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Operator
Welcome to Inogen's fourth quarter 2025 earnings conference call. (Operator Instructions) As a reminder, this conference is being recorded today, February 24, 2026. I would now like to turn the call over to Lorna Williams, Senior Vice President of Investor Relations and Strategic Planning.
Lorna Williams - Senior Vice President of Investor Relations and Strategic Planning
Thank you for participating in today's call. Joining me are President and CEO Kevin Smith and CFO Michael Bourque. Earlier today, Inogen released financial results for the fourth quarter and full year 2025. The earnings release is available in the investor relations section of the company's website along with a supplemental financial package.
Please note we have also published a new investor presentation on our investor website which contains forward-looking statements and long-term financial goals.
As a result, the information presented today will include forward-looking statements, including, without limitation, statements about our growth prospects and strategy for 2026 and beyond, expectations related to our financial results for the first quarter and full year 2026. Progress on our strategic initiatives including innovation, our expectations regarding the market for our products and our business, and supply and demand for our products in both the short-term and long-term.
The forward-looking statements in this call are based on information currently available to us as of today's date, February 24, 2026. These forward-looking statements are only predictions and involve risks and uncertainties that are set forth in more detail in our most recent periodic reports filed with the Security and Exchange Commission.
Actual results may vary, and we disclaim any obligations to update these forward-looking statements except as may be required by law.
During the call, we will also present certain financial information on a non-GAAP basis. Management believes that non-GAAP financial measures taken in conjunction with US GAAP financial measures provide useful information for both management and investors by excluding certain non-cash items and other expenses that are not indicative of Inogen's core operating results.
Management uses non-GAAP measures internally to understand, manage, and evaluate our business and make operating decisions. Reconciliations between US GAAP and non-GAAP results are presented in tables within our earnings release.
With that, I will turn the call over to Inogen's President and CEO Kevin Smith.
Kevin Smith - President, Chief Executive Officer, Director
Good afternoon and thank you for joining our fourth quarter 2025 conference call.
I want to use today's call to recap our 2025 success, outline progress on our strategic initiatives, and share why I am confident in delivering improving performance in 2026 and beyond. Our focus remains anchored on three priorities: driving topline growth, advancing profitability, and expanding our innovation pipeline.
Let me start by discussing our recent results. We delivered approximately $82 million in total revenue in the fourth quarter and nearly $349 million for the full year, reflecting 4% year-over-year growth and meeting our goal to deliver mid-single-digit growth for 2025. Although we experienced a shift in the timing of a few orders from the fourth quarter into the first half of 2026 due in part to capital and budgeting constraints from certain customers, it was not a loss of customers, and our underlying market fundamentals remain encouraging. Unit volumes grew more than 20% year over year in the fourth quarter and for the full year, driven by continued demand for our products and the conversion from traditional portable oxygen tanks to POCs.
Looking forward, we are well positioned to continue building on the progress made in 2025 to drive revenue growth and penetrate the substantial market opportunities in front of us. In the US, we're investing deliberately to educate both patients and providers on the economic and clinical benefits of Inogen products. Our products are engineered to a fundamentally different standard than competing POC manufacturers and oxygen tanks. We believe our superior reliability, extended life cycles, and better patient outcomes justify our premium positioning today and going forward.
We are also seeing positive early traction with our newer products in the US, including Voxi 5, SIMEOX, and our Aurora CPAP masks which I will touch on shortly. Growth from international customers is also central to our strategy. Our international business delivered $32.5 million in Q4 revenue, representing 15% year-over-year growth and a clear bright spot in our recent results.
The team has executed well on deepening HME relationships and securing key international tenders, which is expanding our brand visibility and reinforcing our position as a trusted global partner in Oxygen therapy. This performance underscores why international expansion remains central to our long-term growth strategy.
The global COPD market is both large and under penetrated, with long-term oxygen therapy remaining significantly underutilized in many regions. We see substantial opportunity to leverage our portfolio breadth, brand reputation, and local partnerships to reach more patients worldwide. As healthcare systems continue shifting care into the home, international markets represent a sustained multi-year growth driver for Inogen.
Moving on, I'm proud to report meaningful progress on our second strategic priority, advancing profitability. Through operational excellence and disciplined cost management, we fundamentally strengthen our financial foundation. 2025 represented a turning point for Inogen. We delivered positive adjusted EBITDA of $2.7 million for the full year. This is our first year of adjusted EBITDA profitability since 2021.
This significant milestone demonstrates the operational leverage in our business model and validates the efficiency initiatives we've implemented over the past two years. This improvement extends across our P&L. Net loss for the full year 2025 was $23 million. Our adjusted net loss narrowed to $8 million, a 61% reduction from $20 million in 2024.
Equally important is the strength of our balance sheet. We ended the year with $120.9 million in cash, cash equivalents, marketable securities, and restricted cash with zero debt outstanding. This financial flexibility is critical as it allows us to invest in the growth drivers I outlined earlier, develop our innovation pipeline, and execute our international expansion strategy.
In addition to investing back in the business, our strong balance sheet and cash flow enables us to pursue a share repurchase program. We announced today that our board of directors has authorized a $30 million share repurchase program, and we intend to execute those buybacks over the course of 2026 and 2027 or until the maximum authorized dollar amount has been utilized. The share repurchase program reflects our confidence in our strategy, our flexibility to deploy capital, and our commitments to enhance shareholder value.
The trajectory is clear. We've returned to adjusted EBITDA profitability, dramatically reduced our losses, and strengthened our cash position. As we drive improved revenue performance in 2026, we expect to see meaningful operating leverage flow through to the bottom line. We're building a sustainably profitable business.
Turning to our third strategic priority, expanding our innovation pipeline, where our team delivered transformative progress in 2025. For years, Inogen was synonymous with portable oxygen concentrators. While that remains our core strength, we've now established a multi-product portfolio spanning four distinct areas of respiratory care: oxygen therapy, sleep therapy, airway clearance, and digital health solutions.
This diversification significantly expands our addressable market, de-risks our business model, and positions us to better serve patients across the full respiratory continuum. First, we have now initiated a limited market release in the United States of SIMEOX, our airway clearance device for effective bronchial decongestion.
The methodical approach of a limited release allows us to build clinical evidence, establish reimbursement pathways, and refine our commercial strategy before a broader launch. We've already achieved an important milestone. Our US trial to support reimbursement has kicked off and is actively enrolling its first patients, marking a critical step towards securing coverage and competing meaningfully in this market. We expect to gather enough data to provide CMS with a compelling case in the near future. Simultaneously, we initiated a clinical study in China. We are nearing completion of the trial, which we expect to support our commercial launch anticipated in the second half of this year pending NMPA regulatory clearance.
Meanwhile, we are seeing strong commercial traction and enthusiastic customer feedback for SIMEOX in Europe, which reinforces our conviction in its clinical differentiation and potential to become a meaningful contributor to both our portfolio diversification and long-term growth. SEMIOX represents a clear and strategic expansion into an underserved area of respiratory care. Over time, we believe this will position us to offer a differentiated solution that enhances patient outcomes, deepens clinician engagement, and extends our leadership across the respiratory care spectrum.
As a reminder, we see an incremental $500 million total addressable market opportunity in the US airway clearance. Importantly, airway clearance devices carry attractive gross margins, making SEMIOX a key driver of our strategy to grow at or above market rates while simultaneously expanding profitability over time.
Shifting to our other innovations in oxygen therapy, we introduced Voxi 5, our newest stationary oxygen concentrator, expanding our addressable market by an incremental $300 million. This launch is strategically important for several reasons. First, it addresses the significant GAAP in our portfolio. HME providers typically furnish new patients with both stationary and portable units, and until the launch, we can only compete for half of that equation.
Voxi 5 allows us to capture the full scope of patient requirements and deepen partnerships with our existing distribution network. Early market reception has been positive. More importantly, Voxi 5 demonstrates our ability to extend our oxygen therapy leadership into adjacent product categories with high-quality, cost-effective solutions.
Our most significant portfolio expansion in early 2026 is our entry into sleep therapy with Aurora CPAP masks developed in partnership with UL. This marks a natural and meaningful extension beyond oxygen therapy into the large and growing sleep apnea market, which represents a $2.2 billion total addressable market growing at a high single-digit rate. We believe this expansion will be a key driver in sustaining a return to double-digit growth over time.
The strategic rationale is compelling. There is a substantial patient overlap of 20% to 30% between COPD and obstructive sleep apnea, which means we can leverage our existing brand recognition, commercial infrastructure, and trusted patient relationships to reach an adjacent high volume market.
Aurora allows us to access new revenue through distribution channels and clinical partnerships we already serve. The Aurora portfolio includes three mask options: the F1 full face, N1 nasal cushion, and P1 nasal pillows, all designated to meet diverse patient needs and facial structures and are FDA 510(k) cleared. Importantly, Aurora is supported by patient-used data showing high satisfaction rates, which give us confidence in both clinical acceptance of commercial viability. This is a scalable, synergistic growth opportunity that meaningfully broadens our addressable market and reinforces our position across the respiratory care continuum.
Finally, we launched the Inogen patient portal to enhance our digital health capabilities and improve the patient experience. The self-service platform empowers patients to manage insurance details, order accessories, and access on-demand support tools seamlessly. As healthcare continues its digital transformation, tools like this strengthen patient engagement, reduce service costs, and differentiate our offering.
Collectively, these launches represent a fundamental transformation in what Inogen is and what markets we can address. We've moved from a single product company dependent on one market to a diversified respiratory care platform with multiple growth factors. From a market opportunity perspective, this transformation is substantial. Our estimated TAM has expanded from approximately $400 million in POC concentrators alone to a market growing low single-digits to over $3 billion across our combined portfolio, with the broader opportunity growing high single-digits. This sixfold expansion in the estimated TAM coupled with accelerated growth rates has the potential to change our financial trajectory and long-term value creation.
Going forward, we are committed to launching at least one new product per year, and critically, we expect these new launches to be gross margin accretive as we increasingly focus on higher margin clinically differentiated solutions that address unmet needs across the respiratory care continuum. With that, I will pass the call over to Mike for an overview of our financial results. Mike.
Michael Bourque - Chief Financial Officer, Executive Vice President, Corporate Treasurer
Thank you, Kevin, and good afternoon, everyone.
Unless otherwise stated, our financial comparisons presented refer to the prior year comparable period. I will now walk through the results, starting with the income statement, cash flow, and then ending with guidance.
Please note that today we are updating our revenue reporting structure to provide investors with insights into more meaningful trends in our business. This change reflects the evolution from a single platform, single disease state company to a diversified respiratory care platform serving multiple disease states across COPD, sleep apnea, and broader respiratory conditions. I will detail our revenue performance in our new reporting structure which includes US sales, international sales, and US rentals. A reconciliation of our revenue results from the prior reporting structure to the new reporting structure is available in the supplemental financial tables on the investor relations website.
Total revenue for the fourth quarter of 2025 was $81.7 million an increase of 2% on a reported basis. Total revenue for the full year 2025 was $348.7 million an increase of 4% on a reported basis, primarily driven by higher growth in international POC sales of 18.4%, partially offset by lower US sales and US rentals. US sales for the fourth quarter were $36.1 million, down 5.1% from $38 million in the prior year.
From a product mix perspective, our US business remains predominantly POC revenue today, but we're seeing the early stages of diversification. Voxi posted strong sequential growth from Q3, demonstrating solid commercial traction despite being in the very early stage of launch. As we execute our 2026 commercial plan, we expect Voxi to emerge as a more meaningful growth driver for the US business.
On the POC side, we experienced a shift of large customer orders out of Q4 into the first half of 2026. Our customers cited capital constraints and year on budget limitations as the reason for the delay. We expect them to materialize as customer budgets are approved for the first half of 2026. Our international business for the fourth quarter was a bright spot with revenue of $32.5 million, up 14.8% from $28.3 million in the prior period. The strong performance was driven by higher demand and a successful expansion into new geographies, validating the growth potential Kevin outlined earlier.
POCs continue to gain traction while SIMEOX is building meaningful momentum internationally with strong commercial feedback reinforcing our confidence in its applicability in the US. We are excited to share that we generated over $6 million in global revenue from SIMEOX in 2025, reflecting strong early interest in the strength of our unique value proposition. Rental revenue was $13.1 million, down 4.5% from $13.8 million in the prior period, primarily driven by a higher mix of lower private payer reimbursement rates and fewer patients on service.
Now I want to discuss fourth quarter gross margins. Total gross margin was 43.1% in the fourth quarter of 2025, decreasing 220 basis points from the same period in the prior year, primarily driven by channel mix as a higher proportion of POC sales shifted to business customers. For the full year 2025, gross margin was 44.2%, a decline of 190 basis points from 2024. (technical difficulty) The remaining 1/3 reflected higher premiums.
Now turning to what I'm particularly pleased to discuss our profitability trajectory. Operating expenses in Q4 of $44.5 million. Adjusted operating expenses in Q4 decreased to $41.4 million from $43.7 million in the prior period, representing a 5.2% reduction. This improvement reflects our disciplined approach to cost management and ongoing efficiency efforts, but we continue to invest in R&D and new product launches to support long-term growth.
GAAP net loss in Q4 was $7.1 million an improvement of 27% from the prior year period. On an adjusted basis, net loss was $4 million compared to an adjusted net loss of $5.8 million in Q4 of 2024. Loss per diluted share was negative $0.26 in the fourth quarter. Adjusted loss per diluted share improved to a negative $0.15 per share versus negative $0.24 per share in the fourth quarter last year. For the full year 2025, GAAP net loss was $22.7 million an improvement of 36.6% compared to $35.9 million in the prior year period. Adjusted net loss was $8 million an improvement of 60.6% from the adjusted net loss of $20.4 million in the full year 2024. GAAP loss per diluted share was a negative $0.86 per diluted share for the full year 2025. Adjusted loss per diluted share was $0.30 per share versus $0.86 per share of the prior year.
Fourth quarter, adjusted EBITDA improved to negative $1.7 million from negative $3.6 million in Q4 of 2024. For the full year, these improvements were even more pronounced. We delivered positive adjusted EBITDA of $2.7 million for 2025. This is our first year of adjusted EBITDA profitability since 2021.
We fundamentally reshaped our cost structure while investing in our future. As of December 31, 2025, we had cash, cash equivalents, marketable securities, and restricted cash of $120.9 million with no debt outstanding, an increase of $3.4 million from year ended 2024. As Kevin mentioned, our balance sheet positions us well to continue investing in growth drivers for our business while also pursuing our share repurchase program of up to $30 million.
Looking ahead, I want to outline our expectations for 2026. As a reminder, Q2 and Q3 are typically our strongest quarters seasonally. We are initiating full year revenue guidance of approximately 6% year-over-year growth at the midpoint of the range of $366 million to $373 million. This guidance reflects our commitment to continuing to drive healthy mid-single-digit growth and includes the contribution of new product launches and a strong demand for our POCs, which we expect to drive stronger growth in the back half versus the first half of 2026.
The full year 2026. We expect to continue to drive positive adjusted EBITDA, building on the momentum we established in 2025. We're committed to improving profitability while strategically investing in innovation, commercial execution, and product launches that will accelerate revenue growth.
The first quarter of 2026, we're expecting reported revenue to be in line with the first quarter of 2025. This reflects overall POC unit growth offset by a change in channel mix and declining rental revenue. The expected decline in rental revenue is driven by a change in our overall reimbursement mix and fewer customers on service.
While we continue to expect demand for antigens POCs to increase, there is an important market dynamic that is changing how POCs are delivered. Historically, most new long-term oxygen therapy patients received oxygen tanks for the ambulatory needs. Today, we estimate that 59% of new patients start with a POC, which is provided by either HMEs or directly from manufacturers. As a result, we are expecting higher growth with our large business customers or B2B sales channel, creating pressure in our channel mix. Bottom line, we expect to continue to grow our POC business just in a slightly different way.
Summarized, we've returned to adjusted EBITDA profitability, dramatically reduced our losses, strengthened our balance sheet, and improved our operational efficiency, all while investing in new product launches and strategic initiatives that will drive future growth.
Looking ahead, our focus is clear to continue transforming Inogen from a single product POC company into a comprehensive home respiratory care platform. We'll do this by growing our existing POC and SOC products, scaling Voxi, launching CPAP masks, and building momentum for SIMEOX, all while driving continued leverage and improving our bottom line. With a diversified product portfolio and expanding addressable market increasing from approximately $400 million to approximately $3.4 billion and multiple growth vectors across geographies and disease states, we're building a fundamentally different and more valuable company. We're excited about what lies ahead, and with that, I will pass the call back to Kevin.
Kevin Smith - President, Chief Executive Officer, Director
Thank you, Mike.
Building off the 2026 guidance Mike described, we are also pleased to share our long-term financial goals today. Fitting with our strategic priorities for the business, we are working to improve revenue growth, profitability, and our innovation engine. We are excited to share that as we execute those priorities, we see a path to achieving high single-digit revenue growth and reaching 10% or better adjusted EBITDA over the next three to five years. And as I mentioned earlier, launching at least one new product per year going forward. We look forward to updating you on the progress towards these goals over the course of this year and beyond.
Before we open it up for questions, let me step back and frame what we have accomplished over the last two years in this turnaround and what it means for Inogen going forward. When I look at the financial recovery, the numbers tell a clear story. We've achieved average revenue growth of 5% over the last two years, which is a meaningful turnaround from the 16% decline in 2023. We delivered seven of eight quarters of mid-single-digit revenue growth, which shows we've stabilized the business and built consistent momentum. Gross margin expanded to over 44% in 2025, up 411 basis points from 2023.
At the same time, we reduced total adjusted net loss to $8 million in 2025 versus $48.3 million in 2023, and we did that while continuing to invest in the new products that are going to drive our future. But the more important story is the strategic transformation in 2025 was the year we fundamentally transformed Inogen from a single product oxygen company into a diversified respiratory care platform with meaningful presence across oxygen therapy, sleep therapy, airway clearance, and digital health. We also delivered strong international growth that validates our global expansion strategy and returned to profitability for the first time in four years.
2026 is about translating the strong foundation into future growth. We have the strategy, products, market dynamics, and financial strength to execute, and I am confident in the path forward. With that operator, please open the call for questions.
Operator
(Operator Instructions) Anderson Schock, B Riley Securities Holdings Inc.
Anderson Schock - Equity Analyst
Hi, good afternoon. Thank you for taking the questions.
So first, you attributed the fourth quarter miss to multiple large customer orders shifting into the first half of this year. Can you help us understand the magnitude of these orders and of what shifted, how much has already been shipped in the first quarter versus what is expected in the second?
Michael Bourque - Chief Financial Officer, Executive Vice President, Corporate Treasurer
So, Anderson, this is Mike. I think we talked about at the pre-release that we figured it was maybe a couple 100 basis points of impact but we really haven't gotten to the specific dollar amounts to that. But what I would say is that what's an important thing is that we have received some of those orders, today, but we did talk about having these orders spread out over the first half of the year. So, some of those items will continue to sprinkle in as we go through the first half of the year as opposed to just in the first quarter.
Kevin Smith - President, Chief Executive Officer, Director
And maybe, Anderson, if I can just add a little bit here. Because I think there's some important dynamics here that we need to consider as well. So, POC demand is up nearly 20% in 2025, and we expect that to continue to be up in 2026. So the HMEs are now more likely to provide a POC to patients and, our research tells us that in 2019, they were a little bit under 40% for new starts for portable oxygen. Patients were getting a POC compared to tanks. Now we see that has shifted and it's about 60% of those patients are getting a POC on a new start basis. And this is an important dynamic because while this is a good shift for the B2B, it creates some headwinds in some other areas of the business. But when we talk about the growth going forward, we look at Q1, we look at beyond. This is, we continue to expect the B2B channel to grow. We expect to have mid-single-digit growth in Q1 for B2B and for the full year in B2B, and that's specific for the for the POC business.
So again, while that is a good shift, creates some headwinds in the DTC and the rental business, while we're committed to those, it is an important dynamic. So when we think about that shift that happened from Q4 into Q1, as Mike said, it's not just going to be in Q1, it's going to be sprinkled throughout the year. But even where we're guiding to get to the Q1 revenue that we have here, that doesn't give the proper illustration for where we see the B2B continuing to grow.
Anderson Schock - Equity Analyst
Okay, got it. Thank you. And then on the move to the new US sales reporting category, so you're blending the growing domestic B2B channel, the declining or historically declining DTC channel. So with the myth driven by B2B orders pushed into the first half and through this year, how did the DTC channel perform in the fourth quarter and how should we think about the blended growth here going forward?
Michael Bourque - Chief Financial Officer, Executive Vice President, Corporate Treasurer
First, I can answer your direct question first. We're moving to that new format but one of the things that we talked about with the direct to consumer channel was that we're looking at the tough concept that during the course of the year related to the fact that we re-based that business about a year ago. What we have seen and what we expected to see was those negative growth numbers continue to improve each quarter and that continued into Q4. So, if you go back, Q1, we were off 27%. That dropped to 21% in Q2 to 18% in Q3, and then you'll see the numbers, and supplemental schedules, direct to consumer was down 15% in Q4, so continue to improve.
In terms of the new reporting structure, the change is really to simplify the overall reporting structure and really allow us to focus more on product growth drivers as opposed to how we've done in the past, as sales channels and that's really I think going to be helpful given our new focus on innovation. The change really reflects, Kevin talked about this and then we mentioned in our prepared remarks, from a single platform single disease state company to a more diversified respiratory care platform and in crossing multiple disease states, COPD, sleep apnea, and broader respiratory conditions, again, as Kevin mentioned.
So, our goal really is at the end of the day is to provide investors with more meaningful trends in our business. And the last thing I would say, just keeping in mind that not all products are sold in all channels. So I think the old reporting format kind of really is more relevant to the POCs as opposed to some of these other things we're getting into.
Anderson Schock - Equity Analyst
Okay, got it. That's helpful. And then just finally, how should we think about the ramp of revenue from the Aurora mask launch through 2026 and what's the go to market strategy here? And can you walk us through what gives you confidence that you can carve out share in this market?
Michael Bourque - Chief Financial Officer, Executive Vice President, Corporate Treasurer
So, we view this as a transformational strategic decision, really kind of an important step moving again from, this is somewhat of a repetitive thing, but moving us more from a single product company to broader home respiratory care company, getting into these other areas that we just talked about. As we look at 2026, we're not really necessarily guiding to what the expectation is on a quarter-over-quarter basis but the expectation is that we'll probably see not too much in the first quarter regarding the masks but as we progress, keeping in mind that Q2 and Q3 are normally our strongest quarters, we expect to start getting traction, but we expect it to be more back end loaded with the masks.
Kevin Smith - President, Chief Executive Officer, Director
And we are primarily going through our B2B channel with the masks. We've been building out the sales organization, adding some additional headcounts into that area. But when we brought the masks to market prior to that, we conducted a patient satisfaction study and we had exceptional results with that. We're very happy with how that played out. The early indications that we have from the customers that we've been engaging has been very positive. It's a process that you go through because this is a patient preference market. We feel that we have an extremely competitive mask in that market. The early engagements that we've had, the sampling, the feedback from the respiratory therapists that work with the HMEs, as well as the initial patient feedback is, has given us the confidence that we're going to be able to grow that business.
Remember, it is a $2.2 billion dollar market here in the United States for the masks. That's a repeatable business. Once a patient gets satisfied, they like a mask, they get a good night's sleep, it's hard to get them off of that mask. And the patient study that we did demonstrates that we're able to bring something that's competitive that will be preferred by the not just the RTs, but ultimately of course by the patients. And remember, every 1% growth in that market is about a $20 million opportunity for antigen. So we're going to leverage the relationships that we have with the POCs, the antigen brand name, the reputation for quality, and we're bringing the clinical evidence to support that launch.
Anderson Schock - Equity Analyst
Okay, got it. Thank you for taking our questions and congrats on all the progress.
Operator
Thanks, Anderson.
Joseph Stringer, Needham & Company
Joseph Stringer - Analyst
Kevin, Mike, thank you for taking our questions today. This is Joseph on for Mike. Maybe one on SIMEOX. I believe you both said $6 million in 2025 from SIMEOX. I guess the assumption is that's all international but I'm curious, was this consistent orders from existing customers kind of flat throughout the year, more or less, or was there a large step up in the second half of the year, more customers have become familiar with the platform and maybe just on top of that, what are your expectations there, I guess internationally, for growth, for SIMEOX in 2026.
Kevin Smith - President, Chief Executive Officer, Director
Yes, thank you for that question. The SIMEOX was a steady growth although we did have in the first quarter into the second quarter of the year, we did have a one-time buy that was Eastern European tender. That was for multiple years on the disposable sets that happened in the first quarter. We anticipate still being able to grow that business, of course, on top of that, but we're really happy with the results that we've seen, happy with the feedback that we have and what the data is telling us. We have the clinical trial that is running internationally that will be able to support our European reimbursement submissions. We have a clinical trial that is running that I've mentioned in China which will be able to support the commercial launch of that and we've started now, of course, the first trial that we need to have for reimbursement support here in the United States. We're actively enrolling in that. But that revenue was of course primarily outside the United States and so we continue to expect to see that grow.
And remember that $6 million is cash pay. This is out of pocket payments in a market that are primarily tax-based healthcare systems, and that's not usual for patients to to want to pay that out of their pocket for a therapy. That gives us confidence. It gives us some of the information that we need to be able to take that to market both in the United States as well as other markets across the globe, and it gives us confidence that we'll be able to succeed.
Joseph Stringer - Analyst
Okay, great, that's helpful. The cash pay speaks to the therapeutic benefit, you can imagine.
Maybe just on the EBITDA guidance, the expectations for 2026, I think you said you're guiding towards improvement. I assume that's obviously on a year-over-year basis and not phasing quarterly but I'm just curious on a quarterly basis, is image in targeting or expecting to be EBITDA positive in every quarter in 2026? I know, I think it's the fourth quarter usually has higher expenses versus the prior three, so I'm just wondering how you guys are thinking about that.
Michael Bourque - Chief Financial Officer, Executive Vice President, Corporate Treasurer
Yeah, Joseph, this is Mike. Yeah, I guess the first way I would say about that is keeping in mind that a lot of this starts being driven by the strength of that quarter, right? So, again, we look at Q2s and Q3s, historically, those are our strongest quarters, and we've been adjusted EBITDA to positive in the last two years, both of those quarters have been cash positive.
So when we hit Q1 and Q4, it's a little bit more challenging. I think I'm going to answer your question on an overall basis and maybe can help you with the quarterly cadence piece of it. So the way we're looking at, adjusted even in the future is, and we're not guiding to a number today, not even on a full year basis but we remain committed to improving that profitability metrics, generating it, and we do expect to generate positive adjusted EBITDA again this coming year. But, I will say is we need to keep in mind we do have some additional investments planned in 2026 to further our diversification strategy. We are planning on investing more in R&D in 2026 as opposed to previous years. So, depending on the timing of that, that will impact the adjusted EBITDA. Again, depending on the cadence of those, the strength of those quarters. So that I think that's something to keep in mind.
But again, I think if you're looking at the cadence of how we look at each quarter, I think you can look at maybe the historical years and they should be relatively consistent to what you've seen in previous years. They shouldn't be too far off. They'll be a little different, but they shouldn't be too far off.
Joseph Stringer - Analyst
Okay, thanks. That's very helpful and congratulations on the improvement and profitability this year, as well as the transformation in the gym that's ongoing.
Michael Bourque - Chief Financial Officer, Executive Vice President, Corporate Treasurer
Thanks, guys.
Operator
Thank you. We've reached the end of our question-and-answer session. I'd like to turn the floor back over to Kevin for any further closing comments.
Kevin Smith - President, Chief Executive Officer, Director
Okay, thank you very much and I appreciate the questions that we had here today. But before we end the call, I'd like to highlight that we did announce a share repurchase authorization for $30 million today. This program reflects my confidence in our strategy, our ability to generate cash in the future, and that we believe our stock is undervalued.
And I'm going to close by recognizing the Inogen team. 2025 was a demanding year that required us to drive operational improvements, launch multiple new products, expand internationally, and execute on our three strategic initiatives. The progress we've made is a direct result of their dedication and execution, and I'm grateful for their commitments to our mission and to the patients we serve. To our shareholders, thank you for your continued support as we execute this turnaround. We've built a stronger, more diversified, and sustainably profitable Inogen, and we look forward to demonstrating that progress throughout the year ahead.
Operator
Thank you.
That does conclude today's teleconference and webcast. You may disconnect your lines at this time and have a wonderful day. We thank you for your participation today.