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spk_0: hey and welcome to new addicts fourth quarter and four year two thousand twenty two conference call at this time operatives meant analysts multimode after the figures presentation to be a question is recession and chefs to be given at that time as reminder this cause being recorded oh like show the call over to mark clause know you may begin
spk_1: the morning and thank you for joining us for the neural net exporter quarter in full year twenty twenty two conference call joining me on today's color you're an addict president and chief executive officer keith silva and and chief financial officers be for long before we begin i would like to caution listeners that certain information discussed by management during this conference call will include forward looking statements covered under the safe harbor provisions of the private securities litigation reform act of nineteen ninety five including statements related to our business strategy potential revenue guidance the impact of covered nineteen and other operational issues in metrics actual results can differ materially from those stated or implied buddies forward looking statements you to risks and uncertainties associated with the company's business or discussion of restaurant certain be associated with your next business i encourage you to review the company's filings with the securities and exchange commission including the company's annual report on for ten k which will be filed later today the company disclaims any obligation to update any forward looking statements made during the course of this fall except as required by law during the call will also discuss certain information on a non gap faces including even not management believe the non gaap financial information taken in conjunction with us gap financial measures provide useful information for both management and investors by excluding certain non cash and other expenses that not indicative of trends and are operating results management uses not get financial measures to compare our performance relative to forecast in strategic plans the benchmark our performance externally against competitors and for certain compensation decisions reconciliation between us gap and non gap results are presented in the tables accompanying or press release which can be viewed on our website with that it's my pleasure turn the call every neuron next president and chief executive officer he saw them
spk_2: thank you mark
spk_1: good morning and thank you for joining us all began by providing an overview of our recent performance followed by an operational update the will then review our financial results and i'll conclude with some thoughts on twenty twenty three before turning to una
spk_2: we are pleased with our performance threat twenty twenty two a year which included several record quarters and the achievements a key milestones we shipped over two hundred and ten system for customers bringing total system ship all time to over two thousand
spk_1: in addition our efforts to drive increase treatment session utilization as continue to pay off as a be ended the year the number of all time treatment sessions surpassed five point three million across roughly hundred and forty five thousand patients
spk_2: it's all contributed to the total revenue growth of eighteen percent for twenty twenty two
spk_1: proof that the investments made over the past two years in marketing practice development and patient education initiatives are working a very proud of everything that we have accomplished and twenty twenty two which we kept off by a strong fourth quarter and i'd like to thank our employees who delivered this high level of success by way of their hard work throughout the year for the fourth quarter total revenue was eighteen point two million of twenty one percent over the fourth quarter of twenty twenty one the strong performance with primarily driven by record treatment session revenue as well as continued capital equipment sales growth as we seen our programs and it
spk_3: yes she did take root
spk_2: star system revenue was four point six million of sixty four percent over the fourth quarter of twenty twenty one
spk_1: the success is due to the ongoing hard work of are strong team of areas fails managers who found their groove and nurturing and converting a robust pipeline which was strengthened by yet another sold out neurostar summit
spk_2: the u s treatment session revenue was an all time record of twelve point five million a level percent over the fourth quarter of twenty twenty one
spk_3: it's record revenue is the result of positive growth at the local per click sites and was accomplished despite slower than anticipated growth and our largest service provider as they work their way through merger integration
spk_1: our per plate success was driven by our investment in five stars training program the expansion of our ph you can tool in a more offices and greater availability of practice management training
spk_3: now turning to our operational highlights
spk_1: our first focus area is increasing customer and patient awareness we once again had a completely sold out neurostar summit in chicago attended by fifty participants from thirty eight different practices
spk_2: this event received outstanding feedback which led to the conversion of several high quality customers and the growth of our pipeline
spk_1: the north stars planets had proven to be the number one of and for educating and partnering with new pms practices are area failed managers has done an excellent job helping these potential customers see the benefits neurostar can bring to them
spk_3: and their patients
spk_1: the implementation of our proprietary ph d ten digital assessment tool which allows our eurostar practices to easily identify patients with the their practice who are candidates for and have expressed interest in a neuro start treatment has been extremely fruitful we color
spk_3: acted ninety eight thousand page q ten and twenty twenty two and we will continue to enhance this tool to include new features within track star you better manage and identify patients who are candidates for neurostar start treatment
spk_1: or neurostar university in charlotte north carolina continue to receive excellent reviews from our customers
spk_3: by year end we had hosted a full capacity classes with attendees representing seventy five accounts
spk_4: and we now have a lengthy waiting list
spk_1: as we continue to evolve the capabilities of the platform as well as a support services that we offer our customers these classes will continue to be highly beneficial for both the new and existing users as we see to leverage the power of neurostar the help more patients suffering from an old
spk_3: source we have begun to see positive benefits linked directly to the and as you training classes but as the increase of twenty three percent in treatment session utilization and an increase in phd you can utilization and least and as you attendees
spk_2: our second focus area is the continued optimization of our commercial organization
spk_4: in the quarter we started to see some benefit from the efficiency gains from our newly implemented salesforce reporting tools which help our pt as better understand our customers they are patient base and utilization trend
spk_3: these tools allow the pdf to help our account set goals
spk_2: and measure their progress towards achieving that in particular allowing accounts to more efficiently and more effectively identify and treat people in need from within their own existing patient race
spk_3: as plan we hired for additional pt ems earlier this year due to the new account growth over the course of twenty twenty two these additions will support the growth of our install base and ensure we provide our customers with the highest level of service and support
spk_1: our third area focus is leveraging exclusive commercial partnerships we recently announced and expanded commercial partnership with greenblatt pms which run through year and twenty twenty eight under the agreement we will be the exclusive supplier of tms equipment to bring broke with all other pms devices being replaced with nora stars as there
spk_3: and the thing leads to expire
spk_2: this expand partnership will deliver several important synergies including cobranded and come marketing opportunities and have patient and clinical awareness improve patient access to care and a collaborative and product development and publication
spk_1: importantly agreement converse the entire greenberg organization including success vms to our consumable pricing model and away from a fixed price one we will offer our full spectrum of support and programs to greenberg centers and practitioners in particular we will offer taylor and as you classes and integrate are thq ten and track star to help greenberg reach and treat patients more effectively
spk_2: the help of this agreement drug addicts and green brock will be able to make neurostar advance therapy for mental health accessible to a growing number of people who are struggling with mental illness
spk_3: while we are enthusiastic about the long term partnership with brain rock and our ability to help them dried increase patients are you in their spatters i did want to highlight that we have continued to see disruption resulting from the merger of green broken success and it's a sequel integration
spk_1: of the two businesses as the will mention later when he provides are guidance we expect some revenue headwinds in twenty twenty three as they continue to work through combining their company lastly i want to provide an update with our clinical and regulatory progress in january we announced a peer reviewed publications which shows neurostar tms as an effective non drug treatment for depression wipo more bit anxiety significant anxiety symptoms are present in the vast majority of depressed individuals and the majority of patients with anxiety disorders also have associated depression
spk_3: we were able to study actual results and establish the effectiveness of this crucial therapy option for patients with anxious depression thanks to the strength of track star and the largest political dataset for gms in depression
spk_1: now for a quick update on the expanded medicare coverage
spk_3: in february and ngs updated their healthcare policy allowing nurse practitioners and physician assistants who are within their scope of practice to order and provide pms treatment in their patients with major depressive disorder
spk_1: this is a welcome change as we have always recognize the importance of psychiatric nurse practitioners in delivering mental health care this is especially true now given the shortage of health care professionals
spk_3: in addition united healthcare recently announced a positive coverage change which expand access to neurostar therapy ofcom the behavioral health benefit manager for united reduce the number of prior medication failures repeat them as eligibility from for down to two and removed a requirement for a trial of evidence based psychotherapy
spk_1: as the largest health care ensure in the country covering twenty three point eight million live united healthcare is optimal decision to make neurostar more easily acceptable and make a real difference in helping to alleviate the burden of drug resistant depression to continue to provide greater access to neurostar therapy we recently expanded our reimbursement keep is larger team will be able to increase our advocacy effort related to favorable health policy and provide our customers with best and class reimbursement in billings support in closing i'd like to express my gratitude to our team for their dedication and perseverance in navigating the challenges of the current operating environment with these is hard work has enabled us to successfully execute on all initiatives during the year and bring relief to patients
spk_5: suffering from depression
spk_2: looking ahead to twenty twenty three we anticipate that the momentum we have built will continue to grow as we build on a solid foundation we have blade throughout twenty twenty two
spk_3: with that i'd like to turn the call over steve
spk_6: thank you keep total revenue for the fourth quarter was eighteen point two million dollars an increase of twenty one percent of our fourth quarter twenty twenty one revenue of fifteen million dollars
spk_4: us narrow star advanced therapy system avenue was four point six million dollars compared to the prior year revenue at two point eight million dollars it was up sixty four percent the company ship fifty eight systems and que boy up from forty eight this them shipped in the fourth quarter of twenty twenty one
spk_6: us treatment best and revenue was twelve point five million dollars an increase of eleven percent of a fourth quarter twenty twenty one revenue of eleven point two million dollars the revenue growth was primarily driven by increasing realization in particular among our local park like customer stagnant in the fourth quarter of twenty twenty two revenue for active site was approximately eleven thousand five hundred dollars compared to approximately twelve thousand two hundred dollars in the prior year quarter
spk_4: excluding greenberg in success revenue for active site was consistent year over year despite having added approximately a hundred new active states during the year
spk_6: gross margins where seventy six percent consistent with the fourth quarter of twenty twenty one operating expenses during the quarter or twenty one point five million dollars an increase of three point one million dollars compared to the fourth quarter of twenty twenty one the increase was primarily driven by our expanded salesforce the opening of and as you higher than expected sales commission's incremental headcount and product development investments in clinical as well as increased costs from inflationary pressures during the quarter we incurred approximately two point one million dollars of nine cast stock based compensation expense
spk_4: net loss for the fourth quarter of twenty twenty two was eight point three million dollars or thirty one cents per share
spk_6: as compared to a net loss of seven point six million dollars or twenty nine cents per share during the fourth quarter of twenty twenty one he better for the fourth quarter of twenty twenty two was negative six point five million dollars as compared to negative six point three million dollars for the fourth quarter of twenty twenty one as of december thirty first twenty twenty two cash in cash equivalents or seventy point three million dollars we continue to work with our land their slr capital partners on an updated credit facility we are on track to close on this new facility in march twenty twenty three
spk_7: now turning to guidance
spk_6: the four year twenty twenty three we expect revenue in the range of sixty six million dollars the seventy two million dollars as keep mentioned or guidance for twenty twenty three and lower treatment as in revenue and thirteen service providers
spk_4: but continued strength from our local park like customers
spk_6: for the first quarter of twenty twenty three we expect revenue as it's the million dollars is sixteen million dollars we expect total operating expenses for the full year twenty twenty three the be in the range of eighty four million dollars to eighty eight million dollars
spk_4: for the full year we expect castle is a symptom operations to decrease year over year
spk_6: castle as a symbol be the highest during the first quarter as it it clear our national sales meeting as well as prior year bonus payments as commission and retention costs our operating plan continues to show that we will achieve cashflow break even with cash on hand our path to profitability is still on track thanks to our projections for top line growth valid gross margin profile and the careful management of are operating expenses i would now like to turn the call back over to keep
spk_3: thank you steve twenty twenty two with the critical year for known next as we continue to drive the accelerated adoption of neurostar we have shown that the clinical results are superior we have made significant investments in building the latest and most talented commercial team in the business we have demonstrated unmatched ability to support our practices by assisting them with patient education and awareness campaigns to promote long term success to continue that success we will focus on a number of key initiative three twenty twenty three
spk_1: one increasing the number of customers who participate in neurostar university to working to incorporate a high percentage of customers in to call out marketing three creating a network of towns across the country that fallen eurostar best practices
spk_3: beginning with increased customer participation in eurostar university as the initial cohort of customers has gone through training at and as you we have clearly seen the immediate positive benefit as these accounts including better ph you can update and increase to treatment session utilization because of this we are working to increase the number of existing and prospective customers attending and as you classes
spk_1: which provide important education to the providers to allow them to deliver better patient outcomes
spk_3: the classes are crucial as we continue to develop neurostar capabilities and features such as our expansion and go cd as well as the introduction of detect and the anti cat
spk_2: going forward we are offering up to two classes per month throughout the year and incorporating attendance cause into our co op marketing program our second focus for twenty twenty three is to incorporate a higher percentage of our customers into our call margin program
spk_1: there are over sixty customers who are currently utilizing the benefits of our color marketing program on a regular basis the color marketing program is one of the time in the tms industry it provides us with an incremental opportunity to partner with our customers to help support their business and provide patients with access to care through increased awareness with cobranded localized marketing campaign customers you are participating call out marketing program have seen an average increase of four patients for core we will continue to emphasize the expansion of customer participation throughout the year to bring the benefits of the program to more customers and their patients turning to our third and final focus for twenty twenty three creating a network of accounts across the country that fall on eurostar best practices
spk_2: over the past few years our company has made significant investment in the organization and the development of best practices for each customer to market effectively and drive long term growth
spk_3: we would like to take certain aspects of these proven practices to a broader network of our accounts
spk_1: as we look ahead to twenty twenty three we want to set certain standards across the accounts we serve such as offering consistently high levels of service and increasing patient marketing within their offices
spk_2: we expect to see these standards in customers who fully utilize the uniqueness of the nearest offering and our approach to the market
spk_1: we will continue to follow our plan and twenty twenty three we have done tremendous work of the last two years to set ourselves up for success and we have the strategy in place to drive the accelerated adoption of neurostar and bring relief to more patients suffering from mental health disorders
spk_3: with that i'd like to open the line for questions
spk_0: if you like asked a question please press guy one one if your question has been answered you like to lose yourself lucky you please specify one one again while i'm on the law the compile the q and a roster as first question council bill plotnik with canaccord your land is open
spk_8: a great thanks good morning so obviously at the addictive biggest question is a guidance and gil greenberg a one else what do you contemplate it the well whirlwind in high end in term in gil hodges that reflected with green greenberg and a what percentage of read these are they today and what do you expect other that vs kind of the rest your business
spk_9: thanks rebels to steve i'm obviously with a press release yesterday and we didn't have to scramble and adjust guys at this point i'm all we know it yeah they do anticipate clothing fifty stores with a ten percent impact on revenue we don't now the next we don't know which stores the north star we don't know which percentage of revenue is as for that alvarez alvarez's the a mat and so you know we took the a proud really based on their contributions and twenty twenty two verses our expectations and twenty twenty three for growth now i think we're in a way to see mode at this point so he signed i pay their while you haven't seen a actor yet but you well the other little bit north of twenty percent of our business so we believe the sixty six to seventy two million range is is appropriate at this time time he could also see we did expand their brains in revenue from are typical four million for the edit sex again we just a to see how this plays out he had through the month of march and into the early part of to tail and greenberg broken apathy and demise and maybe they'll be some are clarity
spk_8: he
spk_10: into their plans and how it impacts that
spk_8: what a see best his other wait what do you expect a year for business and twenty twenty three and yeah you've historically if i look back he grew eighteen percent twenty two and twelve percent and twenty one and even to go out of the growth as we actually twenty two with
spk_6: how did the non in brook businesses though
spk_9: you're given that eighty percent of your business can wait what do we speak contemplation of of for growth added that core business is you think about twenty twenty three thanks yeah i think it'll be consistent with what we saw in the second half of twenty twenty two so in that twenty percent range
spk_8: again if you look at our cue for number no twenty one percent over prior year yeah that was negatively impacted by greenberg and successes performance though
spk_11: that the park like consumable segment and some of the other segments are performing quite well so you know a guy think it'll be in that twenty percent range
spk_6: it and then last on this guidance question and and i'll jump back in is just how how do we how do we think about kind of the capital verse disposable especially in you'll get their hands around like gear the assumptions probably given their shut down fifty centers they can move
spk_9: the capital around your how do we think about capital and twenty twenty three vs disposable thanks for taking my questions care about yeah capital is gonna be consistent with twenty twenty two so in a week communicate between forty five the system a year we get slightly more than that last year
spk_8: and we anticipate that consistent level and twenty twenty three for the what the an impact from the grain black integration efforts
spk_0: we also expect international revenues to be flat fell all of the growth and twenty three will be related to treatment that
spk_12: mean forty five to fifty systems a quarter not for the full yet correct what i get things
spk_9: thank you are next question comes from adam mater with piper sandler airline is open
spk_12: a keith i steve beshear questions here wanted to follow a little bit on on the guidance i'm like a question and i guess i'll ask about and else you know cadence yet yeah to get q and guidance maybe a here lighter than expected but ah he just that help but think through and how you see
spk_9: you know your business and progression over the year the media will start yeah the follow produce thanks
spk_6: thanks adam yeah if if you look at artist walk or performance and and i go back the two thousand and eighteen so of the year prior to i pl in our revenue cadence by quarter es el que one is twenty one to twenty two percent of annual revenue to to he was about twenty four to twenty five percent
spk_9: two three twenty five to twenty six and eighty four hours that strongest quarter at twenty eight to twenty nine percent and so in a key one we always have the reset up deductibles
spk_12: the patients have to go through and get their benefits investigations we done and so the at the internal themes year there have been practicing about four hundred or so be either way the met continued into early march though that's really the biggest pressure on t won by again get it is very typical for the past five years okay appreciate their colors even i guess if either one one the guidance but i don't have a follow up that gets kind of obviously a lot of focus on the greenberg
spk_9: or announcement yesterday and have an impact you guys ah that if we just look back ah you know more broadly you know it it it sound like you are very confident in the business actually green brock and is it so i i guess one question i am just on the macro is your how are you thinking about this year twenty twenty two you know a and a potential recessionary environment if anything factored into the guidance there are you allowing for some additional conservatism just kind of maybe walked through the the pull off of the up under outlook yeah i'm i mean there was there are no discretionary impact in our guidance
spk_8: oh i'm sure you remember adam admire your car brands in new york that you know i communicated we were comfortable with where the consensus was for the year and that was in that seventy three million range you know we were also anticipating
spk_9: mid to high clean growth year over year again that the grape press release yesterday but the little bit surprising and so you know who i think we need just them time to work through the impact you know otherwise he saw performance include you you for you know even with i would say
spk_13: no the slow growth from them we were still at that one percent level and i think we're confident that he i will be able to maintain that in the other segments
spk_9: at okay people from from a girl from drink standpoint we have been working closely over the past couple months with the greenberg team
spk_13: putting together a plan on how they would attend and a few how they would market within their practices
spk_9: how we would help them get ph coupons in so there was some hints of the the closing of the stores but i believe that
spk_12: we have put together a solid plan with bill and his team to see if we can take the remaining stores and get them back up to their prior service levels
spk_6: okay appreciate the collar guys in one one that's one of my major than than the the on the pay gg expanded medicare coverage and and the united news from from this week
spk_14: ah i'm nina streamlining syrupy ah
spk_12: maybe just kind of a how do you think about the impact from from those development
spk_13: something i can impact the business near term or ah the think we need several quarters the kind of he he any sale and ultimately materialized thanks again to begin to questions to adam on the reimbursement side i think with united healthcare dropping from forty two it is a it is a great side many of the other payers follow what united healthcare goes
spk_12: as recently as last fall aetna went from two to four because that's where united healthcare was so
spk_13: i we are hoping that the other payers drop their requirements to and follow united healthcare sleep
spk_0: the are quite honestly there are plenty of patients out there that have failed for drugs so we're not in a there's there's no shortage it does expand the market when we owe you drop it down to two and i think or hope now is that united and the other payers make it easier to go
spk_15: through the prior authorization process so he does expand our market it does help our our our patients now we need to help our accounts with with simplifying prior authorization thank you your next question come from margaret kayser with william blair your line is open
spk_9: good morning executing a question that amount of china and with all my cup of the summer and the got inside the about apologies lab at it gets my more and and itself and the simple one the i guess what gets you are high and low and of the rage can obviously quite broad felt and more specifically i guess the need greenberg him through the gets to that high end of the range or to the base do that and then kind of a similar question on the low end of that right no i margaret i i think we need some contribution from grand rocket and based on the relief
spk_15: in there in a wreck revenue haircut related to the fifty stores we don't need any incremental growth from rainbow to get to either one of those figures and that should really be the other growth from the other segments and would represent that when it was that target
spk_9: i'm so sorry dad that the twenty percent growth from the other bigger than a month it again it's a it's a wider range of the twenty percent kind of the midpoint of the range as and another to kind of high and low and him to putting in space and better could put to better or worse
spk_15: my understanding of it yeah because it represents the midpoint perfect and then you know i wanted to follow up on the strategies could be spent on a lot of time both beginning and the any kind of walking through that and and twenty twenty two and and cow the goals for twenty twenty three in a phd tab than a few bags hydra is twenty twenty three year where those efforts i guess can scale on a broader basis
spk_13: near where you can get may be fewer three accurately and twenty percent of the base through though or is is kind of more of a continuation with them and solid growth that engagement thanks to a question margaret i think if we look at
spk_3: did and as you we have seen the accounts the come through an issue a gop almost all of our programs are on a universal basis and as a result their business has gone up so i think that we are focus is to try and get more
spk_16: of our accounts through the neurostar university program and i think that we have been our number of accounts that are using the ph few and just in the fourth quarter went from a little over three hundred to four hundred and fifty so it it is gay
spk_0: interaction so i think twenty twenty three is gonna be a standout year for at night think that we can anticipate some that that is gonna be what's going to help as drive growth
spk_9: thank you guys
spk_17: thank you and next question that comes some daniels daughter with gmp security your line is open
spk_11: yeah hi thanks and is touching back in the previous question surrounding the coverage frothy updates
spk_13: i mention the street a larger funneled patients in front of the market but i do feel that the coverage criteria has been getting factor for adoption the path
spk_8: i think what slows down our implementation within a practice is getting physicians credentialed and on to the insurance programs
spk_13: so that's that's the number one factor number two is getting the reimbursement actually paid and goes the struggle that we have is that every single patient has to go to a prior authorization process with them of the payers it simple with other the other payers they rejected outta hand and then you have do you have do and appeal
spk_17: will typically they approved the appeal if the patient has met all the criteria so yeah it it it is a gating factor here but quite honestly i think you know with the moves in medicare and now united healthcare leading the way i think we're encouraged that
spk_9: that they are finally recognizing that they need to make the access to care simpler great minutes one followed for me
spk_1: he called out higher yield to be shinier for a quick segment at the driver a stream session revenue for a few quarters here think double digit for like two quarters but i'm a pilot some of your new she in a drive in it but if point to one or two aspects that's really leading the charge here will get those be and then you're lucky to suck like and twenty twenty three
spk_3: thank you
spk_12: psychic the couple of points that that helped drive that utilization number one is our practice developing managers in a we have invested heavily into a team of people right yeah we have forty seven of them that are each account is a sign
spk_13: through one of our practice develop and managers and each one of those managers is responsible to generate awareness education and help captured those patients within the practice and educate their staff from the front desk to the trigger on exactly how to do that education so i think your practice development managers are that kippur the spear for us and they're the ones that are deploying the ph keep pens in the practice
spk_18: who are doing the by start to success which is a pure education
spk_0: at at various levels within the practice including marketing
spk_8: so i i i think those are really are are driving force we rely heavily on our practice development managers and now of northstar university to help educate the accounts right and quiet thank you and next question of the follow up from bill know with canaccord your line is open a great thanks just just the asked the question again on the the green broken me is a reread the announcement you know the weather shutting down the ladder centers they say that it's only a little of wrote and percent of revenues if i do back of a napkin math the of the space and some the commentary it sounds ikea at the low end you're looking for green broke down closer to twenty five to thirty percent
spk_13: if you're assuming at the midpoint the rest your business is growing twenty percent is that the trends you're seeing in the business today a greenberg or given the newness of the information
spk_3: if you're kind of the low end of the games is almost assuming a worst case scenario a just because you don't have a lot of information upon which to make that decision today
spk_13: the built we we monitor the utilization on all segments of our couch
spk_3: every single week and green
spk_13: utilization as as decreased over the past five months yeah which i think as we've said before and they have that i think it's expected that there would be some disruption but we saw a significant amount of decline in their in their growth and que for
spk_19: and we were able to grow in spite of it i think that if we are able to deploy that training and the education that we're going with the rest of our accounts in the green brock which yeah i think bill is is very very supportive of us working closer together
spk_8: to get that that i think we can help them get back on track
spk_1: but we did see that decline in not in the third and fourth quarter
spk_8: okay and then
spk_13: yeah just clarity and the impact to the ngs the oh starting on april first given a nurse practitioners the ordering tree how important are significant is that it's a great question so we have been looking state by state pair by pair at the opportunity that out there with nurse practitioners
spk_3: some of the states have
spk_13: say that nurse practitioners have fourth already if they have been under the guidance of a psychiatrist for five years during the pandemic virginia as an example lowered the requirement under a psychiatrist
spk_8: two two years but they have since reverse that gone back to fight so there are
spk_20: areas that a country where nurse practitioners are allowed to a to diagnose the patient to do the motor threshold and creek and we are beginning the process of identifying what what areas that is and then how we're going to educate goes nurse
spk_0: practitioners on the opportunity to help their patients
spk_13: great thanks for taking my question
spk_0: thanks bill
spk_21: thank you there no further questions at this time election call back over to keep solomon for closing remarks
spk_0: thank you again for joining us today we look forward to updating you and our next quarterly call thank you
spk_1: ladies and gentlemen to seven include the program you may now disconnect everyone have a great day the conference will begin to t to raise and lower your hand during una you can dying star one one okay you're welcome to learn addicts fourth quarter and four year two thousand twenty two conference call at this time operatives meant analysts multimode after the figures presentation to be a question is recession and chef to be given at that time as reminder this cause being recorded of like show the call over to mark clause know you may begin the morning and thank you for joining us for the neural net exporter quarter in full year twenty twenty two conference call joining me on a scholar you're an addict president and chief executive officer keep silva and and chief financial officers be for long before we begin i would like to caution listeners that certain information discussed by management during this conference call will include forward looking statements covered under the safe harbor provisions of the private securities litigation reform act of nineteen ninety five including statements related to our business strategy potential revenue guidance the impasse lack of covered nineteen and other operational issues in metrics actual results can differ materially from those stated or implied buddies forward looking statements to to risks and uncertainties associated with the company's business or discussion of restaurant certain these associated with your next business i encourage you to review the company's filings with the securities and exchange commission including the company's annual report on for ten k which will be filed later today the company disclaims any obligation to update any forward looking statements made during the course of this fall except as required by law during the call will also discuss certain information on a non gap faces including he did not
spk_2: management believe that non gap financial information taken in conjunction with us gap financial measures provide useful information for both management and investors by excluding certain non cash and other expenses that are not indicative of trends and are operating results
spk_1: management uses not get financial measures to compare our performance relative to forecast in strategic plans the benchmark our performance externally against competitors and for certain compensation decisions reconciliation between us gap and non gap results are presented in the tables accompanying or press release which can be viewed on our way
spk_2: website with that it's my pleasure turn the call every neuron next president and chief executive officer he saw them
spk_22: thank you mark
spk_1: good morning and thank you for joining us all began by providing an overview of our recent performance followed by an operational update the will then review our financial results and i'll conclude with some thoughts on twenty twenty three before turning to una we are pleased with our performance threat twenty twenty two a year which included several record quarters
spk_2: and the achievements a key milestones we shipped over two hundred and ten system for customers bringing total system ship all time to over two thousand in addition our efforts to drive increase treatment session utilization as continued to pay off
spk_1: as a be ended the year the number of all time treatment sessions surpassed five point three million
spk_3: across roughly hundred and forty five thousand patients
spk_1: it's all contributed to the total revenue growth of eighteen percent for twenty twenty two
spk_3: proof that the investments made over the past two years in marketing practice development and patient education initiatives
spk_2: are working a very proud of everything that we have accomplished in twenty twenty two which we kept off by a strong fourth quarter and i'd like to thank our employees who delivered this high level of success
spk_1: by way of their hard work throughout the year
spk_3: for the fourth quarter total revenue was eighteen point two million of twenty one percent over the fourth quarter of twenty twenty one the strong performance with primarily driven by record treatment session revenue as well as continued capital equipment sales growth as we seen our programs and initiatives
spk_1: take root north star system revenue was four point six million of sixty four percent over the fourth quarter of twenty twenty one
spk_2: the success is due to the ongoing hard work of are strong team of areas fails managers who found their groove and nurturing and converting a robust pipeline
spk_3: which was strengthened by yet another sold out neurostar summit
spk_1: the u s treatment session revenue was an all time record of twelve point five million of eleven percent over the fourth quarter of twenty twenty one it's record revenue is the result of positive growth at the local per click sites and was accomplished despite slower than anticipated growth and are largest service provider as they work their way through merger integration
spk_2: our per plate success was driven by our investment in five stars training program the expansion of our ph you can tool in a more offices and greater availability of practice management training now turning to our operational highlights
spk_1: our first focus area is increasing customer and patient awareness we once again had a completely sold out neurostar summit in chicago attended by fifty participants from thirty eight different practices
spk_2: this event received outstanding feedback which led to the conversion of several high quality customers and the growth of our pipeline
spk_1: the north stars planets have proven to be the number one of and for educating and partnering with new pms practices
spk_3: our area failed managers have done an excellent job helping these potential customers see the benefits neurostar can bring to them and their patients
spk_4: the implementation of our proprietary ph d ten digital assessment tool which allows our eurostar practices to easily identify patients with the their practice who are candidates for and have expressed interest in a neuro start treatment has been extremely fruitful we collect
spk_1: did ninety eight thousand page q ten and twenty twenty two and we will continue to enhance this tool to include new features with a track star you better manage and identify patients who are candidates for neurostar start treatment
spk_3: or neurostar university in charlotte north carolina continues to receive excellent reviews from our customers
spk_4: by year end we had hosted eight full capacity classes with attendees representing seventy five accounts
spk_3: and we now have a lengthy waiting list
spk_2: as we continue to evolve the capabilities of the platform as well as a support services that we offer our customers these classes will continue to be highly beneficial for both the new and existing users as we see to leverage the power of neurostar the help more patients suffering from mental does
spk_3: source we have begun to see positive benefits link directly to the and as you training classes but as the increase of twenty three percent in treatment session utilization and an increase in phd you can utilization and least and as you attendees
spk_1: our second focus area is the continued optimization of our commercial organization
spk_3: in the quarter we started to see some benefit from the efficiency gains from our newly implemented salesforce reporting tools which help our pt as better understand our customers they are patient base and utilization trend
spk_1: these tools allow the pdf to help our account set goals and measure their progress towards achieving that in particular allowing accounts to more efficiently and more effectively identify and treat people in need
spk_23: from within their own existing patient race
spk_3: as planned we hired for additional pt ems earlier this year due to the new account growth over the course of twenty twenty two these additions will support the growth of our install base and ensure we provide our customers with the highest level of service and support
spk_2: our third area focus is leveraging exclusive commercial partnerships
spk_1: we recently announced and expanded commercial partnership with greenblatt pms which run through year and twenty twenty eight under the agreement
spk_3: we will be the exclusive supplier of tms equipment to bring up with all other pms devices being replaced with nora stars as their existing leads to expire the to expand partnership will deliver several important synergies including code branding and come marketing opportunities and have patient and clinical awareness improve patient access to care and a collaborative and product development and publication
spk_1: importantly agreement converts the entire greenberg organization including success vms to our consumable pricing model and away from a fixed price one we will offer our full spectrum of support and programs to greenberg centers and practitioners in particular we will offer taylor and as you classes and integrate are thq ten and track star to help greenberg reach and treat patients more effectively with the help of this agreement know that exceed green brock will be able to make neurostar advance therapy for mental health accessible to a growing number of people who are struggling with mental illness
spk_3: while we are enthusiastic about the long term partnership with brain rock and our ability to help them dried increase patients are you in their spatters i did want to highlight that we have continued to see disruption resulting from the merger of green broken success and it's a sequel integration
spk_1: of the two businesses as the will mention later when he provides are guidance we expect some revenue headwinds in twenty twenty three as they continue to work through combining their company lastly i want to provide an update with our clinical and regulatory progress in january we announced a peer reviewed publications which shows neurostar tms as an effective non drug treatment for depression with more bit anxiety
spk_24: significant anxiety symptoms are present in the vast majority of depressed individuals and the majority of patients with anxiety disorders also have associated depression
spk_1: we were able to study actual results and establish the effectiveness of this crucial therapy option for patients with anxious depression thanks to the strength of track star and the largest political dataset for gms in depression now for a quick update on the expanded medicare coverage
spk_3: in february and ngs updated their healthcare policy allowing nurse practitioners and physician assistants who are within their scope of practice to order and provide pms treatment in their patients with major depressive disorder this is a welcome change as we have always recognize the importance of psychiatric nurse practitioners in delivering mental health care
spk_1: this is especially true now given the shortage of health care professional in addition united healthcare recently announced a positive coverage change which expand access to neurostar therapy ofcom the behavioral health benefit manager for united reduce the number of prior medication failures repeat them as eligibility from for down to two
spk_5: and removed a requirement for a trial of evidence based psychotherapy
spk_2: as the largest health care ensure in the country covering twenty three point eight million live united healthcare is optimal decision to make neurostar more easily acceptable and make a real difference in helping to alleviate the burden of drug resistant depression
spk_3: to continue to provide greater access to neurostar therapy we recently expanded our reimbursement keep is larger team will be able to increase our advocacy effort related to favorable health policy and provide our customers with best and class reimbursement in support
spk_6: in closing i'd like to express my gratitude to our team for their dedication and perseverance in navigating the challenges of the card operating environment with these it's hard work has enabled us to successfully execute on all initiatives during the year and bring relief to patients
spk_4: suffering from depression looking ahead to twenty twenty three we anticipate that the momentum we have built will continue to grow as we build on a solid foundation we have blade throughout twenty twenty two with that i'd like to turn the call over steve
spk_6: thank you keep total revenue for the fourth quarter was eighteen point two million dollars an increase of twenty one percent of our fourth quarter twenty twenty one revenue of fifteen million dollars us narrow star advanced therapy system avenue was four point six million dollars compared to the prior year revenue a two point eight million dollars it was up sixty four percent
spk_4: the company ship fifty eight systems and que por up from forty eight this them shipped in the fourth quarter of twenty twenty one
spk_6: us treatment best and revenue was twelve point five million dollars an increase of eleven percent over fourth quarter twenty twenty one revenue of eleven point two million dollars the revenue growth was primarily driven by increasing realization in particular among our local park like customer stagnant in the fourth quarter of twenty twenty two revenue for active site was approximately eleven thousand five hundred dollars compared to approximately twelve thousand two hundred dollars in the prior year quarter excluding greenberg in success revenue for active site was consistent year over year despite having added approximately a hundred new active states during the year gross margins where seventy six percent
spk_4: consistent with the fourth quarter of twenty twenty one
spk_6: operating expenses during the quarter or twenty one point five million dollars an increase of three point one million dollars compared to the fourth quarter of twenty twenty one the increase was primarily driven by our expanded salesforce the opening of and as you higher than expected sales commission's incremental headcount and product development investments in clinical as well as increased costs from inflationary pressures during the quarter we incurred approximately two point one million dollars of nine cast stock based compensation expense net loss for the fourth quarter of twenty twenty two was eight point three million dollars or thirty one cents per share as compared to a net loss of seven point six million dollars or twenty nine cents per share during the fourth quarter of twenty twenty one
spk_7: he better for the fourth quarter of twenty twenty two was negative six point five million dollars as compared to negative six point three million dollars for the fourth quarter of twenty twenty one
spk_6: as of december thirty first twenty twenty two cast in cash equivalents or seventy point three million dollars
spk_4: we continue to work with our land their slr capital partners on an updated credit facility
spk_6: we are on track to close on this new for still be in march twenty twenty three now turning to guidance
spk_4: the four year twenty twenty three we expect revenue in the range of sixty six million dollars to seventy two million dollars as keep mentioned or guidance for twenty twenty three assumed lower treatment as in revenue and certain service providers
spk_6: but continued strength from our local park like customers for the first quarter of twenty twenty three we expect revenue as it's the million dollars is sixteen million dollars we expect total operating expenses for the full year twenty twenty three the be in the range of eighty four million dollars to eighty eight million dollars for the full year we expect cash utilization from operations to decrease year over year
spk_25: castle as a symbol be the highest during the first quarter as it it clear our national sales meeting as well as prior year bonus payments as commissions and retention costs
spk_1: our operating plan continues to show that we will achieve cashflow break even with cash on hand
spk_2: our path to profitability is still on track thanks to our projections for top line growth valid gross margin profile and the careful management of are operating expenses
spk_3: i would now like to turn the call back over to keep thank you steve
spk_1: twenty twenty two with the critical year for know next as we continue to drive the accelerated adoption of neurostar we have shown that the clinical results are superior we have made significant investments in building the latest and most talented commercial team in the business
spk_3: we have demonstrated unmatched ability to support our practices by assisting them with patient education and awareness campaigns to promote long term success
spk_1: to continue that success we will focus on a number of key initiative three twenty twenty three one increasing the number of customers who participate in neurostar university the working to incorporate a high percentage of customers in to call out marketing
spk_3: three creating a network of accounts across the country that fallen eurostar best practices
spk_2: beginning with increased customer participation in eurostar university as the initial cohort of customers has gone through training at and as you we have clearly seen the immediate positive benefits as these accounts including better ph you can update and increase tree my session utilization because of this we are working to increase the number of existing and prospective customers attending and as you classes
spk_1: which provide important as education to the providers to allow them to deliver better patient outcomes the classes are crucial as we continue to develop neurostar capabilities and features such as our expansion into a c d as well as the introduction of detect and the anti cat going forward we are offering up to two classes per month throughout the year and incorporating attendance cause into our call up marketing program our second focus for twenty twenty three is to incorporate a higher percentage of our customers into our call caught marching program there are over sixty customers who are currently utilizing the benefits of color margining program on a regular basis
spk_2: the color marketing program is one of a tie in the pms industry
spk_3: it provides us with an incremental opportunity to partner with our customers to help support their business and provide patients with access to care through increased awareness with cobranded localized marketing campaign
spk_1: customers who are participating call up marketing program have seen an average increase of four patients for core we will continue to emphasize the expansion of customer participation throughout the year to bring the benefits of the program to more customers and their patients
spk_2: turning to our third and final focus for twenty twenty three creating a network of accounts across the country that follow eurostar best practices
spk_4: over the past few years our company has made significant investment in the organization and the development of best practices for each customer to market effectively and drive long term growth
spk_1: we would like to take certain aspects of these proven practices to a broader network of our cats as we look ahead to twenty twenty three we want to set certain standards across the accounts we serve such as offering consistently high levels of service and increasing patient marketing within their offices
spk_3: we expect to see these standards in customers who fully utilize the uniqueness of the eurostar offering and our approach to the market
spk_0: we will continue to follow our plan and twenty twenty three
spk_8: we have done tremendous work of the last two years to set ourselves up for success and we have the strategy in place to drive the accelerated adoption of neurostar and bring relief to more patients suffering from mental health disorders
spk_6: with that i'd like to open the line for questions if you like asked a question please specify one one if your question has been answered you like to lose yourself in the queue please specify one one again while i'm on the law the compile the q in a roster
spk_9: as first question council bill plotnik with get a court your land is open a great thanks good morning so obviously at the ethic the biggest question is a guidance and yeah greenberg one else what you contemplate it the whirlwind in high end in term in your how does that reflected with greenberg and a what percentage of you read these are they today and what do you expect other that vs kind of the rest your business thanks they melted steve i'm obviously with a press release yesterday and we get at the scramble and adjust guys at this point i'm all we know it yeah they do anticipate clothing fifty stores
spk_8: with a ten percent impact on revenue we don't know the next we don't know which stores the north star we don't know which percentage of revenue is as for that alvarez's a and so you know we took the a proud really based on their contributions
spk_10: and twenty twenty two horses or expectations and twenty twenty three for growth
spk_8: you know i think we're in a way to see mode at this point so he signed i pay their while you haven't seen an actor yet but you well the other a little bit like of twenty percent of our business sell it we believe the sixty six to seventy two million range is is appropriate at this time
spk_6: time he cannot the see we did expand their range in revenue from are typical four million for the edit sex again we just take the see how this plays out the through the month of march and into the early part of to tail and greenberg and as the and demise and maybe they'll be some are clarity
spk_9: he
spk_26: into their plans and how it in fact that
spk_9: oh i see best his other wait what do you expect a year for business and twenty twenty three m e o uk stork leave i look back he grew eighteen percent twenty two a twelve percent and twenty one and even to go out of the growth as we actually twenty two how did the nine in brook businesses though
spk_8: you're given that eighty percent of your business can a wait what do we speak contemplation of of for growth added that core business is you think about twenty twenty three thanks
spk_11: yeah i think it'll be consistent with what we saw in the second half of twenty twenty two so in that twenty percent range
spk_6: again if you look at our cue for number no twenty one percent over time
spk_9: year yeah that was negatively impacted by greenberg and successes performance though
spk_8: that the park like consumable segment and some of the other segments are performing quite well so you know a guy think it'll be in that twenty percent range
spk_0: in the last on this guidance question in and i'll jump back in is just how do we had we think about kind of the capital verse disposable especially in you'll get their hands around like the assumptions probably given their shut down fifty centers they can move
spk_12: the capital around your how do we think about capital and twenty twenty three vs disposable thanks for taking my questions
spk_9: sure yeah capital is gonna be consistent with twenty twenty two so in a week communicate between forty five fifty system a year we get slightly more than that last year
spk_12: and we anticipate that consistent level and twenty twenty three for the wealthy an impact from the grain black integration efforts we also expect international revenues to be flat fell all of the growth and twenty three will be related to treatment that mean forty five to fifty systems a quarter not for the full yet correct or that get thing
spk_9: thank you next question comes from adam mater with piper sandler airline is open a keith i steve they say questions here
spk_6: they wanted to follow a little bit on on the guidance i'm like a question and i guess i'll ask about and else you know cadence yet yards to get q and guidance maybe a here lighter than expected but ah you know just couldn't help but think through and of how you see
spk_9: you know your business and progression over the year maybe will start yeah the follow produce thanks thanks adam yeah if if you look at artist walk or performance a and i go back to two thousand and eighteen so of the year prior to i pl in our revenue cadence by quarter is a key one is twenty one to twenty two percent of annual revenue to to
spk_12: you is about twenty four to twenty five percent you three twenty five to twenty six and eighty four though is that strongest quarter at twenty eight to twenty nine percent
spk_9: i'm and so in a key one we always have the reset up deductibles the patients have to go through and get their benefits investigations we done and so the the internal teams here you have been practicing about four hundred or so the eyes a week and has continued into early march though that's really the biggest pressure on t won by a get it is right typical for the past five years
spk_8: okay appreciate that colors the than i guess if one one the got into but i have a follow up at this kind of obviously a lot of focus on the greenberg
spk_9: or announcement yesterday and other impacts you guys are that we just a look back ah you know more broadly you know it it it sound like you are very confident in the business actually green brock is it so i i guess one question i am just on the macro is your how are you thinking about this year twenty twenty two
spk_6: ah i'm you know a and a potential recessionary environment if anything factored into the guidance there are you allowing for some additional conservatism just kind of maybe walked through the the philosophy of under outlook
spk_9: yeah i'm i mean there is there are no and recessionary impact in our guidance oh i'm sure you remember admire your car conference in new york that you know i communicated we're we're comfortable with where the consensus was for the year and that was in that seventy three million range you know we were also anticipating you know
spk_13: mid to high seeing growth year over year but again that the graber press release yesterday with a little bit surprising and so you know who i think we need just them time to work through the impact
spk_9: otherwise is saw performance include rank you for you know even with i would say you the slow growth from them we were still at that twenty percent level and and i think we're confident that he will be able to maintain that in the other segments
spk_6: at okay people from from a from getting standpoint we have been working closely over the past couple months with the greenberg team
spk_14: putting together a plan on how they would attend and a few how they would market within their practices
spk_12: how we would help them get ph few pens in so there was some hints of the the closing of the stores but i believe that
spk_13: we have put together a solid plan with bill and his team to see if we can take the remaining stores and get them back up to their prior service levels
spk_11: okay appreciate the collar guys and one one that's when if i may just than than the the on the pier gg expanded medicare coverage and and united news from from this week ah
spk_13: the to streamline inferiority ah
spk_3: maybe just kind of how do you think about the impact from from those
spk_15: development something i can impact the business near term or are you think we need devil quarters the kind of he he any tail and ultimately materialized thanks again to begin to questions
spk_9: the adam on the reimbursement side i think with united healthcare dropping from forty two it is a it is a great side many of the other payers follow what united healthcare goes as recently as last fall kirchner went from two to four because that's where united healthcare was so i we are hoping that the other payers drop their requirements to and follow united healthcare sleep the are quite honestly there are plenty of patients out there that have failed for drugs so we're not in a there's there's no shortage it does expand the market when we owe you drop it down to two and i think or hope now is that united and the other payers make it easier to go
spk_15: through the prior authorization process so he does expand our market it does help our our our patients now we need to help our accounts with with simplifying prior authorization think your next question come from margaret kayser with william blair your line is open very good morning links between the question that amount of time and with all my couple the summer on the got inside so apologies lab and it my more mm itself
spk_9: and the simple one the i guess what the field are high and low end of the range can obviously quite broad felt and more specifically i guess the need greenberg improve the gets to that high end of the range or to the base do that and then kind of a similar question on a low end on that lines
spk_15: no i don't margaret in i think we did some contribution from grand rock and based on their relief in there in a wet revenue haircut related to the fifty stores we don't need any in from mental growth from rainbow to get to either one of those figures and so that should really be the other growth from the other segments and would represent that when it was that target
spk_13: i'm sorry dad the twenty percent growth from the other figure that in it again it's a it's a wider range of is twenty percent kind of the midpoint of the range as and another to kind of high and low and him to putting a space and better could put them better or my understanding it yeah because it's represents the midpoint okay perfect
spk_16: and then he died i wanted to follow up on the strategies because he on a lot of time both it became the and and a walking through that and and twenty twenty two and and cow the goals for twenty twenty three in a phd said that a few bags sandra
spk_0: his twenty twenty three year where those efforts i guess can scale on a broader basis
spk_17: the where you can get may be viewers reactionary and twenty percent of the base through those or that is kind of more of a continuation with some solid growth and engagement thanks to a question margaret i think if we look at the and as you we have seen the accounts the come through an issue a gop almost all of our programs on a universal basis and as a result their business
spk_11: gone up so i think that we are focus is to try and get more of our accounts through the eurostar university program and i think that we have seen our number of accounts that are using the ph few and just in the fourth quarter
spk_3: or went from a little over three hundred to four hundred and fifty so it's it is gaining traction so i think twenty twenty three is gonna be a standout year for at night think that we can anticipate some
spk_13: that that is gonna be what's going to help as drive the growth thank you guys
spk_12: thank you and next question that comes from daniels daughter with gmp security your line is open
spk_17: yeah hi thanks and was touching back in the previous question surrounding the coverage policy updates
spk_13: i mention this creates a larger funneled patients in front of the market but you feel that the coverage criteria has been getting factor for adoption the bath
spk_1: i think what slows down our implementation within a practice is getting physicians credential and on to the insurance programs
spk_3: so that that's the number one factor number two is getting the reimbursement actually paid and because the struggle that we have is that every single patient has to go to a prior authorization process with them of the payers it simple with other than other payers the
spk_12: they rejected outta here and and then you have to have do an appeal typically they approved the appeal if the patient has met all the criteria so yeah it it it is a gating factor here but but you know quite honestly i think you know with the moves in medicare and now united healthcare
spk_13: are leading the way i think we're encouraged bet that they are finally recognizing that they need to make the access to care simpler great minutes one followed for me and he called out higher yields addition euro per click segment at the driver of stream session revenue for a few quarters here in double digits last two quarters but i'm a pilot some of your she had a drive in his but few points a one or two aspects that's really leaving the charge here what were those he and then you're lucky discipline twenty points to thank you
spk_18: psychic the couple of points that that helped drive that utilization number one is our practice developing managers in a we have invested heavily in into a team of people right yeah we have forty seven of them that are each account is a sign
spk_0: one of our practice develop and managers and each one of those managers is responsible to generate
spk_8: awareness education and help capturing those patients within the practice and educate their staff from the front desk to the trigger on exactly how to do that education so i think you know our practice development managers are that kippur the spear for us and they're the ones that are deploying the phd pens and the practice who who are you a five stars to success which is a pure education at at various levels within the practice including marketing so i i i think those are really are are driving force we rely heavily on our practice development managers and now of eurostar university to help educate the accounts right in front
spk_13: thank you and next question of the follow up from build plotnik with canaccord your line is open a great thanks
spk_3: just just the asked the question again on the the green broken me is a reread the announcement you know the weather shutting down the ladder centers they say that it's only a little of wrote a ten percent of revenues if i do back of a napkin math
spk_13: me of the space and some the commentary it sounds yell at the low end you're looking for green broke down closer to twenty five to thirty percent if you're assuming at the midpoint the rest your business is growing twenty percent
spk_3: is that the trends you're seeing in the business today it greenberg or given the newness of the information
spk_13: you're kind of is a low end of the games is almost assuming a worst case scenario a just because you don't have a lot of information upon which to make that decision today the built we we monitor the utilization on all segments of our couch
spk_19: or every single week and greenberg
spk_8: utilization as as decreased over the past five months you know which i think as we've said before and they have that i think it's expected that there would be some disruption that we saw a significant amount of decline in their in their growth and queue for a we were able to grow in spite of it i think that
spk_13: if we are able to deploy that training and the education that we're going with the rest of our accounts in the green brock which yeah i think bill is is very very supportive of us working closer together forget that that i think we can help them get back on track but we did see that decline in not in the third and fourth quarter
spk_3: okay and then
spk_1: yeah just clarity under the impact to the ngs the i'm starting on april first given a nurse practitioners to ordering tree
spk_13: how important are significant is that
spk_8: it's a great question so we have been looking state by state pair by pair at the opportunity that's out there with nurse practitioners of
spk_20: scum of the states have
spk_0: say that nurse practitioners have the already if they have been under the guidance of a psychiatrist for five years during the pandemic virginia as an example lowered the requirement under a psychiatrist
spk_13: two two years but they have since reverse that gone back to fight so there are
spk_0: areas that a country where nurse practitioners are allowed to a to diagnose the patient to do the motor threshold and treat and we are beginning the process of identifying what what areas that is and then how we're going to educate those nurse for
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