Good afternoon, everyone, and welcome to the P3 Health Partners third quarter results conference call. Currently, all participants are in a listen-only mode. Later, we will conduct a question and answer session, and instructions will follow at that time. As a reminder, this conference is being recorded. I will now turn the conference over to Karen Blomquist, Vice President of Investor Relations of P3. Please go ahead.
Thank you, Operator, and thank you for joining us today. Before we proceed with the call, I would like to remind everyone that certain statements being made during this call are forward-looking statements under the U.S. Federal Securities law, including statements regarding our financial outlook and long-term targets. These forward-looking statements are only predictions and are based largely on our current expectations and projections about future events and financial trends that we believe may affect our business, financial condition, and results of operation. These statements are subject to risks and uncertainties that could cause actual results to differ materially from historical experience or present expectations. Additional information concerning factors that could cause actual results to differ from these statements made on this call is contained in our periodic report filed with the SEC.
The forward-looking statements made during this call speak only as of the date hereof, and the company undertakes no obligation to update or revise the forward-looking statements. We will refer to certain non-GAAP financial measures on this call, including adjusted operating expense, adjusted EBITDA, adjusted EBITDA per member per month, medical margin, medical margin per member per month, per medical margin per member per month for persistent lives and cash burn. These non-GAAP financial measures are in addition to and not a substitute or superior to the measures of financial performance prepared in accordance with GAAP. There are a number of limitations related to the use of these non-GAAP financial measures.
For example, other companies may calculate similarly titled non-GAAP financial measures differently. Refer to the appendix of our earnings release for a reconciliation of these non-GAAP financial measures to the most directly comparable GAAP measures. Information presented on this call is contained in the press release that we issued today and in our SEC filings, which may be accessed from the events and investors page of the P3 Health Partners website. I will now turn the call over to Dr. Abdou, CEO and Co-Founder of P3.
Thanks, Karen, and thank you all for joining our third quarter 2023 conference call. I would like to update you all on our third quarter financial results, 2023 guidance, as well as provide preliminary 2024 guidance. I will start off with some few big picture comments. We are pleased to be able to report that we are tracking towards our 2023 full year guidance as expected. Our overall momentum remains very strong. While our third quarter EBITDA is lower than anticipated by approximately $15 million, this is predominantly due to some timing elements impacting our EBITDA realization, which Atul will provide further details on shortly. The key point is that we expect about $15 million-$20 million of final payment for 2023 for 2022 data services to be realized in the fourth quarter, and that will drop to the.
Down to adjusted EBITDA. I'm also pleased to be able to report that our cash burn, defined as cash flow from operation, less CapEx for the third quarter, was $8 million, and we are on track to be cash flow breakeven in 2024, as previously discussed. We are providing a preliminary 2024 adjusted EBITDA guidance of $20 million-$40 million. The guidance range assumes $60 million EBITDA from Persistent Lives. That's our baseline. We will provide more detailed guidance in January 2024. Onto our third quarter and year-to-date highlights. Revenue for the quarter was $288 million, an increase of approximately 16% over the prior year's quarter, and year-to-date, revenue of $920 million also grew 16% versus the prior year period.
Medical margin for the quarter was $36 million, $126 million year-to-date, on track to meet our guidance of $155 million-$175 million for the year. Medical margin per member per month for the quarter on all lives was $115 per member per month and $135 PMPM on a year-to-date basis. Medical margin PMPM for our persistent lives was $241 PMPM on a year-to-date basis. That is consistent with the mature market range of $150-$200+ PMPM reported by our peer, agilon health, which we consider a valuable benchmark. Persistent lives are defined as the lives were on our platform in December 2022 and are on our platform in January 2023.
Medical claim expense PMPM for our Medicare Advantage lives were approximately -2% year to date. That is a reflection of the power of the P3 model and ability to bend the cost curve with more Persistent Lives on our platform. Adjusted EBITDA for the quarter was -$22.3 million, compared to -$40.3 million in the prior year. The $22.3 million includes the impact of a non-cash in the quarter, $3.8 million true-up of employee healthcare costs, and does not take into account the accrual for the revenue recognition for final payment of 2023, for date of service 2022, that we expect will be captured in the fourth quarter. Year-to-date Adjusted EBITDA was -$41.2 million, compared to the prior year of -$87.9 million, which is 53% improvement.
Said differently, we cut our losses in half. As we look forward to 2024, we would like to provide you with some insight on as to how we see next year shaping up. As I just shared, our baseline for 2024 starts with the expectation that our persistent lives will contribute approximately $60 million of EBITDA in a year. Additionally, we expect to take on meaningful new lives and growth in 2024. We are expecting to achieve this growth in a very capital-efficient way, by continuing to focus on existing and adjacent markets, while leveraging our existing infrastructure in a meaningful way. We have various conversation ongoing with payers, providers, and health systems, including potential JV and strategic partnership opportunities. Based on all this, I remain bullish on our opportunities to thrive in the years to come. Now, I would like to turn the call over to Bill Bettermann, our Chief Operating Officer.
Thank you, Sherif. I plan to cover three topics today. First, how we judge our own operating performance and the effectiveness of the P3 model. Second, ACO REACH, and third, highlights from our California market. We, as a management team, judge our own operating performance on a PMPM basis, as well as versus publicly available benchmarking data. On the last point, we have a publicly traded peer, agilon health, with a similar affiliate business model, so the data is readily available and relevant. We have the utmost respect and admiration for what agilon health has achieved and use it as a natural benchmark for the P3 business, knowing there are some differences in the model and mix in membership. The first relevant data point is revenue per member per month growth for the quarter.
This is a relevant data point to answer the question: Is the P3 model effective at engaging patients and assessing the disease burden appropriately? P3's revenue PMPM growth for the quarter was 11%, and agilon's was the same. P3's revenue PMPM year-to-date was $985. Agilon's was $945. We are pleased about that. The second data point is medical margin PMPM, which is directly tied to the effectiveness of P3's model in absolute terms and relative to a JV model. It answers the question: Does the P3 model bend the cost curve as effectively as the JV model? It is the fundamental value prop in value-based care, premiums less medical claims. P3's medical margin PMPM is $135 year-to-date. Agilon's was $119 PMPM year-to-date, and $134 PMPM for two-year-plus markets.
P3's persistent lives medical margin PMPM is $241 year-to-date. We're already operating at mature margins of a JV model. The third data point is gross profit PMPM. P3's year-to-date gross profit PMPM was $56 PMPM versus agilon's at $45 PMPM. We feel really good about that. There are some differences in the two models. We are not fully scaled yet and expect to leverage our infrastructure in a similar fashion as we grow over the coming years. P3 owns roughly 100% of its Adjusted EBITDA, and so we don't expect significant minority interest expense going forward as we become Adjusted EBITDA profitable. We don't have significant geographic entry costs. We generally grow adjacent to our existing markets, given the significant white space available to pursue this strategy.
P3's cash burn year-to-date was $61 million versus agilon at $107 million. We also enjoyed lower costs of membership acquisition than our peers. The majority of our provider adds are driven by inbound inquiries by those attracted to our operating model, and this really allows us to avoid long sales cycles. Additionally, 20% of P3's revenue is delegated, which has positive cash flow dynamics attributed to it. We expect to grow that over time, so our cash flow dynamics will mirror that of a health plan. Premiums up front, pay claims later. The delegated model also enables important operating benefits related to better data clarity, accuracy and timing versus non-delegated, which is helpful to drive physician adoption of our P3 model and better manage medical cost trend. Finally, we have a lower mix of ACO REACH lives today.
Regarding ACO REACH, we have roughly 7,000 lives today and plan to increase that substantially over the coming years. With our current 2,700 and growing PCPs that we have, the ACO REACH program allows us to create greater depth into each of our practices by offering the benefits of this program to patients being seen by those PCPs who are not currently in a risk-based arrangement. Migrating those patients to an ACO REACH program further entrenches the Value-Based Care concept with our clinicians and allows us to better serve those patients. We continue to see an increase in engagement level of our clinicians as they deepen their understanding of the Value-Based Care program due to proper incentive alignment, increased use of our data tools and education, as well as working with our care management teams for very sick, high-utilizing patients.
This increased adoption and engagement is very encouraging and bodes very well for our clinical, financial, and operational performance going forward. Lastly, I want to take a minute to focus on one of our newer markets, California, which we entered in December 2021. We have approximately 8,500 Medicare Advantage members in this market. Much of this market is based solely on affiliate providers, as we don't have a medical group presence here. If we compare the California market from September 2023 year-to-date versus prior year-to-date, you will see some significant improvements we've made in this market's performance. If you start with revenue, PMPM, third quarter 2023 year-to-date, it was $1,134 PMPM, versus year-to-date prior, it was $976 PMPM. That's an increase of 16%.
Medical margin PMPM third quarter year-to-date 2023, it was +$244 PMPM, versus year-to-date prior, it was -$45 PMPM, a nearly $300 positive swing. One key element driving this performance is our commitment to building very strong relationships with our affiliate providers. We've partnered with them to see many of their patients in our senior center, where we believe we have done a tremendous job of closing care gaps and identifying their chronic conditions to help aid their PCPs in providing the best care. We believe we have also optimized our health plan contracts to assure full alignment with our payer partners, and we'll expand upon the coordination of care with the stronger performing plans. I want to thank you for your time today, and now I will turn the call over to Atul Kavthekar, our CFO.
Thanks, Bill, and good afternoon, everyone. I'll start by discussing our recent quarter and how we are progressing towards meeting our full year guidance. Then I'll provide updates on our liquidity position and our significantly lower cash burn in the quarter, and finish up with some thoughts around our preliminary 2024 Adjusted EBITDA guidance. I'll begin with our results for the quarter and year-to-date. Top line results for the third quarter were strong, with capitated revenue of $285 million and total revenue of $288 million, representing growth of 17% and 16%, respectively, compared to the prior year. Year-to-date, capitated revenue was $910 million, and total revenue was $920 million, representing an improvement of approximately 16% on each metric compared to the same period in the prior year.
On a PMPM basis, this roughly equates to a 16% improvement, reflective of improved funding on the nearly 75% of persistent members on our platform, which we define as members who have been with P3 since the start of the calendar year. In the third quarter, our medical margin improved to $36 million, or $115 on a PMPM basis, which is a roughly 6x improvement compared to the prior year. Year-to-date, medical margin improved nearly 25x to $126 million. Gross profit in the quarter improved significantly over the prior year to $9 million or $29 PMPM, compared to a slight loss in the prior year. Year-to-date, gross profit increased to $52 million or $56 dollars PMPM, compared to a loss in the prior year.
This is yet another quarter in which we have demonstrated significant progress on these measures, and that provides a clearer picture on our ability to manage and improve our members' health. Going forward, we've targeted several new initiatives that we will be laser-focused on that are designed to be even more impactful in managing our medical costs. We'll be sharing much more about them and the delivered results in subsequent calls. As it relates to operating expense trends, we saw a significant drop in our platform support costs, going from 12% of revenue in the third quarter of 2022, down to 9% in the current quarter. I continue to be very pleased with the team's commitment to continuous improvement and operational innovation. As I've said in the past, we will continue to monitor our spending carefully and incorporate this mindset into our everyday cash management.
Adjusted EBITDA for the quarter was a loss of $22 million, a significant improvement compared to a loss of $40 million in the prior year. Year-to-date, 2023 adjusted EBITDA loss was $41 million, compared to a loss of $88 million in the same period of 2022, another significant area of improvement. Let me provide some additional color on this quarter's adjusted EBITDA. Our adjusted EBITDA for this quarter reflects several notable elements, including a favorable IBNR adjustment recommended by our actuaries, a roughly $3.8 million non-cash charge related to employee insurance costs, and finally, no recognition of any revenues in connection with our estimated 2023 final payment related to the 2022 dates of service. All in all, we are pleased with the quarter's results and plan to drive the company to higher performance over the next several quarters.
To that end, we are reaffirming our full year 2023 guidance. We still expect 2023 revenue to be between $1.2 billion and $1.25 billion, Adjusted EBITDA of between -$30 million and -$50 million, and our medical margin to be between $155 million and $175 million. With regards to our liquidity, our position is solid. We ended the quarter with approximately $58 million in cash, and consistent with our messaging last quarter, our cash burn was substantially lower than in prior quarters, at approximately $8 million of burn in Q3. While this is reflective of a more normalized burn rate in the near term, we continue to march down a path that leads us to profitability next year and positive cash flow soon thereafter.
Looking forward, and as Sherif mentioned earlier, we are expecting to continue the positive trends we've seen in terms of member growth, revenue, medical margin, and operating expenses. Specifically, we have high visibility into some of the key drivers of our business, including our per-persistent member economics, our new membership growth pipeline, our funding in 2024, adjusted for the V28 model, our growing ACO REACH penetration, along with its better unit economics, and specific areas of opportunity in our medical cost management. We will provide further details at a future investor conference in early 2024, but are expecting to generate Adjusted EBITDA between $20 million and $40 million. We are pleased to share our continued optimism and excitement at the near term and long-term prospects of P3, and look forward to sharing more specific details with you in the coming weeks.
Operator, let me make some closing comments, and then we'll go to Q&A. So today in the call, we shared with you, reaffirmed our EBITDA and medical margin guidance for 2023. We shared with you that our revenue was up 16%, our capitated revenue was up 17%. We also shared with you that our Medicare Advantage medical expense, year to date, per member per month, when you compared with the Medicare Advantage, year to date, 2022, the trend is down negative 2% improvement in the medical cost, and that reflects the power of P3 model and the success that we're seeing. The medical margin had improved 306% year-over-year, $36 million for the quarter, over $9 million last year quarter.
Gross, gross profit was $9 million positive versus $6 million negative, last year, same quarter. OpEx is down 18%-20% year-over-year. Our cash burn, as we shared with you, is $8 million for the entire, quarter. Our EBITDA had improved from last quarter and year to date, 2023 over 2022 by 53%. As we mentioned, shared with you, that, basically, we cut our losses in half over, this year. And we've shared with you our preliminary, projection for EBITDA positive 2024, between $20 million and $40 million. So with that, operator, we're ready for, Q&A.
We will now begin the question and answer session. To ask a question, you may press star, then one on your touchtone phone. If you're using a speakerphone, please pick up your handset before pressing the keys. If at any time your question has been addressed and you would like to withdraw your question, please press star then two. Our first question comes from Brooks O'Neil with Lake Street Capital Markets. Please go ahead.
Good afternoon, everyone, and congratulations on the significant progress you've made. I have a couple questions. I guess I'd like to first just ask you. I think Sherif you mentioned that you expect a meaningful drop down in Q4 related to the claims experience in the prior year. When you're thinking about the $20 million-$40 million of positive EBITDA you commented about expecting in 2024, is that dependent on any kind of similar drop down from prior year?
Well, I think, Brooks, first, thank you very much, and I appreciate the question. That's exactly why I put those summary caps at the end. It's, we're gonna continue to improve that. The revenue will continue to go up 16%-17%. The medical costs will continue to trickle down, and as a result, our actuarial set recommended that we start releasing some of the reserves that we put in IBNR. Our medical margin is improved 300% year over year. I don't even have to do that, but if it continue to improve, and the contribution from the persistent life is $241 PMPM.
So you can extrapolate that continuation of revenue, medical costs go down, medical margin go up, gross profit go up, OpEx. We're all focused on continuing to be more efficient and leverage the infrastructure. The cash burn will continue to go down. Then that's our path for $20 million-$40 million EBITDA.
That's great. I think it's gonna be important for you to get there, and it sounds like you're on track to do so, so that's fantastic. Let me just ask you about the growth you commented about in new lives for 2024. Obviously, historically, when you've had new lives come in, they tend to be depressing to some of the profit and performance you've had. How confident are you that you can bring in new lives next year and still continue the improvement you're seeing now?
We're very confident, Brooks, because we've added some lives this year. We've added on the same network, we've added on the same geography and markets. We went to the market and the county next door, so that we can leverage the infrastructure, and we're gonna continue to do so. And we're seeing more and more as not only the patient maturation take place, but the physician engagement maturation takes place. The time from landing in our platform and soaring into a successful medical margin is getting shorter and shorter. So we're very confident that we will be able to grow and maintain the trajectory that we shared with you today.
Great. Let me ask one last question. I think it was Atul mentioned the funding improvement that you've achieved this year. My sense is that our friends at CMS have made some changes to the risk adjustment mechanisms in Medicare Advantage. Again, how confident are you that you can continue to drive improved funding next year in the environment we all anticipate for 2024?
I'll turn the answer to Dr. Bacchus, who's here with us in the room. He's our Co-Founder and Chief Medical Officer, Dr. Bacchus.
Hey, Brooks, good to hear your voice again.
Hi, Amir.
Yes, I mean, for us, as you've heard me describe before, a few different factors are real important in making sure that we can continue to perform in driving not only proper documentation for each and every one of our patients through our education modules and things that we do today. But also, it comes from, as Sherif is describing, the maturity of those practices that understand it. So those things all bode well for us upfront. In addition to that, as we've talked about, we've also had, we have a better opportunity in regards to when we're looking at where we currently reside in our current RAF, with the opportunity that still exists. So in analyzing our populations, we still know we have significant opportunity even with the revenues that Sherif described. So we are quite excited as we move to version 24 to 28 to continue to perform in the risk adjustment coding sampling.
Great. Thank you, Amir, and thank you all for taking my questions today.
Sure.
The next question comes from Josh Raskin with Nephron Research. Please go ahead.
Hi. Thanks. Good evening, guys. I got a couple as well. I think I heard affiliated PCPs was 2,700. Correct me if I'm wrong, if that's not the updated number. If you have a total member, total at-risk membership number for the quarter as well.
Yeah, thanks for that question. So that's right. So we are just a little over 2,700 PCPs in the overall platform.
And members?
Total members are about 110,000 members.
Y ear-to-date?
Medicare.
At-risk, yeah.
Yeah.
At-risk, yeah. Yep, that's what I was looking for. And then-
There are a lot more on the platform, but-
Right
I f you just count the at-risk population, the 100-
Yep
thousand, and there's 4,000 or 5,000 that we on value-based share savings, share risk with Humana and Blue Cross in Arizona. So it's, you can put the Medicaid at 114,000.
Okay, gotcha. Then, you know, can you talk about negotiations with payers for 2024? I assume you're mostly set on all of that. I'm specifically thinking about how you're dealing with, you know, those changes to the risk model that you mentioned. And then, you know, are they, you know, are your cap payments increasing? Or are they cutting out some benefits? I'm just curious on data like that. And then also curious if you're having conversations with any new payers at this point that you don't currently work with.
Yeah. So, we're pleased to announce that we did sign a multi-year, multi-state contract with SCAN Health, which we did not have a contract with before, and that's probably the only new payer that we did not have any contract with. We expanded our relationship with Aetna in Oregon. We expanded our relationship with the ATRIO, the local health plan, to multiple new counties in Oregon.
Oregon.
And that's about and I think we haven't signed anything new in California, but we will.
Okay. And then, but how are the negotiations, just in terms of, you know, how are they trying to keep you whole and, you know, in light of the reimbursement changes for 2024, are you getting an extra 1% or 2% on the cap payments or, you know, just any color on that would be helpful, too?
Yeah. So, the biggest driver for the percentage of premium, that as you improve the rev, the value of that percentage of premium would increase. As you saw, we had a 17% increase in our PMPM year-over-year. So that-- there's no change in the percentage of premium that we negotiated. We have a multiyear contract that's not open for negotiation. Most of them aren't this year. However, we participated. You know, two things about the benefit. We participated in putting the benefits that impact our and I think vast majority of health plans were very logical and very supportive and very mindful of that impact downstream on us. Second, we have a language to protect us in the medical benefits change, and that will adjust our premium if there's any adjustment. And adjusted only upward, not downward.
Okay, got you. Got you. That's helpful. And then just to sneak one last one in. It sounded like $60 million of EBITDA expected in 2024 on the persistent members. So if you think about the 20-40, sort of the expectation would be to lose $20 million-$40 million on sort of the new cohort of members. I'm just curious, how does that compare on a PPM basis, maybe relative to what new members are losing in 2023?
So, I'm not sure if we wanna go back to 2023, and I'll have Atul either answer that or can get back to you on this. As far as 2024, the only thing that we're giving right now, Josh, is the EBITDA guidance. We'll have a lot more details by January, maybe J.P. Morgan conference or so.
Okay.
Yeah.
All right. That's fair. That's fair. We can, we can wait. Thank you.
Our next question comes from Gary Taylor with TD Cowen. Please go ahead.
Hi, good evening. Just a couple from me. I do just want to make sure I understand the timing issue you're referring to from 3Q to 4Q. So this is $15 million-$20 million of non-delegated revenue? That you're gonna go revenue line straight to EBITDA, that doesn't run through any of your health plan receivables, and that's just primarily from one plan. Just is there any more you can tell us about that?
Those are that is in reference to the settlement, the final settlement that is associated with 2022 dates of service, that's, that is considered 2023 revenue payment. And so, the, the expectation, and, and we're working with our auditors to make sure that that's auditable and recognized in the year in which we believe it's, it should be, and there's and that's consistent with the way we've treated in the past, is to, is to be able to recognize that. And that's just sort of our rough estimate. That's a constrained estimate that we, you know, we've, we've arrived at based on a couple of years now of history and, and performance. So that's what that's in reference to, Gary.
Okay. But that's, you're still treating that on a cash basis, basically. It's not anywhere-
Well, what we're
in the accrual so far.
So far, Sherif had mentioned this at the end of the last call, in fact, but today we're treating it all as cash basis. What we feel is, it is more informative, and it is easier for our investors to understand if it's treated on an accrual basis in the period in which it's to be recognized. And that's something that we're working with the auditors on. It's just, it's not really a question of whether or not it's 2023 revenue. The question is: Are we able to audit it and actually recognize it on an accrual basis before the end of the year?
But this is different from the sweep revenue, for example, you booked in the 2Q? Is it different?
It is the same. The sweep revenue that was booked in the second quarter, the sweep revenue that was booked in the second quarter is related to 2021 dates of service. That is really 2022 revenue. But since the 2022 year was closed, that was recognized in this current year. So if you recall, in 2021, we booked essentially two sweeps. In 2022, we booked essentially no sweeps. And what we are trying to do is to get back into much more of a systematic basis of accruing this once a year. And this is the year we think we can demonstrate that, you know, from an audit standard, that we can get back on track to accruing it again in the year that it should be recognized. Is that helpful?
Yeah, I think so. And so, I was just trying to piece together a little bit of seasonality, but if that would've showed up this quarter, EBITDA would be better, fourth quarter EBITDA would be worse. That would reflect the typical seasonal pattern in your profitability, I think. Is that correct?
I think that's correct, Gary.
Okay.
And going forward, but I think here's the key. Going forward, what it does is I think it just takes. It sort of smooths out revenue to a degree, and I think it just makes it a little bit easier to understand. And that's the whole point of this, is to get away from some of this choppiness that makes it more challenging to understand the model.
Last one for me. I mean, the 2024 EBITDA guidance is pretty impressive, well above consensus. I know you don't want to give us a whole lot on 2024 at this point, but, you know, that, that, you know, that's gonna be driven by obviously medical margin improvement, but also depends on the size of the cohort you bring in. And at this point of the year, I think you'd have pretty good line of sight on new payer contracts, new physician affiliations, et cetera. So I guess maybe could you answer this? Do we think about, you know, you'd kind of slow down the growth in 2023 as you, you know, focused on, you know, medical margin. Is 2024 a year where we think the new cohorts materially start accelerating again in size? Or do we think, fairly static in size? Or give us sort of any sense on, on what you're thinking about the direction of revenue growth next year.
Yeah. So we expect meaningful growth in revenue and membership and improvement on the EBITDA as we shared with you in 2024.
Okay. I'll rock with that. Thank you.
Thanks.
Our next question comes from Ryan Daniels with William Blair. Please go ahead.
Yeah, guys. Thanks for taking the questions. I'm gonna continue with that, trail of questioning, and I'm curious, at this point in the year, how visible the growth in at-risk lives is for you. Meaning, you know, do you have new partners or new payers signed? And if we take that and the move with more ACO REACH lives, kind of how visible is the, member growth at this point in the year as we look to 2024?
It's very visible, Ryan. It's comfortably. That's why we're comfortable calculating the EBITDA. We're just not prepared to give any guidance on membership revenue or any other items. But it will be meaningful growth, it will be new counties, it will be a couple new payers, it will be some partnerships as well.
Yeah, so a little bit of everything. Then, a couple financial questions. The corporate G&A costs obviously down nicely year-over-year, but still up about $6 million sequentially. I think you mentioned there was an insurance hit of nearly $4 million, which explains a lot of that uptick. I would assume it's in that line item, but how should we think of that SG&A spend on a go-forward basis for our models? Is this a pretty good quarterly run rate, or do we need to adjust that?
No. So for the quarter, I think you hit it correctly. So in the quarter, we actually had about. It was closer to $5 million of a hit. About $3.8 million of it is related to periods outside of the third quarter. So that's kind of how you can think of a normalized, you know, about $1 million bucks, a little bit over $1 million per quarter. But going forward, I think one of the things that we've been stressing here, and you've seen some demonstration of it, is a continued prioritization, focus on efficiency. And, you know, we'll just continually get better. I think over time, you know, OpEx will grow as the company grows, but I think it'll grow at a much, much slower rate than what you've seen in the past.
It's gonna be disciplined, and it's gonna be, you know, in a way that is that is more appropriate for a growing company. So I think if you looked at the third quarter, if you you know, shave off about $4 million for sort of out of period dollars, I think that gives you a good starting point. But I think that, you know, we'll still expect to see. I'm still expecting to see a little bit of improvement in the fourth quarter. But. And we'll, and we'll as I said, going into 2024, we'll give some more specific guidance around that, but.
Yeah. No, that's very helpful, though. And then last question, I just wanna make sure I have a complete understanding of the nomenclature you're using. When you talk about persistent lives, can you remind us, is that lives that have been on the platform for more than a year, or that were on the platform, you know, at the start of, like, 2022. What, what defines that? Because those are some impressive metrics and kind of shows the power of the model over time. So I want to make sure I understand that.
So our definition of persistent is similar to what CMS use. So the patients that are in our platform of December of the prior year, as I said it in, on the call, the December 2022, the definition of our persistent life in 2023, anybody that was on the platform in December that showed up again in January, we consider those persistent lives. Some of them been here only for like a month, some of them have been for 36+ months, some of them have been for 11 months, since the beginning of the year. So that's the distance traveled.
Do you have an average age of that cohort for patients that are persistent, given that, you know, some of them were on in December, but they've been on for multiple years? Do you know the age of that cohort? I don't know if that's something you've calculated.
I'm sure somebody does. So, I can get it to you by the end of the day today. As a matter of fact, I'm already gonna message our analytics folks. Certainly, somebody does. Yes, I'll get it to you, and I'll share it with the group.
Okay, great. Thank you so much.
Our next question comes from David Larsen with BTIG. Please go ahead.
Hi, this is Jenny Shen on for David Larsen. Congrats on the quarter, and thanks for taking my questions. I just wanted to know if you could elaborate more on the opportunity that you see with the fully delegated lives. I think you mentioned that you're ranging around 20% right now. Just the opportunity there and maybe what percent you expect to reach by 2024.
So, thank you, Jenny, and nice to meet you, tell David, and say hi. So the delegated lives are now, like I said, is about 20%. We are targeting to reach about, I wanna say 30, 35%. Pretty much all the new contracts that we sign, like with SCAN and others, are fully delegated, so a lot of that growth, and Humana that we signed in Nevada, is fully delegated. So all this will come in with the full delegated, and we're hoping to grow those. We are in discussion with United, Aetna, and Centene, to convert, and that would be the other 60% of, of lives that we have, that then we will hit the 90% mark. So that is the trajectory that we have.
Okay, that sounds great. And then just on the ACO REACH side of the business, I think you've mentioned before that they generally start out with lower margins than MA, but they ramp up to be equal or even better. Just any thoughts on that opportunity and the timeline to ramping?
Hi, Jenny, this is Bill. So actually, some of the recent data that we've seen is that even overall, the new lives coming in on ACO REACH are actually quite profitable. But as we see over time, they continue to grow, just like our Medicare Advantage lives. So we actually see a very nice pop with our new ACO REACH lives, as well as those persistent ACO REACH lives that we will see in the coming years.
Okay, great. And just the last one for me. Any thoughts on the current utilization trends and any details in terms of, like, inpatient versus outpatient utilization, and maybe some thoughts on GLP-1? Thanks.
Sure. Hi, Jenny. Dr. Bacchus here. So, as far as reset, I mean, we've actually been able to bend that cost curve down. You know, we are down by 2% over this last year with the expenditures that people were very, very concerned with. So jumping right to the GLP-1 question, yes, we do have patients that are utilizing GLP-1, but we're also seeing, you know, clinical improvements in regards to cardiovascular disease and the other things that we use GLP-1s for, not necessarily just for blood sugar alone. It is nice to see that, you know, for our population, being senior populations, it's not necessarily something that you see like in commercial populations, where a lot of people are using GLP-1 for potential weight loss and things like that.
So we are a little bit, I'll say, covered with our senior populations that we manage. From an inpatient standpoint and things like that, we continue to do and work with our plans. We are able to do concurrent reviews, especially on the not only those delegated lives, but also we do have some UM opportunities where we're not fully delegated. So we're continuing to do that as well and work with our plans to improve inpatient utilization, whether it's direct hospitalization or even post-acute.
So those are all things that we look at, as well as being able to risk stratify our population very, very well, to understand who are those populations at risk, that are very high cost, high risk, rising risk populations, so that our care management teams are working directly, with not only our CMOs and our markets, but with directly with our providers and patients to maximize their care and access. So these are all things that we do collectively to drive down that medical expense, and we have some real, good actions going forward into 2024.
Great. Thanks for taking my questions, and congrats on the quarter.
Thank you very much, Jenny. Ryan, by the way, the question about the age, the average age of the persistent life is 73 years old.
This concludes our question and answer session. I would like to turn the conference over to Dr. Sherif Abdou for any closing remarks.
Thank you, operator. So, today, we reaffirm the guidance for EBITDA and medical margin for 2023, as I shared with you before. I shared with you revenues up 16%-17%. Our medical claim expense for the Medicare Advantage lives, 2% better, negative, lower than it was last year, and our medical margin is 300% improved. Our gross profit is $15 million better than it was the same quarter last year. Our OpEx is 18%-20% improved and lower year over year. Our cash burn is down to $8 million for the entire quarter, and our EBITDA loss as compared to last year, is 53% better. We've also shared with you our 2024 preliminary EBITDA adjusted EBITDA guidance of +$20 million to +$40 million for 2024. With that, I thank you all very much and look forward to our next conversation.
The conference is now concluded. Thank you for attending today's presentation. You may now disconnect.