LifeStance Health Group Q3 2024 Earnings Call Transcript

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November 7, 2024

There are 9 speakers on the call.

Operator

Thank you for standing by. My name is Liz, and I'll be your conference operator today. At this time, I'd like to welcome everyone to the LifeStance Health Third Quarter 20 24 Earnings Call. All lines have been placed on mute to prevent any background noise. After the speakers' remarks, there will be a question and answer Thank you.

Operator

I would now like to turn the call over to Monica Perkotsky, Vice President of Investor Relations. Please go ahead.

Speaker 1

Thank you, operator. Good morning, everyone, and welcome to LifeStance Health's 3rd quarter 2024 earnings conference call. I'm Monica Perkoski, Vice President of Investor Relations. Joining me today are Ken Burdick, Chief Executive Officer and Dave Borden, Chief Financial Officer. We issued the earnings release and presentation before the market opened this morning.

Speaker 1

Both are available on the Investor Relations section of our website, investor. Lifestance.com. Before turning the call over to management for their prepared remarks, please direct your attention to the disclaimers about forward looking statements included in the earnings press release and SEC filings. Today's remarks contain forward looking statements, including statements about our financial performance outlook, business model and strategy. Those statements involve risks, uncertainties and other factors as noted in our periodic filings with the SEC that could cause actual results to differ materially.

Speaker 1

In addition, please note that we report results using non GAAP financial measures, which we believe provide additional information for investors to help facilitate comparison of current and past performance. A reconciliation to the most direct comparable GAAP measures is included in the earnings press release tables and presentation appendix. Unless otherwise noted, all results are compared to the comparable period in the prior year. At this time, I'll turn the call over to Ken Burdick, CEO of LifeStance. Ken?

Speaker 2

Thanks, Monica, and thank you all for joining us today. Last month on October 10, we observed World Mental Health Day. Within our own country, the growing disconnect between the demand and supply of mental health services remains one of the largest challenges facing Americans today. Through our mission of providing affordable and accessible mental health care, we at LifeStance relentlessly fight each day to mitigate this crisis. Turning to financial performance.

Speaker 2

We are very pleased with the team's continued execution in the Q3. For the 8th consecutive quarter, we have met or exceeded our expectations. Our revenue growth of 19% and our disciplined execution created solid operating leverage that yielded a 9.8% profit margin. Based on the strong performance in the 3rd quarter, we will again be raising our full year guidance for all financial metrics. I cannot emphasize enough the role that our clinicians have played and our achievements in the Q3 and throughout the year, as well as the value they deliver every day in providing high quality patient care.

Speaker 2

We now have a team of over 7,200 clinicians, an increase of 285 just this quarter. Turning to operational execution. We continue to make progress on our initiatives to streamline the business and improve performance. 1st, we continued the implementation of our new operating model. As a reminder, this initiative standardizes our organization with consistent staffing and processes across our 33 states and over 5 50 centers.

Speaker 2

We are confident that this higher level of administrative and clinical support will position the business to scale efficiently in 2025 beyond. Additionally, we continue to roll out our new digital patient check-in tool. We have implemented it successfully in 11 states and expect to complete the national rollout by mid year 2025. While still in the early stages, we are seeing higher patient satisfaction, operational efficiencies and significant improvements in patient collections where this tool has been deployed. Shifting to payer strategy, we are proud of the success that our payer engagement team has had in securing improved rates.

Speaker 2

While this represents progress, we still have a long way to go to achieve parity with physical health reimbursement. As previously communicated, the 3rd quarter is the first one where the decrease in rates from a single outlier payer with above market reimbursement is reflected in our results. However, much of the impact of this initial rate decrease was mitigated by negotiated rate increases with other payers. Many of the new rate increases went into effect sooner than we had expected, which drove the outperformance in total revenue per visit. Before concluding, I want to take a moment to comment on the recent hurricanes Helene and Milton.

Speaker 2

My thoughts go out to each and every one of the LifeStance patients, clinicians, team members and the communities we serve that have been impacted by these storms. Dozens of our centers were affected and all but 2 were back up and running within 1 week. The remaining two centers reopened by mid October. I am proud and appreciative of the way that our teams responded to these disasters. Yet another testament to the resilience of the team and dedication to putting our patients first.

Speaker 2

With that, I'll turn it over to Dave to provide additional commentary on our financial performance and outlook.

Speaker 3

Dave? Thanks, Ken. Like Ken, I'm pleased with the team's operational and financial performance in the Q3. We delivered strong top line results with revenue of $313,000,000 representing growth of 19% year over year. The outperformance was driven by higher total revenue per visit and increased visit volumes.

Speaker 3

Visit volumes of $2,000,000 increased 15% year over year, driven primarily by clinician growth. In the Q3, we added 285 net clinicians, which exceeded our expectations. This brings our total clinician base to 7,269, representing growth of 13% year over year. There is variability in the pace of clinician adds throughout the year. Similar to last year, we expect a lower number of net clinician adds in the Q4.

Speaker 3

With regard to clinician productivity, it came in slightly ahead of our expectations in the 3rd quarter. Total revenue per visit increased 3% year over year to $159 primarily driven by payer rate increases that came in earlier than our previous expectations and to a lesser extent one time favorability. Regarding profitability, the better than expected top line results flowed through the center margin. Center margin of $100,000,000 in the quarter increased 32% year over year, primarily due to higher total revenue per visit, higher visit volumes and operating leverage in center costs. Outperformance in the quarter relative to our expectations was primarily driven by higher total revenue per visit, higher visit volumes and lower than expected spending.

Speaker 3

Adjusted EBITDA of $31,000,000 in the quarter was very strong and exceeded our expectations increasing 110% year over year. This is the 4th consecutive quarter of doubling our adjusted EBITDA year over year. Adjusted EBITDA as a percentage of revenue grew over 4 points year over year to 9.8%. The outperformance in the quarter was primarily attributable to the improvement in center margin as well as lower than planned spending in G and A. Turning to liquidity.

Speaker 3

In the Q3, we generated solid free cash flow of $18,000,000 We exited the quarter with $103,000,000 in cash and net long term debt of $279,000,000 Year to date, we have generated approximately $30,000,000 of free cash. In the Q4, we are making an enhancement to our clinician value proposition by implementing a biweekly payroll cycle for our clinicians who were previously paid on a monthly basis. This will have a roughly $15,000,000 negative impact on cash in Q4 related to the change in pay periods. Even with the impact of this payroll change, we expect to be free cash flow positive in the Q4 and now expect to finish the full year with meaningful positive free cash flow due to stronger year over year operating results, disciplined capital deployment and progress towards resolving collection issues. DSO improved 2 days sequentially to 47 days in the quarter.

Speaker 3

We are continuing to work through the impact from the change healthcare collections disruption along with some delays from a couple of payers updating their systems to reflect higher negotiated rates. These are all timing issues that we are actively working through and we expect DSO to further improve in the Q4. We continue to see improvement in our leverage ratios with both our net and gross leverage ratios improving nearly 50 basis points sequentially to 1.7 and 2.7 times respectively. This represents a significant decline from 4.4 net and 5.3 gross leverage in Q3 of last year. In terms of our outlook for 2024, we are raising our full year revenue range by $17,000,000 at the midpoint to $1,228,000,000 to $1,248,000,000 We are also raising our full year center margin range by $17,000,000 at the midpoint to $382,000,000 to $398,000,000 and the full year adjusted EBITDA range by $15,000,000 at the midpoint to 105 dollars to $115,000,000 For the Q4, we expect revenue of $302,500,000 to $322,500,000 center margin of $89,000,000 to $105,000,000 and adjusted EBITDA of $18,000,000 to $28,000,000 Due to some of the one time rate favorability in the 3rd quarter, we expect modest quarter over quarter decline in total revenue per visit.

Speaker 3

As previously stated, based on the adjusted EBITDA outperformance so far this year, we continue to give ourselves flexibility through the remainder of the year to make additional investments to better position us to achieve our 2025 growth objectives. Additionally, we continue to expect stock based compensation to be at or below the bottom of our previously guided range of $80,000,000 to $95,000,000 This represents a significant reduction from $99,000,000 last year. We will open 6 de novos in 2024 with an additional 5 to 10 originally planned for this year shifting into early next year. As a result, we expect substantially higher de novo openings in 2025 and will provide specifics when we deliver guidance next quarter. Looking ahead to 2025, I'd like to provide an early view on headwinds and tailwinds for the business.

Speaker 3

In regards to headwinds, as a reminder, we stated we would experience downward pressure in total revenue per visit, not only in the back half of twenty twenty four, but also the 1st part of 2025 due to the single outlier payer negotiating their reimbursement to be more in line with our overall book of business. In the Q1, we expect the last rate drop related to that same payer negotiation. In addition, the current CMS rate proposal for 2025 is a reduction of almost 3%. We expect to be able to offset both of those decreases by improving reimbursement with other payers and now anticipate that our overall rate growth next year will be roughly flat. In regards to tailwinds, we continue to see strong growth of clinicians and patient demand, which will drive visit volumes.

Speaker 3

In addition, we expect continued operating leverage. As a result of these headwinds and tailwinds, we expect minimal margin improvement next year. We feel good about our ability to navigate and absorb challenges such as the rate dynamic, while also delivering on our commitments regarding mid teens revenue growth and exiting 2025 with double digit margins. With that, I'll turn it back to Ken for his closing remarks. Thanks, Dave.

Speaker 2

As we enter the final stretch of 2024, I'm looking forward to maintaining the momentum of the last eight quarters. Thanks to the tremendous dedication and commitment of the team, we have outperformed our expectations on nearly every metric this year, including revenue, adjusted EBITDA and free cash flow. In a year with significant disruption to collections and an unprecedented rate reduction by an outlier payer, I'm incredibly proud of the resilience demonstrated by our entire team. We acknowledge that 2025 will be a particularly challenging year due to the rate dynamics that Dave highlighted. 2024 is shaping up to be a year of very strong margin expansion.

Speaker 2

We are well ahead of schedule in delivering on our multiyear financial commitments. As this is our last earnings call in the current calendar year, I'd like to take a moment to express my appreciation to our 10,000 colleagues who delivered the results that Dave and I have the privilege of sharing with all of you today. We will now take questions. Operator?

Operator

Your first question comes from the line of Craig Hettenbach with Morgan Stanley. Please go ahead.

Speaker 4

Yes, thanks. Ken, just on the point of total revenue per visit, you managed to put up flat sequentially, still up 3% year over year despite that large payer headwind. So can you just give some context in terms of the payer engagement team, some of the success you're seeing there and what rate increases are looking like at other payers?

Speaker 2

Sure, Craig. I'm really, really proud of the payer engagement team. They've done a heck of a job this year. And as you might recall, this team didn't even exist until the early part of last year. So they are they've sort of gotten their sea legs and they are executing beautifully.

Speaker 2

We had some very meaningful increases from other payers who were quite a bit below the average reimbursement and that certainly helped to offset as Dave described. So I would describe the sort of the payer environment as positive, constructive, but it's not lost on us that payers right now are going through some unique challenges between the B-twenty eight risk scoring, coding changes, higher than expected utilization and Medicaid rate disconnect because of the acuity difference between the pre COVID and then the post redetermination demographic. So it's we take none of this for granted. We feel really good about the relationships that we are building, but we do recognize that it is a difficult time in the payer space.

Speaker 4

Understood. And then just a follow-up, you touched on before the supply demand imbalance for the industry. So clearly the demand is there. For LifeStance specifically, can you hit on just some of the efforts to continue to grow clinicians? And importantly, just the mix of clinicians working more full time like what that means

Speaker 2

for you? Yes. That's clearly our long term strategic intent. We would like to have the vast majority of our clinicians working full time. But given this supply demand imbalance, we're being really thoughtful and quite careful about how we do it.

Speaker 2

I've mentioned before that we put some incentives in place to make it more attractive to work full time. We have not seen this massive shift. We thought there might be, it hasn't worked out. We're seeing sort of modest movement. So I expect it's going to be sort of a multiyear effort.

Speaker 2

One of the things that we probably don't talk enough about, Greg, is the fact that we do an awful lot of hiring of people that have recently graduated. So we have become a significant training ground for those folks that graduate and are looking to obtain their license. And that serves in my mind 2 very positive things.

Speaker 5

Number

Speaker 2

1, we're adding to the number of practicing clinicians in the mental health space. Number 2, we can sort of teach them and if you will, orient them to the LifeStance way of doing things. And that makes it, we think, much, much easier for them to get ramped up and establishing a career at LifeStance.

Speaker 4

Got it. Thank you.

Operator

And your next question comes from the line of Ryan Daniels with William Blair. Please go ahead.

Speaker 6

Hey, everyone. Congrats on the quarter. This is Jack Sampton for Ryan. First, maybe on your capital allocation strategy going forward. Your cash balance seems to be in a pretty good spot and I know you're reiterating the free cash flow positive guidance for the year, but you also have some long term debt on the balance sheet.

Speaker 6

Are you planning on paying that down at all or will you look at opening more de novo clinics and maybe even M and A before that in 2025? Just wondering if you can kind of dig a bit deeper into what your priorities for capital are going forward? Thanks.

Speaker 3

Hey, good morning, Jack. This is Dave. I'll take that one. So as you mentioned, we feel good about our financial flexibility. Now I have over $100,000,000 of cash on the balance sheet.

Speaker 3

We have the $50,000,000 of revolver still. So we feel good about our flexibility. When I think about capital deployment and our priorities as we step into 2025, 2026, The primary use of that flexibility is number 1 is going to be funding internal growth. So as you mentioned, it was de novos, technology projects, things like that. Number 2 would then be acquisitions.

Speaker 3

We said we would be more acquisitive once we were positive free cash flow and that we would be funding acquisitions from our balance sheet. I think of those as the 2 primary uses of capital. I do not anticipate buying down debt, especially when you look at our leverage ratios being so healthy right now.

Speaker 6

Okay, perfect. Understood. Thank you. And then just another follow-up too. You mentioned offsetting the negative rate impacts with other payer rate increases.

Speaker 6

Just kind of wondering how those rate negotiations and talks have gone with the other payers that are helping you to offset the impact. I think you I mean, as you noted that the payers are kind of in a tough environment now. So just kind of curious how those conversations have gone, if there has been a good amount of pushback or just if you can give us any detail on that? Thanks.

Speaker 2

Yes, Jack, this is Ken again. I'll just reiterate that the team that we have built is doing a really good job so that we have ongoing conversations with payers as opposed to there's no communication until it's time for one party or the other to renegotiate rates. So I think that's really healthy. I wouldn't say it is easy, but I would say that the continued loud and sustained cry from employers to gain better access for their employees and dependents is probably our single greatest lever as we have these conversations. And the fact that there really is a shortage in many, many instances, somebody tries to access mental health care and gets exhausted before they ever get their first appointment because they go through a long list and too often they find out that these clinicians are not open to seeing new patients.

Speaker 2

So that is a very legit dynamic that frankly hasn't improved in spite of sort of more attention and more focus on the issue. So they are not simple. These are not sort of one conversation and done. These conversations can often take months. But as I've said, encouraged that they continue to be very constructive and productive in spite of the fact that payers are going through a challenging time right now for all the reasons I mentioned earlier.

Speaker 6

Perfect. Makes sense. Thanks. If I can just sneak one final really quick one in here. G and A had a nice sequential decrease.

Speaker 6

Is this kind of a level we should expect going forward and maybe into 2025? Just can you just touch on G and A expectations? Thanks.

Speaker 3

Yes. So I'll give certainly give more specifics on 2025 at the Q4 call when we're doing our guide for next year. But as you think about G and A and there's an implied step up in our Q4 guidance and that's related to 2 things that I would point to. The first being some increased hiring related to our operating model and just the overall business in general and then the second being some investments that will position us better for achieving our 2025 target. So you should see a step up from the Q2, Q3 level as we finish the year.

Speaker 6

Okay, perfect. Thank you again and congrats again.

Speaker 2

Thanks, Chad.

Operator

Your next question comes from the line of Jamie Purce with Goldman Sachs. Please go ahead.

Speaker 7

Hey, good morning. I was hoping you could focus on the clinician recruiting environment for a minute. Obviously, pretty healthy number here in the Q3. But maybe just an update on how many clinicians are in the markets you're actively recruiting, what the funnel and conversion rate looks like these days and maybe some thoughts on the competitive environment including remaining independent?

Speaker 2

Yes, Jamie, I'll take that. I would say it's fairly stable. We have not noticed a dramatic change either that has become much, much easier to recruit or more difficult. We obviously have a particular compensation model, so it attracts those that are more entrepreneurial. And if somebody wants sort of straight salary that this is not going to be the location for them.

Speaker 2

So that takes out some portion, but we continue to find significant interest on the part of both, as I mentioned earlier, people coming right out of school as well as people that are in a smaller independent practice because of some of the benefits that they will receive by coming to LifeStance. Not the least of which is that we have multiple license types so that they are in a position where they can learn and have a collegial environment with clinicians. We surround them with tools that most independent practices can't afford. And the professional development opportunity that we offer is something that we're going to continue to weigh into because we had a lot of feedback that that's highly desirable. So I would say we continue to be pleased with the pipeline and with our conversion.

Speaker 7

Okay, great. And then, you've had improvement really all year in center cost per visit. How should we think about that progressing going forward in light of some of the de novo comments next year that ramp in? And then just relatedly, I mean, how are you thinking about in person versus telehealth as you start to ramp up de novo openings next year? Thank you.

Speaker 2

Yes, I'll take that one, Jamie. There's a couple

Speaker 3

of pieces there. So first of all, address the de novo question. So as I mentioned in my prepared remarks, we're only going to open 6 this year, but we had 5 to 10 that just because of timing and how long it takes for the approval process and construction are pushing in the Q1 of next year and that there would be a meaningful step up next year. Now we're not at a point of guiding, but I mean, but I want to make the point that we're not going back to the old days of building like 100 de novos next year. You could think of it, it's going to be in the zone of something like what we started this year with, make roughly 20 de novos and then add the 5 to 10 that are delayed from this year pushing into next year.

Speaker 3

So that's it's going to be in that zone, but we'll tighten that up again on the Q4 call when we're giving guidance. In regards to the in person utilization, it's pretty stable 2nd quarter to 3rd quarter, just a little bit over 70%, virtual 30% in person. And for new patients, we're still seeing that in person level being about 10% higher than the average, so about 40% in person for the new patient visit.

Speaker 7

Okay, really helpful. Thank you.

Operator

And your next question comes from the line of Brian Tanquilut with Jefferies. Please go ahead.

Speaker 8

Roble in for Brian. Thanks for taking my question. Center margin in the quarter came in really strong. And Dave, in your remarks, you noted you expect them to be relatively stable into 25%. And I'm just curious if you all think the implied Q4 center margin is a good run rate for the business as we look over the next 6 to 12 months?

Speaker 3

Yes, it's Dave. I'll take that one. The way I think about 2025 is that overall we will see some minimal margin expansion versus 2024 because of the big outperformance we're seeing here in the back half of the year. And the components of that is I expect to see some modest compression on the or pressure downward on center margin margin next year because we'll have flat TRPV and we're still going to increase our clinician costs. So you're going to have some pressure on center margin.

Speaker 3

At the same time, we will see the benefits of operating leverage on the G and A line and then you could net those 2 together and you end up with some minimal increase in overall margins.

Speaker 8

Got it. Thank you. And then Congress has been waffling on whether to permanently extend telehealth Medicare reimbursements and just curious on your outlook on the extension of these reimbursements considering the government funding deadline next month?

Speaker 2

Yes. Obviously with the new administration, we don't know exactly how it will play out. But as we monitor this, the increased recognition of the importance of improving access to mental health and the effectiveness of telehealth visits, we believe that there is a high, high degree of likelihood that the telehealth visit reimbursement will be sustained and maintained on into the future. So, I would probably describe it as it's a discussion, but I don't sense that there's a lot of waffling sort of back and forth as to whether there should be a change, especially given the environment that we've described the disconnect between supply and demand.

Speaker 8

All right. Thank you.

Operator

And your final question comes from the line of Stephanie Davis with Barclays. Please go ahead.

Speaker 5

Hey, guys. Thanks for taking my questions. I saw you had some really solid improvements in your clinician count and we've been hearing some of your more virtual peers on the public and private side talk about excess clinician capacity. So I wanted to hear if that is more a function of platform improvements or kind of the backdrop in the market improving. And because of the excess capacity comments I've heard from the private peers, have you looked at their platform improvements and considered borrowing any learnings from them or have you borrowed any learnings from them in order to kind of improving your clinician retention?

Speaker 2

So Stephanie, maybe you can help. The excess capacity, can you explain what you're referencing?

Speaker 5

So we've heard of virtual only peers actually having more inbound applications from clinicians than they're able to hire or able to have utilization for, which is very opposite from what you've been seeing. And they've attributed it to platform improvement. So I've been curious if this is a function of the market or if this is a function of platform improvement. And if it is platform improvement, maybe what learnings you guys could borrow?

Speaker 2

Yes. Well, that's actually new information to us. We have I mean the number of people sort of graduating and going through a training, we have not seen a substantial uplift based on your question, we'll obviously look into that.

Speaker 5

But Sounds like when you talk in the call back,

Speaker 2

Pardon me?

Speaker 5

I said it sounds like we need to go and do a little more deeper diving in the call background. I'm not sure to go help you on that one.

Speaker 2

Yes. Again, we don't see a change. I'd love to see a change in the disconnect between the demand for outpatient mental health and the supply of clinicians able to provide that as your question suggests. Perhaps as you talk about some of these virtual only companies, they're just at a scale where whether it's their platform, whether it's their compensation model, etcetera, they are seeing more interest. I have so much respect and appreciation for the work that our clinical recruiting team does because as we talk about 285 net clinicians, obviously that means we've hired substantially more than that given that on a base of 7,000, we do have meaningful turnover that has stabilized, but it's nonetheless a factor.

Speaker 2

So, I hope that what I find when we research this further is that there is an increase in professionals that want to go into, the mental health practice. But, that is not something that we've seen and frankly, it's not something that I've heard in or read in the literature. So we will follow-up on that. That would be very good news.

Speaker 5

And a follow-up I guess related to that, when you think about some of the investments you're making in our improved clinician retention, have you considered any of the Gen AI tools that can kind of take the back end and documentation burdens off of folks? Or is that price point just not at an area where you've gone into investing?

Speaker 2

No, no. That is squarely within our fairway and very much on our radar screen. So we are piloting some of that right now. I would describe it as machine learning where we can provide tools that dramatically improve the experience of note taking and documentation after a visit. So again, it's one of the advantages of our size that we can access the very best in tools that are out there, but we're being thoughtful in the way we deploy it.

Speaker 2

We're being really disciplined in our change management initiatives. But we are not only improving the tools and look to continue to do that. But as we've talked about this new model, the model is improving the support that we provide our clinicians. So both in terms of increased administrative support and then increased clinical leadership support. So we think that while I would never say we're done, we actually still have more to do towards the back half of this year and certainly into next year.

Speaker 2

We're going to be creating an even more positive environment within which our clinicians perform their valuable services.

Speaker 5

Awesome to hear. Thank you, guys.

Speaker 2

All right. If that was the last question, I just have a couple of closing remarks. Again, I appreciate everybody's interest in LifeStance. I don't think I talk enough about the incredible work that our clinicians do. So I'll simply share that the very best part of my work week is when I read through the patient testimonials.

Speaker 2

We get literally several 100 every week and it is a bright spot my day. The impact that we're having on lives is extraordinary. And then finally, what I'd say is, we're finishing 24 strong. I'm incredibly appreciative of the work that's done. Sometimes I have to remind myself that this company is only 7 years old.

Speaker 2

We've gone through a hyper growth phase and more recently we've been in what I'll call the 3 S's, stabilize, standardize and strengthen. But what the future holds is incredibly exciting. The industry tailwinds are palpable and I don't see any change. And so the best is yet to come. Once again, I want to thank 10,000 of my teammates who have gone through this 2 year period where we are fortifying the foundation and strengthening the platform so that we can grow profitably and look forward to the years to come.

Speaker 2

So thank you, operator, and this could conclude the call.

Operator

Thank you. Ladies and gentlemen, that concludes today's call. Thank you all for joining. You may now disconnect.

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Earnings Conference Call
LifeStance Health Group Q3 2024
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