IQVIA Holdings, Inc.

Ladies and gentlemen, thank you for standing by. At this time, I would like to welcome everyone to IQVIA third quarter 2021 earnings conference call. All lines have been placed on mute to prevent any background noise. After the speaker's remarks, there will be a question and answer session. If you would like to ask a question during this time, simply press star then the number one on your telephone keypad. If you would like to withdraw your question, press the pound key. As a reminder, this call is being recorded. Thank you. I would now like to hand the conference over to your speaker today, Nick Childs, Senior Vice President, Investor Relations and Corporate Communications. Mr. Childs, please begin your conference.

Thank you. Good morning, everyone. Thank you for joining our third quarter 2021 earnings call. With me today are our... Ari Boosby, Chairman and Chief Executive Officer, Ron Brooman, Executive Vice President and Chief Financial Officer, Eric Sherbet, Executive Vice President and General Counsel, Mike Fedock, Senior Vice President, Financial Planning and Analysis, and Brian Stengel, Associate Director, Investor Relations. Today, we will be referencing a presentation that will be visible during this call for those of you on our webcast. This presentation will also be available following this call in the events and presentation section of our IQVIA investor relations website at ir.iqvia.com. Before we begin, I would like to caution listeners that certain information discussed by management during this conference call will include forward-looking statements. The actual results could differ materially from those stated or implied by forward-looking statements due to risks and uncertainties associated with the company's business, which are discussed in the company's filings with the Securities and Exchange Commission, including our annual report on Form 10-K and subsequent SEC filings. In addition, we will discuss certain non-GAAP financial measures on this call, which should be considered a supplement to and not a substitute for financial measures prepared in accordance with GAAP. A reconciliation of these non-GAAP measures to the comparable GAAP measures is included in the press release and conference call presentation. I would now like to turn the call over to our Chairman and CEO, Ari Busby.

Thank you, Nick, and good morning, everyone. Thank you for joining today for our third quarter results. Our strong momentum from earlier in the year has continued despite the resurgence of COVID-19 due to the Delta variant. This has not had an impact on our operations as we have learned to manage through these disruptions. Our outlook for the longer term remains unchanged. The backdrop for the life science industry continues to be very strong. Biotech funding continues to run at record levels. According to the National Venture Capital Association, funding totaled $35.8 billion through September 2021, already exceeding the full year of 2020. The pipeline of late-stage molecules continues to expand and is at an all-time high, with almost 3,000 molecules in active Phase II or Phase III developments. Clinical trial starts are trending well ahead of recent years with year-to-year date starts up 23% over 2020 and 13% over 2019. And finally, new drug approvals by the FDA are keeping pace with the historically high levels of 2020, with 40 new drugs approved year-to-date, which sets the stage for a strong volume of upcoming commercial launches. The bottom line is the dynamics in the industry are strong, and we remain bullish on our outlook for our end markets and for IQVIA in particular. As we think about our longer-term plans, I want to remind you of our upcoming Analyst and Investor Conference on November 16th in New York City. At that meeting, we will provide financial guidance for 2022 ahead of our usual timeline, which is normally coinciding with the end-of-year results in early February, and we will share as well our midterm outlook and plans for the next phase of Acuvia's growth. Look forward to seeing everyone and hope you can join us then. With that, let's review the third quarter. Revenue for the third quarter grew 21.7% on a reported basis and 21.1% at constant currency and was $64 million above the midpoint of our guidance range. The beat was driven primarily by higher pass-throughs, which, as you know, dilutes our margin somewhat, as well as by stronger organic revenue growth. Third quarter adjusted EBITDA grew 20.5%, reflecting our revenue growth as well as productivity measures. The $8 million beat above the midpoint of our guidance range was entirely due to the stronger operational performance. Third quarter adjusted diluted EPS of $2.17 grew 33.1%. That was 7 cents above the midpoint of our guidance, with a bit coming from the adjusted EBITDA drop through, as well as favorability in below the line items. Let me now provide an update on the business. Our real-world evidence business continues to take a leading role in informing healthcare. In late September, the FDA released their draft guidance on how electronic health records and medical claims data can support regulatory decision-making, and it cited several IQVR publications. With the growth of rare disease therapies and personalized medicine-driven trials, the number of single-arm clinical trials increases every year, and external comparators provide important context for these studies for both regulators and payers. Our clients recognize our leading expertise in this area. For example, we had a recent major win to deliver an external comparator in a cardiovascular study for a top 20 pharma client. In another example, we were awarded a 15-year follow-up study to demonstrate the long-term effectiveness and safety of a newly launched gene therapy. Regulatory guidance requires extended follow-up for patients exposed to cell and gene therapies, and IQVS innovative real-world capabilities combining direct-to-patient solutions as well as IQVS technology platforms to capture secondary data was pivotal in this award. On the technology front, our suite of offerings continue to be adopted in the marketplace. You're familiar with our OCE platform and other commercial technology applications, and we have, of course, continued to expand our footprint here. We have 10 new client wins in the core, bringing the total number of OCE wins to date to 169 customers. But we are also very excited to see increased adoption of our orchestrated clinical trial suite, OCT. This quarter, for example, a leading biotechnology company in Asia selected our site portal module within OCT to power site engagement across all of their trials. We now have 165 customers that have bought the site portal module, representing 155,000 sites and 1,716 active studies that are using our site portal module. Similarly, our award-winning e-coop platform continues to experience strong demand. We have successfully deployed over 150 projects across 35 different therapeutic areas. To date, we have over 70 customers using this platform, including eight of the top 10 pharma clients. The platform has processed over 10 million unique patient responses in 65 countries and across 28 languages. Now, I want to say a few words about a fast-growing part of our industry. You're familiar with decentralized trials, or DCT. The IQVIA decentralized trial offering combines several tech modules within our OCT suite, including ECOA, e-consent, telemedicine, and connected devices, as well as other service capabilities, including home nurses and phlebotomists, along with our decentralized trial patient concierge and study coordinators, all organized around our decentralized trial platform. Importantly, we've developed innovative clinical patient engagement offerings, including direct-to-patient services to accelerate recruitment and improve patient diversity and inclusion in clinical trials. When we step back and look at the growing importance of DCT in our own portfolio, we find that up to 30% of our active full-service trials utilize one or more components of our DCT offering. Incidentally, when our competitors speak about their own DCT offerings, this is often what they report as their DCT business. When we look at trials that actually fully utilize our DCT capabilities, meaning they are fully run on our decentralized trial platform, we've been awarded 89 trials to date, totaling over $1 billion. These awards are with 34 unique sponsors, of which 10 have multiple decentralized trials ongoing with us. These trials span 12 different therapeutic areas, 32 unique indications and have recruited over 200,000 patients in 40 countries. Our ability to combine advanced clinical technology with an extensive network of investigators and care professionals differentiates us in this space and makes us the partner of choice for decentralized trials that utilize the full capabilities. Our overall RMDS business continues to build on its strong momentum. We had approximately $2.6 billion of net new bookings in the quarter, bringing our LTM net new bookings for the first time to over $10 billion, including pass-throughs. This resulted in a contracted net book-to-bill ratio of 1.39 including pass-throughs and 1.28 excluding pass-throughs. At September 30, our LTM contracted book-to-bill ratio was 1.38, including pass-throughs, and 1.37, excluding pass-throughs. Our contracted backlog in our MDS, including pass-throughs, grew 12.7% year-over-year to $24.4 billion at September 30, 2021. As a result, our next 12 months revenue from backlog increased to $6.9 billion, up $300 million sequentially versus the second quarter. As we have signaled several times in the past, we've ramped up investment in our lab capabilities. We recently announced the opening of our new 160,000 square foot innovation laboratories in North Carolina. This facility provides customers with access to cutting-edge bioanalytical, vaccine, and genomics capabilities along with an expansion into exploratory human biomarker discovery services. These new services would enable us to partner closely with sponsors in the development of essential biomarkers to support new molecules moving into clinical development and throughout the life cycle. And this expansion, of course, comes on top of the investment we announced last quarter in our 130,000 square foot facility in Scotland. I will now turn it over to Ron for more details on our financial performance.

Okay, thanks, Ari, and good morning, everyone. Let's start by reviewing revenue. Third quarter revenue of $3,391,000,000. through 21.7% on a reported basis and 21.1% at constant currency. Year-to-date revenue was $10,238,000,000, going at 27% reported and 25% at constant currency. Technology and analytics solutions revenue for the third quarter was $1,337,000,000, which was up 10.8% reported and 9.9% at constant currency. Year to date, technology and analytics solutions revenue was $4,038,000,000, which was up 17.6% reported and 14.9% at constant currency. In the third quarter, R&D solutions had revenue of $1,853,000,000, up 32.4% at actual FX rates and 31.9% at constant currency. Excluding the impact of pass-throughs, third quarter R&D AS revenue grew 24.7% year-over-year. Year-to-date revenue in R&D solutions was $5,612,000,000, up 37.7% reported and 36.2% at constant currency. Finally, contract sales and medical solutions, or CSMS, revenue of $201 million was up 12.3% reported and 12.8% at constant currency. Year-to-date CSMS revenue was $588 million, growing 6.5% reported and 5.1% at constant currency. Now let's move down to P&L to adjusted EBITDA, which was $728 million in the third quarter, up 20.5%. Year-to-date adjusted EBITDA was $2,194,000,000, growing 33.1% year-over-year. Third quarter GAAP net income was $261 million, and GAAP diluted earnings per share was $1.34%. Year to date, we had net income of $648 million, or $3.32 of earnings per diluted share. Adjusted net income was $423 million for the third quarter, and adjusted diluted earnings per share grew 33.1% to $2.17. Year to date, adjusted net income was $1,264,000, or $6.48 per share. Turning now to the R&D Solutions backlog, as already reviewed, R&D Solutions delivered another outstanding quarter of net new business. Backlog now stands at $24.4 billion. In the last 12 months, net new bookings, including pass-throughs, rose to over $10 billion. Okay, turning to the balance sheet, at September 30th, cash and cash equivalents totaled $1.5 billion, and debt was $12.2 billion. This resulted in net debt of $10.7 billion. Our net leverage ratio at September 30th came in at 3.65 times trailing 12-month adjusted EBITDA. Cash flow was, again, quite strong in the third quarter. Cash flow from operations was $844 million. And with CapEx of $162 million, this resulted in free cash flow of $682 million. This third quarter performance brought our free cash flow year to date, that is through the first three quarters, to almost $1.8 billion, which continues the strong improvement trend we've had over the past three years. In the quarter, we repurchased $125 million of our shares, which leaves us with $697 million of share repurchase authorization remaining under our latest program. Okay, let's turn to guidance. As you saw, we're raising our full-year 2021 revenue guidance by $188 million at the midpoint, this reflecting the third quarter's strength in the continued operational momentum in our business. Our new revenue guidance is $13,775,000,000 to $13,850,000,000, representing year-over-year growth at 21.3% to 21.9%. I'll note that included in this guidance is a $30 million headwind from FX versus our previous guidance. Now, looking at the comparison to the prior year, FX is a tailwind of about 120 basis points, to full-year revenue growth. We're also raising our profit guidance. As a result of a stronger revenue outlook, we've increased our full-year adjusted EBITDA guidance by $20 million at the midpoint. Our new full-year guidance is $2,980,000,000 to $3,010,000,000, which represents year-over-year growth of 25% to 26.3%. Moving down to EPS, we're increasing our adjusted EPS guidance by $0.10 at the midpoint. The new guidance range is now $8.85 to $8.95, which represents year-over-year growth of 37.9% to 39.4%. Now, our full year 2021 guidance assumes that September 30th foreign currency rates remain in fact for the balance of the year. Of course, the four-year guidance implies a fourth quarter guidance, which we show here. And before getting to the numbers, I'll say for context, you'll probably recall that last year's fourth quarter was unusual due to a snapback in the general business as we rebounded from the effects of COVID-19, picked up incremental demand from mega vaccine studies in R&DF and government-related COVID work within TASC. Fourth quarter revenue is expected to be between $3,537,000,000 and $3,612,000,000, representing growth of 7.2 to 9.5%. FX in the quarter is a headwind of growth of about 100 basis points. We expect fourth quarter TAS revenue growth to be mid-single digits, reflecting the expected year-over-year decline in government COVID-related work and the FX drag. I'll note, though, that underlying constant currency organic growth for TAS will be in the high single digits, which is a level that TAS has recently accelerated. RDS revenue growth will be in the low teens, with services growth in the mid-teens, despite last year's difficult comparison due to the COVID vaccine work. CSMF will be slightly down. Adjusted EBITDA in the fourth quarter is expected to be between $786 million and $816 million, up 6.9% to 11%. And adjusted diluted EPS is expected to be between $2.37 and $2.47, growing 12.3 to 17.1%. So in summary, we delivered a very strong third quarter with strong results on both the top and bottom line. RDS backlog improved to $24.4 billion. That's up 12.7% year over year. Next 12-month revenue from backlog increased to $6.9 billion, up $300 million sequentially versus the second quarter. We reported another strong quarter of free cash flow, which at $1.8 million through the first three quarters of the year is a market improvement over prior year. And finally, we're once again raising our full-year guidance for revenue, adjusted EBITDA, and adjusted diluted EPS. And with that, let me hand it back over to the operator for questions and answers.

At this time, I would like to remind everyone, in order to ask a question, press star then the number one on your telephone keypad. We'll pause just for a moment to compile the Q&A roster. Your first question comes from the line of John Krieger with William Blair.

Hey, thanks very much. Ari, thanks for all the detail around the OCT and DCT offerings. That was great. I'm curious, if you could just take that one step further, what do you think the operational implications are for you guys and your clients as you see greater adoption of some of these newer technology tools?

Well, I mean, operationally, obviously, you know that one of the single most important challenges we and actually the entire industry has is the ability to deploy people against the strong book of business that we've all generated. And so this is a great development because what DCT does is it kind of increase productivity, reduces labor, and enables us to essentially execute more efficiently. So I think operationally, we are just adapting to this. Now, again, the full productivity only comes when the trial is fully decentralized trials, as I explained, because there's a lot of confusion in this space. As soon as someone uses a digital platform, they say, well, we've got a decentralized DCT award here, but that's not the case. Now, if we do that, as I mentioned, about 30% of our full clinical trials, which is just a Probably we have a little bit under a thousand trials that are full service clinical trials ongoing. So it's a larger number that already utilize one or several of our DCT modules, eConsent or eCOA or other connected devices. Our clients are, you know, experimenting, quote unquote, with smaller trials and trying the full uh dct platform which puts together all of the capabilities and the maximum utilization of the digital tools that we have at our disposal i think hands down i believe we are um you know leader in this space sounds good thanks

And one quick follow-up on staffing. Obviously, there's a lot of talk about a tight labor market. Is that proving to be any sort of a headwind for you guys on EBITDA margins? And have you seen your staff attrition rates change at all as we've moved through this year?

I mean, there's no question about it. It's not a secret. This is true across industry sectors and in our sector in particular, since we have such a strong industry backdrop, there's a lot of competition for talent. We have all of the peers in the CRO space are a hunting ground for talent. So obviously we are responding, we are actively recruiting and hiring to meet this demand. We recruit thousands of employees every year, so we've got a whole talent acquisition capability that's global and that's actively at work. Does it create cost pressure? Yes. And it's already included in our guidance. That's certainly a headwind. But as you well know by now, hopefully you know that when you look at our overall results, you see that there has been margin expansion despite these cost headwinds. In fact, even when you see in this Q3 results that our operating margins are flat to slightly declining, when you actually take out the pass-throughs, you actually see that our operating margins expanded quite nicely. And this is despite the cost headwind that we have. So yes, it is a headwind. And we are dealing with it and offsetting with the usual productivity and efficiency programs that I hope we've been demonstrating we're good at. Thank you very much. Next question.

The next question is from the line of Eric Caldwell with Baird.

Thanks. Good morning. I have a couple as well. First one, I think the number one inbound this morning is on your M&A spend in the quarter, obviously a much higher number than we were anticipating with the myriad deal sizing being known. I'm curious if you could address that in a couple of ways. One, the type of deals, nature of deals, number of deals, but also what impact you expect on a

revenue basis both in the fourth quarter as well as uh you know any thoughts on the the run rate of the companies that you've uh recently acquired thanks very much and I might have a follow-up as well okay uh so let me take this a lot of part of your question first for in the quarter um the contribution of MNA was minimal I mean maybe a little over a point. And that's the same basically for RMDS and for TAS. That's correct. In the fourth quarter, Nick, a little bit more than that?

Yeah, in the fourth quarter, total company were a little over a point and a half.

Yeah, a point and a half of contribution to our revenue growth. Now, Yeah, we had a big spend this year. It's going to be lumpy. We always say acquisitions is binary. It happens or it doesn't happen. I will note that we didn't spend very much last year. I think in the entire year we spent $177 million. um and um there are quarters where we spent uh 10 or 15 million dollars and this quarter uh and this year actually we spent quite a bit more money as you know the largest acquisitions we've done is simply the consolidation of our joint venture request um in the lab business and that was a 760 million dollar transaction we did in the second quarter uh so that represents uh really uh a very large portion, almost half of the spend today. In the quarter, we were very active. We actually closed only a handful of transactions. The two largest account for the vast majority, say almost 90%, you would say, or something like that, 80-90%. of the span. It's two transactions only. One is the Myriad RBM lab, which we had announced during our second quarter earnings, and it actually closed in the third quarter. It's a lab that performs sophisticated biomarker detection and testing. It supports early and late stage drug development in very specific therapeutic areas, oncology, CNS, and immunology. We also purchased DMZ, DMD is a leading provider of analytics and digital marketing solutions to healthcare professionals. It brings advanced tech-enabled analytics and insights for intelligent, omnichannel marketing. And we consider that acquisition to be a strategic asset. And, yes, it did come in with a lot of – it cost quite a bit. So these two transactions, again, is basically the bulk of the spend. You had a second question, right?

Yeah, just a clarification on the first one. So the last one, I think you said DMV, if I understood correctly. DMV, okay, got it. And then is that actually a CSMS segment deal, or is that a tech and analytics deal?

Yeah, it's a tech and analytics deal.

Okay. And then my follow-up is my typical burden on you to talk about COVID contributions in 3Q for revenue and bookings, specifically in R&Ds, but also other segments as necessary. If you could update us on the backlog of COVID work in total in R&Ds. And then talk about bookings in 3Q related to total COVID-related activity. It would be great.

Yeah. I mean, as we think our COVID work is obviously going to continue a little bit. There is a tail to it. But certainly on the TAS segment, it's a significant step down. We had signaled this before. The government-related COVID work is gradually going away, and certainly will start down dramatically in the fourth quarter and going forward. And we're just going to return once you eliminate the noise of all that happened last year. the TAS underlying organic growth rate is in the high single digits. You will remember TAS historically was in a mid single digit grower and in our investor conference in June 19, we said that TAS would accelerate to high single digits and that's where we've been most of the year. We've told you that when we reported prior quarters, that the TAS growth rate included significant COVID-related work, and excluding that, the growth rate was in the high single digits, and it remains so when you take out the noise of the compares, et cetera. On the RMDS, can you give us the numbers? Yeah, sure.

Look, first, we like to look at the contribution of COVID to the backlog. And if you strip out the mega vaccine trials, Eric, from the backlog of R&DS, it's less than 5% of the backlog. If you take out all COVID-related work, it's less than 10% of the R&DS backlog. And, you know, you were asking about the contribution of COVID to revenue, I think, two in the quarter. And, look, RMDS had very strong growth, even accepting the COVID-related work. You know, if you take out the large, fast-burning COVID work, you were in the high 20s. for R&DS revenue growth. And even if you take out all COVID-related work, you were still strong teens growth. So, you know, COVID did contribute, of course, and the work will trail down over time. But the underlying business in other therapeutic areas is very strong and ramping up as we go forward in R&DS. Thanks very much, guys.

Your next question is from the line of Jack Meehan with Nefron Research.

Thanks. Wanted to continue on the COVID conversation, but looking at the TAS business, you know, I think you referenced when talking about the fourth quarter guidance some headwinds versus the prior year, but could you just maybe talk a little bit about how you feel like the longer-term durability of COVID work in the segment, just your thoughts around that?

Yeah, again, there's no headwind in the fourth quarter for TAL. The growth rate is slower simply because it's a math question. We're comparing last year's fourth quarter, which included the COVID work and a bunch of noise with the fourth quarter here, which eliminates that noise. Again, when you eliminate all of that, The underlying organic growth rate for tile is in high single digits in the four core. So there is no headwind in the underlying business. And we expect that trend and momentum to continue. We will, as you know, provide, we generally provide guidance on the year. concurrent with the release of our fourth quarter earnings. Last year, because it was such an unusual year, we decided to give guidance for 2021 concurrent with the release of our third quarter earnings. This year, we plan to do it at our November investor conference, which is just two weeks away.

Great. And I don't want to steal any thunder from the investor day, you know, a few weeks from now, but I was curious if you could talk a little bit about some of the puts and takes for 2022. You know, the funding environment, as you referenced, seems very strong. You know, are there any takes that you would consider? And then the one thing that stands out to me is pass-throughs. You know, they've obviously been elevated this year.

um just any color around how that might phase in the next year would be helpful yeah so i mean look it's always important to to put things in context and look at the uh at the longer term trends as you're asking um and if you go back to um june 19 we gave a three-year set of targets for revenue, profit, EPS, capital deployment, leverage, etc. Now, no one could have predicted then that six months later we would be starting the pandemic and we would have such disruption across the world for all businesses and including for ours. But And I think people like to look at 19 to 21 to kind of try to eliminate COVID. I don't think that's fair because the whole COVID effect is not gone yet because you still have these disruptions that I just talked about. I think it's important to look at the three-year 19 to 22 timeframe. And if you go back to the targets we gave, we certainly are running ahead, actually well ahead of the growth rates we predicted for 2022. We are ahead of that. A little bit of this is because of COVID and the pass-throughs that you just referred to, but even if you strip that out, we're still ahead on every single one of the metrics. Now, I don't know if you were at that conference, but as you're doing now and as your colleagues were doing, trying to push me for even more precision on what the numbers would be, I said then that I was hoping to exit 2022 at a 10% growth rate for the company. Now, I've said before, earlier this year, that we reached our end of 2022 target in 2021. And I believe that that momentum will continue into 2022. So that's all I can say, and I have to wait for more precision in three weeks. But I certainly, sitting here, feel very, very confident that we will certainly exceed those numbers that we did three years ago and set the stage for further acceleration beyond.

Great. Thank you.

Your next question is from the line of Shlomo Rosenbaum with Steeple.

Hi, good morning. Thank you for taking my questions. Ari, can you talk about where you are in general with the OCE implementations, particularly with like Roche and AstraZeneca? Have you gotten to the point where the implementations are not a significant drag on the margins that you have to offset in other areas? And just where are you seeing the business progress in terms of hitting kind of a steady state of revenue or revenue exceeding the cost to implement?

I mean, you bring up a good point. Implementations are very costly, and because we have a large number of wins, and I referenced an additional 10 new wins, so every time you win a new award, again, you have to implement. So it's not like when you are behind the curve of implementation and you start generating the license revenue, you still have to implement the new one that you sold and we're happy with it. so we're not past that uh you know headwind if you will in terms of of the implementation cost that's a significant drag and we're not seeing yet we haven't passed if you with that inflection point where you've now essentially plateaued um your market penetration and you're essentially sitting tight and and collecting license revenue you know from all these installations we're not there you know, you're not going to get it.

Okay. And then just maybe this one's for Ron. The free cash flow was incredibly strong. You know, something, you know, there's more this year, 33% more than you had all of last year, which was, I think, a record quarter. Can you talk about what's going on? There was a significant increase in unearned revenue and some other working capital changes. And how should we be thinking about this on a go forward basis? Obviously, very healthy numbers. Is this something that you can keep up or is it more adjusting and catching up on some of the working capital items?

Well, Sean, we've made a really concerted effort internally here to improve our processes around receivables, which, of course, is one of our largest classes of assets. We don't have inventory like you would in a manufacturing firm. Receivables are really where we have a lot of our assets other than our deferred software investments. And that's been – our efforts have been on several fronts. First off is collecting on time. We had a – you know, go back a little while, we had a large amount of overdue receivables, and that's just kind of focused to go and collect what's due from us. You know, the next is billing on time. I mean, we had a large amount of unbilled receivables. And that comes down to internal processes about billing more quickly in a more timely fashion so we get paid in a more timely fashion. And, of course, the third that you mentioned is the deferred revenue, the customer advances that we get. Again, made an effort internally to negotiate contracts with our customers so we get paid more up front, so we're not out of pocket. And this has helped substantially. And I expect all three of those to continue to be a driver of strong cash flow in the future. Now, of course, having said that, cash flow is lumpy. Quarter to quarter, it's difficult to predict. And you do get instances where you'll get an unusual amount of advances because some of the work you're doing that will burn out off over time and then rebuild up. So I would urge you not to focus too much on the quarter to quarter. But yes, what you're saying is that fundamentally, we've improved our collections processes. and improved our underlying free cash flow generation as a result.

Yeah, I mean, if I just might add to that, we're very pleased with the performance, but let's be honest. You know, this was a bad point for us, and I think some of you have pulled that out, you know, the past three years or so. Our cash flow performance was simply very poor. So the fact that we are now performing very well, you know, is not an unusual thing. I mean, I think not too long ago, in 2018, we generated just barely over $600 million of free cash flow for the entire year. And here we are, three quarters into the year, we've already generated three times that number. Obviously, we are a much bigger company and so on, but But, look, our performance was just not good. And we said that, and it was on us, and we worked on it, and we continue to pay attention and have the right metrics and the right incentives and the team focus on it. And, as always, when you shine the light on something, it improves. And that's what happened here. And where we are now is the normal, not, you know, unusual. All right. Thank you.

Your next question is from the line of Dave Lindley with Jefferies.

Hi, thanks. Good morning. Good morning, folks. Appreciate you taking my question. I wanted to follow up on, I believe, a John Krieger question around DCT. He asked around operational. Ari, I wanted to ask around financial. It seems like you now have a pretty substantial number of trials going where you're running pretty fully on your DCP platform. I'm wondering if you could relate to us how that changes the dollar value of a trial, and does that give you the opportunity to garner more margin in that trial because of the technology-enabled efficiency?

Yeah, I mean, look, there's a high degree of interest from clients, okay, on how to operationalize VCT, and it's not like it's going to overwhelm and all of a sudden become 100% overnight. As I said, large pharma in particular is experimenting. A lot of trials are using one component or the other, so it's going to take time. So this is not next year or the day after that we're going to have to face the issue that you're raising. In our experience, customers are struggling with how to make various point solutions fit together. So we are actually being very aggressive here. We want to move to DCT. We've said this since the merger five years ago, we want to accelerate and not and not slow down technology introduction and changing the model. Now, obviously, the question you ask is a question people asked of us many years ago, which is, as you seek to replace labor in a model where pricing is largely based on labor inputs, then aren't you lowering the value of the trials and etc. What are the implications of the market? We don't believe so. As you know, we have a long-run effort to switch pricing to value and deliverables and outputs. That's number one, and that has made substantial progress. Our clients I'm not looking at saving a couple of pennies here or there. They're looking at getting the answers that they want faster, more efficiently, with less error, and with higher quality. And they are willing to pay a premium for that. Now, they're not going to pay more than what they were paying before, but they're not going to pay less than what they were paying before. And so, you know, now the margin implication is correct over time. The more we deploy technology, the less we need people, the more, you know, there's going to be margin accretion. But again, this is going to take time. There are also new delivery roles, which offset some of the reduced CRA visit activity. You know, so I think it's too early to comment on the exact margin impact for this overall. We are monitoring. We do not anticipate this to disrupt our margin performance. You know, RMDS is a very long cycle business. We have, I mentioned, 89 fully decentralized trials ongoing that we want. But we're working on, if you look at, as I said, just under maybe 900 or so full-service trials. So it's a fraction of that. As you look at the total trials we're involved in, it's over 2,500 clinical trials that we're involved in globally. So it'll take some time to penetrate. It's a slow-moving business. But it's a good point. We are totally focused on it. We do not anticipate a value deterioration. We do anticipate a margin accretion over the long term.

Great. If I could ask a second follow-up around a question on COVID, it seems like a lot of focus on how much revenue now and how much in backlog now, it seems equally important to me, if not more so, to focus on how that will phase out. And I think you've made comments in the past that you see projects booked out through 22 and maybe even into 23, would it be appropriate to call the COVID contribution kind of a soft landing, so to speak, that it's not going to drop off, it's just going to slowly taper over time? Is that the right way to think about it?

On the R&D business, absolutely. No question. What you said is exactly what I would say. It's a soft landing, 22, 23, and it frankly will get lost in the rounding. Very helpful. Thank you. Unless, of course, God forbid, there's another variant or another COVID or another. But right now, as we see, based on what we know today, it's a soft landing. We get lost in the rounding by 23.

The last question is from the line of Dan Leonard with Wells Fargo.

Thank you, and good morning. Can you comment on trial site operations? Are there any continued bottlenecks you flag, or is site activity normalizing?

Yeah, look, the site accessibility numbers remain around 80% or so. But, look, we've managed to – work around that and operate it close to normal. And, you know, not all sites are equal. The larger sites are open. And that hasn't been an issue for us. We've seen site startup and patient recruitment at near pre-pandemic levels, not quite, but near pre-pandemic levels. The patient visits are still lagging a little bit, just gradually coming back. And so when we look at our overall operations, we're not totally back to pre-pandemic level yet, and we'll expect a gradual improvement over time back to pre-pandemic level. But it really hasn't been a major issue for our operations. As Ari mentioned in his opening remarks, we've learned how to manage through and around the issue. Yeah.

I mean, you know, the members of the I got the numbers here in detail, but basically it's 80% or so across all of those metrics. A little bit higher for site startup, which is more, again, a percentage of 2019 base levels. So site startup is a little higher, is that more 85% or thereabouts globally. The bottom line is these metrics that we see provide confidence that the non-COVID trial pipeline is not only being awarded, as you can see from the strong new bookings, but it's also starting to be delivered. And the sites are enrolling, the patients are enrolling, and the patient visits are ongoing. So I think there hasn't been any major change from this as a result of the new variants or anything like that.

And as a follow-up, Ari, can you comment on perceived market share trends and R&DS in the quarter? You've been pretty open about the various strategic actions by your competitors potentially allowing an opportunity for share gain.

Look, it's hard to look at market share in a given quarter. Okay, slumpy trial can be awarded, you know, the last day of the quarter or the first day of the following. You know, I wouldn't look at, we like, as we always say, look, we were defeated and, you know, gave you quarterly book-to-bill ratios. But really, we believe we should focus on longer-term book-to-bill ratios because it's slumpy. and focus also on business from the backlog over the next 12 months. Now, if you look at our competitors, there's been a lot of disruption. And yeah, I mean, we've had conversations with customers, but just as you don't win a new customer overnight, you don't throw out a CRO overnight, you're in the middle of trials, right? So some of those mergers will have an impact on market share. I think it's favorable to us. You know, maybe we'll remain the last CRO standing. I don't know. But we feel that, you know, and we know from experience what a merger and a large acquisition does to, you know, to the underlying business. There's a lot of disruptions. There is... people lose their jobs people who don't like the new arrangement and that's just life and the result of that is some market share we had that problem after our merger in 16. let's be honest about it and we had some some some some market share issues which we rebounded once we put together the company and integrated i think we are the future is very bright for us we continue to uh gain new customers And, you know, the biotech environment in particular is extremely, extremely hot right now. We are gaining new clients. In Europe, we're making inbounds with customers we never had before. In Asia as well, the teams are extremely energized, and I think we are on a on a winning momentum here. And no doubt that when we look back, we will see that our market share has improved.

Appreciate all that context. Thank you.

This is going to be our last question of the day.

And your last question comes from the line of Patrick Donnelly with Citi.

Hey, thanks for fitting me in, guys. Ari, maybe to follow up on that last question, you talked a little bit about kind of all the murders going on in the space, again, headcount disruption. Following up on one of the earlier questions in terms of labor costs, does that position you guys better in terms of being able to acquire some talent that got rattled around during some of these mergers, kind of being a stable ship there and kind of grab some people, maybe at not quite the inflationary costs you're seeing in the labor side? And then secondarily to that, maybe with a focus on R&DS. How much can you pass some of these price increases on to customers? I know, you know, full-service contracts and backlog are typically tough to adjust, but just wondering, you know, how much you can pass on in terms of some of the price pressure you're getting there.

Okay. Well, on the personnel question, you've got to differentiate between the, you know, executive management leadership level and then the the actual field force, the CRAs, etc. So on the first group in general, the first category you'll get, there is an opportunity to bring in talent that somehow is dissatisfied with where they are and that may occur. And it has happened already in a few cases. But again, these are small numbers. On the CRAs and the project leads and so on, that's much more difficult because it's driven by the book of business and by the execution that our competitors are also in the midst of trials and they need those people as much as we do. There's just an inflation on wages, which is the result of all the factors we talked about before. the mergers don't affect, at least immediately, the CRAs and the people in the field. Your other question had to do with... With pricing, if they're willing to pass a long cost. Yeah. So as you noted yourself in your question, it's very hard. You can't We sold projects with certain assumptions, and there are some escalations and some factors built into those contracts, so that will be reflected. But by and large, the pricing was set based on different assumptions, and when you have higher costs, then you have to absorb that. But then as we move forward, obviously the pricing is affected. You know, there's no magic here. It's all going to get passed on, and there's no secret. But it's going to lag because of the nature of our business, certainly in the R&D business.

Right. And, of course, on the TAS side of the business, short-cycle business, a greater ability to pass along costs increases. Right. But there's less labor. So that's less labor. That's correct.

Okay. Thank you, guys. Thank you very much.

Thank you, everyone, for joining us today. We look forward to seeing everyone on our Investor Day in a few weeks. If you have any other follow-up questions, feel free to reach out. We're happy to answer them. Thanks for joining today.

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