ICU Medical Inc
NASDAQ:ICUI
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ICU Medical Inc
Earnings Call Analysis
Q4-2023 Analysis
ICU Medical Inc
The company reported a robust fourth quarter with revenue reaching $576 million, marking a 2% growth. An adjusted EBITDA of $86 million was achieved despite it being an 11% drop from the previous year, and earnings per share (EPS) were recorded at $1.57, slightly under the $1.60 from the previous year. This quarter's performance was primarily highlighted by legacy ICU product families such as IV therapy and oncology, which grew to record levels, including an 11% increase in absolute sales. This growth was somewhat inflated due to a tax accrual issue in the previous year. The vital turnaround story this quarter is Vascular Access, which has shown stability and reached the levels of Q4 2022.
While the IV systems segment reported a slight decline, down by 1% in constant currency and 2% in reported revenue, the company's LVP pump business notably grew by 11%, witnessing the best performance since 2021. The Vital Care segment expanded by 2%, signaling an operational enhancement that positions the company at its best performance in the past two years. Efforts in innovation and the newly cleared Plum Duo infusion systems are expected to become integral to the company's offerings, with early feedback aligning with expectations.
Gross margin was stable at 34%, in line with what was expected, considering a strategic inventory reduction leading to a $60 million cash flow benefit. Adjusted operating expenses showed a year-over-year uptick of 3.5% due to increased selling expenses that accompanied higher revenues. The company maintained a positive free cash flow of $61 million in Q4, improved from $14 million in Q3, marking a significant cash flow jump primarily driven by over $60 million inventory reduction.
The 2024 outlook anticipates a revenue growth in the low to mid-single-digit range with mild expectations on the P&L impact from Plum Duo. The projected gross margin is about 35%, balancing the effects of price hikes against labor inflation and exchange rate pressures. Operational free cash flow in 2024 is forecasted to be similar to 2023 levels, focusing on driving future returns. Adjusted EBITDA for 2024 is expected within $330 million to $370 million, with an EPS between $4.40 and $5.10 per share. These figures consider a net interest expense of around $105 million and an adjusted tax rate of approximately 23%.
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Good day and welcome to the ICU Medical, Inc. Fourth Quarter 2023 Earnings Conference Call. [Operator Instructions] Please note, today's event is being recorded. I would now like to turn the conference over to John Mills. Please go ahead, sir.
Good afternoon, everyone, and thank you for joining us to discuss ICU Medical's financial results for the fourth quarter and full year of 2023. On the call today representing ICU Medical is Vivek Jain, Chief Executive Officer and Chairman; and Brian Bonnell, Chief Financial Officer. We wanted to let everyone know that we have a presentation accompanying today's prepared remarks as well. To beat the presentation, please go to our Investor page and click on Events Calendar, and it will be under the fourth quarter 2023 events.
Before we start our prepared remarks, I want to touch upon any forward-looking statements made during the call, including beliefs and expectations about the company's future results. Please be aware they are based on the best available information to management and assumptions that are reasonable. Such statements are not intended to be a representation of future results and are subject to risks and uncertainties. Future results may differ materially from management's current expectations. We refer all of you to the company's SEC filings for more detailed information on the risks and uncertainties that have a direct bearing on operating results and financial position.
Please note that during today's call, we will also discuss 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 ICU Medical's ongoing results of operations, particularly when comparing underlying results from period to period. We've also included a reconciliation of these non-GAAP measures in today's release and provided as much detail as possible on any addendums that are added back.
And with that, it is my pleasure to turn the call over to Vivek.
Thanks, John, and good afternoon to everyone. I'll walk through our Q4 revenue and earnings performance, highlight and provide some commentary on the main topics of 2023 and then turn it over to Brian to recap the full Q4 and fiscal 2023 results and provide our 2024 guidance. After that, I'll come back with some brief comments on our medium-term outlook and the actions and opportunities in front of us to improve our performance.
Revenue for Q4 was $576 million for total company growth of 2%. Adjusted EBITDA was $86 million and EPS was $1.57. We added $56 million of cash to our balance sheet as a result of the actions we've been taking on inventory combined with modest growth. As we had anticipated, we had sequential growth in all the segments and a larger inventory reduction in Q4 versus Q3. The broader demand and utilization environment in Q4 was the most positive since 2021 across almost every geography. The capital environment with status quo, and it does appear investments that customers need to get done do get done. There were no additional macro headwinds or tailwinds as compared to earlier in the year but the inflationary labor environment in some of the larger production countries continued.
Getting into our businesses more specifically, our consumables segment grew 4% in constant currency or 5% reported. The legacy ICU product families of IV therapy and oncology combined, again hit a record level in absolute sales with 11% growth, which is probably a few points overstated due to the Italian tax accrual in Q4 of '22. But more importantly to us, all 4 product lines in this segment grew well sequentially with Vascular Access finally turning around and at least reaching Q4 2022 levels. The sequential growth was driven by new customer -- new global customer implementations, improved census throughout the quarter and increased capacity and ability to serve the market with focus on clinical differentiation and creation of niche markets.
Our IV systems business was down 1% constant currency or down 2% reported and was the best quarter of the year in total. There was a wide range of performance across the product lines here. Our LVP pump business grew 11% with the best performance since 2021. This was due to strong census environment, a larger installed base and the usually robust Q4 for capital. Syringe pumps sold near normal quarterly levels but were down year-over-year due to the higher shipments in Q4 of 2022 from the release of certain product holds. Ambulatory pumps and their dedicated consumables were down year-over-year and are still below historic levels, but had a nice sequential improvement as did the segment. Since our last call, we've been putting our newly created -- newly cleared Plum Duo infusion system and LifeShield IV safety software through real-world use cases in a large U.S. IDN environment, and we're starting to be production ready to make Plum Duo generally available. The early feedback is meeting our expectations, and we're incorporating super user feedback into our road map and believe we have a hardware product and related safety software that can be the anchor of our offering for many years to come.
Just wrapping up the business segments, our Vital Care 7 grew 2% with IV solutions being up 6% and flat sequentially. Temperature Management and respiratory, both had nice sequential improvements. From an operational perspective towards our customers, the company is running the best it has in the last 2 years. Customer backorders at the lowest levels in 8 quarters and fulfillment has been very stable because all of the efforts of our team. And finally, what appears to be a more predictable supply chain and logistics environment. The discussions have shifted far more to innovation and the integrated value of what we've amassed.
Quality has been an area of heavy investment. We feel we're on solid footing. We have had and likely will have a few more important customer notifications, all as part of the overall remediation efforts previously discussed and enhancements we have made. We started 2023 with 5 goals that we reiterated on each call last year. Ultimately, we had revenue growth in most, but not all of our differentiated product lines. We did progress our quality remediation and ensured quality for patients and high compliance for regulatory authorities, respectively. We finished the TSA separation and have the groundwork and operational stability in place to pursue remaining synergies. We finally improved cash flow towards the end of the year but continue to be burdened by necessary investments in quality and integration projects to unlock additional synergies as well as certain underutilized production assets that we're working to address. And we're improving the portfolio from a revenue growth and quality perspective, which will increase any opportunities to rationalize the portfolio at sensible levels. That's my brief recap of Q4 and 2023 at a high level.
I'll now turn it over to Brian and then come back with a few comments on our medium-term outlook, some targets and a few other thoughts.
Thanks, Vivek, and good afternoon, everyone. Since Vivek covered the Q4 revenue for each of the businesses, I'll focus my remarks on first, recapping the full year revenue performance compared to our original expectations; second, discussing Q4 performance for the remainder of the P&L, along with the Q4 balance sheet and cash flow; and third, providing guidance on our expectations for 2024.
So to recap our full year 2023 revenue performance, consolidated adjusted revenue was down 1% on a reported basis and flat constant currency. At the business unit level, consumables revenue for the year was down 1% reported in flat constant currency compared to our original expectations of mid-single-digit growth. The shortfall was due primarily to the vascular access product category where the decline was larger than anticipated along with a few other variances within the business unit. But Q4 was important because after 3 previous quarters of stability in Vascular Access, we finally saw a sequential improvement.
Infusion Systems revenue for the year was up 2% on a reported basis and up 4% constant currency, in line with our original guidance of mid-single digits, driven by a combination of the LVP and syringe product lines. In Vital Care was down 3% reported and down 2% constant currency for the full year, which is at the low end of our original guidance range of flat plus or minus a little. Here, IV Solutions was the largest gap to our expectations, offset partially by solid growth within the temperature management and critical care product categories.
Moving on to Q4 results and further down the P&L. As you can see from the GAAP to non-GAAP reconciliation in the press release, gross margin for the fourth quarter was 34%, which was in line with our expectations and reflects the impact from lower manufacturing absorption as we continue to reduce inventory and improve cash flow. Recall that for the first 6 quarters following the acquisition, we increased inventory levels each quarter by an average of almost $50 million in order to, one, address the legacy SM backorder situation; two, build bridge stock in anticipation of the new EU MDR requirements, the effective date of which was eventually delayed; and three, bolster safety stock levels across the combined company. However, as each one of these situations evolved, in early 2023, we took action to bring inventory levels in line with underlying demand. And during the third quarter of '23, we decreased inventory levels for the first time. We said on the Q3 earnings call, that we expected inventory reductions to accelerate in the fourth quarter, and they did as we saw a cash flow benefit from inventory reduction of over $60 million. However, the lower production levels in Q3 and to some extent, Q4, negatively impacted gross margins in the quarter.
Adjusted SG&A expense was $113 million in Q4 and adjusted R&D was $22 million. Total adjusted operating expenses were up 3.5% year-over-year and reflect a combination of increased selling expenses from higher revenues, along with lower incentive compensation in Q4 2022. Restructuring, integration and strategic transaction expenses were $11 million in the fourth quarter and related primarily to acquisition integration. Adjusted diluted earnings per share for the quarter was $1.57 compared to $1.60 last year. The current quarter results reflect net interest expense of $24 million which is an increase over the prior year of $4 million and equates to just under $0.15 on a per share basis.
Fourth quarter adjusted effective tax rate was a benefit of 1% and includes certain discrete benefits in year-end items that contributed approximately $0.35 per share. Diluted shares outstanding for the quarter were 24.3 million. And finally, adjusted EBITDA for Q4 decreased 11% to $86 million compared to $96 million last year.
Now moving on to cash flow and the balance sheet. For the quarter, Free cash flow was a positive $61 million, which represents a significant step up relative to Q3 free cash flow of $14 million. And if you recall, Q3 was the first quarter of positive free cash flow since the acquisition if you exclude the onetime benefit from the accounts receivable sales program in Q1 of 2023. This improvement was driven primarily by a reduction in inventory during the quarter of more than $60 million. The focus on inventory allowed us to generate meaningful free cash flow while still investing in the areas that will drive future returns. These investments included $14 million of cash spend for quality system and product-related remediation, for legacy SM, $11 million on restructuring and integration and $30 million on CapEx for general maintenance and capacity expansion at our facilities as well as placement of revenue-generating infusion pumps with customers outside the U.S. And just to wrap up on the balance sheet, we finished the quarter with $1.6 billion of debt and $255 million of cash and investments.
Moving forward to the 2024 outlook, we expect full year consolidated adjusted revenue growth in the low to mid-single-digit range, and we expect the growth rates for each of the underlying business units to be in line with the longer-term outlook that we've discussed before, which is mid-single digits for both consumables and infusion systems and roughly flat for Vital Care. The consumables growth reflects a combination of volume and some price with volume increases driven by continued share gain in core infusion, modest recovery in vascular access and the benefit of higher growth markets for oncology and specialty. The infusion systems growth reflects normal market growth, a little bit of price and the assumption of limited P&L impact from Plum Duo in 2024, given the usual lag between customer contract signing and implementation.
Moving further down the P&L, we expect adjusted gross margin for the full year to be approximately 35%. The 35% includes price increases offsetting the negative impacts from labor inflation in our Mexican plants as well as continued pressure from the peso exchange rate and assumes a relatively stable environment for freight rates and fuel. It also reflects the temporary impact from lower absorption as we expect further inventory reductions over the course of 2024.
In terms of progression over the year, we expect gross margin to be lowest in the first quarter as a result of the delayed P&L recognition from the inventory reduction that occurred in Q4 of 2023 with improvement over the course of 2024 from higher manufacturing volumes as inventory reductions taper and revenue growth takes effect. We are planning for adjusted operating expenses as a percentage of revenue to be similar to 2023 levels, which is just under 24%, reflecting the benefit from synergies, offsetting the impact from resetting incentive compensation plans and general inflationary increases.
Net interest expense is expected to be approximately $105 million based on current market forecast for interest rates as well as the roll-off of a portion of our interest rate swaps. The adjusted tax rate should be around 23%, which is our normalized tax rate before discrete items and finally, diluted shares outstanding are estimated to average $24.6 million during the year. Bringing these components together results in 2024 adjusted EBITDA in the range of $330 million to $370 million and adjusted EPS in the range of $4.40 to $5.10 per share.
Now on to cash flow. We ended 2023 with $83 million of free cash flow for the year, which is driven mostly by the onetime benefit from the implementation of the accounts receivable factoring program during the first quarter. For 2024, we expect free cash flow to be around the same levels as 2023, but to be driven entirely by operations. And the final amount will depend on, one, the degree of inventory reduction; and two, the amount that we choose to invest in quality remediation and integration activities as there is value in completing this work sooner to capture additional synergies.
In terms of remaining inventory reduction, we said on the last call that the total opportunity was ballpark $100 million. And after more than $60 million captured in Q4, that would leave roughly $40 million left to go and we think that's a fair assumption headed into 2024. In addition, we expect to see our CapEx requirements in 2024 to be in the range of $90 million to $110 million. Timing of free cash flow throughout the year should be consistent with our historical trend, which is lighter in the first quarter as a result of payments for prior year annual incentive compensation with improvement over the remainder of the year helped by the benefit of revenue growth.
To wrap up, we're happy with the sequential improvements in Q4 revenue that we saw across all 3 businesses as well as the meaningful step-up in free cash flow. For 2024, we're focused on foundational work that will drive earnings improvement in 2025 and beyond, which Vivek will expand upon.
Now I'll hand the call back over to Vivek.
Okay. Thanks, Brian. And that's the reality of where we are right now. But what's not lost on us is the reality of where we should be. Profitability in parts of this industry has obviously been impacted by the lag between inflation and pricing and the underlying competitive dynamics and differentiation in each category. But even with all that, we think most reasonably efficient companies in these types of markets now are somewhere in the low 20s EBITDA margin level. We do not think this can apply to our IV Solutions business, which has its own unique competitive dynamics and with a general misvaluation of the product in the market. But we do think the rest of our portfolio is capable of achieving such a margin over time. Given what we have been through the last few quarters, we are not willing to commit to a certain date of being there, but our experience in time in the category makes us believe that, that's a fair metric. For our lean type of company, achieving this metric is all about revenue growth and our gross margins which for us include all costs related to logistics and many other areas. And most of the improvement opportunities with these items should be directly under our control.
We still need to prove that we're capable of predictable, sustained revenue growth, which has not been the case as certain lines are going backwards, but we are on more solid footing now. Our original model for a number of these products and our goal was to just get back to near historical sales levels, and we will need additional price given some of the share losses. But in the background, we've been actively refreshing the portfolio to ensure we're capable of either creating new markets or protecting product families that can take share. Plum Duo was the first step of a series of products in our next generation of infusion technologies. We should have a single-channel plum solo and a refreshed syringe pump on file at the FDA by the end of this year. These products will work with our already cleared LifeShield infusion safety software and would be just at the beginning of a long cycle in that space.
Alongside that, over the last year or 2, there have been a number of new launches, examples include a series of capital and disposable devices in the Diana family to be used in drug preparation that should help our CSTD prep products, a refreshed tracheostomy series called Blue Select, and a refreshed hemodynamic monitor that upgraded the already New York Cogent. We would expect certain new filings over the next 12 to 24 months in our consumables area and the valuable temperature management business. We're growing our positions with the existing products of today, and these will be supplemented by a significant refresh in key parts of the portfolio with a large portion already done. We've been carefully targeting these investments because, obviously, innovation drives sustained revenue growth.
But the other challenge has been gross margin volatility, and we mentioned some of the areas for optimization on this call last year, where we have businesses at record levels, those production environments are fully utilized and improving efficiencies. But where we have businesses that are smaller, we have real inefficiencies where the pain has been compounded with the inventory choices we've made or the loss of revenue. There's no magic here nor do we need to talk about transformational programs or anything like that. This is the basic blocking and tackling of network consolidations. Some have been announced like the move of our syringe and ambulatory pump production at Costa Rica and our U.S. pump service center consolidation at Salt Lake City and other projects are in flight. Simply said, have less places and have them in the right place in full, and the same goes for real estate.
Logistics network consolidation is also embedded in this gross margin work for us, but it's more in the planning stage and it depends on our IT system integration. That foundation has been laid, and we'll integrate our U.S. system sometime in Q3 of this year. We've done that type of project several times now. This list of actions is economically meaningful and contributes a huge portion of getting where we need to be and offsetting the normal bumps that happen in business, but they do take some time to execute. Out of our control are interest costs, which we do expect to change eventually. But from a value perspective, we felt it more sensible to bear more interest expense as long as manageable versus eroding value by not maximizing the assets where the revenue, earnings and quality of those assets is improving.
Debt paydown continues to be our highest capital allocation priority, and any extra cash above our needs would go to repayment. To be direct on our goals for the next year or 2, we won our consumables and systems businesses to be reliable growers with an industry acceptable profit margin with the tightest and most optimized manufacturing network and each with a multiyear innovation portfolio. And we want the rest of the portfolio to add up to levels where we deliver an acceptable profit margin that ultimately allows us to transfer value from debt to equity.
There is no confusion within the company and the pursuit of these goals, and we don't really have any frivolous activities here. We produce essential items that require clinical training, hold manufacturing barriers and in general items that customers do not want to switch unless they must. The market needs ICU Medical to be an innovative, reliable supplier and our company is stronger from all the events over the last few years. Thanks to all our team members and customers as we improve each day.
And with that, I'll open it up to questions.
[Operator Instructions] And today's first question comes from Jayson Bedford with Raymond James.
And thanks for all the additional details, especially on '24. So maybe just to start on the revenue guide. Just given the comps, can we assume that the growth is higher in the second half than the first in terms of revenue growth?
Probably a little in between, Jayson. I mean Q2 was pretty low for us in I'd say it's probably a little more balanced throughout the year. Maybe the revenue part is so back-end weighted, right margins might be a little different.
Q1 may be a little bit lower than the average guidance that we provided, but the remainder of the quarters are probably pretty consistent.
Okay. And then you mentioned price a couple of times. Is the expectation that price is a bigger tailwind in '24 than it was in '23?
No, it wouldn't be of greater magnitude probably around the same impact.
Okay. Okay. And then just on IV Solutions, good growth in the fourth quarter. Is this kind of the right level here to think about on a quarterly run rate for '24?
Yes. We think that's -- that's kind of the same level it should be at from here on out.
Essentially, Jayson, the gap would be the [ 80 ]. We used to be at minus products we were getting from Pfizer as we've talked about in the previous calls.
Right. Okay. Sorry, I'm just going to ask a few more here. But just on IV Solutions margins, you kind of called that out. I think we all understand that. But maybe other than price, what else can you do to improve IV Solutions margins?
I think, Jayson, it's a traditional manufacturing industry. And I think we try to find the right balance between ensuring high quality and reliability of the customer. There are areas for opportunities in terms of, one, how the value chain works for the customer. specifically what type of service model, what type of service delivery, logistics costs, et cetera, which are a huge component of the products. There is improvements available on the factory floor there are improvements potentially available if we put CapEx into the business, but we've -- we try to think about that very clinically. So it's sort of more normal manufacture -- outside of long-term price and trying to get the category revalued a bit, it's really more traditional manufacturing operations -- operational improvements.
Okay. And then maybe lastly, and I'll let someone else jump in. But just on the Smiths integration, kind of what's left and what's the potential impact of those efforts on the P&L?
Well, some of this gap to held margins would be where we are, are underpinned by cost savings and synergies that come from a full system integration that allows us to get after duplicative logistics networks, duplicative service orgs and some spots. That work, similar like it was when we do Hospira is on track, it's probably simpler than we do with Hospira. It's scheduled to happen in Q3 of this year. And if you went back and looked at some of the previous scripts, we tried to detail where those things are valuable both in terms of logistics as well as support functions that still have some duplication.
And the next question comes from Larry Solow with CJS Securities.
I guess first question -- first of all, I appreciate lots of color on this call. And I appreciate the sort of long-term guidance. And it sounds like you're confident in the business. And I guess that is reflected in checking out some recent filings if you were our recent investment. So good to see that. But just in terms of that margin, the fact that low 20s EBITDA margin, is that like a 3- to 5-year target? I know you don't want to put any back target on that, but is that a reasonable time line for that expectation?
I mean, I think, Larry, we would feel -- the short answer is yes. But I think we would feel comfortable right now saying all the cost savings aspect of those activities, the network consolidation will largely be fully implemented by the end of next year with the big step-up in value actually next year over this year. So some of the things take time to get in, but there's some big stuff happening balance over this year. Then to get the last couple of points, it's about revenue growth, and that's where I think you're saying is we don't want to put a line in the sand on most people's LRPs rarely come exactly in the way they think. We prefer not to do that in revenues, but the part that is clear to us is all the synergies that are still out there for us to get.
Got it. And in terms of revenue growth, obviously, you kind of gave that 5% target for your consumables and your systems at least for this year. Do you feel out a place now once we can maybe get a little bit better pricing in vital care that you have sort of sustainable, that target of mid-single-digit revenue growth and maybe you'll need a little bit more or maybe when you actually get to that target, it may take a little while to get that leverage to get to that margin goal. But without -- again, without putting a time line on it, but do you feel like you're in a comfortable spot now and have somewhat visibility and confidence that you can kind of maintain these revenue growth levels?
I mean, look, we're giving guidance for this year, and we're giving it with at least 2 years -- the last 2 years of some struggles under our belt. So I think we do feel that way, certainly about '24 revenues. We do feel that way for the synergies and expense items out there. The short story is the company is running and the best it has in a long time for customers, for patients with innovation, we're just under earning. And the margin talk is in -- there are moments in our history where we overearned. But right now, a moment is frankly where we're under earnings, and we need to work to get that in line.
Just lastly, just your state of the union or just your brief summary in the hospital outlook, obviously, your major customers and hospitals in terms of just operational trends, utilization, maybe to a lesser extent, budgets and capital expenses going forward. But just how do you feel about just the general customers today?
I tried to say it in front of me. I really -- I think our view is this is reliable as it's been in a long time. It seems like the lag time between reimbursement changing and labor utilization sort of sorting itself out is all happen, if it feels like it's getting back to normal. So we don't really have anything negative to say on the customer environment, right? It's really under our ability to execute.
And the next question comes from Kristen Stewart with CLK.
Can you guys hear me okay?
Kristen, as a first-time caller.
I was wondering if we could just focus a little bit more on gross margins. I appreciate all the long-term color you share on EBITDA margins getting back to the low 20s. What does that imply for gross margins? And how quickly, I guess, can you get to a more normalized level?
Yes. I guess thinking about gross margins in the context of the EBITDA margin improvement that Vivek laid out. First is, I think we would expect most of that EBITDA margin expansion to also show up within gross margins given the nature of the items that will drive that. And then, I guess, thinking about gross margin rates kind of over the near term, we did say '24 full year rate is at 35%, and we expect improvement throughout the year, which means we'll probably exit '24 slightly above the 35% rate. But I do think it's important to note that where we exit '24, it won't be at the same level of gross margin that we saw in Q1 and Q2 of 2023 because those quarters very much benefited from manufacturing volumes that were in excess of underlying demand. But for us to get back to those levels does require some of the cost savings that be talked about as well as some revenue growth on top of it.
Okay. And I think Vivek mentioned that those cost savings would largely come towards the end of 2025. Is that correct? Or can we see some improvements in 2025?
Sorry, Kristen, if I wasn't clear. I was saying of the synergy items, the cost-saving items, it would take to the end of '25 to have them fully implemented, meaning all the actions done, but the actual economic value would be more meaningful '25 over '24 than it would in the future. there would still be some beyond that. But the value capture was fully intended to make a difference next year.
Okay. Perfect. And then last question, Vascular Access that seems to be stabilizing. What's the outlook for 2024, embedded in your forecast for that product line?
I think the words Brian used -- I'm going from memory here in the script, I think you said modest growth. So I would consider it just sort of in line with the mid-singles that we talked about for the segment.
And the next question comes from Brett Fishbin with KeyBanc.
Just wanted to start off with a quick follow-up to Kristen's question because I wanted to ask about a couple of the product lines that have been more headwinds to growth in 2023. So maybe following on the vascular access question, you could just touch on ambulatory pumps as a category, understanding that was a headwind in the past few quarters, if you're seeing any visibility toward improvement into 2024.
Yes. Also, welcome, Brett. It's nice to hear you. I think it's an incredibly important line you referenced there. It was really one of the key value category that underpin the acquisition. And it's until maybe Q4 of this year has been pretty bumpy because of the operational challenges we've had and those operational challenges, meaning not being able to necessarily supply all the dedicated sets in the first couple of months of the transaction led to lower utilization of those pumps and/or potentially a little bit of customers looking for alternatives, that has finally been very stable over the last 2 quarters, 3 quarters or so, and that product still continues to hold a global leadership position in medication delivery, certainly in the home care environment. and many other spots, it feels better today, it's still selling reasonably below historical levels with an aging fleet. And so we have multiple opportunities there in our minds. One is the normal capital refresh that happens in the pump business as the world is opened up -- starting to open up more, there's an opportunity for more of that as the fleet is aged and two is just driving utilization of the pumps, the pumps that are out there making sure they're all pumping. And so I think there's been 3 or 4 reasons ambulatory has been challenging that is all of the operational challenges are gone and there's real opportunities to prove there, really important line.
All right. Super helpful. And then maybe a follow-up kind of on a similar topic around pumps. Definitely understand you're still pretty early in the cycle of plum and talking to customers. But just curious how the initial customer reception has been in the early conversations? And then maybe just a little bit of a broader question around the competitive opportunity in pumps and how you see demand coming off of several years of the Becton recall and a couple of years of limited capacity to implement upgrades and just how you see that progressing through the year?
Yes, yes, it's the right -- it's also a really insightful question in terms of the value picture. There is more pumps in the United States right now that need to be addressed, both either through the age of the devices or the virus recalls than there has been in many years. And my comment in my opening remarks saying choices that -- or investments that do need to get done, do get done, customers actually have the capacity to buy and implement. As it relates to -- and are almost forced to on a reasonable time line. As Brian tried to reference, we didn't put a lot in for the Duo in 2024 because things -- even though it's a period of activity, installs contract signings do go slowly, and we just want to make sure we're doing that properly. And we're just getting into the general release phase. I think big picture, the tone of the pump market is good, all players are sort of armed and it's competitive, which is we take that right now. People have to make choices.
All right. Great. And then last question from me. I think you guys gave a bunch of really good figures. Just think about the inventory drawdown and absorption topic for 2024. Just thinking you -- you were able to wind down about $60-plus million in this past quarter. And you put that in context of a $100 million total opportunity, your goal. So is it fair to think that most of the remainder of that takes place in 1Q based off of kind of the pace you're on? And how do we think about the tell, understanding like the 4Q drawdown impact 1Q margins? Just how to think about like once that drawdown is completed, how long the tell is where that's impacting margin -- gross margins?
Yes, Brett, I guess thinking about kind of the pace of further inventory reductions, the work that we have to do around that, you do tend to be able to capture the easiest stuff first. And I think we saw that phenomenon happen in Q4. And why -- such a big number. But I think what happens is sort of each incremental reduction becomes more difficult. And so the remaining $40 million is probably going to be spread out over the first 2 or 3 quarters of '24 as opposed to kind of coming all in Q1 just because it does get a little bit harder, the further you get into it.
All right. Got it. Just -- I'll just clarify like the last point. So assuming more like a midyear 2Q to 3Q time line. Just how to think about like the tell where that inventory drawdown is impacting the gross margin of future quarters?
Yes, just that delayed impact showing up on the P&L is probably kind of a 1 to 1.5 quarter lag, generally speaking. So there will be some ongoing impact.
The next question is a follow-up from Larry Solow with CJS Securities.
Just a quick follow-up. Just on the free cash flow, you gave -- Brian, you gave some pretty good guidance this year. Essentially, it's not even with last year. Just longer term, I would think is it just a remediation of the expenses that are holding you back and at least getting free cash flow somewhat near net income. And in the future, is that something that you guys hope to target getting to over the next couple of years as remediation expenses ease off?
Yes. The two items are spending on the remediation work. That's the largest bucket and then followed by the spend on integration.
That's why -- and it was inventory, right? So we got that one done. Now we have to get the remediation finish, and we got to get the integration done in the remediation finish. That's exactly that.
Got it. Because not inventory the time is a good guy at least in the short run.
And the next question is the fall from Jayson Bedford with Raymond James.
Yes. Sorry for the additional question. Just on the gross margin, Brian, did I hear you right that exiting '24 gross margin will be slightly above 35%. I thought it would be a little higher, but it kind of depends on the first half. So is that correct, slightly higher than 35%?
Yes. I think that's our assumption at this point.
Okay. And then just on the whole EBITDA margins ex IV solutions, where are we today? I was kind of doing back of the envelope at about 19%, but that seems a little high. So I'm just kind of wondering...
That's high, Jayson. That's high. I mean I think it's -- again, we don't segment report the individual business units on the EBITDA level. But ballpark, I think I'd say, somewhere in the 17% range, 16.5%, somewhere like that on EBITDA margins ex IV Solutions. It is love, that's why I said we're under earning.
Okay. For some reason, I thought IV Solutions was lower than that in terms of contribution.
So again, approximately, we don't care at a on that level.
Thank you. And this concludes our question-and-answer session. I would like to turn the floor back over to Vivek Jain for any closing comments.
Thanks, everyone, for your interest in ICU Medical. We look forward to speaking to you again. Most will just be in a matter of weeks on our Q1 call, and I appreciate everybody's efforts to keep improving the company and your interest in the company. Thanks very much.
Thank you. The conference has now concluded. Thank you for attending today's presentation. You may now disconnect.