What changed in this filing

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Item 1. Business

2021-04-06 compared with 2020-04-03 · 90 added, 82 removed, 237 unchanged (42% of the section changed)

American Shared Hospital Services (“ASHS” and, together with its subsidiaries, the “Company”) provides Gamma Knife stereotactic radiosurgery equipment and radiation therapy and related equipment to fifteen (15) medical centers in fourteen (14) states in the United States and one Gamma Knife unit at a stand-alone facility in Lima, Peru as of March 1, 2020.

American Shared Hospital Services (“ASHS” and, together with its subsidiaries, the “Company”) provides stereotactic radiosurgery equipment and advanced radiation therapy and related equipment.

The Company currently provides Gamma Knife units to thirteen 13 medical centers in twelve (12) states in the United States and Gamma Knife units at stand-alone facilities in Lima, Peru and Guayaquil, Ecuador as of March 1, 2021.

The Company provides Gamma Knife services through its 81% indirect interest in GK Financing, LLC, a California limited liability company (“GKF”).

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ASRS is the majority-owner of GKF.

GKF has established the wholly-owned subsidiary Instituto de Gamma Knife del Pacifico S.A.C.

(“GKPeru”) for the purpose of providing similar Gamma Knife services in Peru.

GKF has established the wholly-owned subsidiaries Instituto de Gamma Knife del Pacifico S.A.C.

(“GKPeru”) and HoldCo GKC S.A (“HoldCo”) for the purpose of providing similar Gamma Knife services in Peru and Ecuador, respectively.

GKF also owns a 51% interest in Albuquerque GK Equipment, LLC (“AGKE”) and Jacksonville GK Equipment, LLC (“JGKE”).

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A 40% minority ownership in LBE is owned by radiation oncologists.

On June 12, 2020, GKF, through HoldCo, purchased approximately 98% of the total outstanding shares of Gamma Knife Center Ecuador S.A.

(“GKCE”), from GKCE’s majority shareholders (the “Acquisition”).

As of December 31, 2020, the Company acquired additional shares that increased its ownership to approximately 99.3% of the total outstanding shares of GKCE and intends to acquire the remaining 0.7% at a later date.

The base purchase price for the Acquisition, including acquisition of the minority shares was approximately $2,000,000.

This purchase price was paid with $575,000 in cash and a $1,425,000 loan from the United States International Development Finance Corporation (“DFC”).

The purchase price is subject to certain post-closing adjustments, including adjustment for GKCE's working capital and excess cash.

The DFC loan is denominated in U.S.

dollars, which is also the currency of Ecuador.

The Company continues to develop its design and business model for “The Operating Room for the 21 st Century” SM through its 50% owned OR21, LLC (“OR21”).

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In 2015, Elekta introduced an upgrade to the Gamma Knife Perfexion unit called Icon.

As of March 1, 2020, all of the Company’s fifteen (15) Gamma Knife units in the United States are Gamma Knife Perfexion units and one (1) of these Perfexion units has the Icon upgrade.

As of March 1, 2021, all of the Company’s thirteen (13) Gamma Knife units in the United States are Gamma Knife Perfexion units and two (2) of these Perfexion units have the Icon upgrade.

The Gamma Knife treats selected malignant and benign brain tumors, arteriovenous malformations, and functional disorders including trigeminal neuralgia (facial pain).

Research is being conducted to determine whether the Gamma Knife can be effective in the treatment of epilepsy, tremors, and other functional disorders.

As of December 31, 2019, there were approximately 120 Gamma Knife sites in the United States and more than 340 units in operation worldwide.

Based on recent data, an estimated percentage breakdown of Gamma Knife procedures performed in the U.S.

As of December 31, 2020, there were approximately 116 Gamma Knife sites in the United States and 345 units in operation worldwide.

Based on 2019 case mix data, an estimated percentage breakdown of Gamma Knife procedures performed in the U.S.

by indications treated is as follows:

malignant (65%) and benign (21%) brain tumors, vascular disorders (4%), and functional disorders (10%).

The Company, as of March 1, 2020, had fifteen (15) operating Gamma Knife units located in the United States and one in Lima, Peru.

The Company, as of March 1, 2021, had thirteen (13) operating Gamma Knife units located in the United States and two (2) in South America in Lima, Peru and Guayaquil, Ecuador, respectively.

The Company’s first Gamma Knife commenced operation in September 1991.

The Company’s Gamma Knife units performed 1,530 procedures in 2020 for a cumulative total of approximately 43,500 procedures from commencement through December 31, 2020.

Revenue from Gamma Knife services for the Company during each of the last five (5) years ended December 31, and the percentage of total revenue of the Company represented by the Gamma Knife for each of the last five years, are set forth below:

As December 31, 2020, the Company recognized a loss on the write down of impaired assets of $8,264,000.

The impaired assets included six (6) Gamma Knife units and related removal costs, and two (2) deposits towards the purchase of proton beam systems and related capitalized interest.

The six (6) Gamma Knife units that were impaired consisted of two (2) units that had been taken out of service in prior years, one (1) unit that was taken out of service in 2020 and three (3) units that have already, or the Company anticipates will be taken out of service in 2021, totaling $3,051,000.

In addition to this impairment write-off of $3,051,000 were estimated costs of de-install and removal (ARO) of four (4) of the Gamma Knife units of $1,350,000 (of which, the Company has paid $80,000) as of December 31, 2020.

Total impairment related to the Gamma Knife business was $4,401,000 for the year ended December 31, 2020.

The Company reviews the carrying value of its long-lived assets for impairment on a quarterly basis, or as events or circumstances might indicate that the carrying value may not be recoverable.

The Company has reviewed its Gamma Knife equipment, in light of available information as of December 31, 2020 and based on current customer prospects, the probability of future contract extensions or renewals, and the high turnover rate in contract terminations compared to the Company's historical contract termination rate, the Company determined that these six (6) Gamma Knife units were more-than temporarily impaired.

Gamma Knife treatment was included in the Radiation Oncology Alternative Payment Model (“RO APM”).

However, for the Company's customers included in the RO APM, there does not appear to be a significant reimbursement impact.

Revenue from Gamma Knife services for the Company during each of the last two (2) years ended December 31, and the percentage of total revenue of the Company represented by the Gamma Knife for each of the last two years, are set forth below:

Total Gamma Knife

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2019 $ 13,551 65.8 %

2017 $ 14,848 75.9 %

2016 $ 16,076 86.0 %

2015 $ 16,077 97.2 %

The Company conducts its Gamma Knife business through its 81% indirect interest in GKF.

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GKF, formed in October 1995, is managed by its policy committee.

The policy committee is composed of one representative from the Company, Ernest A.

Bates, M.D., ASHS’s Chairman and CEO, and one representative from Elekta.

The policy committee is composed of one representative from the Company, Craig Tagawa, ASHS’s President, Chief Operating and Financial Officer, and one representative from Elekta.

The policy committee sets the operating policy for GKF.

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The policy committee selects a manager to handle GKF’s daily operations.

Tagawa, Chief Executive Officer of GKF and Chief Operating and Financial Officer of ASHS, serves as GKF’s manager.

Tagawa, Chief Executive Officer of GKF and President, Chief Operating and Financial Officer of ASHS, serves as GKF’s manager.

GKF’s profits and/or losses and any cash distributions are allocated based on membership interests.

GKF’s operating agreement requires that it have a cash reserve of at least $50,000 before cash distributions are made to its members.

From inception to December 31, 2019, GKF has distributed $49,600,000 to the Company and $11,635,000 to the non-controlling member.

Image Guided Radiation Therapy Operations (“IGRT”)

The Company’s radiation therapy business currently consists of one IGRT system that began operation in September 2007 at an existing Gamma Knife customer site.

Revenue generated under IGRT services accounted for approximately 4.1% of the Company’s total revenue in 2019.

This contract is currently on a month-to-month basis and the Company expects it will terminate during the second quarter of 2020.

IGRT technology integrates imaging and detection components into a state-of-the-art linear accelerator, allowing clinicians to plan treatment, verify positioning, and deliver treatment with a single device, providing faster, more effective radiation therapy with less damage to healthy tissue.

IGRT captures cone beam imaging, fluoroscopic and/or x-ray images on a daily basis, creating three-dimensional images that pinpoint the exact size, location and coordinates of tumors.

Once tumors are pinpointed, the system delivers ultra-precise doses of radiation which ultimately leads to improved patient outcomes.

Additional information on our operations can be found in Item 6– “Selected Financial Data”, Item 7– “Management’s Discussion and Analysis of Financial Condition and Results of Operations” and Note 1 of our consolidated financial statements.

From inception to December 31, 2020, GKF has distributed $50,005,000 to the Company and $11,730,000 to Elekta.

Advanced Radiation Therapy Equipment and Services

The Company is continuing its efforts to contract new radiation therapy customers both domestically and internationally.

The Company has increased its product offerings from standard linear accelerators to more advanced linear accelerators that incorporate Magnetic Resonance Imaging (“MRI”) and potentially Positron Emission Tomography (“PET”) imaging technologies.

The Company believes that these more advanced technologies, with a higher capital cost component, may be potentially a more receptive market segment for its business model.

The Company’s radiation therapy business consisted of one Image Guided Radiation Therapy (“IGRT”) system that began operation in September 2007 at an existing Gamma Knife customer site.

This contract terminated in July 2020 and did not generate any revenue in 2020.

Additional information on our operations can be found in Item 7– “Management’s Discussion and Analysis of Financial Condition and Results of Operations” and Note 1 of our consolidated financial statements.

Proton Beam Radiation Therapy Operations (“PBRT”)

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More than 200,000 patients have been treated with protons worldwide.

Prior to December 31, 2020, the Company had $2,250,000 in deposits toward the purchase of two MEVION S250i PBRT systems from Mevion.

The Company reviews the carrying value of its deposits for impairment on a quarterly basis, or as events or circumstances might indicate that the carrying value may not be recoverable.

The Company has reviewed the deposits, in light of available information, as of December 31, 2020 and based on its current customer prospects, the impact that the COVID-19 pandemic has had on medical centers undertaking large capital expenditure projects for a limited patient base, and the length of time required to negotiate and implement a proton therapy project, the Company determined that its deposits of $2,250,000, related capitalized interest of and other charges of $1,613,000 were other-than temporarily impaired.

Total impairment related to the proton therapy business was $3,863,000.

Introduction of PBRT in the United States, until recently, has been limited due to the high capital costs of these projects.

The Company believes that the current development of one and two treatment room PBRT systems at lower capital costs and the level of reimbursement for PBRT from the Centers for Medicare & Medicaid Services (“CMS”) will help make this technology available to a larger segment of the market.

However, the introduction of the RO APM and the inclusion of PBRT in this model potentially limits the adoption of PBRT by medical centers.

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The business is capital intensive;

the total cost of a Gamma Knife or IGRT facility usually ranges from $3.0 million to $5.5 million, including equipment, site construction and installation;

the total cost of a Gamma Knife facility usually ranges from $3.0 million to $5.5 million, including equipment, site construction and installation;

the total cost of a single room PBRT system usually ranges from $30.0M to $40.0M, inclusive of equipment, site construction and installation.

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Kettering Medical Center Kettering, Ohio 10 years 1999 Revenue sharing

Tufts Medical Center Boston, Massachusetts 10 years 1999 Fee per use

University of Arkansas for Medical Sciences Little Rock, Arkansas 15 years 1999 Revenue sharing

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Kisco, New York 10 years 2005 Fee per use

Tufts Medical Center (IGRT) Boston, Massachusetts 10 years 2007 Revenue Sharing

USC University Hospital Los Angeles, California 10 years 2008 Fee per use

Sanders Regional Medical Center Knoxville, Tennessee 10 years 2011 Revenue Sharing

Vincent’s Medical Center Jacksonville, Florida 10 years 2011 Revenue Sharing

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One customer accounted for approximately 35% and 30% of the Company’s total revenue in 2020 and 2019, respectively.

At December 31, 2019 and 2018, three customers individually accounted for more than 10% of total accounts receivable, in the respective years.

The Company markets its Gamma Knife services through its preferred provider status with Elekta and a direct sales effort led by its Vice President of Sales and Business Development, its Chief Operating Officer and its Chief Executive Officer.

The Company markets its PBRT service through a direct sales effort led by its Vice President of Sales and Business Development, its Chief Operating Officer and its Chief Executive Officer.

At December 31, 2020, four customers each individually accounted for 11%, 11%, 11% and 20% of total accounts receivable, respectively.

At December 31, 2019, three customers each individually accounted for 12%, 15% and 30% of total accounts receivable, respectively.

The Company markets its Gamma Knife services through its preferred provider status with Elekta and a direct sales effort led by its Senior Vice President, its President, Chief Operating and Financial Officer, and its Chief Executive Officer.

The Company markets its PBRT service through a direct sales effort led by its Senior Vice President, its President, Chief Operating and Financial Officer, and its Chief Executive Officer.

The major advantages to a health care provider in contracting with the Company for its services include:

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The Company currently does not have customer contracts for its second and third PBRT units.

The Company believes the business model it has developed for use in its Gamma Knife and IGRT placements can be tailored for the PBRT market segment.

The Company believes the business model it has developed for use in its stereotactic radiosurgery equipment and advanced radiation therapy placements can be tailored for the PBRT market segment.

The Company is targeting large, hospital-based cancer programs.

The Company’s ability to develop a successful PBRT financing entity depends on the decision of cancer centers to self-fund or to fund the PBRT through conventional financing vehicles, the Company’s ability to capture market share from competing alternative PBRT financing entities, and the Company’s ability to raise capital to fund PBRT projects.

The Company’s ability to secure additional customers for Gamma Knife services and other proton beam radiation therapy services, or other equipment, is dependent on its ability to effectively compete against the manufacturers of these systems selling directly to potential customers and other companies that outsource these services.

The Company’s ability to secure additional customers for stereotactic radiosurgery equipment, advanced radiation therapy equipment and services and other proton beam radiation therapy services, or other equipment, is dependent on its ability to effectively compete against the manufacturers of these systems selling directly to potential customers and other companies that outsource these services.

The Company does not have an exclusive relationship with any manufacturer and has previously lost sales to customers that chose to purchase equipment directly from manufacturers.

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The Medicare program is subject to statutory and regulatory changes, administrative rulings, interpretations and determinations, requirements for utilization review, and federal and state funding restrictions, all of which could materially increase or decrease payments from these government programs in the future, as well as affect the cost of providing services to patients and the timing of payments to our client hospitals.

The Company’s Gamma Knife, PBRT and IGRT customers receive payments for patient care from federal government and private insurer reimbursement programs.

Currently in the United States, Gamma Knife, proton therapy and IGRT services are performed primarily on an out-patient basis.

The Company’s Gamma Knife and PBRT customers receive payments for patient care from federal government and private insurer reimbursement programs.

Currently in the United States, Gamma Knife and proton therapy services are performed primarily on an out-patient basis.

Gamma Knife patients with Medicare as their primary insurer, treated on either an in-patient or out-patient basis, comprise an estimated 35%-45% of the total Gamma Knife patients treated nationwide.

PBRT and IGRT patients with Medicare as their primary insurer are treated primarily on an out-patient basis and comprise an estimated 45% to 50% of the total radiation therapy patients treated.

Congress enacted legislation in 2013 that significantly reduced the Medicare reimbursement rate for outpatient Gamma Knife treatment by setting it at the same amount paid for linear accelerator-based radio surgery treatment.

Prior to April 1, 2013, Medicare’s reimbursement rate for Gamma Knife treatment had been relatively stable.

The Company’s IGRT services are reimbursed by CMS and other insurers.

Reimbursement for these services has remained fairly stable.

On July 10, 2019, CMS issued a proposed rule that would implement a new mandatory payment model for radiation oncology services:

the Radiation Oncology Alternative Payment Model (“RO APM”).

The proposed RO APM would treat prospective episode payments to hospital outpatient departments and freestanding radiation therapy centers for radiation therapy as episodes of care.

The RO APM would significantly alter CMS’ payment methodology for radiation oncology services.

Under the RO APM, payment would be determined by the patient’s cancer type, as opposed to a traditional volume-based fee-for-service model, and would include select radiation therapy services provided within a 90-day episode.

If the RO APM is finalized as proposed, radiation therapy providers and suppliers may be mandatorily required to participate in the model based on whether the radiation therapy is provided within selected geographic areas.

CMS projects that approximately 40% of the radiation oncology providers within randomly selected Core Based Statistical Areas (CBSAs) will be included in the model and approximately 60% will continue to receive reimbursement based on fee-for-service methodology.

The Company, along with other interested parties, submitted comments to CMS on the proposed rule as part of the notice-and-comment rulemaking process.

The comment period concluded on September 16, 2019.

It is uncertain whether CMS will finalize the rule as proposed.

As a result, the Company cannot estimate the potential impact of adoption of the proposed rule.

However, reductions in the reimbursement rates or changes in reimbursement methodology or administration for radiosurgery and radiation therapy could adversely affect the Company’s revenues and financial results.

For centers not included in the proposed model, Medicare reimbursement in 2020 for the most commonly used proton therapy delivery codes has recently been established by CMS and is expected to increase by approximately 15.5% and by approximately 3.6% for Gamma Knife.

PBRT patients with Medicare as their primary insurer are treated primarily on an out-patient basis and comprise an estimated 45% to 50% of the total radiation therapy patients treated.

On September 18, 2020, CMS issued the final rule that would implement a new mandatory payment model for radiation oncology services:

The RO APM is scheduled to commence January 1, 2022 and will be in effect for a five (5) year period.

The RO APM significantly alters CMS' payment methodology from a fee for service paradigm to a set reimbursement by cancer type methodology for radiation services provided within a 90 day episode of care.

Under the RO APM, hospital based and free-standing radiation therapy providers are mandatorily required to participate in the model based on whether the radiation therapy provider is located within a randomly selected Core Based Statistical Area ("CBSA").

CMS projects that providers treating approximately 30% of radiation oncology patients have been selected to participate in the RO APM.

The remaining providers not included in the RO APM will continue to receive reimbursement based on a fee-for-service methodology.

The RO APM includes but is not limited to PBRT and Gamma Knife services.

Four (4) of the Company's Gamma Knife centers are scheduled to be included in the RO APM.

It is not anticipated that inclusion in the RO APM will have a significant impact on the Company's Gamma Knife revenues.

The Company's PBRT center was not selected for inclusion in the RO APM.

For centers not included in the RO APM proposed model, Medicare reimbursement in 2021 for the most commonly used PBRT delivery codes increases by approximately 4.1% and decreases by approximately 1.7% for Gamma Knife.

See additional discussion under “Item 1A Risk Factors.”

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Any changes to Medicare or Medicaid reimbursement through the repeal or modification of the Affordable Care Act could affect revenue generated from these sites.

Some of the provisions of the Affordable Care Act have yet to be fully implemented, while certain provisions have been subject to judicial and Congressional challenges as well as recent efforts by the current U.S.

President’s administration to repeal or replace certain aspects of the Affordable Care Act.

Since January 2017, the current U.S.

President has signed two Executive Orders and other directives designed to delay the implementation of certain provisions of the Affordable Care Act or otherwise circumvent some of the requirements for health insurance mandated by the Affordable Care Act.

Concurrently, Congress has considered legislation that would repeal or repeal and replace all or part of the Affordable Care Act.

Some of the provisions of the Affordable Care Act have yet to be fully implemented, while certain provisions have been subject to judicial and Congressional challenges.

While Congress has not passed comprehensive repeal legislation, it has enacted laws that modify certain provisions of the Affordable Care Act such as removing penalties, starting January 1, 2019, for not complying with the Affordable Care Act’s individual mandate to carry health insurance and delaying the implementation of certain Affordable Care Act-mandated fees.

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District Court Judge in the Northern District of Texas, or Texas District Court Judge, ruled that the individual mandate is a critical and inseverable feature of the Affordable Care Act, and therefore, because it was repealed as part of the Tax Cuts and Jobs Act, the remaining provisions of the Affordable Care Act are invalid as well.

While the Texas District Court Judge, as well as the current U.S.

President’s administration and CMS, have stated that the ruling will have no immediate effect, it is unclear how this decision, subsequent appeals, and other efforts to repeal and replace the Affordable Care Act will impact the Affordable Care Act.

While the Texas District Court Judge and CMS, have stated that the ruling will have no immediate effect, it is unclear how this decision, subsequent appeals, and other efforts to repeal and replace the Affordable Care Act will impact the Affordable Care Act.

In addition, other legislative changes have been proposed and adopted in the United States since the Affordable Care Act was enacted.

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The Company is not involved in the practice of medicine and therefore believes its present insurance coverage and indemnification agreements are adequate for its business.

The Company’s Peruvian Gamma Knife center is a free-standing facility operated by GKPeru.

GKPeru’s treating physicians and clinical staff are independent contractors.

The Company maintains general and professional liability insurance consistent with the operations of this facility and believes its present coverage is adequate for its business.

At December 31, 2019, the Company employed nine (9) people on a full-time basis in the United States and five (5) people on a full-time basis in Lima, Peru.

None of these employees is subject to a collective bargaining agreement and there is no union representation within the Company.

The Company’s Peruvian and Ecuadorian Gamma Knife centers are free-standing facilities operated by GKPeru and GKCE, respectively.

The treating physicians and clinical staff are these facilities are independent contractors.

The Company maintains general and professional liability insurance consistent with the operations of these facilities and believes its present coverage is adequate for its business.

At December 31, 2020, the Company employed ten (10) people on a full-time basis in the United States, five (5) people on a full-time basis in Lima, Peru, and six (6) people on a full-time basis in Guayaquil, Ecuador.

None of these employees are subject to a collective bargaining agreement and there is no union representation within the Company.

The Company maintains various employee benefit plans and believes that its employee relations are good.

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The executive officers were appointed by the Board of Directors and serve at the discretion of the Board of Directors.

83 Chairman of the Board of Directors and Chief Executive Officer

Tagawa 66 Senior Vice President - Chief Operating and Financial Officer

Bates 53 Vice President of Sales and Business Development

Bates, M.D., founder of the Company, has served in the positions listed above since the incorporation of the Company.

A board-certified neurosurgeon, Dr.

Bates is Emeritus Vice Chairman of the Board of Trustees at Johns Hopkins University and serves on the Johns Hopkins Neurosurgery Advisory Board.

He also serves on the boards of Shared Imaging and The School of Nursing Dean’s Advisory Council at UCSF.

Bates currently serves as President and Director of the Ernest Bates Foundation.

From 1981-1987 he was a member of the Board of Governors of the California Community Colleges, and he served on the California High Speed Rail Authority from 1997 to 2003.

Bates is a member of the Board of Overseers at the University of California, San Francisco, School of Nursing.

He is a graduate of the School of Arts and Sciences of the Johns Hopkins University, and he earned his medical degree at the University of Rochester School of Medicine and Dentistry.

Tagawa has served as Chief Operating Officer since February 1999 in addition to serving as Chief Financial Officer since May 1996.

Stachowiak 62 Chief Executive Officer

Tagawa 67 President, Chief Operating and Financial Officer

Bates 54 Senior Vice President

Stachowiak has served as Chief Executive Officer of the Company since October 1, 2020.

Stachowiak served as Interim President and Chief Executive Officer effective as of May 4, 2020 through September 30, 2020.

Stachowiak joined the Board in 2009.

Stachowiak previously served as President and Chief Executive Officer of Shared Imaging, a preferred independent provider of CT, MRI and PET/CT equipment and services, from its inception in December 1991 until his retirement in March 2013.

Stachowiak sold 50% of his interest in Shared Imaging to Lubar Equity Fund and remains a 50% owner of Shared Imaging.

Stachowiak is the sole owner of RCS Investments, Inc., and owner-manager of Stachowiak Equity Fund, both of which are private equity funds.

Stachowiak received a B.S.

in Business and an M.B.A.

from Indiana University.

He is a Certified Public Accountant (inactive), Certified Internal Auditor (inactive) and holds a Certification in Production and Inventory Management.

Tagawa assumed the title of President on October 1, 2020 along with his duties as Chief Operating Officer since February 1999 and Chief Financial Officer since May 1996.

Tagawa also served as Chief Financial Officer from January 1992 through October 1995.

Previously a Vice President in such capacity, Mr.

Tagawa became a Senior Vice President on February 28, 1993.

He is also the Chief Executive Officer of GKF.

Tagawa became a Senior Vice President on February 28, 1993 and President on September 16, 2020.

He is also the Chief Executive Officer and policy committee member of GKF.

From September 1988 through January 1992, Mr.

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Tagawa currently serves as Chief Financial Officer and Secretary of the Ernest Bates Foundation.

He is a former Chair of the Industrial Policy Advisory Committee of the Engineering Research Center for Computer-Integrated Surgical Systems and Technology at The Johns Hopkins University.

He received his undergraduate degree from the University of California at Berkeley and his M.B.A.

from Cornell University.

Bates joined the Company in January 2007 as Vice President of Sales and Business Development.

Bates joined the Company in January 2007 as Vice President of Sales and Business Development, and assumed the title of Senior Vice President of Sales and Business Development, International Operations on October 1, 2020.

In October 2020, he was appointed to and currently serves as a member of AHMC Seton Medical Community Advisory Board.

He was on the Board of Directors of the Company from 2004 through February 2007.

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degree from The Wharton Business School.

Bates is the son of Chairman of the Board and Chief Executive Officer Dr.

Bates is the son of Chairman of the Board Dr.

Bates, founder of the Company.

AVAILABLE INFORMATION

Our Internet address is www.ashs.com .

We make available free of charge, through our Internet website under the “Investor Center” tab in the “Corporate” section, our annual report on Form 10-K, quarterly reports on Form 10-Q, current reports on Form 8-K, and amendments to those reports filed or furnished pursuant to Section 13(a) or 15(d) of the Securities Exchange Act of 1934 (“Exchange Act”) as soon as reasonably practicable after such material is electronically filed with or furnished to the SEC.

We make available free of charge, through our Internet website under the “Investor Center” tab in the “Corporate” section, our annual report on Form 10-K, quarterly reports on Form 10-Q, current reports on Form 8-K, annual proxy reports, and amendments to those reports filed or furnished pursuant to Section 13(a) or 15(d) of the Securities Exchange Act of 1934 (“Exchange Act”) as soon as reasonably practicable after such material is electronically filed with or furnished to the SEC.

The information contained on our Internet website is not part of this document.

Compared sentence by sentence after normalising whitespace, quotation marks, case and digits, so re-formatting and restated figures do not read as changed language. Wording changes appear as one removal and one addition. The current filing and the prior one are authoritative.

What changed 10-K

Item 1. Business