Constantine Davides

Constantine Davides asked about Progyny's expectations for CapEx in 2026, following a significant step-up in 2025, and also sought color on the operating cash flow conversion for 2026.

Answer

Mark Livingston, CFO of Progyny, stated that CapEx for 2026 is anticipated to step up but not double, reflecting the full-year impact of platform and product investments that ramped up in 2025. For cash flow conversion, he noted a significant reduction in outstanding DSOs and suggested that a 75% conversion rate from adjusted EBITDA to cash flow is a more realistic metric going forward, after the company has exceeded it for the past couple of years.

Constantine Davides asked about Progyny's CapEx expectations for 2026, specifically if another step-up or a drop-off is anticipated, and sought color on the operating cash flow conversion for 2026. Davides also inquired about learnings regarding targeting and marketing newer solutions like maternal health and menopause, and where the most success has been seen to date.

Answer

Mark Livingston (CFO) expects a CapEx step-up in 2026, but not a doubling, reflecting the full-year impact of 2025 investments. He indicated that a 75% conversion rate from adjusted EBITDA to cash flow is a more appropriate metric going forward, given limits on DSO reduction. Pete Anevski (CEO) explained that for expanded products, the sales force is trained, marketing is done to clients, subject matter experts are utilized, and individual members are marketed to in conjunction with client partners.

Constantine Davides inquired about the market opportunity for the Benefit Bump acquisition and its financial scale, and also asked how channel partnerships are impacting sales activity.

Answer

CEO Peter Anevski described Benefit Bump as a complementary service for all employers with family-building benefits but declined to provide financial details. President Michael Sturmer explained that partnerships are a fundamental go-to-market channel that adds credibility and eases contracting, viewing the new health plan partnerships as a beneficial long-term investment.

Constantine Davides asked about the hospital alliances, specifically regarding the outpatient rates, potential profit headwinds in early 2026 during the stand-up phase, and whether these relationships are exclusive. He also sought more details on the new service offerings and capabilities gained from the recent Injury Prevention (IIP) acquisition. Finally, he inquired about the company's M&A pipeline preference between PT and IIP segments, and the typical size of PT acquisition opportunities.

Answer

Chris Reading (Chairman and CEO, U.S. Physical Therapy) confirmed there would be no profit headwind during the stand-up of hospital alliances. He described the rates as 'hospital outpatient rates,' which are meaningfully better than traditional outpatient rates, though varying by market, and confirmed these would be exclusive partnerships. He elaborated on the new IIP acquisition in New York, which adds different testing capabilities for infrastructure projects, including mobile facilities for OSHA/DOT testing, exposure testing, drug/alcohol testing, physicals, and blood work. Regarding M&A, he stated he is agnostic but noted IIP has better organic growth and fewer targets. He confirmed continued focus on PT, seeking opportunities like Metro, especially where hospital partnerships can be integrated, and mentioned that smaller clinics can be immediately accretive, particularly with hospital relationships.

Constantine Davides inquired about the nature of rates for the new hospital alliances, potential profit headwinds during their setup, their exclusivity, and how these rates compare to the current blended average. He also asked for more details on the new service offerings from the recent Injury Prevention (IIP) acquisition and the company's M&A pipeline preference between PT and IIP segments.

Answer

Chris Reading, Chairman and CEO, clarified that there would be no profit headwind during the setup of the hospital alliances, and the rates would be comparable to hospital outpatient rates, which are meaningfully better than the company's current blended average. He confirmed these are exclusive partnerships. Regarding IIP, he explained that the recent acquisition provides new testing capabilities, including blood work, OSHA, DOT, drug and alcohol testing, and physicals, particularly for infrastructure projects, building on existing ergonomic and industrial sports medicine services. For M&A, Chris Reading expressed agnosticism but noted IIP's better organic growth, despite fewer acquisition targets. He indicated a continued focus on both larger, Metro-like PT opportunities, especially in markets where hospital partnerships can be leveraged, and smaller, accretive clinics.

Constantine Davides asked how the company delivers home care profitably, whether the trend of onshoring manufacturing could benefit the IIP business, if there are cross-selling benefits from IIP to outpatient clinics, and if the company is discussing a 'PT as gatekeeper' model with commercial payers.

Answer

CEO Christopher Reading explained that home care is profitable because it is paid on a per-visit basis without the overhead costs of a physical clinic, making it margin-accretive. He viewed manufacturing onshoring as a long-term positive but theoretical for now. President Eric Williams noted that cross-selling from IIP to outpatient is in "early innings" but showing promise through new government contracts and by leveraging existing PT-employer relationships. Reading added that while direct talks with commercial payers on a 'gatekeeper' model are nascent, the successful Medicare-based EQIP program in Maryland provides powerful data to advance those discussions.

Constantine Davides asked about the company's experience with the Metro acquisition, its view of the New York market, and plans for de novo growth there. He also inquired about the broader opportunity in home-based therapy and asked for the workers' compensation mix and the drivers of its recent growth.

Answer

COO East Eric Williams described the Metro deal as a strategic entry to the Northeast with significant de novo and tuck-in potential. He and CEO Christopher Reading identified home-based therapy, which is 20% of Metro's business, as a key expansion opportunity for the entire company. Williams attributed the strong workers' comp growth to tripling payer relationships and focused training. CFO Carey Hendrickson stated the workers' comp mix was 10% in Q4.

Constantine Davides asked about the interoperability features of myClinicalExchange that are most resonating with customers and prospects, and sought clarification on the remaining legacy product revenue, its decline, and the company's strategy for sunsetting these applications.

Answer

Robert A. Frist Jr., CEO and Chairman, detailed myClinicalExchange's growth and provided an example of interoperability: a widget connecting student rotation data to managers via the MyTeam application to enhance recruitment. He quantified legacy revenue at approximately 10% of total revenues (a little over $30 million), noting it's desired revenue but not growing. Frist mentioned successful migrations of large customers like UPMC and Sutter from legacy to CredentialStream and indicated that sunsetting decisions for certain products would be evaluated in the coming years.

Constantine Davides asked about the interoperability features of myClinicalExchange, specifically which integrations with the broader hStream Platform are most impactful for customers. He also inquired about the remaining legacy revenue on the platform, its current decline rate, and when HealthStream might consider a sunsetting strategy for these older products.

Answer

Robert A. Frist Jr., CEO and Chairman of HealthStream, highlighted myClinicalExchange's growth since acquisition and provided an example of interoperability: connecting student rotation data to hospital managers via the MyTeam application to enhance recruiting. He quantified legacy revenues at approximately 10% of total revenues (over $30 million), noting they are desired but not growing. He stated that while two large credentialing customers (UPMC Health System and Sutter Health) successfully migrated from legacy products, the company has not yet set official sunset dates for the remaining legacy applications but will evaluate this over the next few years.

Constantine Davides asked for an update on the number of claimed hStream IDs, whether the platform initiative will primarily impact top-line growth or margins, and if ShiftWizard's growth is now eclipsing legacy product attrition.

Answer

CEO Robert Frist stated the primary goal of the hStream platform is to accelerate top-line growth by enabling faster new product development and better cross-selling opportunities. He did not provide a specific number for claimed hStream IDs but suggested it could be a topic for a future Investor Day. He also indicated that a detailed analysis of the crossover point where ShiftWizard's growth surpasses legacy attrition would be suitable for a future investor event.

Constantine Davides asked about AMN Healthcare's cash flow expectations for the year, particularly considering the outsized strike benefit in Q1, and the expected CapEx level for 2026. He also inquired about the pipeline for new business in Nurse and Allied, specifically the volume of opportunities in 2026 compared to last year and any notable trends.

Answer

CFO Brian Scott projected CapEx in the low-to-mid $40 million range for 2026, with a focus on enhancements and AI initiatives. He noted that while 2025 saw very high free cash flow conversion due to favorable working capital, 2026 might experience a working capital drag, but still expects healthy free cash flow. He anticipates the net leverage ratio to fall below 3x on an LTM basis in Q1. CEO Cary Grace described a healthy, broad-based pipeline for Nurse and Allied, with wins in MSP and vendor-neutral segments expected to come online, alongside momentum in direct opportunities and cross-selling to existing clients.

Constantine Davides of Citizens asked about AMN Healthcare's cash flow expectations for 2026, specifically the impact of the outsized Q1 strike revenue and the appropriate level for capital expenditures. He also inquired about the pipeline for new business in Nurse and Allied, including the volume of opportunities and any notable trends compared to the previous year.

Answer

Brian Scott, Chief Financial and Operating Officer, projected 2026 CapEx in the low-to-mid $40 million range, allowing for continued investment in enhancements and AI. He noted that while 2025 saw very high free cash flow conversion due to favorable working capital, 2026 would likely have a working capital drag, but still healthy free cash flow, aiming for a net leverage ratio below 3x in Q1. Cary Grace, President and CEO, described a healthy and broad-based sales pipeline for Nurse and Allied, with recent wins in MSP and vendor-neutral segments, momentum in direct opportunities, and continued cross-selling to existing clients.

Constantine Davides asked for the international business run rate, details on the '10 solutions per top client' metric, and the stickiness of clients with more solutions.

Answer

Executive Randle Reece specified the international business is expected to be $180M in Q4, with the gross margin headwind tapering significantly after Q1 2025. President and CEO Cary Grace explained the 'solutions' metric refers to major service categories, with the average for top clients rising from 9 to 10. She identified Locums programs and RCM as key penetration opportunities and confirmed that clients with more solutions are inherently more sticky, fostering broader relationships.

Constantine Davides from Citizens JMP Securities asked for an update on the M&A pipeline, particularly regarding larger clinical assets, and also inquired about other states being monitored for potential favorable rate movements.

Answer

Chairman & CEO Dirk Allison explained that the M&A focus is on smaller, strategic deals like the recent Helping Hands acquisition, as high valuations in hospice and uncertainty from the proposed home health rule have delayed larger clinical transactions. EVP & CFO Brian Poff identified New Mexico and Pennsylvania as two states they are watching closely for potential personal care rate increases in the next legislative cycle.

Constantine Davides from Citizens Bank asked about the origin of the three new Personal Care locations added in the quarter. He also requested an update on the company's technology initiatives, specifically the in-house caregiver application and the broader rollout of Homecare Homebase.

Answer

W. Bickham, President and COO, clarified that the new locations came from a small tuck-in acquisition in Michigan. He detailed the successful rollout of their caregiver app in Illinois and its current deployment in New Mexico. Regarding Homecare Homebase for PCS, he stated it remains in the pilot phase, with a potential enterprise-wide rollout targeted for late 2025 or early 2026.

Constantine Davides of Citizens JMP questioned the M&A strategy in Texas given Addus's large presence there, asked about the potential for a rate increase in the state, and inquired about any cost savings from the corporate office lease write-off.

Answer

CEO R. Allison explained that despite being the largest provider in Texas, the market remains highly fragmented, offering significant growth opportunities. President and COO W. Bickham noted that a proposal to increase personal care funding is currently with the Texas legislature, but the outcome is uncertain. CFO Brian Poff clarified that the lease write-off will not result in P&L savings in 2025, as the expense will be flat.

Constantine Davides asked for an update on the expected full-year financial impact from Stellara biosimilars, whether operating margins for acute and chronic therapies remain comparable, and if the M&A focus is still on the core business.

Answer

CFO Mike Shapiro estimated the full-year Stellara impact would be at the higher end of the previously guided $60-70 million range and confirmed that while gross profit dollars are the focus, acute margins are generally higher than chronic. CEO John Rademacher stated the M&A strategy remains disciplined and focused on core capabilities and enablement areas like nursing.

Constantine Davides asked how the dialogue with health plans has evolved over the past year and what innovative strategies progressive payers are implementing for infusion benefits to manage costs.

Answer

CEO John Rademacher explained that due to shifting market dynamics and payer focus on medical loss ratios, Option Care Health is increasingly seen as a key partner to reduce total cost of care by transitioning patients from expensive inpatient settings. He highlighted that innovative payers are actively promoting site-of-care initiatives, steering members toward lower-cost settings like the home or Option Care Health's infusion centers, and the company is partnering with them to identify and transition these patients.

Constantine Davides from Citizens JMP Securities asked for more detail on the two new 'state-of-the-art' pharmacies and whether they signal a broader footprint rationalization. He also requested an update on infusion suite utilization and the extent to which payers are pushing for site-of-care shifts.

Answer

CEO John Rademacher described the new pharmacies in New York and Tampa as having advanced clean rooms, improved workflow, and expanded capacity, enhancing both local responsiveness and network resilience. CFO Michael Shapiro reported that over one-third of nursing visits now occur in infusion suites, a significant increase driving over 20% nurse productivity. Rademacher added that there is a noticeable uptick in payer interest and the implementation of site-of-care programs to manage total healthcare costs.

Constantine Davides followed up on STELARA, asking how the current pricing negotiations deviate from historical precedent and whether the economics could improve by year-end. He also requested the revenue split between chronic and acute therapies for the quarter.

Answer

CFO Michael Shapiro explained that the situation is atypical because the manufacturer intends to dramatically reduce the acquisition spread, whereas historically, pricing changes were felt through the reference price, not the spread. CEO John Rademacher added this is unprecedented as the spread is compressing early, not following a typical 'glide down.' Shapiro also provided the revenue split as approximately 75% chronic and 25% acute.

Constantine Davides of Citizens JMP Securities asked for clarification on the timing of a $2 million services cancellation impact and whether AI initiatives would require higher R&D spending.

Answer

CEO Shawn O’Connor explained the canceled project had a minor impact on Q3 but was expected to contribute more significantly in Q4. Regarding R&D, he stated that while opportunities are significant, the company will balance R&D investments with its goal of improving adjusted EBITDA margins.

Constantine Davides of Citizens JMP asked if the projected Q3 to Q4 step-up in revenue would also apply to EBITDA. He also inquired about the reason for the sharp increase in sales and marketing expenses and whether achieving the long-term 35-40% margin target depends on a macro recovery.

Answer

Executive Shawn O'Connor confirmed that since the expense load is linear, the back-half revenue increase will flow through to EBITDA. Executive William Frederick attributed the Q2 sales and marketing spike to the timing of industry conferences, not increased headcount. O'Connor then clarified that reaching the 35-40% margin target is an operational objective driven more by cost management, such as matching capacity and leveraging AI in services, rather than being solely dependent on revenue growth or a macro inflection.

Constantine Davides of Citizens JMP Securities asked about the primary growth drivers for the CDB (Consumer-Directed Benefits) accounts and the sustainability of this growth. He also requested an update on the HPA (Health Payment Account) initiatives.

Answer

CFO James Lucania explained that CDB growth is coming from the core bundled offering, with HRAs remaining strong and FSAs now contributing positively after being a drag. President and CEO Scott Cutler added that the HPA product is seeing good uptake with large enterprise clients, as it helps remove the high-deductible barrier and strategically drives adoption of HSA-qualified health plans.

Constantine Davides requested more color on the sales pipeline, including its size, win rates, and average deal size. He also asked about the terms of subscription deals, specifically if they are multi-year, and questioned whether the high end of the revenue guidance correlates with the high end of the EBITDA guidance.

Answer

CEO Stephen Silvestro described the pipeline as growing with an improved conversion ratio, particularly for data components, but declined to give deal size specifics. He noted subscription deals are currently 1-year evergreens, as multi-year contracts are difficult in pharma. CFO Edward Stelmakh explained the guidance range is primarily hedged on gross margin and product mix, not on variable operating expenses.

Constantine Davides questioned the expected timeframe to achieve 'Rule of 40' status, the balance between revenue growth and margin expansion to get there, and any notable quarterly seasonality for 2025.

Answer

CFO Edward Stelmakh projected a 3- to 5-year journey to reach the Rule of 40, driven by a combination of top-line growth and significant operating leverage that expands the EBITDA margin. Executive Andrew D'Silva outlined the expected revenue seasonality for 2025: Q1 at 15-20%, Q2 at 20-23%, Q3 at 25-30%, and Q4 at 30-40%, advising to follow historical trends for margins.

Constantine Davides asked about the competitive landscape for the self-service business and whether additional investment is needed to scale it. He also requested clarification on the five new DAAP deals, specifically if they were new or renewals, and what trends are being observed with earlier DAAP client renewals.

Answer

CEO William Febbo and executive Stephen Silvestro stated that the necessary investments in team, technology, and data platforms for the self-service business have already been made. Mr. Febbo noted their competitive advantage comes from combining dynamic, compliant audiences with an HCP component, which most DTC competitors lack. Mr. Silvestro added that the number of DAAP deals has doubled year-over-year, encompassing both new deals and renewals, and the renewal rate for DAAP is very high, reflecting its value.

Constantine Davides of Citizens JMP Securities asked for more details on Evolent's AI and automation investments, their impact on efficiencies, and the company's updated expectations for spending and impact through the end of the year.

Answer

Executive Seth Blackley reiterated that AI and automation represent a significant opportunity, expected to be a material contributor by 2026. He highlighted two benefits: increased efficiency in the review process and full automation for auto-authorizations. He emphasized that AI is used exclusively for approvals, never for denying care.

Inquired about the motivations for the IMS practice to partner with Privia, what specific aspects of Privia's platform were attractive to them, and whether IMS is transitioning away from a previous enablement partner.

Answer

The executive highlighted that Privia's comprehensive model, which supports all specialties and payers while allowing physicians to maintain clinical autonomy, was key. IMS, being fiercely independent, found this alignment crucial. While IMS did have other enablement partners, Privia's all-encompassing solution will be evaluated against those existing contracts over time.

Constantine Davides of Citizens JMP asked about the role of technology, specifically the athenahealth backbone, as a key differentiator and enabler of Privia's success and scalability compared to competing medical group strategies.

Answer

CEO Parth Mehrotra agreed that technology is a factor but emphasized the broader unique model. He described Privia's key differentiator as the combination of creating integrated medical groups on a single tech platform with a unified governance structure, and a fully embedded risk-bearing entity. This deep integration into practice workflows, he argued, is what drives superior performance and is not easily replicated by others.

Constantine Davides requested an update on the scaling and engagement of Certara Cloud and inquired about the progress of migrating the Phoenix software user base to a hosted solution.

Answer

CEO William Feehery expressed satisfaction with the adoption of Certara Cloud, which is integrated into the renewal process for products like Phoenix and exposes customers to the full software portfolio. He characterized the migration of Phoenix users to a hosted solution as being in the 'earlier innings' but expects the adoption rate to increase as ongoing R&D investments add more functionality to the hosted product this year.

Constantine Davides asked about the expected quarterly cadence for revenue and margins in 2025, particularly concerning Chemaxon. He also questioned if the Q4 rebound in regulatory services alters the company's thinking on its strategic review of the business.

Answer

CFO John Gallagher advised that the historical pattern of second-half weighted revenue is expected to continue in 2025. Regarding the regulatory business, he acknowledged the strong Q4 performance driven by Tier 1 customers would positively impact 2025 revenue but declined to comment on how it affects the ongoing strategic review process.

Constantine Davides asked about the key drivers behind the growth and unusual seasonal strength in the Locums business, and inquired about its margin profile and scalability.

Answer

CEO John Martins attributed the Locums strength to sustained high demand for revenue-generating hospital roles like anesthesiology and CRNAs. CFO William Burns noted that of the 10% year-over-year Q3 growth, 60% was volume-driven. He stated the segment's margin is a few hundred basis points above the consolidated average. Martins affirmed that the business currently has the capacity to support further growth and that they hire proactively.

Constantine Davides asked for commentary on conflicting industry data for Locums, the drivers behind Cross Country's growth and unusual Q4 seasonal strength, and the segment's margin targets and scalability.

Answer

CEO John Martins attributed the Locums strength to continued high demand for revenue-generating roles like anesthesiology and CRNAs, as hospital census remains up. CFO William Burns noted Q3's 10% YoY growth was 60% volume-driven. Regarding margins, Burns stated they are a couple of hundred basis points above the consolidated average. Martins affirmed the business has the capacity to continue growing and that they hire proactively to meet demand.

Asked about the full-year cash flow outlook and the company's M&A strategy, including their appetite for deals and preferred target areas.

Answer

Executives expect cash flow to normalize to standard EBITDA conversion rates as DSO improvements are largely complete. Their capital allocation remains balanced between buybacks, tech investment, and M&A. The M&A focus is on diversifying into areas like allied, Locums, education, and technology, rather than scaling the core nursing business.

Constantine Davides asked for the outlook on cash flow following a strong quarter and improved DSO. He also inquired about the M&A strategy, specifically whether the focus is on scaling the core business or diversifying.

Answer

CFO William Burns explained that with DSO now normalized, future cash flow will be driven more by EBITDA conversion than working capital changes. CEO John Martins outlined a balanced capital allocation strategy including buybacks and tech investment. For M&A, he confirmed the focus is on diversifying into Allied, Locums, Education, and technology to complement existing lines, rather than simply scaling the core nursing business.

Constantine Davides of JMP Securities asked for an outlook on full-year cash flow following a strong Q2. He also questioned if the confidence in a market inflection changes the company's capital deployment strategy for M&A, and what types of acquisitions would be prioritized.

Answer

CFO William Burns explained that with Days Sales Outstanding (DSO) now near its normalized level, future cash flow will be more directly tied to EBITDA conversion. CEO John Martins stated the company will maintain its balanced capital allocation strategy of share repurchases, technology investments, and disciplined M&A. For acquisitions, he noted a preference for deals that diversify the portfolio, such as in Allied, Locums, Education, and complementary technologies, rather than scaling the core travel nursing business.

Constantine Davides from Citizens JMP asked for an explanation of the specific challenges in the per diem (local) staffing business, which saw a significant sequential decline. He also inquired about the outlook for this business embedded in the Q2 guidance.

Answer

CEO John Martins attributed the decline to a pullback in acute care settings, similar to travel nursing, and a significant drop in utilization at skilled nursing facilities as government funding dried up. CFO Bill Burns clarified that the Q2 outlook assumes the local business will be 'essentially flat sequentially,' as the sharp deterioration has leveled off.

Asked for specifics on revenue from a recent labor disruption, details on technology spending for 2023 and 2024, and an update on the migration of MSPs to the Intellify platform.

Answer

The Q4 labor disruption contributed $3-4 million in revenue, with no similar events anticipated for Q1. The ~$20 million in 2023 tech spend was a combined figure (capitalized and expensed), and a similar amount is planned for 2024. The migration of MSPs to Intellify is about 80% complete and is expected to be fully finished by the end of the first half of 2024.