Auna SA

Good morning, and welcome to AUNA's first quarter 2025 earnings conference call. My name is Rob, and I will be the operator for today's call. At this time, all participants are in listen-only mode, and please note that this call is being recorded. There will be an opportunity for you to ask questions at the end of today's presentation. Now, I would like to turn the call over to Ana Maria Mora, Head of Investor Relations. Ma'am, please go ahead.

Thank you, Operator. Hello, everyone, and welcome to AUNA's conference call to review our first quarter results. Please note that there is a webcast presentation to accompany the discussion during this call. If you need a copy of the presentation, please go to our investor relations website or contact AUNA's investor relations team. Please note that when we discuss variances, we will be doing so on a year-over-year basis and in FX neutral or local currency terms. with regards to Mexico and Colombia unless we know otherwise. Let's move to slide two. In addition to reporting an edited financial result in accordance with international financial reporting standards, we will discuss certain non-IFRS financial measures and operating metrics, including foreign exchange mutual calculations. Investors should carefully read the definitions of these measures and metrics included in our earnings press release of yesterday to ensure that they understand them. Non-IFRS financial measures and operating metrics should not be considered in isolation as substitutes for or superior to IFRS financial measures and are provided as supplemental information only. Before we begin our remarks, please also note that certain statements made during the course of today's discussion may constitute forward-looking statements which are based on management's current expectations and beliefs, and which are subject to a number of risks and uncertainties that could cause actual results to materially differ, including factors that may be beyond the company's control. These include, but are not limited to, our expected adjusted EBITDA growth, the expected impact on revenues and profitability of certain initiatives we are pursuing in Mexico, and long-term financial position and flexibility as a result of certain initiatives we are pursuing related to payers in Colombia and our target leverage level. For a description of these risks, please refer to our Form 20-S filing with the U.S. Securities and Exchange Commission and our earnings press release. On today's call, we have Susan Zamora, our Executive Chairman and President, Giselle Remy, our Chief Financial Officer and Executive Vice President, and Lorenzo Massaro, our Executive Vice President of Strategy and Equity Capital Markets. They will discuss AUNA consolidated and segment financial and operating results for the first quarter and will also provide updates on our various strategic growth initiatives. After that, we will open the call for your questions. Tuzo, please go ahead.

Tuzo Garcia- Thanks, Ana Maria, and good morning, everyone. We appreciate you joining our results call. As reported, Aona delivered consolidated lower-than-expected results this quarter. Peruvian operations strongly outperformed in the first quarter, and our risk-sharing strategy gained traction in Colombia. we encountered operational setbacks which added to softness in the market, causing us to lose our growth momentum in this key market. Thus, our results were disappointing, with revenue and EBITDA increasing just 4% and 1%, respectively, on an FX-neutral basis. However, We fully expect to recover our volume growth in Mexico during the remainder of the year, having quickly implemented corrective measures, which I'll explain in a moment. In Peru, the benefits of vertically integrating our healthcare plans into our healthcare operations continue to accrue value, notwithstanding operating at high utilization rates. In addition, we expect to make additional gains through the efficiency program implemented in Peru last year. Peru's consistently strong performance bodes well for our Mexico operations, where we've been gradually replicating the AUNA way. However, as we know from our experience transforming and modernizing Peru's healthcare market and improving Colombia's sector, implementing a disruptive business and care model is complex, AND THE ROAD HAS BEEN BUMPY AT TIMES. FOR EXAMPLE, OUR MODEL REQUIRES THAT DOCTORS, NURSES AND OTHER CARE PROVIDERS SET ASIDE TRADITIONAL PRACTICES TO ADOPT THOSE OF THE OWNER WAY. WHILE THIS IS CENTRAL AND PRODUCES GREAT EFFICIENCIES AND PredictABILITY, IT IS AS WELL A CULTURAL AND OPERATIONAL SHIFT IN THE HEALTHCARE SECTOR. AS PART OF OUR STRATEGY, WE HAVE REDUCED THE NUMBER OF LEGACY SUPPLIERS IN MEXICO. SPECIFICALLY THOSE WHICH WERE CONSIDERED OBSTACLES TO THE IMPLEMENTATION OF THE AUNA WAY. PAYERS OF COURSE ARE ALIGNED WITH AUNA IN WANTING TO SEE THESE PRACTICES ELIMINATED IN MEXICO. HOWEVER, MANY PHYSICIANS ARE INTEGRATED ECONOMICALLY TO SUPPLIERS AND AS WE INITIATED MORE STRINGENT CONTROL AND APPROVAL OF MEDICAL SUPPLIES, PHYSICIAN PRODUCTIVITY FELL AT OUR HEALTHCARE FACILITIES DURING THE QUARTER. It is fair to declare we underestimated the economic impact this would have on physicians. Realizing this, we have put in place a progressive approach that allows our physicians to better consistent into our practice and standards. We have seen volumes starting to recover, indicating that we've taken a step in the right direction. Again, I want to emphasize This is one of many challenges we have overcome in the past and resolved, where gradual shifts are needed to achieve the right balance between the traditional economics of physician practices and the modern medical protocols that we are implementing. This is a threshold event, one that, once crossed, will allow us to reap the full benefits of the efficiencies and profitability of the Auna Way in Mexico. We are also encouraged by the results of the strategy and measures that we implemented in Columbia since last year to mitigate payment risk. Revenue increased modestly in the first quarter, and we continue receiving timely payments from Nueva EPS, although we continue to prudently increase provisions, which continue to constrain the bottom line. In addition to improving payment flows, we are diversifying the mix of payers. reallocating service volumes to those that haven't been intervened by the country's regulator. Taken together, our cash flow outlook in Colombia has improved considerably. Although our debt leverage was unchanged from the fourth quarter, we remain committed to reaching our midterm target of three times or less. We'd also like to point out that AUNA's net income was positive for the fifth consecutive quarter. LET ME PUT ALL OF THIS INTO CONTEXT. DESPITE THE QUARTER'S OPERATIONAL SETBACKS IN MEXICO, THE UNDERLYING FUNDAMENTALS OF OUR HEALTHCARE PLATFORM ARE STILL VERY SOLID, AND WE ARE CONFIDENT ABOUT RECOVERING OUR GROWTH MOMENTUM IN MEXICO AS THE YEAR PROGRESSES. OUR STRATEGIC DIRECTION HAS NOT CHANGED, AND WE REMAIN EXCITED ABOUT OUR OWN ADMIT TO LONG-TERM EARNINGS POTENTIAL. Let's move to slide 5, please. As I've noted, Peru's outperformance drove our results in the first quarter. This was true for our operating results as well, with Peru nicely running at high capacity utilization. As a reminder, we are focused on increasing utilization through higher levels of high complexity services, not bed occupancy alone. These services have higher margins and are core drivers of profitability. In Peru, total capacity utilization increased 4.4 percentage points versus last year's quarter, while also increasing the delivery of high complexity services. In Mexico and Colombia, capacity utilization decreased 0.9 and 2.1 percentage points, respectively. BOTH DUE TO THE VOLUME DECLINES THAT I EXPLAINED EARLIER. THE HEALTHCARE PLANS SIDE OF PERU ALSO PERFORMED WELL DURING THE QUARTER WITH PLAN MEMBERSHIPS INCREASING 10% YEAR OVER YEAR AND THE ONCOLOGY MLR DECREASING 1.4% TO 51.6% VERSUS THE PREVIOUS QUARTER WHICH IS A VERY HEALTHY LEVEL. SLIDE 7, PLEASE. In Mexico, revenues decreased 4% and adjusted EBITDA by 5%, both on an FX-neutral basis. More generally, the macroeconomic environment and the uncertainty around tariffs and employment have tempered investment and consumption, including for medical services. In addition, we consider the impact of the supplier relationships on productivity to be transitional. This is reflected in volumes beginning to recover. To a lesser extent, softer market conditions with stronger than expected seasonality effects also limited our top line and profitability during the quarter. Nonetheless, we were able to maintain our attractive margins, a product of the cost efficiencies we began implementing since last year. Let's move to Peru on slide eight, please. As you can see in the chart on the right side of this slide, operating leverage drove a 19 percent increase in adjusted EBITDA on the 10 percent increase in revenue during the quarter. You can also see that per use EBITDA margin continued improving. The impact of the efficiency initiative that we've implemented is particularly gratifying when you consider our current utilization levels improved. THESE LATEST RESULTS FURTHER DEMONSTRATE THE EARNINGS POWER OF OUR VERTICALLY INTEGRATED BUSINESS MODEL WHEN IT'S MATURE AND OPERATING AT SCALE. SLIDE 9, PLEASE. AS PREVIOUSLY COMMUNICATED, WE MOVED TO SLOW DOWN OUR GROWTH IN COLUMBIA TO MITIGATE PAYER PAYMENT RISK AND PRIORITIZE A POSITIVE CASH CYCLE. THESE INTERIM MEASURES WHICH INCLUDE DIVERSIFYING OUR PAYER MIX ARE PAYING OFF. with improved payment flows, including those from Nueva EPS, and a much better cash flow outlook, while partially offsetting provisions. It's important to note here the marked decline in adjusted EBITDA. Please recall that in the fourth quarter, Colombia benefited from retroactive price adjustments and procurement rebates, which typically happen in the fourth quarter of each year. I'LL NOW TURN THE CALL OVER TO GISE, WHO WILL PROVIDE SOME MORE DETAILS ON OUR FIRST QUARTER RESULTS.

THANK YOU, SUSA. MY REVIEW BEGINS WITH REVENUE CONTRIBUTIONS ON SLIDE 11. AS SUSA HIGHLIGHTED, PERU HELPED PARTIALLY OFFSET THE FIRST QUARTER DECREASE IN MEXICO'S REVENUE. PERU'S 10% REVENUE INCREASE WAS MAINLY DRIVEN BY HIGHER SURGERY VOLUMES AND IMPROVED PRICING DURING THE QUARTER. which you also see reflected in higher capacity utilization. At OncoSalud, our health plans business in Peru, revenue was driven by annual inflation price adjustments and a 10% increase in plan memberships. In the case of Colombia, the implementation of risk sharing models was in part behind the 5% revenue increase in local currency. These are upfront payments for high complexity services such as cardiology and oncology services. Another factor in the revenue growth was the diversification of our payer portfolio as we are proactively managing our contracted services and diversifying our payer mix, which is another way we have been mitigating risk and preserving cash flow in Colombia. Let's now turn to slide 12, please. As Suso explained, Mexico's revenue decline and additional impairment provisions in Colombia slowed EBITDA growth and compressed our margin, which finished the quarter a percentage point down versus the first quarter of 2024. Helping offset the lower profitability in Mexico and Colombia was the 19% increase in Peru's adjusted EBITDA. That increase and the 1.7 percentage point margin expansion reflects the top-line growth and efficiency gains of our most mature and scaled business. It's important to note that despite the volume decrease in Mexico and the capacity investments that we've been making in this market, this segment's adjusted EBITDA margin remained high at a healthy 33.2%. Let's now move to slide 13, please. We delivered our fifth consecutive quarter of positive adjusted net income. On this slide, we break down the 33 million soles increase from the first quarter of 2024 to the first quarter of 2025. The 43 million soles decrease in operating profit is mainly explained by the non-recurring 23.7 million soles in upfront payments to the doctors of Opción Oncología, as well as the impact from the depreciation of the Mexican and Colombian pesos versus the Peruvian sol. This was more than offset by a 53 million decrease in interest expense. The first quarter was also impacted by a positive FX variance related to the appreciation of the Peruvian Sol relative to the US dollar outside the levels of our call spread hedges. While the decrease in interest expense was mainly due to first quarter 2024 transaction costs related to the 2023 refinancing. Slide 14, please. Despite the 15% decrease in cash, we maintained a solid cash position at the end of the quarter. Looking at the cash flow bridge on this slide, you can see that we generated 165 million soles of pre-tax operating cash flow, including interest received during the first quarter, and paid 58 million soles in taxes. Operating cash flow was primarily impacted by a drop in collections in Colombia, specifically related to Nueva EPS in the months of January and February, only partially compensated by a recovery in collections in March after reaching a payment plan with them. They have continued to honor that payment plan into the first two months of the second quarter. In addition, CapEx was 4.5% of revenues, in its majority related to maintenance, with a small 2 million soles payment to Opción Oncología doctors, bringing total capex to 47 million soles in the quarter. Another 17 million soles in cash was used for amortization of the earn out and hold back obligations related to the past acquisitions of IMAT OncoMedica and OCA, respectively. Amortizations of the holdback obligation finalized in the second quarter, while the remaining balance of the earn-out obligation is now only 12.7 million soles. As a result, free cash flow was 42 million soles. Organic free cash flow, which excludes the amortized earn-out and holdback payments, was 59 million soles. Lastly, on this slide, interest payments during the quarter totaled 76 million soles. Let's now turn to slide 15, please. At the end of the quarter, we maintained a healthy debt structure and maturity profile. And even though our leverage remained unchanged versus the previous quarter, we remain focused on further reducing our net debt leverage to our three times net debt to EBITDA medium term target through a combination of EBITDA growth and debt amortization. Lastly, as announced a couple of weeks ago this month, we refinance 62.1M dollars of short term debt. Through a successful reopening of our existing 2029 senior secured notes. Despite challenging conditions in the credit markets at the time. We were well oversubscribed and managed to price the issuance at a highly competitive yield of 8%, while at the same time extending maturities. That concludes my review of our first quarter results. I'll now pass the call over to Suso, who will wrap up our presentation before we move on to Q&A.

Thank you, Giselle. To wrap up our prepared remarks, all of us at AUNA remain 100% committed to transforming healthcare in Spanish-speaking Latin America through our proven value-based care model. Implementing this model in fragmented, inefficient, and underserved private healthcare markets like Mexico has enormous potential. And we have demonstrated our ability to do this. As the strong results in Peru make clear once again this point, While growing our scale and furthering our vertical integration, we expect Peru to continue being a strong earnings driver in the medium to long term. We have effectively stabilized our cash flows in Colombia, and the risk-sharing programs are delivering. Until the government resolves the current situation with intervened payers, we intend to continue diversifying the payers we serve as another means to manage risk. Longer term, we are bullish on Colombia, which remains an important contributor to our platform scale and to maintaining best practices in patient care and healthcare. Finally, our immediate focus is reengaging doctors to recover volumes in Mexico during the remainder of 2025. We have acted swiftly, and we are taking the right approach to adjust our model to strike the best balance possible between physician economics and best practices under the AUNA way. We also continue advancing the expansion of AUNA's oncology capabilities in Mexico, using Opción Oncología to build a best-in-class oncology platform. And we continue to be excited about OncoSalud in Mexico, which is the country's first mono-risk health insurance product, and the potential of which is enormous. That concludes our prepared remarks. Operator, please open the call for questions.

At this time, we will open the floor for your questions. As a reminder, you can also submit your questions online by using the Q&A function of the webcast platform. Your first question comes from the line of Mauricio Cepeda from Morgan Stanley. Your line is open.

Hello, Susu, Cicelli, Lena. Thank you for the opportunity here. I would like first to ask about Mexico. If I understood correctly, it's almost a cleanup of the relations you have with the physicians and suppliers there, a little bit more towards the AUNA way. So in that regard, why trying to make this kind of transition at this point in time? What led to the decision to make this kind of transition now? And if you foresee that a ramp-up out of this transition would be something to happen in the short term, or is something that you foresee to happen a little bit more towards the medium term? And the second question is about Colombia. If you could update on the conversations you're having there with the interventors there, if there is any room for further risk sharing agreements there. Thank you.

Thank you, Mauricio, and nice to hear you. On Mexico, I would not want to consider what you said, a cleanup. As I indicated before, the owner way is transformational, and it's tough for physicians that are so well integrated into the supplier chain. So the main source of lost volumes would be to disclose relationships between the suppliers and physicians. This is critical for the owner way, and this is critical for our focus on high complexity. And this is very important, specifically in our relations with the payers. we are a unique player that has high credibility from insurance companies because we control and we are very predictable on what happens in the clinical aspects of healthcare and the patient journey of healthcare and also in our margins. So this is not a thing that can be postponed, but has to be managed gradually to make sure that our volumes do not decrease. And that we continue to grow and penetrate, especially high complexity, higher margin services. So I would say that is critical Mauricio. I think that in Colombia, with respect to our risk sharing models, we are now approximately 20% of our revenues is in risk sharing models. You may recall Mauricio that this was something like 15% last year. and we are targeting 30% towards the end of the year and even more in mid next year. This is consistent with our strategy to favor cash flows as payment terms are very favorable and margins are stable, I would say. Thank you, Mauricio.

Thank you, Suso.

And there are no more questions on the phone line, so I will now turn the call over to Ana Maria Mora from ONA, who will proceed with the questions from the webcast platform.

Thank you, operator. So, the first question comes from Alex Stephenson. Please provide more detail about what has happened with operations in Mexico.

Great. I'll respond to that. Thank you very much, Alex, for that question. So again, the main source of lost volumes was due to this close relationship between suppliers and physicians. Our model, as I said, is disruptive. It challenges many intrinsic practices, in particular, traditional practices that aren't easy to accept by some physicians. Our model allocates high volume to doctors who abide to our medical practices, and this does take some time, some months to implement. What I'd like to represent, I think the important part is that we have reacted quickly and we are already in the process of seeing, harvesting some of the results of our action. We are, as indicated before, Noting a recovery in volumes, but of course, this is a work in progress. We are confident in the recovery in the coming quarters, but it is early to quantify. These are coming from a variety of practices, medical practices, especially on those that we are focused on, in high complexity again, that have a higher dependence also on medical devices. So getting this right is something important. This is also... something that we have confronted in the past. This is not something unique to Mexico, to Monterrey. Healthcare in the world is fraught with the challenges of fee-for-service models, highly incentivized by big pharma and medical device manufacturers. Our model disrupts this, and it works, but it needs to be implemented gradually. This is not a problem. It is a well-known hurdle in the industry. Dealing with it is part of the process of transforming the market and makes AUNA much stronger. And it's something that we've done in the past as well. Thank you, Alex.

Thank you, Suso. The next question comes from Xiomara Tantalian. Thank you for the call. Could you please share how your guidance for Mexico has evolved compared to the initial expectations?

So this is something we discuss a lot internally. Given that we manage the company as an integrated regional play, No, we have not given guidance by country. We have given guidance in the past about the consolidated results, but early this year, we decided to make sure that the market understood that Colombia in particular and now Mexico have given us enough facts to say, let's wait off before we give guidance for the full year. We have an internal target, and I've discussed it in the past, a full year EBITDA growth of 20%. We have been doing more, 20% or more, over a decade. However, as I indicated right now, at the beginning of the year, we were reluctant to call it a guidance because of what was occurring in Colombia. That was outside of our control. first two results in Mexico, we need to see how the recovery day shapes up in the next few quarters to have a better visibility in the full year. But we are confident we will recover growth and our growth trajectory in Mexico in the coming quarters. So I don't think we're changing the way we manage the business, the way we project the business, the way we budget the business. But we're being a little We're being very conservative in what we will call a guidance. Our expectation in Mexico, just to be a little more conceptual on it, our expectation in Mexico is within what we expect. We manage the business with stable margins and a growing penetration of high complexity volume. That's happening this quarter. We had this reversal. But that's generally happening since we took over the operations. We have a great opportunity in Mexico. We still have a lot of capacity to use. We have a great, you may recall what we represented last quarter with our acquisition of the Opción Oncología group in Monterrey. That's already seen very interesting results at Doctors Hospital in Monterrey. So we're growing in what we want to grow, and we want to make sure that we're stable, and it actually has a qualitative impact on how we deal with the physician practices and the physician integration into the suppliers. Thank you very much, Alex. I'm sorry.

Thank you, Susum. The next question comes from Omar Avellaneda, and it is, what is your Evita and CAPEX guidance for 2025? Do you expect additional impairments in Colombia in 2025? What is the current status of the deployment of OncoSalud in Mexico?

Thank you, Annie. I can take the first part of that call about that question, maybe pass it over to Suso to talk a little bit about OncoSalud in Mexico. I think Suso already answered the question on EBITDA guidance, which we did not give specific EBITDA guidance for the year. As far as CapEx guidance, this continues to be the same levels that we've seen in previous years, which should be at or below $50 million annually for CapEx investments in the regular course of business. In the case of provisions in Colombia, as we've previously mentioned, our policy continues to be based on an expected loss model, and there is a differentiated treatment for the intervened entities. We will continue to see impairments in accounts receivable in the coming quarters. But as previously mentioned, this does not reflect a view that we won't be able to collect on those accounts. It's just a matter of de-risking the balance sheet, you know, basically through the coming quarters. But we still remain confident and constructive on the medium-term outlook and on the fact that we will be collecting on those accounts. Suso, I don't know if you want to compliment on the progress of OncoSalud in Mexico.

Sure. Thank you very much, Andisa, and thank you very much, Omar. So, again, we continue to be very excited about OncoMexico, OncoSalud in Mexico. We have a very strong pipeline. I've spoken about this last quarter, and I think that we made really good progress in closing the network outside of Monterrey, which is a key deliverable from most of the prospective large clients that want to be covered by Uncle Mexico. That is outside of Monterrey. In this quarter, we have already secured a national network in three major cities. in addition to Monterrey, of course, in Mexico City. In Guadalajara, I was in Tijuana the day before yesterday, on Monday, and we're closing on Tijuana this month. So the market should read this as very positive for Uncle Mexico, given that we're closing these agreements and this platform of services, No, we will have it in the four principal cities of Mexico. No, for the benefit of the pipeline that we have. That is also, of course, demanding national coverage. So we don't give guidance on Uncle Mexico. No, but I clearly am very optimistic. And as you can tell from what we're closing in terms of this network, This is definitely related to a demand from this pipeline that I represented before. Thank you, Omar.

Thank you, Suso. The next question comes from Gerard Moore. Could you share your outlook on capital expenditures expenditures for the rest of the year? And do you see the effective tax rate stabilizing around 30% level this year?

Thank you for the question. I think the CAPEX part was already answered with the outlook basically being at or below $50 million for the full year. And in the case of the effective tax rate, which has, you know, I think last year was around, 33% this year. We expect it to be closer to around 38%. This having to do also with, you know, when you make payments intercompany in the subsidiaries of the group, you do have some tax effects. We continue to recognize deferred tax benefits in that effective tax rate, which should lead to an improved tax cash rate. in the coming years, which I think will also be very positive for liquidity.

Thank you, Jason. The next question comes from Saikat Majumder. Can you please elaborate the business development expenses in Mexico? Is this related to OncoMexico, and will this continue in coming quarters?

So the approximately 27 million soles in business development expenses, which were adjusted from EBITDA in the first quarter, correspond to the upfront payments made to the doctors from Opción Oncología who joined us in March. Those payments will be made throughout 2025, but they were recognized as part of the expenses in the accounting EBITDA in the first quarter and are completely non-recurring and only due to an upfront payment.

And I would just add, and you said that, and yes, they are related to OncoMexico, of course, because we manage the oncology platform as an integrated platform on the insurance and option oncology, which is a platform of services that are a center of excellence for oncology.

Thank you, Susel. Thank you, Giselle. The last question comes from Caio Muscardini. How long did it take for the ONAway to be fully accepted by suppliers and physicians when you started its implementation in Peru?

Well, that's a very good question, Caio. So in Peru, it took various years. In Colombia, it was a little quicker. And in Mexico, we expect it to be also quicker than what we've seen in Peru. Given that we've learned and given that the scale that we have today in terms of engaging suppliers directly and not through third party intermediaries, that are the ones that are integrated into the physicians themselves. This is the way we manage it, Cayo, is practice by practice. Orthopedics and trauma has a big component of integration. Cardiology, a little bit as well. Some surgical procedures. And we manage by practice and by supplier. And gradually. Gradually because It's very important to recognize doctors have a total income, family income, let's call it, that includes the payments they get from this integration. So we have to be careful and we have been careful in the past in helping them better transition their total income from suppliers to owner and their own personal physician practices. Thank you, Annie.

Thank you, Suso. At this time, I'm not showing any more questions. Maybe I would like to turn the call back over to Suso for the closing remarks.

Thank you very much, Annie. Just in finalizing, we have had a bump in the road. We're in control. No, the model is disruptive, as I made the case on occasion. No, it is, I like to call it a threshold event. Once you get the model going, you know, it scales, it reaps the benefit for both patients and doctors, and of course for ONA. I thank the investor community for your commitment to ONA and to the community behind ONA. I want to thank you for your attention on this call. Thank you very much.

This concludes today's conference call. You may now disconnect.