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All right, thanks. Afternoon, everyone. I'm Whit Mayo. I lead Leerink's efforts covering healthcare providers and managed care. It's my pleasure to have the team from Alignment here with us today, John, Thomas, thank you so much for joining us. Sorry about the elevator situation. It's a little frustrating. I've done the stairs a few times today, so I've got my steps in. 2024, breakout year. You guys hit EBITDA profitability for the first time. You've sidestepped a lot of the more challenging, controversial issues that have taken down some other managed care companies. Maybe just reflect back on the year and how you were able to successfully outperform the market.
Do I need this? Can you guys hear me?
Very well.
Whit Webcast.
Oh, it's Webcast. Okay. Sorry, guys. Yeah, so thanks, Whit, for having us. Great conference. Yeah, I mean, I think we got to go back to the first quarter of 2023, actually. And by that time, we knew that the model was going to produce relatively competitive Star Ratings relative to our competitors. And we also knew that V28 was going to create some disruption in the sector. And we also knew that our relative advantage and our relative exposure to V28 was going to be less than our competitors. So when you take those two in combination, we knew we were going to be able to grow just from a unit economic advantage for the 2024 bids and 2024 AEP. And so to get ready for that growth, we made a lot of investments in our member experience chassis.
We had to replace out our Flex Card vendor. We insourced our member services, and we just took control over the member experience. The whole idea was to make sure that we improved retention. We kind of realized that if we're going to grow to the extent we were going to grow, we need to keep the members. That's pretty much what we did, and that's pretty much what happened. When we bid for 2024, I think we had really good growth for that year. We ended up last year at 60% growth. The thing I'm most proud of is the business model, the industrial logic of the business model held. Our ingestion and onboarding of members was really, really good. Our clinical scalability to manage the growth was really, really good.
All of that, I would say, is a function of the way our data is organized, the business model of identifying the polychronic and the frail members, and making sure that we provide really good quality outcomes for that cohort that needs it the most. We have done everything the same for the last four or five years. I just think that the market is realizing that with V28 and tighter Tukey Stars, you have to do what CMS really intended, which is higher quality at a lower cost. It is not higher quality at a lower cost playing kind of coding games or just pawning off risk to undercapitalized providers with global cap deals or embedding AI and prior auth. Those things, I think, are yesterday's methodologies to be successful in MA. Going forward, I really think it is all about service delivery, high quality, low cost.
When I look at—thank you, John. When I look at the—you guys have historically said when you look at your year one members, year zero members, maybe that's the way to look at it, is we typically see MLRs in the low 90s, 91, 92, something like that. If I apply that math to the growth that you saw last year, it would imply the prior year saw a decline overall in the MLR, and certainly the guidance would imply further improvement this year. Is that an accurate conclusion to look at that we're seeing the cohorts improve?
Yeah, yeah. Maybe just one slight point of clarification. I think that year one member is typically kind of high 80s to low 90s. Depends. I think last year, right, we were probably on the higher end of that range in terms of our year one experience. To your broader question, I think we're feeling really good about sort of the overall cohort maturation story still. When we talk about sort of the profitability in 2024 and then kind of the 2025 guidance, keep in mind that that's capturing the fact that over 50% of our members this year are in a year one or year two cohort.
When we think about the kind of short-term margin trajectory, but also the longer-term margin trajectory, we think there's a lot of opportunity to continue to expand consolidated margins while continuing to invest in the product and drive growth. It is a big part of the story, both in the kind of near term, but also over the medium to long term.
Yeah. Looking at the '25 MLR, any other optical factors that are influencing the change year over year that we should be aware of as we just think about the comparability?
Yeah, I think we kind of broad buckets. Obviously, a tailwind is what I mentioned on kind of the year one to year two cohorts. Beyond that, it depends on the market and the product, but there were some slight benefit changes we made that should help us into 2025. I think on the other side of the coin, we do have the ongoing impacts of the Inflation Reduction Act and the Part D changes. Those are, I'd say, intended to be mostly neutral for us, but particularly on the low end of our guidance range, where I think we're probably a little more conservative. That is probably a slight headwind. The ongoing impact of the second year of V28. As we've said before, we feel really good about our competitive positioning across the three-year phase-in of V28.
On an absolute basis, we do have a modest impact we're navigating for 2025 as well.
You're growing your membership a lot. You have in the last two years, and that probably will continue. How do you get comfortable with the pace of growth, that this is the right pace of growth that is sustainable going forward?
Yeah, it's actually very consistent with the way we run the business from day one. That is a very tactical approach, market by market. As we did that heading into the year, we knew that we had the ability to reduce benefits a little bit and be more margin-focused and still be able to grow. The only way you can do that is not at a kind of corporate macro level, but at an individual market-specific level. We're looking at competitors. We're looking at MA county values. We're looking at broker relationships. We're looking at hospital relationships. We're looking at doctor relationships. It's really like we kind of call it war game simulations, market by market. Then you build that up.
You have very tactical operating plans that resulted in the kind of performance that we had in 2024, which we're really happy with. We did the same thing heading into 2025, but we also knew, again, that people were still going to be more margin-centric in our competitors. We said, "Okay, it's okay to be a little bit more margin-centric ourselves." We took benefits down a little bit, and we still got the kind of growth that we were able to achieve. We're happy with that.
I want to spend just a second on Care Anywhere. Your clinical care model, I think it's so unique versus what we've had the opportunity to do diligence in the market. How quickly can you get your members this year into that clinical care model? Actually, if you could step back and maybe help us understand how you identify the members that are appropriate for that level of care.
Yeah, it's kind of our hood ornament. What it really does is it reflects the culture and a core competency of the company, which is care management. And we've said this: that to be successful in this business, we think you have to have a core capability to actually manage care. Just to remind everybody, the model starts with our unified data architecture. You get the data. You've got the eligibility data, the member accounting data. You've got all the claims data, the auth data, the lab data, the pharmacy data, the admission discharge transfer data from the hospitals, encounter data. You get this data in one area. The way I describe it is different functional parts of the company and our trading partners externally look at the data through different viewers. The data there's integrity in.
What that allows for is we to take actions around that data. It starts with the data. We run it through our AI algorithms, and we stratify the members. The whole idea is if you know where the 10% of the membership is that's accounting for 80% of your spend, you pinpoint and you laser focus your resources on that 10%. That 10% is you're vulnerable, you're frail, you're polychronic. This notion of providing more care for that population, not less care, but more care, actually is just good business. We tell people, "We make more money when we provide more care, not less care." That's a key, I think, philosophical difference. Once you know who those people are, the whole idea, step two, is you got to engage them.
You have to outbound outreach to them, engage them. We're right around 60% engagement. We're working hard to get that number up to 75%. If you know, if you kind of like, if you have, let's just say, let's just pick a number, 10,000 members you know are eligible for this, engage 60% of them, that means you've got 6,000 in your cohort that you're actually managing. It stands to reason, if you can get the 60% up to 75%, you're going to be even more effective in driving utilization management. Once you know who the list is, and then you engage them. The third part is we have interdisciplinary care teams of doctors, nurses, advanced practicing clinicians, social workers, case managers, mental health experts, et cetera, that form this team. They do virtual rounds every day on that population.
We take care of those people at the home with these resources. At the home, depending upon acuity. The whole concept, if you just think about it, you have visibility with the data, and then you have control to do something about it that's actionable. Last year, we had hotspots in certain markets in the first quarter of last year. We were not immune to high utilization like the rest of the market. We just happened to know specifically which providers, which members, what delivery systems were the issue. We had boots on the ground clinicians that solved the problem within 60 days. There are lots of little technical things that we worked with their doctors, and we solved for it. That is how we managed the business. That is how we managed the high growth. We did it pretty seamlessly.
Is that 10% of your membership, is that the number?
Yeah, it's about 10%. And I would say of our shared risk membership, we're managing the institutional. And so just to remind everybody, about 70% of our membership is shared risk. And so what that means is we're managing the institutional dollars. We are at risk for managing that. We prefer that model as opposed to the other 30%, which were globally capitated, because it differentiates our ability to lower overall costs. If you can lower overall costs, you have a competitive advantage over everybody else because your cost structure is fundamentally lower for the bids. If we globally cap somebody or somebody, let's just say whatever, 85%, and that global cap provider is also globally capping competitor A, B, C, and D at 85%, we have no cost advantage.
If we're managing our shared risk and we're at 80%, that 5% delta is what the cost is embedded for these other folks and their cost structure. Our cost structure is 80%. That 5 points is what we're investing in benefits. It all stems from the data and the Care Anywhere care management competency to provide higher quality, i.e., Stars at a lower cost. Last year, our admissions per thousand as an enterprise was 149 admissions per thousand. That's like insanely good. Insanely good. Milliman would say best practice well-managed is about 205, and fee for service about 250. Just managing that institutional dollar and specifically the acute institutional dollar, because of the data and the care delivery mechanism, we found to be the most capital-efficient way to manage utilization. You don't need to own all the PCPs, for example.
We don't have a lot of bricks and mortar we got to worry about. You make the community doctors more successful. That's the model.
IRA, how did you maybe walk me through the process on how you got comfortable with the planned liability this year that you put into your bids? I know it's early, but just any observations thus far in 2025?
Yeah. I would say just broadly speaking, in terms of our markets, Part D and the benefit offering across our product portfolio is really important to the overall competitive positioning. As opposed to nationally, where I know a lot of plans were cutting Part D benefits, we did not really do that. Frankly, neither did our local competitors. I would say there is a lot of stability in our markets on the Part D offering year over year. I think in terms of how we approached in the bids, I think obviously we took into account our normal course trend assumptions and then tried to add some buffer on top of that in terms of what we might expect as a result of these changes, like the lower maximum out of pocket for seniors.
We're sitting here 60-70 days in, and we feel really good so far about what we've seen. I think as the year progresses, we'll provide more commentary on how we think it impacts overall seasonality quarter by quarter. In general, we think it'll be a modest tailwind to our MBR year over year. The MBR, while it will still sequentially improve on Part D throughout 2025, will improve at less of a clip than years past. By the end of the year, kind of Q3, Q4, there will probably be a modest headwind to our MBR year over year. Based on where we're at through the first quarter, we feel good about those assumptions.
When I look at the changes you made in your Part D deductible, it did not stand out as looking as much of a change as we saw from many of the nationals. When I look at it more at the state-local level, everything sort of aligns with what your competitors are doing.
Yeah, absolutely. I think beyond that, we got in the question just in terms of have we seen big pockets of growth stemming from our choices on Part D benefit design relative to others? The answer is really no. I think we are probably top three in a lot of our markets on the Part D component of our overall product, but we're not number one across the board. I think from an overall value proposition standpoint, it's an important piece of the overall product, but it hasn't been sort of this outlier aspect of our benefits that's really been driving the growth.
Coming into this year, I think you said you swapped out your Flex Card vendor. There've been some other changes in terms of benefits, maybe some of your agent broker strategy. Just what are some of the high-level tweaks that you made to your benefits this year and/or just your overall strategy with the distribution channel?
Yeah. I would say in general, where we did modestly change our benefits or take down benefits was probably more on the supplemental side. It is really about making sure that we're offering the right sort of the right benefit in the right market to the right consumer. I think in general, over the last, call it five years, the industry has doubled the amount of value to the senior at a pace that probably was not sustainable. We looked at certain categories, OTC and flex cards, things that are still very, very rich to the senior, but pulled back slightly where we thought we could afford to from a competitive standpoint and create that lasting durability in the marketplace. I think we did a really nice job of balancing those decisions with our growth ambitions.
As a result of these financial pressures, many of our competitors are facing on Stars and V28 phase in over three years, we were still able to have obviously a very successful AEP in spite of those changes.
Thanks. Comments that you've had on open enrollment after the December 15th close date or whenever it is? Are we seeing, I had this hypothesis that perhaps that as members would show up at Walgreens or CVS or whoever, it's like, "Oh my God, my drug's not covered," or, "The cost sharing is different," or, "Changes in my benefits." Are we seeing elevated switching at nothing at all?
No. In fact, our retention, just given the overall product value proposition, which again, we typically are top three in the market on our benefit richness, and then the quality, the Stars, the member experience, et cetera, our retention is continuing to run this year similar to last year. Last year was our best year ever. I think compared to the overall industry, we typically have about 40-50% lower voluntary turnover as a result of the product and the experience and so forth. I think basically what we've seen so far, because we're still ahead of the pack on most areas, I think we've done a nice job trying to kind of create a win-win scenario for the senior, the plan, and for the taxpayer CMS.
I guess I meant the question more in the context of are you seeing additional growth beyond your expectations from switching towards you, not away from you?
I think we've had a very successful OEP thus far. I think we're feeling good about what we've seen through mid-March. At the same time, I wouldn't say it's disproportionately more successful than we would have anticipated at the start of the year or relative to prior years.
Yeah. I do not think we are going to see the kind of in-year growth that we saw in 2024, if that is what you are asking. I think we will do well. I do not think you will see an extra 30,000 or 40,000 members in the back end, which we are okay with.
Yeah. Okay. Maybe spend a second here on Stars. We've got there's been a lot of fireworks the last year or so, and there's some more changes coming. We know that you're going to do better on the CAHPS reweighting, and you benefit with the Reward Factor transitioning to the Health Equity Index. You've always sat really close on the cut points with that one big contract. I know you're constantly putting a lot of muscle around ways to improve. Maybe just unpack the areas where you're investing a lot more time today than maybe prior years.
Yeah. No, I think that's a very fair question. I think our, I'd say, our analytics and our data science around Stars, and it's nothing short of data science, is really quite good. The investments that we're making are around boots on the ground gap closures, number one. Number two, being just more conservative on our modeling around the cut points. I don't think we were conservative enough this past year. We're not going to make that mistake again. I feel for, again, dates of service in 2025, I feel really good about where we're going.
When you combine that, kind of these operational initiatives along with some of the policy changes that hitting 2027 on the weighting of CAHPS going down from four to two, and then, as you said, if the Health Equity Index survives into 2028 payment, both of those, I think, were very strongly in the four, and maybe we'll get into four and a half. While I can't really talk about the lawsuit in detail, suffice it to say that we think that I just think we are, I think it's a very good case that we have. I'll leave it at that.
Inside Stars, I've always been surprised on the customer service and the care coordination that you don't do better there. Maybe that's not a function of things that are in your control at this point, but how do I make sense of that?
Yeah, it's a great question. And for those of you who don't know, I mean, our HEDIS scores, our Part D scores, our admin scores are all really, really good. The bane of our existence is CAHPS scores. And so I think that's partly a function of just the methodology of these surveys, which, by the way, is the basis of our lawsuit with CMS on we don't think the vendors that we're using that did the right surveys did it in a way that was correct is the basis of the lawsuit. But in California, we have a lot of delegation of certain case management and utilization management to our IPAs and our medical groups.
One of the things we've just done is to say, "If you can't get us to four or five Stars in terms of gap closures specifically focused on CAHPS, we're going to de-delegate you." In other words, we're taking control of that over. When you're a smaller plan, it's hard to do that with some of these IPAs. When you get to a couple hundred thousand lives or more, you're not so little anymore. With the kind of growth rate that we've had, we have the philosophy of, "If you're a medical group working with us, we want you to surplus. We want you to make more money. We want to help you do that. But you got to work with us and hit these quality metrics, basically." That is a pretty significant change that I think will address part of your first question.
That is the real essence of why California, and it's not just us. It's all the folks in California and the competitors in California that rely on these kind of capitated arrangements.
Some of the other things that have been sort of in flight around Stars that CMS has written about or the industry has talked about, there's been the hold harmless provision on those two large quality performance categories that I think in aggregate are 10% of your entire score. I understand the logic for why should we hold everyone harmless? It's four, four and a half, or five. I get the conversation or the debate. Where do we stand on that as a potential change that CMS could look to implement?
Yeah. You know, I think for us, there's sort of two sides of the coin. I think for the California H number, that would be a headwind to us, but it's definitely less of a headwind than, say, the CAHPS weighting going from four to two as a tailwind. I think from a net standpoint, we feel pretty good on that front. Conversely, on other contracts like our five-star contract, North Carolina, Nevada, it would actually probably help us from a competitive differentiation standpoint. I think we'll see how it shakes out, but I think we feel relatively sort of well-positioned either way.
We've got a couple new categories and changes happening with Stars. How do you get confidence or how do you get comfortable when you have a new category that's inserted into the formula when you don't have the experience for it? I mean, you're just seemingly flying blind for the first year.
Yes, but a lot of the time, CMS gives you some notice on certain measures that they're likely to phase in over time. I would say it's not too often that you're just completely blindly surprised by something with no notice. Usually, you have some visibility that, "Hey, we're probably going to phase this in a year or two from now," or, "We're thinking about phasing it in," which gives you as the plan the time to start to pilot things or take different operational workflow changes that need to be made.
Yeah. Tukey is the perfect example. I mean, we took it very seriously, which is why I think we still survived the Stars. It was tight to your point, but we did get it. I think it's something that if we become even more conservative on those cut points, it's the only way to manage it, I think. You just got to give yourself head space, basically.
Yeah. Yeah. That sounds smart. The Advance Notice is sitting at the OMB. I'm going to guess the prevailing view in this room is that there could be a 50-100 basis point increase versus the proposal. Just any thoughts that you care to share around the preliminary rule or?
Yeah. No, I think the way we're looking at it, which is, again, part of the company's business model, is we should win either way. If rates go or held stable, I think we're going to have the same kind of competitive advantage that we've had the last couple of years. If rates go up, I would think it would be even more than 100 basis points. If that happens, I think for the next couple of years, my suspicion is a lot of the larger players at least are going to put that into margin expansion, would be a guess, as opposed to benefits to grow. Either way, I think we would win certainly for the next couple of years.
In the next couple of years, the bigger and stronger we get, I think there is going to be more of a moat around our ability to both grow and increase margins. That is a long-winded way of saying, "I do not know what is going to happen." If they actually factor in some of the kind of first half of 2024 claims experience into the trend, I think that is not an insignificant number.
Right. All right. We are just about out of time here. Harrison, I missed anything?
We got them all.
Got it all? Okay. I've got a bunch more questions here, but we're out of time. John, thanks for coming. Thomas, thanks for everybody. Thank you all.