Yes. All right. Good morning, everybody. Travis Steed, Bank of America medical device analyst. Kicking off the first day here. Glad to have Adam Elsesser from Penumbra, CEO on.
Thanks for having us.
Yeah. Thanks for joining us. Curtis, you wanna just open with any opening remarks or jump straight into Q&A?
Yeah, I think we can go straight into Q&A. We're just a week off of our earnings call.
Right.
I think we've laid out where we feel the business is right now pretty well.
Yeah. Yeah. Sounds good. When you think about the Q1, you know, some of the trends you saw with some of the new launches in January, February, and into April, maybe just to kind of level set us kinda what you're seeing, you know, March, April, you know, versus the earlier part of the year with some of the early momentum that you've had with some of the product launches and overall procedure environment as well.
We'll start with maybe overall procedure. It certainly feels better than last year, where particularly in the second quarter there was a lot of conversation amongst all device companies around staffing and all that. It's obviously not 100%, but we don't hear that. You know, no one is talking about that in the same way. There's a lot more optimism, a lot more positivity, if you will, in the hospital setting. As it relates to the launch of Flash and now Lightning Bolt, it's kind of amazing. It's wonderful. It's the culmination. You know, I shouldn't say culmination.
It's the beginning of the next phase of, 19 years of work, to see the excitement around it, the uptick, you know, bringing in, new customers. You know, being able to treat these patients faster and easier and safer than ever before is, it's kind of fun.
Sure. On, the venous side, procedures grew 30% sequentially, like, how does that look historically? I'm just curious what the step-up was.
Yeah.
Any way to think about historical seasonality, how much of this was really-
Yeah.
coming from the launch.
I think historically most of everyone would agree that the step from fourth quarter to first quarter is not a major step up. It's usually the other way around. Fourth quarter tends to be the best quarter. We called that out because obviously our, you know, customers that were otherwise using Lightning 12 didn't grow 30%. You know, the majority of that came from new customers. The excitement around that, the reorder rates are the same as old customers, as we said. It just, I think is a factual indication of the excitement around this. As everyone knows, launches aren't linear. There's a process. Sometimes you get to try, you know, the hospital gives you permission to buy a couple of products, and if you like them, then you can start the value analysis committee process.
Other times you have to just start that independently, before you can try it. There, there are sort of various methods across all, you know, 1,000+ hospitals that we go into. We're in the early stages of that. What gives us a lot of confidence is the sheer number of physicians and hospitals that are actively involved in that process who really want to use this product. Many of them were able to try it, and then they have to go through the process. Others, you know, there's a little delay there. Others, are able to just, you know, or have to just start the process.
It all comes back to, you know, what we're hearing, what we're seeing, the number of accounts in process that gives us a lot of confidence that this is what people are wanting.
On the reorder rates, are you seeing an acceleration in those reorder rates in April?
You know, I don't have those numbers exactly enhanced, so I don't wanna miscount, but, yeah, the enthusiasm and the business as we continue into this quarter and the next is not going down. It's not staying flat. The business is very strong.
When you think about, like, where you're in the process with the VAC committees, where you are with, you know, opening new accounts, et cetera, like, how do you phrase, like, where you are in this launch? You know, like, if you want to use, like, third inning. I know you're not a baseball guy, I don't think. Just maybe talk about, like, where we are in this launch. You know, how much further it's gonna take to be kind of fully launched, if you will?
For those who know me, using baseball analogy is a little silly 'cause I'm not a big sports fan, but, I think we're in the first inning. I think we have a lot of accounts in this country. We have, a huge number of patients that we know can benefit, that physicians are telling us. You know, we talked about that on the quarter, earnings call where, you know, we put out for the first time in a long time what the possibility was patients we can impact with these products. There's no way we're not in the first inning, toward that opportunity. You know, and maybe it's in the first, you know, part of the first inning. That's the most exciting part.
I've had the opportunity to talk with a number of very, you know, senior physicians in all the subspecialties who have used both Lightning Bolt and Lightning Flash and talk to them more sort of philosophically, like, Can we now see how this ends, if you will? Like, obviously our products will keep iterating. We've been known for that. We'll tweak them, you know, here and there. But within that idea, can we see to where all of these patients that aren't even being treated today, with any kind of mechanical or even interventional means, can they be treated? Can we help them?
Uniformly, these folks are like, the level of enthusiasm and excitement about doing that work to do that and to bring in those patients and help them, is what we've been waiting for. Like, it's what the work has led up to. You know, from my vantage point, you know, having 19 years of this, I personally am so excited about the next five years. I can't wait to be in the middle of bringing this change to this field. It wasn't that long ago, where I was sitting probably in this exact room, in 2016 after we went public, there was a conversation about our vascular business, which was basically a quarter old.
The question was, "Is that a market?" And, you know, for the 800,000 people that we can impact, yeah, it's a market. They wanna, they want relief, and they want their clot taken out, and now we can see how we get there, in the easiest and safest manner.
Yeah, I remember that conversation. You said we would talk about stroke at some point.
I thought that. Here we are.
Here we are. True to your words. maybe just think about like initially, like the initial launch through Q1, what you're seeing in terms of opening the market up, you know, getting into those 800,000 procedures.
Yeah.
Are you seeing like new doctors come in that haven't used mechanical thrombectomy in the past?
Yeah.
Maybe talk about the market development a little bit.
Yeah. It depends on which product we're talking about. With Lightning Bolt, which is our arterial product, the, you know, most... If you're using a mechanical product, there are certainly some other products, but we're the primary one today. Obviously the lot of our conversations now are with people who are doing either catheter-directed lysis or the bigger chunk is people who are doing open surgery. We said on the call that those conversations are really positive and exciting. There's a lot of interest to bring this in and try it. We've had some early success. I mentioned a particular case on the earnings call. That growth, if you will, or that excitement is gonna come primarily from people who aren't doing mechanical 'cause that's the majority of those.
On the venous side with Flash, it's a little bit different. You know, you're really starting with folks who are already believing in mechanical, and we're just sort of getting, you know, the constant innovation and evolution of products. And you know, Flash is. It is leading the way. You know, you can't really stop progress and that's the exciting part of the field. Most of the growth in the short term, you know, in the next Last quarter, this quarter, next couple of quarters, is gonna come from people who are already in. We're not excluding anyone who wants to start to use the product, but by definition, it's primarily gonna be that.
Yeah. Would you think it's fair to characterize like the Lightning Bolt launch a little slower, 'cause it's all 30% sequential growth in the venous side of the business and procedures?
Yeah.
This quarter?
How it ends up, you know, hard to tell, the trajectories are slightly different 'cause you're starting with someone who's not doing an interventional procedure, so it's gonna take a touch longer. Don't expect the same type of numbers, you know, out of the box. It's hard to know, you know, three or four years from now. You know, three or four years from now, there are more venous patients than arterial, by definition, that will still probably be bigger.
Right. What did you assume in the guidance? I know you raised the guidance, you know, f rom $1 billion + to $1.4 billion to $1.56 billion. In terms of that assumption, what are you assuming on those two product launches and-
Yeah.
you know?
We didn't break out by product. you know, and I think it's not probably a smart idea to do that right now. we'll give updates obviously throughout the year as we see those trajectories. you know, directionally, you know, it will be more Flash than arterial.
Okay.
Just, you know, this year.
Right.
Because of the issues we just talked about and the pace of the trajectory.
like, Flash could be like double the size of Bolt by the end of the year?
I. Yeah. I'm not that good at math, so I.
Okay. Fair.
I can't probably answer that.
No, that's fair. Is there a good sense for kind of the breakdown of the arterial versus the venous side of the business now and how to think about which one's bigger?
Yeah. Again, I think it's fair to say that the venous side is bigger, because more people are doing interventional, you know, mechanical device use than on the arterial right now.
Right. Okay. On the VAC committees, follow the same process with Lightning Bolt as Flash?
Yeah. Yeah. There's nothing new about this. You know, 19 years of selling products, you know, the process is the same. You know, some go quick, some don't. You gotta go through all. The reason I mention it is just to in all of our excitement, you know, we still have to do that. You know, there is still a process that we have to take time in, and, you know, it would be awesome if we didn't have to, but, you know, we have to.
I think you said you're moving into some large hospitals. Kind of when you think about that initial launch, were they smaller hospitals that you're just now moving into larger hospitals that take longer or?
I only mentioned that one on the call because I wanted to sort of level-set, you know, that one of the larger systems, we're just getting started-
Right
... which is great, and there's a lot of excitement there. You know, it varies between large and small in the rest of the customers that have already come on board.
Right. That makes sense. Maybe thinking about the market development a little bit more. I know we have bouncing around here a little bit, but the 800,000 patients, on the venous side, like, do you have the technology you need to go after all those patients at this point for future iterations to get there? Kind of the same question on the arterial side of the business as well.
Yeah. That's a great question. The answer is the idea, the technology, the proprietary technology around Computer-Orchestrated Aspiration is the technology that will get us there. That's the most important point. Because we see that, because physicians are now talking about that, we can focus our energies, and I talked about that on the call, around these areas over the next bunch of years. There are gonna be tweaks. There are gonna be additional, you know, things. Somebody asked a question, you know, today, which I thought was an insightful question. We used to call Lightning Bolt. Now we call it Lightning Bolt 7. You know, I think that, you know, it's pretty obvious why we added a number there.
You know, those type of things will come, but none of the things that will come that we think are helpful will be, you know, are sort of new innovations. You know, they're sort of blocking and tackling things that we've done throughout our career as a company. That's pretty exciting. The team's, as I said, really focused on getting there pretty quickly.
Do you need more clinical data, or is it more just like to develop this market?
You know, data's always helpful. It depends on the type of data, you know, there are obviously certain studies like STORM-PE, which we announced, which now that FLASH is here, we'll be enrolling very soon, where we can show, the use of mechanical. Our FLASH device versus anticoagulants. I think that will be helpful in the PE space. I think each other, you know, DVT and arterial are slightly different. I think, you know, we'll add that type whatever data is necessary, I think it's a little bit different than an area like PE.
When you think about You saw the stroke market develop. Like, how would you think about the trajectory of kind of the venous market, arterial market, and when you think about where the stroke market is in relation today?
Yeah. I mean.
So the-
I think that's a great question. I think the biggest difference between the stroke market and these other areas is you don't have to move the patient in a time-sensitive way. That's a huge deal. Some of the procedures are obviously time-sensitive. You know, certain PE cases, certain arterial case, a lot of arterial cases. Not all of them are as time-sensitive. Even if they are, you really aren't moving the patient for the most part, as more and more capability gets built out in the hospitals and desire to treat them interventionally. Without that is the big barrier. I think you're gonna see a different.
Well, we've already seen a different uptick, you know, since 2016 when, you know, we were sort of talking about it. I think that's in large part because the logistics are in our favor.
Right. Maybe more on the, on the vascular side or, sorry, the arterial side. like, what's the awareness like within the physician community? It's like I really just struggle to understand why you would have more of an open procedure or use lytics when now that you've got this new technology.
Yeah. Yeah, I don't see it that way. You know, great physicians have been trying to help these patients for a long time and, you know, vascular surgeons have done great work, you know, by getting out clot, you know, in that manner. They've been doing it for a long time, and it's generally been pretty successful. I don't see it as, you know, that simple, like everyone should stop. They have to hear about it. They have to experience it. I think it's pretty compelling once you do, and that's our experience so far, which has given us confidence.
You know, Obviously, we can't go to every single physician at once, you know, and so it's gonna take some time. All of the reactions and all the positive trends and the reactions are what's giving us this confidence.
Well, that's helpful. I do wanna... If anybody in the audience has questions, feel free to jump in too. Just raise your hand. We can keep this interactive. Maybe on switching to stroke for a bit.
Yeah, yeah.
The Thunderbolt trial. It said, I think you said you'd give an update in the next month or two or quarter two.
Yeah.
Like, is that getting closer?
Yeah.
Getting enrollment?
Let me sort of share. Enrollment, the trial is going well. The enrollment is never as fast as anyone obviously wants. We'll be able to sort of get a better sense of when it will end. None of that should worry anyone. That's a positive thing. The reason is that right now we have this moment in time with RED 43 and SENDit, which goes inside 72, where the ability to track our catheters to the face of the clot is back in fact to what it was back in the days when we had Xtra Flex. Unfortunately, you know, and I don't wanna revisit, you know, those controversies, but there are a lot of people who loved that product, and it really enabled them to treat successfully because the trackability was so good.
Now with SENDit, which is a inner catheter inside, it comes loaded inside 72, we are seeing physicians who had moved away from our aspiration system coming back because it's so trackable. In fact, the comments are like, "Oh my god, this is even more trackable than Xtra Flex," which is a high compliment. Obviously it doesn't have any of the other downsides. We have The team and our sales and marketing team are pretty excited about having time to take share, you know, back and re-penetrate the market so that when Thunderbolt comes, there's no discussion about what catheter? You know, they're already using our catheters, and Thunderbolt just attaches to it.
In some funny way, this actually worked out really well because we have the time to make this about the catheters, and they're performing unbelievably well. We're seeing the share shift back. Again, we don't need it. I mean, from a revenue standpoint, we have a lot of growth ahead in our other business, so we're in pretty good shape right now.
When you think about the share, like I don't know where you think you are in terms of gaining that share back, how much further you can go in terms of, like, how much share you lost. Can you get it all back? Get a portion of it back? How long that takes?
Yeah.
Think through some of the share dynamics in the stroke market.
Yeah. I mean, the market's evolved in stroke. You know, it used to be when we went public, you know, we have some big companies we compete against. Now, there's like six or seven small private companies that all have catheters that, you know, and so on. It's a lot more disjointed than it used to be. It's not one company that we're... You know, it's just the market. Which I think makes it easier, not harder. You know, as we start to take share, you know, it starts to redefine the space. There's a lot of excitement. There's a lot of momentum. The morale on the team is, you know, sort of back to, you know, really good right now because of that. It's fun.
Do you feel like the market's accelerating a little bit as well?
You know, probably. You know, nothing. If you can pretty easily treat the stroke because you can get the catheter there quickly and treat it, you know, you're probably gonna be pretty excited about treating it. That leads to, you know, the effort that is necessary to grow the business. You know, hard to quantify really market growth, you know, across the board versus share right now. You know, it's easier to define share. You know, we're optimistic, you know, but let's wait a few quarters to see.
Right. Makes sense. The Thunderbolt launch, like how would you think about the momentum of that, you know, in terms of comparing it to like the Flash launch, the Bolt launch? Is it a little slower? I mean, stroke's still growing 6% sequentially.
Yeah. Well, Thunderbolt hasn't launched.
Right.
We're just enrolling in the trial.
When it does launch.
Yeah. I think it will be pretty good. Again, the only caution, and it's not a caution about the product or anything, is stroke is the most penetrated and the smallest of the markets we're talking about. The opportunity is still smaller than the other ones. I only say that to remind everyone that's not at all that we're not passionate about the work we're doing and our motivation. What will show up as a driver for us over the next five years, stroke will play, I think, a significant part of that, but it will still be smaller than the other ones.
When you think about the international opportunity, moving some of these products internationally.
Yeah.
I mean, there's obviously China is, a bit bumpy with the VBPs and stuff like that. Maybe just spend some time on getting people comfortable with the launches and growth internationally over this year and the next few years.
Yeah. We've been fortunate to have a pretty strong international business. Jason's answered the question around China before. You know, we're not immune from those issues, but the way the deal is structured and also the fact that most of those products are, you know, prior generations, allows us to have opportunity for growth, you know, in China as well. Where we are now more focused is how to bring these latest generations of product, Flash, Bolt, ultimately Thunderbolt, to the international markets and in what form so that, you know, we're getting proper reimbursement, proper focus, rather than just sort of selling what we can.
That's a great, you know, that's a great place to be where we can sort of step back and do the work, right and not feel rushed, you know, to use international grow because we're gonna have a lot of growth here for a while. I think that puts us in a pretty good spot, not just now, but really over the next five plus years.
Makes sense. I know Maggie's not here, but just to throw in a high-level gross margin question. I'm trying to think of the best way to ask you this question.
Uh-oh.
Maybe one way just to think through, like when you think about innovation, and like how much of a focus is like margins when it comes to innovation and pricing and all that?
Yeah.
When you think about the new product launches, like how much of this margin to 70%-
Yeah.
... gross margin is coming from the launches itself?
Yeah. I was gonna tell a joke and I realized it might not work. You know, I'll say it anyway. We used to obviously not focus on margins. You know, we were all about the pace of innovation, you know, constantly improving the product. We frankly didn't spend a lot of time on it. Obviously with COVID and what, you know, the pressure on margins and our size, the combination of that obviously led to an appropriate need to pay attention to both gross margins, operating margins, and so on. I think what you're seeing is that we're doing that.
I'm pretty proud of that because we challenged, you know, on the operations side coming out of COVID as we were able to get back to sort of more normal, not spread out the lines, not do, you know, have all the safety measures in place to some more normal semblance of a operation that had a sort of different cost structure to it. In addition, this newer group of technologies, computer-orchestrated aspiration, by definition has a slightly more, you know, accretive margin higher. When you add that work together with the product mix coming, I think we're gonna be in pretty good shape. I wish margins, you know, on the gross margin side could change faster. You know, there's things run through over a period of time. It's not immediate.
You know, that's just the nature of running a operation where we make all of our own product and, you know, have all of that plus product launches that come all the time. That's just the nature of where we are. I think we're in really good shape. We have a pretty good visibility to the next year or two, and it puts us in a good shape. On the operating side, you know, I care a lot about, you know, being profitable. You remember when we first went public, I we were profitable. You know, I didn't know you didn't have to be profitable. We certainly know and care about running a profitable business.
We showed that this quarter, obviously, as we are focused on, you know, being focused on our spending, you know, and getting the best benefit. When you go forward, you know, we're pretty built out. I mean, I'm not gonna say we're not gonna hire a lot of people, but, you know, we don't need to hire... You know, we don't need to double our sales force to get where we're going. We have good sales force. They cover the country. We can see some leverage coming, you know, particularly in SG&A, pretty clearly over the next couple of years.
As you start generating cash, how are you thinking about the use of that cash?
That's a good question. Our focus is on driving, you know, the best thing we can do right now, and I'm not saying it costs money, but is to do the work necessary to treat all of the people that can be treated first in this country and then in other countries for clot in their arteries, their veins and their lungs. If we can do that, and stroke, and if we can do that, you know, all of these other issues are taken care of. That is our focus. We don't need to add little things here and there, because that's our focus.
That's helpful. Last 50 seconds here. There were some questions on the MAUDE database. I just wanted to give you the-
Yeah.
... the airtime to, you know.
Yeah. You know, I think everyone knows over the last couple of years, we take complaints and MDRs very seriously. We're obviously quite conservative in the way things are reported. If you go look at those, they obviously, you know, there's nothing about the Flash algorithm or the product really that are relevant to those events. I think everyone knows that. I think it's pretty obvious.
All right. All right. Thanks, Adam.
Thank you.
Thanks for coming.
All right. Thank you. Appreciate it.
With Option Care, the largest home infusion provider in the U.S., today with us is John Rademacher , President and CEO, and also Mike Shapiro , the CFO. Gentlemen, I guess only a few days ago, you made a big announcement, a merger with Amedisys. Maybe first you can, just, you know, very high level, key, you know, main points that we should, you know, keep in mind when it comes to this merger and before we jump into more detailed questions.
Great. Well, thank you, Joanna. Thrilled to be here, excited to talk not only about the progress that we've made as Option Care Health, more importantly, the vision that we have as we see the businesses coming forward. Before we start, certainly want to make certain that everyone understands we may be making some forward-looking statements, based on, you know, our assumptions and expectations moving forward. There's risks inherent with that. We ask and encourage you to go to our investor website to take a look at those risks and understand that, in the safe harbor aspects of that. First and foremost, just wanna hit on how excited we are of the progress that we've made as an organization.
Lost in last week's news was really a strong quarter that the organization delivered. Our team continues to be focused around delivering high quality care, at an appropriate cost in a setting which patients wanna receive that. Really great progress on all of the key initiatives that we have. Such an incredible foundation that we're building from. A lot of really strong momentum. The team continues to be focused around capturing market share from that perspective. Good execution within our procurement area and focus around the cost of goods as we move that.
Also really strong cash velocity as we looked at the way that our revenue cycle management team continues to execute and the concept of having and establishing a perfect claim from the moment we receive the referral. Really strong momentum in the first quarter. Continued solid foundation that we're building from, and I think that builds even more confidence in the announcement that we made and why we're excited about the opportunities that sit ahead of us as we think about combining with Amedisys and creating a very unique platform to serve patients in the home or in an alternate infusion suite.
With this background where you mentioned the strong results, in the home infusion business, so I guess the key question is, you know, why diversify away?
Right.
Why not stay a pure, home infusion kind of, company?
Look, we've worked really hard to establish an incredibly solid foundation to build from, we've been talking for a while around the need to look broader around care as it's being delivered into the home. You know, as we went through a lot of work coming out of the integration work that we did with the BioScrip merger and started to push ourselves forward, we looked at five key trends. As an organization and also, you know, in conversations with my board of directors, looked at five things that really are going to be trends that are going to influence and impact the way that care is delivered moving forward.
First and foremost, scarcity of labor and clinical labor is with us. Organizations that are well-organized to capitalize on that, we think will be well-positioned to continue to grow and succeed in the marketplace. The second area is that payers are really starting to change their view around focusing around total cost of care. Whether you wanna call that value-based reimbursement or other models, we know that the reimbursement model will be changing over time and thinking about what we need to do to provide broader services with that. We believe the home is going to be a important center of care, and that the ability to have additional services and additional capabilities to wrap around the patient is going to be a mission-critical success factor.
We know that aging demographics continue to push more individuals to being Medicare eligible. We know that a vast majority of them are choosing Medicare Advantage as being the platform and the program that they will utilize. The fifth thing is, we know that many of the patients that are on service today that have chronic conditions are polychronic. They have a multitude of needs that they are working through, not just the infusion drug, but they have broad needs, not only for infusion services, but other things that wrap around them.
The ability that we have as an organization and where we think the power of this combination is to really address all five of those areas and being better positioned around a marketplace that's changing, around a need that is developing, and providing additional services while we're in the home in the preferred position that we have.
Right. I guess, you know, thinking about the core of the Amedisys business, the home health, right? The rate cuts that are coming or there is one already happening this year and then potentially more, you know, next year and into 2025. What is the impetus to act on this now ahead of, you know, knowing where these rates will shake out on the Medicare side for home health?
Yeah. We did a lot of research heading into this. You know, one of the things we've heard is, and you'll see it in the proxies as it comes forward, we've been talking with Amedisys since last summer, last fall, and thinking about what this combination will be. This isn't new news. In many instances, folks have been anticipating some of the changes that are in there. As we ran through our analysis, both what we did internally and using experts, that helped to inform us around the process, we think that we have built into the model an appropriate assessment of those types of changes.
We also believe that as we're looking forward, that the marketplace has pretty much factored that in, into the price points and when we looked at the exchange ratio with the Amedisys, you know, transaction. Look, there's certainly a range that's in there. We are conservative by nature in the way that we approach it, and we think that we've been appropriate in, anticipating what, a June and then ultimately a November, you know, announcement will be as we're thinking about that moving ahead.
I guess, you mentioned you've been looking at this asset for some time and kind of sitting where it fits. Just curious, you know, how this came about. Were you looking at different types of, you know, verticals in home care? You know, why did you decide to go with home health hospice platform? Also there's other options as in, like, there's other platforms. Why Amedisys versus, you know, some other platform?
Yeah. We've been doing a lot of work with the strength of the business and with the focus around thinking around how we were going to evolve. We've been talking about opening the aperture for a while. We've been talking about what are there additional services that we can do when we're in the home, and how can we think differently around a model that would be more effective in streamlining the way the care plans are delivered and utilizing critical resources in a more efficient way. We announced a relationship with Amedisys going back to Operation Warp Speed and helping to deal with the public health emergency and thinking about how do we get the monoclonal antibodies into the marketplace.
That partnership or that relationship started at that, at that basis. We continued in conversations, especially with hospital at home and things that were happening in the Contessa space. You know, the orbits continued to circle and we saw a really important opportunity to work more closely and then to create something better, as we looked at the capability sets of both organizations. We're really confident that as we're looking forward, all of the capabilities that exist there today just put us in a better position to meet the needs and the changing needs as we look forward. There's a lot of capability set.
We identified and we called out on the call on Wednesday that the ability to cover a broad spectrum of the care continuum, everything from what we can do with preventative care and focus around those chronics and medication or chronic management through a post-acute event, the hospital at home and SNF at Home capabilities, all the way to palliative, whether it's curative or comfort, to end of life. Having that broad of a spectrum and the ability to cover that much of the care continuum, we think it helps to better position us as a partner of choice for payers. It positions us better to take a look at how to leverage and utilize the clinical capabilities of the broader organization.
I believe it creates a better outcome for patients that move across that continuum across their lifespan.
One thing I'd add, Joanna, specific to your question around why Amedisys within this space, I think as John and I have shared, we've spent an exceptional amount of our time looking at a number of assets, a number of opportunities for us to deploy shareholder capital. As we really dug into the home health space, and we really explored their track record, both around their history of providing high quality results, unparalleled patient satisfaction in this space, and their quality and compliance track record. We found that to be truly, differentiated in this space, and we thought that that was a very complimentary cultural aspect as we looked at building upon the platform that we've established.
In prior questions, you mentioned payer relationships and I guess shifting to different models. I guess before we go there, the other, I guess, headwind for home health, right, is the Medicare Advantage and how this is a negative mix shift as that payer grows and the membership grows much faster than the fee-for-service. With this merger, is one of the, one of the rationale here is that you're gonna try to address it or, you know, as a combined entity, try to influence the MA contract with the on the home health side? Is there maybe some benefits you see also on the infusion side, on the flip side from having those two assets together?
Yes. As we look at it and the conversations that we've had and, until we could announce, they were limited in the format. What we hear from the payer community is this focus around the total cost of care and trying to drive better clinical outcomes at a lower cost and aligning around that. We have in the conversations, and you've seen in some of the announcements that Amedisys has made, is they're starting to make some progress in getting better rates with certain payers that are more of a case rate and episodic as opposed to the fee per visit type of structure. We think that there will be traction there.
I go back to the first trend that I, that I identified, that is access to clinical resources, there's a scarcity value there. I think the better you can align around the aligned needs of the payers, which is they want to get their members into these types of settings and provide high quality care at an appropriate cost, the more we can make certain that we have a position at the table to have those conversations and to make certain that we're paid fair value for the value that we deliver. That's going to be part of it, and I think having both the infusion as well as the home health capabilities and being able to look at how to rationalize the use of the clinical resources.
We know there's waste in the system. There's ways for us to become more efficient and effective in the way that we're addressing the needs of patients in the home. That's a benefit for the patient, that's a benefit for the payer, that's a benefit for us from a capacity standpoint in being able to leverage and utilize the model in new and more efficient ways. I think across all of that, there's an opportunity to really think differently, in delivering care in the home in a much more comprehensive and a much more robust manner.
I guess what gives you confidence that the response from the plans, from the commercial plans will be positive? Obviously the track record for the home health has not been really that great, because even for Amedisys, you mentioned they made some traction on these new contracts, but it obviously has been very elongated process. What gives you confidence that now things, you know, will be different?
We've talked about this in other settings as well. No one's knocking on our door saying they wanna give us more money in the infusion space either. I mean, we fight for every aspect of reimbursement to make certain that we're fairly paid from that standpoint. We believe that there's a compelling value proposition here to drive better outcomes for their members, for their patients. We know that in every conversation that we have at the health plans, and I'd say this is true for home health as well, is, you know, they're focused on making certain that they have appropriate prices, right? Scale is gonna be important to make certain that we can drive operating efficiencies and we can price our products appropriately. The second thing they always look for is access.
They need to make certain that you can have a wonderfully low price product, but if you don't have any access and you don't have the clinicians to be able to take those patients on to service, they're gonna linger in the higher cost settings. You have to make certain that access is part of that. The third thing is quality. As Mike said, we believe with the Amedisys team, they're focused around quality, their star ratings, independent accreditation bodies rank them high in their quality, and that's something that payers really want. We saw the impacts of some of the payers in Medicare Advantage who didn't get the star ratings who suffered some impacts because of that. High star ratings is gonna be very important.
The last thing is around patient satisfaction, member satisfaction, right? They've got to win their members on an annual basis in many of those instances. Our continued focus around those four dimensions and building programs that are in alignment with that, we think is right squarely aligned with the needs of the payers as they move forward. Those conversations can happen. I can tell you know, since the announcement on Wednesday and the news getting into the marketplace, certainly we've had conversations because we now can have more open conversations with some of our key health systems and some of our key payer relationships. I can tell you, they're all excited. They wanna learn more. They want to hear more around what the capabilities will be.
There was positive response from those key, you know, customers that we have in helping to think differently around how to have a smooth transition of care out of the hospital, into the home and how to develop new programs that are aligned with the, with the payer's needs. We're encouraged by that initial feedback and know that there's gonna be a lot of work post-close to continue those conversations moving forward.
I guess talking about payers and previously you mentioned a value-based care, right? The shift, we obviously hearing from pretty much every single payer talking or payer and provider talking about this. On that front, you know, what gives you confidence that you can, you know, do it right and you can coordinate all these different services you're gonna have under one roof? 'Cause obviously we know that at United, Optum is pretty much working on that, but they have a dedicated payer to work with, right? The UnitedHealth plan. I guess, you know, what gives you confidence that you can do it as well as them or maybe better?
I think the independence that we have allow us to have open conversations and strategic conversations with many of the payers in the marketplace. Not all payers are as endowed as United is with its capability set. The ability for us to have those conversations and to start thinking differently and then meeting the needs and building programs that are aligned with the specific plans, we think is an advantage. That independence allows us to do things and innovate with them through the process. You know, that aspect. Look, we have a very productive relationship with United today, even in the infusion space and they have captive capabilities that they have there.
We have very productive relationship with Aetna, and they have, you know, capability sets as well. Our ability to have that independence to continue to innovate, to continue to meet the needs, hear their voice, and respond quickly through that process and the agility that we've been able to demonstrate even in our existing model, we think will be an advantage for us to have those conversations and help to steer the way the market's gonna go. We've had, and I think with many in the room, we've had conversations, it's hard to really define value-based in a clear way, but we know it's evolving. We know total cost of care is something that is front and center, it needs to be dealt with.
Having the ability to think more broadly, not just on the infusion event, but on the total patient care and being a bigger part of that care plan, we think allows us to have a stronger voice in that process and a better position in order to be part of the change that's coming.
Just wrapping it up, because obviously we understand the long-term strategic value and, you know, where you're headed with this combination, but kind of trying to, you know, put numerically some of the, some of the benefits, or, you know, how the model will change after the merger is completed. You know, how should we think about the growth algorithm for this entity, combined entity, you know, longer term?
Yeah, that's a great question. Look, first and foremost, the leadership team on the Option Care Health side has a track record of knowing how to integrate complex organizations in a manner where we can unlock shareholder value while preserving unparalleled patient cares. In the last three and a half years since tackling the BioScrip integration, you know, we've unlocked more than 130% in total shareholder return at a time where we brought together two different organizations with admittedly some challenges, inheriting the BioScrip platform. Looking forward, we get really excited not only with the capabilities on the Option Care Health side, but rolling up our sleeves with the leadership on the Amedisys side to really build a new platform.
From an outlook, as we think about, we talked about, you know, unlocking $75 million in synergies, $50 million of cost side synergies, and $25 million from incremental revenue and programs with payers and referral sources. That would be by year three. That's not the end zone, that's not the finish line. That's an interim expectation. As we draw the line out, we see a compelling financial proposition. We see this combined organization generating top line of high single digits. We see low double-digit adjusted EBITDA earnings going forward, which would imply that, you know, out of the gate, we'll be in the neighborhood of 10% EBITDA margins, and we would expect to modestly accrete. Double-digit earnings growth compounding and expanding the EBITDA margins over time.
You draw the line out, you know, we're three and a half years post-BioScrip. If we were to draw the line out, assuming we close the transaction later this year in 2027, that implies we'll be generating north of $9 billion in revenue. Our profitability from an adjusted EBITDA perspective, we estimate will be between $900 million and $1 billion with a double-digit EBITDA margin. Out of the gate, from a cap structure perspective on a pro forma combined basis, we're 2x leverage. I think one of the other key headlines is the cash generation capabilities. You know, I think by 2025, a couple of years getting into the integration, we would expect to be exceeding half a billion dollars of cash flow from operations.
Given the capital efficiency of this platform, we think the ability to down the road deploy further capital in shareholder-friendly manner is incredibly compelling. We're really excited about building on the track record of integration and delivering growth, and we think that that doesn't change with this combination by any means.
Good to hear that. On the synergies, can you give us a little more details? The $75 million, the 50s, the costs?
Sure.
Can you kind of flesh it out a little bit what this entails and maybe, you know, on the timing of when we should start seeing some benefits of that saving?
We start getting after that day one. Even with the BioScrip, the transaction three and a half years ago, we've never stopped driving, whether we call it acquisition-related synergy or whether we call it doing our jobs and driving cost efficiency in the business. Naturally bringing two public companies together, you would expect things like public company costs, board expenses, public filing, audit, et cetera. We look more broadly across this enterprise. Just the indirect spend pool alone, excluding the cost of the clinicians in providing care, there's $1.3 billion in SG&A. I think most folks know our track record at being relentless around focusing efficiencies while also making sure that we're investing to grow.
I think most folks know where they would place their bets on the over-under on delivering the $50 million of cost synergies. We have a very high degree of confidence in that. I think what's more exciting or equally as exciting is, you know, the momentum that we see from the commercial strategies going forward, which we think complements that. From a cost side, we think we'll start unlocking that in the first year and build on that momentum from thereafter.
I guess the other piece is the 2025 EBITDA from the revenue synergies. Can you give us a sense of the magnitude of these revenue synergies and what it actually entails? Is it the commercial contracting benefits? Is this cross-selling? Kind of more details? Is it more on the infusion side or home health side, or is it equally spread out when it comes to these revenue synergies you would expect?
I'll start and Mike certainly can add to it. Out of the blocks, we'd look at probably four key areas in which we do it. Certainly, making the commercial team more effective to capture demand in the marketplace, to make certain that we are well-positioned there. We've talked before about reach and frequency and taking a look at where our position on that. There are situations today where both organizations may have resources embedded within a facility. We may need two there. We may need one, and we could redeploy to other opportunities in that marketplace. We'll be thoughtful around that commercial execution and looking for those opportunities for cross-sell, upsell through that process.
I'd say both in the opportunities that sit with the infusion side to potentially pull more patients onto infusion services that require that. We'll focus there, but also in helping those discharge planners look for a one-stop shop to be able to discharge a patient that may need home infusion services and home health services and helping to coordinate that in a better way. I'd say the secondary is in the hospital at home and the focus around the Contessa platform and what exists there. A big portion of that cost and the spend there is on infusion products, which is why we've got a partnership with them and had really fostered that.
We'll look to capitalize there, and drive some efficiencies and effectiveness as they're thinking about that program and how to effectively utilize it. That, that builds into SNF at Home, as well as the hospital at home program. The third area is, and I talked about some of the things that are necessary to wrap around the patients, in the chronics to provide a better care coordination to be able to provide additional services while we're in the home and think differently around not just the infusion event, but the space in between those infusion events to drive better clinical outcomes. The last area is. Look, this creates an incredibly strong platform in order for new products to enter the marketplace, so new therapeutical categories.
We've talked, and folks are very familiar with what's going on with some of the Alzheimer's therapies and what may come there. We've been very conservative around our approach that we need to have a clear understanding of the path to payment and how that would be reimbursed through the process. You would have a platform that would allow you to really capitalize on the footprint, the community-based service model, and be a partner of choice if there's a clear path to payment, and that would move forward. This platform just gives us a tremendous opportunity to participate different in the marketplace, if those events were to start to happen.
That's not the only reason, but it's an additive benefit of a stronger platform and more capability sets that are required to have a comprehensive solution.
We have a few minutes left. Just coming back all the way to your introductory comments about your the home infusion business. Obviously, we didn't spend that much time on the call on Wednesday talking about the quarter, and you mentioned it was strong. You know, it came in better. Maybe just two questions there, 'cause in terms of the topics in the conferences around the utilization and labor.
In terms of the volume, sounds like things were tracking there well. Maybe can you flash it chronic versus acute? Also specifically on the acute care business, we heard all the hospitals seeing, you know, very favorable trends even when it comes to volumes in Q1 and also into Q2. Kind of can you talk about the, you know, trends in your business?
We'd love to talk about the first quarter, Joanna. We're really proud, as John mentioned, the momentum coming out of the first quarter, we feel really good. It was balanced execution across the board. We see continued strength in our acute portfolio as we've become and continue to be that dependable partner of choice to health systems transitioning patients out of the hospital. With some of the competitive dynamics from earlier in 2022, we've continued to capitalize on those opportunities, we saw robust growth in the acute portfolio, which we've been very candid. We see longer term growing in the low single digits. We delivered mid-single digit performance, that's some of our higher growth margin profile therapies. At the same time, we continue to be a good collaboration partner on the chronic side.
We're really excited about the balanced t op line results that we've delivered. As we skew more towards chronic, again, that's more of a predictable and stable revenue base, which also helps to flatten out our years more than if, for those of you that have been following home infusion, rewind a few years, you typically saw a little bit more of a depressed start to the year, driven by the acute side. Equally as exciting. Look, our procurement team is the best in the industry. We continue to fight for every basis point on the therapy margin side. We have reached new highs in our penetration of our ambulatory infusion centers, which we continue to aggressively expand. We exited the first quarter with over 26% of our nursing events occurring in one of our centers.
That was in the high teens a couple of years ago before we really started that concerted effort. Not only does that help us from a clinical labor capacity perspective, but it helps us drive margin improvement because we're driving better utilization of that costly clinical labor component. Down below, you know, our focus on spending leverage, back to my earlier comments, continues to be relentless. We continue to deploy automation and technology in our revenue cycle side, which has led to the highest cash velocity we've reported internally as well as, you know, driving better labor efficiency within our indirect labor investments. Just really excited about the momentum. We were north of 9% EBITDA margin in the first quarter.
Equally as important, we generated approximately $90 million in cash flow from operations and actually increased our cash balances despite deploying $75 million for a share repurchase from Walgreens. Just really excited at the strength of the first quarter and the momentum we're carrying that into the back half of the year.
The only other thing I would add to that is we also announced Naven Health, and that was a combination of Infinity Infusion Nursing and Specialty Pharmacy Nursing Network to create Naven Health that's focused around making certain that we have access to the clinical resources that are necessary. Really great progress from that standpoint. Net new, so the number of new nurses that we have available increased over the quarter. We expect as this moves forward, we'll continue to see that progress. Remember, that focus originally was on infusion nursing on that.
We created Naven Health because it will also give us the opportunity to expand as we're looking at a broader need for home health, and hospice into that process to be able to utilize that engine to help support the growth of the business as we move forward. Excited about the potential that that brings us as well.
I think that's all the time we have, but I'm glad you mentioned Naven because it was on my list too which is exciting. Thank you, gentlemen.
Yeah. Thank you.
Thank you, Joanna. Thank you.