Neuronetics, Inc. (STIM) Q4 2021 Earnings Call Transcript

Neuronetics, Inc. (STIM -3.70%)
Q4 2021 Earnings Call
Mar 08, 2022, 8:30 a.m. ET

Contents:

• Prepared Remarks
• Questions and Answers
• Call Participants

Prepared Remarks:

Operator

Good day, and thank you for standing by. Welcome to the Neuronetics fourth quarter 2021 financial and operating results conference call. [Operator instructions] Please be advised that today's conference may be recorded. [Operator instructions] I would now like to hand the conference over to your host today, Mark Klausner.

Please go ahead.

Mark Klausner -- Investor Relations

Good morning, and thank you for joining us for Neuronetics' fourth quarter 2021 conference call. Joining me on today's call are Neuronetics President and Chief Executive Officer Keith Sullivan and Chief Financial Officer Steve Furlong. Before we begin, I would like to caution listeners that certain information discussed by management during this conference call will include forward-looking statements covered under the Safe Harbor provisions of the Private Securities Litigation Reform Act of 1995, including statements related to our business, strategy, financial and revenue guidance, the impact of COVID-19, and other operational issues and metrics. Actual results can differ materially from those stated or implied by these forward-looking statements due to risks and uncertainties associated with the company's business.

For a discussion of risks and uncertainties associated with Neuronetics' business, I encourage you to review the company's filings with the Securities and Exchange Commission, including the company's annual report on Form 10-K, which will be filed today. The company disclaims any obligation to update any forward-looking statements made during the course of this call, except as required by law. During the call, we'll also discuss certain information on a non-GAAP basis, including EBITDA. Management believes that non-GAAP financial information taken in conjunction with U.S.

GAAP financial measures provide useful information for both management and investors by excluding certain non-cash and other expenses that are not indicative of trends in our operating results. Management uses non-GAAP financial measures to compare our performance relative to forecast and strategic plans to benchmark our performance externally against competitors and for certain compensation decisions. Reconciliations between U.S. GAAP and non-GAAP results are presented in the tables accompanying our press release, which can be viewed on our website.

With that, it's my pleasure to turn the call over to Neuronetics President and Chief Executive Officer Keith Sullivan.

Keith Sullivan -- President and Chief Executive Officer

Thank you, Mark. Good morning, and thank you for joining us. I'll begin by providing an overview of the fourth quarter and full-year performance, followed by an operational update. Steve will then review our financial results, and I'll conclude with some thoughts on 2022 before turning to Q&A.

I'd like to begin by thanking our employees for their hard work and commitment as they have seamlessly navigated the complexities of the ongoing pandemic to allow us to successfully execute on our initiatives as we seek to bring relief to patients suffering from depression. I'm very proud of everything that we accomplished in 2021, which was capped off by a strong fourth quarter. Despite the ongoing macro headwinds that existed during the year, we successfully overhauled our commercial organization and fundamentally rebuilt our approach to educating patients and customers, driving awareness of NeuroStar, and helping patients get relief from their depression. These strategies have helped drive the momentum we generated during the fourth quarter, which was continued into 2022.

Total revenue in the fourth quarter was $15 million, in line with the top end of the revenue range provided in early January and above the guidance issued within our last quarterly earnings release. On the capital equipment side, U.S. NeuroStar advanced therapy revenue was $2.8 million, driven by solid demand for new systems as demonstrated by our sequential growth of 8% over the third quarter of 2021. U.S.

treatment session revenue was $11.2 million, a 2% increase over the fourth quarter of 2020 and a 10% increase over the third quarter of 2021 and represents the highest U.S. treatment session revenue quarter in the history of the company. The increase was a result of growth and treatment session volume across our entire customer base. Turning to an operational update.

During the fourth quarter, we announced exclusive commercial partnerships with three leading TMS providers: Zion Healing, Success TMS, and River Region Psychiatry, making Neuronetics their exclusive supplier of TMS equipment. We have seen good early traction from these partnerships and expect a more material impact on our business during 2022. Turning to an update on our commercial strategy and marketing initiatives. Since I joined the organization in the summer of 2020, we have made significant investments to overhaul and realign our commercial organization.

In January of 2021, we launched a new commercial sales force, along with a new communication strategy aimed at driving awareness and educating our customer base on the benefits of the NeuroStar advanced therapy for mental health, and ultimately to help more patients recover from their depression. In addition to bringing in new capital equipment sales force, we launched several customer-focused programs during the year, including our 5 Stars and Precision Pulse programs. Since August, we have piloted a tool designed to help our customers identify existing patients within their practices who are candidates for NeuroStar therapy and are looking for a new alternative to treatment for their depression. During the second half of the year, we work to optimize the screening process to make it as simple as possible.

We have seen encouraging results from our patient tool, and we intend to expand it into a greater percentage of our customer base during 2022. Lastly, we made strides toward executing our long-term clinical and regulatory strategy as we spoke with our customer base regarding NeuroStar. One of the most common pieces of feedback we received was a desire to simplify the motor threshold process or MT, which is at the beginning of the patient's treatment protocol. In December, we announced that we received 510(k) clearance on the MT Cap technology for NeuroStar.

The MT Cap technology makes mapping and determining a patient's motor threshold seamless and eliminates several steps previously needed during the patient's initial evaluation. When combined with the recently launched Fast MT, [Inaudible] can reduce the average motor threshold time by 40%. We have begun a launch of the technology and expect a national rollout during 2022. We are planning to launch other tools over the course of the next 12 months to continue to make the MT faster and more efficient for our clinicians.

Over the past two months, we have had significant collaborative interactions with the FDA regarding our pending 510(k) application for a new indication. We have received and responded to several sets of questions from the agency. And based upon our latest interaction, we anticipate receiving the clearance during the second quarter of this year. We also have a second pending 510(k) application with the FDA, and we would anticipate receiving questions in the next one to two months.

2021 was a transformational year for Neuronetics, during which we revamped the way we drive the commercial adoption of NeuroStar advanced therapy for mental health. While there were certainly growing pains at points during the year, we are happy with the way we closed out 2021. In addition to building positive momentum during the year, we made substantial progress on several of our strategic priorities, putting us in a strong position to drive future growth, including signing new exclusive commercial agreements and making progress toward expanding NeuroStar's indications for use. With these pieces in place, we are laser focused on the execution of our strategy in order to drive future growth in the business.

Now, I'd like to turn it over to Steve for a financial review.

Steve Furlong -- Chief Financial Officer

Thank you, Keith. Unless otherwise noted, all results discussed will be related to the fourth quarter of 2021 compared to the fourth quarter of 2020. Total revenue was $15 million, compared to prior-year revenue of $15.6 million. U.S.

NeuroStar Advanced Therapy System revenue was $2.8 million. As anticipated, we increased the number of systems shipped each quarter on a sequential basis. In the fourth quarter, we shipped 48 systems, up from 23, 36, and 40 systems during the first three quarters of the year. U.S.

treatment session revenue was $11.2 million, an increase of two 2% over prior-year revenue. Revenue per active site was approximately $12,200, compared to approximately $12,100 in the prior-year quarter. Gross margin was 76.4%, compared to 75.8% in the prior year. The increase was primarily a result of higher system average selling prices, as well as a higher mix of treatment session revenues during the fourth quarter.

Operating expenses were $18.4 million, an increase of $3.9 million compared to the prior year. The increase was primarily driven by the implementation of new marketing initiatives, personnel costs related to our sales force, and additional stock-based compensation expense compared to the prior-year quarter. During the quarter, we incurred approximately $1.7 million of non-cash stock-based compensation expense. Net loss was $7.6 million or $0.29 per share, as compared to a net loss of $3.7 million or $0.19 per share in 2020.

EBITDA was negative $6.3 million, as compared to negative $2.4 million in 2020. Moving to the balance sheet. As of December 31st, 2021, cash and cash equivalents were $94.1 million. Now turning to guidance.

For the full year 2022, we expect revenue in the range of $58 million to $62 million. For the first quarter 2022, we expect revenue in the range of $13 million to $14 million. In January, our business was impacted by omicron with trends improving during February. For the balance of the year, we expect to see year-over-year growth in each of the remaining quarters and a return to a more normal seasonal pattern with a sequential increase in revenue during the second quarter, followed by a slowdown in the third quarter before a strong fourth quarter, which is typically the largest of the year.

In 2022, we are accelerating our investment into sales and marketing, as well as research and development initiatives to support our continued long-term growth, which we are uniquely able to do because of the strength of our balance sheet and our market leadership position. We expect total operating expenses for the full year 2022 to be in the range of $86 million to $90 million. As a result of accelerated top-line growth, as we execute our commercial strategy and the planned moderation of operating expense growth in future years, we expect to be EBIT breakeven in 2024. I would now like to turn the call back over to Keith.

Keith Sullivan -- President and Chief Executive Officer

Thank you, Steve. 2021 was a critical year for Neuronetics, and we believe the strategic pieces are now in place to drive the accelerated adoption of NeuroStar. We have demonstrated the superiority of the clinical outcomes. We have a proven unparalleled ability to support our practices by helping them educate patients and raise awareness to drive long-term success.

And we have invested heavily in developing the industry's largest and most talented commercial organization. While we face challenges in late 2021 from omicron, which continued into the first quarter of this year, our physician offices remained open, which allowed us to continue training customers and deploying marketing efforts. Because of this, we believe we are well-positioned to execute through the remainder of the year. To that end, we have several key initiatives in place to help capitalize on the solid foundation built last year and support growth in 2022 and beyond.

This year, our key focus areas to drive growth are as follows: one, drive increased awareness among customers and patients; two, the continued optimization of the commercial organization; three, leveraging exclusive partnerships; and four, executing on the clinical and regulatory strategy. Beginning with driving increased awareness among customers and patients. In 2021, we hosted several successful NeuroStar summits. These summits focus on providing prospective customers an in-depth understanding of our technology and the different customer programs we offer.

As a result of the success of prior events, we will host four summits starting 2022. We recently hosted our first summit of the year in San Diego, which was completely sold out and included over 85 prospective customers making it our largest event to date. Events like these are just one of the areas we are investing in to increase awareness and better educate physicians. We are also expanding our efforts to drive awareness among patients and psychiatrists through the marketing partnerships.

Last quarter, we announced a partnership with Dr. Melissa Shepard. Dr. Shepard is a board-certified psychiatrist and psychotherapist who is an active mental health advocate.

In addition to being a key opinion leader in the industry, she is a well-known social media influencer with over 1.1 million followers. During the fourth quarter, we also partnered with Drew Robinson. Drew is a former professional baseball player who has battled with depression most of his life. At the start of COVID, his symptoms escalated and resulted in a suicide attempt.

Fortunately, he survived. And after his recovery, he is now a passionate mental health advocate and also a NeuroStar success story. He completed his course of therapy earlier this year and is now working with us to help spread awareness. We expect our partnership with Drew will provide a voice with an incredibly powerful story to amplify Neuronetics' name through earned media opportunities, video content, and paid and organic social media.

As part of our marketing expansion efforts in 2022, we recently introduced a new marketing campaign called Tap into Possibilities for Depression. This new campaign is designed to reach a broader audience, including a larger target age demographic, as well as a focus on families and caregivers of patients suffering from mental health disorders. We are continuing to leverage high-impact channels such as digital and social media to accomplish this and now are targeting incremental touchpoints like digital TV, health portals, podcasts, and partnerships with influencers. This campaign will also include improved practice support materials and a new look and feel.

Our ability to make this kind of investment into marketing differentiates Neuronetics from others in the industry who are not interested in supporting the long-term success of their customers. A new component of our educational strategy is the launch of a state-of-the-art training center that educates our practices on the 5 Stars solution, which includes operationalizing their NeuroStar practice, staff training, and patient marketing. In April, we will open NeuroStar University or NSU in Charlotte, North Carolina, and host our first training class. During the two-day program, customers will become experts in our proven methodology by focusing on how to achieve the best clinical outcomes for their patients and how to market their NeuroStar business.

We believe the benefits of this program, reinforced by our practice development team, will help ensure the success of NeuroStar within our customers' practices. Our second focus for 2022 is the continued optimization of our commercial organization. As a part of the planned expansion of our sales force, we have opted to rebrand our NPCs to practice development managers or PDMs to more closely align with our strategy of supporting the growth and development of our customers' practices by enhancing patient awareness and access to care. We now have 42 PDMs in the field.

Five of whom are dedicated to fixed-price accounts, and the remaining 37 are focused on our per-click customers. Each practice development manager will have a smaller number of accounts to allow for more focus in each office and to better support. In January, we kicked off the year with our national sales meeting in Phoenix, Arizona. The theme of the meeting was simplifying everything.

Our goal is to simplify everything from clinical training to marketing support in order to make working with Neuronetics as seamless as possible for our customers. To that end, we trained our new -- our team on the new MT Cap and other technologies in order to make the patient journey simpler. Included in the event were the recently added PDMs, who are now out in the field helping customers treat more patients. Turning to our third focus for 2022, exclusive commercial partnerships.

As noted earlier, we have seen good early traction so far with the national accounts signed during the fourth quarter and expect to see an increase in capital and disposable revenue as a direct result of these contracts. We will continue to evaluate additional exclusive partnerships with providers across the country. Our fourth and final focus is the execution of our clinical and regulatory strategy, and we continue to be encouraged by the recent interactions with the FDA regarding additional potential label extensions and new indications. Over the past 18 months, our organization made significant investments in the reorganization and reinvigoration of both the commercial and regulatory teams to drive long-term growth.

As we look ahead to 2022, we expect to see the accelerated positive impacts of these investments, as well as the variety of growth drivers we've put in place. We are incredibly excited about the position we are in to take advantage of the opportunity that lies ahead to help treat patients suffering with mental health disorders. With that, I'd like to open the line for questions.

Questions & Answers:

Operator

Thank you. [Operator instructions] And our first question comes from the line of Adam Maeder with Piper Sandler. Your line is open. Please go ahead.

Adam Maeder -- Piper Sandler -- Analyst

Great. Hi, Keith. Hi, Steve. Congrats on the Q4 progress, and thanks for taking the questions here.

Wanted to start with one on the guidance front. So top-line guidance $58 million to $62 million for 2022. Can you just maybe flesh that out for us a little bit more? Talk about how you're thinking about the mix of capital and treatment sessions. Anything contemplated from either a COVID-19 standpoint or associated challenges relating to capacity constraints or staffing, etc.

Just any additional color on kind of the key inputs there would be helpful, and then I had a follow-up. Thanks.

Steve Furlong -- Chief Financial Officer

Thanks, Adam. I mean, you mentioned some of the key variables that we did build into our guidance for 2022. On a positive note, we don't have any constraints or staffing issues that would impact revenue in 2022. You know, from a supply chain perspective, the team has done a great job getting ahead of those issues and secured all of the materials that are necessary to support the build plan this year.

And, you know, omicron, it's still, I would say, impacting business. We did have a slower January, which is typical, but we did see a nice rebound in February. The -- I think one of the most important considerations into the guidance was just not to get ahead of ourselves. You know, we have a brand new marketing program being rolled out, new branding, many new programs that were built upon some of the foundational programs that we put in place in 2021.

And we wanted to make sure to give the team some time to digest and then implement those programs. So, you know, again, what we've seen in February and early March, those trends are very positive. And, you know, going from the $55.3 million to the $62 million number, we thought that was a respectable growth rate to start the year with.

Adam Maeder -- Piper Sandler -- Analyst

OK. That's helpful, Steve. And I guess is any more flavor, you know, kind of between treatment session revenue and, you know, the capital piece and then I had a follow-up. Thanks.

Steve Furlong -- Chief Financial Officer

Yeah. I mean, we're going to see continued leverage on the treatment session revenues. You know, we're targeting in that 70 -- the low 70% range. We do anticipate a nice increase on the system side.

You know, a number of our new national providers didn't have significant purchases in 2021. You know, a lot of the agreements were signed late in the third quarter, early fourth quarter. So we are anticipating a nice bump from them. And so, you know, from a percentage basis, there may be a higher percentage in capital revenue year over year.

But, you know, the programs are focused on following the patient, building awareness, and increasing utilization in our existing accounts. So I think, you know, there'll be very significant increases in the treatment session revenue as well.

Adam Maeder -- Piper Sandler -- Analyst

Got it. That's helpful, color. Appreciate that. And then just for the follow-up, wanted to ask about the pipeline.

I think Keith, in the prepared remarks, had an update on, you know, indication expansion. It sounds like one FDA approval is expected potentially in the Q2 timeframe. The others may be a couple of quarters behind that. Just wondering if there's more color you can share there.

I think you previously talked about pursuing PTSD and bipolar. Can you remind us which one is likely to come first? And then how do we think about any potential impacts on the business? Thanks again for taking the questions.

Keith Sullivan -- President and Chief Executive Officer

Hi, Adam. This is Keith. The indication that we're expecting in the short term is OCD, and we've had good interaction with the FDA on that. You know, as I've said a couple times, we are really on their timeline, not ours.

So all indications are positive. But, you know, we're -- the ball's sort of in their court at the moment.

Adam Maeder -- Piper Sandler -- Analyst

OK. That's helpful. And any flavor for kind of the other, you know, pipeline opportunity that you're pursuing, indication opportunity that you're pursuing down the road?

Keith Sullivan -- President and Chief Executive Officer

Yeah. I'd rather not get into those at this time, but I think, you know, we have one that is projected in a closer timeframe and one that would probably come at the beginning of next year.

Adam Maeder -- Piper Sandler -- Analyst

OK. Understood. Thanks so much, Keith. Appreciate it.

Operator

Thank you. And our next question comes from the line of Margaret Kaczor with William Blair. Your line is open. Please go ahead.

Brandon Vazquez -- William Blair and Company -- Analyst

Hi. This is Brandon on for Margaret this morning. I just wanted to start kind of focus at a high level, and there's been a lot of commercial strategy. I guess I'd call them tweaks or improvements over the past couple of months, if not a couple of quarters.

So just curious, Keith, if you could talk a little bit about what are some of the -- even if they're anecdotal and early here, what are some of the proof points you're seeing out in the field that are making you comfortable that these are the right changes and that these will start to kind of deliver some growth benefits as we move through 2022?

Keith Sullivan -- President and Chief Executive Officer

Yeah. Hi, Brandon. How are you? I hope Margaret's doing well. Let's see.

There are a couple indicators for us. You know, one is our attendance of the number of people, physicians, and their staff members at the summits that we've been holding. You know, even in the middle of COVID, we were able to get 70 to 80 people to fly to various cities. And last weekend, we had 86 that went all the way to San Diego, and these were accounts from all across the country.

So I think there is absolute interest in adding NeuroStar into the practices and, you know, helping more patients with it on their treatment session front. We monitor a number of metrics. One of which is our motor threshold starts, which, as I said in the remarks, is the first test that a patient has before they start their treatment. By that point in their patient journey, they have been identified, their questions are answered, they've had a benefits investigation, and they have a prior authorization completed.

So these people are pretty committed. So if they get a motor threshold test done, there's -- you know, we're in the high 90s as a percent that will continue. And our motor thresholds have been increasing. We monitor on a weekly basis.

It's -- they've been increasing since the beginning of February. They were strong in January. But as Steve indicated, I think there was, not only with the benefits resetting for the patients and their payor programs, but I think omicron had a little bit of impact on us. But in February and the early indications in March is -- they're coming back strong.

Brandon Vazquez -- William Blair and Company -- Analyst

Goit it. Thanks. And then on the P&L, the -- in terms of the opex guide, it was a -- it's pretty healthy growth which is encouraging. There's clearly some good investments you guys can make on the commercial side.

I'm just curious if you could give us a little detail on -- you know, you talked about some of these commercial investments, but when do you expect to see some of the ROI on this? You know, it's a pretty healthy increase in opex. Is that something to expect already in '22? Or is that something as we kind of exit the year and into next year? Thanks.

Steve Furlong -- Chief Financial Officer

Yeah, Brandon. From an ROI perspective, I think you really see the benefits toward the end of 2022 and into 2023. I mean, we're essentially doubling the spend in R&D and clinical year over year. We also have healthy increases in sales related to, you know, the additional PDMs that we brought on board and also the annualization of hires that we made in 2021.

Marketing as well is up year over year. Again, new branding and a lot of new initiatives, as well as continued spend to drive awareness. And also, you know, from a stock comp perspective, with the increasing employee base there's a, I would say, a modest increase in that non-cash stock comp based expense. And so if you look at it year over year, it does look like a pretty significant increase.

But considering that, you know, product development, really, the company didn't invest in it substantially in the past three or four years. It's really time to, you know, develop that pipeline and really set ourselves up for the future growth in the next few years.

Brandon Vazquez -- William Blair and Company -- Analyst

Got it. Thank you.

Steve Furlong -- Chief Financial Officer

You're welcome.

Operator

Thank you. And our next question comes from the line of Bill Plovanic with Canaccord. Your line is open. Please go ahead.

Bill Plovanic -- Canaccord Genuity -- Analyst

Great. Thanks. Good morning. Couple of questions for you here.

First, just, you know, you're mentioning the different programs or you change some of the programs as you move into '22 versus from '21. Just give us a flavor for what are the changes you've made and why. And then just a capital question with these partnerships, we've seen more leasing kind of flow in. Is that something we should expect to continue, or will it kind of transition more back to capital sales with the exclusive partnerships?

Keith Sullivan -- President and Chief Executive Officer

I'll take the first part, and I'll give it over to Steve. How are you doing, Bill? So the change in the marketing for this year was brought about when we brought in Claire Sears. Claire is our vice president of marketing. And through the market research that we did when she joined, we decided to go broader.

We were -- in 2021, we were targeting patients with depression. And now we believe that there's an opportunity to not only target that group, but target the people that are around them, that are affected by their depression, whether that's family members or whether that's caregivers or whether it's friends. And if we can educate a broader audience about it, maybe more people will seek out help. So I think the changes in our programs, in our marketing, and our look and feel are all targeted around that.

And our market research shows that the changing to the Tap Into Possibilities for your Depression resonated with that larger audience that we're trying to get to.

Steve Furlong -- Chief Financial Officer

And, Bill, regarding the move to operating leases in 2021, those weren't really related to the new partnerships. By and large, they were in support of the rolled-out Star Boost program. I would say it was a very successful program in 2021, although we did have to make some accommodations with internally holding some of these transactions. Based on that success, we are moving away from internally financing some of those transactions, so that will diminish in 2022.

And again, it's not -- the program stands on its own merits at this point, so we really don't have to offer those types of financings any longer.

Bill Plovanic -- Canaccord Genuity -- Analyst

OK. And then just on the new debt facility you're putting in place, can you -- I think you're, you know, extending out the interest only. Are you increasing the capital available? And then what kind of impact will this have on the P&L?

Steve Furlong -- Chief Financial Officer

So so what we ended up doing with our partner Solar Capital is really reset the revenue covenants, which enabled us to extend the interest-only period on the facility through March of 2023. And what we did actually was redo some of the availability from the $50 million in total to the $35 million we have outstanding. We do not envision any near-term needs for accessing the original debt capacity and there is a cost in carrying that. So we decided just to limit it to the $35 million.

Again, Solar's great to work with, very accommodating and understanding. And so, you know, I think it was a win-win for both parties.

Bill Plovanic -- Canaccord Genuity -- Analyst

And then if I could ask one last question is just, you know, it's -- I think, Keith, you've been on board for two years now; Steve, maybe two and a half, three years, something like that. I mean, the last two couple of years have been challenging to say the least. But it -- you know, you've given guidance. You've done all these different things.

But, you know, as you've transitioned the company, how should we think about it going forward? I mean, you know, I have a perspective. It looks like you've kind of get everything in place and now it's going to be rubber meeting the road. But just love to hear kind of how you think this will play out over the next 12, 24, 36 months. Thank you.

Steve Furlong -- Chief Financial Officer

I mean, personally, I'm extremely optimistic. You know, I think the strategy that we've rolled out and modified during Keith's tenure is spot on. Extremely excited about the marketing initiatives and what Claire has been rolling out. You know, the influencers, Dr.

Shepard, and then spending time with Drew Robinson, it really does validate, you know, the mission of the company. You know, executing in the midst of a pandemic certainly wasn't easy. And again, truthfully, we're not excited about, you know, the last couple of years performance. But we do believe, you know, we're set up nicely to execute as omicron wanes and people get back to normal.

You know, you can see our investments in R&D and clinical. I mean, hiring Cory Anderson last March was great, and he's forged a very strong relationship with the FDA that the company didn't have since I joined. So, you know, again, and I know we've said this before, it's all about execution, but I sincerely believe that we have the blocks in place to execute and really turn things around this year and then be able to accelerate growth in 2023 and beyond.

Keith Sullivan -- President and Chief Executive Officer

And I'll add to that, Bill. You know, there are a couple of indicators that we're on the right track. I think, you know, having 86 people fly across the country to learn about NeuroStar and how to implement it into their practice, every one of those people know that there are opportunities other companies out there that they could buy from and yet they chose to give up three days of their personal and professional time to come out and learn about it. And the level of excitement that those events are really remarkable.

I -- as we indicated, I think we look at metrics on a weekly basis for our existing accounts, the metrics of our sales organization, and the activities that they're doing in the field. And everything points to the fact that we are getting to those patients and we are helping these practices be successful and we're helping more patients get treatment. You know, I think our focus right now is to go where the patients are, not necessarily where the physicians are. And I think we are identifying those strong opportunities, you know, for -- to get to more patients.

Bill Plovanic -- Canaccord Genuity -- Analyst

Thank you for taking my questions.

Operator

Thank you. [Operator instructions] And our final question comes from the line of Marie Thibault with BTIG. Your line is open. Please go ahead.

Marie Thibault -- BTIG -- Analyst

Hi,. Thank you for taking the questions this morning, I did want to ask one here on the investments you're making in opex, and perhaps I could get Steve to talk a little bit about the longer-term perspective. Certainly as we get into 2023 and 2024, you talked about getting to EBIT breakeven. What needs to happen in those two years to get you there given that opex will be stepping up quite a bit? We've talked about a little bit of a slowdown in that spend in the out years.

So how do you envision getting there? We -- are we talking about getting back to 20-plus percent growth? What needs to happen in those out years?

Steve Furlong -- Chief Financial Officer

Hi, Marie. Yes. It's going to be a combination of expense control and also an acceleration of top-line growth. And we went through a pretty extensive three-year plan exercise most recently presented to our board last week, and it does show a moderation of operating expenses in '23 and '24.

You know, as a reminder, we significantly scaled back the company's opex in 2020 in the midst of the pandemic and have been gradually adding back resources to support the revenues that we attained in 2021. You know, we are again investing significantly in sales and marketing, you know, the sales headcount, adding the additional practice consultants as well as other spend related to those decisions. It's a healthy year-over-year increase. R&D, again, there's been a big push in the past year or so, and we believe, you know, we're almost at steady state once we fill some of the openings and get through some of the pipeline developments that the team is working on.

Again, you know, foundationally, you know, in headquarters, we have the team in place to scale. So we don't need to add to G&A or any of the other supportive functions, you know, to get us to $80 million or $100 million. So there will be operating expense leverage over the next couple of years. And then on the top line, you know, again, when I joined, the average per-click customer was only treating about a patient and a half per day.

And, you know, through the pandemic and those pressures, that really hasn't increased. And so, you know, in our minds, for every patient -- incremental patient per day that's treated across our installed base, you know, it adds between $15 million and $18 million of incremental treatment session revenue. And with our focus being on the patient and driving awareness, you know, our goal is to get that to two and a half, three and a half, or four patients per day across the installed base. And that's really where you'll see the acceleration and that treatment session revenue.

Also, you know, from a NeuroStar system perspective, you know, this year, you know, we saw nice sequential increases in the midst of the pandemic. But, again, the contributions from some of our larger service providers and then the new partners that we signed up, you know, I think we're going to see nice increases in '22 and also in '23 and beyond. And so, you know, I think the preliminary driver to get the cash flow breakeven is going to be that top-line acceleration.

Marie Thibault -- BTIG -- Analyst

Makes sense. OK. Thank you for that, Steve. Very helpful.

And if I could ask my follow-up here on the new potential indication for OCD. Can you remind us where the market is in terms of reimbursement coverage for OCD? And do you have any sales factored into your 2022 guidance for that potential clearance? Thanks.

Steve Furlong -- Chief Financial Officer

So from a reimbursement perspective, you know, BrainsWay and MagVenture, they do have the indication and they have been able to secure some reimbursement. But it's by no means universal at this point. The market compared to MDD is very modest. And so, you know, while we do think our technology will benefit those patients suffering from OCD, we're not anticipating a large contribution in revenue this year.

You know, in fact, I would say it's not even worth mentioning. You know, we do have it included in '23 and '24, but it is really dependent upon the reimbursement and how the various companies are successful in securing that reimbursement from the providers.

Marie Thibault -- BTIG -- Analyst

All right. Thank you so much.

Steve Furlong -- Chief Financial Officer

You're welcome.

Operator

Thank you. And I'm showing no further questions, and then I would like to turn the conference back over to Keith Sullivan for any further remarks.

Keith Sullivan -- President and Chief Executive Officer

Thank you, operator, and thanks again for joining us this morning. We're incredibly excited about the future here at Neuronetics, and we look forward to updating you on the progress on our next quarterly call.

Operator

[Operator signoff]

Duration: 45 minutes

Call participants:

Mark Klausner -- Investor Relations

Keith Sullivan -- President and Chief Executive Officer

Steve Furlong -- Chief Financial Officer

Adam Maeder -- Piper Sandler -- Analyst

Brandon Vazquez -- William Blair and Company -- Analyst

Bill Plovanic -- Canaccord Genuity -- Analyst

Marie Thibault -- BTIG -- Analyst

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