All right. Good morning, everyone. Thanks for joining us at the William Blair Growth Stock Conference. My name is Margaret Kaczor Andrew, and I'm the analyst here at William Blair & Company that covers Neuronetics. I am required to inform you that you can find a complete list of research disclosures and conflicts of interest at williamblair.com. With that, very pleased to have Steve Furlong, CFO of Neuronetics, as well as Sara Grubbs, Chief Revenue Officer. Guys, point it over to you.
Good morning. Thank you for having us. Again, I'm Sara Grubbs, the Senior Vice President of Sales and Chief Revenue Officer here at Neuronetics. We truly appreciate this opportunity to share a mid-quarter update on our top initiatives outlined here that have had the most significant impact on both our revenue and our growth. I'd like to start with one of our key metrics, new patient starts on the NeuroStar system. New patient starts are the precursor to treatment session utilization and revenue. This first graph represents new patient start trends since 2022 across all of our NeuroStar customers. If I can draw your attention to the far right of the graph, I want you to take note of the trends we've seen this year, January through May, with consistent growth. Last month, we achieved a historical record for new patient starts, with no signs of slowing down.
Again, this is all of our NeuroStar customers, so let's now dig into our most critical category of our business, which is our local consumable accounts. These customers represent our per-click model and have the largest potential impact on our revenue. Again, focusing on the new patient starts for this year to the far right of the graph, you can see the consumable accounts have seen the most growth, and in fact, are up 22% year-over-year. We've seen great momentum this year, and you may be asking: What is contributing to this accelerated growth? One key initiative is the impact of our industry-leading NeuroStar University. As a reminder, NeuroStar University is our state-of-the-art training center located in Charlotte, North Carolina.
This enhanced training program has been a home run for our NeuroStar customers, providing a greater in-depth knowledge on how to educate more patients and offering advanced clinical protocols. We did a look back over the last two years, and since inception, we now know NeuroStar accounts who attend NeuroStar University treat and use 58% more treatment sessions than those accounts who have not attended. The real magic happens by bringing together 20-30 attendees, including physicians, nurse practitioners, business owners from across the country, to dedicate two full, uninterrupted days on how they can enhance their NeuroStar business. We've now hosted over 30 classes, and our goal is to continue to encourage every NeuroStar customer to attend NSU and allow us to help them treat more suffering patients.
With new patient starts and utilization both on a positive trajectory this year, I would now like to transition and provide a quick update on the Change Healthcare cyberattack. Keith addressed the timing and temporary impact on the cyberattack on our customers during our Q1 earnings call. To better understand the full scope of this cyber breach, we conducted a survey to our customers asking two simple questions. First, has your practice been impacted by Change Healthcare? And if so, what part of your TMS business has experienced the most challenges? We heard from 105 NeuroStar accounts, representing 152 sites across the country, and know that 60% of our customers have been impacted, and of those accounts, the most challenges have been with TMS reimbursement.
These delayed reimbursement issues have ultimately affected their practice cash flow, as we reported on our call. On the brighter side, we are starting to see improvement in the TMS prior authorizations and the TMS patient starts this quarter, as the backlog of patients are now starting to get approved and finally move into treatment. We anticipate this backlog of patients and reimbursement delays to resolve in Q3. Now, we have two main highlights for this year we would like to provide updates on. First is the Better Me Provider Pilot. We launched this pilot in January this year, initially with 100 sites, and now have 250 participating sites.
The entire goal of this program was to connect suffering patients from both inside and outside the practice with NeuroStar customers that would promptly respond to them and help educate and move them through the TMS process quickly. To participate, each site has to commit to five standards, all centered around patient care. First, answer your phones. When a patient sees an ad and finds your practice online, you are required to now answer your phone during business hours. Second, provide a prompt response. When potential patients see an ad and complete a web form inquiry or a PHQ-10 mental health survey, practices must follow up with these patients within one business day. Update their website. We know most patients will go to the practice website first to learn about all of their treatment options, and this NeuroStar content needs to stay updated. Treat to complete.
When a patient does move into treatment, these practices are committed to delivering a full course of therapy with 36 treatment sessions to achieve the greatest clinical outcomes. And finally, the capstone of the entire program, each site must attend NeuroStar University to know how to effectively implement each one of these standards to provide the best care for their patients. And when a practice executes all five standards, NeuroStar commits to investing our marketing dollars all around their practice to help drive more awareness and ultimately identify more patients for treatment. With the help of our 45 practice development managers across the country, we have truly seen a shift in behaviors inside our NeuroStar practices. The first major behavioral shift we have seen was in the practice response time to potential patients. We have struggled for years to get practices to respond to patient inquiries quickly.
We know that the sooner the practice responds, the more likely they are to get a hold of the patient and provide the help they're seeking. In fact, our data shows the most likely chance to connect with a potential patient happens in the first 30 minutes from submitting their web form. This is why the practice response time is absolutely critical. So as a reminder, to participate in the Better Me Provider Pilot, practices need to respond to patient inquiries, both inside and outside the practice, within one business day. Let's first review the patients inside the practice who received the NeuroStar Mental Health Survey, or what we call the PHQ-10. This survey is our most valuable tool we offer our customers to help identify patients inside the practice who want to learn more or perhaps book a consultation for this non-drug alternative to treat their depression.
As you can see in the chart, our non-Better Me Providers only followed up with patients within one business day on average, 13% of the time. In comparison, our Better Me Provider Pilot accounts had a 78% successful follow-up rate in one business day with these patients who completed the PHQ-10. We saw similar results with potential patients outside the practice coming in from our Better Me ads and our physician locator website. Again, our non-BMP accounts only followed up at a rate of 14%. However, we saw a 90% successful rate of prompt follow-up from our Better Me Provider participants. So how does this translate into a successful program? Our measurement of success is in two ways: first, new patient starts, and also the time it takes from awareness to treatment.
Looking back at Q1, we measured, on average, how many new NeuroStar patients started treatment within our three customer groups. Our non-BMP providers averaged three new NeuroStar patients in the quarter. Those committed BMP practices, meaning they're not in the program yet, however, they are working on the implementation of the five standards, averaged just over seven new patients in the quarter simply by doing the right things and following up with patients. Finally, our Better Me Provider participants averaged just under 11 new patients in Q1. This lift in new patient starts was absolutely incredible, but the metric that is equally as important is the time that it took patients to move into treatment. With the Better Me Provider Pilot, our practices were able to move patients into treatment 5x faster.
If we compare this to 2023, on average, from the time a patient saw a NeuroStar ad to the time they started treatment was 82 days. Today, with the Better Me Provider Pilot, we've reduced this time to 17 days, all due to faster patient response time and better awareness and education. Our goal is to continue to increase the number of patients moving into treatment in the fastest time as we roll out the Better Me Provider Program nationally in the back half of the year. Our next 2024 highlight is our achievement of the adolescent indication. Only NeuroStar is now indicated as an adjunct for the treatment of major depressive disorder in adolescent patients aged 15-21. Most notably, the FDA cleared NeuroStar as a first-line treatment option without having to fail prior medications.
As Keith mentioned on our earnings call, this is our greatest achievement since our original FDA clearance in 2008. So let's look at the opportunity in this new, younger patient population. We have two opportunities with adolescents. First is a new group of mental health providers to target for our NeuroStar expansion, and second is adolescent patient treatments inside our existing NeuroStar practices. Focusing on new provider targets first, we know there are approximately 8,000 adolescent-focused child psychiatrists and 6,000 adolescent-focused nurse practitioners across the country. We've already started to reach out and educate this group on the benefits of NeuroStar for their patients, and I'll speak more about these efforts in just a moment. In the short term, our largest opportunity is adolescent treatments inside our NeuroStar customers.
In fact, in the last year, 50% of our customers have treated patients aged 15 to 21. Our goal is to better educate these parents and patients on the non-drug alternative and continue to support our practices in seeking insurance coverage for these patients. With more awareness, we expect to see a ramp-up in adolescent treatments in the back half of this year, with our greatest opportunity coming in 2025. So what is our plan to drive more awareness of NeuroStar and our new indication? We hosted a media event on May 15th in New York City that included approximately 30 editors, producers, and influencers across multiple media outlets. In addition, we invited a NeuroStar key opinion leader to do a live NeuroStar demonstration and speak to the clinical benefits.
We also had a 15-year-old patient, Chrissy, who shared her desperate journey in depression and how NeuroStar treatment transformed her young life. This patient's story was so moving, there wasn't a dry eye in the house, and many of the attendees posted on their social channels from the event to bring awareness to their viewers. As a result of this event, we saw a 120% increase in NeuroStar Google searches, over 30 social posts, and two published articles, all reaching an audience of 1.5 million people. Just last week, Vogue published an online article on vogue.com, highlighting our recent FDA indication and citing NeuroStar TMS as a promising new option for adolescents that is slowly earning more mainstream awareness. The article goes on to share Chrissy's story from our media day and her transformation and success with NeuroStar TMS.
With the success of this event, we are expecting even more media opportunities, potentially on a national scale. Continuing our awareness of the adolescent indication, we also invited adolescent providers to our most recent NeuroStar Summit and updated our curriculum to include this new indication. As a reminder, our NeuroStar Summits, hosted once a quarter, are the most successful event we do to build a pipeline of new customers. We typically sell out at 50 attendees, but for this most recent summit, due to the demand, we expanded this event to allow 70 attendees. Of these attendees, 20% were providers who treat adolescent, and 50% of our capital sales from this event were to this new group of mental health providers.
The feedback from the physicians and nurse practitioners who focus primarily on adolescent patients was extremely positive, and they were blown away by the clinical evidence presented at the event. We look forward to partnering with more providers in this adolescent category throughout the year. I would now like to turn it over to our CFO, Steve Furlong, who will provide an update on our road to profitability.
Thank you, Sara. For those of you that have familiarity with the company, I've been here five years, and it's been quite an exciting ride. There's obviously a disconnect with our stock price versus the company's performance. You know, essentially trading lower than revenue, approaching trading for cash, which really doesn't make a lot of sense. If you look at this chart here... Oops. We've been able to leverage our operating expenses as a percentage of revenue since 2022. We completed a follow-on raise in January of 2021 that we believe gave us sufficient cash and runway to get to cash flow break even, and we've continued to communicate that over the past three years.
What this chart illustrates is our ability to leverage operating expenses and actually grow revenue, while reducing operating expenses, down to $79 million, which is our midpoint forecast in 2024. So we are revising and lowering our operating expense guidance for the year from $80 million-$84 million to $78million-$80 million. The reduction is really a result of prudent expense control and management without reducing the commercial spend. So we do continue to add to sales. Marketing spend has become more efficient over the years, just the media and the way things are purchased and leveraging the social media channels. We don't have to add incremental marketing expense to support our growth.
As a reminder, our revenue midpoint for the year is also $79 million, and so having that 100% with gross margins approaching 80%, I think you can tell we're not that far off from getting to cash flow break even. We've taken the approach of having a balanced top-line growth picture with profitability, and at one point, a year or so ago, I asked Margaret, "What's more important?" And most folks would say top-line growth, but there's obviously a fear that the company has to go out to the capital markets and dilute our existing base. So that's something that we do not wanna do and continue to say that we're not gonna do. And so, you know, we have balanced the top line with our approach to profitability....
Once we do approach cash flow breakeven in 2025, we will start strategically growing our top line. Obviously, growth conference, we'd like to see our consolidated growth, you know, in that 20%+ range. Again, we do not want to go to the capital markets, which is why, you know, we're prudent in our expense management. A couple examples of where we could invest and see pretty robust growth would be our NeuroStar sales. So for the past three years, we've communicated that we plan on selling 200 NeuroStars a year. And the reason why we target 200 is we have one NeuroStar University, we have about 47 practice development managers supporting our customers.
I could increase that 200 to 250 and get between $4 million and $5 million of incremental top-line growth. But with that, I would have to set up another NeuroStar University, and the annual cost of running that is approximately $2 million. And I would also have to add practice development managers to support the new customers. So there's a trade-off, but again, we don't wanna spend ahead of revenue growth, and so that's why we've chosen to wait until we get to cash flow breakeven. Another example is international sales. Again, we've been pretty consistent with $2 million revenue contribution the past three years. We could certainly make an investment overseas, but again, it does come at a cost.
So, you know, we do see that we have significant growth drivers at our disposal, but we just wanna wait until we're in that self-sustaining mode. Regarding cash flow. Oh, so those of you that wanna look at our corporate presentation, it was just updated this morning. Slide 37 really illustrates our philosophy regarding growth. So we have about $25 million of revenue that doesn't grow, and it's deliberate. But we do continue to invest in the treatment session revenue that is our significant growth driver, and it's really our annuity business that continues to fund the company, and I think that's important to note. Regarding our cash flow, we did generate $1.5 million of free cash in Q4 of 2023. That was a year ahead of schedule.
In Q1, we did have lower collections due to the Change Healthcare cyber breach, but we are seeing a gradual recovery and do expect things to be back to normal by August or September of this year. Our second quarter cash burn is gonna be significantly lower, and then we are targeting to be cash flow neutral to slightly positive in the second half of 2024. This really sets ourself up to validate our expectation that we will be cash flow positive in 2025 on a full year basis.
You know, we do have the growth drivers in place with the BMP program and the adolescent indication, along with strong expense management and gross margins in the 80% range, and that's why we remain convicted that we will be able to execute on what we said we would do. In closing, we did achieve record results in Q1. The Better Me Provider Program, great, great initial metrics and indications, raises the bar for response time, gets patients in the chairs five times faster, generated awareness for adolescent indications among over 1.5 million people. Customer impact from Change Healthcare cyberattack is improving. There was actually an article published yesterday that they are improving, but they still have some wood to chop. And we are on track to achieve cash flow breakeven in 2025.
We do continue to invest in customer growth, while leveraging operating expenses from the infrastructure in our headquarters in Malvern, Pennsylvania. So with that, I would like to turn it over to any questions folks may have.
Well, like I've been telling folks, obviously, we're probably answering your questions and not, but so feel free, raise your hand. Happy to obviously take those questions. But, you know, the... Oh, there is a question. Mm-hmm.
Have you guys told the street what the future impact is gonna be about the cyberattack in terms of its actual number or you don't know?
We think it's temporary and that we'll fully recover by the end of Q3. And so there's a backlog of patients, a backlog of reimbursement, but we do see it recovering. So no financial impact to Neuronetics.
Thank you.
You're welcome.
Perfect. Well, you know, this kinda goes in line with that, but, you know, you look at the first couple slides that you guys presented, which was around new patient starts, both on a local basis and then on a global basis, as it relates to April and May. And so I asked this at the beginning before you even started the presentation, but maybe you can kinda share with the crowd. You know, it just seems different than historical trends because we normally see April come down, and yet, you know, now here we are, kind of five months into the year, and it's almost kinda straight up and to the right.
Mm.
So, maybe walk us through that, first, and then I'll have a follow-up to it.
Sure, I can answer that one. So historically, with treatment session utilization and new patient starts, there's some seasonality to it, and this-
... This is going to vary quarter by quarter. And Margaret's absolutely right. We have seen some greater trends in the first half of this year, and those trends in both the utilization and new patients starting treatment has really been accelerated by the Better Me Pilot Program. So as we add more sites into the program, we're really trying to drive that growth and accelerate it even more, and that's really what our intention is in the back half of the year, is we roll this out nationally to even more sites. So it's been very intentional with a slower rollout in that first half of the year, but the program's working, and I think you can see that in our trends.
Well, and I think that then brings you to, well, why won't it compound, right? And so what's included in your guidance, Steve, on that as well?
So, again, we continue to focus on supporting that program and that customer segment. And so it's really targeting the per-click or the local consumable business, which is approximately 60% of our business, and that grows about 32%. And so we are forecasting that to continue. It's really the offsets of fixed-price customers, and some of the other segments that kind of dilute that overall growth rate. But if you look at our guidance, and again, the infamous Slide 37, you can see that 100% of our growth is all in that local consumable segment, so it's really we are guiding and forecasting that similar type of growth.
Okay. So, so not compounding, just to clarify.
Well, to clarify, we have 250 sites out of approximately 1,200. They just started in January, and so as that number grows, it will compound. But I think the compounding impact will be, we could see some of it in Q4, but it's really gonna occur in 2025, when they have a year of this program under their belt.
Okay. And then, as it relates to Change Healthcare, you know, you guys have talked about, you know, the 60% impact and, you know, 22% impacted by, prior auths, 24% on new patient starts, and then, yet again, I look at those numbers in April and May trends, and it doesn't really seem like it shows up. So are you telling me it would be even higher than that, I guess, you know, barring this event?
Well, we are tracking these practices very closely now that we better understand the actual impact. Really, I feel like in May is the first month we started to see patients move into treatment who were in this backlog, from authorization, from Change Healthcare. I think the bigger impact that we're seeing still carrying over to Q2, though, it's on the reimbursement. So although these trends are all extremely positive, at the end of the day, many of our practices, especially our smaller, local, consumable, you know, single-provider practices, are being hit hard, and it's impacting their cash flow. So, you know, they may not be in purchasing at the historical treatment session levels they were previously, but they're just getting these patients into treatment, and, you know, we're trying to be very supportive and sensitive to the situation with them.
Okay. And then, you know, you guys hosted a summit. I think the number that I saw was 50% of sales were-
Yeah
-adolescent-focused practices, and I don't believe that they were 50% of attendees, so.
That's correct. Yeah.
Yeah.
That's right.
So, you know, I guess, was it 100% hit rate on those attendees that had gone in there, you know, that had adolescent practices? And then have they indicated at all in terms of when they could kind of be up and running and start adding patients?
Yeah, I think the last summit last month was a total success just in terms of starting to educate a new audience of providers. Not all of them purchased while they were there, and sometimes that education does take a little bit longer. It's very promising, though, and we're absolutely kind of putting them in our pipeline for system sales this quarter and moving over to the back half of the year. But the feedback from this group is they are eager to finally have a new solution for their patients, where right now, up until the NeuroStar indication, had very limited options for depression in the 15- to 20-year-old category. So it's promising, but it will take time as we educate kind of this broader audience now.
Okay. And then just last question, and we'll head over to the breakout. But, you know, that chart that you guys showed of folks that had attended NSU and kind of the difference in their growth profiles versus the non-NSU folks-
Mm-hmm
... was that one single vintage, or did you keep kinda adding folks within it?
No, it's all-time retrospectively looking back. So we track these metrics and show them across our executive group every single week, but. That goes back all-time, so we really track... And what's interesting, and I think most impressive about NeuroStar University, we saw a huge bump in utilization almost immediately after our first set of accounts went through the program. We didn't know if that would sustain, though, and that utilization would continue to grow. And, you know, we're a year and a half into this, and it's still growing, so we're just really pleased with the performance of the university.
Fantastic. Well, with that, we're gonna-