Great. Good morning, everyone. Thanks for joining us for our next session. My name is Nathan Rich. I cover the managed care space here at Goldman. Very happy to have the Cigna Group with us today. We have Brian Evanko, CFO, and now also President of Cigna Healthcare, so the title continues to grow. Really appreciate the time. Thanks for being here today. Brian, I maybe wanted to start. So last week, you had an 8-K out, reaffirmed guidance for the year. I guess, as you've seen the second quarter play out, was there anything that differed relative to your expectations within the quarter, positively or negatively?
Yeah, and thanks, Nate, for you and Goldman Sachs hosting us here this week. Enjoying the conversations so far with investors. So if you didn't see, we had an 8-K last week, where we essentially reaffirmed our full-year EPS outlook of at least $28.40, which was a $0.15 raise from where our guidance was we entered the year. So after the strong first quarter, we, we raised the full-year outlook and reaffirmed that, in the quarter.
Also, if you didn't see the details of that, we also described some of our capital deployment plans for the year, specifically the share repurchase activity that we have underway, where we recently completed the accelerated share repurchase program we had in place, which was $3.2 billion, and indicated that we've done year to date $4.4 billion of repurchase, which includes some open market share repurchase subsequent to the ASR being completed. And we intend to complete at least $5 billion in the first half of the year in terms of share repurchase, and have the majority of our full year capital available for deployment go to repurchase. So just wanted to provide a little bit of clarity to investors of our capital deployment plans to augment the strong EPS performance.
As it relates to the second quarter and specifically your, your point about what we're seeing there, so far, things are broadly in line with expectations. So we would expect, as we talked about with Cigna Healthcare, tracking where we had intended, stepping into the quarter. Our second quarter MLR guide is to be within the full year range, which is 81.7%-82.5%, and so far, what we're seeing is, tracking to that expectation. And if you rewind the clock, back in 2023, we had expected elevated utilization in 2023 and 2024, which we priced for, guided for. And so we are seeing elevated cost trends across the portfolio, but in line with what we had priced and expected.
Okay. On utilization in the second quarter, any lines of business that have trended differently than expected? And, maybe I'll start there and then ask a follow-up.
Really, no.
Okay.
Things have been, you know, broadly tracking to expectations. Our commercial employer book, which is the lion's share of Cigna Healthcare, again, we, we priced for elevated trends. We're seeing cost trends all in a little higher in 2024 than we saw in 2023, but the second quarter so far has been more a continuation of what transpired in the first quarter. And importantly, if you think about our Cigna Healthcare portfolio, we're not in the Medicaid business, so some of the discussions on acuity levels and redetermination is kind of a non-issue for us.
We're not in the Medicaid business, and our Medicare business is relatively small, and as we prepared the bids for 2024, we did not chase growth in that business, so we were able to make sure that the pricing was calibrated to the expected medical cost utilization.
Okay. And I guess, with a little more distance, I guess, from the Change disruption, I think, you had kind of you know, put some conservatism into the, the guidance for that, and I think specifically maybe $200 million, of claims that you maybe expected to receive that you hadn't received yet at the, the time of the first quarter call. I guess, you know, can you talk about how those have maybe developed relative to expectations?
Yeah. So at the end of the first quarter, we had about $650 million of total reserve associated with the Change Healthcare disruption. To your point, only about $200 million of that was incurred but not reported estimates that we had prepared. The other $450 million or so was essentially claims that we received, but just hadn't paid out yet.
Yeah.
That $450 million you can think of as essentially fully paid at this point. The $200 million, which is our estimate of the incurred but not reported, is gradually working its way through in the second quarter, and we would expect that we'll have a full picture on that by the end of the second quarter. But no real surprises so far in terms of how that's trended on the first couple of months into the quarter. I'd also note our operations, as a practical matter, are essentially back to normal now in terms of provider claims submissions and provider claims payments. So that was a disruptive event in the first quarter, but we've really worked through that from an operational standpoint now.
I think within the employer book, you had, in the first quarter, called out some elevated inpatient activity, maybe offset by some favorable trends in outpatient. I guess, as you think about, you know, there's been a lot of focus on inpatient trends and, you know, the growth numbers that we've kind of seen in some of the external data month-to-month. I guess, can you maybe just talk about what your expectations are for, you know, how that develops, and maybe also if there's any calls on the outpatient side, just in terms of expectations over the balance of the year?
Yeah, we've expected for the full year that we'll continue to see elevated inpatient activity throughout the entire 2024 calendar year. So first quarter was elevated. We're seeing it continue into second quarter, and that's our expectation for the balance of the year as well. The outpatient dynamic, we think, was a bit impacted by the Change Healthcare disruption.
Okay
in terms of we believe the activity was there, but not necessarily the claims submissions in the first quarter.
Okay.
So for the balance of the year, we're expecting that kind of normalized level to persist into second quarter, third quarter, fourth quarter. We continue to see mental health utilization at high levels. Small part of the overall total cost of care pie, but high cost trends in mental health, which we think is a good thing over time, given the strong linkage to physical health, in the long run. But those would be a few of the dynamics as you think about the texture of the year.
Okay, that's helpful. Maybe wanted to talk about the Cigna Healthcare segment. I guess maybe from a selling season standpoint, you talked about like an uptick in RFPs expected this year. I guess, you know, are there any areas of, you know, you think will be of greater importance to employers as you go through the selling season? You've talked about, you know, for 2024, kind of not chasing price in a few instances. Can we just talk about, you know, where pricing is today in the market, how you feel like Cigna is positioned relative to competitors in the commercial space?
Yeah, there's a lot in that question, so maybe I'll start with the last piece, and then I'll bifurcate the different buying groups-
Sure.
within Cigna Healthcare. So I'd say, pricing is rational. It's a very competitive market, but it's rational. So we're seeing, carriers price for the elevated cost trends I was talking about earlier, across the different segments. So in that sense, a firm market, if you will, you know, relative to the pricing environment. Now, importantly for Cigna Healthcare, we have, different size employers who have different needs, so we tend to talk about it in national accounts, we call our middle market, and then we call our select segment, and each of those have different buying dynamics. So when we talk about RFPs being up, that's really a national accounts comment because we're talking about January 2025 activity.
The smaller employers really haven't started their 2025 purchasing yet at this point in the year, but the RFPs being up is a function of national accounts specifically. To your point on what are employers looking for, there's a few themes that have tended to persist across the national accounts buyers as we enter the 2025 cycle. One would be, there's continued interest in more personalized solutions, whether that's networks or whether that's plan designs. So things we're introducing would be, for example, our Pathwell Specialty and our Pathwell Bone & Joint, which are site of care-oriented network solutions, specifically for different types of conditions, in that case, specialty pharmacy injectables or musculoskeletal conditions.
We're also seeing more and more demand for mental health-oriented capabilities, so we're, we're fortunately situated very well with our capabilities there, whether that's virtual mental health or or face-to-face mental health engagements. We're seeing a lot of interest from employers in care navigation capabilities, so often digitally enabled through a, a mobile phone. So there's interest there from employers. And then we're seeing a lot of larger employers looking to consolidate down from their point solutions that they've been testing over the years. So a lot of them will use the terminology point solution fatigue with us, or maybe they're not getting the ROI on some of the vended solutions, and so they're looking for carriers like us and some of our competitors who have a more fulsome suite, where we can integrate capabilities across the board.
So all of that points to opportunity for us, in the larger end of the market. Now, over the long term, we expect to be maintaining our share in the larger end of the market, both national accounts and middle market, and we expect the select segment to be where we get the outsized growth, in the Cigna Healthcare portfolio. And for us, the select segment is 50-500 size employers, where we would expect that business to be growing similar to what it's done historically in the high single digits annually. And that's less concentrated on January 1st, so we see more intra-year growth. We'll see growth within 2024 as we get July 1st, October 1st, and then as we head into 2025 with that business as well.
I guess you plan to double revenue from that segment, I think over five years. Maybe what's the key to doing that, and where you feel like you're kind of differentiated in that segment of the market?
Yep. Yeah, so your memory's right. Over the next five years, we expect to double the select segment revenue. Today, we have about 7% market share nationally. If you look across, a little bit less than that right now, 6%-7% market share across the country. Compare that to double-digit share that we have in the over 500-sized employers. So it just gives you a sense of the, the headroom that's available to us. So, one important lever is the cost competitiveness of the solutions. So one of the things we talked about at our Investor Day back in March was our footprint, geographically, in terms of where we're cost competitive. It was about 30% of all the geographies five years ago, now it's 60%.
So we've doubled the footprint of what's cost competitive, and we have upside from that 60% as we make more and more progress with unit cost and site of care strategies. So that's one important driver. The second one is we bring a level of agnostic funding arrangement choices to employers, so we don't require a fully insured arrangement. So a lot of the employers in this segment are interested in a self-funded arrangement, but the incumbent might be a fully insured carrier. So we're able to offer a self-funded arrangement, and, and not have to worry about the dynamics within the company's revenue changing around, et cetera.
So that funding agnostic approach to the market's been really important, and that goes alongside a consultative orientation to making sure we understand what the needs are of the employees and the dependents of that employer, because the products are not a one-size-fits-all, even though it's smaller employers, 50-500, there's still a good amount of flexibility in the product offerings there.
I guess, do you—we've heard some payers talk about, you know, working maybe more closely with the adoption of ICHRA. I mean, do you feel like there's much overlap with that, with the select segment and the type of employer that may be interested in that type of arrangement, as you think about the future competitiveness of that space?
Yeah. So our view of the ICHRA market is that, there is some interest from some employers, but likely in more of a niche context. So we think that the ICHRA market will develop into more of a niche market. And the reason we say that is, the nature of ICHRAs, while it enables an employer to say that they're offering health benefits, it's a little bit of an outsourcing of the health benefit, because it's going to the individual exchange carriers ultimately. And so the employers we serve, which again, are predominantly 51 and up-
Yeah
employee size, more often than not, use health benefits as a talent attraction and retention tool, as well as something to enable productivity, absence management, and the ongoing health and well-being of the employees and their dependents. So most of the employers that are attracted to us, we don't expect will be interested in exploring ICHRA. We do think for the under 50 size employers, there's likely to be some interest from some employers who want to be able to say, "I have health benefits available to you.
Right.
But don't necessarily feel as vested or invested in the health and well-being of the employees."
Right. And you're not really participating in that under 50?
Not in any meaningful way.
Meaningful.
We have about 60,000 customers today, but a very, very small percentage of our total book.
I guess, maybe kind of higher level, can you talk about your outlook for just, you know, kind of U.S. employment? You know, there's been a lot of focus on maybe a little bit of softness in the more recent payroll data. You know, how do you think that plays out over the balance of 2024 and into 2025? I feel like your expectations for this year were for pretty modest, you know, assumptions for, you know, the employment environment. You know, can you just maybe talk about what you see going forward?
Sure. Yeah. I mean, so far in our book of business, we're not seeing any signs of fracturing in the employment base, across the U.S. That said, we're respectful of the fact that interest rates have been elevated for some time, and the cumulative effect of that could eventually create some cracks in the U.S. employment market. And so our outlook for the balance of the year, for example, embeds a little bit of softness in the overall enrollment levels under the expectation that... Again, the cumulative effect of interest rates and fiscal activity will lead to some level of disruption in the employment markets.
So we've expected a little bit of enrollment pressure in the back half of the year from that dynamic, but it remains to be seen whether the economy is a soft landing or something that's more significant.
Great. Maybe just one more on the exchange business and how you're approaching that for 2025. You know, I think you took some pricing actions this year. I don't think you're quite in, expect to be in your target margin range at the end of this year. Kind of, what does that mean for how you approach the market in 2025? And, you know, can you also touch on long-term, kind of, where you kind of see the relative attractiveness of this market being just as a growth market?
Yeah, the individual exchange market, in aggregate, we see as an important part of the U.S. healthcare system for those individuals who don't have access to an employer-sponsored plan or a government-sponsored, coverage from Medicare, Medicaid, or TRICARE, et cetera. So, there's a need there. We expect, over time, this is gonna grow in our business at the clip of 10%-15%, per year on average. That's embedded in our long-term guide off of the 2024 base. To your point, we did some repositioning from 2023 to 2024. With the benefit of hindsight, we realized a couple of our geographies, needed adjustments to benefit design, product, and pricing. So we took those actions. It's resulted in some attrition here in 2024 in the membership base.
So our membership's down about a third this year compared to where it was in 2023. Off that base, we expect to grow annually 10%-15% on average. So part of that's secular growth, so we expect the market will grow. Part of that is, today, we're only in about 12 states, so we see opportunity to go into more and more geographies over time with appropriate product solutions, culminating in that sort of growth. Now, importantly, this is about a $4 billion book for us today, so call it 2% of the company's revenue. So it's a small sliver of the overall company, but it's an area that we do expect to see, growth on a go-forward basis.
I guess, would you expect to see—it sounds like you'd expect to see growth in membership next year. You think you're kind of pricing to achieve that, as well as kind of further margin expansion to kind of get into your target range?
This year, we expect to be slightly below our target margins.
Yeah.
Our target margins are 4%-6%, so we expect to be slightly below that. Next year, at the portfolio level, we would expect to be in that target margin range. Now, we're not done with all the pricing yet. There are different deadlines for different states, so the next two months, we'll be finalizing all the pricing, but we would expect to be in that range next year based on what we see now.
Okay. Maybe moving over to Evernorth. At the Analyst Day, you raised the growth outlook for specialty, I think, to 8%-11%. You know, the market, you know, I think, you know, is pretty well understood. The fundamentals remain pretty robust and attractive. I guess you also see opportunity to gain market share. Can you maybe talk about where you feel like there's still opportunities that would allow you to grow above the market?
Sure. Yeah, so the specialty pharmacy market, which, to your point, we profiled in quite a bit of depth at our Investor Day-
Right
is one of the company's greatest strengths, but also greatest growth opportunities going forward. If you think about the way our company's comprised, the income breakdown, about 40% Cigna Healthcare, about 30% Pharmacy Benefit Services, and then about 30% Specialty and Care Services. That 30%, that Specialty and Care Services, has been growing double digits, and we expect it to grow 8%-12% on an annualized basis going forward. So that's the piece that we wanted to profile at the Investor Day, 'cause it's one we're really excited about. We're also really proud of the business today already being scaled. $400 billion addressable market.
The addressable market will grow high single digits going forward, so lots of secular tailwind there, and we're positioned as the leader in the specialty pharmacy space with all the capabilities that we've amassed over time, with the brand Accredo is our brand for the specialty pharmacy. So, we're active with Express Scripts Pharmacy Benefit Services clients. We also have a number of patients who come through other pharmacy benefit managers. So 40% of the Accredo patients come through other PBMs. That's a continued growth opportunity for us as well in the specialty space. But over time, the capabilities we've developed there. You should think of this business as essentially care delivery. This is high touch, clinically intense, high-cost drugs that have temperature control requirements, or they're injectables that require a physician's assistance.
These are high-cost drugs. They're not the ones you fill at the retail pharmacy down the street. So this, this business is clinically complex, high secular growth. We're the leader in the space, and we're prepared to capitalize on it going forward.
I guess with biosimilars, how does that kind of fit into the growth and maybe more importantly, profit algorithm? You know, you've introduced for biosimilar HUMIRA your dollar out-of-pocket cost option. Why have you chosen kind of that approach? You know, I think you're still kind of offering choice. Some of, you know, your competitors may be pushing more aggressively to drive conversion. Just, you know, what the level of uptake you've seen since you've launched that as an option and you know, why that's maybe, like, the right approach to take for the company.
Yeah. So one of the things that as a company, we're very passionate about is the drug innovation that's transpiring and the opportunity to create value for our clients, for patients, and ultimately for our shareholders as well. So over the next decade, we see a wave of drug innovation transpiring. So we're feeling it right now with GLP-1s and everything that's happening there. We're feeling it right now with cell and gene therapies. We're feeling it with Alzheimer's drugs. We're feeling it with, to your point, biosimilars, and finally, the U.S. starting to open the door to more biosimilar adoption. So the HUMIRA biosimilar, which I think was the core of your question, we're introducing...
In the next few weeks, we'll have a $0 patient out-of-pocket available through Accredo, which is essentially us working directly with biosimilar manufacturers under our Quallent, distribution arm, which we launched in 2021. This is important because it allows us to have some predictability of supply, over the biosimilars over time. It allows us to drive great affordability outcomes with $0 patient out-of-pocket, a lower net cost than what the plan sponsor will get from the reference drug, HUMIRA, as well as for us, on a per script basis, a greater income contribution, since we'll capture a piece of that shared savings that the plan sponsor is able to, to deliver.
So over the back half of this year, we would expect some degree of share shift for the biosimilars, given the $0 patient out-of-pocket that I was just making reference to. That's embedded in our, our guidance for the year. That's not 100% adoption, but some degree of shift to the biosimilars in the back half.
And HUMIRA, the reference product, would still be on the formulary at parity. It's just it would come with a higher out-of-pocket cost, or still be covered, I guess. I'm sorry.
We've chosen to co-prefer the biosimilars with HUMIRA-
Okay
for the time being, to facilitate choice. A lot of our clients want the choice available, and that's a strategy we'll continue to evaluate over time.
Okay. And I guess one of the other growth opportunities you highlighted at the Analyst Day was, maybe growth into the, the drugs in the medical benefit space, and how, you know, Accredo, maybe your, your specialty business overall with CuraScript could play a bigger role. Could you maybe talk... You know, it's not an area where kind of the traditional PBM has been involved historically. What you see is the opportunity to maybe penetrate that space more deeply?
Yeah, we see great opportunities here, and I'll try to be concise with my answer because it's complicated, but the $400 billion specialty pharmacy market I made a reference to, think of that as about 60% pharmacy and about 40% medical. So the 60%, meaning it's under the pharmacy benefit, 40% typically under the medical benefit. So it could be an injectable that a physician administers in their office. That would be under the 40%. That's the medical, which is where your question was geared toward. So we have a distribution business called CuraScript, which is essentially taking specialty pharmaceuticals and distributing them directly to physicians or to hospital systems. This has been a double-digit grower for us in recent years.
It's an over $10 billion business, and we see a tremendous future growth opportunity there in terms of distribution to physicians as well as to hospital systems. And so we're investing in this space. We made an investment in Carepath Rx last year, to facilitate growth in the health system services business specifically. But we see an opportunity there to increase our share because we only have about 5% market share on that 40% of the $400 billion that's under the medical benefit today. So, a significant growth opportunity for us, and that's part of the 8%-12% all in specialty and care services income growth we expect over time.
Now, are there still specialty pharmacy assets where you think you could benefit from greater scale that you don't have today? Thinking of, like, things like infusion or areas like that, where there's maybe an opportunity to continue to build those from a BD standpoint.
We feel like we have the vast majority of the capabilities-
Right
we need, certainly to grow with the commitments we've made-
Yeah
but even to capture, maybe addressable market that we're not fully in today. So there's nothing I'd really point to explicitly. And we do have—we have 600 home infusion nurses across the country, so-
Yeah
it's not like we're not doing that already.
Yeah.
Your question, I realize, is more of a scale question, but we do feel like, you know, given the fact that this is already a really big business, all the capabilities that we have in-house position us really well for the future.
Okay. Maybe moving over to capital deployment, I think, you know, you maybe talked more so at the Analyst Day about sort of a capital light approach than you have in the past. I guess, you know, can you maybe talk about? Does that change the type of deals that the company kind of prefers to do in this environment? And, you know, has your thinking changed around kind of the type of assets that are attractive to you?
Yeah, just one slight edit. I think-
Sure.
We were not intending to signal a different posture around asset light with our investor day. So for some time, we've said we don't think we're necessarily good owners of physical care delivery. And going forward, we continue to believe that's the case.
Yeah.
So we were not intending to signal a change in strategic direction-
Okay
in regards to asset light, in the investor day. Now, broadly speaking, when it comes to capital deployment, as I started this conversation, we continue to view the repurchase of our shares as a great use of our available capital. Because as long as we have a depressed multiple, we continue to see that as a very valuable way to deploy capital to shareholders. And so, as I said, we intend to do at least $5 billion to share repurchase in the first half. The majority of the full year cash flow will go to, the discretionary cash flow will go to repurchase, and we expect to use the majority of the proceeds from our pending Medicare divestiture in 2025, also for share repurchase.
Now, broadly, when you ask about inorganic activity, we continue to view inorganic activity through the lens of it needs to be strategically attractive for the company. It needs to be financially attractive from the standpoint of accretive EPS over time and exceeding return on capital hurdles, and it needs to have a high probability of close. And if all three of those criteria are not met, we will not pursue inorganic activity, and we don't need to do M&A either. So when we talk about our EPS growth algorithm of 10%-14% over time, we're fully confident in our ability to do that with the way the company is comprised right now. So M&A would be an accelerant in the right circumstances or the right instance.
You know, U.S. government was one of the areas you kind of highlighted as, you know, a potential area of M&A. Has the strategic attractiveness to the point you just made, around some of the government businesses like Medicare and Medicaid, changed from your point of view? I think, you know, a lot of investors are sort of reevaluating what the five-year growth outlook looks like for markets like Medicare and Medicaid. I'd just be curious to get your perspective on that.
Yeah. So right now, the government space is clearly going through a period of disruption.
Right.
Both Medicaid and Medicare. We expect that's likely to transpire, over the course of the next couple of years, meaning it's gonna take a couple of years to work its way through. Whether it's the, Medicaid redeterminations and the net result on health status and acuity and rate matching, whether it's in Medicare, the, funding environment with where the rate notices have landed, whether it's the Stars methodology changes, whether it's the risk adjustment model changes, all of that's gonna take a few years to sorta sort its way through as it relates to those, those government markets. For us, with our Medicare divestiture, still working its way through, we're through the DOJ clearances, as we shared in our first quarter earnings release.
So that's a matter of just getting it across the finish line, which we expect to occur in the first quarter of 2025. After that, we won't have any Cigna Healthcare presence in Medicare or Medicaid, but our Evernorth business serves millions of lives in Medicare and Medicaid, and we're really well positioned to do that. We're thrilled with the Centene relationship that we've established and launched on January first, but we also serve lives through other payers, in the Evernorth business, and we see a significant growth opportunity there, and that contributes to our all-in 5%-8% annual income growth expectation in the Evernorth segment, the government lines, as well as all the commercial employer business that we serve there.
Okay, great. I guess, I wanted to go back to, the comments on utilization, and I think for the second quarter, you kind of said you're tracking in line with the annual guidance, which is what you had guided to. I think if, if we kind of look at history, it seems like, you know, it would, typical seasonality would kind of put you towards the lower end of that annual range in the second quarter. I just, do you have any commentary at this point of just, like, where in the, the kind of annual range you would expect to land in the second quarter just based on that seasonality? Because like I said, I think the midpoint is a little bit higher than where, what we would typically see.
Yeah, the last couple of years, the seasonality for our medical care ratio has been less. It's been a little flatter.
Yeah.
So the first quarter and the second quarter have been flatter. But if you go back to pre-pandemic norms, we had more seasonality-
Yeah
in the medical care ratio, and that's more of what we expect this year. So, the step up from 1Q to 2Q is partly a function of we expect the seasonality to be more like pre-pandemic norms.
Okay.
We also talked about in the first quarter release, our individual exchange book has more bronze, which tends to have a steeper pattern of seasonality. And, and we had the benefit in the first quarter also of some net prior year development favorability, which kinda artificially lowers-
Okay
the first quarter. So all those factors taken together result in a little bit of the greater, kind of step up-
Yeah. Okay
of the slope in the MCR this year.
Okay. Makes sense. I wanted to ask a couple of questions on the PBM. I guess one of the ones... You know, the FTC kind of is planning to release its findings from their investigation into the PBM industry. I guess I don't know if you've heard or gotten any sense of update on timing around that, but I guess maybe bigger picture, can you talk about, like, how you see rebates and spreads, which you guys have talked about being 20% of Evernorth profit, what you see the trajectory for-
That really seems to be the focus of the FTC investigation and some of the-
How that trends over time.
Yeah, on the former, the FTC review that's underway. So we've supplied all of the documents that have been requested, complied with all the requests, and have gotten some questions over the last several months, kind of back and forth, some of them clarifications, some of them, "What is this number relative to that number?" That sort of thing. So we've gone through and answered those questions and have a constructive dialogue with the representatives from the FTC. Unclear exactly when or what will come out of this. So again, we just continue to comply as required.
We're confident that what the data will show is that our focus on lowest net cost generates value for our clients, for patients, and ultimately for the healthcare system, and that it's an important check and balance on pharmaceutical pricing that the pharmacy benefit services industry plays. So we're confident that that's the conclusion that will come out of this. Now, to your point on the levers, rebates, et cetera, we've constructed the Evernorth business to be essentially agnostic to how clients wanna pay us. So some of them want to pay us in the form of retained rebates, others want to pay us purely administrative fees, so it's just kind of a cost-plus concept. Others want something more exotic with guarantees and different levers. So we're agnostic to that.
We can do, you know, any of those, essentially, payment mechanisms. So as long as the return we're, we're yielding for the risk we're taking is appropriate, it doesn't really matter to us how we get paid. Now, to your point, about 20% of the income right now is in rebates and spread. We expect that percentage will trend down over time, just with the way the market has unfolded. It, it was a little higher than that a few years ago. So it's already been coming down naturally, and we would expect it to come down further, kind of independent of what happens with regulation, just because that's the direction that our client preferences have gone.
Is there any meaningful difference in that 20% between the different lines of business, like commercial, TRICARE, DoD, and the other government businesses?
It's lower in the government lines.
Okay.
That percentage is lower in the government lines, and it's a little bit higher in the commercial employer lines.
Okay. Then maybe just in the minute we have left, you know, government's negotiating prices on the top 10 Part D drugs. I guess, you know, one of the questions we've gotten is, you know, does that have any ramifications for the broader market, especially on the commercial side? You know, I guess the thought being, like, you know, does it give you guys an additional reference point to kind of point to on sort of like fair value for a product and, you know, as you think about kind of products, and that list will grow over time, obviously.
Yeah, I mean... needs to settle, if you will, on the implications of the IRA and drug pricing.
Yeah.
But there's an analog here in the way that medical services, you know, costs are set, where, you know, generally speaking, providers lose money on Medicaid, break even on Medicare, make money on employer business. You see the dynamics start to transpire if drug prices are lower than where the manufacturers need them-
Yeah
- in Medicare, dynamics start to unfold. Whether that does or not, we don't know, but we're well positioned on behalf of our clients to make sure we're negotiating the best possible lowest net costs on all the lines of business where we serve.
Yeah. Okay, great. And then, maybe just lastly, on the GLP-1 cost guarantee that you announced at the Analyst Day, maybe just what's been the general feedback from clients, you know, since you've launched that product, and just to kind of what you feel like the uptake or interest will be there?
Yeah, I mean, as I was saying earlier, there's this pharmaceutical wave happening right now, and GLP-1s are right in the midst of that. So there's a lot of interest from our employers in covering GLP-1s, but in a manner that is controlled and that they have confidence that there's not gonna be off-label or compounded usage of it. They wanna understand what indications it's being used for, 'cause GLP-1s were hatched for diabetes, now they've moved into weight management. Now there's, you know, obviously, there's other indications that are being explored. So employers want a bit of a controlled environment for all this. So the good thing about Encircle Rx is it gives them the controlled environment around weight management, because we're only covering the FDA-approved drugs. They have to meet clinical thresholds.
We have behavior modification programs through our Omada digital tools that wrap around this. The appetite has been there so far for discussions. We haven't had a seismic uptick in the program, but we have right now over 1.5 million enrolled lives. We had over 1 million at the time we rolled the program out at Investor Day. So we've already seen some growth in the number of covered lives, and we expect over time, the percentage of employers that are covering weight management likely ticks up, enabled by programs such as Encircle Rx.
Okay, great. I think we're just about out of time. Brian, thanks so much for joining us today.
Thank you, Nate.
We really appreciate it.
Covered a lot of ground there.