Inspire Medical Systems, Inc. (INSP) Earnings Call Transcript & Summary

The thumbs up, and we've got a lot to talk about. So Jon Block with Stifel, and excited to have Inspire Medical Systems with us. We've got the full crew, Tim Herbert, President and CEO Rick Buchholz, CFO; Carlton Weatherby welcome, Chief Strategy Officer; and Ezgi is not up on stage, but she's out there, I see her, Vice President of Investor Relations.

Tim, I just sort of said to you, I'm looking for clarity. And I think when I speak with investors, that's the common theme I'm getting. So for the quarter, 40% revenue growth, off a mere 77% comp, but not the upside that we sort of have grown accustomed to, I think there was some confusion coming off the third quarter call. On the second quarter call, you sort of said, look, we've got a greater percent of Medicare Inspire patients than normal. But you didn't really give the Street a definitive reason why you flagged it, you called it out, but there wasn't a definitive reason why. On the third quarter call, you called out the challenges that you experienced at a certain number of centers with their prior off submission process, okay? You're running a pilot program with a certain number of customers to try to streamline their prior auth process. Maybe the first question would just be, you got 1,000 centers out there involved in the pilot. When did that start? What percentage of the 1,000 are on the pilot? And then when did that start?

Perfect. Thank you. It's great to be here. It's great to be here, and we love this conference every year and love being -- having the chance to talk to everybody. We like the quarter, 40% growth. That's still pretty impressive, getting up to over $150 million in revenue. And certainly, we know what's expected of us. We know what's expected of ourselves and as we certainly hold that in high regard and to continue to work hard for everybody. But I'm very happy with the quarter. And the way the team performed, but I obviously know that we can do better. Let's back up a little bit on the prior auth. We got to talk a little bit about why are you doing that in the first place, right? And that's really to clarify what's happening there. We're growing up, and part of the maturing process is you need to start to teach independents. And so when we work at those centers, as they do with every normal procedure that you have when you go to see your doctor, that they take care of the prior authorizations for you. And so with neurostimulation, it's the same thing. We did the same thing back in the old days of InterStim, when we transitioned from prior auth into teaching independents. Of course, those were all done independently today. For circle nerve modulation even spinal cord stimulation, that used to be a very intense prior op model. So it's a natural process to be able to teach independents and then also work to build some more automaticity to it, make it more easier for everybody, so it's a standard submission. The other side to it is, for most patients who are in the sweet spot in the -- they're on label within the policies of the payers. Those are routine submissions. So get the right information submitted into the payer, those can get approved at a greater than 90% clip within 2 to 5 days. So it lends itself to start the process. So we have to run a pilot program on this, first, to make sure that we can teach and debug it. So we start with a small single-digit percentage of the 1,000 centers. Now you got to remember, there's 4 quadrants. And so the centers you're going to choose, are the centers that have patient throughput. So yes, the centers we're choosing have a higher throughput. So obviously, there's kind of a double multiplier in there that, one, accelerates the pilot, but also helps us identify any challenges we may have, earlier.

And that was in early '23 that you started that process.

We started in early '23, and we start training centers just a few at a time through the first quarter. And into the second quarter, and then other centers actually took on so we can do this independent by yourselves. So other centers jumped into this as well. And when we get to the end of the second quarter, we see a higher mix of Medicare, that's not completely unnatural because we're coming -- in Q1, we always know is high Medicare. Q4 is high commercial because everybody has the high deductible insurance programs they need their Inspire procedure done before the end of the year, before the resets and then it usually transitions in between. So as we get into the end of Q2 and we see that mix, there's always still a little carryover to COVID, but we started to really dig in a little bit more. And then what we realized is that we have a logistics challenge. And I'm careful to say logistics challenge because what we did is have our territory managers actually inspect every site, not just those independent, but really look at where are the -- what's the patient flow in there, and we're seeing all these prior authorization files stacked up.

And that's just sitting with the pilots.

Right. And so we're not -- we don't have a challenge with a policy issue, where the bad files are being submitted and rejected. Our challenge is the files are not being submitted, so the patients don't have a chance. So we quickly pulled those back in house. Our team jumped on and get those submitted in, and so we saw the big uptick in prior authorizations in the second half of the quarter, but we need to kind of look at the centers. And so why aren't they ready to do this? And -- go ahead.

And let me just jump in there for a second, and I don't want to split weeks and days or even months, but I just want to make sure I have the timing down. When you go ahead and you intervene because you see the prior auths aren't going through, and that happens around sort of that third quarter I think on the call, you talked about improving trends exiting the third quarter, but those surgeries might take a couple of months to get scheduled, right? So you stepped in, you intervene, you've got your arms around the problem. But did we actually see the surgeries improved exiting 3Q? Is that more of a 4Q '23, 1Q '24?

I think as soon as you turn the prior authorizations, you can start to see uptick in surgeries in Q3. The fact of the matter is we didn't use our capacity in the beginning of the quarter, right? We used more so of the capacity when you got to the second half. And so we're a little bit -- and I hate to use the term of sawtooth, but a little slow in July, but strong in the second half of the quarter, along with the uptick in prior authorizations, that's what gives us the confidence as you're going into the fourth quarter. A lot of the sites, by the way, continue to be independent today. So a lot of the larger sites that have the prior auth team in-house, they can handle this. And they are being successful with it. Smaller centers that don't have the staff to do it or it's a -- it tends to be a job that might have more turnover, so you train somebody then there's turnover, you got to train again. There's a little bit of a staffing challenges. Those are the centers that have more of a challenge, that we need to kind of pull back in and build through.

So the thought is this isn't being scrapped. This is still certainly the goal for Inspire. It's just you put the pilot out there, you'll make some tweaks to it or changes to it. And these guys will still eventually stand up by themselves and handle this process, going forward?

We need to have a deliberate process with it. And so you don't just scale inside with full-time equivalents. So we've contracted with a third-party company, that's what they do. It's prior authorizations. And so they have -- we're under contract. We have brought them in. They've been trained. They've assigned a number of patients, just for Inspire cases. And so all files come to Inspire. The inspired lead will look at the files, the more routine cases can go to the third party, anything challenging a high BMI, a high AHI a payer who might be more difficult, that will stay in-house with our experts. And so we'll be able to streamline the whole throughput. And then as we kind of move on in the future, that third party can kind of help us as a bridge forward.

So then, let me go back to, you fix or you rectify the problem. You start to see some of that volume toward the end of the third quarter. The rest of that, that pulls into 4Q '23 and maybe some into 1Q '24 because you're fighting the capacity issue.

Correct.

To push there a little bit, what about the ones that go to 1Q '24 because their commercials, their deductible will reset, will they proceed in 1Q '24? Or does that sort of flow a little bit later than that?

That's the Q4 phenomenon, when we're always talk about our seasonality. And I think the high deductible commercial cases tend to get a priority in November, December to get done because the patients are really pounding on the table. Look, you got to do it before January 1 because my $3,000 is out-of-pocket reset. So you tend to try and prioritize those at the end of the year. And hence, you see the Medicare kind of get moved more to Q1, hence the mix. That's why Medicare goes high in Q1 and commercial is high in Q4. But the doctors and the staff, they work really hard to make sure they try and get those patients scheduled as best as they can.

Okay. Maybe just 1 or 2 more down this particular talk track or path. When we think about your visibility at the time of the earnings call, and I've been getting that question, so 3Q calls, first week in November, you go ahead or the centers go ahead and they schedule out. When you're sitting there in early November and you come basically in line, but you raised, what's your line of sight? Does that take you out for weeks? In the first week of November, are you seeing the schedule? Do you only have 3 or 4 weeks of, call it, sorry, vulnerability before the end of the quarter? What's your line of sight there?

Well, I mean you got the holidays, too. I think we already -- we know historically, Q4 is a strong quarter for us, right? And we know 2 of the busiest weeks of the year are the last 2 weeks of December. And so our teams out there right now are reserving as much OR time, as they can get. Do we have pure line of sight? No. Do we know the -- how the physicians and how the team and how the patients are motivated to proceed? Yes. And so we know that while we don't have pure line of sight out that far, we certainly know the number of patients in the pipeline and therefore, have confidence going forward.

Okay. And there's just -- even in this short period of time since the earnings call, nothing else has popped up or come to light that you'd say, you know what, it wasn't all about that prior auth. There was something else out there. You're still very convinced as we sit here today, that temporary weakness, and again, it's a little unfair 40% growth of a 77% comp, but it's all relative. That was solely a prior auth thing.

Well, I think that just as we laid out in the earnings call, I think we changed behavior with the reps, too. But absolutely, we have confidence that we had an acute issue that we're able to go and address. And we're working with all the centers going forward. So yes, it's confidence going forward, and that's why we, even having a successful quarter, 40% growth, we're really proud of that, over $150 million, cross over 50,000 patients treated with Inspire. So a lot of positives in the quarter as well.

Guys, any other questions from the audience down that particular road. I know there was a lot of questions, at least incoming for me on that particular topic. If not, I'm going to move I think called GLP-1. I don't know if you've heard about that.

What is that?

Okay.

I don't know what that stands for. What's GLP...

So let me give you a couple of metrics, and I'll try to go down a particular road. On Inspire STAR trial, average BMI and AHI was roughly 28 and 29, respectively. Yes. Okay. For SURMOUNT OSA, BMI 38, 39 AHI greater than 50.

Yes.

For Inspire, let's fast-forward 3 or 4 months here comes to data for Inspire, what's a good outcome versus a bad outcome on that data?

Well, a good outcome as patients go on a GLP-1 and they lose weight, right? Great for the patients, great for their health, they'll feel better. But it's hard to imagine those patients taking AHI from 50 to less than 20 because really the study is set up to really assess the weight loss, the patients know it's a sleep apnea study. It's designed to show a reduction in AHI, but it only shows a statistical significance between therapy and placebo in 2 different arms with and without CPAP, but it doesn't have a clinical relevant endpoint to it, meaning when we did the STAR trial you referenced. We did a responder rate analysis. You needed to show, it's called the Sher criteria. Sher as S-H-E-R, a doctor that developed this criteria, needed to do a 50% reduction in AHI, yet the result in AHI had to be less than 20%. So not only did you have a significant reduction in AHI, it had a clinically relevant endpoint being less than 20%. Publications over the literature, over the years have already shown the cut point for the increased risk of comorbidities or the causal effect of untreated moderate sleep apnea is where the AHI greater than 20%. So that's kind of how that bar got set. We like to see patients go further, get down to 10%. But this study isn't going to test that out. And I think that what we believe is it will show a statistically significant reduction in AHI, but I don't think it's going to be clinically relevant. And what our desire is that patients will lose enough way to relieve the lateral wall, such that they can qualify for Inspire, and we can give them therapy to take them all the way home to get them treated. Right now, most patients in that study are -- wouldn't qualify for Inspire anyways. That's not our market, right? It's just too high a BMI. They're going to have too significant of a lateral wall so most are going to all have complete concentric clouds doing a sleep endoscopy procedure.

So maybe to try to push a little bit there. I mean, it would seem like the great outcome is the BMI comes down to the 28% range, and the AHI reduction is less than 50% because if that were the case and you're dealing with what was sort of the standard patient in STAR around those levels. Clearly, a bad outcome is at the AHIs goes all the way down to 15%. But what about that level of an AHI of 20%? And we had a panel here the other day, and I'll lead with both the sleep specialists and the surgeon said, yes, even at an AHI 20%, I'm referring them for HGNS. But do you think that's really the case? Do you view that, that patient would still proceed with HGNS therapy after their AHI comes down from 50% down to 20%, 21%? Do you lose that patient? Or is that still in your suite?

Well, I think it also has to do a little bit how much weight loss did they have. I mean how good do they feel? The patients with sleep apnea, they don't -- I mean, having 20 events per hour throughout the night, you're not getting restful sleep. Your quality of life is not strong. But you got to remember, these patients are coming from a quality of life, a lot higher with a high BMI. So they lose weight, they're going to feel a little bit better. But that's -- there's still going to be very symptomatic obstructive sleep apnea. AHI 20% is right in their sweet spot. We get that -- we're approved for any patient with an AHI greater than 15%. And we see quite a few patients in the range 15% to 25%. So I would expect a lot of those patients would go through. But again, the good news is those patients will feel better.

And I think in STAR, the lower bet was actually 18, right? I mean, in the STAR trial, you had...

STAR trial is a little bit different. STAR trial, we actually screen patients between the range of 20 to 50. But then we did another sleep study, post-implant, and then average that and the average is 15 to 65.

And ultimately, they were down to 9, I believe.

In the results.

Yes, in the results.

12 months, yes.

Okay. Okay. So you're still very convinced or adamant that at the end of the day, this is a net positive. We're going to have movements within the funnel. You're going to have these AHIs, that are at the lower band, they lose weight, they might go to 15 or below and they're out. But really you're going to have a big amount that fall into the funnel, especially as you work on your label expansion and taking the BMI and AHI a net positive for you guys?

We want to take care of people. We want to take care of patients. And we have patients that come to our website, you have to go through a little questionnaire, you have to put your height and weight there and your BMI is high. The probability of having complete concentric collapse is significant. You don't want to give the patient bad news like that. And so we always want to refer them on. And so those patients with a BMI that get screened out because of complete concentric clouds because we do tongue-based stimulation. We don't address the lateral wall, that's frustrating. And this is an opportunity that these patients can go on a GLP-1, lose some weight and relapse the lateral wall such that they can be treated with Inspire. This is an opportunity for us. We really are comfortable with that.

And you're comfortable with that, and you've been very consistent conveying that to investors, until obviously, I mean all this is respectful, but the stock is down, right? So is there anything the company can do and be more proactive about any data that you can gather that you can show greater evidence, as to why this is a net positive, some of the diabetes guys have tried to go down that road. But is there anything at your disposal, not imminently, but over the next 6 to 12 to 18 months, where you might be able to strengthen that argument?

Sure. And so Dr. Sparks, the Chief Medical Officer, is working with our advisory committee. We have both the ENT and a Sleep Advisory Committee, and they're looking at the history of weight loss and how that applies in the Inspire. One example is a doctor that we have in Florida, who is a sleep physician, but also manages a weight management clinic. And so he has experience with patients on bariatric surgery, losing weight and being able to refer them over to the ENT and they've received Inspire. He's had cases where they failed the sleep, because of complete concentric collapse, whereby they were prescribed to GLP-1 lost weight and now qualified and have received Inspire. So there is some evidence, although you're talking a very low number today. But so they are working together to begin to start to digest this weight loss and the benefits for reduction in sleep apnea and how do we help patients get qualified for it. So they're working on that. We're going to be looking to put something out in the near future to help clear of where the facts are on this.

Okay. And just to put a bow on SURMOUNT OSA, I mean, the thought is anything north of 20 or above is a positive. It were 25 or above an AHI, pardon me, that's sort of closer to a home run because you're in that streamlined STAR's characteristic.

But what if it's 35? I mean we have to look at what -- look at the data from this past weekend. It didn't show a significant weight loss, but it also showed more of a non-compliance. And so we have to watch that and when the AHI, depending upon where that comes to, we feel comfortable with that, and we want to be there to help those patients if we can.

Okay. Let's get off prior authorizations and GLP and Inspire V. So you've been excited about that for years now, and still very excited and submission to the FDA. The timeline seems to get pushed a little bit by 6 to 9 months on the earnings call, you're talking about sort of the full rollout in '25. Just talk about the extent of the questions back from the agency and then where you guys are going to go from here?

Sure. We submitted at the end of Q2, which was great. 1,300 paid submission. It's a Class III active implantable device. It's a complex submission. We give our partners at the FDA a lot of credit. They really worked through that. And remember that first risk of government shutdown, they got us the questions, right the day before the government was supposed to shut down. And then afterwards, you kind of work for them interactively to kind of clean up, a lot of the questions because they really work hard to get that out. And so a lot of it is the question is just kind of clarifying what's in the submission. So that's the first group. There's always questions that come around biocompatibility of the device, which kind of remembers, the Inspire IV device, really all we're changing going from IV to V is the circuit card inside. There's not a lot of other material that's exposed to the body. So biocompatibility we'll be able to handle. Electromagnetic compatibility, can it work in a noisy environment as another standard set. So really no major surprising questions that we saw. But because with the FDA, we're going to submit and we're going to have a full package ready to go, meaning we're going to have our production fully qualified, all the test equipment qualified, fully documented. So the package, that we sent in early in the year, is going to be a complete package that they're going to be able to review. It's a range of time. If they hold the same clock, it could get approved in the second quarter. If they go reset the clock because of the extensive review, it could go to Q3, but we're going to do a limited market release, before a full launch. And the limited release is we're going to be interfacing with the pace of remote, with the new physician programmer with Inspire Sleep sync, right? And so we're going to make sure across the board, everything is working fine. Remember going from Inspire -- I'm sorry, from 3 incision to 2 incision. And that converted so quickly. We believe when we come out with V, it's such a significant improvement, we're going to see an immediate conversion. We're going to see everybody going to want to transition over. So we're going to do a limited launch to make sure everything is lined up before we do the full commercial. Hence, that's why we kind of just said look, we're going to talk about the [ Vault Commercial ] in '25. But we're going to gain a lot of experience in '24 to be ready to go.

And can you talk about your expectations in terms of surgeon's time or the reduction in the savings, moving from -- or going over to Inspi V. And it's funny I scribbled down, just remind us of what took place when you went from 3 incision to 2 incisions?

Well, just to remind everybody, we used to do 3 incisions. So you do one incision for the stimulation lead, one for the neurostimulator and would go down to the fourth or fifth intercostal space, where we made the incision for the pressure sensor. And the physicians wanted to ease that. So the ENT physicians led the challenge to let's put that up in the same pocket, as where the neurostimulator is. So we can only do 2 incisions. Once we got the data on that and got confirmation with FDA, that converted to every physician doing 2 incision probably within 1 quarter. So I think the same thing is going to happen with Inspire V. Today, the average time is between 60 and 90 minutes to do an Inspire IV procedure. We believe as we go to Inspire V, that could go down to 45 to 60 minutes. So it's a significant cost savings, but that's not the most of it. What's the most important factor, I think, is remember, we have ear, nose and throat surgeons, right? While they do this procedure putting the sensor in the chest between the intercostal muscles, it is the one kind of unnatural, uncomfortable part of the procedure. It's safe and they get trained, they do it. It's not an issue. We've done more than 50,000 cases. But if they could have that internal sensor, that's going to give them just a little bit more confidence going forward.

So you just nailed what went on at the panel yesterday, right? The doc, the ENT up there said, look, I'm going to be able to shave about 1/3 of my time he thought with Inspire V, which sort of foots to your comments. And then I asked him -- you'd been planning you guys for a number of years, but hey, it's going to bring another slew of surgeons because the procedure simplified and you said absolutely. And if I think about new surgeons and reduced time and he threw out a number where you thought he can do an extra procedure a week, if you could get the surgical times down by 1/3. These are drivers for freeing up capacity now in '25 though, right? And you're fighting capacity sort of 3Q, Q4, '23 help us get comfortable in what the company can do. I mean you're going to add your centers, but what are the drivers to free up capacity in '24 to sort of bridge you to Inspi 5 and freeing up time from that event?

Sure. Many things. We've got so far as -- I'll have to talk to the surgeon, we had on panel yesterday, but they -- we -- this sounds -- we do time studies. Where is it -- where do you spend your time? If I'm asking for half of your practice to do Inspire cases, and you work 40 hours a week, I know you work lot more than that. I mean they're at the -- we only get 20 hours a week to work with. We've somehow got to make sure that most of that time is in the operating room doing procedures. So we have to assess what other elements of the Inspire procedure have to be taken care of by somebody else. A practitioner in the office can handle a lot of the diagnostics, the patient flow. We have patient navigators to help them through the whole process. The key individuals having a sleep position that can help with the diagnosis, but can also do all the longitudinal management, right? And with SleepSync, the ENT is still engaged on how their patients are doing, but they know they're comfortable that the sleep physicians are managing their patients so they can focus on doing surgery. So that's one, just pure efficiency in their practice. Two is telling them that we got to train their partners. Every ENT practice has how many ENTs in there. And to think one surgeon says, I got it all, I can do all this. No, it's more important that we train their partners. It's, one, they have a backup. But two, multiple surgeons can do the procedure to offload and reduce the pressure. And then going forward, we talked about predict or predictor, we believe that most patients will not have to have a steep endoscopy, even though CMS helped us up by doing a tenfold increase in reimbursement recently. That's also a procedure that we would rather have the ENTs doing implant procedures than we were doing sleep endoscopies, and we'll continue to open new centers as well.

Okay. So you have those near-term initiatives. One thing that I didn't hear you mention just there were the ASC, right? The ASCs, I think earlier on, you talked about increasing that as a percentage of the overall facilities. I think it's around 23%, and it's been in and around that number, for the past 6 or 7 quarters. Is this a rate thing? How do you move that number higher? Because obviously, that could help aid capacity.

We're going to have old projects starting on this, but it's really a reimbursement thing. It's really more a CMS thing. And the challenges is while Medicare will reimburse fairly in the major cities and primarily in the North here in New York, the ASCs pay very, very well. You get into the south in the Mississippi and Alabama, it can put the ASC into a loss position with Inspire, and that's going to create a challenge. It all is based on the way that CMS does device-dependent procedures where they discount not only the labor rates, but they discount the material as well, and that's unfair. So that's going to be a longer-term project. And how do we handle the reimbursements from a Medicare standpoint. Most ASCs can handle commercial cases, if they have a contract, they have to do individual contracts United, Anthem, Aetna. And once they get them in place, it is a profitable position for the ASC, but it's difficult for a surgeon to say, I'm going to do all the Medicare at the hospital and now I'm going to take all the private over to my ASC, where it's profitable. The hospitals push back on that alot. So we had a lot to do on that. But I think, long term, ASCs will play, but we do have to fix the reimbursement challenges.

All right. Let me see what else I can push on in 3 minutes. And Rick, I'm going to go over to you. And again, the model is not up here. But when I look at my estimates, the guidance sort of implies U.S. utilization of flattish year-over-year for the back half of '23. I actually at the third quarter, where utilization, we might all count, get slightly different, but utilization for the third quarter was up low single digits. And the fourth quarter has implied flattish, right? And I don't want to make it out it seems like it's a low bar, but 4Q utilizations implied flat, 3Q was up low single digits. But Tim, to your point, you didn't really use a lot of the capacity that you had in 3Q. So how do I think about that? And is that sort of lend itself to maybe a small area of conservatism?

Well, we haven't changed our guidance philosophy at all, and we're really focused on scheduling that procedure time and getting a OR time before those high deductibles reset. So we're going to continue to focus on. We've worked through the prior authorization issue. We're scheduling those cases. We saw a robustness in the second half of the quarter, and that gave us confidence to raise our guidance, despite Q3. And so we're excited at the opportunity to close out the year strong.

Okay. Maybe I'll jump over to a slightly different topic. After the third quarter, your '24 numbers came down a smidge. But I mean, in the first time since I've been covering you guys, it really was the first time the out-year came down. But you got a lot of tailwinds still as we go into '24 and the commercials and BMI goes up and AHI goes up and pediatric down and there's international opportunity then in the backgrounds getting some traction. So let me just -- when we think about the BMI and the AHI and taking those up at some of the commercials, you already knocked down a couple. What does that mean for utilization? Let's pick a utilization number for center this year, '23. What -- are those a couple of extra procedures per center just attributable to BMI, AHI pediatric downs?

And efficiencies and experience as surgeons do more cases, they become more proficient with the procedure. Top surgeons are doing it within an hour now. I think all of it is additive, right? We're going to have continued technology advancements as well with the digital just to streamline the whole patient flow. So yes, the -- we're going to continue our pathway of opening new centers, but that's going to be a lesser percentage of the overall number of centers. So the growth is going to come from the higher utilization from the same-store sales.

So and like a soft commitment then when we look to 2024, should be still another robust year of utilization growth at the centers.

Correct.

Okay. And then I'm going to run down the clock as much as I could. Just quickly, Rick, help us out with the points of leverage, which is another area that some investors will focus on. And maybe I'll quickly work my way through. GM with Inspi V, you eliminate the lead, maybe you take some price, GMs would seem to have an up arrow in that regard. R&D is running really hot right now as you finish in Inspi V and you're actually bringing on some of those expenses. And then SG&A, Tim, you've talked about a little bit more of a targeted approach. That doesn't mean the number comes down, but it's more targeted. All 3 of these are areas of leverage that we can think about, longer term?

Yes. But I think the real driver is the fact that we're really still early in the commercialization. We're -- our utilization rate per center is under 2 procedures per month. So the real driver, we're going to continue to make investments, but -- and we've shown leverage. We're going to continue to drive utilization, trying to increase that number of procedures per month with our 84% gross margins. That will drive further profitability or towards profitability and more leverage. And that's a real focus for us in 2024.

I love the running down clock. That's great. We'll keep going on that over time. Touch on DTC. I mean, DTC mentioned that. And the key is maintaining our direct-to-patient awareness campaigns, and that really is an effective way to educate them, but we have learned so much, since the early days of newsprint and radio. And then we went to social media, then we made a TV commercial inside local TV, and then we did some national bias. We've taken the next step to be, can I use the term surgical, to really talk about using direct advertising to really target our demographic, thereby getting higher yield on the inbound patients inquiring. So we're not going away from direct-to-consumer. We're not cutting back on it. What we're doing is continue to educate, refine our programs to get a higher yield and still keep the same quality of patients going to our centers.

Okay, we've got well over. So I've got to be respectful. Really appreciate the time, guys.

Thank you, Jon. Thanks, everybody.