Option Care Health Inc. (OPCH) Q2 2021 Earnings Call Transcript

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Option Care Health Inc. (OPCH 1.33%)
Q2 2021 Earnings Call
Aug 3, 2021, 8:30 a.m. ET

Contents:

• Prepared Remarks
• Questions and Answers
• Call Participants

Prepared Remarks:

Operator

Ladies and gentlemen, thank you for standing by, and welcome to Option Care Health Second Quarter 2021 Earnings Conference Call. [Operator Instructions]

I would now like to hand the conference over to your speaker for today, Mike Shapiro. You may begin.

Mike Shapiro -- Chief Financial Officer

Good morning, and thanks for joining us this morning. Before we begin, please note that during this call, we will make certain forward-looking statements that reflect our current views related to our future financial performance, future events and industry and market conditions. These forward-looking statements are subject to risks and uncertainties that could cause actual results to differ materially from our comments. We encourage you to review the information in the reports we file with the SEC regarding the specific risks and uncertainties. You should also review the section entitled Forward-looking Statements in this morning's press release. During the call, we will use non-GAAP financial measures when talking about the Company's performance and financial condition. You can find additional information on these non-GAAP measures in this morning's press release posted on the Investor Relations portion of our website.

With that, I'll turn the call over to John Rademacher, Chief Executive Officer.

John C. Rademacher -- President and Chief Executive Officer

Thanks, Mike, and good morning, everyone. As you can imagine, we are quite pleased with the overall progress we are making. The expanded number of patients we are serving and the financial results the team has delivered in the second quarter, and our confidence in this enterprise has never been higher. We continue to translate strong revenue expansion into leveraged earnings growth on our scalable platform. And as we sit here today, we are increasing our growth and earnings expectations for the full year based on the first half momentum. Equally important, we continue to invest in strategic initiatives to build upon our unique national platform.

As we entered 2021, we remained in the midst of the pandemic second wave, and we were also managing supply chain dynamics for certain therapy. Consequently, we guided to 6% to 7% revenue growth. Over the past few quarters, we've seen referral patterns return to pre-COVID levels, and in some instances, including several chronic therapies, we've seen referrals considerably above pre-COVID levels. The team has remained on offense, so to speak, and we focused on balanced growth across both our acute and chronic portfolios through collaborations with our payer partners and referral sources. In the second quarter, we saw strong sequential growth over the first quarter in both therapy portfolios as momentum has clearly increased. Recall, the comparative quarter for 2020 is challenging given the disruptive referral patterns with the onset of the pandemic.

Regardless, we saw high single-digit acute growth over prior year and high-teens chronic growth, with particular strength in newer therapies for multiple sclerosis and myasthenia gravis. Our top-line results affirm that our unique value proposition is resonating with manufacturers, payers and referral sources, and for the full year, we now expect to generate double-digit top line growth based on the momentum generated in the first half. Despite our strong top line results, we remain in a very dynamic environment. Our supply chain situation is clearly improving, especially with respect to immunoglobulin, which we highlighted as a risk entering into the year. Like most companies, we are facing challenging labor market and given our strategic investments in clinical expertise, we continue to manage tight labor conditions for skilled clinicians.

We have been able thus far to successfully navigate the challenging labor market to maintain our reputation of dependability with referral sources that has been the hallmark of the Option Care Health team over the challenging pandemic situation. We continue to monitor this situation closely, and we are proactively addressing the situation through talent development, technology enhancements, labor efficiencies and deepening partnerships with home health agencies. Aside from the solid growth in the second quarter, we continue to invest in future growth catalysts.

Early in Q2, we closed on the BioCure acquisition, and I'm pleased to report that the integration is already complete. This complementary tuck-in has reinforced our IG go-to-market efforts and strengthened a number of key geographic markets for us. We also recently announced the technology collaboration with AlayaCare, one of our existing trusted technology partners to co-develop market-leading patient engagement and clinical management software. As we have articulated on many occasions, we have invested tens of millions of dollars into our integrated technology suite to optimize the patient experience and maintain an efficient operating model. AlayaCare here has been in the trenches with us for quite a while, and we are excited to introduce additional tools to improve the therapy experience for our patients and their families.

Over the past six months, we've invested in an additional infusion suite capacity and are aggressively moving to open 10 to 15 additional stand-alone infusion centers by year-end. Infusion center capacity is a key growth enabling initiative to improve the patient experience and optimize our clinical workforce. To my earlier point, infusion center capacity provides additional labor efficiency and partially mitigates the challenging labor market we currently face. I'm also thrilled with the addition of Dr. Seema Kumbhat to the newly created role of Chief Medical Officer. The patient experience is at the forefront of everything we do, and Seema brings a unique perspective to my leadership team, as we continue to raise the clinical bar in this industry.

Mike will unpack the results in a few minutes, but I'm very encouraged by the top line growth and our ability to leverage our infrastructure to deliver higher levels of profitability. As we announced in the release this morning, we have significantly increased our guidance for the full year for both revenue and adjusted EBITDA based on the momentum the team established in the first half of the year. The midpoint of the guidance range implies an EBITDA margin north of 8% for the year, and we're are only getting started, and our ability to translate earnings to cash flow has been quite strong, delivering over $70 million of cash flow from operations in the quarter. We also achieved our full year leverage target of 4 times at mid-year.

Again, I couldn't be prouder of the team and how they continue to execute our strategy in light of continued market dynamics. Before I turn over to Mike, I want to spend a few minutes on the recent approval of Aduhelm for Alzheimer's. As an organization that serves patients with challenging chronic conditions every day, we are encouraged that new therapies are emerging for what is a devastating condition for patients and their families, and clinically, the profile of Aduhelm fits quite well with the alternate site setting, given an older patient population, many with complicating conditions and a preference for limited travel for therapy. Aduhelm does not adequately reimburse for home infusion at levels to support care. We continue to monitor CMS and the payers approach to coverage determination and separately work with the industry coalition to seek a legislative improvement to reimbursement for home infusion.

In the current landscape, we do not see Aduhelm, as a near-term opportunity until the Medicare reimbursement environment changes. Consequently, none of our guidance reflects any benefit from Aduhelm at this time. So overall, I am very pleased with the second quarter results, the performance by the entire team and where we are positioned heading into the second half of the year. You will recall in the first quarter call, I commented that we were quickly pivoting from integration to acceleration, and clearly, we've made that turn.

With that, I'll turn the call over to Mike, to review the results in a bit more detail. Mike?

Mike Shapiro -- Chief Financial Officer

Thanks, John, and good morning, everyone. Overall, the second quarter can be summed up in strong top-line growth that translated into margin expansion and spending leverage to deliver accelerated earnings growth and cash flow generation. Remember that similar to virtually all healthcare enterprises, the second quarter of 2020 is a typical comp, as we saw an initial spike in patient referrals followed by a stagnant period, as individuals stayed away from medical facilities.

Nonetheless, we generated 16% top line growth overall, with high single-digit growth in acute and high-teens growth in the chronic portfolio. Sequentially, we generated a little over $100 million in revenue over the first quarter, as referral volumes continue to rebound off the pandemic Lowes. Our results continue to reflect some ASP headwind for certain therapies, but clearly, the volumes more than offset.

Despite the faster-growing chronic portfolio, we drove a gross margin rate expansion in the quarter as we continue to drive network efficiencies and manage our procurement strategies within each portfolio. We don't talk much about bad debt, as it has considerably improved over the past few years, but in the quarter, we drove bad debt down to a little over 2%, which represents about 0.5 percentage point improvement over the prior year. As that improvement drops straight through, that helped offset the chronic mix headwind at the margin line. Again, the team fights for every basis point of leverage at the gross margin line, and thus far, we have been able to offset the mix impact. Spending leverage continues to improve as SG&A as a percent of revenue dropped by 130 basis points, driving an EBITDA margin of 8.5%.

This is the first quarter that we have delivered a margin north of 8%, and as John mentioned, we are just getting started. Cash pays the light bills, not EBITDA, and our ability to translate earnings into cash flow continues to accelerate. In Q2, we generated cash flow from operations of more than $73 million and increased cash balances by $48 million despite deploying more than $18 million to acquire BioCure, and we finished the second quarter with a net debt to leverage ratio of 4.0 times, which was our full year commitment. So our cash and working capital profile continues to improve and provides considerable flexibility as we open the aperture on inorganic opportunities.

And just a reminder that we maintain a favorable covey light debt structure with no maturities until 2026. As we think about the back half, we clearly expect revenue to exceed previously communicated guidance. We anticipate continued sequential improvement, albeit not at the level we saw from Q1 to Q2. With solid acute levels maintained in chronic acceleration, we see full year revenue growth of 10% to 15% based on the revised guidance issued this morning, and we are increasing profit expectations based on the solid top line and are increasing EBITDA expectations to $275 million to $285 million. Relative to our initial guidance back in March, we have increased our EBITDA midpoint by approximately 11% based on better visibility around revenue trends and our procurement strategies. That will translate into higher cash flow generation and an improved leverage profile before potential capital deployment. We remain active on the M&A front, and our guidance does not incorporate any inorganic contribution in the back half other than the BioCure acquisition.

Before we wrap our prepared remarks and open the call to Questions and Answers, I wanted to clarify a few items regarding the most recent secondary share offering by our primary shareholder in June. At the time of the merger two years ago, an entity formed by Madison Dearborn Partners and Walgreens Boots Alliance, held approximately 136 million shares, excluding escrow shares that have since been canceled or approximately 80% of the total outstanding shares. Over the past year through a series of secondary offerings, that entity, which has been and continues to be controlled by Madison Dearborn has sold approximately 68 million shares and has reduced its investment as of today to approximately 68 million shares or just under 38% of the total outstanding shares. Until the most recent secondary offering, Madison Dearborn and Walgreens allocated the proceeds from such offerings based on their pro rata interest in the entity or approximately on a 52, 48 basis, respectively. However, with the recent offering of 17.25 million shares, Madison Dearborn and Walgreens agreed in principle to allocate all of the offering proceeds to Madison Dearborn and other shareholders.

Thus, as of today, Walgreens has an indirect financial interest in approximately 21% of the total outstanding shares of Option Care Health with Madison Dearborn and affiliates indirectly holding the remaining 17%. While we wanted to clarify their respective financial position given the recent dynamics, we don't have any further comments on their investment strategy or any insight on future intentions by either of the shareholders.

So in closing, we are very encouraged by the strength of the second quarter results and have raised our expectations considerably in the second half based on the first half momentum. And with that, we will open the call to Questions and Answers, Operator?

Questions and Answers:

Operator

[Operator Instructions] Our first question comes from the line of Pito Chickering with Deutsche Bank. Your line is open.

Pito Chickering -- Deutsche Bank -- Analyst

Good morning, guys. Just a couple of ones here. On the top-line growth this quarter, obviously, extremely strong. Can you give us just some more color on sort of chronic versus acute? And then within a chronic, you mentioned, I think, a multiple sclerosis as a growth area. Just give us some more detail as to what really performed this quarter, whether sequentially versus year-over-year?

John C. Rademacher -- President and Chief Executive Officer

Good morning Pito, it's John. Yes. So first and foremost, really pleased with the balance that we saw across both the acute and chronic portfolio. I think as we've talked about before, as we expected things to start opening up within the hospital and as patients return to receiving care we saw increased flow of referrals, as we had mentioned, and really some strength in the acute area that, in some ways, had been lagging through that process. So referrals increased, as we had called out. We've done a really good job of converting those referrals to starts. And I think that some of the investments we made to increase our reach and frequency are starting to pay dividends as things open up. On the chronic side, again, good execution by the team. We continue to see strength across the portfolio there. I do believe that, as we called out, we were able to navigate the IG marketplace pretty adeptly, and so, really didn't feel any constraints from the IG side because of supply chain issues.

So all in all, very balanced. All in all, good execution by the team and deepening those relationships with the referral sources, to be their partner of choice, they're looking for opportunities to transition patients on to care with us.

Mike Shapiro -- Chief Financial Officer

Hey, Pito, it's Mike. The only thing I would add is, look, as we mentioned, obviously, the prior year comp is a little wonky given the results in the second quarter and just the state of the market back then. I think, as John said, on the chronic side, great payer collaboration, more of the same, and the value proposition is resonating. And on the acute side, again, we had an easier comp. And I think as we have said, we prided ourselves on our dependability and reliability, and what remains a very challenging market dynamic. And so relative to the first quarter and prior year, there's more trips into the batter's box. And I think based on the phenomenal team in the field and their focus, we're getting more hits every time we are walking into the batter's box.

Pito Chickering -- Deutsche Bank -- Analyst

On -- a follow-up question for you on margins. For SG&A, obviously, huge top line growth here. We got some SG&A leverage, I guess, sequentially. I guess, just trying to understand sort of how much leverage we should be modeling on the SG&A line when you have sort of these big revenue beats? Or where is that conversion ratio kind of as you think about the next door a year or 2? Can you help us understand, as revenues continue to grow at these levels or what is your fixed variable component within SG&A kind of just assuming I'd ask you the primary margin driver going forward in the next couple of years?

John C. Rademacher -- President and Chief Executive Officer

Yes. The spending leverage is really parcel to our overall strategy, where, going forward, based on the infrastructure that we have established over the last several years. And we have estimated that within our SG&A line, it's roughly 75% to 80% fixed. There's obviously some natural inflation, and there are some variable components, but that gives us the confidence that with this -- with the top line growth outlook that we have, we are highly confident that spending will grow at a pace meaningfully below the top line. That gives us the confidence, obviously, in margin expansion. We are never going to give up on driving spending leverage. And I think, going forward, we have even more confidence that we'll continue to be able to drive that.

Again, also in the disclosure this morning, our integration costs, which are included in that line are really starting to decelerate as well. And as we look going forward, again, I don't think we have a spending as a percent of revenue leverage, we just have a very high degree of confidence that it will continue to drop. Maybe not at the pace that we have realized over the last year because, again, remember in the second quarter of 2020, we were still in the process of harvesting SG&A synergies. But nonetheless, like every other organization, we have learned a lot during the pandemic about how much more efficiently we can operate, and we'll continue to look for those cost outs.

Pito Chickering -- Deutsche Bank -- Analyst

And then a quick follow-up. I understand that you guys are not guiding to any impact this year for Alzheimer's, but just curious sort of two questions. Number one, on the commercial customers, those should be able to sort of fall within home infusion, although they are a much smaller customer base relative to Alzheimer's. But is Alzheimer's -- do those gross margins track generally in line with the chronic business? And just any color on what you are seeing on the commercial side of business on managed care or just a position pushback?

John C. Rademacher -- President and Chief Executive Officer

Yes. Look, I think it's too soon to tell on some of that stuff, Pito. As I said in my prepared remarks, I mean, we are trying to be very thoughtful in the way that we look at this. There are still a lot of questions around coverage determination and which payers are going to allow this from authorization standpoint. So at this point in time, without knowing kind of what payers are in and how they're actually going to provide coverage determination, we really don't have an answer to that question, which is why we were conservative in our approach of -- it's not really in our guidance. And in the near term, we don't expect a significant amount of value.

But I will say, as I said in my opening comments, look, we do think that we have a really great platform in order to support these types of products, and it's a matter of making certain that we are working both in Washington as well as with our payer community to let them understand the value that we can bring to this patient population.

Pito Chickering -- Deutsche Bank -- Analyst

Great. Thanks a lot guys, and excellent quarter.

John C. Rademacher -- President and Chief Executive Officer

Thank you.

Operator

Our next question comes from the line of Matt Larew William Blair. Your line is open.

Matt Larew -- William Blair -- Analyst

Hi, good morning. Congratulations on the quarter. Just wanted to follow-up on a comment you made. I think you mentioned there were several chronic therapies that were trending well above pre-COVID. So could you maybe give us a sense for where particularly you are seeing strength? And is that from payer site of care redirection efforts? Is that new therapies you're involved in? Just any more color there would be interesting.

John C. Rademacher -- President and Chief Executive Officer

Yes. Matt, it's John. So specifically to your question. So a couple of areas. In chronic inflammatory disease, we have seen that move ahead of where we were from a historical basis. A lot of that is in payer collaboration, in working around site of care initiatives and helping support patients' choice as they are making decisions around where to receive care. Sometimes out-of-hospital outpatient departments and physician practices onto service with us. So we continue to work closely across the payer community to identify those opportunities and find ways to deepen our partnership in supporting their goals of providing high-quality care at an appropriate cost. So that's been part of our overall strategy, and it's -- the execution was strong in the second quarter.

Matt Larew -- William Blair -- Analyst

That sounds sustainable to me. The second one, again, interesting comments, John and Mike, you both made today, we are just getting started in terms of the EBITDA margin, building off levels from today. And I think just a couple of years ago, the idea was getting to this sort of 8%, 9% level over some time. So I think this is as bullish as I have heard you on the long-term margin picture. So I guess maybe just if you could expand on the -- we're just getting started comments and what in particular you have been encouraged by there?

Mike Shapiro -- Chief Financial Officer

Sure, Matt. It's Mike. Look, when we put these organizations together, we were making a lot of expectations around the margin expansion. Those were comments made in the locker room, so to speak. And now that we have been out on the paint for a number of quarters and have been able to truly demonstrate how scalable this platform is, it just gives us a higher level of confidence. In the middle of the integration, we got a couple of curveballs with the pandemic, and I think we just continue to learn around how much bricks-and-mortar we need, how virtually we can operate this business. And I think it continues to add to the number of areas where we think we can leverage technology and infrastructure.

We announced the collaboration with AlayaCare, which has been just a phenomenal technology partner of ours, and we see additional areas where we can, A, improve the patient experience at the same time that we can provide that value to payers and patients, and at the same time, do it in a more efficient manner. And so look, the kind of reality as we go forward, we continue to believe that the chronic portfolio will grow faster than the acute. Again, we got -- we have received some benefits and been able to offset that mix shift with bad debt and procurement strategies.

But regardless of what we view, as the reality of portfolio mix headwinds, we are highly confident that we will be able to grow the spending components of this business and the capital efficiency of this business considerably below the top-line. And so I don't think we'll see the EBITDA expansion of the big steps that we've seen over the last two years, as we are almost at the two-year anniversary of the merger. But nonetheless, I think we have a high degree of confidence we'll continue to chip away the higher and higher EBITDA margin. And I wouldn't put an upward limit on what that could be.

Matt Larew -- William Blair -- Analyst

Okay, that's great. Thanks.

John C. Rademacher -- President and Chief Executive Officer

Thanks, Matt.

Operator

Our next question comes from the line of David McDonald with Truist. Your line is open.

David MacDonald -- Truist -- Analyst

Thank you, good mornig. Guys, just a couple of questions. First, on home health. We have seen some interesting announcements out of some of the bigger home health guys about treating a more acute patient. I mean, when you look at the services that they're bringing, home infusion is really a whole across the board. So can you just talk about the opportunity to work more collaboratively with the major home health players? You mentioned a little bit during the prepared remarks around staffing, etc. But if you could just spend a minute on that, that would be helpful.

John C. Rademacher -- President and Chief Executive Officer

Hey, Dave. Good morning. So look, we continue to look for those opportunities to deepen the relationships. I think as you will recall, we had announced earlier or late last year and then again earlier this year around some of the work we are doing with the Amedisys on the monoclonal antibodies. We do think there is opportunities for us to be a partner in that process, both in looking at opportunities to leverage clinical resources as we did with the Amedisys team as well as support their patient population. So we're pleased at the position that we are in. We think there are opportunities for some additional deepening of partnerships and creation of new ones there. And we're well positioned in order to participate in that activity, as we move forward.

David MacDonald -- Truist -- Analyst

Secondly, you talked about ten to fifteen new infusion centers by year-end. Can you give us a sense either a percentage of revenue a percentage of nursing hours or whatever is you can the best metric, that are currently running through these centers? And then how much you think you can potentially push that just given the pretty significant leverage in -- around labor within those centers?

John C. Rademacher -- President and Chief Executive Officer

Yes, Dave. We've -- we continue to monitor and track. And I think as we have talked about before, we look at the percentage of nursing visits that we conduct in those facilities, as opposed to in the home. We have been running in the high-teens, and we have been really focusing on that.

Through the second quarter, we were at 20% of our nursing visits were being done in one of our infusion suites. Our expectations as we move forward is we can be pushing that both by the expansion that we talked about of opening more centers and having more convenient facilities available for the patient population as well as the growth that we are seeing in the patient census, especially on the chronic side. I think that we are looking to push north of that. Whether we can get to 23% to 25%, I think those are realistic, and that's kind of the goals that we are pushing the organization on that. There is a level of patient satisfaction and convenience that we are factoring into, not only the efficiencies that we can gain out of that, just the retention and satisfaction of the patient population, given the facilities and the features and benefits that we build in there. So we have talked historically around -- look, we had a lot of work to do on integration and a lot of work to do to rationalize some of the redundant infrastructure that we had there. So as we move past that integration effort and now really start focusing around these growth levers, we expect that this will be a bigger part of our go-to-market strategy and a bigger part of our point-of-care service model as we are looking at the opportunity ahead. And we're building that into our capex plans as we move forward. So it's not a deviation from kind of where -- what you have seen historically as we're pretty efficient in being able to stand these up in a capital-light way.

David MacDonald -- Truist -- Analyst

Okay. And then just last question for me. If I look at net debt to the midpoint of '21 EBITDA guidance, to actually south of 4 times. When you think about kind of the long-term outlook here, what range would you like to run the business in, in terms of leverage? And then on a go-forward basis, is it fair to assume further deleveraging will be more growing the denominator as opposing to shrinking the numerator?

John C. Rademacher -- President and Chief Executive Officer

Thanks, Dave. I was waiting for the leverage question. So I owe you one. Look, we are thrilled with the capital efficiency and the cash flow generation of the business. I mean, we mentioned we want to be at or below 4 times net levered by the end of the year. We are there at mid-year, and that's in a quarter where we deployed $18.5 million for M&A. And so that's another area where we get really excited because we -- with cash interest dropping and with capex relatively static, we see the incremental earnings to incremental cash flow, quite significant. I think we expect to operate this business below 4 times. How far below it's going to -- that will be dictated partially by what are the strategic opportunities that lie ahead of us. And I would tell you that the M&A activity is robust. I think it's more likely than not that we will have some additional news to share before the end of the year. And I think that's an exciting aspect and a serious responsibility that we take in terms of how do we best deploy capital to create value for the shareholders. And I think given where we are at mid-year and given the fact that we are we will continue to drift south, just based on the earnings and cash flow trajectory access to capital will be substantial. And so more to come on that front.

David MacDonald -- Truist -- Analyst

Okay, thanks. Congratulations.

John C. Rademacher -- President and Chief Executive Officer

Thanks, Dave.

Mike Shapiro -- Chief Financial Officer

Thanks, Dave.

Operator

Our next question comes from the line of Jamie Perse with Goldman Sachs. Your line is open.

Jamie Perse -- Goldman Sachs -- Analyst

Hood Morning, John and Mike. I wanted to just touch on the long-term growth algorithm and levels that how you guys are all thinking about that. Just given the step-up in growth this quarter, the growth investments you talked about, the new infusion suites. Is it time to kind of level set us on where you think this business can grow long-term?

John C. Rademacher -- President and Chief Executive Officer

Yes. Jamie, look, obviously, we're not in a position to provide longer-term guidance. But the way we have characterized it as we see this industry in a mid- to high single-digit top-line. I think we have tried to establish a reputation of laying out guidance that we have an extremely high degree of confidence that we will deliver. We also believe over the last couple of years, we have demonstrated we think we can grow faster than the market. Just based on the unique aspect of this model, and we have said that we see that in -- as a base case before inorganic capital deployment of somewhere in the the low to mid-teens. Look, this year, we are thrilled with the momentum in the business that we have built.

Again, one note of caution just around relative to the comp of 2020, it gets a little atypical, I guess, is the term I would like to use. And so look, as we go forward, I think we have a very high degree of confidence in that base case. And as we get closer to 2022, we will revisit that. But for now, I still think that longer-term is still a logical zip code to focus on.

Jamie Perse -- Goldman Sachs -- Analyst

Okay, fair enough. I wanted to come back to the Medicare reimbursement and the issues there. I know that's a barrier to increase confidence on the Aduhelm side. I'm wondering if that were to improve what that would mean to the base business, for getting to Alzheimer's for the moment. How could that change the number of therapies that are addressed in these alternate sites and your outlook for the business?

John C. Rademacher -- President and Chief Executive Officer

Yes, Jamie. Look, as we've talked about before, the current way that Medicare reimbursed, it is especially in the home, it's just inadequate for the care that's provided. We are working on multiple approaches to that, both with the industry and independently through the process of getting a better reimbursement scheme that reflects not only the care plan and oversight as well as the nursing interventions that we provide, not just the drug and the drug reimbursement for their process. Look, I think on the near term, our focus is getting the calendar date fix around getting up per DM for when a patient is truly under our care, and we are managing them through that process. And that's been the focus. I think more broadly, we will continue to look for expansion, opportunities to expand access to the Medicare population, but this is going to take time, and it's pretty complex, given all of the different priorities in Washington these days.

Jamie Perse -- Goldman Sachs -- Analyst

Congrats on the quarter.

John C. Rademacher -- President and Chief Executive Officer

Thanks, Jamie.

Operator

Our next question comes from the line of Lisa Gill with J.P. Morgan. Your line is open.

Mike Minchak -- J.P. Morgan -- Analyst

It's actually Mike Minchak on for Lisa this morning. Just a couple of questions. So first, with respect to gross margins, clearly, a very strong quarter there with nice year-over-year growth. I was just wondering if you could comment at all on sort of the trends you saw within both segments of the business. Was this -- was the growth there sort of more mix-driven? Or given the pickup of growth in the acute therapies, are you seeing favorable margin trends within both categories? And if so, maybe what are the key drivers there?

Mike Shapiro -- Chief Financial Officer

Mike, it's Shapiro. I will start. So look, I think a couple of key dynamics within gross margin. First and foremost, we continue to aggressively drive down bad debt. We -- any amount of bad debt is unacceptable, and we have driven it down a couple of full percentage points over the last year. And so as we have seen bad debt drift down toward 2%, that's an immediate gross margin benefit. Aside from that, within each of the therapy categories, we have been aggressively working on our procurement strategies, and we have got a procurement team that's second to none. And we also continue to work with our -- with the manufacturers and suppliers.

Again, we benefit from having direct relationships with most of our suppliers. And as we collaborate with them on market expansion and promoting the therapies that can result in better margins within each of those categories. So I would say, A, we still saw some ASP headwind. We still saw some mix headwind from chronic growing a little faster than acute. Again, acute did benefit from an easy comp in terms of the year-over-year. But I think the way I would characterize it as probably your latter assertion that we saw good margin traction within each of the individual portfolios.

Operator

Our next question comes from the line of Kevin Fischbeck with Bank of America. Your line is open.

Joanna Gajuk -- Bank of America -- Analyst

Good morning. Actually, this is Joanna Gajuk filling for Kevin today. I want to follow-up on a couple of these things you were discussing already for on the infusion suites that you expect to add, I guess, 10% to 15%. It sounds like in the second half of this year. So for the kind of reference point, can you talk about how many of the suites did you add this year or over the last 12 months or maybe before the pandemic. Kind of get a sense of acceleration seems in those suites being added. And I guess to that, as you mentioned that it's a very cost-efficient way of growing. So can you give us a ballpark, I guess, of capex expectations for the year?

Mike Shapiro -- Chief Financial Officer

Sure. It's Mike. So today, we have a little north of 120 infusion suites, almost 400 shares post the coast. And again, a lot of these are stand alone. A lot of these are incorporated into our care management centers and pharmacies. And this, as John mentioned, today, roughly 20% of our nursing events occur in one of our suites.

Again, this is -- we view this as both a clinical labor efficiency strategy as well as a growth support platform as these suites are quite amenable to many of the chronic conditions and patient cohorts that we support. And so look, as we think about -- we have added some in the first half. We have an aggressive expansion plan in the back half, these are relatively, these are relatively efficient investments. And I would say that as we've characterized our capexs in the $25 million to $30 million range that has been and will continue to be absorbed and funded through what we view is a very efficient capital investment amount on annual basis. And we don't see that $25 million to $30 million really growing. We can accommodate quite a few suite expansions in addition to our other technology and infrastructure projects within that estimate.

Joanna Gajuk -- Bank of America -- Analyst

Growing faster than the market, so we are trying to assess what is driving that? I mean, it sounds like it's sustainable. But just any color there, whether adding these suites the last couple off quarters maybe it's another reason to think those market share gains are sustainable?

John C. Rademacher -- President and Chief Executive Officer

Yes. It's John. I guess I would respond to that in two ways. Certainly, the infusion suites and adding the additional shares that we did, certainly give broader access, and we will capitalize on that. But the growth -- a lot of that was driven by, again, the deepening partnerships that we have with the payer community, the deepening partnerships we have with the referral sources and the focus of our commercial team to make certain that from a reach and frequency that they are getting out into the market and that they are capitalizing on the platform that we have. So I think it's just one component of what is a comprehensive go-to-market strategy. And our expectations are that given the investments we have made into the team, given the training that we have provided them, that we are going to be well positioned to continue to capture our fair share of demand in the marketplace and look for those opportunities to continue down the growth momentum.

Joanna Gajuk -- Bank of America -- Analyst

And to follow-up on something you said also on this topic of gaining market share. Can you talk about your relationships with your payers? Or is there a clear drive for these payers to shrink their networks? And I guess, are you a beneficiary of that dynamic?

Mike Shapiro -- Chief Financial Officer

Yes. Look, they will give you their strategy. From our perspective, look, if we are offering high-quality care at an appropriate cost in a setting in which patients want to receive the care, we think we are really well positioned on that. The national network that we have gives them the confidence that patients or their members regardless of their location will be well served and have superior clinical outcomes-based on the capability set that we have. And so look, we think we are on the right side of narrowing of networks because we should be a preferred partner for them there. And that -- our focus is around patient satisfaction and high-quality outcomes. And if we do that, we expect that we will be on the right side of any of those conversations.

Joanna Gajuk -- Bank of America -- Analyst

Yes, definitely. Because I guess there is not really a unified quality scoring system for home infusion, but I guess it's really more about the payer relationships than I guess what you deliver to them and I guess, how this relationship progresses. So I understand it. And thank you for answering the questions.

Operator

Our next question comes from the line of Mike Petusky with Berington Research. Your line is open.

Mike Petusky -- Barrington Research -- Analyst

A couple of questions. Mike, I guess, on the bad debt expense improvement, was that driven by maybe some of the old BioScrip stuff being cleared out or gone through or the things that you guys have done. And then, I guess, I think I had always thought that maybe 2% was about as good as it could get there. And I am just curious if you think there's meaningful room there below 2%?

Mike Shapiro -- Chief Financial Officer

Look I'll arrange a call with our revenue cycle team who will assure you that 2% is way too high. All kidding aside, Mike, Look this is what we've focused on for the last five years. Revenue doesn't pay the light-bills, converting into cash and getting cash in the bank. And so, through our technology we have dramatically improved our collectability both on the Option Care side as well as what I would call the legacy BioScrip side. And so I would say it's more around when we are providing the services. We're making sure that we are presenting clean claims and following up with payers. The amazing thing is, if you present an accurate timely claim to a payer, they pay you very timely.

And so that's as complex as it gets, and we have just become relentlessly focused on doing so. And if you look since the -- our accounts receivable came down dramatically on a combined basis and there's some modest growth that nowhere as close as revenue, and so, our DSO continues to improve. And I would say 2% might have been the theoretical low. I will tell you that we have got a team that is just getting started on that front. And I would expect that we will dip below 2%. How far? What really matters is just getting that cash in the bank.

Mike Petusky -- Barrington Research -- Analyst

Okay. Terrific. And then, John, I guess you guys, along with a lot of other healthcare companies have expressed that they have learned things about their businesses during COVID in 2020 and into early '21. I am just curious, are there things that you can sort of call out that if this delta variant or another variant becomes a thing for at least a period of time that you guys learned last year or earlier this year that you feel will position you well, as you deal with any challenges related to a variant heating up?

John C. Rademacher -- President and Chief Executive Officer

Yes. So a couple of things that we have talked about previously. Some of the investment in the technology stack allows us to be efficient in discharges on a virtual basis, on virtual thesis, on the ability for us to utilize that tool to improve patients' engagement and support. So we are going to continue to leverage that where appropriate. Our team has become very adept at being able to capture the demand in the marketplace even though for a while, we weren't allowed into the facilities or we had restricted access. And so we are going to continue to execute around those paths. I think Mike had called out. Look, from an operating standpoint, we have figured out how to be very effective with remote workforce and leveraging the technology to collaborate in ways that, honestly, we just weren't doing in advance of the pandemic, and we are going to continue those as we move forward because we expect that we will continue to get the efficiency and the effectiveness of those collaboration tools as we look ahead.

Mike Petusky -- Barrington Research -- Analyst

Can I just ask? According to an article, I think I read this morning, it looks like the delta variant has sort of rip in through a couple of key states or bigger states. Have you guys noticed any meaningful dip in patient referrals or anything else in the states that appear to be hit the hardest with this variant?

John C. Rademacher -- President and Chief Executive Officer

Yes. Look, we certainly feel impact as hospitals reset if they move toward reducing or eliminating elective surgeries or they move toward being more responsive to the pandemic in their marketplace, we feel the impact of that. We also feel the impact when patients aren't going to specialists for diagnosis or for care. And so that's -- we kind of monitor on a market-by-market basis. But yes, I mean, we feel the impacts of those. But right now, it's been a pretty short duration for the variant, and we are trying to monitor and manage that very closely.

Mike Petusky -- Barrington Research -- Analyst

Thanks, guys.

John C. Rademacher -- President and Chief Executive Officer

Thanks, Mike.

Operator

Our next question comes from the line of Richard Close with Canaccord. Your line is open.

Richard Close -- Canaccord -- Analyst

Great, thanks. Congratulations on a great quarter. A lot of questions been asked here. But first of all, Mike, I would ask, you made some comments with respect to your conservatism in the past, obviously, because in the merger, first and foremost and then obviously -- and then COVID last year. Just to be clear, your sort of conservative stands hasn't necessarily changed despite your updated guidance correct?

Mike Shapiro -- Chief Financial Officer

I think, that's fair.

Richard Close -- Canaccord -- Analyst

And then maybe just to dive in on the technology side a little bit, you talked about technology with respect to the bad debt, and then on this new collaboration for engagement. I'm just curious, on the $10 million you spent previously, do you think you have realized all the benefits from that technology as of now? And then looking forward on this collaboration, where do you see the benefits coming from the technology and maybe how quickly?

John C. Rademacher -- President and Chief Executive Officer

Yes. So first and foremost, we are filled in a process, we will fully deploy the technology here in August across all of our platforms. So there is still some opportunity that we see from interoperability and kind of tightening some of the process and efficiencies that we can receive out of that. We are really excited about the opportunity to have that patients' interface and drive a better patient experience and engagement through the collaboration with AlayaCare and the co-development there.

So look, we still see some additional opportunities to drive efficiencies and effectiveness. And in many instances, a better engagement in outcomes for the patient population.

Mike Shapiro -- Chief Financial Officer

Yes. I think from a return perspective, Rich, I think we absolutely have. As we've talked about throughout the merger and integration process. We started years ago with very scalable platforms using market-leading platforms, then we've retooled and replaced a lot of clean rooms and pharmacy infrastructure. And I think pre-merger, the mid -- the EBITDA margins were in the mid single-digit range, and we are now -- we're just printed an eight. And I would say that from the cash and from the earnings ROI, I think we have absolutely generated the returns or greater than we expected. And I think those platforms continue to be highly scalable going forward.

Richard Close -- Canaccord -- Analyst

And then, John, I just wanted to touch on the labor market. You did mention that quite a bit in your prepared remarks. Is that the biggest headwind for you guys, as you look forward just managing the labor component? Just any thoughts there is helpful.

Mike Shapiro -- Chief Financial Officer

Yes. I mean, look, it certainly is a headwind. You don't pick up many newspapers that don't highlight some of the constraints. It is market-by-market driven. Certainly, some of the clinical resources, nursing being one of those areas that we are watching closely. We like our model in the sense of we have full time, part-time per DM and then the strength of some of our agency relationships that allows us to flex through that process. But yes, I mean, that is an area that we are keeping our eye on. I think the other thing that we are keeping our eye on as we have just talked about was the Delta Variant and how that's going to have impact in the second half of the year.

Richard Close -- Canaccord -- Analyst

Okay. Great. Congratulations

Mike Shapiro -- Chief Financial Officer

Thank you, Rich

John C. Rademacher -- President and Chief Executive Officer

Thanks, Rich.

Operator

Our next question comes from the line of Frank Takkinen with Lake Street Capital Markets. Your line is open.

Frank Takkinen -- Lake Street Capital Markets -- Analyst

Thanks for taking my questions, and congrats on the quarter. A lot's been covered, I'll keep it to one, relatively simple one. Mike, can you just remind us interest expense thoughts, as well as any potential or likelihood of a refinance. And I think there's a rate lock expiration coming up. So just maybe give us an overall thought process around interest expense, as we think about the back half of this year and into 2022?

John C. Rademacher -- President and Chief Executive Officer

Sure, Frank. So look, when we started this journey, we were burning about $110 million in cash interest. We are right now in the second quarter at an annual rate in the low-60s that still includes as you always keep me honest it includes a rate swap that swaps out our rate to 2% fixed. That expires near the end of the third quarter. And at that time, going into the fourth quarter, we should take another meaningful step down to somewhere, depending on where LIBOR and rates are, somewhere in the low to mid-50s, which represents a 50% cut in our cash interest from a couple of years ago. So a very good decline. Again, goes back to our comments around converting incremental earnings to cash flow. regarding a refinancing, look, as I mentioned in my prepared remarks we've got a great cap structure that's probably light, we have no maturities for five years, and it's all at L-plus 375, we will continue to look opportunistically at our cap structure. And if there's opportunities to further improve it, you can bet we will absolutely capitalize on those opportunities.

Frank Takkinen -- Lake Street Capital Markets -- Analyst

Perfect. And congrats again on the quarter

John C. Rademacher -- President and Chief Executive Officer

Thanks, Frank.

Mike Shapiro -- Chief Financial Officer

Thanks, Frank.

Operator

I am shown no further questions in the queue.

I would now like to turn the call back over to John for closing remarks.

John C. Rademacher -- President and Chief Executive Officer

Great. Thank you. In closing, look, I am very pleased with the performance of the team and the strength of our first half results. Our focus remains on providing extraordinary care for the patients that we serve and capitalizing on the momentum we are gaining even in this dynamic environment. Thank you for joining us this morning, and please stay safe.

Operator

[Operator Closing Remarks]

Duration: 57 minutes

Call participants:

Mike Shapiro -- Chief Financial Officer

John C. Rademacher -- President and Chief Executive Officer

Pito Chickering -- Deutsche Bank -- Analyst

Matt Larew -- William Blair -- Analyst

David MacDonald -- Truist -- Analyst

Jamie Perse -- Goldman Sachs -- Analyst

Mike Minchak -- J.P. Morgan -- Analyst

Joanna Gajuk -- Bank of America -- Analyst

Mike Petusky -- Barrington Research -- Analyst

Richard Close -- Canaccord -- Analyst

Frank Takkinen -- Lake Street Capital Markets -- Analyst

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