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spk10: Good morning, and welcome to the Seniors Health Fourth Quarter and Full Year 2020 Earnings Conference Call. At this time, all participants are on a listen-only mode. Later, we will conduct a question-and-answer session, and instructions will be given at that time. I would like to hand the conference over to Ronnie Spade, Senior Vice President of Investor Relations.
spk11: Please go ahead, sir.
spk01: Good morning, everyone. With me on the call today are Alistair McDonald, our Chief Executive Officer, Jason Meggs, our Chief Financial Officer, Michelle Keefe, our President of Commercial Solutions, and Paul Colvin, our President of Clinical Solutions. In addition to the press release, a slide presentation corresponding to our prepared remark is available on our website at investor.cineoshealth.com. Remarks that we make about future expectations, plans, growth, Anticipated financial results and prospects and our expectations regarding the COVID-19 pandemic constitute forward-looking statements for purposes of the safe harbor provisions under the Private Securities Litigation Reform Act of 1995, and we disclaim any obligation to update them. Actual results may differ materially from those indicated by these forward-looking statements as a result of various important factors. These factors are discussed in the Risk Factors section of our Form 10-K for the year ended December 31, 2020. During this call, we will discuss certain non-GAAP financial measures which exclude the effects of events and transactions we consider to be outside of our core operations. These non-GAAP measures should be considered a supplement to, and not a replacement for, measures prepared in accordance with GAAP. For a reconciliation of non-GAAP financial measures with the most directly comparable gap measures, please refer to the appendix of our presentation. I would now like to turn the call over to Alistair MacDonald. Alistair?
spk12: Thanks, Ronnie. Good morning, everyone, and thank you for joining us today. I hope you and your families are safe and in good health. I'm pleased to report that we delivered a solid fourth quarter of full-year financial results as we continue our recovery from the impacts of COVID-19. As demonstrated by our strong sales performance in the quarter, which capped off a record year of awards, our growing portfolio of innovative and integrated product development solutions continues to resonate with customers of all sizes. Revenue across both segments grew sequentially. Overall profitability was also strong, growing both sequentially and on a year-over-year basis. We continued to deliver on the value creation plan outlined at our investor event in December. executing on our key growth strategies of further penetrating large pharma, enhancing our leadership position with SMID customers, and accelerating our innovative Cineos One and full-service commercial offerings. We expect strong growth in both our segments in 2021, which will become most apparent from the second quarter onwards, primarily driven by the robust new awards added to our backlog since late 2019 beginning to ramp, along with our COVID vaccine trials. Our robust backlog now exceeds $10 billion, providing us with a consistent revenue pipeline and highlighting our confidence in the long-term strength of our business. We have maintained our balanced approach to capital deployment, remaining focused on strategic M&A activity that will help expand our access to new markets and add key services to our portfolio. During the fourth quarter, we closed the acquisition of Sinterac, which provides us with an expanded presence in the emerging biopharma market, where strong biotech funding and innovation are driving double-digit growth. We are also excited about our more recent acquisition of the Illingworth Research Group, a leading global provider of clinical research home health services, which covers 46 countries and enables clinical trial participation from the comfort and safety of a patient's own home. COVID-19 has accelerated the decentralization of healthcare delivery and the need for in-home clinical trial services, and we believe this trend is favorable as it relates to demand for Illingworth services. Illingworth expands the scale and capabilities of our decentralized solutions, allowing our customers to realize efficiencies in patient recruitment and engagement with improved patient access and diversity. Now for other key highlights from the quarter. First, we closed Q4 with strong net new business awards, resulting in book-to-bill ratios of 1.52 times for clinical solutions 1.63 times for commercial solutions and 1.55 times in total. During full year 2020, we achieved a record $5.9 billion of net awards and an aggregate book-to-bill ratio of 1.33 times, resulting in robust backlog growth and record-ending backlog. Second, we experienced strong profitability for the fourth quarter with 3.3% year-over-year adjusted EBITDA growth, and a 160 basis point adjusted EBITDA margin increase to 17.1%. This brings our full year adjusted EBITDA margin to 14.3%, a 50 basis point increase over 2019. And third, we generated another quarter of robust operating cash flow at $114.3 million, resulting in a record total of $425.5 million for the full year 2020. further strengthening our overall financial position and liquidity. Now, getting into the detail of our results. During the fourth quarter, we continued to sequentially recover from the impact of COVID-19, with total revenue growth of 3.7% compared to the third quarter. Clinical solutions revenue continued its sequential recovery, growing 3.2% over the third quarter. Our clinical team also delivered a strong fourth quarter of net awards, resulting in net awards growth of 13.3% for the full year. Full-year clinical net awards were a record $4.7 billion, resulting in a strong TTM book-to-bill ratio of 1.42 times and year-over-year backlog growth of 24.6%, including the impact of acquisitions. Clinical Solutions is well positioned to see accelerating revenue growth in 2021 as a result of this strong backlog growth and robust pipeline. We also won over 80 COVID-related clinical projects during 2020. These represent approximately 7% of our gross awards for 2020, and we continue to see a substantial pipeline of additional COVID-related opportunities. While we continue to see some operational delays in studies, we have not experienced any meaningful cancellations as a consequence of COVID-19. The pandemic continues to drive a higher utilization of remote monitoring and lower patient enrollment in some therapy areas, although we anticipate a return to normal levels as we progress through 2021. Turning now to commercial solutions, revenue grew 5.4% compared to the third quarter, including sequential growth across all businesses. Our commercial team once again had a strong fourth quarter in awards, resulting in a $1.16 billion of net awards and a book-to-bill ratio of 1.05 times for full year 2020. Importantly, our full-service commercial awards more than doubled in 2020 compared to 2019. demonstrating that our integrated delivery model is increasingly penetrating the market, particularly with our SMIT customer base. This awards performance drove deployment solutions backlog to a record level, with growth of 4% compared to the fourth quarter of 2019. Deployment solutions also executed a record number of new team starts in 2020, spanning our diverse field team resources and our virtual engagement center. Although Net Awards and Book the Bill for 2020 were impacted by higher cancellations during the first half of the year, our commercial pipeline remains robust given the growing complexity of customer product strategies and the rapid pace of FDA new drug approval. We continue to deliver high levels of innovation to our customer base, including the evolution of Kinetic, our modern customer engagement capability. Kinetic combines insights, intelligence, and the omni-channel expertise to strengthen relationships between field teams and HCPs via targeted digital messaging. PM360, a leading publication for marketing decision makers, recently recognized Digital Amplifier, a key component of Kinetic, as an innovative 2020 service. An example of Kinetic's powerful impact includes enabling a customer to reach 80% of targeted HCPs despite the fact that personal access was not possible due to COVID-19. It also created subsequent double-digit prescription growth for those HCPs who received digital messaging that complemented personal messaging. Kinetic results are increasingly driving new business with our customers who are looking to transition to a more digital footprint. contributing to 14% of our commercial gross awards during 2020. Additionally, as we continue to deliver innovation across the lab-to-life spectrum, we are now leveraging Kinetic in our clinical programs to fuel innovation in patient outreach and recruitment for our customers. While originally designed to optimize HCP outreach for our commercial field teams, we are now working with our clinical customers to apply Kinetic to their active clinical projects. We are seeing very positive early results in patient engagement and enrollment by using Kinetic's digital amplification capabilities to enhance patient outreach and referrals through targeted physicians. We are accessing our dynamic assembly network to optimize a variety of data sources, media types, and advanced analytics to customize a Kinetic program for any given clinical therapy. These innovations are further accelerating uptake of our insights-driven product development model. With that broader context, let me provide an update of some of the key operating metrics we have highlighted in recent discussions. Our clinical teams continue to see gradual improvement in their physical access to investigative sites, with about 70% of sites permitting some level of physical visit. Similar to the third quarter, some of these sites are facing capacity constraints, requiring a higher mix of remote monitoring visits than we previously anticipated. Another 25% of our sites are now accessible only via some level of remote monitoring activity, while about 5% of sites remain inaccessible. While sites generally continue to be somewhat cautious amid localized increases in COVID-19 cases, we believe they are much better prepared to operate in this environment than they were in early 2020. Therefore, we expect site access to continue to improve gradually through the first half of 2021. Our clinical teams are also experiencing continued improvement in the pace of both patient enrollment and the startup of new clinical trials. By early February, new patient enrollment rates approached 120% of pre-COVID levels, and new site activations are trending at about 150% of pre-COVID levels. We expect this strength in site activations and enrollment to drive the ramp of our core backlog, along with our COVID vaccine trials, creating year-over-year organic growth in the first quarter when excluding the impact of reimbursable expenses and our 2020 divestiture of contingent staffing. Further, we expect clinical solutions year-over-year organic revenue growth to accelerate in the second quarter of 2021 and for the balance of the year as we lack the initial 2020 impact of the pandemic. Within commercial solutions, our deployment solutions field teams are executing on their omnichannel strategy while experiencing a gradual return to in-person visit, currently in about 65% of our territory. The pace of this return to physical visit varies by customer, with some of our large pharma customers taking a more cautious stance on allowing their teams back into the field. However, we continue to leverage our innovative kinetic capabilities to optimize HCP engagement through a combination of face-to-face and virtual field team activities, with total contact volume trending well above pre-COVID levels. Importantly, we are seeing significant improvements in the average weekly productivity of our reps through the utilization of kinetic and other virtual capabilities. The primary impact of COVID-19 has been reduced revenue from reimbursable expenses, along with increased cancellations and the delayed startup of new customer programs. However, as we have helped customers adapt to the current environment with our virtual capabilities, new program startups have begun to accelerate, which we expect to continue in 2021. Our communications business continues to see increased demand for strategic integrated programs. Our unique combination of services across advertising, public relations, and medical communications enables customers to navigate the dynamic modern landscape, including DE&I and CSR programs, COVID-19 response, virtual engagement, and other timely issues. This comprehensive approach is fueling growth in our full-service commercial services, particularly with our SMID customers. In addition, the performance of our diverse consulting practices remains strong, delivering double-digit revenue growth in 2020 while building a record backlog of work entering 2021. We expect to see year-over-year commercial solutions growth in the first quarter when excluding the impact of reimbursable expenses and the medication adherence divestiture, primarily driven by continued new team starts in deployment solutions. We expect to see this year-over-year growth accelerate in the second quarter of 2021 as we begin to lap the impact of our elevated 2020 cancellations. Before I turn the call over to Jason, I want to welcome our new colleague, from Cinteract and the Lingworth Research Group to the Cineos Health team. I again want to offer my heartfelt thanks to the entire Cineos Health community for their ongoing resilience, focus, and collaboration as they continue to provide superior execution for our customers on the very challenging circumstances. Jason will now provide additional comments on our financial performance and guidance. Jason?
spk05: Thank you, Alistair, and good morning, everyone. Our total revenue for the fourth quarter of 2020 was $1.14 billion, down 6.1% and 7% in constant currency compared to the fourth quarter of 2019 on an adjusted basis. Our clinical solutions revenue for the fourth quarter was $855.6 million, down 5% or 5.9% in constant currency compared to the fourth quarter of 2019 on an adjusted basis. These declines include a contribution of 140 basis points from acquisitions, partially offset by a headwind of 120 basis points from the second quarter divestiture of our contingent staffing business. Clinical solutions revenue growth included a 470 basis point headwind from the slower recovery and reimbursable expenses as more of our site visit activity remained remote and patient enrollment continued to recover. Our fourth quarter commercial solutions revenue was $284.5 million, down 9.3% or 9.9% in constant currency. The decline in commercial revenue was primarily due to the impact of elevated cancellations during the first half of 2020, as well as the impact of COVID-19, including a disproportionate decline in reimbursable expenses and delays in program starts. This decline in reimbursable expenses represented a 660 basis point headwind to commercial solutions year-over-year revenue growth in the fourth quarter. Commercial solutions revenue for the fourth quarter outperformed our expectations, despite being negatively impacted by our divestiture of the medication adherence business. In addition to this strengthening performance, we also have a robust pipeline of commercial opportunities highlighting the demand for our innovative solutions. Adjusted EBITDA increased 3.3% year-over-year to $194.8 million, representing an adjusted EBITDA margin of 17.1%, an increase of 160 basis points. The increase in adjusted EBITDA margin for the fourth quarter was primarily a result of our synergies, cost management initiatives, including forward bound, and lower reimbursable expenses. For the full year 2020, adjusted EBITDA was $633.6 million, a decrease of 1.8%, with margin increasing 50 basis points to 14.3%. With 2020 being our final year of measurement, we realized our targeted $140 million in total merger synergies prior to the impact of our strategic reinvestments. In addition, it is important to note that our unadjusted EBITDA grew by 10.8% in 2020. This was primarily driven by a reduction in restructuring, transaction and integration related expenses as we wind down the bulk of our merger related costs. We expect this trend to continue in 2021 with faster growth in unadjusted EBITDA as we continue our focus on cash flow conversion. Adjusted diluted EPS of $1.11 for the fourth quarter increased by 7.8% year-over-year, primarily driven by the increase in adjusted EBITDA and lower interest expense. For the full year of 2020, we generated adjusted diluted EPS of $3.41, up 5.6% compared to 2019, primarily driven by lower interest expense. Our operations generated $114.3 million in cash flow for the fourth quarter, bringing the full year to a record $425.5 million. DSO for the quarter improved to 44.5 days. We ended the quarter with $271.9 million in unrestricted cash and total debt outstanding of $2.97 billion, resulting in net leverage of 4.3 times. Although net leverage increased primarily due to the financing of Center Act and Illingworth acquisitions, we remain committed to achieving our net leverage target of three to three and a half times by the end of this year. During the quarter, we repaid $13.5 million of our term loan A and $200 million of our term loan B and repurchased $8.1 million of our outstanding shares. Further, we issued $600 million of senior notes bearing interest at 3.625%. These notes mature in 2029, providing additional flexibility in our capital structure. For the fourth quarter, the issuance of these notes resulted in an incremental $2 million of interest expense compared to our guidance. Our non-GAAP effective tax rate for the fourth quarter of full year 2020 was 24%. Given the benefit of our NOL deductions, our actual net cash outlay for income taxes in 2020 was approximately $23 million. Turning now to our 2021 guidance, this guidance contemplates our current view of the estimated impact of COVID-19 on our business, recognizing that factors related to COVID-19 are outside of the company's control. Since we issued our initial guidance, we have seen some movement in foreign exchange rates that has resulted in an incremental revenue tailwind for the full year, while also generating a partially offsetting headwind to our adjusted EBITDA. Given that we are still early in the year and have seen only a limited potential impact we are maintaining our existing guidance ranges. We continue to expect full-year 2021 revenue in the range of $5.13 billion to $5.33 billion, representing growth of 16.1% to 20.6%. This growth includes an estimated contribution from acquisitions of 540 to 580 basis points and a headwind from our 2020 divestitures of approximately 110 basis points. With this strong revenue growth and the success of our forward bound programs, partially offset by headwind from the expiration of our temporary cost saving measures in 2020, we expect total adjusted EBITDA on the range of $745 million to $785 million. This represents an adjusted EBITDA margin of 14.5% to 14.7% up 30 basis points from 2020 at the midpoint. Lastly, We expect adjusted diluted EPS of $4.09 to $4.38, or year-over-year growth of 19.9% to 28.4%. As noted on slide 8, our guidance incorporates interest expense of $94 million, a non-GAAP effective tax rate of 24%, and an estimated diluted share count of 106.7 million shares. Further for 2021, we expect our net cash outlay for income taxes to range from $50 million to $60 million. I also want to provide you with some commentary for the first quarter, given our normal seasonality and current expectations for the continued pace of the recovery from COVID-19. As Alistair highlighted, we expect year-over-year growth to accelerate in the second quarter in both businesses as we begin to lap the 2020 impacts of the pandemic. For clinical solutions, we expect this to be powered by the ramp in our core backlog conversion, along with our COVID vaccine trials. For commercial solutions, we expect this growth to be driven by robust new team starts and deployment solutions, along with continued strength in communications and consulting. We expect first quarter revenue of $1.17 billion to $1.21 billion, and total adjusted EBITDA of $141 million to $151 million. This reflects as reported growth of 0.6% to 4% compared to the first quarter of 2020. This revenue growth includes an estimated contribution from acquisitions of approximately 490 basis points and a headwind from our 2020 divestitures of approximately 170 basis points. This growth is also net of an expected headwind of approximately 210 basis points due to the continued slower recovery and reimbursable expenses. This completes our prepared remarks, and we'd be happy to answer any questions. Operator?
spk10: Ladies and gentlemen, as a reminder, to ask a question, you will need to press the star, then the one key on your touchtone telephone. To withdraw your question, please press the pound key. Please stand by while we compile the Q&A roster. And our first question coming from the line of Eric Caldwell with Baird. Your line is now open.
spk16: Thanks very much and good morning. I was hoping to dig into these commercial bookings a little bit. You always have fourth quarter favorable seasonality, or at least that's the expectation, but this was obviously a very good number. I'm curious if some of these awards were related to anything you'd call out as sort of unique, whether it's COVID-related therapies or maybe something interesting happening in CINEOS 1 with some of the projects you've talked about in your recent presentations. or if it was really just broad-based. I just was hoping to dig in a little bit more on the booking strength. Thanks so much. Okay.
spk12: Morning, Eric. Alistair here. Yeah, we're very pleased with that, obviously. 1.6, you know, in excess of 1.6 times booked to bill for commercial is a great result. You know, yes, it is seasonality, but we're always pleased to see the growth in that number. And I think it's, A little bit of all the things you suggested to a certain degree. You know, there's some COVID work in there. There is, you know, which we are starting to see more and more of coming through into the commercial realm. There is a broad-based effort around the kinetic platform. We're winning a lot of work with that platform now as people look for a more digital approach to field teams and HCP engagements. So, you know, the investments that we've made in that technology and the processes and people that sit around that are important. I think we're seeing good traction in full-service commercial, and that's work that's coming in from Cineos One, as you said, but also just integrated full-service commercial on its own. So people buying the whole package from Michelle and her team as we go. And I do think there's also a sense of optimism in that commercial space around the recovery from COVID. So we're seeing vacancy management come back. We're seeing teams launched. We had a record year in 2020 for the number of teams launched. And a lot of that work is coming from our SMIT sector where it's more teams but smaller, which helps us to continue to diversify the backlog. So really... really very broad, a very broad basis. And with, you know, to Ixnay, your follow-on question, with a robust pipeline going into Q1 of this year, so very pleased with how that's shaping up.
spk16: I like how you read my thoughts there a little bit. But actually, my real follow-on question was a little bit different angle. We I think last year we saw, if memory serves, the second best or tied for second best year of FDA approvals for new drugs. And there's been the sense that pharmas really weren't launching their new products the way they historically did and that there were maybe delays in that traditional, if you go back years ago, the original blitzkrieg that you get upon approval. I'm just curious, what does the backlog or the pipeline look for these newer products and what kind of decisions are clients making around these launches? And, you know, is it really a pig in a python situation or is it, no, we're changing the game and we're just, we are, as you said, maybe smaller teams, maybe more omni-channel, we're going forward, but don't expect the big blitzkriegs of the past.
spk12: Yeah, I think some of those bigger efforts will be there. You know, we've seen that a little bit in 2020. Some of the more strategic partnerships that we've won certainly include some of those. But I do think it's the nature of the products that are coming through. It's more specialty. It's higher science. It's less, you know, boots on the ground, more educational, more support through MSLs and nurse educators to make sure that you know, the physicians that are seeing these specialty patients are, you know, supported very strongly in the field with everything that they need in a more omnichannel way. I think omnichannel, one of the legacies of COVID for us that we see is really that shift over to a more permanent shift over to a digital footprint in commercial launches, in commercial detailing. You know, and the support that we give around that with the kinetic platform, I think, is really you know, has been a great recent driver for us. So yeah, that innovation needs to be there. I mean, Michelle, your thoughts on the style of launches now compared to where we were just a few years ago?
spk00: Yeah, that's a great question. And I totally reiterate everything that Alisher said. But what I would add is that, you know, I think that customers are getting very smart about how they communicate with all their stakeholders, right? And It's really about data and insights around your different customer mix, whether it's HCPs or payers or patients, and creating a very personalized experience for that individual. And so I think what we're finding is that it's not one strategy anymore, right? It's not these large sales teams that go out at launch and a bunch of tactics and effort early on. It's really very focused around creating the right message at the right time for the right customer. customer and that those customers, the ROI on those individual customers are different and the relationship you need to have with those different customers is different. So I think it's great for the commercial business because it diversifies the type of solutions we're bringing forward and diversifies our backlog. So I do think it's something that we're uniquely positioned to address because of the breadth of our capabilities. but it also creates what I think we all want to see, which is a more diversified backlog.
spk16: Thanks very much, guys. I appreciate it.
spk10: Our next question coming from the line of Robert Jones with Goldman Sachs.
spk02: Yeah, thanks. Good morning. Thanks for taking the questions. I guess maybe just one on clinical, Alistair. You and your peers have consistently talked about you know, delays but not cancellations, you know, as it relates to COVID and COVID work and COVID complications from conducting trials. I guess just given that dynamic, could you talk a little bit more about to what degree there is really pent-up, you know, clinical trial demand? And as it relates to that, anything you could share on how we should be thinking about backlog burn as we get into 2021?
spk12: Yeah. Morning, Bob. Thanks for the question. I think you see a little bit of that pent-up demand starting to flow through, not just our Q4 book-to-bill, but those who have reported ahead of us all have pretty strong book-to-bills across the space. So we're starting to see that flow come again. This mid-pipeline is very strong. And the pipeline that lags a little bit still is large pharma. I think they're very cautious to come out, making sure that they're not going to put people in harm's way, etc., So, you know, we're seeing that pipeline recovery, which indicates that that pent-up demand is there. Some of it is still COVID-driven as well. We still see a fairly healthy pipeline of COVID in our overall pipeline, treatment trials as well as some vaccine trials still. So, you know, we see that coming through. I think as we start to recover from the lack of... site kind of participation because of COVID, right? Because of the site closures. You'll see that burn rate pick up for us. Our burn rate starts to pick up kind of as we go through Q2 and then accelerates into the back half of the year as those COVID restrictions come off. But also as the work that we won kind of from the end of 19 onwards and 2020 for us being a record year in sales, you know, helps us to bring that backlog through. Plus on top of that, you've got the COVID restrictions Our COVID trials are slightly, you know, we're probably a quarter behind where some of the others were in terms of the COVID vaccine trials coming through. So you kind of get that double acceleration for us where our backlog ex-COVID starts to burn again at a higher clip because of site access, et cetera, and enrollment picking up. We got new trials obviously built up to go on top of those that are going through startup now. I mean, we talked about our startup figures. We're at 150% of site activations compared to pre-COVID. We weren't exactly hanging around before COVID. Now we've got this massive pile of startup work that's starting to work its way through the model. Those trials will come on to enroll Q2 and onwards. And then you've got COVID that's kind of driving a little bit extra on top. So a lot of growth this year. The slope is a little bit steeper because of the recovery from COVID than we'd normally expect to see. But we've been preparing for that and recruiting slightly ahead of the curve to make sure that we can handle the growth. So it's an unusual year in that sense that the growth is so quick. But it's got three or four elements in it that are really all tailwind.
spk02: No, that's helpful. And some of this might tie into my follow-up. But Jason, if I heard the 1Q numbers correctly, it looks like the EBITDA margin at the enterprise level is somewhere around 12% at the midpoint. I know 4Q is seasonally high, but even looking back at 2Q, 3Q, that's kind of in line to below. Anything specific, and it might actually obviously relate to some of the things Allison just shared, but any specific dynamic that you would point to as far as why 1Q EBITDA margin might be a little lower?
spk05: Hey, Bob. Good morning. Yeah, I mean, typically, you know, if you go back and look, we're in that sort of 12, 12.5% range in quarter one. You know, come out of a very strong quarter four from a margin, you know, percentage basis and dollars, frankly, because of, you know, the push of everyone to get all their change orders finished. You know, all the taxes have capped out for the year. You know, on the payroll side, you have your PTO vacation reversals where, you know, things, you know, really just drive that quarter four high and then all that resets and starts over and you have sort of this double, you know, whammy to quarter one there on the cost side. So it's really in line with what we typically see from those seasonal items and nothing really to point out that's, you know, different.
spk02: Okay, got it. Thanks so much. Thanks, Bob.
spk10: Our next question coming from the line of Tycho Peterson from JP Morgan. Your line is open.
spk17: Hey, thanks. Actually, I want to follow up on one of Bob's questions about the recovery trends. You know, Alastair, you talked about site activations at 150% of pre-COVID levels, enrollment 120% of pre-COVID levels, but obviously you're only at 70% of site accessibility. So I'm curious how you think about kind of resolving the bottlenecks there is the answer, you know, leveraging Ellingworth and doing more remote monitoring and making investments there. to try to kind of, you know, leverage that channel more? Are there ways to kind of free up the bottlenecks?
spk12: Yeah, yeah, there are. I mean, you obviously have to get the approvals in place to be able to do the Alingworth piece, you know, the at-home health piece. So, you know, there are steps to do to get through that. And also, one of the factors in those numbers, obviously, is as our COVID work starts to ramp, we've got a lot of COVID patients and COVID sites coming through those startup numbers. So, it skews the overall of it so if you look at that just keep just keep that in mind when you think about those those numbers that you know that acceleration does uh have a bit of covet in it but i think you know sites are handling issues on a local level through um you know ppe and local kind of uh protocols they're engaging more they're getting back into the into the enrollment phase we see covid starting to clear in a lot of different countries I was on a phone call on Tuesday this week with a customer in India who was talking about the COVID rates. They're dropping down. We see that in the U.S. We're seeing that in Europe with, you know, there's a lot of optimism, I think, in the sites that they can get patients back in and get moving forward quicker. So, you know, yeah, those bottlenecks need to be managed carefully. One of the real bottlenecks is actually the amount of time people on site can spend on each project. So getting CRAs on site can be a little bit more difficult, but that's where the remote monitoring access comes in to clear out backlogs so you don't have to spend so much time on site. So a lot of different strategies to deal with it. But, yeah, certainly we'll be leveraging Illingworth to do that wherever we can.
spk17: And then you talked about FSP awards doubling. You know, obviously Cineos won helping there. Now that you've got Cinerac, can you talk a little bit more about, you know, how that may help drive more FSP in this MCAP biotech-based?
spk12: Yeah, well, we don't really think about FSP from Sinterax. They're more full-service models for the emerging biotechs. But, yeah, I mean, overall, we're very pleased with our FSP growth. It continues to be a tool that we use with our large pharma partners and anybody really with scale to support either a hybrid model or just full FSPs. There's a lot of interest in that. But on the Cinteract side, that's really about full service. There are a few little biometrics, data management FSPs that they had that we've already rolled into our main FSP effort.
spk17: Okay. And then last one, you just mentioned the opportunity to leverage Kinetic into the clinical side. How do you think about that? Is that really just to drive faster enrollment, or maybe what's the opportunity there?
spk12: We're really excited about using Kinetic in clinical. We've used it now probably a half a dozen times or so on big trials, and the impact it has is quite very marked. So we're very pleased with that as a new tool for us. It really helps to, you know, the clue's really in the name of digital amplifier. It's something that helps to identify trials in a broader way to people and referring physicians, networks of physicians that we can target, and the way that the technology works to make sure that folks with potential patients are actually seeing the information around trials that are in their vicinity in general or in their specialty. So we've seen a lot of referrals through that to actually investigative sites, and that's been a great kind of... proof point of the model using our insights from commercial. We use this platform on HCPs to communicate to them, and it's really about audience engagement. The patients, referring physicians, et cetera, are all an audience, and this helps us to get the right materials in front of them at the right time when they're receptive to finding out information that could be useful for their patients. So a great tool. We've got a lot of interest in it from our large pharma clients, um about using it kind of across their platforms already and that's pretty significant if you you know we know how slowly some of our customers move sometimes but some of them have used this tool and they want it for everything so we're very very excited about that great yeah thank you taiko i just wanted to hop back on the on the fsp question the full service i think in alistair's prepared remarks he mentioned that we've seen a doubling of our full service commercial
spk05: awards in 2020 which is you know the model we've been driving over the last several years which things like kinetic and other investments we've made help put those services together so think of it fsp on the clinical side has moved to full service and you know we have a combination of both businesses we're driving that way on the commercial side as well point solutions in the past we're driving more toward full service commercial and overall you know commercial services, and we've seen a doubling of those awards during 2020.
spk17: Got it.
spk05: Thank you.
spk17: Thanks, Tucker.
spk10: Our next question coming from the line of David Windley with Jefferies. The line is open.
spk04: Hi. Thanks for taking my questions. Good morning. I first wanted to, just a clarification, kind of a housekeeping one around backlog, where I was looking at the role, and it looks like there's a fairly substantial add of some sort. Maybe it's the Center Act backlog or an FX adjustment or both. Is that kind of the plug I need to get to the $10.2 billion at the end of the year? It doesn't look like bookings by themselves would do it.
spk05: That's right, Dave. So you would add the Center Act and the billing work backlog to the, you know, core Cineos Health backlog, and that's how you would get to the full $10.2 billion.
spk04: Do you have numbers for those, or I guess I can just back into the total?
spk05: Yeah, I mean, it's roughly, I think, in the half-billion range for the combined. Okay.
spk04: Okay, and then Alistair, really both of you have talked about ramp, you know, to Bob's question about first quarter, ramp of revenue, backlog burn rate kicking in in the second quarter. I wanted to understand that a little bit better in that I think you're telling us that your site activation activity is running hot because, at least in part, because of COVID, which Sounds to me like those are already starting to contribute in the first quarter, but the burn rate not really growing until the second quarter. So if you could just kind of flesh that out a little more, I'd appreciate it.
spk12: Yeah, sure, Dave, and good to hear from you. Yeah, you're exactly right. So you get the study startup activities going now, you know, end of Q4 and into through Q1. And then the real revenue starts to flow out of these trials when those patients are enrolling, the monitoring is being done, the visits are being captured. So, you know, that really starts to come on stream end of Q1, Q2 for us, because that's when the COVID, we get that COVID acceleration coming through from the vaccine trials that we're running. And, you know, remember a lot of the work that we won in COVID is, the majority of our work in COVID is on the treatment side, which run a bit more like regular trials. So they're not starting up in one month and enrolling the next. They are you know, a bit more slow and steady, take a couple of months to get opened up, and the enrollment's a bit slower. So, you know, that spreads it out a little bit, which is why our backlog accelerates through Q2 and into Q3 and not immediately as we hit Q1.
spk04: Okay. Final question for me. Jason, you mentioned in your prepared remarks continued focus on improvement in cash flow conversion and wanted to understand if you're thinking on that you know, say, CapEx declining or just further improvement in DSOs? What do you think your levers are there to improve that percentage?
spk05: Yes. So, all those things, absolutely, Dave, in terms of, you know, continuing to focus on, you know, improvement of our DSO accounts, which is very, you know, important. And you can see some of that coming through the end of the year here, particularly as you look at deferred revenue and and what we've done there on the DSO. We are and will continue to pay close attention to CapEx, but not, you know, we're not trying to underinvest in the business by any stretch. And then the below-the-line items, you know, over the years as we've put the companies together, right, we've had to spend money to do that and launching forward bound, and we're just, you know, focused on all those, you know, those areas as well.
spk07: Okay.
spk05: Thank you. Mm-hmm.
spk10: And our next question coming from John from .
spk14: Hi, thanks very much. Alistair, just following up on the comment you made about some of the COVID work a few minutes ago, what is the duration of those awards that you're seeing now across both clinical and commercial? For clinical, can we think of those as sort of a two to three year sort of typical study or will they burn faster from your impression?
spk12: That's a good question. I'll pass you over to Paul for some specifics in a second. But, yeah, you know, they are faster, particularly the vaccine trials. I think, you know, they're typically obviously going to run a lot faster. The treatment trials tend to have a bit more of a follow-up on them to see the overall, you know, the long-term impact, talking about people with hepatic failure or, you know, ongoing lung, breathing, respiratory issues. that will need to be followed for a longer period. So they're a little bit more graceful in terms of timeline. So, but Paul, your thoughts on the overall burn kind of timelines for those trials?
spk03: Yeah, no, I think you're spot on there, Alistair, that again, the treatment trials, our experiences are more aligned to our normal burn rate. But certainly when you have the vaccine trials, there's a faster enrollment and both indirects and direct spend on those. So I think that's the typical that we've seen. I'd say the bigger mix issues will just be around therapeutic care when you think about burn rate.
spk14: Great. Thanks. And Jason, in the 21 guidance that you've given us for the top line, can you give us a sense about what you expect COVID work to contribute both in clinical and commercial?
spk05: Yeah. Hey, John. Good morning. yeah when if you look at the uh we'll start commercial if you go back to um one of the earlier questions i think it was eric's question on our quarter four bookings in commercial we we've seen some bookings on the the covid work that we've talked about in prior quarters but nothing major yet from that those are those are still out for approvals so we're doing some pre-launch work that's coming through but it's immaterial but the the larger bookings and the revenue from that would be, uh, I would say more second quarter, even second half on, uh, of 21. Uh, so not too, too much there. In addition to some of the work we've done, um, which has been less than, you know, you know, probably 25 million in communications and consulting for COVID in 2020. So nothing material there. And on the clinical side, uh, not material in 2020, we talked about the awards being less than 7%, backlogs even less than 5%, close to 4% if even that, and the revenue has been quite low in 2020 as well, again, probably less than 25 million. That does go up quite a bit as we pull through the trials that are now launching and starting. We haven't guided exactly or provided insight into that, but it is a substantial part of the ramp from 2Q onwards, but we just haven't provided specific numbers on that.
spk14: Great, thanks. And then, Alistair, maybe one more last quick one. With another year under your belt post-merger, what are your latest experience around sort of integrated wins? Are you seeing those go up or down as a percentage of the total, and are you still seeing those primarily in your sort of SMID client base?
spk12: Yeah, it's a good question. So integrated wins for me fall into a couple of categories now. You know, broad-based, large client kind of cross-sells where, you know, we're penetrating customers in clinical with commercial, particularly around communications and consulting and vice versa. But then, obviously, the CineOS One platform continues to gain traction in the SMID base, certainly. You know, we've got one big partner who uses that model as well, which is exciting. And then I think the area that we've seen the most growth, which is, it goes back to Tycho's question a little bit about where we saw this double, is full-service commercial. We saw full-service commercial packages double in 2020 over what we've done in 2019. And I think that's a model that will gain traction more and more so as we move into that more kind of full-service commercial launch phase. So, yeah, very excited about those things.
spk05: Great. Thank you.
spk12: Thanks, Sean.
spk05: Thanks, Sean.
spk10: Our next question coming from the line of Patrick Donnelly with Citi. Your line is open.
spk06: Great. Thanks for taking the questions, guys. Maybe, Jason, just on the reimbursable expenses part, I know you talked about it remaining a headwind in one queue. Can you just talk about that sequentially and then also kind of the split between commercial and clinical? Is it still pretty similar between the two?
spk05: Yeah, hey. Patrick, it's difficult to hear. They're cutting in and out. I don't know if it's my phone or not, but the reimbursables, yeah, I mean, it's been, you know, disproportionately, you know, impacting commercial, but it's been impacting both businesses. Sequentially, you know, when you think about just an organic basis, we've seen it step up, you know, quarter two, quarter three, quarter four, and we expect to see that again in quarter one in terms of the sequential growth. but both businesses still being impacted year on year from quarter one of last year where we were, you know, pre-COVID. So, you know, that's a big driver. If you sort of back out the reimbursable expense impacts in quarter one, I mean, the business is largely flat. So it's a pretty big impact as we outlined. And then we expect to see that continue to grow throughout the year to when we get, you know, hopefully through everything first half, and we'll see it, you know, continue to go up in the back half. But we don't anticipate, as we've said earlier, and I guess in a quarter three call, that we'll ever see it back to the percentage of our total revenue that it was, you know, pre-COVID, just given the changes in remote monitoring and, you know, remote detailing, et cetera, and the digital capabilities that are now in the commercial business.
spk06: Okay, that's helpful. And then Alistair, maybe one for you. I know you guys have talked about bringing the leverage ratio down to three, three and a half by year end. How should we think about capital deployment M&A this year given the balance there?
spk12: Yeah, I mean, we want to remain opportunistic as we go forward. You know, the primary priority for us is to continue to pay down debt. We've been bringing leverage down over the last two or three years, you know, on that basis. But, you know, if there are deals to be done that help us drive towards strategic goals, you know, like we did with Cinteract and Ellingworth, we're going to be interested in taking a look at those kind of token level deals that can take us into a high growth market or can open up channels for us like Ellingworth does. So, you know, priority is going to be paying down the debt, obviously. But, yeah, we'd still be open to more deals like that or if there was something geographically we wanted to do. you know, we'd look at that as well. All right. Thanks, guys. Thanks, Pat. Thanks, Patrick.
spk10: Our next question coming from the line of Erin Wright with Credit Suisse. Your line is now open.
spk13: Great. Thanks. Can you talk about the sustainability of the strains that we've seen in real-world evidence and what the growth was in the quarter and what your expectations are for the durability of of that strength in 2021, just because that's been a theme across the CRO world lately.
spk12: Yeah, morning, Erin. Yeah, we got a ton of questions at JPM around real-world evidence, and it is a very interesting space. You know, we've grown a very good capability there from a smaller base, you know, and we saw great growth last year. I think it was our fastest-growing organic group So, you know, we're interested to keep hiring in that space. We've had a lot of success bringing into that group from other CROs as well as pharma. And I think it's a really important space to hire people in from a large pharma who are typically the biggest customer of that kind of service. I do think it's going to be a growth area for the next several years, not just 2021. And I think COVID will fuel that as well. There's a lot of patients that are going to need longer-term follow-up, either those that were in the vaccine trials or those that are in some kind of deficit from what they call long COVID or who have been in a trial to look at some of the treatment impacts. Because governments need to see lots more data on these patients because a lot of it wasn't collected as they went through phase three because of the speed. So I think that will fuel demand in the long-term follow-up real-world space, as well as people looking at data, using data to answer questions that come back from regulators. So you see organizations who've got the capability to produce regulatory-grade submission packages. We work with constant AI on that kind of thing in the oncology space. So that's the ability to pull that data together and then look at the gaps that you still have to answer a question from the regulator is going to be a big part of that real-world growth as well.
spk13: Okay, great. That's helpful. And then can you speak a little bit about the acquisition of Ellingworth and how much that adds to top-line growth? Presumably that was all embedded in guidance and margin profile as well as the customer-based profile, any sort of overlap there and And do you anticipate meaningful near-term stepped-up investment associated with your positioning around decentralized trials?
spk12: I'm going to try and remember all of that question there. So I think I'll start with customer profile. So Illingworth's a pretty small organization in comparison to the largest Cineos, right? But one of the things that we immediately attract to is customer base. They work with all the big farmers globally. Um, so, you know, you get access to new contacts, new channels through that as well. So that's, you know, a good element of that. Yeah. We'll continue to investing in them with, obviously we'll be bringing them onto some of our systems, but you know, we're going to use them as an independent business unit. They obviously have some other CROs as customers too. So, you know, we've, we've had conversations with those and it's a quite a rare asset. So, you know, we have to, we'll obviously be delivering for other CROs as well as direct farmer customers. But also being able to introduce that to our SMID customers, you know, we work with Illingworth, we'd outsource work to Illingworth and had a good relationship and they do great work, which was a big driver of the acquisition itself. You know, we'll continue to invest in it. Yes, their numbers have been, you know, incorporated into the overall guidance. And, you know, it's a fast growing area, I think fueled by COVID, but it was a fast growing area before COVID as well. So, You know, we want to make sure that we ride that as we implement it as part of our decentralized trial approach. You know, it's all great and well having the right technologies to do decentralized trials. You've still got to go and check on those patients that are being dosed at home. And Ellingworth gives us the capacity and the reach to do that on a lot of trials in a lot of locations. So we're very excited to be able to bring that to customers as an option and as people are a little bit more reluctant to go to a trial site or go to a hospital for treatment if it can be delivered at home, we can now do that. So we're excited about that. I think that covered it all, but did I miss anything?
spk13: Nope, that was great. Thank you so much.
spk12: Okay.
spk10: Our next question coming from the line of Elizabeth Anderson with Evercore ISI. Your line is open.
spk09: Hi, good morning, guys. Maybe just sort of a follow-on to Aaron's question. How are sponsors sort of thinking about some of the, you know, remote patient monitoring and remote trials as we move out of COVID? You know, would you say that, you know, it was sort of a stopgap measure? Are they more willing to engage in the trial? I just wanted to see how that pacing had changed as we're sort of moving towards a post-COVID world.
spk12: Yeah. Hey, Elizabeth. Great question. Obviously, it was used as a big stopgap you know, at the height of COVID, that's for sure. But now, and it's been something we've been pushing as Cineos, but also as I think as the CRO industry for a while to customers that, you know, we can do remote monitoring, et cetera. You know, we've certainly been very active on ACRO on these discussions and talking directly with the FDA on it. The reluctance has always been customers are worried about what the regulator will think of data that's been monitored more remotely. But I think a lot of those concerns are now put to bed because this has been a big test. There's been no real, that I've seen anyway, no real big quality issues associated with remote monitoring. So it can be a strategy. I don't think it takes over. I think it becomes an adjunct to a well-monitored trial. So You know, maybe you have several visits within an overall program that can now be done remotely or through telemedicine rather than, you know, having to have a patient come all the way into a site, et cetera, particularly if there are a lot of visits. Maybe some of those visits can be done remotely. So I think you will end up with a hybrid where you still have a lot of in-person trial work at the site supplemented by remote monitoring or alternatively or done from home. you know, in the home health channel that, you know, we can now service the living with. So I think it becomes a, it's here to stay. I think it, you know, if you look to trials, I think it's in 2019, 3% of them had, you know, a high level of digital implementation. And I expect that to go up to, you know, 15, 20% over the next four or five years. You have to design these things into new trials as it comes through. So yes, we'll see it more and more. But I think we and others like us, we're all very prepared to be able to deliver that.
spk09: That makes sense. Thank you.
spk12: Thanks, Elizabeth.
spk10: Our next question coming from the line of Sandy Tripper with Truth Securities. Your line is open.
spk08: Hi, thanks. This is Stan for Sandy. Maybe we can keep the distributed trial thing going here. I'm just thinking about, obviously, distribution of trials, it kind of flips the script on the quantity of sites that you're working with. How do you think about maybe the capacity to handle a more of a distributed trial type of environment? Is there a theoretical ceiling to how many trials you can handle that have a distributed component to them?
spk12: Good question. I don't think so. I mean, obviously, You know, down the home health channel, Ellingworth is a smaller organization, but we tap into big home health networks, you know, big home health nurse networks. So the capacity for that is pretty good, and it can expand and scale very rapidly. So in that sense, no. And remote monitoring actually takes some of the burden down on the site. So I think, you know, as trial designs mature, and maybe incorporate a little bit more remote and a little bit more home health. It probably takes a little bit more pressure off of the in-person monitoring, you know, where those resources have been pretty thin over the years and, you know, it's always a bit of a talent war in there. So, you know, I think it probably helps rather than hinders in a way and helps us service more down because you've got, you know, two or three channels potentially within any one trial rather than one single channel.
spk08: Got it. That's helpful. Maybe one more for me on Synterect. Just curious about your integration plans. Is the plan here to fully roll up Syntract into your core operations? Is it going to operate separately? And maybe how does the go-to-market strategy relate in the same way? Is it separate or is it going to be integrated with the core of Cineo's offering?
spk12: Yeah, I mean, we're holding it as a separate business unit, which, you know, services that emerging biotech group. And I think the Syntract team has been phenomenal since they joined us. you know, in working out how they plug in. You know, what we saw in due diligence with them was a very different customer base. And their customer base wants that agility. They don't need the big kind of institutional hammer that Cineos Health can be sometimes. But, you know, they want that nimbleness in the project team. They want that, you know, direct contact, high-touch kind of engagement. And we do a lot of that with our SMID clients. But a lot of our SMID clients are quite big now. where they need that structure. The Sinterac group have that more agile, boutique-y kind of CRO feel, so we're trying to maintain that. Obviously, the back end, the G&A, that's starting to be integrated now, and where we can support from a functional perspective, study start-up, biometrics, et cetera, that's coming together. But also, one of the big elements of working with Sinterac You know, they had a limited geographic footprint, really, to Western Europe and the U.S., or North America, I should say. So when they won work that was truly global, which they do win quite a lot of that, they weren't able to service all that work in Japan and, you know, Asia and Latin America. And what we do now for them is we are their network. So, you know, if they win a study that's you know, got a couple of million bucks worth of monitoring out in Japan or China or Argentina or wherever it may be, we now do that work for them. So there's a good revenue synergy there between the organizations as we build. So we'll keep it as a separate business unit targeting that high-paced, high-growth emerging biotech sector and, you know, is integrating well so far. Got it. Thank you. Thank you.
spk10: Our next question coming from the line of Dan Brennan with UBS. Your line is open.
spk07: Great. Thanks for taking the questions. I may have missed it, Jason and Alistair. So just in terms of the outlook for 21, did you discuss kind of clinical versus commercial, what to expect there? And I know the burn came up a few times, Jason, but just what would the clinical outlook imply for the burn rate as we go through the year?
spk05: Yeah. Hey, Dan, we haven't talked about know specifically about clinical you know versus commercial um but when you look at obviously center act and illingworth and the contributions we we talked about there on the m a side um you know that's clinical and then if you look organically with without you know all the divestiture activity that has happened you'll you know because we've had a divestiture of contingent staffing and clinical and then the medication adherence and commercial You know, think about commercial being, you know, above the sort of organic growth rates that we've talked about in the business and clinical as well. So, I mean, that's kind of a steer of how we're looking at it. So strong years, as Alistair said, for both segments. On the burn rate, on the clinical side, you know, we've talked about how, you know, we bottomed in quarter two. And COVID at 8.7 and it's come up to that 9.2, 9.3 range. You know, typical seasonality in quarter one that we see every year where the burn rate can step down. Plus we've had, you know, strong awards that just mathematically can cause it to step down. So it'll step down some in quarter one as we've outlined. And then, you know, start to recover again, you know, through Q2 and through the back half. But not getting back up to that you know, 11, 11 and a half percent, given we've seen our average study period extend from, you know, low 50 months to 60 months, uh, given all the oncology and phase three, you know, work that we're winning. So that's how we're looking at it, thinking about it on the burn rate side.
spk07: Great. Thank you. And thanks Jason. And then maybe within commercial, could you just give us a little bit more color on deployment and communication, how we're thinking about the outlook in 21 there, um, and ODs talked about some pharma sales headcount reductions that they're anticipating in 21. Are you seeing anything on that front, or is that factored in the guidance? Thank you.
spk05: Yeah, I mean, you know, consulting has been growing, continued to grow, just really strong business. The communications business has been performing really well, winning a lot of new work. and, you know, really starting to hit their stride there, and deployment solutions, you know, I think Michelle's talked about, Alistair talked about, you know, we've launched a record number of teams in 2020, and, you know, we'll continue to see that this year, and that's before we start seeing the Cineos One team, you know, come in, that we've talked about, the COVID opportunities, that if they're approved, you know, so really all businesses doing well, and you know, we expect to grow. And then, you know, Michelle, I'll let you talk a little bit about the reps and the Viva discussion.
spk00: Sure. So, no, it's a great question. So one thing I always say is that, you know, there's more than one CRM company. So I, you know, they have to, how that's managing market share between companies and CRMs, I can't, you know, speak to that. But the jump that that means that there is a reduction in overall sales representative, I don't know if you can make that leap. I think what we're seeing is a diversity in the types of people that pharma needs to launch their brands, right? So, you know, you hear us talk about nurse educators, clinical trials, liaisons, you know, reimbursement specialists, et cetera. With the way the FDA is approving, you know, new products, I think it was 57 in 2020 that they tend to be more specialty products and they're more complex. So the types of people calling on customers is a much more, um, you know, diverse group of backgrounds. And then when you layer on the fact that we have been very successful in enabling them to be fully digitally enabled and virtually enabled and orchestrators and, um, you know, that managing, you know, their HCP interaction, we're finding that it's, um, you know, it's just a different type of commercial model launch. So overall, um, you know, we, we have seen a lot of interest in the business and we see folks starting new teams with us. I think as, as Jason said, we had a record number of teams start in 2020. And, um, we also, because of our full service commercial, which is another piece of information, you know, we have good line of sight between Cineos one and full service commercial. to brands that we're currently doing clinical and, um, I'm sorry, uh, consulting and communications work on that have not launched teams yet. And it's not in our backlog and it's not in our, um, and it, and it's not in our gross award target yet. Right. Cause it's, you know, 12 months out. And so we have good line of sight for that as well. So, um, we, we feel very strongly that our business, that's not the case.
spk07: Great. And then if I could speak one more in, um, With the variants that have come up, there's likely a longer tail to a lot of the COVID work that's being done. Would you care to give us a view? And I think COVID bookings are less than 7% of total in 21. What do you think that takes out in 22 from the pipeline of less than 7% of bookings in 2020? So what do you think that takes out for this year, given the pipeline of demand that you're likely seeing now for additional COVID work?
spk12: Yeah, that's a good question. I think with the variance that we're seeing and, you know, we're moving into the long-term follow-up real world, you know, I could see it being, I could see the pipeline staying roughly where it is for a quarter or two more. And then, you know, it depends what happens with the virus, right? I mean, in all previous pandemics like this, you see two peaks and then it fizzles away. We've had second peak largely. seeing lots of virus numbers dropping around the globe, either through lockdowns or a little bit more naturally. So there's a lot of environmental factors to kind of pick a number around that. But I think we'll see a continued kind of RFP flow in and around COVID for several quarters yet, possibly through the end of the year and maybe into 2022. It's just hard to call at the moment. where that goes because, you know, if everybody gets a handle on it, vaccine rollouts are successful, does that demand drop away? I don't know. You know, but will you see more demand for ongoing longer COVID long, you know, long COVID trials? Again, I think probably yes, but I just don't know to what level. So it's a really hard question to answer, I think.
spk07: Great. No, that was really helpful. Thanks again. Thanks, Dan. Thanks, Dan.
spk10: Our next question coming from the line of Jack Meehan with Nefron Research. Your line is open.
spk15: Thank you. Good morning. Wanted to continue on the vaccine work. It sounds like you've won some more business since the last time we spoke. Just to clarify, is any of this OWS related? And then just thoughts around, you know, given we have the approved vaccines and there's some variants out there, just the level of visibility into this work progressing you know, as it's built into the ramp and any risk around cancellations, just your thoughts around that.
spk12: Yeah, thanks, Jack. So I think the answer to the OWS is no. You know, we've worked on some of the OWS things in terms of functional support, data management, analysis, et cetera. And, you know, the new work that we're working on tends to be not that. The smaller companies, it non-US entities, so kind of more global work. Yeah, with the profile, I mean, the majority of our work is the treatment, is on the treatment side. So there's obviously a lot of that going on, good access to patients. We're seeing good enrollment in those trials. On the vaccine side, I mean, I think the vaccine trials that we've got up and going are enrolling well. There's still a lot of, even though the numbers are trending down in several Western markets, you've still got a lot of COVID in other locations. So these are global trials where we're seeing a lot of enrollment in, you know, around the globe, Latin America, Asia, et cetera. So, yeah, I mean, if the vaccines work well and there's vaccine equity, so all countries are getting a good vaccine program going, distributed, then, yeah, it'll be harder to find patients as we go out, which is great, right? That's kind of what we want almost as a society. Well, that's what we do want as a society. But we'll deal with that as we go. You know, you've got to stay flexible and be able to move to different sites where there's local outbreaks or, you know, to countries where they have a higher level.
spk15: Appreciate it. And, Jason, one clarification for the first quarter guide is For the two segments, appreciate all the qualitative commentary you gave. There's obviously a lot of moving parts with M&A, divestitures, FX, reimbursed expenses. I was wondering if you can just help us with maybe some revenue ranges for clinical and commercial for the first quarter.
spk05: So I guess we're not officially guiding Jack by by segment, just given the integrated nature of all we're doing these days and, you know, how Cineos won and the different full-service product development capabilities are dropping in. But I think, you know, the way to think about it is, you know, with reimbursables performing the way they are, these teams standing up on the commercial side, you know, think of that sort of flattish to down a little bit, um, you know, sequentially, uh, just given seasonality and then clinical is obviously going to be, uh, when you think about, you know, core Cineos plus the, uh, uh, plus the acquisitions. Yeah, that's all Jack. Okay. I mean, I think that'll help you solve for, you know, getting to the range there.
spk10: That's all the time we have for questions today. I will now turn the call back over to Mr. Allison McDonough for closing remarks.
spk12: Okay, thank you. So our sincere thanks to the entire Cineos team for all they've done in the face of these unprecedented conditions that we faced over 2020. You know, we remain very confident in our market positioning. and look forward to strong growth and profitability in 2021 as the recovery from COVID-19 continues. So thanks for your attendance today, everybody, and be continued interest and investment in our organization. Please be safe, have a great day, and be good. See you soon. Thank you.
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