Q4 2023 Oncology Institute Inc Earnings Call

Participants

Mark Hueppelsheuser; General Counsel; The Oncology Institute, Inc.

Dan Virnich; CEO; The Oncology Institute, Inc.

Mihir Shah; CFO; The Oncology Institute, Inc.

Jack Slevin; Analyst; Jefferies

Presentation

Operator

Good afternoon, and welcome to The Oncology Institute's fourth quarter 2023 and full year 2023 earnings conference call. Today's call is being recorded, and we have allocated one hour of prepared remarks and Q&A.
At this time, I'd like to turn the conference over to Mark Hueppelsheuser, General Counsel at TOI. Thank you. You may begin.

Mark Hueppelsheuser

The press release announcing The Oncology Institute's results for the fourth quarter and full year 2023 are available at the investors section of the company's website, theoncologyinstitute.com. A replay of this call will also be available at the company's website after the conclusion of this call.
Before we get started, I would like to remind you of the company's Safe Harbor language included in the company's press release for the fourth quarter and full year 2023. Management may make forward-looking statements, including guidance and underlying assumptions.
Forward looking statements are based on expectations that involve risks and uncertainties that could cause actual results to differ materially for a further discussion of risks related to our business, see our filings with the SEC.
This call will also discuss non-GAAP financial measures, such as adjusted EBITDA. Reconciliation of these non-GAAP measures to the most comparable GAAP measures are included in the earnings release furnished to the SEC and available on our website.
Joining me on the call today is our CEO, Dan Virnich, and our CFO, Mihir Shah. Following our prepared remarks, we'll open the call for your questions.
With that, I'll turn the call over to Dan.

Dan Virnich

Thank you, Mark. Good afternoon, everyone, and thank you for joining our fourth quarter full year call. To start, I'm pleased with our performance during 2023, including several important milestones, which will set us up to drive value to our shareholders in 2024 and beyond.
As always, none of this would be possible without the contributions of our many physicians, clinical staff and teammates who deliver outstanding care to the patients that we serve each day. Our strong performance led to a year over year revenue growth of 20% in Q4 2023 versus Q4 2022 and 28% for the full year 2023.
We exceeded the high end of our annual revenue guidance range by over $4 million with both patient services and dispensary segments contributing to our outperformance.
Gross profit came in at the low end of our annual guidance range, primarily due to the negative impact of unusually high direct and indirect remuneration or DIR fees on our part D drug margins. Our experience with pharmacy benefit managers or PBMs generated DIR fees in the fourth quarter is being felt across the oncology industry and is related to the point of sale DIR mandates that went into effect on January 1.
Importantly, we expect to help offset this margin compression in 2024 as our California pharmacy and medically integrated specialty drug dispensaries across markets had been significantly outperforming expectations on sales and revenue contribution.
For 2024, we are forecasting our California pharmacy to generate over $30 million in incremental revenue, and we expect full year growth of approximately 50% in our part D business.
The strong revenue performance we have generated so far in Q1 gives us confidence that we will achieve our gross margin target for part D sales.
On that note, I want to provide some encouraging updates about the growth of our value-based contracts as we begin 2024. First, demand for our services has never been stronger, leading to a highly successful start to the year for our business development team.
We have signed for our near completion on six new full-risk contracts in Q1. These new relationships will benefit several existing and new markets and include risk that extends beyond our historic part B medical oncology capitation to include part D and radiation oncology services.
Due to the higher utilization patterns we see outside of California, as well as the predominance of medicare advantage only contracting opportunities, many of these new relationships have a significant improvement in economics on a per-member basis versus the highly competitive rate environment in California.
In an effort to provide more clarity to analysts and our shareholders on our performance, we have moved from reporting value-based members to reporting revenue per value-based member. We believe this change is important because we are evolving our business to take on adjacent specialty risk and establishing more medicare advantage only contracts outside of California. This will provide a clear picture of the impact of incremental contract signed and growth across markets on a quarterly basis.
Now I would like to highlight a few operational achievements since our last call. On January 1, we started our first capitation contract in Florida with a health plan that is a member of the element's network. This relationship is off to a very good start, and we are encouraged by the strong operational and clinical performance from serving their members.
During Q1, we signed our first three independent practices to our MSO model in Florida as we scale our ability to provide value-based oncology services to patients outside of our employed clinic model. In the fourth quarter, we added seven new employed physicians, primarily in Southern California, bringing our total employed physician and advanced practice provider count to 119.
We successfully acquired and launched our California-based pharmacy in December and have already completed over 1,300 specialty medication fills. We recently announced a new partnership with Max Health in Florida to take on medical oncology Part B and D, and radiation oncology cost of care risk, across five Florida counties for their medicare advantage members. This will be a service funded contract.
We also announced a partnership with Karen Health in Nevada on our new prospective bundled payment model for breast cancer patients, which is our first partnership to serve patients on behalf of employer groups.
Finally, before I turn it over to our CFO, Mihir Shah, I would like to walk you through our 2024 guidance. For the full year 2024, we expect revenue of $400 million to $415 million, representing 23% to 28% growth over full year 2023.
This growth is driven by several factors, including our dispensary business, particularly our pharmacy, as well as the continued expansion of our value-based contracts in organic growth, especially in Florida. We expect gross profit in the range of $68 million to $79 million and adjusted EBITDA in the range of negative $18 million to negative $8 million, reducing our EBITDA loss in the range of 30% to nearly 70%.
Finally, while we've been impacted by the recent change healthcare cyber-attack, which has caused disruptions to healthcare companies across the US, our team has been actively collaborating with our practice management vendor to swiftly establish alternate channels for transmitting claims to payers.
Significant progress has been made in successfully submitting claims to commercial payers, and we've completed applications for medicare and medicaid agencies to accept our claims through a new intermediary, which is pending approval.
It's anticipated that the delays in claims submissions will lead to an increase in our days sales outstanding DSO and temporarily impact our cash flow in the first and second quarters of 2024. Nevertheless, we do not believe the impact to be material and remain confident in our ability to resolve these challenges.
Now I'll turn the call over to our CFO, Mihir Shah, to provide additional details on our fourth quarter and 2023 financial results.

Mihir Shah

Thanks, Dan, and good afternoon, everyone. I will start with our quarterly results. Consolidated revenue for Q4 2023 was $85.8 million, an increase of 20% compared to Q4 2022 and a 4.6% increase compared to Q3 2023.
Gross profit in Q4 2023 was $14.4 million, a decrease of 8% compared to Q4 2022. This decrease is attributed to the increase in DIR fees Dan previously mentioned. We are continuing to see the results of our reduced overheads, which produce an SG&A, including depreciation and amortization of $29.7 million in Q4 2023, a decrease of 3.6% compared to Q4 2022.
As a percentage of revenue, SG&A was 35% in the quarter, down 8.5% from Q4 2022. Loss from operations for Q4 2023 was $15 million, a decrease of $9.8 million compared to Q4 2022. Net loss for Q4 2023 was $18.8 million, an increase of $7.7 million compared to Q4 2022, primarily due to the change in the fair value of conversion options, derivatives and earn-out liabilities, offset by an increase in gross profit. Adjusted EBITDA for Q4 2023 was negative $6.3 million.
Moving to full year results, I'm pleased to report that we have achieved financial guidance for the year while outperforming on revenue. Revenue per capita per member was $40 per member per year at December 31, 2023, an increase of 10.5% compared to 2022.
Consolidated revenue for 2023 was $324 million, an increase of 28% compared to 2022. Gross profit in 2023 was $60 million, an increase of 14% compared to 2023. SG&A including depreciation and amortization of $120 million in 2023, a decrease of $4.4 million compared to 2022.
As a percentage of revenue, SG&A was 37% in 2023, down 1200 basis points from 2022. Loss from operations for 2023 was $77 million, a decrease of $5 million compared to 2022. Net loss for 2023 was $83.1 million, a decrease of $83.2 million compared to 2022, primarily due to the change in the fair value of conversion option derivatives and earn-out liabilities, offset by an increase in gross profit. Adjusted EBITDA for 2023 was negative $25.8 million.
Further details on how we define non-GAAP financial measures can be found in our Form 10-K and press release. As of year-end, our cash and cash equivalent balance was $33 million and we had $49 million in short-term investments for a total of $83 million of cash, cash equivalents and short-term investments.
Finally, we have remediated previously disclosed material weakness in internal controls over review of complex accounting transactions and concluded that our internal controls for financial reporting were effective as of December 31, 2023.
I will now turn it back to Dan for closing comments.

Dan Virnich

Thanks, Mihir. I want to close our call by providing an update on progress towards our four key strategic priorities at The Oncology Institute. Priority one, eliminate cash burn. In the fourth quarter, we reported the lowest SG&A as a percent of revenue since going public.
Net cash and cash equivalents used in operating activities decreased 49% in the second half of 2023 comparison to the first half of 2023, following our restructuring at the end of Q2. Since we are a rapidly growing business and margins remain fluid, we will continue to carefully manage our overhead as we scale to ensure we have enough capital to continue funding our long-range growth plan.
Priority number two, grow and drive margin in our legacy markets of California, Nevada and Arizona. Grow high-value capitated contracts despite some of the pressure on capitated rates in California, we continue to have several near-term growth opportunities for medical and radiation oncology, which will expand our already dominant footprint as a value-based oncology provider in these markets.
Expansion of radiation oncology, expanding radiation oncology provides enhanced continuity of care for patients requiring radiation is a differentiator to pure-play medical oncology practices and drives margin on our fee-for-service business.
We continue to see growing patient volumes at our six radiation oncology centers as well as the opportunity to add capitation to this important service line. Expansion of our ability to serve patients through our new specialty pharmacy in California.
As noted, our pharmacy has been outperforming expectations on sales and is helping drive convenience fast fill times and affordability to our very important medical patient population.
Priority number three, proving new markets. As announced on our last earnings call, we started our first fully capitated agreement with a national payer in Florida on January 1. So far it has been a very successful partnership, and we followed this up with our recent announcement of our expanded agreement with Max Health, which is another key milestone for TOI.
We have several other near term follow-on growth opportunities in the very important Florida market and other new markets where we are seeing substantial opportunity to drive value due to higher utilization and the opportunity to work directly with health plan partners.
Priority number four, leading the value-based oncology market. We remain the largest value-based oncology physician group in the country by live, serve and revenue under value-based arrangements. We strongly believe we can continue to advance this lead by being an employer of choice for oncologists and driving innovation in community-based cancer care for the patients and payers that we serve.
We look forward to updating you on our continued progress toward our key priorities on our next earnings call. With that, we're now ready to take your questions. Operator?

Question and Answer Session

Operator

Thank you. (Operator Instructions)
Jack Slevin, Jefferies.

Jack Slevin

Hey, good afternoon, guys, and congrats on the quarter and all the announcements. Maybe to kick it off, I'm thinking about the six opportunities you discussed. Can you give a sense for sort of what does that look like and maybe sort of pushing that against the most recent things that you've announced being the contract in Florida on the MA side, the Karen Health announcement, and then the expansion on the Max Health agreements.
Using those three areas and six, what do you think are the biggest opportunities going forward, sort of across the board? Is it more M&A deals, primarily it or should we expect to see sort of a wide variety of things.

Dan Virnich

Thanks so much for the question, Jack. Yes. So we see a couple of things. One is an increased opportunity to grow our business through new value-based contracts as top-line pressure from risk-bearing primary care groups and health plans seek better partners, community-based oncology care.
Overall, our strategy is to be obviously the oncology practice of choice for both plans and delegated medical groups. And the way that we do that is by not just running great medical oncology services at BD, but also expanding to radiation oncology.
So as we noted in our script, we're seeing opportunities to when possible on take on as many of those services as we can preferably under capitation or risk agreements. And that covers the majority of the opportunities we see in the pipeline.
And we also did announce the partnership with Karen, which is our first employer based partnership model. And again, that opens up a whole new channel of opportunities for us that we see as expansion opportunities over the next couple of years.

Jack Slevin

Got it. Appreciate that. And then maybe turning to the guidance and looking at gross profit in particular, I guess the DIR challenges and some of the things in the quarter, I'll make sense when you think about the low end and the high end of the guidance.
Is the right way to think about it sort of and the low end is sort of a continuation of the pressure you're seeing. And then the unlocking further upside comes mostly from sort of alleviating some of that pressure on the pharmacy margin? Or maybe if you could just walk me through sort of what gets you to the high end versus the low end of the gross profit guide, that'd be helpful?

Dan Virnich

Yes, absolutely. That's a great question. So in general, the low end of our range assumes no improvement in some of the macro issues that are facing oncology right now related to DIR fees and margin compression on drugs throughout the rest of 2024 as well as no additional growth beyond our kind of high certainty opportunities that we're seeing in Q1.
And then everything upside to that is driven by both improvements in some of those macro headwinds on the drug side, which there's obviously not a great deal of certainty on timing on right now. Strategic efforts we are taking internally specific to try to drive margin to counteract those macro pressures and then additional acceleration and growth beyond what's baked into the high certainty pipeline for Q1.

Jack Slevin

Awesome. And then last one for me. The free cash burn rate sort of coming down to below $5 million, by my math looks really nice in the quarter. I understand sort of change creates some noise in the first half. I just want to make sure I got all that right.
So is the right way to think about it. You'll sort of see drag on DSOs in Q1 and Q2, but the thought process is all of that should reverse in the back half? And maybe more broadly, how should we think about the progression on free cash going forward?

Dan Virnich

Yes. Absolutely. That's another great question. I'll let our CFO, Mihir Shah address that one. Mihir?

Mihir Shah

Perfect. Hey Jack, I think you called it the right math, our Q4 was the lowest cash burn since we went public around $5 million Q1 calling out the DSO issues and also want to point out there are some Q1 cost related pressures related to the payroll taxes and other pieces so that some anomaly that happens in Q1.
But outside of that, the trajectory of our cash burn being low compared to the each prior quarter is what we are targeting as well.

Jack Slevin

Okay. Got it. Really helpful. Appreciate it, guys, and congrats again.

Dan Virnich

Thank you so much Jack.

Operator

That does conclude our question and answer session. I would like to turn the floor back over to Daniel Virnich for closing comments.

Dan Virnich

Yeah. Thank you so much. As I mentioned, we'd like to thank all of our providers and employees for a phenomenal 2023 and strong start to 2024 as well as all of our investors and folks that joined the conference call today and the great questions you received.
We look forward to updating you in future quarterly earnings calls as we progress through 2024. Thank you so much.

Operator

This concludes today's teleconference. You may disconnect your lines at this time. Thank you for your participation.