Good afternoon. My name is Rachel, and I will be your conference operator today. At this time, I would like to welcome everyone to Oscar Health's 2021 fourth quarter and full year earnings conference call. All lines have been placed on mute to prevent any background noise. After the speaker's remarks, there will be a question-and-answer session. If you would like to ask a question during this time, simply press Star followed by the number one on your telephone keypad. If you would like to withdraw your question, press the pound key. Thank you. I would now like to turn it over to Cornelia Miller, Vice President of Corporate Development and Investor Relations, to begin the conference. Ma'am, please go ahead.
Thank you, Rachel, and good afternoon, everyone. Thank you for joining us for our fourth quarter and year-end earnings call, where we'll discuss our financial results, the benefits of our increasing scale, and reaffirm our 2022 outlook. Mario Schlosser, Oscar's Co-Founder and Chief Executive Officer, and Scott Blackley, Oscar's Chief Financial Officer, will host this afternoon's call, which can also be accessed through our investor relations website at ir.hioscar.com. Full details of our results and additional management commentary are available in our earnings release, which can be found on our investor relations website at ir.hioscar.com. Any remarks that Oscar makes about the future constitute forward-looking statements within the meaning of the Safe Harbor provisions under the Private Securities Litigation Reform Act of 1995.
Actual results may differ materially from those indicated by those forward-looking statements as a result of various important factors, including those discussed in our quarterly report on Form 10-Q for the quarterly period ended September 30th, 2021, filed with the SEC, and our other filings with the SEC. Such forward-looking statements are based on current expectations as of today. Oscar anticipates that subsequent events and developments may cause estimates to change. While the company may elect to update these forward-looking statements at some point in the future, we specifically disclaim any obligation to do so. The call will also refer to certain non-GAAP measures. A reconciliation of these measures to the most directly comparable GAAP measures can be found in our fourth quarter of 2021 press release, which is available on the company's investor relations website at ir.hioscar.com.
With that, I would like to turn the call over to our CEO, Mario Schlosser.
Good evening, everyone, and thank you for joining us. We have created something unique here at Oscar. We enter 2022 with strong tailwinds in our business and a clear strategy set for the years ahead. Building on our record-breaking growth, we remain focused on scaling operations and driving towards profitability. We are leveraging the technology we have built to reduce medical costs, to provide better clinical outcomes for our members, and to reduce our operating expenses. The healthcare system is changing towards consumerization, towards risk-sharing, and towards increased disruption by technology, and we believe we are delivering on a unique set of business proof points to capitalize on the shifts. We are well-positioned to deliver on our vision of making healthcare more accessible and more affordable for all. We are doing this through both our risk-based business and our +Oscar client relationships.
As you would recall, we shared some preliminary Q4 2021 results as well as 2022 guidance on January 27th. We will dig deeper into those metrics now. To start, Scott is going to take you through our Q4 and full year 2021 financials, and then I will come back and highlight the key themes for Oscar in 2022. For that, I would like to turn the call over to Scott.
Thank you, Mario, and good afternoon, everyone. Today, I'm going to walk through in more detail the 2021 results, and I'll reaffirm our 2022 guidance. Before I jump into the numbers, I'll call out three key themes that are emerging in our results. We are seeing strong traction gaining new members and retaining the majority of our existing ones. We have made great progress on efficiency with our higher scale, and there is room for more progress. Lastly, we see opportunities for MLR improvement. Turning to the results. We had a number of one-time items in 2020 that impacted our year-over-year results, the largest of which was a $52 million net risk corridor settlement, which was recognized in the fourth quarter of 2020. We excluded this non-recurring item from all of our 2020 key results, including adjusted EBITDA. Moving to membership.
We ended the year with approximately 598,000 members, an increase of 49% year-over-year, driven by growth in our individual, C+O, and Medicare Advantage books of business. Membership growth continued to exceed our expectations throughout the year as consumers continued to select Oscar's plans throughout the special enrollment window. Powering our growth, we retained more than 80% of our year-end individual members in 2022. Fourth quarter direct and assumed policy premiums increased 59% year-over-year to $873 million, driven by higher membership as well as business mix shifts towards higher premiums, Silver plans, and modest rate increases. For the full year, direct and assumed policy premiums increased 50% year-over-year to $3.4 billion, largely driven by the same factors. This represents more than 70% annual top-line growth over the past four years.
Our enhanced scale drove greater efficiencies across our businesses in 2021. Specifically, our Q4 2021 InsuranceCo Administrative Expense Ratio was 24.5%, an improvement of 12 points year- over- year, and our full-year InsuranceCo Administrative Expense Ratio improved 430 basis points year- over- year to 21.8%. Fixed cost leverage, variable cost efficiencies, and the elimination of the health insurer fee in 2021 drove the ratio lower year- over- year. Scale benefits also positively impacted our newest metric, our Adjusted Administrative Expense Ratio, which was 34.4% in the quarter and 28.9% for the full year. The full year metric improved by 560 basis points. Turning to medical costs. Our Medical Loss Ratio was 97.9% in the quarter, down 10 points from the fourth quarter of 2020.
We recognized $35 million of favorable development in the fourth quarter of 2021, driven by lower than expected utilization in the third quarter of 2021 and some positive prior year development. The full year MLR of 88.9% was at the low end of our guidance as utilization came in as expected, and we benefited from the favorable development. Compared to 2020, MLR increased 420 basis points year-over-year, largely due to higher net COVID costs and higher SEP growth in 2021, which was partially offset by favorable development. Let me spend a moment on COVID. Overall net COVID costs were in line with our expectations in the fourth quarter of 2021. We continue to see direct COVID costs being partly offset by lower non-COVID utilization.
Our overall combined ratio, which is the sum of our medical loss ratio and the insurance company administrative expense ratio, was 122.4% in the quarter and 110.7% for the full year. The full year 2021 combined ratio was essentially flat on a year-over-year basis as improvements in administrative efficiencies were offset by higher net COVID costs in the MLR. Our fourth quarter 2021 adjusted EBITDA loss of $164 million was $52 million better year-over-year, and for 2021 it was $430 million, an increase of $27 million year-over-year. In addition to the drivers impacting the MLR and the administrative ratios year-over-year, we had a release of premium deficiency reserves in 2021 versus an increase in 2020. Turning to the balance sheet.
We ended the quarter with over $2.5 billion in total company cash and investments, including roughly $740 million of cash and investments at the parent, and another $1.8 billion of cash and investments at our insurance subsidiaries. The new funding of $305 million that we announced two weeks ago provides us with strong balance sheet resilience as we start the year. We are also reiterating our 2022 guidance, which reflects the increased scale of the business and builds on the momentum we saw last year. This includes an expectation for more than 80% growth at the midpoint in our direct and assumed policy premiums to $6.1 billion-$6.4 billion, as well as 400 basis points of improvement at the midpoint in our MLR to 84%-86%.
I'd note that our MLR guidance assumes non-COVID utilization returns to baseline levels this year. We have had a strong track record of delivering high growth while still driving MLR improvement. Our direct policy premiums increased 70% on average annually over the past four years, and during that period, we decreased our MLR roughly 8 points. Excluding COVID, our MLR decreased 13 points since 2017 as we effectively absorbed higher membership while reducing medical costs. We're also seeing a step change in our +Oscar business results as we are expecting $65 million-$70 million of fee-based revenue in 2022. Our positive top-line momentum and increased scale continues to drive meaningful progress on our administrative expense ratios. Our Adjusted Administrative Expense Ratio has declined roughly 500 basis points over the past two years, and we're expecting another 300 basis points of improvement in 2022.
Importantly, the majority of these costs are in our control. All told, for 2022, we are expecting an adjusted EBITDA loss between $380 million and $480 million, which at the midpoint is roughly consistent with 2021 on an absolute basis. On a relative basis, this is roughly half of that of 2021, measured as a percentage of premiums before ceded reinsurance. Our larger scale is a tailwind for reaching our 2023 profitability target for the insurance company. We look forward to discussing this in more detail at our March 25th Investor Day. With that, let me turn the call over to Mario.
Thank you, Scott. I want to close with a summary of why Oscar is positioned for success in 2022 and beyond. I firmly believe that Oscar is the vanguard for the new way healthcare will be delivered in the U.S. We feel that we have found a model that works in consumer-driven markets that are best served with deep provider partnerships and with a frictionless experience. We see clear signs that more of the U.S. healthcare system will move further in this direction in the future. The ACA market has been a proving grounds for the value of this frictionless end-to-end experience in healthcare. Our innovative approach, which couples our full stack technology with industry-leading member engagements, resulted in a powerful open enrollment season. We saw monumental growth and record high retention rates.
To the point where today, approximately 1 in 15 ACA members are now served by Oscar. The value of the experience we deliver is also evident in our retention with just above 80% of our IFP members, 85% of the groups in Cigna + Oscar, with 90% in our latest co-branded +Oscar Medicare Advantage Plan staying with us year-over-year. Our fourth quarter 2021 Net Promoter Score reached 42 and remains meaningfully higher than the industry average of three. As we see it, our resulting growth to more than one million members is driven by our strong brands, by our member experience, and by our innovation in plan design and product offerings. Let me just give you a couple of examples for these product offerings.
We now have 40% of our members on a plan offering our Virtual Primary Care, which has made the Oscar Medical Group the number one or number two primary care group in every market where it is available. We also recently updated our Cost Meter tool, which can price claims in real-time and empowers the member with control and choice when it comes to their care decisions. It's these kind of offerings that enable us to price to achieve growth and improve margins for 2022, where we in fact increased our premium rates at the overall book level. In this past open enrollment periods, so for 2022, only 16% of all of our new initiations came from markets where we had the lowest price plan offering.
If you look at where membership is now, only 13% of our total individual membership is in markets where Oscar is the lowest price offering. Now, we're also successfully bringing our unique model to +Oscar clients, and the platform we have is delivering clear business results for them. Take Cigna + Oscar, for example. We pointed the platform at a different market segments, small group segments, and in one year we have had 9x growth to now more than 30,000 members, actually doubling from the year-end number of 16,500 members. Our broker NPS score in the small business segment is 66, which highlights the value our other stakeholders find in our frictionless technology.
We continue to build out this kind of +Oscar business, and we expect, as Scott said, +Oscar generates $65 million-$70 million of revenue in 2022. Our platform has key applications across the healthcare system. For example, one of our clients realized administrative savings of 20% by leveraging +Oscar. We are encouraged by our negotiations with prospective clients and look forward to sharing more details on this during our upcoming Investor Day. Now, to me, the best illustration of our path forward is the following. When we look across all of our markets, we generally see that the lower the Medical Loss Ratio, the higher the Net Promoter Score. In my view, there couldn't be a better illustration of where a more consumerized healthcare system is going and of how Oscar is going to deliver on our mission of making healthcare accessible and affordable.
Because that mission motivates us to deliver our business model of consumerizing healthcare profitably. Our growth today provides scale and operating leverage that we will harness to drive improved efficiency in our administrative costs and Medical Loss Ratio. A good early sign, by the way, is that despite our nearly 2x membership growth, we have swiftly met the demands of new members and are seeing higher member satisfaction scores year-over-year. That said, we still have plenty of ways to operate more efficiently and to leverage our provider and member engagement initiatives to reduce healthcare costs, and that's what we are focused on. In many ways, we are still a young company with meaningful improvement opportunities ahead.
To that end, over the last several years, we have added experienced healthcare executives to our bench, including most recently, former Chief Legal Officer at Everside Health and career-long healthcare executive, Ranmali Bopitiya, as EVP and Chief Legal Officer, and former Aetna CEO, Mark Bertolini, as strategic advisor. Before I close, I want to reiterate our strategic priorities for 2022 and 2023. First, we will continue to drive meaningful growth across our business, both for the insurance company and for +Oscar. Second, we continue to target profitability for our insurance company in 2023, and we are committed to becoming profitable at the overall company level over time as our businesses are reaching scale and we gain more efficiencies from our technology.
Now, finally, I want to thank the Oscar team for working so tirelessly during our first year as a public company to serve our members and work toward our mission of making a healthier life affordable and accessible for all. As we say here at Oscar, we're powered by our people, and I continue to be inspired by the creativity, the tenacity, and the dedication Oscar team members show every day. I'm very, very proud of what we can accomplish when we come together as a team. With that, I'll turn the call over to the operator for questions.
Thank you. As a reminder, to ask a question, you will need to press star and then the number one on your telephone keypad. To withdraw your question, just press the pound key. Given time constraints, please limit yourself to one question and one follow-up. Thank you. Please stand by while we compile the Q&A roster. Your first question comes from the line of Ricky Goldwasser with Morgan Stanley. Sir, your line is open.
Yeah. Hi, good afternoon, Mario and Scott. So my question is on the exchange enrollment that you've seen. I mean, clearly phenomenal results, significantly surpassed your expectations and ours. Can you just give us some color on sort of any contribution that you had from marketing or sales channels and how that helped you sort of achieve this milestone growth? Then also, as we look ahead to 2023, do you expect to see continued scaling, or do you believe that now you have the scale that you need, and from now on you're gonna focus on that kind of like margin expansion and MLR improvement opportunity?
Yeah. Ricky Goldwasser, great questions. Let me hit on both and then have Scott Blackley come in on the second question there as well. In terms of channels that members come through, I think we see a couple of different things. Generally, we grow in markets where we've got kind of the perfect mix of product design being right, networks being built well and provider partnerships, and ideally word-of-mouth and a brand as well. That's where it works best. Now, the other piece to this is the distribution as well. We have worked quite a bit with the broker channel in particular, and I mentioned earlier the NPS the brokers have when they work with us in our small group business, for example, because we're able to deliver fast turnaround times there.
We're able to help them deliver frictionless appeals to their members when they enroll, and that also helps us grow in these markets, in really all of our market segments. That's been where the focus has been. You really can't take any of these elements out of the equation, I would say. It's got to be the mix of products, network, brands, and distribution, and that then works best. Now, in terms of where we are as a company and what our focus will be, I really want to reaffirm these two strategic goals we have for 2022. One is to continue the growth in insurance company and in +Oscar, and we think we have a lot of runway ahead of us there.
We're only in half the markets for the care markets right now. You know, we're only in eight states for the C+O products. We have a ton of more runway ahead of us in delivering MA growth through Plus Oscar partnerships as well. We're gonna keep doing that. However, we have a great focus on making sure we target profitability insurance company next year. As I said, profitability of the overall company over time, truly as well. That is where right now a lot of our internal focus really is going, both MLR improvements and in the sort of efficiency improvements as well. Scott, do you wanna add more?
No, Ricky, I think that on that point, we'll be sharing more information about future plans at our Investor Day in March, so I won't jump ahead of that.
Okay. As a follow-up, if you think about +Oscar, Mario, you talked to the pipeline and the negotiations that you're having. Can you maybe kind of talk a little bit about what's sort of the profile of the companies in the +Oscar pipeline?
Yeah. You know, it really is the kind of three major segments we've talked about before, which is health systems who want to add more risk and go deeper into the risk markets, where we've seen quite a bit more people pick up their heads even just in the last 12 months. We have several of those examples in the pipeline right now. The second segment is health systems who already have a plan in the risk business, and there's examples of that in the pipeline as well. The third segment is sort of midsize insurance companies who are realizing that, as I said in my prepared remarks here, the healthcare system is inevitably going to what is demanding more frictionless and provider experience.
Where we can really help both take a minute to cut the costs out and enable them to put more innovative plan designs out there. All three of these are in the pipeline right now, and we're excited about both where that will go in the next couple of years, and how we can turn this increasingly from a business process as a service model towards a software as a service model as well, and also where we are for this year.
Thank you.
Thank you. The next question comes from the line of Kevin Fischbeck with Bank of America. Your line is open.
Hey, thanks for the question. This is Adam Ron on for Kevin. We were a little surprised by the fact that you weren't getting more SG&A leverage. I know we talked about this last time with the 2022 guidance, given that you grew revenue and membership at such a rapid pace. From here, would you expect most of the cost leverage that you're underwriting going forward to come from higher revenue on the same SG&A base, or is there actually a chance that, you know, on a dollar basis it could actually decline?
Yeah. Excuse me. Adam, thanks for the question. I'll start out by saying that I think that our greater scale that we're seeing in 2022 is going to help us to achieve better cost leverage on our fixed costs and our variable costs going forward. We can negotiate better costs with vendors. We have an opportunity to continue to optimize our operations and, you know, the opportunity for even further fixed cost leverage as we head into next year. You know, we certainly see opportunities on the cost side, beyond just what's available from increasing revenues into the future.
All right. Great. Then on 2023, if exchange subsidies were to end up expiring, do you think the overall marketplace would shrink? Would you be able to grow in that environment? If not, would that hurt your ability to drive that SG&A leverage and ultimately achieve insurance profitability? Also in that scenario, are there any offsets, like potentially lower membership, meaning better MLR?
Yeah, Adam, I'd say a couple different thoughts on this one. One is, we now have several different business lines that are growing, right? C + O, +Oscar deals and so on. So I do think we are diversifying ourselves in a sense there. That helps. The second point, though, is that, if you're looking for a company that has maybe had the highest volatility of regulatory environments, it might just be us over the last 10 years. I mean, we have lived through so many cycles of ACA on, ACA off, I can't even count them anymore. What we have generally believed, and I think this has proven out to be true, is that a benefit like now insuring 50 million+ people. It's very, very unlikely to get the clock turned back on.
In some shape or form, I would very strongly believe that these subsidies will remain in place or will be replaced by similar subsidies under a different name, perhaps. That's sort of like generally what we're assuming there. However, we have also lived through cycles, plenty of them, where, you know, silver loading happens and some CSR subsidies were repealed and things like that. We have fought through them and always improved throughout these cycles, which makes me very confident that, if somehow we had to deal with some upheaval there, we certainly could. I'd say the final point there is that we've been building our platform internally, partly because we want to be able to react quickly.
If there is a regulatory change, like for example, more testing reimbursements, that we can flip a couple switches and very quickly react to it, and thrive through it, really. I think that the same applies here. You know, if there's a new regulation, we'll adapt to it quickly. The kind of inevitable march of the healthcare system towards more consumerization, I don't think will be stopped by any of what might come our way there.
Just to pile on to your questions about efficiency and scale. I would just say this: one, you know, we continue to think that the company is built to be able to grow. Regardless of what we see on the growth side, we still think that there are opportunities to create additional leverage in our model. That means that, you know, we see opportunities of improving both fixed costs as well as variable costs. At the scale that we're seeing at 2022, you know, I'm anticipating that we will be able to, as I mentioned in another question, I am expecting that we're gonna be able to drive down vendor costs, that we are going to be able to continue to optimize our operations against that larger base.
That is going to, you know, even within 2022, we're starting to see significant fixed cost leverage, and I would anticipate that we're gonna be able to continue to deliver that.
Great. Thanks.
Your next question comes from the line of Stephen Baxter with Wells Fargo. Your line is open.
Yeah. Hi, thank you. Can you talk a little bit about how your breakout of metal tiers for the exchanges is kind of shaping up? I'd love to hear you give a reminder on where you ended up for 2021 in terms of your bronze and your silver mix, and then how that is shaping up for 2022. Any specifics there would be very helpful. I would also like to hear a little bit more about, you know, how you're thinking about your risk adjustment position as you move from 2021 into 2022, and how that's impacted by any of your product mix changes or just how you guys are thinking about things. Thanks.
Yeah. Steve, let me start with the metal tier mix, and then, Scott, you can talk a bit about risk adjustments. We talked about this in the IPO and even before that, but we were off the market average for quite some time with a higher book of bronze membership, lower PMPM, therefore a higher risk of a payout as well as a result. Part of our march towards profitability has been that we turn that dial towards higher PMPM membership, actually more chronically ill members as well, and older members, and more silver membership. I think we've done this really very successfully. If you trace just the last three OEs, we went from 37% silver in OE 2020 to 50% silver in OE 2021 to now 65% silver in OE 2022.
We had a very nice shift there really towards these higher PMPM silver plans. That's again, a mix of the same kind of factors I gave Ricky earlier, which is work with the distribution, different plan designs, branding, what we put into these plans and so on. That's been a really important shift there for us. You see this also continuously in the numbers and that the PMPM revenue always goes up, and so revenue grows faster than the actually head count, membership count there. We're gonna continue to pursue that swing that same way. Now, we also constantly change our plan designs in other tiers, and are very confident there that those plan designs can also deliver value, and have certain focus there as well.
Scott, you can maybe talk a bit about these as well.
Yeah. In terms of the risk adjustment, you know, we've seen strong performance in that line item. We've had you know, primarily positive adjustments on an ongoing basis. I would just say in terms of you know, RA as a percentage of direct and assumed premiums, I would expect that with the changing mix towards more Silver, we'll see you know, slightly improved RA as a percentage of that. I would expect to see. We saw some of that in 2021, would expect to see further improvement in 2022.
Got it. Thanks. Just as a, you know, quick follow-up or second question, just the fee-based revenue you're expecting in 2022, you know, any insight into how that's expected to ramp up through the year? Is expected to be a more even contribution? As we think about, you know, the contribution margin against that incremental revenue, I guess, how should we be thinking about the incremental margin or sort of the cost profile of that revenue as you bring it online? Thanks.
Yeah. On the fee-based revenue, you know, I would just say on fee-based revenue, we started the Health First contract on January first. That's going to be relatively stable throughout the year. Then in our Cigna + Oscar book of business, you know, that's an area where we're hopeful and expect that we'll be able to continue to ramp that up, and that'll drive fee-based revenue to increase throughout the year. You know, I would say that in general, it's going to be, you know, stable but growing throughout the year. On margin, look, I think that I would just say that we're expecting that fee-based revenue is contributing positive margin to the bottom line starting in the first quarter. You know, we're seeing that business generating positive returns and positive contribution to adjusted EBITDA.
Thank you very much.
Thank you. The next question comes from the line of Jonathan Yong with Credit Suisse. Sir, your line is open.
Thanks for taking a question. Thanks for the details on the percent that's in silver tier. I guess, is there something structurally difficult within the bronze mix where it's just more difficult to make money there? Obviously, one of your peers today called out that, you know, they effectively exited the bronze side of the tiers and moved all to silver. I'm curious from your perspective, given you have shifted more to silver, what is the structural issue there? You know, could you eventually re-expand into bronze, or is it really just all a silver game right now?
Yeah. Let me answer this with facts first. Bronze is a bit more structurally difficult to make money in. That part is true as compared to Silver for a couple of reasons. One is it is a lower PMPM number generally, right? You're a tier below. The second piece is that it often attracts more members, relatively speaking, who don't really utilize a whole lot, and that has two effects. One is it actually is worse for risk adjustments, again, relatively speaking, than having members who utilize sort of like average amounts in a sense. The other part actually is that those tend to also be members who have higher churn rates.
There is sort of like a chunk of the ACA marketplace that is more easily changing plans from year to year, and it's gonna chase the lowest priced plans. You know, in the past, that was maybe 15%-20% of the marketplace. It's hard to put a finger on, really. You have that membership a bit more concentrated in bronze as well. Now, those effects are not new. They've been in place for the past many years, and we've found a number of antidotes, I would say. We think that some of what we're doing in Virtual Primary Care is actually meaningful to build more attractive plan designs in bronze.
Some of what we're doing around certain deductibles and other plan design elements we have in our bronze plans has helped us shift up the PMPM of the bronze tier. Obviously, I think I mentioned last time that generally, even when you have a member who is not utilizing healthcare a whole lot, if we get that member into our digital interactions, we get higher retention rates out of them. About 6 percentage points higher retention the members engage with us digitally than the kind of the average book of business base in a year. That is not any different in the bronze plans either.
With all of these things together, you know, we're comfortable in that tier and have creative ideas what else to do there in the years going forwards.
Great. That's helpful. Then, you mentioned that you have an expectation of being at non-COVID utilization. It'll be at baseline levels. I'm assuming this is a bit more gradual over the year. Just wanna confirm that. Is there any view of deferred care stepping up as COVID subsides? Thanks.
Yeah. You know, with respect to the MLR, I would say a few things kind of looking at 2022. One, this year, as we've talked about, we priced for better margins. We're assuming that we've priced to cover cost trends, and we've priced for an endemic level of COVID spend. That's going to be a positive factor for us. Secondly, I would just say that when we think about COVID, as we've seen, you know, kind of Omicron starting to fade, and some of the effects of that dropping off, we are based on having an endemic level of COVID in our assumptions, you know, we are expecting that we'll see utilization from non-COVID sources normalizing throughout the rest of the year.
At this point, you know, again, I'm anticipating that we're gonna have about, on a year-over-year basis between 2021 and 2022, we'll have about, you know, 400 basis points of improvement in the MLR, primarily driven by COVID to a lesser degree, some of the SEP things that we saw. Then we also have opportunities in the MLR from some structural advantages of scale and having a larger membership book. We think there's some other opportunities for us to continue to drive improvements as well. Those are kind of the key points that are gonna drive the year-over-year change.
Yeah. I'll maybe add two more data points that I find interesting. One is that we have not seen a lot of catch-up care, as I think we talked about in the past as well. If we look at that number and refresh that, then the metastatic cancer rates, for example, and cancer diagnoses have been very much on the same level in 2019, 2020, and 2021. There's not a lot of evidence there that somehow disease burden's getting worse because care has to get caught up to. The other point we pointed out last year is that SEP members, when they came in last year, they tended to have a bit higher ER utilization early on, bit higher preventative care utilization early on.
You know, you can wonder if they are sort of a different segment of the market, of the market now suddenly coming in there, and what will that do? One new data point we have there is that the retention rate on those SEP folks was actually the same as the retention rates into this year of the non-SEP folks last year, about 80% as we talked about. I would say that is at least a data point that the population is not that different. Like, behaving similarly, and therefore, you know, not a lot of evidence there that will be the catch-up care either. Obviously gonna watch that very, very closely.
I think we can do a fair amount on that also with our engagement on the members, with the provider enablements, and so on.
Great. Thanks.
Thank you. The next question comes from the line of Josh Raskin with Nephron Research. Please go ahead.
Thanks. Good evening. My question is around consumer engagement. Mario, you were talking about this, and I'm specifically interested in the digital engagement on the consumer side. Can you give us a sense, and I think you gave us some data when you guys were going public, but can you give us a sense on differences by demographic and if that's changing at all, or any expectations in 2022? Are you finding a correlation? I heard the NPS correlation with digital engagement, but is there an MLR correlation that you guys are seeing in terms of those that are, you know, digitally engaged versus not?
Yeah. Just so in terms of statistics, you know, we've talked in the past about how members who create a digital profile, for example, got 80% in the fourth quarter of last year, and that's still been around 75%. Obviously, yeah, that's probably influenced by SEP, where we need always some time to kind of create that digital engagement for people to come in. If you look at mobile app downloads of membership base, we still have a much higher mobile app download rate there when we last refreshed this a few weeks ago than pretty much anybody else out there in the health insurance industry from what we can tell. So look at kinda App Store numbers and things like that there.
That's how we drive engagements. Where we see. In terms of how that looks across the age ranges, there is an impact. You have in the 56 to 64-year-old segments, probably about 25% or so lower digital engagement as compared to the younger segments there. If we then look at the overall engagement with Oscar, that tends to be pretty similar because they then end up having more conversations with their consumer teams, for example. You know, the other nice statistic that I mentioned in the last earnings call that I wanna reiterate as well is that if you look at all of the conversations we've had with members since the beginning of this year, right?
This is, again, obviously doubled membership, and we got a year older on average membership base, shifted more toward Silver, chronically ill and so on. If you look at all those conversations—say, beginning of the year, 40% of those conversations were digital, meaning in secure messages between the care guides and the member through the mobile app effectively or the website. That's, I think, also a very powerful proof point there that even a new segment in a sense or a new membership base, we can right away get some engagement there. Final number that I think is very interesting is that we just do a lot through outbound engagement as well. The latest number I have there for you is that on a weekly basis, there's about 25,000 members who engage with one of our outbound messages.
You know, this can be email campaigns, text messages, secure messages in the mobile app and things like that. I think that's all very consistent. Now, the impact on the MLR, we like to really look at in more sort of like nuanced detail there and trace it through directly. One piece of data we have there now is that when you look at the members in virtual primary care plan designs, the number I gave, I think last time, was that about 44% or so of those members say that they didn't have a PCP before they came on board with our essentially virtual or the Oscar virtual PCP. We are seeing impact there on the total cost of care on a monthly basis.
That is coming through, for example, by having referrals to the better, more efficient downstream specialists, and by kind of some other moves in shifting more towards drugs that are more effective and efficient from a cost point of view as well. That to us suggests also that we have more of an opportunity there of getting that MLR down. That's kind of a couple data points for you there. We're gonna keep very closely working on that this year. As I mentioned, we're happy with how we've really grown membership base in the last couple of years, but at the same time really gotten goodness on the MLR as well. There really, in our view, is quite a bit of more opportunity of continuing to do that in the next couple of years.
Great. I think that MLR data would be super helpful to understand.
Yeah.
The engagement. Just a quick follow-up. Can you just remind me, and I know I should know this on the accounting side. The PDR was up in Q4 this year versus down last quarter. Was that indicative of any change in expectation for 2022 over the last three months or why what was the difference there?
Yeah. You're right. We built PDR in 2020. You know, obviously, that build was related to our expectations for 2021. In 2021, we had a smaller PDR, so we had a release of reserves. I would just say in general two things. The PDR that we had in 2020 was kind of split between individual and MA. As I look at the 2021 PDR, that's really related more towards our non-individual businesses. You know, I think it just really represents the fact that as we are seeing better performance across our book, you know, we're certainly getting more scale as we've talked about that results in, you know, fewer plans that have an efficiency reserve related to them.
That's really the driver of why you see a lower PDR at the end of 2021.
Gotcha. There's still a PDR accrual. It's just the change in the amount of accrual that got better.
Exactly.
That's the way to think.
You got it.
Yeah. Yeah.
Again, the balance sheet, we had $85 million at the end of 2020. We've got about $29 million at the end of 2021.
Thank you. This will be our last question, and it will be from Nathan Rich with Goldman Sachs. Please go ahead.
Hi, good afternoon. Thanks for the question. On the MLR, Mario or Scott, could you update us on what you've seen in the cohort data and how MLR tends to trend in, you know, the second and third years that members are with you? Relatedly, is there a kinda target level of MLR that you feel like the business needs to achieve to reach profitability for the InsuranceCo?
Yeah, you know, with respect to the MLR, we certainly have, you know, data about how membership is, you know, how that performance accrues over time. You know, I would say that, there's actually not a huge amount of difference in the near term as you see members in the first year, there's a little bit of a lull as those members are onboarding and getting into their, you know, routines with their physicians and pharmaceuticals, et cetera. And then, you know, that starts to stabilize over time. Nothing in the near term there that I would call out.
On a broader perspective, you know, if we think about MLR in general with that new population, you know, I think that we feel like this is a population that we have, you know, pretty consistently been able to grow and see these kinds of new members come into the book, and we've got good experience there. You know, our track record gives us confidence that we're gonna be able to continue to bring on these new members, and manage that MLR.
Okay, great. Thank you.
Thank you. This concludes Oscar Health's 2021 fourth quarter and full year earnings conference call. Thank you for participating. You may now disconnect.