Oncology Institute Q1 2024 Earnings Report

Oncology Institute EPS Results

• Actual EPS: -$0.22
• Consensus EPS: -$0.12
• Beat/Miss: Missed by -$0.10
• One Year Ago EPS: -$0.10

Oncology Institute Revenue Results

• Actual Revenue: $94.67 million
• Expected Revenue: $95.17 million
• Beat/Miss: Missed by -$500.00 thousand
• YoY Revenue Growth: N/A

Oncology Institute Announcement Details

• Quarter: Q1 2024
• Date: 5/14/2024
• Time: After Market Closes
• Conference Call Date: Tuesday, May 14, 2024
• Conference Call Time: 5:00PM ET

Oncology Institute (NASDAQ:TOI), an oncology company, provides various medical oncology services in the United States. The company operates through three segments: Dispensary, Patient Services, and Clinical Trials & Other. It offers physician services, in-house infusion and dispensary, clinical trial, radiation, outpatient blood product transfusion, and patient support services, as well as educational seminars, support groups, and counseling services. The company also provides managing clinical trials, palliative care programs, stem cell transplants services, and other care delivery models associated with non-community-based academic and tertiary care settings; and conducts clinical trials for a range of pharmaceutical and medical device companies. It serves adult and senior cancer patients. The company has a strategic collaboration with Healthly Forge to offer cancer care services to patients in Southern California. The Oncology Institute, Inc. was founded in 2007 and is headquartered in Cerritos, California.

Oncology Institute Q1 2024 Earnings Call Transcript

Key Takeaways

• Revenue growth: Q1 2024 revenue rose 24% year-over-year, led by a 64% jump in oral drug sales.
• Capitation contracts: TOI signed a record 7 new value-based contracts across 3 states, forecasting ~$16 million in annual capitation revenue from these deals.
• Margin compression: Industry-wide DIR fee shifts and IV reimbursement drops drove a 130 bps decline in top-10 drug margins, resulting in larger than expected Q1 operating losses despite a 70 bps improvement in April.
• Cash position and burn: TOI ended Q1 with $65.8 million in cash and equivalents, incurring a $17 million cash burn primarily from AR timing and margin pressures, which management expects to reverse in Q2.
• Operational expansion: The company added 7 clinicians, opened 2 clinics in Florida, and will enter the Oregon market in Q4 while onboarding a new CDO to accelerate value-based growth.

Presentation

[Operator]

Good afternoon, and welcome to The Oncology Institute's first quarter 2024 earnings conference call. Today's call is being recorded, and we have allocated one hour for prepared remarks and Q&A. At this time, I would like to turn the conference over to Mihir Shah, Chief Financial Officer at TOI. Thank you. You may begin.

[Mihir Shah, CFO at The Oncology Institute]

The press release announcing The Oncology Institute's results for the first quarter of 2024 are available at the investor section of the company's website, theoncologyinstitute.com. A replay of this call will also be available at the company's website after the conclusion of this call. Before we get started, I would like to remind you of the company's safe harbor language included within the company's press release for the first quarter 2024. Management may make forward-looking statements, including guidance and underlying assumptions. Forward-looking statements are based on expectations that involve risks and uncertainties that could cause actual results to differ materially. For further discussions of risks related to our business, see our filings with the SEC. This call will also discuss non-GAAP financial measures such as Adjusted EBITDA.

[Mihir Shah, CFO at The Oncology Institute]

Reconciliation of these non-GAAP measures to the most comparable GAAP measures are included in the earnings release furnished to the SEC and available on our website. Joining me on the call today is our CEO, Dan Virnich. Following our prepared remarks, we will open the call for your questions. With that, I will turn the call over to Dan.

[Daniel Virnich, CEO at The Oncology Institute]

Thank you, Mihir. Good afternoon, everyone, and thank you for joining our first quarter call. In Q1 2024, our revenue grew 24% compared to Q1 2023, driven by an astounding 64% increase in oral drug revenue in the same period. The first quarter of 2024 saw TOI hit some significant milestones related to growth, with seven new capitation and value-based contracts signed across three states, our highest number ever in a quarter. Full-year capitation revenue related to our seven contracts signed in Q1 is estimated to be in the range of $16 million and includes expansion of our risk business in both medical and radiation oncology. We are expecting termination of one legacy capitation contract in California in Q3, which we believe will be offset by better-than-expected new capitation contract starts and continued growth in our oral drug business.

[Daniel Virnich, CEO at The Oncology Institute]

As a result, we are not changing full-year guidance at this time. As noted, Q1 also saw TOI hitting a record amount of prescription fills and revenue through our medically integrated dispensaries and pharmacy, with over 4,500 fills, representing over $39 million in revenue in Q1. Oral drug gross profit in the segment remains on track to expectations at $31 million for the full year due to outperformance of top line. Our newly acquired pharmacy in California continues to exceed expectations, and our latest projection shows incremental growth of over $45 million from this location from full year 2023.

[Daniel Virnich, CEO at The Oncology Institute]

Despite top-line outperformance, the first quarter came with challenges, particularly related to drug margin compression on both Part B and Part D drugs, with the transition in Direct and Indirect Remuneration, or DIR fees, to point of sale, and intermittent disruption to collections due to the Change Healthcare cyberattack, which was deemed to be not material. In addition to the industry-wide drug margin compression related to DIR fee changes, we historically see compression in our IV margins in the first quarter, driven by manufacturer price increases and shifts in reimbursement. This year was no exception, and several of our most utilized IV medications saw decreases to reimbursement while costs increased. Our top ten drugs saw a decline of 130 basis points in margin.

[Daniel Virnich, CEO at The Oncology Institute]

This margin compression culminated in operating losses above our expectation for Q1, although, as with prior years, we expect this trend to improve as the year progresses and have already started to see improvement in margin in April by 70 basis points. We are also proactively making changes to our procurement strategy as it relates to our distributors, which we project to positively impact the second half of the year. Now, I would like to highlight a few operational achievements since our last call. We added seven new clinicians, primarily in Southern California, bringing our total employed physician and advanced practice provider count to 126. We opened two new clinics in South Florida, bringing our total clinic count to 73. One of our new capitated contracts will bring us to a new market, Oregon, with a legacy capitation partner.

[Daniel Virnich, CEO at The Oncology Institute]

We expect to commence clinic operations there in Q4. All issues related to the Change Healthcare cyberattack have been mitigated. This incredible effort by our revenue cycle management team has led to record cash collections in the month of April. Finally, before I turn it over to our CFO, Mihir Shah, I have some important updates regarding our leadership team at TOI. On April first, we welcomed Jordan McInerney to oversee growth as our new Chief Development Officer.... He joins our other outstanding growth executives and joins us from the value-based orthopedics platform, HOPCo, where he had a strong track record of driving value-based agreements. We believe his deep network and knowledge of value-based care, particularly in the important Florida market, will further accelerate our growth in upcoming quarters. Now, I'll turn the call over to our CFO, Mihir Shah, to provide additional details on our first quarter financial results.

[Mihir Shah, CFO at The Oncology Institute]

Thank you, Dan, and good afternoon, everyone. Consolidated revenue for Q1 2024 was $94.7 million, an increase of 24.2% compared to Q1 2023, and a 10.3% increase compared to Q4 2023. Gross profit in Q1 2024 was $11.97 million, a decrease of 16.8% compared to Q4 2023. This decrease is attributed to the lower IV and oral reimbursement Dan previously mentioned. SG&A remains flat despite the strong growth in our top line. SG&A, including depreciation and amortization, was $29.9 million in Q1 2024, a decrease of 50 basis points compared to Q1 2023.

[Mihir Shah, CFO at The Oncology Institute]

As a percentage of revenue, SG&A, including depreciation and amortization, was 31.6% in the quarter, down 300 basis points from Q4 2023, and 790 basis points from Q1 2023. Loss from operations for Q1 2024 was $18 million, a decrease of $14.9 million compared to Q1 2023. Net loss for Q1 2024 was $19.9 million, an improvement of $10.1 million compared to Q1 2023, primarily due to goodwill impairment charges of $16.9 million in Q1 2023, that did not occur in Q1 2024. Offset by gains in the fair value of earn-out and derivative liabilities of $4.2 million in the prior year quarter that did not occur in the same quarter of the current year.

[Mihir Shah, CFO at The Oncology Institute]

Adjusted EBITDA for Q1 2024 was -$10.9 million. As of end of Q1 2024, our cash and cash equivalent balance was $36.1 million, and we had $29.7 million in short-term investment, for a total of $65.8 million of cash, cash equivalent, and short-term investments. The impact of Q1 operating losses, the Change Healthcare cyber impact, and AR lag in our new pharmacy resulted in reduction of cash and cash equivalent of $17 million related to Q4 2023. Thanks to our swift response to Change Healthcare situation and work around pharmacy collections, we project the cash flow impact to be simply one-off timing without full year impact on cash flow. I will now turn it back to Dan for closing comments.

[Daniel Virnich, CEO at The Oncology Institute]

Thanks, Mihir. I want to close our call by providing an update on progress towards our four key strategic priorities at The Oncology Institute. Priority number one: eliminate cash burn. While we had year-over-year improvement in burn relative to Q1, 2023, the drug margin compressions in Q1 did result in higher use of cash than Q4. We are confident that this will improve over the remainder of 2024 as a result of both our already signed and near-term growth in new contracts, procurement improvement efforts, and ongoing efforts to ensure we tightly manage SG&A down as a percent of revenue following our restructure last year. Priority number two: grow and drive margin in our legacy markets. Our newly signed medical and radiation oncology contracts in California and Nevada represent important new partnerships and expansion of our risk across both radiation and medical oncology.

[Daniel Virnich, CEO at The Oncology Institute]

These new partnerships, coupled with outperformance on orals through our California pharmacy, will continue to help drive profitability in our legacy markets. We will adjust variable staffing related to areas served by our one terminating contract to mitigate margin compression. Priority number three: improving new markets. Our first full quarter of capitation in Florida with Elevance has gone well as we welcomed new patients to our clinics, and we anticipate several other near-term capitation arrangements in this market. As already mentioned, we are also starting services in Oregon in Q4 through another new capitation deal signed this quarter. This new deal represents tremendous opportunity to improve quality and utilization versus the legacy high rates seen in this market. Priority number four: leading the value-based oncology market.

[Daniel Virnich, CEO at The Oncology Institute]

Our significant uptick in new capitation contracts signed and continued momentum in our new contract pipeline represents validity of our model with payers as risk-bearing primary care groups and health plans seek partnership with TOI to help manage the unsustainable cost trends in oncology. We strongly believe we can continue to advance this lead for the patients and payers that we serve, and we look forward to updating you on our continued progress toward our key priorities on our next earnings call. With that, we're now ready to take your questions. Operator?

[Operator]

Thank you. We will now be conducting a question and answer session. If you would like to ask a question, please press star one on your telephone keypad. A confirmation tone will indicate your line is in the question queue. You may press star two if you would like to remove your questions from the queue. For participants using speaker equipment, it may be necessary to pick up your handset before pressing the star keys. One moment please while we poll for questions. The first question comes from the line of Jack Slevin with Jefferies. Please go ahead.

[Jack Slevin, VP and Equity Research Analyst at Jefferies]

Hey, good afternoon, guys, and nice work on the quarter. Wanted to start with the DIR impacts in both IV and on the dispensary side. Just wondering if you can give a little more color in terms of, you know, how heavily that was weighted in each of those areas. You know, did one side see a little bit more than the next? And then maybe sort of using that as a jumping-off point for how you're thinking about progression of margins throughout the year. Obviously, patient services margins came down pretty significantly under some of those headwinds, and just trying to get a sense for how you're thinking that's gonna progress. Is it sort of more gradual? Is there a snapback in Q2? Just want to understand what the latest thinking is. Thanks.

[Daniel Virnich, CEO at The Oncology Institute]

Yeah, hi, Jack. Thanks for the great question. I think, there's a couple factors that impacted drug margins in Q1 on our fee-for-service business that we expect to see improve throughout the course of the year. The first factor, which we deal with every year, is seasonality, as we commented about, on our earnings call. So, we've already started to see that improve in April and expect that trend to continue to improve over the course of the year, driven by both, changes in the level of sophistication we're bringing to procurement, and just that seasonality impact. The DIR fee issue, which is, the other major factor that we faced in Q1, which compressed margins on our fee-for-service drugs.

[Daniel Virnich, CEO at The Oncology Institute]

Again, I think there's industry-wide momentum on driving change, and that throughout the rest of the year, but the time course of that is really hard to predict at this point. So again, you know, we're trying to control the factors we can and expect the remaining three quarters of the year to drive improvement in those margins, but it's hard to say at what pace that DIR fee issue will resolve itself.

[Jack Slevin, VP and Equity Research Analyst at Jefferies]

Got it. That's really helpful. Here, I want to ask on the Change impact. If the right way to think about that, sort of the just over $16 million of AR drag that you saw in the first quarter, should we just see a reversal of that? Is that a decent way to size up sort of how to think about the snapback in Q2 now that you've resolved that issue?

[Mihir Shah, CFO at The Oncology Institute]

Yes. So, about $15 million of that, we believe, will be timing. Couple of million will be related to the increased revenue that we have seen, so it's just adding slightly more to the working capital, for the pharmacy revenue that we added in Q1.

[Jack Slevin, VP and Equity Research Analyst at Jefferies]

Okay, got it. Really helpful. And then next, you know, appreciate all the commentary on the new cap contracts, and it sounds really good. Sounds like there's one incremental one to when we last spoke on the 4Q call. Maybe just, you know, I heard the $16 million of annualized revenue. Sounds like a great number. Just wanna make sure I got all the commentary on the pacing of how those should launch, those seven contracts. And then, you know, maybe if you could touch a little bit more on how the pipeline's looking. You know, is it still strong? Should we expect to have sort of a steady flow of announcements, or was it a little bit front-loaded as far as the 1Q deals closing for 2024?

[Daniel Virnich, CEO at The Oncology Institute]

Yeah, another great question, Jack. So, the contracts were all signed and executed, the seven in Q1. The pacing of start on those contracts, the majority of them are Q3 timing for go live. And you know, that's the way to think about that in terms of impact to revenue this year versus full year. I would say on the pipeline question, our pipeline at this point is, I mean, as robust as we've ever seen it. So we've got a lot of good stuff in the near-term pipeline, which we expect to continue to announce over the rest of the year 2024. And I think there's a lot of different reasons for this.

[Daniel Virnich, CEO at The Oncology Institute]

I think one is just increasing sophistication of our growth team with sort of implementing our model in new markets, expanding our, our range of clients that we can work with beyond just delegated medical groups to plans and even now employer groups. And then lastly, I think a lot of the top-line pressure related to V28 has resulted in groups that are taking risk, you know, finding other ways to try and drive their MLR through finding better ways to manage their specialty costs. So again, you know, phenomenal Q1 in terms of number of contracts signed. I can't promise an exact number for, for second quarter, but we are seeing a, a pretty tremendous pipeline ahead of us.

[Jack Slevin, VP and Equity Research Analyst at Jefferies]

Okay, thanks. That's great color, Dan. Then last one for me here. I think all things considered, the cash burn looked really strong, you know, the performance there, considering Change. Normalizing for Change, does it feel like we're sort of in the right ballpark area on cash burn? Or, sort of, what's the outlook at this point as we progress through the rest of 2024?

[Mihir Shah, CFO at The Oncology Institute]

Yeah. So, Q1 had cash burn from the AR growth related to Change and increase in our pharmacy revenue, and also some compression in margin in Q1 that we saw, right? We will see both of them reverse, AR reverse much faster in Q2 and continue in Q3. Our margin compression should also improve in Q2 and Q3. So I would say this Q1 would be potentially the extreme scenario of our cash burn.

[Jack Slevin, VP and Equity Research Analyst at Jefferies]

Got it. Really helpful. Appreciate all the color, guys, and congrats on all the progress.

[Daniel Virnich, CEO at The Oncology Institute]

Perfect. Thank you.

[Operator]

Thank you. Ladies and gentlemen, that concludes our question and answer session. I would now like to turn the floor over to Daniel Virnich for closing comments.

[Daniel Virnich, CEO at The Oncology Institute]

Thank you so much. Thanks to everyone who joined our earnings call today. The management team at TOI is incredibly excited about the number of new partnerships that we were able to effectively start in Q1, and look forward to serving patients associated with those new contracts as they go live throughout the remainder of 2024. We're also very excited about the near-term prospects in our pipeline related to growth, as well as all the activities that our team is taking to again combat some of the margin compression on the drug side of the business, which we saw in Q1. We'd like to thank everyone for joining our call today and look forward to updating you on continued progress in our business in subsequent quarters. Thank you so much.

[Operator]

Thank you. This concludes today's teleconference. You may disconnect your lines at this time. Thank you for your participation.

Participants

Executives

• Daniel Virnich, CEO
• Mihir Shah, CFO

Analysts

• Jack Slevin, VP and Equity Research Analyst at Jefferies