All right, let's kick this one off. Thanks everyone for joining. I am Jack Slevin, Research Analyst here at Jefferies. I lead our coverage of the value-based care sub-sector. Really happy to be joined here by agilon health. We have Jeff Schwaneke, CFO here. Jeff, thanks for joining.
Thank you. Appreciate it.
Awesome. Maybe just to jump right in. 2Q report was a month ago, roughly, let's call it and nice performance coming out. Maybe just setting the stage for what you have seen thus far this year, state of the union, so to speak, with the business as it stands right now.
Yeah. Maybe first, for those of you new to the story, I will provide a little overview who agilon is. First, we are a primary care centered, value-based care company, really focused on improving outcomes for patients by empowering primary care physicians. We do this through high engagement, providing our PCP partners with technology, analytics, capital, and operational support to allow the primary care doctors to do what they do best, which is take care of their patients. Through our over 2,300 physicians in our network and our partners, we serve approximately 445,000 members in the Medicare Advantage space. Then we have approximately 110,000 members in the ACO. So fee for service members that we are partnered with the primary care physicians on the ACO side. Over the last 18 months, we have executed on a transformational strategy, really pivoting the company towards profitability from growth.
If you go back to 2024 and prior, the company was scaling. Matter of fact, we doubled the size of the company in 2024. There was this macro dislocation between underlying cost trends and revenue reimbursement, so we pivoted to a more profitability focused approach. Over the last 18 months, we've executed on that strategy, which included disciplined operating execution, improving data and visibility, superior clinical and quality outcomes, and then technology enabled scalability and using AI with data. Over the past 18 months, we've executed on these initiatives, and some of those initiatives had included, excuse me, the rollout of clinical programs. We've talked about heart failure, which is our most mature clinical program. It's across 90% of our network.
We've seen great outcomes for patients in that program, where we've seen first time heart failure diagnosis from an inpatient setting going from roughly 25% - 5%. Overall great care for the member and reducing overall hospital admissions. We also have other clinical programs that are on the way, including COPD and dementia. Additionally, we've continued to enhance our data and workflow, providing that information to the providers, our PCP partners on a real time basis and using AI from a suspecting perspective. We took a disciplined approach to contracting as part of this transformation strategy. We touched 80% of our contracts a year ago, generated over $120 million of value for 2026. We have 50% of our book open this year, and 20% of that 50% we didn't touch a year ago. More to come on that.
Last but not least, we emphasize cost control. At the end of last year, we undertook an exercise to reduce overall operating expense, and took out roughly $35 million of operating costs, and of course, that benefit falls right to the bottom line. I would say this pivot from growth to profitability has been meaningful. We're in a long cycle business, so a lot of the work that you do over the last 12 to 18 months doesn't show up financially until this year. I think you're seeing that value come through the earnings in the first and second quarters.
Super helpful. You highlight on a lot of the points that tell you about what the pathway's been for the last 12, 18, 24 months as you guys have pushed forward on those things. If I think about this year specifically, I think come into it, initial guidance versus expectation, you can swing the lever and go to profitable on EBITDA line. That's obviously stepped up, now $75 million - $95 million expected of EBITDA this year. Can you maybe talk a little bit about specifically what's going right? Obviously, there's underlying assumptions in the guidance, but as you think about the first half of this year and the performance thus far, maybe more specifically, what's going right in the near term?
Yeah. Certainly, all of those value creation levers that I mentioned, part of this transformation strategy, contracting was very important. We took a disciplined approach with our payer partners and we focused on percent of premium. That's really our revenue. Making sure that we're getting adequately compensated for the risks that we're taking. Two is enhance quality incentives. We have in-year quality incentives with most of our payers, where they put dollars on the table for us to achieve quality scores. These are obviously metrics that we can influence and control, so it's the same CMS Star measures that you're familiar with. Last but not least, carving out risk for things we don't control, like Part D. We've been very successful in carving out risk with Part D. In 2025, 30% of our members we carried the full Part D risk.
This year, it's less than 15%, and we will make further progress on that in 2027. We've already had a payer agree to carve that out next year. But we're not done. We're in the middle of our contracting process, and so we'll give you the final number when that happens. Certainly contracting is a big piece. Second would be our Burden of Illness program. As you noted, first and second quarter, I think we started out the year with a guide of roughly 40 basis points for a risk adjustment lift, if you will. First quarter, we moved that up to 1.5% net of the impact of V28, and now we're sitting here today with roughly a 3% net increase.
All that's really been driven by the work that we did over a year ago, specifically with the clinical programs, heart failure clinical pathway being the most progressed and the most mature, and certainly this year with the rollout of dementia and lung health will also be very important. I think there's more room to run there. But certainly that's been a huge contributor to the value that we've seen here early in the first half of the year. Of course, OpEx and then a little bit of favorability on the cost trend, right? Last year ended at 5.8. We've seen some favorable restatement from Q1 so far. I think that appears to be heading in the right direction as well.
Okay. Makes a ton of sense. Maybe the favorable restatement and talking a little bit about how you've sort of stepped up what's implied or what's assumed in your financial outlook from BOI, to me, that speaks to some of the work you did on the payer data pipeline. Maybe if we'd use that segue, if I think about the payer data pipeline, can you maybe just talk in a little more depth of detail for everyone about what that's done for your business? If there's a way to think about framing how visibility, both from a revenue or cost trend perspective, sits today compared to where it would have been, call it two years ago for this business.
Yeah, certainly the enhanced data pipeline has been meaningful. We have roughly 85% of our payer partners on that data pipeline, and the difference is, we get bifurcated revenue and medical cost information. That information reconciles to the financial arrangement with the payers. We turned that pipeline on in the first quarter of 2025, and it's been monumental for us on estimating risk adjustment and medical claims. We completely redesigned our entire reserving process and estimation process for both revenue and cost around that data pipeline. Sitting here today, we have capabilities that we didn't have a year ago on the revenue estimation, specifically for risk adjustment. We can actually calculate member-level risk scores. We can compare those to the prior year and calculate what our expected risk score improvement is. I think that's what you saw a little bit of in Q1.
Obviously, there's a timing delay on data because it's medical claims from it's codes from 2025. I think what you've seen is we got a little bit of that information in Q1, so we moved it up to 1.5% net. In Q2, we had full validation with getting the mid-year information from the government. That data pipeline is kind of the source of what we'll be able to use going forward from an estimation perspective. The other thing is on medical cost, again, completely redesigned the medical expense reserving process. We're still on a data delay. We get the data between 30 and 60 days later after the payers have the data. So we're still on a little bit of a data lag.
I think the first thing for us was let's get as many payers into the pipeline that we can, and we obviously started with the largest volume first. Where do we go from the 85%? I think we'll push into the 90s eventually, but there's a lot of number of payers there, right? Smaller groups of membership with smaller payers throughout our ecosystem. I think that that progress is going to be slower. But the first thing was let's get everybody into the pipeline, and then after that, let's talk about, okay, how do we reduce that time lag? So we're in a much better position from a revenue estimation, medical cost estimation process. Of course, we're taking all this new data and we're pushing that across our entire enterprise. So we're using that for suspecting and all the other things.
Okay. Makes a ton of sense. From your seat as a CFO, right, it's not the easiest thing in the world in a risk-based business to have to put stuff out there. It seems to me, and maybe confirm that this is how you feel, but you're much better positioned than you would've been entering the seat to be able to say that you feel like you've got a conservative place on where you're positioning things.
Yeah. Certainly. I think it is important to note, you could say, well, you started with 40 basis points and now you are at 3%. This was the first time that we were able to take the new data model and go through a full reconciliation period with the mid-year data from the MAO and the MMR data from the government. Certainly we have had our challenges with this in the past, so we definitely took a conservative position going in, not have gone through a reconciliation process. But we have been through that now, and we feel pretty confident that we have got a data model that provides the information that we need.
Makes a ton of sense. Maybe to just backtrack slightly and come back to the guidance, right? Outperformance on cost trend that you called out, closer to 6% in the first half, still assuming 7% in the back half of this year. When I look at it, that looks like the biggest swing factor in the guidance that is left to go. Can you maybe just talk a little bit about what went on in the first quarter, first half, excuse me, to drive the outperformance, and why you stuck with 7% and sort of see that as the level to ride with going forward?
Yeah. Certainly. Just go back in time. Our original guide was roughly, it was 7%, right, of cost trend. We ended the year in 2025 sitting here today at roughly 5.8% cost trend. In the first quarter, we recorded 7.4, and now that is restated into the low 6s. So sitting here today, Q1 is in the low 6s. Remember, because we have this data delay, Q1 at the end of Q2, it was not all the way complete. So there is still more paid claims that happen in that time period. For the second quarter, we mentioned this on our Q2 call. We recorded in the low 7% range, and that is mainly driven by the delay in data that we have, right? We have roughly 20% paid claims information.
Any time we close a quarter, so when we get to Q3, we will have the same phenomenon where the most recent quarter, we will just have a limited amount of paid claim information. So not necessarily enough to run a full medical claim triangle that you would normally use. Any time you have absence of data, you would record additional risk margin. I think that is what you are seeing from us, is we are just trying to put the company in a more prudent position here, recognizing that we do not have all the data and information to come up with an estimate. So we are putting what we think is our best estimate on the books, and that was 7%. For the back half, you are right, 7% for Q3, low 7s for Q4. Again, I think it is more being prudent around a guidance number.
And we've quantified what the value of a 1% change is. If you assume medical costs are going to be 1% better or worse, that's roughly $50 million of medical margin, $25 million of EBITDA. You can pick your own cost trend, whatever you think it's going to be, and do the modeling there. But I think from our perspective, we feel pretty comfortable that the 7% in the back three quarters is the place to start.
Okay. Super helpful. Maybe turning to the revenue capture side. You had alluded to it, and pointed out 3% now is where you sit, even net of V28. To me, I think that stands as a really impressive number to talk about the work that was done on the BOI front in 2025. If you take a little bit of a longer approach and think about the other clinical programs you have in flight, the general sort of arc of the business as you mature partnerships that you've had and get more of the providers comfortable with exactly how you're running the model, what's the right way to think about where that sort of revenue growth capture can be on diagnoses going forward annually? It's a little bit lower than that. I guess I'm trying to feel out of, like, what's a general range to think about?
Yeah, certainly. I think I'll take you back in time a little bit. When the government rolled out V28, at that time, we have kind of commented that for us, we were coded at the Medicare average.
I think it was roughly a 10% number reduction spread over a three-year period, so a little over three and change per year. As you put the 3% in context for this year, really that would be a gross trend of in the 6% range, right? Because we had to more than offset the impact of V28. On our Q2 call, what we commented on was, for 2027, as you think about that, we wouldn't expect a 3% number for 2027. But sitting here today, we're pretty confident that it's going to be a net positive, so more than offset normalization. I would think about a range of 0% - 3% as you think about 2027. I think longer term, driven by the success of our Burden of Illness program and the clinical pathways that you've mentioned, there's certainly more opportunity there.
That fact is because we were coded at the Medicare average. That is our starting spot. The clinical pathways, their importance is really to bring in the members, diagnose and treat their conditions, ultimately to ease their disease burden, and that is what they are designed to do. We have been very successful with those. Certainly the rollout of dementia and the COPD will be meaningful going forward, and I think there is still a little bit more room in CHF as you think about variability with our network, and it is only across 90% of our network at this point.
Okay, makes sense. Maybe turning to the contracting side, right? Picked up the comment on expectation to bring Part D down. Obviously, those discussions are ongoing, so maybe not to focus so much on next year, but more on a multi-year basis to think about the path forward. There is a lot of value you bring to the table, whether it is quality or other things for payers. When I talk to investors, sometimes there is a little bit of, doubt is maybe not the exact right word, but there is a thought that maybe the payers at some point grab back, right? They are trying to carve more margin into the bids they are putting forward as they look down the chain at value-based care providers broadly.
Perhaps that is an area they could also look to extract value. How do you think about, on a multi-year basis, what contracting can be? Is it something that should remain positive the way that it has been? How do you sort of square that circle on a multi-year basis?
Yeah, I think short term, certainly, it is an opportunity for us because as I mentioned, we only touched 80% of our contracts a year ago, so there is still the 20% to come. I think what we are focused on is getting adequately compensated for the value that we deliver. Not so sure that has happened in the past, and that was, I think, the sea change that you saw from us on pivoting to profitability. Listen, there were 50,000 members where we did not come to terms with payers at the beginning of this year that are no longer in risk arrangements with us.
We are taking that same discipline approach into 2027 and beyond, because from our perspective, we are delivering a high level of quality and cost management outcomes for the members that are with the payers, and we believe we should be adequately compensated for that. The other thing is there were a grouping of members, 35,000 members roughly, that are in care coordination fee arrangements. As we think about those could flip to full risk potentially next year. The point is, we held the line on economic terms, and we intend to do that going forward.
Got it. Okay. Maybe if I think about it just a little bit, the industry, MA industry broadly, there has been a margin reset, right? As you said, right? Things got hit out of that growth phase for y'all in the industry. Everyone saw that revenue trend and cost trend, got sort of turned against each other or crisscrossed, maybe.
Yeah.
With that margin reset, and obviously, the comment on the care coordination possibly moving up to full risk is helpful. How do you think about when the right time to look at the conditions in the industry are prime for you to return to growth, right? You have shown that you can grow very nicely during periods. It has been a time of profitability. What would you be looking for to be able to say we can turn growth back on?
Yeah, I think first and foremost, what we are trying to do is set a solid foundation for growth. I think we are well on our way. All the actions that we have taken over the past 12 - 18 months to get us where we are now, I think, does set that foundation for growth going forward. Just a couple of points, though. For a new partner, the lead time is usually 12 - 18 months. If you think about bringing a new partner into our network, that is not really on the table for 2027. However, we do have other ways to grow, and I mentioned some of those, the 35,000 members that are in the care coordination fees, that we get paid a small PMPM, and then we have upside, depending on our quality or in cost of care performance.
Certainly, the care coordination fee construct was not a permanent home. That was a bridge to full risk. We are going through the contracting process as we speak. We are in the early stages, and we will see what happens to those members. The 50,000 I mentioned earlier, we couldn't come to terms. Certainly, a possibility of those coming back into full risk for 2027. Last but not least, I have mentioned on the ACO programs, certainly, I think we would anticipate some growth there. We announced a partner last week, an existing primary care physician group where we partner with them on the MA side. We are now going to partner with them on the ACO side. I think there are other opportunities for us to grow in the near term, and then obviously longer term, think about adding new partners to the platform.
Okay. Super helpful. You teed me up with the segue there on the fee for service side to talk about REACH or the post-REACH business, maybe. Obviously, REACH coming to an end this year. A little over 100,000 lives. You guys have had scale and really strong performance in that program. Well positioned. You can go MSSP, you can go LEAD, depending on how things look. You sort of set that up. As you look at next year, and you just alluded, that could be an area where you grow again. What does that look like, and I guess, how do you think about the opportunities to grow there? Is it just existing partners? Could it be a piece of how you go to market later on? Just curious to think about what the setup is as we look at that.
Yeah, all of those options are on the table. I certainly think having an existing partner seems to make it easier, right? They are already on our platform. We run the same effectively operational structure for MSSP, ACO REACH, and MA, and Medicare Advantage. It is roughly all the same. There would be, obviously synergies, for an existing partner who is partnered with us on the MA side to come in and participate in the ACO LEAD or the MSSP. We have filed both ACO LEAD and MSSP as options, and we are in the process right now of determining which model makes the most economic sense for our partners. The unique thing about ACO LEAD is if you participated in the REACH program, you get a prior savings adjustment that you get to carry forward into the next year.
That is obviously beneficial for us because we have performed very well in cost savings, saving over 200 basis points against the benchmark over many years, and we are very high quality performers there as well. I think, for us, we are optimistic about the fact that we can grow that. I think we know we are going to have growth evidenced by the new partner we announced last week. From a profitability perspective, we would expect that line item that is in our financials to be at least as consistent, if not a little bit more, in 2027.
Okay. Very helpful. My sense, Reach ending kind of puts a finer point on the end of an era in some ways of like there is a bunch of businesses that entered, got a bunch of funding, entered, grabbed some lives for Reach. Performance has been varied across that population of entities, for lack of a better phrase. Is there opportunity that you sense among maybe MA partners that had another partner in other areas? Are we in an environment where there is just going to be more opportunity for people to think about new entrant, new points, or new partners in that space?
I would say it is an opportunity for companies like agilon who perform very well in either model, right? I think for us, the way we look at it is we think there is plenty of opportunity for us in MSSP, ACO REACH, now ACO LEAD and MA.
I think from our perspective, one of the benefits of our model is we can do all three, and it is roughly run through the same operating process. We have ultimate flexibility there, and of course, we have been a very strong performer in ACO REACH in the past, and we would look to continue that performance in LEAD.
Makes sense. A point of conversation that had been, I will just say, more in focus before the really nice turn in EBITDA of late was sort of cash burn and where that sits. Can you just maybe think about an update on where we sit from expectations exiting the year in terms of where cash balance will be, and then, my presumption being next year with a bit of the lag in how the contracts work, next year is when we would see the positive EBITDA from this year probably flow through. Is it right to think that that sort of is the turn of the quarter from a free cash perspective?
Yeah, absolutely. Our cash flow dynamics, you are exactly right. We settle up with the payers on our margin in usually the third quarter of the following year. We do get advanced payments from the payers, generally for a certain percentage of our estimated margin throughout the year, but then we ultimately reconcile with them after run-out on the third quarter of the following year. Right now, at the end of the quarter, $257 million of cash on the balance sheet. That excludes the ACO entities, and there is another 83 in those. What we have said is we expect to at least have $125 million on the books at the end of the year. We have had some favorable prior period development, roughly $22 million this year.
That helps cash flow for this year because that is in the settlement that is upcoming here in the third and fourth quarters. I think our view is we have the capital we need to get into next year, and obviously, with this year's EBITDA performance, we would be cash flow positive for next year.
Okay. Helpful. We talked about the clinical pathways and all the different things you are doing there are great. CHF and dementia you mentioned as the next ones that are going to ramp. How do we think about a rollout for a clinical pathway and what is the work you are specifically doing on those two programs?
Yeah, I think the CHF program kind of created a great roadmap of what success looks like from a rollout of a clinical program, and I think dementia and COPD and lung health are following fast in those footsteps. Again, I think it is all about the proximity and the collaboration with the primary care physicians in those local markets. As I said, the CHF program has been a huge success, and dementia and lung health are following on quickly behind.
Makes sense. Jeff, a little over three minutes left here. Maybe a lot more people have been paying attention to the story of late, but there's a lot to learn, and it's a complicated business. Maybe if you want to think about one or two things in the business or in the investment story for agilon that you think people aren't quite picking up on despite the elevated interest of late, what do you think those would be?
Yeah. I would say overall, the growth opportunity still exists like it did before. We intentionally paused growth to focus on profitability, which, at the time, given the dislocation between medical cost trends and reimbursement, was kind of a necessity. We still field inbound calls, and we still have groups that want to join our network and our platform. We're pretty confident in our capabilities around managing overall medical cost, delivering superior quality, and extracting the appropriate reimbursement to make the model successful, and I think we've demonstrated that here in 2026. I think the growth opportunity exists. We're excited to go execute against that. It's a long lead time, right? In this business, generally, everything you do takes a couple of years to play out. We've already started, but there's more to come.
Awesome. Well, Jeff, thanks so much. Really appreciate having you here, and it's been a great conversation.
Thanks. Appreciate it.