Good afternoon, everyone. Joining me on our call today is our CEO, Vivek Garipalli, our President and CTO, Andrew Toy, and our interim CFO, Mark Herbers. We will discuss fourth quarter and full year results, recent trends, and answer your questions. This call is being recorded. Before we get started, I would like to remind you that our fourth quarter and full year earnings materials, including the release, are available on our website at cloverhealth.com. I'd also like to caution you that we may make forward-looking statements during today's call that are subject to risks and uncertainties, including expectations about future performance. Factors that may cause actual results to differ materially from our expectations are detailed in our SEC filings, including in the Risk Factors section of our latest annual report on Form 10-K and in our other periodic SEC filings.
The forward-looking statements are made as of the date hereof. We assume no obligation and do not intend to update these forward-looking statements as a result of future events or developments. Information about non-GAAP financial measures referenced, including definitions and a reconciliation of those measures to GAAP measures, can also be found in earnings materials available on our website. With that, let me now turn over the call to Vivek. Vivek?
Thanks, Derrick, and thanks everyone for joining us today. We are really excited about where Clover sits today, the progress we expect to make in 2022, and our goals for the future. Not just enabling physicians to provide great healthcare to all, especially those in underserved communities, but to do this with a growing, sustainable, and ultimately profitable model. Let me now reflect quickly on the past year and some recent accomplishments and events. 2021 was an eventful year for us. We went public, dealt with COVID challenges, and we accomplished a lot. We more than doubled our revenue to $1.47 billion. Lives under Clover management increased by 124% to approximately 130,000. We launched our first non-insurance line of business, Direct Contracting, underpinned by the Clover Assistant.
The Clover Assistant continued to be a differentiator with an MA MCR differential of over 1,000 basis points for returning members whose PCPs use the Clover Assistant versus those who don't. We did this while operating on a wide network and driving a positive impact on health equity with more minority and underserved beneficiaries than typical for Medicare Advantage plans of scale. We also had a strong AEP in Medicare Advantage, growing well above industry levels at 28% year-over-year. In Georgia, we nearly tripled our lives and believe we're on a trajectory there similar to New Jersey, where we are a market leader. We believe our increasing scale, attractive benefit plans, and the Clover Assistant will enable us to keep gaining share in core markets while at the same time driving improved MCRs.
In Direct Contracting, we started 2022 with over 100,000 more lives than we ended 2021 and with providers in over 20 states. Largely due to this growth, our lives under Clover Assistant management increased to approximately 200,000, and our non-insurance lives now represent about two-thirds of our total lives. We believe the more lives under Clover Assistant management, the more opportunities we'll have to drive clinical and financial improvements for Clover and our participating providers. Finally, I wanted to touch upon the recent CMS calendar year 2023 advance notice for MA. Obviously, many in the industry are pleased with the rate increase. We are as well. We are even more excited about the increasing focus on health equity, specifically CMS's commitment to continue to explore ways to revise risk adjustment model in order to more appropriately pay for subgroups of Medicare beneficiaries.
This is something that will get much more focus over the next year or so, but we believe Clover is well-positioned given that almost half of our MA beneficiaries are in underserved communities, compared to 34% for the average MA plan. We encourage you to read our health equity white paper for more specifics. With that, let me hand over the call to Andrew to talk about the Clover Assistant and specifics around how it is driving a material impact.
Thanks, Vivek. 2021 was a great year for the Clover Assistant. Along with unlocking an entire new business line with our entrance into Medicare fee-for-service through Direct Contracting, we continued to invest in its evolution as the preeminent physician enablement platform and increased our annualized Medicare under Clover Assistant management to over $1 billion. The Clover Assistant was built on open FHIR standards in an effort to break down data silos and improve interoperability across the healthcare system. This enabled us to deliver our first major integration of Clover Assistant within athenahealth's market-leading EHR, with more integrations coming soon. We also launched clinical programs and data models specifically targeting some of our most vulnerable members suffering from cancer and chronic kidney disease. These successes are validation of our differentiated software-first approach.
The Clover Assistant allows us to iterate quickly, and we can adapt it to fit the needs of different facets of Medicare, as demonstrated by our rapid scaling of both our MA and fee-for-service businesses. To summarize our opportunity, we believe we can fundamentally change healthcare by providing an easy-to-access on-ramp to value-based care for every single provider in the country. In 2021, the Clover Assistant platform surfaced nearly 1 million clinical recommendations to clinicians and flagged more than 200,000 potential care gaps for action. Clinicians that use the Clover Assistant grew 43% year- over- year to approximately 3,000 in the fourth quarter, and on average, the platform aided physicians in managing more than 35,000 care plans per month.
By leveraging the Clover Assistant platform, we believe we can raise the level of care given by every provider and rapidly and broadly scale in ways that traditional managed care plans and risk-bearing provider groups cannot. This engagement translates to improved MCR. Not only is there a difference in MCR between members whose providers use the Clover Assistant and those who don't, but there is also a benefit from the length of Clover Assistant use. We measure this in terms of cohorts of when the physician went live on CA. For example, in service year 2021, our MA members with PCPs who went live on Clover Assistant in 2019 had a 2.7% lower incurred MCR than members with PCPs who went live on Clover Assistant in 2020.
Similarly, members with PCPs who went live on Clover Assistant in 2018 had a 4.9% lower incurred MCR than members whose PCPs went live on Clover Assistant in 2019. Further, the Clover Assistant is a key to unlocking non-insurance business lines. For example, in Direct Contracting, we principally scale our model of care by deploying physician enablement software to providers versus acting as an insurer. In these scenarios, we provide care coordination primarily through our software, the Clover Assistant. This year, we expect to have approximately 250,000 lives under management, with about two-thirds of these lives and two-thirds of our revenue to come from these non-insurance scenarios. We'll be talking more about expanding this non-insurance opportunity in the future.
Ultimately, we believe our success in fee for service is not indicative of anything program specific regarding Direct Contracting, but rather proof of our ability to provide software that allows any physician to be successful in value-based care. This has been demonstrated by our leading growth in fee for service, and we fully believe our software platform will be successful in other Medicare value-based models as well. We are highly supportive of innovation in the healthcare space, whether it be through new programs like Direct Contracting, Medicare for All, or Medicare Advantage as it evolves. In all these cases, the one constant, one that we feel we are well poised to address, is how do we quickly bring more physicians into these programs and make them successful.
We believe the Clover Assistant is proving to be this digital on-ramp onto value-based care, and we feel very confident about our ability to be successful as new programs launch and old programs are changed. With that, I will now hand it to Mark for the financial update.
Thanks, Andrew. I'm going to quickly cover the important items from the fourth quarter before handing it over to Vivek to wrap up the call. We delivered $432 million in revenue in the fourth quarter, up 160% year-over-year. This growth was driven by the launch of Direct Contracting and growth in our MA membership. As of year-end, we had approximately 129,900 lives under Clover management, and this was comprised of MA membership and Direct Contracting lives of 68,120 and 61,876 respectively. Moving to medical expenses, our net medical claims incurred for the quarter were $442 million.
Our GAAP MA MCR was 102.8%, up only 30 basis points compared to the third quarter, despite increased direct COVID costs of approximately 200 basis points, typical seasonal trends, and higher outpatient utilization, which has carried over into January and is something we'll be keeping an eye on. Also, our non-GAAP normalized MA MCR was 96.7% compared to 98.0% in the third, - year ago quarter. We recognized a net premium deficiency reserve expense in the quarter, equating to a non-cash net expense of $62 million. This was primarily driven by a $110 million reserve recorded for the 2022 financial year to reflect an estimate of the sum of future medical costs, claim adjustment expenses, and administrative costs exceeding related future premiums in 2022.
This was partially offset by the amortization of the remaining 2021 premium deficiency reserve of $48 million. Direct Contracting net medical claims incurred on a GAAP basis were $235.4 million, and our Direct Contracting margin was 103.0%, up only slightly compared to the third quarter due to seasonality and increased COVID costs relating to the Omicron spike in New Jersey and New York, both of which ranked at the top in terms of hospitalizations by state in early January. Excluding direct COVID costs and prior period development, non-GAAP adjusted Direct Contracting margin was 102.1%.
Fourth quarter non-GAAP adjusted operating expenses, which excludes non-cash stock-based compensation, SEEK and Clover Therapeutics from salaries and benefits, plus general and administrative expenses, were $77.5 million, representing 18% of total revenues compared to $46.8 million and 28% of total revenues in the fourth quarter of 2020. We expected adjusted operating expenses to grow at a more moderate rate and become a smaller portion of revenues as we scale and drive efficiencies, which is a key focus in our 2022 operating strategy. Our GAAP net loss for the quarter was $187.2 million. Our adjusted EBITDA loss for the fourth quarter was $154.8 million.
After excluding gross loss from Direct Contracting, PDR, SEEK and Clover Therapeutics, and normalizing our MA business for the MCR impact of COVID. Our normalized adjusted EBITDA loss for the quarter was $68.5 million. Clover had approximately 471 million total shares outstanding at the end of the fourth quarter, which includes the $52 million shares we issued in November as part of our capital raise. Our cash equivalents, and investments totaled $791 million as of December 31, 2021, and included $285 million in net proceeds from our capital raise. Now let me turn over to Vivek for some closing comments.
Thank you, Mark. Just to wrap up, we are excited about our expected improvements for 2022 MA MCR. In addition, we believe we will see another stepwise improvement in MA MCR in 2023. As it relates to operating expenses, we expect there will be only a moderate increase this year versus our Q4 2021 run rate, driven by operating leverage and efficiency efforts. There is much more work being done this year to drive further cost efficiencies, and because of that work, if a number of things fall into place, it is even possible we may be profitable next year on a non-GAAP basis, excluding non-cash expenses and non-recurring expenses. Our mission is to improve every life.
As part of that, I want to reiterate that we are very pleased with the CMS proposal that is now out for comment that lays out a path to narrowing the health equity gap around risk adjustment and stars. With that, let's take questions.
At this time, if you would like to ask a question, please press star one now on your telephone keypad. To withdraw yourself from the queue, you may press the pound key. Once again, that is star one on your telephone keypad. We'll take a question from Richard Close of Canaccord Genuity.
Yeah, thanks for the question. Andrew, I was wondering if you could go over that 250,000 lives again, in more detail. You said something about non-insurance, and I just wanna make sure I understand that.
Yeah. Basically, the way that we're looking at this is that, we have the insurance line of business, which is obviously Medicare Advantage, where we act as the insurer, and that you understand that business, obviously. In other areas which started with Direct Contracting in the fee-for-service space, we consider that to be non-insurance because we are not acting in an insurance capacity. We're not an insurance company. That's not how we're covered underneath sort of like, sort of HIPAA and regulations. We are actually signing business associate agreements with, practices and physicians, providing them with Clover Assistant and then helping them go at risk, within fee-for-service, with the government in a value-based program.
Where we're assisting physician groups and enabling them to go into value-based arrangements but are not acting as an insurance company, that's what we meant by that. The bulk of those are right now in the, obviously in fee-for-service and Direct Contracting, but we intend to look at expanding that business too by enabling physicians to go at risk in other programs as well.
Okay. Do you think you'll have lives in other programs during, you know, 2022?
Yes. We're very looking at this very seriously. It's something that we're looking at right now. If you want to think about it's quite straightforward for a physician who's already using Clover Assistant to have started with either fee-for-service and Direct Contracting or one of our MA plan and then bring that into other areas of their panel. We do want them to use Clover Assistant for as much of the panel coverage as possible. While we don't have any guidance around that, it is something we're looking at very seriously this year.
Richard, just to be clear, so you know, the breakdown of that almost 250 is 160-165 Direct Contracting lives and 84-85 MA lives. Sorry, 84,000-85,000 .
Okay, thanks. Andrew, I was wondering if you could talk a little bit about, you know, now that you have some scale with expected 160,000-165,000 lives on Direct Contracting, have you guys been successful in getting MA physicians essentially, you know, more interested in utilizing Clover Assistant? How has that worked, you know, since you're entering the third quarter of this?
Yeah, absolutely. What we're seeing here is that there are definitely synergies the more, as I referenced just now, the more lives that a physician can use to manage their panel using Clover Assistant, the better. It results in more of that development of software muscle memory and engagement with the platform. We definitely are seeing that. We track, you know, physicians who are using it for both fee-for-service and MA, and we're encouraged by what we see there. In addition, we definitely are going out and bringing in folks who are not basically in a region that's served by our MA plan.
I just wanna also emphasize that that's something that we think is very successful as well, is to be able to approach people on just the fee-for-service side and not necessarily on the MA side at all. We actually do believe that non-insurance segment could be a very fast-growing segment for us, as shown by our initial success in fee-for-service. There are certainly folks that once they start looking at our actual sort of success of Clover Assistant, that it's easy to integrate into their practice. We see that it's very quick to bootstrap them on that direct contract fee-for-service side. We can talk to them about moving onto at risk with either our own MA plan or with others.
Okay. I'll jump back in the queue. Thanks.
We'll take our next question from Kevin Fischbeck of Bank of America.
Hey, this is Adam on for Kevin Fischbeck. Couple questions. I think based on the MA MLR disclosure and commentary, you're kind of saying that you've baked in a little less COVID costs and probably most of the risk adjustment benefit. Are you basically saying that this 600-ish basis points of COVID that you're building into MA MLR, like if things are gonna come in better than that's all upside?
Yeah. This is Vivek. Are you asking specifically around the guidance side, the 95%-99%?
Yeah. You've guided to the GAAP MA MLR, and you said you built in slightly less COVID costs. Just wondering if the risk would be upside if it came in better than the 600 basis points-ish that you're implying.
Yeah. Well, yes. I can't remember the exact specific amount and if we guided specifically to the amount of COVID costs baked in, but in our last earnings call, we did talk about baking in a few hundred basis points of COVID impact this year. Again, we're not delineating specifically between kind of risk adjustment portion or pent-up demand or just increased utilization driven by COVID impact. But, you know, to your point, if COVID subsides and there was an impact over this year, that technically would be upside.
All right. Thanks. I guess, not sure how much you have to say about this, but there's just been some controversy around Direct Contracting in the headlines. I'm wondering if you have any thoughts. Also, you guided to slight improvement in MLR year-over-year. Is it fair to say, you know, any adjustments are unlikely to actually be impactful to earnings given that it's largely breakeven in the near term?
Yeah. No, great question. Andrew, if you just wanna hit maybe kind of our perspective on Clover's direct contract, and I can add some follow-up.
Yeah, absolutely. You know, obviously, Direct Contracting is something that's always being reviewed. As a CMMI program, the government is entitled to review this. But what we believe is there's definitely a focus on bringing more physicians into value-based care, and this is something that's just as applicable on the traditional original Medicare side as well as in Medicare Advantage. We definitely believe as a company that it's a consumer choice, a legitimate consumer choice for someone to pick original Medicare, and that may be with or without Medicare Supplement, or they might pick Medicare Advantage. Our goal is to provide Clover Assistant in either of those scenarios.
Right now, we access the original Medicare market through the Direct Contracting program, but there have been other, you know, forms of value-based contracting between providers and the government before, whether it be like MSSPs or similar ACOs and similar structures. We believe that's gonna stick around a while. Value-based care is around for a while. What's really necessary is so many physicians have been unsuccessful, have not been able to move into value-based constructs, which are better ways to create better outcomes at lower cost, and Clover Assistant is a way for them to do that. We feel good about the success we've had. We believe that we're accessing a part of the market by helping physicians with our software platform who need the help and who are not getting that help from others.
We believe that's a durable value that we are providing.
Just to kind of add to that, when we go back to kind of the original founding vision of Clover, it really was always about how do we enable clinicians to make great decisions at scale, and that's the Clover Assistant, our software platform. We made a very intentional decision that we felt we could build the best software inside of a wholly owned insurer, in this case, an MA plan. We don't think the debate around payment models is gonna slow down. I think it's only gonna accelerate, whether it's Medicare for All, Medicare Advantage, Direct Contracting.
We're generally agnostic long-term to payment models, mainly because the vast majority of our R&D effort doesn't go into the payment model side, but very much around clinical decision support and how do we help physicians make great clinical decisions on a day-to-day basis. That demand, I think we're at the very early part of that demand curve. As we kind of look out over the next five- 10 years, that's really where the big business opportunity, clinical opportunity, consumer opportunity is really developing that platform and making that much more powerful.
Yeah. That's a fair point. And then my last question would be around the commentary around MLR improvement into 2023. Was that mostly in reference to stars coming into your, you know, P&L, the benefit from 3.5 stars? And then given some of the leeway that CMS gave those plan rated years in 2023, I was wondering if you can remind us about the confidence level in maintaining at least 3.5 stars into 2024. Thanks.
Yeah. From a guidance perspective, our original guidance was to have three stars for payment year 2020. We ended up with 3.5. Our guidance for 2021 was 3.5 stars. Nothing has caused us to change that guidance that would affect the payment year 2024. As it relates to looking out past this year and into 2023, I think one of the things that is unique to Clover is Clover Assistant is constantly improving. There's actual feature iterations happening every three weeks or so.
That by definition we feel good is gonna cycle into impact throughout the course of this year and definitely the next year. Beyond that, in terms of actual clinical programs, one program that we stood up at the very beginning of this year as part of our in-home primary care program is a palliative care program that this is the first time we've launched that as part of our in-home primary care program. Couple that with what we started to execute on towards the back half of last year on our partnerships with Thyme Care and Cricket Health in oncology and chronic kidney disease respectively. We expect to start having an impact, you know, going into next year as well.
There's a multitude of other programs that may have more of a modest impact, you know, beyond getting to kind of the stars improvement impact to next year.
All right. Thank you.
We'll take our next question from Jonathan Yong of Credit Suisse.
Hi, thanks for taking the question. Appreciate the commentary on MA and the advance notice. I guess when you think about 2023, how are you thinking about benefit design kinda moving forward? You obviously have rich benefits already, so I guess given some of your larger peers are thinking about going back into the market a little bit more heavily, you know, how are you thinking about that competitive landscape and, you know, if you have to redesign your benefits a little bit more in 2023?
Yeah. I think if you just take a step back and if you look at where the growth has been in Medicare Advantage over the last, particularly the last five years, it's really been on the PPO side. I don't have the numbers in front of me, but I think the growth rate for PPO versus HMO plan segments has probably been double, maybe even more than double. When you look at kind of the incumbent plans that you're probably referring to, their HMO book of business is twice that of their PPO book of business, but is growing at a much lower level. When they think about driving gross margin, it's really on their HMO side.
They don't really have the capabilities to drive attractive gross margin at scale on their PPO plans for a multitude of reasons. Their models are very much generally tied to having strict control around the network, and really using kind of that stick approach. The vast majority of our business on the MA side, 90% plus, is on the PPO end. You know, irrespective of what competitors do in terms of pouring dollars additionally into benefits, they still have to go up against the option of flexibility. You can make an HMO plan more attractive, but you're still competing against, at least in the markets we're in, an attractive PPO model where that's actually our core business.
If we fast-forward, you know, to next year, the year after, and so forth, the incumbents are getting into a business model that they're not actually well-equipped to execute well on, which is a world of choice and network flexibility and technology. We feel very good about continuing to invest in building a great PPO plan model, but again, powered by the Clover system. I think taking a step further, you're absolutely right. There is definitely, in terms of your initial point, a huge gap between our plan design attractiveness versus the competitors. You know, we're still, though, in the very kind of early stages in terms of thinking through bid design, how we wanna adjust that and which markets we may adjust that in.
I think a lot of work to do there between now and bid submission or in the May timeframe. You know, in terms of thinking about balancing growth versus MA MCR, it's very much top of mind, something we're super focused on. You know, we made reference in our earlier comments around, you know, if some things fall into place, there's definitely that potential on a non-GAAP basis to get to profitability next year, and MA MCR is definitely gonna be a huge lever towards that.
Okay, great. Just going back to DC again, kind of on turning around the program, I guess. I guess, are there any steps you're taking in case there are, you know, significant changes to the program? I understand that you're obviously gonna continue to build out the software and develop it as needed, but I guess, is there any contingencies in case there are major changes to the DC program? Are you looking to go into the other ACO programs perhaps? Anything of that nature?
Yeah. Without speaking to specifics, because obviously we just wanna see what the CMMI decides to do here before we react too much, for obvious reasons. Yes, we believe that we want to serve as large a portion of a provider's Medicare panel as possible. That includes fee for service and original Medicare. That can be through Direct Contracting program, but there will be programs in this area that we can move into, as well as being able to serve across the Medicare Advantage gamut, whether or not we're the risk-taking entity or not. That's why we're thinking of it as our non-insurance businesses, where we're not playing the role of the insurer.
I think when you look at our success in Direct Contracting and our rapid growth there, that's just a sign of the demand and the fact that we're in that blue water market and have access to this very large TAM, where everyone else is sort of competing for a very small number of sophisticated providers who know how to go into value-based programs. And that's fine. That's sort of like, you know, people can compete over those providers. We're able to access the majority of providers who need help going into these programs, haven't been successful in the past, but with Clover system can be successful. That model, we are sure is going to continue to exist and the need for that will remain in the fee for service world as well.
We don't think we need like a direct backup plan here, but we intend to stay in the fee for service market.
Okay, great. Just last one. You broke out the cohorts for your MA MLRs. I guess if we think about that from the DC side, should we expect kind of similar improvements in terms of cohorts? You're obviously adding a lot this year for 2022. I guess, you know, should we expect, you know, 10 or 100 basis points improvement on the 2021 cohort? You know, how should we think about the 2022 cohort coming on? Just any color around that?
Yeah, very fair question.
Sorry, go ahead.
Yeah, I was gonna say, I think it's a little too early for us to actually look at this right now. Very fair question to ask, but we need more data to do that cohorting. DC and MA are obviously different programs, similar and almost identical in terms of clinical care, as Vivek pointed out. One's a benchmark-based program, one is a capitated program, right? We wouldn't expect identical, just 'cause the dollars flow through slightly differently. We'll share more as we actually are able to track and create those cohorts.
Great. Thanks.
Thank you. We'll take our next question from Gary Taylor of Cowen.
Hi, good evening. Just a couple questions, if I could. I wanted to go back to Vivek's comment that could actually be non-GAAP profitable in 2022. I just wanna make sure I'm understanding the point there. If we take the midpoint of your MLR and revenue guidance and your G&A number, I think it implies an EBITDA loss of roughly $240 million. To flip that even to break even, you'd have to outperform your MLR by 750 basis points or so. Am I kind of in the ballpark on those numbers? And is that MLR piece what you're describing as sort of the key way that profitability could be plausible for...
When you went next year, do you mean 2023 versus, maybe I'm off a year, and it's 2023 versus 2022, but just to clarify that.
Yes. No, meant 2023. Just to your point.
Okay.
Around MLR. Obviously there's two parts of a P&L. There's the revenue line and then you have the expense line. I think, you know, as you've seen, there's been a top-line growth component this year versus last year. If we kind of look at next year, we expect growth again. You know, one of the things, you know, Gary, given that you've spent kind of the vast majority of your career with managed care organizations in terms of researching them, I think you're pretty familiar that kind of a typical OpEx as a percentage of aggregate MA premiums is anywhere from kind of 8%-12%, depending upon the size of the plan. You obviously see we're well above that.
It's not rocket science, you know, past a certain size organization to be able to right size leveraging growth in terms of operating synergies to get there. That's a big prong. There's a ton of efficiencies we have ahead of us to be able to achieve, particularly on the technology side and the synergies across different lines of this MA and beyond, as Andrew referenced. On the MLR side, again, kind of few parts of the equation. There's definitely the MCR side on MA, but, you know, I'm gonna, you know, resist on giving you any specific guidance around that, given there's lots of different paths to that.
Again, you know, we described it as real realm of possibility, and we do think it is possible, but we're not necessarily guiding to that.
Got it. Do you have a parent cash figure for us at the end of the calendar year?
I think total cash, I wanna say, was around $800 million, but Mark can correct me.
For the end of the year, I don't have a number I can share at the moment.
Gary, we'll get back to you on parent.
Okay. We'll look for it in the K then. Last one for me. Can you just describe a little bit about how you've grown the Direct Contracting? So you've raised guidance, you know, twice, in terms of your enrollment there for 2022. Could you just break out how much of that enrollment's coming in through claims alignment versus voluntary? And then really is your strategy around, you know, is there a per visit financial incentive for the physicians? Is there a profit split? Is it really the attractiveness of getting to use, you know, Clover Assistant? I'd like to see sort of the breakout of claims versus attribution, but just sorta how are you finding the success of signing up these physicians as participants under your DCE?
Yeah. Thanks, Gary. So basically, I don't have the exact number, but the heavy majority of it is coming through claims alignment, and that's part of our strategy here. The reason is that the success we're coming from is we go to existing physician groups, like I said, who want to move into—largely, they've been on fee-for-service. Maybe they've tried to put their toe in the water with value-based contracting, and we say to them, "We can help you move into a value-based contract, and be successful in that." We are actually having a B2B, a business to business motion there, where we contract with an existing physician and then their lives move into the DCE as claims aligned lives. The normal methodology.
This is as opposed to other models which are heavily relying on voluntary alignment, which means that they're trying to switch folks oftentimes because by definition, if they were claims aligned, they would be claims aligned. If you need to use voluntary alignment, that means that you actually didn't have the plurality of claims from last year, and you're trying to switch them into your practice. There's no switching required for us. We just get the people who are already seeing these PCPs, and that's how we're able to grow so rapidly, basically.
Yes, we have a similar model to MA, where we have an economic structure where they are able to predict and say, you know, "This is how much we were earning before." We give them extra compensation around, like, Clover Assistant, just like we do on the MA for the time and the effort they're using to provide value-based care, and then we move onward from there.
Thank you.
We'll take our next question from Whit Mayo of SVB Leerink. Your line is open.
Hey, thanks. Good afternoon. I wanted to go back to sort of an industry development that's occurred in the last year with CMS enhancing a lot of the compliance around third-party marketing organizations, and there was a notice that was issued, I wanna say October 8th, that, you know, I think created a little bit of, I don't know, some anxiety and some concern among certain carriers as to how they were supposed to comply with some of the mandates that CMS had. I guess, Vivek, I was hoping to get just your overall perspective and view on what happened and how Clover responded. Maybe I'll just stop there to get your response.
Yeah, that's a great question. We're very supportive of, particularly the recent efforts by CMS to create a much higher bar and compliance requirements around third-party marketing. I think, you know, we've seen a lot of third-party organizations sort of pop out of nowhere over the last many years, really just trying to generate leads and selling leads to various organizations. We do think it creates a lot of confusion in the marketplace. Consumers don't generally know always what they're signing up for. It's no secret that churn is meaningfully higher with those strategies than kind of the normal word-of-mouth or independent field agent type approach, and that churn's higher because there's confusion in the sales process.
You know, we're definitely bearish on kinda all those models that aren't taking a very sophisticated approach in really trying to explain plan options. I think suffice to say, you know, I think we would expect to see continued rules and regulations on gearing MA to make sure it's serving its kind of intended purpose and following kind of the policy intent. I think this just is another example that you know, we referenced in our opening remarks, some of the meaningful proposals that CMS is making around health equity that can impact risk adjustment in a way dramatically to help those that are most in need. I think this, that's just another example of that.
I expect those types of changes and proposals to accelerate. Andrew, I don't know if you have any other comment for that.
Yeah, real quick, just quick on that. I think Vivek covered the main points. A couple different things is, you know, we talked about this in the past, but we've had less exposure to some of the online brokerages, and then as well, as Vivek said, to the field marketing organizations where there's been a bit of a game, we think, that's been built up to use marketing dollars routed from managed care plans into these organizations to sort of bypass the caps that are provided on broker commissions, which is obviously not in the spirit of the regulation. Very pleased to see that closing down.
On the electronic side, we have definitely seen, again, as Vivek alluded to, high churn coming from those particular lead sources as well as a very rapid race to the top in terms of cost per lead. Again, we are sold by those electronic brokerages too, but our exposure to them has been significantly more limited than other managed care plans. I think that's probably why you saw our success in this prior AEP. We're pleased with our success in this prior AEP.
Got it. One follow-up question is just as you sort of reflect back on the 2022 open enrollment cycle and looking at some of the growth that you've had in some newer markets, and I guess I should say not newer, but not your legacy core New Jersey markets. But what lessons were learned in terms of the receptivity, the benefits, what the plan design looked like? I mean, when you look at some of the success stories that you guys have internally, what do you think was resonating, you know, out in the field with brokers, with consumers? Just anything that would be helpful for us. Thanks.
Yeah. Great question. So I think, I mean, I know Andrew has some thoughts on this as well. I'll throw in a few. You know, I think from our initial sort of readout from a lot of the conversations we've had is, you know, Clover from day zero, it has just been a very transparent organization, to individuals who are selling MA plans, in terms of consistency around benefit design, being easy to engage with, and I think importantly, driving, you know, when we think about the plan design feature, driving true flexibility in network choice. We're a broken record on that point.
I think to kind of Andrew's point, you know, all this AEP really showed is that we've been able to maintain an attractive growth rate by sticking with our core principles of making sure it's a very pure sale process. Individuals selling Clover know what they're selling. Making sure consumers are picking the right plan for them, irrespective whether it's Clover or another plan design. Leading with choice, leading with PPO. I think, you know, it's gonna be a bigger and bigger and bigger struggle with any organizations that lead with HMO, where the majority of their margin or business side is driven by HMO, they're gonna struggle. Nothing's gonna change that trajectory on a go-forward basis. That theme is just only accelerating.
I think we're now getting to that point where it's surfacing into some of the results that investors are seeing, public market investors. You know, kind of Occam's razor, you know, sometimes the most simple answer is basically what's happening, which is HMO is just not what people want.
Yeah. Really the corollary that I have to this question, and I'll stop, is just any way to frame or size the coverage that you have within these newer markets with Clover Assistant? I guess, you know, the key is to deploy the technology, get it in the hands of your physician partners. Where do you stand today in terms of the adoption levels and that physician engagement? Thanks.
Yeah, absolutely. A great point, and I think we can share some stats. I don't think we've publicly shared them yet, so we'll think about doing that. A great feedback there. Qualitatively, the way we think about this is, obviously, having access to Clover Assistant physicians is core to our model. It's something that we think every single one of our members, whether it be on the fee for service side or the MA side, is entitled and deserves great data-driven primary care. We always make sure that folks have CA doctors they can go to. It takes a little bit of time sometimes for us to see where our new membership is going.
Where we're growing very rapidly, like in our newer markets, we obviously have a majority of newer members. It takes a little bit more of a time for us to find out where those doctors are and go and talk to them about working with Clover, getting on CA, et cetera. We tend to have CA coverage up front when we build our networks for adequacy, and then we build out the networks throughout the year as we see it in our data, where our members are going. More to share on that in the newer markets, but that's certainly the trend we've seen in you know, the core markets of New Jersey and what we're replicating in places like Georgia as well.
Yeah. Thanks, Andrew.
We'll take our next question from Jason Cassorla of Citi.
Great. Thanks. Good evening, guys. Great. Thanks for taking my questions. Just really quickly, around the incremental 10 states that you're entering in for the DC program in 2022, will those new states help inform you in terms of how you think about MA state and county expansion for 2023 and beyond? Or is there any way you can kinda like help frame that at all? Thanks.
Sorry. You said the DC states framing MA expansion, is that what the question? Just make sure I heard it right.
Yeah, you had an extra 10 states. You're going into 10 states. You're in 10 states in 2021. You're going to 10 states in 2022. Just thinking about if those new states will help frame the way you're thinking about the expansion.
Yeah. The way I would think about this, which I think is a useful framing here, is that previously when we just had MA, in order for us to sort of like test out a new market or a new state, we had to build a network, do adequacy, do the bid, which was, you know, we were fine doing that, and we've been showing that we're very good at that actually by our expansion rate. But there's material overhead in terms of resources, operational costs, like Vivek said, to do that. With something like Direct Contracting, we're able to much more easily work with physicians directly in any given state, and we don't have to necessarily have all that overhead of building the network, et cetera.
That does give us meaningful signal earlier. I think, I'm not saying that we won't also sort of test out markets with MA. It just allows us to have higher conviction before we do that, by testing the waters with some of our physician partners on the fee for service side first.
Got it. Okay, thanks. That's really helpful. Maybe just shifting over to MA. I mean, you're talking 26%-27% MA growth year-over-year on average. Is there any way to help delineate the attribution of that growth between existing counties and the, you know, call 101 new counties for 2022? Just any way consideration around that would be helpful. Thanks.
Yeah. I can't remember what we publicly shared here, so we can make sure that we're consistent and get you more information. But what I'll say is that we're definitely very pleased with our growth in the core counties as we've always been in New Jersey. Then we've also talked about how we've been quite happy, and we have some slides on this that we shared at conferences and things like that Georgia is absolutely pacing along the historical growth path that we've seen New Jersey grow along. We have markets sort of like where we're landing still establishing our footholds. We definitely think that you know, our core markets in New Jersey are, I wouldn't say they're mature yet, but we've always done well there.
Somewhere like Georgia, where we've shown that the New Jersey playbook is working well and is on a, you know, obviously a couple of years back, but growing in a way that we saw with the Jersey markets. We're pretty happy about that.
Got it. Thank you. Just really quickly a follow-up on that comment around Georgia. I mean, that's definitely coming in. I think, you know, latest enrollment shows around 12,000 members in the state. I know you talked about replicating what you did in New Jersey and Georgia, but maybe just really quickly, the thought process around jumping into Georgia specifically and then, you know, what's kind of helping to drive that outsized growth relative to your expectations from before. That's it for me. Thanks.
Yeah, absolutely. You know, we're very data-oriented. I think someone else alluded, we've been in. We tend to have a land and expand strategy with MA. With DC, we have more opportunities to do the land as well, a little bit more flexibly and cost efficiently. As we look at signal on the market, we look at networks, there's not any one thing, certainly other plans. I do think that it's a combination of the provider landscape locally, the benefits we can offer, but very centric on do we think we can offer very, very strong PPO in this market and provide that network choice that Vivek was alluding to. It really is all about that.
I think that, you know, we try to emphasize this because so few other MA plans will emphasize the wide network because narrow network is a priority. Certainly, you know, most people coming out of commercial are understand that you pick the HMO when, you know, you wanna compromise and have a narrower network in exchange for some cost savings. In general, if you can have it, you want the PPO. I think that thinking carries over into Medicare as well. People are just been trained that you get these narrow network HMO MA plans, but the PPO is the more desirable product. As long as we have people thinking about that's really the core of what we've always believed, that's that choice is good.
What we're also seeing to add to that is that that resonates with physicians as well, right? Being able to work with Clover provides some de-leveraging from this sort of from working the large incumbents, helps them with their network negotiations a little bit. I think that also helps on the physician side.
We'll move next to Calvin Sternick of JPMorgan.
Yeah, thanks. I had a question going back to the cohort analysis. So I know it's not apples to apples exactly. It's the non-GAAP versus that, you know, 95%-99% GAAP MCR range you gave. But if I just think about the year-over-year improvement across the cohorts, I mean, presumably a big chunk comes from, you know, the earlier, or I guess your more recent cohorts from risk scores improving. But you know, as we think about the year-over-year improvement, how does that get allocated really across the different cohorts? Is it more skewed towards more recent cohorts, or does it come really through some of the more mature vintages?
Thanks. Let me answer this way, and you can ask a follow-on if it doesn't make sense. I definitely, when people start using Clover Assistant because we have the ML, the engine, the rules engine, because we look at total comprehensive body truth, there certainly are additional diagnoses, in the first year where we say, "Hey, have you thought about this? Have you thought about kidney disease? Have you thought about this?" You know, the risk factors. That results in risk adjustment, credit, through diagnoses. However, what we also see is that because we push for and insist on care planning for all those, which is appropriate from a primary care physician, that doesn't really actually increase that much into later cohorts.
Like, as a physician stays on Clover Assistant in later years, what we're seeing is that it's really the care planning over longer duration of time. 'Cause obviously if you catch CKD earlier, and you weren't thinking about that, and you're able to catch it with a lab test and plan for it earlier, that does move the overall med cost curve. It might actually increase med cost in the short term, but it'll smooth the med cost curve over a number of years. The increase from cohort to cohort within the same physician tends to be the effects, we believe, of the better care planning on med costs and not from something like risk adjustment.
Okay. Just one quick one on modeling. A couple of other companies have, you know, called out something, some stuff around, you know, MCR seasonality from COVID. I'm just wondering if there's anything that you guys have seen in your population so far, that would be notable as we were thinking about modeling out 2022. Thanks.
Yeah. I think one thing that the data's publicly available now, but it's a look. We're set up a little bit different in the sense that we look on the MA side. So a significant percentage of our members are in New Jersey. And so when you look at publicly available data, so you look at 2021 and even into January of this year, and you go back to 2020 as well, the state of New Jersey ranked number two in the country just behind New York of highest per capita COVID Medicare costs divided by total per capita Medicare costs. I think it was a few hundred basis points above the median.
I know we've gotten a lot of questions over prior kind of earnings calls around, you know, how is New Jersey different? Well, the data is now kind of pretty loud that it is pretty different in terms of the experience. We don't exactly know kind of the entire derivation of that. I think it's a little bit harder for us to sort of map to a COVID seasonality, given that, and we don't know what this year is gonna hold versus last year. We obviously assume it's gonna be a little bit of a lessened impact.
Got it. Thanks.
At this time, I would be happy to return the call to Derrick Nueman for the Reddit portion.
Great. We have time for a couple Reddit questions. The first question is, when will Clover announce a permanent CFO, Vivek?
We've been meeting some great candidates. I think, you know, a couple things as we're thinking about is we're obviously looking for someone to be with us for a long time. We're being pretty patient with our choice, and we're creating a pretty high bar. At the same time, Mark has done a great job as interim, and I think has given us, you know, the luxury of time of being able to be pretty patient with the choice. We've been able to bring on some great talent into the organization over the last few months outside of the CFO role as well. We've created a really strong finance team over the last kinda six months to a year underneath Mark.
Great. Next question: What other possible business pivots, fee for service, licensing software, expanding to new healthcare markets are you looking at? Andrew?
Yeah. I wouldn't call it a pivot. I think that we're very comfortable in the Medicare space right now, but there's a lot of room within that to get to that trillion-dollar TAM that we've always talked about, right? Our goal is to be the preeminent physician enablement platform within Medicare for value-based care. We started in MA. We brought back to fee for service, where we've been very successful, I think, in using our software platform to be able to enable physicians to come to value-based care in fee for service.
There are other places where it would make a lot of sense for us to enable them to do similar things, perhaps in their other MA plans, perhaps like, you know, with the areas like Medicaid, for example, which are very adjacent to Medicare. Plenty of room for us to be able to explore new models while staying very consistent and building on top of our current success.
The final question from Reddit, given our time constraints, is what new enhancements are being added to Clover Assistant in the near future? We'll turn it over to Vivek for closing remarks.
Yeah. You know, there are big features and there are small features, but what we're always doing is, like, just top of mind for me is constantly iterating and doing tests to see, like, everything down to the smallest things. For example, I know we're looking at stuff right now where we're making it easier for physicians to see, you know, data points that didn't come from their own practice. Maybe those are lab reports or maybe those are from other physician practices, and they wanna use that information to be able to, you know, aid in their own decision-making. We're making more of that data available. We're constantly building more integrations to pull that stuff in, and then making sure that's very easy to access in CA.
That's core to what we do, but even just saying something as simple as that, there's, you know, dozens of different sub-features underneath that that we could build to serve that particular need. Really excited about that we're constantly iterating, trying new things. Then we'll launch, you know, major new features probably like two or three times a year.
Great. Vivek?
Thanks, Derrick. So just to close, we appreciate everyone's time today. You know, in summary, we feel really good about where we are today, particularly our team, our growth, improvements to MCR, and in particular, lowering our OpEx percentage of revenues expected in 2022. Just reiterating what I said earlier, there's a ton of great work being done this year to drive further margin improvements. Because of that, if a number of things do fall into place, it is even possible we may be profitable next year on a non-GAAP basis when excluding non-cash expenses and non-recurring expenses. Enabling this is Clover Assistant, and that's providing us a true and growing technology moat while we're making a meaningful and positive impact on health equity along our mission of improving every life.
Thank you again, everyone.
This does conclude today's program.
Yeah.
You may now disconnect your lines, and everyone, have a great day.