Neuronetics (STIM) Earnings Call zu Q3 2026: Margenexpansion und positives EBITDA

Neuronetics (NASDAQ: STIM) wies für das dritte Quartal 2026 eine höhere Profitabilität aus, da das Wachstum bei Greenbrook, Optimierungen im Abrechnungszyklus und ein höherer Anteil an Systemverkäufen bei NeuroStar die Margen steigerten. Das Unternehmen hielt an seiner Umsatzprognose für das Gesamtjahr fest und grenzte zugleich mehrere Spannen für Aufwendungen und den Cashflow enger ein.

Wichtigste Erkenntnisse

• Der Umsatz im dritten Quartal 2026 stieg im Jahresvergleich um 12,5 % auf 42,0 Mio. US-Dollar, angeführt von einem Wachstum von 20,1 % bei Greenbrook.
• Die Bruttomarge verbesserte sich von 45,9 % auf 52,2 %, was auf das optimierte Abrechnungsmanagement bei Greenbrook und die neue Go-to-Market-Strategie für NeuroStar zurückzuführen ist.
• Das operative Ergebnis erreichte 0,5 Mio. US-Dollar nach einem Fehlbetrag von 7,3 Mio. US-Dollar im Vorjahr. Das bereinigte EBITDA verbesserte sich von minus 4,7 Mio. US-Dollar auf plus 1,9 Mio. US-Dollar.
• NeuroStar erzielte Rekordverkäufe bei Systemen. Mehr als die Hälfte der im Quartal verkauften Einheiten entfiel auf Kauf- oder Leasingverträge, was die durchschnittlichen Verkaufspreise und die Bruttomarge stützte.
• Die Unternehmensführung bestätigte ihre Umsatzprognose für das Gesamtjahr 2026 von 160 Mio. bis 164 Mio. US-Dollar und hob das untere Ende der Prognosespanne für die Bruttomarge auf 49 % an.
• Die Auslastung der Greenbrook-Kliniken lag zwischen rund 25 % an den schwächsten und 75 % an den stärksten Standorten, womit die Kapazitätsauslastung ein zentraler Hebel für die Profitabilität bleibt.

Wichtigste Finanzergebnisse

Geschäfts- und operative Entwicklung

Greenbrook treibt Wachstum und Margenverbesserung voran

Der Umsatz von Greenbrook erreichte 26,2 Mio. US-Dollar, gestützt auf eine bessere Patientenqualifizierung, fehlerfreiere Abrechnungsanträge, einen effizienteren Forderungseinzug und ein zweistelliges Wachstum bei SPRAVATO. Die Unternehmensführung bezeichnete die Erlöse aus SPRAVATO als relativ stabil, da Patienten in eine Erhaltungsphase übergehen können.

Das Unternehmen begann mit der Einführung von Skypoint, einem KI-gestützten Tool zur Optimierung der Abrechnungscodierung. Nach Angaben der Unternehmensführung führte die Prozessanpassung zu einer Verbesserung der Zahlungseingänge im ersten Monat im niedrigen zweistelligen Prozentbereich und ermöglichte es zugleich, Mitarbeiter im Backoffice für andere Aufgaben einzusetzen. Die meisten Zuwächse im Abrechnungszyklus wurden als nachhaltig eingestuft, wenngleich ein Teil der Erträge Nachholeffekte bei Zahlungseingängen aus früheren Perioden widerspiegelte.

Neuronetics plant, einen Teil seines Werbebudgets für Endverbraucher (Direct-to-Consumer) in die Außendienstorganisation von Greenbrook umzuschichten. Das Unternehmen beabsichtigt, sein bestehendes Team von 20 Mitarbeitern um acht Vertreter auf 28 im Verlauf des ersten Quartals 2027 aufzustocken, ohne die gesamten Vertriebs- und Marketingaufwendungen zu erhöhen. Die Unternehmensführung rechnet damit, dass die neuen Vertriebsmitarbeiter bis Mitte 2027 einen spürbaren Beitrag leisten werden.

Systemverkäufe von NeuroStar gleichen geringere Behandlungserlöse aus

Der Umsatz von NeuroStar stieg um 1,8 % auf 15,8 Mio. US-Dollar. Rekordverkäufe bei den Systemen und ein kräftiges zweistelliges Wachstum bei Investitionsgütern wurden teilweise durch geringere sitzungsbasierte Erlöse ausgeglichen, während das Unternehmen seine erweiterte Go-to-Market-Strategie umsetzte.

Die Unternehmensführung erwartet, dass der Umsatzmix von NeuroStar weiterhin stärker auf Systemverkäufe ausgerichtet bleibt, während die sitzungsbasierten Erlöse tendenziell leicht nachgeben dürften. Allerdings verzeichneten vergleichbare Kunden, die bereits ein Jahr zuvor aktiv waren, einen leichten Anstieg des Sitzungsvolumens.

Das Unternehmen reichte im August einen 510(k)-Antrag bei der FDA für ein beschleunigtes TMS-Protokoll ein. Zudem schloss es eine Vertriebsvereinbarung mit Wave Neuroscience zur Integration des MeRT-Systems von Wave in NeuroStar ab – vorbehaltlich der Pläne, eine FDA-Freigabe zu beantragen, um NeuroStar als kompatibles System für die PTBS-Indikation von Wave zuzulassen.

Neuronetics verknüpfte zudem seine Praxismanagement-Plattform TrakStar mit AdvancedMD. Die Integration, die qualifizierten NeuroStar-Anbietern im vierten Quartal 2026 zur Verfügung stehen soll, soll doppelte Dokumentation reduzieren und Behandlungsdaten mit Terminplanung, Krankenakten sowie Abläufen im Abrechnungszyklus verbinden.

Vorbereitung von Greenbrook auf COMP360

Neuronetics setzte im Vorfeld der erwarteten Markteinführung von COMP360 gegen therapieresistente Depressionen die Zusammenarbeit mit Compass Pathways fort. Die Unternehmensführung erklärte, dass Compass mit dem Abschluss seiner FDA-Einreichung in etwa zwei Wochen rechne und eine Markteinführung in der ersten Jahreshälfte 2027 erwarte.

Greenbrook beabsichtigt, zunächst mit einem Hub-and-Spoke-Modell zu starten, anstatt die Therapie sofort in allen 84 Kliniken anzubieten, die derzeit SPRAVATO verabreichen. Zu den Vorbereitungen gehören Mitarbeiterschulungen, die Ansprache von Ärzten und Leistungserbringern, Kostenübernahmeprüfungen sowie Vorbereitungen mit Kostenträgern.

Prognose der Unternehmensführung

Die Unternehmensführung strebt für die zweite Jahreshälfte 2026 weiterhin einen geringen bis gar keinen Netto-Mittelabfluss aus der operativen und Investitionstätigkeit an. Zudem wird erwartet, dass der Umsatzmix von NeuroStar im vierten Quartal weiterhin leicht in Richtung von Systemverkäufen tendiert.

Risiken und Beobachtungspunkte

• Für die sitzungsbasierten Erlöse von NeuroStar wird ein leicht rückläufiger Trend erwartet, da Kauf- und Leasingabschlüsse einen größeren Anteil am Umsatzmix einnehmen.
• Die Auslastung bei Greenbrook bleibt uneinheitlich und bewegt sich zwischen etwa 25 % und 75 %, während von den neuen Vertriebsmitarbeitern erst ab Mitte 2027 ein spürbarer Beitrag erwartet wird.
• Die Unternehmensführung rechnet damit, dass künftige Verbesserungen im Abrechnungszyklus moderater ausfallen werden, nachdem die einfacheren Effizienzgewinne bereits realisiert wurden.
• Die anfängliche Kostenübernahme durch Kostenträger für COMP360 könnte auf Einzelfallvereinbarungen beruhen, bis sich etablierte Erstattungsstrukturen herausgebildet haben.
• Das beschleunigte NeuroStar-Protokoll befindet sich weiterhin in der Prüfung durch die FDA, während die geplante PTBS-Integration von NeuroStar und Wave Neuroscience vor der Markteinführung noch eine zusätzliche behördliche Freigabe erfordert.

Wichtigste Punkte aus der Analysten-Fragerunde

• Wachstum bei Greenbrook: Die Unternehmensführung führte den Anstieg sowohl auf Verbesserungen im Abrechnungszyklus als auch auf das Wachstum bei SPRAVATO zurück und nicht in erster Linie auf die Auslastung der Kliniken oder den Standortmix.
• Qualität der NeuroStar-Verkäufe: Die Rekordverkaufszahlen bei den Geräten bezogen sich auf neue Systeme oder Behandlungsliegen und nicht auf buchhalterische Umstellungen bei bestehenden sitzungsbasierten Kunden. Mehr als die Hälfte waren Kauf- oder Leasingtransaktionen.
• Nachhaltigkeit des Abrechnungszyklus: Nach Angaben der Unternehmensführung dürften die meisten Verbesserungen von Dauer sein, da Skypoint die Zahlungseingänge beschleunigt und arbeitsintensive Abrechnungsprozesse reduziert.
• EHR-Erweiterung: Neuronetics wird die Akzeptanz und den Kundennutzen der AdvancedMD-Integration evaluieren, bevor weitere EHR-Partnerschaften priorisiert werden.
• Flexibilität bei der TMS-Behandlung: Eine Analyse von mehr als 6.400 NeuroStar-Patienten ergab keinen statistisch signifikanten Unterschied bei den Behandlungsergebnissen für Patienten mit Therapieunterbrechungen, selbst bei Unterbrechungen von bis zu 13 Tagen. Die Unternehmensführung ist überzeugt, dass dies Vorbehalte von Patienten vor Beginn einer Behandlung verringern könnte.

Vollständiges Transkript der Telefonkonferenz

Vollständiges Transkript der Telefonkonferenz

Ausführungen des Managements

Operator

Good day, and thank you for standing by. Welcome to the Neuronetics Reports Third Quarter 2026 Financial and Operating Results Conference Call. [Operator Instructions] Please be advised that today's call is being recorded. I would now like to hand the conference over to your first speaker today, Aman Patel with ICR Healthcare. Please go ahead.

Aman Patel

Good morning, and thank you for joining us for the Neuronetics Third Quarter 2026 Conference Call. Joining me on today's call are the Neuronetics President and Chief Executive Officer, Dan Reuvers; and Chief Financial Officer, Nir Naor.

Before we begin, I would like to caution listeners that certain information discussed by management during this conference call will include forward-looking statements related to our business strategy, financial and revenue guidance and other operational issues and metrics. Actual results can differ materially from the company's business. For a discussion of risks and uncertainties associated with Neuronetics business, I encourage you to review the company's filings with the Securities and Exchange Commission, including the company's annual report on Form 10-K, which was filed in March and the company's quarterly report on Form 10-Q for the quarter ending March 31, 2026.

The company disclaims any obligation to update any forward-looking statements made during the course of this call, except as required by law. During the call, we will also discuss certain information on a non-GAAP basis, including EBITDA. Management believes that non-GAAP financial information taken in conjunction with U.S. GAAP financial measures provides useful information for both management and investors by excluding certain noncash and other expenses that are not indicative of trends in our operating results. Reconciliation between U.S. GAAP and non-GAAP results are presented in the tables accompanying our press release, which can be viewed on our website.

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

Daniel Reuvers

Thanks, Aman, and good morning, everyone. Thank you for joining us for our third quarter 2026 earnings call. I'll first walk you through the quarter, reviewing our results on each side of the business, and then I'll turn it over to Nir to discuss our financial results in greater detail. I'll then come back with how we're thinking about the rest of the year and the setup for 2027 before opening it up for questions.

Turning to the quarter. We continue to execute against the profitability and operating cash goals we outlined earlier in the year, and we made meaningful progress on both fronts. Total revenue for the quarter was approximately $42 million, up over 12% versus the third quarter of last year. The results reflect a record quarter for NeuroStar system sales, driven by a welcome reception from customers toward our expanded go-to-market strategy as well as continued strength within our Greenbrook clinics as we realize ongoing impacts of our revenue cycle management efforts.

Diving deeper into our NeuroStar performance, let me start there. Total worldwide revenue was $15.8 million, up approximately 2% year-over-year. This was primarily driven by our capital equipment business, where we had a record quarter of system sales. We saw strong double-digit year-over-year performance here, and I believe it's being positively impacted by the go-to-market changes we introduced earlier this year. Notably, we believe many of these placements are with customers we would not have been able to compete for with our prior approach, including a recently awarded sole-source agreement with a large national player.

The strength of our capital business was partly offset by sessions revenue being down versus last year, which was expected as we implement our new sales strategy. We continue to expect the overall revenue mix to be weighed more towards NeuroStar Capital versus sessions going forward as we execute on our plan. As such, we expect session revenue to continue to trend slightly downwards. We believe that our go-to-market changes position us well to compete in a broader segment of the market and expect to yield higher overall net growth in 2027 and beyond.

It's also worth reiterating that for customers preferring our treatment session model built around a high-touch partnership with Neuronetics, nothing changes. We believe this sessions model continues to set us apart as we believe we're uniquely equipped to help emerging TMS practices establish a profitable therapy adjunct.

NeuroStar customers perform almost twice as many treatments per chair as the competitive landscape, a velocity differentiator we believe directly reflects the support and affirmation of value we bring. During the quarter, we also had several noteworthy advances that reinforced our commitment to growing the NeuroStar platform. On the regulatory front, in August, we submitted a 510(k) to the FDA for an accelerated TMS protocol and it's currently under review. We expect that condensed protocols can be an advantage for some patients, and this could be another way to expand access to TMS for even more patients.

We also had an important publication in the TMS Journal titled The Impact of Treatment Gaps on the Effectiveness of Transcranial Magnetic Stimulation in Major Depressive Disorder. The paper reflected analysis of over 6,400 patients whose depression was treated with NeuroStar under real-world conditions. It showed that approximately 15% of patients completed their treatment course with no gaps, leaving 85% of patients who missed 1 or more scheduled treatment days. Since missed days can be common, patients and physicians often wonder if a missed treatment day may negatively affect outcomes. The analysis found that there was no statistically significant difference in outcome between patients that experienced a gap in their treatment versus those that didn't. It further concluded that missing treatment for up to 13 days did not reduce effectiveness.

This is an important consideration as patients may otherwise put off initiating treatment based on their availability to commit to an uninterrupted sequence of days. Lastly, we signed a distribution agreement with Wave Neuroscience to integrate its MeRT system with NeuroStar. MeRT uses EEG data to personalize TMS protocols and received FDA clearance in June for treating adults with post-traumatic stress disorder, achieving 68% remission in its pivotal trial.

Prior to launch, we plan to seek FDA clearance to add NeuroStar as a TMS system compatible with Wave Neuroscience's PTSD indication. Approximately 9 million U.S. adults experience PTSD annually with an estimated 4-plus million of those seeking treatment. Thus, this partnership represents a significant opportunity to expand NeuroStar's clinical application. On the operational front, we announced in September what we believe is the first ever integration between a TMS system and an Electronic Health Record, or EHR, connecting our TrakStar practice management platform with AdvancedMD, a cloud-based EHR, practice management and revenue cycle platform serving more than 65,000 practitioners across 13,000 independent practices, including our own Greenbrook clinics.

Delivering TMS means coordinating care across a multi-session course of treatment, along with documentation and clinical notes, while claims and authorizations are often managed in separate systems. This creates duplicate work for practices. With this integration, treatment data flows into the same system where a practice manages its schedule, clinical records and notes and revenue cycle. It will be available in the fourth quarter to NeuroStar providers already using AdvancedMD.

We use AdvancedMD as our EHR at our Greenbrook clinics. So we expect to benefit from this efficiency just like our NeuroStar customers. This inaugural integration further paves the way for us to integrate TrakStar into additional EHRs, extending additional practice efficiencies to NeuroStar customers and prospects alike.

Moving to Greenbrook. Revenue was approximately $26 million, up over 20% year-over-year. Our work on revenue cycle management continued to produce results with better patient qualification, cleaner claims, and more efficient collections, all helping us convert more of each billed dollar to cash. This quarter, we also began deploying Skypoint, an AI-enabled coding optimization tool, which builds on automation technology established earlier this year. This advances the operational discipline we've been building throughout the organization by ensuring insurance claims are submitted quickly and accurately. We are very encouraged by the early results and believe there's still runway ahead for us.

We continue to believe that filling the capacity in our existing clinics remains an important profitability lever. Our focus will continue to be on finding the most efficient ways to serve even more qualified patients that can benefit from our therapies. Two key measures that we monitor closely are relative return on our direct-to-consumer advertising and field sales team effectiveness. We determined, based on what we're seeing to date, that field sales personnel deliver the better return and give us more control over patient acquisition cost and yield. As a result, we're shifting a portion of our direct-to-consumer ad spend towards expanding our Greenbrook field sales team. We expect this to sponsor a bigger sales team without increasing overall sales and marketing expense. We plan to begin this process in the fourth quarter.

We expect the new reps to be fully ramped up and contribute meaningfully by mid-'27. As we execute this strategy, we will update you on our progress. Overall, this quarter, we continued doing what matters most, executing against our new go-to-market strategy for NeuroStar while competing for customers who were previously out of reach, running our Greenbrook clinics more efficiently and delivering on our goals towards profitability and cash generation.

With that, I'll turn it over to Nir to take you through the financials, and then I'll come back with our outlook for the rest of the year. Nir?

Nir Naor

Thank you, Dan, and good morning, everyone. Unless otherwise noted, all comparisons are third quarter 2026 versus third quarter 2025. Total revenue in the third quarter was $42 million, an increase of 12.5% compared to $37.3 million in the third quarter of 2025. The increase was primarily driven by higher Greenbrook revenue. Greenbrook revenue was $26.2 million, a 20.1% increase. These results reflect continued growth of our Greenbrook business and operational gains across our clinics.

NeuroStar revenue was $15.8 million, an increase of 1.8%. As Dan explained, strong capital sales were partially offset by a decline in session revenue as we implement our new go-to-market strategy. Gross margin was 52.2% in the third quarter of 2026 compared to 45.9% in the prior year quarter. The increase was driven by a positive impact of our new go-to-market strategy and improved revenue cycle management within the Greenbrook clinic.

Operating expenses during the quarter were $21.3 million, a decrease of $3.1 million or 12.6% compared to $24.4 million in the third quarter of 2025. This was primarily due to lower sales and marketing expenses, partially offset by higher general and administrative expenses. Income from operations was $0.5 million compared to a loss of $7.3 million in the prior year quarter, an improvement of $7.9 million. Net loss attributable to Neuronetics stockholders was $1.7 million or $0.02 per share as compared to a net loss of $9 million or $0.13 per share in the prior year.

Third quarter adjusted EBITDA was $1.9 million as compared to a loss of $4.7 million in the prior year, an improvement of $6.6 million. Moving to the balance sheet and cash flow. As of September 30, total cash was $27.9 million, consisting of $22.1 million of cash and cash equivalents and $5.8 million of restricted cash as compared to total cash of $34.1 million as of December 31, 2025. Cash provided by operating and investing in the third quarter was $0.8 million compared to negative cash flow from operating and investing of $0.9 million in the prior year.

Now turning to guidance. For the full year 2026, we expect total revenue between $160 million and $164 million, unchanged from previous guidance. Gross margin between 49% and 50% compared to prior guidance of 48% to 50%. Operating expenses, excluding stock-based compensation of between $89 million and $92 million with estimated stock-based compensation of $3.5 million compared to prior guidance of $91 million to $96 million and stock-based compensation of $4 million.

Operating expenses between $92.5 million and $95.5 million compared to prior guidance of $95 million to $100 million. Cash flow from operating and investing in the range of negative $10 million to negative $12 million compared to prior guidance of negative $10.5 million to negative $14.5 million. We continue to target limited to no net cash utilization from operating and investing in the second half of the year.

In summary, this was a quarter of solid financial progress. We grew revenue, expanded gross margin, reduced operating expenses and delivered positive adjusted EBITDA and positive cash flow from operating and investing. Our goal is to turn this progress into sustained profitability and cash flow generation, and I look forward to building on this momentum into Q4 and next year.

With that, I'll turn it back to Dan for his closing remarks.

Daniel Reuvers

Thank you, Nir. I'd like to take this time to recognize and thank our Neuronetics colleagues for their efforts in the clinics, field, and across the organization. Their effort is what delivers value to our patients and the strong performance we're seeing.

As Nir discussed, we're pleased to have delivered another strong quarter, driven by both our go-to-market strategy in NeuroStar as well as our continued momentum at Greenbrook. At the same time, we're making meaningful progress toward profitability and cash generation and we believe we're well positioned for sustained overall growth in 2027.

In addition to the progress we've been making with NeuroStar, Greenbrook and operationally, we also continued our collaboration with Compass Pathways to prepare for the anticipated commercial launch of their psychedelic therapeutic for treatment-resistant depression, or TRD. Compass recently reported 52-week data from its Phase III COMP-005 trial, showing that an additional dose of COMP360 extended the benefit in TRD out to 1 year, which we believe further supports COMP360's differentiated profile and potential for long-lasting benefit.

Compass has reported that they expect to complete their FDA submission in approximately 2 weeks with the launch expected in the first half of 2027. We continue to believe therapies like this will need exactly the kind of delivery platform that we already operate for SPRAVATO, including a dignified in-office drug administration experience, along with monitoring, REMS programs, trained clinical staff, benefits investigation and prior authorization infrastructure.

Greenbrook's experience, scale, and available capacity position us to be an early leader as we look forward to providing the most comprehensive menu of interventional psychiatry options for patients. Looking to the fourth quarter, we continue to expect NeuroStar revenue mix to be weighted slightly towards NeuroStar capital as our expanded go-to-market and targeting efforts take root. For Greenbrook, we're deliberately rebalancing our sales and marketing spend with the goal of positioning us for sustained growth in 2027. And with that, operator, we're ready to open the line for questions.

Operator

[Operator Instructions] Our first question comes from the line of John Young with Canaccord.

Fragen und Antworten

John Young

Congratulations on the quarter. I want to focus on Greenbrook and the performance that you are seeing there. How much of the growth in Q3 was pricing or revenue cycle gains versus just overall patient volume increases? And can you talk about the unused capacity that continues to exist today?

Daniel Reuvers

Sure. Thanks, John, for the questions. First of all, revenue cycle management, I would say, is an area that we've continued to demonstrate really solid progress. So the growth was a combination of revenue cycle management, and we saw growth in SPRAVATO as well. I think we've described the SPRAVATO business as certainly more durable because there's a maintenance phase that patients continue within once they come into network. So it's really a combination between those 2.

I'm really -- I'm pleased with the revenue cycle progress we continue to make as well. I think it really demonstrates that we're positioning ourselves foundationally with just a better run business. From an occupancy standpoint, that continues to be an area of focus. And it's one of the reasons that we're making some of the changes in our go-to-market approach commercially trying to put more of our resources into expanding the sales team and revisiting the utility or efficiency of our direct-to-consumer ad approach.

We've got a pretty big range, John, in occupancy. I'd say it's as low as 25% probably at the bottom and as high as 75% in our highest performers. But clearly, that's a big range, and we want to continue to move that bottom quartile up. So I think the -- some of the changes that we're making, as I said, we expect will certainly have impact as we go into 2027.

John Young

Thanks, Dan. And then just to double-click on SPRAVATO, too. I think last time we checked, you were at 84 sites that you're offering it. Has that changed? And then looking at J&J and their reported sales, I believe SPRAVATO grew about 36% year-over-year. I'm not sure if you're willing to quantify the contribution in a dollar amount that it contributed in Q3. But is that a good way to think about your growth as well, that 36% year-over-year growth?

Daniel Reuvers

Yes. I don't know if we've given that number in SPRAVATO growth. But certainly, as I mentioned, we've seen double-digit growth in SPRAVATO. And again, I think it's a laddered approach as patients come into the network and then continue on a maintenance phase. So the growth that we do see in SPRAVATO, we expect will continue to be quite durable.

Operator

Our next question is from Madison El-Saadi with B. Riley.

Madison Wynne El-Saadi

Congrats on the progress. A couple from us. Maybe on the Compass pilot, have you said how many clinics would be involved in that pilot program? I'm curious how you picked them and what needs to be true before you would roll this out across the network? And Greenbrook ran a SPRAVATO pilot back in 2021. Obviously, that was in the wake of COVID, but just wondering if that's a good proxy. And then a follow-up, if I may, afterwards.

Daniel Reuvers

Yes. Thanks for the question, Madison. We haven't shared how many sites we're going to introduce initially, but I think it's fair to assume that we'll probably initially start with a bit of a hub-and-spoke model. I don't know that we feel obligated to provide it in every one of our 84 SPRAVATO clinics that exists today as much as we want to be in each of the MSAs that we're in. So I think that's probably the key for us.

We expect we will learn a lot with the introduction. And what we're focused on right now are the work streams that are within our control. So things like making sure that we've got training programs and curriculums clearly established for both our caregivers and our sales teams. And I think the next one is taking an extension of that once our sales teams are trained, making sure that we've got a very thoughtful and targeted approach to HCP outreach from our field teams.

And then our whole benefit investigation piece and payer relations team is also attempting to ramp up their readiness. A lot of this in the early days is still going to be hand-to-hand combat. I mean single case agreements initially will likely rule the day until we see some of the coverage components become a bit more mature. But ultimately, we're -- we've got a very dedicated work stream to each of those, and we're downstream with our mitt open and ready to catch.

Madison Wynne El-Saadi

Awesome. And if I may, a second question related to NeuroStar. Sorry if I missed this. But how much of the record system sales was capital and lease conversions of your existing session customers versus new accounts? And then the treatment volume on the installed base grow in 3Q?

Daniel Reuvers

Sure. Yes. First, the question about mix, we do continue to see our mix moving more towards capital and lease. We're not recognizing unit sales if it's an existing customer that just paid off something. So these are new boxes or new chairs and new systems that are going out when we talk about a record number of units.

I think the other thing that we saw was over half of all of our units sold in Q3 were capital or lease units. That was good for ASP. It's also good for gross margin. And I think it's also a reflection that our customers appreciate the choices that we've given them. We're allowing customers to determine where the value they think is. And while the sessions did grow among like customers, so customers that were customers a year ago, modest, but we did see growth on the session side from those customers.

What we're also seeing is that when we start to focus more on larger accounts, multisite accounts, national accounts, enterprise, some of the things that have kind of become our hallmark, which is we can help you with marketing. We can help you build your practice with co-op. We can help you with training, reimbursement assistance, benefits investigation. I mean, bigger systems, they don't need some of those things like the private practice psychiatry offices do. So that's why, again, we've made the choice to expand our aperture on how we go to market, and we've been actually quite pleased on the kind of reception we're getting from each independent type of customer. We think we've got a value proposition for them.

Madison Wynne El-Saadi

Congrats again on the quarter.

Operator

Our next question comes from the line of Sam Eiber with U.S. Bancorp BTIG.

Sam Eiber

Congrats on a nice quarter here. Maybe I can start on Greenbrook and coming back to the revenue cycle management improvements. I guess I'm curious the durability of some of the progress that you made there and ability to, I guess, keep advancing some of that benefit into 2027. And then I'll have a quick follow-up question.

Daniel Reuvers

Sure. Thanks. Sam, I think I've talked a lot about the value drivers within Greenbrook. And I think foundationally, the first one is continued demonstration of improvement in our revenue cycle management approach. I think that the short answer is I think most of these changes are quite durable.

We talked a little bit about deploying an AI-enabled new partner, Skypoint. There's a lot of components of processing a claim that are largely labor-intensive. We have to pair clinic notes depending on who the payer is, what the requirement is, making sure that we're matching up everything for each individual payer, starting to use some software tools, including some AI optimization is bearing fruit. I can tell you that when we deployed Skypoint, just that change in workflow has led to a low double-digit improvement in the first month of collections. So we don't obviously collect all of our collections in the first month.

There's some that gets -- comes in, in month 2, month 3, month 4. But importantly, the faster we can collect, the better it is for the business, of course. And we saw meaningful progress from some of those changes. It also reduced some of the headcount in the back office which we were able to redirect into some other roles. So I do think that there is both durable impact from our efforts and I think there's continued improvement available to us. But I would also add, we're going to have to keep climbing a little higher on the tree to find the fruit. As we continue to get better, the improvements will become a bit more modest, but I do think that there's more runway ahead for us.

Nir Naor

Build on that, Sam. So yes, as Dan mentioned, the very nice improvements that we have done, some further improvements that we can do just built off of them. And basically, the only thing if you look at our, say, gross margin compared to the prior year, those improvements are, for the most part, durable. The ones that are not are simply some prior period RCM catch-ups. But otherwise, yes, they are durable, and we're building on them.

Sam Eiber

Okay. That's great. Makes sense. And then a quick follow-up on the EHR integrations. I'm curious how much of a selling point and maybe a competitive advantage that is seamlessly integrating the EMR platform. And then I think you hinted at maybe additional integrations coming with maybe some of the bigger platforms. Curious if you're able to put any sort of time line on when that might be?

Daniel Reuvers

Sure. Yes, I think that the AMD-TrakStar integration was an important first step for us. And there's a fairly fragmented EHR network of providers out there. AMD is the larger of a pretty long tail of EHRs. So that's why we selected them. We also selected them in part because that's who we use at Greenbrook. So not only could we benefit from the efficiencies of integrating the EHR with TrakStar, but we can also obviously bring it to our NeuroStar customers.

Our goal is to make sure that we are focused on existing AMD customers that aren't yet NeuroStar customers because we think that we bring another very unique value proposition that's unavailable to our competitors. It's -- there's a lot of work that goes on in managing the documentation within health care, as you know. So charting, all the clinic notes, et cetera, often have to be transcribed, entered into 2 places. This allows our clinician customers to be able to do that just once. It also enriches our own TrakStar data. We've talked a lot about how rich and unique the database that we continue to collect within TrakStar is. This will allow us to start to collect even more information on each of those patient experiences, including was the patient pregnant, what medications were they on, all of which I think can continue to be a powerful pool of data that will be available to us.

I think as far as next EHR partners, we're going to monitor how we do with the existing AMD user base, assuming that we can demonstrate the improvements and our customers find value in that. Certainly, we will start to sequence the second and third and subsequent EHRs. We've got a pretty good prioritized list but I want to see that we can make sure that we demonstrate the value through the AMD partnership as a bit of a predicate.

Operator

Our final question comes from the line of Daniel Stauder with Citizens JMP.

Daniel Stauder

I just wanted to follow up on some of the questions for -- on the segment level in terms of margin, specifically on clinics. So strong improvement in gross margin, even more so on the operating margin, and you gave some commentary there already. But was there anything else beyond your progress on efficiency and workflow there that led to a benefit, maybe broader change in the average occupancy or some product mix benefits within clinics.

And it sounds like you still think there's room to improve, but with that incremental sales rep investment, do you think that's going to be absorbed pretty well into margins? Just how should we think about that?

Daniel Reuvers

Sure. I think there's probably 2 components to the margin, and let me just revisit the rep cost issue. On Greenbrook, most of the margin improvement was better revenue cycle management, more so than mix. I think on the NeuroStar side, it's a mix function. We continue to see, as I said, more than half of our capital units went out -- more than half of our units went out as capital or lease purchases. And when that happens, they go out at a premium. So I think the combination between those 2 were probably the most significant contributors on the gross margin side. Just back to the rep cost. Our goal is to add 8 reps to our already base of 20 that would take us to 28 by sometime in Q1. We don't expect any incremental cost associated with that. And it doesn't -- it's not magic. It's just we're going to repurpose a number of the dollars that are going into direct-to-consumer adds and sponsor more salespeople.

And we've done enough data dive to be quite convinced that our return on our field salespeople is much higher. First of all, they have access to pharma data. We know who the prescribers are at a primary care or psychiatry office in the communities where we have Greenbrook clinics. We also know how many patients each of them treat with 2 or more MDD drugs. So it's easier to target the right audience. And what we find is the patients that are referred to us from those practices are come in much better qualified and more likely for us to be able to help them.

Patients who come in through DTC, while they're well intentioned and we'd love to help them if they don't qualify, if they haven't failed on 2 meds, we can't, yet it can clog up our intake teams as well, trying to help patients that ultimately won't qualify and we can't get them into a treatment room. So I think that we expect the yield to be better and we also expect that our allocation of sales and marketing dollars to provide a better return for us.

Daniel Stauder

That's great color. And just a follow-up there. You hit on NeuroStar margins. Just with some of the shifting dynamics with capital, even within capital and session mix, how should we think about a more steady state gross margin here as this normalizes the levels we've seen this quarter and in 2Q, what we should think about going forward? Or is there any puts and takes we should consider?

Daniel Reuvers

Yes. I don't know that I would predict any dramatic swings in gross margin on NeuroStar. I think we're already starting to see the mix settle in a little bit more to a predictable future state mix. So I think we're starting to see a reflection of what that margin might look like. So I think it continues to depend on what the adoption rates are in our offering. But at this point, I don't know that I would expect any dramatic swings either way on gross margin from what we've seen more recently.

Daniel Stauder

Great. And I'll try to squeeze one more in here. Just you talked about some of that data on gap in treatment and missed days. Do you feel that this could alter how providers think about treatment regimens in the future? And how could that give patients more flexibility and optionality? And what's the pathway for that potential change becoming a reality?

Daniel Reuvers

Yes. I think that's a great question. And I think it's an important one. This is the reference to the article in the TMS Journal that we had published demonstrating that a patient could miss days as many as 13 days. It doesn't mean that they don't get their full treatment. It just means that there could be lapses in those days. And with up to 13 days of missed treatments, there was no demonstrated reduction in effectiveness.

And I think the relevance there is that for patients that have been reluctant to say, yes, I will go ahead and start a regimen of TMS. I think a lot of them may -- like all of us in life, life is busy. And gee, I've got a commitment next week or there's a holiday trip I'm going to take or my kids are off school that day or I can't get off work, whatever it might be, it's a commitment to be in TMS therapy for 7 weeks. The ability to be able to understand that I can actually take a break and still get the benefit, I think it's a welcome mat for patients that have been reluctant to start or for referral sources for the same reasons, who've been reluctant to send them our way.

And then even in the fourth quarter, you think about holidays, a lot of times, patients may be reluctant to start. The message that I think this sends resoundingly is start now, don't wait. If there has to be a break, there has to be a break but suffering from depression can be a debilitating condition. So we want to help patients start to initiate the therapy as quickly as we can.

Operator

This concludes the question-and-answer session. I would now like to turn it back to Dan Reuvers for final remarks. Dan?

Daniel Reuvers

Thank you, and thanks for everybody for participating and joining us for the call. We're delighted to continue to demonstrate progress, and we certainly look forward to sharing our full year results once they're completed in 2027. Until then, thank you again.

Operator

We appreciate you for participating in today's conference call. This does conclude the presentation. You may now disconnect. Thank you.