Earnings Call: Q3 2018

Nov 1, 2018

Welcome to Teladoc Health's Third Quarter 2018 Earnings Conference Call and Webcast. All lines have been placed on mute to prevent any background noise. After the speakers' remarks, there will be a question and answer Thank you. It is now my pleasure to turn the floor over to Kelsey Turcotte, Vice President of Investor Relations. Kelsey, you may begin your conference. Thank you, operator, and good afternoon, everyone. I'm Kelsey Turcotte, Vice President of Investor Relations at Teladoc Health. Joining me on this afternoon's conference call are Jason Gorevic, our Chief Executive Officer and Mark Hirschhorn, our Chief Operating Officer and Chief Financial Officer. We look forward to discussing our Q3 2018 results with you. Today, after the market closed, we issued a press release announcing our Q3 2018 results and filed our Form 10 Q. The release and filing are available in the Investor Relations section of teladochealth.com. As a reminder, Teladoc Health intends to avail itself of the Safe Harbor provisions of the Private Securities Litigation Reform Act of 1995. Certain statements made during this call will be forward looking statements within the meaning of that law. These forward looking statements are subject to risks, uncertainties and other factors that could cause Teladoc Health's actual results to differ materially from those expressed or implied by the forward looking statements. For additional information on the risks facing Teladoc Health, please refer to our filings with the SEC. We'll start today's call with brief prepared remarks followed by Q and A. Today's call will also contain certain non GAAP financial measures that we believe are important in evaluating our performance. For more details on these measures, the most comparable GAAP measures and a reconciliation of the 2, please refer to the press release posted on teladochealth.com. I would also like to inform you that Teladoc Health is presenting at the 27th Annual Credit Suisse Healthcare Conference in Scottsdale, Arizona on Tuesday, November 13 the Jefferies 2018 Global Healthcare Conference in London, England on Wednesday, November 14 the 30th Annual Piper Jaffray Healthcare Conference in New York on Tuesday, November 27 and the Citi 2018 Global Healthcare Conference in New York on Wednesday, December 5. And with that, I'll turn it over to Jason. Thanks, Kelsey, and thank you all for joining us this afternoon. And thanks again to those of you who joined us for our Investor and Analyst Day on September 27. After the market closed today, Teladoc Health reported another strong quarter marked by continued momentum across the business and healthy demand for our full spectrum of services. Some of the highlights include total revenue for the quarter of $111,000,000 which exceeded our expectations and was up 62% on an absolute basis and 29% on an organic basis. Gross margin of 69% which came in on plan reflecting our overall mix shift and the acquisition of Advance Medical. Positive adjusted EBITDA of $6,300,000 strong visit volume of approximately 641,000 visits in the quarter, up 110%. U. S. Paid membership of 22,600,000 members representing growth of 18 percent after adjusting out the 3,500,000 Aetna fully insured lives from 2017. And our average per member per month of 1.08 dollars compared to $0.79 for the same period last year, representing a 36% increase. Mark will provide more details on our strong Q3 financial results. But before that, I'd like to focus on a few key developments for the company. First, we continue to make great progress on the integration of Advance Medical which has now been a part of Teladoc Health for 5 months. The combination of the 2 highly complementary companies gives us global scale that is unmatched in the industry with a local presence to meet the needs of our diverse client base. Interest is very high and we see opportunities to sell into current clients as well as land new ones. I'd also like to take a minute to thank the team for their hard work in bringing the 2 companies together. Your passion for and dedication to transforming how people access high quality healthcare around the world is truly inspiring. To that end, we launched GlobalCare in late September. Targeting large multinational employers and insurers, this new service makes it easy for members to talk to a doctor who has the knowledge and experience to help guide them through the local healthcare system. Global Care is available 20 fourseven in more than 20 languages and delivered through our mobile app. There is no other solution like it in the market and the pipeline is building nicely. On the direct to consumer front, we continue to roll out our integrated product offering with CVS Health adding another 8 states last month to bring the total to 18 states plus Washington D. C. This is a seamless experience for consumers entering through the CVS app and an integral part of CVS Health's commitment to delivering high quality care when and where patients need it at prices they can afford. We look forward to expanding the scope of our relationship with the MinuteClinics and moving ahead with insurance reimbursement. We're now in the final months of this year's selling season and as we discussed at Investor Day, the pipeline is converting at robust rates. Clients appreciate our differentiated suite of services, unique surround sound strategy, global footprint and compelling data driven ROI. This is true across all channels where we are winning new logos, successfully cross selling into existing accounts and displacing competitors. I feel very good about where we are and how well the team is executing. In addition, there was an encouraging regulatory development last Friday as CMS released its proposed rules regarding the ability of Medicare Advantage plans to include telehealth as part of their bids for the 2020 plan year. The proposed requirements are completely consistent with our current commercial health plan offerings, meaning that under these proposed rules, we would be able to offer our full suite of services to all 21,000,000 Medicare Advantage enrollees. CMS also stressed in the proposals what it views as the benefits to access, cost, convenience and quality arising from telehealth. This is a very positive development and welcome recognition of the value Teladoc Health can deliver across all segments of the population. Before I turn the call over for a review of our financials, I'd like to take a minute to welcome Mark Smith to our Board of Directors. Mark is currently a Professor of Clinical Medicine at the University of California at San Francisco, a Visiting Professor at the School of Public Health at the University of California at Berkeley and a nationally recognized health policy and delivery system expert. He is a distinguished physician and healthcare leader with a passion for assuring access to care for all. This not only complements our mission and commitment to transforming the care experience, but stands out as a testament to our intense focus on clinical quality. We are very pleased to have Mark join us. As we close out 2018, I want to emphasize my confidence in our ability to deliver high quality care during our traditionally busiest quarters, Q4 and Q1. As you may recall, last year's flu season was extremely intense but very concentrated due to a late start and an early end to its peak. The 1st few weeks of this year's flu season are tracking very slightly ahead of last year and we've been experiencing a steady increase in volume since mid September. I'm confident that we are well prepared with infrastructure and capacity that will scale accordingly if this flu season resembles last year's. We feel very good about what we've accomplished so far this year and about our leading market position as we enter 2019. Tailwinds in virtual care continue to increase including the positive developments in Washington and our broad suite of services and comprehensive approach to delivering quality care is clearly resonating in the market. We look forward to a strong close to the year and to seeing many of you at the upcoming conferences. And with that, I'll turn the call over to Mark. Thank you, Jason, and good afternoon, everyone. I'm very pleased with the Q3, both from a financial as well as an operational perspective. I've spent quite a bit of time with our wonderful colleagues at Advance Medical, where our integration work is progressing nicely and customer appetite for our global care solution is very strong. We continue to build on our significant differentiation in the market, which is now reinforced by our scale and global presence. In fact, today we launched a new global care initiative with AXA Global Health Insurance Plans. This launch follows a successful pilot that formed the basis for this new client offering. Our 8 geographic hubs will help support AXIS members in over 100 countries. Now I would like to share some of our key financial metrics that Jason referenced earlier. Total revenue for the quarter was $111,000,000 a 62% increase year over year. We grew 29% on an organic basis generating quarterly organic revenue of 88 $300,000 Revenue from subscription fees increased 60% from the Q3 of 2017 to $96,600,000 As expected, 3 quarters of our subscription revenue is domestic as subscription fees from the U. S. Accounted for $72,500,000 or 75 percent of total access fees, while international subscription fees accounted for the remaining 25 percent or $24,100,000 For the 3rd quarter, subscription access fee revenue accounted for 87% of total revenue. As of September 30, U. S. Paid members totaled 22,600,000 an increase of 18% compared to last year after adjusting out 3,500,000 Aetna fully insured lives from 2017. As a reminder, our definition of members includes just U. S. Paid members that are associated with the PEPM or PMPM or paid U. S. Membership. And under this definition, membership totals do not include visit fee only access to our services. At the end of the 3rd quarter, we and Aetna's fully insured population. Our and Aetna's fully insured population. Our average per employee per month or PPM for the Q3 was $1.08 compared to $0.79 in the Q3 of 2017 or $1.06 on a pro form a basis when excluding the impact from Advance Medical. During the quarter, Teladoc Health completed 641,000 visits. That's an increase of 110% from the year ago period. In terms of visits, as you can see in our press release, we categorized visits from U. S. Paid membership, international visits and visits from visit fee only access. Moving on to utilization, which we calculate as total U. S. Visits divided by Teladoc Health's U. S. Paid membership for those members with access to our general medical services, visits from U. S. Paid membership totaled 439,000. 46% of these visits were paid, while the remaining 54% were delivered under our U. S. Visits included contracts. This represents an annualized utilization rate of 7.8% in the quarter, an approximately 222 basis point increase from the 5.6% utilization rate we experienced in the Q3 of 2017. In addition, we completed 166,000 international visits. And finally, we completed 36,000 visits for individuals with visit fee only access. U. S. Paid membership visits generated $11,300,000 in revenue, a 40% year over year increase. This includes revenue coming from general medical visits as well as other specialty visits, which is primarily comprised of expert medical and commercial behavioral health services. Our gross margins were 69.2% and on plan with our expectations following the purchase of Advance Medical. While the quarter's gross margin decreased as compared to the gross margin in the Q3 of 2017, our margins continue to reflect the benefits of our scale and the resulting operating efficiencies in addition to predictable and sustainable positive pricing trends in our evolving business. Total operating expenses in the quarter came in at $92,600,000 representing a 26% increase from the $73,400,000 in Q3 of 2017. Eliminating the impact of principally non cash charges such as stock compensation, depreciation and amortization, our Q3 2018 operating expenses, less integration related costs and gain on sale were $70,500,000 or 64 percent of revenue compared to $52,500,000 or 77 percent of revenue in Q3 of 2017. Our adjusted EBITDA came in at a positive $6,300,000 for the 3rd quarter compared to an adjusted EBITDA loss of $600,000 a year ago. Net loss in the quarter was $23,300,000 compared to a net loss of $31,300,000 for the same quarter last year. Turning to our balance sheet, we ended the quarter with approximately $472,500,000 of cash and short term investments. Our total debt at the end of the quarter was $562,500,000 which consists of our 2 convertible issuances, the 275,000,000 3 percent convertible notes that mature at the end of 2022 and the 287,500,000 dollars 1.3eight percent notes that mature at the end of 2025. With that, I would like to provide our outlook for the Q4 of this year in which we currently expect total revenue between $119,000,000 $121,000,000 and EBITDA loss between $9,000,000 $11,000,000 adjusted positive EBITDA between $4,000,000 $6,000,000 total U. S. Paid membership of approximately 22,600,000 to 23,500,000 members total visits between 720,000,820,000 visits and a net loss per share based on 70,400,000 weighted average shares outstanding is expected to range from a loss of $0.36 to a loss of $0.38 per share. For the full year 2018, our updated forecast is now total revenue between $414,000,000 and 4 $1,000,000 and EBITDA loss between $36,000,000 $38,000,000 adjusted positive EBITDA between $12,000,000 $14,000,000 and total U. S. Paid membership of approximately 22.6 to 23,500,000 members and visit fee only access available to approximately 9,400,000 individuals. Total visits between 2,500,000 and 2,600,000 visits, net loss per share based on 65,900,000 weighted average shares outstanding is expected to range from a loss of $1.48 per share to a loss of $1.50 per share. As a reminder, we will be providing our full year 2018 results and our 2019 guidance when we announce earnings in February. As you can see, the business continues to perform very well and I'm very pleased with the setup as we look into 2019. I want to thank the Teladoc Health team for their hard work and dedication to our mission of transforming how people access healthcare around the world. Thank you all for joining us and we look forward to seeing many of you over the next several weeks. We'll now open the call to questions. Operator? Your first question comes from the line of Sean Dodge of Jefferies. Your line is open. Yes, good afternoon. Thanks for taking the questions. Maybe coming out of the Analyst Day, Jason, it sounded like one of the key focuses was going to be on bundling more of your services together when either selling to new clients or kind of maybe working back through your existing base and cross selling some of the new modules. Now that we're coming out of this selling season, do you have any metrics or maybe some anecdotes you can share with us on how many new clients signed bought 2 or more Teladoc services versus how that would have looked this time last year? Hey Sean, thanks for the question. I would say, well we haven't given any metrics and we're starting to think about whether we start to put something in place that gives a little bit more of a view into that. More certainly there's no question we have more sales that have 2 or more Teladoc products in a bundle of services. We're talking to more and more clients about full enterprise wide solutions. As we talked about on the Investor and Analyst Day, virtual first is becoming a central focus for a lot of the larger employers and especially the larger health plans and that includes the full suite of services in an integrated fashion that's deeply embedded into their health plan. I would say that is still in the planning phases for a lot of our larger clients and prospects, but they are starting the process by engaging us for 2, 3, 4 products in a bundle so that it's more than a single point solution but rather a full virtual care offering. Okay, great. And then one on the CVS launch. Now that you've got a few months under your belt there, can you give us a sense of how many visits that contributed in the 3rd quarter? And then any update on, you said it's available in 18 states now, when we'll see the rest rolled out and when we could see insurance coverage? Yes. So 3rd quarter contribution was still very, very small. This was a soft launch. I think I mentioned at the Analyst Day, this was done as a no marketing push, let's roll it out, continue to get a sort of operational wrinkles ironed out, make sure that everything with the consumer experience is absolutely perfect before we sort of turn on the floodgates of consumer marketing. The goal is to continue to roll out over the course of the year so that by the beginning of the year, early Q1 we're available on a nationwide basis and we can start to look to CVS turning on their consumer engagement and marketing prowess right. So there's a significant engine that they have there especially with their extra bucks and their loyalty program and that provides a very, very strong engine to drive consumer adoption. We have great relationship there as you heard from Troy at our Analyst Day and we see there as significant opportunity for expansion of services in addition to starting to ramp up the visit volume. Okay. And then insurance coverage also sometime between now and maybe early Q1? I wouldn't look for that by early Q1. That's going to be a 2019 effort. As CVS works with their payer partners on modifying their payer contracts to include this. So So I want to make sure that we're clear on expectations around that. I would expect that to happen over the course of 2019. Very good. Thank you. Excellent. Thanks Sean. Your next question comes from the line of Stephanie Demko from Citi. Your line is open. Hey, guys. Congrats on the solid quarter and thank you for taking my questions. Just given some of the recent news flow, I was hoping you could provide any color around your BetterHelp business just as its relative sizing, sales channels or any mix of direct to consumer business? Hi Stephanie, yes thanks. Appreciate your comments on the quarter and the question and the opportunity to address it. First and foremost, I would say we're focused on the tremendous opportunity for us to make a difference to those in need of behavioral healthcare. As I said many times, people don't get the counseling that they require due to issues of access and the stigma associated with mental health. Virtual Care very effectively addresses both of those barriers to getting care and we're pleased to be able to address those needs. I've been clear that our direct to consumer behavioral business has been one of our fastest growing segments and we've been very transparent about it being a growth driver and a contributor to our increasing PMPM. We see these as positives with all of our primary metrics for that business including customer acquisition costs, lifetime value of a customer and membership churn. All of those metrics consistently have been improving over time and this quarter this last quarter was no exception to that. We've consistently described the revenue trajectory of the DTC behavioral business, which of course is our BetterHelp business. And as recently as September, we've said that the business will generate in excess of $60,000,000 of revenue this year. And finally for the past couple of years we've consistently talked about diversifying our marketing channels for that product including the use of influencer marketing of which YouTube is one component. And in fact, if you look at our data in the past 12 months less than 5% of our new subscribers on BetterHelp have come through the YouTube channels. Of course, we're constantly evolving the marketing mix as we seek to optimize performance of that business. And to answer your question about sort of where we are in the cycle, I think I was recently quoted as saying virtual care is it still in the early innings, virtual behavioral healthcare is still in batting practice. We're really just scratching the surface on the opportunity there and I think the growth of that business is a testament to that. Thank you. Those clarifications are super helpful. And then one quick follow-up on a related business. Could you just give us an update on the TRICARE ramp and maybe any risk to that revenue stream as the ramp does continue to be elongated? Yes, sure. As you know Optum is the prime contractor on the TRICARE business and we're the sub. We have a great relationship with the Optum team and we're working very well with Optum on meeting the final implementation requirements in preparation for our launch of that business. We're on track with the launch and expect the first population in Q1. The government hasn't given a timeline for the rollout of the rest of that business, But we have as we put together our projections, we've been very conservative in our view and expectations of the revenue knowing that there are always variables associated with the government's timeline for things. I hear that. So we feel like we've taken a conservative and appropriate approach and notwithstanding that we have great relationships with Optum and fully expect to roll out that business. All right. Good to hear it's Bill on track. Thank you for taking my questions. Thanks Stephanie. Your next question comes from the line of Lisa Gill from JPMorgan. Your line is open. Thanks very much and good afternoon. Jason, let me start with the Aetna business. Is it still the anticipation to be revenue neutral for 2018? Is it tracking as expected? Yes, exactly as expected. Fully insured visits are up 60% year over year. We monitor that revenue on literally a weekly basis and it's tracking almost exactly with where we were last year. And of course that's entering the Q4, which is our busiest season. We've got a great relationship with Aetna. In fact we're building we're integrating our technology into their mobile app using our SDK, our software development kit, which will mean deep integration there which will only be positive in terms of both working together but also the member experience. And in fact what I was talking about there was the fully insured utilization being up 60% year over year. If you look at every segment of that business of the Aetna business utilization is up year over year. Okay, great. And then just your comments around the selling season and to an earlier question around bundling of some of the different offerings in the market. I'm just wondering, can you also maybe just give us some color as to what you're seeing around membership growth, including new versus existing clients? Are you seeing deeper relationships going into 2019? Or is it primarily new relationships? It's a mix of the 2. So obviously we track both sort of same store growth or expansion. We talk about it as the white space within existing customers. And certain segments of the business have more white space than others. So obviously health plans and especially our international insurance clients there's a lot of white space. Not as much when you talk about the direct to employer market. There we're thinking more about sort of upselling and cross selling additional products and services. But across all of our segments, so especially across health plans and the international space, we're seeing expansion within customers of additional membership and then across all of our segments we're seeing new customers, new logos, new membership. That's helpful. Congratulations on a nice quarter. Thank you. Appreciate it, Lisa. Your next question comes from the line of Richard Close from Canaccord Genuity. Your line is open. Yes. Two questions. 1, just additionally on the BetterHelp. If YouTube is less than 5%, what are maybe the bigger channels there? And then I had a question on hybrid models that Mark talked about at the briefly talked about at the Analyst Day. Can you talk a little bit more in-depth on those hybrid models? So I'll take the BetterHelp channels and Mark can take the hybrid models. So we've always said for BetterHelp social and search are the 2 primary drivers. We've expanded into as I mentioned influencer marketing and into providing access through more content oriented sites, which are focused on the delivery of psychological health and our sort of more consumer oriented websites for those who are seeking help. So search and social first followed by other channels, But we're also in other entertainment media through various consumer engagement strategies. We're testing out digital TV and things like that in certain markets. So that is a business where test and learn from a customer acquisition perspective is part of the fabric of that team's daily work and sort of optimizing the various channels. Hey, Richard. I'll just give you a note on the models that we've been seeing. We've closed thousands of new contracts over the last several months. We obviously have another sort of 6 weeks to close 100 additional. Most of, if not the vast majority, are all the traditional per member per month plus a visit fee. Also, those that are at the higher end of the per member per month with the visit fee included, there have been very few visit fee only proposals and contracts executed, but we continue to really see a thrust through the end of the year of those companies that are looking to sign up and have our services available to them on January 1 launch date. Okay. Thank you. Your next question comes from the line of Charles Rhyee from Cowen. Your line is open. Yes. Hey, guys. Thanks for taking the question. Mark, maybe wanted to ask you just follow-up really quickly on that on Richard's question is, any kind of push from clients into maybe a pure PMPM only kind of contract where the visits are included? Are you seeing any kind of uptick in that kind of contract format? Well, I would suggest that the fastest area of growth for new client wins has been in that small and medium sized business with the visits included model that higher PMPM. Okay. And what is roughly that PMPM come out to be if we look at sort of what you're averaging currently? Is it like more than 5 range or where does that kind of average out to typically? I would suggest you're normally in that $3 plus range. It's a significant multiple on what that average dollar and change is over the entire population. Okay. And then the question I really want to ask was around the visit guidance for the next quarter, it's $720,000,000 to $820,000,000 And if we look at the midpoint of the range, and I appreciate that you're giving us the international visit number here. I guess just to break that down a little bit, should we assume that international visits have the same kind of seasonal pattern in the Q4 as it does in the U. S? Yes, that's what we're assuming. So that's correct. Okay. This will be the first time obviously we have such a significant contribution from international, but the range is wide. We'd be conservative to suggest otherwise. The fact is that they do in fact trend in a very similar fashion as a result of either a very strong or a mild flu season. We're done with the 1st month of the quarter. It was a nice month. Trending looks like we're going to have, as Jason noted, something similar to, if not stronger than last year. So then the so is it fair to say the raise that we're looking at is really more flu dependent than anything? That's correct. Okay. All right. And then just sorry, lastly, on the Aetna side, you talked about it's being sort of revenue neutral here. We did $2,500,000 in business fee only revenue. Obviously, the Aetna side has the bigger visit fee value here. Is it that we're expecting a bigger spike in the Q4? Because if we're kind of looking at sort of backing into it, it looks like we're running, by my math, maybe $7,000,000 or $8,000,000 Is that sort of the right range for the full year or is it Yes. You're in the right ballpark. Okay. Great. Thanks guys. Yes. And that would be consistent with where we were. Okay, perfect. Thanks a lot. Sure. Your next question comes from the line of Ryan Daniels from William Blair. Your line is open. Yes, guys. Thanks for taking the question. Jason, one for you. It sounds like the Advance Medical integration is off to a very good start, good feedback from customers. But I'm curious as you've kind of gotten to know the organization more, if there's been any surprises either way, positive or negative from initial expectations? And then number 2 is a follow-up to that. Are there any best practices that you've revealed that you think can be kind of brought over to the U. S. Operations and push to your current customers that could benefit the organization going forward? Yes. Thanks, Ryan. The Advance integration has been fantastic really, working really well with that management team. In fact, Peter is over there right now with the team working on planning for next year further integration discussions and starting to work on client efforts. The team from Advance Medical has been out see all of our material international clients especially in Europe. I'll be over there in November just in a couple of weeks where I'll see a number of our European clients. I think the biggest sort of pleasant surprise is the appetite for product expansion within our existing clients, especially the Teladoc clients, sort of legacy Teladoc clients in Europe prior to the Advance acquisition. We're also seeing a very, very good response to the Global Care product launch which was obviously a result of the Advance Medical acquisition and we're seeing that as strong response both outside the U. S. As well as from U. S. Multinationals. With respect to best practices, I think that the two things are 1 around the global care product was something that quite frankly we didn't have, we hadn't done and the opportunity to bring that to market was clearly an opportunity for us to leverage their best practices. And then the second thing is around we have a team working through sort of comparing the expert medical services processes to figure out the best of breed processes as well as identify ways to generate efficiencies. And so I think that that's going to bear fruit over the course of the next couple of quarters. Okay. That's great. Thank you. And then, we've talked about some of the kind of lesser revenue business segments with behavioral and etcetera. But I'm curious how the provider market is shaping up, especially given some of the recent momentum with CMS and moving forward with payments for some of the Medicare Advantage plans, etcetera, are you seeing that also pick up in the pipeline? Yes. The provider market continues to grow at a really strong clip for us. We just sort of on a percentage basis that's probably number 1 or number 2 in our growth areas. Obviously, it's off of a small base. I would say the 2 things that are interesting in that space are number 1, we have clients looking for more services from us as they expand the use cases for virtual care, which is always encouraging. And we have really good examples of hospital clients who are very, very committed to virtual care and are starting to see the real value and realize the benefit of those services. We continue to have a robust pipeline there. That's a very, very active team. And our win rate continues to be very strong. Okay, great. Thanks. I'll hop back in the queue. Congrats on the strong performance. Thanks, Ryan. Thank you. Your next question comes from the line of Mohan Naidu of Oppenheimer. Your line is open. Thanks for taking my questions. Jason, on utilization, given the traction you're having so far, can you comment on the expectations on utilization expansion? Is the 100 basis point improvement year over year still the right base line? Yes, I think that's right. I think at the Analyst Day we talked about north of 100 basis points, but as that as our outlook on that continues to improve, but you're certainly good at looking at that as a baseline. Okay. And on couple of quick follow ups. 1 on TRICARE, just to be clear, there is no change in contract right now. There's just implementation ongoing right now and scheduled to be online in Q1. Is that correct? That's correct. Okay. Last question on the inpatient side. I have not heard much on that in today's call. Just want to see what's going on in that market and any updates on market conditions there? Can you just clarify what you mean on the inpatient side? The hospital product that you guys sell, how is that market coming along? Yes. So that's coming along really well. We see clients asking for more services from us. We see the pipeline as being really robust and we see more use cases for our technology and our clients asking for us to do some development so that they can employ our technology in additional cases. That's great. Thanks a lot, Jason. Excellent. Thanks, Mohan. Your next question comes from the line of Sandy Draper from SunTrust. Your line is open. Thanks very much. I apologize about hopefully you can hear me okay. My voice is a little shaky. If you probably need to call a doctor. If you could I think I heard it on the comment, Mark, you said pro form a PPM, including Advanced Medical would be a little bit higher. I think that was correct. I'm just curious, so generally it sounds like obviously it's a higher PPM. Is that because typically Advance Medical had a broader adoption across multiple services? Or is it just people were tending to buy more of an all in all inclusive? Just trying to understand that. And you can just say, if the answer is, I misheard it, then obviously there's a different answer. Thanks. No, you heard it correctly, Sandy. The fact is that Advance Medical's, the primary component of their revenue is international. The opportunity internationally, Europe and Asia, Latin America tends to be far greater than that in just the U. S. Alone because of not only faster adoption, but there is less competition and there's a greater appetite to purchase an all inclusive product. Got it. That's helpful. That's my only question. Thanks. Thank you, Sandy. Your next question comes from the line of Ana Gupte from Leerink Partners. Your line is open. Hey, thanks. Good evening. So the follow-up on that rule that came out with CMS and Medicare Advantage for 2020, I mean, it could be a very big opportunity from where we sit covering managed care as well, maybe 25,000,000 total seniors. And how are you thinking about what the potential is for adoption, utilization and the likelihood that you'll get market share from the nationals? And then on the health systems, whether they'll use more of their own homegrown platform or will they work with you on your networks as well? And what are you doing to plan for that opportunity? Yes. Thanks Anna. We're very, very pleased with the proposed regs coming out of CMS relative to Medicare Advantage. They really lend themselves to us rolling out our full product portfolio into the Medicare Advantage Plans and Medicare Advantage Markets just like we have into the commercial markets. The regs really support that. The other thing that was very encouraging is the strong endorsement from CMS of virtual care and the impact that it can have on access, quality of care and cost. And so really couldn't be more pleased with the direction that that has gone. The market opportunity there is about 21,000,000 members across the country who are in Medicare Advantage plans. That tends to be a growing number over time. If you look at the Medicare Advantage membership over the last, as you well know probably better than I do, over the last 5 to 10 years, it's consistently grown that population. And so we are having active conversations with a number of our existing customers. Of course we're north of 35 health plans as clients and many of those clients have MA populations. So we're talking to a lot of them about virtual care in their MA products for 2020. And we're also now starting to be in discussions with prospects around their MA populations. With respect to the hospital systems, we actually don't see too many hospital systems going to homegrown solutions. There are a few of them, they tend to be very large systems with extremely large IT budgets and sometimes a bias toward developing themselves. But for the most part, we see hospital systems going into the market for virtual care telemedicine solutions. So we think that we'll be a beneficiary of that as the hospitals realize and know that they can get reimbursed for these services. This of course is on the MA side. The trend has been good, not quite as strong, but good on the Medicare fee for service side as well. And then lastly, we are hopeful, it's always hard to predict when this is going to happen, but generally the way the state Medicaid regs go and each one of the state Medicaid payment plans goes, follows CMS guidelines. So we are hopeful that that will continue to open up the doors in to the state Medicaid opportunities which of course is moving more and more to managed Medicaid solutions. Thanks, Jason. One follow-up on that. As far as the business model goes, would you see yourself having more of a shared savings model rather than just the specified CMS PMPM and adding on a per visit fee, which can be quite lucrative, I would think, for the MA population with reduced admissions in addition to ER visits and the like. And then are you planning home health integration as typically that's where the virtual medicine is well used? And I think Humana others are articulating digital health approaches around that. Yes. So with respect to the payment models, I think it's a little too early to say. We're just starting to have some of those discussions because of course the preliminary regs were really just published on Friday. I think we'll see some a variety of models and we're always happy for models in which we can get paid for the value that we bring. So we're certainly always open to those discussions. And then and we do see the opportunity being there for us to integrate with some home care plans. We've done some early pilots on that, but those are still in pilot phase. I do think as we go more and more toward the Medicare population, that will be a bigger and bigger opportunity. And as I've said before, that also opens the door to more integration with remote monitoring devices as those tend to be valuable in that population. Your next question comes from the line of Donald Hooker from KeyBanc. Your line is open. Great. Good afternoon. Thank you for a question here. I guess maybe kind of high level when you're bringing together best doctors, Advanced Medical, Now that you have best doctors under your belt for a little over a year now and you're ramping advanced medical, when do you kind of feel like you hit full kind of synergies with all this from a selling standpoint? I mean, is this going to take a couple of years? I'm sure each year gets a little bit more synergized. But what is your perspective now on sort of the ramp of potential revenue synergies as these three companies come together? Yes, it's a good question. I would say, the 2019 selling season will be the first one. It will be sort of the mature selling season for bringing together Teladoc and Best Doctors. The 2019 selling season will be the 1st selling season overseas that we're thinking about the sort of legacy Teladoc, Best Doctors business being combined with the legacy Advance Medical. So I would say that's year 1, year 1 is never maturity, year 2 tends to be sort of 1st year 1 is never maturity, 1st year 2 you hope to get to a more mature experience understanding about sort of what the optimal mix is, what the optimal pricing looks like, what the optimal pitch is, what clients react to and how you meet their needs best. So I would say U. S. Think about the 2019 selling season for 2020 as being more mature. Internationally think about the 2019 selling season as being year 1 with the 2020 selling season being mature. So just to be clear, not this selling season for best doctors, but next year selling season going into 2020? Correct. Got you. And then my next question and then I'll hop off and you probably won't answer it, but I'm going to ask it anyhow. With respect to UnitedHealth, how is the relationship there developing in terms of your exposure and opportunities within that health plan going into next year? Well, I'll provide an answer that we feel great about our relationship with United across multiple segments of their business. We continue to see growth and expansion again in multiple segments of their business. And I think the best sort of thing I can point to is not only do we continue to see expansion, but wherever we do comparisons of the impact that we're having versus other virtual care providers or telehealth providers, we come out on top. So I'm optimistic, feel good about the relationship and the progress that we're making with United. Thank you. Thanks, Don. Your next question comes from the line of Sean Wieland from Piper Jaffray. Your line is open. Hi, thank you. So just to button up the conversation on better health, can you just address what the certification and licensing requirements are that you have in place for providers on that network? So we have a thorough vetting process. We look at state licensure. We look at the licensure of the providers. We are fully compliant with all the state regs and we take an approach that we do with all of our business which is that clinical quality is paramount to the delivery of the care. We take very seriously the membership who comes to us for assistance there. And at the same time, we are always refining and improving our processes around that, which is why we have a clinical quality committee of our Board of Directors. And I mentioned bringing Mark Smith on to the Board. I think that's another good example of us focusing on clinical quality. That's great. Thank you. And then, I may have missed it. On Advance Medical, did you update us on the number of members today on Advance Medical and what you think the total year revenue contribution will be? No, we didn't address any update on members of Advance Medical. When we provide end of year numbers, we'll provide the domestic Advance Medical contribution. All right. Thank you very much. Thanks, Sean. Your next question comes from the line of Jalendra Singh from Credit Suisse. Your line is open. Hi, thanks a lot. I have a couple of questions, if I can ask. First, I want to get clarification around your comments around gross margin. I believe on the last earnings call, you talked about because of business mix, gross margin will drop to like 65% in second half. Clearly, 3rd quarter have come in better than that. So should we assume like high-sixty percent as a normal run rate going forward and maybe improvement from there? And what's the expectation for 4th quarter gross margin? Hi. The guidance that we provided a month ago remains intact. The margin impact from a very heavy flu season and obviously much more projected visit volume in Q4 and Q1 should in fact bring the margins into the realm of what we had guided at previously. We did have a stronger margin quarter in this Q3, but that's principally seasonality. Okay. And then let me follow-up on the CMS MA proposal comments on telehealth. Given all the uncertainty around how telehealth will be adopted or received by seniors and some concerns around whether they'd be willing to use it, at least compared to the younger commercial population. What gives you comfort that MA plans will not push for more like visit only model given they are probably going to get paid like dollar for dollar? And in fact, CMS estimates like $0.09 BMPM benefit, I mean included in the bid submission process. Can you give some color like your feedback on that? Yes. So I know what you're talking about with the $0.09 Actually I don't think that's exactly what CMS said. They gave an example, but they actually explicitly came out and said that they don't know what the cost impact will be because they don't really know what the impact of movement from one provider to another. They don't really know what the impact of improved healthcare by people getting care earlier than they otherwise would. They don't really know the full impact of transportation costs avoidance. And so they gave what I think was an example of how they work up, but I think they acknowledged themselves that they don't really yet know what that cost impact is going to be. Just to be as transparent as I can be, all of the government the payers we're talking about, about both managed Medicaid as well as MA, we're talking about more traditional models relative to what we've done in the past with a visit fee and a per member per month. It's not to say that's going to always be the case or that that's always going to be that there won't be other models that we look at as I said when I responded to Anna. But I think we're not seeing that as a macro trend. Okay. And then last question, I don't know if you have this data. What percentage of your 3rd quarter visits were actually repeat users? Do you have the data for 3rd quarter? Repeat users, I don't have it off the top of my head. Sorry. Yes, no sorry, neither Mark nor I are staring at that number, sorry. Okay, No problem. Thanks a lot. Thank you. Your last question comes from Matt Hewitt from Craig Hallum Capital. Your line is open. Hi, there. Most of my questions have been answered, but maybe 2 to wrap things up. Regarding the Advance Medical acquisition and the software integrations, have those all been completed at this point? And is your plan to have a consolidated platform that will be used in all markets going forward? Or will the markets have differentiated models depending upon some of the different offerings? Now our goal is in fact to have a ubiquitous platform throughout the world providing those individuals who are either in country or traveling with the same exact access point, same format and same expected high quality of service regardless of where they request their medical consultation. The integration of the app has taken place for certain parts of the Advance Medical existing services. The real in-depth and very deep integration will take place throughout 2019. And that really ties into what Jason was suggesting regarding selling seasons. When the team has that integrated app, we feel that we're going to be in the best possible position to offer those services on a, again, a ubiquitous platform, but on a comprehensive basis throughout 2020. I think I'd just add to that that we see a pretty significant opportunity to roll out our engagement capabilities among the Advance Medical clients. And that was a clear area to Ryan's question earlier about best practices. That was a clear area where the Advance Medical team was excited to get the access to our assets and capabilities with respect to our surround sound engagement. Okay, that's great. Thank you very much. Thank you. So thank you all. We appreciate it. We had a really great quarter. We feel very good about our momentum going into 2019. Our broad portfolio of services and our geographic footprint are being very, very well received and as you can see we have a lot of tailwinds in our business. So we appreciate your time today and your questions and look forward to seeing you at some of the upcoming conferences.