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Inogen Inc (NASDAQ:INGN)
Q4 2019 Earnings Call
Feb 25, 2020, 4:30 p.m. ET

Contents:

  • Prepared Remarks
  • Questions and Answers
  • Call Participants

Prepared Remarks:

Operator

Good day and welcome to the Inogen Fourth Quarter 2019 Financial Results Conference Call and Webcast. [Operator Instructions] I would now like to turn the conference over to Matt Bacso with Investor Relations. Please go ahead.

Matt Bacso -- Investor Relations Manager

Thank you for participating in today's call. Joining me from Inogen is CEO, Scott Wilkinson; and CFO and Co-Founder, Ali Bauerlein.

Earlier today, Inogen released financial results for the fourth quarter of 2019. This earnings release and Inogen's corporate presentation are currently available in the Investor Relations section of the Company's website.

As a reminder, the information presented today will include forward-looking statements, including statements about our growth prospects and strategy for 2020, hiring expectations and strategy, expectations regarding international sales and tender activity, HME strategy and expectations, our rental strategy, expectations for all revenue channels, marketing expectations, manufacturing and cost of Inogen One G5, expectations regarding competitive bidding, our expectation on the TAV rollout and TAV sales, and financial guidance for 2020.

Forward-looking statements in this call are based on information currently available to us as of today's date. These forward-looking statements are only predictions and involve risks and uncertainties that are set forth in more detail in our most recent periodic reports filed with the Securities and Exchange Commission. Actual results may vary, and we disclaim any obligation to update these forward-looking statements except as may be required by law.

We have posted historical financial statements and our investor presentation in the Investor Relations section of the Company's website. Please refer to these files for more detailed information. During the call, we will also present certain financial information on a non-GAAP basis. Management believes that non-GAAP financial measures taken in conjunction with US GAAP financial measures provide useful information for both management and investors by excluding certain non-cash items and other expenses that are not indicative of Inogen's core operating results. Management uses non-GAAP measures internally to understand, manage and evaluate our business and make operating decisions. Reconciliations of US GAAP and non-GAAP results are presented in tables within our earnings release. For future periods, we are unable to provide a reconciliation of our non-GAAP guidance to the most direct comparable GAAP measures without unreasonable effort, as discussed in more detail in our earnings release.

With that, I'll turn the call over to Inogen's President and CEO, Scott Wilkinson. Scott?

Scott Wilkinson -- President, Chief Executive Officer and Director

Thanks Matt. Good afternoon and thank you for joining our fourth quarter 2019 conference call. Before moving into a review of our quarter results, I'd like to take a moment to provide some high level context around our view of the market, our recent performance and our vision for the future.

We believe we are a leader in POC technology with our product offerings in the market for our technology remains underpenetrated. However, following multiple years of high revenue growth, our recent performance has exhibited a slowdown in revenue growth, as well as some headwinds to profitability. We are proud that in 2019, we launched the best-in-class Inogen One G5, acquired New Aera to expand our technology and product portfolio, and improved the productivity of our direct-to-consumer sales force. However, we also recognize we had multiple challenges in 2019, primarily due to a slowdown of orders from a national provider, volatility in business-to-business orders, direct-to-consumer sales force reductions and component availability shortages.

We are working relentlessly to optimize our business with a focus on improving margins and meeting our target growth objectives. We have made progress on some fronts. However, we still expect the home medical equipment providers to continue to have lumpy buying patterns over time, given their restructuring and financing constraints. We are assessing our organization from both the commercial and operational perspective in order to identify how to best maintain an attractive revenue growth profile, while also delivering leverage into our business model. Already, we have identified several opportunities in which to do so, and we are now in the process of evaluating each.

We are committed to our mission to drive freedom and independence for oxygen therapy patients through our innovative products and services. While we have our challenges, we believe we can create long-term shareholder value by focusing on increasing patient and physician awareness of our products.

With that, I will now provide details around our fourth quarter results. We generated total revenue of $78.9 million, reflecting a decline of 8.8% from the fourth quarter of 2018. This was in line with the midpoint of our preliminary unaudited revenue estimate provided on January 13, 2020, and results for each revenue channel reported were in line with those estimates as well. As we previously noted, we experienced some manufacturing challenges in the fourth quarter of 2019, which contributed to a significant amount of unshipped orders, primarily in our domestic business-to-business channel. The primary driver of these delayed shipments was certain component part shortages, which I will discuss later in this call.

While 2019 was a difficult year, revenue increased 8.2% in 2019 when excluding sales from the previously disclosed large national provider who buys through our private-label partner to whom sales decreased $20.4 million from the prior year, and also excluding the $3.1 million foreign exchange impact. Direct-to-consumer sales decreased 2.8% to $35.8 million in the fourth quarter of 2019 from the fourth quarter of 2018. This decrease was primarily due to an approximate 31% reduction in average sales representative headcount in the fourth quarter of 2019 versus the comparative period in the prior year and slightly lower average direct-to-consumer selling prices in the fourth quarter of 2019 versus the comparative period in the prior year.

The reduction in headcount was mostly offset by an increase in productivity from the remaining sales reps. In addition, we continued to hire new sales reps in the fourth quarter of 2019. As of December 31, 2019, our direct-to-consumer sales team consisted of 329 inside sales reps, which represented a decline of approximately 26% from our 2018 year-end total of 446. We remain optimistic in our ability to grow direct-to-consumer sales in 2020 based on productivity improvements and continuing the more measured planned expansion of the sales and rental intake teams.

Domestic business-to-business sales in the fourth quarter of 2019 decreased 18.9% to $20.6 million compared to the fourth quarter of 2018, primarily due to unfilled orders as of December 31, 2019. We also had a decline in orders from the previously disclosed large national provider who is a customer of our private-label partner. Specifically, this provider accounted for revenue of $300,000 in the fourth quarter of 2019, down from $2.1 million in the fourth quarter of 2018. We do not expect significant headwinds from this customer of our private-label partner in 2020, given total sales in 2019 were only $2.5 million as compared to $22.9 million in 2018.

International business-to-business sales in the fourth quarter of 2019 decreased 7.7% on an as reported basis and 5.1% on a constant currency basis to $17.1 million compared to the fourth quarter of 2018. The decline was primarily driven by tender uncertainty in certain European regions and currency headwinds. We do not believe we have lost any major customers to competition, and our strategy in Europe remains unchanged. As we have said before, international sales can be lumpy quarter to quarter. As these tender issues are resolved, we believe demand will normalize for our products in those countries. Our guidance assumes that the UK tenders will be resolved in the first half of 2020.

Rental revenue in the fourth quarter of 2019 declined to $5.4 million compared to the fourth quarter of 2018, primarily due to a 5.9% decrease in patients on service. We had approximately 25,300 patients on service as of the end of the fourth quarter of 2019. While patient count was down slightly compared to the third quarter of 2019, we continued to make progress in expanding our rental intake team, which should lead to increased rental setups as well as increased productivity of the inside sales team. As mentioned last quarter, we expect contributions from this initiative to modestly increase rental revenue in 2020.

Transitioning to the Inogen One G5, over 40% of our total unit volume and over 55% of our domestic unit volume were Inogen One G5 units in the fourth quarter of 2019, which includes the launch of this product in the international business-to-business channel during the quarter. We believe the rapid transition in our product mix toward the Inogen One G5 demonstrates the strong demand for this product and its functionality from both patients and providers. We believe adoption of the Inogen One G5 will further strengthen our competitive position. We also started manufacturing the Inogen One G5 at our contract manufacturer in the Czech Republic in the first quarter of 2020 for our European customers.

Regarding the component part shortage that contributed to unshipped units in the fourth quarter of 2019, we have worked diligently with our supplier, and I'm pleased to say we have currently returned to normal production of the Inogen One G5 now in the first quarter of 2020. However, this situation will have an impact on revenue and profitability in the first quarter of 2020. In addition, we are currently in the process of validating a second supplier for this component to reduce the risk of part shortages going forward.

With regards to the coronavirus, we continue to monitor our Chinese supply chain, but we do not expect this to have a material impact on our business at this time. As you may be aware, we acquired New Aera in August 2019, and we are pleased to say that we initiated a limited launch of the Tidal Assist Ventilator, or TAV, in December 2019. As part of our limited launch, we were able to evaluate product positioning and sales tactics in our domestic business-to-business and direct-to-consumer channels. We are excited about the initial patient feedback from this limited launch, and we continue to expect the full rollout during 2020.

I would also like to comment on the recent 2020 Medicare fee schedules announced in December 2019. Effective January 1, 2020 through December 31, 2020, Medicare reimbursement rates for auction [Phonetic] therapy increased by approximately 1.5% in rural areas, 1.5% in former competitive bidding areas and 3.5% in non-rural non-former competitive bidding areas. We believe this increase in rates should provide a modest tailwind for our 2020 rental revenue and may offer some relief to the HME providers. We expect competitive bidding round 2021 rates to be announced in summer 2020 and to take effect in January 2021.

Following our pre-announcement of the 2019 full year revenue and updated 2020 revenue guidance in mid-January, we are maintaining our full year 2020 total revenue guidance range of $385 million to $400 million, representing growth of 6.4% to 10.5% versus 2019 full year results. We believe that this guidance reflects the headwinds in the first quarter of 2020 associated with the Inogen One G5 supply constraints, the constraints of our HME partners to convert to POCs and also our more measured approach to direct to consumer sales team expansion. Given where Inogen stands today and in spite of the challenges we faced in 2019, we remain optimistic about our future growth prospects, and we believe we will continue to benefit from the shift from oxygen tanks to POCs.

With that, I will now turn the call over to our CFO, Ali Bauerlein. Ali?

Alison Bauerlein -- Founder, CFO, and Executive Vice President, Finance

Thanks Scott, and good afternoon, everyone. During my prepared remarks, I will review our fourth quarter of 2019 financial performance and then provide more details on our 2020 guidance. As Scott noted, total revenue for the fourth quarter of 2019 was $78.9 million, representing a decline of 8.8% from the fourth quarter of 2018.

Turning to gross margin, for the fourth quarter of 2019, total gross margin was 43% compared to 50.4% in the fourth quarter of 2018. Our sales gross margin was 43% in the fourth quarter of 2019 versus 51.4% in the fourth quarter of 2018. The decrease in sales gross margin was primarily due to higher cost per unit associated with certain manufacturing inefficiencies in the period that contributed to higher labor and overhead expenses and product sales mix with increased sales of the Inogen One G5, which was still at a higher cost than the Inogen One G3 during the period. As mentioned previously, we expect Inogen One G5 to be our lowest cost product to manufacture when we reach full-scale production, which we expect as early as the third quarter of 2020. Rental gross margin increased to 43.3% in the fourth quarter of 2019 versus 36.2% in the fourth quarter of 2018, primarily due to lower depreciation and service expense.

As for operating expense, total operating expense increased to $39.2 million in the fourth quarter of 2019 versus $38.8 million in the fourth quarter of 2018, primarily due to New Aera costs of $1.9 million in intangible amortization, $800,000 of expense for the change in the fair value of the earnout liability and $100,000 of acquisition-related costs. These costs were partially offset by decreased personnel-related expenses.

Research and development expense increased to $3.6 million in the fourth quarter of 2019 compared to $1.7 million reported in the fourth quarter of 2018, primarily associated with $1.9 million of New Aera intangible amortization expense.

Sales and marketing expense decreased to $25.5 million in the fourth quarter of 2019 versus $28.3 million in the comparative period of 2018, primarily due to decreased personnel-related expenses associated with the 31% decline in average sales representative headcount and lower advertising costs versus the comparative period in 2018. In the fourth quarter of 2019, we spent $9.5 million in advertising as compared to $10.8 million in the fourth quarter of 2018.

General and administrative expense increased to $10.1 million in the fourth quarter of 2019 versus $8.8 million in the fourth quarter of 2018, primarily due to an $800,000 increase in the fair value of the New Aera earnout liability and increased legal fees, partially offset by decreased personnel-related expenses and bad debt expense.

In the fourth quarter of 2019, we generated an operating loss of $5.3 million and adjusted EBITDA of $2.6 million. In the fourth quarter of 2019, we reported an income tax benefit of $2.9 million compared to an income tax benefit of $4.2 million in the fourth quarter of 2018. Our income tax benefit in the fourth quarter of 2019 included $100,000 of excess tax benefits recognized from stock-based compensation compared to a $6 million benefit in the fourth quarter of 2018.

In the fourth quarter of 2019, we reported a net loss of $1.4 million compared to net income of $10 million in the fourth quarter of 2018. Loss per diluted common share was $0.06 in the 4th quarter of 2019 versus earnings per diluted common share of $0.44 in the fourth quarter of 2018.

Now, turning to guidance, as Scott mentioned, we are maintaining our full year 2020 total revenue guidance range provided on January 13 of 2020 of $385 million to $400 million, representing growth of 6.4% to 10.5% versus 2019 full year results. We still expect direct-to-consumer sales be our fastest growing channel, and we expect domestic and international business-to-business channels to have a solid growth rate. Given the low-single digit Medicare rate increase in 2020 and expected increase in patients on service, we expect rental revenue to grow modestly compared to 2019. We expect minimal contribution to revenue from the Inogen Tidal Assist Ventilator in both the domestic business-to-business and direct-to-consumer channels in 2020.

We are reducing our full year 2020 GAAP net income guidance to $14 million to $18 million, down from the range of $25 million to $27 million provided on November 5, 2019. This decrease in net income guidance is primarily due to lower sales estimates than previously expected, as well as various manufacturing inefficiencies, particularly in the first quarter of 2020. While we do not provide quarterly guidance, we do expect these factors to contribute to a net loss in the first quarter of 2020. Please note that net income guidance assumes an estimated $7.8 million in New Aera intangible amortization expense recorded and research and development expense in 2020 versus $2.9 million in 2019. Net income guidance also assumes a GAAP effective tax rate of approximately 25% in 2020.

We are also reducing our full year 2020 adjusted EBITDA guidance range to $44 million to $50 million, down from the range of $56 million to $58 million provided on November 5, 2019. We expect net positive cash flow for 2020 with no additional capital required to meet our current operating plan.

With that, Scott and I will take your questions.

Questions and Answers:

Operator

[Operator Instructions] The first question will come from Margaret Kaczor with William Blair. Please go ahead.

Margaret Kaczor -- William Blair & Company, L.L.C. -- Analyst

Hi, good afternoon, guys. Thanks for taking the questions. First one for me, as just a little bit of follow-up on the G5, so it sounds like maybe you've been able to get back to that full supply on that one kind of a little bit faster than it seemed like when we met with you in January. So, A, is that fair? And then, can you give us a sense of what the feedback or impact in the field has been given that lack of supply, and again, relative to what you guys have seen or expected in January?

Scott Wilkinson -- President, Chief Executive Officer and Director

Yeah, Margaret, this is Scott. I'll take that one. I would say, your assessment is on target that since we discussed our results at J.P. Morgan and our expectations in the issues around G5 that we kind of were able to fill in that back order maybe a little more quickly than we expected, but not much. We thought it would certainly have an impact in the first quarter. It did. I was hopeful that we would have it resolved, at that time, by the end of February. It was probably more like mid-February, so slightly ahead, but we certainly did have an impact, particularly in the month of January, until we really got the parts flow in and then kind of dug out of the hole. So today, we're back to shipping on time. But as we said, there is kind of some damage done in January with that back order that has going to hurt our results for the quarter.

As far as the providers as well as patients, really happy with the adoption of the product. There is -- that's kind of a good news in this mess is that it's a preferred product. We really think we have a winner. As I said in my remarks, it strengthens our competitive position, but there are a lot of providers that they took the approach that I'm going to wait for my order. They don't place new orders when you're already back ordered and that's why we will have some impact in the first quarter as well on the volume front, and we tried to reflect that in everything that we said from the J.P. Morgan Conference debate [Phonetic]. So, but yeah, we're really pleased with the acceptance. I think we always thought this would be a product that the providers would like. With a higher flow rate, it serves a wider range of patients. So you've got one product is going to serve more patients. So you avoid those switch-out costs from product to product. And of course, you know in this fixed reimbursement environment that providers are really focused on reducing their cost. But I think it's been a real pleasant surprise for us how much the patients have adopted and liked the product as well even to the tune, if you recall, that we have charged a small premium for this product on the retail front so that people have literally put their money where their mouth is and they're willing to pay a little bit more for the product on the patient side.

Margaret Kaczor -- William Blair & Company, L.L.C. -- Analyst

Got it. So, it's fair to say, I guess, at this point that you guys feel comfortable with the visibility going forward, especially now with the relaunch?

Scott Wilkinson -- President, Chief Executive Officer and Director

Yeah. On supply chain, yeah, the thing I'll -- we've continued to caution people, and again I said it in my remarks, well, I certainly don't expect to be into a back order or stock-out situation. The provider channel will continue to be lumpy. It has been forever, and I don't think that that's going to change. So we're going to have our usual lumpiness. Don't see that going away, but as far as kind of back to more predictability and certainly no stock-outs, yes.

Margaret Kaczor -- William Blair & Company, L.L.C. -- Analyst

Okay. And then just one more follow-up. Scott, I think at the front end of the call, you talked about several opportunities you've identified to drive kind of both that top line growth as well as that bottom line growth. So, can you guys give us any kind of examples of that or give us a sense of what you find is attractive for both of those? I don't know if it's mid-single digit top line growth, double-digit, higher, and then kind of that same topic for margins maybe kind of where long-term margins could end up? Thanks.

Scott Wilkinson -- President, Chief Executive Officer and Director

Yeah, let me let me kind of say at the front end, Margaret, we're looking at both top end and bottom end because we've got to drive both. We've got, as I said, a market that's still vastly underpenetrated. So we see a lot of opportunity in front of us. But a lot of that opportunity has come through the provider community, and they're really struggling with the transition. This restructure exercise for them is a tough one. While we've had considerable success over the last few years, we've had the starts and stops that I've mentioned. And so, we're looking for ways that we can capitalize on this opportunity, I'll say, in a more steady manner rather than the lumpiness. Now, when I talk about top line and bottom line, on the bottom line, we've got to attack the cost of G5. One of the good news is, in the earlier adoption, as we've said, when we have the volume up, the cost should come down. When we cost it out, it should be a lower total cost product than our other products in the portfolio. But today it is not. It's my expectation with a more rapid adoption of that product that we can bring that in sooner rather than later, but certainly attacking manufacturing cost and COGS. And then on the top line, I guess at a high level, I'll say, we've mentioned in the past, we still very successfully drive tens of thousands of leads every month through our advertising campaign. We're looking at multiple ways where we can use more of the leads than we currently use. We've paid for them. They are part of our advertising spend. And so, that actually -- if we can optimize our utilize more of those leads, that's going to help us on both the top and the bottom line because I don't need to pay more for that. I just get more revenue out of that pile [Phonetic].

Margaret Kaczor -- William Blair & Company, L.L.C. -- Analyst

Great. Thank you, guys.

Operator

The next question comes from Danielle Antalffy with SVB Leerink. Please go ahead.

Danielle Antalffy -- SVB Leerink -- Analyst

Hey, good afternoon, guys. Thanks so much for taking the question. I guess, my first question is on the new EBITDA guidance, and how much of that is -- and sorry if I missed this in the prepared remarks, but how much of that is tied to the issues that have already occurred versus what you see on a go-forward basis? I guess, how much of that reduction is already behind us? And then I have one follow-up.

Alison Bauerlein -- Founder, CFO, and Executive Vice President, Finance

Yeah, I'll take that one, Danielle. So, on the EBITDA side, as we said, we expect a net loss in Q1. So, that also will translate into lower EBITDA than what we've seen in our historical base, and we expect that to be more similar to Q4 in terms of EBITDA levels in Q1 of 2020. So, as a result, that is a significant driver of the lower EBITDA for the full year 2020 expectations. The other drivers when we look at EBITDA, there is naturally, just like with revenue, a little bit of seasonality in our business with Q2 and Q3 tending to be higher than Q1 and Q4. We still expect that trend this year on the top line, but we do expect EBITDA to be slightly more back-end loaded in the second half versus the first half due to the improvements on the gross margin side expected with the G5 cost improvement really starting in the third quarter. So, that also will contribute to a little bit more EBITDA leverage in the back half versus the first half.

Danielle Antalffy -- SVB Leerink -- Analyst

Okay, got it. And then, just longer term as we look at the business, and obviously the non-invasive ventilation piece of the business that's higher ASP, so that should help be a positive leverage driver. But given what we've learned over the last, call it, 12 to 18 months on the D2C side of things and the spend required to drive the sales etc., and also as this eventually shifts to a more B2B heavy mix, like how do we think about the long-term EBIT margin potential for this set of businesses? Has anything changed in your view? I know you never give long-term guidance, but if you could help frame for us a long-term positive leverage -- levers, that would be helpful. Thanks so much.

Alison Bauerlein -- Founder, CFO, and Executive Vice President, Finance

Yeah, sure. So we're not today also going to give long-term EBITDA guidance, but we do expect to be able to improve that over time. When we look at the drivers of the compressed margin, the real opportunities are on the cost side, as Scott said, on lowering the cost of goods sold, improving the manufacturing, labor and overhead costs, as well as productivity improvements. We have continued to see improvements on that, as well as basically flat cost per lead year-over-year in our marketing spend. So that is also important looking at 2020. We also continue to plan on getting G&A leverage. And long term, as you said, the TAV product should help improve both our operating margins, as well as our gross margin. And we really are looking at those business opportunities to improve our revenue growth and our operating leverage holistically. But Scott's example of looking at direct consumer leads and better utilization, that's one of many ideas that we have to expand our operating margin. And as we get closer to executing on those specific initiatives, we will comment on them.

Scott Wilkinson -- President, Chief Executive Officer and Director

Let me just add to that. At the risk of being a little redundant, we have said in the past, as you drive more leads, drive more volume, obviously that advertising cost goes up. And so, I think we've done a pretty good job of improving our sales force productivity over time to help offset that cost increase. It doesn't offset at 100%, but it certainly pushes that needle in the other direction for an offset. And then, really, the key to really show and leverage here is using more of those leads. Now, that's where -- you mentioned TAV, I wanted to say TAV is a part of that in the long term. Even though this year is kind of a learning and figure out our sales process and who is the right patient for this and we'll run the appropriate pricing trials to figure out what the optimum price is, when we've got this at scale and rolled out to everybody, those leads should be coming right from the current leads that we're driving. So while this year, we've been pretty conservative in what our expectations are on TAV, we've said, let's learn and do this right. If you look at where we're going long term and how we drive leverage, as I said, we've got to use more of those leads, and TAV will be a part of that.

Danielle Antalffy -- SVB Leerink -- Analyst

Got it. Thank you.

Operator

The next question comes from Mike Matson with Needham & Company. Please go ahead.

Mike Matson -- Needham & Company, LLC -- Analyst

Hi, thanks for taking my questions. I guess just -- so starting with the gross margin, the manufacturing inefficiencies that you experienced, was that related to the component shortage? Or was that a separate issue? And is that related to just the scale-up of the G5 or something else?

Alison Bauerlein -- Founder, CFO, and Executive Vice President, Finance

Yeah, it's really both. So it's both the combination of the higher costs for the G5 versus the G3 and with G5 being a larger mix than it had been in prior quarters, as well as the inefficiencies on the manufacturing side that drove higher cost on the labor and overhead because clearly we didn't scale down the team associated with the component shortages, and we also had expedited freight, those types of items. So, all of that was part of those challenges. And that does continue into Q1 of 2020 as a headwind on the gross margin side and a major contributor, just like it was in Q4, to the loss. We expect a loss in Q1 of 2020, again, associated primarily with that lower gross margin.

Mike Matson -- Needham & Company, LLC -- Analyst

Okay, thanks. And then, I guess I'm a little confused about the pricing in the DTC channel in the fourth quarter because I think you said pricing was down, but you also said you are getting a premium on the G5. So how do I reconcile those things?

Alison Bauerlein -- Founder, CFO, and Executive Vice President, Finance

Sure, I'll take that one. So when we look at our year-over-year pricing on the -- in the D2C channel specifically, it was down about a little over 1% compared to the fourth quarter of 2018. So it is a small decline in price. But we do also have a premium for the G5. Now, the G5 has a $100 premium, but other factors offset that in the quarter to bring down that average revenue per unit to little over 1% down.

Mike Matson -- Needham & Company, LLC -- Analyst

Okay, thanks. And then just a couple on ad spending. So it was down, which I guess is a good thing in a way, but I was wondering if any of that was just simply due to the fact that you had limited supply in the quarter? And then in addition, how do we think about the advertising -- the impact of the election this year on your advertising spending?

Alison Bauerlein -- Founder, CFO, and Executive Vice President, Finance

Yeah. I'll also take that one. So when we look at our advertising spend, as we said, it was about $9.5 million in the quarter versus $10.8 million in Q4 of 2018. So, as a percent of D2C revenue, it was down compared to last year, which is a good thing. When we look at the real drivers, our number of leads that we generated were down in the period associated with the smaller sales force. We do scale the number of leads based on the size of the sales force, but we actually had more leads for reps than we had in Q4 of 2018. So we actually had a good number there, and as I said, flat cost per lead and also improved direct-to-consumer close rate as well on a year-over-year basis. So those were positive indicators. Obviously, going into 2020 and looking at marketing spend, that is a key item for us to continue to keep cost per lead relatively flat compared to 2019. And we do that through shifting our strategy on the media side. We don't want to get into the specifics there because we don't want to share specific information with our competitors around our strategy, but we do think that we have some good strategies in place to keep media costs in line with our expectations.

Mike Matson -- Needham & Company, LLC -- Analyst

Okay, great. Thank you.

Operator

And our next question comes from Matthew Mishan with KeyBanc. Please go ahead.

Matthew Mishan -- KeyBanc -- Analyst

Good afternoon and thank you for taking the questions. I just want to start off with, what are the largest DMEs kind of indicating to you on purchasing POCs over the next year? Are they pulling back from the category due to like NCB? Or is it just becoming more competitive with some of the other companies that are going after this market?

Scott Wilkinson -- President, Chief Executive Officer and Director

Yeah, I'll take that one, Matt, and thanks for your question. Certainly, there is a lot of apprehension out there right now with competitive bidding, right? You've got unknown on where the rates are going to go. And when I say the rates, I mean the rates for all the items that were bid out. So their fears aren't just oxygen. NIV is in the mix for the first time. There is some apprehension about where rates might go there, as well as all the other items. So, then you've got the other issue of some people don't know if they're going to be in the game. Now, I think if we are pragmatic about it, I think the big players are going to stay in the game. They may lose an area here and there. They always have lost an area. But if they want that area, they'll buy back in. They will scoop up a small provider. So they're not going to be pushed out of the program, but some of the smaller people might be. You've got some small mom and pops, if they lose, they're out. So if you don't know if you're in or out and you don't know what the rates are going to be, I will say, you are very careful about spending right now. It's kind of like in tough economic times, people don't go buy a new car. They may need a new car. They may want a new car, but they'll drive their older car for a little while until things get better or there is more certainty. It's the same thing with the home care guys. In times like this where competitive bidding has a lot of uncertainty out there, they're going to try and squeeze the assets they have and they're going to be pretty tight on their spending. That's reflected in our guidance. We understand that. So when you say, what are they telling you, they saying, yeah, I'm going to be really careful until I know what the heck is going on, and we should have more clarity, as we said, when the rates are announced in the summer of 2020 according to CMS' schedule. The way the bidding works, once the rate is announced, people should know if they won or they lost or they are under the line because of the way it's been restructured. So our expectation is, once we have that clarity, that now you've got some people that are in the game for the long term and rates should be stable then through those -- that contract period, then they'll make some investment. So we think it's going to be very tough in the first half of the year, probably a little less tough in the second half of the year, at least if you just look at from a purchasing perspective. And then, we still have to earn our share of those purchases from the providers.

From a dynamics of the competition, nothing has really changed. The one company that's launched a new product is us. And as I've said many times, we're very pleased with where we sit from a competitive performance position with the Inogen One G5 and how it stacks up to the other offerings. But people are going to continue to try and knock us off the mountain and they're going to try and do that with price and financing in terms the usual things that they do to get the DMEs' attention, and we've done a pretty good job of keeping up with that game and holding our share, and that's what our plan is to continue to do that. So hopefully that gives you a little color on how we think this is going to go this year.

Matthew Mishan -- KeyBanc -- Analyst

No, that definitely does. And then just shifting it over to direct-to-consumer, when do you annualize the sales -- the lower sales force or the sales force reductions? And when you do annualize it, what is a more sustainable rate of growth for the sales force from there?

Alison Bauerlein -- Founder, CFO, and Executive Vice President, Finance

Yeah, I can take that one. So when you look at our headcount reductions, the largest headcount reductions that we had was in the second quarter of 2019. So once we get through the second quarter, that's really when you annualize those headcount issues or headcount reductions that we saw. And because of that, we do expect still to be down year-over-year in the first quarter of 2020 in that direct-to-consumer channel, returning to growth in the second quarter of 2020 and then getting to the more -- the higher more sustainable growth after that. That should follow more closely with our hiring and how we can expand the sales force as well as a little bit of improvement on productivity. We haven't put out a specific target there, but you should see our strongest growth in Q3 and Q4 compared to Q1 and Q2.

Matthew Mishan -- KeyBanc -- Analyst

Thank you.

Operator

Ladies and gentlemen, this concludes our question-and-answer session. I would like to turn the conference back over to Scott Wilkinson for any closing remarks.

Scott Wilkinson -- President, Chief Executive Officer and Director

Thank you. Although 2019 was a difficult year for us, we are committed to optimizing our business in 2020 and beyond. We maintain our belief that the need and patient preference for our best-in-class portable oxygen concentrators remains strong. Before concluding, I would also like to thank our Inogen employees to whom we remain committed and for all of their hard work to improve the lives of oxygen therapy patients every day. Thank you for your time today.

Operator

[Operator Closing Remarks]

Duration: 42 minutes

Call participants:

Matt Bacso -- Investor Relations Manager

Scott Wilkinson -- President, Chief Executive Officer and Director

Alison Bauerlein -- Founder, CFO, and Executive Vice President, Finance

Margaret Kaczor -- William Blair & Company, L.L.C. -- Analyst

Danielle Antalffy -- SVB Leerink -- Analyst

Mike Matson -- Needham & Company, LLC -- Analyst

Matthew Mishan -- KeyBanc -- Analyst

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