Q4 2021 Inspire Medical Systems Inc Earnings Call
Effective in the final physician hospital and ASC payments have been published the 2022 National average Medicare payment to the hospital is $30063 and $24828 to the ASC.
The physicians professional services are reimbursed separately and the national average Medicare physician fee for the implant is $888.
Finally, the national average Medicare reimbursement to perform their drug induced sleep endoscopy is approximately $115, which is the first time physicians have been compensated for this diagnostic procedure.
As a general rule commercial reimbursement is about one four times Medicare rates.
Switching gears to R&D.
100% of inspire procedures that occurred in Q4 made use of the two incision surgical technique.
The use of this technique resulted in both a benefit to the patient. If there is one less incision and a significant benefit to the physicians as it reduces surgical time to approximately 90 minutes from the previous average of 120 minutes.
On the product development side, we are very excited to announce that the FDA has approved our new Bluetooth enabled patient remote.
This new version allows information from the implanted neurostimulator and the patient remote to be uploaded to the inspire cloud via a patient smartphone, making it easier for physicians to monitor monitor inspire patients.
We are conducting a soft launch of the new remote and the first half of this year to provide a full system level test of the patient remote and inspire cloud interface.
We are planning for a fall product introduction at the America American Academy of Sleep Medicine meeting in June of this year.
The inspire cloud patient management system continues to expand as we add centers in the U S and in Europe .
And inspire cloud will become an important tool for physicians to monitor patient experience and outcomes.
This tool will further expand capacity as physicians can more efficiently manage a greater number of patients.
The next step for our digital program is to upgrade our physician programmer. This project is ongoing and we expect to submit for FDA review later this year.
The project will allow the programmer to also connect with inspire cloud, which is key to the end goal of providing remote patient programming, which we are targeting for 2023.
Moving on during the fourth quarter, we form.
Formally submitted to the FDA our request for full body MRI compatibility. The FDA has been involved during the extensive MRI evaluation process.
And we expect approval within the 180 day review window.
This approval will not require any changes to the existing inspire system.
Longer term the design work for our fifth generation inspire neuro stimulator continues to progress.
This fifth generation device will eliminate the pressure sensor and incorporate <unk> sensing inside the neuro stimulator using an accelerometer to measure respiration.
We are targeting FDA approval in late 2023.
The inspire five device will utilize the existing form factor and we will maintain the average 11 year battery life without the need for recharging.
Collectively these technology enhancements will further strengthen patient outcomes as well as improve patient and physician experience with inspire therapy.
In summary, we continue to experience significant momentum in all key aspects of our business and are determined approach to operating in a COVID-19 environment has resulted in continued growth in the adoption of inspire therapy.
Our focus on patient outcomes, and our unique ability to reach and educate potential patients provides our confidence in the continued growth of inspire.
To reiterate our core focus for 2022 is to increase utilization at our existing centers as well as to increase capacity by opening and training new centers.
An important aspect of the anticipated increases in utilization and capacity is a continued expansion of our call center.
While the most recent surge in Covid cases, driven by <unk>, we will have a short near term impact on our business. We remain extremely excited about our future prospects and are confident that we have the appropriate strategy in place to drive long term shareholder value.
With that I'd like to turn the call over to Rick for his review of our financials.
Thanks, Tim.
As Tim noted the inspire team delivered a strong fourth quarter and full year 2021.
Total revenue for the fourth quarter of 2021 was $78 4 million a 70% increase.
From the $46 million generated in the fourth quarter of 2020.
U S revenue in the fourth quarter was $75 6 million an increase of 77% from.
From the $42 7 million generated in the prior year period.
The growth in the U S reflects a number of factors, including a larger number of implanting centers.
Broad policy coverage and an increased number of territory managers and other sales and clinical team members.
In the fourth quarter revenue from outside the U S decreased 13% to $2 8 million.
The average selling price in the fourth quarter in the U S was $23900, which was consistent with the prior year period.
The ASP for the rest of the World was 22700 during the quarter compared to $23 600 in the fourth quarter of 2020.
The lower ASP was primarily driven by exchange rates and the initial sales of distributed products in Japan, which occur at a transfer price lower than the ASP for products sold directly.
Gross margin in the fourth quarter improved to 85, 8% compared to 84, 4% in the prior year period due to manufacturing efficiencies and higher sales volume.
Total operating expenses for the fourth quarter were $69 1 million, an increase of 50% as compared to the fourth quarter of 2020.
This increase was due to the expansion of our sales organization.
Increased direct to consumer marketing programs.
<unk> product development efforts and general corporate costs.
The increase in operating expenses is reflective of our ongoing plan to drive continued growth and to make investments in key commercial and development initiatives.
Our net loss for the fourth quarter improved to $2 4 million compared to the $7 5 million net loss in the prior year period.
The net loss per share for the fourth quarter was nine.
Compared to a net loss of 28 per share in the fourth quarter of 2020.
The weighted average.
Average number of shares outstanding for the fourth quarter was $27 4 million.
We anticipate that the weighted average number of shares for the first quarter of 2022 will be approximately $27 5 million.
For the full year 2021, our total revenue was $233 4 million, a 102% increase from the $115 4 million generated in the prior year.
The U S revenue was $221 million, an increase of 108% over 2020.
For 2021 revenues from outside the U S increased 34% to $12 4 million from the prior year.
Our net loss for the full year 2021 improved to $42 million compared to the $57 2 million net loss in the prior year.
The net loss per share for 2021 was $1 54 compared to a net loss of $2 19 per share in 2020.
Historically and similar to other elective procedures, we have experienced seasonality in our business in the U S. We have higher procedure volumes in the fourth quarter as patients with high deductible health plans seek to schedule procedures.
To their deductibles resetting at the beginning of the year.
Given the significant progress we've made in scaling our business and despite the headwinds from the omicron variant in January and normal seasonality that we see at the beginning of the calendar year.
We are providing full year 2022 revenue guidance in the range of $318 million to $326 million.
Which would represent growth of 36% to 40% over the full year 2021 revenue.
Moving to the balance sheet.
As of December 31, 2021, our cash and investments totaled $224 million.
Compared to $234 million at the end of 2020.
This strong cash position allows us to remain focused on executing our growth strategy of increasing productive.
An increase in procedure volume at existing centers and training and opening new implanting centers.
In summary, we have significant and sustainable momentum throughout our business.
And we remain well positioned to achieve long term growth.
We are extremely pleased with our performance for the year and are excited to continue executing on our growth strategy in 2022.
With that our prepared remarks are concluded.
Chris can you please open up the call to questions.
Yes, Sir.
And everyone to ask a question need to press star one on your telephone to withdraw your question. Please press the pound key.
Our first question comes from Robbie Marcus of Jpmorgan.
Your line is open.
Oh, great and.
I already say, congratulations on the quarter or a month ago, but I'll ask it again, especially on a really nice guidance here.
Youre IV.
So.
Jim you touched on you gave us the metrics for web traffic in fourth quarter and you made some promising comments on how the national campaign is going so far but I was wondering if you could give us any.
Any qualitative or quantitative.
Commentary on what it's been like in first quarter in terms of increase versus normal levels and do you think that the increases are coming just from the advertising or do you think maybe some of the.
The market recalls are helping you as well.
I think the.
It's probably a combination I think that the advertising is driving most of the activity because we've gone to national levels. We are now reaching areas that had not previously had.
Direct to consumer advertising are running some of the TV ads and these are we now have.
Inspired centers across the U S. So we're able to reach into those centers and so most of the activity is really coming from those pockets of our centers.
That just did not have any prior exposure.
So we're pretty confident that that the advertising is driving the web activity now that being said certainly within those communities are patients who are dealing with the recall efforts and I'm sure they're motivated to get to the website get educated and make inquiries. So it is the key.
Combination.
Of the two I'm sure.
Great and then Rick I didn't hear it in the script, but we.
We got great sales growth, how should we think about the spending in 2022 to support that thanks a lot.
Yeah.
Sure.
We're still early.
In the early innings of our commercial rollout and so we're still heavily investing.
In.
Our operating expenses.
We're continuing to invest in adding a.
Territory managers aggressively as well as adding centers.
In addition, we we see a return on investment with our DTC spend so we've increased that so.
That increased.
About 80% in 2021.
Overall dollar perspective, we will continue to make those investments in DTC, but the growth will slow.
Operating expenses.
Grew.
50%.
In the fourth quarter over the prior year, we're going to continue to make those investments.
We know profitability is important.
We have shown some leverage in our business in the fourth quarter compared to a year ago.
But we're going to continue to make those investments and so.
We want to make those investments that will drive years of.
Future revenue growth rather than optimizing our P&L.
No.
Great. Thanks, a lot appreciate it thanks Ravi.
Thank you.
Our next question comes from Danielle <unk>.
And kelcey.
SBB Leerink.
Your line is hey.
Thank you so much good afternoon guys. Thanks, so much for taking the question congrats on a really great and Q2 of the year.
I had a question they are both kind of on guidance. So I guess the first question really is.
How do you think about the cadence through the year, and particularly Q1 I appreciate youre not going to give quarterly guidance, but even just directionally.
<unk> been so early in the launch and then layer on top of it.
Seasonality is tough to decipher on are and what the impact of seasonality is looking back.
Last year.
Again, Covid muddying the waters, but I think you are only down about 12% or so sequentially consensus has you download a 20% sequentially. This first quarter versus the just reported Q4, just wondering if you could talk a little bit about qualitatively how to think about that and maybe the cadence through the year and just one quick follow.
Sure.
Sure right.
We only provide annual guidance.
Yes.
And our guidance strategy has not changed at all.
Watching the first quarter really closely because of the <unk> variant.
Because it did impact Q4, and we are seeing some impact at the beginning of the first quarter.
Also we do have seasonality.
So.
Despite that.
We have provided guidance on annual basis that we're comfortable with and with this aggressive guidance. It does represent 36% to 40% growth over our 2021 revenue.
But again, we're watching overcrowded closely.
Very recently case numbers have gone down, but we did have a we had a big impact in January and so on.
We are tracking that closely but on overall basis, we feel obviously feel.
With our guidance put forth.
Okay. Okay, that's fair and then on total year.
Guidance for the year, just curious about what.
<unk> in that from a COVID-19 perspective, and maybe more importantly from a permit.
That has all staffing sorry, but like a staffing perspective and as we move through the year, you know trying to get our hands around.
What the impact or what the recovery I am sorry could look like.
The staffing issues that a lot of these health care systems and assays are dealing with so.
What's reflected as we think about a recovery at the low end the high end of the range and thanks. So much you bet Daniel good to talk to you.
Well, we're tracking like everybody Covid and we see the anticipation that COVID-19 is really kind of settling down now we've been able to operate pretty successfully in a COVID-19 environment already obviously, we're going to be little bit careful at the beginning of the year.
As we set the full year guidance.
To make sure that we have the peer confidence coming out of the.
Johnson through the first quarter second quarter and then.
Throughout the rest of the year, we'll continue to <unk>.
Restaurant opening centers and scaling.
The sales team the field team and increasing our.
Training team as well so we're planning that we have.
We'll be able to stay on top of Covid as we have in the past and but be a little bit careful as we kind of set up in the beginning of the year here.
I appreciate that thank you you bet.
Thank you.
Our next question comes from Chris Pascal of Guggenheim Your.
Your line is open.
Thanks, Good afternoon, guys I wanted to start with the New center start guidance. So the 52 to <unk> 56 per quarter I'm, assuming that's a gross number and then we should net out the 25 to 30 that youre going to kind of coal in the second quarter is that right Thats correct, yes.
We set guidance to open $52 56, new centers, absolutely and then as the overall.
We will take out that 25, 30 centers, who really really haven't been contributing.
Caseload anyways right. So we're just allowing the team to really focus.
Those centers that have been.
Able to really take care of the patients.
Yes, and that really plays right into my next question, which is how productive those centers you're stepping away from have been do you have a rough sense of how many cases those centers netted down in 2021.
Well I think thats kind of the start of it and for the most one of the first things. We look for is those centers that really haven't add.
Activity.
Over the last year and then we look at over the last couple of years.
And then we can see if they have already been removed from our website now we go and talk to the center to see who's involved.
At the center and in a lot of certain lot of cases.
The surgeon has moved away and gone to a different location or there's different aspects to it but for the most part.
I haven't contributed a lot of <unk>.
<unk> or helped a lot of patients over the last year.
Okay Thats helps.
And then just lastly for me I thought the announcement on Singapore, and Hong Kong is interesting.
Is that a sort of a first step towards looking at mainland China or is that an entirely different ballgame, it's still going to take you quite a while to expand into.
Yes, it's a yes to both I mean it is first.
Certainly our expansion in the Asia market, and Singapore, and Hong Kong, It's really focused on just a couple of hospitals in each of those locations that are very prominent.
Institutions, but it also does kind of open the door to to start building on our pathway into China, which as you know is a significant.
Project on its own so, but yes, we're excited to open up these two new territories, but it also puts us.
<unk> has inspired with a greater presence in the area and allows us to really start looking at a broader.
Expansion, including South Korea as well.
Thank you.
Yeah.
Our next question we have Adam.
Piper Sandler your.
Your line is open.
Hey, guys. Congrats on the nice finish to the year and thanks for taking the questions here.
Wanted to start with.
One on direct to consumer advertising and some of the encouraging trends that youre seeing to start 2022, I guess it would be helpful. Just if you could level set us on kind of where the conversion rate is today.
From a DTC spend in website traffic and where do you think that kind of hit rate can go in the future and where are the key levers there and then I had a follow up.
Fantastic well, we kind of mentioned in the script a little bit that we realized a lot of the contacts from the community health talks there really kind of more education on them and the patients are able to get the information they need in process unusually come back and go through the adviser care program. Therefore, we are really focusing on the context with the adviser care.
Our program and starting to characterize what is our conversion rates with those don't have the precise numbers, yet, but we do think we're getting into that.
We're getting out of the highest the high single digits and into.
Maybe 10 to low teens and present, but we also think that as the key opportunity and us being able to make sure we find the <unk>.
Techniques to help patients get an appointment with the center and we are starting to use E mail a little bit more at some texting approach. We also are working with patients to remind them to a tender appointments and they follow up with them to make sure that that we.
We received the proper information that they were looking for so there's a lot of techniques that we can use through the whole process of educating them and getting them through the system and to be able to have an implant. So our goal is to get that to the middle teens, if not even higher.
Because thats really the ability for us to really start to grow the adoption of the therapy.
That's really helpful. Tim I appreciate the color and then just for the follow up.
Maybe I'll ask about the progress that youre, making in from an ASC side of things.
I think I heard in the prepared remarks, 22% of your U S. Centers are now afcs can you give us a flavor for kind of volume mix.
Between hospital outpatient and ASC today kind of where that fits and I'm. Just curious if you have kind of any.
Data that you can share around utilization trends between those two different sites of care.
<unk>, showing some kind of encouraging throughput trends thanks for taking my.
Absolutely so while the ASC is make up 22% of the centers today, there is still new and up and coming therefore, theyre not quite making up 22% of our implants to date, which is still trailing behind there and thats still thats going to be a little bit of a trailing factor, but that will catch up.
We're going to keep opening up more ASC, so it's going to be chasing each other.
Along the way interesting enough when we start looking at centers.
Not just <unk>, but also hospitals in those opened in the last several years tend to have a higher utilization.
And Thats a lot because of the training that we're doing and setting expectations of doing a certain number of cases.
Per month.
And also you've got to remember the new centers. They don't have the old education of the struggles of obtaining prior authorizations that are entering the world of inspire with.
A solid reimbursement, where we can get approvals in just a few days and they can be assured that they can get a proper payment levels.
So they don't have that bias to be able to open up more.
Or times and or slots and commit more of their practices. So I think in general centers open up.
In the last few years will have a higher <unk>.
Utilization, but I do think as we get further down the pathway, yes, I think <unk> really have the ability to even accelerate that further.
Great. Thanks, Tim Thanks, Adam.
Thank you.
Next we have Larry Nicholson of Wells Fargo. Your line is open.
Hey, Tim Hey, Rick Thanks for taking the question.
Okay.
Two for me first just a short term question, Tim I understand January was tough, but as cases come down what are you seeing and how much visibility do you have on scheduling and Im curious what youre seeing there and I had one follow up.
Well, we certainly see the schedule and we have access to it we know Covid was again or the omicron was a regional impact again, but this time. It is not just hospital beds, it's really the staff.
The <unk> spread so quickly that we actually had patients and as we've mentioned in the notes now we were dealing with employees to that they are unable to cover cases, so we're moving people across.
Different territories to be able to cover cases, we're able to do that but I do think that as we come out of January just like in 2021.
We're able to kind of hit our stride again in February and March so the same phenomenon with our seasonality, but just again like in 2021, just impacted by the Covid research, but we're encouraged by what all of US are are witnessing with a reduction of corporate cases, which is which is certainly one.
Welcome.
Thanks for that and then just on the Philips recall, Tim are you guys able to track inspire patients that were subject to the Philips recall and if so what are you seeing in did you bake anything into the 'twenty two guidance for that thanks for taking the questions. Thanks, Larry I think we certainly know that we have a benefit from that.
Recall, we certainly know that patients are coming to.
To the website and talking to doctors and looking to find an alternative because they simply don't have the ability to use their CPAP, we can't get them approved through the insurance companies, it's difficult for us to accurately quantify that we do get some indications from the adviser care program, we certainly get indications.
From the prior authorization work that we do when we submit.
United Healthcare and the commercial payers that these are patients coming from Philips, but we don't really have an overall impact certainly yourself and others have reported on.
Subjective measures when when you speak with physicians and they talk about how they feel how many cases on a weekly basis. So we know it does have an impact again, we just have a difficult time to accurately quantify it but we do kind of build then just overall flow when we set our guidance.
Got it thank you guys.
Thank you.
Nick Tim.
Hassan of Goldman Sachs. Your line is open.
Okay.
Hey, Thanks, it's Phil on for Amit.
A lot of a lot of the questions have been asked.
But I thought maybe try and drill in just a little bit to clarify things.
In your prepared remarks, you talked about.
Staffing and COVID-19 related issues kind of.
In conjunction with each other almost as though they were similar issue I'm wondering.
If there is staffing issues beyond the sort of COVID-19 disruption that are contemplated in your 'twenty two guidance and if not what gives you confidence that staffing shortages that you're seeing across the rest of health care arent going to impact inspire at the same level.
Sure. Thanks, Ron I think that we have a little bit better line of sight.
Scheduling cases, and so when we talked about the fourth quarter.
At your conference.
We talked about how we are able to schedule cases about three to four weeks out so right. After Thanksgiving, we were really scheduling cases.
Into the last week of December which is always the most competitive.
For all our time in the U S, but having a little bit of forward look on that schedule. Those cases gives us a little bit of an advantage to not be too impacted by the staffing challenges.
At the end of the year and early in January the staffing affected how much or time could be open and if the staff was focused on working on the floor with the Covid cases, where and that's always a challenge that we have to deal with but having a little advance notice gives us a little bit of an <unk>.
<unk> to be able to get those cases scheduled certainly less impacted in the ASC and less the specific staff and the specific.
Surgeon.
Test positive themselves that obviously affect staffing, but we think that short term. We don't think it's going to really have a significant impact as we.
Move through the first quarter here.
Okay. That's that's great extra color then.
I know that you guys have a little bit of a unique situation on the gross margin line, but it was another strong 80, 586% and things really improved throughout the year I am wondering if there is a kind of a risk is the inflationary environment that we have going on here could potentially impact numbers at some point down the road with that relationship you have on the contract manufacturing side. Thanks.
I think that we have some significant technology advancements coming down the road.
While the new Bluetooth remote was approved the new physician programmers in the works.
Full body MRI, and then, especially the fifth generation inspire Neurostimulator, we did have a new code set in place and so it does.
Provide the proper reimbursement for hospitals.
And now even physician so I don't think we're going to have any kind of compression issues on price I think it might be in the U S might have a little bit more of an opportunity over the midterm that it is.
Our risk of compression.
Okay. Thanks, a lot them.
Thank you.
Thank you.
Next we have Jon block Stifel. Your line is open.
Great. Thanks, guys good evening.
I don't know if it's up a little bit but just the first question I guess is specific to the cadence or.
A different way of attacking and so if I look at 2021.
<unk> was about 17% to 18% of full year revenues again for 2021.
Other years, you always have the seasonality to be clear, but other years. It was like 19% 19, 19% plus and you keep referring back to this seems like a similar playbook to what you experienced in 2021 right at pretty Rob January but then finding your footing and fab in March and so when we think about that cadence is that the right way to.
Weighted if you want to refer to shake out is for $1 22 to fall a lot closer to the 21 playbook on.
Full year waiting versus what we saw in the prior three or four years.
Well, obviously, we're pretty early in the quarter right.
But the <unk>.
January certainly stacks up close to 21 with a combination of seasonality as well as another Covid research right. So that's what I would kind of describe that a little bit just to make sure people are aware of that but again pretty early in the quarter, but we still want to stay kind of aggressive with our overall annual guide.
<unk>.
I guess I'll leave it at that.
Okay Fair enough and then maybe just to shift gears and talk about the utilization drivers <unk> and.
ACP Advisory care program Bema.
Be mistaken, but I think back to coverage and I thought for some coverage policies in the past you've talked about going back to some of the payers and trying to get.
<unk> revised down he was 35 can you get it down to 32 is that still on the cards has added all been Tim do you think a gating factor to growth and if so where are you with some of those initiatives, yes, actually a little bit of the opposite some of the payers actually came out with a limitation of BMI 32, we're trying to get them up.
I apologize.
Okay, and Medicare really helped all of that so when all of those local coverage determinations came out and Medicare came out and set the bar at BMI 35, all of the commercial payers like United and Aetna and add them all of their Medicare advantage programs have to match that so they have to honor the 35.
And United as an example, they just came back and added.
<unk> from 32 to 35 on their commercial policies as well, we'll continue to work through that.
Today.
We're really focused on the logistics of implementing the new code and you can imagine that every single center in every single software package in every payer has to convert over to the new CPT code.
So today, we're just focused on on the.
The brick and mortar of just getting the new code in place to make sure everybody is building and the new code and working through that logistics. Once we get that done that will be done in the next month or it will kind of get back to the the policy work and really working to standardize all the policies across the board So don't think.
It really is a limiting factor.
Growth.
Simply that we.
We just have so many patients enquiring about inspire.
And our conversion rates are still growing but we have so much opportunity that in itself I don't think the policies really are a key driver.
One element you brought this up all I'll talk about it we will be talking to the FDA.
The label that we have with the FDA does have an upper limit of ehi 65, and we have been collecting data over the years most insurance companies policies do not have an upper limit, including the Medicare policies. So we're going to be working with the FDA to see if we can't do a indication expansion to help those.
With the higher ehi, so theyre not <unk>.
And off label, but so there is a lot of work that we're doing to continue to expand expansion as well as continue to standardized policies across the board.
Perfect. Thanks, guys.
Thank you.
Thank you.
And we have Suraj Kalia of Oppenheimer <unk> Company. Your line is open.
Good afternoon, Tim can you hear me Alright, Yes, Suraj are you hope everyone is safe and healthy.
So Tim let me.
He.
Address FY 'twenty two guide from a different angle, okay. The guidance implies even if I remove the 25 nonperforming sites forgive me if I got them.
Jack is wrong, but the 25 sites are removed that.
Would be exiting FY 'twenty, two give or take <unk> 78 to 75 sites.
Remove all use approximate contribution.
Mass is implying.
Our fleet utilization of about $3 six implants per quarter per center.
Seems to be a step down.
There are other new centers.
Quote unquote low volume centers are there some other mitigating factors, maybe if you could tie.
The FY 'twenty two annual guide.
From a utilization perspective, any color would be great yes, okay.
Two things.
The easy.
The answer to that is look at the number of centers, we opened in Q3 and Q4.
And we open I think 81 here on <unk> 72 in the third quarter. So you have 153 centers in the last two quarters and the key with them as they are sold.
A short window to be able to operate in if you took a marlin in average they could only operate for three months and so they would never be at the overall utilization. So you almost have to kind of remove those other 153 centers from your numbers.
Because we're seeing actually a step up in utilization and Thats like the key driver remember the 100 all of the centers that opened in 2021 are considered new.
Centres and the 60% of our growth was coming from existing centers that were opened in the prior year. So you're on the right path of track with your math, but it's got to be a little careful on that.
The centers that we opened late in the year because they are just they are they're not contributing to utilization yet they need a little bit more time and to be able to do more cases in <unk>.
Over the calendar year.
Tim I'll take it offline the methodologies the same throughout but anyway I'll take it offline and we can go with them and keep them on the new sites.
If you can in the U S would you characterize as the pool of new sites.
And specific for FY 'twenty do forgive me if I missed this.
How do you look upon new stores versus full store same store our old stores. Thank you for taking my questions sure Suraj.
<unk>.
As a rule when we talk about same store sales any center that was opened in 'twenty, one or before is considered an existing center.
And the new stores or the new centers are those that are opened in the current calendar year I know that causes a little bit of challenge.
There's a lot of centers that opened in 2021 that will not have a full year of performance in that they may have as little as five days because they opened up late in December to do their first procedure, but thats, how we do it because we always characterize our centers by class the class of 2014, which was our.
Initial year 15, 16, 17, 18, all the way through and so when we do the measurement of contribution of growth.
We only use those centers that are in the current calendar year are used to contribute to the growth.
Very good alright, thank you.
Very much.
Thanks.
And seeing no further questions in the queue.
Conference.
<unk>, Tim Herbert for closing remarks.
Thank you all for joining the call today as always I am grateful to the growing team of dedicated inspire employees for their enthusiasm hard work and continued motivation to achieve.
<unk> successful and consistent patient outcomes the inspire team's commitment to the patient remains unmatched and is the most important element of our success.
I wish to thank all of our employees as well as the health care teams for their continued efforts as we remain focused on further expanding our business in the U S Europe and now Japan.
For all of you on the call. We appreciate your continued interest and support of inspire and look forward to providing you with further updates in the year ahead. Please stay itself in a safe and healthy.
Yes.
Okay.
This concludes today's conference call. Thank you all for participating you may now disconnect and have a pleasant day.
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[music].
Yes.
Yes.
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[music].
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Yes.
[music].
Yes.
[music].
Okay.
Sure.
Yes.
Yes.
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[music].
Yes.
Yes.
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Yes.
Yes.
Okay.
Yes.
Thank you.
Okay.
Yes.
Okay.
Okay.
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Yes.
[music].
Yes.
Yes.
<unk>.
Yes.
[music].
Okay.
Okay.
[music].
Okay.
Yes.
[music].
Yes.
Okay.
Yes.
Okay.
Okay.
Okay.
Okay.
Okay.
Thank you.
[music].
Yes.
[music].
Yes.
Thank you.
[music].
Yes.
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[music].
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[music].
Okay.
Yes.
Please.
Yeah.
Yes.
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[music].
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Yes.
[music].
Yes.
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Yes.
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Yes.
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Great.
Yes.
Sure.
[music].
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Yes.
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Yes.
[music].
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Yes.
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[music].
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[music].
Yes.
Yes.
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Yes.
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Yes.
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Thank you.
Yes.
[music].
Okay.
Okay.
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Okay.
Yes.
Yes.
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Sure.
<unk>.
Okay.
Yes.
Okay.
Okay.
Okay.
Okay.
Thank you.
Okay.
Okay.
Okay.
Sure.
[music].
Yes.
Okay.
Okay.
Okay.
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Thanks.
Sure.
[music].
Okay.
Yes.
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[music].
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[music].
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Great.
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Sure.
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[music].
Yes.
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Yes.
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Yes.
[music] space.
Okay.
Thanks.
Sure.
Yes.
[music].
Okay.
Yes.
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Yes.
[music].
Right.
[music].
Sure.
Yes.
Okay.
[music].
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Yes.
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[music].
Okay.