Tactile Systems Technology Inc

NASDAQ:TCMD

Earnings Call Analysis

Earnings Call Transcript 2024-Q2

[Operator]

Welcome, ladies and gentlemen, to the Second Quarter 2024 Earnings Conference Call for Tactile Medical. [Operator Instructions] Please note that this conference call is being recorded and will be available on the company's website for replay shortly.

I would now like to turn the call over to Sam Bentzinger, Investor Relations at Gilmartin Group, for a few introductory comments. Please go ahead.

[Sam Bentzinger]

Good afternoon, and thank you for joining the call today. With me from Tactile's management team are Sheri Dodd, Chief Executive Officer; and Elaine Birkemeyer, Chief Financial Officer. .

Before we begin, I would like to remind everyone that our remarks and responses to your questions today may contain forward-looking statements that are based on the current expectations of management and involve inherent risks and uncertainties and which could cause actual results to differ materially from those indicated, including those identified in the Risk Factors section of our annual report on Form 10-K as well as our most recent 10-Q filing to be filed with the Securities and Exchange Commission. Such factors may be updated from time to time in our filings with the SEC, which are available on our website. We undertake no obligation to publicly update or revise our forward-looking statements as a result of new information, future events or otherwise.

This call will also include references to certain financial measures that are not calculated in accordance with generally accepted accounting principles or GAAP. We generally refer to those as non-GAAP financial measures. Reconciliations of those non-GAAP financial measures to the most comparable measures calculated and presented in accordance with GAAP are available in the earnings press release on the Investor Relations portion of our website.

With that, I'll now turn the call over to Sheri.

[Sheri Dodd, executive]

Thanks, Sam. Good afternoon, everyone, and welcome to our second quarter 2024 earnings call. Here with me is Elaine Birkemeyer, our Chief Financial Officer. I'm pleased to report strong Q2 performance across both our top and bottom lines as well as improvements in our operating cash flow. Specifically, Tactile achieved total revenue of $73.2 million in the second quarter, representing 7% growth year-over-year. By product line, lymphedema revenues increased 8% year-over-year to $64.7 million, and airway clearance revenues increased 2% year-over-year to $8.5 million. We delivered strong adjusted EBITDA with over 49% year-over-year increase, reflecting our focus on profitably scaling for our business and operating leverage. From a cash perspective, we increased cash and cash equivalents by $12.9 million in Q2, tipping our cash balance to $73.6 million as of June 30, 2024.

Finally, each of our key commercial initiatives for 2024 remain on track. These include: number one, technology and workflow related investments in sales and order operations focused on simplifying and accelerating time to revenue. Number two, development and launch readiness of our next-generation Lymphedema platform, and number three, generation of clinical evidence to support patient expansion.

I'll expand on each of these shortly, but I'd like to begin with a few high-level remarks. This marks my first earnings call as CEO of Tactile Medical. But before I dive in, I'd first like to congratulate Dan Reuvers on his well-earned retirement and thank him for his measurable impact and meaningful contributions to the company and the patients we've served over the last 4 years. I've had a chance to work closely with Dan as a member of Tactile's Board of Directors since 2021 and his stewardship of the business during the pandemic and through the post pandemic recovery period has been admirable.

I'm excited to be in this role and excited about the future for Tactile. The business strengths and opportunities at Tactile are well aligned with my 30-year career in health care at the World Health Organization, Johnson & Johnson and Medtronic. My roles have spanned leadership positions and market access and multiple general management positions. The diversity of these roles and disease states have informed my understanding as a complex care continuum and market access drivers. Fortunately, these are growth opportunities for us at Tactile and they strongly leverage my background.

I've spent my first few weeks as CEO, engaging with external stakeholders and meeting with the executive and senior management teams to get a deeper understanding of what's working and where we have opportunities for improvement. This early experience has reinforced my confidence that Tactile is well positioned to transform to very large and very underpenetrated markets with 2 still woefully underserved patient populations that endure chronic and progressive diseases with life-altering consequences every day.

The market foundations are solid. There's a significant unmet need. Our patients experience an unnecessarily protracted and complicated care pathway from diagnosis to treatment options to successful symptom management. There is so much potential to streamline the care journey. The markets are growing. The U.S. market comprises roughly 2 million patients diagnosed with lymphedema. Additionally, there are an estimated 20 million people who are undiagnosed with lymphedema and struggling to receive a diagnosis and timely treatment. Finally, our therapy is underpenetrated. Specifically for pneumatic compression devices, or PCDs, less than 8% of diagnosed patients with lymphedema receive a PCD. Product innovation, clinical programs and market access initiatives will continue to be areas of focus to drive appropriate therapy penetration.

A growing market and under penetration within our product category are encouraging fundamentals. But it's the patient's unmet needs that drive our sense of urgency, diagnosed or undiagnosed lymphedema patients include breast, head and neck, pelvic and other cancer treatments survivors. There are also men and women of all ages with chronic venous insufficiency, obesity, trauma and surgery. They experienced significant symptoms of swelling, heaviness and tightness that go beyond cosmetic issues. They face cellulitis, pain, restricted range of motion, limitations on activities of daily living and fibrosis. Especially accruals for head and neck cancer survivors is the difficulty swallowing, speaking and breathing. There is no care for lymphedema and their disease is chronic and progressive.

Similar to lymphedema, chronic pulmonary disease also represents a large and underpenetrated market with bronchiectasis being the most common with an estimated 500,000 diagnosed and 4.4 million undiagnosed patients. Bronchiectasis is commonly a misdiagnosis due to the overlap with COPD and the left untreated, the inability to clear mucus leads to a continuous cycle of infection, inflammation and worsening damage. This status quo is unacceptable to our patients, and it's also unacceptable to us. The potential impact from our therapies on patients across these markets is too substantial, and our path to meaningful growth is not only viable but it will be our reality.

I'm excited to continue advancing our mission at Tactile, and I see the company at a critical juncture, supported by 3 points. First, we are the demonstrated leader in lymphedema therapy solutions with a portfolio of patient-focused clinically proven pneumatic compression therapy. Second, we are advancing the standard of care for bronchiectasis patients with a differentiated portable offering. And third, we have a cohesive and experienced leadership team and a talented and committed professional sales organization. The time is right to refine our growth and profitability strategy, and I look forward to sharing more specifics with you next quarter.

With that context, I'd like to pivot back to a review of our second quarter performance, updates on our key commercial initiatives and where our focus lies for the remainder of 2024. Regarding our product lines, we're pleased to see the growth in year-over-year lymphedema revenue despite a strong prior year comp. As a reminder, we added sales reps late in Q1 of this year, and we expect to see their revenue impact materialize more meaningfully in the second half of the year and beyond. Our legacy reps are increasingly productive due to workflow redesign that aims to reduce non-selling activities such as in-home patient demos. These demos are increasingly performed by our trained patient education consultants. And this quarter, 45% of in-home demos were performed by these consultants versus 35% in Q1 and versus 30% at the end of 2023.

We remain committed to our goal of achieving 50% of in-home demos performed by our patient education consultants by the end of 2024. In terms of our overall lymphedema sales headcount, we ended the second quarter with 264 sales representatives versus 269 at the end of the first quarter. While this remains in our target range, we still expect sales headcount in the high 2.60s to low 270s as we exit the year.

With respect to our sales channel mix in the quarter, our non-Medicare lymphedema business grew nearly 20%, reflecting growth recovery in the VA and progress with our commercial payers. While we continue to improve our first-class claims approval for Medicare patients, our Medicare business was down on a year-over-year basis in Q2, which is directly related to the increasingly onerous documentation requirements for Medicare administrators. I'll be speaking in more detail about this after I wrap up the Q2 performance highlights.

Turning to a review of our Airway Clearance product line. Since acquiring AffloVest just 2.5 years ago, we doubled the size of the business by taking both share and growing the market. the AffloVest product fits well within our portfolio and ultimately expands our ability to reach and serve more patients with chronic conditions in the home. The product's differentiated portable design, the broad DME channel reach, strong reimbursement, targeted medical education and a tenured sales force are the right pieces for continued growth and profitability. In the second quarter, we were pleased to see Airway clearance return to growth on a year-over-year basis following the anniversary of the PHE waiver expiration in May.

The expiration of this COVID era waiver affected the ordering patterns for one of our larger DME customers and has been a modest headwind to growth. Shipments continued to stabilize in the second quarter for this particular DME, and we anticipate a return to non-PH ordering patterns. Speaking of ordering patterns. The Airway clearance business is a bit more sensitive to stocking patterns as compared to our direct lymphedema business. While we expect modest ebbs and flows within the distributor model, our overall expectation for improved performance in the second half of this year remains intact. Our confidence in this view is grounded in a couple of factors, namely that a majority of our DME partners are continuing to grow. In fact, if we exclude the 1 DME that was the most impacted by the change in PH, the collective revenue from the other DMEs demonstrates double-digit growth on a year-over-year basis in the second quarter. This continues the trend we saw in the first quarter. We also have several examples of successful DME partner onboarding. For example, a new distributor came online during Q1, and we are already seeing encouraging ordering volumes.

We are making the training investments with our DME partners and successfully demonstrating AffloVest as a valuable offering for their large base of patients on oxygen. We expect to see this customer and our other distributor partners continue to grow their Atos business as a synergistic product in their portfolio. And finally, our Airway Clearance sales organization consists of a very tenured and highly competent team who excel at educating and training our DME reps in bronchiectasis and the role of AffloVest in their care.

We had added reps through Q1 and Q2, and we expect this to help contribute to growth. Before turning to an update on our 2024 key commercial initiatives, I'd like to share more details on our Medicare business and recent changes in Medicare's approach to administering the pneumatic compression pump LCD. This LCD was first established in 2015. And while there have been no additional coverage requirements since then, we are seeing significant changes in the way the MAX are adjudicating claims and increasing their documentation requirements. This increasingly onerous approach to how Medicare administers the LCD ultimately impacts speed and access to treatment for Medicare patients. Earlier this year, we initiated a pilot with an e-prescribing tool, which aims to streamline how we collect and exchange patient medical records with providers during the ordering process. While the change in approach to Medicare documentation was not anticipated, our 2024 tech investment and a flexible e-prescribing tool demonstrates our forward-thinking approach to automating clinical documentation.

We are pleased with the early results of our e-prescribing pilot and are advancing broader deployment of the platform later this year with the anticipated impacts to our business beginning more meaningfully in 2025. In addition to expanding our e-prescribing pilot, we'll be working closely with our clinical partners, professional societies, the MAX and CMS directly to advocate for unhindered access for Medicare patients that meet the clinical and LCD requirements for our therapy. While we are strategically and operationally addressing the change in approach to documentation by the MAX, our current assessment of the potential impact on the revenue in the back half of this year leads us to revise our full year 2024 revenue guidance to $293 million to $298 million.

As mentioned earlier, the number of patients diagnosed with lymphedema is growing. There is no change to the underlying demand for our lymphedema products, and we have started the implementation of technology to streamline documentation and speed to order processing. As the market leader, we have resources and action plans to help mitigate this recent headwind. As I mentioned in the beginning of our call, there are 32024 key commercial initiatives that I want to highlight. The first is technology and workflow related investments in sales and order operations. In addition to our e-prescribing tool, we continue to advance other tech investments, which are designed to enhance and simplify the order and reimbursement process as well as the patient and clinician experience.

Last quarter, we transitioned to a new more efficient electronic method of verifying patient insurance, which contributes to simplifying our workflow and supporting faster time to order completion. Last quarter, we also shared our investment plan in a new CRM tool and partnerships with leading edge tech companies to introduce AI solutions for sales, marketing, operations and service. We are on track with these initiatives and plan to launch the CRM tool at the end of the year.

We are modernizing our business infrastructure and ensuring its design serves our internal operations as well as enhancing the patient and clinical experience. The second key commercial initiative for this year centers around innovation. Product innovation has been and will continue to be core to our business. And in the second quarter, we reached an important milestone with FDA 510(k) approval of our next-generation lymphedema therapy platform, platform, which we call Nimbl remains on track for an early fall 2024 introduction, and we are excited to share a few early details of the product today.

Nimbl represents the next generation of our entry-level entree plus pump and was designed specifically to bring an even more friendly consumer experience to our patients. It's small and lightweight enabling portability when patients are outside of the home. Nimbl also features connectivity to our Kylie digital app, providing patients a way to track their therapy progress at home and share the results with their care team. Nimbl is an exciting addition to our portfolio, and I look forward to sharing additional details on the product and commercial launch next quarter.

Finally, from a clinical perspective, we remain very excited about our investments in first-of-its-kind Flexitouch evidence generation. Last quarter, we shared details of the largest lymphedema study in the VA, which was published in the Journal of Vascular Surgery. Today, I'm pleased to share an update on our randomized controlled trial assessing Flexitouch for head and neck lymphedema. This study is the largest randomized clinical trial ever conducted among head and neck lymphedema patients, of which there are over 400,000 oral cavity or Farnex cancer patients in the U.S. and 90% of these patients are likely to develop lymphedema. We completed enrollment in April 2024 with 235 patients and are wrapping up the 6-month patient follow-up. Once complete, we will analyze the data and communicate results likely in early 2025. These 2024 key initiatives are meeting their milestones and are reflective of our strategy to simplify our business processes in the clinical and patient experience. They also reflect our commitment to new product innovation and clinical evidence. I'm proud of the work that's been done and our employees are excited about them, too. I plan on leveraging my experience to ensure these investments are optimized and our strategies capitalize on our existing commercial momentum and scale.

Now I'll turn it over to Elaine for a review of our second quarter financial results in more detail and an update on our 2024 outlook.

[Elaine Birkemeyer, executive]

Thanks, SherI. Unless noted otherwise, all references to second quarter financial results are on a GAAP and year-over-year basis. Total revenue in the second quarter increased $4.9 million or 7% to $73.2 million. By product line, sales and rentals of lymphedema products, which includes our Flexitouch and entree systems, increased $4.7 million or 8% to $64.7 million. and sales of our Airway clearance products, which includes our AffloVest system, increased $0.2 million or 2% to $8.5 million, continuing down the P&L. Gross margin was 73.9% of revenue compared to 70.7% in the second quarter of 2023.

Non-GAAP gross margin, which excludes noncash intangible amortization in both periods, was 74.3% compared to 71.1% in the prior year. The increase in non-GAAP gross margin was attributable to -- primarily to lower manufacturing and warranty costs, and improving collections reflected in our revenue. Second quarter operating expenses increased $2 million or 4% to $48.3 million. The change in GAAP operating expenses reflected a $0.4 million increase in sales and marketing expenses, a $0.4 million increase in research and development expenses and a $1.8 million increase in reimbursement, general and administrative expenses. Strategic technology investments accounted for approximately $1 million of the increase. These items were partly offset by a $0.6 million decrease in noncash intangible asset amortization and around expense. Operating income increased $3.8 million or 184% to $5.8 million.

Non-GAAP operating income increased $2.9 million or 80% to $6.5 million. As a reminder, our non-GAAP operating income excludes noncash intangible amortization and at expense as well as certain nonrecurring operating expenses. We've provided a detailed GAAP to non-GAAP reconciliation in our earnings press release. Other income net increased $1.1 million or 127% to $0.2 million. The increase was due to higher interest income on our increased cash position and lower interest expense, primarily driven by the retirement of a revolving line of credit at the end of 2023.

Income tax expense increased $0.5 million or 35% year-over-year to $1.8 million, driven primarily by a higher taxable income. Net income increased $4.4 million to $4.3 million or $0.18 per diluted share compared to net loss of $0.1 million or $0.00 per diluted share. Non-GAAP net income increased $3.8 million or 380% to $4.8 million compared to $1 million. Adjusted EBITDA increased to $9.1 million or 12% of sales compared to $6.1 million or 9% of sales. With respect to our balance sheet, we had $73.6 million in cash and cash equivalents and $27.8 million of outstanding borrowings at the end of the quarter. This compares to $61 million in cash and $29.3 million of outstanding borrowings as of December 31, 2023.

our cash growth was driven by a combination of operating income and an increase in net working capital. Turning to a review of our 2024 outlook. For the full year 2024, we now expect total revenue in the range of $293 million to $298 million, representing growth of approximately 7% to 9% year-over-year. This compares to previous 2024 total revenue guidance in the range of $300 million to $305 million, representing growth of approximately 9% to 11% year-over-year. Our updated guidance reflects the impact we are seeing from Medicare's increased documentation requirements that Sheri discussed earlier.

Our 2024 total revenue guidance range assumes that growth in both our lymphedema and airway clearance product lines will be in a similar range. For modeling purposes, for the full year 2024, we now expect our GAAP gross margin to be approximately 73%, our GAAP operating expenses to increase low double digits as we advance our tech-related investments throughout the year. Net interest income of approximately $0.8 million, a tax rate of 30% and a fully diluted weighted average share count of approximately 24 million shares.

As a result of our continued progress with improving profitability, we now expect to generate adjusted EBITDA of approximately $34 million to $36 million in 2024. This compares to previous adjusted EBITDA guidance of $33 million to $35 million. Our adjusted EBITDA expectation assumes certain noncash items, including stock compensation expense of approximately $8.4 million, intangible amortization of approximately $3.8 million and depreciation expense of approximately $3 million.

With that, I'll turn the call back to SherI for some closing remarks. SherI?

[Sheri Dodd, executive]

Thanks, Elaine. To close, we are pleased with our Q2 performance, but even more excited about what the future holds for textile. We are fortunate to have well-defined strategies already in place and actionable initiatives underway to achieve them. Over the next several weeks and months, I'll be having deeper conversations with our leadership team, spending time in the field with our salespeople, and connecting with our physician and patient communities with the goal of refining key elements of our existing strategies and identifying new opportunities to continue driving sustainable and profitable growth.

Importantly, I also plan to share greater detail on our approach to capital allocation in the coming quarters. As Elaine mentioned, we are increasingly benefiting from and generation of free cash flow, a trend we expect to continue. This not only reflects the maturity of our business and our prudent cash management, but also an opportunity to allocate capital in various ways to increase shareholder value. In the coming months, we will be focusing on evaluating several options to leveraging our strong balance sheet, and I look forward to providing updates on our strategy.

With that, operator, we'll now open the call for questions.

[Operator]

[Operator Instructions] Our first question, Ms. Margaret Kaczor with William Blair.

[Margaret Kaczor, analyst]

Maybe wanted to touch on guidance first. The range decreased $7 million on the high and low end, and it sounds like, correct me if I'm wrong, that all of that was kind of on the Medicare side, more likely Flexitouch. But how should we think about that impacting maybe Q4 versus Q3 seasonality and you were clearly able to offset some of those headwinds this quarter as well as the first. So maybe you can give us a sense of is it getting worse? Are you seeing these trends expand. And then -- sorry, it's a loaded question. But how do we -- and when do we expect this to be more normalized? Is it 2025 as some of these documentation elements start to have an impact? .

[Sheri Dodd, executive]

Thanks, Margaret, and definitely anticipated this question. So let me break it down into 3 components. So dispatch. There's been a really distinct change in the documentation requirements for PCD coverage. So Medicare is just demonstrating this increasingly onerous approach to documentation, which is requiring more time to assemble the requisite documentation, which elongates the time from Rx to order completion. And this impacts all PC manufacturers, not just us. This change is really surprising given the fact, as I mentioned before, the 2015 LCD has not increased its documentation requirements.

So this is a new approach. Speaking of approaches. So that's facts. Our approach has looked the following. First is we're addressing this interpretation change both strategically and operationally. So strategically, with policy engagement with professional societies, MAX, CMS level, et cetera, and then operationally with technology investments such as this e-prescribing tool that I shared. We can go into more detail about that, too. With the e-prescribing tool, we're well into our pilot of that technology, and we plan to expand that implementation later in the back half of this year to go more nationally. So that's the second component that I want to share.

On a third, and I'll turn it over to Elaine for more concrete examples of the requested documentation change with CMS. But I really want to emphasize that we see this as turbulence versus an unmitigable headwind. So our non-Medicare business grew 20%, and our business fundamentals are really solid. It's comforting to me and hopefully all of you that I've had over 20 years of experience in both farm and med device and U.S. reimbursement. I'm really confident we have the appropriate strategies and action plans in place, and we can readily adapt to this dynamic reimbursement environment. You asked about new normal. And is this what we can expect. Medicare policies are always going to be dynamic. And while it's difficult to anticipate sudden changes in interpretation for a long-standing policy like this LCD, we're really prepared. Our investments in modernizing technology are designed to be adaptive to whatever requirements are out there, and our strategic approach will be to work with MAX and CMS to position therapy -- PCD therapy, sorry, for Medicare patients that meet the clinical criteria. It takes time to strategically adjust some things and operationally to get everything in place.

But the good news is we started this pilot earlier in the year. and we'll anticipate seeing more and more benefit come through. And Elaine can talk more about the timing of that. But let me first start by asking her to give some examples. So the context of what the documentation change looks like are appreciated.

[Elaine Birkemeyer, executive]

Yes. I think probably a long-standing requirement has always been the need to do confavro therapy. And in the past, documenting that conservative therapy has occurred was sufficient. And what we're learning through both our claims adjudication as well as regular routine audits is that -- now we need to document start and end dates, we need to have measurements on those dates. And in fact, also if the conserve therapy trial extends longer than 4 weeks or documentation as to why. So that specificity as you can imagine, doesn't always make it into the medical records, which then can cause a lot of rework, both on our part, the physicians and really delayed treatment to these patients. And so that's why this e-prescribing platform, which we're able to then facilitate the appropriate capture that first time is very important. And then in addition to the work that we will be doing from a payer policy perspective, we also believe that these are just onerous requirements that really are a detriment to Medicare patients getting speedy access to treatment.

[Sheri Dodd, executive]

One thing just so Margaret, you mentioned Flexitouch only, and I just want to correct you that this is for all PCD pumps, whether they're basic or advanced. .

[Margaret Kaczor, analyst]

Okay. I appreciate that. And then just to touch on the guidance question as well. the $7 million on the high low end, how should we think about that for Q3, Q4? And then your margins obviously were great. Your cash increase is great. I know you referenced you'd give us an update on that later. But as we think about the LRP in 2025, as we think about kind of margin expansion in this story and the cash generation, can you give us any sneak peak of those future plans?

[Elaine Birkemeyer, executive]

So Margaret, I'll address the kind of the back half and quarter question, and then I'll Sherry touch on kind of how we're thinking about I think you asked a question as to does this a cadence change. And I would say, no, I think we would continue to see sort of our normal sequential growth that we would see in a typical year or Q3 is was a little bit bigger than Q2 and Q4 being kind of the bigger quarter, again, this dynamic really driven by the fact that co-pays become less and less as people progress along their plan here. So we wouldn't expect anything different in that regard.

[Sheri Dodd, executive]

As it relates to the LRP, the -- given the guidance reduction, so not going to reiterate or provide any update regarding the LRP in 2025. 1 month plus 5 days, I guess, to be specific, into this new CEO role. And I really need more time to give an informed perspective I have been and we'll continue to collect information we got in the field, talk to both internal and stakeholder constituents and just having more discussions to understand where are we and then where we can go. And that's just going to require a little bit more time for reflection and analysis.

I am really encouraged that our profitability and free cash flow profile do mirror the targets that were set out in 2022 but as we've shared, the revenue is pacing below due to increased MAC documentation. So with more time in this chair, I'll be in a better position to comment more specifically on 2025 expectations in the next months and quarter ahead. I also think, Margaret, maybe asked a little bit about the approach and you didn't use the words, but let me just kind of address is this conservative or aggressive. The guidance that we're putting out is really based on our current view and understanding of the Medicare landscape, which again surprised us because of the documentation requirements really just don't fit with the current LCD guidance. So this is an updated range that we feel comfortable with. And I appreciate it's a 2% cut in revenue, but it's also on the foundation of really strong business fundamentals, growing market, high unmet need, under penetration. And we're going to address this Medicare issue, both strategically and operationally, and I feel that we've got a good chance to get ourselves in a better position, but we need more time to to really provide any guidance on the LRP or 2025.

[Operator]

Our next question is from Adam Maeder with Piper Sandler.

[Adam Maeder, analyst]

Congrats on the Q2 results. And Sheri, welcome, and congrats on the new role. I wanted to follow up on the Medicare documentation requirements. Just a couple of kind of clarifying points there. So first, -- and sorry if I missed this in the prepared remarks, when did this go into a factor when did you kind of really start to see the change? And then I'd be curious in terms of the script to kind of order completion or the elongation of the patient funnel. Can you put more specifics around there? I mean, what does that change in terms of patient funnel, how many days, this would be helpful to get a little bit more granular there? And then I have a follow-up. .

[Sheri Dodd, executive]

Sure. I'll have Elaine first kind of speak to when this all started to go from a one-off to a trend.

[Elaine Birkemeyer, executive]

So I think, as you know, we have been closely monitoring all of our adjudication results. And in fact, that's been a lot of what's attributed to our great success in working down AR, growing cash and improving free cash flow. And we started to see earlier this year denials related to some of this what was increased documentation requirements as well as kind of, like I said, routine kind of audit practices. And really, that evidence has continued to accumulate. And this quarter in Q2, we realized that we needed to change our criteria and what we require for orders to be processed to reflect what has been growing and mounting evidence of stricter and more documentation there. So it was really sort of, I would say, a build across the 2 quarters with that change happening in Q2 and when we implemented it.

[Sheri Dodd, executive]

What I will say, Adam, Is also we talked a little bit about the e-prescribing tool. And again, quite forward thinking in terms of getting that in place, just wanting to automate and simplify the process, both for our team as well as for our providers. But very insightful as it relates to whether there's a realistic expectations that policy environments are going to change. And so now we have this tool in pilot that's going to help us adjust and adapt to whatever the policy requirements are.

What we do know from the pilot are a couple of things is 1 is we've got the right tool that can get to the specificity of the documents that we need. And so we're actually the first partner of this e-prescribing vendor to apply the tool to a PCD. And again, so we're laying the groundwork for the appropriate documentation of how that tool works. And we do know that on the pilot that those who use the pilots, we actually saw product shipping faster when patient orders went through the pilot versus on our overall average. So we are confident that when we can get that tool in place that we will see faster shipping times. So this is our future using this tool and the early feedback has been positive, both on shipping times as well as on the overall experience.

[Adam Maeder, analyst]

That's very helpful color. And for the follow-up, I wanted to ask about Nimbl. Congratulations on the approval. Would love just to hear a little bit more about the commercial strategy. I think I heard early fall for limited market release. But maybe just any more specifics you can give us around nimble, which customers are going to target? Do you have any restrictions or capacity constraints to launch that product? And I guess, just bigger picture, how do you think about the impact on the lymphedema business with this new product in the bag? .

[Sheri Dodd, executive]

Yes. Thanks, Adam. I'm glad you asked because another great time to be joining as CEO is on the heels of a 510(k) approval of this new platform. So you are correct. We're going to be doing a limited launch this fall and are excited to bring this new platform to patients. I got to demo nimble and the Kylie app, and I'm really confident that patients are going to appreciate this lifestyle friendliness attributes, smaller. It's portable. The connectivity on digital with Kylie allows the patient to share data on their progress. with their lymphedema directly with their provider. And it's a great product introduction altogether. We started the nimble platform with the basic pump, and that's very strategic. Owning this entry-level space is part of our sustainable growth plan, and we're always going to be focused on innovation and technology that meets the patient where they are in the lymphedema care continuum. So that's our starting place. We'll be with entree patients, the basic pump patients, and then we'll have a innovation road map that will continue to expand that across our other offerings.

Right now, the limited launch is going to be targeted in specific geographies and then we'll go to full launch. We've built, I think, over 900 demo units now. I don't see any constraints at all in our manufacturing or operations side of it. We're ready to go there. And also really looking forward to this coming on board as a portfolio and adding it to our P&L, we're confident that to be providing exactly what patients need, and it's going to be accretive to our P&L. So we're in a good place and looking forward to sharing more details on the launch in Q3.

[Operator]

Our next question is from Ryan Zimmerman with BTIG.

[Iseult McMahon, analyst]

This is Izzy on for Ryan. So Sheri, just to start with you, given your appointment about a month ago, can you walk us through some of your near-term goals that you have for this new position? .

[Sheri Dodd, executive]

Certainly. You didn't sound like Ryan. So I yes, no, thanks for joining the call. Thanks for the question. Yes, just 1 month in, and so a very intentional and deliberate plan to spend time both internally and externally. Last week, I was with customers have been meeting with not just the executive leadership team, but the senior management team, engagement with the Board product demos deep into financial operations. So I've really been taking a very intentional approach to learn the business. and go in where we have both the biggest opportunities in some of our pain points, as we described with this Medicare issue and fortunate that this is a background. So the language and the strategies are not foreign to me and we'll continue to dive in and continue to expand with the goal on looking to see what is the refinement of our strategy and what are those new opportunities we can put forward. But it's been a really very energizing first 30 days.

[Iseult McMahon, analyst]

Great. And just given the strength of the balance sheet today and the cash generation you guys have been able to deliver, why isn't a share repurchase at these levels, the right strategy?

[Sheri Dodd, executive]

Yes. Thank you for noticing. Because we also are really excited about where we sit, again, another great time to join CEO when the nice increasing generation of free cash flow is not only on the balance sheet, but we expect it to continue. The nice thing is cash is cash and you can't take it and it really demonstrates this improved financial profile that we have. reflects the maturity of the business, we can efficiently scale prudent cash management, we can prioritize, tighten where we can and invest in tech road maps and initiatives. And then we can invest in growth while prioritizing shareholder value. So we have a lot of options in front of us. And in the coming months, I'm really going to be laser-focused on evaluating the choices of which share buyback is definitely one of those, and I'll be able to update you. But also need a little bit more time in the chair before we start pulling on all of those levers, but it's a really nice position to be in with the balance sheet as it does afford us a lot of options.

[Operator]

Our next question is from Suraj Kalia with Oppenheimer & Company.

[Suraj Kalia, analyst]

SherI, can you hear me all right? .

[Sheri Dodd, executive]

Yes, I can, Suraj.

[Suraj Kalia, analyst]

So Sher, a couple of questions. First, the e-prescribing tool. I just wanted to make sure I understand the workflow for these tools your initial point of contact still is the lymphologists or vascular surgeon or someone been -- it basically comes back to you guys in terms of prescribing it or entering the information, and that is controlled by Tata. I just wanted to make sure I understand who controls the prescribing to the authenticity and then basically, how do you determine the ROI from this e-prescribing tool. .

[Sheri Dodd, executive]

Good questions. I'm glad I'll have a chance to add some clarity here, and I'll tag team with Elaine on this. So first, we don't prescribe. So the prescription comes from either the vascular surgeon or it's going to come from the oncologist. And that's where the prescription is going to generate. And then when that prescription comes over to us, then we look to do the inpatient demo and then look to make sure that all the documentation is in place so that we can move it through as an actual order.

What the e-prescribing tool does is it's actually an interface with the physician. So it's the physician who's using the tool for the prescription and then documenting the specific requirements that are required, if you will, for reimbursement and coverage. So that's the that's the process. We don't prescribe this is merely a tool that allows the physician not only to write the prescription but to put all the documentation that allows it to go through as an order, so we can get that first-time claims approval. I'll have Elaine turn over -- I'll move it to Elaine to talk about kind of the ROI and how we saw it as a business investment.

[Elaine Birkemeyer, executive]

Yes. And just to clarify, so the e-prescribing tool, I think, could be a little confusing because they were prescribing. So it's a prescription, but it also collects all the appropriate medical record information. So today, we rely on our physicians to remember everything that has to get documented. And again, remember, this is not a condition that they treat day in and day out, so to commit that to memory is difficult. And as it gets more and more requirements get higher and higher the likelihood 1 would forget an element becomes quite high. And so we get the information, review it, and we realize something is missing. We've got to send it back and you can see how this could really delay having to go back and forth. The e-prescribing tool. Again, we control the fields that we can put in there. So again, we can make sure it's always reflective of what Medicare and other commercial payers are looking for.

So we capture the appropriate information the first time. But from a security perspective, all of that is independent and third party. So it ensures everything has the right level of integrity throughout that entire process, both from a confidentiality as well as ensuring the right information along the process. As far as ROI, we looked at it traditionally as far as investment in the platform and really what we saw in terms of ability to accelerate revenue. We know that -- we've talked a lot about we make it easier for prescribers. We are able to treat more patients. So we expect that we will be able to look at the top line, both also from a back office perspective, as you can mention, if we have to touch this order less because it comes in with everything the first time.

And then third, from a collections perspective, if you have everything that you need your likelihood of getting paid and reimbursed it comes higher. So it really has a couple of different places where the ROI is generated from this investment.

[Suraj Kalia, analyst]

Got it. And my follow-up question. So SherI, during COVID and a little after COVID, a lot of the training was handed out externally. And one of the arguments was training by in-house salespeople or even virtually was yielding dividends. It seems like now reversed, i.e., being handled by external consultants, again. So the 50% bogey, can you help us understand how you'll reach that? What is the rationale in terms of outsourcing half of the training versus presumably all the training .

[Sheri Dodd, executive]

Yes. Thanks, Suraj. So I think this might be helpful. So first, it's not outsourced. So the training that is done in an old model, if you will, prior -- it was our sales reps that did both the selling type of work as well as they did the in-home demos for patients. And so if you think about that on -- it's a patient engagement plus they were dealing with physicians and these other things. And so the development of a new workforce called PEC or patient education consultants, was developed, but these are our employees. And so the patient education consultants are going out and their skill set is in education with patients. And so they're going out and doing the in-home patient demos directly with the patient, which alleviates the cells reps from doing, if you will, kind of non-selling activities. So I want to be really clear. These are our employees. They are trained, they are Tactile employees. And so we had a goal in our sales rep productivity to change the mix of activities that the sales reps were doing and take those non-selling activities off their plate and have these trained patient education consultants be the ones that we're engaging with the patient. And so our goal by the end of this year is to have 50% of those in-home patient in-home demos done by our patient -- our patient education consultants. And so we're seeing that happen. We went from 30% last year to 35% in Q1. And then this quarter, we had 45%. So our goal at the end of the year is to get to this 50%. Again, our employees, patient education consultants during the in-home patient demos, which can help the reps have more productivity in selling activities. I hope that's been helpful.

[Operator]

Thank you. There are no further questions at this time. This does conclude our conference for today. Thank you for your participation. You may now disconnect your lines. .