가디언 파머시(GRDN) 2026년 3분기 실적 콘퍼런스콜: EBITDA 24% 증가, 가이던스 상향

핵심 요약

• 가디언 파머시 서비스(GRDN)는 분기 말 기준 약 21만 8,000명의 입소자에게 서비스를 제공해 전년 동기 대비 한 자릿수 후반대의 증가율을 기록했으며, 처방량은 10% 증가했다.
• 2026년 3분기 매출은 IRA 관련 약가 인하 영향으로 전년 동기 대비 1.7% 감소한 3억 7,100만 달러를 기록했다. 경영진은 해당 영향을 제외하면 매출이 한 자릿수 후반대의 성장세를 보였을 것이라고 밝혔다.
• 매출총이익은 보험 급여, 구매 전략, 플랜 최적화 및 백신 사업에 힘입어 전년 동기 대비 14% 증가한 8,520만 달러를 기록했으며, 매출총이익률은 전 분기 대비 개선된 23%로 상승했다.
• 조정 EBITDA는 24% 증가한 3,390만 달러로 9.1%의 마진을 기록했다. 순이익은 전년 동기 960만 달러에서 1,900만 달러로 증가했다.
• 경영진은 2026년 연간 가이던스를 매출 14억 4,000만~14억 6,000만 달러, 조정 EBITDA 1억 3,600만~1억 3,800만 달러로 상향 조정했다.
• 가디언은 분기 말 기준 약 1억 2,000만 달러의 현금을 보유하고 무차입 상태를 유지해, 외부 자금 조달에 의존하지 않고 신규 지점(그린필드) 확장 및 인수를 추진할 수 있는 여력을 확보했다.

주요 재무 데이터

사업 및 운영 실적

성장은 주로 입소자 수 및 처방량 증가가 견인했다. 경영진은 보험 급여 개선, 구매 전략, 플랜 최적화 및 백신 프로그램 역시 매출과 마진을 뒷받침했다고 밝혔다.

제네릭(복제약)은 가디언 처방량의 90% 이상을 차지하며 매출총이익의 대부분을 창출한다. 회사는 제네릭 처방을 더 중시하고 조제 구성에 수익 구조를 더욱 긴밀히 맞추는 보험 급여 모델을 보험자 파트너들과 함께 마련하고 있다.

켄터키주 렉싱턴에 있는 가디언의 신규 약국이 운영을 시작했다. 회사는 또한 텍사스주 휴스턴과 앨라배마주 헌츠빌에 신규 지점을 개발 중이며, 이는 각 주에서 두 번째 약국이 된다.

7월에 마무리된 버지니아주의 웰니스 컨셉츠(Wellness Concepts) 인수는 통합 작업이 순조롭게 진행되고 있다. 가디언은 또한 노틸러스(Nautilus) 자산 인수를 완료하고 해당 입소자들을 기존 18개 가디언 약국으로 전환 배치했다. 경영진은 이 거래를 자산 경량형(asset-light) 구조로 설명하며, 초기 편입 비용이 흡수된 후 빠르게 실적에 기여할 것이라고 밝혔다.

10월 가디언은 수시티에 소형 약국을 추가해 아이오와주 북서부 입지를 확대했다. 또한 테네시 서부와 켄터키를 담당하는 반스 인스티튜셔널 파머시(Vans Institutional Pharmacy)를 인수해 가디언의 테네시주 약국 수를 5개로 늘렸다.

경영진은 가디언의 생활 보조(assisted living) 시설 시장 점유율을 약 14%로 추산했다. 아울러 약 100개의 독립 장기요양 약국이 회사의 일반적인 인수 기준에 부합한다며, 인수합병과 인접 지역 내 신규 지점 개설이라는 투트랙 전략을 지속할 수 있는 기반이 된다고 설명했다.

경영진 가이던스

가디언은 2026년 연간 전망치를 다음과 같이 상향 조정했다:

경영진은 가이던스 상향 요인으로 3분기 실적 호조, 시장 확장 전략, 보험 급여 개선, 그리고 4분기에도 이어질 것으로 예상되는 운영 모멘텀을 꼽았다. 이번 가이던스에는 이미 완료된 인수는 포함되었으나 추가 인수는 가정하지 않았다.

2027년에 대해 경영진은 수치화된 가이던스를 제시하지 않았다. 경영진은 성숙 단계에 접어든 약국군이 플랫폼 수준의 마진으로 계속 수렴해 갈 것이나, 새로운 지역 확장에 대한 투자로 인해 지난 2년과 대체로 비슷한 수준의 마진 압박이 이어질 수 있다고 밝혔다.

위험 요인 및 주시 영역

• 입소자 수 및 처방량 증가에도 불구하고 IRA 관련 약가 인하가 공시 매출에 지속적인 부담으로 작용했다.
• 가디언의 사업이 배송 집약적이기 때문에 연료비는 여전히 높은 수준의 운영 비용으로 남아 있다. 경영진은 연간 가이던스에 높은 연료비의 지속이 이미 반영되어 있다고 밝혔다.
• 신규 약국 개설과 인수는 일시적으로 마진을 희석할 수 있다. 2024년 이후 완료된 확장 전략으로 인해 3분기 조정 EBITDA 마진이 44bp 감소했다.
• 경영진은 수년간의 노력 끝에 보험 급여, 구매 및 플랜 최적화 관련 여러 사업에서 이례적으로 큰 성과를 거두었으며, 향후 분기에도 동일한 규모의 혜택이 발생할 것으로 예상되지는 않는다고 주의를 당부했다.
• 비용 부담 능력, 고금리, 높은 운영 비용이 전반적인 우려 요인으로 남아 있으나, 가디언은 비보험(자기부담) 환자 비중, 현금 창출력, 무차입 재무상태표를 완충 요인으로 제시했다.
• 메디케어 파트 D와 IRA에 영향을 미치는 잠재적 정책 변화는 여전히 불확실한 상태다. 경영진은 상황을 모니터링하되 현재는 운영상의 실행에 집중하고 있다고 밝혔다.

애널리스트 Q&A 주요 내용

자체 시장 점유율 성장: 가디언은 일반적으로 생활 보조 시설 운영사의 선호 약국으로 지정되어 사업을 수주한다. 초기 입소자 채택률은 회사 평균인 약 90%를 밑돌 수 있지만, 복약 관리와 기술 기반의 간병인 지원을 통해 점진적으로 침투율을 높일 수 있는 기회가 생긴다.

인수 전략: 경영진은 가디언의 타깃 기준에 부합하는 독립 장기요양 약국이 약 100개에 달해 파이프라인이 여전히 활발하다고 밝혔다. 회사는 자본을 효과적으로 투입할 수만 있다면 인수와 신규 지점 개설 사이에 특별한 선호를 두지 않는다고 설명했다.

텍사스 및 앨라배마 확장: 가디언은 두 시장 모두에서 수요가 증가하고 있다고 언급했다. 헌츠빌 지점은 북부 앨라배마 지역 서비스를 강화하기 위한 것이며, 휴스턴 지점은 텍사스 전역으로의 추가 확장을 뒷받침할 것으로 기대된다.

보험 급여 및 제네릭: 경영진은 사업의 마진 구조를 조제 구성과 더 긴밀히 일치시키는 것이 목표라고 밝혔다. 이는 처방량의 90% 이상을 차지하는 제네릭을 중심으로 이루어진다.

백신 접종 프로그램: 경영진은 생활 보조 및 전문 요양 시설 운영사들이 입소자 대부분에 대한 백신 접종을 우선시하기 때문에 전반적인 독감 유행 추세에 상대적으로 덜 민감하다고 밝혔다. 다만 냉장 공급망, 클리닉 일정 조율, 급여 청구 요건 등으로 인해 운영상 복잡성이 여전히 존재한다.

노틸러스 인수 거래: 전통적인 약국 인수와 달리 노틸러스의 입소자들은 기존 18개 이상의 가디언 약국에 분산 배치되었다. 이번 거래는 기존 인프라와 역량을 활용하기 때문에 초기 편입 절차가 마무리된 후 실적 기여가 더 빠르게 나타날 것으로 경영진은 기대하고 있다.

실적 발표 콘퍼런스콜 전문

전체 실적 발표 컨퍼런스 콜 녹취록

경영진 발표

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.

질의응답

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.