Conferencia de resultados del 3T de 2026 de Guardian Pharmacy (GRDN): el EBITDA sube un 24%, eleva las previsiones

Puntos clave

• Guardian Pharmacy Services (GRDN) atendió a aproximadamente 218.000 residentes al cierre del trimestre, lo que supone un incremento interanual en el rango alto de un solo dígito, mientras que el volumen de recetas aumentó un 10%.
• Los ingresos del tercer trimestre de 2026 cayeron un 1,7% hasta los 371 millones de dólares debido a las reducciones de precios de medicamentos asociadas a la IRA. La dirección señaló que, sin dicho impacto, los ingresos habrían crecido en el rango alto de un solo dígito.
• El beneficio bruto aumentó un 14% hasta los 85,2 millones de dólares, con una mejora secuencial del margen bruto hasta el 23%, impulsado por iniciativas en materia de reembolsos, compras, optimización de planes y vacunación.
• El EBITDA ajustado aumentó un 24% hasta situarse en 33,9 millones de dólares, lo que representa un margen del 9,1%. El beneficio neto se elevó a 19 millones de dólares frente a los 9,6 millones del año anterior.
• La dirección elevó sus previsiones para todo el ejercicio 2026 a unos ingresos de entre 1.440 y 1.460 millones de dólares y un EBITDA ajustado de entre 136 y 138 millones de dólares.
• Guardian cerró el trimestre con aproximadamente 120 millones de dólares en efectivo y sin deuda, lo que le otorga capacidad para financiar expansiones desde cero (greenfield) y adquisiciones sin recurrir a financiación externa.

Datos financieros clave

Desempeño operativo y del negocio

El crecimiento estuvo impulsado principalmente por el aumento de residentes y del volumen de recetas. La dirección indicó que la mejora de los reembolsos, las iniciativas de compras, la optimización de planes y el programa de vacunación también respaldaron los ingresos y los márgenes.

Los medicamentos genéricos representan más del 90% del volumen de recetas de Guardian y generan la mayor parte de su beneficio bruto. La compañía está trabajando con entidades pagadoras asociadas en un modelo de reembolso que dé mayor prioridad a las recetas de genéricos y alinee mejor los resultados financieros con su combinación de dispensación.

La farmacia de nueva creación (greenfield) de Guardian en Lexington, Kentucky, ya está operativa. La compañía también está desarrollando nuevas ubicaciones en Houston, Texas, y Huntsville, Alabama, que se convertirán en su segunda farmacia en cada uno de estos estados.

La adquisición de Wellness Concepts en Virginia se cerró en julio y su integración sigue según lo previsto. Guardian también completó la adquisición de activos de Nautilus y transfirió a sus residentes a 18 farmacias existentes de Guardian. La dirección describió la operación como ligera en activos (asset-light) y afirmó que debería generar valor rápidamente una vez absorbidos los costes de incorporación.

En octubre, Guardian incorporó una pequeña farmacia en Sioux City, ampliando su presencia en el noroeste de Iowa. Además, adquirió Vans Institutional Pharmacy, que atiende a la zona occidental de Tennessee y Kentucky, elevando a cinco el número de farmacias de Guardian en Tennessee.

La dirección estimó la cuota de mercado de Guardian en residencias asistidas en aproximadamente un 14%. Asimismo, señaló que unas 100 farmacias independientes de atención a largo plazo cumplen los criterios habituales de adquisición de la compañía, lo que respalda la continuidad de una doble estrategia de adquisiciones y aperturas adyacentes desde cero.

Previsiones de la dirección

Guardian elevó sus perspectivas para todo el ejercicio 2026 de la siguiente manera:

La dirección atribuyó el incremento a unos resultados más sólidos en el tercer trimestre, a las iniciativas de expansión de mercado, a la mejora de los reembolsos y a la continuidad del dinamismo operativo previsto para el cuarto trimestre. Las previsiones incluyen las adquisiciones ya completadas, pero no contemplan operaciones adicionales.

Para 2027, la dirección no facilitó previsiones cuantitativas. Señaló que las cohortes de farmacias en fase de maduración deberían seguir avanzando hacia los márgenes de la plataforma, mientras que la inversión en nuevas expansiones geográficas podría mantener una presión sobre los márgenes ampliamente similar a la de los dos últimos años.

Riesgos y aspectos a vigilar

• Las reducciones de precios de medicamentos asociadas a la IRA siguieron lastrando los ingresos reportados a pesar del crecimiento en residentes y recetas.
• El combustible sigue siendo un gasto operativo elevado debido a que el negocio de Guardian es intensivo en entregas. La dirección afirmó que sus previsiones anuales ya asumen la persistencia de estos mayores costes de combustible.
• Las nuevas farmacias y las adquisiciones pueden diluir temporalmente los márgenes. Las iniciativas de expansión completadas desde 2024 redujeron el margen EBITDA ajustado del tercer trimestre en 44 puntos básicos.
• La dirección advirtió de que varias iniciativas de reembolso, compras y optimización de planes generaron ganancias extraordinarias tras años de trabajo y no se espera que aporten beneficios de la misma magnitud en los próximos trimestres.
• La asequibilidad, unos tipos de interés más altos y los elevados costes operativos siguen siendo motivos de preocupación general, aunque Guardian citó su exposición al pago privado, la generación de efectivo y un balance libre de deuda como factores atenuantes.
• Los posibles cambios normativos que afecten a Medicare Part D y a la IRA siguen siendo inciertos. La dirección afirmó que vigilará la evolución de la situación, pero que actualmente se centra en la ejecución operativa.

Aspectos destacados de la ronda de preguntas y respuestas con analistas

Crecimiento orgánico de la cuota de mercado: Guardian suele captar negocio al convertirse en la farmacia preferida de los operadores de residencias asistidas. La adopción inicial por parte de los residentes puede situarse por debajo de la media de aproximadamente el 90% de la compañía, lo que crea una oportunidad para aumentar la penetración a lo largo del tiempo mediante la gestión de medicamentos y el apoyo a cuidadores respaldado por tecnología.

Estrategia de adquisiciones: La dirección señaló que la cartera de oportunidades (pipeline) se mantiene activa, con cerca de 100 farmacias independientes de atención a largo plazo que encajan en el perfil objetivo de Guardian. La empresa no tiene una preferencia expresa entre adquisiciones y aperturas desde cero, siempre que el capital pueda desplegarse con eficacia.

Expansión en Texas y Alabama: Guardian aludió a la creciente demanda en ambos mercados. La sede de Huntsville está destinada a mejorar el servicio en el norte de Alabama, mientras que se prevé que la de Houston respalde una mayor expansión en todo Texas.

Reembolsos y genéricos: La dirección afirmó que su objetivo es alinear más estrechamente el perfil de márgenes del negocio con su combinación de dispensación. Esto gira en torno a los genéricos, que representan más del 90% del volumen de recetas.

Programa de vacunación: La dirección indicó que la actividad es relativamente insensible a las tendencias generales de la gripe, ya que los operadores de residencias asistidas y de enfermería especializada dan prioridad a una vacunación casi universal de los residentes. El programa sigue siendo complejo desde el punto de vista operativo debido a las cadenas de suministro refrigeradas, la programación de clínicas y los requisitos de reembolso.

Operación de Nautilus: A diferencia de una adquisición tradicional de farmacias, los residentes de Nautilus se distribuyeron entre más de 18 farmacias ya existentes de Guardian. La dirección espera una generación de valor más rápida tras la integración inicial, ya que la operación aprovecha la infraestructura y la capacidad existentes.

Transcripción completa de la conferencia de resultados

Transcripción completa de la conferencia de resultados

Comentarios de la dirección

Operator

Hello, everyone. Thank you for joining us, and welcome to Guardian Pharmacy's Third Quarter 2026 Earnings Call. [Operator Instructions] I will now hand the call over to Ashley Stockton, Investor Relations. Please go ahead.

Ashley Stockton

Good afternoon. Thank you for participating in today's conference call. This is Ashley Stockton, Vice President, Investor Relations for Guardian Pharmacy Services. I'm joined on today's call by Fred Burke, President and Chief Executive Officer; David Morris, Chief Operating Officer; and Will Mudd, Chief Financial Officer.

After market closed today, Guardian posted its financial results for the quarter ended September 30, 2026. A copy of the press release is available on the company's Investor Relations website. Please note that today's discussion will include certain forward-looking statements that reflect our current assumptions and expectations, including those related to our future financial performance and industry and market conditions.

Such forward-looking statements are not guarantees of future performance and are subject to risks and uncertainties that could cause actual results to differ materially from our expectations. We encourage you to review the information in today's press release and quarterly report on Form 10-Q as well as the specific risk factors and uncertainties discussed in our annual report on Form 10-K. We do not undertake any duty to update any forward-looking statements, which speak only as of the date they are made.

On today's call, we will also use certain non-GAAP financial measures when discussing the company's financial performance and condition. You can find additional information on these non-GAAP measures and reconciliations to their most directly comparable GAAP financial measures in today's press release, which again is available on our Investor Relations website.

And now I will turn it over to Fred for high-level commentary.

Fred Burke

Thank you, Ashley, and good afternoon, everyone. We're extremely pleased with our performance this year and the momentum we're seeing across the business. Our results reflect the strength of the Guardian model, the dedication of our teams and growing demand for high-quality pharmacy services in the long-term care setting.

Given our performance year-to-date, we are raising our full year guidance which, Will, will discuss in more detail. Before I hand it over to David on operations, I'd like to take a few minutes to discuss the broader economic environment, industry fundamentals and how Guardian is positioned for continued growth.

Looking across the broader economy, affordability, higher interest rates and elevated operating costs all remain concerns. We believe the characteristics of the markets we serve and our business model help insulate Guardian from many of these issues. First, on affordability. It's well documented that those 75 and over are among the wealthiest segment of the population. We believe this provides an important foundation for long-term demand for private pay assisted living, which represents approximately 70% of the residents we serve.

Second, on interest rates, our debt-free balance sheet eliminates direct exposure to higher borrowing costs, while our cash generation has allowed us to fund our typical pace of market expansion without relying on external financing. Finally, our business is delivery intensive, making fuel an important operating expense which unfortunately remains elevated.

However, as we stated last quarter, our full year guidance already assumes these higher costs will persist through the remainder of the year. Beyond these macro considerations, conditions across senior housing remain favorable and reinforce the value of Guardian's service model. Assisted living occupancy continues to improve, reaching 89% in the third quarter according to NIC MAP data and is expected to continue to climb.

At the same time, resident acuity remains elevated and labor challenges continue to pressure facility operators. As occupancy approaches historical highs and residents' care needs become more complex, operators increasingly need a sophisticated pharmacy partner like Guardian that can manage higher prescription volumes, support complex medication regimens and invest in the capabilities needed to meet these evolving demands.

While rising occupancy provides a modest tailwind for the long-term care pharmacy industry overall, it is important to emphasize that Guardian's growth is not dependent on this trend. With approximately 14% market share, we have substantial runway for growth through new facility wins and expansion into new markets. These opportunities remain firmly intact even if industry occupancy eventually reaches maximum capacity.

At the heart of Guardian's strategy is our commitment to delivering exceptional high-touch pharmacy services to benefit the residents and facilities we serve. To sustain best-in-class service levels, it is imperative that we are appropriately compensated for the value our services provide in supporting better clinical outcomes and helping bend the cost curve in long-term care.

Today, generics account for over 90% of our prescription volume and generate the vast majority of our gross profit. Accordingly, we are advancing a reimbursement model that better compensates us for the services we provide and places greater emphasis on our generic portfolio. This shift represents a meaningful evolution in our approach, one that we are helping to pioneer alongside our payer partners who increasingly recognize the need for greater transparency.

Ultimately, we believe this approach will serve to derisk our business model and enhance our longer-term stability. Taken together, favorable industry fundamentals, substantial market share opportunity and our differentiated service model should position Guardian exceptionally well for the future. Coupled with our efforts to strengthen reimbursement economics, consistent cash generation and our highly liquid balance sheet, I am ever more confident in Guardian's ability to deliver durable growth and shareholder value.

With that, I'll turn the call over to David.

David Morris

Thanks, Fred, and good afternoon, everyone. I'd like to focus on our operational progress, where we made meaningful strides this quarter in expanding our resident base, both through greenfield start-ups and acquisitions. Our greenfield start-up in Lexington, Kentucky announced last quarter is now operational. We are also moving forward with plans to further expand our presence in Texas and Alabama with new locations in Houston and Huntsville, respectively.

These additions will mark our second pharmacy location in each state. Our wellness concepts acquisition in Grados, Virginia closed in July. While still early, the integration is on track. We also completed the Nautilus asset acquisition late in the quarter, representing a unique opportunity to add scale across our existing pharmacy network.

[indiscernible] has previously served assisted living communities across 14 states through a centralized mail order model. We now have transitioned all of these residents to 18 Guardian pharmacies already operating in their respective markets, providing them access to our locally managed high-touch pharmacy services.

From a financial perspective, this is an attractive asset-light transaction that allows us to leverage existing infrastructure and operating capacity to absorb additional residents with limited incremental investment. As a result, this transaction is immediately accretive after we absorb the cost of onboarding.

In October, we added a small pharmacy in Sioux City, collectively with our existing pharmacy in that area, gives us a more significant presence in Northwest Iowa. Lastly, earlier this week, we also completed the acquisition of Vans Institutional Pharmacy, a well-established long-term care pharmacy serving communities across Western Tennessee and Kentucky.

This acquisition brings our total pharmacy count to 5 in Tennessee. Vans is slightly smaller than our typical acquisition, but it is an excellent cultural and operational fit, having built a reputation for high-quality service over a period of more than 50 years that aligns closely with our commitment to service excellence.

Looking ahead, our acquisition pipeline remains active. Additionally, we see significant potential to build greater scale and density in adjacent markets through our contiguous greenfield start-ups. Maintaining both our organic and inorganic growth requires the right leadership, which is why we established our regional SVP structure earlier this year. This team is already driving greater consistency, accountability and collaboration across our pharmacy network while preserving the local decision-making and entrepreneurial culture that have long been central to Guardian.

More specifically, we are seeing benefits through increased sharing of best practices, better coordination of sales and account management efforts and opportunities to improve operating efficiencies, both within individual pharmacies and across regions. This is particularly important as we expand relationships with regional and national customers who rely on Guardian to deliver consistency across multiple states and markets. And while our regional leaders play an important role, it's the dedication of our people across the entire organization that makes all this possible.

On behalf of our senior management team, I'd like to thank everyone for their hard work and commitment to the customers and residents we serve. Our people remain the foundation of Guardian's success.

With that, I'll turn the call over to Will for a more detailed review of our financial performance and updated outlook.

Will Mudd

Thank you, David, and good afternoon, everyone. As David mentioned, we delivered another strong quarter with solid growth in residents served, prescription volumes and adjusted EBITDA. We ended the quarter serving approximately 218,000 residents, representing high single-digit growth compared with the prior year period.

Alongside this growth, prescription volumes increased 10% year-over-year. Reported revenue was $371 million compared with $377 million in the prior year period, representing a reported decline of 1.7%. Absent the impact of IRA-related drug price reductions that took effect earlier this year, revenues would have increased high single digits, in line with what we guided to last quarter, mostly reflecting organic growth.

Note, Wellness Concepts, our primary acquisition year-to-date was on the smaller side, and Nautilus did not meaningfully contribute to this quarter. Gross profit was $85.2 million, up 14% year-over-year. Gross margin was also up sequentially to 23%. Revenue and margins continue to benefit from improved reimbursement, ongoing purchasing initiatives, plan optimization efforts and a successful launch to this year's vaccine programs. Adjusted SG&A was $57.4 million, representing 15.5% of revenues.

We continue to benefit from operating leverage as our resident base and prescription volumes grow, allowing us to spread our fixed operating costs across a larger base of business. Share-based compensation was close to $2.8 million. Adjusted EBITDA increased 24% year-over-year to $33.9 million. EBITDA margin was 9.1%.

Acquisitions and greenfield start-ups completed since 2024 are collectively contributing positive adjusted EBITDA, although they dampened our adjusted EBITDA margin by 44 basis points in the quarter. The effective tax rate came in at 26%. Net income was $19 million, up from $9.6 million in the year ago quarter.

Given our strong year-to-date performance and current expectations for the fourth quarter, we are raising our full year 2026 guidance. We now expect revenue in the range of $1.44 billion to $1.46 billion, up from $1.43 billion to $1.45 billion.

Adjusted EBITDA is now expected in the range of $136 million to $138 million, up from $129 million to $131 million. Our updated outlook reflects our stronger-than-expected third quarter performance, various market expansion initiatives David laid out and the continuation of improved reimbursement and other strong operating trends into the fourth quarter. As in the past, our guidance does not assume any additional acquisitions beyond those already completed.

Turning to our balance sheet. We ended the quarter with approximately $120 million in cash and no debt. Our capital allocation priorities remain focused on supporting long-term profitable growth while maintaining the financial discipline that has been a hallmark of Guardian's strategy.

Finally, I want to highlight an important milestone related to our share structure. On September 27, the final tranche of approximately 13.5 million shares of Class B common stock that were originally issued in connection with our September 2024 corporate reorganization and IPO converted into Class A common stock. Ahead of the conversion, our founders, executive officers and certain other employees entered into lockup agreements covering approximately 30 million shares or close to 80% of the Class A shares held by our founders, executive officers and other pre-IPO employee shareholders.

These shares will remain subject to lockup restrictions through September 14, 2027, subject to limited exceptions such as a small allocation to 10b5-1 plans. The strong continued insider ownership in Guardian reflects long-term confidence in the company and alignment with our public shareholders.

With that, operator, please open the line for questions.

Operator

[Operator Instructions] Your first question from the line of Brian Tanquilut with Jefferies.

Preguntas y respuestas

Brian Tanquilut

Congrats on a solid quarter. I guess my first question, Fred, to your comment that you made in your prepared remarks about how there's room to grow even if industry occupancy starts to taper off or top out. I'm curious, how do you think about what drives market share to Guardian and why the senior housing facilities would pick you as your partner over to the competition? And with that in mind, how do you think investors should be thinking about the right growth rate over the next 3 to 5 years as you think through the opportunities that you have in front of you?

Fred Burke

Thanks, Brian. The main way that we grow organically is through convincing an assisted living operator to declare Guardian as their preferred pharmacy. And when we do that, it's a big decision for our customers. But when they do, we then begin servicing that facility. As we've mentioned, typically, we'll find a lower adoption rate at the outset than what we typically enjoy, and we'll set about the task of then growing the adoption over time to our 90% corporate average.

The reason that an assisted living operator would choose Guardian as their preferred pharmacy is because of the value-add services that we provide with the focus on managing the drug regimen of the residents, providing the tech-enabled platform for their caregivers to administer demands and all the various services that we render to make sure that resident is on the proper drug regimen and also adhering to it, both of which bend the cost curve and improve outcomes.

Brian Tanquilut

Got it. Okay. That makes sense. And then obviously, good acquisition activity during this quarter, 2 different flavors of deals. When we think of the remaining opportunity to roll up in the space, Fred, how are you thinking about that? And just in terms of the size of that market, in terms of assets out there? And then what does that look like once you plug it in? I know, again, 2 different kinds of acquisitions this quarter. How do we think about how that accrues and how that plugs into your business?

Fred Burke

I'll start, but pass it to David Morris, who is day-to-day heavily involved in the business activity. We've mentioned before, Brian, that there are hundreds of long-term care pharmacies that are independent, but about 100 or so would fit our target. That would be to say, typically a closed door, 100% focused LTC pharmacy. There are still many of those left to go. So David is working that pipeline every day, and we're in constant contact, and I can assure you that we have a very robust opportunity over the next few years.

David Morris

Brian, David here. Just if you step back, we've got about a 14% market share of our primary market assisted living. As Fred said, it's a very fragmented group of operators, hundreds out there. We're focused on a certain group that fit what we're looking for and what they're looking for. But we're going to continue to do what we've been doing really the last 10-plus years. It's a two-pronged approach, and we had a lot of that in this quarter where we're doing contiguous greenfield start-ups with operators in existing territory where customers are asking us to expand.

And then with our other hand, we're finding like-minded operators to put new pins on the map. So that's what we've been doing, and that's what we're going to continue to do. And the opportunity is bigger than probably we've ever had.

Operator

Your next question comes from the line of Zach Haggerty with KeyBanc Capital Markets.

Zachary Haggerty

I want to ask about the plan to expand in Texas and Alabama. What does the opportunity look like within those specific markets with respect to demand? And then any comments on competition? And do you have a bias towards organic or M&A in those markets over time?

David Morris

Yes. I'll start with the last question. We really don't have a bias. We feel like we can effectively deploy capital, both in acquiring an existing business and through contiguous start-ups. If you look at Alabama, that's a market we've been in for over 15 years, but it's growing, and we've been looking and serve our customers in the North Alabama area, and we just felt like it's time to expand our footprint to better serve those customers in that growing region. Texas is a market we've been in for 5 to 6 years and have a lot of demand there. And I think Houston is a great opportunity, and I think there'll be many more as we expand our footprint to better serve that state.

Zachary Haggerty

Great. And then just on 2027, maybe if you guys have any high-level thoughts about next year, any contribution from the maturing cohorts of pharmacies and any headwinds or tailwinds that we should be keeping in mind?

David Morris

I think we'll -- as we have over the years, we'll see our existing cohorts continue to mature. Will mentioned that the prior quarters, we had about 80 basis points of margin depression. That's 44 points for this quarter, but that will ebb and flow as we invest in roll out more continuous start-ups, it may go back up. So it will move around. So we've constantly got pharmacies maturing to the margins of our overall platform, but we'll also continue to invest in new geographic expansion. So I think what you'll see is an investment level similar to what we've had in the past couple of years from a margin standpoint.

Operator

Your next question from the line of Raj Kumar with Stephens.

Raj Kumar

Maybe just one on kind of midterms and I think the policy environment. I appreciate that you guys haven't needed to depend on policy, especially with the kind of IRA dynamics playing out this year. But as we kind of think about the Democratic sweep and the kind of already introduced bills in place around correcting the unintended consequences of the IRA, would just love to hear your thoughts on kind of if there's more fuel there given the kind of the landscape shift or kind of still just in the background while the main focus remains just executing on the operations of the business.

Fred Burke

I would say at this point, it's the latter, but it's too early to call. We'll certainly be keeping our ears to the ground and monitoring any policy proposals coming out of Washington. But for the moment, it's steady as we go. Don't forget that Part D is arguably the most popular of the government benefits, very successful. And at least in my personal opinion, I think politicians are very, very careful to touch that rail of something that's working and popular, but we'll see and monitor, keep you posted.

Raj Kumar

Got it. And then as a follow-up, I guess curious on kind of how you think about CVS announced a pending split in 2028 for Craft's Health Insurance PBM and pharmacy assets. I know there's not a lot of overlap in the business, especially with Omnicare kind of being set to the side for them. But curious how you see that dynamic for kind of the long-term care pharmacy space that presents an opportunity or if that is an area where it increases potential competition just given differentiated focus on some of those assets? Just kind of curious on that development and your thoughts.

Fred Burke

Raj is certainly not our prerogative to speak to their strategy. But with respect to the impact on our business, we don't see any at all. Retail pharmacy is not equipped to properly serve our customer base. And we would be hopeful, frankly, that CDS operating as an independent company would be stronger, and that's what we need in our -- broadly in our industry is our strong competitors. So we're pulling farm and hope this works out well, but do not see much impact on our particular space.

Operator

Your next question from David MacDonald with Truist Securities.

David MacDonald

Congratulations. Would love to ask a kind of a payer partner question. Fred, during the prepared remarks, you talked about demand for high-quality services. And when we look at the focus at the payer level on quality, I mean, I guess, number one is the quality of the services that you provide becoming an even bigger differentiator.

And then secondly, you also mentioned during the prepared remarks just contracting in generics. Any additional detail you can provide there? I mean it feels like that's kind of an aligned incentive game if you're getting a larger and larger percentage coming from generics, which is where the payers want to go anyway. But any additional detail there would be helpful.

Fred Burke

That is exactly the situation, David. It's in both our interest to align the margin profile of the business with the dispensing profile. And that's what we've set about to do. And if we're a long way toward that goal. And I think it will strengthen both sides of this equation, both the payers and the providers such that we are aligned in what we're trying to accomplish.

David MacDonald

And then, guys, just one other quick question. Your margins kind of continue to outperform at least what we had estimated. I'm just curious, you laid out a bunch of operational efficiencies that you guys are driving, the new regional structure et cetera. But is it more of that? Or is it also a combination of that? And are your acquisitions as you bring them on, are those ramping quicker than maybe they have historically?

Fred Burke

David, I'll start at 30,000 feet and say that we are the beneficiary this year of some outsized gains that are resulting from business initiatives that have been ongoing for multiple years. And we're very pleased with that. I'll let Will walk you through some of the items where we're experiencing these positives.

Will Mudd

David, yes, you mentioned that we had -- obviously, we had to step up to 22% margins going into the year with IRA. But what Fred is referencing, we've been working these initiatives. It's a combination of reimbursement, purchasing, plan optimization, several of these things that are really kind of contributing equally to that lift. But again, it's kind of another step up because these are longer-term initiatives and not something that we will see to this magnitude in the quarters going forward. But yes, we're happy with these initiatives sort of bearing fruit.

Operator

Your next question from the line of Parker Snure with Raymond James.

Parker Snure

Just wanted to ask one on the flu season and your fourth quarter program. So the flu season appears to be tracking hotter this year than it's been the past couple of years, at least according to the publicly available data. Just curious if a hotter flu season, could that lead to more activity in your fourth quarter flu vaccine program? Is that something that you've historically seen? Or is this program somewhat agnostic to flu activity and it just happens regardless of the flu season?

Fred Burke

I think it's the latter, Parker. It is a very important initiative for assisted living and skilled nursing operators to ensure that their resident population is vaccinated. So the numbers you see with the public at large don't apply as much to this particular resident population, which essentially is virtually 100% vaccinated. We can add more color. We're out of the gate, very proud to have continued refining this vaccination initiative that we are so proud to have developed. It's a great service that we're proud to render to our residents and our assisted living operators, but it's extremely complex logistically, supply chains, refrigerated product, scheduling clinics to make sure that all the residents and staff can be available for the vaccination. And then it's a complicated reimbursement challenge. So we continue to refine the program and hope to see that it will improve each and every year.

Parker Snure

Okay. Yes. No, great. That's super helpful. And then just kind of following up on Brian's question earlier. Just in the assisted living market, you have a few big name customers, but it's my understanding that you aren't currently serving every single one of their facilities, but you already have the existing relationships with those customers.

So I guess how should we think about the embedded growth opportunity just from further penetrating some of these existing relationships that you have and how that gives you better visibility and some easy wins when you expand into these new markets? And I won't ask you to give specific names, but could you just give us maybe a flavor or a general feel of for some of your larger customers, what percent of their facilities do you kind of currently serve? And what is the remaining opportunity?

David Morris

Parker, it's David. I'll start with -- keep in mind that even the national providers are a small percent of our overall book of business. So none of them are significant. But as we look for partners in geographic markets to expand into or as we look to do contiguous expansions in a market like Houston, the national account relationships we have play into that decision, and there is growth there as we get into markets that they need services from a provider like Guardian. So all that's factored into our organic growth that we're providing to the Street.

Operator

[Operator Instructions] Your next question from the line of Allen Lutz with Bank of America.

Allen Lutz

This wanted to go to really either of you 3, Fred, Will and David. So I don't know who to address it to. But you did a really interesting acquisition of Nautilus Pharmacy, which was a file buy a couple of months ago, which is different than your traditional M&A where you're buying the physical pharmacy itself. Can you speak at a high level to the difference in accretion we should expect from that type of transaction versus the typical one that you do? And then as we think about the scale of your pharmacy footprint, it's obviously much larger than it was 5, 10 years ago. What percent of the country do you think you have the scale where if this type of opportunity presented itself, you'd be able to do a file buy as opposed to having to purchase a specific pharmacy. Would love any high-level commentary around that.

Fred Burke

I'll start, Allen, by saying that there have been attempts over the years to serve assisted living via mail order. And inevitably, it has failed. So there are not very many of these opportunities to start with. This particular one is very exciting because the customers of this pharmacy are very excited to be able to receive our high-touch service from local bricks and mortar.

I'll let David or Will talk to the accretion. But once we get these residents onboarded, which does have initial cost, we do -- it is accretive quicker.

David Morris

Yes. And I'll add to it. I mean, there are other providers who have attempted to start and run their pharmacies. They're not a lot like this. We happen to have a close relationship with these guys. And as Fred said, the assisted living locations are very excited to be coming back to Guardian from the mail order. And as we distributed this through, I think, 18-plus pharmacies, it's highly accretive. And we have to absorb the onboarding cost of bringing the residents back on, getting them into our systems, but it's accretive and accretive quickly.

Operator

There are no further questions at this time. This concludes today's call. Thank you for attending. You may now disconnect.