Tactile Systems Technology, Inc.

Please stand by. Welcome, ladies and gentlemen, to the first quarter of fiscal year 2023 earnings conference call for Tactical Medical. At this time, all participants have been placed in a listen-only mode. At the end of the company's prepared remarks, we will conduct a question and answer session. Please note that this conference call is being recorded and will be available on the company's website for replay shortly. Before we begin, I would like to remind everyone that our remarks and responses to your questions today may contain forward-looking statements that are based on the current expectations of management and involve inherent risks and uncertainties, which could cause actual results to differ materially from those indicated, including those identified in the risk factor section of our annual report on Form 10-K, as well as our most recent 10-Q filing to be filed with the Securities and Exchange Commission. Such factors may be updated from time to time in our filings with the SEC, which are available on our website. We undertake no obligation to publicly update or revise our forward-looking statement as a result of new information, future events, or otherwise. This call will also include references to certain financial measures that are not calculated in accordance with generally accepted accounting principles or GAAP. We generally refer to these as non-GAAP financial measures. Reconciliations of those non-GAAP financial measures to this most comparable measures calculated and presented in accordance with the GAAP are available in the earnings press release on the investor relations portion of our website. I would now like to turn the call over to Mr. Dan Revers, Tactical Medical's President and Chief Executive Officer.

Please go ahead, sir. Thanks, operator. And welcome, everyone, to our first quarter of 2023 earnings call. I'm joined on the line today by Elaine Berkemeyer, our Chief Financial Officer. Let me provide you with a quick agenda for today's call. I'll begin with a high-level overview of our quarterly financial performance in the first quarter, followed by a discussion of the key drivers of our sales performance. I'll cover our first quarter operational progress, highlighting some of the most notable accomplishments made by our teams. Elena walked through our quarterly financial results in greater detail, as well as our financial guidance for 2023, which we updated in today's press release. And I'll conclude by discussing our outlook and strategic priorities for the rest of 2023 before opening the call for questions. With that, let's get started with a review of our financial performance. In the first quarter, we grew our total revenue by 23% year over year. to $58.8 million, exceeding our expectations. We were especially pleased to demonstrate that such strong performance in both of our key product lines. We posted another strong performance within our lymphedema products, growing 22 percent year over year to $48.9 million. We also saw strong contributions from sales of our airway clearance products, increasing 24 percent year over year to $9.1 million. We were pleased to deliver notable improvements in our operating results, with year-over-year reductions in our operating loss and net loss on both a GAAP and non-GAAP basis, and positive adjusted EBITDA results. This is the first time we've generated positive adjusted EBITDA in the first quarter since 2019. With that as a backdrop, I'll share some of the primary factors that contributed to our revenue performance, beginning with our lymphedema product line. In the first quarter, we were pleased to see another strong quarter of retention and engagement within our sales team. Our headcount remained consistent throughout the first quarter with 250 sales representatives at quarter end, unchanged since the beginning of 23, and up approximately 5% in comparison to the 238 reps that we had at the end of the first quarter of 2022. We also saw improving contributions from our newer sales reps that have joined since late 2021 as they got another quarter under their belt. The productivity of our sales team was aided by our recently introduced new products, most notably our Comfort Ease lower extremity garments. Comfort Ease, which we launched last summer, continues to resonate with prescribers and patients and provide our reps with an opportunity to reengage with key accounts. As a result, we saw our strongest growth among patients suffering from lymphedema related to vascular disease who often require our therapy for bilateral and truncal use in the lower extremities. Experience is made easier with Comfort Ease. Our sales performance also continued to benefit from a recent policy change made by CMS as of the first of the year when they discontinued the requirement for certificates of medical necessity. removing yet another administrative requirement for prescribers. As I mentioned on our last earnings call, our sales team focused on engaging with clinicians and educating them about this policy shift in the months before it became effective. This change in policy, along with the simpler internal submission process that we introduced, was welcomed by clinicians as it helps reduce the administrative burden associated with prescribing our therapies for patients covered under Medicare. And lastly, from a macro perspective, we continue to see evidence of improvement in patient throughput at many of the clinics that we serve, as staffing and patient velocity both continue to regain stability. Moving to our airway clearance product line, after working through some supply-related challenges in 2022, we were pleased to enter this year with a more secure supply chain and a second supplier up and running to provide us with expanded production capacity to support customer demand. This reassurance on the supply side has further empowered our team of respiratory specialists to engage our existing DME channel partners and work with them to confidently expand the availability of AfloVest to new prescribers, branches, and reps within their networks. During the first quarter, we saw solid demand from these DME distributors as the reps continued to identify patients among existing customers that they already served who qualify for AfloVest airway clearance therapy and stand to benefit from its use. As we've shared in the past, we believe that the majority of these patients may have otherwise gone either undiagnosed or untreated. And with this in mind, we're excited to play a role in helping expand the overall market by making good on our mission to both reveal and treat underserved patients with the chronic conditions like bronchiectasis. providing them with the only truly portable at-home solution that's clinically proven to reduce recurring pulmonary infections and pneumonia. Turning to an update on our operational performance, during the first quarter, we made strong progress on multiple fronts, educating clinicians and their patients, advancing the evidence to support the diagnosis and treatment of lymphedema, expanding our portfolio of new products, bolstering our balance sheet, and enhancing our leadership team and board of directors. I'll address each of these in a bit more detail, starting with our initiatives to educate clinicians and patients in the lymphedema market. Our team continued to develop and implement new educational programming to raise awareness of lymphedema and its comorbidities within the medical community. We hosted a total of 39 educational programs during the first quarter, which were attended by approximately 1,700 clinician participants. We are also pleased to see important new additions to the overall body of clinical research focused on advancing the medical community's understanding of lymphedema, including the importance of its effective diagnosis and treatment. At the American Venous Forum's annual meeting in February, Dr. Alexandra Tedesco presented the results of a study whereby researchers analyzed claims data from nearly 86,000 patients to determine the incidence and costs associated with various forms of lymphedema. They found that among three common ideologies of lymphedema, breast cancer-related lymphedema, chronic venous insufficiency-related lymphedema, known as flebolymphedema, and lymphedema related to gynecological cancer, the incidence and costs related to episodes of cellulitis in these patients, a deep and painful bacterial infection of the skin can present serious consequences. The researchers found that patients with a history of cellulitis were four and a half times more likely to develop subsequent cellulitis infections. Fleeble lymphedema patients in particular were three to five times more likely to develop cellulitis in comparison to patients with other forms of lymphedema. Fleeble lymphedema patients also had the highest healthcare utilization for cellulitis episodes ranging from $6,000 to $9,000 per episode This work further underscores the importance of effective management of lymphedema to reduce the incidence of cellulitis. Our FlexiTouch Plus system has been clinically shown to reduce the incidence of cellulitis in patients by more than 70%. And in March, we were pleased to see a new clinical article published in the medical journal Supportive Care in Cancers. The article titled, Under Recognition in Treatment of Lymphedema in Head and Neck Cancer Survivors, a Database Study, featured the results of a study that evaluated commercial and Medicare claims data from nearly 17,000 head and neck cancer survivors. While the head and neck lymphedema is estimated to be prevalent in approximately 90% of head and neck cancer survivors, the researchers found that only 6.5% of those nearly 17,000 patients that they evaluated had been diagnosed with head and neck lymphedema. Among these patients that were evaluated for lymphedema treatment, 80% received manual lymphatic drainage therapy but completed only 1.5 courses of treatment on average, and less than 9% of patients received an advanced pneumatic compression device. This publication adds to the evidence, highlighting the fact that head and neck lymphedema remains a woefully underdiagnosed and undertreated condition among cancer survivors. Our FlexiTouch Plus system remains the first and only pneumatic compression device cleared and commercially available to treat this region, and we remain committed to further expanding the clinical evidence demonstrating its effectiveness as we progress through the enrollment of our 250 patient randomized controlled clinical trial, the largest trial ever conducted for the treatment of head and neck cancer-related lymphedema. We're convinced that our resolve on behalf of this patient segment will lead to improved access in the future. Shifting to an update of our new product efforts, we're seeing strong adoption and utilization of our Kiley mobile application following its launch last summer. In February, we introduced a new version of our Kiley application, which provides Bluetooth connectivity-related features to our patients for the first time. Our latest FlexiTouch Plus systems now include Bluetooth compatibility, enabling users to automatically track and log their treatment activity with Kiley and generate summaries to share with their healthcare practitioner, an important first step towards providing patients and prescribers with a new resource to better inform and personalize their treatment process. I'm also proud to announce that we commenced the full market release of our next generation Entrez system at the end of the quarter. Our new basic pump system, Entrez Plus, has been redesigned to enhance the patient's experience during daily therapy without compromising therapeutic coverage. Its features include a new LCD screen with an enhanced user interface, as well as multiple ports to enable patients requiring bilateral therapy to treat both limbs simultaneously. Entrez Plus also features garments that actively deflate following the treatment, making them easier to take off and store. It's important to remember that the market for basic pneumatic compression devices, like Entrez Plus, is significantly larger today than that of advanced pumps like our FlexiTouch Plus. The introduction of our next-generation Entrez system is part of our commitment to enhance the experience for patients, whether they qualify for a basic pump or demonstrate the need for advanced pump therapy, and establishing Tactile Medical as the provider of choice for all at-home lymphedema therapy options. With this goal in mind, Entrez Plus has been redesigned to be part of the consistent product family with our more advanced FlexiTouch Plus system, which we believe will also make it easier for patients that may graduate to FlexiTouch Plus with a reduced learning curve if their condition warrants it. With respect to AfloVest, we introduced an additional size in March, adding to our ability to treat an even larger patient population. And with these enhancements across our product portfolio, we're continuing to maintain the pace of product innovation that we began with the introduction of Kiley and ComfortEase last year. another way in which we're enhancing and establishing our leadership positions in the markets we serve. And with respect to our balance sheet, on February 27th, we raised $35 million in net proceeds through an underwritten public offering of common stock, the first equity raise since the company's IPO in 2016. This offering provided us with additional capital to strengthen our balance sheet and support our initiatives as we progress towards achieving our stated longer-term revenue, profitability, and free cash flow goals. I'd like to thank our new and existing shareholders for their participation and support. And lastly, during the first quarter, we enhanced both our leadership team and board of directors with the addition of key personnel. In January, we announced the appointment of Carmen Volker, who joins our board of directors with over 40 years of financial and managerial experience. Majority of Carmen's career has been within the medical device industry, where she served as the chief financial officer for Nextera, Tournier, SpineWave, and American Medical Systems. More recently, in March, we were pleased to announce the appointment of Elaine Berkemeyer as our chief financial officer. Elaine joined our executive leadership team following a more than 25-year career in healthcare, consumer, and retail industries. with senior leadership experience at leading companies, including UnitedHealth Group, Best Buy, Sleep Number, and Target. In the course of her nearly nine-year tenure at UnitedHealth Group prior to joining Tactile Medical, Elaine served as Chief Financial Officer of Rally Health, a UnitedHealth portfolio company focused on digital health, and most recently as Chief Financial Officer of Optum's Care Solutions Portfolio. And I'm proud of the level of talent we've been able to attract with our recent appointments. And I'd like to take this opportunity on today's call to welcome both Carmen and Elaine to our team. And Elaine will now review our first quarter financial results in more detail, along with our financial guidance for 2023, which we updated in this afternoon's release. Elaine?

Thanks, Dan. I'm excited to have joined the TocTel medical team during a pivotal time in the company's history. and especially pleased to have such strong operating performance to outline on my first quarterly earnings call. Turning to review of our financial results. Unless noted otherwise, all references to first quarter financial results are on a gap and a year-over-year basis. Total revenue in the first quarter increased 10.9 million, or 23%, to $58.8 million. By product line, sales and rentals of Lymphedema products which includes our FlexiTouch and Entrez systems, increased $9.1 million, or 22%, to $49.8 million. And sales of our airway clearance products, which includes our AfloVest system, increased $1.8 million, or 24%, to $9.1 million. Continuing down the P&L, gross margin was 70.5% of revenue compared to 70.6%. Non-GAAP gross margin, which excludes non-cash intangible amortization in both periods, was 71% compared to 71.2%. GAAP and non-GAAP gross margins in the first quarter of 2023 were impacted by higher labor rates and material costs, as well as higher costs related to new product launches relative to the first quarter of 2022. First quarter operating expenses decreased $3.5 million, or 7%, to $45.3 million. The decrease in GAAP operating expenses was driven by a $5.8 million decrease in non-cash intangible asset amortization and earn-out expense and a $783,000 decrease in reimbursement general and administrative expenses. These items were offset partially by a $2.4 million increase in sales and marketing expenses and a $713,000 increase in research and development expenses. Operating loss decreased $11.1 million, or 74%, to $3.8 million. Non-GAAP operating loss decreased $3.2 million, or 59%, to $2.2 million. The decrease in non-GAAP operating loss was driven by a 22% increase in non-GAAP gross profit offset partially by a 10% increase in sales and marketing expenses, a 9% increase in reimbursement general and administrative expenses, and a 47% increase in research and development expense. By way of reminder, our non-GAAP operating loss excludes non-cash intangible amortization and around expenses, as well as certain non-reoccurring operating expenses in prior year period. We provided a detailed gap to non-GAAP reconciliation in our earnings press release. Importantly, our non-GAAP operating loss in Q1 reflects our continued focus on prudent investments in the business to support our longer-term strategic and financial goals. We were pleased to deliver strong operating leverage in the first quarter as our non-GAAP operating margin improved by approximately 750 basis points year over year. Other expense net increased by $0.5 million or 118% to $1 million, primarily due to an increase in interest expense. Income tax benefit was $2.9 million compared to an expense of $211,000 in the first quarter of 2022. Net loss was $1.9 million, or 7 cents per diluted share, compared to a net loss of $15.6 million, or 78 cents per diluted share. Non-GAAP net loss was $0.7 million, compared to $8.4 million. Adjusted EBITDA was $0.5 million, compared to adjusted EBITDA loss of $2.6 million. Turning to the balance sheet and our recent financing activities. As Dan mentioned in February, we closed an underwritten public offering which consisted of 2,875,000 shares of common stock at a public offering price of $13 per share. We raised $34.6 million of net proceeds from this offering after deducting underwriting discounts, commissions, and offering expenses. As of quarter end, we have $55 million in cash and $48.3 million of outstanding borrowings. This compares to $21.9 million in cash and $49 million of outstanding borrowings as of December 31, 2022. Shifting to a review of our 2023 outlook, which we updated in today's press release, we now expect full-year 2023 total revenue of approximately $271 to $275 million, representing year-over-year growth of approximately 10% to 11.5%. compared to our prior guidance of approximately 9% to 11%. Our 2023 total revenue guidance range now assumes sales and rentals of our lymphedema product increase approximately 9% to 10% compared to our prior guidance of 8% to 9%. And sales of our airway clearance products increase approximately 18% to 21%, largely unchanged versus our prior guidance range. For modeling purposes for the full year 2023, we expect our GAAP gross margins to be in the low 70% range, our GAAP operating expenses to increase in the low single digits year over year, interest expense of approximately $4 million, a GAAP tax rate of 61% compared to our prior guidance of 25%, and a fully diluted weighted average share count of approximately 23.5 million shares. Based on the stronger than expected profitability performance in Q1, we now expect to generate adjusted EBITDA of approximately $23.5 to $25.5 million in 2023, an increase of approximately $0.5 million versus our prior guidance range. Our adjusted EBITDA expectation assumes certain non-cash items, including stock compensation expense of approximately $11 million compared to $12 million previously, intangible amortization and changes in fair value of contingent consideration of approximately $5.8 million, and depreciation expense of approximately $2.5 million, both unchanged versus prior guidance. With that, I'll turn the call back to Dan for closing remarks.

Thanks, Elaine. In summary, we're proud of the financial performance and the operational progress we achieved in the first quarter, which exceeded our expectations. We're raising our full-year guidance based on this strong start to the year, while keeping an eye on the emerging macroeconomic backdrop as 23 unfolds. And we remain committed to achieving double-digit organic revenue growth on an annual basis, along with year-over-year improvements in our profitability. As we progress through 2023, we intend to continue our recent pace of progress as we execute against the following four strategic priorities that I outlined at the beginning of the year. First, to improve the productivity of our lymphedema field sales team. Next, to expand and deepen relationships with DME providers and their reps for our airway clearance product line. To develop and introduce new products and innovations focused on addressing the lifestyle needs of our patients and improving digital functionality and therapy optimization. And finally, enhancing our operational efficiency to continue to reduce our overall cost to serve. In light of our recent performance and progress, We believe our continued execution with respect to these strategic priorities will position Tactile Medical to deliver strong, sustainable growth in 2023 and the years ahead as we progress towards achieving our longer-term strategic and financial goals. Thanks to everyone on the Tactile Medical team for your efforts this past quarter and to our customers, suppliers, shareholders, as well as those on today's call for your support. Operator, we'll now open the call for questions.

Thank you. Ladies and gentlemen, at this time we will be conducting a question and answer session. If you'd like to ask a question, you may press star 1 on your telephone keypad. A confirmation tone will indicate your line is in the question queue. You may press star 2 if you would like to remove your question from the queue. For participants using speaker equipment, it may be necessary to pick up your handset before pressing the star key. We ask that you limit yourself to one question and one follow-up and then re-poll if you have additional questions. Our first question comes from the line of Adam Mader with Piper Sandler. Please proceed with your question.

Hey, Dan. Hey, Elaine. This is Simran on for Adam. Thank you for taking the question. Hi, Simran. Hi. I want to start out with a guidance for a moment here. You raised your revenue outlook by about $2 million despite... about a $5 million fee at the midpoint of your prior Q1 guide. So maybe just walk us through what you're seeing in the procedure environment, you know, throughout the quarter and exiting Q1. Or, and then also from a macro perspective to help inform that decision. And then I also didn't hear Q2 guidance. So what are your expectations for this quarter?

Yeah, so let me try and unpack that one if I can, Simran. I'll start a little bit with what are we seeing in Q2 so far. I think nothing terribly surprising. We've seen some ongoing stability resuming in the clinic volumes. I think we saw that through Q1, and I think that's continued largely into Q2 as well. We've said several times that I don't know that we see velocity of volumes getting back to 100% of pre-COVID levels. But we don't need to get back to that level either. I think that we have seen good recovery on a macro basis, and I think that's been consistent with our expectations. We're hearing staffing issues are getting progressively better in the clinics and the therapy clinics that we serve. And I think, you know, so far we've had a good reception to the recent introduction of our Entree Plus. And ultimately, you know, all those are kind of considered in the guidances. We are not updating quarterly guidance at this point, but rather we just opted to update annual guidance. And I think to your question that where you started relative to how we got there. So, you know, first of all, we knew Q1 was going to be our strongest quarter. Our original guidance suggested that it would grow faster than our overall full year. But if you take a look at where we finished up, we beat our high end by about $3.6 million. We raised it by two on the high end. So it's a little over a million and a half delta. And frankly, I'm not sure we're good enough to have that much precision at this point. We got nine months of wood left to chop. And I think that with a more balanced comparison of sales headcount as we progress through the year, we got the biggest benefit in in Q1 where we were still trying to get roles staffed. Ultimately, those are some of the things that contribute to that. We have not seen any of the macroeconomic backdrop that would take us to the lower end. And I think we talked about that. We initially posted guidance in February. But that's certainly something that we'll keep an eye on. And in the meantime, you know, we were just really, really pleased to be able to raise guidance. and feel confident about the latest guidance, which puts us in the double-digit kind of 10% to 11.5% range.

Awesome. Thank you for that response. And I guess for my follow-up, I'll ask about AfloVest, another nice quarter here in Q1. Did you see any impact from those prior supply chain headwinds in Q1 and Q2? Was there any pull-through from potential backlog, that being from those headwinds? I guess what I'm trying to get at is are you in a position now to take full advantage and supply the market?

Well, I think the answer to the last question is we are in a full position to supply the market. And we didn't really carry anything in the line of a backorder position. into Q1 or into Q2, for that matter. But I think that now that we've been able to communicate our expectation that we have ample supply capacity, I think it's an opportunity for us to make sure that the sales channels are fully reengaged. There were some, I would say, admittedly, at points throughout the last handful of quarters that would express some reluctance to put their shoulder behind it with the uncertainty about whether or not we'd be able to to supply them at the higher end. So I think that we've certainly communicated the fact that we feel like we're in a good spot from a supply chain standpoint going forward. And we're hopeful that that will lead to ongoing demand that will continue to increase. And those are things that we factored in as well.

Perfect. Thank you.

Our next question comes from the line of Margaret Kayser with William Blair. Please proceed with your question.

Hey, good afternoon, everyone. Thanks for taking the question. I'm going to try my hand one more time on the guidance side just to follow up. So, you know, I'm just kind of going through the math and the multiples, especially on the LinkedIn side of the business. You know, you guys had this tremendous 22% growth. I know the comps get a little bit tougher as we go on throughout the year, but If all I do is just try to average to that 9% or 10% for the full year guidance number, I get to this kind of mid to high single-digit lymphedema growth for the next three quarters. So Juan, tell me if I'm right or wrong about that. And that's below the long-term guidance that you've given for lymphedema. So I appreciate the conservatism and the thoughts around macro, but It seems like maybe there's a little bit of room to that number and why or why not.

Yeah, I think that I'm not sure the answer is a lot different, Margaret. I think that, you know, we certainly tried to express our confidence by raising our full year guidance. That said, I think it's a little early for us to declare victory. But, you know, we felt really good about the fact that we saw some solid productivity from our sales force. I think the administrative process that we've tried to streamline has been certainly good for the business in the first quarter. And, you know, Comfort Ease has continued, I think, to resonate well. So I'd say we feel confident about, you know, the double-digit growth guidance that we've updated to. And I think we'll have a lot clearer vision of this once we get through Q2 and into the, you know, later part of the summer. So, you know, I think that's... That's still pretty consistent. Okay.

I appreciate it. I had to try.

So just to follow up on some other things, right, you had talked about some of the CMS changes, eliminating medical necessity at the beginning of the year. That seems like it's maybe a potentially more meaningful change. So how does that help accelerate getting the product to the patient? Maybe they're in sales rep productivity, if at all, and then could it even increase the close rates?

Yeah, I think it remains to be seen, but it's a really good question. So there's a couple things going on in that space with the Medicare patients. First of all, I think there have been a fair amount of those patients that would have been overlooked, partly because the administrative effort was, frankly, pretty burdensome to the clinic. So the elimination of a CMN, and then maybe just as importantly, some new processes that we introduced as far as how we can collect that information, what information is going to be necessary, some forms that are more user-friendly. And I think all of those, we're hopeful, will continue to help make sure that patients that can benefit from our therapies get recognized, not overlooked, and that we don't make the work harder than it's going to need to be for the HCPs. As a result, we hope to reveal more of those patients that we can treat. On the flip side, the PHE waiver is ending in mid-Q2. Actually, it's in a few days if my calendar memory is right. So there's a little bit of an offset there that there were some things that were a little bit easier that will go back to the olden days. But we think that the offset on the good side is is that the processes that we've introduced, we're hopeful to continue to demonstrate that it shouldn't be a burden on the HCP to do the right thing and help these patients that haven't gotten therapy to date. Okay.

Great. Thank you, guys.

Our next question comes from the line of Ryan Zimmerman with BTIG. Please proceed with your question.

Hey, good afternoon. Congrats on the quarter. I want to ask, I know you're not guiding quarterly here, Dan. That's pretty evident as we've all tried, but remind us about seasonality and kind of how you expect the seasonality to progress, particularly in the second and third quarters. You know, you've historically had, you know, this nice linear improvement. Recently, But as we come out of COVID, kind of help us think about the pace for the next three quarters.

Yeah. I mean, I think you can look at history and see that typically our revenue ramps throughout the year and kind of resets. So we would certainly expect to continue to see incremental growth sequentially throughout the year, with Q4, of course, continuing to be our biggest one as co-pays come down and typically decrease. the device gets effectively less expensive for the patient. Probably even more true with the AfloVest, just because of the average cell price is higher than some of our lymphedema therapy products. But sequential growth would certainly continue to be an expectation that I would say is fair. Okay.

And Elaine, it's nice to have you on the call, and especially on a strong quarter, you know, start your time here with Tactile. Just remind us kind of your near-term goals that you have in the position as you take hold here?

Yeah, maybe I'll take this time to just share a little bit of what my observations and kind of how that leads me into my goals here. So coming from a large organization, I've been really impressed by the talent, the alignment around our strategy, and really how mission-driven the organization is. In fact, I was just at our national sales meeting last week, and it was clear that Our mission for me, it's everything that we do, and we're really making a difference in people's lives. And I think that's going to be a key to our success and what I was looking for when I joined the organization. I also had a chance to dive into our long-range financials and took a look at the guidance that we put out for 2025. And just as a reminder there, we said we would deliver over $350 million in revenue, over $50 million in adjusted EBITDA, and $75 million of chemo-free cash flow. I feel confident we can deliver that. And, you know, I see a team here who's focused on driving top line growth while expanding profitability. And that, too, is going to be one of my objectives and things that I focus on this year. And then lastly, another focus area for me. Oh, sorry. It would be to leverage. I'm sorry. Go ahead.

No, I was saying, please go ahead, Elaine. Sorry for interrupting.

Oh, okay. Yeah, no, no problem. And I just say, lastly, another opportunity I see is really to be able to leverage my healthcare experience to drive improvements in our revenue cycle management. I think this represents a significant opportunity for Tactile and should result in improvements in our networking capital as we're able to lower our accounts receivable. So I see that, too, as a focus area and a way for us to achieve those 2025 goals that I mentioned. Okay.

Very helpful. And the mention of Counselor Striegel actually prompts me to sneak in one more question, which is Medicare as a percentage of sales this quarter was up, you know, pretty significantly relative to last year. And, you know, just given the payment terms on those Medicare cases you get, you know, how do you think about that dynamic coming through in terms of your cash balance and just, you know, the overall shifting dynamics of the payer mix of the business?

Yeah, so I think one thing I've been excited to see is that the team, as I moved in here, has been spending a lot of time with our Medicare administrative contractors to increase our first-pass approvals. I'm really encouraged by the latest engagements that we have with them. We've gotten greater alignment on our submissions, and we're seeing improvement in our first-pass adjudication. So that really points to a really good momentum, especially, as you mentioned, that we see strong growth in the Medicare space.

Yeah, I would just add, too, Ron, to Elaine's comments, that I think this team's doing a really good job working with the MACs. We've made some pretty good progress. And I think we're going to demonstrate that it's not the curse to support the Medicare business that it was a few years ago as we go forward, as we continue to get better at working at the first pass adjudication, which her team, I think, is making really good progress on. Okay. Thanks for asking the questions.

As a reminder, it is Star 1 to ask your question. Our next question comes from the line of Shiraz Khalia with Oppenheimer. Please proceed with your question.

Good afternoon, Dan. Elaine, can you hear me all right?

We can.

Perfect. Apologies. I'm under the weather a little bit. Hey, so, Dan, in terms of Kylie, remind us what percent... of patients currently have Kylie? And more specifically, what kind of a tool do you all envision Kylie to be? Would it help improve patient compliance? Or is this more as a data gathering tool for payers, so to speak?

Yeah, I think, good question, Suraj, and, you know, frankly, Kylie's got a variety of different complexions to it. We originally talked about Kylie as a learning tool that we can make available to patients so they can better understand their condition and, frankly, advocate for themselves. We know that so many lymphedema diagnoses are missed or misdiagnosed, so equipping the patients with more information via this Kiley app was the first goal of the application. And then the next one is we think that it can have an impact on our training. We have training vignettes, and that's a cost-to-serve component. We can meet patients where they want to be met. If they want to be trained in the home, we can support that. If they're adept with a smartphone, we may be able to provide them the assistance that they need more efficiently, like so many of us depend on smartphones. There's another piece which then becomes the ability to communicate with their physician their progress. And while there's, Kylie was introduced back in the summertime last year, we've continued to have incremental drops with new features. The most recent addition was we started adding Bluetooth chips to FlexiTouch in December. We've already had over 35,000 patient sessions that have been captured and downloaded through Kiley. These are opportunities for patients to bring the results to their physician, share with them when and how they're using it, and how they're benefiting or responding from it. So I think that those are some of the ways that we see Kiley. Currently, they're also able to track their orders. So, you know, from a contact and customer service, it offloads some of the human burden. and can even more immediately give them that feedback. And then as we get into the back half of this year, Suraj, we're going to continue to have some advances on how patients can record and track their measurements. We'll have prompts, just like my iWatch does, about, hey, it's probably time to do your therapy or celebrate the fact that you did, and a number of other things, I think, on the cost-to-serve side as far as order processing engagement. I'd say, in summary, it's an opportunity to educate. It's an opportunity to engage with patients and reduce our cost to serve, and also an opportunity for them to share more useful information with their providers.

Got it. And, Dan, if I could ask a higher-level question. Dan, what do you think would be the next iteration of product development in more specifically to reduce the minutes spent per day by the patient? Thank you for taking my questions.

Yeah, really good question. There's a lot of ways that we want to continue to improve the utility and the efficiency of patients' therapy sessions. I think the introduction of Entrez Plus is a great example where it's easier for patients with bilateral lymphatic disease to treat both legs at the same time. And we've already got the ability to do that with the FlexiTouch as well. So I think that being able to treat multiple parts of the body in one treatment session is already a way to optimize that. There's certain limits about, I think, that we can't shortchange it because there's a component that's necessary to make sure the therapeutic outcome is good. Again, being able to do multiple parts of the body simultaneously certainly helps rather than having to treat those parts of the body sequentially. So I think that's one that is certainly more visible in the latest iteration of our Entrez system. And then, you know, Suraj, we continue to invest in product development. There are additional solutions that we continue to work on. And ultimately, we expect those to produce a better therapeutic experience that's always optimizing efficacy but starting to continue to appreciate some of the consumer features that we know patients want.

Thank you.

It appears there are no further questions in the queue. This does conclude today's teleconference. Thank you for your participation. You may disconnect your lines at this time, and have a wonderful day. you Thank you. Thank you. Thank you. Welcome ladies and gentlemen to the first quarter of fiscal year 2023 earnings conference call for Tactical Medical. At this time, all participants have been placed in a listen only mode. At the end of the company's prepared remarks, we will conduct a question and answer session. Please note that this conference call is being recorded and will be available on the company's website for replay shortly. Before we begin, I would like to remind everyone that our remarks and responses to your questions today may contain forward-looking statements that are based on the current expectations of management and involve inherent risks and uncertainties, which could cause actual results to differ materially from those indicated, including those identified in the risk factor section of our annual report on Form 10-K, as well as our most recent 10-Q filing to be filed with the Securities and Exchange Commission. Such factors may be updated from time to time in our filings with the SEC, which are available on our website. We undertake no obligation to publicly update or revise our forward-looking statement as a result of new information, future events, or otherwise. This call will also include references to certain financial measures that are not calculated in accordance with generally accepted accounting principles or GAAP. We generally refer to these as non-GAAP financial measures. Reconciliations of those non-GAAP financial measures to this most comparable measures calculated and presented in accordance with the GAAP are available in the earnings press release on the investor relations portion of our website. I would now like to turn the call over to Mr. Dan Revers, Tactical Medical's President and Chief Executive Officer. Please go ahead, sir.

Thanks, Operator. And welcome, everyone, to our first quarter of 2023 earnings call. I'm joined on the line today by Elaine Berkemeyer, our Chief Financial Officer. Let me provide you with a quick agenda for today's call. I'll begin with a high-level overview of our quarterly financial performance in the first quarter, followed by a discussion of the key drivers of our sales performance. I'll cover our first quarter operational progress, highlighting some of the most notable accomplishments made by our teams. Elena walked through our quarterly financial results in greater detail, as well as our financial guidance for 2023, which we updated in today's press release. And I'll conclude by discussing our outlook and strategic priorities for the rest of 2023 before opening the call for questions. With that, let's get started with a review of our financial performance. In the first quarter, we grew our total revenue by 23% year over year. to $58.8 million, exceeding our expectations. We were especially pleased to demonstrate such strong performance in both of our key product lines. We posted another strong performance within our lymphedema products, growing 22 percent year-over-year to $48.9 million. We also saw strong contributions from sales of our airway clearance products, increasing 24 percent year-over-year to $9.1 million. We were pleased to deliver notable improvements in our operating results, with year-over-year reductions in our operating loss and net loss on both a GAAP and non-GAAP basis, and positive adjusted EBITDA results. This is the first time we've generated positive adjusted EBITDA in the first quarter since 2019. With that as a backdrop, I'll share some of the primary factors that contributed to our revenue performance, beginning with our lymphedema product line. In the first quarter, we were pleased to see another strong quarter of retention and engagement within our sales team. Our headcount remained consistent throughout the first quarter, with 250 sales representatives at quarter end, unchanged since the beginning of 23, and up approximately 5% in comparison to the 238 reps that we had at the end of the first quarter of 2022. We also saw improving contributions from our newer sales reps that have joined since late 2021 as they got another quarter under their belt. The productivity of our sales team was aided by our recently introduced new products, most notably our Comfort Ease lower extremity garments. Comfort Ease, which we launched last summer, continues to resonate with prescribers and patients and provide our reps with an opportunity to reengage with key accounts. As a result, we saw our strongest growth among patients suffering from lymphedema related to vascular disease who often require our therapy for bilateral and truncal use in the lower extremities. Experience is made easier with Comfort Ease. Our sales performance also continued to benefit from a recent policy change made by CMS as of the first of the year when they discontinued the requirement for certificates of medical necessity. removing yet another administrative requirement for prescribers. As I mentioned on our last earnings call, our sales team focused on engaging with clinicians and educating them about this policy shift in the months before it became effective. This change in policy, along with the simpler internal submission process that we introduced, was welcomed by clinicians as it helps reduce the administrative burden associated with prescribing our therapies for patients covered under Medicare. And lastly, from a macro perspective, we continue to see evidence of improvement in patient throughput at many of the clinics that we serve, as staffing and patient velocity both continue to regain stability. Moving to our airway clearance product line, after working through some supply-related challenges in 2022, we were pleased to enter this year with a more secure supply chain and a second supplier up and running to provide us with expanded production capacity to support customer demand. This reassurance on the supply side has further empowered our team of respiratory specialists to engage our existing DME channel partners and work with them to confidently expand the availability of AfloVest to new prescribers, branches, and reps within their networks. During the first quarter, we saw solid demand from these DME distributors as the reps continued to identify patients among existing customers that they already served who qualify for AfloVest airway clearance therapy and stand to benefit from its use. As we've shared in the past, we believe that the majority of these patients may have otherwise gone either undiagnosed or untreated. And with this in mind, we're excited to play a role in helping expand the overall market by making good on our mission to both reveal and treat underserved patients with the chronic conditions like bronchiectasis. providing them with the only truly portable at-home solution that's clinically proven to reduce recurring pulmonary infections and pneumonia. Turning to an update on our operational performance, during the first quarter, we made strong progress on multiple fronts, educating clinicians and their patients, advancing the evidence to support the diagnosis and treatment of lymphedema, expanding our portfolio of new products, bolstering our balance sheet, and enhancing our leadership team and board of directors. I'll address each of these in a bit more detail, starting with our initiatives to educate clinicians and patients in the lymphedema market. Our team continued to develop and implement new educational programming to raise awareness of lymphedema and its comorbidities within the medical community. We hosted a total of 39 educational programs during the first quarter, which were attended by approximately 1,700 clinician participants. We are also pleased to see important new additions to the overall body of clinical research focused on advancing the medical community's understanding of lymphedema, including the importance of its effective diagnosis and treatment. At the American Venous Forum's annual meeting in February, Dr. Alexandra Tedesco presented the results of a study whereby researchers analyzed claims data from nearly 86,000 patients to determine the incidence and costs associated with various forms of lymphedema. They found that among three common ideologies of lymphedema, breast cancer-related lymphedema, chronic venous insufficiency-related lymphedema, known as flebolymphedema, and lymphedema related to gynecological cancer. The incidence and costs related to episodes of cellulitis in these patients, a deep and painful bacterial infection of the skin can present serious consequences. The researchers found that patients with a history of cellulitis were four and a half times more likely to develop subsequent cellulitis infections. Fleeble lymphedema patients in particular were three to five times more likely to develop cellulitis in comparison to patients with other forms of lymphedema. Fleeble lymphedema patients also had the highest healthcare utilization for cellulitis episodes ranging from $6,000 to $9,000 per episode This work further underscores the importance of effective management of lymphedema to reduce the incidence of cellulitis. Our FlexiTouch Plus system has been clinically shown to reduce the incidence of cellulitis in patients by more than 70%. And in March, we were pleased to see a new clinical article published in the medical journal Supportive Care in Cancers. The article titled, Under Recognition in Treatment of Lymphedema in Head and Neck Cancer Survivors, a Database Study, featured the results of a study that evaluated commercial and Medicare claims data from nearly 17,000 head and neck cancer survivors. While the head and neck lymphedema is estimated to be prevalent in approximately 90% of head and neck cancer survivors, the researchers found that only 6.5% of those nearly 17,000 patients that they evaluated had been diagnosed with head and neck lymphedema. Among these patients that were evaluated for lymphedema treatment, 80% received manual lymphatic drainage therapy but completed only 1.5 courses of treatment on average, and less than 9% of patients received an advanced pneumatic compression device. This publication adds to the evidence, highlighting the fact that head and neck lymphedema remains a woefully underdiagnosed and undertreated condition among cancer survivors. Our FlexiTouch Plus system remains the first and only pneumatic compression device cleared and commercially available to treat this region, and we remain committed to further expanding the clinical evidence demonstrating its effectiveness as we progress through the enrollment of our 250 patient randomized controlled clinical trial, the largest trial ever conducted for the treatment of head and neck cancer-related lymphedema. We're convinced that our resolve on behalf of this patient segment will lead to improved access in the future. Shifting to an update of our new product efforts, we're seeing strong adoption and utilization of our Kiley mobile application following its launch last summer. In February, we introduced a new version of our Kiley application, which provides Bluetooth connectivity-related features to our patients for the first time. Our latest FlexiTouch Plus systems now include Bluetooth compatibility, enabling users to automatically track and log their treatment activity with Kiley and generate summaries to share with their healthcare practitioner, an important first step towards providing patients and prescribers with a new resource to better inform and personalize their treatment process. I'm also proud to announce that we commenced the full market release of our next generation Entrez system at the end of the quarter. Our new basic pump system, Entrez Plus, has been redesigned to enhance the patient's experience during daily therapy without compromising therapeutic coverage. Its features include a new LCD screen with an enhanced user interface, as well as multiple ports to enable patients requiring bilateral therapy to treat both limbs simultaneously. Entrez Plus also features garments that actively deflate following the treatment, making them easier to take off and store. It's important to remember that the market for basic pneumatic compression devices, like Entrez Plus, is significantly larger today than that of advanced pumps like our FlexiTouch Plus. The introduction of our next-generation Entrez system is part of our commitment to enhance the experience for patients, whether they qualify for a basic pump or demonstrate the need for advanced pump therapy, and establishing Tactile Medical as the provider of choice for all at-home lymphedema therapy options. With this goal in mind, Entrez Plus has been redesigned to be part of the consistent product family with our more advanced FlexiTouch Plus system, which we believe will also make it easier for patients that may graduate to FlexiTouch Plus with a reduced learning curve if their condition warrants it. With respect to AfloVest, we introduced an additional size in March, adding to our ability to treat an even larger patient population. And with these enhancements across our product portfolio, we're continuing to maintain the pace of product innovation that we began with the introduction of Kiley and ComfortEase last year. another way in which we're enhancing and establishing our leadership positions in the markets we serve. And with respect to our balance sheet, on February 27th, we raised $35 million in net proceeds through an underwritten public offering of common stock, the first equity raise since the company's IPO in 2016. This offering provided us with additional capital to strengthen our balance sheet and support our initiatives as we progress towards achieving our stated longer-term revenue, profitability, and free cash flow goals. I'd like to thank our new and existing shareholders for their participation and support. And lastly, during the first quarter, we enhanced both our leadership team and board of directors with the addition of key personnel. In January, we announced the appointment of Carmen Volker, who joins our board of directors with over 40 years of financial and managerial experience. Majority of Carmen's career has been within the medical device industry, where she served as the chief financial officer for Nextera, Tournier, SpineWave, and American Medical Systems. More recently, in March, we were pleased to announce the appointment of Elaine Berkemeyer as our chief financial officer. Elaine joined our executive leadership team following a more than 25-year career in healthcare, consumer, and retail industries. with senior leadership experience at leading companies, including UnitedHealth Group, Best Buy, Sleep Number, and Target. In the course of her nearly nine-year tenure at UnitedHealth Group prior to joining Tactile Medical, Elaine served as Chief Financial Officer of Rally Health, a UnitedHealth portfolio company focused on digital health, and most recently as Chief Financial Officer of Optum's Care Solutions Portfolio. And I'm proud of the level of talent we've been able to attract with our recent appointments. And I'd like to take this opportunity on today's call to welcome both Carmen and Elaine to our team. And Elaine will now review our first quarter financial results in more detail, along with our financial guidance for 2023, which we updated in this afternoon's release. Elaine?

Thanks, Dan. I'm excited to have joined the TocTel medical team during a pivotal time in the company's history. and especially pleased to have such strong operating performance to outline on my first quarterly earnings call. Turning to review of our financial results. Unless noted otherwise, all references to first quarter financial results are on a gap and a year-over-year basis. Total revenue in the first quarter increased 10.9 million, or 23%, to $58.8 million. By product line, sales and rentals of Lymphedema products which includes our FlexiTouch and Entrez systems, increased $9.1 million, or 22%, to $49.8 million. And sales of our airway clearance products, which includes our AfloVest system, increased $1.8 million, or 24%, to $9.1 million. Continuing down the P&L, gross margin was 70.5% of revenue compared to 70.6%. Non-GAAP gross margin, which excludes non-cash intangible amortization in both periods, was 71% compared to 71.2%. GAAP and non-GAAP gross margins in the first quarter of 2023 were impacted by higher labor rates and material costs, as well as higher costs related to new product launches relative to the first quarter of 2022. First quarter operating expenses decreased $3.5 million, or 7%, to $45.3 million. The decrease in GAAP operating expenses was driven by a $5.8 million decrease in non-cash intangible asset amortization and earn-out expense and a $783,000 decrease in reimbursement general and administrative expenses. These items were offset partially by a $2.4 million increase in sales and marketing expenses and a $713,000 increase in research and development expenses. Operating loss decreased $11.1 million, or 74%, to $3.8 million. Non-GAAP operating loss decreased $3.2 million, or 59%, to $2.2 million. The decrease in non-GAAP operating loss was driven by a 22% increase in non-GAAP gross profit offset partially by a 10% increase in sales and marketing expenses, a 9% increase in reimbursement general and administrative expenses, and a 47% increase in research and development expense. By way of reminder, our non-GAAP operating loss excludes non-cash intangible amortization and around expenses, as well as certain non-reoccurring operating expenses in prior year period. We provided a detailed gap to non-GAAP reconciliation in our earnings press release. Importantly, our non-GAAP operating loss in Q1 reflects our continued focus on prudent investments in the business to support our longer-term strategic and financial goals. We were pleased to deliver strong operating leverage in the first quarter as our non-GAAP operating margin improved by approximately 750 basis points year over year. Other expense net increased by $0.5 million or 118% to $1 million, primarily due to an increase in interest expense. Income tax benefit was $2.9 million compared to an expense of $211,000 in the first quarter of 2022. Net loss was $1.9 million, or 7 cents per diluted share, compared to a net loss of $15.6 million, or 78 cents per diluted share. Non-GAAP net loss was $0.7 million, compared to $8.4 million. Adjusted EBITDA was $0.5 million, compared to adjusted EBITDA loss of $2.6 million. Turning to the balance sheet and our recent financing activities. As Dan mentioned in February, we closed an underwritten public offering which consisted of 2,875,000 shares of common stock at a public offering price of $13 per share. We raised $34.6 million of net proceeds from this offering after deducting underwriting discounts, commissions, and offering expenses. As of quarter end, we have $55 million in cash and $48.3 million of outstanding borrowings. This compares to $21.9 million in cash and $49 million of outstanding borrowings as of December 31, 2022. Shifting to a review of our 2023 outlook, which we updated in today's press release, we now expect full-year 2023 total revenue of approximately $271 to $275 million, representing year-over-year growth of approximately 10% to 11.5%. compared to our prior guidance of approximately 9% to 11%. Our 2023 total revenue guidance range now assumes sales and rentals of our lymphedema product increase approximately 9% to 10% compared to our prior guidance of 8% to 9%. And sales of our airway clearance products increase approximately 18% to 21%, largely unchanged versus our prior guidance range. For modeling purposes for the full year 2023, we expect our GAAP growth margins to be in the low 70% range, our GAAP operating expenses to increase in the low single digits year over year, interest expense of approximately $4 million, a GAAP tax rate of 61% compared to our prior guidance of 25%, and a fully diluted weighted average share count of approximately 23.5 million shares. Based on the stronger than expected profitability performance in Q1, we now expect to generate adjusted EBITDA of approximately $23.5 to $25.5 million in 2023, an increase of approximately $0.5 million versus our prior guidance range. Our adjusted EBITDA expectation assumes certain non-cash items, including stock compensation expense of approximately $11 million compared to $12 million previously, intangible amortization and changes in fair value of contingent consideration of approximately $5.8 million, and depreciation expense of approximately $2.5 million, both unchanged versus prior guidance. With that, I'll turn the call back to Dan for closing remarks.

Thanks, Elaine. In summary, we're proud of the financial performance and the operational progress we achieved in the first quarter, which exceeded our expectations. We're raising our full-year guidance based on this strong start to the year, while keeping an eye on the emerging macroeconomic backdrop as 23 unfolds. And we remain committed to achieving double-digit organic revenue growth on an annual basis, along with year-over-year improvements in our profitability. As we progress through 2023, we intend to continue our recent pace of progress as we execute against the following four strategic priorities that I outlined at the beginning of the year. First, to improve the productivity of our lymphedema field sales team. Next, to expand and deepen relationships with DME providers and their reps for our airway clearance product line. To develop and introduce new products and innovations focused on addressing the lifestyle needs of our patients and improving digital functionality and therapy optimization. And finally, enhancing our operational efficiency to continue to reduce our overall cost to serve. In light of our recent performance and progress, We believe our continued execution with respect to these strategic priorities will position Tactile Medical to deliver strong, sustainable growth in 2023 and the years ahead as we progress towards achieving our longer-term strategic and financial goals. Thanks to everyone on the Tactile Medical team for your efforts this past quarter and to our customers, suppliers, shareholders, as well as those on today's call for your support. Operator, we'll now open the call for questions.

Thank you. Ladies and gentlemen, at this time we will be conducting a question and answer session. If you'd like to ask a question, you may press star 1 on your telephone keypad. A confirmation tone will indicate your line is in the question queue. You may press star 2 if you would like to remove your question from the queue. For participants using speaker equipment, it may be necessary to pick up your handset before pressing the star key. We ask that you limit yourself to one question and one follow-up and then re-poll if you have additional questions. Our first question comes from the line of Adam Mader with Piper Sandler. Please proceed with your question.

Hey, Dan. Hey, Elaine. This is Simran on for Adam. Thank you for taking the question. Hi, Simran. Hi. I want to start out with a guidance for a moment here. You raised your revenue outlook by about $2 million despite about a $5 million fee at the midpoint of your prior Q1 guide. So maybe just walk us through what you're seeing in the procedure environment, you know, throughout the quarter and exiting Q1, and then also from a macro perspective to help inform that decision. And then I also didn't hear Q2 guidance, so what are your expectations for this quarter?

Yeah, so let me try and unpack that one if I can, Simran. I'll start a little bit with what are we seeing in Q2 so far. I think nothing terribly surprising. We've seen some ongoing stability resuming in the clinic volumes. I think we saw that through Q1, and I think that's continued largely into Q2 as well. We've said several times that I don't know that we see velocity of volumes getting back to 100% of pre-COVID levels. But we don't need to get back to that level either. I think that we have seen good recovery on a macro basis, and I think that's been consistent with our expectations. We're hearing staffing issues are getting progressively better in the clinics and the therapy clinics that we serve. And I think, you know, so far we've had a good reception to the recent introduction of our Entree Plus. And ultimately, you know, all those are kind of considered in the guidances. We are not updating quarterly guidance at this point, but rather we just opted to update annual guidance. And I think to your question that where you started relative to how we got there. So, you know, first of all, we knew Q1 was going to be our strongest quarter. Our original guidance suggested that it would grow faster than our overall full year. But if you take a look at where we finished up, we beat our high end by about $3.6 million. We raised it by two on the high end. So it's a little over a million and a half delta. And frankly, I'm not sure we're good enough to have that much precision at this point. We got nine months of wood left to chop. And I think that with a more balanced comparison of sales headcount as we progress through the year, we got the biggest benefit in in Q1 where we were still trying to get roles staffed. Ultimately, those are some of the things that contribute to that. We have not seen any of the macroeconomic backdrop that would take us to the lower end, and I think we talked about that when we initially posted guidance in February. But that's certainly something that we'll keep an eye on. And in the meantime, you know, we were just really, really pleased to be able to raise guidance. and feel confident about, you know, the latest guidance, which puts us in the double-digit kind of 10 to 11.5% range.

Awesome. Thank you for that response. And I guess for my follow-up, I'll ask about AfloVest, another nice quarter here in Q1. Did you see any impact from those prior supply chain headwinds in Q1 and Q2? Was there any pull-through from potential backlog, that being from those headwinds? I guess what I'm trying to get at is, are you in a position now to take full advantage and supply the market?

Well, I think the answer to the last question is we are in a full position to supply the market. And we didn't really carry anything in the line of a back-order position. into Q1 or into Q2, for that matter. But I think that now that we've been able to communicate our expectation that we have ample supply capacity, I think it's an opportunity for us to make sure that the sales channels are fully reengaged. There were some, I would say, admittedly, at points throughout the last handful of quarters that would express some reluctance to put their shoulder behind it with the uncertainty about whether or not we'd be able to to supply them at the higher end. So I think that we've certainly communicated the fact that we feel like we're in a good spot from a supply chain standpoint going forward. And we're hopeful that that will lead to ongoing demand that will continue to increase. And those are things that we factored in as well.

Perfect. Thank you.

Our next question comes from the line of Margaret Kaiser with William Blair. Please proceed with your question.

Hey, good afternoon, everyone. Thanks for taking the question. I'm going to try my hand one more time on the guidance side just to follow up. So, you know, I'm just kind of going through the math and the multiples, especially on the LinkedIn side of the business. You know, you guys had this tremendous 22% growth. I know the comps get a little bit tougher as we go on throughout the year, but If all I do is just try to average to that 9% or 10% for the full year guidance number, I get to this kind of mid to high single-digit lymphedema growth for the next three quarters. So Juan, tell me if I'm right or wrong about that. And that's below the long-term guidance that you've given for lymphedema. So I appreciate the conservatism and the thoughts around macro, but It seems like maybe there's a little bit of room to that number and why or why not.

Yeah, I think that I'm not sure the answer is a lot different, Margaret. I think that, you know, we certainly tried to express our confidence by raising our full year guidance. That said, I think it's a little early for us to declare victory. But, you know, we felt really good about the fact that we saw some solid productivity from our sales force. I think the administrative process that we've tried to streamline has been certainly good for the business in the first quarter. And, you know, Comfort Ease has continued, I think, to resonate well. So I'd say we feel confident about, you know, the double-digit growth guidance that we've updated to. And I think we'll have a lot clearer vision of this once we get through Q2 and into the, you know, later part of the summer. So, you know, I think that's... That's still pretty consistent. Okay.

I appreciate it. I had to try.

So just to follow up on some other things, right, you had talked about some of the CMS changes, eliminating medical necessity at the beginning of the year. That seems like it's maybe a potentially more meaningful change. So how does that help accelerate getting the product to the patient? Maybe they're in sales rep productivity, if at all, and then could it even increase the close rates?

Yeah, I think it remains to be seen, but it's a really good question. So there's a couple things going on in that space with the Medicare patients. First of all, I think there have been a fair amount of those patients that would have been overlooked, partly because the administrative effort was, frankly, pretty burdensome to the clinic. So the elimination of a CMN, and then maybe just as importantly, some new processes that we introduced as far as how we can collect that information, what information is going to be necessary, some forms that are more user-friendly. And I think all of those, we're hopeful, will continue to help make sure that patients that can benefit from our therapies get recognized, not overlooked, and that we don't make the work harder than it's going to need to be for the HCPs. As a result, we hope to reveal more of those patients that we can treat. On the flip side, the PHE waiver is ending in mid-Q2. Actually, it's in a few days if my calendar memory is right. So there's a little bit of an offset there that there were some things that were a little bit easier that will go back to the olden days. But we think that the offset on the good side is that the processes that we've introduced, we're hopeful to continue to demonstrate that it shouldn't be a burden on the HCP to do the right thing and help these patients that haven't gotten therapy to date. Okay.

Great. Thank you, guys.

Our next question comes from the line of Ryan Zimmerman with BTIG. Please proceed with your question.

Hey, good afternoon. Congrats on the quarter. I want to ask, I know you're not guiding quarterly here, Dan. That's pretty evident as we've all tried. But remind us about seasonality and kind of how you expect the seasonality to progress, particularly in the second and third quarters. You know, you've historically had, you know, this nice linear improvement recently. But as we come out of COVID, you know, kind of help us think about the pace for the next three quarters.

Yeah. I mean, I think you can look at history and see that typically our revenue ramps throughout the year and kind of resets. So we would certainly expect to continue to see incremental growth sequentially throughout the year with Q4, of course, continuing to be our biggest one as co-pays come down and typically the device gets effectively less expensive for the patient. Probably even more true with the AfloVest, just because of the average cell price is higher than some of our lymphedema therapy products. But sequential growth would certainly continue to be an expectation that I would say is fair. Okay.

And, Elaine, it's nice to have you on the call, and especially on a strong quarter, you know, start your time here with Tactile. Just remind us kind of your near-term goals that you have in the position as stakeholder?

Yeah, maybe I'll take this time to just share a little bit of what my observations and kind of how that leads me into my goals here. So, you know, coming from a large organization, I've been really impressed by the talent, the alignment around our strategy, and really how mission-driven the organization is. In fact, I was just at our national sales meeting last week, and it was clear that Our mission permeates everything that we do, and we're really making a difference in people's lives. And I think that's going to be a key to our success and what I was looking for when I joined the organization. I also had a chance to dive into our long-range financials and took a look at the guidance that we put out for 2025. And just as a reminder there, we said we would deliver over $350 million in revenue, over $50 million in adjusted EBITDA, and $75 million of chemo-free cash flow. I feel confident we can deliver that. And, you know, I see a team here who's focused on driving top line growth while expanding profitability. And that, too, is going to be one of my objectives and things that I focus on this year. And then lastly, another focus area for me. Oh, sorry. It would be to leverage. I'm sorry. Go ahead.

No, I was saying, please go ahead, Elaine. Sorry for interrupting.

Oh, okay. Yeah, no, no problem. And I just say, lastly, another opportunity I see is really to be able to leverage my healthcare experience to drive improvements in our revenue cycle management. I think this represents a significant opportunity for Tactile and should result in improvements in our networking capital as we're able to lower our accounts receivable. So I see that, too, as a focus area and a way for us to achieve those 2025 goals that I mentioned. Okay.

Very helpful. And the mention of council actually prompts me to sneak in one more question, which is Medicare as a percentage of sales this quarter was up, you know, pretty significantly relative to last year. And, you know, just given the payment terms on those Medicare cases you get, you know, how do you think about that dynamic coming through and in terms of your cash balance and just, you know, the overall shifting dynamics of the payer mix of the business?

Yeah, so I think one thing I've been excited to see is that the team, as I moved in here, has been spending a lot of time with our Medicare administrative contractors to increase our first-pass approvals. I'm really encouraged by the latest engagements that we have with them. We've gotten greater alignment on our submissions, and we're seeing improvement in our first-pass adjudication. So that really points to a really good momentum, especially, as you mentioned, that we see strong growth in the Medicare space.

Yeah, I would just add, too, Ron, to Elaine's comments, that I think this team's doing a really good job working with the MACs. We've made some pretty good progress. And I think we're going to demonstrate that it's not the curse to support the Medicare business that it was a few years ago as we go forward, as we continue to get better at working at the first pass adjudication, which her team, I think, is making really good progress on. Okay. Thanks for asking the questions.

As a reminder, it is Star 1 to ask your question. Our next question comes from the line of Shiraz Khalia with Oppenheimer. Please proceed with your question.

Good afternoon, Dan. Elaine, can you hear me all right?

We can.

Perfect. Apologies. I'm under the weather a little bit. Hey, so, Dan, in terms of Kylie, remind us what percent... of patients currently have Kiley? And more specifically, what kind of a tool do you all envision Kiley to be? Would it help improve patient compliance? Or is this more as a data gathering tool for payers, so to speak?

Yeah, I think, good question, Suraj, and, you know, frankly, Kylie's got a variety of different complexions to it. We originally talked about Kylie as a learning tool that we can make available to patients so they can better understand their condition and, frankly, advocate for themselves. We know that so many lymphedema diagnoses are missed or misdiagnosed, so equipping the patients with more information via this Kiley app was the first goal of the application. And then the next one is we think that it can have an impact on our training. We have training vignettes, and that's a cost-to-serve component. We can meet patients where they want to be met. If they want to be trained in the home, we can support that. If they're adept with a smartphone, we may be able to provide them the assistance that they need more efficiently, like so many of us depend on smartphones. There's another piece which then becomes the ability to communicate with their physician their progress. And while Kylie was introduced back in the summertime last year, we've continued to have incremental drops with new features. The most recent addition was we started adding Bluetooth chips to FlexiTouch in December. We've already had over 35,000 patient sessions that have been captured and downloaded through Kiley. These are opportunities for patients to bring the results to their physician, share with them when and how they're using it, and how they're benefiting or responding from it. So I think that those are some of the ways that we see Kiley currently. They're also able to track their orders. So, you know, from a contact and customer service, it offloads some of the human burden. and can even more immediately give them that feedback. And then as we get into the back half of this year, Suraj, we're going to continue to have some advances on how patients can record and track their measurements. We'll have prompts, just like my iWatch does, about, hey, it's probably time to do your therapy or celebrate the fact that you did, and a number of other things, I think, on the cost-to-serve side as far as order processing engagement. I'd say, in summary, it's an opportunity to educate. It's an opportunity to engage with patients and reduce our cost to serve, and also an opportunity for them to share more useful information with their providers.

Got it. And, Dan, if I could ask a higher-level question. Dan, what do you think would be the next iteration of product development in more specifically to reduce the minutes spent per day by the patient? Thank you for taking my questions.

Yeah, really good question. There's a lot of ways that we want to continue to improve the utility and the efficiency of patients' therapy sessions. I think the introduction of Entrez Plus is a great example where it's easier for patients with bilateral lymphatic disease to treat both legs at the same time. And we've already got the ability to do that with the FlexiTouch as well. So I think that being able to treat multiple parts of the body in one treatment session is already a way to optimize that. There's certain limits about, I think, that we can't shortchange it because there's a component that's necessary to make sure the therapeutic outcome is good. Again, being able to do multiple parts of the body simultaneously certainly helps rather than having to treat those parts of the body sequentially. So I think that's one that is certainly more visible in the latest iteration of our Entrez system. And then, you know, Suraj, we continue to invest in product development. There are additional solutions that we continue to work on. And ultimately, we expect those to produce a better therapeutic experience that's always optimizing efficacy but starting to continue to appreciate some of the consumer features that we know patients want.

Thank you.

It appears there are no further questions in the queue. This does conclude today's teleconference. Thank you for your participation. You may disconnect your lines at this time, and have a wonderful day.