 8.6% through the rest of the year. Still some good sequential expansion, but that's about 30 basis points below Q2 through Q4 2021.
I was wondering if you could kinda just talk about some of like what the biggest swing factor is between the low and high end of the guide as it relates to the cost side, through the rest of the year?
Sure, Kieran. It's Mike. I think you're thinking about it right. Look, I mean, we try to provide as much transparency as we can. While we're thrilled with the $77 million that we delivered in the first quarter, again, there was in the first quarter the stars aligned, the signs were going the same way. You know, we always see some one-timers here and there. They typically, net to, nothing to write home about. But in the Q1 , we did have a net of around $5 million of benefits that we just wanted to underscore as folks think about that.
Yeah, if you back that off to kind of a normalized 72, and again, I'll use that in "air quotes" since there's always a lot of puts and takes, the balance of the year would imply high single-digit earnings growth. Frankly, as John mentioned, we're seeing very strong momentum on the commercial side. But the reality is, you know, the best of our you know estimates you know there's $10 million to $12 million a quarter of year-over-year inflationary pressures, which you know collectively $30 million in the back half. That's you know that's quite impactful.
We do see that, with the labor adjustments emerging, you know, the impact of crude oil derivatives on everything from medical plastics to mileage reimbursement for our clinical teams in the field, that really ramped up in the Q1 . To simplify, really what we see going forward is continued commercial momentum offset by what are, unprecedented inflationary pressures. Yet we're still, laser focused on expanding, you know, the EBITDA margin to the extent possible.
Got it. Thank you. That's helpful. Just one quick follow-up. I know we've, you know, we've asked you guys this before, but I think this is now the fourth straight quarter of gross margin expansion despite the outsized growth in chronic. I know you guys are fighting for every dollar there, like you said, but just wanted to make sure that none of those dynamics have changed. I know you called out you expect the gross margin pressure to continue or to return through the rest of the year.
Just wanted to make sure, was there anything specific in 1Q that allowed for another quarter of expansion there, or just still kinda just holding the line effectively? Thank you.
Sure, Kieran. Yeah, as I mentioned in my prepared remarks, you know, gross margin was within 10 basis points of where it was last year, so, relatively flat year-over-year. Part of the tailwind in the Q1 was that nice year-over-year growth on the acute portfolio, which again is considerably higher gross margin profile. That year-over-year growth definitely helped us on a year-over-year gross margin rate. T he reality is, and again, you've heard us talk about it several times, we're relentlessly focused on every basis point on growing those gross margin dollars. But again, with that seismic shift towards the chronic portfolio, nothing's changed around our conviction that over time we will face some rate pressure.
Thank you.
Thanks, Kieran.
Thank you. Our next question comes from Joanna Gajuk of Bank of America. Your line is open.
Yes, good morning. Thank you so much for taking the questions here. A couple follow-ups. When you were referring to, I guess, your guidance for the year, you made a statement about, you know, expect quarterly trends to be flat versus prior. Can you clarify that? Are you referring to margins or something else? How should we think about that? Because I guess you just kinda talk about the inflationary pressures picking up in the rest of the year. I wasn't quite sure what you were talking about when you said flat versus prior years.
Sure. Yeah, Joanna. T ypically, when we've articulated the seasonality in previous years, there was a more pronounced step from Q4 down to Q1 and then , a considerable improvement throughout the year. I think with some of the dynamics, what I was trying to articulate is with some of the benefits and the easy comps last year relative to, as John articulated, increasingly tougher comps throughout the year, we would expect as we reflect on our outlook for this year that it would be a relatively flatter year from a revenue successive revenue performance and EBITDA contribution. A little bit of a
Okay.
A flatter year, relative to what we've seen in the past around seasonality.
Okay. No, that makes sense, especially after you kinda talk about those inflationary pressures you said $10 million to $15 million, I don't know, I guess per quarter. Just wanna clarify that. Another clarification, the SPNN acquisition, right, it was closed in April, so I assume it wasn't in Q1 obviously. For the year, I guess, is it adding maybe $3 million or so to EBITDA?
Yeah, that's about maybe a little bit lighter than that. You know, we disclosed that obviously the purchase price was $60 million. We paid, you know, mid-teens, so think of it as a, $4 million to $5 million contribution on an annualized basis. With the transition and, you know, we'll realize around three-quarters of that. Around three, maybe a nudge less than that, but that's within a ballpark.
I guess also, when you were talking about these inflationary pressures, the $10 million to 12 million, it sounds like that was labor, but then you also talk about, you know, these other supply or cost of supply, plastic, also transportation, some other services. So are they included in this number? If not, I guess, you know, are they also meaningful, or I guess it's compared to the labor pressure, it's a number that you're not willing to quantify.
Yeah. When I use the ballpark range of 10%-12%, that would include our, higher than typical inflationary pressures on labor as well as, all of the, whether it's medical supplies, transportation, et cetera. So that 10%-12% is a rough-
Okay.
Estimation of the collective inflationary pressures.
Okay. That's helpful. Thank you. I guess also the last clarification. When you talk about, acquisitions, and obviously you have a lot of free cash flow there, and, so balance sheet situation. You mentioned something post-acute care. So can you expand on that? I mean, is there something you're looking at kinda outside of the core infusion? 'Cause I guess last time we talked, it sounded like you're still kind of more focused on infusion, but I don't know whether there's anything else you're kinda considering outside of the core, home infusion.
Sure, Joanna. Look, I mean, as we reflect where we are, at the onset of the merger, obviously one of the commitments John and I made was to rapidly de-lever and improve the capital structure. A s both of us mentioned, where we're sitting today, we feel very good that, you know, we're at 3.0x net leverage, and we have considerable access to capital. That obviously doesn't lower the bar in terms of how we're thinking about strategic and economic investments. I think, look, as John mentioned, what we've really established is a differentiated national clinical platform now with the, you know, one of the largest clinical teams in the field with the largest independent pharmacy footprint to really support the post-acute space.
I think as we, reflect on the transactions that we've executed on, you know, we've built a national per diem nursing network that's second to none. With Wasatch, we've expanded our patient experience in the infusion suite setting, which is going to, you know, provide learnings for years to come for the broader organization. I think, where we're trying to orient folks is with that differentiated national clinical platform. I think it gives us a broader array of opportunities how to be a relevant partner to our payer and referral partners, or providers in the field, not just maybe around the infusion in the home, but, in the broader post-acute space.
Okay, great. I guess one last one on cash flow. I guess you still have the NOLs, but when do you expect to start paying cash taxes?
We do not expect to have a meaningful cash tax obligation this year. I mean, we'll revisit going into 2023, but for this year we're quite confident that that won't be a meaningful outflow for us.
Okay, great. Thank you so much for answering the questions.
Thanks, Joanna.
Thank you. Our next question comes from Jamie Perse of Goldman Sachs. Your line is open.
Hey, good morning, guys. Two quick questions from me. Mike, you talked about aggressively managing SG&A, just given the environment.
Mm-hmm.
Can you talk about where you're finding sustainable or incremental opportunities to do that?
Sure. I mean, look, obviously entering the year, you know, there is some discretion around when, not if, we make certain investments for future growth. E ntering the year, frankly, the balance is , maintaining the current operations as well as, finding the funding for future investments. Frankly, entering the year, we were a little more thou ghtful on the pacing of some of those more discretionary categories.
To your point, though, Jamie, I think, we continue to push the team and, you know, around finding ways to become more efficient, whether it's through technology to, utilize more automation, on the patient registration and onboarding and support processes around our billing and collecting efforts. Like every other enterprise, we're looking at our bricks and mortar investment and looking at do we need all of the , the administrative facilities and capabilities that we need. Look, I mean, through the technology, we continue to find, value on the margin around how to become more efficient and that doesn't let up and that doesn't ever stop.
I think that's as we've articulated the value of this business and that gives John and I the confidence that going forward, despite inflationary pressures, we're still highly confident we'll grow spending considerably slower than the gross margin dollars.
Okay. I wanna follow up on the first part of your answer there, some of the investments that drive growth. Is that to say that at you know some point when maybe the macro environment is more stable, you can reinvest in some of those opportunities and accelerate growth? Am I thinking about that right? Or just wanted to follow up on that comment.
Hey, Jamie, it's John. So a couple things. One is Mike said, look, we have been investing in the technology infrastructure and so, you know, we're utilizing, some of the advanced tools around robotic process automation. We're looking at machine learning and other aspects to really drive efficiency in the way that we're operating. To that, look, we continue to take a look at not only the structure and design, but the reach and frequency of our commercial team and our commercial resources, as well as thinking about different ways to partner up and down the value chain, from biopharma manufacturers to the patients themselves and looking for those opportunities for efficiency.
Any of the things that we're doing on the SG&A side, just to be clear, we're not doing anything at this point in time that's constraining our ability to grow. Where we are prioritizing our investments is on areas of productivity, efficiency, and expanding our reach into the marketplace. We understand the unique position that we're in, and we wanna capitalize on that. We're also disciplined. I mean, there are things where you know, we can be thoughtful around the way that we're adding overhead staff as opposed to production staff. There's ways that we can take a look at the needs of the business and reorient around it in a more efficient way.
I don't want you walking away thinking that we're holding back on making investments or spending dollars to continue to capitalize on the privileged position that we hold, in the unique position as the only national provider of infusion services.
Okay, understood. My last question is just around your approach to guidance. It's a dynamic macro environment. Modeling these days is as hard as ever. How do some of these macro dynamics just impact your approach to guidance? Are you know, just incorporating more room for unknowns and things like that into guidance this year? Just any color on your approach would be helpful.
Sure, Jamie. Look, I mean, obviously you know, John and I would tend to be more conservative in how we approach our thoughts externally. We operate in a very robust forecasting mindset where, you know, every single quarter we're looking at, you know, dozens of distinct therapies with their own growth and supply chain dynamics. No two metropolitan areas are created equally or operate equally. W e model out several variables at a therapy level, on a geography level, as well as on a cost component level.
You can imagine we model out a significant number of scenarios and, what we're obviously focused on doing is, you know, handicapping those and providing you all with thoughts that represents, a conservative view, but yet also, to your point, acknowledges the fact that there are considerable, you know, variability in a very dynamic environment that we're operating in right now, which, that's part of the lure of this industry and what we love about it, but it also, is something that we take to heart as we articulate.
Obviously, we recognize our credibility is contingent on us doing what we say we're gonna do and so we're very, very thoughtful on how we model out a variety of the variables we're facing.
All right. Thanks for all the color.
Thanks, Jamie.
Thank you. I'm showing no further questions at this time. Let's return the call back over to John Rademacher for any closing remarks.
Yeah. Thanks, Valerie. Thanks for joining us today. As we discussed, we had a very strong Q1, and we are looking forward to continuing with the momentum as we move through the year. I hope you have a wonderful day, and please stay safe. Thanks, everyone.
Thank you. Ladies and gentlemen, this does conclude today's conference. Thank you all for participating. You may now disconnect. Have a great day.