All right, sorry for the delay here. Very pleased to introduce Neuronetics. With us, we have Keith Sullivan, President and CEO, and Steve Furlong, SVP, CFO, and Treasurer. Gentlemen, thanks so much for joining us.
Thank you. Thanks for having us.
Of course. So I wanted to start on Q3. You had a very solid Q3 print. You tightened up your full year outlook. So, you know, I guess, would love just to hear a little bit more about how you're thinking about Q4, specifically capital versus treatment sessions. And then, you know, I, I get a lot of questions about Greenbrook. So, you know, how are you thinking about Greenbrook in the fourth quarter?
So we did have a very solid Q3, and I think the momentum from Q3 is gonna carry forward in Q4. On the capital equipment side, Q4 is always the biggest quarter of the year for us. There are tax incentives for the physicians to invest. So I think right now our pipeline is healthy and we have our summit coming up this week, and once again, we have an overflow capacity there. So I expect on the capital side, we'll do just fine. On treatment sessions, it has been building on our per-click business on a regular basis over the last couple of years. We've talked about NeuroStar University and the impact that that has had on our accounts.
We have designed that facility to house 25-30 people, and next week we have 42 attending. So all of that is building to a good Q4 for our treatment sessions also. On the Greenbrook front, we said on our earnings call, and I'll say it again here: we monitor their activity, their utilization, and their spend every single Wednesday. So, I communicate with the CEO at Greenbrook on a regular basis. We are very close together. They are the first 26 sites in our Better Me Guarantee program. So we see their utilization increasing throughout this whole year, and it is getting stronger and stronger. So, there's been a concern out there that Greenbrook is not gonna make it. That concern is not shared by anybody at Neuronetics.
Okay. That's, that's great to hear. Maybe just to double-click on the, the treatment sessions and specifically the per-click model, you know, which is doing very, very well. Maybe just talk a little bit more, Keith, about the, the primary growth drivers there. Is it productivity? Is it awareness? You know, what is driving the success with per-click?
So several months ago, we brought in a new chief commercial officer, chief marketing officer, and she has done a fabulous job really fine-tuning our digital and social presence. But I would say the biggest driver for us is our NeuroStar University, our practice development managers, and then the whole program around getting their offices to be able to talk to the patients, educate them, and then ultimately get them into the chair for treatment. So, NeuroStar University, for us, is the linchpin for all of that. I think we've talked in the past about our practice development managers, who are trying to educate these practices, have really been the tip of the spear for us. And, you know, in physicians' practices, you often get 20-30 minutes at a time of their attention.
At NeuroStar University, we get their full attention for two days, and then the practice development manager becomes the reinforcement in the field instead of the tip of the spear. So I really think that it's NeuroStar University has made the difference in our practices.
That's good color. And, just as a follow-up there, what percentage of your customers are on a per-click basis?
So close to 80% of our customers today are on a per-click, and that's excluding Greenbrook. If we add them in, it's mid- to upper 80s.
Okay. Okay, that's helpful. I'm trying to think where to go next, but, you know, utilization of existing systems has been really, really good. You know, you've talked about, I think, some of the levers there, but with the sales force, you know, productivity has been good. What are you doing to incentivize utilization growth?
So, our practice development managers, we have 47 of them out in the field. They each have approximately 25-30 accounts. We pay them on the treatment sessions, so we pay them half of their commission when the treatment sessions are sold and loaded onto the machines, and we pay them the other half when they're actually used. So that practice development manager is tied at the hip with the practice itself and is really the key to their success. So there's plenty of incentive there for them. But recently, we've put an incentive in place for the practices themselves. So, you know, one of the challenges that we've had is, psychiatry is a specialty that is unique in the medical world, I think. You know, they're used to-...
being smaller practices with smaller offices, and they, they have a relationship with their patients that is unique. It's not an aesthetic practice, what I'm used to. We need to, get them to be, accepting of a business within their business. That's what, TMS NeuroStar is to them. And quite honestly, nobody teaches them how to be businesspeople, but specifically, no one teaches them how to run a business within their business. So we have, just kicked off the Better Me Guarantee Provider Program, and even though we are, we have been talking to them about what they should do to be successful in their practice, many of them cherry-pick what we suggest. Today, I live in Charlotte, North Carolina.
If there are 10 physicians in Charlotte and we get 10 leads, I have to spread one out to each one of them, even though I know eight out of the 10 don't answer their phone. So we have worked over the past, you know, year and a half to two years with our lawyers to put together a program that will ensure that patients get better care. So we have asked them to do... Under this program, physicians that will participate in it have to do five simple things. They have to attend NeuroStar University. They have to answer their phone with a human being between 8:00 A.M. and 5:00 P.M. They have to do the full prescription of treatment to 36 when medically appropriate.
They have to do our PHQ-9s within the practice and have a dedicated person to respond to those patients. They have to have a website and social media presence that mirrors ours. We co-op market for them, so we pay for half of that. So if they choose to do those five things, they're in the program. We monitor it. We, you know, do secret shopping calls. But if a physician chooses not to do those five things, then they are opting out. And as part of that, we are no longer responsible to send leads to that physician. And therefore, the ones that will provide the best care, that do the five things that we're asking them to do, will get better results for the patients that are looking for help.
That's great color. And just on Better Me Guarantee, remind us how many centers are part of that program, and how do you envision scaling that going forward?
So we launched it to our sales organization on October 2nd, and on October 3rd, they went out into the field. They armed with a DocuSign document that, when the physician signs up for it, he is committing to doing these five things. He's not in the program. He's just committing to letting us help him. Over the actual marketing, the direct-to-consumer campaign will start on January 22, and we will allow 100 accounts that comply with our five standards into that program. We will run the pilot with that group. A second group will be admitted into it on April 8. So ultimately, there will be a direct-to-consumer TV campaign in the end of the third quarter, beginning of the fourth quarter, somewhere sandwiched between the Olympics and the presidential election.
So that's the lure, and it's also created a significant amount of FOMO. These accounts don't want to be left out of the program. So to date, we have well over 200 accounts that have committed to this process and are scrambling to become the first 100.
That's great. Very exciting stuff. You know, maybe just a step back, bigger picture question on the reimbursement front. You know, there's been some positive changes that have kind of come out over the past, you know, let's call it 1-2 years. You press released a lot of them.
Yeah.
Are we seeing the patient funnel to TMS truncated or shrinking? I'm just curious. Maybe it's hard to quantify, but would be curious to get your thoughts there.
So the answer to your question is yes. From hearing about a NeuroStar treatment to receiving it is shorter, but it's not because of the reimbursement.
Okay.
The reimbursement has been getting better. So most of the carriers back in 2016 required four failed drugs, even though our FDA clearance is a single failed drug. But most of them and especially the biggest ones have all moved from four to two. So they're not where we want them to be, but there are enough patients that have failed two drugs out there to make a good living for us for a long time. What has changed is identifying what has to happen from the time the patient walks into the doctor's office to getting them into the chair. So it used to be a couple of months to get them to start the treatment. Now we have it to be under two weeks. So it's a good progress for patients in need.
Okay, great. I wanted to go back to the capital side of the business, and you touched on this earlier, Keith. You know, system placements were maybe just a touch soft in Q3, but it sounds like some of those just kind of got pushed over into Q4. I guess I would just love to hear the latest thoughts there. I mean, it sounds like Q4 is shaping up to be a good quarter from a capital standpoint, but would love for you just to kind of flesh that out.
Yeah, we had a few systems. I think we've always said that we're targeting 45-50 systems a quarter, and that's still our target. You know, it. I can't. If we sold 100, I can't train 100. So we came in at 43 this quarter, but we had several systems that pushed because I couldn't get the paperwork through fast enough. We added a new lender to our mix, and their process, instead of taking 3-4 days, took 10. So I missed it by a few days.
Okay.
Our pipeline is plenty healthy.
Okay, that's good to hear. You touched on the NeuroStar Summit events earlier in our discussion as well. I know they've been very, very successful. How are you thinking about those in 2024?
So we plan to have one a quarter to continue that cadence. You know, the question we get asked frequently is, "Why don't you do one a month? Why don't you do them regionally?" It's, you know, a, I can't burn out my team. There's a lot of work that goes into these. We also have a great panel of experts that come, and I can't burn them out either. But there's also again, there's a FOMO that's created around being invited and then being accepted to come. We do turn people away, so having it once a quarter is keeping our pipeline full for the 45-50 systems that we need.
Yeah, that's great. You know, I'll ask about the indication expansion opportunity, and I think you, you've added, I believe, OCD and anxious depression. Curious if you think those have been tailwinds to the business. And then I, I believe you made some comments about further indication expansion in 2024. You maybe have been a little bit more cryptic there. But just, yeah, have you seen any impact thus far from OCD and anxious depression? And then what can you share regarding other indications in the future?
Most patients that battle depression also have anxiety. We've just never been able to talk about it before. So having that indication really didn't increase the business. I think the market for OCD is much smaller, but it has made the system that these physicians have invested in more valuable to them. So, is it, you know, a 5%-10% pop to our revenue? It's not. But it really enables the physicians to treat more people. We have submitted for a clearance with the FDA. We're working through that process, and we... You know, the FDA is on the clock. We should hear from them by the end of the year.
Okay. And sorry to push here, hear back from them by the end of the year, are you kind of alluding to a potential early approval in the first half of 2024, or?
I would say we would get a response from them, yes or no, by the end of the first quarter.
Okay. Okay, perfect. That's exciting.
It is, and I think it will help a meaningful number of people.
Okay.
How about that?
Piquing my interest.
That's all you guys.
Stay tuned. Great. And, you know, maybe I'll, with about 5 minutes left, get Steve involved here. You know, I guess the first question, and Keith, feel free to answer this one, too. Very fluid macro environment. You know, if we were to kind of go into this recessionary environment next year, you know, one question I sometimes get from investors is, you know: Will patients kind of follow through with a multi-week, you know, treatment course? It's an impossible question to answer, but I mean, what's your response to that?
Yeah, I mean, we've experienced recessionary pressures before, with COVID. I think the lesson we learned with COVID was people stayed away from clinics because, you know, they were worried about getting infected. I don't think a recessionary pressure impacting a patient's copay would be that significant. So it may put some pressure on the business, but I don't think it's gonna be as, I would say, as significant as COVID was in 2020 and 2021.
Yep.
The patients don't go away, and their depression probably gets worse.
Yep.
I think, you know, coming from the aesthetic world, when you went into a recession, people scaled back on all of that. I don't think they're going to scale back here.
Yep. That's great color, guys. Sticking with, you know, the P&L, and maybe just talking about operating expense. You know, Steve, how are we, how should we think about OpEx spend for 2024? What are you planning for the commercial team? Are you gonna be neutral, or are you gonna add? Just flesh that out for us.
Yeah. So I would say since 2021, we've been communicating that our plan is to leverage our infrastructure, i.e., keeping operating expenses flat. You'll see with our guidance for 2023, it's flat to 2022. And our goal and our commitment to our investors is to keep it flat again for 2024. And so, you know, we've been also communicating our plan to get to cash flow breakeven by Q4 of next year. A key component is leveraging that infrastructure and keeping expenses flat. We did have some, I would say, one-time, cash flow events this year. So we did convert $5.9 million of Greenbrook receivables into a senior secured note, so that impacted my cash flow.
Also, we transitioned to a new contract manufacturer, so I picked up about $1.5 million of non-recurring engineering, and then also I had to prepay inventory to get them up and running. And so, you know, our cash burn this year was significantly higher than we had planned, but on the flip side, it's gonna be significantly lower in 2024.
Okay, that's great color there. Maybe just one quick follow-on with the contract manufacturer, and just gross margins. I think the adjusted gross margin was really good in Q3.
Mm-hmm.
Yeah, not sure if that was predominantly a mix effect-
Mm-hmm
... or if there were one-timers. But, I guess what I'm trying to ask is: how should we think about gross margin going forward?
Yeah. And again, we've stated in the past that, you know, we're in the mid-70s now, 76, 77. We plan on, you know, continuing that growth and getting close to 80 as we exit 2024. As you mentioned, the most significant variable is the percentage of treatment session revenues, which are at a 100% margin, versus the system margins, which are about 50%.
That's great. Wanted to actually sneak one in on competition, and just kinda take the temperature there. You know, historically, you've been the best capitalized TMS provider. Anything to call out on the competitive environment, or are you still really like the position you're in?
I think we're comfortable. You know, we certainly have competitors, and we monitor them on a regular basis. There's enough business out there for all of us to survive, but we have created the programs and the avenue that we're going down, and there is no reason for us to change that. I think we're gaining ground. We've got momentum going. We're a treatment session company, not a box company, so if we can drive greater awareness and then educate the accounts on how to capture those patients and educate them, I think we win. So we're good from a competitive front.
That's great to hear. I wanna finish with, one last question, probably an unfair question. I'm gonna try my luck anyways.
Maybe the time will run out.
Yeah. Yeah, exactly. So 2024 consensus revenue is sitting, I think, $79 million.
Mm-hmm.
11% year-over-year growth. I know you're not giving guidance at this juncture, but any reaction to that figure? And, you know, if not, maybe just share kind of some high-level puts and takes as it relates to next year.
You asked me the same question last year at this conference, so-
I did.
Yes. And so, you know, I'm comfortable with where the analysts have us now. I think it does set us up for beat and raise activity in 2024. So you can kind of run with that. So yeah, 11% doesn't scare us. Obviously, internally, we're targeting a much higher growth rate.
Okay, perfect. Well, I know we're a little bit over, and I apologize for starting late, gentlemen. But, thanks so much for joining us this year.
Great.
Thank you.
Thank you, guys.