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Iqms Case

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IQMS – At a Strategic Turning Point?
IQ Medical Services (“IQMS”)
A Live Case Prepared for

Florida Intercollegiate Graduate/MBA Business Case Competition
Laura Kozloski
Steve Barnett

Executive Summary
IQ Medical Services (“IQMS”) is based in Miami, Florida, and was founded in 2007. It is an ISO 9001:2000 certified company that operates globally in collaboration with major healthcare corporations such as General Electric (“GE”) Healthcare. IQMS’ purpose has been to design, construct, and service best-in-class turnkey cyclotron facilities for healthcare systems and academic institutions worldwide; their vison – how they “see” they can accomplish this mission – has been to partner with cyclotron manufacturers such as GE and Siemens.
Cyclotron
facilities produce contrast media drugs known as
FDGs
(FluoroDeoxyGlucose) that are injected into patients to detect and diagnosis serious medical conditions. The most common usage is for PET studies, which are diagnostic procedures to determine the extent to which cancer may have spread within a patient’s body. IQMS has partnered with a variety of cyclotron equipment manufacturers accounting for 80% of the 65 projects IQMS has completed in over 30 countries worldwide since 2007.
IQMS’ core expertise includes:
 PET/SPECT Radiopharmaceutical contrast media injection production
 Equipment selection, procurement and installation, start-Up and qualification with integrated multivendor warranty and service solutions
 FDA and equivalent regulatory consulting services
 Project management

Company organization:
IQMS is an extremely efficient operation, currently employing 18 employees worldwide and working with select subcontractors for its different projects. Most employees are based in the company’s Miami headquarters, which houses the majority of the back office operations, including finance, human resources, supply chain, quality, applications and engineering functions. Members of the business development
(commercial) team are responsible for different regions and are located within their

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IQMS – At a Strategic Turning Point? target markets in the United States, Latin America & the Caribbean, Europe and the
Middle East.
Designing, building and making cyclotron facilities ready to operate is a highly sophisticated and technical undertaking, and, thus, the level of expertise required to participate in these projects is very high. To ensure high levels of quality and operational efficiency, many IQMS employees hold master’s degrees and/or PhDs, have engineering and other technical backgrounds, and have significant experience in the industry. IQMS is highly regarded in the healthcare sector and has established partnerships with key medical equipment providers. In fact, in 2012 GE Healthcare make a strategic decision to cease its cyclotron facility start-up activities and informally designated IQMS as its strategic partner for the design and construction of the facilities that house the GE cyclotron equipment as well as for equipment installation and commissioning. As provider of choice, IQMS designs and manages the entire cyclotron facility start-up process, installing and commissioning GE Healthcare cyclotrons and other OEM equipment required within a cyclotron facility. IQMS and GE Healthcare do not have a formal agreement in place; however, they leverage a strong relationship which has years of working together at its foundation. Maintaining this strong relationship with GE
Healthcare is very important for IQMS because members of the GE Healthcare salesforce in the field have the best visibility of potential new cyclotron projects; they then bring IQMS into a project as their partner of choice. In such situations, GE retains
IQMS to complete their cyclotron projects, and IQMS becomes a subcontractor to GE
Healthcare to ensure the proper set-up and functioning of the cyclotron facility. For other projects IQMS is the lead, responding to client requests for proposals (RPFs) or negotiating solutions and contracting directly with a healthcare provider, government entity or academic institution.
What is a PET/CT scan?
A PET/CT scan imaging technique combines positron emission tomography (PET) and computed tomography (CT) into one machine. A PET/CT scan reveals information about both the structure and function of cells and tissues in the body during a single imaging session. Currently, 95% of the PET/CT scans performed by cyclotrons are for cancer patients; the remaining 5% is for neurological and coronary diagnoses.
Neurology will become more significant in the next 20 years; however, oncology will continue to be the key driver for the next 5 years for sure.
During a PET/CT scan, the patient is first injected with a glucose (sugar) solution that contains a very small amount of radioactive material, called a radiopharmaceutical.
Over a short period of time, usually about one hour, the glucose/radiopharmaceutical substance is absorbed by the particular organs or tissues being examined. For the
PET/CT scan, a patient rests on a table and slides into a large tunnel-shaped scanner.
The images produced during a PET/CT scan show the patient’s damaged or cancerous cells where the glucose solution has been absorbed (cancer cells often use more glucose than normal cells) as well as the rate at which a tumor is using the glucose (which can

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IQMS – At a Strategic Turning Point? help determine the tumor grade). The procedure is painless and varies in duration depending on the part of the body that is being evaluated.
Market dynamics:
PET/CT equipment is made by several well-regarded multinational corporations and is widely available in different markets around the world.
However, the challenge healthcare organizations face with regard to offering PET/CT scans to their patients is the difficulty and cost of producing and transporting the radiopharmaceuticals injected into patients for PET imaging. Radiopharmaceuticals have very short useful lives; for instance, the half-life of a dose of radioactive FDG is only two hours. Radiopharmaceuticals must be made within a cyclotron facility, each of which costs between $4 million and $6 million to construct and equip. Ideally, a production line (cyclotron facility) for the radiopharmaceuticals needed for PET scanning should be within a 2 - 3 hour driving radius from the PET/CT machine where the patient will have his/her test.
The cyclotron market is challenging for IQMS and its competitors given the long duration of the entire project cycle, the required advanced level of sophistication and experience of the design and installation team, and relatively small number of projects worldwide. Designing and constructing cyclotron facilities is a relatively slow and methodical process and requires a highly skilled and experienced design and development team.
Most customers take 18 to 24 months to decide to begin a cyclotron project. Once a project is given a go-ahead, the design and construction process lasts another 18-24 months before the equipment is fully installed and operational.
In addition to the long cycle of these types of projects, cyclotron projects call for highly skilled designers and project managers. Areas of expertise required include experience in the nuclear medicine field, ranging from FDA or equivalent regulatory agency experience, experience producing radiopharmaceuticals, and significant experience in managing cyclotron projects. During the design and construction phase, IQMS project leaders must maintain continuous interaction with a local contractor managing the build-out of the facility. The design, construction, and operation of all cyclotron facilities are highly regulated given the radioactive properties of the substances produced by the cyclotron. The high levels of regulation and the inherent challenges of building such sophisticated and complex facilities often result in project delays.
A key business challenge for IQMS is that there are relatively few cyclotron projects per year (approximately 40 cyclotron projects are underway worldwide each year).
IQMS’ long cycle dynamic means that the company must maintain a large pipeline of potential new projects and a healthy backlog (projects that have already issued POs) for a two to three year period to ensure healthy revenue and cash flow positions.
Key Competitors: Competition for IQMS is not easy to define as there are many small consultants, or people with previous experience in building cyclotron facilities

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IQMS – At a Strategic Turning Point? who claim they have the same know-how as IQMS. Although these companies or people may understand what IQMS has to offer, they have neither the infrastructure required to manage these project nor the global expertise of IQMS having executed 65+ projects.
In fact, in most cases, these consultants subcontract to individuals or other companies for executing critical parts of the projects, which most of the time, leads to inefficient and unprofitable project execution.
Nevertheless, IQMS’s staff understands the competitive landscape worldwide and continuously seeks to remain innovative and efficient while expanding the company’s portfolio of equipment and services it provides to the nuclear medicine industry. IQMS’
CEO estimates that its “market share worldwide is around 55%,;Lat Am is in the 80%” range. Key Suppliers: IQMS’s suppliers range from local US suppliers providing standard laboratory supplies to very highly technical complex systems from companies like
Thermo Fischer, Varian, and Comecer Spa. These are global companies whose headquarters are in different parts of the world and rely on IQMS to distribute their products for the nuclear medicine industry. Most of these suppliers require full payment for their equipment before it leaves their factories. With some key suppliers, like
Thermo Fischer and Comecer, IQMS has been able to establish favorable payment terms that allow up to 20% of a payment to be made 60 days after a shipment from their factories. Key Customers: Buyers of cyclotrons differ depending on the healthcare environment of the country in which they will be installed. In countries with strong public healthcare systems, IQMS’ customers tend to be Ministries of Health or other governmental agencies. Such countries include Saudi Arabia, Kuwait, Bolivia, Argentina and Peru.
However, private sector customers are the most common customers worldwide, and they are usually hospitals or academic institutions that want to differentiate themselves from the competition by adding PET/CT scanning capabilities in their facilities so they can provide PET/CT studies to patients. Most of the US, Canada and EU countries have domain expertise in this technology. However, in other countries for which PET/CT technology is new, there is a lack of both the expertise for PET/CT studies as well as for building the cyclotron facilities that produce the required inputs (FDGs) for the PET/CT study itself.
The common bond among all these customers is that rarely do they have the local expertise to build their own cyclotron facilities, and they require help from the beginning of the planning stage all the way through the start-up phase.
Regarding payment terms, most customers pay approximately 30% upon signing a purchase order (“PO”), 60% upon shipment of the cyclotron equipment, and the remaining balance of 10% upon the Site Acceptance Test (“SAT”), which is when a customer formally accepts the completed installation of the equipment.
Timing of shipments and the planning of the equipment are critical for IQMS as they directly impact the company’s cash flows given the differing terms of the payments to its suppliers and payments from the customers. On average, from the time equipment is

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IQMS – At a Strategic Turning Point? ordered, consolidated with all other OEM suppliers, and shipped (meaning the customer has the site ready to accept the equipment), there is a lag of four to six months.
Company Dynamics:
In 2012, the then owner-manager of IQMS decided to bring an executive from a leading cyclotron equipment manufacturer onboard as President and CEO of IQMS. The new
CEO/President, Hernan Lara, was challenged to grow the business by balancing the portfolio of equipment and services IQMS provided and smoothing the company’s cash flow and revenue streams. See Exhibit I for IQMS’ income statements for 2012, 2013,
2014 & 2015. IQMS’ portfolio of services continues to include the same suite of services of design, construction oversight, equipment installation, and equipment commissioning that were offered when Mr. Lara assumed the CEO role in 2012.
Since 2012, the company has grown in key markets such as Latin America, the Middle
East, Algeria, and Russia in both new cyclotron projects and the backlog (Order intake) of new projects.

These new projects as well as revised payment terms established in 2012 improved the company’s cash flow stream. Nevertheless, the long cycle of the projects, delays and high human resource costs continue to present challenges to IQMS.
Looking Forward
As part of the annual budget and strategic planning session that take place during
October and November of every year, IQMS is currently preparing its 2016 business plan and its strategic plan for the coming three to five years. Faced with the challenge of reducing revenue and cash flow volatility as well as in light of an anticipated increased growth of cyclotron projects worldwide, the CEO is analyzing a variety of options to maintain IQMS’ current market leadership position. Mr. Lara needs to determine how to keep IQMS financially healthy both from a balance sheet as well as an Income statement perspective.
The CEO has been exploring a variety of strategic opportunities that need to be carefully prioritized. He knows that his team cannot take on all of the activities he is contemplating. Among the opportunities with the highest priority are:

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IQMS – At a Strategic Turning Point?
1. Invest in new human resources to keep up with the demand of new cyclotron design and construction projects. This option does not call for IQMS to expand beyond its current service offering. Although it does allow for IQMS to continue growing its backlog (orders intake), this strategy does not mitigate the delay and payment risks of its current business model.
2. IQMS’s management team has also expressed concern regarding the company’s dependence on cyclotron equipment manufacturers for new projects. They have suggested investing time and effort in expanding revenue generation through a distribution network in Latin America. Through the new distribution network,
IQMS could add the following to its existing product and service portfolio: consumables, service contracts, and other new products related to nuclear medicine.
Such a strategy would lessen the burden on IQMS’ commercial organization and will generate new potential opportunities. However, it is a strategy that has not been explored in the industry, and it may lead to a dead end.
3. Explore investing capital into a new business opportunity that is within the
Healthcare industry but that generates shorter revenue turnover cycles. Given the good cash flow generated through the revised payment term strategy, there may be an opportunity to invest capital, yet, it is very important that the new business generate a rapid, positive ROI before the cyclotron projects start to require utilization of the capital.
4. Invest in owning and operating a cyclotron facility within IQMS’ headquarters offices in Miami. This option requires heavy investment in capital, but it could present the opportunity for IQMS to have a show-site in its home city, provide the company with a training center for new customers worldwide, and enable IQMS to serve the large market for FDGs in the greater Miami area. There is no cyclotron facility in MiamiDade County, and demand for radiopharmaceuticals in the region is growing. A key benefit of this strategy is that it would enable IQMS to manufacture and distribute traditional and innovative radiopharmaceuticals to area healthcare facilities, generating a steady and continuous stream of revenue for the company that would smooth its historically volatile revenue streams. The cost to build a cyclotron facility in Miami will be approximately US$6 million.

The Issue as of 11/1/15
With a strong team of experts and demand for cyclotrons and PET/CET services growing worldwide, IQMS is at a strategic turning point. Within the next few months the CEO needs to finalize the company’s 2016 plan that solidifies the company’s market position while stabilizing its financial position for the coming years. Please prepare and present your recommendations.

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IQMS – At a Strategic Turning Point?

Glossary:
Cyclotron: a type of particle accelerator in which the particles spiral inside two
Dshaped hollow metal electrodes placed facing each other under theeffect of a strong ver tical magnetic field, gaining energy by a highfrequency voltage applied between these electrodes
PET: Positron emission tomography (PET) is a nuclear medicine, functional imaging technique that produces a three-dimensional image of functional processes in the body. The system detects pairs of rays emitted indirectly by a positronemitting radionuclide (tracer), which is introduced into the body on a biologically active molecule. Three-dimensional images of tracer concentration within the body are then constructed by computer analysis. In modern PET-CT scanners, three-dimensional imaging is often accomplished with the aid of a CT X-ray scan performed on the patient during the same session, in the same machine.
SPECT:
Single-photon emission computed tomography (SPECT, or less commonly, SPET) is a nuclear medicine tomographic imaging technique using gamma rays.[1] It is very similar to conventional nuclear medicine planar imaging using a gamma camera.[2] However, it is able to provide true 3D information. This information is typically presented as cross-sectional slices through the patient, but can be freely reformatted or manipulated as required.
FDG: A glucose (sugar) solution that contains a very small amount of radioactive material. Radiopharmaceutical: radioactive tracer, or radioactive label, is a chemical compound in which one or more atoms have been replaced by a radioisotope so by virtue of its radioactive decay it can be used to explore the mechanism of chemical reactions by tracing the path that the radioisotope follows from reactants to products. Radiolabeling is thus the radioactive form of isotopic labeling.

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IQMS – At a Strategic Turning Point?

Exhibit I – Income statement 2012-2015
$MM
Backlog
Revenue
COGS
Op Exp
Net Profit

$MM
Backlog
Revenue
COGS
Op Exp
Net Profit

Q1

Q2

2012
Q3

Q4

1.62
1.13
1.08
(0.59)

3.20
2.24
1.08
(0.12)

2.70
1.89
1.08
(0.27)

11.28
7.9
1.08
2.30

Q1

Q2

2014
Q3

Q4

4.80
3.36
2.01
(0.57)

4.20
2.94
2.01
(0.75)

4.50
3.15
2.01
(0.66)

20.25
14.18
2.01
4.06

Total
25.45
18.80
13.16
4.32
1.32

Total
157.50
33.75
23.63
8.04
2.08

Q1

Q2

2013
Q3

Q4

3.56
2.49
1.71
(0.64)

3.20
2.24
1.71
(0.75)

3.50
2.45
1.71
(0.66)

15.39
10.77
1.71
2.91

Q1

Q2

2015
Q3

Q4

5.40
3.51
3.09
(1.20)

6.20
4.03
3.09
(0.92)

4.80
3.12
3.09
(1.41)

24.60
15.99
3.09
5.52

Total
28.20
25.65
17.95
6.84
0.86

Total
222.50
41.00
26.65
12.36
1.99

Definitions:
Backlog: Accumulated Purchase Orders received that have not been accounted as revenue. Revenue: Invoiced equipment or service based on established payment terms.
COGS: Cost of good sold. Both equipment and services are included in the COGS
Operating Expenses: All other expenses that are not part of COGS. These include:
Salaries, Travel, Marketing, Utilities, rent, Legal fees, etc.
Net profit: Net income before income taxes. There are no significant depreciation or amortization to be considered.
*Q4-2015 Income statement is estimated, not actual.

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