AdaptHealth Corp.

Good day, everyone, and welcome to today's ADAPT Health third quarter 2023 earnings release call. At this time, all participants are in a listen-only mode. Later, you will have an opportunity to ask questions during the question and answer session. You may register to ask a question at any time by pressing star 1 on your telephone keypad. It is now my pleasure to turn today's call over to Richard Barrage, Chairman and Interim CEO. Please go ahead.

Good morning, everyone. Thank you for joining us today to discuss ADAPT Health's third quarter performance. Before we begin, I'd like to remind everyone that statements included in this conference call and in the press release issued today may constitute forward-looking statements within the meaning of the Private Securities Litigation Reform Act. These statements include but are not limited to comments regarding financial results for 2023 and beyond. Actual results could differ materially from those projected in forward-looking statements because the number of risk factors and uncertainties which are discussed at length in the company's annual and quarterly SEC filings. ADAPT Health Corp should have no obligation to update the information provided on this call to reflect such subsequent events. Additionally, on this call, the company will reference certain financial measures such as EBITDA, adjusted EBITDA, and free cash flow, all of which are non-GAAP financial measures. This morning's call is being recorded, and a replay of the call will be available later today. We are pleased with the results of the third quarter. Powered by our sleep business, we generated 6.3% growth over last year. leading to record revenues for the quarter. Equally important, we generated cash flow from operations of 98.8 million and free cash flow of 21.7 million. Adjusted EBITDA fell short of our expectations, largely as a result of unplanned delays in the implementation of the Humana contract. Jason and I will get into more detail on why this happened, but these results do not reduce our optimism that this will be a profitable contract for Adapt Health, nor does it diminish our enthusiasm for more enterprise sales of this type. Other than this contract, we would have met our expectations for revenue, adjusted EBITDA, margins, and cash flow in the quarter. Our sleep product line continues to outperform, resulting in 17% increase over last year. Our new PAP starts were consistent with our expectations, and our PAP resupply business generated record order volumes. An important metric is that our resupply census has grown 12% over the past year and now totals over 1.5 million patients. Among the reasons we continue to grow is that we have focused on electronic ordering, which reduces friction and enhances the patient experience. The relationship that we've established with these patients is a critical aspect of our strategy to become more than just a provider of devices and supplies. Building on the strong trends in the first half of the year, we grew our respiratory net revenue by over 8% year on year. This growth was driven by increased patient census coupled with stabilization in the length of time patients remain on oxygen Diabetes continues to be a work in progress, as discussed last quarter. While the results in the third quarter were a bit softer than we had planned, we are encouraged by the progress we are making to improve this vital product line. To resume growth, we are focusing our sales effort toward the growing government business, especially in areas where diabetes is prevalent. The government market for CGMs and pumps is large and growing, and we are continuing to shift our strategy to specifically focus on the acquisition and retention of these patients. Government sponsored payers are now 79% of our CGM census, up 200 basis points versus last quarter. We are rapidly recruiting dedicated diabetes representatives. in the areas of high diabetes prevalence, leveraging the scale and capability of the entire ADAPT Health sales team. Our objective is to double the number of diabetes sales reps over the next several months. We're also exploring strategies to participate profitably in the growing pharmacy sales channel. This will allow us to regain some of the share that we relinquished as more commercial payers move to the pharmacy channel. Finally, and quite promising, is that we are beginning to execute a strategy to use the data generated from CGMs to create a better patient experience while generating information that is important for their providers and payers. This will enhance our value proposition to all of our constituents. Our experience in the early days of the Humana implementation has not diminished our optimism about the value that this contract will provide to all parties to the transaction. We've established a very strong relationship with Humana, and we've been working to make the transition process as seamless as possible for Humana members who will ultimately benefit from better service for their HME needs. Unfortunately, however, we underestimated the size and complexity of the patient transition process. Onboarding members as taking longer than we had anticipated resulted in a reduction to our expected cap revenues from Humana. Nevertheless, we remain confident that this agreement will achieve positive results for ADAPT Health. Since ADAPT Health went public in 2019, we've increased revenue and adjusted EBITDA each year and have recently improved our cash flow and strengthened our balance sheet. However, we must take responsibility for issues, some self-inflicted, that have caused a reduction in investor confidence, including setbacks around the CEO search. The top priority for our board is to fill the CEO job with the best candidate as soon as possible. We are currently talking to highly capable candidates with the goal of having the post filled by year end. In the meantime, we're not slowing down, and I'd like to describe the key initiatives and goals that our board and management are aligned on. Further increases in cash flow from operations and free cash flow is a high priority. The company continues to focus on better collections, better inventory management, and more efficient capital spending, all of which have contributed to our improved cash flow results. We recently used some of our free cash to buy back stock, but we were also addressing our balance sheet. During 2023, we paid down our revolver and reduced our leverage from 366 to 351 times. We are fortunate to have a comfortable debt structure in terms of rates and maturities, but we intend to delever further with the goal of reducing our leverage to under three times by the end of next year. As to the business itself, our short-term priorities are to solidify our diabetes line and resume a market rate of growth, expedite the transaction of the human of business, and expand our enterprise sales effort, continue to reduce the cost of operations through automation and better processes, and implement our strategy to become even more relevant in the healthcare ecosystem. Finally, I'd like to comment on the effect of GLP-1s in our sleep and diabetes product lines. Most important, we are seeing no current impact on our sleep product line. Our total sleep census, which is a combination of new starts, and ongoing PAP resupply patients continues to grow at a pace that bodes well for continued revenue growth. Further, we have seen recent analysis that indicates that the effect of GLP-1s on PAP utilization may have been overstated in some earlier analysis and resulting market reactions. For example, one recent study indicated that only 3% of GLP-1 users with obstructive sleep apnea were able to stop using their PAP therapy. Another recent piece highlighted the lack of adherence to GLP therapy over time. Others, ourselves included, think that the sleep TAM may actually grow as a result of more awareness and increased diagnosis of OSA as a result of the publicity around GLP-1. Our working assumption, though, is that GLP-1 drugs will likely have a significant impact on obesity over time, which may cause some leakage to the current sleep time. How large and how soon are the subject of much speculation, but we will proactively respond to this potential pressure. If there is a net reduction in sleep TAM, we can overcome it by continuing to increase market share, decrease costs through automation and better processes, and focus on patient retention. We've improved on each of these measures over the past few years, and the GLP-1 conversation will accelerate our efforts in these basic areas. There is more consensus that GLP-1 usage may accelerate growth more GLP usage may accelerate growth in CGM usage. We believe that diabetes patients on GLP-1s are actively engaged in their health and will be inclined to monitor their A1C levels through CGMs. We also believe that increased insurance coverage of CGM, especially in the government sector, is a strong tailwind. Adapt Health is at the epicenter of efforts to improve the health of people with chronic conditions like obesity, diabetes, sleep apnea, and COPD. We occupy a unique position connecting providers, patients, and payers. We currently have an ongoing relationship with over 1.5 million people with sleep apnea, roughly 170,000 diabetics, and 300,000 people with chronic respiratory conditions. We interact with these folks on a regular basis to help them with adherence to their therapies by supplying and resupplying needed equipment and coaching them as to better usage. Better adherence alone will improve outcomes and reduce downstream costs, but we are just now beginning to understand how we can compliantly use the data we are generating to do even more to improve the health of our patients, especially those with with comorbidities. One early example is that we recently surveyed 10,000 people who set up on PAPs last month. Of these, 7% of those who responded, and by the way, the response rate was over 40%, so we think this is a reasonably good sample. Of these, 7% are taking GLP-1s, which indicates that GLP-1 usage can coexist and will coexist with CPAP therapy. Further, 20% of this group has diabetes, but only 15% of the diabetics are using CGMs to monitor their results. If we extrapolate these findings to our entire population, we will find many opportunities to identify and better service patients with comorbidities.

Thank you, Richard, and thanks to all for joining our call today. Let me begin by reviewing our third quarter results. We achieved record revenue of $804.0 million, an increase of 6.3% over the third quarter of 2022. Other than the Humana details that Richard described, this quarter met our expectations for top-line growth and adjusted EBITDA, and cash flow exceeded our expectations. Our total sleep revenue of $315.4 million increased 17% against a year ago, driven by PAP equipment setups and increasing resupply. Our new PAP equipment starts were consistent with our expectations in the third quarter. Our PAP resupply business achieved record order volumes. Our resupply census now totals over 1.5 million patients, and our electronic ordering utilization broke company records. Respiratory revenue of 151.1 million increased 8% over the third quarter of 2022. As we continue to revamp our diabetes product category, CGM census was up 4.3% year-over-year, resulting in flat CGM revenue. As expected, pump and pump supply revenue was down $9 million year-over-year, as our tube-based pump volumes remain under pressure from tubeless pumps. We expect this pressure to continue into the fourth quarter. As Richard said, we are bolstering our sales force and focusing on growth in the government sector. Outsized growth in our sleep product category largely offset a shortfall in diabetes and a modest increase in operating expenses. So overall, except for the unexpected losses on the Humana startup, our top line and bottom line results were in line with our expectations for the quarter. The primary reason for the shortfall on the Humana contract was a delay in patient transitions in corresponding capitation deductions, resulting in a $10 million top and bottom line miss against our expectations. It will take longer than originally expected to transition all patients, but we believe that we will indeed get substantially transitioned by early next year. As we continue transitioning patients, we expect sequential improvement in both our top and bottom lines. Our adjusted EBITDA was $161.2 million in the quarter, resulting in an adjusted EBITDA margin of 20.0%, down from 21.6% in the second quarter, primarily related to the patient transition backlog. Cash flow from operations in the third quarter was $98.8 million. CapEx was $77.1 million, or 9.6% of revenue, resulting in free cash flow of $21.7 million. For the first three quarters of 2023, we generated $76.6 million of free cash flow, which was more than 2.5 times the first three quarters of 2022. We re-arrayed our full-year free cash flow goal of between 3% and 4% of revenue. For the third quarter of 2023, BSOs of 42.1 days were down over a day against 2022. And for the first three quarters of 2023, BSOs were 42.5 days, down from 44.8 days for the first three quarters of 2022. We continue to realize the benefits of our refining of revenue cycle process and investments we've made in our technology and workflow. Our net leverage ratio at the end of the quarter was 3.51 times, down slightly from the second quarter. During the third quarter, we made principal payments of $10 million, and after the end of the quarter, we repurchased approximately 2.5 million shares in the open market for a total cost of $19.4 million. As part of our third quarter results, we recorded a $511 million impairment to Goodwill, as we discussed in our earnings release this morning. This non-cash pre-tax charge was triggered by our stock price as of September 30th. Turning to guidance, we are revising our prior outlook as follows. We are narrowing our expected revenue range to 3.160 to 3.185 billion. We are updating our expected adjusted EBITDA range to 630 to $650 million. and we are maintaining our expectations for total capex, representing 10% to 12% of revenue, which should yield free cash flow of 3% to 4% of revenue. To close our comments today, we believe we're well-positioned heading into the final weeks of the year. We are turning around diabetes. We are focused on transitioning patients as part of our new relationship with Humana, and we are optimistic about our business overall. With that, we will open the call for questions. Operator?