All right, great. Thanks. I want to thank everyone for joining us today on the third day, or I guess the fourth day, of the BofA Virtual Health Care Conference. It's my pleasure to introduce Cigna. Cigna is one of the largest providers of health insurance through the U.S. and globally, and also is one of the largest providers of pharmacy benefit management services through its Evernorth subsidiary. Presenting today, we have Brian Evanko, who's the Chief Financial Officer, and Alexis Jones from Investor Relations. Brian, if you had a few prepared comments before we jump into Q&A?
Sure. Thanks, Kevin, and good morning, everyone. Thanks for being with us here today. Hopefully, you had a chance to listen to our first quarter earnings released last Friday and/or our investor day, which we held about two months ago. All that information is available on our website under the investors section at cigna.com. A few of the headlines in case you did miss that, relative to the first quarter, our overall earnings performance was somewhat ahead of our expectations for the quarter, driven by strength in our Evernorth Health Services subsidiary, as well as the net benefit from three non-recurring items in our U.S. medical segment. Overall, our U.S. medical segment, excluding those items, was right in line with our expectations. Our Evernorth performance was strong and broad-based, and it continues the strength that we saw over the past couple of years.
Despite the pandemic, that business is performing really well for us. Overall, we had a strong start to the year with a good first quarter performance. As it relates to our full-year 2021 outlook, importantly, we reaffirmed or increased our guidance on all of our key metrics. Specifically, our full-year EPS outlook was raised to a guide of at least $20.2/ share, which was a raise of $0.20. Our Evernorth segment earnings were raised to at least $5.65 billion, which was a $50 million operating income raise. Our enterprise revenues were increased to at least $166 billion, which was a $1 billion raise. Finally, our weighted average share count was reduced by 1 million shares at the top end, just implying that we've continued on our share repurchase objectives. Overall, strong start to the year, increased the full-year outlook on some key metrics, and reaffirmed all the others.
We're pleased with this start and look forward to talking with you in the future. Kevin, wherever you want to go, conversation, I'm all yours.
Sure. I think one of the questions that we've been asking pretty much all the companies is just how you guys are thinking about the pace and timing of the return to volume normalization through the year. What are you expecting that to look like?
When you say volume normalization, you're talking about medical utilization?
Medical utilization, medical spend. Yeah.
Yeah. In the first quarter, the quarter was almost chopped in half, is the way I would describe it. Meaning the first half, from January 1 to February 15, COVID testing, treatment, vaccinations were quite high. They were elevated. They were in line with our expectations, but they were high. Conversely, the non-COVID utilization was quite depressed. That was also in line with our expectations for the first half of the first quarter. For the back half of the first quarter, think February 15 through March 31, COVID direct costs actually started to come down, and they were below our expectations. Non-COVID utilization picked up in an offsetting fashion, and the non-COVID utilization was a little bit ahead or above our expectations. The net of those two things ended up being right in line with what we anticipated to happen for the overall first quarter.
We expect that in the back half of the quarter to continue to persist for the balance of the year, meaning we expect continued sellers in a setting fashion through the balance of the year. As you kind of fast forward all the way into the fourth quarter, we would expect the fourth quarter of the non-COVID utilization to start to approach the seasonal baselines or be right in line with the seasonal baseline. That's big picture how we're thinking of things. In 2022, we're expecting to look a little bit more like a non-COVID or a pre-pandemic type of claim cost base.
That's great. Are you at all worried about the concept of pent-up demand and some period of excess utilization and/or the potential that as this volume returns, it will maybe from a utilization perspective kind of return to normal, but might be higher acuity because people delayed things and are now at a higher acuity when they present?
Thus far, we don't have evidence of those types of situations emerging, either at an individual level or in aggregate. I think importantly for us, we've focused quite a bit on preventive services over the past 12 months since the pandemic really started to heat up. We talked about this in our first quarter call on Friday as well. In the quarter, our preventive services, particularly for things like mammographies, colonoscopies, et c., were in line with pre-pandemic levels for preventive care. We think that's an important indicator that there is not acuity building up in the system or massive amounts of pent-up demand to come. On top of that, keep in mind our book of business within U.S. medical is about 60% commercial.
Through our commercial employer book of business, we saw less care deferral throughout the pandemic in our commercial employer business compared to our Medicare business or our individual business. The commercial business had a little bit less care deferral. As a result of that, we believe less bounce-back utilization risk later in the year or in 2022. This is certainly something we're very focused on, Kevin, but thus far, we don't have indicators that would suggest a significant amount of pent-up demand or acuity above any seasonal baselines later in the year.
All right, great. You mentioned the quarter was strong in large part due to Evernorth. I guess I'd like to think about how you are positioning Evernorth. You obviously rebranded the segment Evernorth, I think in part to position it as more than just a PBM. I guess how much of that business is PBM vs the other services that you're building out today?
Yeah, so our Evernorth segment, as you said, whether you call it a rebranding or a reframing, that certainly happened last year. Importantly, we view that as a health services business with multiple different growth pillars within it. One of those is pharmacy services. Today, as you cited, the pharmacy services drive the lion's share of the Evernorth revenue and the lion's share of the Evernorth earnings. Importantly, beyond PBM services, we have a specialty pharmacy, Accredo, which is industry leading. We also have a mail or a home delivery service business in there as well. I tend to think of the PBM as processing, if you will. Then we've got specialty. Then we've got mail or home delivery, all within the pharmacy service chassis.
Additionally, the other three pillars within Evernorth, which are a little more nascent but are actively being grown as we speak, one of them is care solutions. When you think about coordination of care across the ecosystem, or in some cases, delivery of care, such as our MDLIVE acquisition that closed last month, we will look to step into on a capital-weight basis, care delivery and care coordination, particularly in alternate sites of care, such as virtual and home care, etc. The care solutions business is very focused on that. Thirdly, our benefits management business, which traditionally you can think of as eviCore, our eviCore subsidiary, which does utilization review and prior authorization, etc. We see a big growth opportunity there with both health plan clients as well as employer clients. Finally, intelligence and insights, which again is a little bit more of a nascent business.
Today, you can think of this as data analytics as a service, both for external clients as well as Cigna's U.S. medical customer base. Today, our Evernorth business, 80% of the business actually comes from non-Cigna affiliated clients, whether those be health plans, employers, or government entities. We see significant opportunities in all four of those growth pillars to expand the relationships with that 80% of the revenue that's not affiliated with Cigna.
OK, that's great. I guess when we think about the non-pharmacy solutions business, how big can that become as part of Evernorth? Is it ever getting clear how long would it take to be half of Evernorth?
Yeah, we haven't specifically mentioned targets for that or time frames, et c. Obviously, the pharmacy services business, we're not looking to shrink that. That will continue to grow in the future as well. As the overall pie grows, your question about the piece that's non-pharmacy services is something we're quite focused on for a few reasons. One, we see those businesses as likely helping to improve the margin profile over time of the overall Evernorth subsidiary. Two, we see them as being very synergistic with our U.S. medical book of business, making the value of each U.S. medical customer that much more with additional non-pharmacy services. It will take some time for us to get to, you used the number of 50%. It will certainly take some time to get to a level such as that.
We'll look for targeted inorganic actions to accelerate the path as well on top of the organic investments that we're making this year. It'll take some time before we get to that sort of size and scale, Kevin.
OK, I guess when we think about the inorganic opportunity, you guys are now generating a significant amount of free cash flow post the Express acquisition and the deleveraging you did. How should we think about capital deployment? What are the priorities? With an incremental dollar of capital, what is the best use?
Sure. The capital deployment framework that we outlined at our investor day on March 8, which, again, you can find all those materials if you haven't seen that, to the audience here on our website, we outlined the fact that over the next five years, we expect to generate $50 billion of cash flow from operations. From 2021- 2025, that five-year period, we expect to generate $50 billion of cash flow from operations, which again is a testament to the capital-light service-based model that our company has been built upon. Of that $50 billion, about $10 billion we expect to be used for internal purposes, so it's in capital expenditures as well as surplus to fund growth. The remaining $40 billion, about 20% of that will go to shareholder dividends, so $8 billion out of the $40 billion roughly.
The balance, the $32 billion, will be split approximately equally between strategic M&A and share repurchase. In any given year, those proportions will vary just based on the opportunity set in front of us from a strategic M&A standpoint. We're very interested in targeted inorganic activity that will accelerate our strategy. We also view our stock as an attractive place to put money as well, given the current valuation as well as the intrinsic value that we see there. We expect both inorganic activity as well as share repurchase in approximately that 50/50 split over the course of the next five years.
OK, and then where more specifically would that targeted M&A be?
Sure, Kevin. There are four areas that we've talked about over the past few months, which at our investor day, I think we specifically targeted these four for the first time with the investment community. One being Care coordination at alternate sites of care. You can think of the MDLIVE acquisition, which closed just under a month ago, as an example of that. We see one of the mega trends unfolding in the U.S. health care system being alternate sites of care, whether that be virtual, home care, or care navigation, et c., where care will move away from bricks and mortar toward these alternate sites, not entirely, but to a much greater degree than it was pre-pandemic. The pandemic accelerated those trends undoubtedly, but they've been persisting over the course of the last 15 months, and we expect them to continue in perpetuity.
Importantly, we're focused on that, both in terms of the coordination of the care across different sites, but also in some respects owning pieces of care delivery in alternate sites, which is the rationale for our MDLIVE acquisition. The second area of focus for us is Government programs and services. You can think of this through two lenses, one being the services chassis with Evernorth and the second one being the health plan chassis, our U.S. medical portfolio. Our services chassis, importantly today, serves millions of Medicare and Medicaid lives through both the pharmacy services business as well as through our eviCore benefits management subsidiary. In some instances, that's health plans. In some instances, that's states directly, Medicaid programs, et cetera. We serve millions of lives today in the Medicare and Medicaid space through Evernorth. In our U.S. medical space today, we are active, as I'm sure you know, in Medicare Advantage, looking to continue to grow that footprint geographically and have the expectation of 10%- 15% annual customer growth for M&A for the foreseeable future. For Medicaid and the health plan side, we are not very active today. We obviously recently announced our intent to divest our small piece of Medicaid in Texas and Molina. Going forward, government programs and services is a targeted area for us in terms of inorganic activity, but through both the services chassis and the health plan chassis and potentially synergistically between those two on a case-by-case basis.
The third area we're focused on is technology and specifically information-oriented capabilities in areas such as interoperability and transparency, et c., the things that are very much in focus with the current administration that focus on information flow, data flow between providers, between customers, between payers, et c. That's an area of interest for us as well. Finally, International health care capabilities are of interest since we have a business that produces $900 billion+ of income outside the U.S., and it's an area that continues to be attractive for us from a growth standpoint.
That's helpful. I think that the commentary about the government business, I just want to clarify that because I think the interest in M&A is pretty clear and not surprising. I think that the market generally viewed Medicaid as a place that you would look to grow. It was a little bit surprising that you exited the Texas contract because it is a high-acuity Medicaid contract, which seemed like the type of way that you wanted to participate in Medicaid in the health plan business. Should we be thinking about your Medicaid participation really more through the lens of the Evernorth services opportunity? Could you envision getting back into the Medicaid health plan business as well at some point?
I appreciate the framing of the question because I realized the divestiture may have been a surprise to some. Just a little bit of context here, we had three service areas within Texas where we were active, about 50,000 Medicaid lives, about $1 billion of annual premium, a de minimis earnings contribution to the enterprise. Not big today is where I start. Secondarily, we see the opportunity to organically grow our Medicaid footprint in the health plan as being pretty limited. We believe that that's a steep hill to climb to organically grow the Medicaid health plan business. Also, the Texas reprocurement is coming up likely later in the year for a 2022 award. We weren't sure we would be awarded a renewal in that instance given the relatively limited footprint.
We kind of saw this as a win-win with our counterparty Molina, who has an existing Texas footprint and could essentially keep these lives in its existing chassis and get the leverage off the fixed cost base, something that we didn't have the benefit of being able to do. We saw it as a win-win in that regard. Big picture, as you step back and you think about government programs and services, think about it as both the services chassis and the health plan chassis. We're not necessarily shutting the door on health plan opportunities in the government space, whether that be Medicare or Medicaid. They have to be the right financial opportunity. They have to be the right strategic opportunity for us to pursue it. Again, we see the opportunity to grow organically in the Medicaid health plan space as one that's unlikely to be a path we pursue.
OK, that's helpful. I guess when we think about what you're talking about doing on the Evernorth side, it seems like every company is trying to build out these ancillary services and benefits. A lot of them are talking about a little bit more kind of bricks-and-mortar position practices, at least. It sounded like that was not part of your priority, that your care coordination helping sites probably didn't include that. I just want to make sure that I have that right. If that's true, why is that not the right way to pursue it?
You got it right for sure. That continues to be our strong bias, and it comes back to our capital-weight service-based framework. We believe that that's the right strategy for our company. That's not a verdict on anyone else, but for our company, we believe that's the right strategy. We have proven success that we can partner with physicians effectively, both those that practice today in bricks-and-mortar settings and those that are migrating to more alternate sites of care. That's a strategy we'll continue to employ. Coming back to what I was talking about earlier regarding alternate sites of care potentially stepping into owning more care delivery on a targeted basis, we look to do that. We don't expect to have scaled bricks-and-mortar assets.
Coming back to capital-weight service-based, our FG&A ratio, as I'm sure you know, is the lowest in our space, something we pride ourselves on because we believe it gives us the strategic flexibility to be nimble as conditions change and the ability to flex the business model if needed. We've got proven results both in Medicare Advantage and in commercial, in our ability to drive great total cost of care outcomes in a partnered model with physicians as opposed to an owned model.
OK, no, that makes sense. Talk a little bit about the 2022 selling season, how that's shaping up for both the managed care and the PBM journeys.
Sure. On the commercial employer side of the house, RFP volumes are definitely up compared to last year. Last year was a bit of a depressed year because many employers decided with the pandemic they would defer their cycles, if you will. Volumes are definitely up, whether you look at it on a number of RFPs or you look at it on a member-weighted basis. They're certainly up year- on- year, and we're getting quite a number of looks. We also have our own clients that are out to bid in some instances. We've got some wins already for 1/1/22, which we're quite pleased about, and we'll certainly share more as the year unfolds. Overall, we're in line for a good 2022 commercial employer growth performance. Again, I'm not going to get more specific just yet because there's still quite a lot of dust to settle.
The volumes are definitely up, and so far, we're having a good season. On the PBM selling side, I think David mentioned this in our first quarter call, we're trending toward a mid-90% retention statistic relative to measured on scripts for the PBM client base that we have. The primary driver of that was two known health plan losses that occurred earlier in the year. Excluding those, we would have seen retention very much in line with historically where we've been, which is typically high 90%. We had a 98%+ retention in 2021, but for 2022, trending a bit lower due to those two known health plan losses. On a sustained basis, we would expect 2023 and thereafter to be more in line with our typical levels of retention.
OK, is there anything that you'd point out or point to as far as these two larger contracts that kind of make them more unique? Are there any trends you're seeing?
I don't think there's anything you could really generalize out of those. I think we're finding each bid has its own set of unique characteristics, and each client has their own set of unique needs. Some are more price sensitive than others. Some are looking for specific rebate flexibility or spread pricing flexibility. There's a little bit of a different story client by client. It just so happened that these two were up for the cycle.
OK. If I just heard you right, you say that you kind of longer term target something closer to the high 90% than the mid 90% retention?
Historically, if you look back, we tended to trend in the 96%- 98% range. That tends to be the number that we would look for on a sustained basis. This year, I would view as a bit of an outlier. Importantly, though, as Evernorth continues to diversify, the retention on prescriptions becomes a less and less important metric as you think about the ability for us to grow that business more broadly and have more non-pharmacy services. Not to downplay it, but just over time, it's a little less of a direct driver to the P&L than it has been historically for us.
OK, that makes sense. I think your guidance for this year assumes that commercial membership will kind of keep ramping through the year. How much of that growth is because of known wins that are coming online versus things you still have to get? What is the outlook for in-group trends through the rest of the year?
Yeah, our medical customer growth, which we increased the guide for the full year to at least 350,000 net customers, growing from the year-end 2020 to the year-end 2021 data point. Importantly, though, that includes a number of different books of business in there. It's not just the commercial employer book of business. It also includes our Medicare business and our individual business, et c. There's a few different moving pieces that contribute to that calculation specifically. Overall, for commercial employer, we expect continued disenrollment in our national accounts business. We saw net disenrollment in the first quarter in that business with essentially December 31 to 1/1, the membership was pretty flat. We lost some customers in quarter due to net in-group disenrollment in national accounts. We expect that to persist for the rest of the year.
The select segment, which is our 51- 500, we expect continued growth over the balance of the year. Steady growth in that pipeline, and we're seeing good activity there from a volume flow perspective. Those tend to be smaller employers. They tend to renew or buy on a tighter window to their effective date. Right now, we're working on July 1s. We'll have August 1st cases coming up, et c. Those tend to be a little bit more rolling as the year unfolds. In our middle market, we do have some successes for the balance of the year that are known. There's still some cases that are open that we're working on. I'm not going to exactly spec out quarter by quarter our expectations, but you should expect there to be some gradual build as the year unfolds on those two lower-end segments of national accounts.
We expect a little bit of deterioration from in-group disenrollment.
OK. I guess one of the things that historically has been a question for Cigna is that, you know, although the company's obviously diversified from a business perspective, within the health plan business, you are still largely a commercial managed care company, which is not a segment that in general we believe is going to grow. How exactly do you think about the growth opportunity within the commercial segment that you're targeting? How long can you continue to kind of grow share within those businesses?
Yeah, so a few things I'd highlight there, Kevin. For one, as you think about our footprint today, while we have a national footprint, we're not cost competitive in all the geographies where we compete in across the U.S. commercial business. A key priority for us, and it has been for several years now, is to continue to strengthen the affordability footprint, meaning we want to be either best in class or within a few percentage points of the best in class carrier from a unit cost standpoint in more geographies. That tends to manifest itself first in the select segment, where the buyers often are a little more price sensitive and therefore more fully insured. As a result of that, the cost competitiveness becomes extremely important.
We expect we can continue to grow in the select segment for the foreseeable future, which involves, by definition, taking share as we continue to make strides on our affordability journey. Secondarily, keep in mind the relationships we have today within U.S. commercial are not fully penetrated. We have opportunities to continue to attach additional services and solutions to many of our existing medical customers. Some of those are Evernorth services that exist today. Some of those are Evernorth services that will exist in the future. In some cases, their services have been carved out to a competitor that we believe are better within the Cigna family. That gives us an opportunity to expand, whether you call it share wallet or expand the scope of the relationship with many of our in-force clients.
Those are two examples of ways that we expect to continue to be able to grow within the U.S. commercial employer book of business and achieve the longer term 8%- 10% growth that we've outlined for our investors.
That's helpful. I guess one of the other concerns that people have around the PBM industry is just the potential for drug price reform. I mean, obviously, there's a lot of different proposals out there and thoughts about how to control drug spending. How do you think about the PBM model today and how much risk there is if there was to be government price setting or limiting on rebates or spread pricing? How do you respond to that concern?
The fact that drug pricing continues to be a topic, prior administration, current administration, with seniors, et cetera, indicates that the market's not happy with the current state of affairs here in the U.S. We start with that as the problem statement that affordability is a problem. The customer experience still has opportunities to be improved, et cetera. We're not of the view that we need to protect the status quo. However, we constructively engage with folks in D.C., both ourselves and through our trades, et cetera, to make sure that the proposals that are working their way through are logical. A lot of the proposals that have made their way through have downstream implications that are potentially very negative.
More and more stakeholders are appreciating some of those downstream implications, which is why something like the rebate rule continues to get pushed out as people realize it might benefit some, but it actually can be harmful to many with the premium increases that would likely transpire if the rebate rule were to materialize. Similarly, on the government procurement of drugs, we view that as a dangerous and a slippery slope. While you can understand directionally why that might be something of interest, the downstream implications of government price setting lead to other distortions in the marketplace. We've, again, been working actively with stakeholders to try to protect against some of those negative downstream implications coming to light. Importantly, you can step back and say, what does this mean for Cigna ? What does this mean for our Evernorth business?
We've constructed the business to be durable and to be resilient through a variety of different scenarios, whether those be regulatory scenarios, competitive scenarios, et c. We have a high level of confidence that our business will be able to flex. We've demonstrated that over time, whether that's more paths through rebate arrangements with clients. Yet our profitability has continued to be strong. We think any of those potential drug pricing reforms will also just be a pivot moment for us in terms of the economic model potentially changing, but still being able to deliver on our longer term 4%- 6% revenue and earnings growth at 4.5%- 5.5% margin levels in Evernorth.
OK. I think that's actually been really interesting in how you've worked with some of the companies that I guess we might view as your competitors. You've worked with Amazon on discount cards and Haven on insurance. You have a JV with Oscar. You're helping Prime improve their drug spend. How do you guys balance that? These are some strong competitors or potential disruptors. How do you balance the risk that you're creating if somebody's going to compete with you down the road vs the short-term kind of business opportunity?
Yeah, I appreciate you calling out those examples. Certainly, your question is a topic we often touched on internally before we decide to enter any of those types of partnerships that you outlined. Importantly, we see our growth framework as having three components to it. First and foremost, delivering affordability and value for our clients. The second one, partnering and innovating. The third one, expanding our addressable market. That second one, partnering and innovating, is a really important part of our DNA historically as a company. It comes back to the we don't necessarily feel we need to own all the assets in the space. We feel we can partner and still drive great outcomes, or in some cases, better outcomes than by owning all the assets in the ecosystem. Those specific examples you called out were situations where it felt like 1+1 could equal more than 2 .
Every time we step into one of those partnerships, we have three pieces of paper. We say, what's the value that can be created for Cigna ? What's the value that can be created for the partner? What's the value that can be created for the market? If there's not a clear and compelling reason for each of those three, then we don't move forward with it. To your point, threats are introduced in some instances when you partner with someone that's traditionally viewed as a competitor. We also think we need to make ourselves better each and every day. The U.S. health care system is not in an optimal position yet. We need to keep pushing ourselves to be better and better. Those partners often help us to achieve that mission.
All right, thank you. I think that's unfortunately all that we have time for. I want to thank you for joining us today and looking forward to doing this in person in Vegas next year.
Thank you very much, Kevin. Have a good day.