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BioTelemetry Inc (BEAT) Q1 2020 Earnings Call Transcript

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BioTelemetry Inc (NASDAQ: BEAT)
Q1 2020 Earnings Call
May 6, 2020, 5:00 p.m. ET

Contents:

  • Prepared Remarks
  • Questions and Answers
  • Call Participants

Prepared Remarks:

Operator

Thank you for joining us for the Biotelemetry First Quarter 2020 Earnings Conference Call. Any statements during the conference call and question-and-answer period to follow may relate to future events and expectations and, as such, constitute forward-looking statements within the meaning of the Private Securities and Litigation Act of 1995. Such statements involve known and unknown risks, uncertainties and other factors which may cause the actual results, performance or achievements of the company in the future to be materially different from the statements that the company's executives may make today.

These risks are described in detail in our public filings with the Securities and Exchange Commission, including our latest periodic report on Form 10-K or 10-Q. We assume no duty to update these statements. During this call, we will present GAAP and non-GAAP financial measures. A reconciliation of GAAP to non-GAAP measures is included in today's earnings press release, which is distributed and available to the public through the Investor Information section of the Biotelemetry website at gobio.com.

[Operator Instructions]

It is now my pleasure to turn the floor over to your host, Mr. Joseph Capper, President and CEO of BioTelemetry. Sir, you may begin.

Joseph H. Capper -- President and Chief Executive Officer

Thank you, operator, and good afternoon, everyone. I'm Joe Capper, President and CEO of BioTelemetry. With me for today's call is Heather Getz, our Chief Financial Officer. Well, the world certainly has changed quite a bit since our last call just a few months ago. First, let me say that I hope and pray that you and your families are staying safe and healthy. I usually wait until the close of these calls to thank the BioTelemetry family for the outstanding support they provide to our many patients, doctors, pharmaceutical and commercial partners that depend on our services.

Since there is nothing else I will say on this call that will be nearly as important, I need to say it now. Team BioTelemetry, you are amazing. It is in times of great duress that the real character of an individual comes out. And because of the way you've reacted to the challenges of COVID-19, I can say without a doubt that our company is filled with people of extraordinary character. That intangible quality certainly helps explain how we have become the best in the business. It is truly impressive how quickly you adapted to the challenges of the day. I want to thank you from the bottom of my heart. The pride you take in the important work you do does not go unnoticed. I have never been prouder to lead our exceptional company.

In an effort to be responsive to what's top of mind for the investment community, we will start with comments about our first quarter performance because it's important that you understand just how great the company was performing prior to the outbreak. We will then share details that will hopefully help answer the question investors and analysts are trying to figure out these days, what is the near- and longer-term outlook for the company based on what we know today. To that end, we will update you on our business initiatives; the current state of the company, including steps we have taken to fortify our business during the downturn; and our expectations as we move forward. Heather will then provide detail on our Q1 financial results, and as always, we will open up the call for questions after our prepared remarks.

All in all, the business performed exceptionally well during the quarter. The revenue guidance we gave for Q1 was $113 million to $116 million. Through the first two weeks of March, our internal forecast had us tracking to finish between $117 million and $118 million of revenue, 13% over prior year quarter and above the high end of our guidance. All parts of the business were performing above expectations. However, the economic slowdown swiftly took hold just prior to mid-March as numerous states began shutting down businesses and instituting stay-at-home orders. Various healthcare institutions started to restrict outpatient services, and in-office visits plummeted as doctors quickly attempted to convert to telehealth models, which was not a very smooth transition. In our market, cardiology outpatient work was also dramatically reduced. IQVIA office visit data showed cardiology visits down as much as 60% in parts of the country.

Our monitoring business experienced a sharp decline as well over the last 2.5 weeks of March. In spite of the drop off, we still grew the business 9% annually, posting record quarterly revenue of $113 million. This was within the range of our guidance and represented our 31st consecutive quarter of revenue growth. We estimate that the slowdown cost us between $4 million and $5 million of revenue in the quarter, which would have put us well above expectations. During the quarter, we also recorded $29.5 million in adjusted EBITDA and built more cash on the balance sheet. Prior to the slowdown, our Healthcare Services division was off to an excellent start to 2020 with MCOT growth trending toward double digits and extended wear Holter at close to triple-digit growth.

This is the division, however, that was has been most impacted by the crisis as remote cardiac monitoring volume aligns closely with physician office visits. Conversely, the Geneva business, research and other segments have performed much better than expected, a trend that continues into Q2. New account activations for the Geneva service, a business which extended our remote monitoring capabilities into the implanted cardiac device management space, continued to perform better than originally anticipated, driving a 45% sequential revenue growth rate. As mentioned on our last call, the entire Healthcare services sales team has been trained on the Geneva solution and is now carrying quota for the sale of this service.

In addition to all of our account executives and regional sales directors now having responsibility for Geneva sales, we have been in the process of adding 12 sales professionals across the country completely focused on selling this solution, most of which are now in place. Our research business posted unexpected growth of 7% in the quarter and again experienced a pickup in bookings momentum, a positive leading indicator for this important segment. The coronavirus may also create additional demand for both cardiac safety and lung imaging services with many pharma sponsors planning randomized clinical trials for treatments and vaccines. And in our emerging population health business, we made good progress on our growth initiatives. While still relatively small in scale, our pop health program is perfectly suited for the current environment.

We expect these areas of the business to be minimally impacted by the economic slowdown. This is a really important point as it relates to the execution of our strategy. On each of these calls, I remind you of the main elements of our strategic plan, which is centered on innovation and diversification. Specifically, our focus has been on continuing to build our leadership position in the remote cardiac monitoring market through vertical and horizontal expansion, adding technology and additional service capabilities to our research business and creating new opportunities for growth in the faster volume field of digital population health. Now more than ever, it is evident that the actions we have been taking have made BioTelemetry a stronger organization.

As we entered 2020, we expected our revenue to approach $500 million, 20% of that coming from Geneva, research and pop health, areas of the company we have built as a direct result of executing our strategic plan. This speaks volumes about the importance of having a well-thought-out and multifaceted growth strategy. Moving on, let's now turn to the current state of the business. I am pleased to report BioTelemetry is extremely well positioned to weather this challenge for a host of reasons. First, we run a positive cash flow business. Second, we have an excellent balance sheet with plenty of cash in the bank and additional borrowing capacity if needed. We are not highly levered, with net debt of $120 million, slightly less than one times our 2019 EBITDA.

Third, we support a critical function in the healthcare process, and the use of our products can only be delayed for so long. Fourth, we are well suited and have the experience to operate our business remotely. Fifth, as stated on our last call, we are not overly concerned about supply chain continuity. And last, our business development efforts continue to uncover interesting opportunities to accelerate our growth plan. As mentioned, our monitoring business began to decline starting in mid-March, consistent with the drop in physician visits. We immediately took steps to curtail expenses and adjust to the lower business level without dismantling our team and infrastructure in order to provide seamless service excellence and ensure that we are poised for growth as we emerge from this crisis.

We were able to do this thanks to our strong financial position and sound business practices. I will also note that none of these changes to our cost structure will affect our business development resources, which will play a key role in our ongoing growth. Throughout the month of April, the cardiac monitoring business, less Geneva, was down from Q1 by approximately 35%, with some uptick in the second half of the month as doctors shifted to telehealth models, requiring us to conduct remote patient activations outside of the doctor's office. Fortunately, this was an easy conversion. We have quite a bit of experience with at-home patient starts.

In fact, there was a time when all of our patient activations were done at home, with us having mailed the device directly to the patients. Over time, the market shifted to an in-office patient activation, which offers some benefits. However, nearly 30% of our business was still conducted using the original mail-to-patient model. Since the infrastructure and know-how were already established, it was a smooth transition and ramp-up. We are also proud to be supporting an expanded service using MCOT to monitor COVID-19 patients in several major institutions. The use of hydrochloroquine and azithromycin can cause an abnormality in the heart's electrical system known as QT prolongation. This serious condition can unfortunately lead to sudden cardiac arrest or death.

As part of its FDA 510(k) clearance, MCOT has a specific indication for use with patients requiring measurement, analysis and reporting of QT interval. MCOT can be used to help physicians monitor and adjust the dosing of COVID-19 medications as well as detect any other arrhythmias that may occur during treatment, augmenting limited in-patient telemetry capacity. Additionally, our research division has a long history and deep knowledge in this area, having conducted thousands of QT studies on drugs as they move through various phases of development. As such, our company is particularly well suited to provide this assistance.

So what is the likely path forward in the coming quarters? Like other companies, we have been tracking external information as well as our internal sales trends to help gauge the ultimate impact of the economic shutdown. As mentioned, we expect our noncardiac monitoring businesses, Geneva, research and pop health to be relatively stable throughout the second quarter. The research segment may start to feel some negative impact if new studies get delayed, but we have not seen any signs of this yet. If our current business trends continue, April will be our worst month, with improvement in May, June and beyond. Just how much is hard to say, which makes providing guidance for the second quarter and full year impossible until we know more. Much of our recovery will be dictated by the economy at large.

We did, however, model a scenario for Q2 where May and June performance looks just like April, which would cause our total revenue to drop by as much as 30% versus Q1. Remarkably, we would remain EBITDA positive for the second quarter even in this highly unlikely scenario, an amazing testament to the strength and flexibility of the company. Because we already started to see some uptick in the business in the latter part of April and would expect this to continue as the economy reopens, we will manage through the second quarter in relatively good shape and should record results better than the worst-case scenario I just mentioned.

We would then expect accelerated growth in the third and fourth quarters, consistent with national economic forecast, but slightly ahead of the curve given the nature and urgency of healthcare. We also have reason to be extremely optimistic about the long-term prospects for the company. This crisis has necessitated rapid change in healthcare, much of which will be permanent. For instance, the adoption of telehealth solutions, which has been unnecessarily slow given the obvious benefits, is experiencing a tremendous surge. Regulatory and reimbursement organizations, the traditional obstacles to change in healthcare, have adapted like never before.

If there is a silver lining in any of this, it may well be that regulators and payers will find it impossible to slide back into outdated positions and outdated policies. The post-corona healthcare environment will demand greater access and payment for telehealth and remote monitoring applications. We are fortunate to be so far out in front of this next wave in healthcare evolution. And as one of the largest, fastest-growing and most profitable connected health companies in the market, we are perfectly positioned to capitalize on this opportunity.

I'll turn the call over to Heather for a detailed financial review of the quarter. Heather?

Heather Getz -- Executive Vice President, Chief Financial Officer and Chief Administrative Officer

Thank you, Joe, and good afternoon, everyone. As Joe just announced, we started 2020 with our 31st consecutive quarter of year-over-year revenue growth and our highest quarterly revenue in the company's history. Total revenue grew 9%, reaching $113 million and within our guidance range even with a significant drop in March volume due to COVID-19. This growth resulted from revenue increases in all of our business lines. Healthcare revenue increased $7.7 million or 9% to $95.7 million driven by patient volume growth of over 75% in extended Holter service lines as well as the addition of Geneva's revenue from the monitoring of implantable cardiac devices.

Our research revenue increased 7% to $13.8 million, benefiting from new studies utilizing our ePatch, extended wear Holter device and the acceleration of certain imaging studies. Lastly, our other revenue increased 17% to $3.5 million, resulting from partnerships in our digital population health business. Moving to gross profit. Our margin for the first quarter was 62.4% versus 62.3% in the prior year period. While we saw a higher-margin in our research segment due to efficiencies created by automation put in place later in 2019, that benefit was offset by decreases in our healthcare segment largely due to inefficiencies caused by the drop-off in volume later in March.

Our first quarter adjusted EBITDA was $29.5 million, an increase of $600,000, representing a 26.1% return on revenue. The increase in our adjusted EBITDA dollars was primarily due to the increased revenue, partially offset by the impact of investments we are making in technology and our sales organization. Our EBITDA margin percentage decreased slightly compared to the prior year period due to the increased investments as well as the impact of the acquisition of Geneva, which is at an early stage growth stage and is as a result, currently carries a lower EBITDA margin compared to our core business.

As for our tax rate, in the first quarter, we had a GAAP tax rate of 42%. This higher rate is primarily a result of permanent differences largely due to stock comp that is not deductible when expensed. Ultimately, we will get a GAAP benefit when the related stock options are exercised. While our GAAP tax rate for the full year will most likely be similar to Q1, we are expecting to only pay about $2 million in state and local cash taxes in 2020 due to the use of our federal net operating loss carryforward. Moving on to our balance sheet. We ended the quarter with $106.8 million in cash and $227 million of indebtedness, putting our debt-to-EBITDA ratio at 1.4 times. Year-to-date, we generated $12.7 million in cash from operations and used $7 million for capital expenditures.

These expenditures were driven by purchases of our MCT and extended wear Holter patch devices as well as for capitalized software and hardware as we invest in our IT infrastructure. Free cash flow was $5.7 million. To note, while we believe our operating cash receipts will continue to be sufficient to cover our operating needs, for added flexibility and enhanced liquidity, early in the COVID crisis, we did draw $35 million on our line of credit, leaving an additional $168 million in undrawn capacity. We have also received funds from various COVID-related government stimulus programs in Q2. If you recall, in January 2020, we refinanced our term debt to an upsized five year $400 million revolver with more favorable terms, including lower pricing of about 50 basis points.

The company will benefit from the additional capacity, no set amortization payments and the flexibility to pay down and draw on the facility while maintaining access to capital. Shifting gears, I will now touch on the outlook for 2020. On our year-end call, we provided guidance for the full year and first quarter of 2020. As stated, we delivered results in the range of this guidance for both revenue and EBITDA in the first quarter even with the impact of COVID in March. Looking forward to the second quarter and the remainder of 2020, we are withdrawing our full year guidance, and we'll be unable to provide specific guidance for Q2 due to the uncertainty surrounding the extent and impact of the pandemic.

Our results will be dictated by the length of time that states and localities remain in lockdown and how quickly they reopen their economies. That being said, as Joe stated, our business is flexible in terms of our ability to adjust the cost structure to the appropriate level in response to the demand for our services. As such, while our top line may be down sequentially in Q2, we believe that we will still be EBITDA positive. In addition, we believe we have sufficient operating cash flow to meet our operating needs. Along with the added insurance of our credit line and government stimulus payments and advances, we will be able to weather the storm and come out in a healthy position.

I will now turn the call back to Joe.

Joseph H. Capper -- President and Chief Executive Officer

Thanks, Heather. As you've just heard, we had an excellent quarter, especially in light of the challenges posed by the coronavirus outbreak. We started 2020 strong out of the gate, poised to shatter expectations. When the crisis hit, we made adjustments necessary to scale back our operating cost structure without dramatically changing our capabilities. As mentioned earlier, these modifications, coupled with our excellent financial position, allow us to remain EBITDA positive even if the reopening is slower than expected.

Under a far more likely scenario, April will be our most challenging month with growth in May and June and then into the second half of the year. Naturally, our focus is to guide the company through this crisis as effectively as possible. However, because we did not need to make major alterations to our business structure, we are well positioned for a manageable downturn and ready to meet a spike in demand in the event of a rapid recovery. We are also in position to leverage our excellent financial condition in order to advance business development opportunities geared toward accelerating our strategic plan.

Before I close, I would again like to sincerely thank those of you who helped deliver our 31st consecutive growth quarter. And on behalf of the entire BioTelemetry team, we want to extend our deepest gratitude to the many healthcare providers around the country who are on the front lines, battling the coronavirus each day and to all of the other critical workers putting themselves at risk to perform their jobs. Thank you all.

With that, we'll now pause and open the call to your questions. Operator, we are ready for our first question.

Questions and Answers:

Operator

[Operator Instructions] Our first question will come from the line of Brooks O'Neil from Lake Street Capital Markets. You may begin.

Brooks O'Neil -- Lake Street Capital Markets -- Analyst

Thank you. Congratulations on your rapid pivot here. That sounds great, guys.

Joseph H. Capper -- President and Chief Executive Officer

Thanks, Brooks. Books, you're coming in really broken up. I'm not sure if it's the line we're on or your phone.

Brooks O'Neil -- Lake Street Capital Markets -- Analyst

It's probably just me, Joe. I'm getting a little bit anyway, can you hear me better now?

Joseph H. Capper -- President and Chief Executive Officer

A little better, yes.

Brooks O'Neil -- Lake Street Capital Markets -- Analyst

All right. So you outlined an interesting scenario for Q1. Could Heather just give us a sense for what the gross margin might look like under the scenario you've kind of laid out?

Heather Getz -- Executive Vice President, Chief Financial Officer and Chief Administrative Officer

So I think what I heard you say, Brooks, was you were asking for our gross margin in the scenario that Joe...

Joseph H. Capper -- President and Chief Executive Officer

Worst-case scenario gross margin? I don't know if he can...

Heather Getz -- Executive Vice President, Chief Financial Officer and Chief Administrative Officer

Correct, yes. Yes, so what I will tell you is that we would expect, due to we have a certain amount of fixed expenses. While we did adjust our operating structure in Q2, you are going to see a decline in our gross margins. I can't give you an exact perspective of that because I don't know what the volume is going to be.

Brooks O'Neil -- Lake Street Capital Markets -- Analyst

Sure. I get that. Okay, that's helpful. So one question I had is Joe, again, talked a little bit about population health. As you, I hope, remember, I'm very excited about the opportunity there. How scalable do you believe your population health platform is today? And what would it take to see that really take off in the current environment?

Joseph H. Capper -- President and Chief Executive Officer

It's a relatively small business for us today, Brooks, and I think I spoke a little bit about this in the past calls. We're excited about it because of the size of the market and because of some of the inherent capabilities we have in the business, which we believe are leverageable into that market. We do, however, admit that it would take a pretty significant investment to sort of ramp it up and catch up with maybe some other folks that you're familiar with.

And we don't feel like we are in a position to do that. We're talking about a really significant investment, which would require us to lower our operating margins quite a bit. So our approach has been look to leverage other relationships we have as an organization to kind of flank and find other ways into the market without such a huge investment. So not the way you'd love to do it, but it's certainly going to be more of an incremental approach.

I love to rip Band-aid and I'll spend a lot of money and go after the market, but I just don't think our investor base would I don't think our investor base is actually looking for that from us. We have a core business that's very profitable. It grows. We have a leadership position in it. We know that we have double-digit growth in front of us in that core business. So we think we can take advantage of that and to build out this other business that we're talking about.

Brooks O'Neil -- Lake Street Capital Markets -- Analyst

Yes. So you talked a little bit in your prepared remarks about the explosive growth of telemedicine, which we see and hear about pretty much everywhere, which is great. We also continue to be very, very excited about the potential of remote patient monitoring. When I think about your cardiac monitoring business, it's a little bit more short term than some of the other sort of chronic monitoring needs we see in the marketplace. How do you think about the opportunity for BioTelemetry to go after some of those more chronic patient monitoring needs in the market?

Joseph H. Capper -- President and Chief Executive Officer

It's a good question. Remote cardiac monitoring, our traditional core business, is more acute. It's transactional. And you're right. The bigger dollars in healthcare, $0.80 on every $1 is being spent in the chronic market, and now you're starting to see remote monitoring applications applied in those markets. And so again, we think we're we have a the good news is we have a channel, right? We have a sales channel, and we have a distribution channel into the healthcare market that's established that we could leverage. And that's some of the areas that we're working on. And the other important thing is cardiac disease is comorbid with a lot of these other chronics that we're talking about. So it does open up opportunities. Congestive heart failure, it's the same channel that you would sell into.

So you're right. The bigger dollars longer term will be in those product markets. And that's really what we're attempting to do. Our strategy is all about leveraging what we've built. And again, we're one of the few companies out there that have demonstrated a remote patient monitoring business that can be both scalable and profitable. So we think we've got some good core competencies there to leverage in some of these other sectors.

Brooks O'Neil -- Lake Street Capital Markets -- Analyst

Perfect. Thank you very much. Keep it up. I know it's going to be challenging, but I think you guys are up to it.

Joseph H. Capper -- President and Chief Executive Officer

Thanks.

Brooks O'Neil -- Lake Street Capital Markets -- Analyst

Perfect, thank you very much.

Operator

And our next question comes from the line of Kaila Krum from SunTrust. You may begin.

David Rescott -- SunTrust -- Analyst

Hey, This is David Rescott on for Kaila. Can you guys hear me all right?

Heather Getz -- Executive Vice President, Chief Financial Officer and Chief Administrative Officer

Yes. Hi, David.

David Rescott -- SunTrust -- Analyst

Sorry, I had some technical difficulties toward the beginning of the call, so I apologize if what I'm about to ask is kind of repetitive to what you've gone over. But first, I wanted to start on the top line. Revenue kind of came in at the lower end of guidance that you issued at the end of February, which was great, obviously, given the effects of COVID so far. And at that time, you had about two full months of revenue under the belt.

So I was wondering if you could provide some commentary first, around the trends in the first two months of the year that led to the 13% growth, I think you mentioned, and then second to that, around the dynamics that played out specifically within March that enabled you to hit that low end of guidance versus what potentially could have been or could have brought you up toward the upper end of guidance in the pre-COVID world and then in so far as how that's playing out in April.

And then maybe specifically around MCOT, any color around how revenue is traditionally recognized? And given that it's a 30-day device, whether or not some of the revenue that you recognize at the end of March could have been patients who initially had visited a clinic or had gone to a hospital to visit a cardiologist at the beginning of March or February and then really what those implications would be then for how trends play out in Q2.

Joseph H. Capper -- President and Chief Executive Officer

So let me try to get to most of that. If I leave anything out, feel free to jump back in and ask me. But so January and February were really strong. And what we saw, even through the first two weeks of March, so let's call it 2.5 almost 2.5 months into the quarter before we saw the drop-off was that we were trending well above expectations. We would have finished the quarter somewhere around $117 million to $118 million in revs. So we lost about $4 million or $5 million in that last 2.5 weeks, which makes sense. So we were if you break it down by week, we lost probably 20%, 30% of the last 2.5 weeks, something along those lines.

So again, the business was extremely healthy. It was coming from MCOT at nearly double digits. It was coming from extended wear Holter, high, high double digits, close to triple digits, and it was coming from the Geneva platform. And then research performed better than we had expected. Remember from the last call, we talked about research being flat to maybe even down just as we cycle through the backlog. They performed well, and we saw a little bit of uptick in our pop health business. So everything was kind of firing on all cylinders, humming, looked like a great start to a great year, and then obviously, that happened, right?

So as we come into April, the business in the first two weeks of April, all of the cardiac monitoring business dropped way off. And then we so first two weeks of April, it stayed pretty low. And then we started to see a little bit of an uptick in the third week, fourth week of April. So we started to see a build back up. If you just take the April average and apply that to on a per day average, you apply that business to May and June, that was that worst-case scenario that I kind of talked about. Realistically, we anticipate the business continuing to build back up.

If you break down, within remote cardiac monitoring, the four modalities that we offer, our MCOT, Event, Holter, extended wear Holter, the MCOT has experienced the least decline. And that's probably because it is the only real connected solution available. And as patients need to be monitored and evaluated outside the four walls of a hospital, it becomes more important that they are connected, right? And I think that that's an interesting data point because that's the future, right? The future is patients are going to be connected. So again, we saw a drop-off on all four modalities. The least amount of drop off and the fastest recovery has been with MCOT. I think that was most of your question. Was there anything else I left out, David?

David Rescott -- SunTrust -- Analyst

Just around kind of specifically for MCOT, when and how you guys recognize revenue for MCOT. So just thinking about when patients who potentially have been or who came into the clinic or came into the hospital and were prescribed a MCOT patch, if that kind of plays out where you recognize that revenue 30 days after that, so therefore, anything that kind of came in toward the end of the month of February or March could have eventually been from a patient that was previously seen in the hospital at the end of February.

Heather Getz -- Executive Vice President, Chief Financial Officer and Chief Administrative Officer

Yes. So it's not any different than any other quarter sans the fact that our volumes started to drop off at the end of March. So the numbers that Joe is talking about are actual patient starts coming in the door. It's and the rebound that we've seen has happened in concert. So from a revenue perspective, there is revenue that gets deferred into the next quarter or the next period if a patient comes on service and is still on service at the end of the month. But I don't think that you can read anything special into our numbers in the quarter given what's occurred.

David Rescott -- SunTrust -- Analyst

Okay. Great. Yes, that's really helpful. And so I know you mentioned you've touched on a little bit around kind of how MCOTs for COVID patients have been used more given the increased risk of QT prolongation. So I was wondering you guys mentioned that there's kind of a stronger growth there or left off of the decline in the MCOT business, specifically. So I was wondering if you could either tease out or kind of quantify what type of benefit or net benefit maybe you saw from increased usage on actual COVID patients versus what was kind of the overall downturn in MCOT prescriptions in general just due to the overall drop in physician visits.

Joseph H. Capper -- President and Chief Executive Officer

Yes. The use of MCOT in the COVID-19 monitoring program that we talked about is relatively small. And it's in certain regions of the country that had a high concentration of COVID-19 patients. And the intent there was to be able to dose hydroxychloroquine, monitor the patient for potential QT prolongation and not have them lying on a hospital bed. So it's not a lot of volume. A really good program, really critical for those places that needed it, but doesn't really move the needle one way or the other.

David Rescott -- SunTrust -- Analyst

Okay. And then just the last one, and maybe you guys had mentioned this earlier in the call, on Geneva. I know you've previously guided to hiring reps and bringing on reps this year as part of growing that business. And I just wonder if there's any update as far as how the hiring process has been as far as building out that. I think maybe you had mentioned you're trying to build out to 12 reps, so direct reps. So wondering if there's any update there and then also kind of how the growth in that business has been just given the effects of COVID and whether or not you're able to still get into new accounts and still able to kind of drive that business. And I think our checks so far have demonstrated that, that is something that would be definitely a useful business to or useful service toward cardiologists.

Joseph H. Capper -- President and Chief Executive Officer

Yes. So the sales thing, we did two things. We took we assigned sales responsibility to the remote cardiac monitoring sales team, which is north of 100 folks. We for the first time starting Jan 1, they have responsibility to sell that product. They have quota, they have commissions assigned to it. The other thing we did was put in place a dedicated sales professional, one for each of our 12 regions, to drive that whose sole responsibility is to drive that sales process. And I want to say we have 10 or 12 of them, something along those lines. We have 12 in total, but I think all but two of them are filled.

The Geneva sale has been going better than we had anticipated. If you remember you may recall that, at the outset, we talked about potentially doubling the revenue year-over-year. March 1, we annualized the first year owning the company, and we surpassed that objective on a run rate basis. We have more than doubled that business. We are bringing we are early on in the year, we were signing accounts on at a higher rate. Obviously, that's slowed down. New account activation has slowed down a little bit, but we're able to pull through more patients into the same account. So we haven't really seen a slowdown in that business.

Remember, this is at-home monitoring recurring revenue, so we don't anticipate a slowdown. It may be slightly slower growth through the next couple of months, but even that, I think, will be minimal. The team has done a really good job building a funnel, and once they're able and we have activated new accounts. We just can't do it at quite the rate. Very difficult to do when accounts are closed. So pulling through the patients actually has been an area where the team has done a good job growing the business.

David Rescott -- SunTrust -- Analyst

Okay, thank you. Thanks for taking my questions.

Joseph H. Capper -- President and Chief Executive Officer

Thanks, David.

Operator

Thank you. And our next question comes from the line of Jayson Bedford from Raymond James. You may begin.

Jayson Bedford -- Raymond James -- Analyst

Hi, good afternoon. Congrats on the durable revenue growth in the first quarter, and I hope everyone is healthy. So I do have a few questions. Maybe just to pick up on the last line of questioning. Joe, the up 45% quarter-on-quarter on Geneva, is it just due to new center adds? And then I don't know if this is appropriate, but is there a way to kind of update us on kind of where you are in terms of the number of centers, etc?

Joseph H. Capper -- President and Chief Executive Officer

Now we haven't put out the number of centers, and it's really not a great metric because you can have accounts that are varying in size, and we haven't put this out either. But the key metric for us is really new patient activations, and that's trending better than expected. And actually, to the last question, we talked about the first quarter being better than anticipated and maybe not as many new accounts activated in March. But March, patients was excuse me, April patients were actually higher than March. So we did see even a step-up as we move into the second quarter. So really long-winded, the key metric there is new patient activation. There will be a time when we'll probably start to publicize that.

Heather Getz -- Executive Vice President, Chief Financial Officer and Chief Administrative Officer

Yes.

Jayson Bedford -- Raymond James -- Analyst

Okay. And I guess in terms of the revenue model with Geneva, is it more subscription-based that just kind of builds each quarter, meaning once you have activated a patient, that revenue kind of recurs either every month, every quarter? You add a new one on, it just kind of builds on top of that, correct?

Joseph H. Capper -- President and Chief Executive Officer

Yes, I mean it's a recurring typical recurring model like that. The challenge is keeping patients compliant or adhering to the overread protocol, so keeping them doing what they need to do, what they're supposed to do. And then obviously, you have patient attrition. But you've got the right idea. It's a recurring revenue model.

Jayson Bedford -- Raymond James -- Analyst

Okay. And just for clarification, I think the comment was, if May and June looks similar to April, that's your kind of worst-case scenario, down 30% from 1Q. Is that total revenue or just the healthcare services line ex Geneva, ex Research?

Joseph H. Capper -- President and Chief Executive Officer

That was total revenue.

Jayson Bedford -- Raymond James -- Analyst

Total, OK.

Joseph H. Capper -- President and Chief Executive Officer

Yes. So total revenue. The other businesses, we're assuming they stay stable into the second in this scenario, we assume they stay relatively stable. Research even actually drops just a little bit. The other businesses stay kind of where they are. And then Geneva would do what it's doing. Health care within healthcare, the remote patient or the remote cardiac monitoring, MCOT, research, Holter, extended wear Holter, on a volume basis, on a per day average, they would be the exact same in May and June as we saw on average in April.

That's an important point because the back half of April was better than the first part of April. So look, Heather hates when I say this because it sounds like she hates it when I say it. I see this as a highly unlikely worst-case scenario. But and I think we wanted you to hear it, just in case, a; and b, probably the more important point is we're still profitable at that level. We're still running an EBITDA positive, cash positive business at that level.

Jayson Bedford -- Raymond James -- Analyst

Right. But I guess the silver lining here is that trends in this back half of April seemed to tick up, and I think that's similar to most companies that we've spoken to. Okay. And then research, up 7% in the quarter. I guess my impression coming into the year that, that line would be kind of flattish. The up 7%, is that something that can be sustained?

Joseph H. Capper -- President and Chief Executive Officer

Well, we're not forecasting that at this point. We came in the year, we said we would be flat to down a little bit. We had a better-than-anticipated first quarter. Second quarter, I think we're forecasting slightly down year-over-year. We did have a couple of really good bookings months in the first part of the year. A lot of times, you don't see that until the following year, 2021. So it depends on how those studies start. So our biggest concern, frankly, with that business, Jayson, is you have the late starts. We haven't seen it yet, but you never know.

Heather Getz -- Executive Vice President, Chief Financial Officer and Chief Administrative Officer

And we also didn't factor in any of these one-off studies that may be done in response to COVID that might be quick hits. This is really based on the backlog that we saw coming into the year.

Jayson Bedford -- Raymond James -- Analyst

Thank you.

Heather Getz -- Executive Vice President, Chief Financial Officer and Chief Administrative Officer

Thanks.

Operator

Our next line will be from Mitra Ramgopal from Sidoti. You may begin.

Mitra Ramgopal -- Sidoti -- Analyst

Hi, good afternoon. Thanks for taking the questions. I'm just wondering for if you can give us a sense of sort of maybe the incremental cost or expenses you experienced as a result of having to comply with COVID-19 from a safety, PPE standpoint,etc.

Joseph H. Capper -- President and Chief Executive Officer

Not a whole lot, Mitra. So we're kind of fortunate as we went into this, right? We're a healthcare services platform, so we're highly dependent on human resources. We always have the capability to work remotely. Some of our employees work a portion of their time remotely under ordinary times. The Geneva business is almost all virtual. So it's a pretty flexible business model. We were able to flex to a higher percentage of our people, upwards of 90% of our folks working from home. The only people that really are coming into any of our locations are ones that kind of have to.

There are some job functions where you need to be on-site to access certain technology, and obviously, like our distribution centers folks have to be on location to pick, pack and ship boxes. So it was kind of an easy transition for us because of the way we're set up. And even our cost structure, a decent amount of it's tied to product and monitoring time. So we were able to flex the business pretty smoothly.

Mitra Ramgopal -- Sidoti -- Analyst

Okay. No, that's great. And then I know, obviously, as a result of COVID-19, you had talked about the QT prolongation as it related to some of the drugs being used,etc. So I was just wondering, in light of the increased visibility you've gotten from I think you mentioned a few large institutions, etc, had contacted you. You got a request on a number of other places,etc. If this would sort of help just from increasing the potential for greater reimbursement coverage for MCOT going forward.

Joseph H. Capper -- President and Chief Executive Officer

Your lips to God's ears. I'd be happy if it just protects us on the down side. Look, if nothing else, it once again proves that there is a critical, critical need for real-time because this is not patients you can put on an extended wear Holter. These are patients that you really need real-time monitoring for. These are patients that are at risk for sudden death if they have QT prolongation. You have the doctor has to intervene and adjust medication. So if you're putting them on an extended wear Holter, Holter, and you're sending them home, it's not you're not monitoring.

You're recording a result, and hopefully, you're going to download it at some later point. But it's not real critical care. And I think this, again, reinforces the need in some scenarios to have a patient wired and connected and eyes on that patient. The very first patient we monitored, we found an arrhythmia that was non-COVID related. Never would have found that if that patient wasn't on this product.

Mitra Ramgopal -- Sidoti -- Analyst

Okay. No, that's helpful. And then finally, obviously, you're trying to rationalize your costs. And again, the volumes, etc, are not predictable given the environment. But I know you also want to continue to grow the business, and you certainly as you mentioned, you have the capital, the cash, etc, on hand. So I'm just trying to get a sense of the balance you're trying to achieve as you look to obviously add salespeople, etc, and invest in the business while also trying to monitor your costs in this environment.

Joseph H. Capper -- President and Chief Executive Officer

Well, look, the first couple of weeks into this, we were into like most companies, where does this thing bottom out? We just really didn't know. So everything was on the table. And then we instituted changes as we saw necessary. Again, we're fortunate that we have such a flexible business model, that we're highly liquid, a lot of cash in the bank and we run a cash flow positive business.

So all those things are helpful. Lest we saw where the business sort of stabilized in mid-April, then we could then our decision tree changes a little bit, right? You start to think, OK, we can carry this excess cost for a period of time. We don't need to cut any deeper. And then that will position us better relative to others when we come out of this. So if there's a rapid recovery, we believe we're incredibly well positioned for that.

Mitra Ramgopal -- Sidoti -- Analyst

Okay, thanks for going to take your questions.

Joseph H. Capper -- President and Chief Executive Officer

Thank you.

Operator

Next question will comes from the line of Gene Mannheimer from Dougherty. You may begin.

Gene Mannheimer -- Dougherty -- Analyst

Thanks, good afternoon. Congrats on a good quarter in spite of the circumstances here. Certainly, the last couple of months, we've seen kind of a surge in telehealth visits, decline in in-person visits. So my question is can your device orders from telehealth replace the decline in in-person visits that we're experiencing? Or said differently, in your models, are you assuming that the patient volumes do not quite come back to the way they were pre-COVID?

Joseph H. Capper -- President and Chief Executive Officer

No, it doesn't matter to us one way or the other, Gene. The patient if it's a telehealth visit, doctor prescribes a product. We ship it to the patient. We activate the patient remotely. Our infrastructure is completely set up for that. That's the way the business grew up. So we're incredibly flexible from that standpoint.

Gene Mannheimer -- Dougherty -- Analyst

Okay. So you're saying that a cardiologist can prescribe a patch or a monitor without seeing the patient just based on a work-up over the telephone?

Joseph H. Capper -- President and Chief Executive Officer

That's correct. As long as they're meeting their requirements on their end, it doesn't affect us one way or the other.

Gene Mannheimer -- Dougherty -- Analyst

Got you. Good. Excellent. What is Heather, what's your thank you for that, Joe. What's your view on your how long your NOLs will last?

Heather Getz -- Executive Vice President, Chief Financial Officer and Chief Administrative Officer

Well, it kind of depends on how quick things come back. Obviously, our expectation is that will last well into 2021 at this point. Depending on what things look like, it could go further.

Gene Mannheimer -- Dougherty -- Analyst

Okay. Got you. Very good. Thank you.

Operator

Thank you. And I'm not showing any further questions at this time. I'd like to turn the call over to the speakers for ending remarks.

Joseph H. Capper -- President and Chief Executive Officer

Thanks, operator, and thanks to everyone for your continued support and interest in the company. Take care of yourselves, and we'll speak to you next quarter. Operator, that concludes today's call.

Operator

[Operator Closing Remarks]

Duration: 51 minutes

Call participants:

Joseph H. Capper -- President and Chief Executive Officer

Heather Getz -- Executive Vice President, Chief Financial Officer and Chief Administrative Officer

Brooks O'Neil -- Lake Street Capital Markets -- Analyst

David Rescott -- SunTrust -- Analyst

Jayson Bedford -- Raymond James -- Analyst

Mitra Ramgopal -- Sidoti -- Analyst

Gene Mannheimer -- Dougherty -- Analyst

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