Option Care Health Inc (OPCH) 2024 Q4 法說會逐字稿

Good day and thank you for standing by. Welcome to the Option Care Health fourth quarter 2024 earnings conference call. At this time, all participants are in a listen-only mode. After the speaker's presentation, there will be a question and answer session. (Operator Instructions)

Please be advised that today's conference is being recorded. I would now like to hand the conference over to your first speaker today, Nicole Maggio, Senior Vice President and Corporate Controller. Please go ahead.

Good morning. Please note that today's discussion will include certain forward-looking statements that reflect our current assumptions and expectations, including those related to our future financial performance and industry and market conditions. These forward-looking statements are subject to risks and uncertainties that could cause actual results to differ materially from our expectations. We encourage you to review the information in today's press release, as well as in our Form 10K and latest Form 10Q filed with the SEC regarding the specific risks and uncertainties.

Do not undertake any duty to update any forward-looking statements except as required by law. During this call, we will use non-gap financial measures when talking about the company's performance and financial conditions. You can find additional information on these non-gap measures in this morning's press release posted on the investor relations portion of our website. With that, I will turn the call over to John Rademacher, President and Chief Executive Officer.

Thanks, Nicole, and good morning everyone. We appreciate you joining us for this morning's call to review the progress the Option Care Health team made in 2024 and discuss our outlook for 2025. As you'll recall, in early January, we pre-announced our preliminary expected results for the fourth quarter and full year 2024. And as we reported this morning, our results were in line with the preliminary results as communicated.

We will go into greater detail as well as provide more insights into the expectations for the current year later in the call. As we shared previously, the fourth quarter was a very productive for the Option Care Health team and we made significant progress on our efforts to create a sustainable growth enterprise. And the fourth quarter marks the 20th consecutive quarter that we have delivered on the financial commitments we've communicated to the investor community.

We delivered high teen revenue growth, which was comprised of a balanced performance across the portfolio, with considerable contribution from our rare and orphan and limited distribution portfolio of therapies. As the quarter progressed, we saw a notable improvement with respect to some of the supply chain challenges we outlined on our third quarter call.

Specifically, the IV solution supply dynamics improved significantly throughout the quarter and is no longer a constraint with respect to onboarding new patients. We also invested in enhancing local responsiveness by opening two new state of the art compounding pharmacies in New York City and Tampa.

As I've stated on multiple occasions, we intend to continue to invest in our national integrated network of compounding pharmacies and infusion suites to help ensure high quality and responsive care for our patients and referral sources. I would also like to highlight the incredible execution by our team to work around and overcome the devastating impacts of the various natural disasters and weather events that happened at the end of the third quarter and carried into the fore.

The strength and resilience of our team and the platform was certainly tested, but through strong teamwork and collaboration with key partners across the value chain, we were able to continue to support our patients and deliver our key operational and financial results. I believe that our organic growth, along with the strength of our free cash flow, uniquely positions us to continue to deploy capital towards value creation for our shareholders.

In demonstration of this, I'm pleased to share that we closed on our acquisition of Intramed Plus in late January. As discussed earlier, Intramed Plus is a highly regarded infusion provider in the southeastern United States with multiple locations and a long-standing and exceptional reputation of providing high-quality care.

We are thrilled to welcome the Intramed Plus team to the Option Care Health family, and our integration efforts are well underway. This transaction is yet another example of how we believe we can bring our national scale leading technology and an integrated pharmacy platform to local areas through acquisitions to further expand access to care.

Our revised guidance as communicated this morning now includes the impact of the acquisition. One of the attractive aspects of the Intramed Plus acquisition is the expansion of our advanced practitioner model, which we initiated with our Wasatch Infusion acquisition a few years ago. As of today, we have established a footprint of more than 175 infusion locations, including 15 sites with advanced practitioner capabilities.

We believe the advanced practitioner clinical model is highly complementary to our network of compounding pharmacies, and we intend to continue enhancing and expanding our infusion site network to incorporate broader clinical capabilities. And the expansion of our advanced practitioner model remains a priority in 2025 and beyond as we look to provide the most comprehensive set of infusion care solutions to our key stakeholders.

Also in the fourth quarter, we exhausted our prior share repurchase authorization, having repurchased $90 million of shares in the quarter. In early January, our board of directors approved a new $500 million authorization going forward. As we have discussed previously, given the strength of our balance sheet and cash flow generation, we have various options to deploy capital available to us.

We believe deploying capital through both a creative acquisitions and share repurchase will create value over the longer term for our shareholders. Before I turn the call over to Mike, I wanted to share a few thoughts on our expectations for 2025.

Despite a meaningful gross profit reset due to less favorable economics for Stelara, which we estimate at $60 to $70 million for the year, we expect to deliver overall earnings growth from 2024 through our balanced portfolio and focus on delivering value to referral sources to drive top-lying growth. While the Stelara impact is unfortunate, managing through therapy portfolio dynamics is nothing new for this team.

And we believe the clinical program we established to treat complex stelara patients is a testament to the clinical capabilities and power of this national platform. In 2025, we intend to continue to invest in our pharmacy and infusion suite network technology and clinical capabilities to help strengthen our position as a national provider with local responsiveness further solidifying our confidence in the growth profile of this enterprise.

I would like to remind you of our addition of adjusted earnings per share as a part of the metrics we provide for guidance, as we believe this provides investors with a better reflection of our business performance and capital deployment activities.

With that, I'll hand the call over to Mike to provide additional details.

Thanks, John and good morning everyone. Revenue growth was quite strong in the fourth quarter at 19.7% growth over Q4 2023. As John mentioned, we saw balanced growth across the portfolio with considerable contribution from rare and orphan and limited distribution therapies.

The team navigated the IV solution supply chain disruption quite effectively, which directly impacted our ability to take on new patients within our acute therapy portfolio earlier in the quarter. Despite the challenges and with meaningful supply chain improvements over the course of the quarter, we were able to deliver high single digit acute therapy growth which as all of carries a higher gross margin profile than chronic therapy.

With respect to gross profit, we drove 8.6% growth over the prior year fourth quarter on balanced top line growth. Gross profit dollar growth is a key metric we manage and I believe the team did a phenomenal job in driving gross profit growth in the quarter.

SGNA as a percentage of revenue continues to drop and represented 12.2% of revenue in the quarter. For the year, spending growth was under 4% despite continued investments in suit capacity and other growth initiatives. Q4 adjusted EBITDA $121.6 million grew almost 9%.

And recalled that the fourth quarter of 2023 included approximately $8 million in non-recurring procurement benefits. And adjusted earnings per share in the quarter of $0.44 represented 15.8% growth over the prior year. Adjusted earnings per share for the full year of $1.08 represented more than 10% growth year-over-year, and again that's inclusive of approximately $33 million to $35 million in 2023 procurement benefit that didn't continue into 2024.

And we are quite pleased with the cash flow generation performance in 2024. For the full year, we generated $323 million in cash flow and invested more than $35 million back into our infrastructure and repurchased $250 million of stock. Finally, for the full year 2025, we now expect to deliver revenue of $5.3 billion to $5.5 billion. Adjusted EBITDA of $450 million to $470 million. And adjusted earnings per share of $1.59 to $1.69 a share.

Net interest expense is projected to be $55 million to $60 million and the effective tax rate is expected to be 25% to 27%. Finally, we expect to generate at least $320 million in cash flow from operation. Note that our revisions to the preliminary guidance communicated in January primarily represent inclusion of the impact of the Intramed plus acquisition, which closed in late January. So as you can see, despite a $60million to $70 million dollar headwind from Stelara Dynamics, we expect to deliver another year of growth.

And with that we'll open the call for questions, operator.

Thank you. (Operator Instructions)

Matt Larew with William Blair.

Good morning. I wanted to ask on the acute side, obviously you referenced the supply chain, alleviation of those challenges. Obviously there were some larger competitors that were departing, so you're at high single digits in the quarter just in terms of what you're seeing visa competition as well as supply chain and other dynamics, what's your expectation for how that trends throughout this year?

Hey, Matt, it's John. Yeah, thanks for the question. As said in the prepared remarks, throughout the quarter, it continued to improve the supply chain dynamics and we worked across the the value chains to make certain that we were doing a few things. Number one is conserving the product that we did have and making certain that we were being very efficient in the way that we're utilizing it and finding additional supply lines in order to do that as faster continue to improve their their production. I would tell you as we exited the quarter, we were back to being in a really strong position.

We are not hindered today by being able to take on new patients, so we are back to, I'd say normal if you want to think of it that way. In the comments around the competitive environment. Certainly there were shifts in the competitive dynamics in the third and fourth quarter with, some folks exiting and and kind of resetting their portfolio of products. As we've said multiple times, there isn't a market in which we don't have, multiple competitors in that. There's over 800 home infusion providers that are part of the marketplace. We think. We're well positioned to capture market demands.

Our focus around reach and frequency and our commercial team is one in which we want to be that partner of choice, the ability for us to show consistent high quality care and be reliable as a resource to help with that transition of those patients out of the hospital setting to their homes, we think earns us goodwill and earns us credit.

And credibility with those referral sources. So our focus as we go through the year is going to be to continue to execute at that local level to make certain that we are a partner of choice and that our team is out there hustling with reach and frequency to work with those referral sources to bring those patients on. But I feel really good about the supply chain conditions, and I feel as if the the national platform with the local responsiveness is one that is resonating well within those marketplace.

Okay, and then, Mike, you've added, adjusted EPS as as a metric you're guiding to and historically you've, framed sort of the long term algorithm with revenue and adjusted EBITDA. Could you update us on your view of those metrics, but now with maybe a longer term view of adjusted EPS growth as well? That's kind of part one and then the second part would be out.

Between the last two calls we've sort of round tripped the Stelara saga and now we have an idea of the impact in '25 as we think about getting back to this long term algorithm, are there any other, sort of things you guys have your eye on in terms of one-offs over the course of '25 or '26 that could prevent a return to long term growth algorithm in '26?

Yeah, let me unpack that a little bit, Matt. First and foremost, really appreciate the question on adjusted EPS. Look we've consistently been steadfast in articulating that we view this as a high single digit top line low double digit EBITDA growth. Enterprise over the longer term, I think one of the things that we are now injecting is that look through to John's point around the confidence and the cash flow generation and the strength of the balance sheet look over the last two years we've deployed a half a billion dollars towards share repurchase while also actively pursuing.

M&A and I think you know as we articulate the value creation through share repurchase efforts to reduce the outstanding shares, I think that should result in adjusted EPS growing at a at a pace faster than adjusted to what extent that obviously is going to be predicated on the pace of capital deployment, but as we said a couple weeks ago, I think given where we're at 1.6 times levered at the end of the year.

I think the shareholders should expect that we would at least deploy our free cash flow generation that the common denominator would be share repurchase other than M&A activities that one could presume that that would represent a more creative opportunity for us than share repurchase, which I think will continue to be.

The measuring stick as it relates to the portfolio, as John said, look, this team is used to managing through dynamics in the portfolio. I think a misconception is that it is a static portfolio of therapies that we oversee and we knew that Stelara was going to eventually subside in terms of the margin contribution as we articulated a couple weeks ago 75% of our product profit comes from generics and biosimilars which are relatively stable.

And so there will always be, therapies that evolve to an oral or a sub and and that's something that doesn't catch us by surprise. But on the other side of the ledger, matt, we're excited through our business development efforts, looking at the number of rare and orphans.

Limited distribution and product evolutions that are that are emerging as well as John talked about with the advanced practitioner model that opens up the aperture so to speak on therapies that we could administer as well. So I think our conviction, as John said, is that the growth algorithm remains firmly intact.

Okay, thank you.

Thanks Matt.

Thank you. Brian Tanquilut with Jefferies.

Hey, good morning guys, and congrats on the quarter. Maybe Mike, as I think about, the guidance here, I appreciate all the detail. If I think about typical seasonality and all the moving pieces, any call outs that we need to consider, even qualitatively for Q1.

Not necessarily. Again, I think you've been following this. You're old enough to have been following this industry for a while, Brian. Look, there's always a little bit of early Q1 disruption where you typically see a Q4 to Q1 step down as benefits get reverified, plan designs and new contract terms are are entered.

Folks typically are a little slow to go to the dock as as deductibles and co-pay. Breached that, but look, as we as we pivoted more towards chronic therapies, we were around 75% of our revenue was chronic in the quarter. That's a more stable revenue base. So again, on the acute side a little bit of an typical year is yes, you would typically see some of that seasonal step down, but as John said, we saw considerable momentum coming out of the fourth quarter with the supply chain dynamics and competitive environment, so, I think there would be a modest amount of what you would have historically seen from a Q1 seasonality.

Got it. And then maybe as I think about the Stelara impact again, so I appreciate the gross profit dollar impact disclosure. I know you spent a decent bit of money on supporting those patients on the GNA side. How should we be thinking about what you're doing there as a way to adjust or adapt to the changes in the economics for that specific drug?

Yeah, look, I mean, as John said, I think first and foremost I think it's a testament to the ability for us to devise and develop, targeted clinical programs for highly complex patient cohorts. I think, look, as Stelara evolves as a therapy, it's still a therapy that, is attractive for us, maybe not as attractive as it was in the past, but we're going to continue to put the patient first and maintain.

The clinical support for those complex patients, how behind the scenes we reallocate and redeploy. Scarce spending resources to support the growth initiatives is something that has been a hallmark of this platform that we've done for for years. And so, look, we we're confident in the, low single digit growth profile of spending and behind the curtain, so to speak, there's a lot of redeployment and reallocation, but our commitment is that given the complexity of these patients, we will continue to support them, as we have in the past.

Awesome thanks Mike.

Thanks Brian.

Thank you. Lisa Gill with JP Morgan.

Great, thanks so much and good morning. Just have a couple of questions. So first, Mike, I have a number of questions. You talked about raising revenue by 100 million, EBITDA by 5 million and said primarily that's Intramed. How should I think about the margins at Intramed? I mean, that would have seem that there's roughly a 5% EBITDA margin on that business based on your comments, is there an opportunity to get that, towards the low double-digit overall, or I'm sorry, high single-digit EBITDA that you have on the business overall, or is there there's something that we should think about within that that line of business would would be my first question.

Yeah, I think at least as we think about the the intermed, as John said, we're really excited about, the expansion and the local presence that they have in South Carolina, which is an important market, and it was really unmatched. I think, look, this. This has been an algorithm that we've focused as we think about a creative M&A is looking at folks that might not have the same procurement leverage technology tools and capabilities that we have. And so I think, the algorithm that we think about this is naturally this was somewhere in the mid-teens from a multiple. Again it's not a perfect apple to apples comparison.

But the strength and conviction we have in in pursuing some of these smaller assets is bringing the leverage and the tools and capabilities that we have, and we'd be confident that this would be in, low double-digit multiple. Too long and as John mentioned, integration efforts are well underway. You think about the obvious things around some of the limited distribution therapies that we have that frankly, they did not. The leverage from a procurement perspective, as well as just a lot of the efficiencies and repcycle and other automation tools that we've developed over the last couple of years.

And then just we think about the comment that John made around, 800 home in fusion providers out in the marketplace and and as I think about your acquisition strategy, right? You're 1.6 times leverage right now, so obviously a lot of opportunities to make those tucking type of acquisitions. How should I think about, what you're targeting, what you think you could do in a given year?

Is there any parameters around, hey, we only want to do X number of transactions or I think you brought up both limited distribution, advanced practitioner, is it specific types of practices that that you're looking for and then just bringing that back to the numbers side you talked about what you pay for for intramed right amid team kind of multiple how would you say that the current environment is from from a pricing perspective when we think about capital deployment?

Yeah.

A lot to unpack. Look, from our perspective, I'll start and let John jump in. Look, it's a pretty simple lens, and first and foremost, we do not feel capital constraint. We are very active in the M&A area. We see pretty much every book coming to market and frankly it's not that big of a neighborhood. We know everybody living on the street. The challenge for us, Lisa, is as we think about going after core infusion providers. Again, we have 93 compounding pharmacies across the United States.

There isn't a major metropolitan area that we don't have a presence in. So, the first question John and I always ask is what's the strategic value that's sustainable for this opportunity? And the economics are relatively straightforward in terms of the equation that we bring around procurement leverage and other sources of synergies, but candidly, we have an expansive brick and mortar footprint, so, the challenge really becomes what's that strategic value. I think Intramed is a perfect example of where we've known and we've been envious of years of the presence that they've had in this local market, and they definitely are solidifying our competitive position, so. From a and we have a very solid integration playbook, so we are not constrained from, the number of transactions we can pursue a year. Moreover, it's really more around making sure that we can articulate the shareholders the sustainable strategic value of pursuing these assets.

Yeah, and the only other thing at least is, as we have talked about that ability for us to identify these organizations that have some unique capabilities and or density in a market. You take a look at Intermed Plus and the model that they were operating at both a blended. Advanced practitioner as well as the pharmacy infrastructure, there's just some unique capabilities that they had there that we were really excited about, through that process. But as Mike said, with the footprint that we have today, we'll be very disciplined in the way that we'll look to deploy that capital. There are organizations that kind of are in alignment with the.

The characteristics of what we found with Intramed Plus, and I think we'll continue to look for those opportunities and pursue them through the process, but it'll be in a very disciplined way and knowing that we have multiple ways in which we can deploy capital in our strategy. We don't feel as if we have to do M&A because we have a share buyback program that we think can deliver value to our shareholders or in turn if we find the right type of assets in the right locations with the right characteristics, we can deploy the capital in a creative way.

Great, thanks so much and congratulations on the good numbers.

Thanks, Lisa.

Thank you. Pito Chickering with Deutsche Bank.

Hey, good morning guys. Looking at your guidance, do you guys assume any impact of biosimilars for Solera, and I just signed contracts with the biosimil manufacturers because many of those are interchangeable at the pharmacy level, would those be accretive to your guidance assumptions?

Yeah, Peter, I mean the stelara impact that we called out is really just a change in dynamics from our procurement. Again, it's going to continue to evolve. I know a couple of biosimilars have already been approved and so the way I would characterize it is, we have handicapped behind the curtain how we think that, the biosimilars will evolve, but I wouldn't characterize it as any material impact in the current year from the biosimilar impact.

Okay, fair enough. And then on the on the acute side of the business, normally when you see large exits, you get scale up labor pretty quickly and that pressures your labor price you know costs in the near term. Can you sort of talk about your labor, what you guys saw in the fourth quarter, or did that pressure you guys into that fade in 2025 and how should we think about the acute growth in 25 sort of from these market ex exits?

Hey, Pito, look from a labor standpoint, we feel we're in a pretty strong position. I mean, clinical labor itself is always a bit of a challenge, as but as an organization with the stability that we can provide with the program. That we offer from employee benefit standpoint as well as the opportunity that we can present to team members as they're joining the applicant care team, our ability to recruit and retain talent, we we think we're pretty well positioned to do that.

With the shifts in the market dynamics, our team from our our search and staffing and and recruiting teams were active early. We learned through a couple other incidents in the marketplace where there were shifting dynamics, a, what works in that process, we have a pretty strong playbook, that we executed around. That and I think that ability to recruit the talent that was necessary to start to take on some additional volumes we feel like we're well positioned in in those markets and have the capacity to take on additional patience as the IV bag shortage started to diminish and the referral sources were looking for alternatives in those marketplaces.

Okay, last one here for me, with the exits of those payers who also do acute infusion does that change any of the negotiations as relates to the chronic side of the business with those payers because they need you more on the acute side and less capabilities there? Thanks.

We certainly use the balance of our portfolio as being part of the value proposition that we're offering to the payer community, the ability to take on their members across the various therapeutic categories that we have, we think is an advantage and something that, we're always looking to make certain that we are extracting fair value for the value that we're delivering.

So, that opportunity that We have to have dialogue around the total cost of care of how we can help support their members by providing that high quality care and appropriate cost in a setting in which their members want to receive it and help them with the high level of patient satisfaction that we're able to deliver, we think is a very compelling value proposition and one that we will look to make certain we're extracting fair value for.

Great thanks guys.

Yeah, thank you.

Thank you. Constantine Davis with citizens. Your line is now open.

Thanks. John, in your prepared remarks, you mentioned those two new, state of the art pharmacies that opened in the 4th quarter. Can you just maybe expand a little bit about how those might differ from a typical, pharmacy?

And is there an opportunity to further rationalize your legacy footprint or is this just really capacity that you need to, needed to add to support future growth?

Yeah, we continue to evolve our thinking and certainly advance from both the technology as well as the the build of those facilities based on, best practices and learnings over the years of of putting shovels in the ground and building pharmacies.

It most of of the advancements that we see is certainly in the clean room structure, whether we have different. Redundancies within the clean rooms as well as how we manage them to remain aseptic in in the structure but also the workflow of being able to be more efficient in bringing product in and product out of those clean room facilities.

So, the New York market certainly, huge opportunity to continue to grow there. This was as much of a move to upgrade and on the technology and the infrastructure aspect, but also to expand capacity in what is a really important market. So we think that helps support not only the Northeast and that tri-state area, but also gives us plenty of capacity to continue to capture demand in the New York metro area on that.

Florida is a really important market for us and again similar to what we did in New York, we took that state of the art concept of having redundancy within the infrastructure and really an opportunity to build out a bigger, more regional type of focused facility in Tampa that helps to support the entire peninsula. We still have other facilities within the state, but that opportunity that we have to have a stronger footprint and an ability to reach across the entire state, which is a really important geography for us, again, gave us that strength and stability within the the infrastructure, but also capacity to continue to grow.

So, we continue to always look at the network design. We like the resilience that we have. We have the ability to move product and doses around if necessary due to natural disasters due to work work flow management and load a balancing that at times is necessary within this business, but we're always going to look to make sure that we have an optimal network design and as we continue to say use this national scale but be able to be very responsible at a local level.

Thanks for the call on that and then I guess just lastly, I don't know if I missed this, but can you just give us an update on the in-suite utilization and to what extent is the calendar turned to 2025, any payer partners are increasingly looking at maybe mandating certain sites of service this year and beyond.

Yeah, that's been a great story, Constantine. I mean today we're well over a third of our nursing visits are occurring in one of our infusion suites and just to replay the tape, we really started our aggressive infusion suite expansion in the latter part of 2021 when we were about 16%-17% of our nurse events were occurring in one of our suites. So not only has the pie grown substantially over the last four years, but the concentration of nurse visits into our suites has has effectively doubled. That obviously provides us with a more efficient clinical labor deployment equation. We're seeing well over 20% nurse productivity uplift from those suites, and again I think it's important to underscore, and we always do that we don't force patients into a suite. We make them aware of conveniently located suites.

This admittedly is a little more applicable for those longer haul maintenance chronic patients that are on service, but interestingly, we actually see quite a few of our acute patients utilizing the suites as well and so.

The payers understand this is part of your first question about our multi-year sustained capital investment to provide the highest quality of care, and that's going to continue and I think this is an area we'll continue to invest in, especially as we can enhance that footprint of over 175 infusion locations. To incorporate our advanced practitioner capabilities which expands the scope and not just the scale of the suite capacity.

And then the last part of your question Kontine, we have seen an uptick in activity around site of care initiatives at the payer level, certainly a higher level of interest, and I think as we've been in dialogue, with the payer partners, that are looking at this. There's just opportunities as they're looking at the total cost of care to help to influence their members to making good choices around where to receive care within the healthcare ecosystem on that. So we are. Being an increased level of interest and and programs that are being put in place to help to influence those decisions at the at the patient level and utilize these lower cost high quality settings of care.

Great thanks for taking the questions guys.

Thank you. Joanna Gajuk with Bank of America.

Hi, good morning. Thanks so much. So, I guess, several, follow up. So first very quick on the guidance raised versus January, so the $100 million revenue and $5 million Evada versus Brier branch, that's only the deal, correct?

I'd say it's generally Joanna. There's been a little bit of a revision on the revenue side, but yeah, the profitability is really just the inclusion of Intramed for the most part.

Okay, great. Thanks for that. And then, I guess on this last, discussion, so maybe two topics first on the suite and then specifically these advanced prac practitioner model. So is this something you're including in your suite or this is a completely separate clinic because I was under the impression that this is separate clinics. And also, can you give us a sense of, how many of these you have and, utilization, because I guess when you give us the stats of, 1/30 of your nursing visits in suits like does that include this new model or is there something separate? And also can you expand, the on the on the benefit, it sounds like you can do, more different therapy. So what specifically I guess those clinics are used for, is it more oncology, Alzheimer's or anything, good picture in terms of the reasoning for having a different model.

Yeah, Joanna. So the Advanced practitioner model, we had acquired Wasatch Infusion a few years back that operated this model. So, we have been in a stage of certainly understanding and learning how to operate the advanced practitioner clinics through that process. The 175 locations. We have today, as we as we we call out, are, pri primarily infusion suites, not these infusion centers with advanced practitioner, but our ability to convert them over to an advanced practitioner model is the things that we're looking at and and and pursuing. Today we have about 15 sites that operate with this advanced practitioner model.

Our Expectations are that's going to grow over time. And what that allows us to do is really three things. One is having the advanced practitioner allows us to offer a more comprehensive clinical services for patients that have more complex needs and or therapies that are more complex in the administration and and oversight that's required.

The second thing it does is it does provide broader market access, especially in areas for Medicare fee for service in which there is not a broad access for home infusion for those patients. So it broadens that market access to be able to do that. The third thing it does is, from that clinical complexity standpoint, it does allow us to be a deeper partner with pharma, who may have some very unique products that they're bringing forward in that rare and orphan space and or that have again higher levels of complex needs given that the opportunity that the nurse practitioner and that advanced practitioner model had to manage the patient more holistically. So we believe this is an interesting adjacent.

For us to continue to invest in and grow, one of the, real positive things that we found with the Intramed Plus acquisition was they're operating both the pharmacy as well as the advanced practitioner model within South Carolina. There's really good learnings that we can take and utilize across our platform that we are gaining through that acquisition and as we look at the integration. And over time we expect that'll expand the number of products that we have available as well as broaden the market access given that we can offer solutions to patients in the home, through the pharmacy in one of our infusion suites or with this advanced practitioner model, we think we will have the most comprehensive solution that to be able to provide infusion services to to patients in the marketplace.

No, this is great, wonderful. And if I may justify the last one, also follow up on the discussion around your payers, but I guess specifically on the Medicare Advantage because I guess those guys are seeing, pressure on the cost trend and reimbursement and such. It sounds like, you're seeing actually the increased push, when it comes to the shift, right, and into the lower cost settings right, so is that what's happening like despite the fact that they are getting pressured. The contract negotiations are not getting, too tough or can you kind of talk about, where you are on, maybe the year you're negotiating now, when it comes to those negotiations with M&A plan.

Thank you.

Yeah, number one, I mean, we have over 800 pair relationships over 12,000, 13,000 contracts. So, not everyone operates the same way on that, Joanna, but I can tell you we have very constructive relationships with our payer partners. We continue to have conversations around the value that we can provide in helping them manage the total cost of care and really help to support reducing those medical loss ratios as they're trying to manage what is increasing utilization and and some pressure on on those being pushed higher. We continue to extol the fact that we are high-quality care at an appropriate cost in a setting in which their members want to receive it. And so that ability to partner with them to help be a solution in in improving that medical loss.

We have very constructive conversations and those are things that we're continuing to be in in deep conversations across a wide number of pairers in that you know our expectations as we move forward is we we've always believed that we play a very valuable role in helping them manage that when they're thinking about member satisfaction, when they're thinking about the quality of care, and when they're thinking about that total cost.

We're well aligned with and with them and we we've got mutual targets in which we're trying to drive to. So you know I'm always cautiously optimistic that we're on the right side of the and on the same side of the table with them as we're moving those forward and we're going to make certain that we extract fair value for the value that we're delivering, but we think that it's it's one in which they benefit as well.

Thank you so much.

Thanks Joanna.

Jamie Perse with Goldman Sachs.

Hi, this is Sarah Conrad on for Jamie. Your SGNA dollars and gross stepped up in 4Q. Can you discuss what investments you're making in the operational or commercial infrastructure? And then is this also a good rate run rate to consider for 2025?

Sure, Sarah, good morning. Yeah, look, I mean, I think as we talked, John talked a little bit about what some of the acute opportunities. I think we, invested commensurate with what we saw were some of the market opportunities. There are some indirect investments around patient registration, rep cycle some of the indirect support efforts to make sure that we could be responsive to some of the acute local market opportunities, additional commercial resources, etc. To make sure we're being responsive to.

To our referral sources, and I think that's that's a reasonable expectation. I think, the great news is indirect spending as a percent of revenue continues to drop. It was 12.2% of of of revenue in the fourth quarter and I think that's back to the earlier question around the growth algorithm that's central to our thesis, and I think that remains. We remain confident in that. So I think it's to your, to the latter part of your question. I think it's a reasonable, baseline as you think about 25.

Helpful, thank you. And then on the juvic, can you provide an update on the traction in that product and have unit Economics changed at all since launch or do you expect those to change going forward either from a gross profit or an operating profit perspective?

Yeah, look, I mean, we don't provide specific economics on specific therapies for obvious competitive reasons. I think Baijuvic is one of several LDD and rare and orphan therapies that, I think is a is a clinical success story as we partnered with Crystal Biotech to commercialize what was a new revolutionary treatment for DEB. And look, I think we've also been very candid that, as we launched these rare and orphans. And LDD. These are typically mid single digit gross margin profile therapies because the therapy cost is quite is considerable relative to other therapies in our portfolio.

But yet at the dollar gross profit line, it's it's still an attractive therapy for us to collaborate on with innovative biotech enterprises. No fundamental change in that again, I think as we've tried to articulate these, over time as we build patient cohorts. We can drive relatively modest improvements in in the margin, but that's over a course of year so the short answer is while we remain really excited about our collaboration with Crystal and others no fundamental way we're thinking about the economics on the therapies.

Thank you.

Thanks sir.

Thank you.

This concludes a question and answer session. I would now like to turn it back to management for closing remarks.

Thank you all for joining us this morning and participating on our call. As we outlined, 2024 was a very productive year and our team continued to execute at a very high level. We understand the important role that we play in delivering care to our patients and their families, and we look forward to serving even more patients and delivering value to our shareholders in 2025. Take care and have a great day. Thank you.

Thank you for participation in today's conference. This does conclude the program. You may now disconnect.