Q3 2023 Zynex Inc Earnings Call

Participants

Anna Lucsok; COO; Zynex, Inc.

Daniel J. Moorhead; CFO; Zynex, Inc.

Donald Gregg; President of Zynex Monitoring Solutions; Zynex, Inc.

Thomas Sandgaard; Founder, President, CEO & Chairman; Zynex, Inc.

Jeffrey Scott Cohen; MD of Equity Research; Ladenburg Thalmann & Co. Inc., Research Division

Shagun Singh Chadha; Research Analyst; RBC Capital Markets, Research Division

Yi Chen; MD of Equity Research & Senior Healthcare Analyst; H.C. Wainwright & Co, LLC, Research Division

Quinn Callanan

Presentation

Operator

Good afternoon, ladies and gentlemen, and welcome to the Zynex Third Quarter 2023 Earnings Conference Call. (Operator Instructions) As a reminder, this conference is being recorded.
I would now like to turn the conference over to Quinn Callanan from MZ North America.

Quinn Callanan

Thank you, operator, and good afternoon, everyone. Earlier today, Zynex released financial results for the third quarter ending September 30, 2023. A copy of the press release is available on the company's website.
Joining me on today's call are Thomas Sandgaard, Chairman, President and Chief Executive Officer; Dan Moorhead, Chief Financial Officer; Anna Lucsok, Chief Operating Officer; and Donald Gregg, President of Zynex Monitoring Solutions.
Before we begin, I'd like to remind you that during this conference call, the company will make projections and forward-looking statements regarding future events. We encourage you to review the company's past and future filings with the SEC, including, without limitation, the company's 2022 Form 10-K and subsequent Form 10-Qs, which identify the specific factors that may cause actual results or events to differ materially from those described in these forward-looking statements. These factors may include, without limitation, statements regarding product development, product potential, the regulatory environment, sales and marketing strategies, capital resources or operating performance.
With that, I'll now turn the call over to Thomas.

Thomas Sandgaard

Thanks, Quinn, and good afternoon, everyone. Thank you for joining us today for our third quarter 2023 earnings call. The third quarter was highlighted by ongoing revenue momentum, leading us to our 10th consecutive quarter of profitability and 6-quarter record-high order numbers.
We once again received the highest number of prescriptions in the company's history, beating our previous record and celebrated our 1 millionth patient treated since we founded of Zynex. These records led to total revenue for the quarter of $49.9 million, a 20% increase over the same period in 2022, and we produced $0.10 of earnings per diluted share. Our sales force continues to increase productivity and grow orders significantly each quarter, a testament to a great sales force, leadership and great products.
Orders increased 39% year-over-year, and we believe that there is considerable runway for us to continue growing orders into the future. The results we continue to show and the good work we are doing towards reducing the impact opioids have on communities are beginning to be recognized by the broader community, with the latest example being our ranking as the 23rd amongst the top 100 health care companies according to The Healthcare Technology Report.
To help drive our growth, we introduced 3 new rehabilitation products in the third quarter, building on our holistic noninvasive approach to pain management. The new products include Zynex Pro Thoracic Lumbar Sacral Orthosis or TLSO, a dual-purpose back brace for the mid and lower spine; Zynex Pro Wrist Brace for a broad spectrum of wrist-related pain management, including carpal tunnel syndrome; and the Zynex Cryoheat, a localized cold or hot fluid therapy system for home or hospital use.
We continue to focus on profitable growth by adding products to our portfolio in a complementary way that combine with our industry-leading prescription strength pain management device, the NexWave. In addition to the impressive results from our profitable pain management division, ZMS or Zynex Monitoring Solutions, continue to move forward in the third quarter in the development of our blood and fluid monitor and our laser-based pulse oximeter or CO-Oximeter.
We were excited to announce FDA clearance earlier this year for our second-generation blood and fluid volume monitor and noninvasive wireless technology targeted to improve patient outcomes with better fluid management in hospital settings. We continue to collect additional data in clinical trials, and Don Gregg will provide further updates on this product in his prepared remarks.
We have 3 additional products in the pipeline in our hospital monitoring division: a laser-based pulse oximeter, NiCO is the trade name for it; a monitor for early detection of sepsis; and a noninvasive, laser-based monitor of total hemoglobin levels, the HemeOx. Overall, we are making great progress in the patient monitoring division, which we believe will have a game-changing growth potential for the company.
Looking ahead, we are making significant progress building on our holistic noninvasive approach with at-home pain management devices and diversifying with new products. We're rapidly expanding direct sales that is delivering accelerating and high recurring revenue as we continue to execute operationally and strategically.
In tandem, we are focused on ramping up our hospital monitoring division, which represents a large and growing market opportunity. We expect consistent growth and strong financial performance for the remainder of 2023, following the double-digit growth we have produced year after year.
We also expect an additional catalyst and regulatory milestones in 2023, as we work to execute on our strong pipeline of new products. We look forward to additional updates in the months to come as we build our sales force and execute on growth objectives to improve the quality of life of patients suffering from debilitating pain or illnesses and bring long-term value for our shareholders.
With that, I'll turn the call over to Anna Lucsok, our Chief Operating Officer, for a more detailed business update on the pain management division.

Anna Lucsok

Thank you, Thomas. Zynex' pain management division had another impressive quarter marked by a sequential increase in order volumes over the second quarter and a 20% year-over-year increase in revenues. We were also incredibly proud to have surpassed treating 1 million patients during the quarter. Reaching such a tremendous landmark for the company is a testament of the tireless efforts and teamwork that each of our employee brings to this company.
As Thomas mentioned, we also added 3 new products during the quarter. Expanding our pain management product line helps us diversify our revenue streams and provides our sales force with more opportunities to break into new prescribers. We've seen continuous increase in volumes of our distributed products, including strong initial volumes of TLSO, wrist braces and Cryoheat.
The key to growth in pain management is the continued build-out of our sales force. We ended the third quarter with approximately 480 sales reps. During 2023, we've added a net of approximately 50 sales reps. And as we've mentioned previously, we continue to be aggressive in offboarding reps who are underperforming, so our overall rep growth has been a little slower than normal.
Revenue per rep on an annualized basis was approximately $430,000 during Q3, which is up 10% from Q2. As a reminder, it takes approximately 3 years for reps to meet our $1 million target in annual sales. The average tenure across the sales force is currently under 18 months, so we're still on track with that metric. We continue to make improvements in evaluating potential sales reps and evaluating productivity of new reps, which has allowed us to maintain revenue per rep at a high level despite the large numbers of reps we're adding.
We're ultimately working to fill out our 800 sales territories and continue to improve our processes to do so in a profitable manner. We expect that by the end of the year, we should reach roughly 500 sales reps. I look forward to another profitable year for the pain management division and updating you all on our market expansion in future calls.
I'll now ask Don Gregg, President of Zynex Monitoring Solutions, to provide updates related to that business division.

Donald Gregg

Thank you, Anna. Our patient monitoring division is a long-term investment for Zynex to diversify our revenues into one of the world's largest medical technology companies. Our pain management division's tremendous growth and profitability allow us to self-fund the build-out of a world-class patient monitoring business that leverages industry-transforming technologies developed through acquisition and organic development.
We can build the monitoring division while maintaining profitability and positive cash flow. Zynex participated in the American Society of Anesthesiologists Conference in October. Developing familiarity with our technologies capabilities amongst physicians is critical as we prepare for the launch of our monitoring products. From the ASA conference, we gathered several hundred leads, met with many key opinion leaders, continue to conduct market research and presented the underlying science and benefits of our laser pulse oximetry technology to this critical anesthesia group. Attendance at this conference and others have indicated strong demand for our monitoring products and rebuild several unforeseen potential sources of demand amongst noncore customers. Zynex will continue to be active in similar venues in the future that allow us to present our technologies to key opinion leaders.
We continue to develop NiCO, our laser-based pulse oximeter for commercialization in 2024. We continue to work toward FDA submission with several clinical trials. The clinical work has reinforced our confidence in NiCO and the benefit it will provide to clinicians and patients. We've continued to prepare patent submissions to the USPTO and have continued revising our commercialization and marketing launch plan accordingly.
Our next-generation noninvasive CM blood and fluid monitor continues to advance positively. Having received FDA clearance for the CM-1600 last quarter sets up our next-generation CM device, meeting our R&D and clinical milestones nicely for a smooth entry into the market. The CM monitoring technology is an entirely new addition to operating rooms, so market uptake will likely follow the elongated trajectory and rely on extensive engagement with medical advisers, key opinion leaders and industry audiences to build momentum.
I will now turn the call over to Dan Moorhead, Chief Financial Officer, for a more in-depth look at financial performance for the quarter.

Daniel J. Moorhead

Thanks, Don. Please refer to our press release issued earlier today for a summary of our financial results for the third quarter of 2023.
After commenting on our financial results, Thomas will review our guidance for the fourth quarter of 2023. In the third quarter, orders grew 39% year-over-year to the highest number of orders in company history for the sixth consecutive quarter. Net revenue grew 20% to $49.9 million from $41.5 million in 2022, primarily related to the growth in device orders.
Device revenue increased 49% to $16.9 million compared to $11.3 million in the third quarter last year. Supplies revenue increased 10% year-over-year to $33.1 million from $30.2 million in the third quarter last year. Gross profit in the third quarter increased to $40.4 million or 81% of revenue as compared to $33.1 million or 80% of revenue in 2022.
Sales and marketing expenses were $22.1 million in the third quarter of 2023 compared to $17.2 million in the same period in 2022, primarily due to increased head count of our sales force and increased incentive compensation related to order growth. G&A expenses were $12.7 million in the third quarter of 2023 compared to $9.4 million last year. Approximately 10% of the increase in G&A is related to investments in our Monitoring Solutions division and related head count to launch our new products. The remainder is primarily for back-office head count related to order growth.
Tax expense as a percentage was 27% effective rate for the quarter. Net income was $3.6 million and produced $0.10 per basic and diluted share in the third quarter of 2023 compared to $4.9 million or $0.13 per basic and diluted share in 2022. Adjusted EBITDA for the 3 months ended September 30, 2023, was $7.3 million versus $8.1 million in the quarter ended September 30, 2022.
We ended the quarter with $52.4 million in cash and cash equivalents and short-term investments and working capital of $83.1 million. Cash flows from operations for the 3 months ended September 30, 2023 was a record $8.9 million, and for the 9 months, cash from operations increased 29% year-over-year to $11.6 million. In the third quarter, we continued our stock buyback and repurchased $14.9 million of common stock, bringing the total repurchases in the past 18 months to $51 million.
As we've stated before, we believe this to be a signal to our shareholders that we are incredibly confident in our management team, the growth opportunities for both divisions, and we remain committed to creating shareholder value in the near and long term.
With that, I'll turn the call back over to Thomas.

Thomas Sandgaard

Thank you, Dan. It is becoming increasingly evident that we still have a long runway in our pain management division, growing revenues from the current just below $200 million to $800 million over the next few years with a strong bottom line. We have the monitoring division on the brink of launching, not just 1 but 4 game-changing product lines, and Zynex continues to operate on the backdrop of a strong balance sheet.
We've had a strong start to Q4 in terms of orders and expect to post our seventh consecutive record quarter. With the continued growth in orders in the fourth quarter of 2023, we expect total revenue of $52.5 million to $57.5 million, which is approximately 13% greater than the fourth quarter of 2022 and diluted earnings per share of $0.17 to $0.22.
As for our 2023 outlook, we are reiterating our initial guidance and expect total revenue to be $189.5 million to $194.5 million, representing growth of approximately 20% over 2022 and diluted earnings per share of $0.40 to $0.45.
With that, operator, please open up the call for questions.

Question and Answer Session

Operator

(Operator Instructions) The first question comes from Jeffrey Cohen with Ladenburg Thalmann.

Jeffrey Scott Cohen

So just a few. So I wondered if you could drill a little bit on the devices versus supplies. Have you seen a lag effect, if you will, on supplies behind devices historically? And should we assume that the stronger side of devices gets further pull-through on the supply side?

Thomas Sandgaard

I think Dan can obviously give you a little more technical detail. But overall, when we have for -- several months have had a very strong growth in orders. A lot of the revenue on the initial claims that is paid by insurance companies. A lot of that is obviously devices, and the supplies is revenue that typically sits on the tail end of those orders. So with the current uptick in orders, we typically see a lot of device revenue and as a percentage, not in absolute numbers, but as a percentage, we see a little less on supplies. But I don't know if you have any thing more technical to say there, Dan.

Daniel J. Moorhead

No, I agree with you. I think if you do look, device usually gets a little stronger as compared to supplies as the year goes on. And so that's just kind of a general trend we have. And I would agree with Thomas, the strong order growth is driving that number. So maybe instead of 25-75 going forward, it's more of a 30-70 just because the order growth has been so strong. But again, both are growing well.

Thomas Sandgaard

Yes. Long term, you'll see that percentage for supplies creep up again.

Jeffrey Scott Cohen

Okay. Got it. And then next, could you talk a little bit about some of the distribution channels that the physical therapy offerings you're going through and how those channels may have changed over the past few quarters and what they may look like going forward?

Anna Lucsok

There is no significant changes that we've seen over the last few quarters. It's still the same channels that are producing our prescriptions and orders.

Jeffrey Scott Cohen

Got it. And then lastly for us on the buyback front. I think you talked about $51 million over 18 months. So was the last piece of $10 million concluded and now you're on to the sixth one versus the fifth one?

Thomas Sandgaard

Not yet. It's obviously something considering how well we are doing organically, how strong our balance sheet is. We here recently have primarily been investing in 2 areas, the monitoring division and also because of how inexpensive the stock is right now, we find good use of the capital by buying back stock. And considering how it sits right now, we are actively debating to deploy more of our cash to buybacks.

Daniel J. Moorhead

So the fifth, there's been 5 recently, Jeff. There's one finished October. So it wasn't quite done at September 30 when you look at it, but that last $10 million finished up in October.

Operator

The next question comes from Shagun Singh with RBC.

Shagun Singh Chadha

So I was hoping you could elaborate a little bit more on the revenue momentum you're seeing. You indicated the highest level of orders in the company's history. Can you provide some color on what is driving that? Is it new or is it existing accounts? Is it adding more sales reps in regions? And then on the order growth, it grew about 39% year-over-year, which was below the -- which was higher than the sales growth of 20%. So just what are the implications of that? And how should we think about it as a predictor of future sales?

Thomas Sandgaard

Net-net, our sales force is becoming more productive. We keep adding more sales reps. However, we are also proactively not letting sales reps that may not produce as much as we'd like to see long term and doesn't seem to have a potential to get there. So overall, we continue to see a higher productivity in our sales force as we get better and better at hiring new talent. So the order growth comes from that.
It's also, relatively speaking, been very strong here for a number of months compared to last year. 1.5 years, 2 years ago, our order growth was not -- we're in the -- more in the single digits. And therefore, when we get some momentum in terms of the order growth, it turns into some very high percentages.
And obviously, the average order growth, if you look at the last 2 to 3 years, is more in the -- just over 25%, a little less than 30%. If you look at that on an annual basis, which correlate pretty well with our revenue growth. There's still a little bit to come there. We expect the full year to come in at 20% revenue growth. And we expect, with the orders we are getting now and the revenue that will generate for many quarters to come, that we have strong revenue growth still in the pipeline. That's already landed on the books in terms of prescriptions that now needs to get build and battling with insurance companies to get paid, et cetera, that those things will be executed here over the next many quarters for the orders that we've recently received.
So there's always a lag there between when we have a growth spurt in orders and when revenue catches up to that.

Shagun Singh Chadha

Got it. That's really helpful. And then I was wondering if you could maybe share some directional outlook for 2024 as it relates to your pain management business is plus 20% growth achievable next year. It seems like that's somewhat of a base case, given how you're tracking this year. And then on the patient monitoring side, just contribution from the CM-1600 and anything we should factor in for NiCO. And any color on the OpEx side would be great, too.

Thomas Sandgaard

Yes. I think in terms of the pain management business, we are tentatively looking at growth a little lower or 20%. So somewhere in the range of 20% to 25% is probably a good guess for how we're going to fare in terms of order and revenue growth next year in that division. We'll probably be -- because we expect a lot of the activity in terms of additional data collecting and also would be dealing with the FDA to take place in the first half of 2024 for the NiCO and CM-1600 and further generations of that, we expect that. So we'll be lucky to see some revenue in the second half of next year.

Daniel J. Moorhead

And then Shagun, as far on the profitability side, I think this year, we're kind of in the flattish range. I think next year, we would expect to be up at least 10%, somewhere in that range on the EPS side as we leverage some of the investments we've made. But right now, I think the ZMS contribution on the revenue side is probably immaterial.

Operator

The next question comes from Yi Chen with H.C. Wainwright.

Yi Chen

Could you comment on the 3 new products for pain management in terms of the origin of the products, whether they are prescription products and how these products are used in connection with NexWave?

Anna Lucsok

Yes, absolutely. So the 3 new products that we added, the TLSO, Cryoheat, hot and cold therapy and the wrist brace are Zynex private-labeled devices. They are all prescription only, and they fall within our pain management line and complement our flagship NexWave device and are frequently prescribed together. So they fall within -- we -- essentially, what we're trying to accomplish is become a one-stop shop for noninvasive, nonaddictive pain management solutions for prescribers looking for that.

Yi Chen

Okay. So the reported 39% order growth for the third quarter, does that include the 3 products as well?

Anna Lucsok

Yes.

Yi Chen

So going forward, your reported order growth will include those 3 products, correct?

Anna Lucsok

Correct.

Daniel J. Moorhead

Correct, but they have always included -- Yi, we distribute a number of products. These are 3 new products, and those distributed products have always been included in order growth. So it's pretty consistent with what we've done in the past.

Thomas Sandgaard

Yes. A prescription is a prescription. And by the way, low back support or, in some cases, same patient gets 2 prescriptions and they get paid independently by insurance companies. A good example is the Cryoheat, which the cold portion of that is really fantastic to use along with the NexWave, right after and immediately after orthopedic surgery. So that would be an example. We get 2 prescriptions, the same patient, and it will be 2 billing lines that insurance companies pay separately for.

Yi Chen

Could you give us a rough estimate as to the percentage of revenue represented by these 3 new products as a percentage of the total revenue in the third quarter?

Daniel J. Moorhead

The distributed products are about 15% of our device revenue.

Yi Chen

Okay. And they have a similar gross margin compared to NexWave?

Daniel J. Moorhead

Yes, it's similar.

Thomas Sandgaard

Almost the same, else we wouldn't take them on.

Operator

This concludes our question-and-answer session. I would like to turn the conference back over to Thomas Sandgaard for any closing remarks.

Thomas Sandgaard

Yes. Thank you for joining us today. We are pleased with our performance this quarter and the consistent growth our team is delivering. We look forward to leveraging that momentum throughout the rest of the year and speaking to you at upcoming investor events. We appreciate your time and interest in Zynex. Have a great day.

Operator

The conference has now concluded. Thank you for attending today's presentation. You may now disconnect.