Good morning. My name is Lisa Gill, and I'm the head of Healthcare Services here at JP Morgan. It is with great pleasure this morning that I have with me, agilon health. Presenting for agilon health will be Steve Sell, the CEO. Then Steve will join myself, and Tim Bensley for a fireside chat here, just for a few questions after the presentation. With that, let me turn it over to Steve.
Thanks, Lisa. It's good to be back. Good morning, everyone, and thanks for being here. Before we dive in, I'd like to make a few key framing points for you to take away. The first is, when you look at primary care today, the demand for a strong alternative to fee-for-service, and specifically fee-for-service in Medicare, has never been stronger. Second, our business model is working for doctors, patients, and payers, and we'll show you those results. Third, 2023 was definitely a challenging year, but in many ways, the work that we did this year has set the foundation for meaningful improvements in 2024 and beyond. Our 2024 guidance assumes the benefits from that work and a higher utilization trend continues through this year.
And finally, the long-term thesis and opportunity remains firmly intact, and the state of primary care and the overall healthcare system only reinforces that point. Let's start with the problem. It's very challenging to be a primary care doctor in fee-for-service, and particularly in the Medicare program in terms of fee-for-service. As we show you here, I don't know of another business that has seen a 20% decline in the effective unit economics, but that's the reality for a primary care doctor in Medicare today. When you look at the fee schedule, when you look at the changing mix of their practice, with more seniors growing, as you see on the right, and the escalating cost of running a practice, not only are they upside down, it's getting worse.
Not surprisingly, doctors are burning out, and one in five primary care doctors are considering leaving the practice in the next few years. At the same time, key stakeholders like CMS and health plans are saying the key to solve this is to make the move to value. There is incredible structural support from the nation's capital and beyond for this move, and it lines up very well with the desire of primary care doctors to improve access and deliver high-quality, cost-effective care. And while everyone says primary care doctors are the key, the problem is they don't have the business model to do it. They don't have the time, nor do they have the capacity. We're solving that problem for primary care doctors and for the healthcare system.
Our Total Care Model takes the same doctors, the same patients, and the same health plans and moves them from the challenges of fee-for-service into a total care relationship, in which there is a budget, the ability to invest ahead of the outcome with additional resources, and far more information than they've ever had. When we talk about the model working, this is the one data point I constantly look at that gives me great confidence: our ability to deliver consistent results across our network. To be successful in Value-Based care, you need to do a few things. You need to have high-quality access for senior patients. We're seeing a 2-3 times increase in annual wellness visits relative to fee-for-service. From a quality perspective, across these diverse geographies, across all types of groups, we are delivering quality scores at four and above.
All of our year two partners, regardless of where they start, are getting across this critical threshold in which Medicare will pay health plans a 5% bonus, strengthening our value proposition to health plans. Better quality care translates into better cost care. We're driving significant reductions. Seniors are spending far less time in the hospital. Far fewer seniors are accessing through the ER, which is really the last place that you want to enter the healthcare system unless it's absolutely necessary. We're seeing a substantial reduction in terms of readmissions. An example of this great work is in the peer-reviewed palliative care study recently published in the Journal of Pain and Symptom Management. The survey looked at 900 patients treated by agilon partner physicians and compared those enrolled in a palliative care program versus a control group.
What the survey found was an alignment between the wishes of the senior patient and their family to have a passing at home and the outcomes that the program was able to generate. We saw a 65% reduction in hospital-based deaths, seniors able to spend an additional five days at home at the end of life, and a 33% reduction in the total cost of care. In our business, there is a natural flywheel in which better performance drives higher growth, and it follows what you see here. Docs join, we make an investment in care delivery that keeps patients out of the ER and out of the hospital unnecessarily, and as a result, our physicians do better. It changes their practice. It changes their outlook.
More doctors want to join, and you can see the impact: 31 markets, 2,400 primary care doctors, and 650,000 senior patients. These are the drivers of our long-term financial model. Growth, particularly of new partners and members, is tracking meaningfully ahead on the success of our model, and the demand from PCPs for an alternative to fee-for-service is accelerating. Our ACO REACH business tracked well ahead of our expectations in 2023, and we expect that to be strong again in 2024. Operating leverage continues to be ahead of pace as we leverage investments we have made in technology and the ability to centralize and standardize many activities that previously occurred in our respective markets. I'll drill down now on Medical Margin and 2023 performance.
When we think about our 2023 performance at a more detailed level, I would call out two components that sit in our 2023 full-year guide. First, Medical Margin was off by $172 million. This was a result of two factors: an initial forecast assumption of a net 2.3% expected medical and non-medical cost trend that was too low and influenced by our recent experience and the expected in-year impact of our clinical initiatives. And then our being slow to predict and adapt to the utilization surge that began in the second quarter around outpatient surgeries, Part B drugs, and associated specialist costs. 2023, though, was also a year of significant investment at the corporate and market level as we transitioned to a global center of excellence to improve performance.
We expanded local market staffing for clinical programs and stood up a large year one class. While these costs created a greater burden on the 2023 P&L, they have facilitated both medical margin expansion and greater operating expense leverage in 2024. As we outlined on our call last Friday, we have taken a clear set of actions to improve our performance and enhance the predictability of our results against a market dynamic that is far more challenging. We believe our model provides us with a meaningful set of controllable levers that will allow us to buffer our performance against a potentially adverse set of uncontrollable factors, like macro utilization. For example, on this page, I double-click into our changes to date and a 2024 set of milestones that can be quite impactful.
First, from a data and analytics perspective, we have added new data and actuarial leadership and coupled that with a trusted third-party reviewer. We are presently building a digital financial data pipeline that will provide standardized and actionable data with our 7 largest payers, covering 75% of our senior patients. This claims and eligibility data will be complemented by system-wide data to improve forecasting and operational insights. From a physician education and onboarding standpoint, we are focused on 2 groups of new doctors: those joining in new markets with new partners and those joining veteran partner practices that have not had the benefit of an initial orientation on our partnership. For both, we've created a structured training. In 2023, 90% of the docs in our new markets went through the training and delivered outstanding results during their implementation year.
In the first half of this year, we will similarly educate 90% of the docs in our targeted, more mature markets using the same program, which should help narrow the variability between newer and veteran primary care doctors. I previously talked about our global center of excellence, and in 2024, we will take more burden off of our primary care doctors and allow them to maximize their time with senior patients. Finally, our strategic relationships with our payer partners are built around mutual need and candid exchange, allowing us to take on difficult topics like risk-sharing and the division of financial responsibility.
This is a very important slide, and it brings together many of the concepts we are discussing today: the effectiveness of our business model, the ability to take out variability across markets, and the power of a standardized process to drive consistency in terms of medical margin performance across a disparate set of primary care doctors from different markets and medical group types. What this chart shows is one key process metric to identify, assess, and ultimately manage complex chronic condition patients, and it shows the class of 18 on the left up through our newest class on the right from 2024. In 2018, in the first year, our first market of Columbus reached a CCR rate of 82%. In each year, they and every other market have progressed.
But in 2023, as we standardized both information and process and aligned our doctors through consistent incentives and increased capacity, we have seen every market class reach at least 90%. That's an all-time high, many with meaningful improvements, and both Columbus, our first market, and our most recent new class of 2024 have both reached 92%+ . This has meaningful implications for quality and cost management. The better assessment I just showed you drives better clinical enrollment. Earlier, we talked about the strong results from our palliative care study published in 2023. A 65% reduction in hospital-based deaths, a 33% reduction in total cost of care, and much greater satisfaction for the patient and the family.
Here we show you a strong step-up in our earliest two markets with palliative care programs, reaching roughly 3.4% of the population, which is impressive when you consider that the potential universe is somewhere between 4% and 6% of that population at any one time. We attribute these strong results due to a combination of a better assessment process, combined with a long-term primary care doctor-patient relationship that is built on trust, and a skilled palliative care discussion around personal and family goals and overall program options. Better enrollment in clinical programs for complex patients results in meaningful reductions in avoidable inpatient hospital spend. In 2023, through the effectiveness of our various clinical programs, we saw a 2.6% reduction in inpatient utilization.
This outcome demonstrates our ability to move the needle when we identify and engage senior patients around a specific condition or need, and lays out a roadmap for further expansion across our markets. So when we think about our 2023 earnings and our 2024 guide, we see a business that has well more than doubled our MA membership from 230,000 members in 2022 to 550,000 members in 2024. Next year, we will grow our reach membership north of 100,000 members. We are very cognizant that utilization continues at elevated levels, and that has been reflected in our revised 2023 outlook and our utilization assumptions for 2024.
The meaningful step-up in Medical Margin and Adjusted EBITDA for 2024 is driven in large part by 2023 actions in areas like chronic assessment and management, a 2024 class that leverages all of these platform strengths, and significant operating leverage that allows for a much greater pull-through of MA and reach Medical Margin dollars to the Adjusted EBITDA line. When we think about the earnings power of our business and how we generate cash, it is important to break apart the market classes into a few key categories: Year 2+, Year 1, and Year 0. While the progression of these classes gets shown to you in a composite Medical Margin, it is important to understand that Year 2+ classes drive the entirety of our Adjusted EBITDA and cash flow power.
Year one classes historically run just above or below break even, although the class of 2024 is expected to contribute immediately. The year zero implementation classes bring on a new class at roughly $500 per member to onboard, and in 2023, we spent $71 million to onboard the 140,000 members from the class of 2024. And all of this lays across a corporate expense of roughly $100 million. These dynamics set up a business in which as we reach critical scale through both MA and Reach, medical margins to Adjusted EBITDA will increase nicely, although they can be more difficult to see in our reported figures. So in closing, from a macro perspective, when we look at the power of our business model, we see a strong long-term opportunity built around the following key factors.
One, the demand for a new primary care model that rewards patient outcomes has never been higher, and the continuing pain of the fee-for-service system only accelerates that demand. Two, the agilon platform is driving more value each year to our existing primary care doctors, making the case even stronger for our prospective PCPs looking for an alternative. Third, membership continues to accelerate, creating long-term value through more members on the platform earlier. And then finally, as we've talked about in our mature markets, variability in the system creates a great opportunity. And in fact, it's a central reason the company was created, and the value proposition is so compelling for primary care doctors around the country in medical groups of every different kind. Thanks, Lisa.
Thanks very much, Steve, and thanks for all the comments. Let's first start off when we think about 2024. Maybe, Tim, this is a question for you. When we think about, you know, the potential headwinds and tailwinds as you start to put together more of the detailed guidance, I know you've given us some preliminary numbers, but are there anything specifically we should be thinking about?
[crosstalk] You want me to start? Yeah, sure. Yeah. I mean, I think, Lisa, in terms of the headwinds, I think the utilization assumption-
Yeah
... I just talked about, we see 2024 as another high utilization year. I think V28, everyone is balancing that, but we obviously see that as manageable. I think supplemental benefits year over year we see as another step-up, although not nearly as great as what we saw in 2023. In terms of tailwinds, 270,000 members generating an incremental $150 million, these last two classes that have doubled the company. That's huge. You know, our platform just continues to get stronger, and our clinical operations and the programs that we've got that expand around that. And then finally, as I just talked about, our operating expense leverage is greater.
And Steve, the only thing, and the other thing that you mentioned in the presentation, just to tack on, in the 270,000 members, that's half our, you know, 140 of that coming from the class of 2024, that is gonna contribute positively.
Right.
Even though that's a tailwind versus what we would've had certainly in 2023 or before.
Just kind of digging in a little to that utilization comment, right? So if I go back to the third quarter-
Yeah.
You had raised your MLR expectations by $50 million.
That's right.
And then, you know, we had to have a discussion on Friday-
We did.
as to where things actually had
Yeah
... come out thus far for the December quarter. Can you maybe just help us to understand? I know you've talked about outpatient surgeries, some inpatient volumes, et cetera, et cetera, but was there something that really changed with your book of business? Was it just that you weren't capturing, you know, what was actually happening? How do I think about, you know, just that short period of time from when you reported at the beginning of November, right, to two months later?
Yeah. I mean, I think the goal with what we talked about on Friday in our, you know, revised 2023 guide, is to really set a solid foundation.
Yeah.
We're trying to step off 2023 in a good way and move into 2024. That led to us, as we saw higher paid claims come in, you know, really re-intensifying our discussions with all of our payers, looking at a variety of, of external data. I just talked about some of the changes we've made in terms of our leadership and bringing in kind of a peer review, third party. All of that led to, you know, a revised guide that had us see higher paid claims, revise those completion factors to Q2 and Q3, and elevate Q4 just based off that- those higher utilization and, and what we saw around all of that, and that continues forward, Lisa, into 2024.
You know, data visibility has been a challenge this, this year, and you talked last week about getting payers that had previously been on a two-month lag, moving to a one-month lag. You just talked about 75%, where you'll have better visibility.
Yeah.
Can you maybe talk about, is there a difference in the type of payer? You said 75%, but is that... Were the large payers always giving you visibility, and it was more of the small payers that there was a lack-
It was-
of visibility? Or was everybody the same, and you needed to get everybody on the same-
No
-plan?
... There, there's kind of a, a mix, Lisa, between some of our, the big national payers are on very different lags. You know, we have our largest payers actually are most current, but we have a couple of other large ones that are actually on quite a bit larger lag, and some of our regional payers are both as well. I mean, overall, our average lag across all of our payers is about 1.6 months. So it's not horrible, but obviously it's a little bit slower than what if, you know, you would have if you were the actual payer. I think one of the bigger things that we're doing moving forward is putting a lot more expertise and infrastructure in place to do more with that information-
Right
... that we're getting, even on that one point, and that's one of the things that Steve talked about in, you know, taking the way that we ingest data today, which is we get, as you can imagine, an immense amount of data that we're dealing with every day. But really dealing with it in the format that, you know, each individual payer gives it to us, and on a payer-by-payer, market-by-market basis, doing all of our estimates and using that to drive our operational, -
Right
... you know, go-forward plans, et cetera. And really now putting that in through a model that allows it to be in a standardized agilon format, so it feels like-
Right
... our data, the way we want it, that we can drill down to. And it'll give us the ability to do, I think, you know, even more analysis and better, a better job on our estimates going forward. And we'll have, you know, 50% of our payers on that by the end of Q1, 75%-
Right
... of them on the end of it, or membership by the end of Q2.
Lisa, I think if you, at the macro level, you think about we're building, we have a scaled multi-payer platform across 30 markets-
Right
... and, you know, 14 states, and so I don't know anyone else that has that. I think if you talk to us in 6-12 months, this is gonna be a massive area of differentiation. I mean, I think not only are we getting the information in a standardized way with our payers, not only getting the surround elements around that, but we're able now to have a much more integrated conversation with our payer partners. You know, I ran a payer for a long time.
Yes.
They're on a lag as well.
Right.
And I think we're all managing through this utilization environment, and so the richness of that, that's allowing us to, you know, with this team that I-
Mm
... I talked about, really make these judgments and reads on it, I think is, has been a step up. But the inputs into that, not just the receipt and timing, but also just sort of the actionability around it and consistency, I think is fairly unique. Looking across 30 payers-
Mm
... a whole bunch of different claims systems-
Right
... being able to have that view, I think that's gonna be a differentiator for us long term.
Is there an opportunity, if I think about it from that data perspective, right? When you think about many of the medical procedures, there's a prior authorization.
Yeah.
I would think that most of your primary care doctors have an idea of what's going on with the patient. Are you collecting that level of data to maybe preemptive-
Well-
... you know?
So one, there's typically a referral-
Yep
... to the specialist, which is one. The prior auth is typically in an HMO product, right?
Mm-hmm.
And this is the new world of Value-Based Care, and we're, which over half our memberships with, sits within a PPO.
That's right.
There's not always that indicator. Sometimes there's something like hips and knees are an area-
Mm
... that we talked about. For a senior, there could be an echo test in front of that. There could be another indicator for that. So I think there are a variety of those things, but I think, you know, getting data in from surgery centers-
Mm
... looking at, you know, what the manufacturers are talking about around, somebody has to produce a hip and a knee. It's just, it's just all of that, that I think... with our precision can get much better, and then can sort of tune things regionally. Because part of what we're seeing as utilization is it's not equal everywhere.
Right.
It varies across markets, et cetera.
And I think that that's part of one of my other questions. Like, when I think about that $100 million of additional medical costs, is it concentrated with any single one payer or in any single one region?
So-
You got it.
... Okay, so I think when you look at the, the difference between what we were saying when we guided it in the Q3 and what we're saying now, so that, that incremental, it's, you know, about 40% of it or so is actually in our new markets. So we do have, as we're getting more complete information and better information from the payers in the new markets, you know, we did see obviously a-
Mm
... you know, higher costs there, and we're recognizing that. And then the rest of it is essentially spread across the rest of our markets. I think if you go back to the very beginning of the year and say: "How does our, you know, expectation about, claims expense and overall medical margin look across our markets?" It's, you know, we have, you know, that difference is pretty well spread across our year two-plus markets.
Yeah, I mean, I think it's distributed propor- to your question about payers-
Yeah
... distributed proportionally to sort of the membership mix we've got. I think the concentration is in the categories-
Okay. Yep
... right?
Yeah.
The hips and knees, the Part B drug, the, you know, oncology and orthopod specialists-
Mm-hmm
... that sit within that. That's a little bit more of it. And I think, you know, part of that is this pent-up demand that we talked about on Friday. You know, our estimate is that we're 60% through the backlog of delayed outpatient procedures for things like hips and knees-
Yep
... that maybe someone got a referral during COVID, but has taken time to sort of,
Right, feel comfortable, right.
... feel comfortable-
Yeah
... and pursue that. That factors into our guide for 2024, that that stays at a higher level. But it also factors into actions, like we've entered into a Value-Based Care relationship with a partner in one of our very large markets that saw a very elevated trend to take the risk around that, go to an alternative site of care, and a subset of orthopaedics.
So just so I understand that, so you're subcapitating some of that risk when we think about certain categories? Is that-
That's right. So you're just like we've done with partners around renal and palliative-
Right
... where we've done very well, and we showed you the inpatient results-
Mm-hmm
... around that. Now, as we pivot to the outpatient side, there are partners that we can work with around that. It can be a global cap. It can be kind of a corridor relationship. I mean, there's a lot of ways-
Right
... to pass risk.
Right.
And so, but that, that's the idea. And I guess my point, going back to the scale we've got, that's the opportunity for us.
Okay. No, that makes sense. When I asked about headwinds or tailwinds, you talked about supplemental benefits, and that, you know, that'll be an area of continued pressure as we move into 2024. I know in the past we've talked about maybe having conversations with payers around potential ways to restructure some of this-
Yeah
... and potentially mitigate this for 2025. Can you maybe talk about some of those discussions and opportunities that you see?
Yeah. I mean, I think I gave you the sense on the data side.
Yeah.
But I think the richness of our discussion, maybe the intensity of our discussion with payer partners-
Mm-hmm
... is, is pretty robust right now, and I think, you know, we sit in a very privileged seat. Our partners are the scaled groups in these communities.
Right.
25, 30, 35% of the adult primary care capacity and essential to a network for different payer partners, and so I think that's really being recognized within these discussions. And so I think we've been able to work with these payer partners. Some of it shows up in 2024. Our, you know, we're projecting a 5%+ trend, same geo. I think that's pretty strong. Part of that is increased percent of premium-
Right
... arrangements with payers, some of those, you know, relatively recently, but I think most of it's going to go towards 2025 in terms of how we look at that. But I think it does come back to, this is not you have to wait for a renewal discussion. These conversations go on all the time. It's so dynamic-
Right
... in terms of benefits that are being filed and how that flows through, that there's an opportunity for us to work on that.
Yeah, you talked about physician variability as you know, contributing to some of the issues in 2023.
Yeah.
You've also talked about some of the educational programs and other things that you'll do, when we think about doctors in the marketplace. Do you think that the rapid growth has contributed to that variability?
So I think one is opportunity, variability is just a massive opportunity for us, right? And it's everywhere in the healthcare system.
Right.
When we grow and we enter a new market, or new physicians come into one of our existing partner groups, by definition, there's going to be variability for us. You know, the slide that I showed, I call that as a really important slide. That's an example of narrowing variability.
Mm-hmm
... across all of our markets. So I think we've got a track record of being able to do a really good job around that. To be able to have that year one market start at that place that a veteran market is-
Right
... that means you have to narrow the PCP variability within that market. So I think it's something that we can really dig into. You know, your question about growth, you know, sort of leads me to, we are growing really smartly. I think if you look at the class of 2024-
Mm-hmm
... and their performance, not only is this the largest class, but it's the highest starting point of any class we've ever had. And that's a function of a, they're fantastic groups, and they bring tremendous capabilities to the table, long history in Value-Based Care. But also, our platform is getting better, and so we're able to get them into clinical programs far earlier than they've ever been, Lisa.
Yeah.
That, coupled with the capabilities they bring, I think is really distinctive.
So when you talked about that higher Medical Margin for this class, right?
Twenty-four.
and so if we think about that delta between the $76 PMPM that you talked about for the class of 2024 versus, call it, kind of average of $45 PMPM-
Yeah
On the midpoint from previous classes, how much of that delta is from better risk coding versus better, you know, medical margin, or something else that you would call out? So any additional detail you can give us to better understand that.
Yeah, I mean, I think so the class of 2024 is... We're very lucky. I mean, the best groups in the country are choosing to join us. These are in markets that everyone wants to be in, whether it's Georgia, whether it's Central Pennsylvania, whether it's Dallas, Texas. You know, Catalyst in Dallas, Texas, is an example that I'll call out. I mean, they are an incredibly reputable group. They bring 100-plus PCPs, so they're scaled.
Yeah.
They've had a long history in value-based care, and so that helps all of that. Two, long implementation cycles. So this class has had a longer implementation than any group we've ever had.
Right.
Every month, we always talk about is worth a lot as they work through that. That allows you to take advantage of your platform benefits earlier. So the Chronic Condition Reassessment Rate, this is the first class that's got the benefit of that.
Okay.
So that helps. Two is our clinical programs like renal, palliative, those were live this month as we go live.
Right.
That has never happened in a year one class before. So I think the combination of all those things, but something that's really cool is our network just keeps getting better. So Catalyst has a medication adherence program called Stellus that they've had great success with. We've actually brought that in, and we're using that in multiple markets.
Mm-hmm.
When you look at our quality scores, which I think are very distinctive, as I showed you.
Yes
... that's, those are triple-weighted measures, right?
Right.
Those are super important around it. I think it's a combination of those things that's helping us to get better.
You talked about the changes to the risk adjustment model that start here in 2024-
Yeah
called V28. And I know we've talked in the past around where your PMPM came in more towards the lower end of the average versus some others that maybe had a lot of dual eligibles or had some risk coding adjustments in there. Can you talk about, though, the impact that you're projecting in 2024?
Yeah, I mean, again, our revenue trend is projected at 5%, and that's inclusive of a 2% impact-
Mm
From V28. Benchmark bid rate, our percent of premium is nice within that in terms of part of that. But what I would say is, all along, we said this was manageable for us.
Yeah.
We do start, to your point, at a lower level.
Mm-hmm.
But with the work that we've been able to do, very detailed work, we've been able to get that overall sort of outcome around that. The global cap, the chronic condition reassessment rate, all feed that.
Let's talk about health systems for a little bit.
Yeah.
So, can you spend a little time just talking about what's driving the interest from health systems more recently and what the pipeline of opportunity looks like?
Yeah. So, I mean, just for context, we have three health systems that we work with today: MaineHealth, that went live in January of 2023, and then we've just brought two health systems live, Premier in Dayton-
Mm-hmm
... and Holland in western Michigan. I think for Maine and for the current two folks and the people that we're talking with, it's a combination of a structural thing in which they've got a large PCP base. Maybe they acquired it along the way, or they've grown it, and it's becoming a challenge for them. Can they take that PCP base and really turn it to an asset for them?
Right.
So that there's and then a Medicare strategy-
Mm-hmm
... right? So Medicare can be challenging, and so the ability to be able to enter into a partnership to really leverage these PCPs and put them at the front, to reduce the amount of time that seniors are spending in beds and in the ER, and in the case of some of these, you know, replace that with a commercial mix-
Right
... all of that is very attractive to them. The two that are added this year, they're in existing markets that we've been in, and so-
Okay
... they know the independent partner there, and they're able to leverage that. They're able to leverage all of the infrastructure and the team and the contracts, and so it's a comfort level with that.
Mm-hmm.
But it kind of goes back to those structural points.
Is there one that you would prefer versus another? If I think about you know, health systems versus independent physician practices.
I mean, the majority of our model is around independent groups.
Yeah.
I mean, I think the natural advantages they have is they're typically, you know, a single tenant. Many are on a single EMR or moving in that direction. They've got tight governance. They've got tight economics. So I think that will continue to be the majority, Lisa.
Mm-hmm.
However, health systems face the structural challenges I talked about, and what we've learned from Maine is there are advantages they have that the independents do not. One is resources. The level of medical director resources in Maine is richer than any partner we've ever seen, and then their Epic EMRs, I mean, it's kind of a beast to integrate with.
Right.
Once you do that, I mean, there's a real sort of step function improvement around that.
... Let's spend a couple minutes to talk about ACO REACH, which has actually been a bright spot, right? So ACO REACH has been a very strong performer and a big contributor to your adjusted EBITDA driver. Can you talk about what's driving the strength in that business?
Sure, Lisa. I mean, a couple things. One is, I mean, the overall strength of the performance is obviously being driven by everything that we're doing on the MA side, too.
Yeah.
They're benefiting from everything that we do. All the programs that we have in place, you know, just pour right on top of the ACO REACH population in those markets where we have it. A little bit of a difference this year in ACO REACH though versus MA is in a higher utilization environment, the revenue rate for ACO REACH-
Right, yeah
... actually adjusts within the year. So as long as we're continuing to have our cost trend outperform the overall fee-for-service reference population, we're gonna—that gap is what's driving essentially our profitability out of the model, and we're continuing to do that really well. The other thing that maybe is worth mentioning for ACO REACH for us this year, and one of the reasons why we remain confident in our outlook, is we also get really good current, complete data from CMS.
Mm-hmm.
So as the year comes through, both on the revenue side and on the claims side, they pay pretty quickly, and they give us really current information, so we can kinda keep up with it really well. But, I mean, this overall idea of, hey, we're making an impact on those ACO REACH patients, with the same techniques, the same clinical program, everything that we're doing against MA, and then we're getting the benefit of the, you know, the, the revenue rate kind of adjusting real time-
Right
... for the environment, so.
Lisa, I guess what I would just add is, you know, our year-two-plus classes, both MA and REACH, are running north of $100 PMPM in terms of medical margin.
Mm-hmm.
I think in terms of the way the financials come out, sometimes it can look like REACH is producing more than MA is. But the reality is-
Mm
... they're getting a lot of OpEx leverage in terms of those corporate costs that are-
Right, right
... fully being charged against MA.
Right, because of the way you're accounting for it.
So proportionally-
Yeah, exactly
... MA will still drive that. So but it's super strategic for us. For the doc, it's really valuable. If you've got a full patient-
Yeah
... of 400 senior patients, and you're able to get both of those, and you're able to drive that $100, I mean, you're talking about potentially $240,000 of incremental incentives that are going back-
Right
... to the practice per doctor. And so that value proposition across that, what we hear again and again, continues to really differentiate - be one of our differentiators -
Right
... that these groups are looking at.
You know, ACO REACH is projected to run through 2026. It really started as Direct ontracting under Trump-
It did, yeah.
... and then Biden had to change it to ACO REACH. Any thoughts from a political perspective in D.C. as to what could change with this program post-2026?
Well, I think the partisan piece comes into what you name it and who sort of named it. So-
Right
... setting that piece aside, I think there's bipartisan support for a full-risk program for the Medicare fee-for-service program. That could come through another innovation center program-
Mm
... whatever you would call it. Or it could come through a full-risk vehicle in the traditional Medicare program. But there is a lot of support, and whether you talk to OMB-
Yeah
... whether you talk to people on the Hill, in Ways and Means, Energy and Commerce, et cetera, people are very supportive of that. And I think when you think about the long-term Medicare trust fund and sort of the budget implications of being able to move into a program like this, that program, just to remind you, is CMS takes, you know, a percent, 3.5% off the top.
Right.
They pay themselves first.
First, and then-
And then you go earning... So they really like the way the economics work-
Right
... in comparison to a lot of other programs.
Right.
You know, you don't have that sort of guarantee that's built into it. Obviously, if you're able to beat the national trend, that's a good thing.
Right. Well, we're out of time. Thank you very much, everyone, for joining us. And thank you, Steve-
All right
... and Tim. I appreciate it.
Thanks, Lisa.