Cuộc họp công bố kết quả kinh doanh Quý 2/2026 của American Shared Hospital Services (AMS): Doanh thu tăng 19,2%

Điểm tin chính

• American Shared Hospital Services đã báo cáo doanh thu quý 2/2026 đạt khoảng 8,4 triệu USD, tăng 19,2% so với cùng kỳ năm ngoái. Doanh thu nửa đầu năm tăng 17,7% lên khoảng 15,5 triệu USD.
• Doanh thu Dịch vụ Bệnh nhân Trực tiếp tăng khoảng 40% lên 4,9 triệu USD, chủ yếu nhờ khối lượng ca điều trị tăng ở Rhode Island cùng sự tăng trưởng mạnh mẽ tại Peru và Puebla, Mexico.
• Doanh thu từ xạ trị bằng chùm proton tăng 22% lên khoảng 2,3 triệu USD, nhờ khối lượng điều trị cao hơn và mức hoàn trả chi phí được cải thiện tại Orlando.
• Dòng tiền từ hoạt động kinh doanh trong nửa đầu năm đạt 4,4 triệu USD. Tiền, các khoản tương đương tiền và tiền bị hạn chế sử dụng tăng lên 6,8 triệu USD từ mức 3,7 triệu USD vào cuối năm 2025.
• EBITDA điều chỉnh giảm xuống khoảng 1,3 triệu USD từ mức 1,7 triệu USD của một năm trước đó. Báo cáo kết quả kinh doanh bao gồm khoản dự phòng tổn thất tín dụng 909.000 USD và 285.000 USD chi phí pháp lý và tư vấn chuyên môn liên quan đến thỏa thuận tín dụng sửa đổi.
• Công ty đã gia hạn thời hạn khoản vay tại Fifth Third Bank đến ngày 30 tháng 6 năm 2027 và huy động được 2 triệu USD tài trợ nợ thứ cấp sau khi kết thúc quý. Ban quản lý cho biết họ đang xem xét "mọi lựa chọn" cho cơ cấu vốn.

Dữ liệu tài chính chính

Kết quả kinh doanh và hoạt động

Dịch vụ Bệnh nhân Trực tiếp tiếp tục là động lực tăng trưởng chính. Ba trung tâm xạ trị ung thư tại Rhode Island ghi nhận số lượng ca điều trị bệnh nhân cao hơn và hiệu quả hoạt động ở cấp trung tâm được cải thiện. Ban quản lý cho biết mối quan hệ hợp tác chặt chẽ hơn với các bác sĩ, năng lực thực thi vận hành và khả năng tiếp cận của bệnh nhân tiếp tục hỗ trợ sự phát triển của khu vực này.

Trung tâm xạ trị Puebla cũng ghi nhận hoạt động điều trị bệnh nhân tăng cao và được hưởng lợi từ xu hướng hoàn trả chi phí thuận lợi. Tại Peru, việc nâng cấp Gamma Knife Esprit hoàn tất vào năm 2025 đã rút ngắn thời gian điều trị, nâng cao công suất phục vụ bệnh nhân và tăng mức độ sử dụng.

Doanh thu Cho thuê Thiết bị Y tế tương đối ổn định. Việc hết hạn một hợp đồng khách hàng Gamma Knife trong nước vào năm 2025 đã ảnh hưởng đến hoạt động nội địa, nhưng sự tăng trưởng mạnh mẽ của mảng xạ trị bằng chùm proton đã bù đắp đáng kể tác động đó. Doanh thu xạ trị proton tại Orlando tăng hơn 22% nhờ khối lượng điều trị và mức hoàn trả chi phí được cải thiện.

Ban quản lý xác định mức độ sử dụng là động lực chính cho khả năng sinh lời trong dài hạn. Công ty cho biết nhiều cơ sở có đòn bẩy hoạt động đáng kể, do đó các ca điều trị bổ sung có thể hỗ trợ ngày càng nhiều cho khả năng sinh lời và tạo ra dòng tiền khi khối lượng tăng lên.

Các kế hoạch mở rộng bao gồm một trung tâm xạ trị tại Bristol, Rhode Island, và một trung tâm xạ trị bằng chùm proton tại Johnston theo các giấy chứng nhận nhu cầu đã được phê duyệt trước đó. Trên thị trường quốc tế, AMS đang hợp tác với Hospital San Javier để nâng cấp trung tâm Gamma Knife hiện hữu của bệnh viện này tại Guadalajara, Mexico.

Rủi ro và các vấn đề cần theo dõi

• AMS đã ghi nhận khoản dự phòng tổn thất tín dụng trị giá 909.000 USD liên quan đến các khoản phải thu tại Rhode Island tính đến ngày 31 tháng 5 năm 2025. Ban quản lý cho biết các khoản dư nợ này chủ yếu liên quan đến các công ty bảo hiểm nhưng cung cấp rất ít thông tin chi tiết bổ sung về lý do chưa thanh toán.
• Chi phí bán hàng và quản lý bao gồm 285.000 USD chi phí pháp lý và tư vấn chuyên môn liên quan đến việc đàm phán sửa đổi lần thứ ba đối với thỏa thuận tín dụng của Fifth Third Bank.
• Công ty đang nợ Fifth Third Bank khoảng 15,5 triệu USD. Ban quản lý cho biết các khoản giảm nợ theo kế hoạch sẽ đưa dư nợ xuống khoảng 13,3 triệu USD tính đến ngày đáo hạn đã được gia hạn là ngày 30 tháng 6 năm 2027.
• Thỏa thuận vay sửa đổi yêu cầu công ty và các công ty con phải tìm kiếm các phương án bán tài sản tiềm năng. Ban quản lý nhấn mạnh rằng việc tái cấp vốn và các lựa chọn chiến lược khác vẫn đang được xem xét.
• Khối lượng cho thuê Gamma Knife trong nước tiếp tục phản ánh tác động từ việc hết hạn một hợp đồng khách hàng trong năm 2025.

Điểm tin Q&A với chuyên gia phân tích

Tăng trưởng khối lượng quốc tế: Ban quản lý cho biết kiểm soát vận hành tốt hơn và mở rộng quan hệ với các bệnh viện cũng đang hỗ trợ sự tăng trưởng các ca điều trị quốc tế. Công ty đề cập đến khối lượng tăng ở Peru sau khi nâng cấp Esprit, hoạt động gia tăng tại Puebla và kế hoạch nâng cấp Gamma Knife tại Guadalajara.

Tái cấp vốn so với khả năng bán tài sản: Một chuyên gia phân tích đã đặt câu hỏi về cách chiến lược dài hạn của công ty phù hợp với các điều khoản yêu cầu họ tìm kiếm việc bán một phần hoặc toàn bộ tài sản. Chủ tịch Điều hành Raymond Stachowiak cho biết AMS đang đánh giá "mọi lựa chọn", đồng thời bày tỏ niềm tin rằng công ty có thể tìm ra giải pháp tái cấp vốn cho khoản nợ tại Fifth Third Bank trong thời gian gia hạn đáo hạn.

Các khoản phải thu ở Rhode Island: Một nhà đầu tư cá nhân đã chất vấn ban quản lý về khoản dự phòng tổn thất tín dụng trị giá 909.000 USD và liệu các khoản chi phí tương tự có thể tái diễn hay không. Ban quản lý cho biết các khoản phải thu liên quan đến một số bên thanh toán, chủ yếu là các công ty bảo hiểm, nhưng không đưa ra giải thích cụ thể hơn về các vấn đề thu hồi nợ.

Toàn văn Biên bản Cuộc họp Báo cáo Kết quả Kinh doanh

Toàn văn cuộc gọi công bố kết quả kinh doanh

Phần trình bày của ban lãnh đạo

Operator

Good day, and welcome to the American Shared Hospital Services Second Quarter 2026 Earnings Conference Call. [Operator Instructions] Please note, this event is being recorded. I would now like to turn the conference over to Kirin Smith, Investor Relations. Please go ahead.

Kirin Smith

Thank you, Nick, and thank you, everyone, for joining us today. AMS' second quarter 2026 earnings press release was issued earlier today. If you need a copy, it can be accessed on the company's website at www.ashs.com under the Investors section.

Before turning the call over to management, I would like to make the following remarks concerning forward-looking statements. Please note that various remarks that may be made on this conference call about future expectations, plans and prospects for the company constitute forward-looking statements for the purposes of safe harbor provisions under the Private Securities Litigation Reform Act of 1995. Actual results may vary materially from those indicated by these forward-looking statements as a result of various important factors, including those discussed in the company's filings with the SEC, including the company's annual report on Form 10-K for the year ended December 31, 2025, and Form 10-Q for the quarter ended March 31, 2026. Company assumes no obligation to update this information contained on this conference call.

Before I turn the call over to management, I'd like to remind everyone about our Q&A policy where we provide each participant the time to ask one question to follow-up. As always, we'll be happy to take additional questions offline. With that, I'd now like to turn the call over to Ray Stachowiak, Executive Chairman. Ray, please go ahead.

Raymond Stachowiak

Thank you, Kirin, and good afternoon, everyone. Thanks for joining us today and for your continued interest in American Shared Hospital Services.

Before we begin, I'd like to take a moment to point out that we recently promoted Alexis Wallace, our long-standing Chief Accounting Officer, to the role of Interim CFO. Our previous CFO, Scott Frech, has moved on to pursue other endeavors. We wish Scott all the best and appreciate his contributions while welcoming Alexis to this well-deserved role after her many years of excellent service on our accounting team.

Now let's get into the quarter. The second quarter represented another period of meaningful operational progress for our company. We delivered strong quarterly revenue of approximately $8.4 million, representing year-over-year growth of 19%, while first half revenue increased 18% to more than $15.5 million. These results were driven by continued strength across our Direct Patient Services business, increasing proton beam radiation therapy activity and improving performance from our international operations. More importantly, we believe these results validate the strategic direction we've been executing over the past several years. We have intentionally transformed American Shared Hospital Services from a company primarily dependent on equipment leasing into a more diversified radiation oncology platform with multiple avenues for growth.

Today, we benefit from recurring revenues generated through our direct patient care operations, long-standing hospital partnerships, international treatment centers, Gamma Knife's leadership and our participation in proton beam radiation therapy. Each of these businesses contribute differently to our overall growth strategy. But together, they provide us with a broader, more resilient operating platform than at any point in our history.

One of the most encouraging trends we continue to see is improving utilization across our network. Our Rhode Island centers continue to experience higher patient volumes and improved operating performance. Our proton beam radiation therapy partnership in Orlando, Florida delivered another strong quarter, benefiting from increased treatment volumes and favorable reimbursement trends. Internationally, our Gamma Knife center in Peru continues to demonstrate increased treatment volumes compared with the prior year following the Esprit upgrade that we completed in 2025. These operational achievements are especially encouraging because higher utilization remains one of the most important drivers of long-term profitability in our business model.

I'm also proud to report that our operating activities over the first 6 months generated $4.4 million of cash, and our cash balance at the end of the second quarter increased over 80% since the beginning of this year to $6.8 million. It is validating to see the improving cash-generating capability of our business as our operating performance continues to strengthen.

We also made important progress subsequent to quarter end with respect to our capital structure. As many of you know, we entered into a third amendment and forbearance agreement with Fifth Third Bank. Although our financing discussions have required considerable management attention over the past several months, we believe the agreement provides a defined framework that allows us to remain focused on executing our operating strategy while we continue pursuing longer-term capital solutions. A few months ago, I formed a new company that recently purchased additional shares of our company from a private investor. In addition, this new company has invested $2 million of subordinated financing after quarter end, which reflects our continued confidence in the long-term prospects of the company and provides additional financial flexibility as we move forward.

Importantly, none of these financing activities have changed our long-term strategic priorities. In Rhode Island, we continue advancing opportunities created through our certificate of need approvals, including plans for a new radiation therapy center in Bristol and a proton beam radiation therapy center in Johnston. Internationally, we remain excited about the continued development of our operations in Latin America and the opportunities we see to further expand our presence in attractive markets.

An important component of our international growth strategy is in Guadalajara, Mexico, where we are partnering with Hospital San Javier to upgrade their Gamma Knife center. Importantly, this is an established Gamma Knife market and a well-established clinical partner. Hospital San Javier has been providing Gamma Knife treatments since 1994, giving us an experienced physician and institutional platform from which to build. While we recognize there's still important work ahead of us, particularly regarding our balance sheet, I remain extremely confident in the underlying strength of our business.

Our focus remains squarely on growing patient volumes, expanding and diversifying our installed base of advanced radiation therapy technologies, strengthening our partnerships with leading health care systems and allocating capital where we believe it can generate attractive long-term returns.

With that, I'll turn the call over to our Interim CEO, Craig Tagawa, who will provide more detail on our operational performance. Craig?

Craig K. Tagawa

Thank you, Ray, and good afternoon, everyone. I'd also like to thank all of you for joining us today and for your continued interest in American Shared Hospital Services. The second quarter was another quarter of solid operational execution and meaningful progress across our businesses.

While our reported financial results include several substantial items that Alexis will discuss in greater detail, I believe the most important takeaway from the quarter is that the underlying business continues to move in the right direction. We generated strong quarterly revenues of approximately $8.4 million, representing 19% year-over-year growth, while first half revenues increased to more than $15.5 million. Those results were driven by continued growth in our Direct Patient Services segment, improving proton beam radiation therapy performance and higher procedure volumes across our international Gamma Knife operations.

More importantly, we continue to see encouraging trends in the metrics that matter most to the long-term success of our business, patient volumes, utilization, physician engagement and center level operating performance. Beginning with Rhode Island, our three radiation oncology centers continued to improve during the quarter. These facilities once again generated strong revenue growth, supported by increased patient procedures and continued operational improvements. Since acquiring these centers, our primary objective has been to strengthen physician relationships, improve operational execution and expand patient access to high-quality radiation therapy services. We believe we are making meaningful progress against each of those objectives. While there are still additional opportunities ahead, we are encouraged by the trajectory of these operations and believe they represent an important long-term growth platform for the company.

Our Puebla, Mexico radiation therapy center also delivered another strong quarter. Patient activity remained healthy, reimbursement trends continue to be favorable and the operational improvements we've implemented over the past year are translating into better financial performance. Pueblo continues to demonstrate the value of our international operating strategy, and we believe it provides a strong foundation for operational opportunities throughout Latin America.

Turning to proton beam radiation therapy. Our leasing arrangement in Orlando delivered another excellent quarter. Revenues increased over 22% year-over-year as both treatment volumes and reimbursement improved. Proton beam radiation therapy remains an important component of our diversified treatment portfolio, and we're pleased with the continued performance of this asset. Our Gamma Knife business also continued to make encouraging progress. While domestic leasing volumes continue to reflect the expiration of one customer agreement last year, we experienced strong growth across our international Gamma Knife centers. The Esprit upgrade completed in Peru last year continues to produce operational benefits through shorter treatment times, improved patient throughput and higher utilization. We believe these improvements demonstrate the value of continuing to invest in next-generation technology across our installed base.

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

Beyond our current operations, we're also excited about the opportunities ahead. In Rhode Island, we're continuing to work toward development opportunities associated with our previously approved certificates of need. These projects have the potential to significantly expand our presence in one of our strongest operating markets and represents an important component of our long-term growth strategy. As Ray mentioned earlier, we also made important progress regarding our financing capabilities after quarter end. While much of the public attention has understandably focused on the balance sheet, I believe it's equally important to recognize the progress occurring throughout our operating business.

Revenue continues to grow, patient volumes continue to improve. Our clinical partners remain strong, and our operating teams continue to execute at a very high level. Taken together, these trends reinforce our confidence that the business is becoming stronger and better positioned for sustainable long-term growth. While there is still work ahead, I believe the progress we're making today lays the foundation for meaningful long-term value for our shareholders.

With that, I'll turn the call over to our Interim Chief Financial Officer, Alexis Wallace, who will review our financial results in greater detail. Alexis?

Alexis Wallace

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

Beginning with revenue. Total revenue for the second quarter increased 19.2% to approximately $8.4 million compared with $7.1 million in the prior year period. For the first 6 months of 2026, revenue increased 17.7% to approximately $15.5 million from $13.2 million in the first half of 2025. The primary driver of this performance continues to be our Direct Patient Services segment. Second quarter Direct Patient Services segment revenue increased approximately 40% to $4.9 million, while first half revenue increased 35% to approximately $8.9 million. This growth was driven by primarily higher patient procedure volumes at our Rhode Island radiation oncology centers, together with another strong quarter from our Peru and Pueblo, Mexico facilities. Importantly, these centers continue to demonstrate the operating leverage we anticipated when we made these investments. As patient volumes continue to grow, we believe this business will become an increasingly meaningful contributor to both revenue growth and long-term profitability.

Within our Medical Equipment Leasing segment, overall revenue remained relatively stable compared with the prior year. While domestic Gamma Knife leasing activity reflected the expiration of one customer agreement during 2025, this was substantially offset by continued strength in our proton beam radiation therapy business. Proton beam radiation therapy revenue increased 22% to approximately $2.3 million during the quarter and approximately $4.3 million for the first 6 months of the year, benefiting from both higher treatment volumes and improved reimbursement levels.

Gamma Knife revenue also increased modestly during the quarter as procedure volumes continued recovering at our international treatment centers following completion of the Esprit upgrade in Lima. The improved efficiency of the upgraded platform has enhanced patient throughput and contributed to stronger operating performance across our international operations.

Turning to profitability. Gross margin for the quarter was approximately $1.4 million. While modestly below last year's level, it improved sequentially from the first quarter of 2026 despite the continued expansion of our Direct Patient Services business, which carries a different cost structure than our traditional equipment leasing operations. We believe this reflects continued operational execution as we scale that business. Adjusted EBITDA for the second quarter was approximately $1.3 million compared with $1.7 million in the prior year quarter. On a year-to-date basis, adjusted EBITDA totaled approximately $2.5 million, reflecting the continued cash-generating strength of our operating platform.

Moving further down the income statement, selling and administrative expenses increased year-over-year, primarily reflecting legal and professional costs of $285,000 associated with negotiating the third amendment to our credit agreement. In addition, we recorded a higher allowance for credit losses of $909,000 against Rhode Island receivables prior to May 31, '25. As we mentioned in prior calls, we've been focused on improving our accounts receivable and billing systems and have made good progress in that area, so we are well positioned going forward. These two items represented the primary drivers of the increase in our reported net loss during the quarter. We view both as largely independent of the operating trends within the business. Excluding these items, our core operations continue to perform well, supported by higher patient volumes, improving reimbursement trends and disciplined operating execution. Another encouraging development was the continued decline in interest expense as our average debt balances decreased, reflecting our ongoing efforts to strengthen our balance sheet.

Turning to liquidity. We ended the quarter with approximately $6.8 million in cash, cash equivalents and restricted cash compared with $3.7 million at year-end of '25. Perhaps most encouraging, operating activities generated $4.4 million of cash during the first 6 months of the year. This strong cash generation enabled us to fund scheduled debt repayments and distributions to our minority partners while simultaneously increasing our cash position. We believe this demonstrates the improving cash-generating capability of our business as operating performance continues to strengthen.

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

Looking ahead, our financial priorities remain clear. First, continuing driving sustainable revenue growth by increasing utilization across our existing treatment network while expanding our installed base of advanced radiation therapy technologies. Second, translate that revenue growth into improved profitability and operating cash flow through disciplined execution and continued operating efficiency. And third, continue strengthening our balance sheet and capital structure while maintaining the flexibility necessary to support future growth opportunities and create long-term shareholder value. Overall, we are encouraged by the progress achieved during the first half of 2026. The underlying fundamentals of our business continue to improve, our operating cash flow remains strong, demand across our treatment platform is healthy, and we believe the company is well positioned to build on this momentum during the remainder of the year.

With that, Nick, you may open up the call for any questions.

Operator

[Operator Instructions] The first question will come from M. Marin with Zacks.

Phần hỏi đáp

Marla Marin

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

Raymond Stachowiak

Thanks for your question, Marin. This is Ray Stachowiak, Executive Chairman. Yes, we will be growing and have been growing our volumes at our international sites. Peru has seen substantial volume increases, especially since we upgraded their technology to the latest and greatest Esprit model, Gamma Knife. And our linear accelerator in Puebla, Mexico has also experienced increases in volumes. We're also excited about the opportunity to proceed forward with the Gamma Knife upgrade in Guadalajara, Mexico in our relationship with San Javier Hospital there, so we're anxious to get that project going and moving forward as well. And yes, by having greater control and negotiating, expanding our relationships with our hospital partners, that's been a key consideration in our business model.

Operator

The next question will come from Tony Kamin with Eastwood Partners.

Tony Kamin

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

However, I'm trying to reconcile that with when I look at the third amendment, on Page 31 of it, it says the loan parties shall cause their respective subsidiaries to pursue a sale of all or any portion of all of the assets of ASHS. So I mean, that seems pretty clear, too, that in your agreement, it mentions Lake Street, it mentions bid books that you have to start to try to sell the company. I guess I would have preferred that maybe you were able to replace this loan agreement with one from another institution, so you didn't have to do that. But again, it seems it's written very clearly. So again, in the interest of wanting to capture the long-term opportunity here, how do you do that with at the same time being entering into agreement where you have to sell all or part of the company?

Raymond Stachowiak

Well, I think it's fair to say we're pursuing any and all options. It's very clear that we've been given a 12-month extension of the maturity plus -- over 12-month extension of the maturity of our loans to June 30, 2027, so our credit agreement with Fifth Third buys us some time so that we can pursue these different options. We owe Fifth Third about $15.5 million by the end of June of next year. It will be down to about $13.3 million. If you look at our business, we generated $4.4 million of cash in the first 6 months of this year. That number is going to be right off our statement of changes in financial position, $4.4 million of cash generation. We ended the quarter with $6.8 million of cash plus the $2 million deposit we have as well. So I think we're going to be able to find a solution over this period of time to refinance our indebtedness with Fifth Third Bank.

Tony Kamin

That won't necessarily require a sale of the company?

Raymond Stachowiak

We're looking at any and all options as I would expect our shareholders to expect us to do. So we're pursuing any and all options, and we're confident to reach a solution.

Operator

[Operator Instructions] The next question will come from Anthony Marchese, private investor.

Anthony Marchese

I'm trying to figure out how almost $1 million charge for accounts receivable occurs over a year later. I just don't -- I mean, is it one account, multiple accounts? I'm just trying to figure out what happened. It just seems like every quarter, there's something, if it's not a center that was closed, it was maintenance, if not maintenance, now it's accounts receivable. It just seems like every quarter, the company has some hiccup. So I'm just trying to figure out what was the nature, if you could, in more detail of the $900,000 accounts receivable charge and why it took this long to figure it out.

Raymond Stachowiak

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

Anthony Marchese

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

Raymond Stachowiak

Yes. For the most part, it comes from the insurance carriers that we have relationships with.

Anthony Marchese

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

Raymond Stachowiak

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

Anthony Marchese

Of course not.

Operator

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

Craig K. Tagawa

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

Second, the strategic investments we've made over the past several years are producing meaningful results. Our Direct Patient Services business continues to grow, our international operations are gaining momentum, and we have an exciting pipeline of future expansion opportunities that we believe will support long-term value creation.

Finally, while we remain focused on strengthening our balance sheet, we have taken important steps to enhance our financial flexibility and remain committed to executing our long-term strategy with discipline and transparency. I'd like to thank our physicians, clinical teams, employees, hospital partners and shareholders for their continued confidence and support. We appreciate your interest in America Shared Hospital Services and look forward to updating you on our continued progress next quarter. Thank you, everyone, and have a great evening.

Operator

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