American Shared Hospital Services Q3 FY2024 Earnings Call

Thank you, Nick, and thank you, everyone, for joining us today. AMS' Third Quarter 2024 earnings press release was issued today before the market opened. If you need a copy, it can be accessed on the company's website at www.ashs.com at press releases under the Investors tab. Before turning the call over to management, I would like to make the following remarks concerning forward-looking statements. Please note that various remarks that may be made on this conference call about future expectations, plans and prospects for the company constitute forward-looking statements for the purposes of safe harbor provisions under the Private Securities Litigation Reform Act of 1995. Actual results may vary materially from those indicated by these forward-looking statements. As a result of various important factors, including those discussed in the company's filings with the SEC. This includes the company's quarterly report on Form 10-Q for the 3-month period ended June 30, 2024. The annual report on Form 10-K for the year ended December 31, 2023, and the definitive proxy statement for the Annual Meeting of Shareholders that was held on June 25, 2024. The company assumes no obligation to update the information contained in this conference call. Before I turn the call over to Ray, I'd like to remind everyone about our Q&A policy where we provide each participant the time to ask 1 question and 1 follow-up. As always, we'll be happy to take additional questions off-line at any time. With that, I'd now like to turn the call over to Ray Stachowiak, Executive Chairman and CEO. Ray, please go ahead.

Thank you, Kirin. Good afternoon, everyone. Thanks for joining us today for our third quarter 2024 earnings conference call. I'll begin with some opening remarks, then turn the call over to Bob Hiatt, our Chief Financial Officer, for a financial review of our third quarter results. Following the prepared remarks we'll open the call for your questions. Before we review the quarter, I'd like to highlight a key addition to our executive management team that we previously announced in mid-October. Gary Deans has joined our team as our Executive Vice President and Chief Operating Officer. Gary's deep experience with physician and Taylor relationships, billing and collections, policies and procedures, lends itself directly perfectly to our overall growth strategy as we further expand and optimize our overall business. Gary is a seasoned executive with a wealth of progressive health care management experience, providing innovative and proven solutions to physician groups, health systems, ACOs and health plans. He has significant Board of Director experience with various health care systems based in California, West Virginia, Rhode Island, and Michigan. Prior to this role, Mr. Deans served as Senior Vice President, U.S. Operations at 21st Century Oncology responsible for daily operations at over 140 radiation therapy centers, working with over 160 radiation oncologists treating thousands of patients daily. Clearly, he is more than qualified and is a welcome addition to our team. We also announced the promotion of Ranjit Pradhan, the Senior Vice President, Sales and Marketing. Ranjit played a critical role in the company's success recently renewing and expanding 5 of American shares 10 domestic Gamma Knife agreements over the last 18 months. In his new role, he will spearhead the company's strategic business development and marketing initiatives and drive growth in new business, further strengthening the company's impact and outreach and oncology services. Now let's review our quarterly results. We reported another quarter of strong revenue growth and our enthusiasm for our overall prospects continues to grow. We've continued to show solid improvement and advancement in several important ways and we're extremely excited about the upcoming year. This is, of course, not without our fair share of challenges as we navigate through seasonality and procedure volume fluctuations, integrate the Rhode Island acquisition, invest in much-needed upgraded equipment, and implement additional operating efficiencies that in the short run, impacted our margins and profitability, but positions us for success over the longer term. We followed our quarter 1 and quarter 2 with another solid quarter of revenue growth, which totaled $6.99 million, up nicely from the comparable quarter in 2023 of $5.1 million. The 36% year-over-year revenue growth for this past quarter was showcased by continued early benefits from the Rhode Island acquisition that we closed this past May as well as from our new facility in Puebla, Mexico. The gross margin declined by $732,000, which was affected by lower Gamma Knife treatment volumes and also is reflective of the change in mix from the strong growth of our Retail segment. Additionally, we recorded a small net loss of $207,000 or $0.03 per share for the quarter compared to a small gain of $118,000 or $0.02 per share in the third quarter of '23. Our balance sheet remains strong. We ended the third quarter with over $14.1 million in cash and equivalents, which is roughly equal to $2.17 a share. We also had $4.5 million outstanding on our $7 million line of credit as of September 30, 2024. We continue to leverage these resources carefully for additional long-term revenue streams. We're fortunate to have this strong balance sheet with significant capital to deploy in strategic initiatives such as the Rhode Island acquisition, as well as other business opportunities that we come across. As a reminder, the Rhode Island acquisition is a great example of how we deployed $3 million, and we're able to strategically acquire fair market value and net assets worth $8 million. This was clearly an excellent allocation of capital. Furthermore, of the assets acquired, $2.4 million alone was cash. We've been implementing operating efficiencies to better optimize this business. Specifically, we have invested $1.1 million in CapEx in our Rhode Island centers. We've replaced 2 very old CT simulators which are needed for treatment planning and purchased the third CT simulator, which was being leased. We've also added software packages for improved efficiency and patient care. We've also begun converting some higher-cost temporary staffing at the previous Rhode Island facilities owner, GenesisCare was utilizing as it was struggling to bring on permanent employees, which are more cost-effective and provide longer-term stability overall. We've also recently put our linear accelerators on service and maintenance agreements, which adds to our dependability and high uptime for better quality service. It should be noted that we acquired 3 radiation therapy centers, which are generating positive income. But they were being managed by a company that was going through the bankruptcy process. Let's keep that in perspective. The team also continues to focus on strengthening our core business by working with clients to increase utilization of our equipment. This focused strategy has led to the signing of 5 lease extensions in the last 18 months from our 10 domestic Gamma Knife clients, and we have others in the pipeline. Again, this is not without heartache. In this quarter, we navigated through the loss of a site that we had in third quarter '23. We had scheduled downtime for an equipment upgrade. In addition, there are lower treatment volumes partially due to physician shortages and seasonal staffing factors at some of our sites. Despite the challenges our team faces, we believe these extended agreements are a testament to our partnership business model, our financial flexibility and a very important growth driver. We have already noticed an uptick in our Gamma Knife treatment volumes in the month of October. Our international business represents a large growth opportunity. We're also expecting continued momentum. As many of you know, we have the only Gamma Knife systems in the countries of Peru and Ecuador. Just a few months ago, we announced that our third international center in Puebla, Mexico had begun treating patients. The newly opened linear accelerator LINAC that we installed has BMAT, IGRT, and radiosurgery capabilities that offer the most advanced radiation therapy available in our target area. In early July, we announced our fourth international center with the signing of a joint venture agreement for a Gamma Knife facility in Guadalajara, Mexico. This facility will have 1 of only 3 Gamma Knife systems in a country of 130 million. I'd like to also comment that we've been incurring incremental costs related to our Rhode Island acquisition in excess of $300,000 or $400,000 a quarter. We expect to see a decrease in excess of $300,000 in our fourth quarter. I'd also like to remind our investors that we announced early this year, we had 3 unique business opportunities. The first of these was the closing of our 60% majority interest in the 3 radiation therapy cancer centers in Rhode Island. We closed that in early May. These are our first direct patient services or retail centers in the United States. This new business, which is the first from our expanded team and new pipeline clearly reflects the power of our growth strategy. I'd like to talk about the second. The second is the CLN certificate of need that we have been granted to build a fourth radiation therapy center in Bristol, Rhode Island. And the third business opportunity is a very powerful one. We have applied for a sophisticated need to provide a radiation therapy center with proton beams. A proton beam radiation therapy center in the state of Rhode Island. This proton beam radiation therapy center will be the only system between New York City and Boston and represents a significant growth opportunity. As of now, I'll think about this, we would be the 100% owner operator of this proton beam radiation therapy center. We look forward to announcing additional progress on this matter as appropriate. As we look into the coming months and the year ahead, we expect stronger international growth from additional treatment capabilities in Ecuador. Strong volumes from our center in Peru and the new centers in Guadalajara and Puebla. The recent closing of the Rhode Island acquisition adds 3 new revenue streams to our business, in addition to the other exciting new business opportunities moving through the long sales cycle. Our backlog continues to give us strong confidence in the overall business for our long-term future.

Thank you, Ray, and good afternoon everyone. Third-quarter revenue increased 36.3% to $6.99 million compared to $5.13 million in the year-ago quarter. Revenue benefited from the Rhode Island acquisition that closed last May as well as from the new facility in Puebla, Mexico. Revenue from the company's direct patient services or retail segment was $3.7 million for the third quarter ended September 30, 2024, compared to $988,000 for the year-ago quarter, marking an increase of 273%. The increase in retail revenue was primarily due to revenue generated by the Rhode Island companies we acquired on May 7, 2024, and the startup of the Puebla operations in the third quarter. Rental revenue from the company's medical equipment leasing segment, which we now refer to as leasing, was $3.31 million for the third quarter of 2024 compared to $3.95 million in the year-ago quarter, a decrease of 16.1%. The decrease in leasing revenue was driven by lower Gamma Knife volumes. The prior year comparison does exclude the $200,000 equipment sales recorded in the third quarter of 2023. Third-quarter revenue for the company's proton therapy system in Florida was $2.3 million, an increase of 4.4%, primarily due to continued cyclical volume changes. Proton therapy fractions in the third quarter were 1,252 compared to 1,188 proton therapy fractions in the third quarter of 2023, a 5.4% increase, again due to normal cyclical fluctuations. Total Gamma Knife revenue decreased by 32.9% to $1.82 million due to the expiration of one contract in the third quarter of 2023, as well as two months of downtime at one of our sites due to a scheduled equipment upgrade and staffing shortage at two of our other sites. Gross margin for the third quarter of 2024 decreased to $1.37 million compared to gross margin of $2.10 million for the third quarter of 2023, which was affected by lower Gamma Knife treatment volumes and the strong growth from our patient services segment, which has a lower gross margin. Selling and administrative costs increased to $1.93 million for the third quarter of 2024 compared to $1.74 million in the year-ago quarter. This was due to acquisition and development costs for Rhode Island as well as legal fees. Interest expense was $336,000 in the 2024 period, compared to $277,000 in the comparable period of last year. The increase is due to an increase in interest rates and borrowings on the company's variable rate debt. The operating loss for the third quarter of 2024 was $889,000 compared to a slight operating income of $90,000. The year-over-year decline was due to increased operating costs from the company's recently acquired facilities in Rhode Island and the company's main facility in Puebla, Mexico, combined with lower Gamma Knife treatment volumes. The bargain purchase gain recognized on the Rhode Island transaction in the second quarter was increased by $263,000 net of income taxes in the third quarter, primarily due to changes in the valuation before unserviced naval state holdings and noncontrolling interests as well as expectations related to recoverability of acquired receivables. The income tax benefit of $169,000 for the third quarter of 2024 compared to income tax expense of $60,000 for the same period last year. Net loss attributable to American Shared Hospital Services in the third quarter of 2024 was $207,000 or $0.03 per diluted share, compared to net income of $118,000 or $0.02 per diluted share for the third quarter of 2023. The period-over-period decrease was primarily due to losses incurred by the leasing segment, driven by lower Gamma Knife volume as well as increased depreciation from planned equipment upgrades. Fully diluted weighted average common shares outstanding were relatively unchanged at $6,483,000 for the third quarter of 2024 and $6,432,000 for the third quarter of 2023. Adjusted EBITDA, a non-GAAP financial measure, was $1.37 million for the third quarter of 2024 compared to $1.67 million for the third quarter of 2023. Moving on to the 9-month financial statements. For the 9 months ended September 30, 2024, revenue increased 23.3% to $19.27 million compared to revenue of $15.63 million for the first 9 months of 2023. Revenue from the company to a Patient Services or Retail segment was $7.81 million for the 9 months ended September 30, 2024, compared to $2.44 million for the year-ago period, marking an increase of 220%. The increase in retail revenue was primarily due to revenue generated by the Rhode Island company we acquired on May 7, 2024, 25.1% revenue growth in Peru and Ecuador and the start-up of the total operations in the third quarter. Gamma Knife revenue decreased 14.6% to $7.13 million for the first 9 months of 2024 compared to $8.35 million for the first 9 months of 2023. The number of Gamma Knife procedures in the first 9 months of 2024 was 831, a decrease of 9.5% compared to 918 Gamma Knife procedures in the comparable period of 2023. This was due to the Gamma Knife procedure declines in the third quarter, as discussed earlier. Proton therapy revenue increased 4.4% to $7.39 million for the first 9 months of 2024, compared to $7.08 million for the first 9 months of 2023. Total proton therapy fractions in the first 9 months of 2024 numbered 3,764, a decrease of 8.1% compared to 4,094 proton therapy fractions in the comparable period of 2023. Net income attributable to American Shared Hospital Services for the first 9 months of 2024 was $3.51 million, a $0.54 per diluted share compared to net income of $195,000 or $0.03 per diluted share for the first 9 months of 2023. The large increase was due to the bargain purchase gain generated from the Rhode Island acquisition and the net income earned from the Rhode Island facilities acquired. Adjusted EBITDA, our non-GAAP financial measure was $5.12 million for the first 9 months of 2024 compared to $5.51 million for the first 9 months of 2023. September 30, 2024, cash and cash equivalents and restructuring cash was $14.1 million compared to $13.8 million at December 31, 2023. Shareholders' equity, excluding noncontrolling interests in subsidiaries was $26.42 million or $4.14 per outstanding share as of September 30, 2024, compared to $22.62 million or $3.59 per outstanding share at December 31, 2023. This concludes the formal part of our presentation. Thank you again for joining us today. We look forward to updating you on our progress in the quarters ahead.

So I want to follow up on something you said in the prepared remarks, Ray, about certain start-up costs, I guess, I guess they would be as you bring on new business launch in Rhode Island and Puebla. But I'm also wondering if when you bring on a new business, if there's a bit of a ramp-up period during which that new center or new centers sort of are ramping up to reach their peak operating efficiency. And Puebla, I think, came online during the quarter. So would you say that that is something that we're seeing right now in the third quarter?

You mentioned two main categories of costs that affected our third quarter results. The first is related to the Rhode Island acquisition, where we have been facing costs around $300,000 to $400,000 per quarter, primarily due to legal and accounting fees. These expenses include valuations required for asset assessment and for preparing our opening balance sheet to satisfy audit and review standards as a public company. The second category involves expenses associated with integrating our Rhode Island radiation therapy centers, which were previously managed by a company in bankruptcy. This situation has led to us having to replace outdated equipment, specifically two CT simulators, and enter service and maintenance agreements for our new equipment. We have retained nearly all the existing employees from Genesis Care, but we also faced significant costs from outside staffing firms, which became necessary due to a shortage of radiation therapists and physicists. We transitioned from these third-party staffing costs to direct employee hires, which included bringing in two out of four temporary radiation therapists supplied by outside firms. While we are actively addressing these inherited costs, it will take some time to bring everything under proper management.

Yes, that's helpful. I have a follow-up regarding the Puebla facility. You've been operating that facility since August; can you provide any insights about it in terms of what you expected and whether you are satisfied with the results?

I’d say that the start-up was delayed – we did not start generating revenue until early July. But I’ll tell you, we are very pleased with the results; the revenue that’s being generated at that site keeps increasing every month since we’ve opened. We’re very pleased with its performance.

Could you provide a different perspective on the Rhode Island facility? You mentioned in your prepared remarks that it was being managed out of bankruptcy. I'm curious about the impact of the older equipment on the business, particularly regarding the utilization from patients and doctors recommending others, as well as the uncertainty surrounding the bankruptcy. Do you believe you can attract new business through increased referrals from customers and doctors?

Thank you, Tony. I think we definitely can increase our volumes. Let me give one example. One of the CT simulators that we replaced was in a nonoperating condition for several months. It was, in effect, down. It couldn't be used prior to our acquisition. So that was the first one we replaced, and there was a referring physician that would not refer to that site because the CT simulator was down. Since we've replaced that CT simulator, that referring physician has started referring his patients back to our center. So I mean, that's just like an ideal case situation of the efforts that we're deploying to increase our volumes.

Are you actively informing doctors about the upgrades at the center? Additionally, could you provide some insight into the challenges faced with the Gamma Knife this quarter? Do you have a strategy in place to improve the situation with the Gamma Knife?

Sure. So two questions: We are definitely increasing awareness of our radiation therapy centers in Rhode Island. Our joint venture partners, who own 20% and are the second largest healthcare system in the state, are aware of this acquisition and actively refer patients to our centers. Additionally, our other 20% partner is the third largest healthcare system in the area. The largest healthcare system is also well aware of our activities and open to discussing how we can enhance our relationship. There is significant awareness in Rhode Island about our presence, particularly among the Health Service Council that reviews our CON applications. Leaders throughout the state are informed of our efforts as well. Regarding the Gamma Knife, we experienced what I would describe as an atypical third quarter in terms of treatment volumes. Factors included vacations taken by physicians, such as radiation oncologists and neurosurgeons, as well as one physician on maternity leave, and some downtime at one of our locations due to system upgrades. These issues are manageable, and while I am not pleased with the results, we have analyzed the situation and developed a plan. We are more committed than ever to raising awareness of our Gamma Knife services within these communities.

Looking at the stock, it was at $3 in March, and as you know, the small cap market has been thriving. As a shareholder, I feel frustrated because each quarter there seems to be an issue that leads to either very good or very bad results. I hope you can be more transparent about the factors affecting the upcoming quarters. For instance, if a center is closing or if there’s downtime that isn’t renewed, it would be helpful to mention that on these calls. It feels like every quarter brings surprises, such as downtime due to vacations or missed renewals. When you check the stock, it’s trading at cash value with no growth since March. Why not consider buying back some stock? I understand you'll say the money is needed for expansion, but a small buyback program could reassure investors that management believes in the company's future. I also see you have ZAC, the independent research service, but there's been a lack of sell-side coverage. I'm frustrated because without any forward guidance or warnings about what’s ahead, investors lose confidence and look for other opportunities, especially with the activity in small cap markets. Those are my thoughts.

Anthony, thanks for your question and observation. Our business model calls for our investors to be patient in a very long-term-oriented. I hear in your voice, the frustration. I stick with us long-term. I know many of you already have. But look at the transition we're making in our business model. If you look at our transition, we're expanding geographically. We're expanding our product diversification. Four years ago, we had Gamma Knife and a proton beam. Today, we have added four linear accelerators and Rhode Island, another one in Puebla, Mexico. In fact, we're going to add a fifth linear accelerator at our fourth radiation therapy center in Bristol, Rhode Island. We also are expanding into our second proton beam system. And the other diversification play that we're making is changing from the leasing segment company being dominated by leasing segment and being more dominant and prevalent in the retail segment. Our proton beam center in Rhode Island, subject to the CON is exactly another proton. We've been asked when are you going to get your second proton beam. We're getting one here in Rhode Island. And oh, by the way, it's not going to be lease where we get a percentage of the revenue that the hospital care system collects. No, we're going to be 100% owner and operator if and when we get that CON approved; and just stay tuned on that matter.

What about a small buyback? I apologize for interrupting. Considering your cash resources and borrowing capacity, it appears to me as an investor that purchasing the stock at cash value, assuming the business has a future, would be a great use of funds, especially since you're buying well below tangible book value. I'm not suggesting it's the entire strategy, just a small buyback.

Anthony, duly noted. Thank you, Nick. Thanks, everyone, for joining us today. We are very clearly excited by our future. American Shared at a critical inflection point especially following the Rhode Island acquisition and the other growth opportunities we're currently pursuing. We fully appreciate it will not be a straight line up. There will be challenges along the way. We’re very confident we’ve got the right strategy in place. We have a strong team now to execute on our growth initiatives. We look forward to updating you on our continued progress. If you have any questions, don’t hesitate to contact; we will accommodate further conversation. Thanks for your continued interest in American Shared Hospital Services. Have a great remainder of the day and the week. Goodbye.

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