All right. Thank you. Good afternoon, everyone. I'm Jamie Perse, the Healthcare Provider Analyst at Goldman Sachs. We've got our next panel, Option Care. We've got the on my far left, Mike Shapiro, CFO, and John Rademacher, President and CEO. Thank you guys for joining.
Pleasure being here. Thank you.
One quick note before we get started. This will be a release to some, others will be disappointed, due to Goldman Sachs' advisory role with the company, we won't be discussing Amedisys or the transaction today. We can focus just on Option Care and your strong 1Q results is where I want to start. Maybe just high level, I mean, what's the message coming off 1Q? I've got a bunch of follow-up, don't need to be exhaustive here, what's the message from 1Q?
I'll start, and Mike can certainly put some additional color on. First and foremost, just a really strong quarter, as the organization continued to execute. We knew we had some inflationary challenges, and the team really rallied around the opportunities that we had before us to think about productivity and efficiency as an organization, and continue to execute on our plans, which are to make certain that we are expanding reach and frequency in the marketplace. We're capitalizing on the position that we have in the infrastructure from a pharmacy network standpoint, and really being a partner of choice, across, you know, the stakeholders that we operate with. All in all, very pleased with the progress that the team made.
Still opportunities for us as we're looking moving forward. Really solid performance and again, really good execution.
Yeah, the only thing I'd add is I'd really agree with everything John said. I'd really describe the first quarter as really balanced growth and execution across the portfolio. As you know, we have two very distinct portfolios of therapies: the acute therapies, which are admittedly a slower growth category of therapies, typically aiding in the discharge of individuals from a hospital setting, and our faster-growing chronic portfolio. We really had solid performance across both of those portfolios. Even in the first quarter, where we went into the year knowing we still had some year-over-year inflationary pressures, the team really took that as a rally cry to offset, and we were thrilled to be able to expand margins despite some of those year-over-year headwinds.
Well, let's start with the top line. You guided 5%-11% back in February. 1Q results were the top end of the range, 11% growth, and it's your most difficult comp of the year by, like, 500 basis points. You know, really strong start to the year. I want to start with the acute piece, the smaller piece. You've historically said this is a low single-digit grower. You grew mid-single digits in the first quarter. I wanna, you know, tease that apart a little bit. You know, what drove acute specifically in the first quarter? Just in terms of the overall volume environment, the things that drive the business, you know, downstream, what are you seeing?
Yeah, on the acute side, there's a little bit of a nuance with that, and we do expect the back half, or as you know, Jamie, we don't give quarterly guidance. We would expect the acute growth to temper a little bit in the back half. If you recall, middle of 2022, a number of scaled competitors exited a number of markets across the U.S., which presented us an opportunity to really execute to a greater extent on the acute side. Again, those are typically the therapies where you need the local presence to be a partner of choice with the hospital teams. So, we really saw an uptick in the middle of 2022, given some of those competitive closures, which really allowed us to seize the opportunity.
In the back half of this year, obviously, the comps become a little bit more difficult, but nonetheless, I mean, we're thrilled with how well we've executed across the country. It's stepping in and being that hospital discharge partner of choice.
What about on the utilization side, just, you know, procedures and things that tend to drive acute more broadly? Are you seeing changes in utilization or, you know, recovery? It was generally a strong quarter for.
Yeah, I think if you take a look at some of the hospital discharge information, you saw some building strength through the quarter, as things started to get a little bit more normal around that. Certainly an earlier flu season that was being dealt with. You know, as we built through the quarter, you saw hospital admissions and discharges kind of build through that, and we're well positioned, as I said, with that focus around reach and frequency and the relationships that we've developed at that local level, the opportunity to participate where that demand signal was in the marketplace, our team executed very well.
On the competitive dynamics, the market exits, are you able to quantify at all just how much that might have incrementally contributed to acute growth?
Yeah, I mean, I think we, you know, we've characterized the acute portfolio of therapies. These are more mature, established therapies, like intravenous antibiotics, parenteral and enteral nutrition. These are therapies that have been established and are widely used, you know, with the transition of care out of the hospital. You know, these are more mature categories that we've characterized. The overall markets are growing in the 1%-3% range. You know, we've always tried to strive to outperform the market, but I think just given some of those dynamics, I think that's really the difference between, you know, that lower growth profile and the mid-single digits that we've delivered over the last three quarters.
One question I often get asked, and would love your perspective on it, why are folks exiting this market? I mean, it seems like a good market. You guys have a great margin profile in this business. Why do you see, you know, people leaving the market?
I'll speak from our perspective. You know, when we went through both the spin-out from Walgreens, but then more importantly, the integration with BioScrip, we saw a really unique opportunity to have a best-in-class pharmacy infrastructure. We made investments into the people, process, technology, and facilities that are required to effectively and efficiently be able to compound, dispense, and distribute those products. It's not easy, and it's local, and it requires a, you know, a discipline within an organization in order to execute on that. Given the investments that we've made, you know, our team continues to excel to operate with a level of excellence within that area. Other, you know, competitors just haven't prioritized it the way we did within the opportunity as we saw it.
As Mike said, it's just. You need to be local. The responsiveness to be able to meet with the discharge planners, to be able to take a patient at 4:00 P.M. on Friday, to have that smooth transition, and then all of the infrastructure that's required to get the right dose to the right place at the right time, it's just what we do, and it's core to our operating platform. As I said, I think we're very well positioned to continue to have a leading position in that as we look forward.
If the market's growing in this 1%-3% range, and you just spoke about the, you know, the infrastructure you've built to be really competitive in this market, you know, maybe others aren't as well positioned and exit the market, or, you know, just speculating here, but do you think you can grow above the market? I guess, the question is: Why is the low single-digit guide the right guide in the context of, you know, it seems like you guys are positioned to take share?
I mean, I think the way we approach the market, Jamie, is, like, overall, with these more mature therapies, it's really, as John mentioned, a local market. You know, at the high level, we fight for every referral every day in every market. You know, if we do that, if we try to be the partner of choice at Mount Sinai in New York, and Baptist in Little Rock, and Northwestern in Chicago, you know, we're gonna do quite well.
As John said, it's a challenging onboarding cycle, a challenging commercial interaction, because, again, a lot of times, I always like to use the baseball analogy of it's a lot of diving catches, and it's not easy, and I think we're pretty good at it, and I think if we can execute at the local level, 'cause John's absolutely right, it absolutely is that hospitalist and that case manager that's making the decision. If we do that consistently, I have no doubt we'll outperform the market. Again, from a margin perspective, this is an attractive portfolio for us because even though it takes a lot of assets and investment in technology to be responsive, it's a favorable margin profile.
I mean, these therapies typically are in the 50%-70% gross margin range, given the fact that, you know, most of the drug components are generics.
Okay, two more on the acute side of the business. You laid out some headwinds to start the year in your guidance, some prescription patterns with hydroxyprogesterone and then pricing pressure in the anti-infectives. Did those play out in the first quarter like you expected? Again, I'm just trying to tease out, you know, the strength in 1Q, if there's anything that was. If that piece was, you know.
Yeah, just to clarify, when we went into the year, we called out that there's about 200 basis points of headwind from a couple of chronic therapies that were exiting the market. One was hydroxyprogesterone, which is for high-risk pregnancies, as well as Radicava, which was an infused therapy for ALS, that had an oral indication approved. Both of those really started to affect us later in the first quarter, so we still benefited from some of that revenue. On the antibiotic side, we did also call out that we saw collectively ASPs representing about 1 point of headwind. you know, that did start to feather in in the first quarter, but that'll become more pronounced throughout the year.
Okay. last one on this. Are you generally seeing momentum continue? I know you won't say too much about the quarter, but just in terms of the environment, the drivers, are they generally intact at this point?
Again, we're in the middle of the quarter, so we won't necessarily speak of that. You know, as we exited the first quarter, certainly we felt really good about the position that we had and continue to execute around that as we move forward with our execution plans and the depth of the relationships that we're building in those local markets.
Okay. Let's go to the chronic side, the 70% of the business or so. It's been a really nice growth story over the past, you know, 3 or 4 years. It seems like it's growing about mid-teens now. It's, you know, acute grew mid-single digits. Here, too, I mean, what are you seeing generally? What's driving the growth in the first quarter?
As we position ourselves, and working both upstream with biopharma around, you know, helping them move product into the marketplace and thinking of it as the channel and the platform that we have, as well as the deepening of the relationships that we have with specialists, in the marketplace, we have a dedicated, selling, part of our organization that is calling on those physician practices, those clinics, those, specialists, to really, broaden the portfolio of products that we're able to bring, to make certain that we have programs that meet their needs. Then we work upstream with biopharma to execute the clinical protocols or put programs in place to support their patients and the disease states and the needs of those patient cohorts.
You know, from an execution standpoint, again, reach and frequency is a big part of the strategy of building that out and making certain our team is in the right place, understanding where, based on market data, where to best position people in the marketplace and the right call points. We utilize technology in order to manage our teams and align them for their territorial alignment and their call points through that process. I think all that continues to set us up to be able to execute. You know, payers continue to focus around site of care initiatives, thinking about how do they look to reduce the total cost of care while maintaining quality and member satisfaction.
When we look at what we bring to that, it's a lower cost setting, it's high-quality care, it's in a place in which patients want to receive it, whether it's in one of our infusion suites or in their home. We have really strong patient satisfaction scores. We continue to capitalize on not only the infrastructure we're building in the infusion suite, but our ability to have the right clinical resources in order to continue to grow and expand and meet the needs of the marketplace. Really pleased from that standpoint, around the way that we've positioned and the way that we continue to innovate with our teams, to be that partner of choice for those referral sources.
Are there any specific categories of therapies that are driving a disproportionate, you know, piece of dollar growth? Has that changed at all over the last, you know, 2 to 3 years? You know, the growth drivers under the hood of chronic, you know, changing at all.
Yeah, the fascinating thing is, I think this might be one of the misconceptions of the chronic portfolio, that everything's growing double digits. The fascinating thing is, you know, John and I have been here over 7 years. The portfolio of therapies that we're infusing on the chronic side today is completely different than the therapies that we were infusing 5, 6, 7 years ago. Interestingly, we see some therapies get introduced, like Radicava, which was introduced 5 years ago, which is a phenomenal therapy that was introduced for ALS patients, which then effectively exited the infused market as it received the oral indication. As we look at the portfolio right now, it's actually quite balanced. Now, that's not to say that there aren't some therapies that are in decline. A perfect example is hemophilia factor.
It was one of the biggest therapy categories when John and I joined. It's really gone more of the specialty pharmacy model. We've seen some therapies in decline, but overall, the growth has been quite balanced across a broad array of gastro and neurotherapies, chronic inflammatories, immune globulins, the portfolio of muscular dystrophy infused therapies that we collaborate on with Sarepta. You know, we just introduced or we just announced a couple of weeks ago that we have a new partnership with Krystal for a new innovative therapy that actually is a topical indication that we can talk about. As John said, I mean, the team is constantly looking for those new therapies, and so we feel really good that, you know...
The word we like to use a lot internally is balance, balanced growth across the portfolio.
I'll come back to Krystal in a minute. Just on the, you know, when you look out over the next one to two years, you've got some of these products that are in decline, some new drugs coming to market. How does it look relative to, you know, the last couple of years, just in terms of the cadence of new products and new growth drivers taking over as some of these others decline?
You know, there's always introduction of new products. Certainly, biosimilars get into that equation. As Mike said, our focus is around that balance in the portfolio. You know, with IVIG and what we've seen there, is a lot of, you know, products have kind of been introduced as a category, still big, but there's different, you know, products that kind of fit within that portfolio. You're seeing a lot within the chronic inflammatory disease. Certainly it was Remicade years ago, and now there are new biologics, and biosims that are entering into the marketplace. Our relationship upstream with biopharma to, again, be a channel partner and help to bring those products into the marketplace, we think we're very well positioned there.
We focus around the limited distribution drugs, and the opportunity to use the platform to its fullest through that perspective. We look at the pipeline, you know, upstream on what's coming through the FDA pipeline of new products. There's a lot of infused products that are moving down that path towards approval. A lot of work in conjunction to make certain that we are well-positioned to utilize the platform to its fullest, to deepen partnerships where, and relationships where we can, and to really tap into the clinical expertise that the organization can provide. It's a constant move.
As Mike said, we have, you know, some products that are accelerating, some that are in decline, but that ability to deepen those relationships, not only with the referral sources, but upstream with biopharma is important. The other aspect is to make certain that we maintain our market access, right. Our independence, the ability that we have to work with all of the, you know, top ten of the, of the payers, we have over 800 payer relationships, over 1,400 contracts. Having that broad spectrum of market access being an easy, you know, provider to work with because of the range and the depth of those relationships and how broad it is across all of the payers, just makes it easier for us to do business with.
That helps us be a preferred provider for those referral sources that are looking to move their patients on to service.
I mean, it sounds like you feel like you're well-positioned for new therapies coming to market. What about on the headwind side? Are there drugs in the portfolio that, you know, are exposed to lots of exclusivity and, you know, might have, you know?
Sure.
competitive dynamics over the next couple years? What does the headwind side of that equation look like?
Yeah, look, I mean, John and I are always like the kid, we get paid to be paranoid. You know, we have a team that's constantly partnering with biopharma and with payers and prescribers to think about what are those next generation of therapies. There's new therapies that are coming out, whether it's a new administration, whether it's subcutaneous or oral, or topical. There's biosimilars that are coming out. There's disruptive therapies that, you know, could disrupt some of the kind of the more historical therapies. That's where we're constantly looking, not only around how do we make sure we've got the broadest portfolio and thinking through what are some of those evolutions, and making sure that we can still play a role, but it's also...
Part of the fun is, Jamie, we're able to challenge ourselves with the platform that we've built to think about how to better utilize the infrastructure that we've established. A couple perfect examples. A couple years ago, we would never have thought about injectables, but now for a new category that requires healthcare professional oversight, whether it's Cabenuva for HIV or SKYRIZI for patient onboarding, because of our more efficient administration site infrastructure with our infusion suites, which provides a much more efficient clinical care model, those are the kind of things where we can also challenge ourselves, not only around the current portfolio of therapies, but also, are there other therapies that we can bring into the mix?
Okay. Let's talk about just the partnership with Krystal for a minute. This is not an infused drug.
Sure.
You're leveraging your pharmacy infrastructure. What is the strategy, and, you know, is this something new for you guys, or is it starting to open up a new opportunity for non-infused drugs and to use the pharmacy infrastructure?
Yeah
in a different way?
Again, the platform that we have, we'll look for ways to utilize the clinical resources that we have to the fullest. We love the acuity level that we operate with and the ability to focus around having our team work at the closest to the highest level of their licensure. This is a product that just had all of the dynamics and characteristics that really work within our infrastructure well. Be able to compound, dispense, and distribute the product, get it to the right place, whether it's in one of our infusion suites or into the home. It's a gene therapy. It requires special handling within the pharmacy when you're compounding for a patient-specific unit dose to be able to do that.
The clinical wrapper that we can put around it with our nursing, or as we announced, also in partnership with the Amedisys Nursing Network, to be able to do this, it just allows us to use the clinical resources, not only in the practice of pharmacy, but also in the practice of nursing to their fullest. It requires a healthcare professional to oversee. It is a pretty sophisticated, you know, product from that standpoint. Gene therapy, small cohort of patients, there's about 3,000 patients in the United States that are afflicted with this disease.
The ability to work with Krystal, to partner with them around the clinical protocols, and then utilize the infrastructure that we have to meet a unique need that they have with their channel partner, couldn't be more thrilled about that. You know, I think to the broader part of your question, you know, we'll always look for those opportunities. If it's an oral solid that's just being dispensed in a normal fashion and doesn't require a high level of oversight by clinical resources, there's probably better paths for that product to follow.
If it requires, you know, manipulation in an aseptic clean room, if it requires healthcare professional oversight, if it requires very tight supply lines and networks to be able to get the product from the pharmacy to the home in a very efficient and effective manner, there are a lot of things that we can do with that infrastructure to expand the portfolio, but really to capitalize, I think, on the unique position that we have in the markets that we serve.
Last one on this, and then we'll go to margins. The long-term guidance here is high single digits. That's what kind of gets you to this 5%-7% that you've guided to for the company long term. I guess, first, what do you think the market is growing? You know, given all the things that you've talked about and the track record over the last couple years, it seems like you're taking share. So is the market growing slower than that? You know, you're embedding share gains in your long-range plan, or how should we think about that?
First and foremost, our goal as an organization is always to take share. As we work with our go-to-market plans, our commercial team, we have a lot within the platform. We spend, you know, a lot of time making certain that we're training and we're developing our teams, and we're putting them in the right position to win. We think we have a compelling value proposition on that standpoint. From my chair, always my expectations are that we're going to be taking share, that we're utilizing the position that we have to capitalize on the relationships that we're building. As we continue to move forward, you know, that forward view remains that, you know, the opportunities are with there. We do see, as we've characterized, you know, the acute products are gonna be growing at a slower rate.
They're mature in their life cycle. Many of them have high utility, but not an explosive amount of growth within that. Part of the chronic is, you know, there are going to be some years in which it's going to, you know, with new introductions and new products, move at a higher rate. There's other ones that it's going to move at a lower rate. Our position all along is to make certain that we are looking at the totality of the, of the portfolio. We're looking at the depth of the relationships at the call points. We're looking at the opportunity to work more deeply with payers around programs that they're looking to reduce the total cost of care.
All of those things kind of fit in towards that longer view of if the market's growing in, let's call it the 5 to 7, our expectations are that we'd be above that. Our expectations are that we can sweat the assets and really think about leverage growth by utilizing the platform to its fullest and continue to look for ways to drive productivity, efficiency, and effectiveness of the infrastructure and the workforce that we have the honor of being a part of.
Well, you keep mentioning payers and I haven't asked about this yet. I'll save my margin questions for one more after this. What are you seeing from the payer community in terms of new models, and how do you participate in and shape those and be part of... I mean, you keep mentioning the shift to total cost of care. Well, how does Option Care fit into that?
Well, when you look at, again, the focus around high-quality care at an appropriate cost in a setting in which patients want to receive, we pretty much check all those boxes when you're looking from that perspective. The conversations that we have with the payer partners on that is always looking for ways to leverage the infrastructure to where they can help to support patients receiving care in this lower-cost setting. We do a lot of work to demonstrate not only that we can do it in a very cost-effective way, that we focus around patient satisfaction, their member satisfaction, that we're hitting on all of the quality metrics that we put forward, that we're doing everything we can to have the broadest access to be able to bring their members on to service with us.
All those things kind of fit within that. When you're looking at the totality of the total cost of care, you know, we're a small piece in the infusion event alone, but it's a lower cost within our settings, whether in the infusion suite or in the home. We're looking for ways to wrap around those patients on a broader basis. How do we start thinking differently around not only the clinical protocols that we can execute, but especially for the chronic patients, how do we follow them more on a longitudinal basis that help manage them more effectively through that process? In conversations from that end, continue to think about our position and the influence that we can have on the way that care is delivered.
We also look at our role as being an extension of the four walls of the, of the physician practice, right? We are administering their plan of treatment. We're helping to drive that forward. We've done a lot to put in place data capture and then sharing that back to help them improve the way that they're executing their plans of treatment and developing more comprehensive care plans.
Okay, that's helpful. Let's talk about the inflationary pressures that you saw last year, those anniversaried in the first quarter. Where are we now in terms of just the inflationary pressures that you're seeing?
Yeah, look, mid last year, in the middle of 2022, we saw an interesting emergence of just a number of inflationary pressures, a lot of them related to crude oil, whether it was transportation, medical, plastics. Obviously, we saw some inflationary pressures around some of the clinical labor categories. Obviously, crude oil and gas prices affect what we pay our nurses from a reimbursement perspective. You know, I think for the most part, the cost categories, they're not improving, but they've more or less stabilized. We've kind of saw that in the tail end of last year. You know, the team has taken that as a rally cry, and I think one of the things that we were excited about and was demonstrated in the first quarter results is our ability to offset those cost pressures.
You know, as John likes to talk about, you know, we've deployed a lot of technology in our revenue cycle area, where, you know, four or five years ago, every single claim was touched by a human. Now, that's about 80%. We've automated about 20% of our revenue cycle, that obviously drives a level of efficiency. That's just one category. We've been looking at, you know, delivery optimization, medical supplies rationalization, looking at our pump platforms and how to drive more efficiency across that. It's just embedded in the culture that look, costs are going to do what they're going to do, but it's our role to drive efficiencies and offset. You know, we like to say we fight for every basis point.
You know, the other area where we've invested, which has paid considerably, in terms of labor efficiency, is the expansion of our infusion suite, and infrastructure. You know, we're going to open more than 20 this year. That just allows us both from a growth strategy perspective because we can utilize our nurses more efficiently, which gives us confidence to take on new patients, but it also lowers that cost of service considerably.
Just to clarify, when you say the inflation pressures are not getting better, but they've stabilized, I mean, the baseline has reset since we've anniversaried.
Yeah.
Has the growth rate come down, you know, relative to what it was in one Q, now in two Q? I mean,
Yeah, I mean, it's a little hard, given how dynamic the business is with changing volumes and therapy mixes and geographic shifts. The way I would answer the question, Jamie, is I'd say we're back to what is more of a normal inflationary environment.
Of course, we're always going to give merit increases. Of course, you know, transportation companies and medical supply manufacturers aren't calling us to give us rate cuts, but the increases or the adjustments are more commensurate with what we're used to in the past. I'd say, you know, we're probably facing that, you know, low single-digit cost inflationary environment that we were used to prior to the shocks of 2022.
Okay. You mentioned in a moment ago, you've moved in clinic up to 26% of your infusions. When you look at the capacity coming online, the capacity that you already have that's untapped today, where do you think that can go over the next 1 to 2 years? You know, any help on how to think about the margin difference in clinic versus in-home, the savings you get from, you know, windshield time and things like that?
I think our normal answer on that is above 26, right? It's gonna go north of 26. We don't force patients into the infusion suite, right? We offer it up. The way that we've looked at where we place those infusion suites, we take a look at gravity maps. We understand where our patients', you know, demand is. We want to be within a short driving distance of where they live or work in order to capture that. We offer it as part of the way that we bring them on board and move that forward. Part of it's gonna be a little bit dependent around kind of the mix of the business and how that flows.
There's a concerted effort by the organization and by our team to offer that and to make certain it's as convenient as possible. We're always gonna be able to deliver care in the home for the medically fragile and those that really require it there. As we continue to build out the portfolio, especially in the areas of chronic, a lot of these patients are out doing activities of daily living. They're ambulatory, they're going to work. What we hear loud and clear from them is those that use the infusion suites honestly give us really high scores from a patient satisfaction. They can schedule the visit on their way to or way to work or going back home. They can schedule during a break, if required.
There's a convenience factor of being able to use the infusion suites. We'll capitalize on that as we move forward. Again, depending on what new products move through the pipeline, get approved and start to move those forward, we just think there will be a significant opportunity to continue to expand and to utilize the capacity of those facilities. Today, we're not utilizing them at full capacity. Even in the best markets that we have, we still have opportunities to expand hours of operations or expand, you know, the utilization to continue to capitalize on that capacity and to meet the needs of the market at this point in time.
Mike, any comments on the margin profile difference between?
Yeah, I mean, it really depends. And not to give you a non-answer, but, you know, part of the way we think about it is, it's just a platform for more efficient administration. Whereas we may have had to send an infusion nurse across town so that he could do a blood draw or a dressing change, just utilizing that platform for more efficient administration, it's almost hard to put a finger on it. You know, the way we think about it, we've said that, you know, in the more recent tranches of infusion centers that we've opened over the last 2 to 3 years, we're seeing north of a 10% labor productivity uplift. If you assume that we're, you know, on average, a nurse is spending 2 hours with a patient for...
Again, there are some that last 30 minutes or some that last 6 hours. On average, if a nurse is spending about 2 hours on a patient infusion, and we're driving a 10%-20% productivity factor, you can kind of get within a hand grenade range of what that's worth, too.
Okay. Running out of time here, last quick one. EBITDA margin's 9.2%. I mean, you're basically at all-time highs. Can you get to double-digit margins sustainably with this business? How to think about the-
I wouldn't rule it out. Again, we've always said, look, we could be a double-digit EBITDA margin today, but it's about balancing growth in some of the lower margin profile chronic therapies. Look, we fight for every basis point, and I definitely wouldn't bet against it.
All right. We'll end there. Great place to end. Thank you, guys.
Thanks, Jamie.
Thanks, everyone.