TruBridge - Q2 2023

Transcript

Operator (participant)

Greetings! Welcome to the CPSI's second quarter earnings conference call. At this time, all participants will be in listen-only mode. A question and answer session will follow the formal presentation. If anyone today should require operator assistance during the conference, please press star zero from your telephone keypad. Please note, this conference is being recorded. I'll now turn the conference over to Dru Anderson. Dru, you may now begin.

Dru Anderson (SVP of Corporate Communications)

Thank you. Good afternoon, and welcome to the CPSI second quarter of 2023 earnings conference call. Leading today's call are Chris Fowler, President and Chief Executive Officer, and Matt Chambless, Chief Financial Officer. This call may include statements regarding future operating plans, expectations, and performance that constitute forward-looking statements made pursuant to the safe harbor provisions of the Private Securities Litigation Reform Act of 1995. The company cautions you that any such forward-looking statements only reflect management expectations and predictions based upon currently available information and are not guarantees of future results or performance.

Actual results might differ materially from those expressed or implied by such forward-looking statements as a result of known and unknown risks, uncertainties, and other factors, including those described in public releases and reports filed with the Securities and Exchange Commission, including, but not limited to, the most recent annual report on Form 10-K. The company also cautions investors that the forward-looking information provided in this call represents their outlook only as of this date. They undertake no obligation to update or revise any forward-looking statements to reflect events or developments after the date of this call. At this time, I will now turn the call over to Mr. Chris Fowler, President and Chief Executive Officer. Please go ahead, sir.

Chris Fowler (President and CEO)

Thank you, Dru, and thank you to everyone for joining us this afternoon. These are not the results that I'd hoped to be sharing with you all today. There are bright spots in the quarter, and we are still confident about our strategy and optimistic about our future. While this has always been a story about transformation and change, the change is taking a little longer than we forecasted. The lesson learned is results from change take time, and we simply were too optimistic about how quickly the payoff would start to show in our results. As I've taken the time to reflect on the year so far and on our planning for 2023, our message should have been that this was our year for investment and change and establishing a foothold for our future. Instead, I felt crap of wanting to show positive results.

Change this year is significant. We've reorganized our sales team, we've transitioned to the public cloud, we've moved to a global workforce and focused on becoming a people-first organization focused on talent. These initiatives have been successful and have put us in a position of strength for our next phase, they have come at a cost, including both an add to the bottom line and a longer lead time to show results. This has been a valuable lesson for me and for our team regarding optimism versus realism. We have been guilty far too long of being overly optimistic when it comes to our results, that ends now. I'm going to share an overview of what happened in the second quarter and touch briefly on guidance, and then let Matt delve into the nuances of both topics.

Our revenue in the second quarter came in at $84.6 million. While the EHR business was in line with our expectations, our RCM business was lighter than we projected. Digging deeper, half of the RCM miss was due to a couple of recent TruCode contract wins. We initially thought these were going to be term licenses, where GAAP calls for mostly upfront revenue recognition, but when it was finalized as a SaaS deal, the revenue was instead smoothed out evenly over the next few years. The other main source of the problem in our RCM business was a result of over-optimism as it relates to volume. We saw volume outperformance in the first quarter and modeled a continuing trend into the second quarter, but the volume shifted back towards the mean as some short-term projects that we hoped would continue actually lapsed.

The final piece, the patient engagement license, was then under plan as well. Adjusted EBITDA for the second quarter was $11.2 million, also below our expectations. The relatively fixed cost in our model made it tough to absorb the lower revenue, and much of the miss flowed through to the bottom line. While we have the leverage to scale our cost structure, depending on anticipated demand over the next few quarters, it's admittedly challenging to do intra-quarter if a significant fluctuation has been detected. Now, to be clear, it's not all doom and gloom. Despite the choppy financial results, we did make progress on several fronts during the second quarter. I previously shared that customer retention and cross-selling are critical to our long-term growth, and I'm pleased to report we performed well in both areas in the quarter.

Halfway through the year, EHR retention is coming in on the higher end of our projections. From a cross-selling standpoint, we signed two RCM contracts with existing EHR customers, each worth over $1 million of annual recurring revenue. Additionally, we signed a large EBO contract with a non-EHR customer, Ozarks Medical Center, in Missouri. Lastly, just subsequent to the close of the second quarter, we signed a $1.5 million EHR agreement that was a competitive take. Another positive note, in May, we wrapped up a voluntary retirement program that we initiated to help streamline our organization, with roughly 130 of our employees accepting the offer. By our estimates, this will lead to roughly $3 million in savings this year and around $6 million on an annualized basis. To summarize, our pipeline continues to grow.

We are seeing stability in our EHR customer base, and we have taken the necessary measures inside the organization to better position us for the future. That said, our missteps in the quarter led us to rethink the remainder of 2023. As we think about the second half of the year, we remain confident in our revenue forecast, but there are a couple of factors that have caused us to deviate from our initial EBITDA forecast. I'll share some initial thoughts. Matt will discuss each in more detail. In terms of cost pressures we are seeing for the back half of the year, I think about this in two primary buckets. First, on the RCM side. Over the course of the first half of the year, we saw certain RCM deals take longer to close compared to our historical rate.

In hindsight, we were far too bullish on our sales force expectations following our reorganization last fall. We should have taken into account that sales is a relationship business, and that it would take a few quarters for the reorg sales force to establish the new contacts needed to close new business. As a result, bookings are coming in just shy of expected levels, but we are up the learning curve now and back on track for the second half of the year. As it relates to the RCM bookings that we signed in the first half of 2023, the mix between pure technology solutions and tech-enabled services is skewing more towards the services than we expected.

While we think our technology solutions are great standalone products that complement in-house RCM offerings, our target market of small to mid-sized hospitals often have staffing challenges and look to us for more than just tech-enabled services because they don't have the people. While we're glad we can provide this service to our market, it does have an impact on our revenue mix and ultimately on our margin. Finally, at the same time that bookings are tilting more towards services, we are seeing outpaced labor pressure in our domestic market. While we believe our voluntary retirement program and the ramping of our offshore initiatives should alleviate some of this pressure over time, it is not enough for the current year. All of the RCM factors combined account for an approximate $6 million of EBITDA headwind in the back half of the year.

The other area where we are seeing expenses come in higher than we initially projected is around our cloud migration to Azure, which began earlier this year. It is proceeding faster than we anticipated, and unfortunately, the associated costs are increasing as well as the result of having to pay for duplicative cloud services during this migration period. While we anticipated the redundant services to a degree, we did not correctly estimate the length of time we'd need to operate these redundant environments. This migration has caused an additional EBITDA headwind of around $2 million for the year. While we expect these costs to continue to scale throughout 2024 with the migration of our hosted customer data, we anticipate that the duplicative spend for redundant public cloud environments will effectively wind down by the end of the year.

While it is a bit of an undertaking, we feel it is ultimately the right thing for our customers. Given our second quarter financial results and where we stand in the year, there's not enough time to make up the difference, so we are reducing our adjusted EBITDA outlook accordingly. We now expect EBITDA to be between $52.5 million and $54.5 million. Lastly, before I turn the call to Matt, I'd like to welcome our newest board member, Mark Anquillare. Mark joins us after almost 30 years with Verisk. While at Verisk, Mark served as CFO and COO, playing a key role in their IPO and their subsequent outsized growth. We welcome his decades of experience and insight and look forward to leverage his growth-minded approach, coupled with thoughtful execution.

We are thrilled to have him on the team as we continue our evolution as an organization. I'll now hand it over to Matt.

Matt Chambless (CFO)

Thanks, Chris, thanks to everyone joining the call. I'll now review the second quarter results. Net patient revenue, which represents our total NPR of just our end-to-end RCM customers, was $3.2 billion, an increase of 9% year-over-year. Total bookings in the quarter were $21.9 million. RCM bookings of $13.6 million comprised 62% of total bookings and were the second highest in our history, behind only the second quarter of last year. Cross-selling RCM to our EHR customers, which is a key factor in our success, represented 74% of total RCM bookings in the quarter. Total revenue of $84.6 million increased just 2% compared to last year. For the quarter, RCM represented 56% of total revenue, EHR was 41%, and patient engagement rounded out the remaining 2%.

Gross margins in the quarter of 47.8% decreased compared to 49.2%, due in part to the labor pressure that Chris noted. We believe globalizing efforts will begin to relieve the labor pressure as we scale. Operating expenses as a percentage of revenue was 50.1% in the quarter, compared to 43.6%. We saw an uptick as a percentage of revenue in product development due to our cloud migration and other modernization efforts, general and administrative costs related to increased severance and other non-recurring charges. These all resulted in adjusted EBITDA of $11.2 million, compared to $13.2 million a year ago. Adjusted EBITDA margin of 13.3% was down 260 basis points due to the expense pressure that Chris highlighted earlier in the call.

Wrapping up the financials, operating cash flow for the second quarter was $700,000. Turning to guidance, Chris gave you a rundown of some areas where we expect to see outsized expenses in the back half of the year. To provide a little more context on each factor we've taken into consideration. First, our domestic labor market costs increased roughly 10%. Specifically, in RCM business, we saw labor costs increase 13% versus a 2% increase in revenues, despite our successes in the global workforce initiative. As Chris mentioned, we've put in place a strategy to alleviate the labor pressure by leveraging our global workforce, but it won't be enough to offset the impact in 2023.

As added context, we ended the quarter with 203 offshore team members in compared to 100 at the beginning of the year and a goal of 400 by year-end. Second, our RCM bookings are coming in at a different mix of services and technology than we expected. We initially thought our bookings would be more of a balanced split between tech and services. So far this year, our actual bookings mix was much more heavily weighted towards services. As a reminder, our tech RCM solutions typically have a gross margin in the 70th percentile ranges, compared to our tech-enabled services, which are more labor-based, with gross margin in the 30s.

Third, as Chris mentioned, our sales force reorg last fall caused a temporary elongation of RCM deals, as these new relationships need time to gel, but we believe it was a necessary phenomenon and temporary phenomenon, given the data that we're seeing. For example, our average decision time frame, which we measure from open opportunity, open to close for end-to-end RCM deals, doubled from the first half of 2023 compared to full year 2022. We've started to see that trend down meaningfully over the past couple of months. Those three factors combined equate to an approximately $6 million impact to our EBITDA this year.

Giving everything I just covered, as well as the incremental cost of our cloud migration this year, and the half-year benefit of the voluntary early retirement program, we are approaching our guidance as follows: We're reiterating our revenue range of $340 million-$350 million, reducing our adjusted EBITDA range of $59 million-$63 million to between $52.5 million and $54.5 million. Introducing a non-GAAP net income range of $25.6 million-$27.6 million. Looking at the distribution between the remaining quarters this year, for Q3, we see revenue relatively flat compared to Q2, with revenue gains and low margin RCM lines offset by lower non-recurring revenues from EHR and patient engagement.

In terms of profitability, we expect a sequential increase, likely in the low double digits, with lower seasonal costs in the third quarter. Thank you all for your interest in our story, and I'll hand it back to Chris for some closing remarks.

Chris Fowler (President and CEO)

Thanks, Matt. To close, let me just say that while we're taking a step back in 2023, I know our organization is stronger and better prepared to capitalize on the opportunities in front of us. Like I said in the beginning, this has always been a story of transformation and change, and it still is. I thank you for your interest in CPSI. I sincerely look forward to sharing an update on our progress in the coming quarters. That concludes our prepared remarks. Rob, let's open up the call to questions.

Operator (participant)

Thank you. If you'd like to ask a question, please press star one from your telephone keypad. A kind of confirmation tone will indicate your line is in the question queue. You may press star two if you would like to remove your question from the queue. For participants using speaker equipment, it may be necessary to pick up your handset before pressing the star keys. One moment, please, while we pull for questions. Thank you. Our first question is from the line of Jeff Garro with Stephens. Please proceed with your questions.

Jeff Garro (Managing Director of Healthcare IT Equity Research)

Yeah, good afternoon, and thanks for taking the questions. Maybe we'll start out on the demand side of things. You talked about the pipeline continuing to grow, but was hoping you could comment on how pipeline conversion has been and, and what you could do to accelerate that in the future. You know, realize that it might be a, a bit of a balance, that you're not always in competitive procurements, but that lends itself to maybe less urgency on behalf of your customers and, and prospects. Would appreciate your comments there.

Chris Fowler (President and CEO)

Yeah. Hey, thanks a lot, Jeff. I'll start, and then Matt may have some additional color on the back end of that. You know, I, I, I think it's a great point to, to call out that, you know, we've seen this elongation in the pipeline, and I think a big portion of that is the fact that, you know, again, remember that we're selling something, to your point, where it's not necessarily competitive, we're creating the demand as well. So we're going into these opportunities, which aren't even opportunities in the beginning, and so we're having to, to, to first sell them on the idea of outsourcing and then sell them on the idea of TruBridge. I, I, I think that there's always gonna be a natural additional link to that compared to, you know, our historical.

process on the EHR side. As we continue to, to refine that value proposition and show, show the benefit of, of this being one of the things that the hospital can take out of their operation, I think we'll see that shorten. I also think there's gonna be a natural acceleration on the, on the buying side of this, because the pressures are only intensifying from a labor standpoint, specifically. As those labor challenges continue to, to, to, to be emphasized at the facilities, I think that's gonna have a natural acceleration to the, to the, to the timeline.

Matt Chambless (CFO)

Yeah, and Jeff, you know, I think the question around pipeline conversion is really getting to, you know, what's happening in win rates and in the competitive market. And the competitive landscape here hasn't really changed all that much from, you know, when we entered the year, and that story kinda holds true on the win rates as well. For a little bit of context, you know, we, we win roughly 90% or more of the opportunities where we get a chance to, you know, what we call demoing TruBridge's RCM services. So situations where the prospect is really taking the service seriously. And that's been our historical rate. It's been pretty consistent, and, and, and that consistency is maintained throughout the first couple of quarters of this year.

You know, what we're seeing on the, on the pipeline and booking side of things is really just an elongation of that decision time frame, but the outcomes themselves haven't really changed all that much.

Jeff Garro (Managing Director of Healthcare IT Equity Research)

Got it. All, all very helpful. Then maybe to, to switch over to the, the margin side of things, and certainly, it's a little bit related that you're, you know, seeing a, a relatively healthy demand environment, but facing labor pressures. I think the, the natural question is, you know, how would you describe your ability to, to capture more price from your customers while also trying to, you know, accelerate some of that conversion we just talked about? Then the second question there is on the, the labor pressures and looking to globalization as an offset. Is there any wariness of, of moving too fast on globalization efforts, given the, the pressures that you're seeing?

Chris Fowler (President and CEO)

I, I'll take the-- I'll take the second question first, and then may ask for some clarification on the first question. You know, we've said from the very beginning that we were gonna be very intentional about our conversion to the global market. You know, we've always been prideful in the service that, that our team has put forward. It's highly referen- referencable. You know, our, our retention rate is very strong there. We wanted to be mindful that while we were undertaking this initiative, that we, we were, we were thoughtful of the impact on the service to our existing customer base.

You know, with that said, you know, we were looking at, and in our own pace, for our 400 employees by the end of this year and looking at potentially 800 employees by the end of 2024. That was the original plan at the beginning of the year. You know, as we continue to feel the same pressure that's creating the opportunity for us with the new business, you know, we're, we're looking at how can we potentially accelerate that opportunity while not deteriorating the service that we're creating. We will continue to be very thoughtful about making sure that the service is high level, while seeing what levers we have to be able to, to put our foot on the gas, for lack of a better term, about seeing this conversion happen sooner rather than later.

On, on the first question, come back to... If you don't mind, help me out again, you said, an opportunity to take more price from the customer?

Jeff Garro (Managing Director of Healthcare IT Equity Research)

Yeah, you know, maybe a bit of a concern that labor pressures are causing or, or causing demand for your services, but they're, they're also pressuring your, your profitability. If, if, if you could speak to your ability to deliver these offerings more efficiently, these services more efficiently than your customers can, and, and not just, you know, kind of take on their labor pressures.

Chris Fowler (President and CEO)

Yeah, absolutely. So I think that speaks right into the heart of, right into the heart of, of, of the globalization and then also automation. I would say those are the two main levers we have the opportunity to pull from a providing this at a more efficient rate than our customers can. One dynamic that, that we've really, you know, another, another learning of the year is we were anticipating the ability to start with a higher offshore model from the beginning with our customers. What we're seeing is that as we take their employees on, that, that ramp is taking a little bit longer than we maybe had thought it would.

For an example of that, you know, if we take on a customer that's got 20 employees in their business office, we will, we will, we will take those employees on in our own as, as our employees, and either continue to keep them on the account, find opportunities to, to, to uptrain them, and place them throughout the organization. That just creates another dynamic for us to, to continue to keep that right size of the, of the percentage of onshore to offshore of cut of employees. Again, I think that's a big part to, to our future success, is again, remembering these small, mid-size towns, that they're a crucial part of the employment process in the, in the community, a big part of the economic development.

We've, we've got to continue to be mindful of that to some extent. As, as we, as we have learned more of what that looks like, I think we've refined the approach of what the ramp to get to that maximum utilization is. While it may take a little longer than we thought, I think over the long term, you know, as we, you know, as we sign three- and five-year contracts, we're gonna be better, better down the road. Got it. That helps. I'll jump back in the queue.

Operator (participant)

Thank you. If you'd like to ask a question, you may press star one. The next question is from the line of George Hill with Deutsche Bank. Please proceed with your question.

George Hill (Managing Director and Equity Research Analyst)

Hey, good evening, guys, and thanks for taking the questions. I'll say, Chris Fowler and Matt Chambless, you guys talk faster than I can take notes, so some of this might be a little bit repetitive. On the impact of the sale that was a license sale, that you guys thought was gonna be a license sale that went SaaS, was that EMR or TruBridge? I missed if you talked about what the revenue impact was. I guess I, I'd ask for both the quarter and the expectation for the year.

Matt Chambless (CFO)

Yeah. As far as the, the, the license mix impact, you know, you, you are calling out an important, an important, you know, nuance here, and is that these were not EHR contracts. EHR contracts have been 100% SaaS. That's all we've signed in probably the last three years. Instead, these were large TruBridge contracts, specifically the TruCode product. Large TruCode deals that, frankly, were a lot bigger than our average deal size that we see in total. Average deal size, average contract value for TruCode arrangements is fairly small, you know, in the grand scheme of things, so these were kind of outliers. That's, that's the context between these, these couple of sites that we were talking about. Sorry, what, what was the back half of that question, George?

George Hill (Managing Director and Equity Research Analyst)

Well, you, you, you clarified my, my first question on the product, which is I knew what it was. I guess, what's the financial impact for the year? How do, how do we think about what is because you guys kept the revenue guidance the same, but there you, you also indicated a slowing revenue recognition from the nature of this contract. How do we think about the headwinds and the puts and takes on the top line? I have a couple more questions.

Matt Chambless (CFO)

Yeah. The puts and takes on the top line, while we did see, you know, this headwind stir up with regard to these two TruCode contracts, you know, we have had some, some tailwinds on the top line. They're gonna help offset some of the, some of the overall top-line impact from the year. I think Chris mentioned it earlier, you know, one of the positive surprises I say, I would say for this year has been that the EHR retention of that customer base, while we expected it to be strong coming into the year, it's outpaced even our expectations, and this is probably the second or third straight year, where, where that business unit's been stronger and more, more stable than what we had, had, had even expected.

That's kind of what's, what's offsetting that and resulting in a, a top-line guidance that's kind of unchanged right now.

George Hill (Managing Director and Equity Research Analyst)

Okay, that's helpful. If I think about the SG&A in the quarter, came in about $7 million higher than what I had modeled, and that kind of. That's pretty close to the EBITDA guide down for the year. I guess, should we look at Q2 as kind of the high watermark from a discretionary expense perspective as we go through the balance of the year? You guys kind of indicated the cost-cutting initiatives that should kind of like lead for that number to go through with the employee retirement programs and stuff like that.

Matt Chambless (CFO)

Yeah, so if you're looking at SG&A, you know, there are a couple of items that are making that really pop in the second quarter. First of all, you know, we do have some seasonal costs in there with our National Client Conference. That takes place in May of every year, and as much as we'd love to be able to smooth that cost out throughout the year, the costs have to be, you know, have to be booked when they're actually incurred, and that all happens in the second quarter. I think that was for, you know, somewhere between $1.2 million and $1.3 million in SG&A.

Frankly, the rest of the SG&A cost increase in the second quarter was really all EBITDA-neutral stuff from non-recurring charges, you know, partly related to the severance event that Chris mentioned on the voluntary early retirement program.

George Hill (Managing Director and Equity Research Analyst)

Okay. Then my last one will be, given what you guys discussed as it relates to inflation, and this kind of piggybacks on Jeff's last line of questions a little bit, is: How does this change how you guys were thinking about the longer-term guidance of the, the re-accelerating the revenue growth profile and the earnings profile, given that it looks like we're gonna be operating from a higher cost basis as we go through 2024... 2023, probably into 2024 and 2025?

Chris Fowler (President and CEO)

Yeah. I-I'll start there, and then Matt can fill in any blanks that, that I leave. You know, what I would say is that, you know, we have taken a really hard look at the second half of this year and really, really sharpened the pencil to make sure that we are, we are fine-tuned on where we're going to come in. We continue to do work on what we have understood, or what we have seen happen through the first half of this year and what we know will happen in the back half, and what impact that'll have on next year. I don't think, I, I don't think that we're ready to give any, any guidance into 2024, but that's something that we'll be doing in the, in the next call or two.

Know that we understand that that's something that we've got to, we've got to get out there. I will say, as we look at it big picture, and I, you know, I'm not gonna put a date on this, we still feel like the, the levers that we have in front of us as it relates to the offshore initiative, and what we had talked about at the first of this year, the offshore initiative, our opportunities, with automation, that we still see a path to get to, to those 20%+ EBITDA margin gross, and we still see that opportunity to see the revenue growth continue. Let's stay tuned on sharpening what 2024 looks like for the next call.

George Hill (Managing Director and Equity Research Analyst)

Okay. We'll stay tuned. Thanks, guys.

Operator (participant)

Thank you. At this time, we've reached the end of our question and answer session. I'll turn the call over to Chris Fowler for closing remarks.

Chris Fowler (President and CEO)

Thanks, Rob, and thanks for everybody for your continued interest in CPSI. Have a wonderful evening.

Operator (participant)

This will conclude today's conference. You may disconnect your lines at this time. Thank you for your participation.