All right, let's get started. We good to go? Okay, welcome to Strata's 2025 Investor Day. I'm Matt Schneider, VP of Finance and Investor Relations and CFO of our Clinical Services business. I want to thank everyone for coming today, for everyone here in person, and for joining us online. Strata is at the early stages of a transformation, and we're really excited to be here today to share with you our plans for growth and value creation over the coming years. Our plan today, our goals today, are to provide a deep dive into our business, to walk through the attractiveness of our core organ transplant market, focus on our key growth strategies, and provide a financial framework for 2026 and the medium term. A few housekeeping items before we get started. Today's presentation materials have been posted to our website.
We'll start with a series of presentations from leaders across the business, and we'll follow with a Q&A session. If you have questions throughout the presentation, you can email investors@srta.com, and we'll do our best to address everyone's questions during the Q&A session. Following the Q&A session, for those of you here in person, we'll have a cocktail reception. Please note we'll make forward-looking statements today, and actual results could differ materially from these forward-looking statements. For a full list of factors that could drive these differences, you could see our Form 10-Q and 10-K filings with the SEC. With that, let's get started. I'd like to turn it over to our Co-CEOs, Will Heyburn and Melissa Tomkiel.
Hi, everybody. It's great to see you all here. For anyone that's new to the story, I'm Melissa Tomkiel. I'm Co-CEO of Strata, and I'm thrilled to introduce you to our company. We now have a laser-sharp focus on logistics and other critical services in one of the fastest-growing and most resilient sectors of the healthcare industry today, organ transplant. Our differentiated end-to-end model has us well poised to outgrow the market with ample runway to accelerate that growth even further through acquisition. Our mission is simple: increase the number of organs for transplant. Our goals are aligned with all stakeholders in the transplant ecosystem. When Strata wins, we save lives. The majority of our business is in organ transplant, specifically logistics, which for these cases is incredibly challenging. Organs only have a few hours outside of the body before they reach their intended recipient until they expire.
Once an organ is available, it's a tremendous effort to mobilize medical teams and equipment, sometimes across the country, to respond in time. We recently diversified into cardiac care through our acquisition of Keystone Perfusion. This is non-transplant related. We provide perfusion staffing solutions to hospitals performing heart surgeries. These perfusion resources augment our transplant program. Let's walk through our service offerings. We bridge the gap from organ donor to transplant recipient, working alongside our customers every step along the way, an end-to-end solution for all of these critical services. Our organ placement and matching division are clinical administrative teams that work within transplant centers. They assess organ offers and accept them or reject them, depending on the patient's needs. Our recovery and perfusion teams are recovery surgeons. They go to donor ORs, and they procure organs on behalf of our OPO or transplant center customers.
They're assisted by our perfusionists who are using techniques like NRP, which we're going to spend a lot of time talking about today. NRP increases the viability of the organs post-procurement. Our air and ground logistics experts move the medical teams and organs quickly and safely from the donor OR to the transplant centers. I'll note now that we are the largest air provider of hearts, livers, and lungs, the transporter of hearts, livers, and lungs in the country. As you can see here, there's plenty of room to grow, both in logistics and all the other business lines as well. We are the only full-stack end-to-end organ recovery platform. We work alongside our customers while supporting any equipment they may choose.
This is particularly relevant when it comes to machine perfusion, which is a hot topic these days and we're going to spend a lot of time talking about during this presentation. What's important to note is that we are a true partner with an open-source philosophy. We're not a vendor pushing any particular captive asset. We are doing all of this at national scale. We have aviation, ground, perfusion, and NRP and surgical recovery teams based strategically around the country, close to donor ORs and transplant centers. Having locally based planes reduces callout times, which for these mission-critical flights, every minute counts. Having a locally based plane also eliminates the need for a repositioning leg, which means flying an aircraft empty from its base to the pickup site. We don't have to do that with our locally based assets, as this saves our customers time and money.
I can't emphasize enough the importance of having locally based surgical recovery. Every day, transplant centers fly out their medical teams on airplanes across the country, only to find out when they land that the organ is not recoverable. They then pack up and fly back empty. This is called a dry run. We'll talk a lot about this later. Will's going to walk you through it next. It is a huge pain point in the industry, and we are the first provider that offers a solution to these transplant centers. They don't have to undergo that financial risk. Our hope is that this will encourage them to pursue more organs, and it will increase transplant volumes, and we're already seeing this play out. Our competitors don't have this scale. They're very small carriers with a couple of airplanes based at one hub.
That means for every case, they have to reposition an airplane. That costs a lot of money and time. They're also typically reliant on only one type of aircraft, whereas our distributed asset light model gives us the flexibility to choose the right aircraft for the mission that's based in the right location. It doesn't make sense to fly a mid-sized jet in 200 mi from its base to do a 90-mile run from Tierbrode to Philadelphia when we have a locally based turboprop that can do that mission for a fraction of the price and way less time. This is how we're saving our customers time and money every single day. We partner with our customers to support any equipment that they may choose, whether that's machine perfusion or a specific aircraft make and model.
We are a true open-source platform with the belief that the customer is always right. Our competition is often incentivized to promote their captive assets. As far as the quality of surgical recovery goes, all of the Strata physicians are licensed; all the Strata surgeons doing recoveries are licensed physicians. This is very important because the quality of the procurement has a direct impact on the likelihood of success of the transplant. Our in-house surgeons are in our program overseen by one of the best heart transplant surgeons in the country, Dr. Scott Silvestri, who's here today and you'll meet shortly. This is why transplant centers trust using Strata's local surgical recovery teams. We are the only one-call organ recovery platform in the country. Our competitors have a more narrow focus.
They only offer one or two of these services, which means they are saying no to the customer and having them figure it out for themselves. We, on the other hand, are fully integrated, and we coordinate every element of transplant matching, recovery, logistics, all in-house in our program that is overseen by our highly trained logistics coordinators and our 24/7 control tower. I have walked you through why our one-call end-to-end organ recovery platform makes us the best-suited partner for our transplant center and OPO customers and how our differentiated business model has us best poised to scale. I am going to hand it off to my Co-CEO, Will, to cover why we are so excited about the growth opportunities in this industry.
Thank you, Melissa. And thank you all for being here. Let's talk for a minute about why we're here. Why is there such a growing unmet need for transplants in the United States ? Why do we see an attractive opportunity to help solve this life-or-death problem? And why are we, as the market leader, positioned to grow even faster than the already rapidly expanding non-correlated organ transplant marketplace? Let's start with the problem. Americans are in dire need of organs. There are more than 100,000 on the transplant waitlist today, and this statistic actually masks a much larger problem: millions more who are suffering but are not sick enough to qualify for a transplant. Failure is tragic. Thirteen Americans die every single day while they are waiting for an organ that will not come in time. Success, however, is a win-win. Last year, nearly 50,000 American lives were saved through the organ transplant system.
It's also one of the most cost-effective life-saving interventions in the healthcare system. Regulators are responding to this reality by supporting the transplant ecosystem financially and changing regulations to get organs to people who need them the most first. Look at the evolution we've seen in donor allocation methodologies. As recently as 2017, most organs had to match within an arbitrary donor service area. This prioritized getting an organ not to the person who needed it the most, but the person who's closest. We've now evolved to acuity circles and, more recently, continuous distribution, which uses a points-based matching system where geography is just one of several factors. When you get the organ to the person who doesn't have longer to wait first, you can successfully complete more organ transplants, and it benefits the entire system. It also puts incremental pressure on logistics.
This is a problem that we are well positioned to solve. Even with these things still playing out, we've seen a 64% increase in the average distance between donor and recipient over the last six years. Only lungs have moved to the continuous distribution algorithm. When lungs made that transition, average distances between lung donors and recipients increased by 80%. Liver and heart, which form the majority of the hearts, livers, and lungs that we work with, have still not moved over from acuity circles. We do not underwrite any incremental regulatory change in the guidance that we are going to talk about today. There is significant upside to what we will be talking about. This is not the only tailwind in the industry. Technology has rapidly grown what used to be a very small part of the donation system. This is donation after circulatory death, or DCD.
Donation after a donor's heart has stopped. Historically, this was a very small part of the ecosystem because significant damage is done to the internal organs when a donor's heart stops. Perfusion, pumping oxygenated blood through the organs, can repair this damage and make those organs just as good as an organ that comes from the more historically common brain death donors. These technologies have massively increased the size of the donation after circulatory death donor pool. It has quadrupled in the last seven years, growing at more than a 20% compound annual growth rate. This is another area where Strata is poised to outgrow the market because our technology that we offer directly, normothermic regional perfusion, is used in about 40% of DCD cases. This penetration rate continues to grow. Last year, NRP accounted for about 20% of DCD donors.
First half of this year, about 40%, and the most recent month where we have data, about 46%. We view this as evolving to become the standard way that DCD organs are recovered in America, but we're not underwriting that in the guidance that we talk about today. Look at kidney as an example of a potential benchmark. Low-cost machine perfusion is available for kidneys today, and it's used in about 70% of the cases. You can see the possibility for increased penetration of NRP. It's also one of the most low-cost ways to recover a DCD organ, and it's deployed locally, which has significant implications for reducing the cost of a dry run. Melissa's talked about this, and we'll talk about it even more today because it's a really important part of how we can deliver our services to hospitals more efficiently.
Machine perfusion is also going through somewhat of a revolution. Multiple new market entrants are coming into the American marketplace. This is making machine perfusion more widely available. It's also creating competition, which we believe will lower costs. Costs are a significant barrier for hospitals when they're determining whether or not to go after a DCD organ. The lower the costs are for all kinds of perfusion, the more likely hospitals are to take an attempt of an organ recovery, and the more attempts they make, the more organs that will be successfully transplanted in America. What has all this meant? It's meant a significant acceleration in the growth of the number of successful transplants in America and an even faster acceleration in the overall size of the organ transplant marketplace.
That's because as these processes get more complex, it pushes the boundaries of hospitals and organ procurement organizations' internal resources, and they turn to third parties like Strata to help them manage the growth, often with more national scale than they could build themselves. We are exposed to the fastest-growing parts of this marketplace and are poised to outgrow the growth in number of cases because as cases grow, distances grow more, and our unit of economics and our logistics business is not a case, but a flight hour, one of several different ways where we're exposed to the faster-growing parts of the marketplace. On top of this, we have nearly a $1 billion market in non-transplant clinical services that we're excited to walk through with you later today. What does this mean for us financially?
In short, organically, we have an opportunity to double our adjusted EBITDA over the next four years with guidance that's built on conservative assumptions that doesn't incorporate many of the things we just talked about. We assume the current state regulatory environment, no move to continuous distribution for livers and hearts. We don't assume an acceleration of transplant growth beyond what's been normal in the last few years, and we don't assume that NRP becomes the standard way of recovering DCD organs. Perhaps the most important thing that we're not including in our guidance is the significant capital allocation opportunity in this very fragmented ecosystem. We estimate that we'll have about $200 million to deploy over the next four years in the transplant ecosystem. This could add another $25 million of EBITDA if we deploy just 75% of it at our target mid-single-digit multiples.
That is before growth in the acquired companies and assuming no synergies. We will talk about why we expect to have significant synergies in the businesses that we acquire. First, let us talk at a higher level about our capital allocation philosophy. We see a significant opportunity to acquire established, profitable businesses in our core service areas in the U.S. This is a fragmented marketplace that is full of regional players that are performing at the highest levels. Because of our national scale and because we have more customers than anyone else in the industry, we are uniquely positioned to verify those regional players' track records of success. For us, these acquisitions do not just generate a great financial return. They also add power to the overall Strata platform. A big part of what we can provide to our customer base is that local availability of resources.
By making these acquisitions, we actually make the platform more powerful for all of our customers and bring more resources for the target company's customers as well. Of course, the price has to be right, but I'm happy to report that we have multiple opportunities in the pipeline in the mid-single-digit area of adjusted EBITDA multiples. Let's talk about the specific areas that we're focused on. At the top of the list are targets in the transplant clinical area. These are NRP businesses, normothermic regional perfusion, surgical organ recovery, organ placement, or organ preservation. This significantly expands our local service footprint, and we'll talk more about why that's so important for hospitals to be able to save them money and lower the risk of recovering a DCD organ. Also, most of these targets have very limited logistics capabilities.
This gives us an opportunity to put all the pieces together for their customers and provide a lower-cost, seamless solution, creating a synergy for us and an opportunity for multiple buy-down. On the logistics side of things, there is a great industry full of asset-heavy operators of aircraft that have a long track record of successfully serving a handful of transplant centers and OPOs in their specific geography. This is a great opportunity for us. They rarely have any clinical services to offer, and they have no national footprint. Our platform will often be able to save money for their customers, and it gives us more aircraft and more places that we can launch without having to reposition, saving money for our customers. There is also an opportunity to take those airplanes and fly them more. The more you fly airplanes, the less it costs to fly per hour.
That can reduce the cost for the target company's customers and for our customers that are using those airplanes. Outside of the transplant space, we see an opportunity to continue on with the great track record that our clinical team at Keystone has established, acquiring small businesses in the clinical perfusion space. They've had a great record of success doing this at low- to mid-single-digit multiples, and this provides not just a financial benefit to us, but it also brings us a pipeline of perfusionists that feed the transplant business as well. The same perfusionists that we recruit for this part of our business can be used to perform normothermic regional perfusion, which we use to recover DCD organs. It feeds the entire platform.
In short, this is a great opportunity to use capital allocation not just to generate a financial return, but to improve the service that we provide to our customers. As you can tell, we are incredibly excited for our role in the transplant space and for the evolution that we're seeing in transplant right now. We built a full-service business that is going to benefit from all the dynamics that we just talked about and has additional exposure to the fastest-growing parts of the industry: donation after circulatory death, normothermic regional perfusion, longer distance flights, and we'll realize economies of scale while we grow, leading to margin expansion. This is a non-correlated market where we can grow market share, and we get paid by hospitals, not by insurance. Our mission is aligned with regulators, with customers, and with transplant recipients.
Everyone is focused on improving the number of organ transplants that happen because it saves lives, and it does so cost-effectively. We're sitting in the midst of multiple growth catalysts for Strata specifically and for the industry more broadly, many of which we do not underwrite in the guidance that we're talking about today. We're also armed with a balance sheet to consolidate that will generate a great financial return and also improve the service we provide to our customers. We're going to talk about all these things in more detail today, but first, a little bit of history on how we got here.
Thank you. Okay. We'll take a little walk down memory lane here. Strata was founded in 2014 as Blade, an asset-light passenger air mobility company with a focus on customer service.
We leveraged our customer service mantra and 24/7 availability to partner with NYU Langone in 2019. That was our very first transplant center customer, and we did air and ground logistics for their organs and medical teams. We quickly grew to be the largest organ transporter in the Northeast. In 2021, we went public. That gave us the capital and the opportunity to scale our medical business. We were looking for acquisition targets in the partners that we were working with that would benefit from our expertise in aviation but bring to us institutional knowledge and industry relationships in the transplant space, all wrapped in a scalable operational platform. We found that in Trinity, who we acquired in 2021. Over the next few years, our medical business outgrew our passenger business.
Part of the stagnation of the growth in the passenger segment was the delay of certification of eVTOL, which is Electric Vertical Takeoff and Landing Aircraft. We really viewed eVTOL as the unlock for growth in passenger. That led us to conclude that the passenger business would be better served within the confines of a pure-play eVTOL company and that by separating the businesses, we could then focus 100% of our time, efforts, and resources on the rapidly growing and profitable medical business. This strategy came to fruition. In August of 2025, we announced the sale of our passenger business and the Blade brand to Joby, which is an eVTOL manufacturer, for proceeds of up to $125 million. With the divestiture of the passenger segment, we rebranded to Strata Critical Medical. We changed our ticker to SRTA to reflect our 100% focus on healthcare.
Simultaneously with the divestiture of passenger, we were working on a very strategic acquisition of Keystone Perfusion, who has been a commercial partner for several years. The combination with Keystone brought to us the key clinical service lines: recovery, perfusion. That cemented our position as an end-to-end provider in the transplant space. We are now a pure-play, open-source, end-to-end logistics and critical services provider in a rapidly growing contractual and macro uncorrelated marketplace. This is a great place to be. We're really excited to walk you through all of our business lines in depth. We have a deep bench of management who's here today, who are the people running these businesses and saving lives every single day. Before we do that, I'm going to hand it right back to Will.
He's going to briefly walk you through how transplantation works to give you a good background on how this all comes together.
Thanks, Melissa. Before we dive more into the details, we're going to take a quick step back and talk about how the transplant ecosystem works together. We'll mostly be discussing today deceased donor transplants of hearts, livers, and lungs. That's because these are the organs where time is of the essence. They have only four to eight hours typically to reach the recipient for them to be usable in transplant. We'll talk about how some technology is extending that, but we'll focus on the most typical methodology for organ transplant. First, let's talk about the different parties that are involved. We'll start with transplant centers.
There's about 250 transplant centers in the United States , and these are the hospitals that have the patient that will ultimately receive the organ transplant. In a heart, liver, or lung, they are the quarterback of the overall process. On the other side of the equation are 55 organ procurement organizations. They carve the country up into geographic areas where they have responsibility for identifying potential organ donors. They also obtain authorization from families and prepare that donor for the procurement process. Within each donor service area, the geographic area that an OPO is responsible for, are any number of donor hospitals. This is the hospital where the donor initially presents, and they are primarily responsible for patient care for the donor. In most cases, the organ procurement procedure will take place at that donor hospital.
All of these groups work together and are supported by a variety of third-party service providers like Strata. It's easiest to understand if we walk through a real example of how the process works. Let's do that. A donor hospital will first identify that someone meets the criteria to potentially become an organ donor. They will flag that donor to the OPO that is responsible for their donor service area. The OPO will then send a team to the donor hospital to evaluate that potential donor and also obtain any family authorization. They'll use third-party service providers for the logistics and the diagnostics at this step of the process. Once they've done tissue typing and blood typing, they will make what's called an organ offer based on federally mandated allocation methodologies to a transplant center.
The transplant center will then have a little bit of time to evaluate whether or not they want to accept the organ. They'll often use a third party like Strata to help them with both the clinical and administrative work of evaluating whether or not to accept that organ. Why would you not accept an organ? There's plenty of reasons. A good example might be a younger recipient who matches to a 70-year-old plus liver and is not so sick that they need to accept an organ at exactly that moment. That's an example of when a transplant center might reject an organ, and it would immediately go on and be allocated to the next person on the list. Once the transplant centers accept the organs, the OPO will begin to prepare that donor for the transplant procurement process.
Remember that each organ almost always will match to a different recipient at a different transplant center. You have multiple parties flying in all on different aircraft from all different locations, and it's the OPO that's arranging the OR time and making sure that this goes seamlessly. They'll also use a lot of third-party service providers like Strata for logistics, for third-party surgical recovery, for normothermic regional perfusion, which we'll talk much more about later, and for machine perfusion. Once the procurement process is completed, each organ will fly immediately on its own aircraft, sometimes on ice, sometimes on a preservation device, to the location of the recipient where it will be immediately transplanted. This is where there are some significant differences depending on what kind of donor we're talking about.
We've talked about donation after brain death, DBD, and donation after circulatory death, DCD, but let's take a minute to unpack it in a little more detail. Donation after brain death is historically the most common kind of organ donation, and it's also the most straightforward from a procurement perspective. That's because this donor has no brain activity and is legally dead. Their organs are just being kept working using machines. Once the procurement team arrives, they can immediately start the process of procuring the organs and fly them to the recipient. In this case, machine perfusion may not be necessary, particularly if the distances involved are not very far, though it's often used for longer-distance trips or for marginal organs. Donation after circulatory death, or DCD, is a very different situation.
These donors are terminal, but they have low-level brain function, and the family, in consultation with the patient care team at the donor hospital, has made the decision to withdraw life support to end their loved one's suffering. After they make that decision, they've made a separate decision to pursue organ donation so they could save other lives with their loved one's loss. Because of this, there is an additional step once transplant teams arrive to procure those organs. Once all the teams are on site, the local hospitals or patient care team will withdraw life support and wait for the donor to decease. Only once the donor has deceased are procurement teams authorized to begin the recovery procedure. If this process takes too long, the organs may sustain too much damage to be useful in a transplant procedure. This is what's called in the industry a dry run.
If the process takes the appropriate amount of time, perfusion is almost always a best practice for a DCD recovery, and it can be completed in a number of different ways. Normothermic regional perfusion perfuses all the organs inside the body, pumping oxygenated blood through those organs to repair the damage that was done when the donor's heart stopped, and it's able to, before the organs are removed, complete that process, and then they can be carried on ice or in a preservation device to the recipient. Organs can also be removed immediately after the donor deceases and be perfused inside a machine one at a time, which can happen while in transit, or it can happen once they reach the destination in what's called a back-to-base model.
We'll talk a lot more about why it could be more efficient to perfuse all the organs at the same time through normothermic regional perfusion, which Strata offers, and why that service can be delivered much more efficiently locally without needing to fly out staff and equipment. We just walked through the most typical process for organ donation, but some areas are different. For example, in kidney transplants, it's OPOs that are the quarterbacks of the logistics, and because they can survive on ice for one to two days, they are often shipped. We have a service offering for kidneys where we hand-carry kidneys in the cabin of a commercial aircraft, ensuring that they're going to get to their destination and won't get lost in cargo. In all of these cases, it is a complex, multi-party process, and the stakes couldn't be higher. It's life or death.
Strata puts all of these pieces together in a seamless end-to-end solution, and we're honored to be trusted by more transplant centers and OPOs to complete this work than anyone else in the United States . Now we're ready to dive into the details, and we'll start with our logistics business. I'm happy to turn it over to Scott Wunsch, CEO of our logistics. Is there a chain of custody requirement here? The question was, is there a chain of custody requirement? We keep detailed track all the way from the beginning of the clinical services that we provide. In a few minutes, our clinical team is going to show you how we're tracking the biometrics through the entire process of recovering an organ.
We'll talk about our technology that tracks the chain of custody, ground, air, every step of the way in logistics, but it is an important part of the process, though it's actually something that we do better than the competition, and it's not necessarily something that has strict rules around. We'll talk about all that in a lot more detail. Scott?
Great. Good afternoon. As Will said, I'm the CEO, Scott Wunsch, the CEO of the logistics division of Strata Critical Medical. A quick introduction about myself: I spent many years taking care of kidney dialysis patients, and then I spent 13 years as the vice president of operations for an OPO in Seattle. We covered Alaska, Washington, Northern Idaho, Montana. As you can imagine, the logistics were great. We navigated pilot duty times, flying into Alaska, flying to Montana.
All those different things were a very big part of what we did to help make sure people got transplanted within that service area. I started at Trinity in 2018 when we were primarily serving Arizona and a bit of Nevada and California. We grew quickly and began working closely with Strata, and I would talk a little bit about our successful partnership. After a very successful commercial relationship, we were acquired by Strata in 2021. As Melissa said earlier, it was an outstanding—it's been an outstanding partnership, as you can see from this graph. I'm sorry. Side by side, between Strata's aviation expertise, the capital, and our operational expertise, we helped the logistics division scale rapidly. Today, Strata owns aircraft, has additional dedicated aircraft, serving the transplant community. That growth hasn't been on accident.
We have worked hand in hand to deliver an extremely high-level service, placing aircraft where customers need them, offering a true one-call solution, and operating several service lines to fit each mission. Our capabilities are built on an infrastructure at scale. More than 30 owned or dedicated aircraft across 20 bases, 50+ vehicles across 14 ground hubs. That depth of assets creates operational efficiency and real cost savings for our customers. All of this is powered by our proprietary dispatch software, which leads our team to manage complex requests, and gives customers visibility into trip details through our TAC application system. Within the transplant industry, Strata is a trusted partner, not just because of the depth of our footprint, but because of the deep relationships we have built over years of service. As we continue to grow, we compete for 100% of our business.
I think it's very important we compete for 100% of our business. The majority of that business is contractual, where we're provided logistics for 100% of the transplant business rather than a case-by-case basis. This keeps us relentlessly focused on our resources, responsiveness, and the level of service our customers expect. Over time, logistics has transformed from a background function into a strategic cornerstone of the modern transplant process, especially as the field has grown far more complex than the historical two-party relationship between a transplant center and an OPO. Today's broader organ-sharing policy, as Will explained earlier, extends geographic reach and increases coordination demands, making precise logistical management essential. At the same time, advanced technologies such as machine perfusion require meticulous timing and seamless transport integration to preserve organ viability.
The involvement of multiple third-party recovery partners adds additional layers of collaboration, requiring unified communication and streamlined operations across organizations nationwide. Ultimately, effective logistics directly influence outcomes, ensuring that each organ arrives safely, efficiently, and in optimal condition to maximize the transplant success. Jumping into a one-call solution that we've created, Strata's scale and fleet diversity allow us to tailor the mode of service to each mission while delivering cost savings. I'll go into some detail here about the one-call model. Our communication center evaluates the mission and moves immediately, matching the need with the best mode of transportation so our customers can focus on saving lives. Air charter logistics is a major driver. With our expertise and aircraft positioned in the right places, we deliver the right aircraft at the right time in the right location.
Ground logistics, as I said, we have 50+ vehicles around the country, operate nationwide with our own vehicles and W-2 employees moving transplant teams, organs, machine perfusion devices, and other critical items. Where we do not have owned assets, we use vetted third-party providers. Next, we provide a service called Next Flight Out. This is when we are placing kidneys in cargo hold of commercial airlines. It is cost-effective when cold-ischemic time allows. It is a good alternative to a charter flight. Lastly, and Will mentioned it earlier, is hand carry. Hand carry is a newer service that we collaborate directly with airlines to make happen, allowing kidneys, lungs, and livers to travel in the cabin of a commercial airline with an attendant. The organ stays with the attendant and can be rerouted quickly if needed.
When time allows, this is a lower-cost alternative, but a much lower risk of delay since the organ is always with an attendant. These four services give our customers options to make the best decisions when lives are on the line, from urgent aircraft flights to cost-optimized commercial solutions, so we can meet the need every time. On the left, you're going to see our national footprint, and we've shown this a little bit, but 30+ aircraft, 50+ owned vehicles dedicated to the transplant community. This fleet and our assets are working directly with our transplant centers and OPOs. The scale enables customers to accept more organs more economically. On the right is a great example of us placing aircraft where it can help our customers.
Before Strata supported this transplant center in Jacksonville, Florida, the customer's operator was based in Gainesville and had to reposition every trip. Gainesville to Jacksonville, Jacksonville to the donor hospital, back to Jacksonville, and then back to Gainesville. That added time, cost, and at times, required two aircraft to actually stay within the FAA duty time limits. We based an aircraft in Jacksonville, repositioning dropped dramatically, saving the customer thousands of dollars per flight and simplifying the mission. Jacksonville to the donor hospital and straight back to Jacksonville. We have several other cost-saving measures to include one-way flights or using one plane with two pilots, again, providing cost savings back to the customer. At the heart of all this is safety. I'm proud to introduce Keith Trepanero, our Chief Safety Officer, to share how Strata embeds safety into the decisions we make. Keith? Thanks so much. Hello, everyone.
My name is Keith Trepanero. I am the Chief of Safety here at Strata. I've been doing this for about three and a half years. Before that, I served 25 years in the military on active duty in the Army and in the Coast Guard as a pilot and a maintainer. I did operational roles as well as leadership roles that included some safety-focused positions as well. One of the highlights was I was part of the Coast Guard's aviation standardization program. We would verify that safety and best practices across the entire Coast Guard fleet were maintained by checks and balances with on-site visits. After the military, I was the aviation safety manager at Mayo Clinic. While I was there, we established our own Part 135 to better support the medical mission.
I also worked with the transplant teams and the operators that worked with the transplant teams to ensure that they had the best, safest flight possible while they went out there and did that. As you can see, there's a lot going on in this operation. My role here at Strata is very straightforward. I'm here to keep the customers and our staff safe during the transportation process. This means we work closely with our aviation providers to meet our safety expectations and to deliver reliable service to those teams. Safety matters because the impact of an event is not just a line item. It affects families. It affects people. It affects lives. That is a keystone of what we do in our operation.
We built a culture where safety is supported at every level, and we have open communications that helps us identify issues before they become a problem that could affect us further down the line. I'm fortunate. I have an experienced team of evaluators in my safety team, decades of experience, lots of aviation knowledge. With that, we've created a lot of standards and expectations with our operators that we use that exceed the FAA requirements in many instances. Some of the examples here is our own fleet of Strata aircraft are managed by an operator that holds an ARGUS Platinum rating. That's a really unusual thing to achieve in this industry. Additionally, we've implemented enhanced requirements for some of those operators. That includes dual-pilot operations for any passenger flights, and we also require a higher experience level for the pilots that are flying.
Safety is not just a priority here. It's the base of what we do, and it keeps our mission strong. We want to make it an operation that's dependable and reliable for all parties involved. With that, I'll pass it back to Scott, who can continue the conversation. Thank you.
Thanks, Keith. I'll wrap up that we continue to be very excited about growth opportunities across air and ground and expanded use of commercial flights. We're in an extremely strong position. As we discussed on last week's earnings call, Strata continues to outpace the industry transplant volumes in both air and ground. Driven by our dedicated fleet, customer focus, and our national diversification that I've clearly pointed out today of our services, we see continued opportunities to gain, share, and win new customers.
With that being said, I'd like to ask Andrew Murrill, our Director of Business Development, to walk through the air and ground opportunities in more detail.
Thank you, Scott. Hello, everyone. I'm Andrew Murrill, Director of Business Development at Strata. I oversee the sales team with a focus on new business acquisition and growth opportunities. As Scott mentioned, we have seen consistent growth of our customers over the past several years and expect this to continue for years to come. Despite our current scale, there is still significant opportunity to acquire new customers across both air and ground logistics. Our market share today stands at 30% in air and 15% in ground. Our primary acquisition channels include our sales team, competitive RFPs, customer referrals, as well as cross-business referrals, particularly from our organ placement and recovery services.
Breaking down the 70% of the air market, we expect 10% of this market to come up for RFP over the next two years. Given our expertise, scale, and capabilities, we're extremely well-positioned to not only compete and win these opportunities. We have a historical win rate of 80%. Another key focus of our sales efforts are transplant centers and OPOs currently served by non-scaled operators. These accounts stand to benefit significantly from our platform's reliability, extensive reach, and integrated services, enabling greater access to organs through a streamlined one-call solution. Cross-selling from other business lines continues to be a powerful driver of logistics growth. We provide both air and ground logistics for our transplant center customers, but we typically support ground services through third parties if we don't have a ground hub in that region.
Once we reach sufficient scale in a region, it becomes financially and operationally sound to implement a ground hub and bring services in-house to further compete for the OPO ground business. Today, we operate 11 ground hubs nationwide and hold a 15% share of the OPO ground logistics market. This represents significant growth opportunity over the years to come as we expand our ground hub network and win new OPO business. While our core focus remains on heart, liver, and lung logistics, we've launched new services in the past year to support our customers on the logistics of kidneys, including Next Flight Out and hand carry solutions. We currently serve 35 customers in this segment with significant opportunity to expand within our existing customer base.
Beyond transplant logistics, we're leveraging our network of logistics resources to support time-critical shipments for radiopharma, clinical trials, tissue, and blood, extending our value proposition and diversifying our logistics portfolio. I'd like to welcome Melissa back to the stage to talk about our own aircraft.
Thanks, Andrew. Let's talk for a minute about this strategy around aircraft ownership, as we always get a lot of questions on this one. Up until last year, we were 100% asset light. We were building so much scale that we realized if we invested in some aircraft, we could generate some margin expansion. We bought a fleet of 10 Hawker 800 aircraft in 2024, and we're already seeing the benefits of margin improvement. There are also significant strategic benefits of owning aircraft. It brought us a significant competitive advantage.
In the last year, we won two key accounts whose RFPs required asset ownership. By owning the planes, it allows us to select the best make and model for the mission profiles of our customers. It allows us to place them around the country in the strategic way that we've been doing, close to our customers to save them time and money. We get the most operating leverage from the owned planes. The owned planes represent about 30% of our flying. Here, we pay the fixed costs directly and the variable costs as we incur them. The more we fly, the more fixed cost leverage we get. 50% of our flying is done on dedicated planes. With these planes, we contract and we make guaranteed flight hour commitments to the operators in exchange for exclusive capacity of the airplanes. We do this at fixed rates.
We do get some fixed cost leverage here because typically, our rates will go down as we achieve certain target thresholds for hours during the year. The least amount of flying is done through safety-vetted third-party operators. Here, we pay as we fly. For every hour we fly, we pay. We do not make a guarantee for minimum net hours, but this allows us, very importantly, to scale our capacity up or down without having to take any financial risk. It also provides us with additional and deeper geographic diversity and access to more makes and models of aircraft without having to make an additional capital investment. Our current capacity mix gives us the flexibility of being mostly asset light with the competitive advantages of ownership. That was a lot of logistics, and I just want to summarize it all now here. These transplant cases are getting more complicated.
This highlights the importance of our expertise and scale and really increases our strategic value. While we are currently the largest air transporter of hearts, livers, and lungs in the country, there is still plenty of room to grow, both by taking share and through acquisition. We are very well-positioned given the scope and the quality of what we've built and our continued belief that the customer is always right. Now it's my pleasure to turn it over to Lou Verdetto. Lou is the founder of Keystone. He runs our clinical services and cardiac care business lines. We're going to focus now on the clinical services. Hello?
Thank you, Melissa.
Sure.
And thank you all for being here, both in person and online.
This is a very exciting time for our company, and I'm sure you could sense the level of excitement and enthusiasm for everything that we have going on. My name is Lou Verdetto, and I'm the CEO of Strata Clinical Care Service Lines. I'm a cardiovascular perfusionist by trade, and I have been for the last 17 years. For those of you who may not be familiar with what a perfusionist is or what they do, a perfusionist operates the heart-lung bypass machine primarily during open-heart surgery. Just as in recent years, especially here within the U.S., we're taking that same clinician and we're using them in organ procurement to operate the normothermic regional perfusion pump. I'm accompanied today by some key members of our executive leadership team. Michael Hancock is our vice president, Dr.
Scott Silvestri, our organ recovery service line champion and Medical Director, and our Vice President of Clinical Operations, Christie Campbell. Each one of them will have an opportunity to come up and tell you a little bit more about their contributions on scaling the company into what it is today, and also tell you about the service lines that they manage within Strata. Before they do that, I'd love to give you a little bit more background on Keystone Perfusion. I'd love to tell you where we started, what we've accomplished as a private company throughout the last 12 years, and what we intend to accomplish under the Strata Unified brand. Keystone started in 2012 as a locum tenens perfusion staffing company. Hospitals and health systems would lean on us to augment their own perfusion departments.
Over time, we've become a trusted perfusion staffing partner to hospitals where hospitals would outsource the entire departments. We would provide equipment, disposables, and personnel to take over the entire perfusion departments within hospitals. Since we developed a staffing platform, it was only natural to get into other adjacent services, which we'll touch on more shortly. Our company has sustained significant growth since our inception. We've grown in the mid-teen, compounded in our growth rate since we started, and that's just on the organic side. Our inorganic growth, we've accomplished six tuck-in acquisitions throughout the last five years, all of which are performing very well. As Will said earlier, we're able to acquire these companies at single to low-digit multiples. Just in the last two and a half years, we got into the organ recovery space, a natural extension of everything that we're already doing.
We're providing perfusionists for open-heart surgery programs. As I said, we could use those same clinicians for organ recovery. That business has grown significantly for us. I couldn't be more proud and happy to merge a company that I founded into a company with like-minded individuals who are mission-driven and focused. With that said, I'd love to bring up Michael Hancock and Dr. Scott Silvestri to tell you a little bit more about our organ recovery programs.
Thanks, Lou. I think all the notes are a little messed up. That's all right. Oh, good afternoon, everybody. My name is Michael Hancock, and I run Strata's Organ Recovery Service Line. Me, like Lou, I'm a perfusionist by trade, and for the last 13 years, we at Keystone have been providing perfusion services to cardiac surgery centers across the country.
Some of those cases involved transplants, but on the recipient side of things. I can honestly say that my time in organ recovery over the last few years has been the most rewarding and professionally fulfilling experience that I've had in medicine. Not only are we recovering precious organs for a mismatch between the amount of available donor organs and the number of patients on the recipient waitlist, but we're doing something for donor families that I think cannot be understated. You're taking a donor family that's going through the most tragic loss, perhaps the most tragic event that they've ever gone through, and you're giving them an opportunity to establish a legacy for their loved one through organ donation. Not only are they able to save a life by donating their loved one's heart, but maybe up to six organs or maybe more.
We are truly, right now, changing the transplant landscape by innovation on the donor side of transplant and through the need for specialized recovery teams. Organ procurement is becoming more complex, more nuanced, requiring us on the third-party side to have more specialized teams, including more technically gifted cardiothoracic surgeons, abdominal transplant surgeons, and even us in the perfusion space to be able to leverage some of these recovery technologies and techniques to pursue more donation opportunities and increase the yield from the DCD population specifically. Sorry. When we look at where we've come and where we are today, we've established ourselves as one of the premier organ recovery service providers in the country. So far, we've done over 2,000 comprehensive NRP cases and over 700 surgical recovery cases.
One of our operational differentiators is that we have a hub-and-spoke model, which allows us to keep clinical resources, equipment, and supplies at different locations around the country so that when a donation opportunity presents, we can mobilize our clinical team, all of the supplies and resources, and these technology and devices from one of our hubs closest to where the donor hospital is presenting. What that does, it allows us to mobilize and pursue rapid donation opportunities better, cheaper, faster. One of the big things we're all trying to do in the transplant space is reduce costs. This is one of the ways that we do this by offering that true one-call solution, mobilizing our teams, Trinity, being able to pursue the opportunities and deliver these organs to the transplant centers for implantation for the recipient.
When we look at all of our combined service offerings in the organ recovery space, I mentioned that we are one of the only comprehensive NRP service providers in the country, allowing us to mobilize surgical teams and perfusion teams to pursue these opportunities that some host OPOs in other areas of the country do not actually possess. For our OPO partners, we allow them to consider using NRP for every DCD opportunity that presents in their DSA. Some of the top OPOs in this country, they will consider using NRP for every single DCD that comes through the door. For our transplant center partners, we allow transplant centers to keep their internal resources at home, instead sending our specialized teams to go recover these precious organs, allowing their internal teams to stay at home, treat patients within their home facility.
We, as a trusted partner, then carry out the organ recovery using the same clinical standard and expertise that they have come to expect from their program. When we look at our traditional organ recovery service line, we have thoracic and abdominal recovery teams that can pursue both brain dead and DCD donation opportunities. One thing that we're really excited about is how we can support these other machine perfusion technologies. Over the next couple of years, we're going to see many other technologies and devices come to market, allowing our transplant surgeons on the recipient side to have a prescriptive ideology or plan for every single recipient that comes through the door. For us, while we favor NRP, we are agnostic to the technology. We want to be able to support every one of our partners' needs, whether that be an OPO partner or a transplant center partner.
One of the really exciting things for us in Strata is the fact that we can offer a one-call solution. Partnering with our air and ground logistics arm, we can mobilize our teams anywhere in the country, better, cheaper, faster, to pursue opportunities and reduce costs. When we look at the focus and spotlight that exists in the organ procurement space right now, it is very clear that we need operational standards in the procurement space. We at Strata take this very seriously. Through our proprietary software and platform, we utilize electronic documentation, data capture, and have robust policies and procedures so that we ensure that the highest level of quality is upheld for every single organ recovery case. Okay, as Will laid out, there is simply not enough organs to meet the need or to meet the demand in this country.
We have to figure out a way to pursue more organ opportunities and increase the yield, especially in the DCD population. Right now, only 1% of deaths in the United States equates to a donation opportunity. We have to do better. Now, if we look historically at the donor pool of donors presenting to us in the United States, historically, we used to see the majority of donation opportunities as brain dead donors growing at a rate of 3% almost every year. If you look back in the last couple of years, the amount of DCD donors presenting is growing at a rate of over 7% each year. What's happening now in 2025 is we have more of a 50/50 split in terms of brain dead versus DCD donors.
As Will outlined, the challenge with DCD donors is that we have to wait for the donor to pass and be pronounced dead before we can start the recovery procedure. In the time it takes for the donor to pass, there are periods of what we call ischemia or periods of diminished blood flow to these organs that we're targeting for recovery. What does that do for these organs? It calls into question their viability for transplant the longer that wait period extends. The challenge in front of us is if we have more DCD donation opportunities and we know that the yield from a DCD opportunity is significantly less than a brain dead opportunity, we can see the problem, right? The organ mismatch, while there are more donors, the challenge is how do we recover more of these organs for each one of these DCD opportunities?
One of the ways that we do that is through normothermic regional perfusion. NRP allows us to halt that ischemic period, reestablish oxygenated blood flow to these organs that we're targeting for recovery. What that does is it allows the heart to start beating again. It allows the kidneys to start functioning again. It allows the liver and the lungs to start functioning like they normally would. We can evaluate those organs in real time under normal physiologic conditions, and then we can report that viability to the surgeon on the recipient side at the accepting facility. What this is leading to is just more information. It's casting a wider net on donation opportunities. There are many recoveries in the DCD subset that surgeons walk away from these opportunities because the dying period lasts too long.
There's simply not a way to evaluate and feel confident that this organ that's sitting in front of you is going to work when you put it into your recipient. NRP allows that to change. It's a true game changer in transplant medicine. We can give that information and assess how well that organ's going to work prior to preserving it. How is NRP affecting that yield that we spoke of? A traditional DCD not utilizing NRP yields about 1.7 organs per donation opportunity. If you utilize NRP, we can get a 50% and greater increase in organ yield, getting up to about 2.6 organs transplanted per donor. Not only are we recovering more organs, but these organs are of better quality. We're giving that physiologic environment oxygenated blood flow prior to the preservation technique.
In a published study by Vanderbilt, it's been noted that the primary graft dysfunction rate of organs utilizing NRP is significantly reduced to organs procured by direct procurement not utilizing NRP. So we're getting more organs and better quality organs. Now, if we look at how often is NRP used, the NRP utilization rate over the years used to be in the mid-single digits. As Will mentioned, September of this year, it was up to 46% of all DCD donation opportunities were pursued using NRP. Over the next three years, we expect that to get to 55%. We do expect NRP to become the standard recovery technique for DCD donation opportunities.
If we look today, where we're recovering 3,000 NRP donors, a 65% increase over three years can get us up to having over 5,000 NRP donors with an increased yield, casting a wider net for donation opportunities in this country. One of the many reasons you can see we're very excited about this technology moving forward. Now, I'd like to welcome Dr. Scott Silvestri to go over some of the growth opportunities as well as some of our operational differentiators.
Thank you. I'm Scott Silvestri. I'm a cardiac surgeon. I've been a thoracic transplant surgeon for over two decades. It's been my privilege to be in this field. Let's talk about the operational reality in a transplant center.
My good friend, who runs a cardiac transplant program 15 blocks away, called me up one Sunday and said, "Can you get a heart for me when I was in Florida?" He said, "My partner is putting it in. I'm exhausted. I've been working all week. My wife wants me to do something. They want me to get it. The fellow can't go because of the rules and hours that they work. These young guys are terrible," he said. "Can you do me a favor?" I said, "Sure, I'll do it." He said, "I can pay you a little bit because you know the administrators want everything for free and they want value and they want it cheap. Do me a favor." I said, "Okay." That is the operational reality today. The reality is transplant centers are under a lot of pressure.
The old system of using fellows and getting organs for your partners doesn't work because they're not brain dead donors all anymore. When we changed the system, New York started coming to Florida, and Florida went to Tennessee, and Tennessee went to California. The travel times went up, and the slight imposition of getting an organ for your partner became a real hassle. The generational cultural shift has changed to push for third-party procurement because the surgeons want their sleep back, it makes sense, and there's value. The old model has changed and has to change significantly. What's happened as a result of this? Today, 40% of third-party procurement occurs for donation to alleviate these pressures, okay?
That is growing up significantly to 50% or more, and we believe it'll accelerate even further because of NRP, because of longer travel times, because surgeons want their sleep back, because you go out and you spend 12 hours instead of four hours to get an organ, and sometimes you don't come back with an organ. All of that lost productivity and all of that extra work for the teams is taxing them. Transplant centers cannot staff to occur for all of these things. This is a meaningful inflection point. It is generational. It is cultural. It is labor-driven, and it is value-driven. This is driving from 8,000 to over 11,000 third-party procurements. This difference of several thousand, we believe we can serve very well because we already operate in these markets.
These are areas where reliable partners can add value and capacity to transplant centers without compromising outcomes or compromising identity. Our approach is trust-driven. It is partnership-driven. It is not transactional. When this friend of mine called me up, he was giving me his trust that he knew that I could get an organ for him just like he could. He was telling me that he trusted me or my team to do this for him in the same way he trusted the people working in his own program. He was allowing us to expand his capacity. He was allowing us to not change his outcomes and giving us the biggest trust he could. By being trust-driven, we have to be clinically quality-driven as well. All of our surgeons are vetted for education, training, and experience. All of our surgeons are in the AOPO ASIN network, which is required.
Our perfusionists have special training for NRP. Our perfusionists have training for machine perfusion, the additional techniques to maintain the viability of organs. They have maintained clinical standards as they move along. We believe that it's these standards that allow us to leverage this in order to do this. The mission and operational discipline have to be aligned in order to achieve these goals, and that is who we are. Ordinarily, when you have non-local recovery, you send a team from one place to another and bring them back. That is a significant cost. That is historically how it occurred with brain dead donors. Transplant centers would send their teams out and come back. There was a significant cost.
By using local recovery and setting up a hub-and-spoke network and a logistics network, you can allow the teams to go locally to decrease the transport cost, to decrease the dry run rates, and to decrease the cost and fear associated with sending a team, spending 12 hours of investment, canceling surgeries the next day, and then coming back without an organ. It makes sense for everybody to use third-party, and it makes sense for everybody to use it local because the costs go down, the value goes up. Remember, if someone sits on a transplant waitlist for a year and dies, it's all cost. That's what the hospital, that's what we all see. If someone sits on a transplant waitlist for six months and gets transplanted and survives, that's value. That's what we're all after, saving lives and driving value. Our organ growth strategy is four coordinated pillars.
The expansion of regional hubs is critical in order to provide better response times and access. Expanding thoracic presence for procurement is critically important and a strategic value differentiator because thoracic surgeons do other operations besides transplant, and they want to preserve their schedule as well. Building out the abdominal platform, which allows us to leverage our national network and hub and logistics model, allows us to provide more service in machine perfusion and NRP. Machine perfusion partnerships, partnerships with companies, allow us to then enhance the adoption of this technology to allow more organs to be placed more efficiently across the country with minimal problems. These all work together. As the network grows, the response time goes down, the value goes up, the cost goes down. As both abdominal and thoracic procurement goes higher and higher, utilization increases. As the machine perfusion rolls out, the ecosystem strengthens.
This is strategic growth utilizing our strengths as we have them and as we outline them. This is not site-by-site development. Here is our resource, our hub-and-spoke network currently and areas, markets we believe will be ripe for expansion. We generally focus on aligned OPO partners, a lot of NRP activity, and dense transplant activity in these centers. By adding these other centers, we can see areas where there is strain in the system and a need for solutions, as well as rising NRP adaptation and rising NRP use in order to leverage the centers we have and the local ability to deploy teams close by at value and scale. Expanding thoracic recovery service is key. There are very few organizations that can provide skilled, quality thoracic recovery and thoracic NRP at the level that we can. This is critically important. The driver is there's a shortage of surgeons.
The bottleneck is surgeons, the surgeons who want their sleep back, the surgeons who have stopped volunteering their time to go procure, and organizations have to come up with a different solution. We solve the bottleneck, and we maintain the quality, allowing programs to unlock their capacity untethered by the limits of their own staff, instead by utilizing quality, trusted partners in order to enhance their ability. In addition, there is significant headroom in this space. We're partnered with about one quarter of the thoracic transplant programs. One quarter. There's a lot of room to grow there in the small and mid-size programs who have yet to realize the potential of utilizing external quality sources. Similarly, regionalization of abdominal recovery services in our service line is important.
This allows us to leverage the resources we have, the hub, the logistics, the NRP expertise, machine perfusion for kidney and liver, and allows programs to adopt new technology without the burden of having to learn how to use it in the field and also without the burden of having to deploy teams in order to use that technology at that point. Machine perfusion is critical. We believe that machine perfusion will continue to grow, and we have a device-agnostic strategy. We can support all devices. There are six currently. There are 13 projected by 2030. By allowing device manufacturers to partner with us for their clinical and logistics needs, when they release, they can spread their device across the United States using our teams. That is critical instead of having to develop their own upfront.
By doing this, we believe that machine perfusion will be an important part of the next technology innovation and growth phase for transplantation. In summary, NRP is accelerating and reshaping the transplant landscape. It has forced a reevaluation of what labor is available in the transplant centers. Third-party recovery has become essential to the transplant practice in the United States in 2025. We anticipate that NRP and rising NRP use will become the standard for DCD donation, and we believe that to be critical with or without machine perfusion. This is not reflected in our current financial guidance. This assumption and this data is not reflected in there currently. Our hub and network models are uniquely positioning us to scale responsibly. In addition, growth opportunities exist through thoracic, abdominal, and machine perfusion across the country for us.
We believe that these will come together to help us partner with transplant centers and OPOs to allow a more efficient market for more viable organs being placed and transplanted, more lives saved, and more families kept whole. We are aligned with where the field is going, and we have built a platform to support the next growth phase of transplant medicine. Thank you, Jamie.
Hello, everyone. I'm here today to provide a summary of our organ placement services division. My name is Jamie Bucio, and I serve as the Director of this program. I was recruited here in 2023 from the University of Chicago to develop the service line. I have almost 30 years of experience in the organ transplant industry. Our service line launched in December 2023 and currently employs a team of about 40 transplant coordinators who serve multiple transplant centers across the U.S. Since inception, we have evaluated more than 65,000 organ offers, contributing to over 1,500 lifesaving transplants. As Will kind of gave you a little bit of a summary earlier, organ procurement organizations make organ offers to transplant centers. Transplant centers must designate staff 24 hours a day to receive and evaluate these organ offers. Our organ placement service coordinators fulfill this role.
Most of our work is actually spent in the organ offer evaluation phase. Once an offer is accepted for transplant, coordination through the recipient transplant surgery typically lasts 24 to 48 hours. Some of the key services we provide as part of this comprehensive service you can see here below. Stepping in to provide these services significantly reduces the workload for hospital staff. In particular, customers who are also contracted with Strata for recovery and logistics services have benefited from a one-call solution through utilizing our organ placement services because we also coordinate that on behalf of them. Why is there a need for third-party contracted organ placement services? Recent organ allocation changes have led to a significant increase in organ offer volumes for transplant centers. This has resulted in greater workload and capacity constraints amongst hospital staff, creating the need for additional resources.
In addition, regulatory oversight requires transplant centers to optimize organ evaluation and utilization while continuing to balance risk and maintain high-quality outcomes for their patients. This is where Strata organ placement services come in. Instead of hiring additional internal staff, hospitals partner with us to manage their end-to-end transplant coordination. This allows their internal teams to refocus on patient care and strategic transplant initiatives. Our key goals are to serve as a trusted partner and extension of our customers' professional teams and to offer flexible, customized pricing models to meet their needs. A key value proposition that we do offer to all of our partners is enhanced operational efficiency. We go into these institutions and streamline their internal workflows and processes. We optimize their organ acceptance practices. By doing this, we're improving patient access and outcomes.
We strengthen communication throughout the whole process from beginning to end, and we enable program growth and scalability because we are doing this work on their behalf. As noted earlier, there are approximately 250 transplant centers in the U.S. We currently hold about 4% of this market share, which represents a significant opportunity for future growth. Our active pipeline is driven by targeted sales initiatives, customer referrals, and cross-selling across divisions. We are exploring strategic M&A partnerships that can enhance our operations and market position. We are focused on identifying additional needs in areas of opportunity for our current and new customers. Some of these that have recently been identified are quality review and auditing, data analysis, enhanced waitlist management, and supporting industry research partners. In summary, rising organ offer volumes and regulatory demands are straining transplant centers' ability to manage organ placement services in-house.
Strata offers clear value as a trusted partner offering flexible pricing and improving operational efficiency. While we currently hold a low share of the market, there is significant opportunity to acquire new customers. I will bring Melissa back up to close our integrated transplant offerings.
Thanks, Jamie. I hope you've all learned a lot about our transplant-related business lines. Something that's important to note is that while we do offer an end-to-end integrated solution, we don't force our customers to use all of our services. There's a tremendous amount of potential to cross-sell our logistics services to our clinical customers and vice versa. Also, it's important to note that that upside is not included in the guidance that we laid out earlier. We are optimistic that over time, our customers use us as their one-call solution for the full stack of services. We've already seen through our commercial relationship with Keystone prior to the acquisition that 50% of the clinical customers do opt in for our logistics services. Our job is to make sure that trend continues, and we're going to do just that. We've now covered everything in transplant.
We're going to take a short break, maybe about five minutes, and then we'll bring Lou back on the stage. He's going to talk through our cardio line, cardiac care line, and we'll do some technology with our VP of software engineering. We'll bring Will and Matt back on to go through the financials and then some Q&A. Okay, thank you.
Okay, if you wouldn't mind gathering in, we're going to get started for the second part here.
Thank you all once again. I know this is a lot of material, a lot of slides we're getting through. It's very important for us to get the message across. There's a lot of moving pieces to our business, which was once a passenger business, but now a medical business. Certainly, a lot of material we're trying to get through to allow you to absorb it all. On the cardiac care clinical services side, I'd love to give a comprehensive overview of a little bit more on what we're doing there. When we first started the business in 2013, we had nearly 10 employees. Over time, we've grown the company to a national player in the perfusion staffing space.
At the time we sold the company to Strata, we had over 375 clinicians. We perform over 20,000 open-heart surgery cases per year across 31 states. We're growing at a tremendous rate. We are now a national perfusion platform company, not just on the core cardiac business side, but on the NRP side, our growth is tremendous as well. Hospitals and health systems look for us at Strata to provide a comprehensive outsourced solution. It's important to understand how this works. In cardiac surgery, you naturally have the cardiac surgeon who's carrying out the open-heart bypass procedure, the anesthesia providers who deliver the anesthesia to the patients, but the perfusionist who's a very vital part to the operation. They control the patient's blood flow while their heart is stopped so the surgeon could operate on their heart.
Hospitals tend to look for an outsourced solution for that very niche type of clinician. We pride ourselves on being a top player in the most respected perfusion staffing business in the field. We have strong clinical excellence. We're a company of perfusionists founded by perfusionists for perfusionists. The demand for outsourced perfusion staffing is rising quickly. In the last 10 years, the attrition rate for perfusionists has been higher than the graduation rate. There are hospitals and health systems that are struggling to employ these individuals. They're looking for an outsourced solution for them. A little bit more diving deeper into our service lines. As I touched upon the perfusion service, the outsourced solution, we also provide locum tenens services to help augment hospitals' in-house perfusion departments, but not just perfusionists.
We're also supplying nursing staff, cardiac physician assistant staff, all within a locum tenens agreement with hospitals and health systems. We provide ECMO services. ECMO is used for patients who are experiencing acute respiratory distress or cardiac failure. We're providing a perfusionist or an ECMO specialist to manage the ECMO circuitry at the patient's bedside right up until the patient gets decannulated, as we say, which means they successfully made it off of the device, or they get transferred to a tertiary center for greater care. Another part of our service lines are our auto transfusion and blood management service lines. We're providing an auto transfusionist to hospitals to operate a cell saver device in procedures where there's a large anticipated blood loss, decreasing the reliance of donor blood going to those patients, hence the name auto transfusion for autologous.
We have other services that we provide, either as a complement to our full-service perfusion or standalone services, including perfusion equipment rental, disposables that go along with carrying out cardiac surgery. Another adjacent service that we provide, being the experts in extracorporeal technology, is hyperthermic intraperitoneal chemotherapy, where we're circulating a chemotherapeutic agent extracorporeal outside of the body for these types of oncology cases. With that, I'll turn it over to my colleague, Christie Campbell. She'll give a brief introduction and tell you a little bit more about the cardiac care growth drivers.
Thanks, Louis. Thank you all again for your time this afternoon. I'm Christie Campbell, and I'm the Vice President of Clinical Services for Strata's cardiac care service lines. I'm also a perfusionist for the past 20 years. I lead our clinical operations and service line integrations. Together, Louis and I partner closely on the development of our KeyPort platform, the technology that powers our operations and supports how we scale. Louis just walked you through the cardiac care service lines that we offer. These statistics really put the demand side of that business into context. Cardiovascular disease is still the leading cause of death in the U.S., and all of the underlying factors continue to move in the wrong direction. Things like obesity, diabetes, hypertension are all core risk factors, and they've been steadily increasing, especially as the population continues to age.
An older, sicker population means more cardiac interventions and, in turn, more perfusion procedures. These are not discretionary procedures. These are life-saving interventions. That means that even modest population-level increases in these risk factors translate directly to sustained demand for the services that we provide. While demand continues to grow, the number of qualified perfusionists in the U.S. is moving in the wrong direction. There are roughly 5,000 qualified perfusionists in the United States currently. And 40% of those are over the age of 50. Nearly one-third expect to retire within the next decade. At the same time, the number of accredited perfusion programs cannot keep up with demand, graduating around 200 students per year. That is not nearly enough to keep up with retirements, let alone support new open-heart surgery programs. That is why hospitals partner with Strata.
They can't recruit or hire fast enough to keep up with demand, and we provide the stability and consistency that their programs depend on.
Great. Thank you, Christie. Very startling statistics. On the cardiac care clinical services side, we see an opportunity to continue to grow and scale our company through four key areas, certainly through new customer acquisition, for expansion into new staffing services, our ECMO growth potential to continue to grow that existing service line, and the roll-up and bolt-on opportunities, which is an area that excites me most, especially post-transaction with Strata, our ability to deploy capital for add-ons and bolt-ons. The team will share more about that here in a little bit. On the new customer acquisition opportunity, when you look at the outsourced perfusion staffing market in whole, the total addressable market is $350 million, where Keystone is having 7% of that market right now. There is a lot of runway for us to continue to grow and scale the company.
We've consistently added new perfusion retainer customers over the last few years, and we'll continue to do that in many different ways: the full-service contracts, the locum tenens contracts, and our fee-for-service business. The locum tenens business has proven to be a feeder model for our full-service solutions, meaning hospitals will lean on us for locum tenens perfusion services. When they realize that it's difficult to recruit and retain their own perfusionists, we then can partner with them to just outsource the entire department. We generally participate in every RFP that we're furnished. We've got awarded 80% of those, with the other 20% staying with the incumbent.
While we continue to experience organic growth, the real opportunity is how we leverage our existing infrastructure to expand into adjacent service lines. This includes things like intraoperative neuromonitoring, advanced cardiac care practitioners, and even biomedical equipment maintenance and management. These are all natural extensions of our core services, and we're already seeing demand from our existing hospital partners. Oh, that's.
I'm glad to hear.
Because we've built such a strong operational foundation, that allows us to move into these expanded service areas quickly and confidently. It's an efficient, low-friction way for us to grow while adding real value to the hospitals that we already serve.
The cardiac care acquisition opportunities, as I was talking about, and you'll see a clear theme here if you haven't already, our ability to deploy capital to acquire some of these other groups in this highly fragmented market. There's not one particular company that dominates the market. Instead, it's made up of national and regional players that it's very spread out and fragmented. A lot of the smaller players in our space, they generate less than $10 million of revenue, and they trade for low to mid single-digit EBITDA. From our experience on the six acquisitions that we've done throughout the last five years, they traded in that space as well, and they all have been doing very well for us. We have an active pipeline, and that's something that excites me the most.
We continue to lean on some of these possible companies to roll them up into our existing framework. We're looking for companies that fit our culture, they uphold our clinical standards, and help expand our footprint across the country. That's how we're growing. We're adding new hospitals, we're expanding into new service lines, and we're rolling up smaller outsourced staffing providers. To close it out, the cardiac care section, we're looking first, this is a high-quality, high-performing business with strong fundamentals and a clear track record of execution. Second, this gives Strata a platform to move beyond transplant and into the broader non-transplant clinical services with infrastructure that's already built and proven. Last, we have multiple pathways to grow well beyond industry rates through our new customer acquisition, new service lines, expansion within our existing service lines, and disciplined roll-ups and bolt-ons.
We're incredibly excited about where the platform is heading and the value it can unlock across the broader Strata ecosystem. With that, I'll hand it over to Melissa, who will walk us through the regulatory landscape.
I want to briefly address the current regulatory environment because recent federal activity, media coverage, and questions from investors have naturally raised some concerns across the sector. Over the past few months, we have seen what appears to be a temporary cooling around DCD donation behavior. This is not surprising given the recent scrutiny and evolving expectations. As many of you have seen in recent reporting, there have been variations in how DCD has been conducted nationally. At the same time, it's very important to remember that DCD and NRP are two of the most important drivers of organ donation. The more organs that are donated, the more they can be recovered, the more transplants that happen, and the more lives that are saved. What we are watching now is a period of clarification, one that is moving towards greater consistency, transparency, and shared expectations.
That clarity is essential for everyone: OPOs, transplant centers, donor families, and the public. This will reduce uncertainty and, over time, supports greater confidence in the donation process. This is what drives higher donation volumes. From our perspective at Strata, this is not restrictive. This is stabilizing. Our clinical operations have always been built around structured protocols, rigorous documentation, and reproducible practices, including detailed NRP case tracking. This positions us extremely well as standards become more clearly defined. A related topic generating attention is allocation out of sequence. The concerns with allocation out of sequence have to do around equity, making sure that exceptions are governed by consistent, understandable criteria. As clearer guardrails emerge, we believe it will reinforce fairness and strengthen trust in the decision-making process. Again, that trust is what supports more donation and more transplantation.
It's important to remember that across the field, everyone is pulling in the same direction: donor hospitals, OPOs, transplant centers, regulators, and industry players like us. We all share a single objective: help more people receive the organs that they need. Continuous distribution is an example of a policy evolution that is already showing benefits. It's prioritizing the sickest patients first, regardless of geography. It highlights how well-positioned we are at Strata to support these longer, more complicated missions through our logistics network and recovery networks. To summarize, we see these regulatory developments as constructive for the industry and constructive for Strata. Clearer expectations, consistent standards, and increased visibility ultimately expand transplant opportunity, and we are exceptionally well-prepared for that future. With that, I'm going to turn it over to Eric Moore. We're going to talk tech here. Eric is our VP of Software Development and Engineering.
Thank you.
Thank you.
As you have heard from the team, these two platforms represent the technology foundation of our logistics and clinical operations. Each is purpose-built for a specific operational environment, and both are critical to delivering safe, compliant, and efficient services at scale. When we think about what makes our logistics division operationally excellent, tech is the engine behind it all. No matter the type of logistics coordination, every request flows through this system from initial contact through final billing. Our customers get transparency into their service delivery across all transport types, and we get the data we need to continuously improve. This is where we're really changing how the customers interact with us. Traditionally, every trip request came in through phone calls, which works, but it introduces the potential for miscommunication.
Now our customers can log in directly into the portal, submit requests themselves, and they control the information at the source. This is part of the broader strategy to give customers more control and visibility while making our operations more efficient. Tech provides real-time tracking across every leg of transport with full chain-of-custody visibility. Works on any device. There is no special hardware investment required. This kind of transparency is what our customers expect, and it is what makes critical transport cases successful. Data without insights is just noise. Tech turns our operational data into intelligence for our customers. Every month, our customers receive detailed reporting on their transport activity, response times, completion rates, and service metrics. It changes the conversation from how are things going to here is what the data shows, and here is how we can improve together.
This level of transparency builds trust, and our customers see we're not just providing a service, we're partnering with them. KeyPort is our proven operational platform that we're continuing to invest in and scaling. It connects HR, compliance, clinical, and financial data in ways that are essential for the clinical services. We've hardened the security, modernized key components, and positioned it as a long-term platform. This is where KeyPort really shines. It's getting actionable clinical data at the time when it matters during the procedure. What's unique here is we're capturing data from two sources: the perfusion team's clinical observation and directly from the perfusion equipment itself. That equipment integration is crucial. Pump flow rates, pressures, temperatures is flowing automatically into the clinical record with timestamp accuracy. We then sync that with hospital EMR systems so the patient's chart is complete and our documentation meets the facility requirements.
Clinical benchmarking turns this data into insights that improve performance and demonstrates value to the hospital partners. Just like tech, having data is one thing. Turning it into actionable insights is what creates the value. Our hospital partners get live KPI dashboards showing case volumes, perfusionist utilization, response times, and clinical outcomes. For hospital administrators, this visibility helps them optimize their OR schedule, manage the perfusion coverage, and demonstrate quality metrics. From our perspective, this transparency builds trust and makes us stickier. When the customers see our performance data, they understand the value we're delivering. KeyPort is a strategic asset. It handles operational complexity that would otherwise require multiple separate systems. Automated onboarding tracks credentials, training, compliance documentation all in one place. Workforce management ensures the right perfusionist with the right skills is at the right facility. Inventory intelligence tracks equipment and supplies across all the hospital sites.
Accounting integration flows case data directly to billing, reducing errors and accelerating revenue cycle. This allows Strata to scale with proportional increases without proportional increases in administrative overhead. Thank you. With that, I'll turn it over to Will to talk about some unit economics.
Thank you, Eric.
Everybody can relax now. It's the finance section. We're going to give you some acronyms that you already know for a change. We'll start off with unit economics. How do we make money? What's our cost structure? And what structural protections do we have around our business? Let's start with the logistics business, where our revenue unit is an hour of travel time across air and ground. When we're using a third-party aircraft, this revenue unit matches our cost unit, resulting in predictable profit margins, but profit margins that are lower than our owned aircraft. With our dedicated third-party operators, we do often have an opportunity to get some fixed cost leverage with one breakpoint in the contract once we reach the guaranteed number of hours we promised to that operator. With our owned aircraft, things are a little bit differently.
We have an opportunity to leverage the fixed costs of things like pilots, insurance, aircraft depreciation, which is included in our cost of goods sold. This results in a higher average profit margin, but one that is more variable. It's primarily driven by aircraft maintenance schedules and the utilization of each aircraft. That's the number of hours that we fly on each tail. On the ground, we have a similar but smaller opportunity for fixed cost leverage only when we're using our owned ground assets. Across the logistics business, we benefit from multi-year contracts, and we pass through the things that we can't control. Fuel is passed through above a particular level. FBO fees, de-icing, things like that, we pass through to the customer. We have protections against disruptive short trips by having a minimum distance for our trips and also a per-trip launch fee.
We typically include a 3%-5% cost escalator. The most important thing is we ask our customers to give us 100% of their logistics business. This is what allows us to maximize our pricing, and it is also what allows us to move aircraft closer to those customers, which is the most important way we save them money by eliminating that repositioning. For them, it is even more important that it allows us to react more quickly when an organ comes in with little notice. Moving to our clinical services products. In both NRP and cardiac perfusion, we operate under a retainer model. In the cardiac perfusion side of the business, this is essentially a take-or-pay contract in favor of us. Any incremental use is billed above, but happens very rarely.
On the NRP side of the business, we try to minimize the retainer fee to cover only the fixed costs of having our employees ready at a moment's notice to perform NRP for a transplant customer. Most of our revenue and all of our margin is in a variable fee. This matches the reality of the way our customers are reimbursed in this business, which is all linked to the number of successful transplants that they complete. In both NRP and cardiac perfusion, we benefit from one- to three-year contracts with built-in price escalators. On locum tenens and surgical recovery, our revenue cost model for both sides of the equation is almost entirely variable on a per-case basis. This is also a much more ad hoc customer relationship, and rarely are there volume commitments.
Now I'm going to turn it over to Matt to talk about how all of this comes together into our financial guidance. Matt.
Thanks, Will.
Okay. Before we look forward, let's look back over the last five years and see how the business has performed. For this exercise, we're going to evaluate the medical segment revenue and adjusted EBITDA given the divestiture of our passenger segment a few months ago. As you can see from the charts, revenue, EBITDA, and margins have scaled significantly over the last five years. Revenue has grown at over a 40% organic CAGR over this period, including 15% over the last two years. This strong organic revenue growth has been driven by significant new customer acquisition and high single-digit industry transplant volume growth. We've also completed two major acquisitions over this period: Trinity Medical in September of 2021 and Keystone Perfusion a few months ago in September of 2025.
On margins, on EBITDA, the significant increase in EBITDA has been driven by this strong revenue increase along with an almost doubling of adjusted EBITDA margins from 7.5% in 2021 to the mid-14% range in 2025. This margin expansion has been largely driven by our own fleet that we purchased in 2024 and a mix shift to our dedicated aircraft as well. Moving to our 2026 financial guidance, we're introducing revenue between $255 million and $270 million, adjusted EBITDA between $28 million and $32 million, and free cash flow before aircraft or engine acquisitions of between $15 million and $22 million. Let's walk through some of the key assumptions embedded within this guidance framework. Starting with revenue. At the midpoint of the range, we assume high single-digit organic revenue growth in 2026, as we assume some of the factors that are currently weighing on industry transplant volume growth to persist in the near term.
As such, we assume mid-single-digit industry transplant volume growth in 2026. We're also only assuming a modest improvement in NRP penetration, which translates into mid-teens NRP donor growth. We're also only assuming a modest level of new customer acquisitions. Moving to margins, we expect adjusted EBITDA margin in the low to high 11% range versus 7% in 2025. The margin expansion we expect is mostly driven by our own fleet, where lower scheduled maintenance will translate into improved utilization and profitability. There will also be a mix benefit from the Keystone acquisition, as Keystone has a higher margin versus our base business. On free cash flow, we expect CapEx of between $7 million-$8 million, including $1 million of capitalized software development costs. On a like-for-like basis, CapEx will be down year over year. This will be offset by Keystone CapEx.
Working capital will be about 10% of revenue and will consume some cash as we grow. Moving beyond 2026, we're introducing a medium-term value creation framework that covers the period of 2027 to 2029. The key tenets of this value creation framework include low double-digit organic revenue growth, adjusted EBITDA margins reaching 13% by 2029, and free cash flow conversion of adjusted EBITDA between 60%-70%. This should translate into high teens organic adjusted EBITDA growth over the period. On top of this, we expect significant value creation from capital deployment, where we have approximately $200 million of cash available for deployment over this period.
Starting with low double-digit revenue growth over this period, the medium term that we're laying out right now, 2027 to 2029, we expect some of the factors that are weighing on industry transplant revenue growth in 2025 and 2026 to moderate, driving a rebound in industry transplant volume growth to the high single digits. We also expect a modest uptick in NRP growth to the mid to high teens, but this only implies NRP penetration of DCD donors to the mid to high 50% range. As Will mentioned earlier, we're at 40% in the first half of this year and 46% in the latest month. Importantly, this outlook does not assume any change in organ allocation policies.
While we believe that the regulator is moving towards continuous distribution of hearts and livers over the coming years, the timing of this remains uncertain, so we're not including it in our forecast. Margin expansion beyond 2026 will be largely driven by SG&A operating leverage, as we expect revenue to grow faster than operating expenses over the coming years, given the largely fixed cost nature of our operating expenses. We also expect to see a makeshift to higher margin clinical services versus logistical services, as we talked about a lot of the secular growth drivers and penetration stories of NRP and third-party recovery are in this clinical services business line. On free cash flow, we expect CapEx of between $7 million-$10 million over the period, also including $1 million of capitalized software development costs.
The timing of CapEx in any given year will be driven by scheduled maintenance on our own fleet. This outlook does not include any CapEx for aircraft or engines, but we expect spending on those areas will be pretty limited over the next few years. It's important to note that the free cash flow conversion, excluding working capital, would be over 70% in the medium term. Putting this all together, we expect adjusted EBITDA to organically double by 2029. Importantly, this framework is built on conservative assumptions that we're confident in achieving and do not require any heroic assumptions. As Will mentioned earlier, there are several drivers that are not factored into this framework, including NRP penetration, moving towards the standard of DCD donation of 70% plus, stronger industry transplant volume growth, customer cross-selling, or continuous distribution of hearts or livers, and last but not least, capital allocation.
As we discussed earlier, we have approximately $200 million of cash available to deploy over this period, given our strong starting cash position, cash flows over the coming years, and a conservative estimate of borrowing capacity. To illustrate the potential upside from these factors that are not included in our guidance framework, if we were to deploy 75% of this cash at a mid-single digit multiple over the coming years, EBITDA would triple relative to our pro forma 2025. This is one of the most exciting aspects of the Strata Investment Case. We've laid out a framework to organically double EBITDA by 2029 with conservative assumptions, and this does not include several upside drivers that could drive upside to this framework moving beyond to the medium term. That concludes our financial portion of the presentation. We'll now move to Q&A.
I'd like to invite the team back on stage for the Q&A session. Let's restand.
Damn it.
It's okay.
Don't worry about it.
We need to stand.
They're going to bring the chairs in.
If anyone in the audience or online has a question and would rather not ask it live, just a reminder that you could email investors@srta.com. Okay.
Do you want to just pass the microphone? You do. No. I have these questions back here.
Hi there. When you closed the Keystone acquisition, my impression was Keystone was adding about $23 million in revenue year over year, 2024 to 2025. Is that flattered by acquisitions Keystone made prior to the acquisition? Is there any reason why that amount of revenue couldn't be added in 2026?
I could take that one. Keystone is growing. The Keystone clinical services business overall is one of the fastest growing areas that we expect for the business in 2026 and the medium term. I think we laid out a framework here, as we said many times throughout the presentation, of fairly conservative assumptions that we are really confident in. We were not assuming NRP penetration really rises or third-party surgical recovery really rises significantly over the next few years. That is all upside. Another factor just to keep in mind is Keystone really launched their organ recovery business a few years ago and was at the really early stages of scaling that in 2024 and for a portion of 2025. That growth, 50% plus, will normalize, but we expect really attractive growth from their business, from clinical services moving forward.
Hi, I'm Justin Wang with Morgan Stanley. I guess right now I appreciate that Strata is focusing more so on next flight out or hand carry for kidney. Do you expect the possibility of requiring private charter aviation for kidney, even for some DCD cases? Do you think that the organ is just so resilient that there's no real need for this?
I'll take this one. Ultimately, as we all know, look at what just happened in the government, commercial aviation is not the most reliable. Today we are moving kidneys with private aircraft. From a cost perspective and the resiliency of a kidney, the best way to go is to go commercial and go that route. We will continue to see a mix. The majority will be on commercial, but there will be some charter in the future.
Got it. Thank you. And one more from me. I guess longer term, where do you expect the volume mix to be between air logistics and ground logistics? I think over the past couple of years, it's been trending more towards ground in the industry. I mean, do you see this continuing in the next few years?
I wouldn't say we've seen a trend towards ground in our business. The air piece, as we talked about, you're seeing the distance between donor and recipient increase. It's still going on. You got a number of regulatory factors that could cause livers and hearts to start being matched to people who need them most that are farther away. We actually think the opposite, that there's a lot more catalyst to increase the amount of revenue that's coming through air. That's all aligned with getting more transplants to people who need them. You've seen our ground business historically maybe grow a little more quickly. That's because we were building out that ground capability. Remember, when we're on the ground, particularly when we're serving OPOs, we're moving many other kinds of things. We're moving tissue samples, blood samples.
We're moving staff and equipment to prepare that donor for the transplant process. There are a lot of different factors that go into the ground side of the business. Air is really poised for significant growth going forward.
Got it. Thank you so much. Hi, thanks for taking my question. I just had a quick one on maybe the target mix between owned aircraft and then dedicated third-party leasing, and then maybe if you still expect a non-dedicated third-party aspect to kind of move into the mix in the future.
Sure. We do have three categories now. We have owned, dedicated, which is contracted for exclusive capacity. About 20% of our flying is done through non-contracted, safety-vetted third parties. We do have those three categories now. About 30% of flying is done on the owned fleet. We like this capacity mix for right now. It is allowing us to utilize our owned assets pretty well. We'd actually like to see a little bit more robust use there. It also gives us a lot of flexibility still by being mostly asset light. We get all the competitive advantages that we've seen, like a couple of RFPs that require asset ownership, and we still get the competitive advantage there of owning the planes.
It's not that we're--I'm not saying we'll never buy more aircraft in the future, but it's not going to be a significant amount of capital.
Thank you.
Thanks for all the time today. I just wanted to follow up on the Keystone question. When you announced the acquisition, you said $65 million of revenue. If you look at the pro forma nine-month numbers and make an assumption for fourth quarter based off the third quarter, it would seem like it's running a little bit above that. Question one, is that the case? Second question is, in terms of your guidance for 2026, what are you assuming for Keystone relative to, say, that initial $65 million?
Yeah. We talked on our earnings call that we've had an excellent start to Q4, consistent with what you've seen in the industry data. I think things are off to an awesome setup for us going into 2026. We are guided by our historical experience that organ transplant volumes for our particular third of the market that we serve can be somewhat lumpy. We always want to see some consistency of growth. We're not going to guide, nor did we in this situation, off of a sequential comp of what was the best quarter we've ever had in the company's history for the medical business. I think there's different ways that you could look at that.
If it truly was a seasonally weak quarter and we just significantly outperformed, then there's probably a lot of upside to what we talked about today in terms of guidance. We always like to be cautious, particularly when building a base off of one quarter. Does that answer your question, Will?
A little bit, yeah. If I take, though, the revenue drivers of the mid-teens industrial NRP growth, that would be a number to apply to the Keystone number for 2026 based on this concern?
You couldn't apply it to all of Keystone.
Just the NRP side.
Yeah, just the NRP.
What would be the cardiac care side?
It's the majority of the revenue of Keystone.
The NRP side.
The cardiac side.
The cardiac side.
Yeah.
Cardiac side. Right. Okay. Just one additional question. Of the things you did not include in your long-term guidance, one was the cross-selling. You touched on it a little bit, but I was wondering if you could just sort of expand a little bit more on that opportunity in terms of how you're going to sort of tackle the opportunity. What is the potential revenue that could come from that as well?
I think.
Can you talk maybe about the customer, the sales part?
Yeah, absolutely. As Dr. Silvestri pointed out, our presence in the thoracic landscape is about 25% of all transplant centers right now. We feel as though we could conceivably partner with a significantly higher amount. Right now we have our book of business in the transplant center space. Our other adjacent service lines may have partnerships with other transplant centers. Naturally, us opening doors for one another is a strategy that we can employ moving forward. Right now, so much of our growth is organic due to performance, either by transplant centers that talk to other transplant centers, or if we're doing cases for one of our OPO partners that happen to be operating on behalf of another transplant center, that also opens other doors. I don't know if Dr. Silvestri wants to maybe elaborate a little further.
The other opportunity is the TOPS program, which Jamie described. Transplant centers live easy. They live seamless, and they live cheap. Putting that together where the TOPS programs have adopted our services, because if two services are equivalent and one is integrated inside the ecosystem, it makes it easy, as well as equivalent. I think it goes both ways. I think we're starting to see a lot of that getting steam already.
Maybe just on the financial side of it, we said when we did the deal, we have very minimal customer overlap. I think we said it's about 10%. I think a big part of this is the logistics revenue that we get as they're growing. That's what's coming in day one, right? Because Keystone Clinical Services Group is continuing to add new customers. As they add new customers and grow, and we get attached to that, that's growth for our logistics business. That's happening now. We expect that to continue over the coming years. We put a statistic in the investor presentation that it's about $0.20 of the dollar as the clinical services revenue grows, that the logistics revenue grows along with that. That's a significant opportunity.
Beyond that, which we're working on as a team, is how do we then take our logistics customers and then work with them to procure some of the clinical services on top of that, and vice versa. That is a significant opportunity that we're working on. We said that that's a mid to high single-digit millions opportunity of addressable spend that they're spending today with third parties that we can go after. We're working on that. The whole team is coordinated on it. We can provide updates to the investment community over the coming months and quarters as we work on that.
I think one of the things that's really important in our space is instilling trust with our partners. That's something that our organization at Keystone and Trinity on the logistics side has done very well for all of our existing partnerships. When we happen to recommend Trinity Logistics for one of our partners that trusts us as an organization and thinks that we are a quality provider, they trust our opinion and vice versa. That's a significant opportunity in this space. It's difficult for OPOs and transplant centers to outsource some of this work when they have this high bar of quality. There may not be a lot of providers out there prior to our arrival that can uphold that same quality standard. That's something we feel under the Strata umbrella we're doing at a very, very high level.
Thanks. First, can you talk a little bit about the relationship between NRP and machine perfusion? Do you do one and then the other? Can you forgo the second if you do not with NRP? Related to that, can you talk a little bit? Just obviously, you guys do not have your own devices. As more devices come onto the market, how do you guys see that landscape evolving?
Yeah. [crosstalk] That's a great critical question.
That's a great critical question. Think about machine perfusion as being good for the individual organ. Think about NRP as being good for all the organs. If you have an organ in Alaska and you want to transplant it on the east side here, you're likely going to do NRP and, let's say, a liver, and then put it on a perfusion machine so that the eight hours of transport keep the organ as viable as possible and minimize the damage. They can be layered on top of each other. They can also not be layered on top of each other.
If you're in New Jersey and you do an NRP and you just put it on ice or controlled ice or controlled temperature and bring it to the west side, in this case, or Spanish Harlem, you can get that organ done with a smaller, shorter ischemic time without the need. Now, there's another element. Remember how I said surgeons like sleep? What they're doing in a lot of places is they're putting it on machine perfusion, and they're using that time to time the operation when it fits into their workflow. For a surgeon, that might mean during the day or the afternoon as opposed to working all night. We're using the tools fundamentally to change the work process to fit in medicine for a number of incentives. Not all of them are direct patient benefit. Does that make sense?
Yeah. As far as the advent of new machine perfusion coming to the marketplace, I mean, we welcome that. It is very important that we maintain our open-source model because that ties directly to a core value that the customer is always right. Transplant centers down to the surgeons doing the transplantation are going to have their own individual preference on NRP, machine perfusion, back to base, in-flight, all sorts of different criteria that go into this. What we are doing and what we are going to continue to do is scale a platform that supports any and all of those decisions.
Any more questions from anyone in the audience?
Just on continuous distribution, I know it's not in the guidance, but what would be the, I don't know, the expected benefit to volumes if that transition happened?
We talked about the data on lungs, which have already moved to continuous distribution as a potential benchmark. You saw distances between organ donors and organ recipients increase by about 80% once that switch was made. If you think about our unit economic model, we bill by the flight hour, that would be an 80% increase in the average revenue per trip for those organs. It could be a very meaningful increase. We're not underwriting that because we don't know exactly how it would be implemented for liver. We don't know how it would be implemented for heart. It could have a very different impact. We've also somewhat limited a couple of years of data on the lung. In any respect, it would certainly get the organs to folks who need them first and not focus primarily on geography, as the matching system does today.
It is a good thing. It is in the public comment period right now. That is why we are reserving comment as to what the exact financial impact would be. Something, I think, probably what happened with lungs is probably a little on the high end of what the impact could be. Again, it is one of these many ways where our positioning is such that we are in the faster-growing parts of the market and will outgrow whatever the market growth is.
Probably also worth mentioning that lungs represent about 20%-25% of overall heart, liver, lung volume. So a significant amount of the market in terms of available transplants are going to be moving towards distribution, we believe, over the coming years.
Hey, guys. Maybe in the context of stressed industry volumes, I think, Dr. Silvestri, you said that if someone sits on the transplant waitlist for six months and dies, it's lost value and vice versa. Obviously, the hospitals are incentivized to save lives. Any additional detail on how that correlates to sort of the economics of the business of operating as a hospital and why you think that recovers at some point?
Yeah. I think what we're establishing, so this actually, you understand this better than I do. What we're creating is a more efficient market with these tools and enabling technology. You're matching aggressive centers in location A with organ opportunities in location B, C, and D. These organs are available for a moment in time. If the right place cannot have access to those organs, then those organs do not get used. That is critically important. It goes back to what you said. There has never been any allocation change in the history of organized organ transplantation that decreased donor distance. It is always about matching the organ. My friends in Tampa go to Anchorage, Alaska. The guys in Paris went to the Caribbean to get an organ and put it on machine perfusion. The distances are opening up.
I think that all of this enables saving lives at a lower cost, ultimately, because the market is more efficient. I think that's a language most of you get that in medicine we don't get, right? You make an efficient market, costs go down.
Anyone else?
Thank you. My question is on acquisition of equipment. When you acquire aircraft or equipment for perfusion, are these leased, or do you buy them? Do they own the aircraft? When you say 30% of aircraft are owned, are they leased, or are they purchased?
No. We own them outright.
OK. Therefore, it will affect the EBITDA when you depreciate the asset quite a bit.
Yeah. They depreciate them.
What is the EBITDA in that case? Where does it come to? Because that was not.
Yeah. You saw the slide of the increase in margins over the last five years. If you would look at it, there would still be a significant increase in margins after depreciation. I think maybe it is like 150-200 basis points lower, but still a significant improvement in the profitability after depreciation.
In our slides, when we talk about the flight profit increase that we get, that metric is net of the depreciation. We are seeing that increased profitability for the owned aircraft, even taking that into account.
They will. Thank you.
We have no debt on them either. It's important to know.
OK. We could take, I got a few questions emailed. We could take those, and we can wait to see if anyone else has any questions in person here. Maybe just starting off, we're expecting the industry transplant volumes to reaccelerate in 2027. The question was, why do we think that? Will, you can take that one.
Sure. I think Melissa covered this well in the presentation. We think there's been a transitory impact, really, in conversions of potential donors from some of the negative attention that's been coming through the press. The ultimate outcome of this has been really positive, which is the regulators and all market participants are working to restore trust in the system, create uniform procedures across the country for how organ transplant is carried out. As the team talked about, particularly on the clinical side, we have best-of-breed tracking in terms of our ability to ensure that our training is going to result in that predictable outcome every single time. We have the technology to prove that it was done the right way through KeyPort and through the monitoring of the actual biometric systems that we're using during these procedures.
We really think, A, the industry needs this standardization. B, we are set up to be best in class in terms of being able to comply with whatever bar is set in the future. We hope it is set as high as possible because once you restore trust in the system, then folks get comfortable. They go back to the old equation, which is there is something tragic that happened as it relates to my loved one, but I can save one, two, three, four, five lives through this tragedy. That is what the conversation should be about, not about the process of organ procurement. We see that playing out right in front of us with regulators and with participants. That is why we see an expectation of growth returning to those mid to high single digits.
Frankly, with what we've seen already recently in recent months, we're seeing things start to improve already.
Great.
We covered this a few times. Dr. Silvestri, we got a question on NRP and the regulatory scrutiny. About how do we think about the dynamics there and the risk around NRP? Why do you not just cover, maybe summarize what we talked about in terms of our view on NRP and what is going on right now with regulation?
We think that NRP is the maximum benefit for the organs, for the individual donors specifically, and that we have been sort of set back because the process grew up all over and every OPO in different processes. All of that came together. Some of you may have seen the hearings on the Hill. What has happened is the OPTN, HRSA, HRSA has come up with very clear operational parameters to define. This clarity will help ensure process, high-fidelity process, make sure that there are policies, and make sure that every contingency is taken into account. Because we at Keystone had been some of the most experienced clinicians in NRP, 2,000 or more in a year, what has happened is we saw things and developed process, documentation, and contingencies that OPOs in Kansas, in Milwaukee, and other places had never seen.
When we were doing briefs and huddles, we would raise questions, what do you do? What is your policy on? They would say, we don't know. We have to check because they had never seen it. We have brought, as leaders in this field, in collaborating with the OPOs and HRSA, we have brought structure and our high-fidelity process, which is forward compatible, so that when we see things, everyone has clarity in the room as to what happens. At 2:00 A.M., all sorts of things can happen with inexperienced players in a room. That's how these things happen. Everyone wants to do the right thing. Everyone wants to get the organs. Everyone wants to do the right thing for the donor, for the families. Learning how to do that takes time. It was a very nascent field. Keystone's had tremendous experience.
A perfusionist is used to safety, redundancy, communication. We brought that to this process. Now it is being franchised with all the organizations and HRSA and CMS and UNOS throughout the country. We think that this will level set and allow it to grow significantly moving forward. We also think that the central cost of doing this through the OPOs at the donor level makes sense economically and will be the driver for many of these things moving forward, my opinion from what I have seen. Again, everyone wants the least cost possible.
Great. Thank you.
Any last questions from the audience? Great. That is a wrap. Thank you everyone for joining us today. I hope you learned a lot about the business and about how we are thinking about the future and how excited we are for the coming years. Appreciate everyone's time today.