WELL Health Technologies Corp
TSX:WELL
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WELL Health Technologies Corp
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Welcome to the WELL Health Technologies Fourth Quarter and Full Year 2022 Financial Results Conference Call. My name is Michelle, and I'll be your operator for today's call. [Operator Instructions] Please note, this conference is being recorded.
I will now turn the call over to Pardeep Sangha, Vice President, Investor Relations. Mr. Sangha, you may begin.
Thank you, operator, and welcome, everyone, to WELL Health's Annual 2022 and Fiscal Fourth Quarter Financial Results Conference Call for 12 and 3 months ended December 31, 2022. Joining me on the call today are Hamed Shahbazi, Chairman and CEO; and Eva Fong, the company's CFO.
I trust that everyone has received a copy of our financial results press release that was issued earlier today. Portions of today's call, other than historical performance, include statements of forward-looking information within the meaning of applicable securities laws. These statements are made under the safe harbor versions of those laws. Forward-looking statements are necessarily based upon a number of estimates and assumptions that, while considered reasonable by management, are inherently subject to significant business economic and competitive uncertainties and contingencies. These forward-looking statements involve known and unknown risks, uncertainties, assumptions and other factors, many of which are outside of WELL's control and will cause the actual results, performance or achievement of WELL to differ materially from the anticipated results, performance or achievements implied by such forward-looking statements.
These factors are further outlined in today's press release and in our management discussion and analysis. We provide forward-looking statements solely for the purpose of providing information about management's current expectations and plans [ remain ] to the future. We do not undertake or accept any obligation or undertaking to release publically any updates or revisions to any forward-looking statements to reflect any change in our expectations or any change in events, conditions, assumptions or circumstances on which any such statements based except as required by law.
We may use terms such as adjusted gross profit, adjusted gross margin, adjusted EBITDA, shareholder EBITDA, adjusted net income and adjusted free cash flow on this conference call, which are all non-GAAP and non-IFRS measures. For a more information on how we define these terms, please refer to the definition set out in today's press release and in our main discussion and analysis. The company believes that adjusted EBITDA is a meaningful financial metric as it measures cash generated from operations, which the company can use to fund working capital requirements, service future interest and principal debt repayments and fund future growth initiatives. And adjusted EBITDA should not be construed as an alternative to net income or loss determined in accordance with IFRS.
And with that, let me turn the call over to Mr. Hamed Shahbazi, Chairman and CEO. Go ahead, Hamed.
Thank you, Pardeep, and good day, everyone. We hope that you're all keeping safe and healthy. We appreciate everyone for joining us today. To start, I'd like to provide some historical perspective on WELL. We recently celebrated the 5-year anniversary of the acquisition of our first 6 clinics in British Columbia, which took place in February of 2018.
That was WELL's first acquisition and began our journey into the health care market by tech-enabling health care providers in helping them modernize and digitize their businesses. We've seen an amazing journey, during which time WELL's grown from 0 revenue to completing a record year in 2022, in which we achieved over $625 million on a Q4 annualized revenue run rate basis. More than 1 out of every 4 providers in Canada rely on WELL in some way to power their businesses from practice management solutions to revenue cycle management to provider and patient communication tools such as online patient booking or e-referrals.
Over the past 5 years, we've both grown organically and inorganically into one of the leading digital health care companies in North America. I'd like to thank the amazing team at WELL, including the health care providers who help make all of this possible. During the past 5 years, we went through an unprecedented global pandemic, during which our health care providers continued to provide incredible care under difficult conditions. The pandemic also accelerated the adoption of virtual care and digitization in the industry. More recently, we've also had to deal with very challenging circumstances, including worker shortages, supply chain difficulties and rising costs brought about by high inflation. On all occasions, our management team, employees and health care providers continued to overcome all these challenges, enabling the company to deliver phenomenal performances quarter after quarter.
We are now firmly in the post-pandemic period and witnessing a host of new catalysts that speak to WELL's relevance as a company, and our role in helping health care providers digitize and modernize their practices. And in many cases, help make those practices more economically sustainable.
Catalysts that we are watching closely as a team and believe active tailwinds for the company are as follows: one, the increased likelihood of more public and private partnerships to support our health care ecosystem announced by political and public health leaders, most recently in Ontario; two, a commitment by federal authorities in Canada to add significant additional funding to help Canada not only improve the sustainability of its health care ecosystem, but also digitize and modernize it; three, the emergence of artificial intelligence, including generative AI to power tools and tech enablement for health care providers, never even conceived or thought before. By the way, this is an area of intense focus for your management team at WELL. We'll discuss this more later. The demonstration, particularly for -- the demonstration, particularly in the United States of how valuable hybrid care networks are to major pharmacies and other institutions. We seem to be in a new golden age of primary care, where there is ramp in innovation and an opportunity to elevate care and better support providers.
Moving on to WELL's financial performance. We're thrilled to report another record-breaking year, with strong fourth quarter results and significant growth across all key metrics. WELL achieved record annual revenue of $569.1 million for 2022, an increase of 88% over the prior year. I'm proud to report that WELL has healthy cash flows having achieved almost $105 million in operating adjusted EBITDA in 2022, resulting in adjusted free cash flow to shareholders of approximately $49 million. Q4 2022 was also a tremendous quarter for the company. WELL achieved revenue of $156.5 million in the fourth quarter, representing 35% year-over-year revenue growth, most of which was organic.
The fourth quarter of 2022 also marks our 16th consecutive quarter of record revenue. The company's growth was driven by acquisitions made over the past year as well as solid year-over-year organic growth, which was 19% for the full year and 20% organic growth in the fourth quarter. WELL achieved record patient engagements over the past year with approximately 3.5 million omnichannel patient visits and 4.9 million patient interactions in 2022. Omnichannel patient visits grew 50% in 2022 compared to the prior year, and total patient interactions grew 86% over the same period.
This demonstrates our continued leadership position as the preeminent end-to-end health care company in Canada, while our U.S. businesses continue to exhibit industry-leading growth metrics. Our record revenue, profitability and patient visits are a testament to the company's continued focus on delivering accessible and innovative health care solutions. Additionally, our U.S.-based virtual services businesses continue to perform exceptionally well, further strengthening our position in the North American digital health care market.
The company continues to witness healthy growth across all its business segments, including both online and in-person care channels, with minimal impacts due to recession, inflation, supply chain issues or other macroeconomic effects.
With that, I would now like to turn the call over to our CFO, Eva Fong, who will review the annual financials for 2022 and fiscal fourth quarter, and we'll then come back and provide further commentary on our business units and outlook. Eva?
Thank you, Hamed. I'm pleased to report that we had very strong results for the 3 months and year ended December 31, 2022. Our annual 2022 and fourth quarter results were as follows: WELL achieved record annual revenue of $569.1 million in 2022 compared to revenue of $302.3 million generated during 2021, an increase of 88%, driven by acquisitions and organic growth.
Adjusted gross profit was $303.3 million in 2022, an increase of 97% compared to $153.7 million in 2021. Adjusted EBITDA was $104.6 million in 2022, an increase of 73% compared to $60.4 million in 2021. Adjusted EBITDA attributable to WELL's shareholders was $76.6 million in 2022, an increase of 82% compared to $42 million in 2021. Adjusted net income was $53.7 million in 2022, an increase of [indiscernible] compared to [ $16.3 ] million in 2021. Adjusted free cash flow attributable to WELL's shareholders was $48.8 million in 2022 as compared to $34.2 million in 2021. Adjusted free cash flow is defined as adjusted EBITDA attributable to WELL's shareholders, minus cash taxes, minus cash interest costs and minus CapEx.
Our fourth quarter results were as follows: WELL achieved record quarterly revenue of $156.5 million in Q4 2022, an increase of 35% as compared to revenue of $115.7 million generated during Q4 2021. This growth was driven by acquisitions and organic growth. WELL achieved record adjusted gross profit of $80.2 million in Q4 2022, an increase of 26% as compared to adjusted gross profit of $63.5 million in Q4 2021. Growth in the company's adjusted gross profit is attributable to higher revenue in the period.
Adjusted EBITDA was $27.2 million in Q4 2022, an increase of 6% as compared to adjusted EBITDA of $25.7 million in Q4 2021. It is worth noting that we had really strong results in the prior period to Q4 2021, with the highest margins in the CRH history, which included more than $2 million of pandemic-related government incentives, which resulted in exceptionally strong EBITDA performance in Q4 2021.
Adjusted EBITDA attributable to WELL's shareholders was $21.1 million in Q4 2022, an increase of 18% as compared to adjusted EBITDA attributable to WELL's shareholders of $17.8 million in Q4 2021. Adjusted net income was $12.5 million in Q4 2022, an increase of 24% as compared to adjusted net income of $10.1 million in Q4 2021.
I will now review the financial performance of our business segments. First, primary care, which includes our primary care clinics, Allied Health and executive health businesses in Canada. Primary care revenues were $70.5 million in 2022, an increase of 36% as compared to $51.7 million in 2021. Annual results were driven by healthy organic growth, clinic acquisitions and higher government payments for health services. Primary care revenues were a record $21.8 million in Q4 2022, an increase of 55% as compared to $14.1 million in Q4 of last year. The [indiscernible] acquisition completed in the third quarter and 3 new clinics acquired from CloudMD in the fourth quarter positively contributed to strong Q4 results.
In addition, primary care revenues in Q4 2022 benefited from a stabilization payment from the BC's government. This onetime payment of approximately $1.5 million in the fourth quarter is meant as interim funding to help stabilize family practices until a new payment model was implemented in February 2023. Compared to Q3 2022, primary care revenue was positively impacted by seasonality, as the fourth quarter is a seasonally stronger quarter as compared to Q3 as there tends to be an increase in colds, flus and other elements contributing to higher patient volumes.
Secondly MyHealth. MyHealth achieved record revenues of $104.2 million in 2022, an increase of 146% as compared to $42.5 million in 2021. MyHealth was acquired partners through 2021 and hence, the large revenue growth from 2021 to 2022. In Q4 2022, MyHealth achieved record quarterly revenue of $28.1 million, an increase of 21% as compared to $23.2 million in Q4 of last year. MyHealth benefited in Q4 2022 from management's hard work and continued efforts to alleviate staff shortages experienced in the first half of the year, leading to a higher billable time for many of its diagnostic procedures. MyHealth also benefited in the quarter from the addition of new cardiologists and key management specialists.
And third, I will now talk about CRH performance. CRH revenues were $202 million in 2022, an increase of 52% as compared to $132.5 million in 2021. As CRH was acquired in April 2021, the increase in revenue is mostly attributable to a full year's contribution of CRH revenue and acquisitions. For Q4 2020, CRH revenues were $52.1 million, an increase of 11% as compared to $47.1 million in Q4 of last year. In addition, revenues also benefited from having a full quarter of contribution from the Grand Canyon Anesthesia acquisition, which is one of the largest acquisitions that CRH has completed since WELL acquired CRH. Compared to Q3 2022, CRH's Q4 2022 results benefited from seasonality as Q4 is CRH's strongest quarter. Case volumes were also very strong for CRH in Q4 with a record of 133,654 anesthesia cases completed in Q4, an increase of 11% compared to Q4 of last year.
CRH sold 2,138 O'Regan boxes in the fourth quarter. And since each box has [indiscernible] units, a total of 42,000 [indiscernible] units were sold in the quarter.
I would also like to provide an update on CRH billing service provider. CRH entered into a relationship with a new billing service provider, Change Healthcare in Q4 2021. Switching to a new provider has benefited the company with a reduction in payment processing fees, resulting in higher margins. However, CRH also experienced a number of onetime transition-related issues, which includes the predecessor billing service provider subsequently resolved and was not able to carry out normal accounts receivable collections, which resulted in bad debt losses related to 2021 revenue.
As a result of these events, CRH took this onetime loss and was also precluded from recognizing certain patient services revenue under IFRS 15, and as such, revenues would have been higher had this billing change not occurred. Altogether, [indiscernible] has been excluded from the calculation of adjusted EBITDA and these are nonrecurrent and not reflective of ongoing operations. Despite these transition issues and related impacts, we remain confident that the long-term savings from switching to a new billing provider will provider -- will more than compensate for the losses experienced over the past year, as we will ultimately be able to reduce our effective collection rate cost by more than 50%, reflecting over $5 million savings per year.
It is also important to note that our new billing service provider offers better data and business intelligence as far -- as well as far superior risk management characteristics, including much better data security. This was a joint undertaken by our CRH team, and I'm very pleased that we are on the other side of this transition as it substantially derisked both the company and position us for better operating performance and improved data quality.
Lastly, virtual services, which includes WELL's U.S.-based Circle Medical and Wisp as well as the company's technology-based solutions, including EMR, billing and revenue cycle management, OceanMD, digital apps and cybersecurity. Virtual services revenues were $192.4 million in 2022, an increase of 154% as compared to $75.6 million in 2021. Virtual services revenue growth was driven by the exceptional growth in the U.S.-based businesses of Circle Medical and Wisp. On a combined basis, these 2 businesses achieved almost $160 million on a revenue run rate basis at the end of 2022.
Virtual services revenues were $54.5 million in Q4 2022, an increase of 74% as compared to $31.3 million in Q4 of last year.
WELL ended 2022 and Q4 with a solid balance sheet. As of December 31, 2022, WELL have cash and cash equivalents of $48.9 million. WELL continues to be in good standing and fully compliance with all covenants related to with its 2 credit lines, JPMorgan in the U.S. and Royal Bank in Canada. During the year 2022, we paid down about USD 31 million of the JPMorgan line in the U.S. to arrive at a balance of USD 131.7 million as of the end of the year. In Canada, we borrowed a total of $2.5 million in the year to arrive at the balance of $75.3 million. The total value of our credit line debt as of December 31 was approximately CAD 253.7 million.
Keep in mind that USD strengthened from an average of $1.26 in Q4 2021 to $1.36 in Q4 2022. And as such, due to the higher exchange rate, our overall debt level would have been lower on a constant currency basis.
In terms of our share capitalization, as of March 20, 2022, WELL had 253,793,194 fully diluted securities issued and outstanding.
That is my financial update, and I turn the call back over to Hamed.
Thank you, Eva. Now I'd like to speak a bit about our outlook for 2023. We're pleased to report that all of our business units are executing very well as we're expecting to have a strong performance in 2023 across all of our units and for the entire company as a whole. Despite the current geopolitical, inflationary and turbulent economic environment, the company does not see any material influences or challenges that would impair its ability to deliver solid results in 2023. Many of the key variables inherent in the execution of WELL's business are firmly in its own grass and not dependent on outside factors. The company is poised to achieve significant growth, while effectively managing its cost this year. Management is pleased to provide the following guidance for 2023.
We expect annual revenues between $665 million and $685 million, representing 17% to 20% annual growth as compared to 2022. Our revenue guidance is above current consensus estimates for 2023. We expect annual adjusted EBITDA to increase by more than 10% over 2022 levels. Our guidance does not include any unannounced acquisitions. As we indicated last quarter, with future acquisitions, we see a clear line of sight to $1 billion in revenues within 3 years as we continue our organic growth and highly accretive clinical tuck-in program.
As you may have seen from the guidance, we're expecting our revenue to increase at a higher rate than our adjusted EBITDA this year. There are a few reasons for that. Firstly, we're aggressively reinvesting in growth in our Circle Medical and Wisp businesses. While we expect these 2 businesses to have higher EBITDA contribution this year overall, they will still be immature compared to our other revenue streams and pull down the average a little bit. We are very comfortable with this approach as we're confident that both Circle Medical and Wisp continue to acquire market share and improve their operating EBITDA margins over time as they become more mature businesses. Secondly, we continue to experience the effects of inflationary cost pressures and wage increases. These cost increases are prevalent in all industries today. Although we've implemented cost-saving initiatives, we're still expecting additional cost increases this year as inflation remains at elevated levels.
And lastly, in our CRH business, there are a few factors to be aware of. One, we don't have the benefit of some of the pandemic-related incentives provided by the U.S. government that Eva just spoke about during early 2022, which was equaled more than USD 2 million between Q1 and Q2 last year in 2022. We had some of those incentives in 2021 as well that Eva spoke about.
Two, the combined effect of the NSA were No Surprises Act, and our continued move to have our entire payment activity in network will remove some of the elevated billings associated with our out-of-network billings, which we are all anticipating when we bought the company. And three, our most recent large acquisition in the CRH business, Grand Canyon Anesthesia has a lower margin profile than our historic margins for CRH.
Notwithstanding the above, we're still firmly within the Rule of 30 territory as per the company's previous guidance and direction.
I'll now provide some commentary on the business units themselves, segmented first with the Canadian Patient Services Group, then U.S. patient services and then SaaS and technology. First, with the Canadian Patient Services business unit. In Canada, WELL owns and operates the largest network of clinics in the country, which includes over 130 clinics being operated in over 80 physical facilities, consisting of primary care, Allied Health, executive health and diagnostic clinics. As we described on our prior calls, WELL strongly believe in the benefits of an integrated health care offering and is bringing together a diverse multidisciplinary offering of its providers in the same setting. This benefits both patients and providers as many of these physical facilities have multiple clinics operating within the same location. For example, we could have a primary care and Allied Health clinic operating out of the same location, or a cardiology clinic and a diagnostic clinic operating out of one of our MyHealth Ontario facilities. That's how we can have more than one clinic in a facility.
With over 30 clinics across Canada -- 130 clinics across Canada, we own and operate the largest network. To our knowledge, we deliver more omnichannel patient visits than any other nongovernmental entity in Canada. Furthermore, we're 1 of the top 3 providers of telehealth services in the country. WELL's objective is to continue to grow its patient services business unit, both organically and inorganically and increase its market leadership as the country's first pan-Canadian clinical network with a highly integrated network of tech-enabled outpatient health care clinics. Growth in our Canadian patient services business in 2023 will be driven by continuing to focus on organic growth, which includes recruiting more physicians and absorbing or recruiting clinics themselves and executing on highly disciplined capital allocation opportunities to acquire capable new clinics and networks into the business. These would mostly be small acquisitions.
I'd love to share with you what we're seeing and why we're so excited about our growth in primary care in Canada. Given recent times where there are challenges with inflation, shortages of health care workers and other issues, WELL has seen dramatically increased relevancy, which is translating into significant growth in interest from care providers that want to join tbis network. As I've mentioned before, in Canada, historically, in many cases, we force health care providers to provide care and run a business, except that now it's become a lot more difficult to run these businesses due to the increased complexity brought about by hybrid and complex workflows, IT, data security and other challenges, making it very difficult for physicians to run even small practices.
For this reason, we're seeing more physicians seek WELL out as a professional partner to help them run their business so they can focus on providing care. This is working, and providers are really generating benefits from it because they maintain similar per unit economics, but end up seeing a lot more patients which allows them to elevate care, improve earnings and better support the health care ecosystem.
I'd like to now quickly comment on opportunities associated with expanding our MyHealth network in Ontario. On January 16, Premier Doug Ford and Health Minister Sylvia Jones announced the Ontario government's new multipronged strategy to reduce wait times by partnering with independent service providers for Ontarians, including areas associated with MRI, CT, colonoscopy endoscopy services. While Ontario-based MyHealth partners is the largest single license holder and service provider for specialty clinics providing diagnostics in the province of Ontario, and we believe is very well positioned to support Ontario government's mandate, particularly in the areas of diagnostic imaging. We intend to apply for these new MRI and CT licenses, which will be provided by the province of Ontario. We anticipate the new licenses will be awarded in the second half of 2023. Although we don't know -- we won't know for several months yet if MyHealth will be ultimately successful in its applications, we would likely incur additional capital cost to purchasing imaging equipment and for leasehold improvements.
We anticipate lead times of several months to have these services fully operational in clinics, and as such, we expect minimal revenue generation in 2023. Any such meaningful revenue impact would occur in '24 and beyond.
I'll now provide some commentary on our U.S. patient services businesses, including CRH, Circle Medical and Wisp. WELL provides omnichannel health care services and solutions across the United States, targeting specialized markets such as the GI market, women's health, primary care and mental disorders. I'll start with CRH. CRH continues to be a nice cash cow for the company. And as a reminder, under the CRH brand, we are the leading provider of sedation services for colonoscopies in the U.S. in an ambulatory setting. In the U.S., WELL continues to expand its clinical presence with anesthesia services now being operated in 126 ambulatory surgery centers and GI clinics across 18 states. In 2022, CRH continued to benefit from post-COVID pent-up demand for endoscopic procedures, and our team's excellent execution in being able to support that elevated demand. We continue to see elevated interest in demand in CRH services and expect another record year of performance by CRH.
Given the nature of how health plans and their deductibles work, through the year for elective procedures such as colonoscopy, the fourth quarter is CRH's strongest seasonal quarter. We are expecting CRH revenues to decline in Q1 compared to Q4 and then increase again in each subsequent quarter in 2023, with Q4 2023 again, being the strongest revenue quarter this year. It should be noted that between Q1 and Q2 2022, CRH received more than USD 2 million in pandemic-related government assistance.
This grant health offset labor costs and improved EBITDA, which will not be repeated in 2023. In addition, CRH continues to execute on unlocking the value of its O'Regan hemorrhoid banding device intellectual property by creating a clinical offering called GI Rapid Relief that leverages this technology. As of March 21, we now have 11 banding clinics across the United States and Canada.
I'd now like to discuss WELL's U.S. virtual patient services business, which includes Circle Medical and Wisp. Under the Circle Medical and Wisp brand, we are one of the fastest-growing specialty telehealth businesses focusing on areas such as behavioral health and women's health. Our Circle Medical and Wisp businesses are expected to continue to experience healthy revenue growth in 2023. However, we're purposely reinvesting any cash flows generated by these businesses back into growth, primarily on marketing costs to gain new patients and drive additional revenues. As you may be aware, ad rates are much lower in the first 3 months of the year as compared to the last 3 months of the year. As such, we're taking advantage of this and increasing our marketing spend earlier this year.
We will particularly see this effect with Wisp as we're targeting a slightly adjusted EBITDA negative performance in Q1, which will more than be made up in the balance of the year. Our current plan for Circle Medical is to continue to scale their telemedicine business but also now aggressively grow its physical clinic performance or network in 2023, which will improve its hybrid care capabilities and strengthen the company's ability to better support its patients, especially as we see the Biden administration sunset the public health emergency.
As of March 1, Circle Medical already had added 3 new clinic locations in Illinois, Florida and New York in addition to its existing operations in San Francisco. Circle Medical is now in the process of adding additional clinic locations in Washington, D.C. and 10 additional states, including Arizona, New Jersey, Pennsylvania, Nevada, Texas, Massachusetts, Virginia, Colorado, Tennessee and Maryland. We expect to have clinical coverage across all these states in the coming weeks.
Finally, SaaS and technology. SaaS and technology includes our WELL EMR Group, billing, revenue cycle management, digital apps, OceanMD and cybersecurity. WELL is a unique company with both patient services and technology capabilities. We owe significant intellectual property, which drives our industry-leading solutions and has created compelling and relevant links within health care providers all over the country. We have created a best-in-class digital platform with significant IP that we call the practitioner enablement platform.
This platform aims to digitize, modernize and support providers and their clinics. With well over 23,000 medical providers in Canada that are leveraging the platform in some way. What is unique about WELL is that we are the biggest users of our own platform as the vast majority of our revenue is derived by our own patient services businesses. This is because we found that the best way to support providers is to help them run their businesses. When a provider joins WELL, we provide a fully managed solution. This means we look after all aspects of their business from front office, patient management to the management of all staff and back-office execution so they can focus on providing care.
We are industry leaders in technology and innovation in digital health care in Canada. Some of our examples of leadership include: one, we're one of the top 3 practice management service providers in Canada, including EMR, or electronic medical records software; two, we're one of the leading providers of digital patient engagement services, which includes all aspects of connecting patients and doctors digitally; three, we're one of the largest providers, in fact, the largest provider of revenue cycle management and outsourced billing services for doctors in Canada; five, (sic) [ four, ] we are the largest provider of e-referral software services in Canada. And we operate the Canada's only app marketplace for integrated EMR apps called apps.health.
Our outlook looks promising for our SaaS and technology group. OceanMD, in particular, is emerging as a leader in patient engagement at e-referral solutions in the country. Already, the e-referral solution provided by Ocean is in place in the province of Ontario. We feel OceanMD has the potential to become the e-referral standard across the country. Ocean's platform is used at over 2,700 clinics in the country by over 25,000 clinicians with more than 1 million monthly patient users. It is emerging as one of the most important digital gateways for health care in Canada with connectivity to more than 30 integrated solutions in EMRs and provincial assets. To our knowledge, there's no other software or digital health system in Canada that is as deeply connected and embedded in the Canadian health care landscape as Ocean.
We have recently updated Ocean's web presence and invite you to spend some time learning about this amazing network. You can visit the site at oceanmd.com. I'm also pleased to report that as a company with deep tech experience and capabilities, we have made artificial intelligence a key priority within the company and are working on compelling new products and enhancements to roll out to our provider network. Our teams and partners are integrating different forms of AI technology, including generative AI solutions such as ChatGPT. We look forward to unveiling these solutions in the coming weeks and months ahead.
In summary, we're very pleased with our financial performance in 2022 and look forward to delivering the strongest results yet as a company. Our outlook for 2023 remains very positive. Hence, I can confidently provide annual guidance for revenues between $665 million and $685 million for this year, and a material improvement in our adjusted EBITDA to exceed at least $115 million.
Finally, I'd like to thank you all for joining us on this call today and thank our shareholders and investors for their continued support. The capital markets have been very supportive of our vision and have provided us with the funding and patients needed to pursue our goals. I'd also like to thank WELL's senior management team, our employees and contractors, and in particular, our network and team of health care practitioners and other frontline workers who provide unbelievable patient care every single day. They remind us every day why we're here and we're here to support them. Thank you very much.
And with that, we're very pleased to take some questions. Operator, could you please assist?
[Operator Instructions] The first question comes from Allen Klee of Maxim Group.
Congratulations. Could you talk a little about how you feel the impact your company can be from the federal government of Canada providing additional funding to provinces over the next 10 years?
Thanks very much, Allen. As I mentioned in my script, we do see this as a tailwind, particularly because we're so focused on not only serving providers with our tools, but also partnering with them and helping them run their business. Most of our revenue in Canada comes from us sharing revenue with doctors and essentially helping them run those businesses. And we believe a lot of that funding is earmarked for providers. I'll note that Canada's health care ecosystem is worth more than $300 billion annually and close to $40 billion of that has historically been payment for care providers. And we believe a lot of the crisis that we're talking about here in Canada, when we talk about the health care crisis is a shortage of doctors. And so we understand a lot of that potential funding relief will help shore up some of the funding required for care providers. So we do see this as a fantastic tailwind for us.
The next question comes from Rob Goff of Echelon Capital Markets.
And let me echo the congratulations on a good year, a very good year in fourth quarter as well.
Thank you, Rob. And congrats to you for the merger with PI.
We're looking forward to working with any teammate. And you might be surprised if I didn't ask you about Circle. Could you perhaps go into a bit greater detail about the expansion of Circle adding physical locations? Like where you at a physical location? Is there a ramp-up period before it hit this stride, is profitability? Are you pursuing partnerships versus build? Just sort of go into some of the details and the cadence there?
Yes. So generally speaking, not all the locations will look and operate the same. I think what you'll generally see is Circle is still very committed to scaling the business digitally. A lot of what they're doing physically is to ensure that they have the infrastructure to support their patient load, particularly as the public health emergency sunsets and being able to adequately prescribe and support patients within the context of those rules when the public health emergency is over. And so we'll see some flagship locations like the ones they have in San Francisco, L.A. and New York, and then you'll see smaller, much more cost-effective locations in other areas. And so we don't really expect there to be a significant burden on profitability. There'll obviously be some investments, but Circle doesn't have any debt. It's got a solid cash position, and it's generating very nice cash flow. So I think we're in a very good position to execute on that.
Very good. And if I may as a follow-up, could you talk to the ROIs that you are seeing in the U.S. virtual services, and how they may have changed year-on-year?
Can you expand on what you mean by an ROI -- return on what kind of investment?
Return on advertising investment, return on...
Return on advertising investment. Got you. Yes. Yes. No, we continue to see excellent return on advertising investment. And frankly, that's a big part of the reason why we've been so successful. I mean, we've been very successful in ramping up our provider network, but on the engagement side, I think what's really neat about our LTV, obviously, we have similar CACs, I would say, probably better performing CACs than most companies out there.
But the fact that we can advertise a specific specialty need or on-ramp as we call it, to help support a patient through whatever they're going through, depression, anxiety, ADHD, the fact that we can then convert a portion of those patients to being long-term longitudinal care family practice patients, that's a big part of why our returns are as high as they are and why you're seeing these great results and why there's, I think, a distinct advantage by Circle over some of the other partners and players that you're seeing in the industry.
The next question comes from Doug Taylor of Canaccord Genuity.
And once again, congratulations on the strong results. You made some changes to the assumptions regarding MyHealth's earn-outs in the quarter, and I believe, again, since quarter. And can you step us through what's happening there as your commentary and the overall financial performance suggests that businesses are executing well and have a bright outlook. So can you talk through that and when we should now expect those payments to flow through?
Sure. I mean, look, we're always looking at all of our earn-out arrangements on an ongoing basis and assessing them for what's being paid to date, how much time is left that kind of thing. And so that just is a normal course activity for us, and we're correcting any discrepancies that exist with what we have on the book. So that's what you saw there. But as you can tell, MyHealth is operating extremely well, and we're very confident in their ability to continue to deliver for the company.
I'll follow-up with, I guess, a perfunctory question about the M&A kind of backdrop and environment. Since the last quarterly call, we've seen a rebound in sentiment around the digital health space tied to a lot of the catalysts that you've mentioned. Has that worked its way into the M&A landscape in any way in terms of either private company valuations or the quantity of opportunities that you're seeing come across your desk?
Yes. That's a great question, Doug. Where we're operating with M&A? I mean, first of all, we slowed down M&A a lot and focused a lot on organic growth. But where we're focused is, again, those smaller networks because you've heard me say this before, small is beautiful. We are not seeing elevated valuations in those places. We're seeing a lot of need, a lot of -- frankly, a lot of duress because of the challenges that I mentioned, smaller clinics and smaller networks are just not able to optimally perform, and they're seeking out folks like us. So with better run clinics, we're still kind of seeing that 4x to 6x range. But often, we are seeing slightly profitable clinics at much lower valuation ranges. And you're right in that much more scaled and strategically relevant players are seeing much higher valuations, but we're not playing in that market today.
The next question comes from Christian Sgro of Eight Capital.
Congrats on the quarter. The first one, I'll lead on MyHealth as well. The question I've got is it looks to -- it looks like through 2022, MyHealth's performance improved sequentially despite Q2 being the strongest quarter of the year normally. And I think there's some commentary on that being due to staffing with cardiologists and such, but are there any other reasons why MyHealth's revenue climbed into the year? And do you see that trend continuing in '23 with MyHealth being strong?
[ First ] question. The first part, I think my line lift a bit. What did you say on the first part?
I was just going through the 2022 quarterly build on MyHealth, and it looked like it was a nice lift each quarter despite some of the seasonal patterns we'd expect.
Right. Okay. Yes. So you're right. I mean there was definitely change throughout the year. We started the year, frankly, with much more elevated costs. And we saw the same effect interestingly in the United States. Last year, particularly the first half of the year was very challenging with costs and with worker shortages. We think some of that was brought about to by -- again, some of it was COVID-related because the hospitals had cleared their COVID backlogs. They were now back to doing diagnostic imaging and wanted to kind of re-welcome those patients that they'd -- that they were not serving before. And so they were then seeking some of the same experienced technicians that we were in order to power those diagnostic facilities. And so that was a real tough thing because we had extremely strong demand for our services, but our ability to support that demand is really made possible by those experienced professionals and care providers.
We saw that improve a lot in the back half of the year partially, of course, due to the incredible work of our team. But I think, from an industry perspective, we also saw that, that kind of let up a little bit and the worker shortage kind of relaxed a little bit. We saw that particularly in the U.S. as well with Q3, a lot of the worker shortage issues being alleviated. And this just goes to show you that there was just excellent execution in that business as we were able to take advantage of the better workforce availability and deliver great results.
Great. That's all helpful. And for my second question, I'll switch over to British Columbia. Eva mentioned the new payment model that was introduced this year. Just wondering if you could comment on the impact you're seeing regulatory-wise and any impact on WELL's operations?
Well, so it's a very favorable outcome for us. We're hoping actually more doctors switch to the new model. So far, we've had quite a few switch to it. It's something that -- obviously, as we've talked about before, doctors can decide to kind of go with the new model or stick with the old free-for-service model. In any event, there's additional funding available and some of that is requiring us to kind of cut new deals and go through the negotiation process with providers again. But I think we're at the tail end of that, and we think that ultimately this is going to be a nice tailwind for us.
The next question comes from Jason Zandberg of PI Financial Corp.
I just wanted to ask about your recent venture into Europe. I know it's just an initial sort of toe tip into the market, but just wanted to get your outlook in terms of what your long-term plans are for the European market.
Jason, I'm glad you asked that. While our Patient Services business is very North America centric, it's important to note that WELL has a global business in it's technology side of things. And we have millions of dollars of revenue from Australia and New Zealand in our EMR business. And we have a technology platform that can really be sold all over the world. And here, I think we found a phenomenal opportunity to access the German market without having to deploy a lot of capital teams and establish a greenfield office there. Through our partnership and our partners at Horizon Ventures, we identified a great opportunity to invest in Dr. Lee. Dr. Lee is a new EMR in Germany, and it's very difficult actually for there to be new EMRs at all in that market because regulation is so difficult. And it's a pretty substantial journey with a lot of regulatory approvals required in order to be able to launch a new EMR.
And they've been able to do that, and we believe that their EMR is quite disruptive and could acquire a lot of market share. Our investment not only allowed us to co-invest with [indiscernible] group there with Horizon Ventures, but it actually secured us a 5-year exclusive contract to embed our software into the Dr. Lee's software and provide online patient booking for example.
And we believe other digital patient engagement attributes, but primarily that specific software. And we believe that, that will -- there'll be strong revenue potential there, and it will be a great beachhead for us into that market. And I think, from there, we'll watch carefully but without the need to spend a lot of capital because, again, we're just really leveraging our intellectual property and incurring the cost of translating our platform into Germany, which isn't really too bad.
We are looking for opportunities to do this elsewhere in the world, but believe that this will potentially start to impact some of our results in 2024.
That's great. And if I could ask a second question. I just wanted to drill down on the primary care growth. So you posted $21.8 million during the fourth quarter, which was a very impressive 55% year-over-year, and equally impressive 34% quarter-over-quarter. Just wanted to get an idea of organic versus acquired growth. Are you able to break that down?
Sure. Maybe I'll call on Eva to help with this one. I do note that we also had a substantial stabilization payment by the government in Q4, which, I think is fairly anomalous. I don't think we're going to see that again. Our margins on those payments are a lot less. So it's not something that contributed greatly to EBITDA, but it would have contributed quite a bit to organic growth.
Eva, is that something organic versus inorganic that you can speak to?
Yes. So definitely, of course, right, with all the automation and technology we deployed in the clinic, we continue to really improve the workflow of the clinics. And so that continues to help the doctors and improve the automation. And of course, the -- yes, we did have the LFP, [ long ] family practice. I guess, payment from the government in Q4, and then we have some inorganic growth, M&A that we described earlier. So all about that the clinics continue to really good results in Q4, and we continue to see that happening in the next few -- in 2023.
So, Jason, the way I think to think about this is if you even stripped out those anomalous payments, we would have still had elevated double-digit organic growth because our M&A throughout the year was not that extensive. Hopefully, that's helpful.
The next question comes from Justin Keywood of Stifel.
Just want to circle back on the medium-term goal in the opening remarks of hitting $1 billion in sales. If that goal is organic -- so margins could this business generate at $1 billion in sales?
Yes. Thanks, Justin. I think if you just look at the kind of organic growth that we've been exhibiting and you extend that out for 2 or 3 years, you could see that it really wouldn't take that much inorganic growth to get us there. And so that's what gives us the confidence that we're well positioned for that result, especially because we're also getting a lot more confident with our balance sheet.
As Eva noted, we paid down over USD 30 million of our U.S. line, and had USD not dramatically strengthened, we would have reported a significant delevering in Canadian dollars. And so really, what you have in a situation where our core cash flow is growing because our EBITDA is growing, and our commitments and contingent liabilities are decreasing. So we have a lot more capital left to deploy into assets. And we're still finding very cost-effective assets, especially in the small acquisition category.
And you may have noted that I also spoke to this notion that we're not only recruiting doctors, but we're recruiting clinics. This is a new phenomenon that is very interesting for us because we don't buy very small clinics, like very small, meaning 1, 2, 3 practitioners. It's very difficult to do that because there's not really any franchise value in that. What we have started to do is at times actually absorb those because those doctors need so much support and help in running their businesses. So it's sort of a combined collective group of factors that really encourage us about our ability to continue to grow organically and inorganically to meet that result. Hopefully, that's helpful.
That's very helpful. And then just on the margins, I assume there's some operating leverage in the business from now and then. Is there any indication of what the business could generate at that sales level?
Yes. Yes. Sorry, that was your other question. Look, I do think that as this business becomes more mature, it is a minimum 20% EBITDA margin business. I think the reason why we're not generating over 20% operating margins today is really because there's a lot of [ immature ] elements to our business that are continuing to grow. And we're okay with that. We hope we always have a fast growth [ in mature ] businesses in the mix as well. And it's management's goal to make sure that, that's always the case. But I think we will near and eventually cross that 20% threshold.
The next question comes from David Kwan, TD Securities.
I appreciate the color you guys just provided on the call. I guess my first question relates to capital allocation. You're expected to generate some stronger free cash flow, both from an operational perspective and then also some of these, I guess, historical acquisitions. The deferred acquisition costs and earn-outs are expected to moderate this year or next year. So I guess how would you rank the various options that you have as it relates to capital allocation? Obviously, you've talked about M&A and debt reduction, but also potential share buybacks and also investing for organic growth, which you've talked about, too.
Yes. Thanks, David. It's a really good question. I think we really feel confident that clinics are a big area of focus for us. And I'll just characterize it this way. You look at the 2 biggest DSOs in the country, dental support organizations, Dental Corp and 123. Collectively, they own about 900 clinics and operate in the country. And we're the largest MSO, medical support organization, and we own and operate 130 clinics and 80 facilities -- over 80 facilities. It just gives you a very stark and real view of how big the potential is and how immature this market is from a consolidation perspective.
We think it's very reasonable to assume that WELL eventually gets to that sort of 300-, 400-, 500-clinic mark. And I think the real -- and we're ramping up our growth machine, if you will, our integration teams, our M&A team in order to be able to do that. And I think between absorbing clinics, recruiting clinics, acquiring clinics, we feel -- and this isn't just primary care. This is in all aspects of the business, whether it's Allied Health or diagnostics or obviously, some of the specialist businesses that we're involved with, with MyHealth. We just think there's just a phenomenal opportunity for WELL to be the leader across the country and establish that pan-Canadian network.
And so I would say that's a primary goal. We've also successfully continued to tuck in, in our billing business, and that's another very interesting business where you have small kind of informal [ mop pop ] type businesses out there providing services to doctors, our doctor care team is just being really skillful at being able to identify them and acquire them and bring them into the [indiscernible] and unlock synergy and value from those. And I think we're going to continue to look at doing that. And where possible, I think strategic alliance relationships and venture investments like we did with Dr. Lee that interest us very much. When we make an investment, we never really do that purely as an investment. We always accompany it with some kind of strategic alliance agreement that improves our margins to resell a product or service.
And then finally, I'll just say on our cybersecurity group, that's another area where we've been very successful at tucking in assets and building a platform. And we think that there's a lot more out there, and that's just a great sector and it just has the dual benefit for us, too. And when we acquire those assets, we can help make WELL more safe and also help make the industry more safe and obviously generate additional revenues. Hopefully, that's helpful?
Yes. So I guess, based on your comments on it, it sounds like M&A is kind of top of the priority list?
Yes. We're very busy. We're very busy. We have at least half a dozen high-quality LOIs signed. We have a great pipeline. Our teams are firing on all cylinders, and we expect this activity to be sustained at a high level for a while.
I appreciate it. I guess one last related question. You talked about wanting to get the clinic footprint here in Canada is 300, 400, 500. Can you talk about the time lines to get there? Because obviously, you're well below that right now. Like is this something kind of better part of a decade to get there. Just curious to get your thoughts on that.
Yes. Yes. I do think that, in a year like this, we could probably add another 20 or 30 clinics. But I think our objective is to really ramp up the company's ability to dramatically improve that in future years. And so I do see that number -- I'd like to see us to be at those types of numbers within sort of 4 to 5 years. And I think depending on how quickly you roll out, what our capital base looks like, where valuations go, I think we could even potentially do it sooner than that.
That is all the time we have for questions. I will turn the call back to Hamed Shahbazi for closing remarks.
Well, I want to thank everyone for attending the call today and for all the support. We are very excited about everything happening with the business, as you probably heard today. We look forward to being in touch and unveiling some of the exciting product and technology initiatives that we're working on. And I look forward to speaking to you very soon because our Q1 will be out in short order. Have a wonderful day, and thanks, again, for all your support.
Ladies and gentlemen, this does conclude the conference call for today. We thank you for your participation and ask that you please disconnect your lines.