Greenbrook Tms Inc (GBNH) 2022 Q3 法說會逐字稿

Welcome to the Greenbrook TMS, Inc. Q3 2022 results conference call and webcast. All lines are currently on mute to prevent any background noise. I would like to remind you that this conference call is being recorded today and is also being webcast on the company's website at www.greenbrooktms.com under the Investors section events. After the speakers' remarks, there will be a question-and-answer session. Analysts and investors are reminded that any additional questions can be directed to the company at Investor Relations at greenbrooktms.com.

This call contains forward-looking statements, which reflect the current expectations or beliefs of the company based on currently available information. Forward-looking statements are subject to a number of risks and uncertainties that may cause the actual results of the company to differ materially from those discussed in the forward-looking statements.

Factors that could cause actual results or events to differ materially from current expectations are discussed in the Risk Factors section of the company's annual report on Form 20-F for the fiscal year ended December 31, 2021, and in the Risks and Uncertainties section of the company's management's discussion and analysis for the period ended September 30, 2022, and in the company's other materials filed with the Canadian Securities Regulatory Authorities and the US Securities and Exchange Commission from time to time, which are available on SEDAR and EDGAR, and on the company's website.

Any forward-looking statement speaks only as of the date on which it is made, and the company disclaims any intent or obligation to update any forward-looking statement unless required by law. I would now like to turn the meeting over to Mr. Bill Leonard, President and Chief Financial Officer (sic - Chief Executive Officer) of Greenbrook TMS; and Erns Loubser, Chief Financial Officer. Please go ahead, Mr. Leonard.

Thank you, Colin, and thank you to everyone for joining our conference call and webcast today. Q3 2022 was a very busy and exciting quarter for the company. The Success TMS acquisition added significant operating scale and top-line growth to the business and allowed us to achieve a record quarterly consolidated revenue, as well as our highest quarterly treatment volumes and consultations performed to date. Furthermore, we recapitalized the business with a supportive debt partner in Madryn Asset Management.

Revenue for Q3 2022 increased by 58% to a record high of $20.8 million as compared to Q3 2021. Quarterly treatment volumes in Q3 2022 increased by 74% to a record high of 95,046 as compared to Q3 2021. Most exciting, consultations performed in Q3 2022 increased by 156% to a record high of 8,797 as compared to Q3 2021, while new patient starts increased by 87% to 2,848 as compared to Q3 2021, outpacing the revenue growth. We believe that these increases in consultations performed and new patient starts provide strong momentum into the fourth quarter of fiscal 2022.

We're also very excited about the ongoing rollout of our Spravato program at select TMS centers, which continued through Q3 2022. The program supports our long-term business plan of utilizing our existing network of TMS centers to deliver new and innovative treatments to patients suffering from MDD and other mental health disorders. Providing Spravato at our TMS centers enables us to leverage excess capacity in our existing centers, thereby enhancing our profit margin. As at September 30, the company has expanded its offering of Spravato 35 TMS centers across the US, up from 25 TMS centers as of June 30.

While I am reviewing our highlights, I'll repeat that we completed the previously announced acquisition of Success TMS on July 14, 2022, and concurrently entered into a credit agreement for $75 million secured credit facility with Madryn Asset Management and its affiliated entities, drawing down $55 million term loan at closing on July 14, 2022.

From a development perspective, as of September 30, 2022, our footprint consisted of 184 centers in 20 states, up from 131 centers at September 30, 2021. The Success TMS acquisition added 47 TMS centers to our network, all complementary to our existing footprint. During the quarter, management focused on integration of the combined business and the execution of near-term operational synergies with a focus on accelerating the company's timeline to profitability, which included reducing our TMS center footprint by seven. We are very pleased with the progress of the integration and synergies realized to date, but our work is not finished. We see significant synergies that we can take advantage of over the next 12 months.

And for now, a more detailed review of the company's financial and operating performance. I will turn it over to our CFO, Erns Loubser.

Thank you, Bill. Before I move into a detailed financial results review, it's important to contextualize the Q3 2022 results. We consolidated two independent businesses with fully-fledged cost structures. And although we've made solid progress on executing on synergies, we have not had the time to fully realize the material synergies available to us. The current cost structure, therefore, still includes a significant duplication of costs, which we believe when removed can make a material impact to the company's profitability profile.

As Bill mentioned, revenue for Q3 2022 increased by 58% to a record high of $20.8 million as compared to Q3 2021, and 26% to $48 million for year-to-date 2022 [as compared to] year-to-date 2021. This was driven predominantly by the completion of the Success TMS acquisition in Q3 2022 and Achieve TMS East/Central acquisitions in Q4 2021.

Average revenue per treatment decreased by 10% to $218 in Q3 2022 as compared to Q3 2021 and decreased by 4% to $222 in year-to-date 2022 as compared to year-to-date 2021. This decrease was primarily attributable to the geographical distribution of revenue.

We are happy to report that same-region sales growth came in at 17.1% in Q3 2022 as compared to 9.4% in Q3 2021 as a result of the growth in our mature regions. Same-region sales growth was 6.9% in year-to-date 2022 as compared to 14.9% in year-to-date 2021 as a result of the growth in our mature regions. The decrease in the year-to-date figure was predominantly due to tight labor market coupled with prevailing and inflationary environment.

Q3 2022 resulted in an entity-wide regional operating loss of $0.8 million as compared to an entity-wide regional operating income of $0.2 million during Q3 2021. Entity-wide regional operating loss was $2 million during year-to-date 2022 as compared to $0.3 million during year-to-date 2021. As mentioned earlier, the decrease predominantly related to the duplicate costs associated with the Success TMS acquisition and a challenging economic environment earlier in the period.

Corporate G&A for Q3 2022 increased by 87% to $9.6 million as compared to Q3 2021, an increased by 29% to $20.4 million during year-to-date 2022 as compared to year-to-date 2021. It's very important to note that these increases predominantly reflect the one-time professional and legal fees related to the Success TMS acquisition and the Madryn Credit Facility, and the revaluation that the equity-based conversion instruments in connection with the Madryn Credit Facility.

Excluding one-time costs and equity-based conversion instruments, the increase in growth of corporate G&A was 31% and 17% during Q3 2022 and year-to-date, respectively. This indicates a relatively lower growth rate as compared to the growth in revenue, illustrating that the business is scaling into a centralized business infrastructure. Once again, bear in mind, we still believe that we can execute on material synergies, which we believe will rationalize the cost structure even further. Our operating leverage and planned revenue ramp from the Success TMS acquisition supports a near-term timeline to profitability.

The loss for the period and comprehensive loss increased 386% to $16.8 million during Q3 2022 as compared to Q3 2021 and increased by 78% during year-to-date 2022 as compared to year-to-date 2021. This increase similarly was predominantly due to incurring duplicate costs of the combined business after the acquisition of Success TMS, arising from operational synergies not yet executed as previously mentioned. Also increased interest expense, depreciation, and amortization on acquired net assets, loss on extinguishing of loans, and the revaluation of equity-based conversion instruments played a major role in the increased loss.

From a balance sheet perspective, the accounts receivable balance in Q3 2022 increased by $3.4 million as compared to Q4 2021, primarily due to the acquisition. As Bill mentioned, the company completed the previously announced acquisition of Success TMS on July 14, 2022. The company also concurrently entered into a credit agreement for its previously announced $75 million secured credit facility with Madryn Asset Management and its affiliated entities, drawing down $55 million term loan at closing on July 14, 2022.

Importantly, the proceeds from the credit facility were used as follows. $15.4 million to repay the Oxford credit facility, $15.1 million to repay previously loans held by Success TMS, $3.1 million in financing and closing costs, $2.9 million to normalize vendor payments aging resulting from cash management practices prior to strengthening our balance sheet, and $2.3 million in cash investments in new TMS center locations added on the Success TMS side, leaving a remaining balance of the proceeds in respect to the Madryn Credit Facility of $16.2 million. The cash balance of $11.2 million as at September 30, 2022.

Moving to our core operating metrics, as of the end of Q3 2022, the total TMS centers increased by 40% to 184 from 131 a year ago. Compared to Q3 2021, the number of consultations performed increased by a significant 156% to a record 8,797, while the number of new patient starts increased by 87% to 2,848, which we believe will provide strong momentum into the fourth quarter of fiscal 2022. The number of treatments performed increased by 74%, to a record 95,046, as compared to Q3 2021.

These increases were predominantly due to the additional TMS centers acquired by the company in connection with the Success TMS acquisition, as well as operational changes to our intake process. We anticipate that our record highs in quarterly consultations and patient treatment starts, coupled with the Success TMS acquisition and the continued rollout of our Spravato program to be a catalyst for accelerated future growth.

Back to you, Bill.

Thank you, Erns. We are very excited about the scale and reach of our new combined platform. In Madryn, we have a strong strategic partner which we expect will help in accelerating Greenbrook's ability to grow and further expand our mental health platform as we move to profitable operations. Our all-stock acquisition aligns shareholder interest both strategically and financially. Our Spravato program adds to our repertoire of innovative treatments, building on the company's long term business plan of utilizing its center network as a platform to serve patients suffering from major depressive disorder, OCD, and other mental health disorders, making the best treatments available. We expect this to be a core growth driver going forward.

Our record quarterly highs in revenue, treatment volumes, and consultations perform coupled with the continued rollout of our Spravato program demonstrate the value of our business model and growth strategy, allowing us to deliver exceptional patient care to those suffering from mental health disorders.

Over the next couple of quarters, we will continue to focus on the integration of the combined business and our near-term synergies with our focus on positive cash flow.

Before ending, I would like to take a moment to thank our amazing team. We are extremely proud of them as they continue to deliver the highest level of care. Most importantly, we know that we are making a difference. Our services are in high demand as mental health disorders are at unprecedented levels. We have now treated over 27,000 patients with over 1 million treatments performed, an amazing milestone for the company, our physicians, our staff and the entire TMS industry. We are having a significant positive impact on the lives of so many people suffering from mental health disorders. We look forward to keeping you updated on the progress of the company. Thank you for your time today, and with that Colin, we will now take questions.

Thank you. Ladies and gentlemen, we'll now conduct the question-and-answer session. (Operator Instructions) Noel Atkinson, Clarus Securities.

Hi, Bill and Erns. Well done in Q3, and thanks for taking our questions this morning. First off, Hurricane Ian kind of rolled through Florida at the end of the quarter. I was wondering if there was any impact on the revenue there.

There definitely was an impact, unfortunate timing of the hurricane, and feel bad people had to go through it. It was probably somewhere between $600,000 to $700,000 in terms of the revenue hit to Florida. Some of those patients came back into the system. Our staff did amazing job of turning around our centers within a three- to five-day period. But obviously, some patients were lost due to the impact on them on personal level in terms of their house and family. So, definitely had an impact to us at that late in the quarter.

Okay. I was wondering if you'd be able to provide some details on Spravato, like it's now out at 35 centers; you've been growing your deployment quite quickly of that treatment mechanism. Are you able to provide any details about your Spravato activity in terms of percentage of total treatments or how average rate is relative to the corporate average or anything like that?

Absolutely. From a company standpoint, revenue per treatment is north of $300. Again, you're seeing less treatments per month, but at the same time that patient is staying in the Spravato program in a maintenance session as well for two to three months. So, it's consistent revenue.

Interestingly, about half our patients that we've treated thus far have utilized both modalities; whether they started out in a TMS therapy in the past and have come back with Spravato. So, it's really giving you a kind of their reflection on Greenbrook and the care they got in their initial treatment. It is very complementary of one another. Just shy of about 10% of our patients have moved from Spravato to TMS. And in some cases, we do have some patients that are having both modalities.

So, we like what we're seeing with Spravato in terms of growth. But keep in mind, it only represents about 8% of our revenue in Q3. We're still truly focused on being the leader in TMS therapy and continue to grow in that area, which represents about 90%-plus of our business.

And lastly, I don't see us ending the year at 35 centers. I could -- I'll see that continue to grow throughout the Q4.

Okay. So, I think you folks were hoping to get to a run-rate of 5% to 10% of revenues at the end of, you know, exiting 2022 for Spravato and even though Success doesn't do any Spravato treatments, you were already at 8% on the combined business in Q3.

That's correct. We are well within that range and expect to just stay there.

Okay. And then just one last quick thing here. I don't know if you folks have provided this before. Could you just refresh our memories if you've provided any targets for ultimate cost synergies through the Success integration? And then -- or failing that, could you give us a sense of what the savings potentially are for Q4 versus Q3?

Yes, Noel. So, we haven't given guidance on the ultimate percentage of those material. What I can say is, if you take the two businesses as separate and the cost structures versus the combined business, we've managed to take out roughly $1.1 million in recurring costs out of the business. So, that represents just north of $4 million in annualized costs. We've only started scratching the surface as it relates to that. And although I'm not going to pin myself to a specific number, there's still multiples of that out there, as it relates to duplicate costs as we referenced in our public disclosures.

Just to add to that, Noel, I think our initial onset of synergies, really, we tackled the low-hanging fruit. You took a marketing area, two companies with two different vendors, really merged that to create that synergies in the first area. Obviously more material changes and synergies available to us, as Erns alluded to, in the revenue-cycle management area. You want to make sure that when you take over a company the size of Success, you want to make sure you line up those contracts and make sure everything's covered off in terms of the revenue-cycle management side. In addition, the intake side, we're seeing significant opportunities and response in the intake system which we highlighted Success for and their expertise. So, we have plenty more material synergies to go. We took advantage of kind of that low-hanging fruit in the first quarter.

Okay, great. That's great. That's all for me. Thanks a lot.

Frank Takkinen, Lake Street Capital Markets.

Hey, thanks for taking my questions and congrats on all the progress. I wanted to start with the consultations. A number that -- number looked a disproportionately strong. Obviously, the year-on-year comp isn't perfect, given it's inclusive of success, but that number looks to be even more disproportionately strong, even considering the success contribution. So, maybe just to unpack that a little bit, what potentially occurred in the quarter? And how does that provide you guys confidence going into Q4?

So, I think -- yes, as you say, 58% growth in revenue and we consolidated consultations at the same time and 156% growth in there. So, we are very pleased with that and that really is a forward-looking indicator of what that potential pipeline -- patient pipeline looks like. And I think that as a result -- we always said one of the things that the Success platform did very well is kind of on the intake side. And as I think in executing that synergies and integrating the business, we've started to yield results from that. And I think that it obviously took some time to integrate, but we've now seen the results on the consult side; that obviously still needs to translate to patient conversions. But it certainly provides us a strong forward-looking indicator going into Q4.

Got it. Okay. That's helpful. And then maybe one on the business development side, a broader question just top down. I heard the comments around Spravato and continued expansion, but maybe looking at the network now that you've had a couple of months with it, maybe just give us your renewed thoughts on business development as far as new consolidation, closure, optimization, just how you're thinking about the current network you have out there right now.

Yes. So, we did open up a lot new centers this quarter on the Success side of the platform. We're going to give those time to ramp up. We expect a quick ramp, and kind of as we go into the new year. As far as new centers are going to go, we'll always take a look at opportunities that come our way, both with potential partner doctors and also new development. We believe we have great opportunity to kind of continue to ramp the underperforming areas that were impacted by COVID.

Spravato, as I said, we expect that number to grow by the end of the year and then into 2023. And then lastly, we will -- as a management team, we're always going to evaluate the performance of our centers, whether they're impacted by payer criteria or the fact -- to close centers. So, that's going to be a consistent theme throughout each quarter. Right now, we're comfortable where we are and we'll continue to look for ramp-up, both in the underperforming areas, Success, and also with Spravato.

Okay. Then last one for me. I think, Erns, your specific commentary was something along the lines of near-term timeline to profitability. Can you provide any further color around the bridge to profitability?

Yes. So, as I outlined, it is very important to contextualize kind of the cash usage. Obviously, a lot of the cash was used to settle debt, catch up on transaction costs, and also investment in new centers on the Success side. So, the actual operational burn was actually significantly lower as illustrated at first glance; it is kind of $4.5 million to $5 million. And as we said, we have already taken $1.1 million in recurring costs out of the business.

We expect revenue ramp for the reasons that Bill mentioned and while taking out the costs in the business. And that translates to what we've already seen a significantly reduced burn. And as we said, we always said we want to be adjusted EBITDA positive kind of by the end of the year, at least at an exit run rate. And then move to kind of cash flow breakeven early in 2023. And we fairly -- we're laser-focused on executing that and pretty confident that we can do so.

Great. Okay. I'll stop there. Thanks for taking my questions and congrats again on all the progress.

Thank you.

Thanks.

Alex Silverman, AWM Investment.

Good morning, and congrats on the progress so far. A number of the other folks here asked sort of the same question but wondering -- I'm going to ask it in a different way. Wondering if you might give us a sense of what a breakeven model might look like. In other words, what do you need to generate at the regional and central level to be breakeven as a business? Or what are you thinking about below that line in terms of spend? Just help us with what that might look like.

So, Alex, in terms of -- we haven't historically given guidance, but what we have always kind of referenced as that business combination, we essentially a few -- we generated $20.8 million. If you consolidate Success for the full quarter, it would be a kind of a $22 million. So, call it a $88 million run rate. We need to be kind of at the $100 million level and execute on our synergies. That's essentially what the breakeven model looks like. So, the threshold here is to become a $100 million business, and that's kind of the breakeven scenario.

With maybe a 20% regional margin?

Yes. In terms of like -- as we've guided before, the optimal ultimate regional margin is 30% from a breakeven perspective. That obviously needs to be at about 20% and then kind of the corp G&A being kind of 20%, that will cause it to be breakeven, yes.

Got it. That's helpful. Thank you very much. Appreciate that.

Justin Keywood, Stifel.

Hi. Thanks for taking my call. Just on the gross margins of Spravato versus regular TMS services, what's the difference?

So, the gross margins, a very similar profile, slightly higher on the Spravato side because you've got a higher reimbursement rate. As Bill mentioned, it's just north of $300 typical for a Spravato treatment. And the ebb and flows varies. You obviously spend -- you don't spend the device cost on that treatment, but you require more provider time. And so that kind of washes out to kind of a very similar margin profile. If you call it the center of the target margin of 30%, you can probably run Spravato at a full center closer to 40%.

And are there any material setup costs for expanding Spravato to new clinics?

So, no, it's not material. It's a few chairs and kind of dividers and kind of repurposing the room. That's -- if you look at our center development costs, the majority of the cost that's going through there, because we are not -- or going forward for the foreseeable future without a heavy center development plan, is going to be kind of the retrofitting for Spravato. But that's going to be nominal in aggregate.

Yes, just to add to that. It's roughly -- we look to have three to six chairs in each Spravato clinic across our platform.

Right. And I know it's relatively early, but as far as the operating margins for a clinic with Spravato plus TMS versus TMS only, has there been a difference in that? I assume with greater revenue, there's some operating leverage to be had.

Yes, no, for sure. So, in terms of -- a case study would be kind of our Rockville location is where we launched the Spravato program. And that is obviously not reflective of our entire network of centers, but that operates at above a 40% regional operating margin.

Got it. And then just finally for the pursuit of breakeven EBITDA for the consolidated operations, what's the target timing for that?

So, breakeven EBITDA is we really want to push for through, as Bill mentioned, Spravato growth ramp of the new centers in the Success platform plus, some of the things we're doing to enhance underperforming regions. We want to get there, as we've always said, in Q4 to kind of a breakeven adjusted EBITDA level. And then obviously, we have to ramp a little bit from there to be cash flow self-sufficient. And we hope to do that going into 2023.

Got it. Thanks for taking my questions.

No problem. Thank you.

David Martin, Bloom Burton.

Yes, thank you. I had some problems polling in for questions and may have missed some things, so I apologize if they've been covered. But you mentioned the $100 million to get to breakeven and profitability. Do you need new centers for that, or can you achieve that with the network you have now?

So, I think, in terms of we -- we are fairly confident once again, as Bill said, catalysts for -- four catalysts for growth, new centers established. It's essentially since the time we started engaging with Success to now, they've gone from 32 to 47 locations. And so, there's a lot of new centers and investments that's gone into that. Just the fact by virtue of maturing and those increased growth in our Spravato regions, and then some management changes we've made in underperforming regions should have our existing network be able to get there.

And I want to reiterate in terms of, obviously, the $100 million is kind of that benchmark for a breakeven when we've executed synergies and in a steady-state scenario. But that really is the aim for the business. That's where we want to get to.

Okay. And do you believe the cash on the balance sheet now is sufficient to get you to that breakeven point?

Yes. Based on our targets, we are laser focused in terms of doing those two things. Executing on a top-line growth for the reasons that I mentioned and executing on synergies where there is still significant opportunity. And as we speak, we are still executing on those. So, yes, we obviously don't have an enormous amount of cash in the balance sheet but we still believe that through laser-focus execution we can get there.

Okay. Your revenue per treatment in the third quarter was about $11 lower than in second quarter. But the direct center and patient care cost per treatment was $16 lower. So, you were making $5 more profit per treatment. Was this mainly due to differences in Success' cost structure or other factors such as seasonality? And do you expect any changes in these levels going forward? Do you expect the revenue per treatment to go up or down and the cost per treatment to go up or down?

So yes, there's a couple of things at play there. And you're right. It's purely the movement in kind of the cost per treatment and revenue per treatment is purely a product of kind of, like I said, you have to contextualize these results, combining two businesses. The reimbursement rate, I'll address first. That's kind of jurisdiction-based. Obviously, Success has [a heavy presence] in Florida. Traditionally has a little bit of a lower reimbursement rate.

We also -- another factor that played a role, we see -- if you look back, we always see there's a little bit of softer collections in during the summer months with payer folks taking vacation. That's reversed. So, our adjustment for variable consideration was a little bit higher. So, that will reverse an uptick.

And then as we expand our Spravato business, that's a higher reimbursement rate. We will probably pick that up again. So, I'm fairly confident we will see a little bit of a -- even though as an aggregate, the Success Team, as a business, operates at a slightly lower reimbursement, just purely because of where they operate, we will see a little bit of a reversion back to where we were. (multiple speakers)

And David, just to add to that, every year or two, we have the ability to go back and negotiate with payers to try to get our reimbursement rates increased. Again, the more patients we deliver TMS therapy to, and Spravato treatment to, and show value in that, we believe we have a good opportunity to kind of increase our reimbursement rates.

Okay. And is -- on the other side of things, the direct center and patient care cost per treatment, is that because Success has higher capacity utilization at their centers, and should we expect that lower cost per treatment at the center level to remain low?

Absolutely. So, I think that speaks to some of the synergies or some of the reasons why we made the acquisition. Things that Success does really well, specifically relates to their intake process. Their, also, kind of leverage, was more aggressive on using fixed costs and leveraging those, and as you say, capacity utilization. So, with combining the businesses and putting kind of best of breed together, the goal is absolutely to continue to operate at a lower cost per treatment.

Okay. And then last question. Once the dust has settled, where do you expect quarterly regional costs and corporate G&A expenses to track to?

In terms of that -- at what level of revenue is kind of the question. I mean if you normalize out our current G&A -- it was 9.6 in the quarter. If you normalize that out, it's running around 6. We want to take a chunk of that still out. So, that gives you a sense in terms of call it between that through $20 million to $25 million range with the revenue ramp.

Sorry. You said normalized at 6; that would take it back to where you were before you bought Success. Doesn't Success add some to the corporate G&A?

It does, but we are taking out -- we were as an individual business taking out costs and rationalizing our corp G&A. And as we've said, yes, Success will add a little bit of corp G&A, but it is two business fully-fledged cost structures that were put together and part of this, the huge synergistic value here, is kind of eliminating kind of a duplication of -- a large duplication of corp G&A. So, take it to that -- towards the high end of that, the $25 million.

Okay. And then the $8.3 million of regional costs, is that expected to be stable going forward? Or can you get synergies?

There's going to be less synergies in that. There's going to be some synergies as it relates to the intake process. But that's -- it's more scale operating leverage there. So, you're going to ramp your revenue without significantly ramping your cost structure.

Okay. So, expect the cost structure, the regional costs to stay at about $8.3 million per quarter, but the revenues to start growing.

Yes, give or take.

Okay. Okay. Thank you. That's it.

(Operator Instructions) Okay. We have no further questions at this time. I'll turn it back to you.

I want to thank everyone for participating in today's call. This is our last opportunity to speak to you before the end of the year. So, wishing you all a happy holiday season. Stay safe, stay healthy, and we look forward to sharing the progress with you early next year, and look forward to having you again on our next call. Thanks so much.

Ladies and gentlemen, this concludes your conference call for today. We thank you for participating and ask that you please disconnect your lines.