Bayer 2019: Fighting back
As Bayer battles rulings and upcoming trials over the safety of the weedkiller Roundup, the company is continuing to expand R&D capabilities in pharmaceuticals.
51368 Leverkusen, Germany
Telephone: +49 214 30-1
Best-Selling Rx Products
|Product||2018 Sales||2017 Sales|
|Kogenate, Kovaltry, Jivi||$1,010||$1,143|
All sales are in millions of dollars and were translated
using the Federal Reserve Board’s average rate of
exchange in 2018: EUR 1.1817 = $1.00
|1H 2019||1H 2018|
All figures are in millions of dollars,
except EPS, and were translated using
the Federal Reserve Board’s average rate
of exchange in 2018: EUR 1.1817 = $1.00
Outcomes Creativity Index Score: 43
Manny Awards – N/A
Cannes Lions – 15
LIA: Health & Wellness – 3
Clio Health – 5
One Show: HW&P – 1
MM&M Awards – 2
Global Awards – 9
Creative Floor Awards – 8
2018 was a particularly eventful year for Bayer, but it was not an easy one. In 2018, the company completed the biggest acquisition in Bayer’s history, buying Monsanto, which advanced Bayer to the No. 1 position in the agriculture sector.
“With that, we have stringently focused our businesses on the growth markets of health and nutrition, where we are among the best companies in the world with our know-how and innovation capabilities,” says Chief Executive Werner Baumann.
Despite this acquisition, Bayer’s stock performance in 2018 was “very disappointing,” Baumann says.
Operationally, the company experienced a difficult market environment in 2018, with significant negative currency effects and growing uncertainty caused by global trade disputes.
“On top of that, we were unable to fully exploit our growth potential because of production bottlenecks in the Pharmaceuticals Division and structural problems at Consumer Health,” Baumann says.
While the DAX was down 18 percent in 2018, the company’s share price dropped by about 40 percent. Additionally, on Aug. 10, 2018, a California jury ordered Monsanto to pay $289 million after determining that the company’s Roundup weedkiller caused a man’s cancer.
With the ruling, “the strategic progress we made and the company’s solid operational performance were overshadowed,” Baumann says.
“Although it was these topics that dominated the headlines, I believe it’s important to emphasize that last year we again kept our company’s main promise – ‘Science for a better life’ – millions of times over,” he says. “Our products have helped to improve the lives of our customers – patients, consumers, and farmers. That is what defines us, and that is what drives our actions.”
Baumann says Bayer’s success in the coming years will depend partly on accomplishing the integration at Crop Science as well as adjusting the innovation model in its pharmaceuticals business.
“This will put Bayer in the best possible position to deliver long-term value creation as a world-leading life science company,” Baumann says.
Baumann says the company plans to invest some €35 billion ($41.36 billion) in its future through 2022, with research and development accounting for over two-thirds of this figure.
In September 2019, Bayer made two announcements of actions designed to take the company into the future.
The Supervisory Board of Bayer AG decided to reduce the size of the company’s Board of Management from seven to five members, effective January 1, 2020. Dr. Hartmut Klusik and Kemal Malik will leave the company as of December 31, 2019. As part of the previously communicated efficiency measures, neither position will be retained.
“By streamlining the structure of the Board of Management, we are optimizing the allocation of responsibilities and contributing to the company’s ongoing efficiency program,” says Werner Wenning, chairman of the Supervisory Board of Bayer AG. “Driving innovation, leveraging technology and developing our network of partnerships are factors that will remain crucial to our company’s success and will continue to be anchored in our management structure.”
Bayer announced Marianne De Backer, Ph.D., as the new head of Business Development & Licensing of its Pharmaceuticals Division. She reports to Stefan Oelrich, member of the Board of Management, Bayer AG, and president of the company’s Pharmaceuticals Division and joined the Pharmaceuticals Executive Committee. De Backer is based in Berkeley, Calif., and leads Bayer’s external pharmaceutical growth strategy and activities globally in all key areas of pharmaceutical innovation and alliance management.
“Marianne De Backer is a recognized business leader with an impressive track record spanning over two decades in research, commercial, as well as licensing, mergers and acquisitions,” Oelrich says. “Her breadth of experience in successfully forming and managing external alliances will be one of the key drivers for Bayer’s continued growth, ultimately aimed at providing new medicines and solutions to patients.”
De Backer joined Bayer from J&J where she was VP of M&A Operations and Divestitures for the Pharmaceuticals Group and led Infectious Diseases & Vaccines Business Development including transactions, acquisitions, scientific licensing, and alliance management.
Bayer’s problems with Roundup are not over yet. In May 2019, a California jury awarded a couple more than $2 billion, the largest U.S. jury verdict to date against the company in litigation over the chemical. This is the third jury trial Bayer has lost.
As of August 2019, the company was reportedly in mediation to potentially settle thousands of U.S. lawsuits claiming that Roundup causes non-Hodgkin’s lymphoma.
In September 2019, a month away from when from what would be the fourth Roundup cancer trial, lawyers for Bayer sent a letter to the presiding judge in St. Louis County Circuit Court seeking action that would break up the group of plaintiffs into many smaller groups and delay the trial. The date of Oct. 15 was previously set for 14 plaintiffs who had been grouped under the case Winston V. Monsanto, with the venue to be St. Louis City Court.
Bayer’s lawyers wanted the case to be tried in St. Louis County, and after the plaintiffs’ attorneys relented – to keep the group from being broken up into smaller groups – St. Louis Circuit Court Judge Michael Mullen transferred all plaintiffs except Winston to St. Louis County in a Sept. 13 order.
Financial & product performance
In 2018, Bayer had total sales of €39.59 billion ($46.78 billion), 13.1 percent more than in 2017. Net income was €1.7 billion ($2 billion), compared with €7.34 billion ($8.67 billion) in the previous year. Diluted earnings per share were €1.80 ($2.13), compared with €8.29 ($9.80) in 2017. The company spent €5.25 billion ($6.2 billion) on R&D in 2018, an increase of 16.5 percent. In 2018, about 55 percent of R&D expenses were for pharmaceutical research.
In the first half of 2019, the company achieved revenue of €24.5 billion ($28.95 billion), 31.6 percent more than in the same period last year. Net income was €1.65 billion ($1.94 billion), 40 percent less than in first-half 2018. Diluted earnings per share were €1.68 ($1.99), nearly 45 percent less than in the same period last year. R&D expenses were €2.71 billion ($3.2 billion), 17.3 percent more than in the first half of 2017.
The Pharmaceuticals Division achieved 2018 sales of €16.77 billion ($19.8 billion), about the same as in 2017. Executives say this was due primarily to a strong performance overall by key growth products Xarelto, Eylea, Stivarga, Xofigo, and Adempas, sales of which were €6.84 billion ($8.08 billion), 10.4 percent more than in 2017, and to substantial sales gains in China.
First-half 2019 Pharmaceuticals sales were €8.77 billion ($10.36 billion), 5.8 percent more than in first-half 2018.
Bayer’s top 10 pharmaceutical product lines in 2018 sales were Xarelto; Eylea; Mirena; Kogenate, Kovaltry and Jivi; Nexavar; Yasmin, Yaz and Yasminelle; Glucobay; Adalat; Aspirin Cardio; and Betaseron/Betaferon.
The blood thinner Xarelto achieved sales of €3.63 billion ($4.29 billion), an increase of 12.6 percent from the previous year. In the first half of 2019, the product generated €1.94 billion ($2.3 billion), an increase of 12.3 percent from first-half 2018. Executives say sales in the first half were driven by expanded volumes in China and Europe/Middle East/Africa, particularly Russia and France.
Eylea, for treating age-related macular degeneration and diabetic macular edema, was once again Bayer’s second best-selling drug annually, generating 2018 sales of €2.19 billion ($2.58 billion), 16.2 percent more than in 2017. Eylea sales in the first half of 2019 amounted to €1.19 billion ($1.4 billion), 13.7 percent more than in the same period last year. Management says business continued to expand in all regions, with sales developing especially positively in Europe, primarily in the United Kingdom, and in Canada.
The Mirena birth control product family generated €1.14 billion ($1.35 billion) in 2018, 1.5 percent more than in 2017. Mirena sales in the first half of 2019 were €619 million ($732 million), 4.4 percent more than in the first half of 2018.
Once again fourth in yearly sales was the hemophilia product franchise Kogenate, Kovaltry and Jivi, which posted €855 million ($1.01 billion), 11.6 percent less than in 2017. Sales in first-half 2019 were €434 million ($513 million), 1.6 percent more than in the same period last year.
The cancer drug Nexavar had 2018 sales of €712 million ($841 million), a decrease of 17.1 percent. Sales in the first half of 2019 were €355 million ($401 million), an increase of 1 percent from first-half 2018. Sales were negatively affected by the competitive market environments in the United States and Japan, although growth in China and Italy partly offset this development.
The Yasmin, Yaz and Yasminelle line of oral contraceptives generated 2018 sales of €639 million ($755 million), down 1.4 percent versus the 2017 result. During the first six months of 2019, sales improved 4.8 percent year-over-year to €326 million ($385 million).
The diabetes drug Glucobay had 2018 sales of €623 million ($736 million), 10.7 percent more than in 2017. First-half 2019 sales totaled €342 million ($404 million), 10.6 percent more than in first-half 2018.
Sales of Adalat, for the treatment of hypertension, declined 5.7 percent in 2018 to €648 million ($722 million) in sales. In the first half of 2019, sales were €345 million ($408 million), a 1.2 percent increase from first-half 2018.
Aspirin Cardio generated 2018 sales of €557 million ($658 million), 4.1 percent less than in 2017. First-half 2019 sales were €298 million ($352 million), 3.8 percent less than in first-half 2018.
The multiple sclerosis drug Betaseron/Betaferon had sales of €544 million ($643 million), 16.4 percent less than in 2017. First-half 2019 sales continued to exhibit a decline, to €221 million ($261 million), 18.1 percent less than in the same period last year. Executives say the decline was again mainly driven by strong competition in the United States.
Bayer’s Consumer Health business generated 2018 sales of €5.45 billion ($6.44 billion), 7 percent less than in 2017. Executives say growth in the Latin America and Asia/Pacific regions on a currency- and portfolio-adjusted basis stood against declines in North America and in Europe/Middle East/Africa. “As expected, temporary supply disruptions weighed on sales,” management says.
In the first half of 2019, Consumer Health sales were €2.84 billion ($3.35 billion), about half a percent more than in the same period last year.
The division’s leading product is the OTC antihistamine Claritin. Sales were €516 million ($610 million) in 2018, down 11.8 percent, which executives attributed mainly to the primary sales market – the United States – which was affected by the weak allergy season and by intensified competition. Sales also declined in Japan, due in part to statutory price adjustments.
Bayer’s trademark OTC Aspirin generated €418 million ($494 million) in 2018, down 9.5 percent versus 2017.
2018 sales of the Bepanthen/Bepanthol line of wound and skin care products declined 2.1 percent to €371 million ($438 million).
Sales of the analgesic Aleve slipped 6.4 percent in 2018 to €351 million ($415 million). Executives say declines were mainly in the United States, where a product line extension was discontinued.
Sales in 2018 of the Canesten line of skin and intimate health products declined 11.9 percent to €245 million ($290 million). The decrease was attributed to temporary supply disruptions.
The Alka-Seltzer product family had 2018 sales that declined 7.8 percent against the previous year, at €225 million ($266 million). By contrast to sales declines in the United States, business developed positively in the Europe/Middle East/Africa and Latin America regions.
The prenatal vitamin Elevit generated 2018 sales of €209 million ($247 million), up 10.6 percent from 2017. Sales were driven by the Asia/Pacific and Europe/Middle East/Africa regions, where the product benefited from continuing strong demand and product line extensions. The expansion of Bayer’s e-commerce activities also had a positive effect in Asia/Pacific.
Sales of One A Day vitamins were €203 million ($240 million) in 2018, 8.6 percent less than in 2017. Executives say the decline was primarily from stronger pressure on prices in the United States,.
Sales of Dr. Scholl’s foot care products declined 6.2 percent in 2018 to €198 million ($234 million). According to management, the decline was primarily in the United States.
Sales of the OTC laxative Miralax grew 8 percent in 2018 to €176 million ($208 million). The increase was largely due to higher U.S. demand.
In September, Bayer announced the completion of the sale of the Coppertone brand of sun and skin products to Beiersdorf for a purchase price of $550 million. Bayer entered into a definitive agreement in May to sell Coppertone to Hamburg, Germany-based Beiersdorf. According to executives, having successfully carved out the business, Bayer is now able to focus on building its core over-the-counter business.
Beiersdorf took over 450 dedicated brand personnel in the United States, Canada and China including sales and marketing, research & development and others, as well as a production facility in Cleveland, Tenn.
Sales of the Animal Health business declined 4.5 percent to €1.5 billion ($1.77 billion). In the first half of 2019, sales were €875 million ($1.03 billion), up 0.9 percent compared to same-time 2018.
R&D and pipeline progress
In 2018, Bayer received encouraging news about its pharmaceuticals pipeline and ongoing product development.
In November 2018, the company received approval in the United States for Vitrakvi, (larotrectinib), the first-ever oral TRK inhibitor. The drug is for the treatment of adult and pediatric patients with solid tumors that have a neurotrophic receptor tyrosine kinase (NTRK) gene fusion without a known acquired resistance mutation, are metastatic or where surgical resection is likely to result in severe morbidity, and have no satisfactory alternative treatments or that have progressed following treatment.
Vitrakvi represents the first treatment to receive a tumor-agnostic indication at the time of initial FDA approval. In clinical trials of patients with TRK fusion cancer, Vitrakvi showed an ORR of 75 percent, including a 22 percent complete response (CR) rate.
The company also successfully concluded a Phase III study of darolutamide in 2018, with the drug receiving U.S. FDA approval in July 2019 as Nubeqa. The drug was approved under the FDA’s Priority Review designation, with approval granted three months ahead of the target FDA action date.
Nubeqa is an androgen receptor inhibitor (ARi), for the treatment of patients with non-metastatic castration-resistant prostate cancer (nmCRPC). The FDA approval is based on the Phase III ARAMIS trial evaluating Nubeqa plus androgen deprivation therapy (ADT), which demonstrated a highly significant improvement in the primary efficacy endpoint of metastasis-free survival (MFS), with a median of 40.4 months versus 18.4 months for placebo plus ADT (p<0.0001). MFS is defined as the time from randomization to the time of first evidence of blinded independent central review (BICR)-confirmed distant metastasis or death from any cause within 33 weeks after the last evaluable scan, whichever occurred first.
“With the approval of Nubeqa, we now have a new therapy that extends MFS and allows physicians greater flexibility to treat men living with nmCRPC,” says Robert LaCaze, member of the Executive Committee of Bayer’s Pharmaceuticals Division and head of the Oncology Strategic Business Unit at Bayer. “Bayer is proud to take this latest step forward in the nmCRPC treatment landscape. Nubeqa is the newest addition to our prostate cancer portfolio and reflects Bayer’s commitment to finding treatments for men at different stages along the prostate cancer continuum.”
To build its research and development capabilities, in August 2019 Bayer announced that it was fully acquiring BlueRock Therapeutics, a privately held U.S.-headquartered biotechnology company focused on developing engineered cell therapies in the fields of neurology, cardiology and immunology, using a proprietary induced pluripotent stem cell (iPSC) platform.
Following a 2016 joint venture with Versant Ventures to establish BlueRock Therapeutics, Bayer will acquire the remaining stake for $240 million in cash to be paid upfront at closing and an additional $360 million payable upon achievement of pre-defined development milestones. With Bayer holding a 40.8 percent stake, the investment corresponds to a total company value of BlueRock Therapeutics of $1 billion. The closing of the transaction was expected during the third quarter of 2019.
“This acquisition marks a major milestone on our path towards a leading position in cell therapy,” says Stefan Oelrich, member of the Board of Management, Bayer AG and president of the Pharmaceuticals Division. “In line with our strategy to ramp up our investments in technologies with breakthrough innovation potential, we have decided to build our cell therapy pipeline based on BlueRock Therapeutics’ industry-leading iPSC platform. Ultimately, we are joining forces to deliver new treatment options for medical needs that are still unmet today.” BlueRock Therapeutics’ portfolio of cell therapies is focused on neurology, cardiology and immunology with a lead program in Parkinson’s disease expected to enter the clinic by the end of 2019.
Executives say with this transaction, Bayer will own full rights to BlueRock Therapeutics’ CELL+GENE platform, including a broad intellectual property portfolio and associated technology platform including proprietary iPSC technology, gene engineering and cell differentiation capabilities.
In addition to the company’s focus, BlueRock Therapeutics’ platform brings the opportunity to extend to other therapeutic areas beyond the current development programs. Management says to preserve the entrepreneurial culture as an essential pillar for nurturing successful innovation, BlueRock Therapeutics will remain an independent company, operating at an arm’s-length basis.
In July 2019, Bayer announced a research collaboration with Bristol-Myers Squibb Co. and Ono Pharmaceutical Co. Ltd. to evaluate the combination of Bayer’s kinase inhibitor Stivarga (regorafenib) and Bristol-Myers Squibb’s/Ono’s anti-PD-1 immune checkpoint inhibitor Opdivo (nivolumab), in patients with micro-satellite stable metastatic colorectal cancer (MSS mCRC), the most common form of mCRC.
In a Phase Ib investigator sponsored trial from Japan called REGONIVO (NCT03406871, EPOC1603), the combination of regorafenib and nivolumab has shown promising preliminary efficacy results. The detailed data of the study were presented at the 2019 American Society of Clinical Oncology (ASCO) Annual Meeting.
“The data seen in REGONIVO warrant further exploration of the combination of regorafenib and nivolumab in patients with colorectal cancer,” says Scott Z. Fields, M.D., senior VP and head of Oncology Development at Bayer’s Pharmaceuticals Division. “Regorafenib has proven its efficacy and positive safety profile as a third-line monotherapy and we are excited to enter into a clinical collaboration to evaluate this combination with the hope to deliver an additional therapeutic benefit to patients.”
In June 2019, the company announced that Stivarga has become the first compound used in a clinical trial platform to investigate new therapies for brain cancer. Enrollment was opened for the arm of the platform trial GBM AGILE (Glioblastoma Adaptive Global Innovative Learning Environment) for patients with newly diagnosed and recurrent glioblastoma, the most aggressive and common form of primary brain cancer. Executives say the opening of the first clinical trial site, at Henry Ford Cancer Institute in Detroit, marks the start of the international clinical trial program sponsored by the Global Coalition for Adaptive Research (GCAR). Stivarga will be the first drug to be evaluated in this trial.
Bayer will provide drug supply and support the clinical trial at sites enrolling patients in the Stivarga arm. By the end of 2019, GBM AGILE will open in more than 40 academic medical centers and community-based institutions across the United States, with plans to expand across Europe, China, Canada and Australia through 2020.
“We are excited that the regorafenib arm of the GBM AGILE trial is the first to enroll patients and are looking forward to seeing how regorafenib can potentially help these patients in need of treatment options,” Dr. Fields says. “Bayer actively supports the clinical research of regorafenib in a range of different tumor types to explore the potential of this drug to help even more patients in need.”
Also in June, Bayer announced a collaboration with Arvinas Inc. to develop novel Proteolysis-Targeting Chimera candidates for humans and plants. Executives say the collaboration demonstrates the utilization of potential synergies of emerging and converging research across human and plant applications that is “unprecedented” in the life sciences sector.
Bayer will form an exclusive joint venture as the first company to explore the PROTAC technology in agriculture for crop protection, and at the same time, establish a target-based pharmaceutical research collaboration with Arvinas. In addition, Bayer will make an equity investment to sustain its commitment for the technology.
“Today, up to 80 percent of the human proteome is still considered untreatable by small molecule inhibitors, the mechanism underlying many therapeutic drugs currently available,” executives say. “By removing target proteins directly rather than blocking them, protein degraders like PROTACs may provide multiple advantages over small molecule inhibitors. In addition, no inhibitors have been identified for a majority of the targets of interest in drug development.”
“In line with our strategy to adopt novel modalities in R&D, we are entering into a collaboration with Arvinas as we see the breakthrough innovation potential in this technology,” says Dr. Joerg Moeller, member of the Executive Committee of Bayer AG’s Pharmaceuticals Division and head of Research and Development. “Because PROTACs don’t inhibit the target protein’s enzymatic activity, but bind their targets with high selectivity, it may be possible to retool previously ineffective inhibitor molecules as PROTACs for next-generation medicines for patients.”
Arvinas will receive an upfront payment and pharmaceutical R&D support over the next four years, as well as a direct equity investment. These investments, combined, will exceed $60 million.
Bayer will own the rights to novel lead structures generated during the course of the collaboration. As programs advance through R&D and commercialization, Arvinas is eligible to receive pre-defined development milestones of over $685 million and commercial royalties.
In May, FDA granted Breakthrough Therapy Designation for Aliqopa (copanlisib) for the treatment of adult patients with relapsed marginal zone lymphoma (MZL) who have received at least two prior therapies. MZL is an indolent form of non-Hodgkin’s lymphoma (iNHL) and accounts for about 10 percent of all non-Hodgkin’s Lymphoma in the United States.
The Breakthrough Therapy Designation was granted based on data from the MZL subgroup of the pivotal Phase II CHRONOS-1 study, which is the trial that accelerated FDA approval of Aliqopa for the treatment of adult patients with relapsed follicular lymphoma (FL) – the most common histological subtype of iNHL – who have received at least two prior systemic therapies.
Accelerated approval was granted for this indication based on overall response rate (ORR). Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial.
Aliqopa is an intravenous phosphatidylinositol-3-kinase (PI3K) inhibitor with inhibitory activity predominantly against the PI3K-alpha and PI3K-delta isoforms expressed in malignant B cells. The compound is currently not approved by the European Medicines Agency (EMA) or other authorities outside of the United States.
In September, Bayer announced that the company and Partners HealthCare’s founding members Brigham and Women’s Hospital (BWH) and Massachusetts General Hospital (MGH) are launching a joint lab to research new drug candidates to treat chronic lung diseases. The joint lab will host scientists from all three parties and Bayer is investing more than $30 million to fund joint research projects over the next five years.
Within the framework of this new collaboration, four leading experts will combine their expertise in the search for new treatment options for patients who suffer from chronic lung diseases: Edwin Silverman, M.D., Ph.D., chief of the Channing Division of Network Medicine at BWH; Bruce Levy, M.D., chief of Pulmonary and Critical Care Medicine at BWH; Benjamin Medoff, M.D., chief of Pulmonary and Critical Care at MGH; and Markus Koch, Ph.D., head of Preclinical Research, Lung Diseases at Bayer.
“This strategic collaboration complements our in-house research and will bring us closer to providing life-changing treatment options for patients living with chronic lung diseases,” Moeller says. “The joint lab concept continues to be an innovative model for collaboration between academia and industry, enabling novel approaches to drug discovery.”
Bayer executives say scientists will work side-by-side, combining the company’s capabilities in drug discovery and development with the complementary clinical expertise, understanding of disease mechanisms, data analysis capabilities, and insights from leading physician scientists of Brigham and Women’s Hospital and Massachusetts General Hospital. The lab, located at Brigham and Women’s Hospital, will have more than 20 people from all three organizations work in combined teams. The rights to the research findings will be shared equally between the organizations.
The new lab at Brigham and Women’s Hospital, located in the Longwood Medical and Academic Area, bolsters Bayer’s existing presence in Boston. Earlier this year, Bayer committed to opening lab and office space in the heart of Kendall Square to further expand its research and development efforts. In 2018, Bayer established a first joint lab in Boston together with the Broad Institute of MIT and Harvard in the area of cardiovascular diseases. The Pharmaceuticals Business Development & Licensing team of Bayer facilitated this collaboration.
In another unique collaboration, Bayer and U.S.-based digital health company Informed Data Systems Inc. in September entered into a collaboration and licensing agreement to leverage Informed Data Systems’ One Drop digital therapeutics platform to provide integrated solutions and services in multiple therapeutic areas to empower people with chronic diseases to aim at better outcomes.
One Drop offers a digital self-management platform to improve health outcomes. Bayer is investing $20 million in a Series B financing in the company and has signed a licensing agreement worth $10 million for developing and commercializing the One Drop technology platform further.
“As part of our strategy to shape the future of healthcare and build new businesses in digital health, we are investing in integrated digital solutions to improve health outcomes through data driven solutions,” Oelrich says. “This collaboration allows us to obtain access to a world leading self-care platform for disease management beyond the boundaries of medicines with strong artificial intelligence-driven capabilities that could lead to better healthcare outcomes for people with chronic conditions.”
One Drop is an evidence-based and clinically proven innovative digital therapeutic platform through the use of an integrated patient facing application, monitor and coaching/behavioral change programs. Originally developed for diabetes management, this platform will support Bayer in building Integrated Care patient services offerings.