Heron Therapeutics Inc (HRTX) 2022 Q3 法說會逐字稿

Good day, ladies and gentlemen and thank you for standing by. Welcome to the Heron Therapeutics Q3 2022 Earnings Conference. (Operator Instructions)

Now I would like to turn the call over to David Szekeres, Executive Vice President, Chief Operating Officer. Please proceed.

Thank you, Dennis. Good afternoon, everyone, and thank you for joining us. With me today from Heron are Barry Quart, Chief Executive Officer and Chairman; John Poyhonen, President and Chief Commercial Officer; and Kimberly Manhard, Executive Vice President of Drug Development and Board Director.

For those of you participating via conference call, the slides are made available via webcast and can also be accessed by going to the Investor Relations page of our website following conclusion of today's call.

Before we begin, I would like to remind you that this call will contain forward-looking statements concerning Heron's future expectations, plans, prospects, corporate strategy and performance, which constitute forward-looking statements for the purposes of the safe harbor provision under the Private Securities Litigation Reform Act of 1995. Actual results may differ materially from those indicated by these forward-looking statements as a result of various important factors, including those discussed in our filings with the SEC. In addition, any forward-looking statements represent our views only as of the date of this webcast and should not be relied upon as representing our views as of any subsequent date. We specifically disclaim any obligations to update such statements.

Now, I'll turn the call over to Barry.

Thank you, David. Welcome, everyone, and thank you for joining us.

Third quarter has been productive on a number of fronts and disappointing on others. We're obviously delighted with the approval of APONVIE, our fourth commercial product. APONVIE is indicated for the prevention of postoperative nausea and vomiting, or PONV, in adults. APONVIE will be available in first quarter as a very convenient, room temperature stable, ready-to-use 32 milligram single dose vial for direct administration as a 30 second intravenous injection prior to induction of anesthesia. It will be the only intravenous NK1 receptor antagonist available for PONV.

As we discussed on our NDA approval call in September, APONVIE was approved based on the results from 2 randomized controlled trials of aprepitant against the standard of care, ondansetron, in patients undergoing open abdominal surgery. In both studies, more than twice as many patients receiving ondansetron for prophylaxis vomited through 48 hours post-surgery compared to those who received aprepitant. We firmly believe that APONVIE will follow in the footsteps of CINVANTI in quickly becoming an important product for both clinicians and patients.

John will describe the commercial opportunity and our pricing strategy. John also touched on our successful -- John will also touch on our successful DINV franchise, which continues to show growth in the face of generic competition, as well -- which is well on its way to achieving $93 million to $95 million in net product sales this year.

Where we have been less successful is in the launch of ZYNRELEF. We are disappointed in third quarter results. 18% quarter-over-quarter growth in units is not satisfactory. We get it and are doing everything possible to change the launch trajectory. You will hear about good progress in moving IDNs to exchange ZYNRELEF for Exparel.

We're also taking a page from the Exparel launch and have initiated activities to get more field personnel involved through contract relationships, which John will briefly discuss with more information on future calls. Fortunately, as elective surgeries began to rise in October and the early stages of our new strategies take hold, we had our best month ever, and all signs point to an improved fourth quarter.

Last December, we were able to get an improved indication statement with no new data, covering 7 million procedures for ZYNRELEF. We also reached a written agreement with the FDA about what new data would be needed to achieve a full label covering the 14 million soft tissue and orthopedic procedures we originally targeted. We have now completed the agreed upon studies and are deep into preparing what we call sNDA #2, designed to obtain the broader indication. This NDA is planned for submission late this year.

As a reminder, the key endpoints for these studies were safety and pharmacokinetics. I'm pleased to report that no new unique safety issues were observed, and we found consistent bupivacaine PK following ZYNRELEF administration in these additional procedures. You can see on this slide the dose normalized Cmax of bupivacaine with ZYNRELEF is generally stable and lower than bupivacaine HCL. We believe these results will provide the basis for expanded indications next year, alleviating a major headwind for ZYNRELEF.

I will now turn the call over to John.

Thank you, Barry. We continue to make progress across our acute care and oncology care franchises. During my presentation, I'll start with a number of updates on key performance metrics related to ZYNRELEF, then I'll provide an update on our PONV pricing strategy and finish with an update on another strong commercial quarter with our oncology care business.

I'll start by summarizing ZYNRELEF's quarterly performance of our leading indicators. Despite third quarter performance being impacted by a decline in indicated surgical procedures, which I'll describe on the next slide, ZYNRELEF net sales grew to $2.7 million for the quarter, representing an 8% increase over the prior quarter. Third quarter demand units grew to 15,077 units, representing an 18% increase over the prior quarter. This growth was impacted by a much slower than expected July.

The difference between the 8% net sales increase and the 18% unit demand increase was a function of lower ZYNRELEF net price, primarily driven by higher 340B sales and an increase in the percentage of 200 milligram SKUs purchased to support the traction ZYNRELEF is gaining in general surgery and foot and ankle procedures.

Total ZYNRELEF unique ordering accounts grew to 704 with the account reorder rate remaining strong at 84%. Total formulary approvals for ZYNRELEF grew to 416 approvals. Importantly, we're seeing growth with integrated delivery networks, or IDNs, with 66 IDNs that have added ZYNRELEF to formulary. Gaining IDN support is a critical component to drive therapeutic interchanges with key accounts substituting ZYNRELEF for Exparel our indicated procedures in the future. Overall, although we certainly made progress during Q3, we know we can do better. And we have refocused our Q4 priorities to accelerate ZYNRELEF sales in our existing user accounts.

As I mentioned on the prior slide, we believe third quarter performance was impacted by a decline in indicated procedures. This line chart shows the volume of currently indicated procedures since 2019. There are several relevant observations. First, our target indicated procedures still have not returned to 2019 levels. Second, the July to August period in 2022 was the lowest volume in the 4 years measure. And finally, the first 10 weeks of Q3 declined 11% from the first 10 weeks in Q2. While the market -- despite the market weakness, ZYNRELEF grew 18% in Q3, and the brand continues to make steady progress. As a comparison, Symphony data indicates that in the third quarter 2022, Exparel total unit demand volume declined by 3% versus the prior quarter.

As previously mentioned, ZYNRELEF demand unit volume grew by 18% in the third quarter over the second quarter. This translates into an average of 1,160 units per week during the quarter. We are starting Q4 with some positive news. October was our highest volume month in history at 6,534 units. This translates into 1,475 units per week, representing a 27% increase over the Q3 weekly average. Historically, the fourth quarter has been the strongest quarter for elective surgical procedures, and we are encouraged by our start to Q4. Based on this growth, we anticipate ZYNRELEF net product sales to increase in the range of 30% to 40% in the fourth quarter compared to the prior quarter.

ZYNRELEF formulary approvals grew to a total of 416 approvals through the end of October. In those accounts actually making P&T decisions, over 90% of hospital P&T committees continue to add ZYNRELEF to its formulary. Importantly, an estimated 68% of our formulary approvals are for unrestricted usage of ZYNRELEF.

One of the key strategic changes we are making is deploying greater resources to existing user accounts to drive pull-through in the fourth quarter. In addition, our focus is on expanding the procedures and surgeons where ZYNRELEF can be used, especially in IDNs to accelerate ZYNRELEF volume and net sales. While we understand that new formulary approvals help us establish a critical pipeline for new ZYNRELEF business, driving greater usage as our current -- in our current ordering accounts is our key priority for the commercial team.

Next, I wanted to provide an update on key top-down strategy of targeting integrated delivery networks to create new system-wide opportunities for therapeutic interchange from Exparel to ZYNRELEF for indicated procedures. Thus far, 66 IDNs have added ZYNRELEF to their formularies with 35% of approvals for unrestricted use of ZYNRELEF. These 66 IDNs account for over 1 million annual ZYNRELEF-indicated procedures. Finally, our IDN formulary expansion now covers $143 million of annual Exparel sales. We currently have 15 IDNs at various stages of evaluating switching from Exparel to ZYNRELEF for indicated procedures.

Now let's drill down on the 15 IDNs that are interested in potential therapeutic interchange. With ZYNRELEF's existing expanded label indications, it's not surprising that IDNs are looking to save millions of dollars with a product that has demonstrated superior clinical results to the standard of care in head-to-head trials. We're excited to be partnering with both pharmacy and physicians to drive their internal evaluations with ZYNRELEF. Of the 15 IDNs moving forward, all 15 IDNs have initiated their internal trials. Feedback on their trials continues to be very positive across a variety of surgical procedures. While moving a large IDN certainly takes some time, 5 IDNs have now made positive decisions for therapeutic interchange and are now switching to ZYNRELEF for indicated procedures.

Last quarter, we introduced a new metric to help us evaluate the impact we are making with IDNs. As a reminder, the new metric to measure performance is branded market share, which is simply ZYNRELEF units divided by the total number of Exparel units plus ZYNRELEF units. Overall, in the 66 IDNs with formulary approval, we have demonstrated solid branded market share growth. It's important to keep in mind, adding new IDNs actually lowers our share as we build new business in these accounts. For example, last quarter we reported 57 IDNs with formulary approvals, which has now grown to 66 IDNs.

Advancing IDNs to evaluation of therapeutic interchange is an important step in accelerating ZYNRELEF growth. As the table shows, the 15 IDNs evaluating TI have a combined 12.4 branded market share in Q3, which is over 50% higher than the average for the 66 IDNs, which have ZYNRELEF on formulary.

Finally, we've also provided ZYNRELEF's branded unit market share for the top 5 IDN share accounts out of the 15 IDNs evaluating TI. As this table demonstrates, our branded market share can grow very quickly with a high over 50% for Q3. Based on our current indicated procedures, 50% market share is approaching the upper limit until we receive an additional label expansion, which is expected in the second half of 2023.

We've shared different versions of this slide in the past. Today, I'll focus on purchase price, cost savings and reimbursement benefits. Switching to ZYNRELEF provides a cost savings of 25% to 32% based on wholesale acquisition cost. In the fourth quarter, Pacira implemented an estimated 25% discount from WACC pricing, and for the first time are offering 340B pricing for Exparel. Even with Pacira's 340B pricing, ZYNRELEF still provides 340B accounts with a 23% to 31% savings compared to Exparel.

Many 340B customers that we've spoken with have indicated that Pacira's response to the ZYNRELEF pricing strategy is too little, too late. Pacira's move at this late stage in the product life cycle is interesting, considering the significant financial impact it will have on their business. Based on Symphony data, 45% of Exparel's hospital sales are in 340B-eligible accounts, thus, a 23% discount could have a meaningful reduction in top line sales and profits. We don't believe they would have taken this hit if they didn't see us starting to gain traction in 340B accounts and becoming a larger threat.

Finally, from a reimbursement perspective, using ZYNRELEF remains much more profitable with Medicare patients in the hospital outpatient and ASC settings of care. In these challenging financial times, 340B accounts are still experiencing a financial benefit of over $340 per patient by using ZYNRELEF rather than Exparel. Based on these economic benefits, it is not surprising that large IDNs continue to evaluate ZYNRELEF for TI in indicated procedures and are anxious to limit Exparel's usage.

I'll close the ZYNRELEF section with our refocused priorities for 2022. Our top priority is to build consistent usage in ordering accounts. We have nearly 600 accounts that have reordered, and we are working to increase pull-through and build average order size. This will be accomplished by increasing the number of surgeons using ZYNRELEF at each account and the number of surgical procedures where it's used.

During October, we began deploying new flexible resources to ensure that we have additional personnel for in-servicing surgeons and their staff. Simply put, we want the right resources at the right account at the right time. These new resources are especially important in formulary approved IDNs with multiple hospitals in a given geography where there can be too many accounts to cover all at once. These contracted resources provide us with the bandwidth to grow faster. Another advantage is our ability to deploy resources in territories quickly and cost effectively. We are already beginning to see the initial impact of these new resources and believe the true impact will be seen in Q1.

Our second priority is to maximize our separate reimbursement outside the surgical bundle payment for ZYNRELEF. The CMS pass-through status ZYNRELEF has for Medicare patients in the hospital outpatient setting of care continues to make a positive impact, especially in IDNs. In addition, ZYNRELEF is now approved for separate reimbursement in over 200 million covered lives by commercial payers and Medicaid. Finally, we'll continue to gain formulary approvals at new targeted IDNs and hospitals to build our pipeline for growth and therapeutic interchange opportunities.

Now I'll shift the presentation to APONVIE, our new product for the prevention of postoperative nausea and vomiting, or PONV. During my September approval presentation, I focused on the market opportunity. Today, I'll be sharing specific details on our pricing strategy for APONVIE. We truly believe that APONVIE and the PONV market is the next big opportunity at Heron. Let's start with the name APONVIE conveys, aprepitant for PONV. The market research on the brand name was extremely positive from healthcare providers and, importantly, differentiates this lower dosage offering of aprepitant emulsion from CINVANTI, our highly successful product for CINV.

We will be targeting 36 million annual procedures in patients at moderate to high risk of PONV. In this large segment, an estimated 12 million high to moderate risk patients are not receiving prophylaxis. One of our goals will be to utilize the 2020 consensus guidelines to change this practice, growing the market and addressing one of the most concerning side effects for patients undergoing surgery.

Market research identified a number of significant unmet needs in the current market, including a more convenient product with faster onset, which APONVIE meets with a rapid IV push and 97 receptor percent occupancy within 5 minutes. A more effective product is desired, and aprepitant is the most effective product for PONV prevention, alone or in combination. And finally, longer lasting treatment with APONVIE providing PONV prevention for up to 48 hours. The last unmet need is especially important with the growth in outpatient surgeries and patients being discharged hours after surgery. In short, APONVIE is clearly differentiated in this market and positioned for success.

APONVIE is also the perfect strategic fit for Heron based on the synergies with our commercial organization. It starts with tremendous overlaps of accounts we are already targeting for ZYNRELEF. We have existing trusted relationships with anesthesia and pharmacy, which is critical for formulary access and usage. In addition, about 65% of CINVANTI business comes from the hospital market. The existing positive experiences at major hospitals and IDNs should help us jump start APONVIE access and usage.

Next, I wanted to share some market research with healthcare providers and the impact of APONVIE pricing on their market share. The circle graph shows their overall use of PONV prophylaxis for prevention by patient risk factor: low, moderate and high. Not surprisingly, the estimate is 18% share in low-risk patients growing to 59% share in high-risk patients.

The bar graph on the bottom shows the HCP market share based on price points ranging from $75 to $35 per APONVIE vial. A key observation was the change in market share across all 3 patient risk categories as price moved closer to the $65 price point. Based on HCP feedback, we determined that WACC pricing between $65 and $55 was the right range, but we also needed to consider formulary access for APONVIE. Slide #20 provides key market research finding from pharmacy directors on formulary access for APONVIE based on price points ranging from $40 to $96 per APONVIE vial. Once again, there was a significant difference between the $65 and $55 WACC pricing on formulary access for APONVIE, with $60 being the tipping point on access.

Our goal was to select an APONVIE pricing strategy which maximizes the profit contribution to the company. Our final pricing recommendation balances the HCP market share in moderate to high-risk patients and optimizes overall formulary access, including the level of potential restrictions to the product usage. With this in mind, we will launch APONVIE with a WACC price of $58 per vial. APONVIE will only be sold to end users in packs containing 10 vials.

In addition, consistent with our corporate pricing strategy, we'll also offer 340B pricing to accelerate access to healthcare providers and patients. With a discount of at least 23.1% from WACC, 340B pricing for APONVIE will be under $45 per vial. It's important to note that market research showed, and the 2 previous slides also supports, incremental HCP market share and improved formulary access at this lower price level. Finally, as Barry mentioned, we're still on track for APONVIE availability in the first quarter of 2023.

Now I'd like to shift gears and review the third quarter results for our oncology care franchise. During the third quarter, our oncology care team did an outstanding job of growing our CINV portfolio net sales by 13% over the same quarter in the prior year. We're very proud of restoring growth to our CINV franchise following generic arbitrages with both products and believe this will remain a valuable and highly profitable franchise for years to come. We remain on track to deliver CINV net sales in the range of $93 million to $95 million, representing an 11% to 14% increase over prior year.

The outlook for our CINV products remains positive based on continued improving reimbursement tailwinds over the past year. As shown by the table below, both CINVANTI and SUSTOL are in a much more favorable reimbursement position versus the competition than at the same time last year, with generic fosaprepitant down to $20.66 and IV Akynzeo down to $423.12 reimbursement. In addition, the elimination of separate reimbursement for generic fosaprepitant to hospital outpatient segment effective January 1 of this year continues to make CINVANTI value proposition much more attractive.

The new CMS guidelines published in July indicated that effective July 1 of 2023, that reimbursement for 340B accounts will increase to ASP plus 6% compared to the prior rate of ASP minus 22.5%. With the greatest portion of our CINV hospital demand units are in 340B accounts, we believe this opportunity will help us increase sales units in the fourth quarter and in 2023.

Finally, large scale CINVANTI manufacturing is now online with product in the distribution channel, resulting in significant improvements in our gross margin. That completes my prepared remarks, and I'll turn the call back over to Barry.

Thank you, John. We'll conclude the formal presentation with our financial overview slide.

Heron had cash, cash equivalents and short-term investments of $121.7 million as of September 30, 2022. Net cash used for operating activities in the third quarter was $37.1 million, including restructuring fees from our recent reduction in force. The full impact of reducing headcount by approximately 34% will continue to be realized through this quarter and next.

The following slides in the deck contain important safety information for ZYNRELEF and APONVIE. The slides are available on our website.

With that, we're ready for your questions. Dennis?

(Operator Instructions) Your first question comes from the line of Brandon Folkes with Cantor Fitzgerald.

I appreciate being candid about ZYNRELEF's performance, but no surprise, I do want to just dig in a little bit. Can you maybe just elaborate what changed so much from the beginning of August when we held the 2Q call and was guided to sort of that 40% to 50% quarter-over-quarter growth? We were past July at that stage that we called out on this call today. And then similarly, any visibility risks into the October figures you mentioned now just in light of sort of that dynamic of August and July? Were you just expecting maybe a more robust bounce back in surgery? Any color would be helpful. And then maybe just to add something to that. Pacira did call out an improvement in year-on-year trends in mid-August. Is there anything we should look into sort of in that comment with your results today?

Yes. Thanks, Brandon. I appreciate the question. And yes, I think that you hit the nail on the head. We had anticipated a much stronger rebound after a weak July, and obviously that didn't occur. And it's sometimes not 100% clear on a month-to-month basis in terms of the impact of the macro environment that we're in. You mentioned the Pacira call. They had indicated a weak going into -- a weakness going into October. We've seen October as extremely strong. So I think there's going to be

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us, the products in terms of seasonality. I'll let John add any additional information in terms of the second part of the quarter in terms of reasons why we didn't see the rebound that was anticipated. I will also add that we did have a restructuring, which included some of the commercial team. It has been very successful in terms of really invigorating that group. But with any kind of restructuring, obviously, there's always some downtime to get things reorganized. So John, do you want -- anything to add?

Yes. I think the one thing that I would add, Barry, is we feel very good about the direction we're headed in Q4. And really, we're starting to see the claims data, procedure trends support that, Brandon. So if we look at it, what we tend to follow was a 5 week -- over the prior 5 week on indicated launch procedures, and we're finally starting to see growth at that. That was really reflected after Labor Day. We had a very strong finish to September, and then really have backed that up with our strongest month ever in October. And we're a whole 1 week in now, but the November 1st week is higher than October was. So we feel good about the statement that we've made that we're looking for 30% to 40% net sales growth for the quarter.

I appreciate the color. Maybe just one follow-up there quickly. You put out cash runway guidance previously. Obviously on a quarter-over-quarter growth, you're sort of far off, but not really on a dollar denominated amount. So I just -- can you just let us know, do you still stand by the cash runway post this ramp? And then maybe just one more, if I may, just sort of more sort of constructive manner. With the IDNs that are evaluating ZYNRELEF now in these trials, if you are successful in gaining that further label expansion, how should we think about whether these IDNs want to run another round of evaluation? Or do you think they will just sort of fold it in? Are they running it on a broader set of surgeries maybe than the label? Just any color on that would be helpful, too, as we think about the ramp in 2023.

Thanks, Brad. And actually, I'll turn it over to John to answer the last question first on IDNs, and then I'll take cash right runway.

Yes, it's a great question, Brandon. And we believe that it unfortunately will be dependent on an IDN by IDN basis. We've got some accounts that have already gone to the point where they've taken Exparel off formulary. And certainly in those accounts that we feel like the additional indicated procedures that we're going to get, we're going to be able to get a large portion of that business relatively quickly. In others, it may take a bit longer. So it's a bit early to make that call. But I think we're gratified that in some of the accounts, they're having such great results. One in particular that I can think of has got 6 different hospitals within the IDN, and in 3 of them, they've already removed Exparel from formulary. And those are the types of results that we get excited about. We're not looking to have Exparel removed or looking to grow usage. But in those situations where we actually don't have Exparel as a branded competitor, we think that that business can grow much more rapidly with the further label expansion.

Thanks, John. Yes, on cash runway, obviously cash runway delivers our cash burn and revenue. We are working very hard to increase revenue numbers, as John went through in his presentation, and looking at ways to obviously control the burn. We had anticipated seeing an increase in burn this quarter when we gave the original guidance. We were finishing up the validations of large scale manufacturing for both ZYNRELEF and CINVANTI, which takes some additional resources. So that was part of the original plan. And so we are doing everything we can to maintain that guidance.

I appreciate all the color.

Our next question is from the line of Josh Schimmer with Evercore.

I guess the first, do you expect APONVIE revenue to be greater than ZYNRELEF in either 2023 or 2024?

Well, it's a little early to be giving revenue guidance. I think the unit volumes certainly could be higher. Dollar revenue would be a challenging target. John, do you have any other -- any additional color on that?

No, I think that's well stated, Barry. I don't have anything to add.

Okay. And you have not really articulated a clear explanation as to why the ZYNRELEF launch has been so far below expectations. And it makes it kind of hard to have a lot of confidence in some of your commentary and optimism that you're going to be able to get back on track if you can't really explain how it got so off track to begin with. So can you maybe kind of list the top 3 or 4 dynamics that you think we were off relative to the launch and initial expectations and how you're going to be able to correct those?

Well, certainly. I'll start and John can conclude. As you know, Josh, we got a less than ideal initial label for ZYNRELEF that had a much greater impact on utilization than initial market research would have indicated. And I think you yourself have pointed out that was a clear miss on our part that we should have appreciated that would have a bigger impact. We fumbled the ball there in terms of believing the market research, in terms of surgeons not really caring what the indication statement was. And certainly, that was a reasonable view, given the off-label use of our competitors' product in the nerve block space. So it seemed reasonable. Turned out not to actually be the case. We were fortunate to get the label revised in December. That's helped to expand the utilization and has helped to bring on these therapeutic interchanges from IDNs. We're still somewhat hamstrung by the still diminished label. It means that some IDNs are not considering a therapeutic interchange because the scope of the indications isn't broad enough. So we still have obviously efforts in place, as already noted, to fix that issue, and we anticipate that being corrected in the second half of next year.

The other challenge that we have identified is that it is taking more sales rep time per surgeon to get them familiarized with the product, to get the staff familiarized with the product. And with the much larger turnover in staff than certainly we ever anticipated pre-COVID, or even as COVID started to wane, we didn't appreciate the turnover issues that hospitals would have in staff. It's just taking more time of the rep for individual surgeons. And that has resulted in obviously the sales reps getting to fewer new surgeons and not expanding the utilization as quickly as we certainly had projected. John, do you have any other things to add?

Yes, I do, Barry. I think that both of the items that you described were really important. I think the other real big impact has been that what we're finding is that every single account is virtually doing their own evaluation of ZYNRELEF. So even though we have these wonderful well-controlled studies against the standard of care, bupivacaine, and beat them, they're still evaluating the product themselves. And when we ask them that, it's that the reason comes back loud and clear. Exparel told us they were 72 hours, and they're not. They're 24 to 30 hours. And now we need to prove it with ZYNRELEF that you're actually 72 hours. So I think having to go through that type of evaluation at every single account and in multiple procedures oftentimes -- so you might have to do an orthopedic surgeon and a soft tissue -- has taken far more time than we ever imagined. And I think that's one of the reasons that we're really looking forward to making sure that we have the right resources available through this deployment of flexible resources as we go forward, Josh.

Yes, I would just add that we certainly knew that there would be some trials done at hospitals for the reasons that John articulated. But the size and scope of these trials and the time that it's taken is dramatically longer than we would have projected. We're getting excellent results and certainly positive feedback from these. It's just a very timely -- time-consuming process and has slowed down introduction of the product.

That's very helpful.

Your next question is from the line of Serge Belanger with Needham & Company.

A couple of quick questions on ZYNRELEF to start off. It looks like the net price movement was a bit of a headwind in the third quarter. Just curious if you expect additional movement in net price in the coming quarters. And then secondly, maybe just talk about the -- what kind of market share you have in your targeted indicated procedure. Just trying -- and also trying to get an idea where you're displacing Exparel. And then finally, I think John mentioned the deployment of additional resources in the fourth quarter to kind of reinvigorate ZYNRELEF here. Curious what that does to OpEx, and how many additional people are we talking about here?

John, do you want to take that?

Sure. So you're right, Serge. There was definitely some impact on net price. I think as we've seen some shift with the broader indication that we received in December, there's been a bit of a change in the SKU mix. In the first 6 months, it was probably about 80% 400 milligram to 200% -- or excuse me, 20% 200 milligram. This last quarter, it was about 67% for the 400, 33%. So just by virtue of that SKU change, you will see a lower net price. If you take a look at that, combined with the growth that we've experienced in 340B accounts, 340B accounts between second and third quarter probably grew about 25%, which means we're going to be looking at a lower net price. So I would say from a modeling standpoint, probably best to adjust that down as we've shifted to more 200 milligram SKU to a model price of about $1.75 to $1.80 for net price per unit.

With respect to where are we replacing Exparel, I talked a little bit about this concept of branded market share where we look at the percentage of ZYNRELEF units compared to the total of Exparel and ZYNRELEF units combined. And if you look at the overall market with that, right now, ZYNRELEF shows a share of about 3.8%. You compare that to the numbers that we're showing in the IDNs, and you can see the IDNs, even in the 66 IDNs at 8.1% and 12.4%. So we're really seeing very strong growth in those compared to the overall market, and that's one of the reasons that we'll continue to focus on those IDNs and especially those conducting therapeutic interchanges.

And I believe your last question was, how does it relate to OpEx as we look at these flexible resources. The one thing that I'll say is that these are all contracted work that we're having done. So they're not employees of the company, if you will. We have some that are full-time operating room educators that have the ability to travel where the business is. And they're really a HIT, or a hospital implementation team, where they can really help us get an IDN up and running very quickly. The others are more part-time and local flexible support. They include both OR nurses as well as other support staff. We also are using them for in-services and to leverage relationships with surgeons. We're working with some medical device reps. I think the key difference on our strategy with that, compared to what other companies have done, is that we're only paying, if they were actually in a ZYNRELEF case, if they're in the operating room and supporting the in-service of it. So a very different model, and incrementally, certainly more than pays for itself. But as Barry mentioned, we did have some reduction that we looked at from the commercial organization and certainly can more than offset that small incremental costs as we test pilot some of these new flexible resources. So I don't know if you had anything to add, Barry, on that.

No, I think that you covered it well. Really, the incremental cost of these contract personnel are essentially being covered by the original commercial budget. It's not going to have a substantial impact in terms of burn. And as I previously said, controlling burn, obviously, is very important to us. But I do think it's important to just reiterate that these activities that John has outlined, which are just in the early stages, we're seeing clear evidence of the success of these activities in terms of pull-through, in terms of getting IDNs moving more quickly with the therapeutic interchanges. And we're seeing that in terms of weekly sales increases.

And I will say that, as I mentioned previously, in terms of using additional field representatives and co-promote type activities, this is a page out of the Exparel playbook in terms of their initial launch. And it did have important impacts in terms of their launch trajectories. And so I think that this is something that we're probably a little late in the game in implementing, but it's clearly having an important impact. And we feel very confident that these activities are showing fruit and will continue to in terms of meeting the target growth that we've identified for fourth quarter.

Just one last one to finish off. Curious if the oncology franchise at the guided sales rate of $93 million to $95 million is profitable for the company and

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I'm not sure we got the end of your question, Serge. Yes, it's a very profitable franchise right now. So I'm not sure if you were looking for something more specific.

Maybe what kind of changes in reimbursements that could drive additional growth for 2023?

Yes, John outlined what is a very important driver, we believe. And it's, to a large extent, very similar to an important driver for ZYNRELEF in terms of the reimbursement of CINVANTI and SUSTOL, for that matter, in the hospital setting where because of a recent Supreme Court decision, CMS will go back to the original reimbursing 340B hospitals the full ASP plus 6% rather than minus 22.3%. And that's a huge windfall when you have a product like CINVANTI where they can make, say, $40, and fosaprepitant is not reimbursed at all because it's fallen below the threshold for reimbursement. And so we have a lot of 340B hospitals who moved to generic fosaprepitant to take advantage of the arbitrage that are now either coming back or evaluating coming back to CINVANTI. And that will certainly be an important driver for us into next year.

Yes. Just a little more color on that, Barry, if I could. So those IDNs that moved to generic fosaprepitant during the arbitrage, actually, with this new reimbursement windfall for 340B hospitals, we've already signed contracts with 3 IDNs to come back to CINVANTI. Now IDNs, because a number of them are over 30 hospitals apiece, it takes a bit of time to get them back and using the product. But we're very optimistic about what this quarter could look like, as well as going into next year, we think that could help fuel growth. And we continue to talk to other IDNs that were former users of CINVANTI, and it's a perfect discussion because we're going to be out there talking to them about APONVIE as well.

Yes, I will also add that we have been somewhat resource constrained in terms of CINVANTI up until really this quarter with limited supplies being manufactured at small scale. And so we have kind of slow walked some potential opportunities just because of the fact that there was a limited amount of material that could be manufactured, even though we have 2 contract manufacturers. We've now, as already noted, validated the larger scale manufacturing as a 10x increase, which allows us to greatly expand availability. And we've put pedal to the metal in terms of going back out and looking for additional business, and we'll continue to do so.

At this time, there are no further questions. I will now turn the call back to Barry for any closing remarks.

Yes. Well, I want to thank everyone for joining us on the call today. As noted, obviously we're very disappointed with the ZYNRELEF results in the third quarter, but very optimistic for fourth quarter and beyond. We see that the building the base of business that John defined in the call is starting to bear fruit. And with some of the new initiatives we've put in place and the increase in procedures, we're extremely positive about the fourth quarter and moving into next year. So thank you very much for tuning in, and we look forward to keeping you updated in the future.

Ladies and gentlemen, that does conclude today's conference call. Thank you for your participation. You may now disconnect. Goodbye.