Q4 2020 Myomo Inc Earnings Call
Good day and welcome to the <unk>, Inc. Fourth quarter 2020 earnings Conference call. All participants will be in listen only mode should you need assistance. Please signal a conference specialist by pressing the star key followed by zero.
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Please note. This event is being recorded I would now like to turn the conference over to Kim Gala debt. Please go ahead.
Thank you operator, and good afternoon, everyone. This is Kim golf, but that's with L. H, a welcome to the Myanmar fourth quarter and full year 'twenty 'twenty financial results Conference call earlier today, My Yamana issued a news release announcing financial results for the three months from 12 months ended December 31st 2020, if you would like to be added to the comp.
These email distribution list to receive future announcements. Please register on the Companys website at my own Dot com or call. It light chain in New York at 21283837, and 77 and speak with Carolyn Curran.
With me on today's call from Myanmar, or Polka Donuts, Chief Executive Officer, and Dave Henry Chief Financial Officer, before we begin I'd like to caution listeners that statements made during this conference call by management other than historical facts are forward looking statements.
Words anticipate believe estimate expect intend guidance outlook confidence target project and other similar expressions are typically used to identify such forward looking statements.
These forward looking statements are not guarantees of future performance and may involve and are subject to certain risks and uncertainties and other factors that may affect my almost business financial condition and operating results, including the impact of the ongoing COVID-19 pandemic day.
These and additional risks uncertainties and other factors are discussed in the risk factors and other qualifications can change in my almost filings with the Securities and Exchange Commission, including the form 10-K for the year ended December 31, 2020, which was filed earlier this afternoon.
Actual outcomes and results may differ materially from what is expressed in or implied by these forward looking statements, except as required by law Amaya undertakes no obligation to revise or update any forward looking statements to reflect events or circumstances. After the date of this call.
It is now my pleasure to share on the call over to Paul Good honest C. E O of my Elmo Paul. Please go ahead.
Thank you Kim good afternoon, everyone and thank you for joining us today after I provide a business update Dave will review, our fourth quarter and full year financial results and discuss our financial outlook and following the financial update I'll give some closing remarks, and then we'll take your questions.
But first let me once again express my hope that you your families and colleagues are concerned you to take the necessary precautions for health and safety and that you've all remained well as we enter the second year of the COVID-19 pandemic.
When the pandemic began we certainly had no way of knowing how long would the last or how quickly economies in various states and geographies would open back up.
With a view toward preparing for the worst but hoping for the best I am So proud of my team and our own P channel partners in the way that we navigated through what we all hoped was the worst of it.
During the year, we adjusted our operations, particularly in the use of telehealth in online marketing that supported the continuing growth of myeloma during the year.
This digital transformation will have a lasting positive impact on the business and our ability to grow revenues at a much faster rates and operating expenses as more of a patient facing work is now being done online.
As states have opened up we've worked in a diligent and careful manner to bring our powered arm braces to patients and make a mark to involve improvements in their quality of life.
Through the success of our social media and advertising and increased recognition of the mile Pro by health care providers, we achieved record revenue in the fourth quarter and the year.
In fact, our fourth quarter revenue matched the revenue for all of 2019 and impressive achievements, even without the effects of a global pandemic.
Record revenue for the fourth quarter of 2020 was $3 $8 million up 149% over the fourth quarter of 2019 and reflected a record level of myopia deliveries and payments.
Our strong performance throughout 2020 resulted from two shifts in our business strategy that began 18 months ago and were fully implemented during the past year, namely the direct billing channel and direct to patient marketing.
Direct billing revenues increased approximately four X year over year in.
In the quarter and represented 77% of Q4 total revenue. In addition, approximately 90% of those entering the domestic pipeline during the fourth quarter were direct Bill Kansas.
Note that at the start of the year direct billing revenue was just 20% of our total revenue.
With the shift to direct billing our average selling price or revenue per unit has increased significantly. While we also continue to sell our products on a wholesale basis to own providers for their patients. Our gross margins also improved with the emphasis on the direct billing approach compared with other channels as Dave Henry will describe in a moment.
Given that the vast majority of candidates are now in our direct billing channel. It's clear that this strategic shift was a success for the remainder of our revenue came primarily from our U S. A one P channel partners, the VA and European own providers.
We also increased the size of our backlog over the course of the year, which is defined as mile pros that have been authorized by payors, but are either in the process of being delivered to users or are awaiting payment to us.
Dave will explain our backlog decreased sequentially to 131 units due to a record number of revenue units in the fourth quarter and the favorable accounting treatment of <unk> authorized by certain payers that are our revenue upon delivery due to a history of payments.
We continue to add over 200 patient candidates into the insurance pipeline during the fourth quarter slightly fewer than in the previous quarter.
We believe this was due to a combination of factors, including reduced lead generation. The latter half of 2020 and possible changes in consumer behavior due to the economic uncertainty associated with the pandemic.
Our social media advertising was also competing with political advertising in the foam raising the cost of individual ads.
Trolling advertising costs and fewer leads and additions to the pipeline were generated which will result in fewer insurance authorizations in the short term.
However, I am very pleased to see that our leads and pipeline growth is on the upswing. So far in 2021 with over 300 candidates added since the beginning of the year. So the first quarter will be a record quarter for pipeline additions will just takes several months for these candidates to work their way through the insurance process to an authorization.
While our direct billing channel is certainly helpful. In supporting the growth in revenues and margins. This would not have been possible without the use of direct to patient marketing. These marketing efforts are aligned with the growing trend in health care for patients and their families to seek medical the medical information online in order to augment the recommendations that they might receive from their physicians.
And therapists.
Our own online activities are now being augmented by mile Pro users, who are posting videos of themselves and various social media sites, helping to spread the message at no cost in myeloma for example, Sarah who lost the use of her right arm due to an accident by hit and run driver post videos have yourself on tick tock showing how.
You can use both arms to go shopping prepare meals and even play the electric guitar.
Per videos have been viewed more than 700000 times, so far and she is just one of a growing number of influencers, who want others to know about how the mile probe has had a positive impact on their lives.
We also made progress toward our goal of becoming the worldwide standard of care for upper extremity paralysis by growing our business in Europe, especially in Germany, which is the largest smile pro market in the region.
Last month, we announced that additional statutory health insurers have approved reimbursement and the other my approval on a case by case basis. So now we have the foundation for reimbursement in Germany that covers approximately 40% of the population.
And after several years of meeting with potential partners for the China market, We recently announced our agreement to enter into a joint venture and a technology licensing agreement with riser medical a provider of medical devices and rehab Hospital services in China, when we receive all the necessary government approvals, which we expect later this year.
The Chinese partners will fund the Jv's operation the locally manufactured distribute the mile probe in my almost will receive a 19, 9% equity interest in the venture will also receive an upfront license fee and annual license payments over the next 10 years after the ventures established.
At this time I'll turn the call over to Dave Henry Our CFO, who will go over the financial results in more detail then I'll come back and provide some additional updates for you in our plans for the year ahead.
Thank you Paul.
Turning now to our fourth quarter and full year 2020 financial results.
For the fourth quarter of 2020 was $3 8 million, which was up 149% over the prior year's fourth quarter and as Paul indicated was a quarterly record.
Our average selling price along with the sale of a record number of miles from units reflected successful with our direct selling channel and our marketing efforts.
More specifically, we recognize revenue on 97 mile Pro units in the fourth quarter of 2020, an increase of 126% compared with the fourth quarter of 2019.
This includes 13 direct billing units, representing approximately 400000 of revenue that was pulled into the fourth quarter from 2021, having sufficient collection history with certain insurers.
It was to recognize revenue upon delivery.
Our backlog of units, which represents insurance authorization is received but not yet converted revenue was 131 units as of December 31, 2020 <unk>.
Approximately 44% of the September 30th 2020, beginning unit backlog was converted into revenue during the fourth quarter.
Backlog was lower in part due to the pull in of revenue I. Just mentioned the decrease was also driven by a sequential decrease in authorizations and orders in the fourth quarter. We received 86 insurance authorizations in orders in the fourth quarter compared to <unk> 98 in the prior quarter. In addition, 20 candidates drop.
From the backlog in the fourth quarter.
Gross margin for the fourth quarter was 73% up from 72% in the fourth quarter of 2019 and up from 56% in the third quarter of 2020.
The increase primarily reflects a higher average selling price.
There was a small negative impact on gross margin as we delivered 101 units to patients which became cost of revenues in the fourth quarter compared with 97 revenue units.
Operating expenses for the fourth quarter of 2000.
$4 5 million. This is a 22% increase compared with the same quarter, a year ago, and primarily reflects higher incentive compensation accruals and advertising costs.
Operating loss for the fourth quarter of 2020 decreased to $1.7 million from $2 6 million from fourth quarter of 2019.
It was $1 7 million or <unk> 37 per share and this compares with a net loss of $2 8 million or $4 81 per share for the same period of 2019.
Adjusted EBITDA for the fourth quarter of 2020 was a negative $1 5 million and this compares with a negative $2 4 million for the fourth quarter of 2019.
Cash and cash.
As of December 31, 21, net cash used by operations was $1 2 million in the fourth quarter. This was the lowest cash utilization level since the Companys IPO in 2017, which was prior to the investments we made to scale the business.
We do expect cash used by operations to increase in the first quarter due to lower anticipated revenue and the payment of a deposit for inventory to one of our contract manufacturing partners to support planned mile per unit volumes in 2021.
We expect 2021 cash flow to follow a similar pattern as 2020 with higher cash used by operations in the first half of the year and lower utilization in the second half.
With a goal to reduce cash used by operations for the full year 2021, compared with 2020.
With that I'll briefly recap our full year 2020 financial results.
Revenue for the year ended December 31, 2020 was seven 6 million up 98% over 2019, despite the impact from COVID-19 throughout most of the year.
Higher average selling prices driven by the increase in direct billing revenues helped increase gross margins of 66% in 2020 compared to 63% in 2019.
Operating expenses for 2020 were $15 5 million net increase of 17% over 2019, primarily due to higher payroll costs, including higher incentive compensation accruals as well as higher advertising and insurance from.
The operating and net losses for 2020, or $10 5 million and $11 6 million respectively.
Net loss in 2020 included a charge of 700000 related to the partial extinguishment of the company's convertible notes.
Adjusted EBITDA for 2020 was a negative $9 8 million compared with a negative $9 8 million for 2019.
Turning to our business outlook, we expect revenue in the first quarter of 2021 to be higher year over year lower sequentially.
This reflects the usual seasonality in our business as well as the pull in of revenue into the fourth quarter of 2020 as a result of the acceleration of direct billing revenue for certain insurers where.
We have completed delivery and a sufficient history to assume collectability.
We expect a sequential decrease in authorizations and orders in the first quarter, which is expected to result in a sequentially lower backlog at the end of the first quarter.
This is expected to decrease in authorizations is due to a combination of factors that Paul previously mentioned.
As Paul also mentioned pipeline adds are approaching 300, so far in the first quarter.
It's worth noting that it's going to take some time for the higher adds to the pipeline to work their way through and become backlog.
With more than $7 million in proceeds received from the exercise of warrants so far in the first quarter of 2021.
Aleve, we have sufficient cash to fund operations well into 2022.
Barring any re imposition of travel restrictions and public health public health Lockdowns, we are positioned for a strong 2021.
With that overview I'll turn the call back to Paul.
Thanks, Dave as we look forward to the rest of 2021, we plan to increase our efforts to obtain what we believe is appropriate reimbursement for the <unk>. So that more patients have access to our devices.
As you May recall back in January of 2019, the centers for Medicare and Medicaid services or CMS established two new billing codes from the Micropro and certain Medicare advantage plans began paying for the device on a case by case basis, while these Medicare advantage plans cover about 35% of seniors the larger portion of Medicare.
Beneficiaries are covered under part B, where the mile Pro is coded as durable medical equipment rental.
<unk> custom fabricated for each patient and is designed for long term use we continue to seek a correction in the benefit category and we recently applied for such a change with the submission of a code amendment for consideration this year.
However, there is no guarantee that CMS will issue a coverage policy or an acceptable payment amount for the mile probe in which case, we will continue to address the large population of paralyzed individuals covered by other plans.
Also a year ago, we had begun testing our new myopia device, which is designed for the pediatric market, we had to put that work on hold.
But as vaccinations become more widespread and parents are comfortable with our clinicians meeting with their children. We plan to restart the testing and final design work on this project later this year.
This concludes the formal part of our presentation, operator, and so we're ready to open the call to questions.
Thank you we will now begin the question and answer session.
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Okay. Operator, we are ready now for the first question.
Thank you.
First question comes from Scott Henry with Roth Capital. Please go ahead.
Thank you good afternoon, and congratulations you're almost topped your biggest year in one quarter alone.
So what I wanted to dig into.
Why is the new the new pipeline adds because that's the top of the funnel and you know it's important to the long term.
Trend and you know it sounds like Q4 was a little low, but then Q1 could be 400. So the question is why do you think such a discrepancy between Q4 and Q1.
And you know where do you think that the true number is there Scott.
Scott. Thank you for the question I'll address that.
Well, our advertising weeds, we saw a slowdown with the economic situation I think a lot of pain.
Patient candidates.
We are a bit uncertain about whether or not they wanted to proceed maybe where they were concerned about a job or spouses jobs or health insurance I think fee election.
It took a lot of mind share of people and then we ran into the holidays, which tends to be a slowdown as well.
We're doing that purely especially after the election, we ramped up our advertising budget and spend in that.
<unk> did it in a much larger number of leads starting in December and then continue on in January and February and then we also expanded our call Center staff down in Texas, and so we were able to reach more patients.
Our clinical team has been conducting more evaluations and so.
Our trajectory is definitely on the upswing and we will have a record quarter of new patient adds here in the first quarter.
Okay, that's great I appreciate the color.
Just wanted to international question I.
In Germany, how large is that opportunity and when do you think you could see revenue.
Well, we're already seeing some revenue out of Germany.
We're already booked more orders here in the first quarter from Germany. So we expect a good year over year growth in Germany, it's taken a while to get statutory health insurance to approve this word but we've been working with the local one P partners.
Who are in network.
No the local regulations the language so they've been successful in getting this moving forward movement with.
S. H I payers. So that's really set the foundation for easier reimbursement going forward.
We've now got a German version of our website up and running we started doing some test marketing on Facebook social media there in Germany, So with that I expect we're going to keep building the pipeline and we should have good year over year revenue growth in Germany. The other markets in Europe are just starting to open up again, but it's about Germany that he has done the best.
And also.
They tend to like high tech products likes us. So we think we'll do our best international growth in the short term out there in Germany.
Okay, Great and I'll just ask one final question on gross margins were very strong in the quarter.
When we model our gross margins is that mostly a function of just the volume you did that quarter or are there any underlying trends that are perhaps more favorable debt.
I should say.
Yeah, Hi, Scott Yeah.
Contribution margin.
We don't have the only fixed costs really have or like our maybe our quality and fulfillment organizations other than that it's all variable cost. So the contribution margin is in the range and we've said it's around 70% to 75%.
What happened in fourth quarter as debt.
In prior quarters, certainly the third quarter, we there was a large GAAP between the number of units, we delivered and the number of units debt.
We actually took the revenue line that GAAP closed in the fourth quarter due in part to that to the pull in of revenue from the <unk>.
Yeah.
We were able to do because we've got enough payment history now on some on some of these insurers.
That helps sort of close that gap and get our debt.
GAAP between deliveries and revenue units and allowed us to be able to realize a gross margin that was in the range of our contribution margin that we've been saying.
Okay, great. Thank you for taking the questions.
Sure.
Our next question comes from Kyle out there with call yet Securities. Please go ahead.
Good evening and thanks for taking my questions really nice results here.
I'm curious on the digital marketing efforts. If you have any updated estimates for the cost of a patient acquisition or the other cost per click.
What we're finding assets.
Dave Please.
I was just going to say that we don't really look at cost per click, but what we try to manage this debt.
And what we're trying to do is improve the cost per what we what we call internally a good lead a good lead are those.
Are those those insurers that we believe are.
Based on history or more likely to reimburse from a product.
A Medicare lead Unfortunately, right now it's not a good lead.
So.
What we talked about we're trying to do is trying to.
Honestly try to manage the you want to.
Balanced growth on the pipeline and also the increase in the advertising spend but what we're looking towards obviously is.
Something.
Mike do you want to per dollars and.
Maybe in the future drive that drive that even lower as we get better at doing it than me.
Things evolve and we understand where the where the pockets of those potential patients are.
A more thorough way.
Okay got it thanks and and.
You've clearly seen some really nice momentum here and we're just in the early innings can you help me understand your latest thinking on the addressable market I know you've said that about a third of the annual incidence of 800000 patients.
Enter that the prevalent pool for addressable myopic patients so call it 250000 patients and that is.
Further reduce spatter exclusion criteria like reimbursement and patient interest in sufficient shoulder strength, even so so you know.
After considering all the exclusion factors, what's your sense for the true prevalence and incidence for potential mile per hour patients right now yeah. Thanks Kyle.
So in our recent investor presentation, which will be up on our website. Soon here for March we're talking about.
Current chronic arm paralysis prevalent pool in the United States, there's about $3 million and as you described we narrowed down you've you've gotta be living at home, where youre not in a nursing facility you have to have the right type of insurance plan you have to be clinically qualified you have to be interested in where he got robotic device like this so we narrowed down too.
10% of addressable market so.
Our estimate that's probably 300000 individuals right and we're just serving a couple of hundred a year right now so certainly a lot of upside potential there and then probably 10% of those new incidences every year, so 25% to 30000 from those strokes spinal cord injuries, new brachial plexus syndrome.
Reis from traffic accidents and things like that so that's what we identify as our targeted market just in the United States and then of course, it's probably that large in Europe are in.
Places like China. The reason, we wanted to address that market is there is 14 million paralyze arms in China, two and a half million strokes a year or so another 800000, new cases go into the chronic condition every year. So that's our view of the addressable market for us that's great I appreciate that color.
And just a couple more quick ones here. So following up on Scott's previous question. So.
The pipeline is very robust we're seeing some.
Nice new ad numbers.
But if I look at kind of the exits if you will so you know you've got a pipeline you're bringing in new people, but there are people who fall out of the pipeline.
Over time, it's been about 25 per cent and it's and it's kind of stayed at that level. So you can typically expect about 25 per cent of the pipeline and kind of fallout.
Even as we've seen the percentage of the.
Pipeline towards direct billing increase over time, so I am just kind of curious what.
How could we see the percentage of exits kind of decline is there any sort of barrier that would help with this or any kind of color around that well the biggest issues that we see people dropping out from other.
The pipeline is.
They've had a stroke they have another stroke.
So it takes themselves out they say well, let's get back to me in six months, because I've just had a stroke, sometimes they change insurance espouse changes a job and then.
I haven't disappeared totally but we take them out of the pipeline and then we will work with them to resubmit them into their new insurance.
But that's the type of drop out some people change their mind one of the things that we're able to do is the direct billing provider.
To the extent that we can accelerate the cycle time.
Yeah, the longest something drags out through an insurance authorization process people become disinterested. So you know our objective is to get those documents from their physician letter of medical necessity. The other therapy notes. So you can get an authorization as fast as possible and.
And that.
It will help I think in terms of our reduce it pop pipeline dropout rate overtime mhm.
Okay.
Adjusted in terms of numbers, Kyle the pipeline dropped as well.
15% in the fourth quarter by my math it was about a 111.
Oaks dropped out of the pipeline and fourth quarter.
Okay.
Yeah.
Got it yeah, I mean, maybe I'm I'm looking at.
Maybe there's a lag in mind.
But all that I appreciate that color there and just lastly on the E. S. P. We're seeing nice trend upward here obviously.
The mix of direct billing units helps with their site and back of the envelope math share about 39 K for an ASP.
What what's the long term goal here for modeling purposes.
How should we be thinking about that.
Yeah, I think the we did have.
We had some blue birds from an ASP standpoint in the fourth quarter, we had quite a number of.
Yes fairly sizeable reimbursements with we're very happy with.
But we are.
In terms of that we're just I.
I would assume on a go forward basis just.
Because I because of those bluebirds I would I would continue to model it like a mid <unk> DSP mhm.
Great.
Okay, Great. That's it from me thanks for taking my questions. Thank you Kyle.
Our next question comes from Jim Sidoti with Sidoti and company. Please go ahead.
Hi, Good afternoon can you hear me, we can Jim Hello.
Great. So.
Your your revenue for the quarter exceeded even your your pre announced your updated guidance.
Early January is that a function of the <unk>.
Correct.
Fact that you were able to collect.
Alright, it's more reliable collections from these insurance companies.
Well I think it's more of a we won't we wanted to make sure we were conservative when we if you're going to pre announce don't don't Miss it.
Uh huh.
So no I think.
Nothing that nothing.
Nothing happened in the timeframe between when we pre announced and the time that we're in today.
Was there was anything different there was I would just chalk it up to <unk>.
Wanted to make sure we gave a.
Conservative yet realistic estimate.
Okay and then.
Debt 39.
Hey per unit for the quarter, how does that compare to a year ago.
Significantly higher I think ASP.
S P.
Bear with me a second here some ASP last year was.
Around.
35, I'm, sorry, let me.
Mike.
The type of true small yeah. It was <unk> 35 last year.
Yeah, Jim it's increased significantly over the last 18 to 24 months as we developed a hybrid channel and shifted more of our business to our direct billing to the insurance providers and we're getting the full payment.
From the Payor instead of a wholesale amounts from channel partners and.
And that now is <unk>.
77% of our total revenue mix.
Yes.
Alright, Okay, Alright, and then with regards to lead generation.
What were the specific changes you've made to make that improve and how long do you think it'll take for those to turn into.
Actual orders, yes, well, we were looking at the lease situation always looking to figure out okay. What can we do better.
We changed agencies in the fall we selected a local agency here that was really a specialist in digital marketing.
So they looked at the different algorithms that are used by Facebook and some of the other search engines to optimize keywords things like that so we did that plus the increased spending.
And also when you advertise in the social media platforms.
I would say fixed budget and youre basically bidding for AD space against other advertisers and as you know there was a lot of advertising going out with the.
Election campaigns, so and that subsided, we were able to get more bang for our Buck so to speak so combination of that looking at new places to advertise for example, we're now in AARP.
We are on their online sites. In addition, we are using print advertising where in their latest stopped print magazine issue, which goes out to millions of members 50 years of age and older. So that is raising brand awareness as well here in this first quarter.
Alright, thank you.
Okay.
We have time for one more question. Our last question will come from Edward Lu with the Sundance Capital. Please go ahead.
Yes, congratulations on the quarter.
You guys are looking forward to trying to grow your international business, especially in Europe in Germany, and what how should we view asps in those regions.
How do you view Asp's I'm sorry.
Yes, you could get the selling price similar to what it is in the U S.
Obviously EBITDA channels are different but do you think the selling prices can be similar.
It will be.
It will probably be in the middle of all of our channels, it's going to be lower than the direct billing.
ASP in the U S.
But we think it can be.
Higher than in the Asps that we get through the U S O N P channel.
And the and the VA and the VA as well.
Great and then going into Asia.
Congratulations on a joint venture in China.
That only for China or does it include other Asian areas and what are your plans for those other Asian markets.
That joint venture is designed just restricted to just the China market.
I do manufacture just for the China market and to distribute to patients in China.
However that could serve as a model.
For other Asian joint ventures.
Because in the Asian countries, it's often good to have a local partner to help navigate the regulatory and government environment. So we'll see as Covid receipts, we may get the other parties interested into other geographies, but the.
Why is your joint venture is totally focused on the large China market.
Great well congratulations and good luck. Thank you.
Q.
Alright, well, thank you Edward and thank you operator.
So in closing we're hopeful that the economy here in another country markets open up this year and that's a pet debit continues to abate over the course of this year in that case, we'll be able to continue to deliver the milepost of patients in our backlog.
To accelerate our patient pipeline growth and demonstrates strong annual revenue growth for the fifth year in a row.
We're addressing a very large unmet need with a life changing solution, while continuing along the path toward our next milestone of cash flow breakeven.
So once again, thank you for your time and your interest in my almost a day and have a good evening.
The conference has now concluded. Thank you for attending today's presentation you may now disconnect.