Good morning, and welcome to the CPSI conference call to discuss the company's acquisition of Healthcare Resource Group, Inc. During this conference call, we may make statements regarding future operating plans, expectations and performance that constitute forward-looking statements made pursuant to the Safe Harbor provisions of the Private Securities Litigation Reform Act of 1995. We caution you that any such forward-looking statements only reflect management expectations and predictions based upon currently available information and are not guarantees of future results or performance. Actual results might differ materially from those expressed or implied by such forward-looking statements as a result of known and unknown risks, uncertainties and other factors, including those described in our public releases and reports filed with the Securities and Exchange Commission, including, but not limited to, our most recent annual report on Form 10-K.
We also caution investors that the forward-looking information provided in this call represents our outlook only as of this date, and we undertake no obligation to update or revise any forward-looking statements to reflect events or developments after the date of this call. At this time, I will turn the call over to Mr. Chris Fowler, Chief Operating Officer. Please go ahead, sir.
Thanks, Dru, and good morning, everyone. We appreciate you joining us today. Joining me on the call this morning are Matt Chambliss, our Chief Financial Officer, and David Dye, our Chief Growth Officer. Boyd Douglas, CEO, is unavailable due to travel. I'm gonna provide an overview of yesterday's announcement regarding the acquisition of HRG, and after my comments, I'll hand the call over to Matt to speak a little bit about the transaction details. Yesterday afternoon, we announced our acquisition of HRG, which is a leading provider of customized RCM solutions and consulting services that enable hospitals and clinics to improve efficiency, profitability, and patient satisfaction. HRG was founded in 1994 and is headquartered in Spokane, Washington, with a distributed workforce of over 400 employees. This strategic acquisition provides real value to CPSI on two fronts, scale and talent.
The addition of 77 customers to the core services TruBridge provides, such as end-to-end revenue cycle management, medical coding and early out services, cements TruBridge as the growth engine for CPSI. These customers span across 25 states with a high concentration in the Pacific Northwest, which is a region in which TruBridge has historically not had a large presence. Their customer base includes acute care organizations ranging from critical access facilities to large academic centers, tribal health systems, and physician practices. We're also thrilled to add an employee base that is committed to quality service and delivering real value for their customers. While we continue to leverage technology to gain efficiencies, we will always need talented people to deliver our services, and HRG has no shortage, including their service staff, management, and sales executives.
Based on our shared cultures and like services, we are confident that our integration efforts will go smoothly over the coming months. We expect additional value to be realized through the cross-sell opportunity into the HRG client base of our TruBridge RCM product suite, as well as our medical encoder solution that came with our previous acquisition of TruCode last May and our patient engagement and digital front door solutions from Get Real Health. As healthcare providers continue to adapt and rebound from COVID-19, there's a great opportunity to help address the pain felt by hospitals due to the staffing challenges that they are facing. Healthcare organizations are looking for ways to gain efficiencies and collect revenue. With our joint RCM solutions that are both peer-reviewed by HFMA, there are significant opportunities to leverage our combined scale and extend our market reach.
This acquisition of HRG is well aligned with our opportunistic capital allocation strategy, and the combination with TruBridge represents another positive step toward executing our long-term growth strategy. With that, I'll turn the call over to Matt for a deeper dive into the financials of this acquisition.
Thanks, Chris. I'm gonna briefly walk through the revenue and EBITDA profiles of HRG, followed by some brief commentary on the deal structure and concluding with what this means for our near-term guidance. With the acquisition of HRG, TruBridge further cements its position as a leader in the outsourced hospital revenue cycle arena, with the strategic rationale for the deal leaning heavily on the benefits of consolidation within this vital component of the domestic healthcare landscape. HRG brings with it expanded scale, particularly in geographic markets where TruBridge's bona fides were less proven, with a loyal client base generating annual revenues that are more than 90% recurring and an impressive 94% client retention rate.
While the expanded scale is attractive in its own right, we're excited about adding HRG's talented sales and operations teams to drive even greater future revenue growth for the combined company with a sharp focus on operational efficiency and margin optimization. Sales effectiveness at HRG has driven a five-year revenue CAGR of 5.63%, representing responsible growth that has culminated in HRG becoming one of the most respected names in the hospital RCM services market. On the bottom line, HRG's 2021 EBITDA margin of nearly 11% is a testament to its operational excellence while not being optimally scaled on its own to allow for margin expansion through operating leverage. Unlike TruBridge, HRG's margins haven't benefited from higher margin revenue lines such as our TruBridge RCM solution, the TruBridge Encoder, or our remote hosting solutions.
Cross-selling these solutions into the HRG customer base provides opportunities to deepen client relationships while raising the overall margin profile of HRG's client base. In the near term, we also see the opportunity for $2.6 million of synergies between our two companies, with the potential to drive 700-800 basis points of margin expansion for HRG as we exit 2022. Moving to the transaction itself, the purchase price paid was $44 million in cash at closing with no earn-out, funded by a combination of cash on hand and borrowings under our existing revolving credit facility. The initial purchase price of $44 million versus 2021's total EBITDA for HRG of $3.6 million works out to an initial valuation pre-synergies of 12.1x EBITDA, with the forward multiple implied at around 8.5x.
Pro forma for annualized synergies, the EBITDA multiples are around 7.1 on an LTM basis and 5.7 on a forward basis. To close out our prepared remarks, we'll turn to guidance. Two weeks ago, we issued 2022 guidance of $288 million-$298 million for total revenues and expectations for Adjusted EBITDA margins to land between 18.25% and 19.25%. Adjusted to include the 10-month partial year impact of HRG on our totals, we now expect revenues between $320 million and $330 million. Inclusive of synergies that we expect to capture in our 2022 actuals, we still expect 2022 Adjusted EBITDA margins of 18.25% to 19.25%.
Lower margin HRG revenues will soften our consolidated overall margins for a few months before execution on synergy opportunities elevates total margins to be in line with our initial guidance range as we exit 2022. Our long-term target for organic recurring revenue growth of 5%-8% remains unchanged. With that, Donna, we'd like to open the line up for questions.
Thank you. The floor is now open for questions. If you would like to ask a question, please press star one on your telephone keypad at this time. A confirmation tone will indicate your line is in the question queue. You may press star two if you would like to remove your question from the queue. For participants using speaker equipment, it may be necessary to pick up your handset before pressing the star key. Once again, that is star one to register questions at this time. Our first question today is coming from George Hill of Deutsche Bank. Please go ahead.
Hey, good morning, guys. I have a couple of questions if you'll give me the time here, Chris and Matt. I appreciate the color that you guys provided on the acquisition price and the valuation. My first question is HRG appears to operate in the mid- to large hospital space. Does this represent a strategic pivot for CPSI to move into the larger hospital market, or is this more about bringing new and improved functionality to CPSI's current customers?
Yeah. Hey, George, great question. You know, so of the 77 customers, approximately 20 are in the critical access space, so the vast majority are into that mid and upper size. Obviously, that's been an area that we've focused on, and our traction, you know, has not been what we'd hoped over the last several years. Obviously, this gives us an opportunity to expand and accelerate that. While we'll continue to serve, from an RCM standpoint into the CPSI EHR base, we feel like this is a nice accelerant to seeing us move upmarket from a TruBridge perspective.
Okay. That's helpful.
George-
Oh, I'm sorry.
I'm sorry, George.
Go ahead.
It's David. I'll add to that. I think it's worth pointing out too that the TruBridge RCM product, formerly Rycan, has had a great deal of success in larger hospitals in the enterprise space over the last couple of years just within TruBridge. Bringing RCM, I mean, excuse me, HRG now under our umbrella is gonna give us the opportunity to cross-sell that, which is successfully running in a lot of large enterprises.
Okay. That's helpful. I guess second, and David, I'd kinda love your macro thoughts on this space. It's just, you know, you've seen, you know, there's one big public player in the RCM space which continues to have good success and sees good traction and growth. There's another company that probably, you know, there's a second player that probably is close to, you know, wanting to go that route. You just saw Tenet say that it was gonna hold on to Conifer as opposed to spin that business out, given the growth profile that they see for the business.
I guess, given the acquisition and where you guys operate, would just kinda love an update around how you guys are seeing the competitive environment and the macro growth opportunity into hospital health system and RCM. Is it as it seems like you're seeing people wanna hold on to these assets or recognize value for these assets as opposed to part with them, and the space seems to be getting, you know, at the margin, increasingly competitive. Would just kinda love from a macro perspective what you see.
Yeah. You know, I think we've said this on here before, George, but it's kinda like the EHR space before Meaningful Use, right?
Yep.
It feels that way, very much so. Frankly, you know, competition is slowly increasing, but our primary competitor is still the hospital or health system you know, deciding whether or not to continue to just do it themselves or to look to someone like a TruBridge to provide them those services. You know, it's generally a very painstaking decision for the facilities. What's going on from a job market standpoint now, and I know you've certainly heard this from the public players, seems to be accelerating the demand, and we feel like that's likely to continue.
You know, of the companies that I believe you're referring to, we don't see a whole lot of them even down into the 400-bed and under hospital space, which is where, you know, sort of we live in. You know, TruBridge, you know, obviously with the EHR space, our bread and butter is the 100-bed and under. Really for TruBridge, it's in that 400-bed and under space. So we're not seeing a whole lot of them yet. I mean, certainly potentially they may decide that they wanna be more aggressive in that market, but we're not seeing it at this point in time.
Yeah, George, I'll add, too. You know, one of the things that I think differentiates us from the other players that you referenced is the fact that we do have a customer base related to the EHR that we still have a ton of runway to grow TruBridge services. So we're obviously excited about our ability to now accelerate the outside of that installed market, but we have the ability to really focus on both of those fronts.
Okay. Then I guess my obvious follow-up here, David and Matt, is can you guys kinda remind us kinda what is your TruBridge penetration into the EMR footprint, or what % of your clients have outsourced versus continued to in-source?
Yeah. I'll take that first one. You know, if we, you know, when we look at the total business office outsourcing solution for TruBridge, you know, we're penetrated somewhere between 15%-20% within the hospital EHR customer base.
Okay. You guys are being very polite in humoring me. The last one I'll ask is, you guys, I'm looking at my model here. I thought you guys had just shy of $12 million cash at the end of the quarter. You talked about the cost to finance this transaction. Maybe cash balance now and, like, how little cash do you guys feel like you need to run the business?
Yeah. You know, when we're managing the cash balances, you know, the two things we wanna keep an eye on are obviously the balance sheet cash that we have on hand and then also what's available under the revolver. We, you know, obviously feel comfortable with the size of this transaction, and this still leaves us with cash balances on the balance sheet that are, you know, pretty much in line with where we were at the end of the year.
Okay. You guys have humored me enough. Thank you very much. Congrats on the deal.
Thanks, George.
Thank you. Our next question is coming from Jeff Garro of Piper Sandler. Please go ahead.
Yeah, good morning, and thanks for taking the questions. You guys gave some helpful comments on your ability to expand within HRG clients, and you referenced some specific products. I really appreciate that. But maybe to help quantify it a little bit more, if you could, you know, describe HRG's penetration in terms of partially outsourced versus fully outsourced RCM, and then just from a high level, looking at HRG revenue per customer versus TruBridge revenue per customer.
Jeff, I'll take the first one, and I may tag out to Matt on the second half. I would say that the heavy lean in their business is obviously on the fully outsourced model. They have done a very good job over the last several years where they do that partial outsource and then upsell to the full. The vast majority of those 77 customers are in the fully outsourced model. Then as it relates to their average revenue compared to TruBridge, Matt? Yeah. You know, there are, you know, let's just ballpark and say it's 100 hospital customers on the full business office outsourcing, generating somewhere around, you know, what is it? $40 million-$45 million a year in revenue.
You know, that works out to, you know, some fairly easy math there.
Could you help compare that to TruBridge?
Those were the TruBridge numbers that I was providing. I mean, the HR-
Oh, got it. The 100's TruBridge.
That's right.
the 77
Yeah, the 77 is from HRG.
That's HRG. Got it. Thank you.
Yep.
Another one from me is the release mentioned HRG's stable client base. Maybe a few on this front. Could you tell us more about their historical customer retention? Is there any notable customer concentration? Then what's the typical contract length, and just generally, how should we think about where they are in their renewal cycle?
Yes. I'll start. Their average retention is right around 94%. You know, other than geographic, I would say which we referenced in the call, you know, a high concentration in the Pacific Northwest, there's no real other concentration I would speak to. It, you know, very much looks like the TruBridge landscape as far as, you know, a good bit of hospitals and also physician offices just kinda scattered across. What was the second part of your question, Jeff?
The second part was what's the typical contract length, and how should we think about the renewal cycle?
Yeah. The typical contract length there is gonna be, you know, pretty similar to what we see on the TruBridge side. Initial terms, you know, generally somewhere around that three-year timeframe with annual renewals after that. You know, with HRG being founded in 1994, you know, you can see that, you know, they've got a significant amount of history behind them and lots of renewals to support that 95% retention rate. The revenue is, you know, it's over 90% recurring and very sticky.
Great. Last one from me before I jump back in the queue. Is the revenue model based on percentage of collections or subscription-like pricing or consumption of resources based?
It's a percentage of collections. I mean, the way to think about it, Jeff, is it's very, very service-oriented. It's not a tech aspect to this, so to speak. Not a TruBridge RCM offering. It's solely services. It's almost 100% percentage of collections. The medical coding aspects is similar to ours, where it's more of a standard fee, but otherwise it is based on the percentage of collections.
Got it. Thanks for taking the questions, guys.
Yep. Thanks, Jeff.
Thank you. The next question is coming from Joy Zhang of SVB Leerink. Please go ahead.
Hey, guys. Congrats on the nice acquisition. My first question is wondering if you can give us a sense of what the level of automation that HRG has now, just given that, you know, you guys have made great progress on the automation front. Does the $2.6 million cost synergy embed any sort of automations in addition to sort of scaling and cross-sell synergies, or is that upside to that number?
Yeah, I would say. Hey, Joy, thanks for the nice comments. I would say they've developed a homegrown workflow engine that they've used to really optimize the way that they do work. That's something that we'll be, you know, evaluating of how we layer that into the workflows that we have right now. But I think from an automation standpoint, the work that we've done over the last 12 months is obviously something that we're excited about being able to layer into what they're doing as well. There's a tad built into the model for 2022, but we really see that upside probably coming out of that year and more into 2023.
Yeah. Joy, you know, from a substantive standpoint, there's really not much in the way of automation savings within the $2.6 million that—what we announced.
That's super helpful. I guess as a follow-up, you mentioned that this, the rationale for this acquisition is more on the consolidation front, which is a departure from your past two acquisitions were more, tech tuck-ins. Can we sort of draw a pattern going from here that, you know, you're going more towards the consolidation direction on the M&A strategy, or is it a little too early to say?
Joy, I would say it's probably too early to say. I think the one word that I would use as we're thinking about M&A, and we've said this over and over, is that we're opportunistic. You know, obviously, it's the balance between where there are gaps that we can go and fill from a cross-sell standpoint like a TruCode, or is there an opportunity where something becomes available that is more of a consolidation. Obviously, you know, the economics of the deal play a big part of that, but we wanna make sure that we're not getting kind of tunnel vision on one aspect, and making sure that we're evaluating opportunities that could serve the betterment of CPSI going forward.
Perfect. One last question from me. Just given sort of how tough the labor market is currently, what measures are you using to ensure that there's employee retention as the HRG transitions over to TruBridge? Maybe on the integration side, can you give us a sense of how long it takes to get the new employees fully ramped up on TruBridge's processes?
Yeah. From a labor standpoint, you know, and again, even though we're looking at this from a consolidation standpoint, there is a big people aspect of how the services that we provide are delivered. With that, you know, a lot of the organizational structure that they've got from a team level and how they're delivering the service to their customers today will remain intact. That's why, you know, one, we think from a labor standpoint and just the security of these employees with now being part of CPSI should go over very well because their day-to-day world should remain fairly well intact. I also think that feeds into the integration being something that we should be able to manage pretty nicely over the coming months.
We are gonna have a, you know, a period where we wanna make sure that, you know, that there's a stability created, as we plan through the rest of the integration, but we don't think that there'll be a long tail beyond that as far as seeing the true integration of the two organizations.
Very helpful. Thank you.
You bet. Thanks, Joy.
Thank you. Our next question is coming from Shehzad Ochai of Pine Creek Capital. Please go ahead.
Hi. Could you please define Adjusted EBITDA for us? Specifically, how much incremental CapEx and share-based comp is below the Adjusted EBITDA line for HRG?
Yeah. Hey, Shehzad. I'll take that one. When it comes to you know, any capitalization or product development capitalization, which I think is the genesis of this question, there essentially is none at HRG. As a private company, I mean, you can imagine that stock-based comp is minimal or nil, so there's no stock-based comp component either.
Okay. That's really helpful. Then Matt, you referenced changes to the outlook, still targeting Adjusted EBITDA margins of 18.25%-19.25% for 2022. You also mentioned softening margins the first few months. I just wanted to clarify, is the Adjusted EBITDA margin now a year-end exit target, or is it still your full year target, including the 10-month impact of HRG?
Now that's a good question, and to clarify, that is still the full year Adjusted EBITDA margin target for CPSI consolidated as a whole.
Okay. That implies potentially, given the lower profile incoming of HRG, that there are, I guess, potentially incremental cost reduction measures you're putting in place that were not previously being taken into account. Am I reading into that correctly?
Yeah. Well, what we're essentially inferring is that we are going to be executing against this $2.6 million of synergy opportunities throughout the year. We should be able to capture, you know, most of those should be captured at least in run rate by the end of this year. Based off of the plan that we have before us on executing against those opportunities, you know, we feel comfortable that Adjusted EBITDA margins will still land within that range.
Okay. Could you help us understand how much CapEx, including capitalized R&D and share-based comp we should think is reasonable for CPSI for the full year? Just so we can get down to a metric that's more tangible for shareholders.
Yeah. You know, those aren't specific measures that we guide on, and we don't intend to get down to that level of detail. You know, we feel pretty comfortable with the top level, top line guidance that we've given on the top line revenues and then on the bottom line when it comes to the Adjusted EBITDA margins. We'll sit still on that.
I noticed, you know, HRG, I think, is looking for very high growth in 2022. $33.8 million in 2021 to expected revenues of $40 million in 2022. That's quite a bit higher than their five-year revenue CAGR that you quoted earlier of 5%. Could you help us understand what's driving the high growth into 2022?
Yes, Shehzad. This is David. It was the last six months of bookings in 2021 for HRG is what's driving that growth. They had substantial bookings in the last-
Okay.
In the last half of the year.
Okay. Thanks very much.
Thank you. At this time, I'd like to turn the floor back over to Mr. Fowler for closing comments.
Thanks, Donna. Thank you everyone for joining us on such short notice, and also thanks for your continued interest in CPSI. Everybody, have a wonderful day.