Option Care Health - Q3 2023

Transcript

Operator (participant)

Good day, and thank you for standing by. Welcome to the Option Care Health third quarter 2023 earnings conference call. At this time, all participants are in a listen-only mode. After the speaker's presentation, there will be a question-and-answer session. To ask a question during the session, you will need to press star one one on your telephone. You will then hear an automated message advising your hand is raised. To withdraw your question, please press star one one again. Please be advised that today's conference is being recorded. I would now like to hand the conference over to your speaker today, Mike Shapiro. Please go ahead.

Mike Shapiro (CFO)

Good morning. Please note that today's discussion will include certain forward-looking statements that reflect our current assumptions and expectations, including those related to our future financial performance 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 expectations. We encourage you to review the information in today's press release, as well as in our Form 10-K filed with the SEC regarding the specific risks and uncertainties. We do not undertake any duty to update any forward-looking statements except as required by law. 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.

John Rademacher (President and CEO)

Thanks, Mike, and good morning, everyone. Overall, the third quarter was a strong performance, and our team of over 7,500 dedicated members at Option Care Health continue to set the pace in home and alternate site infusion market. And I'm personally quite pleased with our ability to remain focused on our key objectives and expand the census of patients that we serve. Patient care is at the center of everything that we do, and our purpose is to provide extraordinary care that changes lives for the better, and the team continues to fulfill that on a daily basis. Given that there is a loved one on the receiving end of every dose that we dispense and infusion we oversee, I believe our team is relentless in driving for the highest quality and best patient experience.

In the third quarter, our patient satisfaction score exceeded 92%, and we achieved a Net Promoter Score of over 75. So while we continue to deliver solid results for our shareholders, we also continue to deliver unsurpassed service to our referral partners and care for our patients. In the quarter, our team continued to collaborate with our key stakeholders across the spectrum of biopharma, payers, health systems, and physicians to support our patients and to deliver care in their homes or one of our convenient infusion centers. This resulted in balanced performance across a broad portfolio, including acute therapies for our patients transitioning from a hospital setting to patients receiving care for an ongoing chronic condition. There's a lot to unpack in the financial performance, but overall, the results were strong and in line with our expectations.

We generated approximately $110 million in Adjusted EBITDA on revenue of $1.093 billion, resulting in another quarter of double-digit adjusted earnings growth and an Adjusted EBITDA margin of 10%. The capital structure has never been stronger, and we continue to generate solid cash flows and improve the leverage profile of the enterprise. In my opinion, the focus of our revenue cycle management team has been outstanding, and our ability to drive the velocity of cash collections has never been better. On our second quarter call, you will recall that we committed to repurchasing $100 million in stock in the near term, roughly equal to the $106 million gross breakup fee before taxes and fees related to the Amedisys transaction. I'm pleased to share that we completed that repurchase effort in the third quarter.

Year to date, we have repurchased $175 million in stock while continuing to drive our leverage profile well below 2x. I want to shift gears before handing the call over to Mike to share a few thoughts on our M&A strategy, given some of the developments from earlier this year. As we have consistently articulated, we view this deployment of capital in support of M&A as a cornerstone of our strategy to create value for our shareholders. The base business continues to perform very well and has a strong foundation with favorable capital structure. Given this, we continue to be well positioned to evaluate opportunities for strategic capital deployment intended to deepen our market presence or increase our capabilities to serve patients in the home or alternate site setting.

As mentioned on the second quarter call, we have thoughtfully considered feedback from our shareholders as we continue to seek to identify value-creating opportunities and focus our M&A efforts. From my vantage point, we see an array of opportunities to strengthen our offering, and given our strong foundation, we will continue to be disciplined and thoughtful in evaluating potential targets. Our primary focus continues to be on executing on our core home infusion business and maximizing the value of our platform as we evaluate capital deployment strategies. While we are not in a position to lay out details or specifics, as I mentioned, we would anticipate near-term M&A efforts to focus on assets closer to our core business, and would anticipate redeploying capital opportunistically from our cash balances and leverage capacity.

As Mike and I have consistently conveyed, we are comfortable operating at a Net Leverage Profile up to the 3x-4x range. Having said that, we will be quite disciplined in evaluating both economically and strategically, the attractiveness of each opportunity. This is a facet of our strategy that we take very seriously, and I am confident that given our market position and capital structure, we are well positioned to continue our M&A efforts to increase value for our shareholders by delivering value to our key stakeholders. I will finish where I started, which is to reiterate the strong performance of our business and express the confidence I have in our team to continue providing unparalleled patient care in the home and alternate site setting. With that, Mike will provide additional color on the results. Mike?

Mike Shapiro (CFO)

Thanks, John. Overall, the results from the third quarter were quite strong and continue our track record of double-digit Adjusted EBITDA growth with solid cash flow generation, and we expect to deliver another strong year for our shareholders. Revenue of $1.093 billion was up 7% over the prior year, and as John mentioned, was balanced across the portfolio. We've seen growth in our acute therapy portfolio stabilize to lower single digits as we've anniversaried the competitive gains from a year ago. But volumes continue to be solid as we partner with health systems to transition patients from the acute care setting. Chronic revenue continues to be strong across the portfolio, and recall that we exited two chronic therapies earlier this year that collectively represented a headwind of roughly 100 basis points on a consolidated basis in the quarter.

Gross margins continue to be strong, with Q3 gross margin of 23.3%, as gross profit dollar growth outpaced the top line. Our ability to offset the mix shift towards chronic and expand margins was driven by our relentless focus on operational efficiency, as well as some procurement tailwinds. As I mentioned on the second quarter call, our procurement environment is quite dynamic, and we see puts and takes every year. We believe our procurement team is the best in our industry and is constantly collaborating with biopharma, as the majority of our procurement efforts are direct with manufacturers. Earlier this year, we were able to drive favorable margin dynamics for a number of codes that resulted in an approximate $8 million-$10 million benefit to the gross margin line in Q2.

In the third quarter, that benefit was approximately $12 million-$14 million, which benefited margins considerably. Again, this is not an exact figure, as there are many volume, payer, and therapy dynamics at play. We see a similar benefit in the fourth quarter, and that's incorporated into the revised guidance that we shared this morning. While we are not in a position to provide any preliminary thoughts on 2024 this morning, we expect with a high degree of conviction that the favorable procurement dynamics that I'm referring to will subside in early 2024. Adjusted EBITDA of $110 million represented 10% of revenue and grew 28% over the prior year. Even excluding the approximate $12 million-$14 million procurement benefit, we still delivered mid-teens Adjusted EBITDA growth in the quarter.

As John mentioned, we completed the $100 million share repurchase effort in the quarter. You'll recall we announced our first-ever authorization in the first quarter of this year for $250 million and have deployed $175 million to date. We exited the quarter with $386 million of cash on the balance sheet, even after the share repurchase efforts and settling all fees and taxes related to the Amedisys transaction, and we finished the quarter at a Net Leverage Profile of 1.7x. So very pleased with the progress and financial profile exiting the third quarter.

Finally, as you saw in our press release, we've updated our guidance this morning, and for the full year, we now expect to generate revenue of $4.23 billion-$4.28 billion, Adjusted EBITDA of $420 million-$425 million, and cash flow from operations of at least $350 million. So shaping up to be another very productive year for the Option Care Health team. And with that, we're happy to take your questions. Operator?

Operator (participant)

Thank you. As a reminder, to ask a question, please press star one one on your telephone and wait for your name to be announced. To withdraw your question, please press star one one again. Please stand by while we compile the Q&A roster. Our first question comes from David MacDonald with Truist. Your line is open.

David MacDonald (Managing Director)

Yeah, good morning, guys. Guys, just a couple of questions on the ambulatory infusion suites. Was wondering, you know, if you could give us that number in terms of percentage of nursing visits in the quarter. And secondly, just, are you continuing to see, you know, meaningfully higher uptake amongst newer patients relative to kind of the installed base, so we should continue to see that figure drift higher over time?

Mike Shapiro (CFO)

Hey, good morning, David. It's Mike. Yeah, good progress in the quarter. In the quarter, we opened an additional five new infusion suites. So right now, you know, we're at about 160 infusion suites across the country, right around 650 chairs, so good progress. The team continues to identify those strategic expansion areas. We're still around that 28%-29% of total visits. Although, you know, given the top line growth, we actually have seen really solid growth in the number of visits in the infusion suite, even though as a percent of our total nursing, it's relatively consistent with the second quarter. And so, you know, as you mentioned, one of the leading indicators is how well are we penetrating those new patient onboards, and I'd say we're highly encouraged by the traction.

And again, this is part of the snowball rolling down the hill because part of it is making sure we have those infusion suites strategically located near the patient densities of those chronic cohorts.

David MacDonald (Managing Director)

Then, Mike, is 25%-30% kind of the right number to think about on an annual basis? As that footprint continues to expand, you know, any more meaningful conversations with either payers about more aggressively pushing site of service redirection or even, you know, things like hospital JVs, where you could drop a few of these around, you know, a big hospital system, just, you know, anything to update there?

John Rademacher (President and CEO)

Hey, Dave, it's John. Yeah, I think that, you know, the 25%-30% is probably the right range. We will always continue to push that, you know, forward. And, you know, I don't know that we believe there is a cap, at this point, but, you know, it takes time. And as we've talked about before, you know, the different, start up, and then ramp up that happens with that as we're adding more facilities, it just drags down in the near term, some of those percentages. We're working with payers around site of care initiatives.

We certainly continue to have very productive conversations with some of the leading health systems around ways that we can better meet their needs and the needs of their patients, whether it's through utilizing our existing infrastructure or thinking about how we would better partner with them in order to capitalize on that patient flow. So encouraged with those conversations and also encouraged just around the thoughtfulness around thinking about site of care and, you know, providing high-quality care at an appropriate cost in a setting in which those patients want to receive it.

David MacDonald (Managing Director)

Okay. And then just a couple of others, guys. When we think about capital allocation, just given the cash flows of the company and the cash balance, should we also think about buybacks becoming, you know, a more consistent part of the capital allocation on a go-forward basis?

Mike Shapiro (CFO)

Yeah, I think, Dave, we're gonna continue to be balanced. I think as we've been open, you know, given the strength of the balance sheet and the cash flow, I think that has, you know, we've established the right to have a multifaceted capital allocation strategy. I think as John mentioned in his upfront comments, I think, you know, look, we made good progress against the acquisition, much in part due to the receipt of the breakup fee that we thought was appropriate to quickly redeploy. I think we're gonna continue to improve the capital structure because as John said, I think we see a quite attractive landscape on a multiple M&A opportunity front.

And I think while we'll continue to balance both of those strategies, frankly, I think, you know, in the nearer term, I think the priority is gonna be more skewed towards M&A deployment.

David MacDonald (Managing Director)

Okay. And then, guys, just last question. I know you're not giving 2024, but just how we think about kind of the bridge. I guess a couple of questions. One, Mike, when we think about some of the procurement benefits, and it looks like a little bit over $30 million, I would assume that the correct jumping-off point is kind of in the upper 390s. You kind of back that out as you move towards 2024. And then I guess the other couple of questions is on cash flows, the Amed breakup fee, and then on the top line, I think you had talked about those products being you expected roughly a 200 basis point impact for the year. Is that kind of everything to think about in terms of 2023 relative to 2024?

Mike Shapiro (CFO)

Yeah, I'll start with what you would expect is my legal qualification, that we're not in a position to provide-

David MacDonald (Managing Director)

Sure

Mike Shapiro (CFO)

... guidance on 2024. A couple of things. Number one, yeah, look, with and, and these aren't exact numbers, but our best estimate is in Q2 and Q3 from my remarks, you know, the procurement tailwinds were somewhere in the $20 million-$24 million range. We expect, you know, somewhere in that, call it, $10 million-$12 million range for Q4. So yeah, I think high level, the way to think about it is, and, and with a high degree of confidence, those are going away very early in Q1. So think of $30 million of procurement, which we've been very transparent, well, is mostly transitory, and, and so $30 million likely will not continue into next year. On the cash flow basis, yes, I mean, the, our guidance of more than $350 million includes the $106 million break fee.

Although, you know, we demonstrated our relentless focus on cash flow generation and normalizing for the Amedisys receipt, we would continue to expect, you know, high cash flow efficiency. And in the quarter, the two exited therapies, Makena and Radicava, represented a little over 100 basis points of headwind. So there was a little bit of that in Q1 and early Q2, so we'll anniversary. We'll obviously unpack this to a greater extent in February, Dave, but I think that'll be more of a muted impact going into next year with a little bit of the first part of the year headwind.

David MacDonald (Managing Director)

Okay. Thanks very much, guys.

Mike Shapiro (CFO)

Thanks, Dave.

John Rademacher (President and CEO)

Thanks, Dave.

Operator (participant)

One moment for our next question. Our next question comes from Matt Larew with William Blair. Your line is open.

Madeline Mollman (Equity Research Associate)

Hi, this is actually Madeline on for Matt. Thinking about the M&A sort of post-Amedisys deal. I know you've talked about listening to shareholder feedback. Are there any specific criteria or specific, like, things that you look at when you're evaluating deals that have changed in the last couple of quarters compared to how you were thinking about M&A maybe before the Amedisys deal?

John Rademacher (President and CEO)

Hey, Madeline, it's John. You know, as I said in my prepared comments, and I think we even talked about in the second quarter earnings call, our focus and again, based on some of the feedback that we got from shareholders through the Amedisys process, will, you know, be closer to the core home infusion, alternate site infusion business. I don't want to box us in too much on that. We're always going to take a look for opportunities to expand our capability set to ensure that we remain and increase our relevance with our partners in the marketplace, across the key stakeholders of biopharma, of our payers, of our prescribers, you know, in the marketplace. So all of those, you know, components fit in there.

We talk a lot about it needing to be both economic and strategic. And so if there's opportunities for us to increase our market presence, if there's opportunities for us to increase our capability set to provide a better clinical outcomes for the patients that we serve, if there's opportunities for us to expand our capabilities to be more convenient for patients to receive care from Option Care Health, all of those kind of fit into that criteria. We're always looking at it on a cash-on-cash basis. We are focused around, you know, creating value for our shareholders through the process.

You know, as Mike said in the last response, you know, we believe that deployment of capital in a multifaceted way, but more importantly, through deployment on M&A to expand, you know, on our capability set is a really good use of capital and creates that value for our shareholders over the mid and long term.

Madeline Mollman (Equity Research Associate)

Great, thank you. And then one more on the infusion suites. I think you've talked about you're seeing, like, a 10% nursing productivity uplift in the suites, but the suites so far have not been fully ramped. Can you talk about how you're thinking about that productivity uplift going forward as you add more suites and as they ramp up to full capacity?

John Rademacher (President and CEO)

Yeah, Madeline, it's a great question, and great to hear from you this morning. Look, as we talked about, you know, in reality, our AIS expansion strategy is about two years old. We really lit the fuse on this in late 2021. And so, you know, as we've talked about, we have quite a disciplined model that would project that, you know, by the first anniversary around month 10 to month 15, these are breaking even, i.e., the nurse productivity is paying the utilities, the rent, and insurance and cost of the facility infrastructure.

We've said that by the second anniversary of opening these, and again, some of these, you know, these are based on the earlier tranches of the sites that we're opening, we're seeing about a 10% productivity uplift, which is great from two perspectives. Because number one, that helps us with our cost of service and helps our margin expansion. It's also a growth enabler because think of it as we're adding, you know, additional nursing hours, which is a scarce resource. We have not yet tested the upper bounds of what ultimately that productivity uplifts.

I think it's safe to assume that with our ops teams in the field, we would expect that ultimate productivity to be well north of 10%, because candidly, none of our centers are operating anywhere close to full capacity, nor do they have to, for them to be a growth enabler and a margin accretive investment for us.

Madeline Mollman (Equity Research Associate)

Great. Thank you guys so much.

John Rademacher (President and CEO)

Thanks, Madeline.

Operator (participant)

One moment for our next question. Our next question comes from the line of Lisa Gill with JP Morgan. Your line is open.

Lisa Gill (Managing Director)

Very much. Good morning, John and Mike. Just want to follow up on one thing to start, and that is, Mike, on the implied fourth quarter revenue. Historically, if I look back the last few years, you don't see a deceleration between the third and fourth quarter. Is there anything that's shifting this year versus what we've seen historically?

Mike Shapiro (CFO)

No, I mean, I think, you know, if you look at our revised guidance, you know, it's consistent with the comments that we made on the second quarter. We would expect, you know, given a number of dynamics, that things will be a little bit flat relative to the third quarter. The only thing I would say, you know, on the acute business, where we've seen some of that subside back down into the first into the low single digits, Lisa, we did still have a number of transitionary patients last year, you know, when a couple of the competitors exited. You know, we did take a flood of patient transfers, which does create, you know, a little bit of still year over year headwind.

You know, there's some pricing involved as well, but overall, we still see, you know, and, and would expect volumes to be solid going into the fourth quarter.

Lisa Gill (Managing Director)

Great. And then my second question is around managed care contracting. So if I think about this, this time of year, can you just remind us, like, how should we think about managed care contracting? And, you know, kind of going back to one of your earlier comments, talking about working with managed care, getting more people into your infusion suites. Is this something that happens on an annual basis? Is this a three-year type of relationship? And, as you have those contracts come up renewal, is there anything that you would call out that you would say is different on a go-forward basis with the relationships you have across managed care?

John Rademacher (President and CEO)

... Yeah, Lisa, it's John. You know, most of our contracts are evergreen, so they'll have an automatic renewal within them. Some of our larger, you know, national programs, you know, there'll be a three-year on that. So we don't really come up to the edge every year, you know, waiting for the drum roll to see if we renew or not, on that. They pretty much continue to flow through that process. You know, we have been working across the spectrum with, you know, the largest to the smallest health plans, looking for ways for us to help them bend the cost trends.

You know, some of the conversations that we're having certainly focus around site of care initiatives that they have, looking at different cohorts of patients that they're focusing on, are things that happen on a regular basis, and they don't necessarily only happen once a year. They happen through, you know, our quarterly business reviews and other aspects that we are undertaking as a partner, not only to demonstrate the value that we're bringing them, the satisfaction of their members, those types of things. We're doing that on a pretty consistent basis with our team of dedicated, you know, professionals in the market access area. I'd say, you know, some of the conversations, you know, have been focusing really on that site of care initiative, around looking at specific areas of focus, depending on the payer.

We certainly have been talking to them about some of the cost of nursing and trying to, you know, make certain that we are getting rate increases where we can, where contracts will allow us with cost of living adjustments and/or with some renegotiation in that process. And I think that, you know, folks understand some of the pressures on healthcare providers in recruiting and retaining clinical talent in today's environment. So, you know, I'm not going to say that it, it's easy, and Mike and I continually remind everybody that no one's coming to us saying that they want to pay us more.

But I think when you can put a strong fact base behind it, and you can demonstrate, you know, the high quality care that we're providing, the ability to have those conversations and seek some rate increases is something that we are focusing on, and again, having those conversations across the board.

Lisa Gill (Managing Director)

And John, if I could just sneak in one more, you know, as it pertains to staffing. You talked about retaining staffing around nursing, et cetera. Can you just talk about the current environment? Do you feel like it—I mean, obviously, it was really challenged for a number of years. Do you feel like it's better? Do you feel like we're at this equilibrium? I know, like, there continues to be pressure from a wage perspective, but anything else you would call out to us as we think about, you know, the cost from that side?

John Rademacher (President and CEO)

Yeah, I would say it is stabilized. You know, it's not easy by any stretch of the imagination, and you know, I remind our team that we got to recruit our team every single day. And you know, we're looking for ways to put programs in place to you know, provide appropriate incentives and other aspects to make certain that we are an employer of choice and that we have a high value proposition for the team. You know, the ability that we have with Naven, and Naven continues to expand its ranks of nurses that it has in its roster as part of its network.

The ability for us to tap into that has allowed us to continue to grow, as well as the recruiting that we're doing, as Option Care Health for full-time nurses within our, our environment. So, you know, it's not easy, Lisa, but I'd say, it's not as crazy as it was, say, 18 months ago, you know, at the peak of some of the, the challenges that everyone was feeling in healthcare.

Lisa Gill (Managing Director)

That's really helpful. Thank you so much.

John Rademacher (President and CEO)

Yep. Thanks, Lisa.

Operator (participant)

One moment for our next question. Our next question comes from Joanna Gajuk with Bank of America. Your line is open.

Joanna Gajuk (Director and Equity Research Analyst)

Hey, good morning. Thank you. Thanks for taking the questions here. So a couple of follow-ups, I guess, on the very last point on Naven. Can you give us an update on integration there? I guess there was a new system you were introducing, and you added a third smaller asset recently to that platform. So can you give us a flavor, you know, where we stand, and especially on this new system, are you also getting traction with biopharma when it comes to the, you know, to, I guess, staffing their, you know, clinical labs and what, and whatnot? Thank you.

Mike Shapiro (CFO)

Hey, Joanna, it's Mike. Yeah, I mean, look, Naven's just been a fantastic headline. We—John and I couldn't be more pleased with the progress we've made. The platforms are fully integrated. We're on one technology stack. We've got one jersey, the Naven jersey now, and the team has been really gaining traction, both around recruiting, now that we have a national presence and one national platform. As John said, we continue to recruit both our existing nurses as well as new nurses every single day. And I'd say that the platform is having a great degree of traction, both in terms. And again, we operate that as an independent platform to maintain a wall between Option Care and Naven for separation purposes.

But most importantly, you know, Naven is continuing to support growth on the Option Care Health side, and they've had, you know, great traction across the industry, with other Naven clients, including biopharma, as they look at things like, you know, manufacturer programs, clinical trials, et cetera. And yes, as you did pick up, we did make a very small acquisition in the third quarter, a small nursing staffing agency that, frankly, is already integrated into the Naven platform. It was, you know, quite small, but complementary. And now as we think about that platform, the ability to scale it is quite attractive.

Joanna Gajuk (Director and Equity Research Analyst)

On this last point, in terms of adding assets, so you repeated the comment from three months ago in terms of just in the near term, the spending will be more focused on the core infusion or close to core home infusion assets. But I guess we haven't seen much activity this quarter. So, is there some sort of timing of things, or should we expect more, you know, things to pick up in, you know, later this year or into next year? And any, I guess, flavor on terms of the pace of the deals and the closing of those? Thank you.

John Rademacher (President and CEO)

Yeah, Joanna, it's John. You know, we continue to take a look and understand what's available in the marketplace as, you know, as either assets come available or we engage in different conversations. And we don't really put a time box around when that is, right? It's a matter of making certain that we're disciplined in our approach, and that, you know, we're focused around where we can add value. Just to reinforce kind of in that I said in my comments, and that is, we don't feel like we have to do anything. The core business is operating extremely well, as you saw by the results in the quarter. We have confidence that we can continue to do that.

But we also understand that with the capital structure that we enjoy today, and with the ability to generate cash, for us to find opportunities to increase value to our shareholders, deployment of that capital in a multifaceted way, but certainly in us looking at M&A as part of that multifaceted strategy, we think is the best use of that capital as we move ahead. And so I wouldn't time box it. I don't feel as if there's a shot clock, and we have to do something, you know, in the near term. We're going to look for great assets that are complementary to what we do and increase the relevance with the payers, with the prescribers, with our patients.

If we find the right assets that are economically and strategically aligned, then we will look to deploy capital for those types of opportunities.

Mike Shapiro (CFO)

The only thing I'd add, Joanna, is look, for every opportunity that makes it to a headline, there's likely dozens that die on the edit room floor, because as John reiterated, I think we've driven a discipline that, you know, there's a lot of strategically attractive assets, but it has to generate very attractive cash on cash returns and represent economic opportunities as well.

Joanna Gajuk (Director and Equity Research Analyst)

No, I appreciate that. That makes sense. And, if I may last the follow-up, I guess, on the commentary on, next year in 2024. So I understand you're not giving guidance and appreciate a commentary on the, the procurement, you know, benefit this year, creating headwind next year, and also the therapy, I guess, exits, the headwind this year, so I guess easier comp for next year. But any other, you know, big tailwinds and headwinds that we should be thinking about? I guess, there are, subcutaneous formulations may be coming for some of the main drugs, like Entyvio or Orencia, at some point in the next few years. And maybe with that, you know, if you can give us a flavor of, the Alzheimer's drugs for rollout, and are you seeing more MA plans covering it?

So I guess, and any other, you know, things I guess we should be thinking about or as, as we head into next year. Thank you.

Mike Shapiro (CFO)

Sure, Joanna, and again, I'll reiterate my legal disclaimer, which is to say we're not in a position to provide granularity. Look, the reality is, you know, we're still in the process of working on our 2024 budget and expectations, which obviously we'll be eager to share in 2024 in February of 2024. I think I would underscore a couple of things. Number one, John and I have reiterated that, you know, we maintain our conviction in the growth profile of this platform. Having said that, this is a very dynamic environment. We don't operate in a static environment. There are constantly puts and takes, both from a therapy portfolio, disruptive, you know, technologies, procurement dynamics, payer dynamics. And so, as we, you know, formulate and finalize our thoughts, we'll definitely circle back.

But rest assured, there's always going to be, as there have been over the last four years since we consummated the merger, a tremendous number of variables that are moving. And I don't know, John, if you have any comments on that.

John Rademacher (President and CEO)

Yeah, the only other thing I would add to the specific question around the Alzheimer's. Again, it's been slow in the uptake. As I think everyone is aware, we're still working to understand what are the medical policies in which the payers are going to utilize as we move forward. We again believe that the platform that we have and the capabilities from a clinical standpoint are well positioned to support that—these patients. But there's still so much that has to develop before us. You know, we've talked before about you know the challenges of diagnostic aspects of it, as well as continue to track those patients through the process.

So, you know, we're working, you know, both with biopharma as well as, you know, working or listening to, you know, the feedback from payers around that, and are doing everything we can to be a partner, where, you know, appropriate, and look to participate where we can add value.

Joanna Gajuk (Director and Equity Research Analyst)

... Thanks for taking the question.

John Rademacher (President and CEO)

Yep. Thanks, Joanna.

Operator (participant)

One moment for our next question. Our next question comes from Brian Tanquilut with Jefferies. Your line is open.

Brian Tanquilut (Senior Equity Research Analyst)

Hey, good morning, guys. John, maybe as I think about the pending legislation around hospital site neutrality for drug administration, how are you thinking about the potential downstream impact of that if implemented, for infusion providers such as you guys?

John Rademacher (President and CEO)

Yeah, we are. Well, I'll start with just the general, you know, we continue to work in Washington, kind of across the board to try to look for expansion of coverage and expansion of access for Medicare beneficiaries to be able to receive the full benefits of home and alternate site infusion services. And again, well documented and well discussed, the limited access that they have today. You know, as we continue to take a look at other areas where legislation is moving, again, we look at that as potentially being an opportunity for us. We know that the efficiency of our model allows us to operate it extremely effectively within, you know, the home and alternate site infusion delivery aspects of that.

You know, we talk about the efficiency of our nursing in the infusion suites and our pharmacies and the way that they can compound, dispense, and distribute the product. So, you know, if this starts to open up additional opportunities and/or it changes the economic dynamics to you know, to be more aligned with the lower cost providers, you know, we think that there might be an opportunity for us to participate. But again, we're going to need to have some some legislative fix or other elements that allow us to be able to service those Medicare beneficiaries in the home or in one of our infusion suites.

Brian Tanquilut (Senior Equity Research Analyst)

Got it. That makes sense. And then, Mike, as I think about maybe the puts and takes on some of the moving parts with, with the drivers of revenue, you know, exiting some therapies here and there, how are you thinking about the pipeline of drugs as it drives to offset some of the, you know, therapy exits that you're contemplating?

Mike Shapiro (CFO)

Yeah, I, I think that's a, that's a key variable that we're constantly watching. You know, obviously, we've got a business development team, and our procurement team is dialed in. They've got an ear to the rail with all the manufacturers. We know everything in the pipeline from preclinical through, you know, filing the BLAs. And so, that's something that we absolutely take into account. I think you bring up a good point because I think part of what we also are discerning is looking under the, under the, under the lens of how do we leverage our clinical and pharmacy assets across the, the country.

Even as things migrate from, let's say, an intravenous to a self-administered or a subcutaneous administration or with biosimilars coming out, it's really vital that you look at the labels, because a lot of things that are going subcutaneous might still require healthcare professional oversight or injectables that require HCP oversight. And so those are all key variables. You know, there's a couple of things on the horizon with, you know, certain infliximabs that are, you know, going subQ. Stelara, obviously, one of the things that Janssen's been very open, is they expect biosimilar participation before the end of 2024. These are all variables that we're keeping in front of us. You know, in terms of the pipeline of new to world therapies, that's an area where, frankly, you know, we've exercised and demonstrated our ability to excel.

You know, one thing we talked about earlier this year is just a phenomenal collaboration with the folks at Krystal to commercialize, VYJUVEK, which is a topical gene therapy. Not probably the first therapy that would roll off somebody's tongue thinking about things that we're commercializing, but when you look at the value of what it requires, you know, pharmacy infrastructure, healthcare professional administration, it's something that, while again, it's not going to change the growth profile of the industry, or of our platform, it's definitely complementary and efficient for us to launch given the technology and the clinical infrastructure that we've established.

And so we'll continue to look at both, you know, some of those orphan therapies where we can, we can collaborate and be a trusted partner of choice, as well as what are some of those structural therapy dynamics that have been evolving over the last couple of years and will continue to evolve.

Brian Tanquilut (Senior Equity Research Analyst)

That makes sense. Maybe if I can squeeze one more in. So you guys touched on some of the market share gains that you've had from the exits of some of your competitors from the acute business. How are you thinking about remaining market share up for grabs? Or are there more of these situations that are likely coming up where competitors are exiting certain therapy buckets?

John Rademacher (President and CEO)

Yeah, Brian. Look, from our perspective, you know, I think everyone's going to continue to evaluate, you know, their position. We talked about the choreograph that has to happen in some of these therapies and, you know, the work that has to happen at the local level. Can't really hazard a guess as to whether or not, you know, others are going to make different strategic decisions. We have built a dynamic and resilient network that would allow us to take on additional patient volume if that were to come our way. And, you know, we're out every day hustling to try to, you know, capture market demand as it exists, regardless of actions of our other competitors.

So, you know, that's the way we've always approached it, and I think we're well positioned given the resilience and the capacity we have within our existing network.

Pito Chickering (Managing Director)

Awesome. Thank you, guys.

John Rademacher (President and CEO)

Yep. Thanks, Brian.

Operator (participant)

One moment for our next question. Our next question comes from Jamie Perse with Goldman Sachs. Your line is open.

Jamie Perse (Equity Research Analyst)

Hey, good, good morning, guys. I wanted to start with a clarification on the 2023 EBITDA base. I know you guys gave the 100 basis points of ASP pressure and 200 basis points from Makena and Radicava. I think you said that's been actually a 100 basis point headwind so far this year, Makena and Radicava specifically. So I just wanted to confirm that, and that's sort of what we should be expecting to be, you know, a headwind next year. And then similar question on the ASP, just whether that has played out as you expected this year?

Mike Shapiro (CFO)

Yeah. So the 100 basis points I referred to, Jamie, was in the quarter, so, you know, in Q3. We started to see last year some of the Radicava start to ramp down. Again, I don't think that. Again, not in a position to unpack 2024 really, but I don't think we're gonna be talking about Makena and Radicava in early 2024. Yes, there was some early revenue in 2023. It, it's not gonna be a headline on a year-over-year basis. We have seen some further ASP erosion, consistent with how we thought coming into the year, specifically on some antibiotics and on some of the infliximabs for chronic inflammatory. So that has played out relatively consistent with how we projected it going into the year.

The other thing is, obviously, we had, I think, somewhere in the neighborhood of 30-40 basis points of... And again, all this is, you know, not against a backdrop of a static platform, but, you know, we did exit a respiratory therapy business in late Q4 of last year, which I think represented about 30-40 basis points of headwind for this year. That topic goes away going into 2024 as well.

Jamie Perse (Equity Research Analyst)

Okay. And then, secondly, just on the third quarter, were the procurement benefits, you know, in line with your expectations? It was a little higher than I expected in the quarter. So just wanna get a read on that, and then, relatedly, if the underlying business performance was in line with your expectations.

Mike Shapiro (CFO)

Yeah, I'd say overall, you know, the quarter developed consistent with how we were expecting going into the third quarter. Look, on the procurement benefits, they were a nudge better than we expected. And again, this is not, you know, an exact science. It's a little bit of hand grenade range. That's part of the reason, frankly, why we brought up the bottom end of our range to $420-$425, with drifting towards the higher end of the $415-$425 we articulated in late July, was if in fact, some of those procurement benefits manifested at a slightly higher level, which candidly, they did. And so, you know, look, how the... You know, and that's incorporated into our Q4 implied guide.

At the end of the day, you know, it's shaping up to, call it $30 million-$35 million of 2023 procurement benefits, which are real, and hats off to our procurement team. They muscled their way to realize this. But that is something that obviously we wanna highlight to folks, which won't continue into next year.

Jamie Perse (Equity Research Analyst)

Okay, perfect. And then, John, two for you. You know, first, sometimes you talk us through the key drivers of growth, you know, specific therapy classes. Can you spend a minute just giving us a flavor for what's driving growth at this point and where those therapy categories are in their life cycle?

John Rademacher (President and CEO)

Yeah. So we continue to work closely with, you know, our reach and frequency of our commercial team to make certain that we're well positioned to capture demand coming out of the acute setting. And, you know, those antibiotics and nutrition support products, they're kind of in the later stages of those life cycles, right? In the sense of their utility remains high, and we continue to see that. But as we've disclosed before, that's a lower growth profile in the low single digits on the acute. On the chronic side, you know, we continue to see strength in immunotherapy. We continue to see strength in the chronic inflammatories.

You know, we continue to focus around neurologists and gastros, to make, you know, certain they're aware of our full spectrum of capabilities within that. Our team does a really good job and continues to refine its ability to target and focus around the prescribers. And we're always looking to expand, you know, the capability set that we have and the surveillance we can provide or the feedback we can give to those prescribing physicians around how patients are responding to the therapy. So, you know, we feel good about the position that we have. Again, we fully expect that the chronic is gonna grow at a faster pace than the acute, given some of the innovative new products that are entering in.

And you know, as I said in my previous comments, you know, we're certainly looking at new areas of development, whether it's in the Alzheimer's space, and in some of the oncology space, as there are a significant number of products that are in the pipeline for approval, that will require infusion companies to compound dispense, and or our nurses to oversee the infusion or the injection, to ensure, you know, the best clinical outcome.

Jamie Perse (Equity Research Analyst)

... Okay, great. Then one last one. Admittedly, this is the impossible to answer question, but John, if you have any perspective-

John Rademacher (President and CEO)

I'll give that one to Mike then.

Jamie Perse (Equity Research Analyst)

Yeah, you know where this is going, but just your perspectives on GLP-1, if there's any categories within your business that you think are, you know, have exposure to, you know, obese populations and, you know, potential for reduction in obesity, you know, across the U.S. Just any early perspectives would be helpful. Thank you.

John Rademacher (President and CEO)

Yeah, Jamie, you know, at this point in time, we don't see a lot of impact on the products that we dispense or the demand that we're seeing within the marketplace. You know, over the longer term, yet to be determined around, you know, the long-term benefits of this, but at least under, you know, the near or midterm, we don't see a significant impact on the products that we dispense or the services that we provide.

Jamie Perse (Equity Research Analyst)

Okay, great. Thank you.

Operator (participant)

One moment for our next question. Our next question comes from Pito Chickering with Deutsche Bank. Your line is open.

Pito Chickering (Managing Director)

Hey, good morning, guys. Thanks for fitting me in here.

John Rademacher (President and CEO)

Hey, Pito.

Pito Chickering (Managing Director)

A question actually on Jamie's question just there. So looking at the implied fourth quarter revenue guidance, I think you were saying that you're facing about 100 basis points impact from ASP pressure. Was it 150-200 in therapies and 30-40 in divestitures? I think you said that all those sort of don't continue into 2024. Is that sort of like the takeaway, is about 300 basis points of revenue pressure in fourth quarter that doesn't continue into next year?

Mike Shapiro (CFO)

Yeah, I think that's, that's about right. I think you're thinking about that right.

Pito Chickering (Managing Director)

Okay, fair enough. Perfect. Awesome. And then on the procurement benefit, if you pull out sort of the $9 million from 2Q, $13 million, 3Q, and $11 million in fourth quarter, we sort of get to the back half of the year, EBITDA guidance, excluding procurement, of about 9% margins. Again, is that just the right launchpad to think about for 2024?

Mike Shapiro (CFO)

Yeah. I think as much as, you know, we're celebrating and, you know, commending our procurement team for what are real procurement savings, unfortunately, while that's helped, you know, us achieve now two quarters of 10% EBITDA margins, unfortunately, that will subside. And I think you should absolutely adjust the EBITDA margins from a jump-off point perspective, Pito.

Pito Chickering (Managing Director)

Great. Great. Thanks so much, guys. I appreciate it.

Mike Shapiro (CFO)

Thanks, Pito.

John Rademacher (President and CEO)

Yeah, thanks, Pito.

Operator (participant)

One moment for our next question. Our next question comes from Michael Petusky with Barrington Research. Your line is open.

Michael Petusky (Managing Director and Senior Investment Analyst)

Good morning. My GLP question was asked and answered, but let me switch over to M&A. I guess I'm just wondering, obviously, the Amedisys deal didn't you know go through to completion. Your current thoughts on home health assets and how you know that you know potentially could still be a place that makes sense going forward for you guys. Thanks.

John Rademacher (President and CEO)

Yeah. Hey, Michael, it's John. I think as we tried to convey the... We really thought the Amedisys asset was unique in its capability set, certainly with its reach and the star ratings, as well as some of its additional capabilities with Contessa and some of the other aspects of that. So not all home health assets are created equal on that. You know, we still believe that there is opportunity for us to play a meaningful role in the home with the nursing resources that we have and find ways to have better coordination of care for the patients that we serve.

I think as we are looking forward, as we've outlined, you know, both in my prepared comments, but in our commentary, you know, I think in the near term, we will be looking in the M&A activity closer to the core than, you know, expanding broadly into home health through that standpoint. But there's opportunity for us to continue to innovate and to continue to work closely through that process. So, we'll continue to evaluate opportunities that are available. We'll continue to foster relationships where appropriate. We're gonna continue to look at things both economically and strategically, and, you know, make certain that we are ahead of the trends that are happening in the marketplace as the healthcare ecosystem continues to evolve.

Michael Petusky (Managing Director and Senior Investment Analyst)

All right. Very good. Thank you so much.

John Rademacher (President and CEO)

You're welcome.

Operator (participant)

This concludes today's question and answer session. I would like to turn the call back to management for closing.

John Rademacher (President and CEO)

Thank you again for joining us this morning and for participating on the call. As we outlined, it was another strong quarter for Option Care Health and our team of passionate care providers. We look forward to continuing to make progress against our key initiatives and providing you updates on our next call. Take care and have a great day. Thank you, everyone.

Operator (participant)

This concludes today's conference call. Thank you for participating. You may now disconnect.