Avanos Medical, Inc. (AVNS) Q1 2021 Earnings Call Transcript

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Avanos Medical, Inc. (AVNS -1.00%)
Q1 2021 Earnings Call
May 7, 2021, 9:00 a.m. ET

Contents:

• Prepared Remarks
• Questions and Answers
• Call Participants

Prepared Remarks:

Operator

Good day, and welcome to the Avanos Medical First Quarter 2021 Earnings Conference Call. [Operator Instructions].

I would now like to turn the conference over to Dave Crawford, Vice President of Investor Relations. Please go ahead.

Dave Crawford -- Vice President of Investor Relations & Treasurer

Good morning everyone, and thanks for joining us. It's my pleasure to welcome you to the Avanos 2021 first quarter earnings conference call.

With me this morning are Joe Woody, CEO, and Michael Greiner, Senior Vice President and CFO. Joe will begin with an update on our business and then review the progress we are making against our 2021 priorities. Then Michael will review our 2021 first quarter, and provide an update on our current planning environment. We will finish the call with Q&A. A presentation for today's call is available on the Investors section of our website avanos.com.

As a reminder, our comments today contain forward-looking statements related to the Company, our expected performance, economic conditions and our industry. No assurance can be given as to future financial results. Actual results could differ materially from those in forward-looking statements. For more information about forward-looking statements and the risk factors that could influence future results, please see today's press release, and the risk factors described in our filings with the SEC. Additionally, we will be referring to adjusted results and outlook. The press release has information on these adjustments and reconciliations to comparable GAAP financial measures.

Now I'll turn the call over to Joe.

Joseph F. Woody -- Chief Executive Officer

Thanks, Dave. Good morning everyone, and thank you for your interest in Avanos.

I'm encouraged by our team's continued strong execution and resiliency as they respond to the challenging dynamics through our business brought on by the pandemic. Our employees remain focused in the dedication to getting patients back to the things that matter as we meet the needs of our customers. As mentioned on our last earnings call, we began the quarter with some headwinds and uncertainty resulting from rising hospitalizations, and the corresponding negative impact to elective procedures. However, as we exited the quarter, we saw increasing topline momentum across our Pain Management franchise, as a return of elective procedures began to reaccelerate.

Looking ahead, while we are encouraged to see the elective procedure volume increasing, and expected to accelerate, we continue to believe volume likely will remain below its full potential until the end of the year.

As we examine the business environment we are gaining confidence in the direction of our business and have better line of sight to the gradual ablation of challenges presented by the pandemic. As a result, we feel well positioned to provide financial guidance for 2021. Based on current projections, we expect net sales on a constant currency basis to increase 2% to 4% compared to the prior year. Also, we expect to earn between $1.10 and $1.25 of adjusted diluted earnings per share. Michael will share additional information on our financial guidance in his remarks.

During the quarter we established our first Diversity, Equity and Inclusion Council, consisting of 15 global employees across all departments. The DE&I Council will build upon our We Stand Together initiative to better understand our employees' perspectives regarding the issues of racial and gender inequality. Our DE&I initiative remains a critical effort for us to shape the organization's culture where all our employees want to work.

Lastly, we are discussing with the DOJ a potential resolution of their investigation into MicroCool and other surgical gowns that were a part of the S&IP business when we divested in 2018. We anticipate finalizing an agreement with the DOJ in Q2 or Q3.

With that as background, I'll now our review our first quarter results and provide you with an update on our drivers of value creation. Sales totaled $181 million unchanged compared to the prior year, while we earned $0.23 of adjusted diluted earning per share. Earnings were positively impacted by our disciplined cost control measures, but were partially offset by increased transportation costs. Results in our Chronic Care business were mix and Digestive Health will continue to deliver mid single-digit growth of the franchise overall. In Respiratory Health, sales related to the direct treatment of patients impacted by the pandemic were similar to last year. However, overall growth was down slightly as the precautionary measures taken for the pandemic impacted the normal cold and flu season uplift and therefore significantly reduced seasonal sales related to cold and flu season. In Pain Management, as I stated earlier elective procedures remain suppressed at the start of the quarter as COVID related hospitalizations spiked in some regions. The biggest had one was to our ON-Q therapy where a significant percentage of surgeries where ON-Q is used require a hospital stay. Separately COOLIEF was less impacted as it performed as an outpatient therapy. Overall sales grew sequentially throughout the quarter as procedural volume returned. Despite the early quarter headwinds caused by the new wave of the pandemic, we continued to build on our solid foundation to accelerate growth across Pain Management.

Finally, let me provide you with an update on our progress this quarter regarding our four areas of value creation. As a reminder, the four areas are strengthening our growth profile, expanding our gross and operating margins, driving consistent free cash flow generation and deploying capital toward M&A. First, as we look to strengthen our growth profile, we maintained our momentum in driving market adoption and gaining share by growing both our CORPAK and NeoMed portfolios. We are executing our strategy to establish CORTRAK as a standard of care for nasogastric feeding along with increasing the adoption of NeoMed to further address neonatal enteral feeding needs. We delivered record sales for CORTRAK hardware units in the first quarter and are on target to reach our goal for NeoMed account conversions.

On previous calls, we have discussed the progress we're making to expand the clinical evidence for COOLIEF to demonstrate this differentiation as a radio frequency ablation therapy. Also important to this effort, are independent physician-led studies being conducted. During the quarter two independent physician led publications on COOLIEF were published. The first concluded that the use of cooled radio frequency was predictive of a better outcome for patients suffering from knee osteoarthritis. Additionally another large retrospective knee series concluded that COOLIEF was clinically effective for both managing pain and reducing disability. Finally, we continue to execute on our international expansion initiatives. We achieved high single digit organic growth across each of our regions during the quarter. The first time we have seen this level of growth across all of our regions in the same quarter. Also internationally, we achieved growth in both our Chronic Care and Pain Management franchises.

Our second area of focus is on gross and operating margin expansion. I'm encouraged by the continued cost discipline and emphasis on driving efficiencies in our spending. However, we incurred additional transportation costs related to facilitate NeoMed growth from account conversions. We anticipate these increased distribution costs to continue into the second quarter, albeit at a slower rate. As we advance our business, we're looking at all processes throughout the lens of value creation with the goal of enhancing efficiencies by embedding this approach into our culture while more effectively meeting customers' needs.

Our third pathway is to generate consistent repeatable cash flow. Cash flow met our internal expectation for the quarter as we anticipated certain outflows relating to compensation. Taking into consideration a preliminary agreement with the DOJ, we now anticipate delivering approximately $80 million of free cash flow. Cash flow will be driven by improved earnings and the disciplined cost savings that I previously mentioned, as well as receiving an expected $60 million in U.S. tax refunds primarily derived from the provisions available through the CARES Act.

Finally, we continue to examine capital deployment for M&A. Our M&A pipeline remains robust and we maintain active dialog with a number of potential tuck-in targets, which would leverage our existing footprint, generate synergies and enhance our top-line growth profile. While I am optimistic about the prospect of bolstering our robust portfolio in 2021, we will remain disciplined in our assessment of targets, ensuring we generate a strong return on capital.

Overall, we remain well positioned to advance our strategies across each of these four areas of value creation as our focus on execution remain strong. This along with our market leading portfolio gives me confidence we can deliver growth and margin expansion in 2021 and beyond.

Now I'll turn the call over to Michael.

Michael Greiner -- Senior Vice President & Chief Financial Officer

Thank you, Joe. As you know that we continue to battle a range of headwinds and yet the team remains focused on execution and overcoming these challenges. Let's begin with a review of our first quarter results. Total sales of $181 million were unchanged compared to last year. We saw 1% increase in volume and a 1% benefit from favorable exchange rates. Unfavorable price offset sales by 2%. The slightly higher than normal price impact was primarily due to the timing of discounts and allowances paid to customers. Chronic Care sales grew 5% to $121 million in the quarter as we saw mid single digit demand for our Digestive Health products. Double-digit CORPAK growth resulted from the execution of our standard of care strategy while NeoMed growth came from the continued -- continuation of conversions to our ENFit technology mentioned earlier. Double digit international growth bolstered performance driven by new channel partnerships and our Asia-Pacific and Middle East regions for CORTRAK along with share gains across Europe.

Meanwhile performance in Respiratory Health was down slightly due to the weaker-than-normal cold and flu season. Also, we continue to monitor our pandemic related sales and the relationship between sales to distributors and trade sales from our customers. While over the past year, there has been some added variability, it does not appear from the analysis that additional inventory is currently being held by distributors. Thus, while we do expect an impact to Respiratory Health growth from hospitalizations declining over the next several quarters, we do not anticipate an additional headwind from distributors rebalancing their inventory levels.

Moving to Pain Management, we delivered $60 million of sales, 8% lower compared to the prior year. The cancellation of elective procedures impacted performance as well as lower procedural efficiency. The largest change was in ON-Q which is heavily correlated to procedures requiring some length of patient stay in the hospital. As Joe mentioned, we saw sequential growth in ON-Q as the hospitalizations declined and elective procedural volume increased. Despite this challenge to ON-Q for the quarter, sales through lighters increased by double digits, as our partnership with fighters continues to benefit customers as a pre-fill option.

With respect to COOLIEF we're encouraged by the results for the quarter that were essentially flat compared to prior year. While growth was unfavorable for the first two months, we saw significant growth in March as anticipated. A highlight in Pain Management was double-digit growth in Game Ready, where our efforts to expand the rental of units directly from Avanos is progressing well. In addition, the business benefited from the return of sports in both North American and European markets. We continue to meet patients' needs for effective opioid-sparing pain management therapies and believe the return of elective procedures being performed in a hospital will support additional growth for this franchise.

Moving down the income statement. Adjusted gross margin decreased to 52% compared to 59% last year. As we indicated on our previous earnings call, gross margin was expected to be lower given the timing of manufacturing variances and unfavorable product mix. In addition, gross margin in the quarter was also impacted by higher transportation costs to bring NeoMed products from China to the United States to meet customer demand, as well as higher than normal price declines in the timing of discounts and allowances paid to customers. We continue to expect adjusted gross margin to improve as we regain growth in Pain Management and demand for our Respiratory Health products partially normalizes to pre-COVID levels. Adjusted gross margins are still expected to range between our 2019 and 2020 margin levels, as mentioned during our year-end earnings call. However, we anticipate the meaningful improvement in gross margin will now occur in the second half of the year as we will continue to incur higher transportation cost to meet the sales demand for NeoMed during the second quarter.

Adjusted operating profit totaled $16 million compared to $14 million in the prior year. Performance was primarily driven by adjusted operating expense reductions, which is partially offset by the lower adjusted gross margin I just reviewed. Adjusted EBITDA totaled $22 million compared to $20 million last year. Adjusted net income totaled $11 million compared to $8 million a year ago, and we're in $0.23 of adjusted diluted earnings per share.

Now turning to the balance sheet and cash flow statement. As Joe mentioned, keeping a healthy balance sheet, and generating meaningful free cash flow remains a key go forward priority. Our balance sheet remains solid, and continues to provide us with strategic flexibility as we ended the quarter with $100 million of cash on hand, as well as $175 million of debt outstanding on our revolving credit facility. This is an improvement of $5 million versus year-end due to our repayment we made during the quarter.

Free cash flow represented an outflow of $9 million due to the timing of payments related to employee shor-term incentives, and severance payments related to our restructuring announced last quarter. Overall, as Joe mentioned, taking into consideration our preliminary settlement with the DOJ, we are confident in generating approximately $80 million of free cash flow this year, which includes refunds from the CARES Act.

Finally, while some unpredictability of the coronavirus remains, the return of elective procedures and the success of the vaccine rollout enables us to provide a 2021 full-year outlook at this time. Based on current trends in our business, including the expectation of elective procedures returning by the end of the year to normal level, we expect net sales on a constant currency basis to increase 2% to 4% compared to the prior year. This includes an approximate 50 basis point impact from the exit of a non-strategic international Chronic Care business discussed last quarter. Additionally, as we noted on our year-end earnings call, quarter-over-quarter sales results will be more variable than usual, given the impact of COVID on our prior year sales, and how that will impact our quarterly comparables.

For the year, we expect to earn between $1.10 and $1.25 of adjusted diluted earnings per share. We expect higher earnings in the second half of the year from a pacing perspective. This is based on a higher sales and gross margin expansion, along with the continued focus on controlling our operating expenses.

In closing, we are off to a strong start for the year and we've made meaningful progress on our valuation pathway. I'm confident in our ability to execute on the strategy, and to deliver significant free cash flow and deploy capital in a disciplined manner through the duration of this year and going forward.

Operator, please open the line for questions.

Questions and Answers:

Operator

[Operator instructions] Our first question comes from Ravi Misra with Berenberg. Please go ahead.

Ravi Misra -- Joh. Berenberg, Gossler & Co. KG -- Analyst

Oh. Hi, good morning. Thank you for taking the questions. So just couple of questions from me. On the guidance front, Mike and Joe, just wondering you kind of assuming a normalization by the end of the year. Just wondering does that kind of get you to the midpoint of your guidance or the high end. Can you help us think about what's contemplated kind of on the low and high end? I mean should the high-end kind of include getting more aggressive in terms of more aggressive rebound of procedures. And I have a couple of follow-ups. Thanks.

Joseph F. Woody -- Chief Executive Officer

Hey, Ravi. Good morning, it's Joe. I'll say a couple of things, and then Michael may want to add to it, but generally the way I would sort of view that guidance is that the faster electives come back, the better it can be, and Chronic Care is likely to be below the low-end of our range but Pain at the high-end of our -- greater than really the high end of our range. So we are looking at obviously the improvement, less hospitalizations. We really do believe things are going to improve on the electives in the second half of the year. We're watching the speed there, because we don't have full indication that that's across the board from a lot of our customers.

And Michael, do you have anything to add there?

Michael Greiner -- Senior Vice President & Chief Financial Officer

Yeah, I will just say the low-end of the range, Ravi, to your question assumes some continued headwinds into the back half of the year on both the cost side, and as Joe just mentioned some of these electives not returning in order to hit that $1.10. So that's a fairly conservative low end of the range. A lot of things would have to not go right for us in the back half of the year to be there.

Ravi Misra -- Joh. Berenberg, Gossler & Co. KG -- Analyst

Great, thanks. And then maybe just if you could help --- I'll ask my last follow-ups altogether. Just if you can help us understand, your international growth was pretty strong. Just can you help us understand the kind of impact to margin there in terms of how it compares to the overall corporate average? And then finally, any updates on the kind of progress on the breakthrough designation product and that's it for me. Thank you.

Joseph F. Woody -- Chief Executive Officer

So I'll start with just talking about the international business, a good performance. We see that continuing into Q2 as well, and there has been a real focus on geographical expansion through bringing the M&A that we've been able to conduct into those markets and entering new markets. I think that team's done a nice job of managing distributors in EMEA and Asia-Pac. Getting more out of them in some cases going direct, and eliminating distributors that aren't living up to our standards, and then they're very focused on medical education and clinical studies. And so that's therapy adoption that they're really both in Asia-Pac and EMEA that they're getting.

So again, we think it's in a non-pandemic situation in a mid single-digit grower that we're working toward high single-digit, an important lever for us. Early on in my tenure, we did a lot of investment in people. The structure in that area and Michael's looking like he wants to talk a little bit about the margin contribution.

Michael Greiner -- Senior Vice President & Chief Financial Officer

Yeah. So remember Ravi, good majority of the revenue we do have internationally right now is Chronic Care. We are looking to expand our Pain footprint. So by definition our Chronic Care portfolio by and large is a lower gross margin profile. And then as Joe just alluded to, we are doing some key investments internationally that we think are right for the long-term. So our overall margin profile, both at the gross margin levels and the operating margin levels are slightly lower than the overall consolidated companies.

Ravi Misra -- Joh. Berenberg, Gossler & Co. KG -- Analyst

And then just on that breakthrough designation device, can you just....

Joseph F. Woody -- Chief Executive Officer

Oh, sorry.

Ravi Misra -- Joh. Berenberg, Gossler & Co. KG -- Analyst

Talk about that.

Joseph F. Woody -- Chief Executive Officer

Sorry about that. Yeah, we are progressing well and our electronic product really focused on total knee. We're in patients now. We're very impressed with the results and so that portion of the development has gone well and now we're obviously working on the FDA approval applications and how we would view our reimbursement there. When we have an Investor Day, which maybe toward the end of the year, call it fall or, about the time they will rollout an LRP, our new LRP, we're going to highlight that and talk more about it in that meeting.

Ravi Misra -- Joh. Berenberg, Gossler & Co. KG -- Analyst

Thanks.

Joseph F. Woody -- Chief Executive Officer

Yeah.

Operator

The next question comes from Larry Keusch with Raymond James. Please go ahead.

Lawrence Keusch -- Raymond James Financial -- Analyst

Hey. Good morning everyone. Thanks for taking the question. I guess to start off, sorry, I'm just thinking about the guidance for 2021 and thanks for now beginning to provide that. I guess it was a little bit lower than I was anticipating and I'm just -- this is --- I'm trying to parse through the various moving pieces of the business. I'm curious that how you're thinking about that ON-Q. Is that sort of a bit of a laggard as you're waiting for these procedures to come back, because I would assume that given your commentary on the first quarter and the exiting rates COOLIEF should be a pretty substantial grower for the year.

Joseph F. Woody -- Chief Executive Officer

Yes. That's right, Larry. I mean COOLIEF will be a substantial grower and with respect to ON-Q we saw positive growth in March. We've seen continued acceleration, but because of the bulk of our business is in the hospital with ON-Q, it's coming back a little bit slower than the hospital outpatient department with COOLIEF. But again, we do see moving into the second half, good growth, obviously some of that is obviously related to comparator for ON-Q, and we're pleased with the progression and the things where we're headed with the channel partners and what's going on with liners, we got some of that in the commentary.

I think the biggest thing in my mind is just some of the unknowns on the range, it's the with relation to how fast the hospitals do come back with all the procedures as opposed to ambulatory surgical setting. And if you think about last year, I think we caught a little bit of heat saying that things are going to come back as fast as they did in the second half, and then they might even slow again with another wave and that did happen. So we're being cautious there but I did say, I think in the first question that to the extent the electives come back in a much faster manner, that's upside for us.

And I don't know if Michael will be taking. Michael, is there anything to add, I don't know. Larry, you may have a couple of more questions.

Lawrence Keusch -- Raymond James Financial -- Analyst

Yeah, just two more. Thanks for that. I guess Joe on that topic about --- again your commentary you don't expect the full volume potential to come back until -- till the end of the year. As you assess things, what do you think is really the biggest gating factor there? What's kind of driving that assumption. I mean that is, it feels a little bit different than what other companies are assuming. It feels like most are anticipating kind of the second half is much more normalized. It sounds like your commentary is, hey, let's wait and see what happens till the end of the year and I guess, just the second question, I'll just ask and probably for Michael is just how should we think about that SG&A coming back through the year?

Joseph F. Woody -- Chief Executive Officer

Generally for us it's -- the therapy and pain, they're done at different sites. It's a little bit more complex example Game Ready is coming in very quickly as sports come back. We're getting a lot of growth there. And that's done in an outpatient setting. Again COOLIEF coming together quickly in the outpatient setting. So we feel like we're sort of at an 80%, 85% maybe range in the hospital right now and that should climb. This-- our decision to sort of be a little bit more conservative on that is based upon talking to hospital executives. We use some outside consultants. We talk to our own surgeons and customers and our customer base, but again if this quickly comes back in, call it, May, June, July, and we think that H2 will be strong, then that could be good potential for us in the ON-Q space.

Michael Greiner -- Senior Vice President & Chief Financial Officer

Yeah, I think, Larry, one other thing to consider is we don't want to come back and revisit this range. And we believe that we were appropriately looking at the various sensitivities of when things would occur and this range allows us to capture some downside if that were to occur and obviously some upside if things were to come back quicker, so that's part of our thinking just as far as how we thought about the range and putting it out here in the second quarter-- start of the second quarter.

With regards to SG&A, as you noticed, the last three quarters we've had SG&A as a percentage of revenue in the high-30s which ultimately is our long-term goal there. We do believe as we enter the back half of the year there are some investment opportunities on the operating side that we are considering. If we were to do those investments SG&A would increase probably just north of 40% again, temporarily before we get to our longer-term goals of the high-30s in a more permanent way. So that 110 to 125 also considers that we will be doing some of these SG&A investments in the back half of the year.

Lawrence Keusch -- Raymond James Financial -- Analyst

Okay, terrific. Thanks guys. Appreciate it.

Michael Greiner -- Senior Vice President & Chief Financial Officer

Thank you.

Operator

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

Matthew Mishan -- KeyBanc Capital Markets -- Analyst

Hey, good morning guys.

Joseph F. Woody -- Chief Executive Officer

Good morning.

Matthew Mishan -- KeyBanc Capital Markets -- Analyst

So it -- so it's Friday morning after a long week, my listening comprehension skills are not that strong, this morning. But I heard DOJ a couple of times in the presentation. Just, first, can you just go over-- do you still have a liability there, is that Kimberly Clark and did that change your free cash flow expectations for the year excluding $180 million. I think it was $100 million previously

Michael Greiner -- Senior Vice President & Chief Financial Officer

Right. So I'll say a couple of things. And then, I won't go much further for now. But basically we did with the DOJ agree, in principle, and we are continuously discussing a potential resolution. We anticipate that that would be finalized in Q2 or Q3. And if you're referring to, I think the indemnification that with KCI that was, we have no more issues there, we settled with KC, really it was Q4 I think of last year.

Joseph F. Woody -- Chief Executive Officer

Last year. Yes.

Michael Greiner -- Senior Vice President & Chief Financial Officer

And yeah, you are correct, Matt, the change in free cash flow from $100 million to $80 million relates to what we believe will be the settle -- ultimately the settlement amount but DOJ.

Joseph F. Woody -- Chief Executive Officer

And just one other thing, I mean if you think about this and step back a little bit. We've always talked about getting things behind us and moving forward. And I think this is a big step to understand where we might be with this and this couples with putting the IT system deployment and the divestiture of S&IP and then obviously positioning ourselves where we get a lot of cost out of the business and heading into a place where we're getting a stronger growth. So our ability to execute in a more clear manner is as big as any type of agreement.

Michael Greiner -- Senior Vice President & Chief Financial Officer

Yeah. Removing these overhangs we think is important.

Matthew Mishan -- KeyBanc Capital Markets -- Analyst

Okay. Excellent. And then just gross margin trends, how you think they improved from 1Q to the rest of the year. I believe you previously said that you're somewhere between 19 and 20, is that still the case?

Joseph F. Woody -- Chief Executive Officer

Yeah. So Michael is going to take you through some detail, but I'll say a couple of things upfront. It was only about a year ago that we were in the high 50s and low 60s in the business and these things really are temporary and as you'll hear more about it in a second, pandemic related, and we have a lot of confidence. We talked a little bit about these in Q4, that Q1 and Q2 would be light for us and then we would be very strong in H2.

So I think that we've had a lot of progress in the business on the flip side of it, you can sort of look at EBITDA growing the way it did for the quarter. In this call, Michael talked a little bit about the SG&A. So as we get -- this moving in the right direction which we have the plans for and the sales come on, we should be in good shape. But maybe Michael, you may want to talk little more detail about it.

Michael Greiner -- Senior Vice President & Chief Financial Officer

Yeah, Matt. Great question. The reality is we didn't all of a sudden just become a 53%, 54% gross margin company, right. So there is a range of things that happened over the last few quarters that have taken our gross margins, suppressed them in a temporary manner, some self-inflicted which we're fixing, some have been exogenous events that we're working through. But when you look at the first half of the year to the second half of the year, almost 500 basis points, greatest -- greater than 500 basis points of opportunity for us in the second half of the year were temporal items, transitory items around price and product mix, the revaluation for the manufacturing variances and then this NeoMed freight issue that we're dealing with that is important for our long-term growth prospects for NeoMed but also unfortunately has us incurring higher than anticipated freight cost from China where NeoMed is manufactured.

So, second half of the year, we feel really good about, especially given that we know good portions of the headwinds into the second half beyond gross margins relate directly to temporary things in the first half. I mean, you think about first quarter to second quarter, we do anticipate improvement, significant improvement. Although not what we're going to see in the second half but significant improvement primarily related to improved product mix.

Matthew Mishan -- KeyBanc Capital Markets -- Analyst

Right. Like where would you-- what would you -- what's the pathway -- is there a pathway back to 60% plus gross margins from here.

Michael Greiner -- Senior Vice President & Chief Financial Officer

Absolutely, yes. And we believe that we will see a quarter or two in the back half of the year that will show those 60% plus gross margins.

Matthew Mishan -- KeyBanc Capital Markets -- Analyst

Okay. That's fair. And then what -- and you called out unfavorable discounts and allowances in the quarter, can you elaborate a little bit on what those were?

Joseph F. Woody -- Chief Executive Officer

Just generally we're not backing off. Our business has been sort of negative 1 plus 1% overall on price. And this has more to do with timing of rebates and of discounts with some of our customers. So I don't see it as a long-term either.

Michael Greiner -- Senior Vice President & Chief Financial Officer

Yeah, that the price issue that we had in the first quarter was not a -- not related to changes in how we go to business or giving away price. It related more to timing of the products, respiratory and others in the back half of the year and then these were just catch up refunds that we had to get in place that we didn't capture as timely not knowing what some of the measurement criteria was given the different changes in revenue that we saw.

Matthew Mishan -- KeyBanc Capital Markets -- Analyst

Okay and then reimbursement in the ASCs for COOLIEF, has that moved the needle for you guys?

Michael Greiner -- Senior Vice President & Chief Financial Officer

I wouldn't say yeah, I think we talked about that having an impact in the back half of the year. We're doing a full breakdown assessment of all of the ASCs and looking how they're structured and which ones we want to go into to be efficient and profitable about the way that we go about it, but I would think that as you get into Q3 and Q4, we'll see some benefit there.

Matthew Mishan -- KeyBanc Capital Markets -- Analyst

Okay and then just lastly Game Ready. I mean, it's like the first time you measured Game Ready in a while, is that due to I think a new product or what change were like Game Ready all of a sudden is at the forefront?

Joseph F. Woody -- Chief Executive Officer

So a couple of things. One, definitely sports have come back whether our sports injuries. But we have also been very focused on a drop-ship program that the team put together, did a nice job with as well as the rental business and bringing that up to speed and making better connection with our customers and also making that efficient as part of the-- also the synergies as we finished that off last year with Game Ready. So really three things there and we're happy with that momentum.

Matthew Mishan -- KeyBanc Capital Markets -- Analyst

Okay. Thank you very much.

Joseph F. Woody -- Chief Executive Officer

Thank you.

Operator

The next question comes from Rick Wise with Stifel. Please go ahead.

Rick Wise -- Stifel -- Analyst

Alright, good morning

Joseph F. Woody -- Chief Executive Officer

Good morning.

Rick Wise -- Stifel -- Analyst

How are you doing. Just to start off, first with a sort of a little shorter term question. I've been asking every company this quarter. The same thing just to better understand recovery trends like many others, January, February were softer, as you said, Joe, it sounds like March was a nice snapback. Have those trends continued into April or accelerated or are they on that path. And so sort of a two-part question. Are they --- if that's the case, are we on path to sequentially higher second quarter sales or no second quarter is going to look a lot like the first from a sales or margin perspective? You clearly are expecting a stronger second half, but just help us getting the right sort of thought mode for the second quarter as we try to model it correctly.

Joseph F. Woody -- Chief Executive Officer

Sure, Rick. I mean we feel like we will see and are seeing some sequential improvement from Q1 to Q2. Obviously, our business is a stronger H2 performer in noting that, and kind of the way that I think about it is kind of we're seeing in Respiratory Health as expected, our Digestive Health business is pretty consistent.

And international, as we talked about earlier in the call, also starting off strong and performing well and we are seeing improvement in the ON-Q business but faster improvement in the Interventional Pain business because it's in the hospital outpatient department. So things are headed in the right direction, but clearly we do think there'll be much stronger even in H2.

Michael Greiner -- Senior Vice President & Chief Financial Officer

Remember too, just from a comparable standpoint, ON-Q and COOLIEF will both have very attractive comparables versus last year's second quarter. So those will be good numbers. Sequentially as Joe mentioned, we are starting to see some nice improvement there as well, which is good. And then also recall the the flip side is that our restore [Phonetic] business in particular our closed suction catheters had a very strong 2Q and Q3 last year. So those will be much tougher comps at the beginning of the pandemic last year.

Rick Wise -- Stifel -- Analyst

Got you. And ON-Q specifically. So just appreciating the end hospital aspect as you've emphasized, we should see better ON-Q in the second quarter because of the recovery trends you're already seeing. Is that the right way to say?

Joseph F. Woody -- Chief Executive Officer

Yeah. Yes, that's correct. And one of the ways we sort of evaluated that, I think investors can evaluate it as -- as orthopedic procedures in the hospital versus ASC come back at that level, we're somewhat aligned with that.

Rick Wise -- Stifel -- Analyst

Got you. And I want to come back to your M&A pipeline comments, Joe. From sort of two aspects, I mean it's always intriguing, when you are very clear about your robust pipeline and just is not that I'm always amazed, I'm always fascinated, what --- and I know it's hobby, I appreciate, it's very complex price, willingness to sell, timing also good things go into it, but help us understand why you haven't moved even faster? Is it something internal to Avanos right now that you waited until you just feel better about recovery or whether IT systems or people or --- was it that or is it have valuations been too high? I'm just trying to understand what might release the floodgates which could potentially be very exciting, obviously in terms of potential growth and leverage and outlook?

Joseph F. Woody -- Chief Executive Officer

Yeah, it's more of our disciplined approach and waiting for the pandemic to subside. And obviously, we had some other execution issues that we've been highly focused on and we have really told our investors that's where we would be focused. I think we've delivered that sort of, let's call it over the last six quarters. But now we're in high gear. We're talking to a couple of different potential targets. In terms of valuation, that's not going to hold back for us because we are hanging around the same kind of places that we have with private equity, with privately owned businesses in areas that we want to participate, that will enhance our business, and be accretive where we're not having to look at the kind of multiples that you see in some of the deals.

I think we're going to come forward with -- when we do come forward with deals with good value like we've been doing in the past.

Rick Wise -- Stifel -- Analyst

Got you. And just to follow up on that. So we should be cautiously hopeful, optimistic that that you could get one or more of these across the finish line this year or that too much doubtful. Thanks.

Joseph F. Woody -- Chief Executive Officer

No, that's not too much. I mean, you can never predict these, I'd love to do too but we really are pushing hard to do one for sure and we'll see where we land. We've got a good track record. So we'll see where we land at the end of the year.

Rick Wise -- Stifel -- Analyst

Sounds great. Thank you again.

Joseph F. Woody -- Chief Executive Officer

Thank you.

Operator

The next question comes from Marissa Bych with Morgan Stanley. Please go ahead.

Marissa Bych -- Morgan Stanley -- Analyst

Hi, good morning, and thanks for taking my question. Sorry to go back to gross margins, but I just want to tell you, push a little further on the transportation impact. It seems like COGS this quarter were about $8 million higher than consensus estimates. What was the relative impact of the transportation of NeoMed kind of relative to that $8 million total higher COGS, and was there anything else in the next slide COVID-19 overhead expense lingering from last year, really any other kind of one-time impacts that you would call out? Thank you very much.

Joseph F. Woody -- Chief Executive Officer

I think, Michael is going to talk about this a little bit. I just want to make a comment about the NeoMed, the positive side of this. Michael?

Michael Greiner -- Senior Vice President & Chief Financial Officer

Yeah. So about a third of that Marissa, the $8 million If you're looking at, absolute dollar related to NeoMed, another third or so related to the revaluation that we had for the manufacturing variances. And then we had a little bit of that price impact that we just talked about with Matt's question. So that was if you lay out --- and then there were some nicks and knacks. Those are the three primary chunks of that $8 million higher up from a COGS absolute value standpoint.

Joseph F. Woody -- Chief Executive Officer

And just on the Y side of it, and I think it's the right thing to do, if you could imagine the ports in California all transporting, and China, things going on the supply chain. These prices are crazy right now, but we have converted ahead of our expectations of NeoMed customers, and this will be a pay-off in the second half and in 2022. So doing that I think is the right thing to do for more sustainable growth in the business. But obviously, not happy about the price of that transportation. We may have a little bit more of it, not quite as much in Q2 but absolutely subside in the second half.

Marissa Bych -- Morgan Stanley -- Analyst

Okay, great. And my one follow-up would just be on COOLIEF. You touched on this, but, and can you give us any more detail on how the COOLIEF's growth has improved into April relative to the strong growth that you saw in March? And is that more driven by growth in new accounts or more of a reacceleration in existing accounts that you had?

Joseph F. Woody -- Chief Executive Officer

Yeah.

Marissa Bych -- Morgan Stanley -- Analyst

And thank you very much.

Joseph F. Woody -- Chief Executive Officer

Yeah. Thank you, Marissa. Yeah, it's actually accelerated from March into April. So we're seeing that continue and we did sell a number of capital consoles even last year during the pandemic. So there are new accounts coming in with our new technology, but even new customers, but as you can imagine, there's also a backlog of spine and osteoarthritis of the knee patients are coming through. So it's really two things. And then obviously we have some easy pairables, but just generally we've done well with new customers as well.

I think we're ready for the next question.

Operator

[Operator Instructions] Our next question comes from Chris Cooley with Stephens. Please go ahead. Mr. Cooley, your line is open and you may ask your question.

Chris Cooley -- Stephens Inc. -- Analyst

Thank you. Apologize I was on mute. Congratulations on a solid quarter. Just two quick ones at this point from me. First, from the preparation perspective, could you talk about your thinking about the transition of the year. Just to be clear about that commentary that really assumes predominantly related to ON-Q across these business obviously showing strength now. Just wanted to kind of clarify that. Just wanted to [Technical Issues] my follow-up question with the bigger picture, just when we think about margin targets longer term, help us think a little bit you talked about 60% gross margins earlier and that question still being in striking distance, pricing power for these businesses and realizing greater operating efficiency. Is there anything structural preclude you from stepping up the op margin restricted to the business versus kind of where you were previously? I know you're not giving guidance yet now. just thinking about things conceptually as we go in longer term, seeing that you have greater operating efficiencies specially with your new IT systems. Just want to think about gross margin and cash flow longer term as well. Thank you.

Joseph F. Woody -- Chief Executive Officer

Thanks, Chris. And I'll say a couple of things about ON-Q and then let Michael talk about some of the margin elements in the cash flow and some things that we are excited about. But generally with respect to ON-Q, we're happy with the following things. One, lighters continues to be growing at a significant rate. We're adding new customers. As a percentage wise, the business that we had managed under we're actually approaching that same level. Now, we are getting growth out of Summit and the electronic pump and starting to see that that can be beneficial to us for customers that want that solution versus the Elastomeric Pump and we're very excited about the orthopedic channel partners that we're putting in place. We're again-- a greater portion of ON-Q is used there and looking to sign up more of those relationships over time. So I think we're headed in the right direction. And I think to the extent that electives come back in the hospital faster. That will be a plus for us. And then Michael, do you want to talk about this?

Michael Greiner -- Senior Vice President & Chief Financial Officer

Yeah, just longer term on the margins. We've talked about in the fall that we've had three quarters in a row now where SG&A has been high 30%. We believe that ultimately that is where we should live longer term, and that being said, in the back half of the year, we may have some spend in selling and marketing that we think is smart for the longer-term revenue opportunities. And so we may see a Q3 or Q4, where SG&A is a little bit higher than the high-30s similar to gross margin, where we've had some of these temporal things that we've talked about, we've got 500 plus basis points of tailwinds going into the back half of the year for these temporary thing. So we do anticipate seeing a Q3 or Q4, maybe in both quarters being greater than 60%. So these pieces haven't all fit together perfectly yet, Chris, but you can see how we can get there in these various pieces as operating expenses as well as gross margins and how that lends itself to where we want to take ultimately, our EBITDA and operating margins longer term.

To your question around, could we be even better than that given some of the efficiencies that we're building into the organization. I think with M&A as well as continuing to learn over this next few quarters around where some of the key smart spend is, there is marginal opportunity to have margins probably higher than what we've talked about previously, but we'll lay that out in a more holistic view as Joe mentioned in the fall when we issue a new 3-year LRP.

Chris Cooley -- Stephens Inc. -- Analyst

Thank you very much.

Joseph F. Woody -- Chief Executive Officer

Thank you.

Operator

This concludes our question-and-answer session. I would like to turn the conference back over to Joe Woody, CEO, for any closing remarks.

Joseph F. Woody -- Chief Executive Officer

Thank you. I just want to thank everybody for your continued interest in Avanos and while we're executing well in an uncertain environment. We are committed to creating shareholder value. I'm confident the priorities that we detailed today, combined with our portfolio and the attractive markets we're in do position us for sales growth, margin expansion and positive free cash flow in 2021. So look forward to continuing to report that out throughout the year. Thank you.

Operator

[Operator Closing Remarks]

Duration: 46 minutes

Call participants:

Dave Crawford -- Vice President of Investor Relations & Treasurer

Joseph F. Woody -- Chief Executive Officer

Michael Greiner -- Senior Vice President & Chief Financial Officer

Ravi Misra -- Joh. Berenberg, Gossler & Co. KG -- Analyst

Lawrence Keusch -- Raymond James Financial -- Analyst

Matthew Mishan -- KeyBanc Capital Markets -- Analyst

Rick Wise -- Stifel -- Analyst

Marissa Bych -- Morgan Stanley -- Analyst

Chris Cooley -- Stephens Inc. -- Analyst

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