Earnings Call Transcript - GKOS Q4 2024

Operator, Operator

Welcome to Glaukos Corporation's Fourth Quarter and Full-Year 2024 Financial Results Conference Call. Copies of the company's press release and quarterly summary document, both issued after the market closed today are available at www.glaukos.com. This call is being recorded, and an archived replay will be available online in the Investor Relations section at www.glaukos.com. I will now turn the call over to Chris Lewis, Vice President of Investor Relations and Corporate Affairs.

Chris Lewis, Vice President of Investor Relations and Corporate Affairs

Thank you, and good afternoon. Joining me today are Glaukos Chairman and CEO, Tom Burns; President and COO, Joe Gilliam; and CFO, Alex Thurman. Similar to prior quarters, the company has posted a document on its Investor Relations website under the Financials and Filings Quarterly Results section titled Quarterly Summary. This document is designed to provide the investment community with a summarized and easily accessible reference document that details the key facts associated with the quarter, the state of the company's business objectives and strategies and any forward statements or guidance we may make. This document is designed to be read by investors before the regularly scheduled quarterly conference call. As such, for this call, we will make brief prepared remarks and transition into a question-and-answer session. To ensure ample time and opportunity to address everyone's questions, we request that you limit yourself to one question and one follow-up. If you still have additional questions, you may get back into the queue. Please note that all statements other than statements of historical facts made on this call that address activities, events or developments we expect, believe or anticipate will or may occur in the future are forward-looking statements. These include statements about our plans, objectives, strategies and prospects regarding, among other things, our sales, products, pipeline technologies and clinical trials, U.S. and international commercialization, market development efforts, the efficacy of our current and future products, competitive market position, regulatory strategies and reimbursement for our products, financial condition and results of operations, as well as the expected impact of general macroeconomic conditions, including foreign currency fluctuations on our business and operations. These statements are based on current expectations about future events affecting us and are subject to risks, uncertainties and factors relating to our operations and business environment, all of which are difficult to predict and many of which are beyond our control. Therefore, they may cause our actual results to differ materially from those expressed or implied by forward-looking statements. Review today's press release and our recent SEC filings for more information about these risk factors. You'll find these documents in the Investors section of our website at www.glaukos.com. Finally, please note that during today's call, we will also discuss certain non-GAAP financial measures, including results on an adjusted basis. We believe these financial measures can facilitate a more complete analysis and greater transparency into Glaukos’ ongoing results of operations, particularly when comparing underlying results from period-to-period. Please refer to the tables in the earnings press release available in the Investor Relations section of our website for a reconciliation of these measures to their most directly comparable GAAP financial measure. With that, I will turn the call over to Glaukos Chairman and CEO, Tom Burns.

Tom Burns, Chairman and CEO

Thanks, Chris. Good afternoon, and thank you all for joining us today. Today, Glaukos reported record fourth quarter consolidated net sales of $105.5 million, up 28% versus the year ago quarter. These results reflect the continued acceleration of our business and cap off a successful year of global execution, both from a commercial and development perspective, leaving us ideally positioned to sustain our momentum and execute our strategic plans in 2025 and beyond. For the full-year 2024, consolidated record net sales of $383.5 million grew 22% versus 2023. We have also introduced full-year 2025 net sales guidance range of $475 million to $485 million. Our record performance in the fourth quarter and full-year 2024 reflects our unwavering dedication to advancing our mission to transform vision by pioneering novel drop-less platforms that can meaningfully advance the standard of care and improve outcomes for patients suffering from sight-threatening chronic eye diseases. At Glaukos, we are in the business of pioneering entirely new marketplaces within ophthalmology. Innovation is at the core of everything we do. Our mantra, 'we'll go first,' embodies our commitment and determination to take chances, push the limits of science and disrupt the legacy treatment paradigms in glaucoma, rare disease, and retinal diseases through our pursuit of game-changing technologies. Our fourth quarter and full-year record results were primarily driven by both our U.S. and international glaucoma franchises, where we continue to accelerate efforts to pioneer and develop the interventional glaucoma, or IG, marketplace with new stand-alone therapies designed to slow disease progression and reduce drug burden for the benefit of physicians and patients. Our goal to advance and improve glaucoma treatment by driving earlier intervention continues to build momentum as we educate surgeons and thought leaders globally to organically drive this broader evolution in the standard of care for the benefit of patients. While we remain in the early stages of these IG efforts, we are encouraged by the increasing levels of clinical interest for this paradigm-changing evolution. Within our U.S. glaucoma franchise, we delivered record fourth quarter net sales of $56.3 million on strong year-over-year accelerating growth of 45%, driven primarily by growing contributions from iDose TR. As we pass the one-year anniversary of our controlled launch of iDose TR, I could not be more pleased with our team's execution of our plans for this first-of-its-kind intracameral procedural pharmaceutical that was designed to continuously deliver glaucoma drug therapy for up to three years. Over the course of 2024, we accomplished several key objectives that together create a strong foundation to support our future iDose growth plans, including: developing and implementing a superlative training program to support a growing number of trained surgeons and accounts; building an expanding set of clinical literature, now consisting of nine different peer-reviewed publications highlighting iDose TR as a transformative new treatment alternative for patients suffering with glaucoma and ocular hypertension; and establishing key market access objectives to create an optimal reimbursement environment through a permanent J-code, a facility fee, a published ASP from CMS, building professional fee coverage and payment for MACs and expanding commercial and Medicare Advantage coverage. Most importantly, clinical outcomes and product feedback from a growing number of cases and trained surgeons continue to be very positive and reaffirm our view that with the launch of iDose TR, we are pioneering a brand-new therapeutic category that has the potential to reshape glaucoma management as we know it today. Coming off of our national sales meeting earlier this month, the energy and excitement from our sales team and commercial organization for iDose TR and our broader interventional glaucoma strategy was profound. Our primary near-term focus remains on broadening market access among MACs, commercial and Medicare Advantage payers. While there is certainly more work to do here, particularly as we expand efforts into the commercial arena over the course of 2025 and beyond. We are encouraged by the overall progress our teams are making to support increased reimbursement confidence through more streamlined and consistent J-code coverage and payment in the majority of MACs to date with more to come. Alongside this, we are also making good progress securing professional fee coverage and payment with three of the seven MACs now including CPT code 0660T in their professional fee schedules at rates in line with our expectations and generally consistent with comparable stand-alone glaucoma procedures. As noted in the past, we expect increasing adoption as reimbursement confidence is gained by our customers over the course of 2025. This will be further supported by our plan to accelerate marketing investments as the universe of trained surgeons and accounts continue to expand. While we advance our iDose TR efforts commercially, we also plan to expand the robust body of clinical evidence for iDose TR. On that front, we recently announced several positive iDose clinical studies. First, a new 36-month follow-up analysis of iDose TR's two Phase III pivotal clinical trials demonstrating sustained substantial IOP reductions, with approximately 70% of iDose TR subjects remaining well-controlled on the same or fewer IOP-lowering topical medications at 36 months after a single administration of iDose TR versus 58% of timolol control subjects. In addition, iDose TR continued to demonstrate excellent tolerability and a favorable safety profile through 36 months across both Phase III trials. Second, a new six-month follow-up analysis of a Phase IV single-arm clinical study demonstrated iDose TR implanted in combination with cataract surgery achieved a profound mean IOP reduction of 11.3 millimeters of mercury or 44% at six months compared to baseline. Lastly, we commenced a Phase 2b/3 clinical program for iDose TREX, our next-generation iDose therapy, which is designed to be very similar in size and form factor to the original iDose TR, but with nearly double the drug capacity.

Joe Gilliam, President and COO

Sure. Hi, Tom, it's Joe. I'll start. And if Tom wants to add anything, he can at the end. I would really characterize through the quarter as another strong quarter of performance, really heads down execution on all fronts, and that led to what I believe would be probably a doubling of iDose TR revenues in most of your models in the quarter relative to what we saw in the third. I think more importantly, underneath that, as we think about the building blocks of what it takes to build the foundation for long-term success and kind of our progress there, first and foremost, we continue to be really pleased with the real-world outcomes clinically, and that's further supported by the growing body of peer-reviewed evidence that Tom mentioned in his prepared remarks. We continue to see the number of surgeons trained expand rapidly on iDose and, in parallel, the education of the office staff on the reimbursement dynamics associated with a procedural pharmaceutical like iDose. And then on the reimbursement front, we continue to make progress in establishing confidence. It's subjective, as I've said before, but I can now say that five of the seven MACs are adjudicating and processing the J-code in a normalized and efficient manner. That's really kind of emerged here over the course of the beginning of 2025, but an important milestone as we continue to make progress on that front. And then as Tom mentioned, we've recently added Novitas and First Coast alongside Noridian is having established formal professional fee schedules associated with iDose.

Tom Stephen, Analyst

Great. Hey, guys. Thanks for the questions. Tom or Joe, to start with you, can you elaborate a bit on just the trends you saw with iDose in the quarter and then maybe observations year-to-date? Obviously, a lot of investor focus on the ramp. So I guess I'm just wondering if there was anything to call out in terms of new factors that have emerged of late and maybe anything that's different from plan?

Joe Gilliam, President and COO

Yes, it did, Tom. And so let me break down kind of how to understand, I think, the fourth quarter and then certainly, as we think more importantly, in the guidance looking forward. Specific to the latter part of your question, we did see the new LCD restrictions slow our non-iDose or stent growth, if you will, down to kind of the mid-single digits for the quarter. Obviously, that was more than offset by the iDose performance that I referenced in the first part of your question. And so as we think about that guidance, we do expect those LCD headwinds and the volatility that we told you all to expect as well as the expiration of the Hydrus royalty to generate flat to maybe even down low single-digit growth for our non-iDose revenues in 2025. And so when you kind of put all that together, and again, we'll talk about it a bit more throughout the call, you'll see that implied in our guidance is very healthy expectations around the iDose franchise and really growing as we've made our way into 2025 and what we think we'll accomplish this year with iDose.

Unidentified Analyst, Analyst

Hey everyone, congratulations on the quarter. Thank you for taking my questions. This is Simran filling in for Larry. I wanted to follow up on the 2025 guidance. Regarding the U.S. glaucoma market, it seems the core business will continue to face challenges from the LCDs. How should we think about the timing of the impact? Will the first half be more affected, with an improvement in the second half, or should we expect weak volumes throughout the year? Also, what are our expectations for the iDose throughout 2025?

Joe Gilliam, President and COO

Simran, it's Joe. I'll start by discussing seasonality briefly before addressing the question about LCD headwinds. As you know, our typical seasonal patterns show weaker performance in the first quarter, stable performance in the middle of the year, and stronger performance in the fourth quarter. The dynamics of iDose will lead to a greater emphasis on the second half of the year. I would suggest that contributions might be around 21% in the first quarter, 23-24% in the second, 25% in the third, and 30% in the fourth, driven largely by the anticipated ramp-up of iDose. Regarding your earlier question, we expect the peak of the LCD headwinds to occur in the first half of the year, with some alleviation expected in the second half. By the fourth quarter, we have already seen some of that headwind affecting results. It's not a uniform situation throughout the year; we anticipate some improvement. However, overall for the year, we forecast that the combination of the MAC headwinds and the expiration of the Hydrus royalty starting in the second quarter could result in flat growth or even a small decline for the non-iDose segment of our U.S. glaucoma business.

Unidentified Analyst, Analyst

Got it. That's very helpful. And maybe just a bigger picture question on how we should be thinking about iDose sales. If I look at total MIGS procedures in 2024, it looks like there were about 100,000 procedures and the patient population is only about 500,000 to 700,000 eyes. Could the number of iDose procedures eventually surpass the number of implantable MIGS procedures in the U.S.?

Joe Gilliam, President and COO

Simran, I think over the medium to long term, absolutely, especially with the numbers that you just put out there. And maybe to supplement that, what you just said a bit, I think the overall, I'll call it, glaucoma procedures market, which includes MIGS as we define it, maybe some of the more tissue destructive procedures is probably more like 200,000 to 250,000 procedures a year that are being done. That's largely today, as you know, done in combination with cataract and that's where you referenced the 500,000 to 700,000 eye market. When we talk about iDose or quite frankly, iStent infinite or interventional glaucoma overall, you are going after a much, much larger market. So when we think about that, there are north of 20 million eyes at any given time that have either ocular hypertension or glaucoma in the U.S., somewhere in the neighborhood of 13 million to 14 million of those are diagnosed at any given time and around 10 million are actively treated. So iDose and iStent infinite as well as a handful of other products with much broader labels are all going after a much larger market in that 10 million eye market versus the 500,000 to 700,000 that we've been constrained with in combination with cataract surgery historically.

Unidentified Analyst, Analyst

Got it, that's helpful, thank you. Hi, this is Izzy on for Ryan. Thanks for taking the questions. So I just wanted to stick with iDose. So over the course of 2024 and as you guys have rolled out the limited launch, I was curious if you are seeing any share gains from DURYSTA? Or has the growth you've seen so far been more of expansion of the market and bringing in new users?

Joe Gilliam, President and COO

Izzy, it's Joe. I would characterize it as more overall market growth. I think we're just as an extension of the prior question that was asked by Simran, we're in such the earliest phases of a much, much larger market movement towards stand-alone interventional care. I think there's a lot of opportunity for many products, including obviously, DURYSTA and iDose to be growing for the foreseeable future in lockstep. So I see it as an opportunity. It's less about share. I think the real question is, as an industry, how do we continue to take share from legacy eye drops and the shortcomings that are on that front from a clinical perspective.

Tom Burns, Chairman and CEO

Yes, we do. I'll be happy to take that one, Izzy. This is Tom. And so as I promised to investors, this is going to be a process that will take several months. Indeed, it has. We've been in negotiation with the FDA for some time. I think we're in a good position now to be able to submit a post-approval supplement to the FDA for appeal during the first half of this year. And the FDA has a statutory guideline of 180 days once we submit that. And so we should know by the end of this year whether we're successful or not getting a re-administration claim of the iDose. I remind investors, though, that the belt-and-suspenders approach that we have of having iDose TREX already in a clinical trial and potentially being available during the planning period for commercial entry, I see that as a de facto next implantation design product for our current iDose product. So I think either way, we're covered. We continue to be hopeful. But as I have strongly said in the past, we're not counting on anything.

Richard Newitter, Analyst

Hi, thanks for taking the questions. Maybe on iDose to start here, can you give us any color on what your doctor installed base of iDose performing physicians looks like? And anything on how you're going to progress that training effort? I know you last quarter said you're moving into kind of a full commercial launch. And I just want to get a sense for, especially exiting the quarter and you have some of the reimbursement and MAC progress being made, how should we think about that in terms of the number of docs being trained?

Joe Gilliam, President and COO

Yes, Richard, thanks for your question. We haven't focused on the specific numbers yet. The reason is that the training of doctors for iDose isn't a primary barrier to the product's progress. There are already several thousand surgeons trained in angle-based surgery, and iDose builds on that existing knowledge. We ensure they understand the important details that contribute to successful outcomes, but that training isn't a limiting factor. We've had considerable success training doctors quickly across the country, and I anticipate this will continue in 2025, especially as professional fee schedules are initiated and reimbursement confidence grows. However, this hasn't been a hurdle so far. As I mentioned earlier, we're also providing training and education for office staff about the reimbursement aspects related to iDose, which is somewhat unique. We want to support them during the initial cases, and in some respects, this may be a more significant challenge to scaling iDose than the surgical training for the doctors themselves.

Richard Newitter, Analyst

That's helpful. And then a similar kind of question. So we recently pulled some doctors and granted a small sample, but the utilization rates that iDose implanters are talking about are even currently as a baseline and where they expect to go quite high in teens per month. I'm just curious, can you talk at all about what you're seeing in the range of utilization rates from kind of newer users, more timid users, maybe even users that are in more constrained reimbursement regions versus others?

Joe Gilliam, President and COO

Yes, absolutely. I think, obviously, the data that we've now put out there around combination cataract utilization of iDose is terrific and sort of goes in line with what we would expect given the strength of iDose as a stand-alone procedure and when you get that added benefit of the cataract procedure in it. It's certainly taken notice. I think to the second part of your question, what you see in those MAC zones where you have, call it, a little bit more seasoned J-code experience around with certainty and now established professional fees is growth across the board. You see expansion within the accounts, the number of doctors, et cetera, doing the procedure and doing it largely in stand-alone. But as a percentage of the mix, you're starting to see a little bit more combo cataract, which you'd expect. So as they've got their sea legs with the procedure and confidence in the outcomes and you combine it with this data, it's only natural that they would start to utilize this as well in combination with cataract surgery for those patients that they think it qualifies for. So we are seeing it. But I would tell you that our reason for being, obviously, is driving the much larger opportunity of interventional glaucoma and stand-alone procedures, but it doesn't surprise me that falling on behind that is some cataract utilization as well.

Allen Gong, Analyst

Hi, thanks for the question. I guess just touching on the rest of the business. You closed out the year with another really strong quarter from international. I understand that you're losing a bit of a tailwind from France next year, but how should we think about the growth outlook for 2025? And what kind of catalysts you might have in new geographies or any other dynamics to keep in mind over the course of the year?

Joe Gilliam, President and COO

Yes, that's a good question, Allen. We did have another strong quarter, some ways surprisingly strong quarter from our teams internationally delivered broad-based growth of 28% in the quarter, highlighting a year in which we grew north of 20% in its entirety. Now as you referenced a couple of things, so I'll give you the puts and takes. I think as we move forward in 2025, implied in our guidance is something closer to high single-digit growth for that business. The slowdown of that relative to what I was just describing really comes from a combination of things. First, FX headwinds, probably at this point of the earnings calendar, that's not a surprise to anyone here, but it's pretty material on a year-over-year basis as we look at the setup for 2025. Second is potential trialing and trying of competitive product launches in Japan and France. That's also not new. We referenced that on our last quarterly call, and we certainly expect as, in particular, Alcon gets their feet underneath them in these markets that we'll see some impact, if not a transient impact on our business there. And the last is what you referenced, the lapping of the tailwind from the amended French rebate agreement. So when you put all those things together, that lands us on that sort of high single-digit expectation for the international glaucoma business. There are things that we're waiting on, such as getting the MDR approval for iStent Infinite in Europe, in particular, which is a big growth driver that we've not currently baked into our forecast. We really can't until we receive that given the nature of the way the regulatory process now works in Europe. But that has a broader implication to many of the markets around the world for that product and reimbursement associated with it. So that probably being the single biggest one, I would say, could drive an upside to the guidance that we just provided.

Michael Sarcone, Analyst

Hey, good afternoon and thanks for taking the questions. Just to start, I was hoping you could give us an update on iDose TRIO, and whether you stand there. Any change or give us a reminder of what you're expecting on the commercial timeline?

Tom Burns, Chairman and CEO

Yes, I'd be happy to, Mike. This is Tom. And so the iDose TRIO, as we talked about, is going to be really a modification of our existing applicator. And we believe that it will take us right now. Typically, the incision size for an iDose implantation is about 2.5 millimeters. Our hope is to get that down with iDose TRIO somewhere in the neighborhood of 1 millimeter. At 1 millimeter, you have a significantly closed chamber. You have a very reduced risk for any dehiscence of the aqueous humor coming out of the eye, and you're able to maintain chamber pressure. For those reasons, we think that proportionately, this will be in favor of moving into the in-office for clinicians, which has been part of our plan during this planning period process. The FDA has in the drug division required a small safety study to be done. So we'll be in the process midyear or so of beginning a small safety study with the FDA. We'll need to follow those patients for a period of time. Our expectation is to have the iDose TRIO product available in 2026, which is going to align quite nicely with our approach with MACs as we seek MAC by MAC to establish the appropriate payments for this modified code to be able to give surgeons the reimbursement capability and predictability of doing these in-office procedures. So we like what we see, and we like how it lines up. We think certainly by year-end 2026, we'll have this product in the commercial marketplace.

Joe Gilliam, President and COO

Yes, Mike, I think you can imagine the lion's share, if not all, of what the expectations at this point in the year are really being driven by the continued MAC progress, both in terms of the reimbursement certainty around the J-code and those final two MACs as well as the professional fee schedules that we expect to continue to come out as we make progress there. That really forms the foundation of it. As we make our way in the latter part of the year, we expect some commercial and Medicare Advantage volumes to come in. But I will tell you that as you can expect from us, we are going to be very methodical in the launch of that. You want to make sure that these customers can master that process of the prior authorizations and the various things that come along with an expansion outside of traditional Medicare fee-for-service. So we're not going to chase volume there. We're going to make sure that customers are ready and then we're going to continue to expand there as we make our way through the year.

Mason Carrico, Analyst

Great. Hey, thanks for the questions here. Could you talk about initial doctor reception to the Phase IV data in that combo cataract trial? Has there been a noticeable change at all in utilization following you guys releasing that? And then just as a second follow-up there, for the MAC where payment dynamics for the J-code and prophy are farthest along. Could you just talk about what utilization looks like in the combo cataract setting in those jurisdictions?

Joe Gilliam, President and COO

Yes. Mason, it's Joe. I think, obviously, the data that we've now put out there around combination cataract utilization of iDose is terrific and sort of goes in line with what we would expect given the strength of iDose as a stand-alone procedure and when you get that added benefit of the cataract procedure in it. It's certainly taken notice. I think to the second part of your question, what you see in those MAC zones where you have, call it, a little bit more seasoned J-code experience around with certainty and now established professional fees is growth across the board. You see expansion within the accounts, the number of doctors, et cetera, doing the procedure and doing it largely in stand-alone. But as a percentage of the mix, you're starting to see a little bit more combo cataract, which you'd expect. So as they've got their sea legs with the procedure, confidence in the outcomes, and you combine it with this data, it's only natural that they would start to utilize this as well in combination with cataract surgery for those patients that they think it qualifies for. So we are seeing it. But I would tell you that our reason for being, obviously, is driving the much larger opportunity of interventional glaucoma and stand-alone procedures, but it doesn't surprise me that falling on behind that is some cataract utilization as well.

Anthony Petrone, Analyst

Thanks. Maybe sticking on just the MAC dynamic here. The two MACs that issued the pro fees this quarter. When did that happen in the quarter A? And in those MACs, when do you think they'll catch up just in terms of billing cadence to Noridian? And then I'll have a quick follow-up.

Joe Gilliam, President and COO

Yes. Anthony, I'd say, first, the professional fee schedules were announced in mid-January. They were, I think, retroactive to January 1. And that's one piece of that equation, a very important one. As you know, then it's got to be all in their systems and adjudicated properly. Sometimes that can take a little bit of time before you start to see the recurring consistent nature of those payments. But we have started to see that. And then realistically, the impact of the rollout of that, it kind of goes back to what I was saying earlier. These things don't just happen overnight. There's an education process that goes along there. There's a confidence-building process that the account and the doctors see that they're being properly compensated for their time for the procedure. It rolls out over many quarters, if you will, and getting that confidence and then expanding that confidence in many more surgeons. We've seen that in Meridian, to your point, where the professional fee schedule was put out earlier in the end of, I think, the third quarter going into the fourth quarter of last year. And we're still in the process of making sure that accounts and surgeons are aware of that update and driving increasing utilization clinically alongside of it. So it's a journey on that front and one that we've done many times in the past, and we're executing quite well on, I think, today.

Anthony Petrone, Analyst

And just a quick follow-up for modeling. U.S. MIGS and U.S. corneal, call it headwinds. You referenced it, Joe, in a prior question. I think the message here is to essentially have U.S. MIGS maybe flat. I don't know if you were messaging down, but maybe to just touch on that a little bit. And then just the comments in the presentation there, U.S. corneal seeing some headwinds too. Maybe just a little direction there would help.

Joe Gilliam, President and COO

Yes. Let me recap the guidance for each of the franchises. As previously mentioned, we will not revisit the topic of seasonality. For corneal health, we anticipate that the year-over-year growth challenges from MDRP will likely peak in the first quarter or at least in the first half of the year. This franchise can achieve low single-digit growth for the entire year, gearing up for an exciting 2026 with the launch of Epioxa. This year, our focus is on managing the ongoing MDRP challenges and addressing some of the impacts we experienced in 2024. We expect low single-digit growth for cornea in 2025. Regarding international growth and glaucoma, we expect high single-digit growth. In the U.S., we foresee that a combination of LCD headwinds, volatility, and the expiration of the Hydrus royalty will result in flat to possibly low single-digit declines for our non-iDose revenues in 2025. We will monitor this closely and keep you updated throughout the year. Overall, this suggests that initial expectations for iDose should exceed $100 million for the year, with a heavier concentration in the second half and particularly in the fourth quarter, as we anticipate ongoing progress.

Steven Lichtman, Analyst

Hi, this is Ryan on for Steve today. I just wanted to ask a little bit about what you guys are seeing in terms of uptake in iDose in different facilities and systems. Given the high cost of carrying the inventory, are you seeing that any difference between larger and smaller facilities wanting to adopt the device? And do you have any plans on working with people to make sure that they can carry it to make it affordable for them?

Joe Gilliam, President and COO

Yes. So I mean, I think, first off, the relative cost and the carrying cost of it, we mitigate a lot of that as is often the case with pharmaceutical launches as like iDose with longer-dated terms. You've probably seen that in our accounts receivable balance, again, very common with pharmaceutical industry standards. The actual, I'll call it, cash component of that for facilities, we mitigate that way, and we've been pretty successful in doing it. I think there's always a delta between the administration and bureaucracy of larger hospital systems and things like that where you have to go through committees and get a lot more sign-offs, if you will, to get going even when the physician customers themselves are ready and want to do it clinically, versus the nimbleness that exists with your average ASC customer. So I think so far, we've certainly been much more indexed, if you will, towards the ASC side of things, but we certainly expect with the progress we're making that the hospital side of our business will continue to make progress certainly in 2025.

Danielle Antalffy, Analyst

Hey, good afternoon everyone. Thank you so much for taking the question. I just have a kind of high-level question. Sorry, I'm going to stick on iDose for a second. When we were working on an initiation, we looked back at iStent in the first few years of launching, and it looked like you guys sold over, call it, 100,000 iStent in the first three years of launching, but back in 2012, 2012 to 2015. So I guess my question is, what's different about the iDose launch versus when you launched iStent? I appreciate it was like 12 years ago, but that it wouldn't happen quite as quickly because obviously, at a 13.5 ASP, you don't need a high volume to get to pretty big numbers. So just if you could help me better understand the difference between the two launches and what the gating factors are, that would be great.

Joe Gilliam, President and COO

Sure, I’ll start. Tom played a significant role in the first launch, even more than I did. When comparing the two, each has its pros and cons. The most similar aspect of the launches is that you are pioneering a new category in a procedural environment. This means you're not just providing clinical excellence and training but also altering practices and physician behavior. This was the case with iStent during cataract surgery, and it holds true now with iDose in the realm of procedural pharmaceuticals and interventional glaucoma. Today, we have many more doctors trained in angle-based surgery, making the training hurdle much lower than it was a decade ago during the iStent launch. Simultaneously, we're targeting a significantly larger market, but we realize that it will take years to shift the standard of care in this space. These are all positive factors. On the downside, reimbursement, which was a concern back then, is even more critical now due to the higher cost of procedural pharmaceuticals. Additionally, the dynamics of Medicare Advantage are much more pronounced today than they were 10 or 15 years ago. We need to navigate Medicare-covered lives that are less comprehensive compared to traditional fee-for-service, which affects the overall opportunity. Overall, there are many variables to consider, making it challenging to draw direct comparisons. It's likely more beneficial to focus on the opportunities within fee-for-service Medicare, stand-alone patients, combination cataract procedures, as well as the commercial and Medicare Advantage segments, along with the specific patient cases that could encourage surgeons to opt for interventional glaucoma instead of merely prescribing more drops. Thank you. Thanks, Danielle.

Chris Lewis, Vice President of Investor Relations and Corporate Affairs

Okay. I want to thank you all for your time and attention today, and thank you as well for your continued interest and support of Glaukos. Thanks again. Goodbye.

Operator, Operator

Ladies and gentlemen, that concludes today's call. Thank you all for joining. You may now disconnect.