Quipt Home Medical - Q4 2023
December 19, 2023
Transcript
Operator (participant)
Thank you for standing by. This is the conference operator. Welcome to the Fiscal Fourth Quarter and Unaudited Full Year 2023 Earnings Results Conference Call for Quipt Home Medical Corp. As a reminder, all participants are in listen-only mode, and the conference is being recorded. After the presentation, there'll be an opportunity for analysts to ask questions. To join the question queue, you may press star, then one on your telephone keypad. Should you need assistance during the conference call, you may signal an operator by pressing star, then zero. We remind you that the remarks today will include forward-looking statements that are subject to important risks and uncertainties. For more information on these risks and uncertainties, please see the reader advisory at the bottom of the company's results news release. The company's actual performance could differ materially from both these statements.
At this point, I'd like to turn the call over to Chairman and Chief Executive Officer, Greg Crawford. Please go ahead.
Greg Crawford (Chairman and CEO)
Thank you, operator, and thank you all for joining us today on the call. My name is Greg Crawford, and I'm the Chairman and Chief Executive Officer of Quipt Home Medical. Joining me today is Hardik Mehta, our Chief Financial Officer. Quipt Home Medical is a diversified healthcare services company, providing a full spectrum of home medical equipment and services to patients in the comfort of their own homes across the United States. At Quipt, our model is centered around delivering clinical excellence, and we drive this through our patient-centric ecosystem, leveraging technology-enabled equipment solutions in conjunction with our specialized clinical respiratory programs to effectively treat patients at home in a way that best suits their needs. Our core focus is on clinical respiratory care, serving patients with cardio and pulmonary conditions, with over 80% of our product mix being considered respiratory in nature.
The consistent financial and operating success of our business, seen through fiscal 2023, is a result of our targeted go-to-market strategies and end-to-end respiratory solution we offer in the marketplace. Our team of over 1,200 carries out our vision every day, working tirelessly to fulfill our company's central objective of providing exceptional patient care. Our ability to successfully implement our differentiated service model is driving Quipt's record-setting growth and emergence as a growing force in the industry. On this call, we will update you on our record-breaking fourth quarter and full year fiscal 2023 performance, the strong demand trends we are continuing to see across all our product categories, the favorable regulatory landscape, and our strategic insights on the continued success of our core business.
At present, Quipt has expanded to 125 locations across 26 states, with over 287,000 active patients, which has enabled us to strengthen our coast-to-coast reach. This continued scaling of our infrastructure throughout fiscal 2023 has allowed us to monitor our rapidly growing patient base, effectively decrease organizational redundancy, and grow our margins. Through fiscal Q4 and in real time, we are experiencing consistent demand for all of our key product categories, continued success in the ongoing penetration of our primary sales touchpoints, and are thrilled with the integration and performance of our largest acquisition that began the calendar year, all of which has led us to a year of significant financial and operating milestones for Quipt.
During fiscal 2023, we recorded record revenue of $221.7 million, or 58.5% year-over-year growth, with strong margin acceleration to 22.8%, equating to Adjusted EBITDA of $50.6 million or growth of 73.5%. For fiscal Q4 2023, we saw Adjusted EBITDA margins continue to accelerate, reaching 23.5%. This can be attributed to the operational scale we have achieved and our ability to leverage the platform we have built when adding revenue. Due to our focus on growing the continuum of care across selling product categories, taking advantage of the benefits of normalized supply chain and operating in a favorable regulatory environment, we have the opportunity to increase our organic growth performance.
We have been focusing our efforts on regions with a high COPD prevalence and expanding our key sales touchpoints into continual markets to meet our organic growth objectives. We expect steady and continuous organic growth in fiscal 2024, with the objective of 8%-10% on an annualized basis. Furthermore, our strategy of providing a complete range of end-to-end respiratory solutions with our diverse product mix is crucial to sustaining our success and a major component in the expansion of our core markets as we continue to carry out our long-term strategic expansion strategy. By concentrating on our primary sales channels, which are medical facilities such as hospital systems, physicians' offices, long-term care facilities, home health agencies, rehab centers, we can increase overall volume growth, which is the main driver of organic growth.
Moreover, I would like to provide insights into the demand trends within our sleep business, given the recent market speculation and reaction related to the adoption of GLP-1 diabetes and weight loss medications. Our sleep segment has experienced business as usual with absolutely no impact. Demand continues to exhibit strength in real time, and our anticipation is that this robust demand will persist well into the foreseeable future. It is important to emphasize that CPAP and BiPAP therapy continue to be the established gold standard of care for individuals diagnosed with obstructive sleep apnea. Furthermore, leading manufacturers of sleep equipment are also reporting no findings of any decline related to GLP-1 drugs. In addition to that, we hold the firm belief that there are over 20 million Americans who haven't yet been diagnosed with OSA, that have it, representing a substantial untapped opportunity for future market growth.
To this point, we believe it is possible that the total addressable market may grow as a result of more awareness and increased diagnosis of obstructive sleep apnea. Lastly, we continue to believe the key is to work with our sleep patients to ensure their compliance as it relates to the therapy, which is the heart of our patient-centric ecosystem. Moving to the regulatory environment, we see continued stability, and there have been no indications of the return of the competitive bidding. Historically, CMS has begun any competitive bidding process roughly 18 months before contracts and price takes effect. The likelihood of this happening is decreasing because CMS hasn't indicated how returning to the program would result in savings. Additionally, CMS has recently announced a headline CPI increase of 3% to the Medicare fee schedule beginning on January 1, 2024.
Prior to 2022, our product categories were not subject to CPI adjustments while included in the Competitive Bidding program. Over the past year, we have seen positive developments, such as the easing of restrictions through the elimination of the long-standing requirement for providers to obtain certificates of medical necessity for home oxygen, which reduces the administrative burden on healthcare providers. Moreover, we have witnessed the opening of access for patients who visit the emergency care setting and are identified as having either acute or chronic respiratory diseases, and these now can be ordered for home oxygen equipment. Throughout fiscal 2023, we executed on the fundamental pillars of our growth strategy, building out our operational footprint into 6 new states, providing us additional attractive markets to implement our innovative go-to-market strategy.
Moreover, in fiscal 2023, we continued making technological advancements such as an e-prescribing and expanded our commercial insurance capabilities with the addition of Aetna to our national contract roster. Quipt is in a strong position to withstand any potential economic downturns due to the nature of our business, providing necessary respiratory products and services to patients in the home setting throughout the United States. Our unwavering focus on building a robust operational foundation and infrastructure, combined with our proactive approach to both organic and inorganic growth, has uniquely positioned us to seize the multitude of opportunities for expansion that lie ahead. With that commentary, I'd like to hand the call over to Hardik to discuss our fiscal fourth quarter and full year 2023 financial results.
Hardik Mehta (CFO)
Thanks, Greg. On Monday evening, we announced our fiscal fourth quarter and full year 2023 financial results, representing the three months and twelve months ended September 30, 2023. Please note that all financial values are in US dollars. Here are some key highlights. Through the company's continued use of technology and centralized intake processes, respiratory resupply setups and/or deliveries increased to 395,618 for the year ended September 30, 2023, compared to 231,495 for the year ended September 30, 2022, an increase of 71%. The company's customer base increased 65% year-over-year to 285,819 unique patients served in fiscal year 2023, from 173,203 unique patients in fiscal year 2022.
Compared to 516,328 unique setup deliveries in fiscal year 2022, the company completed 754,418 unique setups and deliveries in fiscal year 2023, an increase of 46.1%. Revenue for fiscal year 2023 was $221.7 million, compared to $139.9 million for fiscal year 2022, representing a 59% increase in revenue year-over-year. Recurring revenue as of fiscal year 2023 continues to be strong and exceeds 83% of total revenue. Adjusted EBITDA for fiscal year 2023 was $50.6 million, or 22.8% margin, compared to adjusted EBITDA for fiscal year 2022 of $29.2 million, or 20.9% margin, representing a 73% increase year-over-year.
Revenue for fiscal Q4 2023 was $62.5 million, compared to $40.1 million for fiscal Q4 2022, representing a 56% increase in revenue year-over-year. Adjusted EBITDA for fiscal Q4 2023 was $14.7 million, at 23.5% margin, compared to Adjusted EBITDA for fiscal Q4 2022 of $8.4 million at 21% margin, representing a 74% increase year-over-year. Cash flow from continuing operations was $40.5 million for the twelve months ended September 30, 2023, compared to $26.3 million for the twelve months ended September 30, 2022, a substantial increase of 54%. For fiscal year 2023, bad debt expense improved to 4.5%, compared to 8.7% for fiscal year 2022.
This exemplifies the company's ability to scale and add more revenue through add-on acquisitions without compromising billing and collection capabilities. Operating expenses remain flat as a result. The year ending September 30, 2023, was 46.6%, compared to 46.6% the corresponding period in 2022. The company reported $17.2 million of cash on hand and total credit availability of $41 million as of September 30, 2023, with $20 million available towards the revolving credit facility and $21 million available pursuant to the delayed draw term loan facility. The company maintains a conservative balance sheet with net debt to Adjusted EBITDA leverage of 1.4x. We are very proud to have produced another record-breaking year in fiscal 2023.
Real-time momentum has persisted in fiscal Q1, and we are witnessing continued organic growth and margin expansion that we have been aiming for. For fiscal 2023, our revenue reached $221.7 million, and Adjusted EBITDA margin has reached 22.8%, driven by our diversified respiratory product mix and services, as well as focusing on operational leverage in the business and effective cost management. Annualizing our fiscal fourth quarter, our run rate revenue now sits at $255 million. In Q4, our margin acceleration continues as a result of the scale we have generated, with 23.5% Adjusted EBITDA margin realized in the quarter.
We expect strong organic growth in fiscal 2024 will persist as we continue to drive volume through our growing sales team and the cross-selling of products and continued expansion of the continuum of care in adjacent markets. In real time, setups across our product mix are very strong, including our sleep segment, which continues to drive our resupply business as a sleep patient converts into our program, and we continue to see strong organic growth. As we move into fiscal 2024, we continue to see improving net cash flow from operations. On our last conference call, we increased our guidance to 6%-8% net cash from operations after CapEx and/or lease payments and before any debt service and purchase price payable related payments.
We are very confident in our ability to continue to grow our net cash flow, inclusive of our CapEx needs, and continue to see this as our base case on a go-forward basis, with a long-term goal to further improve on this as we continue growing our business. The continued consistency of our revenue base is driven by our highly recurring revenue model, which accounts for more than 83% of our total revenue mix. Our resupply program is a major component of this recurring revenue base, as we have significantly scaled the program, which now consists of 169,000 patients as of September 30, 2023. The resupply program represents an amazing growth area for us, extending a patient's life cycle with us.
Our healthy balance sheet, with over $58 million of liquidity, gives us ample flexibility to execute our organic and inorganic plan for strategic expansion in an environment with higher interest rates. Our present net leverage is very modest at 1.4x , giving us the ability to deploy a combination of debt and cash for the execution of our acquisition pipeline in accordance with our prudent acquisition approach. In fiscal Q4, we closed on a multi-state acquisition target, expanding our presence in Mississippi, Texas, and Louisiana, adding $9 million in revenue and $2 million in Adjusted EBITDA. We were able to acquire this asset for a very favorable multiple of Adjusted EBITDA on a post-integration basis. In real time, the integration has gone very well, and we are working on organic expansion opportunities within those existing markets on the heel of this acquisition.
The operating footprint aligns closely with regions that have a very high prevalence of COPD, a key target patient group. According to National Institutes of Health, about 1.5 million people across the three states have COPD. We will remain dedicated to the structured acquisition approach and tried-and-true integration process we have developed over many years. We have a strong plan for sustained strong organic growth as well as deep acquisition pipeline. These are the things that have propelled our consistent growth, which is demonstrated annually and has strengthened the company's position in the marketplace. We have the tools needed to execute our expansion and acquisition strategy to drive value for our investors. Thank you. With that update, I'll turn the call back to Greg.
Greg Crawford (Chairman and CEO)
Thanks, Hardik. Providing excellent patient care with an emphasis on treatment of conditions like sleep apnea, COPD, and other chronic respiratory disease is our top goal in each of our markets. We are constantly thinking of methods to expand the number of patients we serve and get access to desirable geographic areas, and we do this by breaking into new markets and forming partnerships with payers, patients, and referral sources. Our competitive advantage stems from our increased market share, reach, and robust clinical services, which enable us to leverage economies of scale. We believe that because we have successfully implemented the essential components of our growth strategy, and we will maintain our strong momentum for the foreseeable future.
These include completing accretive acquisitions, investing in our company's future organic growth, and broadening our healthcare network across the country through the execution of national insurance contracts and the expansion of contiguous markets. Furthermore, we are certain that acquisitions that are effectively integrated contribute to the overall acceleration of our organic growth strategy. At this point, I would like to review with you the three components of our core growth strategy. First is driving organic growth with the goal of 8%-10% annually. We see momentum in fiscal Q1 2024 and have continued growing our sales team, which is one of the core initiatives on this front. This is how we connect with key touch points like hospital networks, doctor's offices, long-term care facilities, and rehab centers.
Furthermore, the aging population and significant increase in the number of people with multiple chronic diseases across the United States are very positive demographic trends for Quipt when looking at the operating environment. Home medical equipment and services are becoming more necessary as the population ages, which provides a very sustainable long-term growth opportunity. Additionally, a lot is being done to make sure that patients receive care at home whenever it is feasible. Secondly, as we continue to expand our business, we remain committed to leveraging technology in every way we can to consistently improve our operational performance. We focus on enhancing our workflow processes, which creates real value and removes friction points. As an example, the significant improvement in our bad debt expense and increased net, net cash flow is a result of improved processes across our billing and collections functions of the business.
Furthermore, we are focused on long-term growth of the e-prescribing industry and have positioned ourselves well with our investment in this area in fiscal 2023. Electronic prescribing is essential to the industry as this technology can serve to boost productivity, cut down on errors, boost compliance, and improve patient outcomes. As of now, less than 5% of our orders come from e-prescribe, and we anticipate this will grow significantly over time, giving us an opportunity to improve the patient, prescriber, and provider experience by eliminating inefficiencies and reducing paperwork. Another key example of the uses of technology is our automated resupply platform, which not only helps us drive organic growth and higher margin recurring revenue, but also provides us with considerable revenue synergies when we make strategic acquisitions.
The third element of our growth strategy is expanding scale by making smart, accretive acquisitions in conjunction with our tried-and-true integration approach, which has effectively integrated 19 acquisitions since 2018, representing over $115 million of annualized revenues. Our attention is on heavily weighted respiratory businesses, which can be successfully incorporated into our scalable infrastructure. Our strategy objective is to increase our payer base and geographic reach into advantageous geographies with a high prevalence of COPD. Thanks to our healthy balance sheet, we will be able to take advantage of opportunities as they become available to grow our revenue, EBITDA, patient base, and overall geographic reach. Given the continued strong performance of our business in real time, we are actively engaging with investors from the United States and Canada to share our ongoing financial and operating achievements and discuss our long-term growth objectives.
In calendar 2023, we participated in 10 investor conferences and expect to be very active throughout 2024, meeting with investors. Moreover, we are thrilled to see our institutional shareholder base on both sides of the border continue to grow as we have moved through 2023. As we look to fiscal 2024, we will continue to drive organic growth, strive to grow our Adjusted EBITDA margin further, which accelerated in the most recent fiscal quarter to 23.5%, and continue building our healthcare network across the country. With our flexible capital structure, we continue to look at different ways to create shareholder value as appropriate and believe in our operational excellence and 1.4x leverage balance sheet provide us with all the resources necessary to execute our expansion strategy.
I would like to conclude that we have been seeing consistent demand across our product mix in real time during fiscal Q1, 2024, and look forward to sharing our fiscal Q1 results in February. Finally, I would like to take this chance to thank the whole Quipt team for their tireless work and our stakeholders for their continued support.
Operator (participant)
Thank you. We will now begin the question-and-answer session. To join the question queue, analysts may press star, then one on your telephone keypad. You will hear a tone acknowledging your request. If you are using a speakerphone, please pick up your handset before pressing any keys. To withdraw your question, please press star then two. Our first question comes from Doug Cooper of Beacon Securities. Please go ahead.
Doug Cooper (Managing Director)
Hi, good morning, guys, and congratulations on a great quarter. I just want to focus in, if I could, on the resupply program. You said in the press release it's 169,000 patients now in the program. Can you give us an idea of what the average reorder rate is per patient for the year and what the average revenue per reorder is?
Greg Crawford (Chairman and CEO)
Yes, sure. This is Greg. Doug, so we continue to see those go up kind of quarter-over-quarter in that. Right now we're seeing patients order in that just about three times a year. We're starting to see the average revenue in that to be just over $200 in that, which is ... That's, that's up about 6-7% in that from where it was this time last year or at the beginning of fiscal 2023 Q1.
Doug Cooper (Managing Director)
Is that, just to be clear, is that 200 for the 3 times or 200 per reorder?
Greg Crawford (Chairman and CEO)
No, that's. Yeah, yeah, that's 200. That's just over 200 per reorder.
Doug Cooper (Managing Director)
So if the average person is 3x a year-
Greg Crawford (Chairman and CEO)
It would be just over $600 per patient.
Doug Cooper (Managing Director)
Okay. So $600, and just the math would be 600 times 169,000, that's $100 million? Is that where the run rate is on the, on the resupply business?
Greg Crawford (Chairman and CEO)
Yeah, that's, that's about right. Yes.
Doug Cooper (Managing Director)
Okay, um-
Greg Crawford (Chairman and CEO)
And the other, the other thing that we're kind of seeing in that side of the business, too, is the average items per order that go in there. That's another metric that we kind of watch. We continue to see that go up, too, so that's that, that slightly increased about 5%-6% in that this year.
Doug Cooper (Managing Director)
This is predominantly hoses and masks, I'm guessing, right?
Greg Crawford (Chairman and CEO)
Yeah. Yeah, the cushions and the filters and tubes, water chambers, anything that needs replaced, which there's a lot of parts and pieces that need replaced in that, on those devices.
Doug Cooper (Managing Director)
Okay. One of your peers said in their conference call that the reorder business gross margin was 42%, in and around there. Is that similar for you guys?
Greg Crawford (Chairman and CEO)
Yeah. Yeah, very similar in that for us.
Doug Cooper (Managing Director)
Okay. So because this is electronic, I guess, you know, the reorder business, the infrastructure is in place, so I'm guessing that the EBITDA contribution from the reorder business is much greater than the rental business.
Greg Crawford (Chairman and CEO)
Yes, than some, than most rental items, yes. We do have some other higher margin in that rental items. But as far as... Overall, if you kind of look at, you know, that side of the business, and that is pretty automated. So over 50% of the orders in that are what we refer to as no touch, and that's where the patient has kind of either ordered through the app, they've ordered via email, and, and it just kind of flows through right to the warehouse if it doesn't need, like, a pre-authorization or a, a new updated prescription or anything. So as those are all kind of worked proactively, so when the patient does-
Doug Cooper (Managing Director)
Mm-hmm.
Greg Crawford (Chairman and CEO)
Request to get additional supplies.
Doug Cooper (Managing Director)
Okay.
Greg Crawford (Chairman and CEO)
That's able to go through seamlessly.
Doug Cooper (Managing Director)
Just to finish off and close the loop then. If respiratory is 80% of your revenue, so you're running, say, $2, whatever that is, $275, I think, Hardik, you said, or you're $36, the Q4 annualized.
Greg Crawford (Chairman and CEO)
Mm-hmm.
Doug Cooper (Managing Director)
80% of that-
Greg Crawford (Chairman and CEO)
Right now, we're about $255. $255 run rate with-
Doug Cooper (Managing Director)
Two-
Greg Crawford (Chairman and CEO)
Yeah.
Doug Cooper (Managing Director)
Yeah, 255, 80% of that is $200 million. In the reorder business, you know, is that sort of 40-50% of your respiratory business is the resupply business now? Is that in the ballpark?
Greg Crawford (Chairman and CEO)
That sounds about right overall.
Hardik Mehta (CFO)
That's about right, yes.
Doug Cooper (Managing Director)
Yeah. Sorry, Hardik, did you say that's in the ballpark?
Hardik Mehta (CFO)
Yeah, that's about right.
Greg Crawford (Chairman and CEO)
Yeah.
Doug Cooper (Managing Director)
Okay.
Hardik Mehta (CFO)
40%-50% is a good ballpark range.
Doug Cooper (Managing Director)
Okay. Just on the M&A strategy, you know, your, you guys are obviously active, and you've been successfully integrated a bunch of companies. Your stock now trades about 4x last quarter annualized EBITDA. So what are the prices you're seeing out there? And quite frankly, I'm assuming you guys are the fifth largest respiratory company in the U.S. There is bigger players than you, who probably are looking at M&A as well. You must be on their radar, I'm assuming now.
Hardik Mehta (CFO)
Well, as far as we can only speak about who we acquire, that's within our control. So, I guess, it definitely has changed some dynamics. I think the overall multiples for the targets we would typically go after have also seen some downward movements, which at this point, if you structure it right, I think there's still opportunities out there that we can acquire and make financial sense of it, right? I mean, at the end of the day, we still have to have two things that we have to keep in mind, given the environments that we are in.
One is, obviously, you have an interest rate component going on, which we carefully monitor and evaluate that against the cash flow of our businesses that we acquire. So we want to at least make sure we come out on top of that. And then, on the other side is what you just said, which is, you know, comparing our multiples to the target that we end up acquiring. That's a little bit of a lesser concern, quite frankly, because, you know, for most of the companies that we have acquired, if you go back and look at our average multiple on a post-close basis, I think that will still be less than kind of what our current trading multiples are.
So, that margin has compressed given our share price and where they stand today, but I think for the right set of acquisitions, the numbers can still make sense.
Doug Cooper (Managing Director)
Just my last question on the GLP-1 drugs, and thank you for your commentary, specifically around Q1. What are you hearing from ResMed or those guys? You know, I listened to, obviously, ResMed's conference call in the last quarter. Same as you, they said they're seeing no impact on the business. You know, that was a few months ago, but these drugs have been out for a couple of years now. You know, and when do you think the market will realize that this is not having an impact? I'm just wondering when that light bulb will go off.
Greg Crawford (Chairman and CEO)
Yeah, that's actually a really good question, Doug. I can just tell you in real time and by looking at our results here, and that we've just seen no slowdown in our business and don't anticipate anything. I think it does make rational sense, though, to think that if more patients do get in the pipeline and that in the funnel of the healthcare system, and they have sleep issues or anything in that and maybe don't qualify for GLP-1s, and that you know, it could drive volumes even further. It's estimated that there's over 20 million Americans that haven't been diagnosed or treated yet for sleep apnea, so there's a pretty big TAM there for us to still, and then have the availability and that to service.
Doug Cooper (Managing Director)
Okay. That's it for me, guys. Congratulations on the quarter, and happy holidays.
Greg Crawford (Chairman and CEO)
Thank you.
Hardik Mehta (CFO)
Thanks.
Operator (participant)
Our next question comes from Ty Collin of Eight Capital. Please go ahead.
Ty Collin (Equity Research Analyst)
Hey, good morning, guys. Thanks for the question. First one for me, just on the margin outlook for next year. Are you kind of still seeing room for meaningful improvement there on an organic basis like you were able to achieve this year? And if that is the case, what are sort of the low-hanging fruits there? Where are those opportunities?
Hardik Mehta (CFO)
Thanks, Ty, for the question. I guess from a modeling perspective, that's kind of the driving force behind the question. I mean, we've always taken a conservative approach, and I would say, you know, if I'm modeling internally, we suddenly model for what we currently have. There has been some recent price increases that we have seen, which we have—you know, we were able to offset that using some other opportunities from a low-hanging fruit perspective. So I would say for calendar 2024, what you see for, you know... Sorry, for fiscal 2024, what you see for fiscal 2023, I think that is still within a good ±5% range in terms of margins. 5%-
Ty Collin (Equity Research Analyst)
Okay, great.
Hardik Mehta (CFO)
The status quo, not from an actual absolute swings.
Ty Collin (Equity Research Analyst)
Right. Right, right. Okay, got it. Got it. And then maybe sticking on that theme, some pretty strong sequential improvement here on the gross margin rate. Looks like about 150 bips quarter on quarter. Could you provide a little more context on how you were able to do that? And maybe if there's any trends to take note of there.
Hardik Mehta (CFO)
I mean, nothing certainly in particular. I would say, I mean, this is a little bit of a year-end audit situation, so there are sometimes adjustments that flow through in your Q4, which could be spread across a little bit farther out. But, I mean, we always say, you know, let's not look at quarters, look at at least two, three quarters in a row, or in this case, you could look at, you know, kind of the whole fiscal year, kind of to look at directions.
Ty Collin (Equity Research Analyst)
Okay, great. And then, and then last one for me, circling back to some of the earlier questions on the resupply patients. What, what's sort of the average duration of your relationship with a resupply patient? Is it, you know, whether you're measuring that in quarters or years, I think that would be helpful to round out that discussion.
Greg Crawford (Chairman and CEO)
Yeah, sure. This is Greg, and we estimate that to be about 4.5-5 years, that the average resupply patient is around.
Ty Collin (Equity Research Analyst)
Okay, great. That's really helpful. Thanks for the questions, guys.
Doug Cooper (Managing Director)
Thank you.
Hardik Mehta (CFO)
Thank you.
Operator (participant)
Our next question comes from Richard Close of Canaccord Genuity. Please go ahead.
Richard Close (Tech-Enabled Health Equity Research)
Yeah, thanks for the questions today. Hardik, maybe if you could just go over the organic growth numbers for the fourth quarter and for fiscal 2023, to begin with here.
Hardik Mehta (CFO)
Sure. Thanks, thanks for that question, Richard. I mean, if we go back and look at our fiscal 2023, our organic growth rate year-over-year came around 6.7%-7% from an organic perspective. It gets a little tricky because, you know, you have companies that are part of the year in both periods. So there is a little bit of hard science, but that's something that 6.7%-7% is what we believe our organic growth was for fiscal 2023.
Now, if we look at our organic growth and break that down a little bit further, you know, the first half of fiscal 2023 had a lower organic growth rate. We know we were still a little recovering from some of the product issues and stuff like that. And then the second half of fiscal 2023 had larger than, you know, the 7% growth rate. So if you break that down into two halves, then they both had a little bit different, but the average is around that. And then for the quarter, you know, we are kind of strong at about 3%.
Richard Close (Tech-Enabled Health Equity Research)
Okay. And then with respect to bad debt, it ticked up a little, I guess, sequentially. I mean, obviously strong improvement year-over-year, but maybe a little tick up from third quarter to fourth quarter. Was there anything specific driving that, or was it year-end cleanup or anything along those lines?
Hardik Mehta (CFO)
I would say, I mean, it's a slow and steady process on our end. We continue to work on it, kind of chip at it, along the way. There weren't suddenly any dramatic or drastic changes. It just, you know, when we acquired Great Elm, we also adopted some of the practices that came along with that. And I think what you are seeing is a kind of a weighted average number for back-end and revenue of the combined entities.
Richard Close (Tech-Enabled Health Equity Research)
Okay. You beat our revenue-
Hardik Mehta (CFO)
But that is, I mean, having said that, we, so we have always said, you know, that is an area that we believe that there is opportunities to continue to work upon.
Richard Close (Tech-Enabled Health Equity Research)
Okay. That's helpful. You beat our revenue estimate in the quarter. I guess consensus I had is $62.9 million, so maybe a little bit below that. Was there anything specific maybe to the fourth quarter that, you know, didn't come through in the quarter, that you can call out or anything to note there? I mean, obviously, you're talking about the first quarter. It sounds like things are going extremely well for the first quarter, but just curious if anything slipped?
Hardik Mehta (CFO)
Yeah. Hey, I due respect to the consensus, but sometimes you know you really can look at it, I mean from that perspective, some people don't get the forecasting right, quite frankly. But if you look at you know without the comparison to the consensus here, I mean you know on a growth basis, I mean there's a pretty strong 3.7% organic growth. If you take out the month of pharmaceuticals that we I mean it's still about 3.5%. So it's a pretty strong organic growth for the quarter.
I understand from a consensus, it's a little shy, but I mean, we were kind of very pleased with the outcome.
Richard Close (Tech-Enabled Health Equity Research)
Okay. As we're thinking about fiscal 2024, I know you guys don't give guidance. You know, it sounds like you have acquisitions in the pipeline. I think consensus for fiscal 2024 on revenue is about $270.1 million. I think some people bake in acquisitions to their numbers. So I'm just curious maybe how you feel about that number for fiscal 2024, the consensus, and then how you're thinking about the acquisition pipeline in terms of timing?
Hardik Mehta (CFO)
Sure. So I guess you're right. We certainly do not provide guidance in the way others do. I guess, one way to think about it is, kind of, you know, what we said is our runway, which is kind of annualizing our last quarter, right? So that's a good starting point. I mean, you, if you throw an industry organic growth rate of somewhere between five, six, seven, I think that's a good modeling exercise from my perspective. We certainly have tried and achieved to beat the market. If you look at the last five years on an aggregate basis, we have witnessed more organic growth than the market averages.
But that's kind of what I would encourage analysts to look at and evaluate, based on that. You're right. Some analysts have considered acquisitions in their pro forma, which is why, kind of the reason why the whole consensus sometimes is, it's not a way to look at our company and our numbers. In terms of acquisition, the pipeline and how we think about it, I mean, my response to Doug earlier is kind of accurately reflects what we have in mind. I think, are there opportunities? 100%, without a doubt, but we certainly want to be more disciplined.
We've been adequately disciplined the whole time, but I think given the situation in terms of higher interest rates, and how the stocks perform, and the arbitrage between, you know, our multiples versus what we pay. So, I think we will continue to responsibly deploy our capital and won't shy away from making the right acquisition.
Richard Close (Tech-Enabled Health Equity Research)
Okay. All right. Thank you.
Hardik Mehta (CFO)
Thank you.
Operator (participant)
Our next question comes from Michael Freeman of Raymond James. Please go ahead.
Michael Freeman (Equity Research Analyst of Healthcare)
Hey, Greg. Hi, Hardik. Congratulations on a really strong finish to the year, and thanks very much for taking our questions. It's about a year hence the Great Elm acquisition. I wonder if you could describe, you know, the status of that integration, any major efforts that are ongoing there. And, you know, being a year after this acquisition, I wonder if you could describe how this asset is positioned today within the Quipt ecosystem and how we might see it evolving into 2024?
Hardik Mehta (CFO)
Yes. Thanks, Michael, for the question in that. It, it's been fully integrated, and that obviously, and that onto our platform and everything. We've been very, very pleased in that, with the results, and that if, if not, you know, it's really outperformed, and that's probably a little bit better than we were expected.
Greg Crawford (Chairman and CEO)
We believe as we get into 2024 in that, we've still got a lot of opportunity in that to cross-sell, other product lines through there, such as home oxygen and ventilation, that we've primarily been focused on, the sleep side, the disposable supply side. We just got that integration finalized there in just about towards the end of summer. So we've been seeing some nice numbers come out on the resupply side. And then, of course, in that, we've really been focused on the sleep there. So we believe that's where we still have a lot of opportunity in that, kind of, going into 2024.
Michael Freeman (Equity Research Analyst of Healthcare)
Okay. All right. That's, that's helpful. There's been a lot of discussion on this call on recurring revenue and the resupply program. So you guys drive, you know, you're posting relatively high proportions of recurring revenue. I wonder what if you could describe what Quipt is doing on the ground to enroll patients in these resupply programs and other aspects of your recurring revenue profile?
Greg Crawford (Chairman and CEO)
Yeah, sure. So we continue to grow in that our new device setups. We've actually seen a really nice uptick in our active rentals in that, in our sleep devices. And then we're also in that working internally, and that to continue to get patients compliant in that. So we've seen our compliance rates in that tick up a couple percentage points in that throughout calendar 2023. So we're gonna continue to make investments and resources in that to get more patients, the more patients we get compliant, the more patients that go into the resupply program.
Michael Freeman (Equity Research Analyst of Healthcare)
Okay, terrific. If I could squeeze just one more in. One big shift that we've noticed from 2022 to 2023 is the shift from sort of positive to negative EPS. And I wonder if you could provide sort of a rough outlook for 2024 in respect to earnings?
Hardik Mehta (CFO)
Sure. Thanks, thanks for that question. If you, you know, compare year over year, you'll see some of the few contributors for the positive cash flow, or not cash flow, my bad, positive EPS and net income were related to a couple of one-time items back in 2022. The biggest one was related to forgiveness of the government grants that companies like us received through COVID. So we, things of that nature were definitely helpful in the positive EPS at the end of last year. In terms of 2023, the factors against us is certainly the higher interest rate is depressing the margins.
But as far as going into the future, I would say we would be either neutral or slightly negative, and most of that would be attributed toward higher depreciation, amortization, and interest expenses. That is expected, at least in the next two years.
Michael Freeman (Equity Research Analyst of Healthcare)
Okay, thank you very much. I'll pass it along.
Operator (participant)
Our next question comes from Bill Sutherland of Benchmark Company. Please go ahead.
Bill Sutherland (Senior Equity Research Analyst)
Thank you. Hey, guys. Greg, could you update us on the sales force, you know, where it sits right now and what the growth was in it?
Greg Crawford (Chairman and CEO)
Yeah, sure. So in kind of real time, we're up to about 90, and not just over 90. So we've seen really nice growth in the sales force. We've seen it both, and really there's two sides to our business when we look at sales. We have our general HME and our respiratory, and then we also have our custom power mobility with the ATPs. And we've seen nice recruitment in that on both sides of that.
Bill Sutherland (Senior Equity Research Analyst)
And so that's up... I think the number you gave us last call was in the seventies, right?
Greg Crawford (Chairman and CEO)
Yeah, it was in the, yeah, around 72 or so. So we're sitting at-
Bill Sutherland (Senior Equity Research Analyst)
Was that-
Greg Crawford (Chairman and CEO)
So we're sitting just over 90 right now, in real time.
Bill Sutherland (Senior Equity Research Analyst)
Were the adds partly the result of the acquisition in September?
Greg Crawford (Chairman and CEO)
There, there were a few in there, but like 2 or 3, that would have been considered sales.
Bill Sutherland (Senior Equity Research Analyst)
Okay.
Greg Crawford (Chairman and CEO)
But the-
Bill Sutherland (Senior Equity Research Analyst)
Okay
Greg Crawford (Chairman and CEO)
Rest have all been new hires.
Bill Sutherland (Senior Equity Research Analyst)
That's fantastic.
Greg Crawford (Chairman and CEO)
New hires from-
Bill Sutherland (Senior Equity Research Analyst)
Yeah, it's impressive.
Greg Crawford (Chairman and CEO)
Yes. Yeah.
Bill Sutherland (Senior Equity Research Analyst)
Can you update us on the insurance contracting front, where you stand with some big negotiations and what you're expecting on rates, out of that?
Greg Crawford (Chairman and CEO)
Yeah, sure, in that, we continue to work with some of the larger payers in that, in the U.S., such as Anthem and Cigna, and that are a couple in that, that, we're continuously evolving in that on contract negotiations with them. We did add Aetna earlier in the year. Then there's also, and that's some other programs out there in that, another one, Centene, in that, that has a lot of the state Medicaid Advantage programs and also a lot of Medicare Advantage programs. We're accepting that a lot around the country right now in that, but it's not on the national contract. So that's one that we're looking to put all the locations and companies in that under one contract.
There's also been several regional contracts that have been signed in that throughout the course of the year, and that, too, that we don't necessarily announce. They're not on a national level in that, but they are on a more of a regional type level or within a state.
Bill Sutherland (Senior Equity Research Analyst)
These are—you're contracting with both sides of these companies, right? Both the commercial and the Medicare, and I guess Medicare Advantage.
Greg Crawford (Chairman and CEO)
Yes. Yeah, it would be for all their commercial lines, Medicare Advantage lines, and also the Medicaid state Medicaid Advantage lines.
Bill Sutherland (Senior Equity Research Analyst)
Mm-hmm. Are you seeing any deals where they want you to be part of, like, a sub-capitation, you know, thinking Medicare Advantage, some of those developments on that side?
Greg Crawford (Chairman and CEO)
Yes, we are. In that, there are some things right now in that that are currently in the very, very, very early stages in that that are more of, seems like a 2025 in that type thing. There are a few of the payers in that are starting to negotiate and figure out what options are in that as it comes to 2025 and that, and how they're gonna do contracting. I think typically they're about a year out in that, on the contracting piece, and then they'll take and go out and sell this to the Medicare beneficiaries when the open enrollment comes in late calendar Q4 of 2024 for the 2025 service year.
Bill Sutherland (Senior Equity Research Analyst)
So you guys are going through the exercise of figuring out what the risk levels are willing to... You know, you have a very particular business, so this shouldn't be too hard for you, right?
Greg Crawford (Chairman and CEO)
Yeah. Yeah, I mean, we haven't actually in that had capitated contracts or anything like that, but we do have a very clear handle on that, on what a, what it costs us to operate. So with census and that, we can get a pretty good idea on that, of what that would look like.
Bill Sutherland (Senior Equity Research Analyst)
Yeah. Okay, great. Great quarter. Thanks, guys. Appreciate it.
Greg Crawford (Chairman and CEO)
Thank you, Bill.
Operator (participant)
Our next question comes from Julian Hung of Stifel. Please go ahead.
Julian Hung (Equity Research Analyst of Healthcare)
Hi, this is Julian subbing in for Justin today. My first question is on recent labor challenges and strikes within the healthcare industry. Have you seen any impact on Quipt in any way? And on the flip side, does it increase demand for home health care?
Greg Crawford (Chairman and CEO)
Yeah, so as far as the labor strikes or anything, that hasn't affected Quipt directly. Maybe in some markets, it's affected us indirectly, and now with a slow in some referrals, and that in our West Coast operations, and that it would've happened in that during our during calendar Q3, I'm sorry. But nothing that was, you know, like a direct, direct impact from an employment standpoint or anything. We've been pretty steady in that with our recruitment efforts and our retention efforts in that throughout 2023. Excuse my voice. I'm about ready to lose it here with a cold that I'm carrying, so if you can't get me through.
Julian Hung (Equity Research Analyst of Healthcare)
Yeah. I had another question about Medicare. With deductibles and premiums going up starting next month at 6%, which is a bit higher than usual, does that potentially impact how much revenue you can make?
Greg Crawford (Chairman and CEO)
Well, it could potentially in that impact our bad debt expense, but, you know, not necessarily how much revenue, I guess, and that because we're still gonna have the top-line revenue, the need's gonna be there for the patient, but we wouldn't anticipate anything that would with the needle or anything with that increase. Most of those Medicare patients, and that would have some type of secondary anyway or otherwise, they'll likely set up payment plans like they have historically.
Julian Hung (Equity Research Analyst of Healthcare)
Great. And just one last question. On the potential merger talks between Humana and Cigna, even though it did fall through, how would it have impacted insurance rates? And, you mentioned you were working with Cigna. Was there any impact on that?
Greg Crawford (Chairman and CEO)
No impact in that from us obtaining our national insurance contract or anything in that. I mean, at least immediate in that, in the ground or anything, we weren't getting any feedback on that. So, you know, as far as predicting where rates, you know, would have gone and that, that's a really tough one to do. Most of these large payers in that, that if you're providing value add service, they are open to rate negotiations and that in order, to help keep these patients in the, home, for home-based care, to keep them out of, hospitals and facilities.
Julian Hung (Equity Research Analyst of Healthcare)
All right. Thank you so much for taking my questions.
Greg Crawford (Chairman and CEO)
Thank you.
Operator (participant)
Our next question comes from Richard Close of Canaccord Genuity. Please go ahead.
Richard Close (Tech-Enabled Health Equity Research)
Yeah, just to follow on to Bill's question on the sales force. Are there any targets associated with fiscal 2024, where you'd, you know, wanna be exiting 2024, with a certain number of sales numbers? Just curious there.
Greg Crawford (Chairman and CEO)
Yeah. Yeah, not as of yet in that. I mean, we had a areas that we wanted to continuum areas that we wanted to add the sales force to. I feel that we've achieved this, if not exceeded this year. But we haven't had a set number or anything yet in that for 2024 to say that we want to cover. We do still have a lot of ground in that to cover in that with continuum areas as it relates to operations west of the Mississippi. Most of the hiring that we've seen has been in our in the Southeast and the Midwest.
Richard Close (Tech-Enabled Health Equity Research)
Okay. And when you guys add, you know, because you added a chunk, I guess, since you last reported, I'm just curious, how long does it take to, you know, for a salesperson to ramp up and really become effective?
Greg Crawford (Chairman and CEO)
Yeah. Typically, in that about two quarters, you know, six months or so. We can usually get a pretty good idea that after 90 days, in that whether or not they're going to be able to make their targets and things. But typically before they're really contributing, you're looking at six to six to nine months, typically about six months.
Richard Close (Tech-Enabled Health Equity Research)
Okay. And then with respect to PAP supply, can you talk a little bit about the supply chain dynamics, you know, maybe what you're seeing on the pricing front?
Hardik Mehta (CFO)
So sorry, I'm not sure I... This is Hardik. Sorry, not sure I follow the question. Can you, can you rephrase that, please?
Richard Close (Tech-Enabled Health Equity Research)
Yeah, I was just curious. You know, obviously, supply of CPAP machines have been, has improved over the course of fiscal 2023. I'm just, you know, curious, you know, whether there's anything to be aware of in terms of, you know, the current levels of, you know, or access to, units, CPAP units for you guys, whether there's been any pricing changes in the market at all for you.
Hardik Mehta (CFO)
Yeah, sure. Yes. Yes, I mean, at this point, the product availability is not as much of an issue. I think we are able to get between various suppliers the products that we are looking for. The ResMed did have a price change, I think which they publicized somewhere in the second, in mid-calendar 2023. And, you know, they increased some price, they decreased some surcharges and stuff like that. But I think what you are seeing here in Q4, Q3, Q4, I think you are seeing more of a baseline or a runway that, you know, we could use for going forward.
At this point, there has not been much of a visibility of, certainly not product availability, nor on a price increase. So we don't have any information which would suggest that we will see any of those.
Richard Close (Tech-Enabled Health Equity Research)
Okay, thank you.
Operator (participant)
This concludes the question and answer session. I would like to turn the conference back over to Greg Crawford for any closing remarks.
Greg Crawford (Chairman and CEO)
Thank you, operator, and thank you all for your participation today. As always, you can find us on the web at www.quipthomemedical.com, where we will be posting a transcript of this call and also updating our investor deck. On the site, you can also view some of our exciting products and developments discussed on the call. Thank you and happy holidays.
Operator (participant)
This concludes today's conference call. You may disconnect your lines. Thank you for participating and have a pleasant day.