Good morning, everyone, and welcome to our next fireside conversation here at Morgan Stanley's 2022 Global Healthcare Conference. I'm Ricky Goldwasser, and I am one of Morgan Stanley's Healthcare Services Analysts. It is my pleasure to have David Cordani, CEO of Cigna , joining me this morning. For any regulatory disclosures, please see the Morgan Stanley website. With that, I will pass it to David for some introductory remarks.
Thank you, Ricky. Good to be with you today, and thank you for hosting this. Hello, everyone. Good morning. I'll just be brief, five minutes or less, and just highlight a few headlines. First, stepping back, we're quite pleased with the performance of our organization broadly across our franchise as we stepped into this year and through the first half of this year. We recognize the environment is dynamic, it's fluid, it's changing, and the marketplace has continued to do that. Against that backdrop, as you think about the future, the next five years that sit in front of us, we believe quite strongly that there are three indisputable forces that are rapidly reformatting and forming the health and well-being space. Those are the rapid evolution of and change around pharmacological innovation.
Second, the acceptance of globally the indisputable connection between physical health and mental health and the opportunity to coordinate both together as opposed to separate. Third, with more advanced technology, data availability, and consumer orientation and interest, what we call alternative sites of care. How do you bring care and service closer to the individual to make it much more personalized, coordinated, convenient, and of higher value? We've worked to position our organization to take advantage of those trends to deliver differentiated value. To do so, we have two operating platforms. We have our Evernorth Service Platform, which I'll come back to in a moment, and our Cigna Healthcare Platform. Think about one as a health service portfolio. Think about the second one in Healthcare as a benefits portfolio.
Within those two business platforms, they're independent in terms of their growth objectives and then codependent from a leverage standpoint at some levels. You can think about our business and our value creation framework in three ways. We have foundational businesses, and the three big foundational businesses you should think about are core pharmacy services, U.S. commercial, and our international benefits business. Those businesses are mature, well-established, scaled, and will generate low to mid-single-digit sustained growth rates. They also happen to oftentimes establish core relationship foundations with corporate clients, health plan clients, and governmental entities. Today, that's about $100 billion of our revenue. Second, we have our accelerate businesses. Our accelerate businesses are our specialty pharmacy business, both direct to patient through Accredo and direct to healthcare professional through CuraScripts. Our Evernorth Care business, which is over $10 billion of revenue already, and our U.S. government business.
That's a bit over $70 billion of revenue within the franchise. Those businesses, because of positioning and secular tailwinds, will have high single-digit or double-digit growth rates. Third to our value creation framework is our enterprise leverage. How do we leverage enterprise assets and the combination of those to cross-pollinate? That could be talent, it could be data, it could be capital in terms of the way we're generating capabilities across the organization. When you take that as a whole, we have a track record, if you look back over the last decade, of generating and delivering on our targets, not establishing targets, but delivering them, which are to deliver 10%- 13% on average compounded EPS growth, plus in the present state, an attractive dividend.
Going forward, we remain committed leveraging that franchise to be able to deliver 10%- 13% on average compounded EPS growth, plus an attractive dividend. To wrap up, strong start to the year, two well-positioned growth platforms, a clear-eyed view relative to a changing dynamic marketplace, but a few forces of changes that are indisputable. Positioning of our businesses to be responsive to, and in many cases, lead into those trends for the benefit of those we serve, and therefore be in position to deliver that sustained, attractive, again, EPS growth as well as dividend performance for the organization. Ricky, with that, I'll turn it back to you.
Great. Thank you for the overview, and we're going to touch on each of these. Before we do, I wanted to start with the macro environment. Clearly, very hard to predict. We've seen on the one hand unemployment data being fairly stable, right, and low. On the other hand, we're hearing kind of like data news on corporates laying off people. Starting with utilization environment that you're seeing, what are you seeing in the marketplace now?
From an employment or utilization?
Let's start with utilization, and then we're going to get to the employment.
Big picture, you step back, first half of the year, in aggregate, we'll take utilization and use utilization as a proxy for overall cost. Overall cost came in a bit better than our expectations. We stepped into the year with an underlying expectation set that the cost structure from a healthcare standpoint, which is where the question goes, was going to remain at an elevated level to, if you will, pre-pandemic baseline. It came in a little bit better, both COVID and non-COVID costs. We're obviously in a quarter right now, in the third quarter, so we'll be reporting month, month and a half down the road, early into the quarter in terms of the data you see, generally in line with our expectations, is what I would say. No major movement there from that standpoint.
To jump into the employment landscape, we step into this disrupted environment in a case where most employers, not all, but most employers in the U.S. remain in an active hiring process while some employers are reevaluating their workforce. Whether you look at the 10 million-1 2 million open jobs in America, most employers are still struggling to get to full employment, while we see some employers going through some right sizings that are manifesting themselves. On average, those that are looking to right size are either slowing down the rate of hiring, stopping the rate of hiring, but risks or reductions are outliers in the current state. Lastly, for our book of business, remember the services book of business, which is a larger portion of our portfolio than the benefit book of business.
Within the benefit book of business, the portion of that that is commercial, so it's a subset of the benefits book of business, tends to be under-indexed on employment-agitated industries and over-indexed on more stable. More indexed on services, less indexed on travel and leisure as an illustration. Our book of business has performed well over time. Stepping back to the agitation, again, we see it as a dynamic market. We have not seen either of those forces create disruption thus far.
I have a few follow-up questions. First of all, on utilization, to your point, first half, costs came below your expectations. You also said it's so far into the third quarter, costs are in line with your expectation. Are they in line with your expectation that they're going to be somewhat elevated as we thought about the year, or are they in line with what you've seen in the first half of the year?
Let's go back through all the same context. As we last year, 2021, mid-year, when we were looking at 2022, we said our posture for 2022 was going to be that we took a position that costs, now we're into the benefit side of the equation, were going to be moved from somewhat elevated to elevated. We took a posture that the costs would remain at an elevated level. Said otherwise, the pattern in 2022 was going to more approximate 2021. Through the first half of the year, it was a bit better than that assumption. On our second quarter call, our CFO indicated that for the last part of the year, our expectations are more like what we had for the full year. If it comes in better than that materially, that may create some additional opportunity. We're not commenting on that yet.
I just say, broadly speaking, in line with our expectations.
OK.
Yep.
My second follow-up question is on employers. Understandably, you're leveraged to the part of the market where we see less attrition and still sort of hiring. How are employers kind of like thinking of the type of benefit they're going to offer? We've gone through a couple of years with benefit expansion.
Yeah.
What are you seeing now?
Yeah, so really important, Ricky. One, if you go back in time, the mental health and physical health benefits were typically viewed as discrete.
OK.
We'll continue unless we're directed otherwise. Back to speaking of reason one's anxiety, the mental health and physical health were historically separable.
Just services hereafter.
Yeah, absolutely. Secondly, over time, more and more point solutions were being purchased by employers to meet individual needs. Employers were aggregating more and more point solutions, and their employees or customers were confronting, I use my hands, multiple touch points that were less connected. Themes today are more directly pointing toward, A, integrated or coordinated solutions where mental health and physical health are more meaningfully tethered together, an evolution of the definition of mental health solutions beyond comprehensive mental health toward depression, anxiety, stress management, et cetera. Third, ensuring that they are integrated into medical solutions around chronic care, and then bringing more point solutions back into combined solutions. That is positive for us. That is a positive for our go-to-market proposition. A, the diversity of what we offer, but B, our preferred approach, which is to coordinate solutions and leverage solutions.
We see more of that, not just at the larger account, at the mid-account and the small account level. Those would be the trends we're seeing currently. Still pressing toward improved affordability unequivocally, but also trying to point toward, can you increase the engagement and productivity of my coworkers by bringing these programs to market?
I have a question in M&A for later, but what you said now just made me think. I have to kind of ask that. From your perspective, as employers are looking for integrated solutions, does this mean that as you think about sort of kind of like your portfolio, that you should have a more active role in bringing these assets together and consolidating them to offer a solution to your employers? Is that something that you expect will happen naturally in the marketplace?
Broadly speaking, when you think about the core pieces of what come together, you have medical, pharmacy, and behavioral in the broader suite. There are navigation capabilities, and there are derivatives of all of the above. Big picture, we're well positioned with all of the above. We're well positioned with medical services. We're well positioned with leading pharmacy services across all aspects, including the most acute and complicated pharmacy services through specialty. From a behavioral health service standpoint, the legacy of Cigna Behavioral Health remains one of the biggest behavioral health chassis in America today. That doesn't mean, Ricky, there may not be tuck-ins to expand capabilities. The big innovation for us is how do you continue to innovate new products, programs, and services. We've launched a digital-first depression and anxiety program in this fiscal year, specifically targeting.
We have a pilot of an MSK musculoskeletal program that takes mental, physical, and pharmaceutical services and drives an integrated MSK program that takes all those services that we're manufacturing internally with new innovation and development. Broadly speaking, we have the capabilities we need. There may be bolt-ons within Evernorth Care that are attractive to us, but the underlying chassis positions us really well today.
My next question relates to Evernorth. Within Evernorth sits Accredo and specialty pharmacies and biosimilars, which obviously is a larger opportunity, especially with HUMIRA, second half of 2023 and into 2024. You've talked about it at your investor day. You even raised the guidance for the segment, incorporating sort of the drivers. It's interesting to me because this is a new concept. I think investors not necessarily appreciate yet the opportunity. I wanted to spend a little bit of time off kind of like Evernorth's role in shaping and changing the marketplace.
Yeah. When you think of Evernorth, think about a few services that are within the portfolio. Most people come into the doorway thinking about what I call the core pharmacy services, or better stated through many people's minds as a Pharmacy Benefit Management, attached to that, specialty pharmacy services. Think about the breadth of what specialty pharmaceuticals are today and with the pharmacological innovation, gene therapies, biosimilars, new vaccines, personalized medications, et cetera. To give you a little color and context, think about within our Accredo operation, which is one of the two largest, I would submit, leading specialty pharmacy services. Think about 15 subspecialties that are managing there through therapeutic resource centers, clinical units that specialize on individual drug classes. In the case of oncology, five different subsegmentations of oncological teams, focusing on tumor types, drug regimens, the specialists across the country.
The value creation there is not just in access to a medication. It's the coordination and cultivation of the care journey. In many cases, the pharmaceutical manufacturer wants to ensure that there's a care team that wraps around a patient to get the clinical efficacy on the back end. As specialty pharmaceuticals continue to be manufactured, the cost profile and the complexity require an intense clinical understanding of how to manage that. That is a core aspect of what sits within the Evernorth portfolio. Adjacent to that is Evernorth Care. Within Evernorth Care, we have our virtual care capabilities, our behavioral care capabilities, and what you would know as chronic care management capabilities. Those are being leveraged for some of the new innovations that we're making reference to relative to a longitudinal musculoskeletal or diabetes program, et cetera, from that standpoint.
Stepping back, Evernorth is quite well positioned to deliver services in today's procurement or purchasing pattern for the largest, most sophisticated employers, health plans, governmental agencies like the DOD, or state carve-outs, and increasingly and importantly, healthcare delivery systems that need extension of their services to either take risk or to have performance-based contracts, or we're actually the supplier of specific drugs to healthcare professionals to deliver those specialty drugs at point of consumption, at point of service from that standpoint. That broad services portfolio positioned us well both to lead in today's model paradigm, but innovate as the marketplace is changing on a go-forward basis. Hopefully, the little illustration I gave you of the specialty pharmaceuticals helps. Lastly, if you click that down, if you think about biosimilars, there's going to be equivalents and similars.
The clinical excellence you have to have and the physician relationships you have to have to be able to figure out what's right for an individual patient and coordinate with the practicing physician and patient is a deep clinical acumen. We have that. It's not as simple as here's the similar, have the similar be prescribed for somebody. It's a care coordination decision one patient at a time with a medical professional. Those are leading capabilities we have within Evernorth.
Switching to another growth opportunity, Medicare Advantage. Clearly an important market, and you've been vocal about your targets and growth opportunities. The market is increasingly more competitive. How should we think about, from a multi-year sort of strategy and target, your positioning in that marketplace?
Again, history for some that don't know, the book of business is completely. Historically, we only participated in a small section of the addressable marketplace, less than 20%. Individual HMO, so not individual PPO, not group, and in the limited number of MSAs, about 19% of the addressable market. We said we would systematically expand our footprint and our offerings to be 50% of the addressable market by 2025. We're well on our way. The 19% eclipsed 30%, staring through 40% of the addressable market. That's a lot of investment. Over the last couple plus years, we've incurred a lot of investment for geographic expansion and platform expansion. Adjacent to the individual HMO is an individual PPO, as well as the ability to accommodate on an employer egg whip. That's the journey we've been on sitting in front of us today.
As it relates to going forward, we expect to be able to grow this business on average 10%- 15% customer growth because of our geographic profile expansion, the capabilities we have in targeted markets that exist, and importantly, our ability to tap into and leverage an under-leveraged capability that we have, which are the agents out of the Cigna commercial book of business, which are about 150,000 likes a year that are essentially geographically matched up pretty well relative to our opportunities. We've historically not leveraged that at all. An attractive market, a growth opportunity, it fits into our accelerate, that second category of platforms. The last couple of three years have had a significant amount of investment in to position us from a growth standpoint. Lastly, I would note that yes, it is a competitive market, Ricky, I agree with you, and it will remain a competitive market.
The last year and a half has also reinforced that. If you enter that market only with a revenue growth orientation, it's also a capital-intensive market with a thin-ish margin. Single-digit margins are thin-ish when it's capital-intensive, so you need to do it well. There's a little shaking out happening in the market right now for some of the players. We remain optimistic for the long-term growth there.
When you think about your Evernorth capability, especially Evernorth Care, because I think care delivery is becoming increasingly important in the Medicare Advantage market, do you think that you have the kind of like the right tools there in order to manage that population?
We do, and it's important to add on, I appreciate your question. Evernorth, the Evernorth services create meaningful opportunity for our business, and in the case of Medicare Advantage, unequivocally. For example, we stood up a post-acute service that's up and running already. That was stood up in Evernorth. It's an Evernorth service designed specifically for the needs of the Medicare Advantage population for post-acute care, coordination, and direction.
May I have your attention, please? May I have your attention, please? The hotel is determined to close in a little office. There's no danger. May I have your attention, please? May I have your attention, please? Closing in a moment. Determined there's no danger. Please resume your normal activities. Thank you.
20 minutes later. OK. Wouldn't just me. That leverage and the illustration of the post-acute care program is a great example of harnessing the Evernorth capabilities, designing a solution, and that solution is now available to other health plan clients of ours. Yes, we have the capabilities. Again, within Evernorth Care, we were clear at our investor day. We will look at bolt-on acquisitions to further expand those capabilities. However, there are great proven capabilities to be able to deliver real meaningful value for Medicare Advantage today.
Staying on the topic of government regulation, I think regulation or lack of more regulation are probably surprising some people in the marketplace, surprising people in the industry. What are you looking for as we head into the midterm elections? Second of all, I just wanted to get sort of your view on the Inflation Reduction Act. There are a lot of questions about that addressed towards pharma companies' executives. Clearly, given sort of your role, you would have taken that as well.
Yeah, you referenced relative to the midterm elections and moving back.
Yeah.
We operate in a regulated space globally, have, do, and will on a go-forward basis. Hence, our space tends to be more active at times versus a little less active at times in terms of new legislation, new regulation, et cetera. It's just a fundamental part. That doesn't mean I'm numb to it or we're numb to it from that standpoint. It's just a fundamental part of the business. Second, as we position our portfolio of services, both the benefit services as well as the Evernorth services capability and the business model we have, we're mindful of what we think the regulatory environment is and will be on a go-forward basis. Hence, movement relative to more services, more transparency, more aligned incentives from a structural standpoint.
There's nothing specific as it relates to midterm elections that are, you know, to me, the midterm elections would say student body left or student body right that sit in front of us. Obviously, the nation will look at the midterm elections and maybe as a proxy toward the 2024 elections in terms of what might transpire. We think health care and health-related services will remain front and center because of the societal need from that standpoint. We're quite proud of the level of value and service we deliver as reinforced by our retention rates, our satisfaction rates, including for governmental entities that we serve. As it relates to the Inflation Reduction Act, there's a lot of moving parts within there. There are no one component within the Inflation Reduction Act that dramatically changed our portfolio.
There will be some adjustments to the PDP side of the framework for the industry as a whole. We're confident in terms of our leading posture relative to our capabilities, relative to procurement, clinical management, and service that on a relative basis we'll be able to have our differentiated value proposition. I think it's just an indication of a relatively active environment, but not one that affects our well-positioned and smartly diversified benefits and services business.
We talked a little bit about the managed care side. We talked about Evernorth. I think that one of the things that are underappreciated is that enterprise leverage and the cross-platform synergies. Can we spend some time on that and the opportunity? What's the time frame to capture that opportunity?
A simple way of thinking about that is today, Evernorth services about 30% of Cigna Healthcare's spend or need. That's up over the last few years, but it's still materially lower than it could be. At our investor day, Eric Palmer, who leads the business, and Bryan Holgerson, our CFO, both referenced the fact that we are on a path to move that from 30%- 50%. A significant, significant opportunity. By the way, the Cigna Healthcare portfolio is a growing portfolio. It's not going from 30%- 50% on a static population. It's going from 30%- 50%, which is growth, and 30%- 50% on a growing block of business. What transpires around that is continued service innovation. I use the simple example of a post-acute care program for Medicare Advantage.
Some of the new longitudinal programs that we're designing around oncology, MSK, diabetes, depression, and anxiety are all examples. They will be designed and delivered and fulfilled through Evernorth. They will be availed to Cigna Healthcare, be it the commercial book of business, the Medicare book of business, or the individual exchange book of business. Importantly, they'll also be offered to the marketplace through Evernorth to health plans that we serve today, to governmental agencies, to integrated delivery systems from that standpoint. We see it as a significant opportunity, and it's an opportunity to create value, first and foremost, for the customer and the patient, and then to capture an appropriate amount of value within both Cigna Healthcare and within Evernorth. The illustration at 30%- 50% is quite tangible.
The 30% - 50% takes place on a growing book of business that we've proven the ability to grow our Cigna Healthcare portfolio quite nicely.
I have a couple more minutes. I'm going to try to squeeze two questions.
Fair enough.
When we think about the M&A environment overall, we've seen a pickup in activity, not just in healthcare services, but over in healthcare. I think what's unique about healthcare services is really that we're starting to see these sort of non-traditional players becoming more active. As you think about the evolution of the marketplace, how do you think their sort of decisions, how they're going to impact the speed of things, the pace of change?
I think if you look at it through the, you know, if we were to go back a decade ago and look at the space and then look back a decade and then try to project forward, you'd see a pace and rate of disruption. You see companies no longer exist. You see companies get reconfigured. You see new companies come into the space. You see small players become large players, et cetera. It's a natural part of the process. It's a wonderful part of a capital-intensive industry and the capital marketplace. Change is ever present. What's pushing on that? Two big forces: demands of the consumer and rate and pace of innovation, largely enabled by technology and data.
You may have regulation that accelerates or decelerates it, but it's essentially demand, need state of the buyer and financier and consumer, and then what's available through technology and data in terms of accelerate, if you will, disintermediate, accelerate innovation, bring new services, et cetera. From our point of view, we don't resist that at all. We don't. In fact, we lean into it. We're a more services-based franchise today than we ever were. If you think about where our innovation is coming from, our innovation is coming from the services side of the equation. Importantly, we're open in terms of our architecture, more broadly than not, in terms of partnering, collaborating, and working with others. Our Cigna Ventures portfolio is a great proof relative to that in terms of how we partner with others.
As it relates to the space, to accelerate the pace of change, you might see us instead of acquiring something, partnering or taking a minority interest to drive accelerated change. Sometimes you think acceleration comes from solely owning. It may come from the leverage effect of partnering or having a minority interest going forward. I think your point is spot on. We don't resist it. We actually lean into that. We have a pretty proven track record of leaning into it more correctly than incorrectly in terms of innovation, partnership, collaboration, and value delivery.
I will still kind of like ask you that last question because I think it's an important question. I follow you on LinkedIn. Recently, I've seen that you've added some pretty prominent hires to your executive team. How do you sell them on Cigna ?
Thank you. We're proud. We feel fortunate when individuals who join pretty much anywhere seek to join your team. If you step back, a lot of what we just talked about, technological enablement, our CIO, our CTO, our Chief Architect, our Chief Digital Officer, they all come from outside the space because we don't think the space has defined itself as it relates to the innovator. Now it's augmented by experts in the space. Most recently, we were fortunate to add a Chief Health Officer to the organization who's well known through a variety of circles, from an innovator, both as an MD, as well as an academic PhD, government service, entrepreneurial service, et cetera, from that standpoint. The basic part of how we sell them on Cigna is two pieces. A, we're a mission-based company still.
We proved the thesis that you could be mission-based, have a purpose, and change people's lives for the better, and not apologize for being publicly traded, performance-oriented, and growth-oriented, and showed that the two cohabitate. That's the first piece of the equation. It's and. It's not or, it's and. That's deeply rooted in our company's culture. Second, we don't resist the change agenda that your prior comments referenced. We actually are agitating ourselves and want to move faster toward that. We want leaders who are part of that change agenda to collaborate with us. It's really those two pieces. The first piece is really important. It sounds like words. They're not. It's a deep belief set. We're not perfect, but it's that we have a responsibility to make a difference in over 180 million customer relationships around the world every day.
We put that upon ourselves because, by the way, we take care of our own loved ones. Our own loved ones consume our services and the ability to deliver more, but be publicly traded, growth-oriented, performance-oriented, and return a fair profit. Those two things have to cohabitate for sustainability in our belief set. We make no apologies for it. It's attractive to a lot of people who want to drive change and who have a great track record of making a significant impact.
Great. David, thank you very much.
Thank you. I appreciate being with you. Thank you for your time, and for the inconvenience of the alarm.