Option Care Health - Earnings Call - Q2 2021

Transcript

Speaker 0

Ladies and gentlemen, thank you for standing by and welcome to Option Care Health Second Quarter twenty twenty one Earnings Conference Call. At this time all participants are in a listen only mode. After the speakers' presentation there will be a question and answer session. To ask the question during this session you will need to press star then 1 on your telephone. If you require any further assistance please press star then 0.

I would now like to hand the conference over to your speaker for today, Mike Shapiro. You may begin.

Speaker 1

Good morning, and thanks for joining us this morning. Before we begin, please note that during the call, we will make certain forward looking statements that reflect our current views related to our future financial performance, future events and industry and market conditions. These forward looking statements are subject to risks and uncertainties that could cause actual results to differ materially from our comments. We encourage you to review the information in the reports we file with the SEC regarding the specific risks and uncertainties. You should also review the section entitled Forward Looking Statements in this morning's press release.

During the call, we will use non GAAP financial measures when talking about the company's performance and financial condition. You can find additional information on these non GAAP measures in this morning's press release posted on the Investor Relations portion of our website. With that, I'll turn the call over to John Rademacher, Chief Executive Officer. Thanks, Mike, and good morning, everyone. As you can imagine, we are quite pleased with the overall progress we are making, the expanded number of patients we are serving and the financial results the team has delivered in the second quarter.

And our confidence in this enterprise has never been higher. We continue to translate strong revenue expansion into leveraged earnings growth on our scalable platform. And as we sit here today, we are increasing our growth and earnings expectations for the full year based on the first half momentum. Equally important, we continue to invest in strategic initiatives to build upon our unique national platform. As we entered 2021, we remained in the midst of the pandemic second wave, and we were also managing supply chain dynamics for certain therapies.

Consequently, we guided to 6% to 7% revenue growth. Over the past few quarters, we've seen referral patterns return to pre COVID levels. And in some instances, including several chronic therapies, we've seen referrals considerably above pre COVID levels. The team has remained on offense, so to speak, and we focused on balanced growth across both our acute and chronic portfolios through collaborations with our payer partners and referral sources. In the second quarter, we saw strong sequential growth over the first quarter in both therapy portfolios as momentum has clearly increased.

Recall, the comparative quarter for 2020 is challenging given the disruptive referral patterns with the onset of the pandemic. Regardless, we saw high single digit acute growth over prior year and high teens chronic growth, with particular strength in newer therapies for multiple sclerosis and myasthenia gravis. Our top line results affirm that our unique value proposition is resonating with manufacturers, payers and referral sources. And for the full year, we now expect to generate double digit top line growth based on the momentum generated in the first half. Despite our strong top line results, we remain in a very dynamic environment.

Our supply chain situation is clearly improving, especially with respect to immunoglobulins, which we highlighted as a risk entering into the year. Like most companies, we are facing challenging labor market and given our strategic investments in clinical expertise, we continue to manage tight labor conditions for skilled clinicians. We have been able thus far to successfully navigate the challenging labor market to maintain our reputation of dependability with referral sources that has been the hallmark of the Option Care Health team over the challenging pandemic situation. We continue to monitor the situation closely, and we are proactively addressing the situation through talent development, technology enhancements, labor efficiencies and deepening partnerships with home health agencies. Aside from the solid growth in the second quarter, we continue to invest in future growth catalysts.

Early in Q2, we closed on the Biocure acquisition, and I'm pleased to report that the integration is already complete. This complementary tuck in has reinforced our IG go to market efforts and strengthened a number of key geographic markets for us. We also recently announced a technology collaboration with AliaCare, one of our existing trusted technology partners to co develop market leading patient engagement and clinical management software. As we have articulated on many occasions, we have invested tens of millions of dollars into our integrated technology suite to optimize the patient experience and maintain an efficient operating model. AliveCare has been in the trenches with us for quite a while, and we are excited to introduce additional tools to improve the therapy experience for our patients and their families.

Over the past six months, we've invested in additional infusion suite capacity and are aggressively moving to open 10 to 15 additional stand alone infusion centers by year end. Infusion center capacity is a key growth enabling initiative to improve the patient experience and optimize our clinical workforce. To my earlier point, infusion center capacity provides additional labor efficiency and partially mitigates the challenging labor market we currently face. I'm also thrilled with the addition of Doctor. Seema Khumbat to the newly created role of Chief Medical Officer.

The patient experience is at the forefront of everything we do and Seema brings a unique perspective to my leadership team as we continue to raise the clinical bar in this industry. Mike will unpack the results in a few minutes, but I'm very encouraged by the top line growth and our ability to leverage our infrastructure to deliver higher levels of profitability. As we announced in the release this morning, we have significantly increased our guidance for the full year for both revenue and adjusted EBITDA based on the momentum the team established in the first half of the year. The midpoint of the guidance range implies an EBITDA margin north of 8% for the year, and we're only getting started. And our ability to translate earnings to cash flow has been quite strong, delivering over $70,000,000 of cash flow from operations in the quarter.

We also achieved our full year leverage target of four times at midyear. Again, I couldn't be prouder of the team and how they continue to execute our strategy in light of continued market dynamics. Before I turn over to Mike, I want to spend a few minutes on the recent approval of ADUHELM for Alzheimer's. As an organization that serves patients with challenging chronic conditions every day, we are encouraged that new therapies are emerging for what is a devastating condition for patients and their families. And clinically, the profile of ADUHELM fits quite well with the alternate site setting, given an older patient population, many with complicating conditions and a preference for limited travel for therapy.

However, we are reimbursed for home infusion at levels to support care. We continue to monitor CMS and the payers' approach to coverage determination and separately work with the industry coalition to seek a legislative improvement to reimbursement for home infusion. In the current landscape, we do not see edge home as a near term opportunity until the Medicare reimbursement environment changes. Consequently, none of our guidance reflects any benefit from ADUHELMA at this time. So overall, I am very pleased with the second quarter results, the performance by the entire team and where we are positioned heading into the second half of the year.

You'll recall in the first quarter call, I commented that we were quickly pivoting from integration to acceleration and clearly we've made that turn. With that, I'll turn the call over to Mike to review the results in a bit more detail. Mike? Thanks, John, and good morning, everyone. Overall, the second quarter can be summed up in strong top line growth that translated into margin expansion and spending leverage to deliver accelerated earnings growth and cash flow generation.

Remember that similar to virtually all healthcare enterprises, the 2020 is an atypical comp as we saw an initial spike in patient referrals followed by a stagnant period as individuals stayed away from medical facilities. Nonetheless, we generated 16% top line growth overall with high single digit growth in acute and high teens growth in the chronic portfolio. Sequentially, we generated a little over $100,000,000 in revenue over the first quarter as referral volumes continue to rebound off the pandemic lows. Our results continue to reflect some ASP headwind for certain therapies, but clearly the volumes more than offset. Despite the faster growing chronic portfolio, we drove a gross margin rate expansion in the quarter as we continue to drive network efficiencies and managed our procurement strategies within each portfolio.

We don't talk much about bad debt as it has considerably improved over the past few years, but in the quarter we drove bad debt down to a little over two percent, which represents about a zero five percentage point improvement over the prior year. As that improvement dropped straight through, that helped offset the chronic mix headwind at the margin line. Again, the team fights for every basis point of leverage at the gross margin line and thus far we have been able to offset the mix impact. Spending leverage continues to improve as SG and A as a percent of revenue dropped by 130 basis points, driving an EBITDA margin of 8.5%. This is the first quarter that we've delivered a margin north of 8% and as John mentioned, we're just getting started.

Cash pays the light bills, not EBITDA, and our ability to translate earnings into cash flow continues to accelerate. In Q2, we generated cash flow from operations of more than $73,000,000 and increased cash balances by $48,000,000 despite deploying more than $18,000,000 to acquire BioCure. And we finished the second quarter with a net debt to leverage ratio of four point zero times, which was our full year commitment. So our cash and working capital profile continues to improve and provides considerable flexibility as we open the aperture on inorganic opportunities. And just a reminder that we maintain a favorable Covey like debt structure with no maturities until 2026.

As we think about the back half, we clearly expect revenue to exceed previously communicated guidance. We anticipate continued sequential improvement, albeit not at the level we saw from Q1 to Q2. With solid acute levels maintained and chronic acceleration, we see full year revenue growth of 10% to 15% based on the revised guidance issued this morning. And we are increasing profit expectations based on the solid top line and are increasing EBITDA expectations to $275,000,000 to $285,000,000 Relative to our initial guidance back in March, we've increased our EBITDA midpoint by approximately 11% based on better visibility around revenue trends and our procurement strategies. That will translate into higher cash flow generation and an improved leverage profile before potential capital deployment.

We remain active on the M and A front and our guidance does not incorporate any inorganic contribution in the back half other than the BioCure acquisition. Before we wrap our prepared remarks and open the call to Q and A, I wanted to clarify a few items regarding the most recent secondary share offering by our primary shareholder in June. At the time of the merger two years ago, an entity formed by Madison Dearborn Partners and Walgreens Boots Alliance held approximately 136,000,000 shares excluding escrowed shares that have since been canceled or approximately 80% of the total outstanding shares. Over the past year through a series of secondary offerings that entity which has been and continues to be controlled by Madison Dearborn has sold approximately 68,000,000 shares and has reduced its investment as of today to approximately 68,000,000 shares or just under 38% of the total outstanding shares. Until the most recent secondary offering, Madison Dearborn and Walgreens allocated the proceeds from such offerings based on their pro rata interest in the entity or approximately on a 52.48 basis respectively.

However, with the recent offering of 17,250,000.00 shares, Madison Dearborn and Walgreens agreed in principle to allocate all of the offering proceeds to Madison, Dearborn and other shareholders. Thus, as of today, Walgreens has an indirect financial interest in approximately 21% of the total outstanding shares of Option Care Health with Madison Dearborn and affiliates indirectly holding the remaining 17%. While we wanted to clarify their respective financial positions given the recent dynamics, we don't have any further comments on their investment strategy or any insight on future intentions by either of the shareholders. So in closing, we are very encouraged by the strength of the second quarter results and have raised our expectations considerably in the second half based on the first half momentum. And with that, we'll open the call to Q and A.

Operator?

Speaker 0

Thank you. Our first question comes from the line of Pito Chickering with Deutsche Bank. Your line is open.

Speaker 2

Hey, good morning guys. Thanks for taking my questions. Just a couple of ones here. On the top line growth this quarter, obviously, extremely strong. Can you give us just some more color on sort of chronic versus acute?

And then within the chronic, you mentioned, I think, multiple sclerosis as a growth area. Just give us some more detail as to what really outperformed this quarter, whether sequentially or versus year over year?

Speaker 1

Good morning, Pito. It's John. Yes. So first and foremost, really pleased with the balance that we saw across both the acute and chronic portfolio. I think as we've talked about before, as we expected things to start opening up within the hospital and as patients return to receiving care, we saw increased flow of referrals, as we had mentioned, and really some strength in the acute area that in some ways had been lagging through that process.

So referrals increased as we had called out. We've done a really good job of converting those referrals to starts. And I think that some of the investments we made to increase our reach and frequency are starting to pay dividends as things opened up. On the chronic side, again, good execution by the team. We continue to see strength across the portfolio there.

I do believe that, as we called out, we were able to navigate the IG marketplace pretty adeptly. And so really didn't feel any constraints from the IG side because of supply chain issues. So all in all, balanced. All in all, good execution by the team and deepening those relationships with the referral sources to be their partner of choice as they're looking for opportunities to transition patients on the care with us. Hey, Pito, it's Mike.

The only thing I'd add is, look, as we mentioned, obviously, the prior year comp is a little wonky given the results in the second quarter and just the state of the market back then. I think as John said on the chronic side, great payer collaboration more of the same and the value proposition is resonating. And on the acute side, again, we had an easier comp. And I think as we've said, we prided ourselves on our dependability and reliability in what remains a very challenging market dynamic. And so relative to the first quarter and prior year, there's more trips into the batter's box.

I think based on the phenomenal team in the field and their focus, we're getting more hits every time we're walking into the batter's box.

Speaker 2

A follow-up question for you on margins. For SG and A, obviously, huge top line growth here. We got some SG and A leverage, I guess, sequentially. I guess, just trying to understand, sir, how much leverage we should be modeling on the SG and A line when we have sort of the revenue beats or where is that conversion ratio? Kind of as you think about the next year or two, can you help us understand as revenues continue to grow at these levels, sort of what is the fixed variable component within SG and A and kind of just assuming that SG and the primary margin driver going forward the next couple of years?

Speaker 1

Yes. The spending leverage is really part and parcel to our overall strategy where going forward based on the infrastructure that we've established over the last several years and we've estimated that within our SG and A line, it's roughly 75%, 80% fixed. There's obviously some natural inflation and there's some variable components, but that gives us the confidence that with this with the top line growth outlook that we have, we are highly confident that spending will grow at a pace meaningfully below the top line. That gives us the confidence obviously in margin expansion. We're never going to give up on driving spending leverage.

And I think going forward, we have even more confidence that we'll continue to be able to drive that. Again, also in the disclosure this morning, our integration costs, are included in that line, are really starting to decelerate as well. And as we look going forward, again, I don't think we have a spending as a percent of revenue leverage. We just have a very high degree of confidence that it will continue to drop, maybe not at the pace that we've realized over the last year because, again, remember, in the 2020, we were still in the process of harvesting SG and A synergies. But nonetheless, like every other organization, we've learned a lot during the pandemic about how much more efficiently we can operate, and we'll continue to look for those cost outs.

Speaker 2

And then a quick follow-up. I understand that you guys are not guiding to any impact this year for Alzheimer's, but just curious sort of two questions. Number one, on the commercial customers, those should be able to sort of fall within home infusion, although they're much smaller customer base relative to Alzheimer's. But is Alzheimer's do this gross margins track generally in line with the chronic business? And just any color what you're seeing on the commercial side of business on managed care or physician pushback?

Thanks so much.

Speaker 1

Yes. Look, I think it's too soon to tell on some of that stuff, Pito. As I said in my prepared remarks, I mean, we're trying to be very thoughtful in the way that we look at this. There are still a lot of questions around coverage determination and which payers are going to allow this from authorization standpoint. At this point in time, without knowing kind of what payers are in and how they're actually going to provide coverage determination, really don't have an answer to that question, which is why we were conservative in our approach of it's not really in our guidance.

And in the near term, we don't expect a significant amount of value. But I will say, as I said in my opening comments, look, we do think that we have a really great platform in order to support these types of products, and it's a matter of making certain that we're working both in Washington as well as with our payer community to let them understand the value that we can bring to this patient population.

Speaker 2

Great. Think it's lot guys. Excellent quarter.

Speaker 1

Thank you. You.

Speaker 0

Our next question comes from the line of Matt Larew with William Blair. Your line is open.

Speaker 3

Hi, good morning and congratulations on the quarter. I just wanted to follow-up on the comments you made. I think you mentioned there were several chronic therapies that were trending well above pre COVID. So could you maybe give us a sense for where in particular you're seeing strength? And is that from payer side of care redirection efforts?

Is that new therapies you're involved in? Just any more color there would be interesting.

Speaker 1

Good morning, Matt. It's John. So specifically to your question, so a couple of areas. In chronic inflammatory disease, we've seen that move ahead of where we were from a historical basis. A lot of that is in payer collaboration in working around site of care initiatives and helping support patient choice as they're making decisions around where to receive care, sometimes out of hospital outpatient departments and physician practices on the service with us.

So we continue to work closely across the payer community to identify those opportunities and find ways to deepen our partnership in supporting their goals of providing high quality care at an appropriate cost. So that's been part of our overall strategy, and it's the execution was strong in the second quarter.

Speaker 3

Okay. It sounds sustainable to me. The second one, again, interesting comments, John and Mike, you both made today. Anyways, we're just getting started in terms of the EBITDA margin building off your levels from today. And I think just a couple of years ago, the idea was getting to this sort of 8%, 9% level over some time.

So I think this is as bullish as I've heard you on the long term margin picture. So I guess maybe just if you could expand on the we're just getting started comments and what in particular you've been encouraged by there?

Speaker 1

Sure, Matt. It's Mike. Look, when we put these organizations together, we were making a lot of expectations around the margin expansion. Those were comments made in the locker room, so to speak. And now that we've been out on the paint for a number of quarters and have been able to truly demonstrate how scalable this platform is, it just gives us the higher level of confidence.

In the middle of the integration, we got a couple of curveballs with the pandemic. And I think we just continue to learn around how much bricks and mortar we need, how virtually we can operate this business. And I think it continues to add to the number of areas where we think we can leverage technology and infrastructure. We announced the collaboration with AlayaCare, which has been just a phenomenal technology partner of ours. And we see additional areas where we can, a, improve the patient experience at the same time that we can provide that value to payers and patients and at the same time do it in a more efficient manner.

And so look, the candid reality as we go forward, we continue to believe that the chronic portfolio will grow faster than the acute. Again, we got we've received some benefits and been able to offset that mix shift with bad debt and procurement strategies. But regardless of what we view as the reality of portfolio mix headwinds, we are highly confident that we will be able to grow the spending components of this business and the capital efficiency of this business considerably below the top line. And so I don't think we'll see the EBITDA expansion of the big steps that we've seen over the last two years as we're almost at the two year anniversary of the merger. But nonetheless, I think we have a high degree of confidence we'll continue to chip away at a higher and higher EBITDA margin.

I wouldn't put an upward limit on what that could be.

Speaker 3

Okay. That's great. Thanks.

Speaker 1

Thanks Matt.

Speaker 0

Thank you. Our next question comes from the line of David MacDonald with Truist. Your line is open.

Speaker 4

Thank you. Good morning. Guys, just a couple of questions. First, on home health, we've seen some interesting announcements out of some of the bigger home health guys about treating a more acute patient. And when you look at the services that they're bringing, home infusion is really a whole across the board.

So can you just talk about the opportunity to work more collaboratively with the major home health players? You mentioned a little bit during the prepared remarks around staffing, etcetera. But if you could just spend a minute on that, that would be helpful.

Speaker 1

Hey, Dave. Good morning. So look, we continue to look for those opportunities to deepen the relationships. I think as you'll recall, we had announced earlier late last year and then again earlier this year around some of the work we are doing with the Amedisys on the monoclonal antibodies. We do think there is opportunities for us to be a partner in that process, both in looking at opportunities to leverage clinical resources as we did with the Amedisys team as well as support their patient population.

So we're pleased at the position that we're in. We think there are opportunities for some additional deepening of partnerships and creation of new ones there.

Speaker 4

Are currently running through these centers? And then how much you think you can potentially push that just given the pretty significant leverage in around labor within those centers?

Speaker 1

Yes, Dave. We've we continue to monitor and track. And I think as we have talked about before, we look at the percentage of nursing visits that we conduct in those facilities as opposed to in the home. We've been running in the high teens, and we've been really focusing on that. Through the second quarter, we were at 20% of our nursing visits were being done in one of our infusion suites.

Our expectations as we move forward is we can be pushing that both by the expansion that we talked about of opening more centers and having more convenient facilities available for the patient population as well as the growth that we're seeing in the patient census, especially on the chronic side. I think that we're looking to push north of that. Whether we can get to 23% to 25%, I think those are realistic, and that's kind of the goals that we're pushing on that. There is a level of patient satisfaction and convenience that we're factoring into not only the efficiencies that we can gain out of that, just the retention and satisfaction of the patient population given these facilities and the features and benefits that we build in there. So we have talked historically around, look, we had a lot of work to do on integration and a lot of work to do to rationalize some of the redundant infrastructure that we had there.

So as we move past that integration effort and now really start focusing around these growth levers, we expect that this will be a bigger part of our go to market strategy and a bigger part of our point of care service model as we're looking at the opportunity ahead. And we're building that into our CapEx plans as we move forward. So it's not a deviation from kind of where what you've seen historically as we're pretty efficient in being able to stand these up in a capital light way.

Speaker 4

Okay. And then just last question for me. If I look at net debt to the midpoint of 2021 EBITDA guidance, it's actually south of four times. When you think about kind of the long term outlook here, what range would you like to run the business in, in terms of leverage? And then on a go forward basis, is it fair to assume further deleveraging will be more growing the denominator as opposing to shrinking the numerator?

Speaker 1

Thanks, Dave. I was waiting for the leverage question, so I owe you one. Look, we're thrilled with the capital efficiency and the cash flow generation of the business. I mean, we mentioned we want to be at or below four times net levered by the end of the year. We're there at midyear and that's in a quarter where we deployed 18,500,000 for M and A.

And so that's another area where we get really excited because we with cash interest dropping and with CapEx relatively static, we see the incremental earnings to incremental cash flow quite significant. I think we expect to operate this business below four times. How far below it's going to that will be dictated partially by what are the strategic opportunities that lie ahead of us. And I would tell you that we the M and A activity is robust. I think it's more likely than not that we will have some additional news to share before the end of the year.

And I think that's an exciting aspect and a serious responsibility that we take in terms of how do we best deploy capital to create value for the shareholders. And I think given where we are at midyear and given the fact that we're we will continue to drift south just based on the earnings and cash flow trajectory, access to capital will be substantial. So more to come on that front.

Speaker 4

Okay. Thanks. Congratulations.

Speaker 1

Thanks, Dave. Thanks, Dave.

Speaker 0

Thank you. Our next question comes from the line of Jamie Pearce with Goldman Sachs. Your line is open.

Speaker 5

Hey, good morning, John and Mike. I wanted to just touch on the long term growth algorithm and level set how you guys are all thinking about that. Just given the step up in growth this quarter, the growth investments you talked about, the new infusion suite, is it time to kind of level set us on where you think this business can grow long term?

Speaker 1

Yes, Jamie, look, obviously, we're not in a position to provide longer term guidance. But the way we've characterized it is we see this industry in a mid to high single digit top line. I think we've tried to establish a reputation of laying out guidance that we have an extremely high degree of confidence that we will deliver. We also believe over the last couple of years, we've demonstrated we think we can grow faster than the market just based on the unique aspect of this model. And we've said that we see that in a as a base case before inorganic capital deployment of somewhere in the low to mid teens.

Look, this year, we're thrilled with the momentum in the business that we've built. Again, one note of caution just around relative to the comp of 2020, it gets a little atypical, I guess, is the term I'd like to use. And so look, as we go forward, I think we have a very high degree of confidence in that base case. And as we get closer to 2020 we'll revisit that. But for now, I still think that longer term is still a logical zip code to focus on.

Speaker 5

Okay, fair enough. I wanted to come back to the Medicare reimbursement and the issues there. I know that's a barrier to increase confidence on the ADUHELM side. I'm wondering if that were to improve what that would mean to the base business. So for getting Alzheimer's for the moment, how could that change the number of therapies that are addressed in these alternate sites and your outlook for the business?

Speaker 1

Yes, Jamie. Look, as we've talked about before, the current way that Medicare reimburses, especially in the home, it's just inadequate for the care that's provided. We're working on multiple approaches to that, both with the industry and independently through the process of getting a better reimbursement scheme that reflects not only the care plan and oversight as well as the nursing interventions that we provide, not just the drug and the drug reimbursement per their process. Look, I think on the near term, our focus is getting the calendar day fix around getting a per diem for when a patient is truly under our care and we're managing them through that process, and that's been the focus. I think more broadly, we'll continue to look for expansion opportunities to expand access to the Medicare population.

But this is going to take time and it's pretty complex given all of the different priorities in Washington these days.

Speaker 5

Okay. Thank you. Congrats on the quarter.

Speaker 1

Thanks, Jamie. Thanks, Jamie.

Speaker 0

Thank you. Our next question comes from the line of Lisa Gill with JPMorgan. Your line is open.

Speaker 6

Thanks. It's actually Mike Minchak on for Lisa this morning. Just a couple of questions. So first with respect to gross margins, clearly a very strong quarter there with nice year over year growth. Was just wondering if you could comment at all on sort of the trends you saw within both segments of the business.

Was the growth there sort of more mix driven or given the pickup of growth in the acute therapies? Or are you seeing favorable margin trends within both categories? And if so, maybe what are the key drivers there?

Speaker 1

Hey, Mike. It's Shapiro. I'll start. So look, I think a couple of key dynamics within gross margin. First and foremost, we continue to aggressively drive down bad debt.

Any amount of bad debt is unacceptable, and we've driven it down a couple of full percentage points over the last year. And so as seen bad debt drift down towards 2%, that's an immediate gross margin benefit. Aside from that, within each of the therapy categories, we have been aggressively working on our procurement strategies and we've got a procurement team that's second to none. And we also continue to work our with the manufacturers and suppliers. Again, we benefit from having direct relationships with most of our suppliers.

And as we collaborate with them on market expansion and promoting the therapies that can result in better margins within each of those categories. So I would say, a, we still saw some ASP headwind. We still saw some mix headwind from chronic growing a little faster than acute. Again, acute did benefit from an easy comp in terms of the year over year. But I think the way I would characterize it is probably your latter assertion that we saw good margin traction within each of the individual portfolios.

Speaker 0

Thank you.

Speaker 1

Our

Speaker 0

next question comes from the line of Kevin Fischbeck with Bank of America. Your line is open.

Speaker 7

Good morning actually. This is Joanna Gajuk filling in for Kevin today. Thanks for taking the questions. I want to follow-up on a couple of these things you were discussing already for on the infusion suites that you expect to add I guess 10 to 15 sounds like in the second half of this year. So for the kind of reference point, can you talk about how many of these suites did you add this year or over the last twelve months or maybe before the pandemic kind of get a sense of acceleration seems in those suites being added?

And I guess to that add, you mentioned that it's a very cost efficient way of growing. So can you give us a ballpark, I guess, of CapEx expectations for the year?

Speaker 1

Sure. It's Mike. So today, we have a little north of 120 infusion suites, almost 400 shares post to coast. And again, a lot of these are standalone, a lot of these are incorporated into our care management centers and pharmacies. And this as John mentioned, today, roughly twenty percent of our nursing events occur in one of our suites.

Again, this is we view this as both a clinical labor efficiency strategy as well as a growth support platform as these suites are quite amenable to many of the chronic conditions and patient cohorts that we support. And so look, as we think about we've added some in the first half technology and infrastructure projects within that estimate.

Speaker 7

Okay. Because what I was getting at is have you added recently these sweets because clearly you're growing faster than the market. So we are trying to assess what is driving that. I mean it sounds like it's sustainable but just any color there whether adding the suites the last to think that those markets for gains are sustainable?

Speaker 1

Yes, it's John. I guess I respond to that in two ways. Certainly, infusion suites and adding the additional chairs that we did certainly give broader access and we will capitalize on that. But the growth, a lot of that was driven by, again, the deepening partnerships that we have with the payer community, the deepening partnerships we have with the referral sources and the focus of our commercial team to make certain that from a reach and frequency that they are getting out into the market and that they're capitalizing on the platform that we have. So I think it's just one component of what is a comprehensive go to market strategy.

And our expectations are that given the investments we've made into the team, given the training that we have provided them, that we're going to be well positioned to continue to capture our fair share of demand in the marketplace and look for those opportunities to continue down the growth momentum.

Speaker 7

And to follow-up on something you said also on this topic of gaining market share, can you talk about your relationships with your payers? Are is there a clear drive for these payers to shrink their networks? And I guess are you the beneficiary of that dynamic?

Speaker 1

Yes. Look, they'll give you their strategy. From our perspective, look, if we are offering high quality care at an appropriate cost in a setting in which patients want to receive the care, we think we're really well positioned on that. The national network that we have gives them the confidence that patients or their members regardless of their location will be well served and have superior clinical outcomes based on the capability sets that we have. And so look, we think we're on the right side of narrowing of networks because we should be a preferred partner for them there.

And that our focus is around patient satisfaction and high quality outcomes. And if we do that, we expect that we'll be on the right side of any of those conversations.

Speaker 7

Yes, definitely. Because I guess there is not really a unified quality scoring system for home infusion, but I guess it's really more about the payer relationships and I guess what you deliver to them and I guess how this relationship progresses. I understand and thank you for answering the questions.

Speaker 0

You're welcome. Thank you. Our next question comes from the line of Mike Petusky with Barrington Research. Your line is open.

Speaker 8

Hi, good morning guys. A couple of questions. Mike, I guess on bad debt expense improvement, was that driven by maybe some of the old bioscript stuff being cleared out or cleared through gone through or things that you guys have done? And then I guess I think I had always thought that maybe 2% was about as good as it could get there. And I'm just curious if you think there's meaningful room?

Speaker 1

The bioscript side. And so I would say it's more around when we're providing the services, we're making sure that we're presenting clean claims and following up with payers. The amazing thing is if you present an accurate timely claim to a payer, they pay you very timely. And so that's as complex as it gets and we've just become relentlessly focused on doing so. And if you look since the first we're basis and it continue there's some modest growth, but nowhere as close as revenue.

And so our DSO continues to improve. And I would say 2% might have been the theoretical low. I will tell you that we've got a team that is just getting started on that front. And I would expect that we'll dip below 2%. How far?

What really matters is just getting that cash in the bank.

Speaker 8

Okay. Terrific. And then John, I guess you guys, with a lot of other health care companies, have expressed that they've learned things about their businesses during COVID in 2020 and into early twenty twenty one. And I'm just curious, are there things that you can sort of call out that if this delta variant or another variant becomes a thing for at least a period of time that you guys learned last year or earlier this year that you feel will position well as you deal with any challenges related to a variant heating up? Thanks.

Speaker 1

Yes. So a couple of things that we've talked about previously. Some of the investment in the technology stack allows us to be efficient in discharges on a virtual basis, on virtual teaches, on the ability for us to utilize that tool to improve patient engagement and support. So we're going to continue to leverage that where appropriate. Our team has become very adept at being able to capture the demand in the marketplace, even though for a while we weren't allowed into the facilities or we had restricted access.

And so we're going to continue to execute around those paths. Think from Mike had called out, look, from an operating standpoint, we have figured out how to be very effective with remote workforce and leveraging the technology to collaborate in ways that honestly we just weren't doing in advance of the pandemic. And we're going to continue those as we move forward, because we expect that we'll continue to get the efficiency and the effectiveness of those collaboration tools as we look ahead.

Speaker 8

Can I just ask, according to an article, I think I read this morning, it looks like the Delta variant is sort of ripping through a couple of key states or bigger states? Have you guys noticed any meaningful dip in patient referrals or anything else in The States that appear to be hit the hardest with this variant?

Speaker 1

Yes. Look, we certainly feel impact as hospitals reset if they move towards reducing or eliminating elective surgeries or they move towards being more responsive to the pandemic in their marketplace. We feel the impacts of that. We also feel the impacts when patients aren't going to specialists for diagnosis or for care. And so that's we kind of monitor that on a market by market basis.

But yes, I mean, we feel the impacts of those. But right now, it's been a pretty short duration for the variant and we're trying to monitor and manage that.

Speaker 0

Great,

Speaker 9

thanks. Congratulations on a great quarter. A lot of questions been asked here. But first of all, Mike, I would ask, you made some comments with respect to your conservatism in the past, obviously, because the merger, first and foremost, and then COVID last year. Just talked about technology with respect to the bad debt and then on this new collaboration for engagement.

I'm just curious on the tens of millions of dollars you spent previously,

Speaker 7

do

Speaker 9

you think you've realized all the benefits from that technology as of now? And then looking forward on this collaboration, where do you see the benefits coming from the technology and maybe how quickly?

Speaker 1

Yes. So first and foremost, we are still in a process. We will fully deploy the technology here in August across all of our platforms. So there is still some opportunity that we see from interoperability and kind of tightening some of the process and efficiencies that we can receive out of that. We're really excited about the opportunity to have that patient interface and drive a better patient experience and engagement through the collaboration with AliveCare and the co development there.

So look, we still see some additional opportunities to drive efficiencies and effectiveness and in many instances, a better engagement and outcome for the patient population. Yes. I think from a return perspective, Rich, I think we absolutely have. As we've talked about throughout the merger and integration process, we started years ago with very scalable platforms using market leading platforms, and we've retooled and replaced a lot of clean rooms and pharmacy infrastructure. And I think pre merger, the EBITDA margins were in the mid single digit range, and we're now we just printed an 8%.

I would say that from the cash and from the earnings ROI, I think we have absolutely generated the returns or greater than we expected. And I think those platforms continue to be highly scalable going forward.

Speaker 9

Okay. That's very helpful. And then John, I just wanted to touch on the labor market. You did mention that quite a bit in your prepared remarks. Is that the biggest headwind for you guys as you look forward just managing the labor component?

Just any thoughts there is helpful.

Speaker 1

Yes. I mean, look, it certainly is a headwind. You don't pick up many newspapers that don't highlight some of the constraints. It is market by market driven. Certainly, some of the clinical resources, nursing being one of those areas that we're watching closely.

We like our model in the sense of we have full time, part time per diem and then the strength of some of our agency relationships that allows us to flex through that process. But yes, I mean that is an area that we are keeping our eye on. I think the other thing that we're keeping our eye on is we had just talked about was the Delta variant and how that's going to have impact in the second half of the year.

Speaker 9

Okay, great. Thanks. Congratulations.

Speaker 1

Thanks, Drew.

Speaker 0

Thank you. Our next question comes from the line of Frank Takkinen with Lake Street Capital Markets.

Speaker 2

Just expense thoughts as well as any potential or likelihood of a refinance. I think there's a rate lock expiration coming up. So just maybe give us a overall thought process around interest expense as we think about the back half of this year and into 2022?

Speaker 1

Sure, Frank. So look, when we started this journey, we were burning about $110,000,000 in cash interest. We're right now in the second quarter at an annual rate in the low the It includes a rate swap that swaps out our rate to 2% fixed. That expires near the end of the third quarter. And at that time going into the fourth quarter, we should take another meaningful step down to somewhere depending on where LIBOR and rates are somewhere in the low to mid-50s, which represents a 50% cut in our cash interest from a couple of years ago.

So very important we're to at opportunities for five years, and it's all at L plus 3.75%. We'll continue to look opportunistically at our cap structure. And if there's opportunities to further improve it, you can bet we will absolutely capitalize on those opportunities.

Speaker 2

Perfect. Thanks and congrats again on the quarter.

Speaker 1

Thanks, Thanks, Frank.

Speaker 0

Thank you. I'm showing no further questions in the queue. I would now like to turn the call back over to John for closing remarks.

Speaker 1

Great. Thank you. In closing, look, I'm very pleased with the performance of the team and the strength of our first half results. Our focus remains on providing extraordinary care to the patients that we serve and capitalizing on the momentum we are gaining even in this dynamic environment. Thank you for joining us this morning and please stay safe.

Speaker 0

Ladies and gentlemen, this concludes today's conference call. Thank you for your participation. You may now disconnect.