iRhythm - Earnings Call - Q4 2019
February 27, 2020
Transcript
Speaker 0
Ladies and gentlemen, thank you for standing by and welcome to the iRhythm Technologies Incorporated Fourth Quarter twenty nineteen Earnings Conference Call. At this time, all participants are in a listen only mode. After the speaker presentation, there will be a question and answer session. Please be advised that today's conference is being recorded. Would now like to hand the conference over to your speaker, Leigh Salvo, Investor Relations.
Please go ahead.
Speaker 1
Thank you, Sydney, and thank you all for participating in today's call. Joining me are Kevin King, CEO Matthew Garrett, CFO and Dan Wilson, EVP, Strategy, Corporate Development and Investor Relations. Earlier today, iRhythm released financial results for the fourth quarter and full year December 3139. A copy of the press release is available on the company's website. Before we begin, I'd like to remind you that management will make statements during this call that include forward looking statements within the meaning of federal securities laws, which are made pursuant to the Safe Harbor provisions of the Private Securities Litigation Reform Act of 1995.
Any statements contained in this call that are not statements of historical fact should be deemed to be forward looking statements. All forward looking statements, including without limitation, those statements related to market expansion and penetration, productivity improvements, reimbursement, release of clinical data, our examination of operating trends and our future financial expectations, which includes expectations for hiring, growth in our organization and reimbursement and guidance for revenue, gross margins, profitability and operating expenses in 2020 are based upon our current estimates and various assumptions. These statements involve material risks and uncertainties that could actual results or events to materially differ from those anticipated or implied by these forward looking statements. Accordingly, you should not place undue reliance on these statements. For a list and description of the risks and uncertainties associated with our business, please refer to the Risk Factors section of our most recent annual and quarterly reports on Form 10 ks and Form 10 Q, respectively, with the SEC.
This conference call contains time sensitive information and is accurate only as of the live broadcast today, 02/27/2020. IRhythm disclaims any intention or obligation, except as required by law, to update or revise any financial projections or forward looking statements, whether because of new information, future events or otherwise. And with that, I'll turn the call over to Kevin.
Speaker 2
Thank you, Lee. Good afternoon, and thanks for joining us. I'll start with a brief recap of our 2019 accomplishments before turning the discussion to our focus and company goals for 2020 and beyond. We entered 2019 with significant momentum and as we've done successfully in the past, built on that throughout the year. Our full year 2019 revenue was $214,600,000 representing 46% growth over prior year and exceeding our initial guidance range of $2.00 1,000,000 to $2.00 $6,000,000 as well as the guidance of $213,000,000 to $214,000,000 issued most recently in late December.
Gross margin for the year was 75.5%, a 1.8 improvement over the prior year. Fourth quarter revenue was $59,100,000 up 41% compared to the prior year period and gross margins increased to 76.5%, a 2.4 improvement over the same period in 2018. Confidence in our ability to grow and expand the business remains very high. Our competitive differentiation, driven by our complete platform, demonstrated clinical superiority and our intense focus on serving the needs of our customers plus puts us in an incredibly strong position to continue to grow in 2020 and beyond. Accordingly, we anticipate full year 2020 revenues to range from $280,000,000 to $290,000,000 which represents annual revenue growth of 31% to 35%.
Matt will provide our complete full year 2020 guidance metrics later in his remarks. We continue to make substantial progress driving each of our growth initiatives as evidenced by several achievements in 2019. Briefly, this past year, we expanded the size of our sales channel to include two new areas, seven new regions and added approximately 30 sales reps along with increases to our customer facing support infrastructure. Sales force productivity improved meaningfully both in terms of time to ramp and peak productivity. We initiated the full commercial launch of Zio AT in October, and we began deployment of our new information system, Zio Suite in the fourth quarter.
Zio Suite is a multiyear architectural software redesign effort that provides a faster and more intuitive experience for physicians and their clinical staff. Designed for desktop, tablet and mobile access, Zio Suite streamlines clinical workflows and makes report interpretation easier. Two major studies were published in peer reviewed journals, bringing the total to over 30. One year healthcare resource utilization data from mSToPS was presented. We initiated the development partnership with Verily focused on next generation atrial fib solutions.
We expanded our market opportunity by beginning a participation in a new randomized controlled study called GUARD AF. And this study measures Zio's ability to diagnose atrial fibrillation, potentially reducing the incidence of stroke in the target population of asymptomatic patients. And lastly, we raised net proceeds of approximately $107,000,000 from a follow on offering in September, which will be used to fund our various growth initiatives. Turning to our strategic initiatives, the three primary components that are key to our short and long term growth strategy are increased market penetration with our single Zio platform increased operating leverage through continued productivity and automation improvements and expanding our addressable market into new indications and geographies. Starting with market penetration, sales force expansion continues to be an important factor in fueling our sustained growth rates.
In 2020, we plan to add 20 additional reps, ending the year with a total team of roughly 160 sales reps. As we've always done, we intend to grow our commercial team to meet the most cost effective size required to capture the full and untapped market potential. In addition to our quota carrying reps, we've built a support team that complements the sales team and ensures that our customers achieve the full clinical, financial and operational value of our Zio service. These support teams focus on account readiness, implementation, systems integration, including EHR, revenue cycle management and customer experience. Collectively, these teams enable us to truly partner with our customers and are a key factor as to why we win and retain customers.
Turning to our Zio platform, the full commercial launch of Zio AT in October has enabled us to be a single supplier to large integrated delivery systems. Faced with patient and information overload and constantly pressed for time, our customers place significant value on using a single platform to improve the effectiveness of their cardiac monitoring capabilities. Our early experience with AT has been quite promising as demonstrated by both the pull through of XT as well as the benefits of AT relative to traditional MCT devices. On the first point, we recently presented data that demonstrated on a cumulative basis for accounts that launched AT in 2018 and 2019, XT volumes grew 27% in the one hundred and twenty day period following AT launch as compared to the one hundred and twenty day period prior to AT launch. And including AT, volumes grew by almost 50% in that same period.
The significant acceleration is encouraging and clearly demonstrates the value of our single platform. Customer feedback on AT remains extremely positive with customers noting the accuracy of our analysis as well as the consistency and reliability of the platform. AT utilizes the same form factor as XT resulting in high patient compliance and wear and is backed by the same detection algorithms and AI tools 've developed with XT over the last several years. This has led to important clinical advantages for AT. When you compare Zio AT to MCT peer reviewed data, Zio AT's diagnostic yields or the ability to find clinically significant arrhythmias in those high acuity patients is 83, approximately 20 points higher than the peer review published data for traditional MCTs.
In addition, the days to detect these clinically significant arrhythmias is shorter by a factor of two or more days. Timely detection and notification is exactly the reason physicians are choosing to put a patient on a mobile telemetry device. We believe AT is well positioned to disrupt the MCT category, much like XT has done with traditional holder and event monitors. It is important to note, however, that while we believe AT is a highly innovative service and device, we remain steadfast in our view that Zio XT is the most appropriate solution for the vast majority of patients. Turning to our second growth strategy, while focused on continuing to increase operating leverage, I'm pleased to see that we're scaling increasing our scale and leverage within revenue generation, cost of service and operating expense categories for the business.
Matt is going to provide details on how we're focused on doing better in each of these categories in 2020. Finally, turning to market expansion opportunities. The silent Afib market is a major part of our expansion strategy, and we're currently participating in three important large scale clinical trials. This includes the mSToPS study, which demonstrated in its first year data that patients who are diagnosed with Afib and iRhythm's Zio service monitoring group had significantly lower rates of hospitalizations and emergency room visits in the twelve months following the initiation than the nonmonitored group. We expect three year mSToPS data, including clinical and economic outcomes to be published at the American Heart Association Annual Meeting in November.
Our second study, Screen AF, which is monitoring the incidence of newly diagnosed Afib at six months, will also report final results in the coming months, potentially at the upcoming Joint European Stroke and World Conference this May. We announced our third study, GUARD AF, a 52,000 patient study sponsored by the Bristol Myers Squibb Pfizer Alliance, which seeks to determine if earlier detection of Afib through screening in previously undiagnosed men and women of at least 70 years of age in The U. S. Impacts the rate of stroke compared to standard medical care. Through our partnership with Verily, we're working to develop next generation atrial fibrillation products that combine both companies' technologies to improve the screening, diagnosis and management of patients with asymptomatic atrial fibrillation.
Verily's StudyWatch is an important potential piece of the solution and recently received five ten clearance as a Class II medical device. In 2020, our teams will continue to develop and integrate our collective technologies and the development of a complete end to end solution. We'll provide further updates as we move forward with this development and achieve certain milestones. Before I close, I want to provide an update on the process of transitioning our Category III CPT code to a Category I code. From previous updates, you may recall the code transition was approved by the AMA in September, and we went to the next stage of initial joint pricing review by the AMA and CMS.
That review occurred last month at the AMA RUC meeting. While we cannot comment on specifics, we believe the AMA RUC will make an RVU recommendation to CMS based on the model reviewed during the January RUC meeting. In the final stage, CMS either approves or modifies the recommended RVUs with public communication of its initial determination in July. The process has continued to go as we have expected it, and our confidence and views of the ultimate outcome are unchanged. We look forward to providing updates when appropriate.
In closing, we look forward to continuing our momentum in 2020 with strong execution across our business. Our innovative approach to driving market penetration and expansion is rooted in our ability to demonstrate clinical superiority with our proven and complete service based platform and driven by our best in class commercial teams. We remain confident in our ability to deliver on our short and long term goals while making a tremendous impact in patients' lives. And with that, I'll turn it over to Matt Garrett, our CFO, for a review of our 2019 financials and guidance for 2020. Matt?
Thanks, Kevin.
Speaker 3
We are very pleased with our performance in 2019 and more importantly, continued initiatives and strategy for the company has set us up well moving into 2020. Our continued focus on sales force productivity, sales support infrastructure, integrated system penetration and gross margin expansion remain the key drivers for the company as we move into 2020. And after three years of heavy investment in the organization to support revenue growth, we see 2020 as a key year to demonstrate productivity up and down our P and L. Highlights for the fourth quarter twenty nineteen are as follows: revenue growth of 41% year over year and sequential growth of 8% non adjusted gross margins of seventy six point five percent and seventy six percent as adjusted an increase of 2.41.9% over the prior year respectively. The successful launch of Zio AT in late October, making our MCT monitoring solution available to all customers across the country.
And finally, continued improvement in sales force productivity levels to the development and onboarding of new reps, investments in the sales organization, continued penetration of large integrated systems and of course the launch of Zio AT. Taking a more detailed look at the fourth quarter financial results, non adjusted revenue for the three months ended December 3139 was $59,100,000 an increase of 41% year over year and 8% sequentially. As we described on our December 23 call, revenue was negatively impacted in the quarter by the one time reserve of approximately $1,000,000 for non contracted revenue. This is in direct response to actual collection rates falling short of historical rates due to rising patient deductibles and co payments. While we continue to monitor this trend closely, non contracted revenue now accounts for only 5% to 6% of total revenue, diminishing the potential for any material impact moving forward.
Without the adjustment, revenue would have been approximately 60,000,000 an increase of 44% year over year and 10% sequentially. As we have done in the past, we'd like to highlight some of the trends we are seeing, which support our confidence in the business and our ability to continue to deliver benchmark revenue growth. These trends include extension of sales productivity levels with a significant number of reps now surpassing $2,500,000 in annual revenue productivity. Coming off the summer months and as we move into the and we moved into the fall, same store new store revenue growth mix returned to our anticipated 60%, 40% split. We view this mix as a positive sign of our ability to penetrate existing accounts with both AT and ST and as we focus on new large integrated health systems.
Related to integrated systems, we also achieved significant milestones in EHR implementations during the year with double digit growth in onboarded accounts. Further, in December, we are approaching 10% of all registrations being completed through customers' EHR systems. In summary, these trends continue to demonstrate our ability to scale this high volume business in a meaningful way. Turning our attention to the rest of the P and L, gross margins for the fourth quarter twenty nineteen was 76.5% compared to 74.1%, a 2.4 percentage point improvement over the same period in 2018. Gross margins as adjusted for one time items in the quarter was approximately 76% or 1.9 percentage point improvement over the same period in 2018.
Non adjusted operating expenses for the 2019 were $62,900,000 compared to $44,100,000 for the same period of the prior year, an increase of 43% year over year. Excluding costs associated with the Verily development, OpEx was 61.7% or an increase of 40%. While OpEx adjusted for Verily was higher than expected, there were a number of one time costs in the fourth quarter that will not impact our run rate moving forward. These one time costs include approximately $1,500,000 for our Q3 twenty nineteen financial statement revision work, dollars 2,500,000.0 in bonus adjustments over plan booked in the quarter and $2,200,000 in expedited consulting work performed on behalf of the company for continued improvement of our revenue cycle management processes. Finally, net loss for the fourth quarter twenty nineteen was $17,300,000 or a loss of $0.65 per share compared with a net loss of $16,300,000 or a loss of $0.67 per share for the same period of the prior year.
Turning to guidance for 2020 and as Kevin noted earlier, we anticipate revenue for the full year 2020 of $280,000,000 to $290,000,000 This represents annual growth of 31% to 35% demonstrating our ability to scale the organization with our single platform, while continuing to produce benchmark top line growth. We are also taking this opportunity to raise sales force productivity levels from $2,500,000 on average for a seasoned representative to 3,000,000 Raising this measure again is due in large part to the productivity levels we are achieving with reps that have been on board for three or four years plus the added opportunity we are seeing with AT launch and the impact of sales support infrastructure. Gross margins for the year is expected to range from 76% to 77% continuing our trends of both price and cost improvements. While the launch of AT could create some volatility on gross margins during the year, early indications are that AT will have less of a drag on gross margins than previously forecasted. We expect operating expenses inclusive of Verily development expenses to range from $265,000,000 to $275,000,000 including $52,500,000 to $57,500,000 for R and D and $212,500,000 to $217,500,000 for SG and A.
For Verily development expenses, we anticipate total expenses of $15,000,000 including $10,000,000 in milestone payments, 4,000,000 in internal development costs, plus $1,000,000 for G and A. For our organic business, excluding Verily expenses, total operating expenses are expected to fall between $250,000,000 and $260,000,000 or $38,500,000 to $43,500,000 for research and development and $211,500,000 to $216,500,000 for SG and A. Beginning this year, we would also like to offer some additional guidance relative to our organic business as we trend towards achieving cash flow breakeven and positive EBITDA. In order to achieve these milestones, we intend to show productivity gains in operating expenses much like we have done in sales and gross margin. For the full year 2020, we expect costs associated with interest, amortization, depreciation and stock compensation to be in a range of 37,500,000.0 to $42,500,000 While the company does not provide quarterly revenue guidance, we would like to take this opportunity to highlight a couple of quarterly assumptions that management believes will help investors with quarterly expectations.
First, we expect Q1 twenty twenty revenue growth to be lower than our historical trends in large part due to the Q3 twenty nineteen revision, which pushed approximately $1,100,000 of revenue back into 2019, thus increasing the comparable year over year figure. And secondly, we remind investors of our summer seasonality as onboarding large integrated health systems, which make up a good portion of our new store sales tends to slow in summer months. For 2020 operating expenses, we anticipate a meaningful reduction in expenditure growth, exclusive of Verily development program and anticipate a material reduction in OpEx growth rates during the year that will provide additional confidence in our ability to scale. Taking the midpoint of guidance, OpEx as a percentage of revenue would be reduced significantly and overall growth is expected to slow to just over 20%. And for the first time publicly stated, management now anticipates the company to achieve cash flow breakeven no later than the 2021.
Before closing, we would also like opportunity to address any concerns that investors may have regarding the coronavirus. As it currently stands, management sees no material impact in the near term to our business as it relates to both revenue and supply chains. IRhythm's revenue is predominantly U. S. Based and the company has made significant investments in the robustness of our supply chain over the past couple of years.
To be specific, iRhythm's supply chain exposure to Asia is limited to circuit board components and exposure significantly mitigated by our reuse of our circuit boards for multiple turns. Further, we have worked with our suppliers to build up significant raw material buffers in our supply chain, which gives us confidence in the near term that no material impact should come from virus. We will continue to monitor the situation and update investments if there's any changes to this outlook. We'd now like to open the call up for questions. And joining me today for Q and A is Kevin King, President and CEO and Dan Wilson, Executive Vice President of Strategy and Corporate Development.
Operator?
Speaker 0
Thank you. Our first question comes from David Lewis with Morgan Stanley. Your line is open.
Speaker 4
Good afternoon. Just a few questions from me. I guess Kevin, first off, appreciate your updated thoughts on the RVU process. It sounds like things are going kind of in line with expectations. At this point, is the best way to think about this is the full disclosure of over year values is probably going to come in July and no sooner?
Speaker 2
It's a full disclosure from us coming in July, David. I'm sorry, I missed I didn't quite hear.
Speaker 4
From anyone. You obviously talked about notification, the AMA will be sent to CMS and probably already has. But from your perspective, the earliest notification that we're going to get around the RVU value is likely to come from CMS in July?
Speaker 2
Yes, I believe that to be the most likely case.
Speaker 4
Okay. Very helpful. And then Matt or maybe Kevin, a couple of questions here. First off, for the fourth quarter, I appreciate the update on the contractual reserve of $1,000,000 But can you just give us a sense of the dynamic of delayed returns that were disclosed in late December? Any sense of the magnitude of those delayed returns had on fourth quarter and ergo would have on the first quarter?
Do you have any sense of the quantification of that?
Speaker 2
Sure. So on December 23 call, the update call that we had, we noted that we were running about a day behind, which we estimated to be about $1,000,000 in total. We received in the final few days of the month, a good portion of those devices, but not all of them. Many of them carried over to January. We now believe that we've received all the ones that we should be expecting.
So think of it as kind of a two third, one third, seventy-thirty type of thing, 70% in December, 30% in January thereabouts.
Speaker 4
Okay. So investors are trying to get a good sense of your underlying growth rate in the fourth quarter apples to apples. If we added back the contractual reserve and maybe $05,000,000 benefit you had expected, perhaps the right way to think about the fourth quarter growth rate is something like 45% to 47% relative to the 40% that was reported. Is that a decent way of thinking about it?
Speaker 2
Yes, I think so. I've got Dan and Matt shaking their head there doing math quickly. Yes, think that's
Speaker 5
a Yes.
Speaker 3
The ACR would raise you to 44%. And if you go two thirds, one third, which is roughly what we perceive it to be, there's another couple of percentage points in there. So yes, that's right, 45%, 46, 47, somewhere right in there.
Speaker 4
Perfect. All right. And lastly, Kevin, maybe for you. I know we're probably not going get an absolute quantification of the AT impact for 2020, but you started to share some slides and case studies around the impact AT could have or XT could have or AT XT, sorry, could have an XT pull through. How should we think about the impact of AT on 2020 from a growth perspective?
Thanks so much.
Speaker 2
Absolutely. This is a really tough balancing act for us, David. We want to be as transparent with investors in the markets as possible. And at the same time, this is a really highly competitive market space. So we're cautious about tipping our hands.
I think you've heard from our qualitative comments that we're incredibly pleased with where we are with AT and it is absolutely contributing to our growth. What's most important, I think for everyone to understand is that AT is enabling us to be a more complete solution and that's evidenced by the Zio XT pull through and wins that we've had than it is on an individual AT device level. Customers greatly value having a single platform, even though the percentage of patients that actually get AT prescriptions is relatively small compared to XT. I think you should think about it as a platform play more than you should individually. We're going to do our best to provide more detail as we go forward, but it's still rather early days for us.
Speaker 4
Okay. Thanks so much. I'll jump back in queue.
Speaker 6
You bet. You're welcome. Thanks, David.
Speaker 0
Thank you. And our next question comes from Robbie Marcus with JPMorgan. Your line is open.
Speaker 7
Great. Thanks and congrats on another good quarter. Kevin, I just wanted to firm up your comments a little bit here. You said no change from your thoughts before on the ultimate outcome of reimbursement. Just want to make sure we should be thinking about no change as before was flat to up in terms of how you were thinking about the potential outcomes for reimbursement.
Speaker 2
No change yes, I'm talking about no change in our degree of confidence and no change relative to the comments we started talking about back in, I don't know, 2017 or so relative to likelihood of this going up as much as it is going down and we're confident that it's going to probably stay pretty much the same. There's no change to that at all. We're not able to comment about that RUC process, but going into and coming out of the RUC process, had absolutely no change. And we're quite pleased and fully anticipate that the AMA put forth the materials that we had sent to them and that's made its way over to CMS. There were still some final meetings going on, but we should be hearing back as in based on the prior question in July timeframe.
Speaker 7
Great. And maybe just one follow-up, just to further discuss the AT here. When you walk into accounts, is this a product you lead with? Or is it mostly coming in established XT accounts? And then if it is new accounts, what's driving them so much to adopt it?
Is they can finally adopt a full work stream of products? Is it the workflow benefits? Is it the better device? What is it? And then I'll leave it there.
Thanks a lot. Sure.
Speaker 2
So when we think about our marketplace today, the market for ambulatory monitoring is largely fully penetrated. And what we're competing against with is changing what we refer to as status quo. And the status quo, unfortunately, is one where physicians and their staffs are just overloaded, have a high degree of job dissatisfaction, have too much information coming at them every day. And unless you give them a solution that requires less inputs and less effort, you don't stand a chance of adopting it. And so to answer your question, the part of your question that you stated there was, is it around workflow?
It's absolutely around workflow, and it's absolutely around being clinically superior. If you don't have a better mousetrap, so to speak, compared to anything else, why would I change? And if I'm already overloaded, why would I take on doing more work? So you have to have a combination of those. Now playing into that workflow theme is, do I have to interface to multiple systems for order entry results reporting?
Do I have to train my staff on multiple devices, etcetera, etcetera? And that's where the single platform for Zio allows clinicians to adopt in a more streamlined fashion. We don't necessarily lead with AT. AT is the high acuity patients is a relatively small percentage and really not likely to cause people to shift from status quo. It's really XT in combination with AT in the full line.
Is that helpful, Robbie? That was great. Thank you. You're welcome.
Speaker 0
Thank you. And our next question comes from Jason Mills with Canaccord. Your line is open.
Speaker 6
Thank you for taking the question, Kevin, Matt and Dan. Good afternoon. Can you hear me okay?
Speaker 2
Yes, we can. Hey, Jason.
Speaker 6
Super. Hey, so I wanted to talk a little bit more about the ATXT pull through. And Matt, it wasn't lost on me. Your voice inflection was fairly seemed fairly bullish as you were talking about the EHR integration. You were talking about that within the context of your targeting of IDNs.
I'm wondering if we could bring it back to what investors care about, which is obviously the growth guidance you've given for 2020. And what you sort of factored in, for the XT pull through, specifically vis a vis AT and IDN? And what, upside exists relative to, I'm sure you've given us more conservative estimates than, various other models you have you've built out with respect to this specific issue. I'm wondering if you'd be able be willing to give us a little bit more color in your thinking on this front.
Speaker 3
I can try at a high level, Jason. I think that what everybody needs to be as Kevin just alluded to and I'll allude to here is, we're still really early days, right? We're really early days. I mean, we didn't actually start the AT launch until October. And thus, when you're trying to identify these sort of trends that we're happy to call out where we can, You have to understand that we're coming off of a baseline in which a majority of those AT units pre and post the overall launch are coming from existing accounts.
So I think we've been pretty bullish and optimistic on XT pull through and that's on accounts that we already had up and running, right? So as we move forward into 2020 and we actually start to bring on new integrated systems, you can imagine that there is a potential for higher XT pull through in those. And I'll just simply state that at this point, it's still early days, but that, as Kevin alluded to, as we get that sort of granular data, we'll try our best to provide more data. Does that help a little bit?
Speaker 6
Yes, it does. So it raises the question, which is sort of an obvious one that you're I mean, on one hand, you have the law of larger numbers as you're trying to set this guidance. On the other hand, you've talked about the percentage of first line monitoring that goes on in these IDNs relative to the overall market. And you just mentioned the level of penetration or lack thereof you are at this point in time. So those two things are somewhat at odds, but nonetheless, it seems like, the conclusion that one could draw is that your guidance leaves room for upside, specifically, if you have more success in IDNs this year than maybe your guidance implies?
Speaker 2
Look, I let if we're talking about whether our guidance is good guidance or not. First, let's take a look at 2019, right? We started the year with 37% to 40% growth. And over the course of the year, many of the investments that we made and plans that we had did better than expected and we turned out with 46% growth. Similar to those years, we have a lot to accomplish this year and we have a lot to digest as we have in the past.
I said in my opening comments, we've added two new areas, we've added seven new regions, we've added 30 new salespeople, We are launching a brand new information system, Zio Suites, and we're launching Zio AT. We have a lot of work to do such that the guidance we're giving you right now is our very best view of where the year will be. As we progress, it could get better. But right now, I want to give you the best estimate that we have knowing all that we have ahead of us to still achieve relative to the people, the products that I just described in the market segments that we're now going after.
Speaker 6
That's helpful, Kevin. And it's not last I mean, the midpoint of your guidance is about where consensus was coming in. So it's not a criticism. It's just a discussion. Last question.
Speaker 2
Yes, no, no, I'm not we're not taking it.
Speaker 3
We wouldn't expect you to ask any other anything less, Jason.
Speaker 6
Thanks, Matt. The last question Clearly, there's data out there and there's data to come. How do you think, the data that we will see later this year, will, if at all, impact your business? Or will that require, perhaps data from GuardAF?
What how should we think about what is coming later this year and how that may impact the market or the way that your customers look at using Zio XT? Thank you for taking the questions.
Speaker 2
Sure. No worries. I think these large market opportunities unfold over time as opposed to make a big splash, right? We're talking largely about changing the value proposition for health plans and their members, their beneficiaries being patients or if they're not sick, they're members. And we have to provide to them compelling evidence to begin a screening protocol or a testing protocol that screens for something that is asymptomatic.
So clinical evidence is clearly important. That said, I think that the economic, the utilization of services is as important. And we intend to build relationships with our health plans that we have contracts with to try to do more mSToPS like studies within health plans to unfold this market over time. I think it's too early for us to begin projecting revenue or adoption. It's a very big opportunity.
It's a complex one. The fact that we've got three major studies and a major partner and we've got some good results under our belt says we've got a lead here. But I'd say it's not going to be a big bang. I'm absolutely convinced of that. As much as we would like it, course, yes.
Speaker 6
Thank you, Kevin.
Speaker 4
You bet.
Speaker 6
Thanks, Jason.
Speaker 0
Thank you. And our next question comes from Margaret Kaczor with William Blair. Your line is open.
Speaker 8
Hey, good afternoon, guys. Thanks for taking the questions.
Speaker 2
Margaret. Hey, Margaret.
Speaker 8
Hey. First one for me is actually following up a little bit on Jason's question. And it regards kind of this high risk population. And so it's multifaceted, so maybe write it down. But one, do you think you need larger trials like GuardAge AF to build some of that business there?
And as you look at it, what do you think will move faster in the transition? Is it health systems and changing guidelines? Is it payers changing what they pay for more individual clinician base? And then do you need some kind of other product or price points to try to better address this population, especially given some of those early partnership comments you guys have made?
Speaker 2
Sure. I don't I believe the larger studies will ultimately help, but I think the power of mSToPS and the design of it is so compelling that its results can stand on its own relative to the utilization of resources. I think relative to where do you begin or which market segment, I don't think it is health systems. I think it is health plans for the reasons that these patients have no symptoms and are less likely to be in front of their doctor. Rather, the health plan that's at risk, they have contracts with employers or they have contracts with the government to provide a service at a fixed cost, want to uncover these patients that are at risk because the cost of diagnosing and monitoring them is less than the cost of the incidence of bad outcomes like stroke.
So the value proposition in my view or in our view is targeted largely at health plans, not so much health providers. And then the third question was, do we have the right product? I think Zio XT is a phenomenally good platform. What we're trying to build with Verily is an even better platform, but there's nothing inadequate about Zio XT in terms of its detection rates, right? We found a threefold increase in AFib in the population that was monitored with XT compared to nonmonitored.
So I think that outcome is good. We hope to improve upon that by having longer and higher detection rates, but it shouldn't preclude us from starting.
Speaker 8
Got it. No, that's helpful. And then just to go back to AT, I know it's been kind of limited launch and kind of early launch in terms of trying to launch it within the existing accounts. But what have you seen so far in respect to rep productivity as a result of AT, both from a revenue perspective as well as from a sales cycle perspective?
Speaker 2
Well, Margaret, I think it's important to think about AT in the context of complete platform sold to an account, not as a separate product line, right? This is not one device and then another product line. This is all one part of an integrated system or solution that we're offering to our customers. The total market for MCT or AT is only onetenth the size of XT. And so we shouldn't see a disproportionate amount of AT coming out of sales reps.
Also, the coverage policies for MCT are quite inhomogeneous across the country. Of the 37 or so Blue Cross and Blue Shield plans, the vast majority of them have negative coverage policies for MCT. And in some states where there is a very high rates of Blue Cross and Blue Shield patients, you see very little market adoption of MCT. So it's a small heterogeneous market. That said, it's a very important segment and that this is a high acuity group of patients.
So we're I tend to think less of it as a product line and more of as a component of our overall platform that's helping us.
Speaker 8
And I think the question really relates that and I think this is what I'm hearing from, is that a rep that has both XT and AT in their bag, whether it's driven by AT or not, by having AT in their bag, they you've seen them be more productive than that rep that only has XT in the bag for whatever reason?
Speaker 2
Yes. I think at the account level, we see higher growth rates within those accounts that do a wider range of patients. I think that's directionally correct. I won't quantify it, but I think it's directionally That's right. That's right.
Great.
Speaker 8
Thank you, guys.
Speaker 2
You're welcome.
Speaker 0
Thank you. And our next question comes from Kayla Grom with SunTrust. Your line is open.
Speaker 9
Great. Hi, guys. Thanks for taking our question. So I think you're giving some new commentary and timing on positive cash flow into 2021. So can you just speak to your visibility and confidence in those metrics?
Again, just given those comments kind of step into 2021. So do you need to hit a certain revenue level? Are you assuming reimbursement for XT is stable? Just want to make sure I'm clear on some of those assumptions there.
Speaker 3
Sure. I'll do what I can. First of all, we are assuming this obviously assumes no material change in pricing. So that is first and foremost. Secondly, we've not really put and I'm hesitant to put a particular revenue point of crossing that chasm, if you will, for any number of reasons.
I think that puts us in a bind in terms of our ability to guide moving forward. And B, it remains very fluid. Again, if we're seeing tremendous uptick in certain markets and we want to continue to invest, we clearly want to give ourselves degrees of freedom to do so. What I would share with you guys is that if you look at the midpoints of the ranges, you're starting to see some material decrease in the OpEx growth. And as I called out on the prepared remarks, a significant decrease in overall operating growth.
What I think is most important to think about is if we're only calling again for the midpoint of the range of $255,000,000 on OpEx, that's $45,000,000 of incremental spend. A good portion of that spend is related to sales support and the additional sales reps that we're going to hire and a little bit related to stock comp. You take those out and you see that they're not a significant amount of growth elsewhere. So I guess I would just caution folks that we're going to try much like with the AAT to be a little bit more open as we move into the year, as it relates to these expenditures. But when you carve out those one areas that continue to invest as it relates to the development of the organization, you really see a scenario where we're cutting back significantly on that kind of core organic growth.
Does that help?
Speaker 2
Organic OpEx growth. Yes.
Speaker 3
Organic OpEx growth, excuse me.
Speaker 9
Well, I guess that leads into the second question on top line growth. So I mean, do you think about the long term growth of your business? Obviously, over 30% growth in 2020 is great. And I realize you don't want to comment on 2021, but you have AT ramping, you have new partnerships coming online. Just any sort of directional thoughts on that long term durable growth of the business would be helpful.
Thanks, guys.
Speaker 2
Yes. Look, I would say our sentiment or view is the same as it has been in the past. We think the market opportunity is large. We believe we have the right strategy. We believe the competitive dynamics fall in our favor and that there's increasing value within and among our brand.
So from that standpoint, we remain as bullish as ever. That said, I'm going to stop short of guiding a number beyond 2020, but there doesn't seem to be anything in our way. That said, as I said earlier, in this year, we have a lot to digest in that we've put in new areas, new regions, we have new sales reps, we still have sales reps that we hired last year that are new to the company, we have new products. There's a lot of execution that still is required. But the good news is that's all within our control, right?
And we've got very talented teams and deep competencies in our business that gives us confidence. Not a cakewalk, a lot of hard work, but the things that we have to do to continue to grow as we have been totally within our control.
Speaker 9
Great. Thank you, guys.
Speaker 2
You're welcome. No worries.
Speaker 0
Thank you. And our next question comes from Suraj Kalia with Oppenheimer. Your line is open.
Speaker 5
Good afternoon, Kevin. Good afternoon, Matt. Congrats on a nice quarter.
Speaker 2
So
Speaker 5
Kevin, one question for you and one maybe for Matt. Kevin, a lot of you guys have consistently expressed your view that Medicare rates will remain stable or at least through this rough process. We haven't talked about the commercial side of the equation, which is about 70% of your business. Would I be fair in saying that if Medicare remains, let's say, status quo, you all do not expect to see any shift short term or long term on the commercial side? And the reason I ask is, our check suggests commercial on average is slightly higher than Medicare.
Any color there would be great.
Speaker 2
Sure. So of the couple of 100 commercial contracts that we have, they have staggered rates of renewal, some of which or many of which are auto renewed, some of which and many of which are multiyear. So the sort of feathering in and feathering out of changes in price never occurs as a thunderclap, if you will, but rather changes over time. We've now seen over the last year, one years, point now that we're nearly fully contracted, less change in pricing because our contract levels are stable. I think the drivers of modifying or increasing our pricing amongst commercial carriers is often associated with evidence.
So if we can drive a new indication or we can drive a broader value to payers, we stand the likelihood of getting paid more. Not necessarily, I don't see much pressure on the downside from we've never had decreases in commercial contract rates, but we certainly have had increases in our commercial rates as our clinical evidence has increased over time.
Speaker 5
Got it. And finally, Kevin, Zio AT, to the extent you can, how is Zio AT are you all using one product for, let's say, up to thirty days? Is it two products? And also just the logistics for billing for AT? Any color there would be great.
Gentlemen, thank you for taking my questions and congrats again.
Speaker 2
No worries. So Zio AT uses the same wearable platform that we have for Zio XT. So it's a single wearable sensor. It is most often prescribed for fourteen days. Multiple patches can be used to get as many days as you like up to twenty eight days, I guess, it's 14 times two.
The evidence that we have says that our diagnostic quality, the quality of our signal, the quality of our algorithms is that we're achieving far greater diagnostic yield and a faster time to diagnose with a single device than it is a second, a full thirty days. And also in our research, even though that the CPT coding language says up to thirty days, The average wear time for most MCT monitors is about eleven point five days. And the RVU calculation for MCT was based on less than twelve days of wear. So a lot of codes say up to a certain period of time, but that's not a requirement nor is our technology limited to a certain period of time. It's just what's optimal for the patient and optimal for a physician to get the diagnostic result that they need.
Your second question was about contracting?
Speaker 5
No, I was just trying to understand and I think so you answered that, Kevin, if you were to use only one form factor for COAT, one product, then the billing, I think, so becomes obvious. So that itself answered my question. Thank you.
Speaker 2
Wonderful. Very good. Thanks, Raj.
Speaker 0
Thank you. And I'm not showing any further questions at this time. I would now like
Speaker 9
to turn the call back
Speaker 0
to Kevin King for closing remarks.
Speaker 2
Great. Thank you, operator. Thank you, everyone, for joining our fourth quarter twenty nineteen earnings call and full year earnings call. We appreciate your support and your interest in iRhythm and look forward to updating you as we move forward in the year. All the best.
Speaker 0
Ladies and gentlemen, this concludes today's conference call. Thank you for your participation. You may now