TELA Bio - Earnings Call - Q4 2024

Executive Summary

• Q4 revenue was $17.6M with gross margin of 64%; sequentially lower vs Q3 ($19.0M) due to sales force attrition and elective surgery disruptions tied to IV fluid shortages from Hurricane Helane; FY24 revenue reached $69.3M (+19% y/y) but missed previously reiterated FY24 guidance ($74.5–$76.5M).
• Net loss improved year over year in Q4 to $(9.2)M vs $(12.9)M; Q4 diluted EPS was $(0.23), better than $(0.53) in Q4 2023, reflecting OpEx cuts implemented in Q3 that continued into Q4.
• FY25 guidance: revenue $85–$88M (+23–27% y/y), Q1 2025 revenue $17–$18M (+2–8% y/y), and OpEx flat vs 2024; management expects normalized growth with rebuilt sales capacity and portfolio expansion (larger PRS sizes, long-term resorbable hernia product).
• Near-term catalysts: sales force rebuild and compensation plan changes, growing adoption of OviTex IHR and LIQUIFIX, and IDE approval for PRS resorbable breast reconstruction study; strengthened liquidity after October 2024 equity offering (gross proceeds ~$46M) supported YE cash of $52.7M.

What Went Well and What Went Wrong

What Went Well

• Record FY24 revenue (+19% y/y) with full-year OviTex unit sales +33% and OviTex PRS +31%; Q4 net loss and opex improved vs prior year due to efficiency measures.
• Portfolio momentum: OviTex IHR sold >1,200 units since April 2024 launch; LIQUIFIX sales nearing $1M; 2025 launches planned (larger PRS sizes; long-term resorbable hernia).
• Strategic positioning: management emphasized long-term tailwinds from market shift away from permanent synthetic mesh and alternatives to cadaveric tissue in PRS. “We are optimistic about TELA’s outlook… restore topline growth… continue our steady path towards profitability.”.

What Went Wrong

• Q4 growth slowed to low single digits (+4% y/y) and sequential decline vs Q3 amid lower-than-planned sales headcount and 11 unplanned TM departures in Nov–Dec; top 44 reps still performed ≥90% to quota, highlighting uneven coverage.
• External headwinds: hurricane-related IV fluid shortages reduced elective volumes in TELA’s two strongest Southeast regions, with impact most notable in Nov–Dec.
• Mix/ASP pressure: higher share of smaller-sized units from robotic/minimally invasive procedures (IHR) pressured average selling prices; Q4 gross margin fell to 64% due to excess/obsolete inventory expense tied to new product generations.

Transcript

Operator (participant)

Good afternoon, ladies, and gentlemen, and welcome to the TELA Bio Fourth Quarter 2024 Earnings Conference Call. At this time, all participants are in a listen-only mode. A question-and-answer session will follow the prepared remarks. As a reminder, this conference call is being recorded. I would now like to turn the conference over to Greg Chodaczek from the Gilmartin Group. Please go ahead.

Greg Chodaczek (Managing Director)

Thank you, Latif, and good afternoon, everyone. Earlier today, TELA Bio released Financial Results for the Fourth Quarter of Full Year 2024. A copy of the press release is available on the company's website. Joining me on today's call are Tony Koblish, President and Chief Executive Officer, and Roberto Cuca, Chief Operating Officer and Chief Financial Officer. Before we begin, I'd like to remind you that during this conference call, the company will make projections and forward-looking statements regarding future events. We encourage you to review the company's past and future filings with the SEC, including, without limitation, the company's annual report on Form 10-K and quarterly reports on Forms 10-Q, which identify the specific factors that may cause actual results or events to differ materially from those described in these forward-looking statements.

These factors may include, without limitation, statements regarding product development and pipeline opportunities, product potential, the impact of various macroeconomic conditions identified in our filings, like changes in surgical procedure volumes, the regulatory environment, sales and marketing strategies, capital resources, or operating performance. With that, I will now turn the call over to Tony.

Antony Koblish (CEO)

Thank you, Greg, and good afternoon, everyone. Thank you for joining TELA Bio's Fourth Quarter 2024 Earnings Call. I'll begin by reviewing the quarter and factors that affected performance. Then I'll turn the meeting over to Roberto for a review of the financials and our outlook before opening it up for your questions. We generated $17.6 million in revenue in the fourth quarter, growing 3.8% versus the fourth quarter of 2023. This was lower than our expectations and marks the first instance of single-digit revenue growth at TELA since the start of the COVID-19 pandemic, despite, as we noted in our Q3 call, October marking the strongest first month of any quarter in TELA's history and trending towards a strong finish in 2024. What happened? There were several minor or hard-to-quantify external factors impacting performance, but ultimately, the primary driver of this underperformance was lower-than-planned headcount in our U.S. salesforce in the fourth quarter, exacerbated further by a number of departures, including unplanned productive losses in late November and into December.

In August 2024, we made some fundamental but necessary changes in our commercial organization to realign our salesforce around a new strategic commercial direction. This realignment included a focus reduction in headcount related to managerial, administrative, and support roles, but also included the departure of approximately 10-15 underperforming sales reps to address gaps in productivity and efficiency, partially offset by the conversion of certain support personnel into quota-carrying roles. Although our top reps continue to drive performance in line with expectations throughout Q4, we also, for the first time in our history, experienced a number of departures from the salesforce of productive reps.

These additional losses included some key reps who were lured away by large financial incentives from companies in the wound care space, as well as a few newer entrants building out their salesforce within the plastic and reconstructive space. When combined with the prior realignment, these losses created a situation where we simply did not have the headcount to make up the difference so late in the quarter. Turning to some of the external headwinds that contributed to fourth quarter results, first, in late September, Hurricane Helene made landfall on the Gulf Coast of Florida and continued north through Georgia, South Carolina, and most notably North Carolina, where the storm caused significant damage to a plant responsible for manufacturing 60% of the IV fluids used in the U.S.

Elective surgeries in our two strongest sales regions slowed down as a direct result of the storm, while the ensuing shortage of IV fluids appears to have affected surgical volumes throughout the U.S. As we had anticipated, feedback from the field indicates that these shortages manifested more in November and December as hospitals depleted their existing stocks earlier in the quarter. Finally, although it is difficult to measure, Christmas and New Year's Day fell on the Wednesdays of their respective weeks, potentially reducing the number of days in those weeks that surgeons operated or that patients scheduled procedures. While there is no clear signal of an impact in our sales, it is possible it had an effect and was cited by at least one other market participant as a cause for softness in Q4 elective procedure volumes.

Despite this disappointing fourth quarter performance, we have already implemented necessary measures to address the challenges we experienced in the quarter. We believe these actions, when coupled with a few substantial tailwinds, will position TELA Bio for strong performance in 2025. The primary adjustment comes from the full implementation of our revised commercial strategy, including those short-term adjustments we made as part of our August or Q3 realignment. This is led by an evolution of our field-based sales organization strategy, where we have redefined our approach to the division of responsibilities between our territory managers, or TMs, and our account specialists, or ASs. The AS position represents a vital direct field-level auxiliary sales role, with each AS brought on board to provide procedural case coverage within the territory of one or more of our top TMs.

This team-based sales strategy allows our TMs to pursue new customer accounts or drive deeper penetration into existing customer accounts while simultaneously helping newer ASs more rapidly integrate into our organization, receiving significant on-the-ground experience under the tutelage of our top TMs, with the potential to transition into a TM role more quickly and efficiently. Where successful, this should set up the promoted AS for long-term success in their new territory. We have seen success with this program so far through 2024, prompting us to allocate additional resources toward recruiting and retaining more ASs. This strategy aims to enhance the reach and productivity of our TMs, strengthen our relationship with customer accounts, and establish greater stability with existing customers, irrespective of future changes with the TMs or other ASs serving on these selling teams.

At the end of Q3, we had 76 field-based representatives, 69 territory managers, TMs, and seven account specialists, ASs. However, if we look at the end of Q4, we had 71 total representatives with 63 TMs and eight ASs. The intra-quarter churn and unexpected departures of several TMs ultimately drove volatility in top-line performance. As we look ahead this year, we expect by the end of this month, we will have 88 total reps with nearly 70 TMs and close to 20 ASs, well on our way to reaching our year-end target of 97 reps, consisting of approximately 76 TMs and 21 ASs. We believe this model positions us well for the future as it allows us to identify and foster top talent while providing a roadmap for developing additional high-performing TMs.

The value of a high-performing TM cannot be overstated, as seen even in our Q4 results, where our top reps continue to perform well, with the top 44 reps achieving over 90% of their quotas in the quarter or virtually 100% of their allocated budget targets, even despite some of the external tailwinds we discussed earlier. Although we won't have full data to report until after the quarter, revenues year-to-date have been strong and are signaling that the crucial Q4 rebuild decisions inherent in this strategy will be important drivers for growth moving forward. Our commercial leadership team, including our CCO, have now completed a full six months in their respective roles. This period was marked by a strong third quarter and was followed by a more difficult period that included strategic shifts, implementation of a new market approach, and the recalibrated sales structure.

With continued stability, we believe this should return TELA to sustained and normalized growth rates for 2025 and beyond. In addition to these meaningful salesforce adjustments, several other factors drive our optimism in our 2025 outlook: an expanding product portfolio, our broadening reach to surgeon customers, and our continued development of clinical data in support of our products. From a broader perspective, there is a substantial portion of the market share that remains available for us to capture in both hernia and PRS. In hernia repair, 80% of all procedures still utilize permanent synthetics. As at least one major competitor is publicly announcing shifts toward their costlier resorbable product lines, TELA has the opportunity to highlight OviTex's consistent clinical performance and value proposition to drive adoption. In the PRS market, where we launched our first products in 2019, we are only beginning to address the $800 million U.S. opportunity, and we have significant runway to generate substantial growth with our expanding portfolio of PRS solutions.

In 2024, we launched, among other products, the LiquiFix and OviTex IHR product families. Both quickly gained traction after launch, with LiquiFix obtaining contract access with two GPOs as an innovative breakthrough technology, and both have afforded us access to customer groups with whom we may previously have had less interaction. Because LiquiFix is indicated for use only with synthetic mesh, we've been able to discuss that product and introduce TELA Bio to surgeons who may not have been active OviTex users. The IHR product line was also quickly adopted by surgeons using minimally invasive techniques to repair inguinal hernias, leading to more than $1 million in sales since its April 2024 launch. Total LiquiFix sales are also nearing $1 million.

We expect both product lines to continue to grow robustly in 2025, further expanding TELA Bio's profile in the hernia repair space and increasing awareness of all of our products. In 2025, we expect to launch larger-sized versions of our existing OviTex PRS products and a new long-term resorbable alternative for our hernia products. The PRS offerings, in particular, are highly anticipated by surgeons since certain techniques within that space require or benefit from access to larger units. We expect both sets of innovations to represent incremental revenues as they are not merely replacing smaller pieces that were already being used. In support of our expanded product offerings, we also continue to invest in medical education and broader surgeon outreach. Several initiatives are already thriving and helping us set the stage for the year, including a live robotic hernia symposium featuring foregut specialists, faculty, Dr. Philip Woodworth and Reginald Bell, both highly respected leaders in this space.

A national webinar with renowned surgeon Mr. Alastair Windsor from London, a leading advocate for shared decision-making. Mr. Windsor's participation elevates our commitment to furthering U.S. adoption of this current best practice in Europe. Our third annual Plastic Reconstructive Summit, an invitation-only event spotlighting emerging technologies designed to enhance outcomes in soft tissue reconstruction, and attended by more than 30 surgeon specialists in this space. Beyond education, we've already made significant strides in regional and national society meetings in 2025, with planned sponsorship of 16 key industry events, providing exposure to nearly 5,000 surgeons. In addition, we hosted a standing room-only lunch symposium at SAGES, where experts Dr. Reginald Bell, Dr. Tripp Buckley III, and Dr. Steven DeMeester led an engaging discussion on paraesophageal hernia repairs.

Our long-term ventral and inguinal data were also presented at this meeting, showcasing their low recurrence rates across hundreds of patients with five years of follow-up, further validating the clinical benefits of OviTex. We remain committed to the collection of clinical data showcasing the value of our products. In the fourth quarter of 2024, we achieved the significant regulatory milestone of obtaining IDE approval for a PRS long-term resorbable breast reconstruction investigational study. This approval underscores our continued investment in clinical research and to the future of our PRS business. In addition, we continue to enroll our OPERA study, a retrospective prospective trial evaluating the safety profile of OviTex PRS in previous prepectoral and subpectoral implant-based breast reconstructions. We are aware of two newer surgeon publications based on surgeon-derived studies involving the use of PRS in these applications, with the understanding that several similar publications may be in progress.

By the end of 2025, we expect to have 300-400 patients under study using our various PRS offerings. Since TELA's inception, we have sold over 65,000 OviTex and nearly 15,000 OviTex PRS units. Our next goal is to reach $100 million in revenue and shortly thereafter to achieve profitability. We foresee reaching these milestones in the not-too-distant future and continuing to establish our products as the gold standard for soft tissue preservation and restoration. With that, I'll turn the call over to Roberto to provide more specifics on our financial results.

Roberto Cuca (COO and CFO)

Thanks, Tony. As Tony mentioned, revenue for the fourth quarter of 2024 increased 4% year-over-year to $17.6 million and grew 19% for the full year to $69.3 million, with revenue from OviTex growing 17% and OviTex PRS revenue growing 21% for the year. The growth was primarily due to an increase in unit sales of our products, resulting from the addition of new customers and growing international sales. OviTex unit sales grew 28% for the quarter and 33% for the year, while PRS unit sales grew 11% for the quarter and 31% for the year. Gross margin was 64% for the fourth quarter and 67% for the full year, compared to 68% and 69% for the prior year periods, respectively. The decrease was primarily due to higher expense recognized for excess and obsolete inventory adjustments in the percentage of revenue, which resulted from the introduction of newer generation products.

Sales and marketing expense was $14 million in the fourth quarter and $64.6 million for the full year, compared to $17.2 million and $59.7 million for the prior year periods, respectively. This increase was mainly due to higher compensation costs, primarily from increased commissions and severance costs, increased travel and consulting, and additional selling-related expenses, which offset decreases in marketing expenses. General and administrative expense was $3.6 million for the fourth quarter and $14.7 million for the full year, compared to $4.1 million and $14.9 million for the prior year periods, respectively. R&D expense for the fourth quarter was $2 million, and for the full year was $8.8 million, compared to $2.7 million and $9.6 million for the prior year periods.

Loss from operations was $8.4 million in the fourth quarter of 2024 and $34.1 million for the full year, compared to $12.3 million and $44.1 million in the prior year periods. Net loss was $9.2 million in the fourth quarter and $37.8 million for the full year, compared to $12.9 million and $46.7 million for the prior year periods. We ended 2024 with $52.7 million in cash and cash equivalents. For 2025, we anticipate revenues to be in the range of $85 million-$88 million, representing growth of 23%-27% over the full year 2024. We expect that operating loss and net loss will continue to decrease, coming in lower in 2025 than in 2024.

Reiterating what we said last year, we expect that the operating efficiency improvements that we made in the second quarter of 2024 will provide a reduction from the first half of 2024's run rate. As a result, we expect OpEx in 2025 to be flat compared to full year 2024. For the first quarter of 2025, we expect revenues to be in the range of $17 million-$18 million, based in large part on our visibility into performance to date. With that, I'll hand the call back to Tony for closing remarks.

Antony Koblish (CEO)

Thank you, Roberto. As we reflect on 2024 and look ahead, our progress is undeniable. We strengthened our global footprint, expanded our educational impact, and continue to differentiate our solutions through clinical validation and portfolio expansion. Most importantly, we have entered 2025 with unwavering momentum and a motivated team and a clear vision for growth. The market's expected shift away from synthetic mesh represents a significant opportunity for us, and our strong commercial strategy positions us to capitalize on this evolving landscape. Coupled with our disciplined operating expenses and a strong cash position, we are well-equipped to execute our plan and drive sustained success. We are motivated by the early successes of this year, from an energized national sales meeting to robust surgeon engagement at key industry events.

With a focus on execution, innovation, and collaboration, we are confident in our ability to deliver meaningful value to our stakeholders as we head toward our next milestone of $100 million in revenue. I want to thank our dedicated team for their relentless commitment, and we look forward to a transformative year ahead together. We will snap back. With that, I'll now ask Latif to open the line for your questions.

Operator (participant)

Thank you. As a reminder to ask a question, you will need to press star one-one on your telephone to remove yourself from the queue. You may press star one-one again. Please stand by while we compile the Q&A roster. Our first question comes from Frank Takkinen of Lake Street Capital Markets. Your question, please, Frank.

Frank Takkinen (Senior Research Analyst)

Great. Thank you for taking the questions. Hey, Tony here, Roberto. Wanted to start with one follow-up around the territory manager departures. I think the net number you gave was down six territory managers from Q3-Q4. Can you talk about gross numbers? How many reps did you lose, and then how many did you hire in the quarter? I know you mentioned compensation as one factor. Any other reasons for some of the rep departures?

Antony Koblish (CEO)

Yeah. I mean, look, there were ins and outs in Q4, but if you look at it, in November and December, roughly, we lost 11 TMs due to unplanned departures, right? They never tell you. You do not see it coming. I guess they come in clusters. This has not really happened to me before, so it certainly got our attention. I guess our reps are coveted. They are sought after. They are good. That was a big number and difficult to recover from late in the quarter. Basically, like I said, some of these wound care companies that are smaller and have these interesting reimbursement positions definitely threw some serious amounts of guarantees and cash around to lure these folks out. I think in 2024, we also had some meaningful players that were building PRS organizations.

For lack of a better word, I think we got poached at the very end of the year. That is kind of where we are. Even with those ins and outs, I think I mentioned where we were with the end of Q4. I will tell you where we are now. Where we are now is about 88 territory managers, Frank, with a mix of about 20 account specialists and the rest being TMs. We have snapped back pretty well. The talent that we have been able to lure in and replace, I think in some cases were even upgrades from some of those 11 that departed. I would consider those 11 that departed to be kind of in the middle to upper middle-class range. Our top performers were not impacted by that, but some pretty good reps went.

We feel good about the energy and momentum we have in the first quarter. I think the growth and application of the account specialists is going to blunt that risk, which we started to set up in Q3 of last year, right? Not only do these account specialists allow our reps to extend their reach, so good for offense, but also good for defense, right? They can have a deeper presence in the accounts with this team selling approach, which should be able to alert us to competitive activity. If we ever do take a loss on the TM side and are depleted in that way, we have very strong account specialists in place as backup. I'll just say a little bit about the account specialists. We used to have a program known as associate reps, and we've really elevated that.

We're hiring more experienced folks in the account specialist role. They have, in most cases, some type of selling experience or, in all cases, a very good clinical understanding and background. These folks will be able to contribute. Our top reps, the two and three-plus million dollar reps, have all made excellent use of account specialists, and it's a very well-proven model for us that extends the growth and performance of our top reps. I think we're in very good shape around the salesforce recovery and reconstruction with about 88 total field-based folks on the ground right now. Our plan for the year, Frank, is to be at around 97. Maybe we get to 100, but 97 with a mix of mid-70s or higher on the TM side and 20 or higher on the account specialist side.

Frank Takkinen (Senior Research Analyst)

Okay. That's helpful. Thank you. Maybe on the outlook for 2025, I'm most curious about kind of unit versus ASP expectation. I think if you back into the ASP, it was down in the 10% range for OviTex, and then still maybe close to double digits for PRS from an ASP perspective. How should we be thinking about your assumptions for volume versus ASP to get to the 2025 guidance?

Antony Koblish (CEO)

Yeah. I think to a certain extent, the advent of the IHR and our collaboration and compatibility with the robot, it's a good thing so that we can be a full-service hernia provider. Obviously, the IHR, the inguinal procedures, the hiatal procedures, they're going to be a little bit of a lower ASP, which can affect things. As we're transitioning from a company that was more focused on ventral and complex, which tends to be higher ASP, bigger pieces, we have to get a more fulsome approach to selling the full bag across from inguinal on up. Perhaps we were a little bit in no-man's land where the growth of the IHR and the LiquiFix products, although great, are coming on, and we think that they should be able to fill that gap.

If you look at Q1, Frank, we did probably, I don't know, half or more, maybe even two-thirds in some case, so far in Q1 of IHR and LiquiFix that we did from April to December last year. We may have had a little bit of no-man's land as we transition to a more full-service provider at the end of 2024. We're just going to have to make it up on the volume. I think that seems to be playing out right now thus far in Q1. On the PRS side, I think we're going to see possible ASP expansion. The two new large LTR pieces will be the largest tissue-based matrices ever developed. We had 30 plastic surgeons in town for a summit meeting last weekend.

I can tell you there's a lot of interest in that product as well, given the shift to prepec and DTI-type procedures. I do think that the PRS ASP will be highly stable to growing. On the hernia side, we have to transition to a full-service provider, and then we'll find a new kind of stable watermark and then grow from there.

Frank Takkinen (Senior Research Analyst)

Okay.

Roberto Cuca (COO and CFO)

Yeah. I mean, I think Tony said it all. The theme is in hernia, we added some smaller pieces that have lower ASPs. In PRS, we've added some larger pieces that have higher ASPs. In both cases, they're non-cannibalistic, so they're incremental to pre-existing revenues, but they'll have dilutive effects in opposite directions.

Frank Takkinen (Senior Research Analyst)

Got it. Okay. That's helpful. If I could just sneak one more in, I was curious if you could comment on your confidence to get to break even with the existing liquidity. Obviously, it's maybe a little bit further out now with the guidance being a little lower than expected, but just how should we think about when that could come and your confidence around getting there with existing liquidity?

Roberto Cuca (COO and CFO)

We remain very confident. One of the things that we've done that we began at the end of last year and that is extending into this year is to take a harder look at our expenses. Obviously, we're signaling that OpEx this year should be flat to last year. My guess is that that was not an expectation that was baked in by a lot of external observers. That's a positive versus what people may have been thinking. We believe that even with the growth of the revenues where it is, on top of the flat OpEx with the potential for further potential decreases if needed in future years, we'll have no trouble hitting profitability.

Frank Takkinen (Senior Research Analyst)

Okay. That's helpful. Thank you.

Antony Koblish (CEO)

Thanks, Frank.

Operator (participant)

Thank you. Our next question comes from Caitlin Cronin of Canaccord Genuity. Please go ahead, Caitlin.

Caitlin Cronin (Director of MedTech Equity Research)

Hey, thanks for taking the questions. I guess just to start with the revenue guidance and maybe talk through the cadence of revenue for this year, starting with the Q1 and your assumptions there and going forward. I mean, is that kind of building in the sales ramp and the sales reps getting up for productivity throughout the year?

Roberto Cuca (COO and CFO)

Sure. In certain prior years, we had sales forces growing across the year. In 2024, we started the year with the target number of sales reps. We're pretty close to the target number of sales reps right now for this year. We're not going to see the sort of extended growth that we saw in, say, 2023. That historical cadence, and I wouldn't point to 2024 since we had two disruptions in the year, that historical cadence of a good step up from the first to the second quarter, a smaller step up from the second to third quarter because of the summer holidays in North America, slightly dampened growth, and then another bigger step up from the third to the fourth quarter is what we expect to see over the course of the year.

With the exception that I think Q1 of this year will be as usual or better given our momentum that we see thus far.

Caitlin Cronin (Director of MedTech Equity Research)

Got it. And then just with the reps being lured away in the Q4, how can you kind of ensure that that won't happen going forward? Any kind of new incentive programs put in place?

Antony Koblish (CEO)

Yeah. I think the account specialist is one of the best backups that we have to blunt that factor, right? I think a team selling approach is one that, frankly, I think is used by many of our larger competitors. There will be relationships, I think, with the account specialists working on a team approach with the TMs such that if we do get a TM poached, we should be able to backfill that much more quickly. It's already kind of baked already. Our specialists, they go through the exact same training process: pre-training, sales school, and then follow-up after training, as our TMs do. They come into the company with the expectation that they have an opportunity in an efficient, timely manner to become TMs themselves, given that they're starting from a higher vantage point from the old associate program.

We like the concept of having our account specialists work in that team approach and chasing a target and a quota. I'll give you a little bit of an anecdotal example to show how we can combat that. At the start of this year, we were very cognizant that if we were going to have continued exodus from the company, it would happen by the end of January based on when bonuses were paid out. That's just, I think, common or traditional. We had one exceptional player take one of these guarantees, and we were able to stop him cold in his tracks and stay with us once he saw our enhanced commission plan and the upside opportunity that we're affording this year.

This year, what we've done is we've adjusted our comp plan such that we pay more if you get close to your quota, right? If it's a near miss, you have an opportunity to keep working and make more money. Whereas in the past, we had a little bit more of a cliff where if you missed your quota, the step down in commission dollars available was marked. That might have worked for us earlier, but I think if we have reps that are in that 90% range, they can still get their payout, and that should still drive them to go forward. The other thing that we've done is we've put some significant upside opportunity for stretch goals. In fact, we've put the whole commercial team on a national year-end stretch goal.

We have quarterly stretch goals for each one of the regions, and there's extra compensation that actually sits outside of the traditional comp plan. They can win two ways. They can win within the comp plan by getting at quota or close to it, and they can really win if they exceed and get beyond quota. There's going to be a lot of competition, and that's going to foster teamwork across the regions and across the whole national organization for this year. We debuted this at our national sales meeting, which we did on purpose earlier this year at the end of January, and I think we stunned them with how awesome the comp plan is. I think we've got a very strong morale, work ethic.

I think it dovetails beautifully with the new go-to-market strategy, which is rolling out, was really rolled out in earnest at the NSM. I think the beginnings of that worked excellent in Q3, and then Q4 is what it is. I think we're back to that feeling of where we were in Q3 and maybe even much better given these enhancements to the comp plan, and everyone's just feeling great right now.

Caitlin Cronin (Director of MedTech Equity Research)

Awesome. Maybe just another quick one if I can sneak it in. I mean, maybe just give a little more color on the composition of the miss in the Q4. I mean, how much was that really due to kind of the sales rep disruption versus the IV shortages and the other?

Antony Koblish (CEO)

Yeah. It's hard to quantify the IV shortages. I think more than anything, we're pretty dependent on the southeast. We've got two regions in the southeast, which are two of our strongest regions. Just the hurricane itself, probably not, I don't know, maybe $500,000 or more off the top. It's hard to quantify. I don't think we're hanging our hat on that. If you look at where we were at the end of October when we reaffirmed guidance, if you just do percentages and just straight mathematics, the amount of sales that we generated in Q4, that's to say we had three strong months in Q3 and then a fourth strong month before we hit the air pocket.

If you just extrapolated what November and December should have been in traditionally a strong seasonality finish quarter four to the year, we were well within guidance range just based on how October finished. Those departures have a very negative effect, right? You do not know when it is coming, right? You wind up with perhaps some of those reps taking their foot off the gas before they go while they are looking, while they are contemplating their next move. Certainly, our products, no matter how good they are, still require care and feeding and servicing and selling. We had significant losses from those regions in November and December. There is just no two ways around it. I think the bulk of it was right there.

Caitlin Cronin (Director of MedTech Equity Research)

Got it. Thanks.

Antony Koblish (CEO)

Thanks, Caitlin.

Operator (participant)

Thank you. Our next question comes from David Turkaly of Citizens. Please go ahead, David.

David Turkaly (Managing Director)

Hey, good evening. Tony, maybe I think you said smaller wound care companies that might have poached you, but I guess I just wanted to follow-up with sort of why do you think that's now? I mean, are they looking to go public? Is there something like what happened that it all came to a head in the fourth quarter?

Antony Koblish (CEO)

Yeah. I mean, I've heard these stories from, let's call it, the more established wound care companies about these organizations and the amount of reimbursement they're driving and the amount of guarantees and poaching that they're doing. I think it was our turn, right? I think it's happened to some of the other players from what I understand, talking to the CEOs there in the past. I think it was our turn. For whatever reason, they were receptive this time around. It could be that the new go-to-market strategy, the accountability and discipline and reporting structure that we're driving sort of collaborated together to make that happen. When I say small companies, some of these companies are driving just outrageous revenue. I don't know if you're familiar with this.

There are companies in some cases that you do not hear much about, but you are pretty dang shocked when you see what they are up to. I understand that they are trying to get a handle on this reimbursement gap that seems to be exploited there. It seems like they have been talking about this for years. Eventually, they have to catch up with it. I mean, the numbers from what I am hearing in actual reimbursement by the government on a monthly basis are just shooting up. There is a geyser of money there. Hopefully, it is temporary. We had a bunch of folks go. There is nothing really to say about it. Incentives and motivation by income to start.

David Turkaly (Managing Director)

I get it. I think you threw out a lot of numbers with the TMs, AS, and everything. I just want to make sure I caught this right. 11 TMs and how many? Was that the big thing, or was there also reps that left as part of it as well?

Antony Koblish (CEO)

We had a plastic surgery director and a regional manager. Like I said, we've been able to backfill very effectively. In a lot of cases, I think we've upgraded. I'm really happy with the talent in certain areas that we've already brought in. Another anecdote is we had two TMs go in a certain state in a certain place. I won't tell you where. We brought in a real, real strong guy, and we gave him a couple of account specialists. One now, we'll get him another one. He's just spending his time reinvigorating 11 consignment accounts that were not producing or underproducing in comparison. This new guy is already rising up the stack rankings and is probably third or fourth in the company. He's been on board for, I don't know, since January. This can be resurrected and rehabilitated very effectively.

We are a very attractive place to come work. We pay superb compensation, and now it's even better given the enhancement of the near quota and the overperformance bonuses that we're laying out there. It's rare that you can have that type of compensation structure with a product that is so differentiated, so good in terms of clinical performance. It's not every day that you get the chance to change the practice of medicine for one of the most common surgical procedures done on the planet, hernia repair, right? I mean, it's not just us. Big competitor, CEO of that big organization is out there at investor conferences talking about, "We got to get permanent plastic polypropylene out of people's bellies." I think that's a quote from one of the conferences we saw somewhere. That's a beautiful thing for me to hear. It's what I say.

I'm rooting that on. I think if we can dislocate 80% of the market, and we're certainly in line to benefit from that, I would say. There's a lot of upside to being here.

David Turkaly (Managing Director)

Thank you for that.

Antony Koblish (CEO)

Thank you.

Operator (participant)

Thank you. Our next question comes from Matt O'Brien of Piper Sandler. Please go ahead, Matt.

Matt O'Brien (Managing Director)

Thanks for the questions here, gents. Maybe just starting to unpack Q4 a little bit more. Tony, you said that things were trending well in October, kind of fell off a cliff in November and December. As I'm looking at my model, it's like $5 million light of what I was expecting. $500,000 of that is hurricane-related. It just seems like even with the losing 11 folks, we still may have come up a little bit short. Is that the right math or not, and why is that? In other geographies where you did not see dislocation, what kind of growth did you see in those territories? I do a follow-up.

Antony Koblish (CEO)

Yeah. Roberto can speak to that. Like I said in the script, our 44 top reps were 90% or better to their target quota plan. Where we had tenure and stability, this thing worked great. Where we did not, it stopped. We are not at the scale yet where these products sell themselves, not by a long shot. I wish that was the case. You have got to be present, making sure that the usage is being done. Both November and December were just lights out on those departures. It was, like I said, plastic surgery directors, really good ones that were contributing greatly. One regional manager who was fairly strong, and then the rest were all TMs who were million, million five or more, right?

Their growth, probably even though we had four good months in a row, their growth probably started winding down unbeknownst to us. They do not tell us when they are going to go well before that. I do not think it is just what they would have done in November or December. I think that whole group sort of took their foot off the gas a little bit, and then really the procedure volume in those territories was fairly low.

Roberto Cuca (COO and CFO)

Matt, I think you're thinking about it the right way. If you back up to the first quarter of last year, we disclosed that we had 86 TMs and six what we then called associate reps at the time. We entered the fourth quarter with 69 TMs and seven associates or seven account specialists now and exited with 63, so a net decrease of six, but 11 gross turnover. We were already light. Notwithstanding that, we had a strong October. Had we had more heads, we might have been in an even stronger position coming out of October and been better able to withstand the disruption of November and December.

What I'd say is that it was a headcount story in the fourth quarter, going into the quarter lighter than we had planned to, and then losing unexpectedly many more than we would have expected. Those two things together accounted for the $4.5 million or so of missed revenue.

Antony Koblish (CEO)

Yeah. I by no means want to place the blame on the hurricane, right? We lost some revenue there, but our two southeastern regions still did fairly well because they were two of the more stable regions. They did lose business for sure. It was all headcount-related.

Matt O'Brien (Managing Director)

Okay. And then as I look at the guide for 2025, with the Q1 commentary, and we're pretty much done with Q1 here, it's a pretty steep ramp in the back half. These salesforce transitions are never a one or two-quarter phenomenon. It takes longer than that to get up to productivity. I guess we're having a—this is a tough print here, but why are we not afraid of continued shortfalls Q2 through Q4 of this year, just given the ramp that you're required to hit the full year guide?

Roberto Cuca (COO and CFO)

I'm going to start with your first comment about the time it takes to get up to speed. We have continued to do that analytic in new territories. We are continuing to get up to speed in six months or under. When you backfill a territory, though, somebody departs and you're able to get them in quickly, get someone in quickly. As you saw in the fourth quarter, if we had 11 gross departures, but only six reductions, we were already in the process of backfilling from previous quarters. If you can get somebody in quickly, they're not starting from a zero quota in their territory. They're starting from something that's not quite what the departing rep would have achieved had they stayed on board, but it means that you can get up the slope faster.

What you're seeing is that as we near the target of 76 TMs and 21 account specialists, starting from where we are today, just under 70 and 20, we should be able to get to that sort of productivity fairly quickly. We feel good about maintaining the standard seasonality across the year. We typically do see a good step up from the first to the second quarter just because of seasonality and the way surgeons and patients schedule their surgeries.

Antony Koblish (CEO)

Yeah. Matt, if I could add, 2024 was obviously a tough year up and down, right? We had a mix of exogenous factors and internal factors. Q2 was impacted pretty heavy last year with cyber hacking and one of our major GPOs slowing down greatly. With that and with the departures in November and December, we still pulled out about 19% growth. With all the elements that I mentioned, enhanced compensation, great morale, great go-to-market strategy, and new stability, and these account specialists working in a team structure, it should blunt any impact. And 23%-27% growth seems very doable based on how we laid out the quotas on a quarter-by-quarter basis. I think by the end of Q1, we'll have the ability to see where we fall, where we land.

The way the rest of the year shakes out will be probably a much better, tighter conversation, Matt.

Matt O'Brien (Managing Director)

Got it. Thank you.

Antony Koblish (CEO)

Thanks.

Operator (participant)

Thank you. Our next question comes from Mike Sarcone of Jefferies. Please go ahead, Mike.

Mike Sarcone (Equity Analyst)

Hey, good afternoon, and thanks for taking the questions. I'll try to keep it quick here. Just follow-up on the rep attrition and the compensation. I understand having the account specialists in place mitigates some of that lost sales risk. I guess what's the appetite to compete with any of these guarantees should they continue to manifest, right? Let's just say you have a rock star territory manager. Also in the context of trying to keep OpEx flat, what kind of appetite do you have there to maintain some of your highest performers?

Antony Koblish (CEO)

I think within reason. Look, our employees are listening to this, but we're going to do what we need to do to retain our best players. Just the fact that the top 44 came in at 90% or above, and just the fact that the old associate rep program was so successful for our top five performers, I think we've got a lot of proof there that it's worthwhile keeping our folks in place. Right now, we feel very good about morale and direction. We don't want this to happen again. I don't think in my career, I've been doing this for 30 years, I don't think I've seen this kind of sort of poaching so concentrated before. Hopefully, it's a one-time.

We've put great steps in place to mitigate or blunt it going forward, and we'll do what we need to do to keep the best, most stable organization on the ground. We made significant changes to our leadership and go-to-market strategy in May or June, right? We liked a lot what we saw a lot in Q3, last two months, actually for the first four months there, and then the last two months were what they were. We like what we're seeing now in Q1. Although the results don't look great for those last two months, there's plenty of positive signals wrapped around those two months.

Mike Sarcone (Equity Analyst)

Got it. Thanks, Tony. I'll leave it there.

Antony Koblish (CEO)

Appreciate it. Thanks.

Operator (participant)

Thanks, Mike. Thank you. I would now like to turn the conference back to Tony Koblish for closing remarks. Sir?

Antony Koblish (CEO)

All right. Thank you, everybody. Stay tuned for Q1. We look forward to 2025. We appreciate your interest in the company. What we're trying to do is important and meaningful, and we will succeed. Thank you.

Operator (participant)

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