Okay, folks, we're going to get started. Good morning, everyone, and thank you for joining us for Cigna's 2019 Investor Day. I am Will McDowell, Vice President of Investor Relations, and I will serve as your host for the day. I'm pleased to welcome so many members of the investment community to our event. We want to express our thanks and our appreciation to you for taking time to be with us today. Today, you're going to hear some key themes across all presentations and breakout sessions. First, Cigna has a clear path for sustained growth across each of our four growth platforms. As we go deep in the existing products and markets, as we leverage the enhanced capabilities we get from the combination with Express Scripts, as we continue to expand both through product innovation as well as geographic expansion.
Second, Cigna delivers industry-leading affordability to our customers and clients, which generates a significant amount of value for them. Third, Cigna has a very attractive long-term outlook for growth, both operationally and financially, as our businesses have significant amounts of free cash flow that position us well for both strategic and financial flexibility. Now, a couple of housekeeping items before we begin. Please note that we will be making some forward-looking statements today regarding our outlook for 2019 and future performance. These statements are subject to risks and uncertainties that could cause actual results to differ materially from our current expectations. A description of these risks and uncertainties is available in our most recent SEC filings. Additionally, I want to remind you that Cigna uses certain non-GAAP financial measures when we discuss our results.
Definitions of these non-GAAP measures are included in today's Investor Day materials, as well as the reconciliations to these GAAP measures. In addition, financial terms and business definitions, we've also included those in our materials. I would also note that today's event is being webcast live, a full set of our slides will be posted to the investor relations section of cigna.com later this afternoon. Now let's get to today's agenda. Our agenda is designed to be very interactive, with multiple opportunities for you to ask questions. You'll hear from David Cordani, our President and Chief Executive Officer, as well as several members of our leadership team, as they discuss our growth path forward, as well as the value we continue to generate for our customers and clients.
We'll then break from the webcast as we host on-site management breakout sessions, where you'll have an opportunity to choose two of the three sessions that we are hosting and an ability to go deeper with additional members of our management team. These sessions each address an area where we have differentiating capabilities and are in continuing to innovate to further fuel our success and growth going forward. The sessions are titled Digital Data and Analytics, Whole Person Health, and Specialty Pharmacy. Each of these sessions is 25 minutes long. We'll open with some brief opening remarks and devote the bulk of the time to Q&A. We'll then break for lunch. We'll ask you to grab your lunch, bring it back into the ballroom for the remaining sessions of the program.
For those of you participating by webcast, we ask that you rejoin us at 12:10 P.M., at which point Eric Palmer, our CFO, will provide a financial update, both for 2019 and the longer term. We'll then have a Q&A session with both David and Eric, and then David will close the formal program with some closing remarks. I'd also mention that once again, we are hosting our Innovation Center down the hall in the Centennial Foyer, where you'll have an opportunity to meet with Cigna representatives who are on hand to describe for you firsthand many of our latest innovations, including Health Connect 360, as well as the Med Center Pharmacy Kiosk. You'll have an opportunity to visit the Innovation Center both at the break and following our formal program.
Additionally, during the breaks today, Cigna management are available and at the tables throughout the room, and you can identify them with the blue band on the top of their name tags. Now let's get started. I want to run a quick video just to demonstrate how we are accelerating health as a company, and following the video, David will take the stage. Thank you.
Morning. First, let me add my welcome to our 2019 Investor Day. We recognize that your time is really valuable, and we appreciate all of you spending time with us, whether it's physically here today or for those joining us via the phone lines. We appreciate that. Today, our objective is to clearly reinforce how we create differentiated value for our customers, our clients, and our patients, and as a result, have the opportunity to create sustained differentiated value for you.
Our objective today is to make sure you come away with a clear understanding of course, our proven track record of delivering results, our clear strategic direction, the fact that we have four well-positioned growth platforms that will serve us well in the dynamic environment we operate in, an appreciation for the depth and breadth of the talent and the culture we've built in our organization that we believe is mission-critical to deliver on the promises both today and in the future. Finally, the significant free cash flow and capital flexibility we've built into the operating model. Let me just highlight my agenda for our brief 25 minutes together. I'm going to start talking about our value creation framework and how we approach the marketplace.
I'm going to do this in the context of what we believe the market needs and demands most from us because we have to fulfill the market's needs. Of course, I'll do that with some context, with the rapid, ever-changing environment we all operate in, including some of the uncertainties that exist. I'll highlight both how we're delivering results today, but also positioned to grow in each of our operating platforms on a go-forward basis. I'll set up each of the business leaders as we go forward. In the context of that, I'll talk about the progress we're making and the momentum we're building as we combine our company, Cigna, with our company, Express Scripts, as part of the organization. I'm going to do that over the course, again, the next 25 minutes or so.
To set the stage, some of you come here with a perception of us, of who we are. Some may think of us as an insurance company. Some may think of us as a health plan. Some may think of us as a pharmacy benefit manager. Let me be clear. From our point of view, those terms represent old models. They do not represent the model we've built nor the direction we are pursuing as we go forward. We built a global health service company, a company that has a unique configuration of assets and capabilities that allows us and fuels us to fundamentally change how health and vitality are pursued, as well as how healthcare is delivered around the world.
In addition to those words, throughout the course of today, you will hear and see specific actions and highlights that indicate how we are driving this direction with our objective of working to fundamentally transform healthcare, importantly, to further improve affordability, which is a global need across all buyers, to grow our businesses with very specific actions across those four growth platforms, to develop on an accelerated basis new targeted innovations that change people's lives for the better. As I mentioned previously, to further enhance our strategic and financial flexibility, specifically with the outstanding free cash flow generation we've positioned this business to deliver. We know, to be clear, there's a lot of work ahead of us. No member of our organization takes this lightly. We have a track record of leading into and leaning into change in the marketplace.
At Cigna, we think about the environment we operate in in phases, and there's three that we believe either have unfolded or are unfolding. The first you could argue is a transactional model. A transactional model in our historic industry is one where basic supply chain management tools and actions and basic benefit management administrative services come together. At Cigna, we've long since moved past that model, while some still cling to it. The second is a transitional model from our point of view. In that transitional model, the market has proven positively that engaging and incentivizing individuals and supporting healthcare professionals in a different way does generate significant and differentiated outcomes. That yields real results for the benefit of customers, clients, and patients. We would submit that Cigna was a leader in that phase, but by its definition, a transitional phase is not an endpoint.
We see many aspects of where society calls for, demands, and deserves better, and we're stepping up to that. That's why we're stepping into what we see as a transformative phase. In that phase, we see three critical building blocks. First and foremost, pivoting to focusing on and treating the whole person, both mind and body. Second, leveraging data and technology smartly to create more connectivity or to be the connected tissue between individual customers or patients and healthcare professionals. Third, targeted, rapid, personalized innovations that better engage and support individuals in their life journey. All of this is with an objective to deliver the right service to an individual anytime, anywhere. Importantly, one individual at a time. As a pause, you can think of Cigna as having positioned ourselves as being the largest custom solution shop in the world, because that's what we do.
We work every day to design one client at a time to put the solutions in place that best work for them based on where they are in their business strategy, culture, and journey. Whether it's how they choose to leverage our collaborative accountable care relationships, specific microsegmentation strategies that are used to understand subsegments of the population and design specific programs for those populations. Ultimately, we've built an organization with the capabilities, talent, and tools to deliver customization at scale, which delivers real personalized benefits, whether through the benefit design, the access profile, or the supporting services, ultimately to deliver anytime, anywhere. This is something that few can do in any industry, let alone an industry both as personal but as complex as healthcare. Our approach is working to date as we build momentum.
Underscoring that is we have the privilege today to serve 165 million customer relationships around the world. Our objective is to, again, lead into this phase to deliver a more sustainable health delivery system in the markets we choose to participate in. Let me dig a little bit deeper into these concepts. First, we see an extraordinarily phenomenal opportunity to deliver more sustainable results by focusing on the whole person, both mind and body, rather than treating individual sick care interventions after events happen. Of course, that's an important part of the equation, but it's an incomplete part of the equation. To achieve this, we see three primary ways in which we need to show up and support that journey. First and foremost is through behavioral and lifestyle management programs. These are often undervalued in the current model in the marketplace today.
Yet behavioral and lifestyle management programs have the ability to truly deliver phenomenal results, one individual at a time, both in quality of life as well as in affordability. Second are pharmaceutical interventions, and third are medical interventions. Relative to the first two, lifestyle and behavior and pharmaceutical interventions, our combined organization with Express Scripts has deliberately positioned ourselves to have leading capabilities in both of those categories. Importantly, we continue to make accelerated, targeted investments in capabilities and in talent that is required to continue to differentiate ourselves in this rapidly changing environment. For example, in behavioral and lifestyle, today we have over 1,000 colleagues and clinical professionals that work every day to help individuals pursue their health, behavioral, or lifestyle management goals, and we see significant positive results coming out of that.
Ultimately, it reduces costs for our clients, be they commercial clients or health plan clients, and the result of that is it makes their businesses better and delivers benefits to their employees and their loved ones. This is underscored by our ability to deliver the market's defining medical cost trend year in, year out, now going on our seventh year in a row. Now with Express Scripts and their leading pharmacy and specialty capabilities, we have the ability to lead in the second area. Just to point to a few results. First, within Accredo, a critical part of the Express Scripts portfolio, patients who are confronting advanced therapies have a Net Promoter Score of about 80. About 80. That's not a number we typically talk about in this marketplace.
Secondly, Express Scripts delivered a commercial trend of 0.4% last year, a result that was 300 basis points better than the nearest competitor and delivered a negative trend for the Medicare business. The result of that is about a $45 billion savings for clients and patients. That, again, makes clients' businesses better, and it improves the quality of life and the affordability for employees as well as their loved ones. Now relative to medical interventions, the third component, we have a clear and proven strategy around partnerships that focus on value-based care programs, where we seek to provide actionable information to help our healthcare professional partners close gaps in care, deliver better clinical outcomes, and as a result, earn more significant rewards for those that are creating the most value. Today, we have over 650 collaborative accountable care relationships.
As we reflect upon our success to date, that is fueled by a few items: our ability to generate alignment with our partners, our ability to earn their trust, and our ability to design the right shared rewards program that fuels the continued innovation, one collaborative at a time. Now, our approach to here is working, as I mentioned, with our medical cost trend track record over the last seven years. Also looking ahead, it has us on our trajectory to achieve our strategic objective of a medical cost trend that looks like CPI by 2021. A number that no one is talking about, but a number that we believe is critical to deliver a sustainable healthcare delivery system from a societal standpoint. The second part of the transformative model is serving as the connective tissue between individuals and healthcare professional partners.
We believe this is increasingly important when you consider the highly personalized nature of healthcare, and unfortunately, the tremendously fragmented picture of healthcare, where people are seeking increasingly more personalized and convenient access and services and comparing this part of the marketplace to other services they experience, be it financial service, hospitality, leisure, and the like. To meet this demand, we strive to bring our human capital with our technology capital and support our human capital with artificial intelligence machine learning that is fueled by pharmacy data, behavioral data, medical data, and iterating to drive the right outcomes for the benefit of our clients, customers, and partners each and every day.
One brief example was our approach to reduce the opioid overdoses by 25%, where we used real-time data transfers to proactively identify the patients and customers who are most likely at risk of an overdose, and importantly, to identify specific, personalized, targeted interventions to avoid those overdoses from taking place. We think that's a great example of what a health service company does, but it's not an example of what you would expect an insurance company to do in the marketplace. Third in the transformative model is continuous innovation. To meet our customers' needs each and every day, we have a proven track record of targeted innovations, but the acceleration is important here. The breadth and acceleration is important here. All with the objective of making access more simplified and more coordinated, and the ultimate services more coordinated for the benefit of our clients, customers, and partners.
For clients, we continue to innovate risk-sharing arrangements. Why do I start with that? It generates alignment, and the generation of alignment creates an opportunity for shared innovation together and ultimately making their business better. For our customers and patients, as an example, we're delivering more information and access through virtual platforms, both to increase engagement, but to increase personalized access to services. Additionally, we're working on an accelerated basis to make medications on a targeted basis, more accessible but more affordable and predictable in terms of their cost. Our Patient Assurance Program is a great reinforcement of that. For physician partners, we're offering now our HealthConnect 360, which offers a 360-degree view of patients to help to generate better, more personalized clinical outcomes on a more accelerated basis.
In our innovation center later today, you'll have the opportunity to see some of these capabilities that are more than concepts, they're reality. Through our breakout sessions, you'll hear some examples of them as well. We're not declaring success. We're reinforcing positive indications along this journey to deliver better, more personalized outcomes for our customers, clients, and patients each and every day. Let me transition. Now that I've briefly mapped out a little bit of the value creation environment that we operate in, I want to spend a few moments on questions that we know are mission-critical to you. In our conversations over the past months, we understand there are certain themes or questions that are mission-critical, and we've heard those. Specifically, the risk of the changing environment, including the regulatory environment. Second, growth. Can this combined company have an attractive growth outlook? Third, execution.
Can you effectively put these companies together and execute and deliver on your promises? We've heard you. We recognize those are important questions. Throughout the course of today, we're going to try to bring each one of those to life with as much tangibility and specificity as possible. Now, relative to risks, we've been able to navigate a complex regulatory environment for some time, and we expect to continue to be able to do so, be it the changing dialogue around regulation or legislation around rebates, the emerging evolving dialogue around the concept of Medicare for all or additional changes and the like that transpires. All with the objective and continuing to maintain an attractive growth and profitability profile. As it relates to growth, we will demonstrate today that we not only have significant attractive additional headwind in our core business platforms, but we have additional expansion opportunities.
My colleagues will walk through those in some good detail today, and I'll tee up a few of those headlines in a few moments. Lastly, as it relates to execution, we will show again that we are already five months into this combination, executing effectively as we work to smartly put these two companies together to get benefit for our clients, customers, and patients, and as a result, for our shareholders. Let me touch upon each of these a little further, and I want to start with the resiliency of our business over time. Good, bad, or indifferent, 2019 is not the first time we find ourselves in a dynamic healthcare environment underscored by unanswered questions or potential government legislative or regulatory intervention.
At Cigna, we have a strong history of leaning into and leading into change, always with the objective of creating value for the marketplace, for our customers, clients, and patients, and as a result, earning the right to deliver returns for your shareholders. If you think back a decade to 2009, we were in a conversation relative to the Affordable Care Act, uncertainty was the norm on the horizon. With significant disruption, we leaned into that change, we seek to continue to lean into that change today. What we learned then and we learn now is it's important to manage and lead through the rhetoric and uncertainty and focus on certain critical items that underscore success under any conditions. First and foremost, stay acutely focused on the needs of the marketplace. Second, continue to invest in sustained innovation to create differentiated value.
Third, and very importantly, remain acutely focused on the key submarkets where you have the right to create the most value, then execute like crazy. For example, in 2009, our assessment of the emerging environment pointed us toward doubling and tripling down on transparency through the ASO, but also through much more integrated solutions. That's what we need to go back to then, but many bet against that strategy. That strategy has proven to work well because it's market-friendly, transparent, it has alignment, and it enabled us to create value as we go forward. It's paid off with our growth and our profitability profile. Our assessment today has pushed us to further accelerate into that transformative phase that I referenced before, because change is ever present, and we need to drive ourself with smart change, but guided by the marketplace.
Our assessment also guided us to our strategic combination with Express Scripts, where we saw it as the most unique opportunity to further accelerate our affordability promise, to expand our reach, and to expand our financial flexibility. Importantly, in environments like this, we don't seek to simply observe the environment. We also seek to engage to shape the environment through principled, nonpartisan-based discussion engagement with policymakers, be they state or federal level, where we continue to advocate for constructive, smart public-private partnerships that embrace innovation and choice to benefit consumers. Where we focus on flexible and innovative solutions that start with the customer in mind, and again, bring choice to the marketplace. Where, of course, we focus on improving access and importantly, accessibility for those that don't have the appropriate level of access or accessibility.
This approach, coupled with our strategic position and financial flexibility, gives us confidence we will continue to deliver strong, attractive results in an ever-changing environment. Let me spend just a couple of minutes on the growth platforms. We have four well-positioned platforms that we believe are mission-critical in this dynamic environment: our health services business, our U.S. Commercial business, our U.S. Government business, and our international portfolio. I would highlight that while each of these businesses have attractive growth opportunities in front of them that I'll tee up in a second, they also feed each other with specific points of leverage, and you'll hear some of those from my colleagues throughout the course of the day.
Specific to the health services platform, we see meaningful growth opportunity through a variety of items, including further penetrating and leveraging the Express capabilities into the Cigna portfolio. Secondly, to expanding access to Cigna Specialty and services like behavioral and otherwise within the Express Scripts portfolio of commercial clients, health plan clients, and governmental agencies. Third, further expanding the already powerful Accredo value proposition in the marketplace. In the U.S. Commercial space, we see significant additional headroom, specifically in the middle market and select segments. That makes up about two-thirds of the addressable marketplace today. Secondly, we see the ability to continue to expand our value proposition, both in affordability as well as flexibility, by leveraging the Express Scripts capabilities. Third, we expect to expand our Go Deep footprint by about 25% over the next three to five years, leveraging the combined power of the franchise.
In our Governmental benefit business, we see our differentiate Medicare Advantage asset as a great growth driver for us. That does have secular tailwinds, but in addition to that, we see the opportunity to further expand our geographic expansion, you'll hear more about that today, broaden our portfolio to include PPO solutions, and further enhance the affordability and value proposition through leveraging the Express Scripts capabilities. In our international markets, we will go deeper in our existing targeted geographies. Second, we will further innovate and expand products, programs, and services for existing and additional segments in those geographies. Third, we will continue to smartly plant new flags and seeds where we see additional opportunities in new geographies. You'll hear more about these in more specificity and detail from my colleagues throughout the course of the day.
Importantly, later today, Eric will also highlight the phenomenal free cash flow production that these platforms position us to generate. In a disrupted environment, let me be clear, we think that asset, the free cash flow production, is more valuable than ever to both allow us to continue to invest in targeted innovations, to allow us to return even more capital to our shareholders, and to position us with phenomenal strategic flexibility. These are critical drivers of our growth platforms, and in this dynamic environment, give us confidence we will deliver on our results. Finally, a couple of minutes on the combination. We're rapidly approaching the midpoint of 2019, we are progressing well on combining our organizations.
First and foremost, we are delivering on our commitments for clients, customers, and patients in the marketplace, and we delivered a strong first quarter in line with our expectations, which demonstrate the strength of the underlying platforms, as well as the leadership resiliency of our colleagues and our 74,000 colleagues around the world to stay focused on our market commitments. Secondly, we are making good progress relative to our integration priorities, and we are on track to substantially complete our integration by the end of next year. Third, as a result, we are accelerating our pursuit of additional client segment and geographic expansion opportunities that will further contribute to our growth profile in 2020 and beyond. Examples of this already include further expanding offerings to our health plan clients, as well as some of the geographic expansion opportunities you'll hear from my colleagues today.
As I reflect on the environment we're in today, but the environment we've been in, I remain highly confident in our path forward and our ability to deliver differentiated results for the benefit of our customers, clients, and patients, and as a result, for our shareholders. Some of you would say, "Why? Why would you remain confident in an environment where some may believe there's more questions than answers and more uncertainty than clarity?" Our job is to create that clarity in an environment of uncertainty. As we look forward, I'd identify five items that give me confidence. One, a proven track record of delivering exceptional results over the last decade in an environment of continued dynamism and uncertainty. Two, a clear strategic direction for our organization that guides everything we do and is guided effectively by dynamically using our GO strategy.
Three, the strength of our talent and our culture, which is needed in a health services environment. Our 74,000 colleagues around the world wake up every day trying to fulfill our mission, which is to improve the health, wellbeing, and peace of mind of those we serve, and that is a powerful asset in a dynamic environment to have that noble premise in front of 74,000 colleagues each and every day. Fourth, we are positioned with four growth platforms, not one or two, and we believe that smart diversification of those four platforms in this dynamic marketplace is really important. Fifth, we've deliberately positioned our portfolio with exceptional capital efficiency and free cash flow generation because we believe passionately that in a dynamic environment, that is mission-critical to maintain strategic and financial flexibility as we look to the future. In closing, I want to again thank you.
I want to thank you for being here today. I want to thank you for your confidence in our organization. Make no mistake, we understand this is a really dynamic environment, and we don't take that lightly, but that dynamism provides even more fire to our leadership and our organization to lead into and lean into change in the marketplace for our customers' and clients' benefit, and to serve our patients and deliver the results for you. Our objective is that when you leave here today, you have the same level of confidence our leadership team has in our direction on a go-forward basis.
As Will mentioned, we've deliberately filled the room with critical leaders from around the globe that are making this come to life each and every day. I invite you to have those conversations during our breaks, as well as during the breakouts, as well as you explore the innovation suite. Our leaders bring this to life each and every day. It's not just their knowledge, it's their passion and commitment to build something better from a societal standpoint, all well knowing we owe our shareholders a phenomenal sustainable return. I'm going to transition the conversation to my friend and colleague, Tim Wentworth, who's going to walk through our health service business, which includes Express Scripts, as well as our broader Cigna Health Services portfolio. After Tim is done, I think we're going to take a break for our first Q&A session.
Thanks for your time. Tim?
Got it. Thanks, David. Good morning. As David knows, as I was sharing with a few of you before, I love this business. I love this business more than I ever have. I was reminded why just two weeks ago when we hosted more than 600 of our clients, representing 40 million Americans that our health services business serves today. If you really want to understand what's happening in the healthcare marketplace, ask somebody that has to manage it every day, which is what we did. The HR leaders, benefits managers, health plans, consultants, all had one message for us, "We need your help." Helping our clients win brings focus and clarity to our mission and opportunities. Today, I'm going to bring more focus and clarity to how we drive strong, sustainable value, both creation and growth, through a health services strategy that transforms healthcare.
Our formula has a few key tenets. Innovation delivers market-leading results to help our clients win. We deepen existing relationships and build new ones in growing markets. We combine the unique capabilities of Cigna and Express Scripts to create and capture new value. We leverage Accredo, the industry's most sophisticated specialty pharmacy, in the rapidly expanding area of specialty pharmacy care. We create and deliver easy-to-use solutions that keep members well. As we succeed, we get more adoption of our industry-leading services, clients win. A few important takeaways. One, our business is strong, powered by our aligned solutions. Two, our growth opportunities are meaningfully enhanced with our relationship now with Cigna. Three, our model is solution-driven and flexible, designed to succeed in any environment, as David said earlier.
A key benefit of our combination is the growing number of care touchpoints we can improve as we align our current core assets. Some near-term synergies are fairly clear. More scaled and efficient operations, improved contracting capabilities with the supply chain, leveraging eviCore and Accredo for the benefit of Cigna's Integrated Medical business, winning a share of Cigna's medical book that uses others for pharmacy solutions today, and integrating behavioral health expertise and other capabilities from Cigna into our clinical pharmacy solutions. Our starting point is powerful. You can see our diversified and well-balanced set of clients, whether they be employers, health plans, federal, and others. Renewal rates in the high 90s mean clients trust us and stay with us for multiple years, creating amazing value. The longer we work with clients, the more the conversation turns to what more can we do together.
A great example is a 30-year client who worked with us to develop Total Performance Management, one of our newest clinical innovations that you may have read about. As we add more lives, we can do more across the supply chain, further improving affordability and access. Our future is rooted in value creation and capture as we drive a unique innovative health services business. Our results are compelling. In 2018, as David said, we delivered a 0.4% pharmacy trend for commercial clients, a record low for us and lower than the industry. We delivered negative trend for our Medicare business. Negative trend, another first. I would point out both results included specialty pharmacy trend, and were achieved while delivering industry-leading patient and client satisfaction. You can achieve both.
In a year where we were putting our companies together, think about that. We were in the marketplace. We'd announced a merger. We achieved 98.5% retention. Dave Queller and his team did an extraordinary job talking about the value of this combination in the long term, opportunities for clients that were going to be working with us, and that was a great achievement. An extraordinary validation, by the way, of not only our team's focus, but the expectation of our clients for the value that we will create. Looking ahead to 2020, we are on track to, again, achieve very high retention in the range of 96%-98%, and as you can see, organically grow by 25 million-35 million adjusted pharmacy scripts. Among the new business wins so far this year, a few stand out specifically.
Two large health plans, which chose Express Scripts over their incumbent provider, and both noted that they see us as their pharmacy innovation partner to help them win for the long term. We are built to help health plans win, as well as our other books of business. Clients are excited about our newly combined capabilities, which include the insights from 165 million global customer relationships, Cigna's more than 650 collaborative accountable care partnerships, and our combined pharmacy, behavioral, and clinical services. I mentioned earlier that clients see us as a pharmacy innovation partner and that we've been busy at work to deliver on that promise.
We've recently introduced a number of first and only customer-centric innovations, including Health Connect 360, an industry first that provides a holistic view of patient health and guarantees better outcomes. Our Patient Assurance Program, where in less than eight weeks, we went from an idea to a solution, and now many more people will have affordable access to insulin and a great chassis that we can build additional products onto. The flexible formulary, which provides an easier way for pharma to introduce drugs at a lower price, something we've long advocated. Most recently, our Digital Health Formulary, helping members make sense of the 300,000 apps and digital therapeutics that are available today. We have a legacy of leadership, whether it's wiring retail pharmacy way back in the day, developing sophisticated clinical tools, driving the generic wave, which many of you know, people didn't actually believe it would happen.
Generics were cheap cola and bad cigarettes 20 years ago. Today, they're 90% of the prescriptions that are prescribed, and they've created headroom for more innovation. Leveraging our clinical expertise to create formulary management and utilization management programs. We are positioned as well to define the future. We are driving a transformational change in how we do business. At scale, we can deliver personalized care with whole person health solutions strengthened by Cigna's expertise in behavioral health and eviCore's medical management capabilities. No one delivers more specialized and tailored care rooted in clinical expertise and sophisticated data insights. We are market leaders in performance-based agreements, ensuring clients and patients get every dollar of value from their benefit. Our solutions deepen relationships with clients and attract new business, particularly within Cigna's commercial and government businesses. Our growth strategy has three elements.
First, leveraging a complementary footprint to deepen existing client relationships, create and add new relationships, and expand the use of our existing innovative solutions, as well as those we will innovate in the future. Second, combining the best capabilities of Cigna and Express Scripts to create and capture new value, like some of the examples I shared earlier. Third, leveraging Accredo and their leadership in the rapidly expanding practice of specialty pharmacy care. There is exceptional room to run across our business, but in the time I've got today, let me just spend a few moments on each of these specific growth drivers. First, as you can see, we go well beyond pharmacy.
We are positioned to deliver data-driven, highly coordinated solutions that will define the future of healthcare, and we do so with a breadth of services, including pharmacy care, specialty pharmacy, clinical management, medical management, supply chain management, and data services. Tremendous platform. Our health services businesses serves an expanding portfolio of health plans and employer clients. Mike Triplett and Brian Evanko will talk later today about how they will leverage our solutions to drive further differentiation and growth. Importantly, we also have over 100 additional health plan relationships that we will enable to grow and flourish as well. Importantly, David said this, our chassis is capital light and very flexible, and we see significant growth opportunities in businesses we're in today and those that we will enter in the future.
Our services platform has a broad portfolio of solutions today, spanning from lower to higher levels of penetration. I mentioned some of the innovation earlier, but let me just highlight a couple of more. First, in rare gene therapies, the newest area of innovation in pharmaceuticals. The new Novartis drug that was just approved last Friday to treat spinal muscular atrophy is a curative treatment. It's a miracle drug for those patients that Accredo is entrusted to manage. With million-dollar drugs becoming more prevalent, we are building new payment models to supplement our world-class care model, ensuring patients and payers get the most value from these novel medicines. Medical benefit management. eviCore adds a dimension that we didn't have before, now in combination with Cigna, we can further leverage an expanded ability to manage medical and pharmacy together.
Just as Accredo is the market leader in specialty, eviCore is in the medical benefit management area, helping payers, providers, and patients achieve optimal clinical outcomes. SafeGuardRx. As many of you know, we have 11 SafeGuardRx programs that address significant conditions, they are condition-specific, by bundling value-based pharma contracts, guaranteed outcomes, specialized care, and data insights to drive the next generation of pharmacy care. From rare diseases to our diabetes care value program, SafeGuardRx represents the best of our health services. Specialty pharmacy. I've mentioned Accredo already, I'm going to talk more about it shortly, but simply put, we have great room to run with a growing need for clinical excellence and affordability in specialty care. As we look ahead, there are many innovations that we've already spoken about will provide more details on both on stage and in the breakout sessions.
Our expansion opportunities go well beyond our existing solution. You can see just a few up here that we have on the drawing board or we are bringing to market. I was telling some of you earlier, I think one of the most underappreciated aspects of our combination is in the incredibly complementary geographic footprint of our combined company. The geographies where Express Scripts has its largest share for pharmacy services, essentially, with a couple of exceptions, do not overlap with geographies where Cigna has its highest market share. You can see that when you look at this map. In fact, we've highlighted states here where our books of business are complementary. If you take a look, there it is. For example, Express Scripts has strong relative share in Michigan, Pennsylvania, Washington, Minnesota, Ohio, and Louisiana.
You would've seen it on the map prior, particularly in the health plan space, which opens the door for us to bring Cigna innovation and solutions to our clients, particularly those health plans. Similarly, in Texas, Florida, and the Southeast, you would've seen Express Scripts did not have strength. Cigna has a more significant presence and opportunities therefore for us to leverage our pharmacy services capabilities. There are a number of states where neither of us today have significant footprints that we view as completely greenfield. Additionally, the Express Scripts national account business provides substantial opportunity for Cigna's commercial medical offering, Cigna's middle market and select footprint provide inroads for Express Scripts products and services. By leveraging our suite of capabilities, we will deliver everywhere truly personalized and tailored services.
Medical management represents a significant opportunity, eviCore, and their medical benefit management solutions, engage 570,000 providers and over 100 health plan clients representing 100 million lives. That reach is expanding through new sales. They offer protocols in nine clinical areas, including radiology, cardiology, and oncology, with plans to grow into additional ologies into the future. In post-acute care, we can take eviCore, we add Cigna's expertise in behavioral care to Express Scripts' ability to lower cost and improve adherence, eviCore's solutions that drive evidence-based clinical protocols. What you get is patients receiving a more comprehensive and predictive care, and payers getting better outcomes. In cancer, we can combine personalized care with emerging therapies and protocols with Accredo, which provides holistic care teams, including specialist pharmacists, specially trained dieticians, and social workers.
Our team works with physicians to drive better adherence to complex and costly treatment regimens. Now what I'd like to do is just go a bit deeper in Accredo, which is the best choice for patients with chronic and costly conditions, payers looking for well-managed, clinically superior solutions, and pharmaceutical companies looking to enable value-based approaches for providers who want a sophisticated, clinically focused care partner. Through Accredo, we are uniquely positioned to deliver better health and financial outcomes for our clients who pay for specialty drugs. Our clinical excellence and deep specialization includes a number of things. We surround patients with the support they need to stay on track, and we do so with 15 condition-specific therapeutic resource centers that provide expert care.
If you go to an oncologist for cancer care, you should have an oncology specialist pharmacist with deep knowledge of those therapies, and with Accredo, you do. Our 550 field nurses and 200-plus trusted physician advisors provide support, education, and counsel to patients, their caregivers, and often people in the communities around them. Accredo and CuraScript, our specialty distribution business, have the broadest access to exclusive and limited distribution drugs in the industry, including being leaders in bringing gene therapy to market. We are the leader in new models of shared risk with pharma manufacturers, and these are at the heart of our safeguard programs, including indication-based reimbursement in oncology. With more patients to care for and our leading position in exclusive drug distribution arrangements, we have a clear pathway for long-term growth.
Now, just as we improved access and utilization of generics over the past 20 years, as I spoke about earlier, we have the exact opportunity to, again, over the next 10 years, do so with the new generic wave in specialty, both biosimilar and specialty generics. A rich pipeline of specialty generics is emerging, and approvals representing about $14 billion have already occurred with another $24 billion in opportunity expected by the end of 2023. Billions in potential savings will materialize as competition comes to high-cost classes, and we are encouraged by the recent focus and regulatory actions taken to develop a U.S. biosimilar market. We have long been advocating for this, we continue to.
Just last week, the CEO of Novartis, who wants to be able to bring innovative products to market, talked about how important the market for biosimilars is, that it's a $60 billion-$80 billion range market. It's critical to get more biosimilars to market so that we create headroom for new high-priced medicines. For clients to realize savings for specialty biosimilars and generics, they need our unique capabilities, our supply chain expertise, our clinical and adherence support, importantly, our physician relationships. Now with an increasing focus on rare and orphan diseases, our work is even more critical. One third of new FDA-approved drugs are for an orphan designation. When you add it up, 30 million Americans, as many as have diabetes, have a rare disease.
A payer can find themselves unexpectedly hit with a patient requiring a one-and-done gene therapy costing $1 million or more, or a family with a chronic and complex condition, such as hemophilia, requiring treatments totaling millions of dollars over a lifetime. This is where our model can help. Our advanced clinical care and outcomes tracking capabilities deliver more efficient and less costly distribution. Additionally, we're able to create new payment systems to spread risk over time and across parties while enabling clinical effectiveness guarantees so that these high-cost drugs are held to an account of actually working. We are chosen more than any other specialty pharmacy by biotech companies because with rare and orphan disease populations, you want the best pharmacy, not every pharmacy, that's what Accredo is.
Now that we've covered some key elements of our growth strategy, I'd actually like to pivot to a topic that I know is front of mind for many of you, rebates. Couldn't leave the morning without talking rebates. Let me start with this. Simply put, rebates are a discount and an important lever we use to deliver low net cost to our clients. You saw our drug trends, a key element. A few facts that I want to point out for your perspective. First, nine out of 10 drugs prescribed today are for generics. They are not rebated. It is a critical part of how we drive low net cost, generics. Of the remaining 10%, many of those do not offer rebates because they are single source and unique in their class.
In fact, if we look at rebates as a proportion of our overall script volume, we would see they apply to about 7% of the nearly 1.2 billion annual core-adjusted pharmacy scripts that we manage. Approximately 95% of all pharmaceutical purchase discounts, price reductions, and rebates we negotiate are passed through to our core commercial and health plan clients and their members. Half of our clients receive 100% of the rebate value, but every client decides what they receive. In rebate sharing agreements, terms are negotiated in concert with waiving other fees or deepening discounts. It's a trade-off. We're not only a custom solution shop, as David said, we are a custom contracting shop. Clients with Medicare Advantage Part D drug plans, they receive 100% of their rebates.
Just for some context, the HHS rebate proposal does not therefore represent a risk to our growth trajectory. It does, however, not help our clients who rely on rebates to help offset the cost of benefits they provide. Also, frankly, the proposal will not lower costs for beneficiaries because it doesn't require drug makers to actually reduce prices. The bottom line is this, our model is built so that regardless of how clients choose to pay us for our services, either directly for our suite of solutions or through rebate share, our profitability is sustainable and a direct function of our performance in improving affordability, access, and care. In fact, a simple equation essentially explains our growth.
First, an expanding platform of innovative solutions, which I've already talked about, plus flexible contracting at the client level equals consistent and sustainable profitability in the way the client wants to align with us. Importantly, rebates are not a core part of our profitability. Clients choose to pay us for our work in different ways, and in any setting, our profitability remains strong and consistent as we align with clients to create more value, to develop things with them, to advance value creation rather than talk about rebates, frankly. We succeed in the bottom line because we do one thing really well. We anticipate and innovate and create market opportunities. We deliver better outcomes and with industry-leading pharmacy trend with a wide array of services. Our flexible model allows us to serve a diverse set of clients and attract new business.
Combined with Cigna, we will continue our heritage of driving better, lower-cost care. In closing, there are some key takeaways I want to make sure that I just punctuate. First, Health Services serves the largest, most sophisticated buyer groups who have, for a while now and certainly in the future, have full transparency and choice, and we do not rely on any one economic lever. Second, we deliver exceptional value to our clients, our customers, as evidenced by our best-in-class pharmacy trend. Third, the differentiated value we're creating enables us to retain, expand, and add new business, as shown by strong retention and script growth expectations this year and, as I've already shared, for next year. Fourth, we have significant future opportunities as we innovate new solutions, leverage our complementary footprint and capabilities, and expand our leadership in specialty pharmacy.
I could not be more excited about our ability to continue to create value and drive growth. I'm going to invite Will back up to the stage to help us with the Q&A as well. I thought I'd bring up Everett Neville, who leads our value creation part of our business, for some questions with me. Will?
Thanks, Tim. Now we'll move to a 20-minute Q&A session with both Tim Wentworth as well as Everett Neville, our Chief Value Officer. Just a couple ground rules for the Q&A session. First, please limit yourself to one question so we can get to as many people as possible. Second of all, please raise your hand, and I'll call on you. We'll have a couple of Cigna representatives walking around with microphones. Third, just please identify yourself before asking your first question. Now we'll move to the first question. Justin.
Thanks. Appreciate all the color during the presentation. A lot of questions around the transition to Cigna and what Express Scripts' core growth looks like. The first quarter, I know there was a lot of accounting changes, moving parts. Can you give us some color on what happened in the first quarter? Did the core business grow? It looks like you're looking for a lot of improvement through the rest of the year. Can you tell us what the drivers are to kind of get to that improvement?
Sure. I'll start. Eric is actually, in his section, going to give you a little bit of additional color as it relates to sort of our expectations off of our 2018 performance. The bottom line is this: in the first quarter, our business performed well. It performed as we expected. We are absolutely on track for what we expected in terms of the full-year growth. As you may know, our business has historically been somewhat back-end loaded when you look at the percentage of earnings that come quarter to quarter, and this year is no different than that in terms of the broadly defined pattern that you would expect to see. As you saw, we had great retention and great claims growth. The new claims take time to make profitability as you obviously implement them and sell more solutions and solve more of their problems.
What I would tell you, Justin, is, from our perspective, everything was on track, performing well, and we felt good about it. Again, Eric will have a piece in his that I think will be interesting to you.
Okay. Thank you. Kevin?
Kevin Fischbeck from BofA. Maybe just to follow up on that, as you think about your retention into 2020 and then some of the growth drivers that you mentioned, how do you think about the profitability of the growth, specifically into next year, but then also, as you talk about adding new service lines and some of these things, is there a change in your view about where the margin profile of this business is? Is it going to be consistent, or do these things come in at a higher margin or lower margin over time?
As you know, over time, keeping clients longer is always a good thing. Increasing your penetration solutions is always a good thing. At the same time, in this business, you always are trying to deliver underlying core value to clients as well and keep them in the game. What I would say is, and Eric's going to hit this in his, again, in a fairly complete fashion, we like the long-term profit picture of the business. It's a picture that, to me, in absolute terms, is all about providing value, which then we get paid for. What I would tell you, again, Eric will show you sort of how that all models into our expectations. Broadly speaking, though, what you've seen from us over the years is not vastly different than what you see in the future.
This is a business where as long as you find value creation levers, and I talked about all the ones we see, you continue to be able to win and retain business with a fair profit, and I see that continuing along into the future.
Pete?
Tim, you always talked about spread-based pricing as being something your clients preferred at Express Scripts because they wanted you to share and have some skin in the game. You always talked about Medicare Part D business as being a lower margin business for Express Scripts. If everything becomes more transparent under where we seem to be going or how PBM pricing is going, does all of your EBIT margin pressure, or does the margins move towards where they are in Part D, and what would that do to your ultimate margins for your business?
Sure. Different market segments, including Part D, have had different profit profiles for a long time due to a variety of dynamics, not that particular dynamic. The bottom line on spread, and I'll let Everett jump in here as well, the bottom line on spread is our clients determine whether or not they prefer spread arrangements or not, and a lot of them do prefer spread arrangements. Again, we are not for the government taking out of our clients' hands choice in terms of how they want to work with us, how they want to create value, and ultimately structure their approach to their marketplaces or their employees. From our perspective, we've long built models for clients that included spread. Medicare, it's obviously, as you say, not an option.
As we look forward, again, from our perspective, our clients who have us using spread arrangements are doing so for very specific reasons that are theirs. If it were to go to a non-spread arrangement, I'll let Everett speak to that, we would continue to be paid for our services, it would just be differently. Risk would transfer to some extent as well.
That's exactly correct. Let me back up a little bit. The reason clients choose spread, and more often than not, the clients that choose spread tend to be smaller clients. It helps them with some certainty of what their costs are going to be. It helps smooth out their payments. Even their member co-payments tend to be more consistent. It's their ability to get predictability and offload some risk, and that's a choice. We very typically offer both at renewal and for new business. On one side is a pass-through agreement, on the other side is a spread agreement. When clients choose that, they typically are choosing that for their own reasons. I do want to also address the Med D business and the profitability there. Big driver of that not being as profitable is that we are not able to sell some of our programs.
Our programs help drive client affordability. They help drive access to the patients. Those programs, for example, Safeguard, are not as easily conforming to the Med D requirements. A lot of that has to do with the business itself, not the transparency of the business.
All right. Over here.
Thanks. Bob Jones, Goldman Sachs. Tim, if I remember, this is usually around the time of year where you guys would give an update around potential claims growth or at least a preliminary view of claims growth for the following year. I know you guys have shared retention. I'm just wondering if you'd be willing to point us in any direction as far as how you see claims growing next year. Then, I guess, just related to that, you touched on converting Cigna Medical over to the Express Pharmacy. Was wondering if you could just maybe dive into that a little bit deeper.
Yeah. I'll talk first. The claims growth, I actually was on a slide, 25 million-35 million scripts for next year, organic claims growth. Let me make sure that I'm clear about that. That was when you take the retention range that we've got and what we know we sold already, as well as what we have in the sales pipeline, and we factor it a bit. We feel very good. Dave Kowal and his team have done just an astonishing job of continuing to lean into the market with our solutions, and those have resulted in high retention and our ability today, in May, to declare that next year we should see claims growth in 25 million-35 million claims organically. That's not new sales, that's net. In terms of the integration into the Express Scripts or the Cigna Medical business, Mike is going to speak.
Mike Triplett, my colleague, is going to speak a little bit about that and how important it is. We are obviously managing the transition of services over, as I think David said, by the end of 2020 or so. That book of business onto our platform so that certain things can be shared with those clients as well. There's some things, though, that are going to happen very quickly, such as Accredo. We see an ongoing kind of cadence of additional value that we'll be bringing through. The bigger idea that I spoke about is this notion where the Cigna Medical client has someone else providing a carved-out PBM, and that is a place where we are now mapping opportunities and out having conversations. Again, Mike can address that more in his presentation in Q&A. Question in the back?
A little bit of a follow-on to your comments on integration. David Windley at Jefferies. To what level have you been able to get into optimizing contracts across the preexisting Cigna pharmacy business and your own, and how are those being handled and delivered through to clients, kept internally, et cetera? How might that also influence, or how is it already starting to influence selling activities in the, when I think about the geographic map overlap that you showed us where each company is relatively strong? Thanks.
Yeah. I'll let Everett talk, because Everett's really been driving our harmonization of contracts and optimization of opportunity in the supply chain, in terms of the plan work, which is, I'll just say it's ahead of schedule, but I'll let you
Yeah. The contracts from the supply chain are going very well. The pharma contracts, we're currently putting them together, and a lot of that work's been done, same thing in the retail space. The contracts are moving quite well. I also want to look at or focus a bit on some of the stuff we've done on the program side. I think I want to highlight one in particular. Safeguard, which most of you are familiar with. It's been the bedrock of our most recent clinical programs that we sell to clients. We realized early on, in conversations with Cigna, that the way we did Safeguard would not really well fit in with their business model. We were able to modify that, tweak that.
We rolled out another version of it that we call Safeguard Bronze, and we're currently in the process of putting that into the Cigna book. That will drive client savings. That'll drive better outcomes for the patients on that side. A funny thing happened. When we retooled that, it turns out it works a lot better for our health plans. We've also sold 20 million lives in the Express Scripts health plan book. That's an example of how putting these things together is working quite well.
Already out in the market. Ralph?
Thanks. Ralph Giacobbe from Citi. First, just to clarify the 25 million-35 million, I think midpoint would be somewhere around 3% script growth. Just want to make sure we're consistent on that. Second and real question, has the rebate discussion trickled down to clients and employer benefit managers at this point? How proactive, I guess, are you in bringing that up and proactively changing the model? I know Cigna historically has been more agnostic to what the employer wants, but how forceful are you being to actually try to drive change as opposed to leaving it up to the employer? Thanks.
Our fundamental principle is choice, as it relates to clients choosing and working with us, as I said, a custom contract shop, in the way they want value to flow and in the way they want their structured benefits to work. As it relates to the rebate rules specifically, we have had, first of all, as you probably know, at Express Scripts, as well as Cigna, but as Express Scripts, we for over 10 years have offered rebates at point of sale to clients that want it. We have a very precise, and it works for those clients that want it works flawlessly. The challenge is most employers today don't want to be told what to do with their rebate dollars, and they value those rebate dollars.
Just to give you some color, at the recent meeting with 600 clients I earlier referenced, I had a room of about 50 national accounts. Some of you work for a couple of those companies, actually. Big names. I asked the benefits leaders that Dave Kowal and I were talking to, how many of them today had rebates at point of sale. I believe two hands went up out of about 40 or 50 people. I asked how many were considering modeling or otherwise talking about it, maybe another four or five hands went up, and it proved the point to me, which is, I said, "Can I assume the rest of you believe it's your money? You want us to maximize that.
You want to do things with it, such as lower your premiums, make other things available, and so forth." They said, "Absolutely, yes." I'll tell you a quick side story. We have a very, very large Taft-Hartley plan that my mother happens to be a beneficiary of. My mom knew I was having dinner with the CEO of that plan, this was a couple of years ago, and said, "Thank that person for adding dental back into our benefits coverage." My mom's married to a retired worker from that particular plan.
I'm at dinner, and I thanked this person for that, and what was said back to me was, "You guys did that." I looked at that person, I said, "Well, how did we do it?" He said, "You over-delivered so much in terms of the value you created, including the rebates, that we were able to actuarially reset the plan and add dental back in." That's what they chose to do with the rebate dollars, and we've got nearly 3,000 employer clients that want to be able to make those same decisions. Not only are we structured to do whatever they want, we are also working in Washington, D.C., we're the only player that has showed up to every congressional hearing, tried to define and help folks understand lowering drug prices and getting rid of rebates don't correlate.
The 3%, Tim.
What's that?
The 3% growth.
3% Yeah. Yes, absolutely. I think you can do the math, and that is correct.
Thanks for that clarification. Ana? Go ahead. Right here.
The whole landscape has transformed a ton, with the two big deals. Anthem is no longer a customer, but a competitor. Centene is bringing business in-house and will probably cater to third-party plans. One could argue the Blue plans will get closer to Anthem with the Medicaid JVs, and they don't compete with Cigna directly. Can you talk about how you're changing your pricing strategy, or how do you think about pricing and go to market, and what that might mean for the market share growth and margin?
Yeah. Again, speaking for health services, which I think in some respects reflects well the broader Cigna strategy, which is around value creation versus simply unit price. The old days, as David talked about, the transition or really the transactional model of just getting low unit price, whether that's in your medical network or. It's insufficient. It doesn't disrupt, it doesn't create long-term value, it doesn't frankly improve care. As we think about how we compete in the future as the market changes, it comes back to just staying relentlessly focused, which is one of the things we said was our goal this year during this merger, and we've done a terrific job, as you've seen us launching innovation after innovation after innovation.
Staying tremendously focused on not only identifying, but creating value levers that are identifiable to an individual plan as something they want, and then sharing that with them. Any single competitor obviously is going to look to the ways they can create value. I think that we are uniquely positioned to create value. Pricing for us increasingly, that's why we've said that even our share of rebates over time has decreased, because our clients are wanting to pay us in other ways as we create other value. TPN, for example, that we launched with our 30-year client, is all about being paid for outcomes. I see us having the flexibility, and the ability, both because of our clinical differentiation as well as our fundamental view, which is different than our competitors, that we want to work with providers, not build things around them or own them.
We believe the value creation through that ecosystem and our approach to it is going to be differentiating, and it's not going to be about us dropping our unit price and therefore our profitability. It is going to be about creating value.
All right. Thank you, Tim and Everett. That's all the time we have now for Q&A. We will have additional Q&A sessions throughout the day. We're now going to move to our session on delivering greater affordability in healthcare, which will be immediately followed by our business leader presentations. Matthew Manders, President of Strategy and Solutions, and Dr. Steven Miller, our Chief Clinical Officer, will discuss how Cigna has delivered industry-leading medical trend, and how we are taking significant steps to further improve affordability as a combined organization. Following that, each of our business leaders will present the growth drivers as well as the value creation that we continue to drive in the marketplace for each of those businesses. Those business leaders are Mike Triplett, President of U.S. Markets, Brian Evanko, President of our U.S. Government business, and Jason Sadler, President of International Markets.
Again, each of those will discuss how their businesses are strategically positioned to continue to create value and to continue to grow in the marketplace. At the end of this session, we have saved an additional 20 minutes for Q&A. Now let's first go to Matt and Steve for a discussion on delivering greater affordability in healthcare.
Thank you, Will, and good morning, everyone. As you heard from David, Tim, and Everett, delivering more affordable solutions in the marketplace is mission-critical to Cigna, and it's mission-critical and central to us to improve the health, the wellbeing, and the peace of mind of those that we serve. Today, Steve and I are going to go deeper into this topic, and we're going to really focus on the U.S. marketplace. We're going to start with a historical context in terms of how the industry has dealt with the affordability challenge, and then we're going to discuss how Cigna's achieved market-leading medical trend over the last several years. Finally, we'll close with how Cigna's going to achieve sustainable cost trends as we go forward for those that we serve. This is a pivotal moment in the evolution of the health services industry.
For far too long, healthcare costs have outpaced consumer price index, or CPI, by very wide margins, and pharmacy has played a very significant role and a major contributor in that trend. There have been significant advancements in the recent years, but there's still tremendous hurdles to clear when you think about it in terms of access, affordability, transparency, or value. We've all seen this through skyrocketing medication costs, particularly for specialty drugs, the uneven adoption of value-based care models, and then the heightened customer expectations that they have around engagement and access to care delivery.
Put simply, the customers, our patients, and our clients are demanding that we take the next step as it relates towards affordability. As David discussed earlier, we characterize the industry's approach to affordability in three different phases. The transactional phase, which is what happened in the past, the transitional phase, which the approach that the broader industry is now progressing through today, and the transformative phase, which we at Cigna are leading into the early stages as of now, as we work towards a more sustainable trend. When you think about the transactional phase, think about this was the turn of the century, and the industry really became focused heavily on demand-driven aspects, very basic tools that made some inroads, but ultimately proved very insufficient.
With the transitional phase, I would call that the last decade or so that we're in, the industry began to address the escalating cost trends with much more sophistication. This is when consumer-driven plans were introduced. New tools and insights and delivery channels were developed so that you could better engage and incentivize the customer so that they can make more informed decisions. Cigna has led the industry during this period by our focus on improved collaboration and better incentive alignment with the supply side, very specifically, the healthcare delivery system. With Cigna now in the transformative phase, we're going to continue to drive down cost trends. Steve's going to share with you in more detail about what we're doing in the transformative phase shortly. First, I think it's critical for me to lay the foundation for which we're building on.
If you look at the industry as a whole, medical cost trend has been impacted by the way that the health service organizations have worked through both the supply and the demand levers. In the unmanaged bucket, the industry really responded to what the customers were demanding, for choice and broader network access. This is when you saw PPO plans were introduced, and they yielded a trend of about 8% or higher. The managed bucket includes the new consumer-driven cost management tools that have been employed by our peers, and this brought trend down to about 6%, which is still three times CPI and is not sustainable in the long run. At Cigna, we've driven the trend down from 6% to about an average of 4% for actually the past seven years. Importantly, over the last three years, we've actually driven an average trend closer to 3%.
As a reminder, we measure trend on a comprehensive basis. That 4% represents our entire U.S. commercial employer book across all of our funding mechanisms. Overall, we attribute Cigna's better trend management to four key efforts. One is our collaborative care arrangements. We have steadily increased these arrangements with the supply side so that more of our customers were impacted at the site of care. We've also put different incentives in place. We work on an even more consultative fashion with providers to ensure that we have better care coordination, that we're leveraging best practices across all of these collaboratives, and we're more tightly aligning rewards to the outcomes. Two is our network configuration.
We're focused on optimizing the networks at the local level that we can meet the customers where they are. Very importantly, ensuring that we have the highest performing providers in the network. Then guiding our customers to those providers using enhanced benefits and incentives. Third area is our site of service initiatives. We have helped to guide our customers away from inpatient facilities to outpatient professional office settings as appropriate. In fact, we've actually reduced inpatient utilization trend to below zero for the past several years. Said otherwise, we have been delivering negative inpatient trend for several years. At this time, though, we've also reduced out-of-network cost by 38% since 2012. Negative trends, less out-of-network cost. Fourth, we have developed specific clinical solutions for better outcomes in five key areas: orthopedic, oncology, cardiac, OBGYN, and gastro.
As an example, we have created a program that's focused on orthopedic treatment. Why? Because this is an area that drives about 15% of the total cost of care. Through initiatives that include surgical engagement, therapeutic care, pain management, and our out-of-network management tools, we have realized approximately $1 billion of cost savings over the last five years through avoidance of unnecessary surgeries. We've also improved access to therapeutic procedures in the appropriate site of care, once again, all while reducing out-of-network cost. These efforts provide the context for all of you of how we've been the industry leader in trend. We've delivered the 4% trend on a consistent basis by investing on four differentiating capabilities. First is the way that we leverage data analytics. You're going to hear that theme repeatedly throughout today.
The second is our consultative client approach. Mike Triplett is going to talk about that shortly. The third is our ability to drive more effective consumer engagement through our tools and our programs that help our customers take control of their health. You're going to see a bevy of these tools profiled in our innovation room later today. Our work around the customer engagement is so important to us and holds so much promise because approximately 80% of all medical costs result from conditions from behavioral and lifestyle choices. Finally, our fourth capability is our choice-based delivery system strategy. The way that we partner with the delivery system allows us to better coordinate the care across the entire health ecosystem and to be more agile.
More agile in terms of determining how and whom we partner with, more agile in terms of bringing new innovations to market faster. Adopting and activating new channels options for our customers to access care. Very importantly, we prefer to partner with, rather than compete with the delivery system. This preserves their entrepreneurial aspects of their physician businesses. It also enables us to create value for our customers and clients in an extremely capital-efficient manner. Our delivery system approach today is anchored in access, accessibility, customer experience, and affordability. We're facilitating the customer's access to the highest quality of care in the preferred and the appropriate setting at the right time. We are not wedded to a particular delivery mechanism.
We partner with the physicians to provide multiple convenient channels so that we can proactively support the customers, whether they need routine, chronic, acute, or catastrophic care. Today, our customers want quality options for receiving care on all the channels, whether they're in the traditional channels, non-traditional, whether they're in person or whether they're virtual. Our approach also supports a more personalized customer experience. We leverage our deep pool of data and analytics, and we use them to help our customers guide them along their health journey. You see that, and that gets carried through our benefit designs, our clinical programs, the care extenders, as well as our network configurations. In the digital data and analytics breakout session, you're going to hear about how we've rapidly scaled our tools, including OneGuide, so that we could deliver a lower cost of care and higher Net Promoter Scores.
For example, our total cost of care trend is 2%-4% lower for the customers that are using our services versus those that are not. Very importantly, these same customers have a six to 10 point higher Net Promoter Score in engaging with us. Related to OneGuide specifically, it has delivered tangible results for us. Two really good examples. We have 21% higher engagement in coaching for chronic diseases with those using OneGuide, and we have a 50% higher use of higher-performing providers for those that are accessing and communicating with us. Finally, our delivery system strategy is centered on driving affordability through our work with healthcare providers. We have a long history of innovative value-based relationships with healthcare professionals in both our U.S. Commercial and our government businesses, and we now have more than 650 collaborative relationships with healthcare professionals.
Very importantly, we are particularly focused now on deepening our relationships with specialists. Why? Because they directly impact outcomes for the most burdensome health conditions. When you look across our top 40 commercial markets, our entire Medicare book of business, we have more than 65% of our payments are now in value-based arrangements. Importantly, 92% of our accountable care program physicians are meeting or exceeding our quality benchmarks. As you heard from David, our work is far from complete, so Steve's going to discuss that with you.
Thanks, Matt. Today, Cigna is taking the transformative steps necessary to deliver greater affordability in healthcare. We have great opportunities in front of us to further improve clinical and cost outcomes through further enabling our existing programs and services, including our proprietary predictive models that deliver personalized care and guaranteed outcomes. Re-envisioning our business with customer-focused innovations that deepen relationships and earn us the right to serve more people. Pursuing new solutions, partnerships, business models where disruptive companies want to partner with us to leverage our size, our scale, and our expertise to improve healthcare. Our work here is fueled by industry-leading medical and pharmacy capabilities, including major steps forward to bring and harness more actionable data, advanced analytics, and technology and digitally enabled tools. Today, most touchpoints in healthcare occur in one of three venues: in the doctor's office, in the pharmacy, or in the lab.
The breadth, depth, maturation, and structure of our data across these touchpoints, combined with analytics, is rapidly advancing. The need for speed in applying these insights is critical. It's about delivering the right information in an actionable way sooner to ensure maximum benefit. At Cigna, as you've heard, we have over 165 million customer relationships globally. But we also have over 1 billion customers through the pharmacy and nearly 600 million lab records over the last three years. This rich insight from all these touchpoints and our role as that connective tissue between the demand and the supply side of healthcare, gives Cigna the opportunity to improve customer and provider decision-making and transform the coordination, quality, and cost of care. With this as background, let's walk through several examples where Cigna has already begun driving improvements in affordability.
First, emerging technologies are enabling digital tools to become increasingly relevant to our customers. FDA-approved devices are available by prescription just as medicines are today. With more than 300,000 health apps on the market, the emerging growth in digital therapeutics, we're applying our formulary management strategies in different ways. Just this month, we announced the industry's first and only Digital Health Formulary. This will help clients ensure the safety, effectiveness, and usability of digital health technology tools available to their members. Second, I would highlight that we have greatly expanded the scope and impact of Cigna's physician collaboratives. Our physician partners will be provided with more timely and actionable information at the point of diagnosis and prescribing. This enables us to further align payment models with the achievement of better clinical and cost outcomes. And third, we have innovative whole person health programs.
An example would be diabetes, a disease impacting 30 million Americans. We leverage new technologies such as remote monitoring, apps, reminder devices to improve adherence, and to spot and help prevent future comorbidities. For example, last year, we expanded our diabetes prevention program in collaboration with Omada Health to deliver an expanded suite of personalized digital tools to help prevent the onset of diabetes. We also have diabetes care value programs with retail pharmacy partners that reward lower costs and higher quality care. And just last month, as you heard, we introduced our Patient Assurance Program, capping patients' out-of-pocket costs at $25 for a 30-day supply of insulin. In the future, we see significant opportunities to leverage Cigna's expertise and add programs and services to further integrate behavioral, medical, and pharmacy solutions.
For example, for people with type 2 diabetes who suffer from depression, we can reduce total cost of care by 28% when we ensure that they receive appropriate antidepressants and psychotherapy. Now, as exciting as the opportunities are to drive value on an individual basis, our ability to deliver transformational value accelerates dramatically when we look at the potential of entire businesses like Accredo. For example, in the near term, we expect to deliver more value through better and more affordable access to limited distribution drugs. These medicines are available only through select pharmacies like Accredo that meet the highest standards in clinical expertise, service, and support. Accredo is already the leader in providing the most access to limited distribution drugs today, and it's at the forefront of value creation opportunities as it relates to gene therapy. In the midterm, Cigna can do a better job of battling cancer.
We recognize that over 40% of cancers are linked to modifiable risk factors. There's tremendous opportunity to support positive lifestyle changes and partner with physicians and clinical teams to better coordinate care management programs. We'll also provide enhanced oncology condition management to ensure customers receive evidence-supported treatment, as well as provide a more automated, holistic experience for providers based on industry-accepted cancer guidelines. Longer term, we'll build upon the unique foundational expertise with Cigna's collaborative care programs and Express Scripts care value programs to enhance our existing collaborative care relationships to manage specialty drug spend, accelerate the creation of new collaborative care programs aimed at those high drug spend areas, and expand collaborative care relationships with specialists by helping them select the appropriate site of care and medications. Overall, these advancements are possible because we're positioned as the innovative partner of choice.
We're leveraging leading capabilities, emerging technologies, and choice-based models to transform healthcare affordability. Lastly, I'd just like to add from a personal standpoint, as a physician by background, and now Cigna's Chief Clinical Officer, I'm excited to be part of this combined organization as we take the next critical steps to make healthcare more affordable and better for the patients we serve. Matt, back to you.
Thanks, Steve. As we're progressing through the transformative phase, we see that medical cost trend of CPI is both necessary and attainable, that's why we've established this important goal for ourselves by 2021. Achieving this goal supports the ongoing growth of our commercial and our governmental businesses, it also further enhances our services business, because many of our programs and our services are also going to be available to the health plan and to the employer clients. We're leveraging what both Cigna and Express Scripts have done already to deliver market-leading medical and pharmacy trend. Now we're positioned to go further by maximizing efficiencies in the unit cost, differentiating on how we're managing utilization, and also by engaging providers and customers to help close the gaps of care and remove unnecessary cost.
We have a number of specific initiatives that are underway to enable us to achieve this goal. First, we're improving pharmacy economics by minimizing the inefficiency and the variability of the pharmaceutical supply chain. We've discussed specialty pharmacy, there are other capabilities that are going to have a significant impact. Some of these include supporting real-time provider decision-making, rewarding pharmaceutical manufacturers based on outcomes, even more so in the future, identifying the optimal drug mix of improving prescription and utilization management, then very importantly, improving medication adherence. Second, we're going to continue to enhance our condition-specific clinical solutions. With the advent of eviCore joining and being part of our organization, we can now leverage their utilization management tools to create better clinical pathways for specialized care. Third, we're going to further expand and strengthen our collaborative care arrangements.
We're going to enhance timely actionable information at the point of diagnosis and the point of prescribing. This includes we're going to provide patient-level dashboards with gaps in care, real-time formulary information on a patient-by-patient basis, very importantly, new data from wearables, from lab testing, from biometric testing. Critical part of this, though, is this helps the providers manage risk, as a result of that further incents them to embrace value-based relationships, which is exactly what we want to achieve. Fourth, we're going to continue to lead the industry in consumer engagement, leveraging digital technologies. We're going to provide convenient access to care, we're going to guide folks to high-performing providers, we're also going to expand our core clinical programs such as live coaching through apps and digital assistants.
Finally, we're deeply engaging with our clients in plan design so that we can enable whole person health by developing personalized care programs that drive healthy choices and encourage personal responsibility, very importantly, wrapping in our choice-based model into the employer health plans so that we can make it easier to access care with our collaborative physicians. In closing, we are very proud of the advancements that we've made to healthcare to make it more affordable for those that we serve. Each of Cigna's businesses are uniquely positioned to deliver greater affordability, which enables growth and differentiated value creation for our stakeholders. You've already heard this conviction from David, Tim, Everett, Steve, and myself, I'm really confident that you're going to hear it over the rest of the day from all of our colleagues.
With that, I'm going to now invite Mike Triplett, our President of U.S. Commercial Markets, to join us up on stage.
Good morning, thanks, Matt. This morning, I will discuss our U.S. commercial employer business and why it is a sustained and attractive growth opportunity for us. I will describe our differentiated consultative sales model through which we make our clients' businesses better. I'll show you how our ongoing investments in technology, solutions, and talent help us to continue to be positioned for success. We meet our clients' and customers' needs for improved health, affordability, predictability, and choice, in turn, earn the right to retain, add, and expand relationships to drive growth. We serve as the connective fiber across a complex healthcare ecosystem, bringing disconnected fragments together in order to have cohesive whole person health, giving us unique and actionable insights into our customers and clients.
Our connecting and partnering orientation runs through our engagement with our employers, starting with our consultative sales approach and through our alignment with our provider partners, as all the time we focus on whole person health to drive improved health outcomes and greater affordability. Our LocalPlus focus drives us to work through community-level partnerships to champion health and well-being in communities where our customers live, work, and play. These efforts ultimately benefit our clients, customers, and our team because we're all members of those same communities. Our differentiated capabilities have driven sustained growth, demonstrated by our organic customer growth in each of the last nine years, which is unique amongst our peer group. In the select segment, which we define as employer groups with 51 to 500 employees, we have delivered double-digit annual customer growth for the last nine years.
In the middle market segment, we have consistently delivered low to mid-single digit annual customer growth. That growth begins with strong retention. As we retain clients and earn their trust, we also earn the right to deepen our relationships, delivering smart coordination of an expanded product suite and driving significant improvements in affordability and predictability, particularly through our value-based care arrangements. This is powerfully demonstrated by the fact that we have delivered industry-leading medical trend averaging 4% over the last seven years, far ahead of our competition. We begin delivering on the value of our whole person health approach and on affordability by recognizing that each client is unique. As David said, we are the largest custom solution shop in healthcare. We engage deeply with our clients to first understand and listen, then deliver what they need in a multi-year benefit strategy.
Given the breadth of our solutions, the network configurations, and the range of funding options, there are millions of combinations and choices clients can make. We've invested in talent, technology, and distribution capabilities to customize solutions one client at a time and do it at scale so it's affordable for our clients. Our teams bring the most effective suite of solutions together, helping our clients to create and sustain a culture of health and well-being in the workplace. Our engagement starts with a deep assessment of the client's culture, their core beliefs, future goals, the readiness to change, and the use of proprietary tools to assess the health risk of their population. We work together with the clients on a recommended action plan, developing the ideal solution suite to drive results.
In the video that we're about to show you will hear from several of our clients on how this approach is being used in their organizations. Video, please.
I feel very fortunate to work with Cigna. I think that we are a team together, and I think through every obstacle that we've gone through, they've been a lending ear. They've been able to give me advice. I can call them anytime, so they're accessible and supportive.
When Cigna came on, they taught us that wellness is not just about the medical side. They helped us to realize that we can do more for our employees and their wellness. There's a mental factor to it. Since we joined with Cigna, we have implemented so many different things, and you can really see it shine with our fairly flat year-over-year expense.
I look at Cigna as more than just a medical insurance company. They provide podcasts on wellness for our employees. We brought that class in on wellness with our wellness coordinator. It's been very helpful. It's understanding what the employee needs before it's too late and you have to do managed care rather than understanding how to be healthy from the beginning.
When Cigna comes in for our consultative analytics, we review the data from previous years, and it helps us to make those decisions for where our future's going with them.
I just feel like it is more than an insurance company servicing a benefit plan. It is really us working together as a team to better provide services and improve the overall wellbeing of our employees.
As you just heard from our clients, we partner together to create the right strategy for them. We evolve that strategy as goals change and as needs are met. This approach and our suite of capabilities is very difficult for our competitors to replicate. To that point, we have invested deeply in our technology, our solution suite, and our talent, and we have invested over $2 billion in the last five years to continue to evolve our capabilities. Our continuous innovation and reinvestment into our business are driven by our mission to help customers improve their health. Our whole-person health approach is much more than simply cross-selling or the bundling of benefit packages, but it is a series of connected touchpoints and interactions that yield results.
We have demonstrated that customers with Cigna Medical, Behavioral, and Pharmacy solutions woven together are more engaged in their health and have better health outcomes. According to our 2018 analysis, employees save approximately 4% or over $380 per employee per year by having integrated benefits. We also drove a 9% reduction in high-cost medical claimants for customers with these coordinated benefits. As you have heard from Matt this morning, our approach has results, and we leverage those results by delivering the lowest medical cost trend in the industry. To demonstrate what this really means, I will walk you through a specific client example. This is the actual experience of Structural Group, a construction and engineering company with about 1,000 employees and 1,200 dependents, and their plan across 36 states. Structural Group has a coordinated suite of solutions, which includes ASO medical, behavioral, dental, and vision.
The increased use of chronic condition coaching, improved medication adherence, and the use of Cigna collaborative care providers have helped Structural Group consistently achieve trend well below the industry average of 6%. Against that benchmark, they have saved about $5.1 million over the last five years by working with us. As I said earlier, we work with our clients to help make their businesses better. In addition to health and productivity, these savings provide real dollars clients can use to invest back into their businesses, for example, for research and development, job creation, or business expansion. As we step back and think about our market approach, we have deployed a strategy of going deep in local geographies, focusing on a specific market to drive value.
This strategy has driven significant growth for us for many years. We still have meaningful headroom with only a 6% market share in our select segment and a 15% market share in the middle market. As Tim Wentworth mentioned earlier, we have significant geographic growth opportunities as a combined company. We expect to continue to drive strong growth with two levers. First, by taking share in our existing markets as we retain, expand, and add client and customer relationships. Second, by our go deep market expansion. Last year, over 80% of our customer growth came from our go deep markets. While today our go deep markets represent a little over 60% of the total U.S. commercial market, we expect to expand in our go deep geographies by 25% over the next three to five years, further expanding our addressable market.
Both of these growth levers are accelerated by our continued innovation, enhanced specialty capabilities, and our meaningfully enhanced pharmacy capabilities and cost position through the combination with Express Scripts. As we drive the CPI trend levels, we will deliver even greater affordability, drive higher client retention, and continue to win new business. Our clients will directly benefit from lower costs, especially those that are in our ASO arrangements. 85% of our book is currently in transparent ASO funding arrangements. In the select segment where we go to market on a coordinated medical and pharmacy-only basis, we see continued significant medical customer growth and specialty solution growth. In the middle market, where we see ongoing opportunities for medical customer growth and deeper specialty relationships. In the national accounts, where we expect to maintain stable medical customer share, we have ample expansion opportunity for our pharmacy and specialty solutions.
Based on our ability to grow in our current markets as well as our expanded go deep footprint, we are confident and we expect to deliver attractive, sustained growth over the next five years. We're building on a strong track record of success, a consultative model, and a capability set that resonates in the market today, and we're expanding and innovating for tomorrow, accelerated through our combination with Express Scripts. We're excited about our future and our opportunity to serve more clients and customers. Thank you. With that, I'll turn the stage over to Brian Evanko.
Thanks, Mike Triplett. Morning, everyone. I'm Brian Evanko, President of Cigna's Government Business segment. At Cigna, we define the Government Business segment as covering our Medicare Advantage operations, Medicare Part D, Medicare Supplement, Medicaid, and individual and family plans. Today, I'm going to focus on our Medicare Advantage business because it represents our most significant opportunity to create value in the market and to drive growth in the near term and the long term as we leverage three key drivers of growth, our strong foundation in this business, the benefits of Cigna's combination with Express Scripts, and an accelerated geographic and product expansion strategy. Let me start with our seniors business today. We operate a differentiated Medicare Advantage business, which drives tremendous value for those we serve. Today, we offer Medicare Advantage solutions in 16 states and the District of Columbia.
Consistent with Cigna's go deeper and go local approach, within those 16 states, there are 43 sub-markets in which we offer Medicare Advantage, and we have a top three position in 80% of those sub-markets, underscoring that we're well-positioned to win in those geographies where we choose to go deep. In total, our current offerings only cover 4 million out of the 22 million Medicare Advantage beneficiaries throughout the country. In those geographies, we have meaningful share, and we participate almost exclusively in the individual MA market with HMO-style solutions. Let's talk a little bit about how we're positioned to expand our addressable markets in Medicare Advantage. As you can see on this slide, there are significant opportunities for us to expand our MA footprint where Cigna already has a significant commercial presence and an aligned collaborative care arrangement.
I show you this visual because our approach to growth in both commercial and seniors leverages our deep relationships with providers who see us as a provider of choice, a partner of choice. If we overlay those geographies where there is a high concentration of seniors, we see there are numerous opportunities for geographic expansion. In fact, approximately 25% of Medicare-eligible seniors live in geographies where Cigna has a significant commercial presence today, but no MA presence. This provides us with a meaningful growth opportunity for the Medicare Advantage business. You might be wondering, what gives Cigna the right to win in a highly competitive Medicare marketplace? It starts with having a really strong foundation in terms of the exceptional value that we deliver for our customers today.
As you've already heard from many of my colleagues today, what Cigna does so well in each of our businesses is we custom-build solutions that work best for the needs of our customers and our clients. In Medicare Advantage, that's perhaps best exemplified by our provider engagement model and the depth and maturity of our value-based care models. We were among the earliest pioneers of value-based care. Today, over 85% of our MA customers are aligned to a physician who's in a value-based care arrangement. Our Medicare Advantage business has historically earned high customer satisfaction rates, and they continue to trend higher. Amongst our national MA competitors, we achieved the top J.D. Power ranking in their annual customer satisfaction survey. On a related point, we continue to drive outstanding clinical quality, as reflected in our continued star rating improvements and our strong HEDIS measures.
Next year, we're projecting 77% of Cigna customers will be enrolled in a 4-star or higher rated plan, which is up from 73% this year. This positions us very well for continued strong retention and satisfaction along with geographic expansions. In our existing geographies with our individual MA HMO offerings, we have a compelling value proposition that drives differentiated outcomes, and therefore represents a strong first pillar of our growth strategy. The second aspect of our growth strategy is the enhancement of our value proposition through our combination with Express Scripts. You've already heard this morning, the Express Scripts combination delivers step function improvement in our affordability proposition.
We're starting by adding Express Scripts home delivery as an additional preferred partner later in 2019 for our Medicare business. We'll begin to realize the full value of our two companies coming together as 2020 unfolds, as we'll benefit from Express Scripts' deep experience in the pharmacy space, improving affordability through networks and manufacturer contracting. We'll customize care management programs for customers and reduce costs by leveraging eviCore's capabilities. We'll take full advantage of Express Scripts analytics and their tools to drive better insights, drug adherence, and an improved customer experience. We'll leverage Express Scripts' expertise in the Part D business to further improve our star ratings. Realizing this value is even more important when you consider that Medicare's share of the nation's retail prescription drug spending has increased from 18% in 2006 up to 30% in 2017.
We are well-positioned to leverage Cigna's enhanced Medicare Advantage capabilities and value proposition in a very attractive growth market. Given the demographic tailwinds of an aging population and Medicare Advantage's increasing popularity as an alternative to traditional Medicare, we see the total national Medicare Advantage market growing from 22 million lives today to at least 30 million lives by 2025. Those secular growth tailwinds are an additional accelerant as we pursue the third aspect of our growth strategy, which is to significantly expand our addressable markets beginning in 2020. I'm excited to share with you today that starting in 2020, we are now embarking on our most significant expansion plans in this space since Cigna's acquisition of HealthSpring. Beginning in 2020 and continuing for the foreseeable future, we are accelerating our geographic expansion and bringing PPO solutions to market for the first time.
By 2025, as you see on the right, we expect to significantly expand our addressable market such that we will have Medicare Advantage solutions available for about half of the nation's Medicare Advantage purchasers. Let's put some numbers around our growth expectations over the next several years. This year in 2019, we expect to grow MA customers at a mid-single-digit percentage rate in 2019 with our current HMO solutions. That's in line with overall individual HMO enrollment growth rates in our markets. However, it's well below what we view as our sustainable growth rate moving forward. A few months ago, we submitted our initial 2020 expansion plans, including new geographies and new products, which represent greater expansion than any other year in our history. We received initial CMS approval for those plans.
For 2020, we anticipate increasing our county footprint by about 15% as we'll open up three net new markets. We'll also expand into adjacent counties in four existing markets. We'll be introducing new products, specifically PPO solutions, in eight markets. This first year of accelerated expansion will serve as the stepping stone for an annualized customer growth rate of 10%-15% on average over the long term, starting in 2020. We expect the 2020 growth rate to be closer to the lower end of this 10%-15% range, with stronger growth rates in the subsequent years.
We'll achieve this accelerated rate of growth through continued strength in our existing geographies through our individual HMO solutions, additional growth in our existing geographies through the introduction of PPO solutions, growth in new geographies with both individual HMO and PPO offerings, and finally, additional tailwind from our combination with Express Scripts. Our growth will come in a disciplined way, through focused expansion where we have a right to win, while investing in products and capabilities, including a more robust digital experience for customers who want to facilitate an omni-channel engagement with us, and a more seamless transition for Cigna commercial customers when they age into Medicare. Along with expanding the tools and processes for our provider partners, including things like clinical data exchange, population health management capability. These investments will help to fuel our 10%-15% sustainable annual growth rate over the long term.
Finally, we see Group MA as a potential future opportunity for us to leverage Cigna's strong relationships with commercial clients on a highly targeted basis. Let me wrap with a few closing thoughts. Cigna's Medicare Advantage business has a strong foundation and a strong value proposition that delivers market-differentiated outcomes. Our value proposition and capabilities are strengthened by our combination with Express Scripts, enabling us to deliver more affordable, highly coordinated solutions for our customers and our provider partners. To accelerate growth, we'll leverage the strong foundation, including our local market HMO model, and expand to new geographies aided by Cigna's commercial footprint and leading pharmacy capabilities. For 2020 and beyond, we'll introduce products and capabilities to expand our addressable markets, including PPO solutions and a range of enhanced customer experience tools such as digital capabilities.
This positions us to achieve a sustainable MA customer growth rate of 10%-15% over the long term starting in 2020. With that, let me turn it over to Jason Sadler, President of our International Markets. Jason?
Thanks, Brian. I'm going to talk to you today about our International Markets business and how our deep local knowledge, combined with our strong capabilities, positions us to respond to global market forces and drive growth. Cigna has an extensive global footprint that spans 30 countries and jurisdictions, serving more than 14 million customers around the world. We serve three primary buying groups. First, corporations, as we serve organizations primarily to support their employees on international assignments, and senior executives requiring more extensive regional or global health coverage. Globally, we are the largest health service provider for expatriates and the leader in serving Fortune 500 companies. Second, we are a market leader in serving governments, non-government organizations, inter-government organizations, as we support their employees both locally and abroad. Third, we serve directly individuals, providing a range of supplemental health, life, and individual private medical insurance plans.
Concerns over access to affordable, quality healthcare are top of mind for our customers and clients outside the U.S. as much as they are here in the U.S. A key part of our success has been our ability to leverage global best practices, but apply them in the most appropriate way to make them locally relevant to the customers and clients we serve around the world. We think global, but act local. We are differentiated and positioned for sustained growth because of five important factors. First, our strong customer insights obtained from data analytics and segmentation, which enables us to offer the right product to the right customer at the right time. Second, our local talent and operating model that drives deep understanding of culture, local needs and regulations, and fuels the creation of locally relevant solutions.
Third, we leverage our global network of $1.5 million healthcare providers, the largest global provider network offered. This provides our clients and customers with peace of mind that they have access to the best quality healthcare anywhere in the world. Fourth, we have a model and a culture of sustained, proven innovation with deep experience in delivering first-in-market products and services that truly meet local customer needs. Finally, our extensive local license base enables us to offer relevant and locally compliant solutions around the world. These differentiators have underpinned our success. They will drive our future growth. We're extremely proud of our track record of delivering strong customer, revenue, and earnings growth across international markets over an extended period of time in both the fast-growing supplemental business and also the more mature global employer business.
In 2018, international markets adjusted revenues were $5.4 billion, which represented an 8% compound growth rate over the last three years. Over that same time period, we've grown pre-tax earnings at a compound rate of 14% to $735 million in 2018, whilst we've continued to reinvest in our business for long-term growth. There are four global trends that continue to provide attractive growth opportunities outside the U.S. First, the growth of the middle class, which continues to accelerate in emerging and developing markets, creating new needs in respect of health, wellbeing, and peace of mind. The middle class is growing at its fastest pace in developing markets, and by 2030, it's forecast that two-thirds of the world's middle class will be living in Asia. Second, the global aging population.
There'll be 1.5 billion people aged over 60 by 2030 and 2.5 billion by 2050, all with greater health and wellness needs. Third, there is a steep rise in chronic diseases globally. Both India and China are now facing immense health challenges in diabetes, obesity, and hypertension. Finally, all payers, whether they be governments, individuals, or employers, face the same challenge of ensuring consistent access to affordable, quality healthcare. All of these forces increase the need for affordable solutions to address health, wellbeing, and peace of mind needs. Cigna is uniquely positioned to turn these global challenges into local opportunities. Our track record of success is a result of our very focused strategy of execution. As we look forward, we have three clear priorities to drive growth. We're going to capture headroom by going deeper in our targeted markets.
We're going to continue to drive innovation and reinvestment. We look to plant new seeds for longer-term growth, including evaluating new market entry opportunities. We're executing on our first priority of going deeper as we continue to offer new, innovative solutions and services to both current and also new customers in our core markets. For example, Korea, which has long been our largest market in the International Markets portfolio. We entered Korea back in 1987, and we were the first foreign life insurer, and today have grown to be the largest foreign insurer in Korea. We're addressing the needs of the aging population in Korea, and we've developed a range of what we call silver products, particularly for those age 55 and above. By focusing on solutions that meet targeted customer needs, we've driven growth.
Today, we serve 3.3 million customers in Korea, and each of them holds, on average, two policies with Cigna. With a continued aging population and growing out-of-pocket spend on healthcare, opportunities for further growth remain. We've also continued to go deep with our globally mobile business, particularly in the Middle East. We are the leader in serving the needs of the globally mobile. In the Middle East, we now have operations in the U.A.E., Lebanon, Oman, Kuwait, Saudi Arabia, and we're continuing to expand our operations, having recently got a license in Bahrain. We are targeting growth by focusing on small and medium-sized enterprises, which have increasing numbers of individuals working either temporarily or permanently outside their home country. 94% of all businesses in the U.A.E. are small and medium-sized enterprises, and they employ more than 40% of the workforce.
We're also going deeper by looking for strategic M&A opportunities, as we did with our recent acquisition of OnePath in New Zealand at the end of 2018. OnePath doubled our presence and made us the third largest insurer in New Zealand. It provided access to a new, yet complementary distribution channel, OnePath's existing force of independent financial advisors. As well as expansion into a new bancassurance channel through a 20-year exclusive distribution agreement with ANZ Bank, who are the largest bank in New Zealand. Opportunities like this enable us to expand our capabilities and scale, enabling us to reach more customers with affordable personalized solutions. The combination of significant unmet local needs and our high-quality team, together with expanded distribution capabilities, mean we see much more headroom for growth as we continue to go deeper in the New Zealand market.
In China, we have a powerful story of organic growth, which has been driven by continuous innovation and reinvestment. We now have a footprint across 15 provinces, and we offer a diverse range of products and services to both individuals and corporate clients. We are one of the top five foreign life insurance companies in China, and we're a leader in group health in the local market, and we have a health network that covers over 56 cities. Today, we help two million customers in China, improving their health, wellbeing, and peace of mind. We've driven impressive compound revenue growth of 33% over the last three years. However, we've only just begun, and we're extremely excited about the continued future opportunity in China, where there's much more room for growth. In summary, Cigna's International Markets has a track record of delivering growth.
We see attractive opportunities for continued growth in the future, we expect to continue to deliver strong annual earnings growth. This is driven by the organic tailwinds of secular market growth across all our geographies, our proven local market capabilities, our deep local talent base, and all of this is built and driven by our deep customer insights, driving sustained innovation in products and services. We believe there are exciting opportunities to plant new seeds for future growth. With that, I'd now like to invite Will back up to the stage, we welcome your questions.
Right here. Sorry. Thanks, Steve. Okay. Thank you, gentlemen. We'll now move to our Q&A session. I'm going to ask both Matthew Manders and Dr. Steven Miller to rejoin the stage. Again, same call out for our last session. I would ask you to please limit yourself to one question. Wait for the mic runners, please state your name before asking a question. With that, let's begin. Scott?
Thanks. Scott Fidel at Stephens. Wanted to ask a question just on Medicare Advantage, appreciate all the details you gave us on the geographic expansion plans over the next few years. Can you help us think about how that will impact the margin expectations for MA? I think in general, the MA business has been operating at the lower end of the government target margins over the last few years, wondering how much opportunity you see to expand margins or whether the growth that you're expecting will be a potential offset to that. Then just sort of a separate question just within Medicare, just on the group MA side, just the thoughts around, putting the entry into group MA into a bit of a longer term type framework as compared to being more active in moving in there in the near term.
Sure. I'll start with the margin piece, we'll get to the group MA. Long term, we expect Medicare Advantage margins to perform in the 4%-5% range. That's over the long term. Today, our larger, more mature markets already perform at that level. Those that are newer and less mature tend to perform at a lower level than that. In the next few years, as we embark on an accelerated expansion journey, we're going to have more markets performing below our long-term margins, gradually they'll get to that 4%-5% level. You should think about the next few years as operating closer to the lower end of that range when you put the total portfolio together, as the book matures, it'll gradually move up towards the upper end of the 4%-5% range that I articulated.
Secondly, as it relates to Group MA, it's really just a focus choice for us. We believe that in the near term, we have a strong right to win individual MA market between HMO and PPO solutions. Therefore, we've chosen to focus more of our energy there. We do believe we have a right to win in the long term on a select targeted basis in Group MA, whether that's existing Cigna group retiree clients who are not in an MA arrangement, but potentially could save money by moving to MA, whether it's the Express Scripts Group PDP book. There may be certain clients in there who want to move to a Group MA, or in some cases, we have an active commercial employer relationship where the retiree business is with a competitor.
There are a few different sources of growth that we see there, but we're going to look at that on a case-by-case, market-by-market basis before we choose to go hard at any Group MA opportunities that are in front of us.
AJ?
All the presenters of the various business lines, at least in the U.S., are talking about the opportunity with Accredo to do more insourcing of what you do outside today. I wonder if there's any way to size how much business there is with third parties. I want to just confirm that you're thinking you can insource that by the end of next year. I've also heard you talking with Accredo about that gives you a capability to change site of service, which could lower cost trend over time. Is there any way to talk about that opportunity?
Dr. Miller?
Yeah. As you've already heard, we're going to move the Cigna book of business to the Accredo specialty pharmacy starting this summer. That should be actually completed this year. That's a tremendous growth opportunity for Accredo. On top of that, Accredo has actually been working for years on both the medical and pharmacy side, moving patients to the appropriate site of care. That's actually just going to grow in capability and in time. Actually, eviCore is an important component of that also. When we have clients that take both Accredo and eviCore, we're able to actually manage where they get their infusions. We like to move patients. If a patient's getting an infusion in the hospital, we like to be able to move them to the outpatient environment if possible.
If they're in the outpatient environment, we like to move them all the way home. One of the great things about Accredo is Accredo has 550 field nurses. We're within about an hour of 90% of the U.S. population. We're actually incredibly effective at moving people all the way to the home. When you look at the growth in spend, especially on the medical side with drugs, this is going to be a tremendous lever for us. It truly adds two things. One, better care for the patient. Two, greater value for the client. We think this is going to be an incredibly important asset as we move forward in the future. Mike, I don't know if you want to add anything to
Yeah. I think the thing I would say is that when you think about pharmacy, when you think about specialty medications, the one reason you have pharmacy really is to identify individuals really at an earlier stage for intervention. As we talk to our customers and clients, especially pharmacy costs are front and forefront on their mind. By having industry-leading capabilities with Accredo, it really is a tremendous asset as we think about our ability to improve costs, improve outcomes. As well as the SafeGuardRx programs. These programs will provide tremendous value to our customers and clients. You think about one of the great innovations with the Patient Assurance Program around diabetes, the ability now to have a fixed co-payment of about $25 for individuals with diabetes.
That's wonderful because as you think about some of the leading causes in gaps in care, diabetes is really one of those leading causes gaps in care. Nine out of 10 diabetics also have either high blood pressure or high cholesterol. Their ability to afford their medications and get other medications will be tremendous. The ability to have Accredo for specialty pharmacy, we view that as a tremendous cost driver. One of the things also we talked about the value of the combination, with the affordability that it was going to create. Because of the work that Accredo does, we actually can come to market with a stronger price point today. We've seen some early wins as a result of that already.
Sarah?
Several points today. You guys have talked about bringing medical trend down to CPI, which I think recently was 2.3, so kind of low 2s, I guess, range. You've given us a few of the pieces, inpatient for the last couple of years being a negative trend, drug trend being an impressive 0.4% this year, and I think each of those typically contribute about a quarter of the total medical spend. How do you build to that low 2s total cost trend range? What are the other buckets, outpatient and physician look like? What do those individual trends look like, or the contribution to the overall cost that gets you to your ultimate goal of 2021 CPI cost trend?
Matt, you want to take that one?
Sure. What I tried to capture today was to give you some of the key themes that we will be driving through in order to make that next step jump from that 3%-4% down to the lower 2s. I appreciate your characterizing CPI in the same context, the way we're thinking about it in terms of what our goals are. I would highlight a couple areas. First of all, I talked a little bit about what we're doing with specialists in particular, and actually, that would be an augmentation to A.J.'s point with Accredo, which is we have the opportunity where initially the vast majority of our collaborative-based arrangements were predominantly through primary care, not exclusively, but through primary care.
We now will have the opportunity to drive those relationships at the specialist level and then create the connectivity of the collaboratives with the primaries all the way through the specialist situation. Then you get into everything from where Steve talked earlier about access and costing around limited distribution drugs, the advanced abilities around closure of gaps in care, all the way through the connection of where the site of service is taking place, which are some of the things that you talked about. One major theme about bringing the two companies together is we think we're going to take a meaningful step jump in reducing gaps in care. Up until this point, and based upon a lot of what we've talked about today, we believe we've done a good job around closing gaps in care, but bringing the combination of these two pieces together.
I would just highlight, first of all, pharmacy will continue to be the largest-growing piece of cost, and we believe we'll be very well positioned there based upon today's capabilities and what will be developed through innovation as we go forward. I also think we're going to materially make an impact on those five specialty areas that I talked about, where I think we have a unique opportunity.
I just want to add a couple points. One is every other company has ignored behavioral health. Cigna has embraced behavioral health. I will tell you, as a physician, it is a fallacy to believe I'm going to control diabetic costs if I don't delve into the behavioral health aspect. The fact that we actually have over 1,000 people that work in behavioral health is a phenomenal opportunity. The second thing is we're building tools to help physicians to make them have more information at the time of diagnosis and prescribing, so we lead the country in real-time benefit check. When a doctor can see the choices across the spectrum for the patients, it's really powerful. The other thing we're leading in is electronic prior authorization.
If I can actually choose the drug that doesn't even require prior authorization, or if I choose a drug that does require prior authorization, being able to do it in real time, these things are going to make a huge difference in making it more predictable, more reliable, and lowering the cost. I think we actually have more tools, more capabilities than most any other company to truly get to CPI, and I think it's a really laudable goal that all 74,000 people really get excited about coming to work every day.
All right. Charles?
Yeah, thanks. Charles with Cowen. It's been mentioned a couple times about exclusivities with drugs for the network into Accredo. Seems like that step further from limited distribution networks. Can you talk about what's the value proposition for drug makers to go exclusive through Accredo, and what does that mean in terms of a margin profile for the company? Is that a better business for you guys, or it's the same? Maybe give a sense on what % of your drugs right now are exclusive and how that's changed.
Yeah. You'll have a better opportunity to talk to Brian Seiz and Vicki Wheeler during the breakouts on specialty. When you think about it, when you look at the FDA pipeline, there are more and more drugs for rare diseases, as you heard from Tim, about a third of the drugs. Those manufacturers actually have to choose who their partner is. The reason they're choosing us is our clinical model is superior than any others in the marketplace. The fact that we have 15 therapeutic resource centers that specialize in disease-specific areas makes a huge difference. To that point, for instance, if you look at the gene and cell therapies right now, we handle all of them. The fact is they're choosing us for this superior clinical model.
When you look at the go forward, and you look at the profile of Accredo go forward, having access to the limited and exclusive distribution drugs, being able to provide those services, because remember, we make money in multiple ways. Not only do we make money on the dispense, we make money on following up on these patients. What's really crucial and why the companies are choosing us is you need to be able to follow these patients long term, and because we have the relationship with them as the pharmacy, we're going to be able to follow them regardless of which insurer the patient moves to over time. We're providing services for the manufacturers that are superior to anyone else, both logistic services, clinical services, and long-term follow-up services.
This is why we believe that this will continue to be a big growth driver for Accredo going into the future.
Josh, up front. Josh, right here.
Question on Medicare Advantage for Brian, again.
I'm thinking about those growth rates, I understand geographic expansion, I look at the history since you guys have bought HealthSpring, it just hasn't been a growth asset. What is driving that expectation of growth? Is there distribution change? Is there provider change? Is there a product change? I think about that in an environment where the other MA competitors are also enhancing benefits and making great strides, it's becoming, feels a little bit more and more competitive every day. Just take it one layer lower as to what exactly around the product is going to sell now that just hasn't done so in the past?
Sure. I touched on a bit of this in my slides, we feel like the foundation we've built the last few years is really strong. It's as strong as it's ever been. As you think about the history of physician engagement, think about our position with customer experience today as evidenced by our customer satisfaction scores and our strong performance in Stars and in HEDIS. We feel like the foundation we're jumping off from is as strong as it's ever been. Secondly, the combination with Express Scripts gives us a bit of a turbocharge relative to the strategic growth agenda that we've set forth. Finally, the amount of expansion opportunity in front of us is huge when you look at how much geography we don't cover today and the fact that we haven't had PPO solutions in the market.
For those three reasons, we feel very confident in the 10%-15% growth rate that we've put forward. The other data point I'd give you is we've capacitized this differently than we have in the past. I have a team of people that's focused squarely on growth right now, separate and distinct from the people running the business day to day.
Matthew?
Let me stick on Medicare Advantage, if you don't mind, because it's obviously a big pivot for you guys. I just want to understand your perspective on the HealthSpring model looking back a bit. This is a model that is a tight network, highly engaged. You talked to those points, and so you should be able to add a lot more value compared to other MA products that are out there, and yet it doesn't seem like that's really made a big competitive difference in terms of attracting new members to the model. Maybe some of the crosswalking that's benefited some of the broader plan offerings has been a factor there. I'm just wondering if you can speak to that because it's been a little bit of a puzzle to me.
Yeah. We're really proud of the history of our Cigna-HealthSpring business and the position that we have. As I mentioned in the slides, 80% of our sub-markets were a top three market share player. Out of the 4 million or so addressable lives that we have today, you can do the math. We've got 440,000 customers today, so pretty strong share, when you look at where we currently play. Going forward, we're going to be continuing to double down on that model. In new markets we're entering into, where possible, we're going to continue to build those strong physician collaboration models, in conjunction with Mike's commercial collaborative accountable care relationships that we already have. As we introduce PPO solutions, it'll leverage those existing physician relationships.
I'm confident we're going to be able to continue to double down on that model and deliver against the 10%-15% growth we put forward.
Yeah, Ralph.
I also want to stick on just MA and just trying to understand the PPO product expansion in MA. Just in terms of the success you've had in HealthSpring has not been PPO. You talked on the commercial side how PPO drives higher trend versus what Cigna has always done of managing more specifically. Just help reconcile what you see in terms of why PPO expansion when it seems like that market and that product's much more focused on HMO and your ability to succeed to 4%-5% margin going into new geographies with this type of product versus a more condensed product. Thanks.
Sure. I'll start. Matt, maybe you can pile on a little bit with the commercial affordability lens and how that plays into this. For one, we're seeing more and more commercial customers as they age into Medicare prefer PPO-style solutions, and we view that as an important growth engine for us going forward to achieve the sustainable 10%-15% annualized growth rates that I described. As we build our PPO networks, we're largely leveraging the existing HMO networks that we have as a starting point, the eight new PPO solutions I mentioned in my comments are being built off of the strong HMO foundation that we have. Those physician engagement, the collaboration that we already have, those are being leveraged over into a PPO environment.
Secondarily, our industry-leading medical cost trend for the seven years, as Matt talked about, that's largely been in a PPO environment. Wherever we can, we're learning from our commercial business and applying those capabilities over into the Medicare space. Matt, would you like to maybe add a little more color around that?
Yeah, the one thing I wouldn't want there to be a confusion from a nomenclature perspective, while our primary commercial product is an open access product, tie that to my comments about the fact that we've pivoted and done our network configurations around the context of really leveraging value-based arrangements and our collaboratives with that as a context. Even as Brian's talking about his build-out through the new PPO products, a core element of that is leveraging some of these commercial arrangements that we have where we've already demonstrated, A, that they practice care at a different level, and B, that we partner with them in a way that there's a coordination of care that's far different just than people randomly accessing care across the network. Very important.
While we have choice in our networks, we still configure them around these core physician groups that practice medicine in a manner that's very different than what would just happen on just a broader base, quote-unquote, 20 years ago, 15 years ago, PPO network from that context. It's very different.
All right, folks, I think we're going to draw this Q&A session to a close. I'd like to thank Matt, Steve, Brian, Jason, and Mike for sharing their insights and perspectives today. Thank you very much, gentlemen. As a reminder for those of you in the room, we're going to move to our breakout sessions. Three breakout sessions that we have are digital data and analytics, where you'll hear how we are leveraging data-driven insights to improve outcomes and affordability. Specialty pharmacy, which we'll be able to go deep in terms of the significant capabilities that we have associated with Accredo, our specialty pharmacy, which we've already spoken about a lot today. Finally, whole person health, where you'll hear how our connected, coordinated care model and holistic approach improve whole person health and wellbeing.
Each of these sessions are going to be up the stairs, as you go out the doors, up the stairs, and along the hallway. I think there's two along the hall, and then the specialty pharmacy will be down the end. All three sessions will run concurrently. After the first session concludes, we ask you to move directly to the next session. We'll have chimes sound with five minutes to go and at the end of each session, we'll know when to move. For those listening to the webcast, we look forward to having you rejoin us at 12:10 P.M. for our financial update, where Eric Palmer, our CFO, will provide that update, and we'll go from there. All right, thanks, everyone. Okay, folks, welcome back. Hope everyone was able to get their lunch, come back in.
In this segment, our Chief Financial Officer, Eric Palmer, will provide a financial update and discuss how the effective execution of our strategy drives strong business growth as well as financial performance for both 2019 and over the longer term. Eric, the floor is yours.
Thank you, Will. Good afternoon, everyone. Today, you've heard from our business leaders about our differentiated capabilities and the market opportunity we have not only positioned us to deliver meaningfully improved affordability, but also open significant runway for growth and value creation. Over the course of the next 25 minutes or so, I'll pull these building blocks together to demonstrate how we'll drive sustained growth, strong margins, and significant shareholder value creation in this highly dynamic market. I'll highlight the strong track record of performance we've delivered and share with you our updated expectations for significant growth in 2019 and beyond. Building on this foundation, we'll turn to the drivers of Cigna's ongoing ability to create sustained shareholder value.
They are our significant headroom in our existing markets, our accelerated ability to enter and grow in new markets, drivers to meaningfully expand our free cash flow generation, and the significant financial and strategic flexibility that's enabled, and our capital deployment plans and priorities. When you've taken together our proven track record, clear strategic direction, talent, growth platforms, and financial flexibility are key differentiators and give us confidence in delivering our near-term, medium-term, and long-term earnings per share outlooks. We're incredibly excited for the road ahead. As an organization, we've consistently delivered strong performance through a very dynamic time in our industry. From 2009 to 2018, we saw the introduction of the ACA, meaningful changes in the political landscape, and M&A activity that reformatted the industry. During that period, Cigna leaned into the dynamic environment, and with an intense focus on our customers' needs, we delivered exceptional value.
Includes 4% average medical cost trend over the last 7 years, growth to over 650 collaborative accountable care partnerships around the country today. The value creation drove 9 consecutive years of organic commercial customer growth, which in turn helped to drive strong compound annual revenue growth of 11% and strong compound annual earnings per share growth of 15% from 2009 to 2018. Furthermore, in 2018, we completed our combination with Express Scripts, who as we talked about earlier, delivered a 0.4% commercial pharmacy trend and a negative 0.3% Medicare pharmacy trend, which are industry-leading. Our businesses have delivered strong margins and a capital-efficient framework, enabling us to deliver and continually to reinvest to drive and fuel innovation, and growth. While we're really proud of the value we've delivered, we're even more energized by the momentum we carry forward.
In the fragmented and frustrating universe of sick care, we see substantial opportunity for Cigna to deliver affordability and predictability and support our customers throughout their health journeys, and as a result, to continue delivering differentiated results for our shareholders. As you heard from Matthew Manders and Dr. Miller, delivering affordability is at the heart of our value proposition. By deeply understanding our clients' needs, engaging our customers in their health, we continue to drive industry-leading trends for our clients. To level set, we defined our trend very simply as the year-over-year change in the commercial, all-in, per member per year claims costs. In 2019, we continue to expect full year medical trend of 3.5%-4.5%, a full 200 basis points below our peers and consistent with the levels we've been delivering for several years now.
With 85% of our commercial medical customers in self-funded relationships, our clients see those savings flow directly to their earnings. As you heard from Mike, our ability to deliver lower trend, and therefore, greater affordability, is a direct driver of our high retention, which is key to fueling growth. We're positioned to drive even greater improvements in affordability through our combination with Express Scripts, which is reflected in our ongoing commitment to drive the trend to a level in line with CPI by 2021. Express Scripts is also focused on driving affordability. It has also driven industry-leading commercial pharmacy trends, 1.5% in 2017, 0.4% in 2018. In fact, in 2018, half, 50%, of Express Scripts clients actually saw a decrease in their pharmacy costs.
With the best-in-class specialty capabilities of Accredo that you heard about throughout the day and in the breakout sessions, Express Scripts has delivered leading specialty pharmacy trend as well. As specialty pharmacy continues to grow as a portion of overall spending, the need to effectively manage these costs is critical, and Accredo is positioned to do just that. Cigna and Express Scripts both have demonstrated track records of delivering leading trend, and together are driving forward to improve health, outcomes, and affordability for customers, patients, and clients. This ultimately translates to growth as we earn the right to retain our clients, to deepen our relationships, and to win new business. Our capabilities are driving our attractive outlook for 2019.
In our 8-K this morning, we reaffirmed our expectation for full year 2019 earnings in the range of $6.24 billion-$6.4 billion, reflecting strong contributions from each of our businesses. We're on track to deliver our 2019 operating expense synergies of $112 million. On a per-share basis, we continue to expect earnings of $16.25-$16.65. Year-to-date, we've deployed $650 million to repurchase approximately 3.7 million shares, and this includes 620,000 additional shares repurchased since our first quarter earnings release a few weeks ago. Consistent with our prior practice, our full year 2019 outlook for earnings per share excludes any expectation for future share repurchases and also excludes any additional prior year claims development beyond the amount we recognized in the first quarter.
We continue to have a consistent outlook for the other metrics, total adjusted revenues, the medical care ratio for Integrated Medical, the SG&A ratio, our medical customer growth outlook, and our adjusted pharmacy scripts for 2019. We are really pleased with the ongoing performance of our business and look forward to continuing to deliver on our strong outlook across the remainder of the year. I know many of you also had questions on our health services outlook following our first quarter earnings call. In terms of the quarter-over-quarter drivers, there is always going to be variability in quarter results from various puts and takes, supply chain initiatives, timing of generic launches, other business drivers.
We are not going to attempt to reconcile each and every quarter, particularly as we continue to evolve this business and run it differently, including making investments in the health services segment that may benefit Integrated Medical and vice versa. We provided strong earnings guidance at the beginning of the year. We reaffirmed our health services guidance on our first quarter earnings call and reaffirmed our earnings guidance today. We have every confidence and want to impress upon you our strong conviction that we will deliver on the guidance for full year 2019 and continue our successful integration. As we have said, our full year health services guidance reflects growth in the core Express Scripts business. To provide some additional clarity, I will walk you through the largest moving pieces year-over-year. We first need to start with the 2018 baseline.
Express Scripts provided EBITDA guidance with a midpoint of $5.35 billion, which needs to be adjusted to remove depreciation and amortization and to reflect EVI, the Enterprise Value Initiative costs, to get it to a pre-tax measure for 2018 that is a more comparable basis. Making these adjustments results in an adjusted 2018 baseline of $4.92 billion. As we step through 2019, we add in the impact of resegmentation, with the largest driver being the inclusion of Cigna's home delivery and health services. We recognize a stranded overhead headwind of $200 million from the early termination of the Anthem contract. I would remind you, this is a temporary impact. We have also realized about half of our enterprise synergies in the health services segment, and we will drive core fundamental growth of 0%-3%, building to our full year outlook of $5.05 billion-$5.2 billion of pre-tax earnings for the segment.
All in, we are pleased with the performance of this business, and it continues to deliver in line with our expectations. We see the range of 0%-3% growth in earnings for health services for this year as a very competitively attractive outlook. Now building on our enterprise momentum from 2019, we are well positioned to drive ongoing growth. Our business leaders described for you the path for growth in each of our respective businesses and shared our excitement about the growth opportunities ahead. With the shared framework, which you have heard throughout the day, for how we will drive growth. First, we will sustain the momentum of our strong Cigna and Express Scripts basis, selling current products in our current footprint. We meaningfully enhance this capability set through our combination, leveraging our improved medical cost and pharmacy cost capabilities to further accelerate growth.
Last, we're able to bring an entirely new set of products to market and bring current products to clients, customers, and patients we can now reach through the combination. We're able to accelerate our entry into new markets, expanding the frontier for growth. Looking specifically at health services, we continue to progress through the 2020 pharmacy services selling season with really strong momentum. All in, we continue to expect total retention of 96%-98% for 2020, as Tim said earlier. We're also very pleased to have several large new client wins, including CareSource. We're excited to be their pharmacy innovation partner, demonstrating the value our clients place on our capabilities and innovation. We continue to be excited about our opportunities to grow in serving the health plan marketplace.
Driven by strong retention and new client wins, we expect adjusted pharmacy scripts growth of 25 million-35 million scripts in 2020. Carrying that momentum forward, we expect continued steady organic core growth of pharmacy scripts in 2021, for a total organic script growth of about 50 million-75 million adjusted scripts over the next two years, from 2019-2021. Additionally, as we've shared, we're insourcing the Cigna pharmacy scripts across 2019 and 2020. We expect that will drive approximately 165 million additional adjusted scripts for health services in 2021, as we're fully ramped in that year. All in, we now expect adjusted pharmacy scripts of approximately 1.4 billion in 2021. I'd also note that we expect an additional $6 billion-$7 billion of annualized revenue for the enterprise, driven by the insourcing of the Cigna pharmacy scripts.
This revenue is in addition to the ongoing organic growth we expect to deliver. As key markers for the medium-term success of our company, we've shared a number of metrics that demonstrate our confidence in the strength of the businesses and the power of our combination with Express Scripts. Our excitement around the growth of our health services business, including our expectation for total adjusted scripts of approximately 1.4 billion in 2021 that I just walked through. That's just one marker. Today you've also heard greater detail from Matt about how we'll drive to a CPI level of trend by 2021. This is a goal we've been committed to since announcing the combination. We're already delivering trend meaningfully below the market, the next step is critical to meet the affordability needs of our customers and clients will be a key differentiator for us.
We continue to ramp our integration activities, we're on track to deliver synergies of about $450 million-$500 million in 2021, ramping to run rate synergies of about $600 million in 2022. It's the fourth year of the combination and consistent with what we provided when we announced the combination. As our capital efficient businesses thrive, they do generate significant free cash flow. This allows us to deleverage to a debt to capitalization ratio under 40% by 2021, while generating our earnings per share goal of $20-$21. We'll achieve the $20-$21 of EPS in 2021 based on the following drivers. First, continued strong fundamental performance of our core businesses, aligned with our top integration priority of delivering on our commitments to our customers and clients.
Headwinds from the timing impact of the Health Insurance Fee returning in 2020 for our commercial employer business, and the absence of the favorable prior year reserve development that we reported in the first quarter of 2019 as the next adjustment. Executing on the deleveraging plan we've outlined. Realizing the administrative synergies consistent with what we've outlined previously, $450 million-$500 million by 2021. Picking up the efficiencies gained from the elimination of the $200 million of stranded overhead from the early transition of the Anthem business. The impact of capital deployment. Our outlook of $20-$21 per share could vary on the exact rate and pace of capital deployment and such, but these are the building blocks to build to our $20-$21 goal for 2021.
All in, we view the $20-$21 of earnings per share as a strong outlook for our shareholders and a reflection of the strong value we're delivering. Shifting focus now to our capital structure. Cigna's very deliberately built a capital-light framework for our businesses. As a service-based business, we have significantly reduced the portion of our business driven by more highly regulated, capital-intensive insurance products. This allows us to more rapidly convert a higher portion of our earnings to deployable capital. Additionally, we've got a strong track record of building effective partnerships with others, whether they're providers, retailers, et cetera, which helps to generate strong results. This partnership orientation is also very capital efficient.
As we seek to maximize the impact of our increased deployable capital capacity, our capital priority framework remains consistent with our prior communications. In the near term, our top capital deployment priority is accelerated deleveraging, and we're on track to return to a debt-to-cap ratio under 40% by the end of 2020. On an ongoing basis, our capital priorities remain, first, reinvesting back into our businesses for continuous growth. Second, deployment of capital for strategic M&A. Third, to return additional capital to shareholders. Looking more deeply at cash flows and the capital available for deployment, we're now using cash flow from operations as our guidance metric. Historically, we've provided various views of capital available for deployment. We're updating our guidance methodology to move to a metric, cash flow from operations, which is the standardized GAAP metric, and which is more consistent with our diversified managed care peers.
To provide a baseline, in 2018, we generated $3.8 billion in cash flow from operations, the majority of which was deployed to surplus to fund growth, as well as the acquisitions of Express Scripts and OnePath. In 2019, we expect to grow cash flow from operations to be approximately $8 billion. Consistent with our stated priorities, we expect to deploy about $4.2 billion to debt repayment. Additionally, we'll deploy about $800 million for capital expenditures for reinvestment back into our businesses to continue to fuel innovation and growth. Of the remaining $3 billion, about half or $1.5 billion will go to statutory and surplus requirements, while the remaining $1.5 billion represents capacity for share repurchase. This represents about $500 million in increased capacity for 2019 versus our prior communications and includes the share repurchases to date of 3.7 million shares for $650 million.
Given the dislocation in our stock price, we do view our shares as materially undervalued and are therefore pulling additional share repurchase forward into 2019 from 2020. Turning to 2020, we expect cash flow from operations of about $7 billion. This is lower than the amount in 2019 because of an expected lower contribution from the transitioning clients, as well as an approximately $700 million decrease in working capital from the runoff of the transitioning clients. Even with this, we're still on track to achieve our 2021 earnings per share objective. In 2020, we plan to deploy about $4.5 billion-$5 billion for debt repayment and continue to fund capital expenditures in our businesses at approximately $800 million. Additionally, we plan to have growth capital of about $1.2 billion-$1.7 billion.
When we define growth capital, it's capital available to fund surplus, to deploy to M&A activity, to return to shareholders, or generally available for discretionary deployment. In 2020, the majority of our growth capital will fund surplus with some residual capacity for other capital deployment priorities, including share repurchase. In looking to 2021, we'll have significant capital flexibility as we expect to generate over $8.5 billion in cash flow from operations to over $7.7 billion available as growth capital. This capital flexibility is a direct result of the strength of our core business and our ability to rapidly delever. As we'll have completed our accelerated deleveraging goal by the end of 2020, we'll have significant optionality as we deploy our growth capital.
Once we fund surplus, we expect to have meaningfully expanded capacity for our capital deployment priorities, creating a bigger opportunity for deeper reinvestment into our businesses, M&A opportunities aligned with our priorities, and the ability to return capital to shareholders through share repurchase and/or through a dividend. Turning our attention briefly to M&A. First and foremost, I want to say that we're excited about our current capabilities and the opportunities we have outlined today to maximize the value we can deliver. Additionally, given our current capital deployment priorities and capacity, particularly as we're progressing through our deleveraging plan, we're focused on strategically aligned tuck-in M&A on an opportunistic basis. Broadly, we're looking for M&A opportunities where we can enhance or accelerate our capabilities within our four growth platforms.
While from a healthcare supply chain and care delivery standpoint, we continue to orient around being a partner versus seeking to own. Specifically, our prioritized areas of M&A focus remain aligned with our strategy. In no specific order, they are to expand and deepen our global footprint, expand and deepen our U.S. seniors capabilities and reach, to expand and deepen our care coordination and facilitation capabilities, our data analytics and digital capabilities, and our state-based high-risk program capabilities. Our financial strength and flexibility, our strong value proposition, and our focused strategies in each of our business will position us to continue to grow for the long term.
For the enterprise, we expect to deliver 6%-8% earnings growth over the long term on an average annual basis while generating greater than $8.5 billion in annual cash flow from operations, driven by the strong growth across all four of our growth platforms. Additionally, we expect to deliver 6%-8% revenue growth, which we view as a strong result.
In our Health Services business, our long-term expectations are to deliver average annual earnings growth of 3%-5%, revenue growth of 3%-5%, and to deliver strong pre-tax margins of 4.5%-5.5%. In Health Services, our growth will be driven by delivering the capabilities of Accredo, coordinated integration of Cigna's broader suite of services, leveraging Cigna's medical book of business to sell additional pharmacy services, bringing new solutions to market, utilizing data analytics and population health management, and leading the industry as biosimilars and specialty generics come to market. As I noted earlier, the impact of insourcing Cigna's pharmacy volumes is incremental to our ongoing revenue targets. In our Commercial Employer business, our long-term expectations are to deliver average annual earnings growth of 8%-10%, revenue of 8%-10%, and to deliver strong pre-tax margins of 12%-14%.
In Commercial, our growth will be driven by capturing additional headroom in our existing markets, driven by our core value proposition, expanded distribution reach by adding 25% more go-deep markets over the next three to five years, and leveraging our enhanced capabilities and pharmacy cost position through our combination with Express Scripts, as well as driving future innovations. In our Government business, our long-term expectations are to deliver annual earnings growth of 11%-14%, revenue growth of 12%-15%, and to deliver competitive pre-tax margins of 4%-5%. In Government, our growth will be driven by new customer additions as we expand our product offerings and accelerate our geographic expansion, increasing our addressable market nearly fourfold by 2025.
In our International business, our long-term expectations are to deliver average annual earnings growth of 9%-11%, revenue growth of 8%-10%, and to deliver strong pre-tax margins of 11%-13%. In International, our growth will be driven by new customer growth as the global middle class continues to expand, product and delivery channel expansions, and by expanding our local health solutions. In our Group Disability and other businesses, our long-term expectations are to deliver average annual earnings growth of 4%-6%, revenue growth of 4%-6%, and to deliver strong pre-tax margins of 9%-11%. In Group, our growth will be driven by deeper penetration of our medical customer base, our organic growth of our existing footprint as we deliver strong return-to-work results with a focus on health and productivity.
Before I leave this page, I'd note that we don't view revenue growth as the most important measure of our success. Generating savings and affordability for our clients can actually drive lower revenue growth for us, even as we deliver value to them and grow our earnings. We've seen this dynamic in the past, as we've generated consistently strong earnings growth with our ASO products, and we'll see this dynamic in the future as biosimilars come into market, and as we continue to move to a more transparent service-based model, driving alignment and affordability for our clients and generating strong earnings growth for us. To be clear, we view earnings, cash flow, and return on capital as our primary financial measures of success.
Long term, we expect to continue to deliver earnings growth of 6%-8%, driven by our ability to capture additional share in existing markets, accelerate our entry into new markets, and to continue to bring innovative products and solutions to the market. In addition to earnings growth, we expect to drive additional per-share growth of 4%-5% per year, driven by additional capital deployment. In total, we're very pleased to reaffirm our long-term earnings per share growth expectation of 10%-13% per year. We're confident in the underlying drivers we've described today to achieve this result on a long-term, sustained basis. We view this as a compelling result, a compelling long-term earnings per share growth target, building off the significant earnings base of our combined enterprise. In summary, we're proud of the results we've delivered, we're excited for the road ahead.
We have a clear strategic direction, which is embraced by our 74,000 colleagues who seek every day to improve the health, well-being, and peace of mind of those we serve. We have strong momentum and high visibility into the growth drivers across each of our four growth platforms. We have exceptional strategic and financial flexibility enabled by our strong cash flow from operations profile, coupled with our capital-light framework. We believe we've shared very attractive and achievable short-term and long-term growth targets, including long-term margin, revenue growth, and earnings growth targets by business, and are looking forward to continuing our dialogue with all of you as we deliver these results. With that, I'll ask David and Will to join me on stage, we'll be happy to take your questions.
Okay, folks. Final Q&A session of the day. Again, same thing, one question per analyst. Please wait for the mic to come to you, and please announce yourself before your question. I'll take the first question. Justin?
Justin Lake, Wolfe Research. I'll just follow up first with my question from the earlier Q&A session. Anything you can do to help us understand. You gave us the full-year bridge, which was really helpful. Anything you can do to help us understand Q1 versus the rest of the year would be great. My actual question is, any color, obviously there are going to be material cost savings on the drug side as you move over to Express Scripts, both the Cigna capabilities that you were doing, like specialty yourselves and then some of the stuff you would outsource to Optum.
Can you put some real meat on the bone in terms of savings that you expect to deliver to customers and potentially be able to accrue to Cigna shareholders as well as you go through this transition over the next 18 months would be really helpful. Thanks.
I'll start on the first piece, Justin. The same types of factors that were in the first quarter over first quarter piece. The magnitude across each of the different kind of items in the quarter were a little different. The net result, the first quarter, was a slight decline year-over-year. Just for the quarter-over-quarter, it was consistent with what we were expecting coming into the quarter. It's consistent with our build for the full year, and consistent with all the drivers that I outlined in the full year-over-year walkthrough. Again, there aren't really other things I'd call out beyond the things we've already talked about in terms of just the timing of expense recognition and the like. It's, again, the macro pieces were consistent with our expectations.
In terms of the savings that we expect to deliver to our customers and clients throughout the year, we do expect those to be meaningful, as we've talked about from the day we announced the transaction. Those largely are going to benefit our customers and clients, both the Cigna Integrated Medical clients as well as the Express Scripts clients, in the form of improved affordability, lower costs, et cetera. We've made the decision not to provide all of the kind of numerics around that, frankly, just to not be giving a roadmap to our competition in terms of the additional improvements we're driving there. We're really excited about that and on track from those. David, what else you'd add to that?
I'm 100% there. Again, the last thing I would color, there are large quantums of cost savings. To be clear, on a book of our size and with a client portfolio of our size, there are large quantums of cost savings. The team is focused on returning additional affordability back to our clients, be they commercial, be they health plan, be they governmental entities. We like the balance of the picture that Eric walked through on the page. The balance of the attractive revenue growth, attractive margin performance, and the sustainability that's built into it. We couldn't be more pleased with the performance thus far.
Thank you. AJ?
This may be a bit of a follow on from that one. One, is the Cigna insourcing of the pharmacy a dilutive Your old business with Optum, bringing that back in, is that dilutive this year because there's cost associated, and then does it become accretive in 2020 or 2021? I'm just trying to understand that. Then second, to the $600 million of synergies, you've been into the deal for a number of months now. Any update on, is there more synergies behind that? You've talked about the reinvestment, and that may have been what you were alluding to, but any update on what you're seeing there and any early read on revenue synergies, potentially?
Sure. I'll start with the components there. AJ, I'll hit the synergy piece first. When we announced the transaction, we announced that we expected there to be about $600 million over the course of four years, and that we thought that that would be roughly pro rata year by year by year. Specifically, we put out a goal of $112 million for this year. We're on track for that. Again, not any additional update I'd provide on that. That pacing reflects a pretty disciplined pacing of moving through, updating how we procure things across the combined organization, the leadership structures, all those sorts of things. We're on track for the goal we had outlined. Not much else to call out on that front. As I noted in the one slide, about half of that benefit inures to the health services segment.
The rest of the benefit you can think about across the rest of the enterprise. Again, on that piece. From a revenue synergies perspective, as we think about new products, new capabilities, new things coming to market, there is opportunity there. You've seen us throughout the innovation portion of the day, some of the other commentary throughout the course of the various other presenters outline some of those opportunities. Think about those largely as additional opportunity in the future, on top of the kind of run rate that we've outlined and such here today. Again, think about those more in the future. At this point, a little premature to put specific dollars on specific programs or capabilities and timing, and things along those lines.
Can I just bridge into that-
Go ahead.
Come back to the PBM accretion? A.J., on Eric's point, just to bridge those pieces together. You'll recall that in prior conversations, the marketplace viewed that the revenue performance of the company was potentially a four to five. Eric just walked you through six to eight revenue performance, which is what we said a year ago, that we positioned ourself for. The team has been working quite aggressively in terms of making sure the foundation is performing well, and it is as we step in the year. As well as as we've articulated throughout the course of the day, mining and probing the additional, we'll call them revenue synergies, if you want to use the term, the additional growth opportunities that exist, whether it's geographic expansion, segment expansion, further penetration in the Cigna book, further capability expansion for health plan clients.
Eric just walked you through a 6%-8% revenue outlook, which we'll step into as we go in next year, and a view that the insourcing of the PBM is additive to that.
That's right. Let's come back to the PBM question, then. Stepping back, those of you that have followed Cigna for some time know that we've had, a number of years ago now-Took a very deliberate approach of looking at our PBM, entered into a kind of a hybrid arrangement with, at the time, Catamaran. We moved certain portions of the PBM to Catamaran, kept other portions internally. As Catamaran became part of Optum, and as we evolved our strategy, the different pieces there had moved back and forth, in terms of what we were directly responsible for versus what Optum was responsible for. As we think about kind of the PBM insourcing and using the best available tools and suite of solutions that we have as part of the broader Cigna family now, we're looking and executing through the different modules.
Things like the transition on specialty pharmacy, which is something Cigna had always kept as part of its family, or within the family. It's not something we'd ever turned over to another party. Pretty easy to move and begin to get value from that straight away. Clearly, the value we're generating, the synergies we can generate, and the improved affordability and outcomes benefit our customers and clients, are accretive for us, and bring down lower costs. There's cost to migrate and such, that's part of the ongoing cost, but I'd think of that as a module, as an example, that's accretive. The other elements, we've talked about a full transition from Optum over the course of 2019-2020. In aggregate, I'd think of that as slightly accretive. Again, the pieces we've been vending were really highly performing.
There's not a big upside in terms of additional opportunities. You'll think of that $6 billion-$7 billion of revenue that I mentioned is coming over without a whole lot of incremental earnings that goes along with it, but it'll be accounted for as our own revenue now versus through the partner.
To attach back to the prior question, save for our deliberate approach to flowing the additional cost savings largely to the marketplace. You could view that as an accretion point. We're choosing to use the additional affordability improvements largely to bring back to the marketplace because the combination was pushing us to drive further affordability. We like our shareholder economics, we like the economics we're passing back to our clients.
Great. All right. Ricky.
Thank you. Ricky Goldwasser, Morgan Stanley. Two parts question. First of all, if you think about the long-term guidance slide, commercial is expected to grow at 8%-10%. Can you help us just think through what % of that growth is coming from just the going deep and upselling the dental division and the behavioral? One of the concerns that I think most of the people in the room struggle with is the fact there's a lot of uncertainty regarding manufacturer's ability to raise price next year, given that it's an election year. Do you have enough flexibility in the PBM contract, in real time, to make adjustments, if comes January, and there's really no inflation in the marketplace?
Sure. I'll take the first one, and then we can tag team the second one, maybe. The first question on the 8%-10% growth. Again, stepping back, this is something that we've done at Cigna within our commercial markets for a number of years now. Drawing back to Mike's presentation from earlier today, where we talked about the opportunity to continue to grow with meaningful headroom in the select and middle market segments. We continue to have opportunity to deepen our relationships across all of our segments are key portions. Again, as a rule of thumb, Rikki, I'd think about the 8%-10% really driven by kind of a third, a third, a third.
A third kind of impact of new customer relationships, a third driven by impact of deepening additional specialty penetration and the like, a third being just the kind of normal CPI-like level of growth in terms of the pieces. Think about those as kind of the key building blocks. Obviously, a little different across the select segment versus national accounts and the like. When you aggregate the whole piece of commercial together, those would be the building blocks I'd think of. Do you want to start on the contract piece?
Yeah. First on the contract piece, to come back, most of the comments you heard relative to the contracting flexibility, I'll come to your question. We're really speaking toward the way in which we contract with clients. We orient around whether it's a medical proposition, an Integrated Medical proposition, a pharmacy proposition, a coordinated multidimensional pharmacy proposition, is to offer flexibility with our clients to how they want to essentially finance their purchase, how much risk transfer they want to have versus shared risk and being performance-based. We believe that's a fundamental strength. As Tim and others articulated, we believe in offering choice. The basic tenet of that contractual flexibility is largely speaking to that dimension of our go-to-market proposition and being consultative from that standpoint. Specific to your question, our business model is as rapidly as humanly possible orienting around a low total cost, high-value proposition.
We're doing everything in our human power to make sure we are aligned with our clients and our customers to generate low total cost with the appropriate quality and the appropriate personalization, to make sure the economic levers are attached to that. We don't want to be beholden to, we have a track record of not being beholden to, needing inflation to drive revenue growth or needing inflation to driving earnings growth. In an environment that we step into next year, to your hypothesized environment of low pharmacy costs, that's a net good for the tens of millions of customers we serve each and every day. We have the structural flexibility, again, to being aligned with our clients as we deliver benefit to them to make sure we benefit for our shareholders on a go-forward basis.
We're excited to continue to drive, as you heard all of our colleagues talking about, to drive costs down prudently to improve affordability for the benefit of clients.
Over in the corner here.
Hi. More of a bigger picture question. I think one of the reasons we're here in this Medicare for All debate, I think we can all agree is not going to happen in the short term, but structurally, health insurance is not a very popular product, and the friction of using it with all the paperwork does not seem to have improved. Is there something you're thinking about longer term to make this product more user-friendly? Also, is there some messaging strategy that's beyond just the traditional, talk to your elected representatives to put the industry in a better position relative to the public debate, as we move through this? I don't think this is going away. It may be a skirmish you win in the short term, but what's the longer-term battle space game plan to put your industry in a better spot politically? Thanks.
I appreciate the question and the latter part. I'm not sure, it's a skirmish or something that people seek to win. Let's hold that aside. Bigger picture, you hit on some really important points. One, consumers demand more value, period, the end, full stop. That's affordability, predictability, and personalization. Those in our industry or the emerging players in our industry that could step up to that are going to win, meaning going to be rewarded. Those who do not will not be rewarded. It requires taking friction out of the system. I talked a little bit in my brief comments around leveraging technology smartly to create more connectivity, less fragmentation, to simplify and coordinate.
From an investment standpoint, we, and I'll talk directly about the industry, we are investing increasingly intensely around the consumer first, using digitization and other services to take some of that friction out of the system. Secondly, when you think about our 650 collaboratives, the more alignment we have with a healthcare professional partner or a pharmaceutical manufacturer, the more friction we can take out of the system as well because we get everybody aligned around delivering that value from the consumer level. As it relates to the industry's point of view, our industry has an opportunity to step forward now, and we are seeking to be a helpful force in that, to talk more proactively and perspectively about what a forward-looking industry needs to bring from a societal standpoint, more oriented around what some refer to as the Triple Aim.
We're on affordability, clinical quality, and the personalization. Our industry has not hit the mark relative to that. This is a little bit of a clarion cry relative to us to lean into that. Back to what Cigna controls, we are leaning into the space that you articulate quite aggressively. Customer first, smart evolution of the application of technology around the consumer to take friction out of the system. Importantly, the end pieces with the healthcare professional and like-minded other supply partners in the system, be they pharmacy, device or otherwise. We can take friction out of the system, align more based on the value, and again, take more burden off the individual and provide more overall value to them. I appreciate your question very much.
Gary.
Hi. Gary Taylor, J.P. Morgan. A two-part question related to PBM. The first is Express historically had said 2%-4% core EBITDA growth. You're saying 3%-5% earnings growth. With some DNA leverage, I think you're sort of underwriting a similar long-term assumption. Why is 2019 core EBITDA growth before all the adjustments, just a 0-3%? You had previously told us that rebate guarantees weren't a material headwind. One, just to kind of explain that 0-3%. Two, I'm not going to ask for 2020 guidance. I know you're not giving it. But at this distance, with Tim saying core PBM scripts up 2%-3% next year and a pretty similar long-term view of margin, is there any obvious reason why we shouldn't think EBITDA grows in that segment next year?
Sure. I'll start and David can certainly add on anything else you'd like. In terms of the 0-3%, Gary, really the biggest thing I'd call out is just we haven't had the time yet to capture some of the benefits of the combination, as you think about the full year. We're spending. We're spending on investing in capabilities. We're spending on the programs, bringing the companies together and the like. Again, those would be the biggest things I'd call out, the underlying kind of structural pieces of the business. Nothing else I would point to in terms of that piece. Again, we're not providing the 2020 guidance yet at this point.
Hopefully, between the different elements of things we have shared in terms of the future outlook here for the business, should give you a good picture of the excitement we have about the opportunity in front of us and the trajectory that we're on.
To the second part of your question, directly, I would just say agree. Be very simple.
All right, folks, just a reminder, if you could limit yourself to one question, just so we can get to as many people as possible. Steve in the back.
Thanks. Steve Ellick from Barclays. Just to come back to an earlier topic, the HHS final rule on rebate reform has obviously not come out yet. I think some investors are wondering, could there be a change in scope with the final rule versus the initial proposed rule? I know when we last met, Tim talked about this hypothesis that there could be a shift maybe with the administration to co-pay reform instead of rebate reform. Maybe just at a high level, curious if there's any change in your thoughts around what the final rule may encompass, because it may be taking longer here for something to be finalized. Thanks.
Simple answer is no. I give a lot of long-winded answers, I'll give a simple answer on that one. Simple answer is no. To add to it, we've worked hard to position our company to be in position to thrive under any scenarios, and you heard some examples of that before. Additionally, you've seen us already proactively step into targeted accelerated innovation using the private ingenuity of our combined company to bring a really responsive solution to market, and there'll be more, that provide a level of predictability like the Patient Assurance Program. As it relates to the rule, simple answer is no.
Kevin?
You guys are talking about long-term kind of staple margins on the PBM, on the healthcare services side of the business. I just want to clarify, because you guys have pretty consistently said throughout today that you expect to be able to maintain margins even if regulatory changes happen. I want to just clarify that that number does assume some sort of regulatory change on rebates, on spread pricing, and that you're comfortable with that type of margin, even with plausible scenarios around regulatory change, one. Then two, is there a regulatory change that you would be worried about? Because it doesn't sound like you're worried about the things that are being discussed now. Is there something that keeps you up at night from a disruption perspective?
Yeah, Kevin, I'll start. I think of the guidance that we've talked about here and the margins specifically as a function of the value we expect to be able to create in a variety of scenarios, right? There's not any one specific assumption around this law or this rule or this or that's built on. In fact, we do expect the space will continue to evolve, and our business will continue to evolve, and the value we'll be able to generate will enable us to earn the margins that we've talked about. Again, we do think that, we'll be in position to deliver the margins that we've talked about in a variety of different regulated or changes in regulations scenarios. I don't know, David, what you'd say in terms of particular more macro risks you think about.
There's a point I want to bridge back to that one. One, to answer that question, there's not any one regulation that I sit here and say, "If this happens, else" Right? There's not one I have front of mind relative to it. More broad, inferred in your question and some of the other questions throughout the course of the day, just a basic philosophical belief. We believe every business has a fundamental margin headwind that it confronts every day for a whole variety of forces: legislation, regulation, competitive forces, supply chain forces, technological innovation, new entrants, et cetera. To overcome that, even hold margins flat, you need to secure additional productivity gains. You need to drive additional innovations. You need to drive additional value for the benefit of your clients and customers on a regular basis.
Throughout the course of today, hopefully, you got a flavor for that. None of us are sitting on our laurels thinking that we have a model that is preserved or preservable, but we have core capabilities that could be applied with a market lens to drive that continued innovation and productivity gain in an aligned fashion with customers. Lastly, you need to keep a business positioned in a dynamic marketplace with flexibility or optionality strategically, with platforms, and with capital and free cash flow. We've sought to deliberately do that as well within the portfolio. There's kind of portfolio management philosophical points that I think are really relevant to all the comments that are made.
Specific to regulation, there's not one regulation that we sit here and say would transcend the business over the course of the next year or two or three years and render the ability to change people's lives for the better and deliver affordability to clients and customers of less value as we go forward, so long as we continue to innovate and deliver that total value.
Okay. Scott?
Thanks. Just wanted to touch on the revenue synergy expectations. I know in prior discussions you've talked about towards the 6%-8% revenue growth, that Integrated Medical could have a 50-100 BPS-type uplift in terms of revenue growth synergies, and services could be more in the 100-200 BPS. Interested first, whether you're still comfortable with those types of assumptions, and then now that we're a number of months into the acquisition, as you drill in, what you feel right now look to be the strongest potential drivers of revenue synergies between the integration.
Scott, I'll take it directionally. Your recollection of the numbers we posted a year ago and my recollection are a little different, but the categories are the same. There's a Regulation FD record out there in terms of how much of it was Medicare, how much of it was commercial, how much of it was services as it relates to synergies, but we're directionally correct. Net-net, the numbers Eric just walked through have accretion built in now to the growth trajectory over our long term in the 6%-8%, with the insourcing of the Cigna revenues, as you articulated, the $6 billion-$7 billion being additive to that. You heard Brian talk about the additional fuel that it does to supercharge his portfolio business. A portion of it's within there.
You heard Mike talk about the additional flexibility, as it relates to the pharmacy solutions and the specialty solutions that could come into the portfolio, both improving the price point and driving some additional penetration and enhancing that value proposition. You heard Tim talk about the excitement relative to expanding the level of services we could bring to our clients, both commercial and health plan clients, on a go-forward basis, right? The team has been at work relative to those. We're delighted to sit in front of you here 5 months into the combination, talking about credible outlook relative to a 6%-8% revenue growth number for the foreseeable strategic horizon that sits in front of us.
None of that is easy. It's achievable, and it's indicative of the synergies that the teams have been working on, relative to the additional contribution to seniors, to commercial, and to the health services business.
Lance?
Thanks. Lance Wilkes from Bernstein. My question is really kind of post-2021 or post-delevering. What happens with the strategic M&A priorities then? Do they change in any way? Also, are there any things that would limit you from a pacing standpoint for a large-scale M&A?
Thinking like integration.
Well, as we talked about, I think the pieces I outlined during my prepared remarks lay out the things we're thinking about in the next couple of years. While we're working through the de-leveraging this year and next year, we would be more focused on tuck-ins and things that help to just drive additional capabilities and such within our existing areas of focus. As we get to 2021 and beyond, again, we're not providing updated 2021's version of M&A priorities as we sit here today. Broadly, I think those categories are the types of things we'd be thinking about in terms of the additional areas that will be complementary to our portfolio, the areas that we would see additional opportunities to grow in, and to add to the portfolio overall. Again, I'd start with that list.
Time will tell in terms of the evolution of time over the next couple of years, but I'd start with that list. In terms of pacing, or anything along those lines, really, no, there's not a particular other factor that comes to mind, Lance. As we think about the overall, we're very targeted and believe the right place to run the organization is at a lower debt-to-cap ratio than where we're at now, and that's why we're working on our de-leveraging plan. Aside from that, and that'll be up in the next 18 months or so, there's really not another factor that comes to mind.
Great. Matthew?
Maybe I'd just ask a question about the areas that you're participating in, as it relates to provider integration and Medicaid and the duals, because we haven't really talked about that as much today, maybe at some other venues. Do you see you maybe getting more involved with ownership of providers? Do you see getting into Medicaid in the foreseeable future as you look to ramp up your ability to access the dual conversion?
A two-part question, Matthew. First, relative to the healthcare professionals, our preferred approach and our strategy guides us to, our preferred approach is to partner and enable. That's our primary option. The 650 collaboratives are good examples of that, and the results we're delivering with that partner, enable, align, perform model is servicing us quite well. In addition to that, as we've always articulated, we're open to owning in key MSAs submarkets, if that is the most critical way or the only way to secure the access, accessibility, quality proposition. For example, we do that today in Maricopa County in Arizona with a scaled asset that we've owned for quite some time. Our preferred strategy is to partner and enable. We like the capital flexibility. We like the constructive collaborative tension. We like the partnership. We like the shared alignment.
We like the longevity and the flexibility that creates. As it relates to duals, we continue to think duals are an attractive part of the market that we can serve. A dual represents somebody with a high clinical burden, and our model performs exceptionally well when there's a high clinical burden. We serve a significant amount of duals today through our HealthSpring and our Cigna-HealthSpring model today, and we see further growth opportunities. As states continue to evolve their programs, we see that as an additional growth opportunity, whether it's states carving out a high-risk Medicaid population. When Eric talked about the fifth priority, state-based risk programs, that's a marker for that, as we see states evolving subsegments of their programs, because we believe we can create significant value there.
As it relates to the duals, we continue to grow that, over time, we may need some additional capabilities that are market specific for that, we've left flexibility within our portfolio to address that market by market.
Final question from Mona.
Thank you. Mona Ereba from TCW. Just two clarification. When we talk about 25 to 35 million scripts, does that include the insourced ones and specialty, or this is new scripts?
No, it does not include the impact of Cigna's volume. Just to be very clear, 25 to 35 million is organic growth on the platform, net organic growth on the platform. The Cigna transition is entirely separate from that.
The retention rate, is that for dollar value of the contracts or just number of clients?
It's prescription weighted, I believe. Yep.
Okay. Thank you.
All right, folks, that wraps up our Q&A. I think we'll turn it back to David for final thoughts.
Thanks, guys. I'll be quite brief. You all have been very kind with the amount of time, and it's been a dense day. I would tactically just invite you all on the back end of this. If you haven't visited, even for 10 minutes, our innovation set up, which is right around the corner, I invite you to do so. You'll quickly get a feel for a lot of the dynamism of the moving parts that we've created. Let me just wrap up a couple of the key messages. I do hope you found the time productive. I do hope you found our orientation responsive to some of the questions, and I do hope you found some excitement in the multiple areas of growth we have within our portfolio.
Our team appreciated the ability to interact with you all, both formally as well as informally, throughout the course of the day. A couple of messages we hope you took away. First, a clear orientation of who we are. We're a global health service company. We're a company that is guided by a very clear mission, and that is to improve the health, well-being, peace of mind of those we serve around the world. We've worked hard to amass a configuration of assets to provide the service capabilities to fulfill that promise each and every day. We're on a journey to fundamentally work to transform aspects of how health and vitality are delivered around the world, because per one of the comments and questions that was asked, it's an unsustainable proposition today.
There are ample bright spots in the marketplace that exist to fuel the direction that we've called the transformative model as we go forward.
Secondly, what do we do? We work to drive this level of transformation focused on one customer at a time. Focused on one customer at a time, being brought largely to market through clients, be they commercial or health plan or governmental agencies, but always focusing on the individual and working our way back, working increasingly to treat the whole person. You even heard it in the video. The ability to understand the whole person's needs is truly how you're able to improve health, well-being, and vitality, and in many cases, take significant quantums of cost out of the equation, but you're taking the quantums of cost out of the equation by improving a person's life in the first place.
Second is working increasingly to be that connective tissue on a constructive basis with our partners, healthcare delivery partners, as well as supply chain partners, by smartly using applied technologies and information flows that, again, keep the individual front in mind, all with the objective of increasing quality and taking some of the friction out of the system. Lastly, driving targeted innovations, which to many of your questions, are critical in any business, especially this business, because the ever-present desire and cry for more value to be delivered on a highly personalized basis with additional speed that's required each and every day. As I indicated in the close of my opening remarks earlier today, I'm excited and confident about our future. We recognize it's a dynamic environment, and we also recognize there's a lot of work to do.
None of my colleagues take this challenge easily, but we take it on gladly, because the payback for changing people's lives on scale is phenomenal, and the responsibility to deliver an outstanding shareholder result is also a very important responsibility we take on our shoulders. As we look forward, we're going to continue to drive forward with our strategy, with our objective to deliver on our promises. Always first and foremost in the marketplace, making sure we're delivering for our customers, our clients, and our patients with our partners, and as a result, to deliver that on a sustainable basis for you, our shareholders. We're guided by a very clear strategic direction. We're empowered and fueled by unbelievable talent around the world and a really strong culture that's built every day as we work to serve our customers and clients.
Our 74,000 colleagues, again, do a phenomenal job driving change as well as servicing our clients. We position ourselves to be able to continue to innovate. Our businesses have core headroom that you could see, feel, and touch, as well as adjacencies to be able to grow, whether additional products, programs and services or geographies that sit in front of us. Throughout the course of today, we tried to bring that to life. Importantly, we do all this in arguably the most capital-efficient structure in our industry, because having that capital flexibility coupled against strategic flexibility in a dynamic marketplace, we believe is mission-critical and positions us to be able to continue to innovate, create, and deliver value back to you, our shareholders, and maintain outstanding strategic flexibility.
We're on track to continue to improve our overall cost proposition as we chart a course to delivering a CPI level of medical cost performance, which we believe society needs and is indicative of a sustainable environment. We have a clear path to delivering on our EPS outlook of $20 to $21, even within this dynamic environment, even with the puts and takes of change, by the strong underlying fundamentals of our business portfolio and the well-performing diverse power of each of those platforms. As a result, we see line of sight to our long-term EPS goal of 10%-13%. I would note, as Eric articulated, we have a track record of delivering at or above that over the last decade. We take our promises really seriously, and we look forward to delivering on those.
On behalf of my colleagues that were here today, the 40-plus members of our leadership team, I want to say thank you. On behalf of our 74,000 colleagues, we want to thank you for your interest and support of Cigna, and we look forward to building phenomenal shareholder returns for you as we go forward. Enjoy your day, and enjoy your weekend. Thanks for your time.