All right. Hi, everyone. Thank you for joining us. Up next, we have Trae Fitzgerald with VieMed Healthcare. Take it away.
Thank you. Thanks for having me. Trae Fitzgerald, I'm the Chief Financial Officer for VieMed Healthcare. We. A little bit about us: headquartered in South Louisiana, Lafayette, Louisiana. We have about 1,100 employees. 300 of those are clinicians. Respiratory therapists make up approximately 35% of our business. We operate in the home medical equipment supply industry, but we operate more in a niche sub-industry of that. We focus on complex respiratory care within that space. There's within the space, it's typically a more commoditized environment of distributing out equipment. Rather, we focus on therapies that allow us to differentiate ourselves from the rest of the field, and for us, that's been complex respiratory. And so that, for us, is non-invasive ventilation, supplemental oxygen, percussion vests.
We'll kinda look at some of those products as we go through. We service about 127,000 patients annually at our current run rate, and we're listed currently on the NASDAQ, our ticker is VMD. So corporate history. Our CEO, Casey Hoyt, and our president, head over sales, Mike Moore, the original founders, are still with the company from inception of 2006. They've been, from the outset, I would say, a very innovative group. They were one of the first ones to adopt home sleep testing in 2010, which at the time, now is a little bit more prevalent, but at the time was pretty new, and you weren't seeing it very much.
And so that was really the catalyst for them having the opportunity in 2012 to be one of the first providers of ventilation in the country. I think we set up our first ventilation patient in March of 2012. And so this has really been the catalyst for the company, is having that first mover advantage over the rest of the industry and becoming the premier provider of ventilation in the country. And after the expansion of ventilation, the company grew quite quickly and was acquired by a public entity, and then further spun out of that into their own corporate entity. And we've been a public company since 2017, when we were listed on the Toronto Venture.
We graduated to the Toronto Stock Exchange and then further listed on the NASDAQ in 2019. Last year, we delisted from the Toronto Stock Exchange and now consolidate all of our operations on the NASDAQ. We have been very proud that we are an organic growth engine, and we'll kinda go through some of those figures. But the success of our organic growth engine has allowed us to, for the first time in 2023, we did augment our growth with our first strategic acquisition. It was Home Medical Products, a Tennessee medical equipment supplier. And so we exited 2023 with a run rate off of 4Q 2023 of a little over $200 million of run rate of top-line revenue.
The investment consideration for us, the thesis really is the healthcare landscape is really changing to focus on trying to drive costs lower and at the same time, drive better patient outcomes, and that is best served in the home. And so that's where we have found our niche with complex respiratory and our specialty and the infrastructure that we have in place. And so we have, we've employed—You know, like I said, we employ over 300 respiratory therapists. We augment them with further technology. We have remote technology that we can monitor our patients. We follow them through the home and through the continuum of care, and are seen more as a partner with our referral sources, rather than a middleman to get equipment back to the patient.
These trends are, you know, across healthcare, are continuing the trend of healthcare spend just all across the board. Specifically in DME, you see that, by 2031, $115 billion of annual spend is expected within the industry. That, in large part, is in thanks to the addressable market that that is untapped within many of these product lines within DME.
Specifically for us, which is 60% of our business and where we focus our efforts on the NIV space, there's less than 10% penetration as best we can see with all claims, and certainly, that number has hovered around there and hasn't really made any substantial progress in the last few years and continues to be the catalyst for our 20%-25% annual organic growth, being that there's such an unaddressed, underserved population of folks, let's say COPD, who need this therapy. We are the third-largest provider in the country, and within that group, it's a very disaggregated group across the country, outside of the top largest, the top ten providers make up 64% of the total market.
And then it's mom-and-pops across the country who traditionally provide a whole you know, a whole suite of all medical equipment supplies, and they just sort of fall into ventilation. But rather, ventilation is really what we do. It's what we specialize in. We don't fall into ventilation. We go out and we seek the therapy, and we do it in a pretty innovative way. So ventilation is, like I said, 60% of our business, approximately, complex respiratory, when you add in oxygen and percussion vest, you're looking at upwards of 75%-80% of our business.
We do provide other services, sleep, and the sleep apnea, which is really the origins as I kind of talked about the inception of the company, where we trace our origins back to, and, we have, we bolted on healthcare staffing, over the COVID, the COVID experience, when we, we saw a necessary need in that space, and just broadly speaking, over those categories, you know, we have a diversified payer mix. Just by nature of being a chronic Medicare-managed care, we're gonna tend to, to bleed into Medicare and Medicaid, primarily, but we, we have commercial, Medicare Advantage, we have self-pay across the country. We, we operate in, more significantly, close to 40 states right now. We have patients in all 50 states. Okay, so the VieMed solution.
What makes VieMed different than your traditional DME supplier? So traditionally, DME suppliers are distributors, for lack of a better phrase. And so it's catching discharges out of the hospital, it's being a resource for, you know, maybe family medicine practitioners. And so they're just, "I'm here, I can provide you all these services whenever you need them." They're more along the lines of account reps working their accounts. Rather, the approach that VieMed takes is really a partnership with our referral sources. A lot of times, our sales reps are respiratory therapists, and so they're selling from a clinical background. It's not a, "Doc, what do you have for me today?" Rather, it's, "Doc, here's what... We've done the research.
We know exactly when a patient should be on therapy. How can I help you identify these patients and initiate service at the right, the therapy at the right time, in order to have the greatest impact on the patient outcome? And so that partnership tends to be a very sticky referral source, and further embeds just us being seen as the premier provider within this industry. And it really is our, you know, our respiratory therapists who we don't call them sales reps, we call them patient care coordinators. They're really bleeding heart sales reps, if you will. You know, they are passionately selling this therapy because they know it's the right thing for the patient.
And they know, you know, just looking back at that prior slide of the addressable market, they just know how much of a need there is for it. Less than 10% of folks on service that really truly need the service. And so complex respiratory for us, you can see ventilation, oxygen therapy, percussion vests, sleep t herapy has some sort of overlap there, but is also in our disease state and sleep apnea that we treat. Our patient engagement platform, again, another item that we're just trying to differentiate ourself from other folks. Our reimbursement is the same whether or not we provide stellar service or not, but rather it's really our selling point of what we do for our patients.
You know, we wanna be able to monitor our patients in the home. We wanna be able to see how they're using their devices. We wanna be able to give our payers, our referring physicians, more data at their fingertips so that they have an advantage to use VieMed because it allows them to better treat their own patients. And, you know, anytime a referral source comes to us, we're treating them, we're treating them in the complex respiratory space, but certainly, they have other comorbidities. You know, 20% of them are gonna have diabetes. They have all these other things they have to manage. So our job is to make the piece that we can touch, to make it as easy, seamless as possible, give them as much information as possible, be as proactive as possible.
You know, we have six data analysts on site. We're constantly trying to find trends in the data. What creates an exacerbation? Why can't we sort of be more proactive, address these things prior to them getting re-hospitalized? And so that's really our focus. And then further, we are very, we're very different, our operating model, than your traditional DME because of the way that we operate. So traditionally, you're gonna have retail shops all across the country, you're gonna have brick-and-mortar everywhere, a physical presence, a lot of infrastructure, a lot of overhead is really a better term for that infrastructure. That's not how we operate. We operate in a very lean environment. First of all, we've narrowly focused where we should be operating.
So we know where COPD prevalence is, we know where the claims are and who's on service, and so by nature, we know what is an underserved population. It may not be readily apparent, it may not be the large metropolitan area. It may be a rural pocket in South Arkansas that is actually implied to have an underserved population, and that's where we tend to do really well. 30% of our business is in these rural pockets. And so that's our bread and butter, is these patients that are underserved, these clinics that are underserved, and us bringing this therapy there, teaching them when it should be on the patient, and really trying to get some adoption as best we can.
And so that model leads us to find green pastures quickly. And then further, we don't operate in the retail space. We don't sell bent metal. That's not really a part of our business, so we don't need these warehouses and other structures like that, right? So we operate more remotely. Our sales reps, our respiratory therapists, they're working out of their cars for the most part. Supplies, we can drop ship to a patient, but they have equipment with them ready to set up a patient. And then further, if I'm gonna get into a new territory, because of the way that we sell from a clinical background, my respiratory therapist is a dual role to begin with.
So we can go into a new territory, and my respiratory therapist can both sell to the referring sources—referral sources, but also service the patients until they get to a scale of having patients that it makes sense that we hire a full-time respiratory therapist for them, and then let them transition fully to sales. And so that gives us the ability, with very low overhead, to go into an area, figure out if we can be successful in that area. With adoption, we have the payer contracts, everything works. If it doesn't work, we're able to pull back very quickly. We don't have a lease we have to cancel. We don't have FTEs we have to terminate. And so it really does allow us to be lean and adaptable and to quickly changing environments.
And so it's been extremely successful throughout our journey. The benefits of our organic model have been that we are. We find ourselves in a very envious position. We have a large $90 million credit facility, largely untapped. $12 million of cash on the balance sheet at 12/31, with $6 million of long-term debt. And so we have negative leverage. We are spinning off cash at this point with over 10,000 vent patients on service. We're spinning off cash at a rate that we faster than ever before. And so it's provided us the opportunity to fund some strategic operations without having to fund it through debt. And at this time, we're funding these through cash.
But last year, June of 2023, we did our first acquisition of Home Medical Products Inc. This one really hit all of our investment criteria of why we would do this acquisition. Much in the same way that we operate differently, we, you know, our sales pitch is different, our operating model's different, our M&A is also gonna be different. It's not, we're not a roll-up story. This isn't what we're looking to do. We're looking to be strategic. Any time that we look for an acquisition, we're really looking if there's revenue synergies for us to augment and to create another VieMed. You know, it's to springboard our organic opportunities, and so HMP really hit all that. They had a good management team.
They had a strong employee culture. They had a footprint that we really weren't in. They were heavy sleep, which is an attractive business by itself, and they did very little respiratory. And so that's attractive to us because we know that there's plenty of opportunity for us to teach their reps, the respiratory space, why we do what we do, how we do it, and how to be successfully deploy that model within their own. You know, traditionally, people in our industry will sort of puff out their chest, you know, mid-single digits. Everybody's happy, 6%-8% growth. That's not the VieMed model. The VieMed model is 15, 20, 25% growth, and that's what we strive for.
And so we think that there's opportunities within these pockets of companies to really teach them, if the infrastructure's in place, they have contracts, they have the folks in place to really operate the same way that VieMed operates. And so that was really the precipice of the HMP acquisition. And, you know, we have a strong pipeline of similar companies, but again, we're VieMed, and so we're gonna... When the valuation is attractive, when we believe that we can actually bolt on revenue synergies, is when we tend to effectuate these. And then just last week, we announced a new prong to sort of our strategic initiatives here with a hospital joint venture. And so East Alabama Health, their hospital system had their own DME company.
This is not uncommon. A lot of hospital systems will look around and say, "All this business is leaving the hospital. Why aren't we capturing it?" And so the idea, first of all, is, well, let me start my own, our own DME company that's sort of attached at the hip to the hospital, probably even on campus or right across the street. And what they find is, it's a good idea in theory, but they know how to run a hospital, they don't know how to run the intricacies of a DME, and then further, they don't know how to follow them to the home real well, right? They get them out of that setting, and that's really not their forte. And so further, we have the ability to say, "We get that.
Let us operate the entity. Let us let you ride along with the success that we believe this will be. "You have a strong brand name." You know, a lot of times, East Alabama is a perfect example. They operate in these rural environments where that hospital is really the hub of healthcare, you know, within that pocket, you know, in that community. And so it's really an avenue for us to sort of springboard, maybe more of a platform approach of, there's a lot of these out there, most likely, right? And so the numbers on this one, you know, isn't the point of talking about this acquisition. I mean, it was a $3 million investment.
It's a small acquisition for us, but rather the idea, we think really does have some legs if we can execute like we're used to in the rest of our business. Again, innovative and progressive, that's our strategy here. Everyone else falls into ventilation. It is our world. It's what we do. So for us, funding studies is a means for adoption, and it's important for us. And so this benefits the whole industry, but we think it's important. Again, the addressable market is so large and so untapped, that we're fine if this is a marketing tool for all of our competitors. We want, you know, in the end, we want them to be with VieMed, but we do want patients to be on service.
And so we've proven with our medical studies that if early intervention, not only do we reduce mortality, but we save costs to the system by reducing hospitalizations. And so it's an easy sell when you can get people to connect with it, and you can let them see it, you know, for their own eyes. You know, and again, our engagement platform, it's a workforce tool, it's a caregiver tool. It marries all of that in order to make us a better provider for our patients and give them better service. Our objectives for the next 24 months are the same as they've been for the last decade, is just continue to execute. The catalyst was March of 2012 for us, and it continues to this day.
There is still so much runway for us to take on, that's what we do. Every day we wake up, it's blocking and tackling. There's no special thing we need to do. We just need to wake up and keep executing it, and we've done that for the last, well, 18 years, I guess, since the company's been in inception. From a financial perspective, we're also operating in the most stable environment that we've ever seen. Reimbursement pressures, competitive bid on, you know, on suspension, all regulation has been really in the favor of suppliers, Medicare Advantage more specifically. And so we are extremely excited about the stability, and we see our path forward. Touch on this very quickly, but we are fee for service. This is a life-sustaining device.
You get a monthly reimbursement here, and the vent has great economics. It's 5-6-month payback. It does come with a lot of expertise needed. We have in-house, you know, repair, certified repair technicians, and so, you know, we have the wherewithal in order to provide this complex therapy. Historically, again, we've been performing on a very linear track. It's up and to the right. It's not really that hard to explain. Last year, we achieved a record EBITDA of $43 million on a $183 million top line, and like I said, we'll be well over $200 million in the current year. Negative debt, $350 million market cap, strong insider ownership, never issued a share.
I actually done two buybacks whenever we were spinning off more cash and we were the most valuable thing to buy was to buy ourself, and so we think that we are positioned to succeed in the future. So thank you.
We have time for one or two questions.
Yeah. In looking at the chart, I see that you had a down year on revenues.
Yeah, it's hard to see in this chart. Go on our website, you'll be able to zoom in, but the little asterisks on 2020 was really... the down year was 2020, a COVID year, and we had a ton of ventilation business that came from that. So it's really one-time sales that were not recurring. So we try to, as best we can, even in our Qs and Ks, you'll see a special line for COVID-related sales and services so that we can differentiate that.
What's the key driver of performance? Is it number of respiratory therapists that you have, or?
The key driver of performance really, I mean, is active patients. I mean, the more active patients we have, but yeah, I mean, that's the...
The active patients come with more respiratory therapists in a sales role, more markets that you can address, more payer contracts, more coverage, more adoption. No, our respiratory therapists, it depends if they're non-invasive or invasive, they're doing a good mix, but typically 45, 50 patients, they can handle that sort of patient load with our technology.