Alphatec Holdings Inc (ATEC) 2020 Q1 法說會逐字稿

Good afternoon, everyone, and welcome to Alphatec's First Quarter 2020 Financial Results and Recent Corporate Highlights Announcement.

We would like to remind everyone that participants on the call will make forward-looking statements. These statements are based on current expectations and are subject to uncertainties that could cause actual results to differ materially. These uncertainties are detailed in documents filed regularly with the SEC.

During this call, you may hear the company refer to reported amounts which are in accordance with the U.S. GAAP as well as non-GAAP or pro forma measures. Reconciliation of non-GAAP measures to U.S. GAAP can be found in the supplemental financial tables included in the press release, which identify and qualify all excluded items and provide management's views of why this information is useful to investors.

Joining us on the call today will be ATEC's Chairman and CEO, Pat Miles; and CFO, Jeff Black.

Now I will turn the call over to Pat Miles, Chairman and CEO of Alphatec Spine.

Thank you, Michelle. Thanks, everyone, for joining the call. Before I get into the presentation, I want to take a minute with some prepared remarks really to the ATEC family because I know many are listening in. So first of all, I want to say thanks for your continued engagement and productivity over the past 2 months. I am so proud of how we've supported each other during this crisis through the donation of paid sick time or foregoing base salary for stock to preserve cash for payroll or the extreme focus by everyone on driving the business forward despite being separated.

I can tell you the business has pushed ahead. Regulatory filings have continued. Alpha evaluations have been completed. Surgeries have been fully supported. Recruitment of key talent and customers hasn't missed a beat. I believe we will exit this challenge stronger than where we entered it, which is what distinguishes great companies. You've been committed to our mission, and we're completely committed to you. You can expect to see an increasing presence in the workplace starting soon as our surgery volume and project work continues to pick up. But it will happen in a methodical way, clearly, to ensure that everyone is safe.

With respect to our outlook on the business, I could not be more bullish. We saw strong momentum going into the crisis, which is reflected in our Q1 results. And while we have certainly been impacted by COVID, the interest from our expanding surgeon community and distribution channel is absolutely palpable. I'm encouraged by signs of recovery in surgical volumes. And while it's way too early to predict when we'll see full recovery, I am confident it will come back strong.

We have taken critical steps necessary to strengthen our balance sheet and secure our runway. We've made strategic decisions to pull back spend in certain areas but with a keen focus on preserving our most valuable asset, our employee base, and maintaining momentum on key development initiatives. We recently secured an additional $35 million commitment from Squadron Capital, extending the runway we need to focus on moving the business forward. We remain unwavering in our commitment to bring innovation to a market that needs it, and we have a team and the resources to make that happen.

So I just want to make sure I didn't miss anything before I jump into the Q1 2020 scorecard. So clearly, the company has strong momentum. When you start to see things like 27% year-over-year revenue growth, you have to be optimistic. Additionally, 56% of that was from new product, which compares to 22% a year ago in Q1 and, really, less than 10% in fiscal year '18. 34% revenue growth was seen within our strategic distribution. And strategic distribution is a reminder of the guys who are going to go to distance with us. You also saw 15% year-over-year average revenue per case growth. And what that speaks to really is the confidence in our new devices and our business. And that's up from 30% from Q1 '18.

We talk a lot about convoyed sales, meaning how many product categories sell into surgery, and we continue to see that tick up, it was 1.7 in Q1. And really, this is our sixth consecutive double-digit year-over-year revenue growth in a quarter.

And so when we go through our business update, the areas that we're going to talk about really is our focus as it relates to revenue momentum, the status of EOS, the balance sheet and really where we see the spine market going. And so I guess, first and foremost is one thing that you'll hear us remind you of is our business is in the operating room. And one thing that we have a penchant for is focus. And our priorities really remain the same, is we're going to continue creating clinical distinction, we're going to continue to compel surgeon adoption and we're going to continue to revitalize our sales force. And really, we did that in Q1. And so what you'll see out of us this year is you're still going to see 8 to 10 releases in 2020 of new products. The design meetings continued in earnest virtually, so the surgeons made time for us. A lot of them were candidly thrilled to engage with us over this period of a slowdown as well. Regulatory submissions continued.

So as it relates to our capacity, create clinical distinction, I will tell you the momentum is palpable. As it relates to compelling surgeon adoption, we continue to evaluate our Alpha products, and we continue to see more and more products used per procedure. And so it's very gratifying to see SafeOp used with our retractors, used with our fixation system or interbody systems. And so you're really starting to see the procedural strategy come into fruition.

Also revitalizing our sales force. I got to tell you, the recruiting is going exceedingly well. Savvy distributors know that the future of spine is at ATEC. And so it's been entertaining to see the volume of distributors that have come our way. And oftentimes, their focus is, "How can I best serve my customer?" And when they ask themselves that question, we're clearly the solution that a lot of distributors run to. We're also trying to elevate the aptitude of our sales force during the slowdown with a number of online calls and whatnot to engage them and keep them versed in terms of what we're doing clinically.

So transitioning over to EOS. Clearly, we've changed directions as it relates to what we're doing there. So really proposing alternative collaborations. So we still believe in the clinical thesis that really drove the transaction, but we do believe that there's been a material adverse event resulting in our terminating the decision. If you really kind of delve in and channel-check, you'll realize that the near-term focus from hospitals is in preparedness and cash generation from elective surgery. And our concern was it really pushed out the acquisition of capital equipment.

But again, back to the original comment, it hasn't undermined our clinical confidence in the collaboration. And so what we're doing is we're exploring other collaborative type of arrangements that really meets both companies' strategic needs. And so I would say that's a big change.

To jump over into the -- what's going on from our view in the spine market, I got to tell you, everybody has opined on this, and I'm not sure that we're going to provide you any new information. We're totally encouraged by the recovery, but it's still way too early to make any concrete judgment. So we see spine surgeries starting to come back, and we see the enthusiasm around elective procedures. The one thing that we know is that hospitals need to generate revenue, and the way to generate revenue is through elective surgery. And probably the closest thing to non-elective surgery in orthopedics is spine. And so we're seeing an expedient return to procedural volumes. But again, don't want to get into a long discussion based upon the volume of uncertainty that still exists.

So with that, I will turn it over to Jeff Black to review the financials.

Thank you, Pat. I'll spend a couple of minutes just starting on a key focus area, and that's our balance sheet. We think it's important to start with that and specifically speak to cash runway.

So we ended the first quarter with $27.5 million in cash. We made a draw in early April on our existing credit facility with Squadron. So we ended the quarter with $47.5 million in cash on a pro forma basis. We also recently executed a commitment letter for a $35 million expansion of the facility with Squadron. A part of those proceeds will pay off our revolver with MidCap, and the remaining will be available to draw as needed. We've also extended the maturity of the entire credit facility by 2 years to 2025. We've removed all financial covenants, and we expect to close this financing by the end of May. We absolutely believe this is the right financing at the right time for us, provides the runway we need to execute on our growth plans.

We've also made some decisions on cost containment across the organization, again, as Pat mentioned, with an eye toward preserving the employee base and maintaining key product development initiatives.

And finally, I think it's important to note that in Q1, our cash burn was elevated over prior quarters, really due to transaction-related and litigation expenditures. Recall that litigation was atypically high in Q4 related to our patent litigation. So we saw that cash impact in the first quarter.

On to revenue. We saw 34% year-over-year growth from our strategic distribution channel. Importantly, as Pat mentioned, this is a mix of not just increases in surgical volume but more case complexity and a continued increase in the products per case, which is driving revenue per case higher. And our legacy distribution channel continues to perform at a level where we -- actually above the level we expected it to be at this point.

Gross margin has held steady, as expected. We continue to see a bit of a margin drag from excess and obsolescence on legacy products. We expect this to continue through 2020 as we continue to transition to new products. We'll start to see this normalize in 2021. And once E&O normalizes, our variations in gross margin will primarily be driven by product mix. But we continue to believe that midterm, we'll maintain margins in the mid-70% range.

A little bit about the P&L and OpEx. Our non-GAAP OpEx profile remains consistent year-over-year, again, in line with our expectations as we continue to make investments in new product development and build out our strategic sales channel. I think importantly, we continue to hold the line on G&A. It's essentially been flat for the last 12 quarters and below 2017 run rates when we started the strategic pivot of the company.

And with that, I'll turn the call back over to Pat for closing comments.

Thanks, Jeff. You got to know that we remain fixated on stewarding better spine surgery. We feel like that's a great business, and we're going to do it through innovation. So I think spine is probably the least of the "elective surgeries," and we know that the volume of spine surgery will return and it is returning, and we're prepared.

So thank you very much for your attention and now happy to take questions.

(Operator Instructions) Our first question comes from the line of Brooks O'Neil with Lake Street.

Appreciate the opening comments and all you're doing to kind of keep the business moving forward. I was just curious, as you look at the spine business and spine surgeries, do you sense there is some growing pent-up demand? Or said differently, have some of the postponed cases gone away permanently? Or do you expect those ultimately to get done when the hospitals and ORs open up for business again?

Yes, Brooks, this is Pat. I think it's abundantly clear that these have been postponed. And you hear a lot of hospitals talk about working on Saturdays and Sundays and increasing the OR hours and a lot of solutions to avail spine surgery to a broader audience. And so I would say, absolutely, that I think people are just holding off until insurance is affirmed, their confidence is affirmed. But in speaking to the surgeons in the hospital, there is a heck of a lot of pent-up demand out there.

Great. That's very helpful. And then second question. Obviously, fairly late in the year last year release of Alpha Informatix or SafeOp. Can you just talk about what the disruption related to COVID has done, if anything, to your launch there? And what you plan to do to try to reestablish the kind of momentum, I think, you all hoped to get when the original plans were put in place?

Yes. Thanks for the question, Brooks. There's so many things that come to mind when you ask that question. I think that -- one of the things I'm so proud of about the team is the product development team has been awesome in the downtime. And so we launched the product in late last year. And clearly, the momentum has ticked up month after month. And then you see the ceasing of our -- the volume of cases in middle of March. But the beauty is we've continued to evolve the system. A lot of -- the system is a software-based system, so the opportunity to continue to create sophistication in that thing is significant. And so super proud of them.

But I got to tell you, I am so confident that, that was the right acquisition, whenever it was, 2 years ago. This is such a distinguishing element for us to provide information into the operating room. And what you'll see us do is to continue to choreograph surgery with regard to providing information. And when you start to look across the landscape and you look at what companies are doing, few companies are providing the limited footprint but the valuable information that the Alpha Informatix platform provides.

And so anyway, exceedingly bullish and excited about us continuing to kind of evolve in terms of integrating that into every type of procedure that we do and the commercial traction that it gets.

That's great. I'll just ask one more, and then I'll turn it over. I heard your comments about the EOS systems situation. Totally get it myself, at least from my perspective, but how do you read the EOS team? And do you think they still hope to find ways to collaborate with you guys? Or is this a jilted partner and they're going to be mad and not going to take it anymore?

Yes. I guess I don't want to speak to their -- I'm sure -- I got to say, I'm probably the most disappointed, Brooks. I like that technology and I think that there is real value in what that technology provides me. So kind of going back to the prepared comment or presentation is the clinical thesis around our collaboration haven't changed at all. The problem becomes is as a small company and in cash being king, you have to look at how both companies are best served. And so I think that there's -- the leadership there is excellent, and there's a great relationship with the guys.

And so I'm bullish on our opportunity to collaborate. I hope we can put it together. I think it will serve the interest of both companies. But it's got to be a different collaboration than what we went into. And it's -- the suggestion that a pandemic hasn't changed things, I think, is false. And so what we're trying to do is steward great spine surgery. We feel like they can help us do that, and that means a collaboration of sorts.

Great. I lied. I have one more question for Jeff. Jeff, could you just update us on how you feel about the availability of capital right now, recognizing the new addition with Squadron? And what the terms? You said it had no covenants, but can you just refresh us what the rate is on that with Squadron and how you feel about where you're at right now?

Yes. Yes. Thanks, Brook, too. Look, we feel -- like I said, I think this is absolutely the right financing at the right time. It gives us the runway we need to go execute this business and maintain the employee base, maintain product development initiatives. The terms in terms of interest are the same. It's LIBOR plus 8%, 10% floor, 13% ceiling. We've extended our maturity by 2 years, removed financial covenants. So we feel we're well positioned here with this available capital to continue to execute the business.

And our next question comes from the line of Matthew O'Brien with Piper Sandler.

Three for me. For starters, just looking back at Q1, the performance was really good, kind of leading among all of spine in terms of growth. Can you just kind of deconstruct where some of that growth came from? And then, Pat, just on the revenue per case side of things, that improvement that you saw there, how much further is there to go specifically with that metric?

Yes. Thanks for the questions. The -- deconstructing the revenue, I would say, the biggest driver, I think, is really kind of confidence in terms of the utility of the new devices and the ability to do more complex things with the new devices and then attracting more surgeons that ultimately utilize the devices and gain confidence. I wish it was more cosmic than that.

I will tell you, I don't think that we have really met the -- kind of our procedural aspirations. And by that, I mean, when all of these things start to get integrated really toward the end of the year, I got to tell you, like I think that the convoyed element will tick up significantly. And so I think a lot of it is, hey, let's see what these guys are doing, it seems like that they're a competent bunch. And then bringing on some distributors that are clinically adept. And so I wish it was more than that. I'll let Jeff comment if he thinks that there's anything I'm missing as it relates to the run.

Yes. I'd certainly add to that. And just in terms of if we try to break it out on the increase, it's really across the board. To Pat's point, it's new surgeons coming on board increasing volumes, existing surgeons doing more business increasing volumes, increasing case complexities that are using actually more parts for every case because you're doing more level and more complex constructs, and then the ability that -- the confidence inspired by a surgeon actually using more product categories per case. So the driver for that increase is really across the board in all 3 of those categories.

Okay. Well, that's great to hear. And now looking forward or maybe looking back to help us look forward a little bit, what did you see towards the end of March as far as procedural slowdowns? And then what did you see in April? And how are you feeling, again, very early days here in May as we think about the rest of this quarter?

Yes. So I'll let Jeff pipe in after I provide the 60,000-foot color, which is, literally, we saw a relatively abrupt slowdown in the second half of March. And so what we saw is mostly trauma cases being done or cases that weren't elective. Like if somebody had foot drop or there is a myelopathy case, what would happen is those cases would go ahead and go. And so April was very slow. And again, I think it was still pretty reflective of the same type thing. You saw some ASCs doing cervical cases and whatnot, but it was profoundly a slowdown.

And so really not going to try to quantify any of it. I think there's too much uncertainty. I would say that we're bullish on what's going on. I think to kind of replicate what a lot of the other companies have already communicated, there's a bullishness in terms of everything coming back and there being a pickup really in the back half of this quarter.

Yes. And just to add, when you think about average daily sales, right, and your fourth quarter being seasonally the highest quarter, going into the pandemic in mid-March, we started seeing the average daily sales approach Q4 volumes. So that was encouraging.

Okay. Okay. Got it. That's helpful. Okay. And then the last one just is looking forward a bit as well. And I've been asking all the spine companies this on these calls. But just thinking about the opportunity coming out of this, you've got a lot of support from Squadron, you've got a lot of cash already, a lot of your smaller competitors don't. Is there a bigger opportunity to take share coming out of this than people realize from the small players? Or if the larger ones are maybe a little bit more distracted by their cut in pay or whatever it may be to even be more successful on the share taking side of things Q4 of this year and into 2021?

Yes. The -- I would tell you that the recruiting dynamics out there are phenomenal. And the recruiting dynamics, especially with the big companies, meaning that we love taking people from the big companies because oftentimes, their lethargy is their Achilles heel. And so the great part is we've created this machine here from a product development perspective where I think these guys are saying, "How do I start new when this pandemic is over?" And what we've seen is we've seen a ton of interest in what we're doing because they know of our commitment toward the continued evolution of spine surgery.

And so the comment that we will evolve out of this better than how we went in it is absolutely real. And so there's been a lot of salespeople and surgeons and otherwise kind of coming our way because, again, I think that they look, who do I want to be with over the next 10 years? And what company do I want to align my interests to serve the interest of my surgeon who's serving his patients? And I got to tell you, this has been a very good time for us.

And our next question comes from the line of Kyle Rose with Canaccord.

So I wanted to kind of touch -- take a step one further than Matt's prior question there. Maybe just help us understand the dynamics you saw specifically in the second half of March and into April. And we've heard on other calls with companies of varying sizes just see procedure volumes decline in the 70% to 80% range for the month of April. So I guess, number one, is that fair when you look at your business? And then number two, maybe kind of help us understand what's happened in the first 10, 11 days as far as the month of May and kind of how that's looking from a go-forward perspective.

Yes, Kyle, this is Jeff. I think to speak to my earlier response, I mean, we saw great momentum going into the crisis in the first half of March in terms of average daily volumes. We saw a pretty abrupt shutdown, if you will, or a decrease in those volumes. But we'll also say that in April, frankly, starting even first or second week of April, volumes are beyond where we expect them to be for April. So we ended April in a much better spot than we expected to. So early signs of a recovery are -- we're very optimistic.

Okay. And then when we think about the types of cases that are getting done, obviously, I understand the dynamic around trauma and anything emergent. But when we think about the recovery you've seen, maybe some of the encouraging trends you've seen for the month of April, what types of cases are being done? And I guess what setting are they being done in? We're hearing more about the ASCs. We're seeing -- hearing more about more of the simple cases, but obviously, those don't carry the same type of price tags as some of the larger, complex cases. So maybe help us understand how much of it is a procedural perspective as far as weakness versus a mix perspective and how that might change.

I think everybody has been relatively correct on this, at least from our view, is -- I think there's a lot of single and 2-level cervical cases going on at ASCs. The -- I think a lot of minimally invasive stuff going on that can be done in a relatively bloodless way. And so I think it's really kind of how you described it, which becomes relatively non-complex stuff so that the ICU beds aren't -- are very unlikely to be utilized. And I think relatively straightforward, short segment in terms of not a number of -- a few number of levels being done. So I think it's what you've described.

Okay. And then one for Jeff. I think, Jeff, you talked about the medium-term margin outlook staying in the mid-70% range. I just want to make sure I heard that correctly. And does that capture any type of the near-term headwinds from a gross margin perspective? And kind of how should we think about how that will ebb and flow as the recovery progresses.

Yes. I mean, I think, clearly, with a decrease in volumes, you're going to see less efficient absorption of overhead. But I would say, we still feel good about our target going into 2021 that we will be in the mid-70s, particularly as this E&O margin drag is behind us. So I think you may see a temporary blip, if you will, because less overhead absorption or less volume to absorb overhead over in the very near term. But in the midterm, we still feel very good about that, mid-70% target.

Okay. And then just a last question for me, and then I'll hop in the queue again. It's just -- you talked about the increase in convoyed sales. Obviously, the SafeOp seems to be a real value driver there. Maybe kind of just talk about the power that, that product has to open up new accounts but then also the distribution talent. And then maybe just how far into that launch are you with respect to where the existing business is now? Is 25% of your distribution channel in physicians using it? Is it 50%? I'm just trying to understand how much of an opportunity it has within the existing users now versus this kind of -- in the future on the combined.

Yes. It's a great question. We are in a profoundly early phase. As you appreciate, these are relatively technical devices and take time for us to train everybody. This kind of downtime has really provided an opportunity for us to do a fair amount of training. I would say we're 25% or less into it, if you will. These things end up taking more time than what you ever want, but the value that they bring is extraordinary. And so when you start to think about the different type of InVictus, which is our pedicle screw system utility, people are starting off very simply with regard to integrating it into our pedicle screw utility with stimulated EMG. And then what they're doing is evolving it into a lateral with regard to the stimulated EMG and the SSEP.

So it's really kind of a walk. And so we're in the very early stages of that walk, likely less than 25% penetrated into our group. But kind of the clinical experience with it has been phenomenal. And candidly, it's a unique technology. And so we're seeing a lot of receptivity to -- from hospitals and from surgeons and really kind of makes me very bullish in terms of what the acceptance is going to be, especially as we continue to assemble this into a procedural way with other adjuncts.

And so the whole SafeOp thing will just be part of Alpha Informatix. There will be a substantial number of elements that will go into how we ultimately provide information into surgery.

And our next question comes from the line of Arthur He with H.C. Wainwright.

This is Arthur for Sean Lee. I have 2 questions. First one is regarding the EOS. Could you guys give us more color on what kind of other alternative collaboration option you would be exploring with them?

Yes. I would prefer not to get into it because there is nothing to announce or nothing that's concrete. It's non-acquisition type of relationships that are more commercial in nature. And so that's probably as deeply as I'd get into it just because it's in such an early stage.

Okay. And on the regulatory side, I noticed you guys had some additional new products, some applications. From your side, have you seen any slowdown or impact from the COVID-19 to the regulatory approval?

Yes. I got to tell you, let me brag 1 second on our regulatory team as they are outstanding. And we really haven't to date. And so we're shoring up a part of our portfolio that I think is going to be as outstanding as the rest of it as we continue to launch new products. And so we have several submissions in, and I think they're moving along as expected. And so I haven't really seen much of an impact.

And I'm showing no further questions, and I'd like to turn the conference back over to Pat Miles for any closing remarks.

Just really appreciate everybody's interest in ATEC. We are really creating a monster and can't be more excited about what's going on. And hopefully, we'll return from this pandemic everybody safe and stronger. So thanks much.

Ladies and gentlemen, this concludes today's conference call. Thank you for participating. You may now disconnect.