American Shared Hospital Q2 2026 Earnings Call Transcript

American Shared Hospital (AMEX:AMS) held its second-quarter earnings conference call on Thursday. Below is the complete transcript from the call.

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Summary

American Shared Hospital Services reported strong financial performance with a 19% year-over-year revenue growth to $8.4 million for Q2 2026 and an 18% increase in first-half revenue.

The company is transitioning from equipment leasing to a diversified radiation oncology platform, benefiting from direct patient services, Proton Beam Radiation Therapy, and international operations.

Management highlighted the importance of increasing patient volumes, improving utilization, and executing strategic initiatives like developing new centers in Rhode Island and expanding operations in Latin America.

Operational cash generation was strong, with $4.4 million generated in the first half of 2026, and the cash balance increased over 80% to $6.8 million.

The company entered into a Third Amendment and Forbearance Agreement with Fifth Third Bank, providing financial flexibility while pursuing long-term capital solutions.

Despite a $909,000 charge for credit losses on Rhode Island receivables, underlying business performance remained strong, driven by increased patient volumes and improved reimbursement trends.

Management remains optimistic about long-term growth prospects, emphasizing the importance of strategic investments and financial flexibility to support future expansion.

Full Transcript

OPERATOR

Good day and welcome to the American Shared Hospital Services second quarter 2026 earnings conference call. All participants will be in a listen-only mode. Should you need assistance, please signal a conference specialist by pressing the star key followed by zero. After today's presentation, there will be an opportunity to ask questions. To ask a question, you may press star then one on a touch-tone phone. To withdraw your question, please press star then two.

Please note this event is being recorded. I would now like to turn the conference over to Kieran Smith, Investor Relations. Please go ahead.

Kieran Smith, Investor Relations

Thank you, Nick. And thank you everyone for joining us today. AMS second quarter 2026 earnings press release was issued earlier today. If you need a copy, it can be accessed on the company's website at www.ashs.com under the Investors section. Before turning the call over to management, I would like to make the following remarks concerning forward-looking statements. Please note that various remarks that may be made on this conference call about future expectations, plans and prospects for the company constitute forward-looking statements for the purposes of safe harbor provisions under the Private Securities Litigation Reform Act of 1995.

Actual results may vary materially from those indicated by these forward-looking statements as a result of various important factors including those discussed in the company's filings with the SEC, including the company's Annual Report on Form 10-K for the year ended December 31, 2025 and Form 10-Q for the quarter ended March 31, 2026. The company assumes no obligation to update the information contained on this conference call. Before I turn the call over to management, I'd like to remind everyone about our Q&A policy where we provide each participant the time to ask one question and one follow up.

As always, we'll be happy to take additional questions offline. With that, I'd now like to turn the call over to Ray Stokowiak, Executive Chairman. Ray, please go ahead.

Ray Stokowiak, Executive Chairman

Thank you, Kieran. And good afternoon everyone. Thanks for joining us today and for your continued interest in American Shared Hospital Services. Before we begin, I'd like to take a moment to point out that we recently promoted Alexis Wallace, our long-standing Chief Accounting Officer, to the role of interim CFO. Our previous CFO, Scott Freck, has moved on to pursue other endeavors. We wish Scott all the best and appreciate his contributions while welcoming Alexis to this well-deserved role after her many years of excellent service on our accounting team.

Now let's get into the quarter. The second quarter represented another period of meaningful operational progress for our company. We delivered strong quarterly revenue of approximately 8.4 million, representing year-over-year growth of 19% while first half revenue increased 18% to more than 15.5 million. These results are driven by continued strength across our direct patient services business, increasing Proton Beam Radiation Therapy activity and improving performance from our international operations.

More importantly, we believe these results validate the strategic direction we've been executing over the past several years. We have intentionally transformed American Shared Hospital Services from a company primarily dependent on equipment leasing into a more diversified radiation oncology platform with multiple avenues for growth. Today we benefit from recurring revenues generated through our direct patient care operations, long-standing hospital partnerships, international treatment centers, Gamma Knife leadership and our participation in Proton Beam Radiation Therapy.

Each of these businesses contribute differently to our overall growth strategy, but together they provide us with a broader, more resilient operating platform than at any point in our history. One of the most encouraging trends we continue to see is improving utilization across our network. Our Rhode Island centers continue to experience higher patient volumes and improved operating performance. Our Proton Beam Radiation Therapy partnership in Orlando, Florida delivered another strong quarter, benefiting from increased treatment volumes and favorable reimbursement trends.

Internationally, our Gamma Knife center in Peru continues to demonstrate increased treatment volumes compared with the prior year following the SPRE upgrade that we completed in 2025. These operational achievements are especially encouraging because higher utilization remains one of the most important drivers of long-term profitability in our business model. I'm also proud to report that our operating activities over the first six months generated $4.4 million of cash and our cash balance at the end of the second quarter increased over 80% since the beginning of this year to $6.8 million.

It is validating to see the improving cash-generating capability of our business as our operating performance continues to strengthen. We also made important progress subsequent to quarter end with respect to our capital structure. As many of you know, we entered into a Third Amendment and Forbearance Agreement with Fifth Third Bank. Although our financing discussions have required considerable management attention over the past several months, we believe the agreement provides a defined framework that allows us to remain focused on executing our operating strategy while we continue pursuing longer-term capital solutions.

A few months ago, I formed a new company that recently purchased additional shares of our company from a private investor. In addition, this new company has invested $2 million as subordinated financing after quarter end, which reflects our continued confidence in the long-term prospects of the company and provides additional financial flexibility as we move forward. Importantly, none of these financing activities have changed our long-term strategic priorities.

In Rhode Island, we continue advancing opportunities created through our Certificate of Need approvals, including plans for a new radiation therapy center in Bristol and a Proton Beam Radiation Therapy center in Johnston. Internationally, we remain excited about the continued development of our operations in Latin America and the opportunities we see to further expand our presence in attractive markets. An important component of our international growth strategy is in Guadalajara, Mexico, where we are partnering with Hospital San Xavier to upgrade their Gamma Knife center.

Importantly, this is an established Gamma Knife market and a well-established clinical partner. Hospital San Xavier has been providing Gamma Knife treatments since 1994, giving us an experienced position and institutional platform from which to build. While we recognize there's still important work ahead of us, particularly regarding our balance sheet, I remain extremely confident in the underlying strength of our business. Our focus remains squarely on growing patient volumes, expanding and diversifying our installed base of advanced radiation therapy technologies, strengthening our partnerships with leading healthcare systems and allocating capital where we believe it can generate attractive long-term returns. With that, I'll turn the call over to our interim CEO, Craig Tagawa who will provide more detail on our operational performance.

Craig Tagawa (Interim CEO)

Thank you, Ray, and good afternoon everyone. I'd also like to thank all of you for joining us today and for your continued interest in American Shared Hospital. The second quarter was another quarter of solid operational execution and meaningful progress across our businesses. While our reported financial results include several substantial items that Alexis will discuss in greater detail, I believe the most important takeaway from the quarter is that the underlying business continues to move in the right direction.

We generated strong quarterly revenues of approximately 8.4 million, representing 19% year-over-year growth, while first half revenues increased to more than 15.5 million. Those results were driven by continued growth in our direct patient services segment, improving proton beam radiation therapy performance, and higher procedure volumes across our international Gamma Knife operations. More importantly, we continue to see encouraging trends in the metrics that matter most to the long-term success of our business: patient volumes, utilization, physician engagement, and center-level operating performance.

Beginning with Rhode Island, our three radiation oncology centers continue to improve. During the quarter, these facilities once again generated strong revenue growth supported by increased patient procedures and continued operational improvements. Since acquiring these centers, our primary objectives have been to strengthen physician relationships, improve operational execution, and expand patient access to high-quality radiation therapy services.

We believe we are making meaningful progress against each of those objectives. While there are still additional opportunities ahead, we are encouraged by the trajectory of these operations and believe they represent an important long-term growth platform for the company. Our Puebla, Mexico radiation therapy center also delivered another strong quarter. Patient activity remained healthy, reimbursement trends continue to be favorable, and the operational improvements we've implemented over the past year are translating into better financial performance.

Puebla continues to demonstrate the value of our international operating strategy, and we believe it provides a strong foundation for operational opportunities throughout Latin America. Turning to proton beam radiation therapy, our leasing arrangement in Orlando delivered another excellent quarter. Revenues increased over 22% year over year as both treatment volumes and reimbursement improved. Proton beam radiation therapy remains an important component of our diversified treatment portfolio, and we're pleased with the continued performance of this asset.

Our Gamma Knife business also continued to make encouraging progress. While domestic leasing volumes continue to reflect the expiration of one customer agreement last year, we experienced strong growth across our international Gamma Knife centers. The Esprit upgrade completed in Peru last year continues to produce operational benefits through shorter treatment times, improved patient throughput, and higher utilization. We believe these improvements demonstrate the value of continuing to invest in next-generation technology across our installed base.

As we look across the entire organization, one theme continues to stand out: utilization. Increasing patient throughput remains the single greatest driver of long-term value creation within our business. Many of our facilities have significant operating leverage. As procedure volumes continue to increase, we expect that incremental revenue will increasingly translate into improved profitability and stronger cash generation. That remains a central focus for our management team.

Beyond our current operations, we're also excited about the opportunities ahead. In Rhode Island, we continue to work toward development opportunities associated with our previously approved certificates of need. These projects have the potential to significantly expand our presence in one of our strongest operating markets and represent an important component of our long-term growth strategy. As Ray mentioned earlier, we also made important progress regarding our financing capabilities after quarter end.

While much of the public attention has understandably focused on the balance sheet, I believe it's equally important to recognize the progress occurring throughout our operating business. Revenue continues to grow, patient volumes continue to improve, our clinical partners remain strong, and our operating teams continue to execute at a very high level. Taken together, these trends reinforce our confidence that the business is becoming stronger and better positioned for sustainable long-term growth.

While there is still work ahead, I believe the progress we're making today lays the foundation for meaningful long-term value for our shareholders. With that, I'll turn the call over to our Interim Chief Financial Officer, Alexis Wallace, who will review our financial results in greater detail. Alexis.

Alexis Wallace, Interim Chief Financial Officer

Thank you, Craig. And good afternoon everyone. As Craig highlighted, the second quarter reflected continued operating momentum across our business. We delivered strong growth in our direct patient services platform, solid improvement in operating cash flow, and continued progress strengthening our liquidity. While reported earnings were affected by several significant items during the quarter, we believe our underlying operating performance continued to improve and provides a solid foundation for future growth.

Beginning with revenue, total revenue for the second quarter increased 19.2% to approximately 8.4 million compared with 7.1 million in the prior-year period. For the first six months of 2026, revenue increased 17.7% to approximately 15.5 million from 13.2 million in the first half of 2025. The primary driver of this performance continued to be our direct patient services segment. Second quarter direct patient services segment revenue increased approximately 40% to 4.9 million, while first half revenue increased 35% to approximately 8.9 million.

This growth was driven primarily by higher patient procedure volumes at our Rhode Island radiation oncology centers, together with another strong quarter from our Peru and Puebla, Mexico facilities. Importantly, these centers continue to demonstrate the operating leverage we anticipated when we made these investments. As patient volumes continue to grow, we believe this business will become an increasingly meaningful contributor to both revenue growth and long-term profitability.

Within our medical equipment leasing segment, overall revenue remained relatively stable compared with the prior year, while domestic Gamma Knife leasing activity reflected the expiration of one customer agreement during 2025. This was substantially offset by continued strength in our proton beam radiation therapy business. Proton beam radiation therapy revenue increased 22% to approximately 2.3 million during the quarter and approximately 4.3 million for the first six months of the year, benefiting from both higher treatment volumes and improved reimbursement levels.

Gamma Knife revenue also increased modestly during the quarter as procedure volumes continued recovering at our international treatment centers following completion of the Esprit upgrade in Lima. The improved efficiency of the upgraded platform has enhanced patient throughput and contributed to stronger operating performance across our international operations. Turning to profitability, gross margin for the quarter was approximately 1.4 million. While modestly below last year's level, it improved sequentially from the first quarter of 2026 despite the continued expansion of our direct patient services business, which carries a different cost structure than our traditional equipment leasing operations. We believe this reflects continued operational execution as we scale that business. Adjusted EBITDA for the second quarter was approximately 1.3 million compared with 1.7 million in the prior-year quarter. On a year-to-date basis, adjusted EBITDA totaled approximately 2.5 million, reflecting the continued cash-generating strength of our operating platform. Moving further down the income statement, selling and administrative expenses increased year over year, primarily reflecting legal and professional costs of 285,000 associated with negotiating the third amendment to our credit agreement.

In addition, we recorded a higher allowance for credit losses of 909,000 against Rhode Island receivables prior to May 31 of 25. As we mentioned in prior calls, we've been focused on improving our accounts receivable and billing systems and have made good progress in that area, so we are well positioned going forward. These two items represented the primary drivers of the increase in our reported net loss during the quarter. We view both as largely independent of operating trends within the business.

Excluding these items, our core operations continue to perform well, supported by higher patient volumes, improving reimbursement trends, and disciplined operating execution. Another encouraging development was the continued decline in interest expense as our average debt balances decreased, reflecting our ongoing efforts to strengthen our balance sheet. Turning to liquidity, we ended the quarter with approximately 6.8 million in cash, cash equivalents, and restricted cash compared with 3.7 million at year end of 25.

Perhaps most encouraging, operating activities generated 4.4 million of cash during the first six months of the year. The strong cash generation enabled us to fund scheduled debt repayments and distributions to our minority partners while simultaneously increasing our cash position. We believe this demonstrates the improving cash-generating capability of our business as operating performance continues to strengthen. Subsequent to quarter end, we completed the previously announced Third Amendment and Forbearance Agreement with Fifth Third Bank.

This agreement provides additional flexibility as we continue evaluating longer-term financing alternatives and executing our strategic priorities. Additionally, we completed a 2 million subordinated financing from a newly created company formed by our Executive Chairman. Together, these actions enhance our liquidity, provide additional financial flexibility, and allow management to remain focused on executing our operating strategy while pursuing opportunities to further strengthen our capital structure.

Looking ahead, our financial priorities remain clear. First, continue driving sustainable revenue growth by increasing utilization across our existing treatment network while expanding our installed base of advanced radiation therapy technologies. Second, translate that revenue growth into improved profitability and operating cash flow through disciplined execution and continued operating efficiency. And third, continue strengthening our balance sheet and capital structure while maintaining the flexibility necessary to support future growth opportunities and create long-term shareholder value.

Overall, we are encouraged by the progress achieved during the first half of 2026. The underlying fundamentals of our business continue to improve, our operating cash flow remains strong, demand across our treatment platform is healthy, and we believe the company is well positioned to build on this momentum during the remainder of the year. With that, Nick, you may open up the call for any questions.

OPERATOR

Thank you. We will now begin the question-and-answer session. To ask a question, you may press star then one on your touchtone phone. If you are using a speakerphone, please pick up your handset before pressing the keys. If at any time your question has been addressed and you would like to withdraw your question, please press star then two. At this time, we'll pause momentarily to assemble the roster. The first question will come from M. Marin with Zax.

Please go ahead.

M. Marin, Analyst at Zax

Thank you. So on the back of the strength of this quarter, I think when you originally went down the path of growing the direct patient operations, one thing you talked about was having much greater control over procedure volumes and control over the ability to drive volume increases. And it seems based on what you've discussed on prior conference calls and on this call, that there are a lot of opportunities for that, particularly in Rhode Island where you have three centers, you have a relationship with the Brown University healthcare system, and you will be opening over time two new centers.

Do you think that you will have the same ability to control and drive procedure volume increases in some of the international facilities?

Ray Stokowiak, Executive Chairman

Thanks for your question, Maren. This is Ray Stokowiak, Executive Chairman. Yes, we will be growing, and have been growing, our volumes at our international sites. Peru has seen substantial volume increases, especially since we upgraded their technology to the latest and greatest Esprit model, Gamma Knife. And our linear accelerator in Puebla, Mexico has also experienced increases in volumes. We're also excited about the opportunity to proceed forward with the Gamma Knife upgrade in Guadalajara, Mexico, in our relationship with San Javier Hospital there.

So we're anxious to get that project going and moving forward as well. And yes, by having greater control and negotiating, expanding our relationships with our hospital partners, that's been a key consideration in our business model.

M. Marin, Analyst at Zax

Thank you.

OPERATOR

The next question will come from Tony Kaman with Eastwood Partners. Please go ahead.

Tony Kaman, Analyst at Eastwood Partners

Yes, hi. First, I think it's really notable that with all the sort of investment and collecting of different opportunities, the company really at this point seems like it's starting to get the benefits of that and starting to fire on all cylinders, which is really encouraging. I also noted that Ray, you, Craig and Alexis all mentioned the word long term in the sense of growing the value of the company for shareholders long term, and as a long-term shareholder, and I'm sure all long-term shareholders, really would be excited to get the full value of all these investments starting to fire in the right direction.

However, I'm trying to reconcile that with, when I look at the third amendment on page 31 of it, it says the loan parties shall cause their respective subsidiaries to pursue a sale of all or any portion of all the assets of ASHS. So, I mean that seems pretty clear too that in your agreement it mentions Lake Street, it mentions bid books, that you have to start to try to sell the company. I guess I would have preferred that maybe you were able to replace this loan agreement with one from another institution so you didn't have to do that.

But again, it seems it's written very clearly. So again, in the interest of wanting to capture the long-term opportunity here, how do you do that with, at the same time, entering into an agreement where you have to sell all or part of the company?

Ray Stokowiak, Executive Chairman

Well, I think it's fair to say we're pursuing any and all options. It's very clear that we've been given a 12-month extension of the maturity of our loans to June 30th of 2027. So our credit agreement with Fifth Third buys us some time so that we can pursue these different options. We owe Fifth Third about $15.5 million. By the end of June of next year it will be down to about $13.3 million. If you look at our business, we generated $4.4 million of cash in the first six months of this year.

That number is going to be right off our statement of changes in financial position, $4.4 million of cash generation. We ended the quarter with $6.8 million of cash plus the $2 million deposit we have as well. So I think we're going to be able to find a solution over this period of time to refinance our indebtedness with Fifth Third Bank that won't necessarily require a sale of the company. We're looking at any and all options, as I would expect our shareholders to expect us to do.

So we're pursuing any and all options and we're confident we'll reach a solution.

Tony Kaman, Analyst at Eastwood Partners

Great, thank you very much.

OPERATOR

Again, if you have a question, please press star then one. The next question will come from Anthony Marchase, private investor. Please go ahead.

Anthony Marchase, Private Investor

Yeah, hi, Ray. I'm trying to figure out how an almost million-dollar charge for accounts receivable occurs over a year later. I just don't—I mean, is it one account, multiple accounts? I'm just trying to figure out what happens. I mean, it just seems like every quarter there's something. If it's not a center that was closed, it was maintenance. It's not maintenance now, it's, you know, accounts receivable. It just seems like every quarter the company has some hiccup.

So I'm just trying to figure out what was the nature, if you could in more detail, of the $900,000 accounts receivable charge and why it took this long to figure it out.

Ray Stokowiak, Executive Chairman

Tony, your comments are very much appreciated. It kind of stands on its own. We had receivables through May 31st of 2025 that related to several payors and our relationship with those payors, and they reached a point where we expect to have a $909,000 reduction in viability of those receivables.

Anthony Marchase, Private Investor

I'm not trying to be difficult. I'm not sure what that means. Are the payors bankrupt? Do they not want to pay you? Was there an issue with the—I'm just trying to figure out, it's fairly large, so I'm just trying to figure out, all these payors, when you call them payors, are these insurance companies? Are these clients, or are these people who, you know, got treatment and then couldn't afford it? I'm just trying to figure out the nature of that charge.

Ray Stokowiak, Executive Chairman

Yeah, for the most part, it comes from the insurance carriers that we have relationships with.

Anthony Marchase, Private Investor

And was there an overriding theme as to why they wouldn't pay you? I mean, these are insurance companies. These are fairly sophisticated, I would think, sophisticated institutions who aren't just going to say, I don't want to pay you, you know, for no reason. So I'm just wondering, was it because the service was not performed properly or there was an issue with the service? And I'm not trying to be difficult, Ray. I'm just trying to understand. Can this happen again?

And if it does, how does it happen?

Ray Stokowiak, Executive Chairman

We're not proud of it, Tony. We're not proud of it. But it is what it is.

Anthony Marchase, Private Investor

Of course not. Okay, thank you.

OPERATOR

This will conclude our question-and-answer session. I would like to turn the conference back over to Craig Tagawa for any closing remarks.

Craig Tagawa (Interim CEO)

Thank you, Nick, and thank you to everyone who joined us today. Before we conclude, I'd like to leave you with three key takeaways from today's discussion. First, our operating business continues to perform well. We delivered strong quarterly revenue, continued to increase patient volumes across multiple treatment platforms, and generated strong operating cash flow during the first half of the year. Second, the strategic investments we've made over the past several years are producing meaningful results.

Our direct patient services business continues to grow. Our international operations are gaining momentum, and we have an exciting pipeline of future expansion opportunities that we believe will support long-term value creation. Finally, while we remain focused on strengthening our balance sheet, we have taken important steps to enhance our financial flexibility and remain committed to executing our long-term strategy with discipline and transparency.

I'd like to thank our physicians, clinical teams, employees, hospital partners, and shareholders for their continued confidence and support. We appreciate your interest in American Shared Hospital and look forward to updating you on our continued progress next quarter. Thank you, everyone, and have a great evening.

OPERATOR

The conference has now concluded. Thank you for attending today's presentation. You may now disconnect.

Disclaimer: This transcript is provided for informational purposes only. While we strive for accuracy, there may be errors or omissions in this automated transcription. For official company statements and financial information, please refer to the company's SEC filings and official press releases. Corporate participants' and analysts' statements reflect their views as of the date of this call and are subject to change without notice.