Computer Programs and Systems, Inc. (NASDAQ:CPSI) Q4 2022 Earnings Conference Call February 14, 2023 4:30 PM ET
Company Participants
Dru Anderson – Corporate Communications
Christopher Fowler – CEO and President
Matt Chambless – CFO
Conference Call Participants
George Hill – Deutsche Bank
Stephanie Davis – SVB Securities
Operator
Greetings and welcome to CPSI Fourth Quarter Earnings Conference Call. At this time, all participants are in a listen-only mode. A brief question-and-answer session will follow the formal presentation. [Operator Instructions]. And as a reminder, this conference is being recorded.
It is now my pleasure to introduce to you, Dru Anderson. Thank you, Dru. You may begin.
Dru Anderson
Thank you. Good afternoon and welcome to the CPSI fourth quarter 2022 earnings conference call. Leading today’s call are Chris Fowler, President and Chief Executive Officer; and Matt Chambless, Chief Financial Officer.
This call may include statements regarding future operating plans, expectations, and performance that constitute forward-looking statements made pursuant to the Safe Harbor provisions of the Private Securities Litigation Reform Act of 1995. The company caution you that any such forward-looking statements only reflect management expectations and predictions based upon currently available information and are not guarantees of future results or performance.
Actual results might differ materially from those expressed or implied by such forward-looking statements as a result of known and unknown risks, uncertainties, and other factors, including those described in our public releases and reports filed with the Securities and Exchange Commission, including, but not limited to, our most recent annual report on Form 10-K.
The company also caution investors that the forward-looking information provided in this call represents their outlook only as of this date and we undertake no obligation to update or revise any forward-looking statements to reflect events or developments after the date of this call.
At this time, I will now turn the call over to Mr. Chris Fowler, President and Chief Executive Officer. Please go ahead, sir.
Christopher Fowler
Thanks Dru and thank you to everyone for joining us this afternoon. I’ll start the call today with a quick review of our financial and operational highlights from the fourth quarter and then I’ll share some of my thoughts on the past year and where I envision CPSI going in 2023.
For the fourth quarter of 2022, we delivered total revenue of $83 million, of which roughly 55% was derived from our RCM offering, TruBridge. Our RCM offering has 98% recurring revenue and grew 29% from the fourth quarter of 2021, further demonstrating our progress towards improving the consistency and predictability of our topline.
We generated $13 million in adjusted EBITDA during that quarter, a decrease of 7.7% over the prior year, which Matt will elaborate on. Our total bookings for the quarter were $25 million, an increase of 59% year-over-year and 20% sequentially.
Looking at a level deeper, bookings from our RCM solution alone increased 1.6 times year-over-year and 19% sequentially with RCM bookings from cross-sell alone up 98% from the fourth quarter last year. Cross-selling into our EHR customer base is the foundation of our growth strategy, so the recent strength in this bucket of bookings is particularly pleasing.
As our business continues to evolve into more RCM dominant themes and to provide more transparency into the health of our business, we are going to start providing net patient revenue under contract or NPR on a quarterly basis. We believe this will be a meaningful metric to track our progress.
After all, improving the financial strength of our hospital customers is the problem that TruBridge strives to solve, and there’s arguably no better metric to measure our performance in scale than NPR. Matt will also share some more about this a bit later on the call.
On the operational side of things, during the fourth quarter, we have a few things to highlight. In our RCM business, we have 30 go-lives across all of the RCM offerings. Additionally, we continued our expansion of offshore resources ending 2022 with more than 100 offshore employees with the ambitious target of quadrupling that rate of offshore utilization as we exit 2023.
This not only represents an abundant margin expansion opportunity for us going forward, but also a strategic imperative to ensure our RCM business can scale as our solutions continue to gain momentum.
In our patient engagement business, I want to briefly touch on the two contracts that we noted were delayed on our previous call. The first is Steward Health in Florida, which was impacted by Hurricane Ian. We’ve been working hand-in-hand with that team, and we are now live and have rolled out our solution to the majority of their facilities.
In regards to the second delay, we anticipate the international implementation to happen in the second quarter. Our conversations with our telecom partner continue to be optimistic as we work through governmental delays in these markets.
It’s also worth highlighting that our revenue recognition and outpatient engagement solution is a little different than the rest of our business. We recognize revenue once implementation is complete and the solution is turned on only when a patient signs up for the solution. While the revenue ramp may not be as steep as it is in the RCM business, it’s a higher margin than RCM, and it’s very sticky once the patient signs on.
Finally, in our EHR business, we continue to realize and focus on adoption and utilization of our products by our customers. Many of our long-term customers, those who have been with us more than seven years have not stayed on track with software utilization, but we’re going to fix that.
The client executive role we’ve been bolstering this past year will be key to our success in this area. As a testament to our dedication to improve our customer experience and overall satisfaction with our product, we made the necessary investment to improve our client executive to customer ratio to less than a third of what it has been. Additionally, this increased investment triples the workforce that is focused on generating the opportunity for us to capture the $400 million of RCM cross-sells.
As we close out 2022, I want to spend a few minutes looking back at what we’ve accomplished this past year and why I was so excited to take on the role of CEO. When I accepted the position this past spring, my goal is to build upon our well-established foundation to drive innovation and growth.
CPSI is a very mature company founded almost 50 years ago with a large loyal customer base and a comprehensive suite of solutions. This is a critical time to remain acutely focused on what’s gotten us to this point and to acknowledge that we’ve hit some bumps along the way.
Moving forward, we will continue to improve as we pivot towards not just execution, but also towards growth. One of my priorities this past year was to strengthen our relationships with our customers, especially since cross-sell conversion will be paramount to our success in 2023 and beyond.
To that end, it has been a high priority during the back half of 2022 to meet face-to-face with as many of our clients’ CEOs and CFOs as possible to hear directly from them and to share my vision for CPSI.
Through a half a dozen regional customer events and getting out to our client sites weekly, the connection has been invaluable. And this commitment to strengthen customer relationships extends beyond me. It includes our senior management team and our client-facing executives.
Not only does this provide scale, but the client executive role, which I mentioned earlier, is key to our customer satisfaction and ultimately, redemption. With the pandemic behind us, we are leaning in heavily to an in-person high-touch strategy for our clients.
We offer solutions for community health systems and their leadership teams. It’s essential that our customers have a good understanding of our solutions as well as our organization and our people because building trust by getting to know each other is an important success factor for our customers.
After talking with our customers lately, I’m particularly pleased with the sentiment they’ve shared with me that they — that as we invest in our clients, we will see the return materialize into their reengagement with our offerings.
The increase in customer-facing activities also raises awareness of our RCM offering and I believe have a real impact on our RCM bookings, which increased 2.4 times in 2022 versus 2021. Our customer retention rate of 95% in 2022 is consistent with the high marks we’ve achieved in years prior, but we will strive to do even better in coming years.
I view 2022 as a year that we put the pieces into place with new leaders at the helm and I feel good about all the work we’ve done. Our expansion of the RCM business opens up a new part of the market, expanding beyond hospitals of less than 100 beds where we have historically focused our EHR efforts.
We are laser-focused on our vision of selling our RCM solution to both our existing customer base as well as to hospitals of 400 beds or under. There are more than 4,500 hospitals in the US that fit that criteria, representing a total addressable market north of several billion.
It’s very clear that RCM is the key to our future growth as these hospitals will increasingly look to outsource partner all of their RCM processes to trusted partners like CPSI to simplify their revenue cycle needs.
By the end of 2023, we feel that RCM will represent close to 60% of our total revenue. We’ve laid the foundation necessary to seize the opportunities ahead of us. We’ve added the right people to our team, and we have the solution that our customers need. I’m incredibly excited to see what 2023 has in store for CPSI, and I look forward to updating you on our progress.
I’ll now turn the call over to Matt for a closer look at the financials.
Matt Chambless
Thank you, Chris and thanks to everyone on the call. As Chris shared, we ended the year on a solid footing, and I’ll run through the numbers in just a minute. Before I jump into the financial results, though, I want to spend some time explaining how Chris and I have evolved our thinking on the business and the metrics we’ll share with you to assess the progress we’re making.
The business of CPSI has evolved meaningfully with RCM now representing over half of our revenue and a significant portion of our growth. Recognizing that evolution, you’ll notice that we’ve slightly changed the presentation of our revenue streams to better reflect the three distinct business units that we see within CPSI; TruBridge’s RCM business, the combined acute and post-acute EHR business, and our nascent high-potential patient engagement unit.
Also, as Chris mentioned, we’re going to start providing net patient revenue under contract, or NPR on a quarterly basis. And with that in mind, we ended the year at a hair below $3 billion of net patient revenue under contract, an increase of 37% year-over-year and a three-year CAGR of roughly 17.5%. This NPR was comprised of $2.4 billion from TruBridge and $600 billion or $0.6 billion from the recent HRG acquisition.
To help you understand this new metric in the context of our past performance, we’ve included a table in the press release with our historical NPR data for each of fiscal years 2019, 2020, and 2021, along with each of the quarterly periods of 2022 for your reference.
Our intent with this new NPR metric is to supplement our bookings disclosures to provide a more complete picture of growth and scale as bookings alone have proven to be an imperfect metric.
If you followed the CPSI story for a while, you know that our bookings metric is quite lumpy as the deal population is characterized by a relatively small number of high-value deals.
The end result is a 90-day measure that oftentimes is more a function of timing for a handful of deals than reflective of any true strength or weaknesses in our sales environment, which can undermine the usefulness of this measure for investors.
On that topic, bookings for the fourth quarter totaled $24.7 million, driven by continued strength in our RCM business with the EHR business unit closing out strong with its best bookings performance of the year driven by net new hospital client wins. RCM bookings were up 163% year-over-year and 19% sequentially, continuously earning its title as growth agent for CPSI.
In looking at the individual components of RCM bookings, cross-sell bookings were up 98%compared to the fourth quarter of last year, while bookings from outside of our EHR customer base increased to 7.6 times the prior year amount as the strength of HRG’s sales force has made this a core competency.
Turning to the income statement. Fourth quarter revenue of $83 million compared to $74 million last year. RCM contributed $45.7 million, EHR revenue was $36 million, and patient engagement made up the remaining $1.6 million.
Our gross margins of44.6% for the fourth quarter were down 520 basis points year-over-year due to the increase in our RCM services business, whether through acquisition of HRG or through organic bookings driven growth, the lion’s share of 2023’s topline gains came from high touchpoint lower margin service lines causing a heavy shift in revenue mix that pulled gross margins down.
As we look to the future, the acceleration of our offshore initiative will be key to the margin expansion. Our operating expenses as a percentage of revenue were 40% in the quarter, the same as last year.
Adjusted EBITDA of $13.2 million decreased by $1.1 million year-over-year. Despite the year-over-year revenue growth, the gross margin gains by the RCM business were offset by gross margin losses in our nascent patient engagement business as high incremental margin non-recurring revenues declined.
The end result was a gross profit number that was flat, while higher benefits cost and strategic investments in our public cloud migration efforts created further headwinds for EBITDA.
Turning to the rest of the financials. Operating cash flows for the quarter were relatively low at $2.2 million. This is unusual for us and is a direct result of timing issues related to the collections associated with the integration of our recent acquisition.
The slowdown in collections negatively impacted the fourth quarter, but we are making progress and saw an improvement in DSOs in January. While we haven’t quite reversed the trend just yet, we’re heading in the right direction, but it may take until early Q2 to fully unwind.
Finally, I’ll conclude my remarks by providing some color on our initial 2023 outlook. For full year 2023, we expect revenue to be in the range of $340 million to $350 million and adjusted EBITDA to be between $59 million and $63 million. As for how revenue and EBITDA will be distributed throughout the year, revenue is expected to be slightly weighted toward the back.
And from an EBITDA perspective, in the second quarter, we see our heaviest cost due to the hosting of our National Client Conference in the fourth quarter is generally our lightest cost quarter as a result of the timing of benefits and vacation utilization.
One final note on the topic of guidance. The company had previously provided an $80 million EBITDA target for 2024, but we now feel the more appropriate target is returned to double-digit organic revenue growth over the next 24 months, with strategic acquisitions being additive to that growth.
From a margin perspective, we believe we can achieve 20% adjusted EBITDA margins over the same time period. Chris and I feel very good about everything we’ve put into place this year and look forward to continuing to update you on our progress in 2023 and beyond.
Thank you all again for joining us today, and we’ll now open the line up for questions. Operator?
Question-and-Answer Session
Operator
Thank you sir. We’ll now be conducting a question-and-answer session. [Operator Instructions]
And our first question comes from the line of George Hill with Deutsche Bank. Please proceed with your question.
George Hill
Hi. Good morning guys. Can you hear me okay?
Christopher Fowler
Yes, we can.
George Hill
Hi. Matt and Chris thanks for taking the questions. The first question is a point of clarification where I want to make sure I heard your commentary correctly. So, the expectation is that you guys expect to return to double-digit organic revenue growth, and that’s for the composite, not just for TruBridge with 20% adjusted EBITDA margins and M&A will be additive.
And I guess can you kind of frame up how you’re thinking about the delivery of that result from the timing? First, did I get it right? And second, I’d like to hear about your thinking about the delivery of that from a timing perspective?
Matt Chambless
Yes. So, I’ll jump in there, George, and thanks for being on the call today. You did hear that right. What we see is return to organic revenue growth for the company returning to double-digits as we exit 2024.
So, we obviously don’t see that in the cards for 2023, but particularly as we get into the back half of 2024, we see the growth opportunity within the RCM business being sufficient enough to pull us across that line returning to double-digit growth.
George Hill
Okay. And I guess kind of the implication there then is that the RCM business is going to have to accelerate to a number that approaches 20% growth. I guess could you talk about kind of the visibility that you have that gets you there?
And you talked about off-shoring as contributing to the margin expansion. Is there anything else that we should be looking for as contributing to the margin expansion? And I asked these questions because I think delivering upon these two goals would kind of, I think, dramatically change the kind of the profile of the stock price.
Christopher Fowler
Yes, I think you’re right on it, George. The way we’re looking at it, again, if you go back to the — we exited 2022 with 100 offshore employees, and we’re looking to quadruple that number by the end of this year. So, when you look out exiting 2024, you will continue to see that growth — and this is obviously related to the expense side.
It has a bit of a slingshot effect. It will be incremental as we go. But when we hit that 400 number by the end of this year and then we continue at that pace, it really has a multiplier effect.
And quite honestly, the same is true on the topline. The big changes we finally hit that point. Matt’s been talking about this for quarters of hitting the bottom of this conversion from one-time revenue on the EHR side to now all — basically all contributions of revenue being recurring, and there’s a bit of a slingshot effect there. So, we see both of those. Modest growth in 2023, but that multiplier effect really taking a hold as we exit 2024.
Now, you put that on the back of the strong retention that we’ve had, we’ve put together some nice quarters back-to-back as it relates to the RCM bookings. Our pipeline continues to be healthy. So, it’s a matter of the market being here for that real conversion of the RCM potential that’s been talked about for the last several years.
George Hill
No, that’s helpful. And if you guys maybe give me another second or two. I guess I feel like in the RCM market, I know that it’s right, the evolution of TruBridge has been a long time in coming. You guys have kind of flown under the radar in this market and by not going after the larger health systems, you’ve competed in a more fragmented segment of the market.
I guess to the degree to which you can, I’d love you to just kind of — like I asked about visibility, but maybe can you talk a little bit, anything you could say about competitive environment? I recognize a lot of this market is either going to be hospitals that either in-source now or there’s a lot of regional mom and pops who participate in this space and maybe kind of pricing environment.
I guess are you seeing terms that we would traditionally attribute to some of the larger RCM vendors and outsourcers in the space? I guess kind of more on kind of visibility and differentiation and then I’ll hop back in the queue.
Christopher Fowler
All right. I’ll try to break that apart a little bit. You almost started answering your own question there. I think you’re absolutely right in the fact that still today in our market, the competition for RCM is primarily the hospital itself.
We referenced that stat. You can go to just about any rag and find this anywhere from 85% to 90% of all hospitals are still doing the billing and RCM management themselves. So, that’s really the main competition.
And to your point, if it’s not the hospital themselves, it is predominantly a regional player. We’re not seeing a lot of RFPs at that level. And so a lot of it becomes our ability to go — in the past, it has been much more from an outbound process of us going and drumming up opportunities.
What we’ve seen that gives us increased optimism going forward is the increase in inbound requests that we’re receiving for information on these services as well, which I think kind of leads to your second part of the question that relates to the pricing pressure on this. The labor market, the challenges in the labor market are really the driver here. And so where pricing was probably the number one concern, let’s say, 24 months ago, right now, the driver is let’s continue to make sure that the cash is coming into the facility.
And so the pricing pressure that we may have seen a couple of years ago is not as prevalent today. However, we are optimistic as we continue to be successful with our conversion offshore that we’ll be able to capture more opportunities because we will be more competitive at scale with the offshore operation.
George Hill
Okay. And then I’m going to sneak in one last one, which is how would you think about deployment of capital as the business accelerates and deployment of — accelerating cash as the business accelerates. You’ve got some debt on the balance sheet, but you’re also talking about M&A. Would love to hear you talk about capital deployment priorities.
Matt Chambless
Yes. So, George, I love the way that each question is prefaced by this is my last question. But when it comes to capital allocation, we really haven’t changed our thought process on that so much. At the end of the day, the decision on capital allocation is going to be determined by what the alternative set looks like, right? So, repaying debt in an inflationary economy does become, obviously, a bit more attractive to us.
But at the same time, we still think that there are lots of opportunities to continue to grow inorganically. And we think there are still some investment opportunities to make inside of the company. So, I know that’s a bit of a non-answer answer, but going forward, it’s really hard to stay with specificity, not knowing what the alternatives are going to be out there.
Christopher Fowler
Yes, the only thing I — I’m sorry, George. The only thing I would add on top of Matt’s comment there is probably maybe a little more aggressiveness as it relates to that internal investment and seeing where there are opportunities for us to continue to drive the different parts of the business that we see opportunity in.
And the call out there is obviously the EHR market is not our growth opportunity by itself as historically, everybody has thought about it. But it is the foundation for $400 million worth of opportunity in that cross-sell market. And so we’ve got to remain vigilant in delivering that value back to that customer set. So, they remain our customers, and we have that connection relationship in place.
And so we’re going to be more aggressive as we look at — to Matt’s point, we’ve got to weigh the different options and make sure the return is there, but looking to make sure that as there are options for us or opportunities for us to put more back into the product that we’re going to be doing so.
Matt Chambless
Yes. And to follow up on that, if we did have to give some sort of general prioritization, I would say that reinvesting back in the business would be priority number one. Again, we do think there are inorganic opportunities there. So, to the extent that the valuations make sense and that it fits from a product strategy and from a service delivery standpoint, inorganic growth through M&A would certainly be another opportunity that we’d look at.
Now, all of that being said, we want to make sure that we protect and that we defend the financial health of our balance sheet and we maintain our target leverage ratio of two and a half times that we’ve set a few years ago, and we’ve stuck pretty diligently through since.
George Hill
All right. Guys I appreciate you humor me. Thanks a lot.
Christopher Fowler
Thank you, George.
Operator
And our next question comes from the line of Stephanie Davis with SVB Securities. Please proceed with your question.
Stephanie Davis
Hey guys. Thanks for taking my questions. I’m back.
Christopher Fowler
Hey. Welcome back Stephanie.
Stephanie Davis
I left you guys and you’re an EHR company. Now, you’re a rev cycle company. What happened? So, maybe let’s dig in there a little bit first. Talk to me about why these businesses are still together. You’ve got one hypergrowth company. It sounds like you’re selling a lot outside of your base. Is it capital needs that keeps it together? Is it the cross-sell up? Why do we not think of splitting this up?
Christopher Fowler
Yes. Stephanie, first of all, welcome back. Obviously, we enjoy — have enjoyed, but glad to have you back. I would say you hit the nail on the head with the second one. One, we have — and let me back up beyond that. Obviously, we’ve had a rich tradition serving this traditionally underserved market in the rural health — rural and community healthcare. So, we have been in that business since 1979.
We do see, obviously, the growth for the company going forward is predominantly being RCM, but we don’t want to leave those roots. And so it does provide an opportunity for us to continue to help serve that segment of the market more holistically. So, not only are we providing a quality and value product on the EHR front, but also being able to deliver in RCM and patient engagement and other services going forward.
Stephanie Davis
So, I guess with that question in mind, could we dig a little bit deeper and see what sort of products would be valuable to cross sell both to your existing base as well as the rev cycle clients that are outside of your base when you think about M&A?
Christopher Fowler
So, okay. I’m sorry, I wasn’t following you to that last little part. I would say that we’re — if you look at our most recent M&A transactions, it’s kind of a nice little nod to how we’re thinking about pulling opportunities in. HRG is obviously a consolidation play with a pure service company with almost like-for-like services that TruBridge already offered. And then you go one more back and you see TruCode, which was a strategic partner of ours for five years but delivered and had a technology that our customers need and also one that we can leverage on the TruBridge side.
So, — but I would say, if we’re looking at the suite of TruBridge services holistically, the area from a tech standpoint would be on the front end. We’re pretty good from the middle all the way to the end. Where I think we may have some opportunity is looking at the very front end.
Now, obviously, you couple that with what we’re getting excited about from a Get Real Health standpoint and the digital front door there. So, that’s M&A plus internal investment opportunity kind of competing against each other.
Stephanie Davis
Understood. All right, last one. I promise this is my real last one. Looking at you, George. You started talking about scaling up offshore and that makes a lot of sense as you grow your revenue cycle business. But have you thought about any AI tools or robotic process automation tools that could also improve upon your cost structure beyond just geography?
Christopher Fowler
Yes, 100%. And it’s a tale very similar to the offshore initiative. We started in earnest our AI or bringing in RPA about the same time we started with the offshore processes. And remember, we’re not the biggest company in the world and so we’ve got to be mindful about execution and what it is that we can take on and remain focused. And so we feel like we’ve got our hands around the offshore initiative really nicely now and see that scaling out over the coming years. And so we’re really turning our efforts to that AI initiative that we started.
We have a team, an internal team that is dedicated to building bots, for lack of a better term, specifically focused on the RCM transactional work that we can deploy into the services that we have.
And so the hope is that as we continue to execute on that through 2023 that we’ll be — we’ll see numbers very similar to what we’ve seen from an offshore perspective, which is what gives us a lot of confidence in that returning to the 20%-plus EBITDA margin in the end of 2024.
Matt Chambless
Yes. And Stephanie we’re obviously fairly excited about the opportunity for offshore, especially seeing how early we are in the development of that lever for margin optimization. But we’re equally excited about the potential for automation. And frankly, we’re probably a little bit earlier in the game there than we are on the automation side.
We still have a lot of business processes within TruBridge that need to be streamlined and consolidated to make them good candidates for automation. So, we’ve got a lot of righting the ship internally process-wise to do to really take advantage of those opportunities, but they’re there and we’re very early in that ball game right now.
Stephanie Davis
[Indiscernible] Thanks as always.
Christopher Fowler
Thank you, Stephanie.
Operator
There are no further questions at this time. And I would like to turn the floor back over to Chris for any closing comments.
Christopher Fowler
Absolutely. Thanks again for everybody joining today and for your continued interest in CPSI. I hope everybody has a wonderful week. And Matt, Happy Valentine’s Day, buddy.
Operator
This concludes today’s conference. You may disconnect your lines at this time. Thank you for your participation and have a great day.
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