Viemed Healthcare Inc (VMD) 2017 Q4 法說會逐字稿

Good day, and welcome to the Viemed 2017 Earnings Release Conference Call. Today's conference is being recorded.

At this time, I'd like to turn the conference over to Casey Hoyt, Chief Executive Officer. Please go ahead.

Thank you. Good morning. My name is Casey Hoyt, and I'm the Chief Executive Officer of Viemed Healthcare, Inc. Joining me on the call today will be Todd Zehnder, Chief Operating Officer.

Thank you for joining us on our call. This call is an extra special day for us, as it marks the first opportunity for us to report to our shareholders as Viemed Healthcare, Inc. For those to you who are new to our story, Viemed is freshly spun out from the PHM company, as of December 2017. I'd also like to thank our management team and employees, who worked tirelessly on making our spin-out a reality.

At Viemed, we specialize in keeping patients comfortable in the home who are primarily struggling with respiratory illnesses. Our primary service offering puts respiratory therapists in the homes of patients across 25 states. We are the largest independent provider of noninvasive ventilation in the U.S. Our care for our patients typically comes at a time when they are at the end stages of their life cycle. This is when their care has reached a critical point in time when they are most prone to visit the hospital. We prevent these unnecessary and costly hospital readmissions from happening by giving our patients service and technology that they can depend on inside the home. With roughly 10,000 baby boomers turning 65 and qualifying for Medicare every day for the next 19 years, we are fulfilling a need in our country for more hospital beds, clinicians and less expensive health care. We are very pleased with our growth during 2017, as we saw active patients grow by 43%. We have set new active patient performance goals for our staff, which have focused our team on maintaining these growth trends for 2018. During the final quarter of 2017, we were able to achieve positive organic growth through our clinical liaison program. This was a new strategy that relied less on geographical expansion and more on additional support and training for our people. We took our top markets and decided to provide further clinical and sales support in an effort to free up our best reps to spread their wings and prospect in the new neighboring areas.

This strategy proved to be successful in the last quarter, as we saw those top areas grow by 75% on an annualized basis. We will look to bring our clinical liaison program to more of our reps located inside of our existing coverage areas.

With that being said, we do not rest when looking for new geographical footprints to expand into. Nevada became our most recent target as their COPD mortality rate ranks as one of the top 10 in the country, as well as their readmission rates being at 28%, which is well over the national average of 20%.

I'm pleased to announce that we have completed our expansion into the state of Nevada. We expect our coverage area to continue expanding as we are licensed in 12 new states. We have also begun to execute on our goal of bringing in 4 new sales reps per quarter with 4 reps already being activated in the first quarter.

Our network development department has also had some big wins as of late. We have signed contracts with 3 different private payers to provide services in Arkansas, Arizona and New Mexico. We've estimated that over 250 patients were denied last year by not being in network with these payers. Our network development team continues to evolve with each passing day, and I'm confident that they will continue to land these types of standard contracts throughout 2018.

We also have very powerful data being analyzed by a third-party KPMG study. Preliminary results of the data are showing that patients are 3x more likely to die in the first 90 days after being diagnosed with chronic respiratory failure, if they go without NIV therapy. The numbers will also tell a powerful story to Medicare and other payers on how we're saving the payer a substantial amount of money when looking at part A, the hospitals, and part B, us the supplier, these expenditures collectively. This study is an additional tool to use in the toolbox of our network development department and is further validation of the good that we are doing, both clinically and financially. We have continued with our initiatives to enhance technology in order to drive efficiencies in our back office. Our first-in-class sales force, coupled with our efficient back office has us positioned to accomplish great things. We are always mindful of our G&A and bottom line, as we understand that revenue and margin growth are not the only important line items. With that said, I'd like to turn it over to Todd, to provide a financial overview.

All right, thank you, Casey. In reviewing the financial results today, all figures are in U.S. dollars and the full results are available on SEDAR. We generated revenue of $47 million during 2017, as compared to 2016 revenues of $32 million, which equates to a 47% increase. Additionally, our gross margin percentages increased to 74% during the current year as compared to 60% last year.

These margins have certain adjustments made to our cost of goods sold that we and our board thought would be more useful. The largest 2 components of those adjustments are depreciation of our ventilators and most of our respiratory therapy costs. All of these are only re-classes, but a better way to report in the future. Adjusted EBITDA, which excludes depreciation and stock-based compensation, totaled $12 million for the year, which is approximately a 26% margin. We have redeployed a majority of this EBITDA during the current year as our property additions totaled approximately $11 million driven by new vent purchases to support our growing patient base. We managed our expansion from an SG&A perspective, as our SG&A increased approximately 35% during a period where revenues grew 47%. We expect to continue to be able to manage our cost structure during our ongoing growth trend. Our balance sheet remains solid with approximately $5.1 million in cash at quarter end, approximately $9.8 million of clean AR, and an overall working capital balance of approximately $4 million. Our AR balance was higher at year-end than prior quarters as the company is undergoing a routine audit by Medicare. These events sometimes freeze a portion of AR and the company fully expects to collect substantially all of the receivables. Additionally, the amount of AR being held will stop during January, so the increase in AR has stopped as we complete the audit.

We have managed our recent growth with utilizing capital leases where available, as well as our vendors, who have been partnering with our growth. Our long-term debt, which is primarily made up of these leases is very manageable, and being serviced with operating cash flow. Moving on to the first quarter, we have provided revenue guidance in the $14 million to $14.3 million range, and feel that our gross margin and adjusted EBITDA percentages should stay consistent with last year.

In general, we are happy with ongoing revenue growth as expected again this quarter and are mindful of pushing that to the bottom line. From a capital perspective, we continue to finance major equipment purchases with leases with our major vendors, and we'll be able to fund our future growth using these same financial instruments. With that said, we recently announced that we entered into a line of credit with Whitney Bank, whereby, we currently have a $5 million borrowing base. This is a fully undrawn line of credit but it is set up as a mechanism to fund any growth capital needs that may come in the future. Lastly, we've hit the ground running as a new stand-alone public entity, as we've began to be much more active in our communication with investors, analysts, bankers and other members of The Street. Our intention is to always keep our eye on the growth and profitability of the company, but also, dedicate the time and resources to keep investors abreast of the current state of events. At this time, I'm going to turn it back over to Casey, to wrap things up.

Thank you, Todd. As you can see, we have a historical pattern of growth and success here at Viemed. I can say with complete conviction that there is no better health care management team in the country that compares to Viemed. We are loyal, passionate and competitive about everything that we do for our patients and one another. Now, with our corporate split behind us, we will look to tell our story to as many institutional investors as possible. For an overview of our investor deck and to hear Todd and I open up the floor for all investor questions, visit our website at www.viemed.com, and click on IR presentations under the Investor Relations page. Looking forward, we expect strategic acquisitions, new payer contracts and favorable market conditions to play the biggest role in expediting our organic growth. I am pleased with how we have positioned our company to deliver patient-centered, value-based care in the home. We remain confident in our strength of organically growing this business, however, we are not resting and always searching for opportunities that bring incremental growth to our company. Lastly, I'd like to thank the health care professionals and employees that work for our company and their continued commitment to add value to our organization. This concludes our prepared remarks. We'll now open up the Q&A session. Thank you.

(Operator Instructions) And we'll go first to Doug Cooper with Beacon Securities.

Just, I want to focus in on, I guess, the 5% penetration of the actual noninvasive vent equipment. It's my understanding that the -- I guess this market really opened up in 2009, when the first product was launched. And I guess my question is, with so many people in late-stage COPD, the choices are what, do nothing or be on noninvasive vents? I mean, so what's going to continue to drive the doctors to prescribe and why isn't everybody on these kind of vents?

Yes. I mean, really the product didn't start getting introduced in the home until around 2012, even though it was around by 2009, Doug. But that being said, what's going to drive the market is really the growing number of patients and the more folks that get diagnosed with COPD. When you look at the 5% market penetration numbers, the most recent data comes from Medicare's postings on NIV usage at the end of 2016, which was only 40,000 beneficiaries on service at that point in time. I mean, you can go ahead and kick that number and ballpark it up to 50,000 for 2017. But still, you're going to be less than 5% market penetration. So we're just scratching the surface on who we can bring it to. The alternative for what these patients are up against is really going to the hospital. They have these shortness of breath and panic attacks and high anxiety scenarios and without this therapy to lean on in the home, they're going into the hospital. There is no other form of therapy that they can choose to relieve themselves.

I'll add one thing, Doug. It takes more results like we've shown, and it's why we are investing time and resources into the KPMG study, which is an independent study that shows we improve mortality rates, and we save money. And so, it's like anything, it was new and now that we have some data to support that NIV is better than going to the hospital, and it's better -- it's a much better alternative to a BiPAP. I think the more we show these results to payers and Medicare and so forth, it will only increase utilization at that point because it's a win for everybody across the spectrum.

And just to clear up, a BiPAP is not something that should be used to treat this patient, but some pulmonologists were leaning on that type of technology before the vent was available. So I mean, that is another machine that if it's set absolutely perfect, could be helpful but there's no data that proves it should be used on chronic respiratory failure patients.

And I'm assuming that you're not doing this in a vacuum. Like Philips or ResMed and these kind of guys, I think, are doing their own studies to show the same sort of outcomes, right?

Yes. I think various entities out there are doing their individual studies.

Can you -- how many states are you in now?

With Nevada that makes 25. But we're licensed in additional states, I mean, you heard Casey say it on the call, we are licensed in additional states. We take the initiative to get licensed ahead of time, and then once we find the right area, the right sales rep, we're not waiting on procedural items to get us going.

Okay. So you have revenue or feet on the ground in 25 states and licensed in additional ones. Is that right?

That's right. That's correct.

Okay. And you mentioned your 3 growth strategies, I think -- Casey, I think I got them, strategic acquisitions, new payer contracts and geographic expansion. Is that -- did I get that right?

That's correct.

Okay. Strategic acquisitions, what kind of things are you looking for?

We're looking at complementary acquisitions. Good management teams that are running pediatric vent companies. Pediatric vents are something that Viemed is evolving into and is set up to do with our respiratory therapist network. And we stand to gain a lot from those guys, if we can acquire one and get them to the help us with protocols. They, on the flip side, are not really the best at doing noninvasive ventilations. So they stand to gain from us teaching them those bag of tricks. But it also is a patient that is more challenging. It's a very emotional business because you're dealing with parents. But because it's so tough, insurance carriers are actually looking for other providers to take on the peds. So we want to be that company that they look to. We'll get into the network with a whole lot more insurance companies that way. And it's also a greater length of stay. Our average length of stay with our patients is 17 months and these kids can live for 10 to 20 years with their diseases. So it's a win-win across-the-board. That's our strategic acquisition strategy right there for growth. The critical liaison program and the geographical expansion is more of what we've, historically, already done and been able to accomplish with our organic growth strategy. The clinical liaison program is a little bit different whereas, we're throwing a heavier hand of support at some of our more successful reps. But we've already proven that, that works here in the back half of 2017. So we're going to expand on that program, and then continue to look for pockets similar to Nevada, where they have higher COPD numbers. They struggle with readmission rates and there's pockets in there where they actually need our service. So that will certainly be a part of our growth pattern. And then the last one is developing relationships with payers. We've had some -- lots of wonderful conversations in 2017 with our top 5 payers, talking about how to build out a shared savings program together. We're very close with these guys, we've yet to land one of these. Everything that we've been able to achieve has been from onesie, twosie types of sales. But if we were to get one of these guys on board, I mean, we could start off with a pilot program of a couple hundred patients. And then sit down at the table 6 months to a year later, talk about the savings that we were able to generate, which we feel confident in as a result of our KPMG study results. And then, build out a program where we get reimbursed by the savings and we take it deeper and wider to all of their patients' lives. So those are going to be the 3 main focuses for our growth model here in 2018.

Okay. Great. And 2 final quick ones. What was the active patient count as of December 31? Do you guys disclose that?

Well, we have vent patients and they are around 4,500. We're going to start disclosing our active -- I'm sorry, there was 4,400 active vent patients at the end of 2017. We're going to begin putting a little bit more disclosure about how we call active patients. And really that just, sort of, normalizes CPAP patients, oxygen patients, home sleep patients to vents. Knowing that vents makes up the majority of our revenue, that 43% growth in vent patients was the most material to our increase in our -- the most material to the active patient number. But we haven't fully disclosed where the theoretical active patient number was. It will probably be roughly 5,000 to 5,200 something like that. But we'll come out with more details later.

Okay. And finally, EBITDA margin for 2017 ended up around 26%. Do you expect that can grow with operating leverage as you continue to grow the top line?

I think so. One of the things that we've been really fortunate to do is, as we've built this business over 5 years now, we've been able to take some of the cash flow and redeploy it into our property additions. We've made a focused effort to go ahead and buy a lot of equipment, which -- that comes with a much more financial burden. It improves your margin, but that's why you'll see us redeploy -- we redeployed most of our cash flow back into the business this year to support the 43% patient growth and also to get rid of some of these operating leases. So I think you're going to see us be able to do that some more. We still have roughly 10% of our vent fleet that is out on operating leases, and we -- it's not the #1 initiative, but it is an initiative of the company to continue to clean that up some. And then just another -- if we continue to grow like we have in the past, like I mentioned earlier, we -- our SG&A was up 35% this year in a period when revenue was up 47% and a period where COGS were down. So that inherently says there is the ability to continue to push up on it, but I just want people to be mindful that one of the things we're doing is really reinvesting into the company and into our patients through the purchase of equipment.

Presumably some of those people who are coming on getting counted in, I guess, the overhead of the company still weren't fully contributing to revenue at the end of the day?

That's correct. That's correct.

We'll move next to Nick Corcoran with Acumen Capital.

I just have a few follow-up questions. Can you just comment on the acquisition pipeline for the pediatric vent? And whether you'd look at any acquisitions for geographic expansion as well?

Yes. I mean, we're -- we have 2 companies right now that we're looking at for pediatric vents. That's what's in the hopper. We don't have an LOI signed. We're in very preliminary discussions with these guys. As far as acquisitions to geographically expand, I mean, you got to keep in mind, Nick, that we have a 17-month length of stay at Viemed. And we're pretty good at what we do. We like to think that we are best in the country clinically, at treating these patients the right way in the home, which brings our active patients -- our length of stay up to 17 months. Mom and Pop competitor that's out and about, they may be lucky to have a 12-month length of stay if they're taking the right patients. So at the end of the day, what are you really buying if you go out and you acquire another vent company? You're just buying a year's worth of revenue, tops. So I get less excited about going out and acquiring another Mom and Pop company. I get more fired up about going in next to them and competing with our program and gaining market share the old-fashioned way, which is just providing a better service and a higher quality level of care in the home.

And then, are there any markets where you might have to acquire to get a license in that state to operate?

Yes. That is a strategy -- I mean, in particular, California and Florida are 2 of those states and there's a lot of retirees in Florida. We get asked that question a good bit. We would have to go in there and acquire somebody, and that is a strategy for us to enter into those markets that could be something that we'd consider. But frankly, there's just so much low-hanging fruit with less than 5% market penetration and there's these pockets all over our coverage area and even in states that don't have us. It's just we're swifter and we get a faster growth rate for less by going in there organically and gaining the market share. So that's one of the reasons that we've kind of just been on the back burner.

Great. And then with the EBITDA margin you had 26% in 2017, can you give any indication of what the upsize would be with operational leverage?

I'm sorry, come back with the second part of the question?

Yes. What the EBITDA margin could be in 2018, just with, I guess, larger scale and as you add more patients?

Yes. We purposely have not guided to a specific margin because we're going to let that come to us. I guess, just generally, like I said to Doug, I think we have the ability to continue to push up the margin, especially with our continued growth. It's hard for me to say -- there are quarters where we're going be up in the 29%. There's quarters where we've been a little bit lower. We just -- we think that staying somewhere around here or maybe a couple of points higher is doable. But we don't have any formal guidance out there. So I really -- I hate to say what we expect it to be.

Okay. And then, one last question for me. CapEx for the year was pretty close to your adjusted EBITDA. Do you expect the CapEx to start to slow down with the growth of EBITDA?

Okay. So this is a -- it's, sort of, one of the beautiful things about our model. We've been deploying so much money into CapEx because we've been funding this growth capital, and then a little bit, like I mentioned earlier, just to move more of our assets into our own owned fleet. We can confidently say that our CapEx will really only be a function of our growth. So to the extent that we're not growing, our CapEx will be pretty minimal. Just because our patients have a 17-month length of stay, and generally, when patients expire, we still own the equipment. And so we pick that up, and we can refurbish it. We have our own in-house certified technicians that can repair machines and preventive maintenance is done on them. So generally, if you think about our company with flat revenue, then it's 0 to very minimal CapEx. To the extent we're growing, and we have grown in the first quarter. We guided that we're going to grow and we expect to grow quarter-over-quarter, then we will have CapEx associated with that. It's just hard for us to guide that until we lay down a growth rate.

We'll move to Mordechai Yavneh now with Focus Capital Management.

First off, you mentioned that December 31, you ended with approximately 4,400 active vent patients. If you could remind me what the comparable number was for September 30?

For September 30?

Yes.

Roughly 4,000. We grew about 10% in the fourth quarter.

Next question. In your press release, you referenced seasonality, presumably to explain the lower-than-expected 5% sequential growth. In past comments I believe you've said that your business typically doesn't see much seasonality. For example, the first quarter of 2017 saw more than 9% sequential topline growth. Now you're guiding to 3% to 5% sequential topline growth, which is significantly slower growth than you've had for a number of quarters now. Can you explain what is driving this slower growth?

Yes. We got hit with the flu epidemic in the country pretty hardcore. We had record numbers in uploads, which meant our incoming referrals were -- have broken record month-after-month in that quarter. But we also had record numbers of pickups, and it was attributed to -- we had a lot of patients who just expired. A lot of our therapists were complaining about the flu, and it's just taking patients out left and right. It was an epidemic across the country that really hit us. So we think it's a seasonality thing, and we hope to shake it here as the seasons change to springtime.

And while we've never cited seasonality per se, the cold season is the hardest on respiratory patients, and then you add in the flu. The flu is -- the flu's biggest killer is respiratory patients. And so depending on where you live, I'm sure you've seen the epidemic that's going throughout the country. So we are very proud of the growth rate that we're posting in light of how hard of a death killer this has been for the first quarter.

You mean, by pickups you mean to say patients unfortunately going from the flu?

Okay, that's correct.

Okay. Perfect. Next question. Medicare and Medicaid contractors have had noninvasive ventilators in their sights for a while now. Noninvasive ventilators have recently been specifically singled out as an auditable issue. As you know, guidelines for medical need and [that's to say, recommendation,] to be eligible for reimbursement are vague. In an audit not very long ago, Medicare contractors rejected more than 90% of claims examined for non-invasive ventilators. I believe there is one audit where they rejected all of them. As the third largest provider of noninvasive ventilators to the Medicare population, it seems this volume has significant audit risk. How do you view your risk of audit? And if you can share some data on how well you have weathered past audits that would also be helpful.

Yes. Audits are a part of our business. They're a part of any DME business. We have -- we get CERT audits, which are computer-generated audits that come on a regular basis. We get RAC audits, which are basically clinical audits that come through a nursing -- a nurse looking at your charts. There has been a lot of scrutiny with the current rules that are out for vents. Basically, we just need a diagnosis code and we can bill and get paid by Medicare. So that's one of the reasons that Viemed has been very active in trying to get more formulary rules written to this game. We've helped author the BREATH Act and have been very active with rounding up Senators, Dr. Bill Cassidy and Grassley, up in West Virginia, we've got bipartisan support for the BREATH Act. But what it does is it stands to write clear defined rules to the game. Our medical director has been up to D.C. and has had -- visited with the last administration, and this administration as well. And we have been working with them on how to write the correct guidelines for this business. And the good news for Viemed is that whenever these regulatory rules come into play, which they will, we're going to be positioned to have been doing business the right way. We've got 40% of our orders that get rejected on -- in our intake department because they don't have documentation that Medicare is going to audit for. They don't do it today. But they will do it tomorrow. So we're very active with that. Furthermore, I mean, Todd and I have been up. We've met with our lobbying group and met with Dr. [G. Gerham] the second-in-command to Seema Verna and have had conversations with him about the part A and part B expenditures. What Medicare did to us back in January of 2016, is they cut us by 35%. Well, the only gain that they had is they watched utilization go up. And from 2012 to 2016, in vents, they saw that it went up. Well, of course it went up. It wasn't around before that time. So as it went up they just cut it without looking at the money that they were saving on the hospital side. All the hospital preventions that we were incurring at that time. So we were able to, with the help of our KPMG study, kind of showed Dr. [Gerham] some of these preliminary results and savings. And we -- the way we view it is, audits are part of the game, but you have to stay active on -- at the very top level, with the big picture conversations and that's what we do. We've got a government relations department that's dedicated to this mission and has helped push the BREATH Act through or is trying to help get it through. It's not through yet. And our medical director stays very active and in communication with their medical director. So that's what it takes. That's why we feel we're confident that we've got runway here to grow this business and to bring it to more folks. I mean, at the end of the day, these are life supporting devices that we are putting on these patients. You pick them up and people expire. So Medicare has got to be very careful about what they do.

I'm sympathetic to your point of view that you're actually saving Medicare money on the hospital side. And I wish you much success in your regulatory and congressional lobbying but in the meantime, with the guidelines now being so vague and RAC really being incentivized to say that you don't have sufficient documentation to show that a ventilator is specifically, reasonably necessary. Of course, as we know, that part of contract is getting -- they're making money for rejecting you, really. What is covering Viemed from seeing a lot of rejects in pre or post audit from these private contractors? In past audits, have you not seen the 90% rejections that have been mentioned as coming from these audits?

No.

No. We have not. And any time we see preliminary results that are even a fraction of that, we show the documentation and we show why this patient is needed -- or needed this therapy. And ultimately, our denials as a result of these types of audits are extremely minimal. So we...

Would you care to put a number on that?

No. No, we won't put specific numbers on that. But until formulary rules are written, there will always be back and forth. And we're confident in the procedures -- just like Casey said, we're confident in the procedures that we have. And ultimately, we're going to be helpful in, one, getting final rules put in place, and saving patients' lives and saving all the system money.

Okay. Great, I wish you the best in that. 2 more questions. I see that account receivables are up a significant percent from last year, but allowance for doubtful accounts is actually down a little. Are you sure that Viemed has its hands wrapped around the bad debt issue, or do we have to be afraid to see future write downs? Because we seem to me to be underestimating doubtful accounts with the rise in accounts receivables.

No. I mean, we're good with the allowance that we have. As we -- the topic that you just talked about, we did have a Medicare audit going on, or we still do. Some of that money was frozen. It is no longer being frozen. So we have a chunk that is frozen with Medicare, right now, that we have allowed under our normal allowance procedures. But we fully intend to collect all, if not substantially all, due to the rules that we have in place. So that's the reason it's up. We have no concern about the allowance that we have in place and we are not concerned about future bad debt. We have a very strong process. Our collections efforts have gotten much tighter over the last year. And so we're good with where we are.

You mentioned a few times that 2012 was an inflection point or really a launching of your noninvasive ventilator business. What precisely happened in 2012? I know noninvasive ventilators existed before then. What exactly happened in 2012 that launched your business?

The manufacturer really just got the word out to the distributors. We're the distributor of the product, and it was really the manufacturer that, kind of, educated a select few of us out there that were ready to bring new technology and a new sales pitch to market for them. So yes, they drove it in 2012.

Is this a specific model vent that you're referring to? Or all the manufacturers?

Yes. I mean, at the time there was a handful of them. You have 3 main manufacturers, Breas, ResMed and Philips, that have the, I guess, the most dominant noninvasive vents on the market right now. And all 3 of those were available. The Astral might have come a little bit later, but it wasn't far behind -- which is a ResMed.

One final question. You mentioned many times now, your success with patients is better than the competition. You have lower readmission rates. You have 17 months of viable -- compared to others. When you open a new territory with a new respiratory therapist, what exactly -- how much training do you give? How long does it take to train? How much do you invest to make a new territory and a new employee in do things your way and differently than, I guess, others do it to get a better result?

Yes. So the therapists that we hire, typically, come out of the hospital. They come out of school. They've been working in the ICU of these hospitals. They've seen a lot of clinical scenarios. They have the clinical expertise already when we find them. And then we bring them in and it takes us about 2 or 3 months to get them fully trained on how to walk and talk the Viemed way and learn our protocols. But these patients, it's pretty -- it's a walk in the park for them compared to what they have seen in the hospital and been used to. So it's fairly easy to get them clinically up to speed. The biggest challenge that we have is really teaching them about our processes and how to communicate the value proposition to case managers and pulmonologists. But that takes about 2 to 3 months.

So you're saying, basically your success compared to other providers is that you hire better -- higher-level employees, ones with more experience?

Yes. The majority of our competitors are full-line durable medical equipment companies, where they drop off a gamut of products. Walkers, wheelchairs, commode beds and ventilators. So often times they can get caught up in a delivery of equipment type of model, where we are very specific to what we do. It's very respiratory driven. And we put a higher class certified clinician in the home to hold their hand and spend a little bit more time with them and make sure that they're comfortable and compliant with their equipment.

At this time I'll turn the call back to management for closing comments.

We want to thank everybody for listening in today. As always, if you have follow-up questions, you can reach out to Bristol Capital, or Casey and I over here at Viemed. And we look forward to future dialogue and seeing people out on the road as we continue to get out and tell our story.

Thank you.

This does conclude today's conference. We thank you for your participation.