Welcome to Teladoc's first quarter 2018 earnings conference call and webcast. At this time, all participants have been placed in a listen-only mode, and the floor will be open for your questions following management's prepared remarks. If you would like to ask a question at that time, please press star one on your touch-tone phone. If at any point your question has been answered, you may remove yourself from the queue by pressing the pound key. We ask that you please pick up your handset for optimal sound quality. Lastly, if you should require operator assistance, please press star zero. It is now my pleasure to turn the floor over to Adam Vandervoort, Chief Legal Officer. You may begin.
Thank you, operator, and good afternoon, everyone. We look forward to discussing our first quarter 2018 results with you today. Joining me for Teladoc's conference call are Jason Gorevic, our Chief Executive Officer, and Mark Hirschhorn, our Chief Operating Officer and Chief Financial Officer. Today, after the market closed, we issued a press release announcing our first quarter 2018 results and filed our quarterly report on Form 10-Q. The release and the filing are both available in the investor relations section of teladoc.com. As a reminder, Teladoc 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's actual results to differ materially from those expressed or implied by the forward-looking statements.
For additional information on the risks facing Teladoc, please refer to our filings with the SEC. We'll start today's call with brief prepared remarks, followed by Q&A. Today's call will contain certain non-GAAP financial measures that we believe are important in evaluating Teladoc's performance. For more details on these measures, the most comparable GAAP measures, and a reconciliation of the two, please refer to the press release posted earlier today on teladoc.com. I will now turn the call over to Jason.
Thanks, Adam, and thank you to everyone on the call for joining us this afternoon. We saw a very strong start to 2018 with continued success across the business and another quarter in which we exceeded our expectations for all of our key metrics. Total revenue was $89.6 million and up 109% on an absolute basis and 47% on an organic basis. Adjusted EBITDA of a loss of $1.4 million beat our forecasts and compares to a loss of $9.1 million a year ago. We ended the quarter with 20.8 million U.S. paid members, up 41% compared to last year on a pro forma basis. Finally, we conducted 606,000 total visits for the quarter, as 554,000 visits came from our U.S. paid members in the quarter, compared to 385,000 last year.
Mark will dive deeper into the financial and operating metrics and will provide more granular data than we have historically given as we increase our transparency by providing more detailed information on our membership and visit volume, which we hope will allow you to better track our success across the business. With several months of 2018 behind us, I'm pleased to see that the leverage in our model is clearly contributing to our improved financial and operational performance. While we forecasted this leverage for quite a while, we are pleased to see it come to fruition and happy to report that we're on track to achieve our long-term financial targets. During the quarter, every one of our cash-based operating expense lines increased less than our top-line growth.
The best example of this is our G&A, which is our single largest operating expense and is declining materially as a percentage of revenue from 34% in the first quarter of 2017 to 27% this quarter. We expect this trend to continue. To be clear, the financial side of things isn't the only place that we're seeing proof of this leverage. For example, our current infrastructure can handle several times the volume we see today. This is evident as we performed over 8,000 visits per day during peak season, meeting our SLAs and actually surpassing our 2017 performance in spite of the intensity of this flu season. Mark will give significantly more detail on our utilization metrics in a moment. First, I'd like to provide some commentary about some positive trends that we're seeing. First, we're very pleased with the early results in our visit-fee-only populations.
The Aetna fully insured population is trending right in line with our projections. The FEP program is off to a strong start. Second, although it was an intense flu season in January and February, the flu moderated quickly in March. However, our utilization continued at a strong pace. Third, perhaps most exciting, we've recently completed an analysis of 15 months of data that clearly demonstrates the value of our comprehensive virtual care platform. Stated simply, the more products serving a population, the greater the engagement by that population. Both average number of visits per user and the number of users per thousand increases with more products. Said another way, by adding more clinical services, we get both greater depth and breadth of engagement with the population. This bodes very well as we continue to expand the scope of our offering, both in the U.S. and globally.
During the quarter, we also continued to make great progress on the integration of Best Doctors, which is on track and proceeding as we anticipated. We are deep in development of the fully integrated guided member experience and are on track to have that in the market later this year. This is the intelligent front-end user interface that employs advanced technology to quickly and seamlessly guide the consumer to the most appropriate Teladoc solution, which has gotten tremendous reception as we've previewed it for some of our largest clients. Furthermore, our cross-selling teams and commercial organizations are working very well together and showing signs of success. In fact, we recently closed the sale of our complex case management services to an existing health plan client worth nearly $2 million per year.
We're seeing sizable interest in our general medical solution in Europe and Canada from our existing customers and feel confident in our ability to leverage those relationships relatively easily as we look to expand our offering into those markets. With deep expertise and established relationships in those markets, we expect to commit additional resources, both organically and inorganically, to expand our product portfolio to more closely reflect our U.S. service offerings. Before I turn the call over to Mark, I want to update you on a few more exciting opportunities we're seeing in the market. There continues to be a massive opportunity for Teladoc here in the U.S. As I mentioned on our last quarterly call, the engagement by our health plan clients and prospects is increasing in velocity, scale, and scope.
We have made very good progress on multiple large opportunities. I feel very good about where we are at this stage in the selling season. Further, as the only comprehensive virtual care platform and with a strong value proposition across all segments of the healthcare market, Teladoc is uniquely positioned to benefit from the large-scale consolidation among payers, providers, PBMs, and other players. We see this as presenting nothing but opportunity for Teladoc. Finally, given the accelerating pace of adoption for virtual care, Teladoc's continued success in driving engagement, and the realization of a comprehensive platform that delivers a multitude of clinical solutions, I believe more strongly than ever that virtual care has passed the point of inevitability as a fundamental component of the healthcare landscape. With that, I'll turn the call over to Mark to review our financial results from the quarter.
Thanks, Jason. Good afternoon, everyone. To echo Jason's sentiment, this quarter represented a strong start to 2018. I'm very pleased with our results across the board. During this afternoon's call, I'll run through the financial results from the quarter and discuss our expectations for the second quarter and remainder of 2018. Turning to the P&L and starting with the top line, revenue in the first quarter was $89.6 million, a 109% year-over-year increase. On an organic basis, our quarterly revenue grew 47% over the same period in 2017. Revenue from subscription access fees increased 109% in the first quarter, coming in at $71.7 million, compared to $34.3 million a year ago. Looking a bit deeper, when we break out subscription fees between U.S. and international, the U.S. accounted for $61 million or 85% of the total access fees, and international generated the remaining $10.7 million.
In the first quarter, subscription access fee revenue accounted for 80% of Teladoc's total revenue. As of March 31, 2018, we had 20.8 million paid members in the U.S. That's an increase of 41% year-over-year when compared to the 14.8 million members we had a year ago after adjusting for 5.4 million Aetna and Amerigroup lives. As a reminder, we've refined our definition of members to include just U.S. paid members that are associated with a PEPM or PMPM or paid U.S. membership. Under this refined definition, membership totals will not include visit fee-only access. At the end of the first quarter, we had approximately nine and a half million individuals with visit fee-only access to our services, including those individuals from the Blue Cross and Blue Shield Federal Employee Program and Aetna's fully insured population.
Last quarter, we mentioned an additional 9 million TRICARE visit fee-only members that we anticipated going live in April. While we have launched a small part of this service, the bulk of this program has been slightly delayed, and we expect it to go live late in the second quarter or early in the third quarter. In the first quarter, our average per employee per month or PEPM was $1 compared to $0.95 in the fourth quarter of 2017 and $0.58 for the first quarter of 2017, or $0.79 on a pro forma basis. Moving on to utilization, which as a reminder, we calculate as total visits divided by Teladoc's paid U.S. membership. For those members with access to our general medical services, we completed 606,000 total visits in the first quarter, an increase of 57% over the 385,000 total visits we completed during the first quarter of 2017.
This represents an annualized utilization rate of 10.9% in the quarter, which is a 242 basis point increase over the same period last year. We segment our visits into visits from U.S. paid membership and visits from visit-fee-only access individuals. Visits from U.S. paid membership totaled 554,000 visits. Going 1 level deeper in the U.S. paid membership visits, 298,000 of these 554,000 visits or 54% of these visits were paid, while the remaining 256,000 visits were delivered under our visits included contracts. In addition to these 554,000 visits I just noted, we also completed 51,000 visits for individuals with visit fee only access. This is the first quarter that the FEP members were live on our platform, and we feel very good about the initial uptake and our ability to meet our full year targets for this population.
The U.S. paid membership visits generated $17.9 million in revenue, a 109% year-over-year increase. Drilling down a level further, $16.3 million in visit fee revenue came from general medical visits, representing a 90% increase from the first quarter of 2017. The remaining $1.6 million in revenue can be attributed to other specialty visits, which is primarily comprised of Best Doctors. Gross margins were 70% for the quarter compared to 71.7% for the first quarter last year. We anticipate the trend of gross margins moderating slightly lower as our revenue mix shift continues to evolve. Total operating expenses in the quarter came in at $81.9 million, representing an 80% increase from the Q1 2017 figure of $45.6 million.
Eliminating the impact of principally non-cash charges such as stock compensation, depreciation, and amortization, our Q1 2018 operating expenses, less integration related costs, were $64.2 million, or 72% of revenue, compared to $39.9 million or 93% of revenue in Q1 2017. As Jason noted, we are starting to see the operating leverage that we anticipated as we mature as a company and continue to successfully scale. Coming off of our first quarter of positive adjusted EBITDA in the fourth quarter of 2017, we ended Q1 with an adjusted EBITDA loss of $1.4 million in the quarter, compared to a loss of $9.1 million in the first quarter of 2017. These results were better than we initially expected. We had guided towards a first quarter loss since the quarter represents the busiest in terms of onboarding and marketing and engaging members from newly onboarded clients.
We remain confident in our outlook for positive adjusted EBITDA throughout the remainder of 2018. Net loss in the quarter was $23.9 million, compared to a loss of $15.7 million last year. This quarter's net loss includes a $1.5 million charge for the abandonment of redundant office space. Turning to the balance sheet, we ended the quarter with approximately $120 million in cash and short-term investments. Our total debt as of the end of the first quarter consists solely of the $275 million 3% convertible notes that mature at the end of 2022. Our GAAP presentation of this debt appears as approximately $210 million as it is presented net of the equity component of this security in our consolidated financial statements. Also, I want to note that the company remediated the material weakness that was noted in our 10-K filed this past February.
We intend to continue to focus on strengthening our control environment throughout this year. With that, I would like to provide our outlook for the second quarter of 2018, in which we currently expect total revenue between $86 million and $87 million, an EBITDA loss between $8 million and $9 million, adjusted EBITDA between $1.5 million and $2.5 million, total U.S. paid membership of approximately 20.8 million to 21 million members, total visits between 450,000 and 500,000 visits, and a net loss per share based on 62.6 million weighted average shares outstanding is expected to range from a loss of $0.35 to a loss of $0.37 per share.
For full year 2018, we affirm our previous expectations of total revenue between $350 million and $360 million, an EBITDA loss between $27 million and $30 million, adjusted positive EBITDA between $7 million and $10 million, total U.S. paid membership of approximately 22 million to 24 million members, and visit fee only access available to approximately 19 million additional individuals, total visits between 1.9 million and 2 million visits, and a net loss per share based on 62.8 million weighted average shares outstanding is expected to range from a loss of $1.36 to a loss of $1.41 per share. I'm very pleased with how we started 2018 and I look forward to continuing to update you on our progress throughout the year. I also want to thank the entire Teladoc team for their ongoing effort
The outstanding work they do for this organization every single day. Thank you all for joining us this evening. We'll now open the call to questions. Operator?
At this time, I would like to remind everyone, in order to ask a question, press star, then the number 1 on your telephone keypad. Our first question comes from the line of Lisa Gill of JPMorgan. Please go ahead. Your line is open.
Thanks very much, and good afternoon. Jason, I'm going to start with your comments around the virtual care platform. I think it really differentiates Teladoc in the marketplace. I want to understand how it's resonating this selling season. You didn't have Best Doctors last year at this point in the selling season. One, what are you hearing in the early parts here of the selling season? Two, what are the opportunities that you see from a cross-sell perspective? My second question was your comments around the vertical integration. Maybe if you could just crystallize for us really how you see Teladoc fitting in as we see this incremental vertical integration within healthcare.
Sure. Thanks, Lisa. A couple of things on the virtual care platform. We're seeing that it is truly differentiated in the market, and it's changing the discussions that we're having with our prospects and clients to be much more holistic, much more strategic, and larger opportunities. That is especially true in the health plan segment, where we have much more senior-level discussions around an enterprise-wide virtual care strategy as opposed to a point solution. There are plenty of point solutions in the market, but really, we are the only ones who can bring this comprehensive platform. Of course, we also see, as you mentioned, the opportunity for cross-sell into our employer clients, where we already have a relationship for Teladoc, and we're bringing in the expert second opinion services, and other more advanced services that are addressing the population toward the top of the healthcare pyramid.
We're seeing good traction there. I mentioned in my prepared remarks, we had a health plan, who had previously been really more of a telehealth client, engage us to provide expert second opinion services for their complex cases. That's just the first of what we see as many opportunities that we expect to close. With respect to the vertical integration and our opportunity there, as you know, both CVS and Aetna are clients of ours.
We've had great discussions with them about how Teladoc can be a part of more of a bricks-and-clicks environment, sort of a seamless continuum of care that's delivered in both the retail setting on an in-person basis, but can bring in a virtual component, in our case, especially a virtual interaction with a specialist who can assist the on-site provider, and also seamlessly interact with us on a virtual basis and direct the consumer to the right resources that are available to them. As you think about that becoming a more fluid experience that includes the benefit design, Teladoc plays really well in that environment. We see that being a benefit for us, but really a way that we can help to change the way that healthcare is delivered.
That's helpful. I'm just wondering, going back to the discussion on the selling season, is there any way for you or Mark to quantify anything as far as size goes, as far as the opportunity? I know that telemedicine is new and evolving, but is there a number to think about as far as incremental lives you connect to the platform and the discussions you're having? Anything on the number side, just because we're analysts.
I would say too soon to tell about comparing sort of the magnitude of the pipeline. What I will say is it's extremely active, at least as active, probably more so than it was last year. Many big opportunities, such as the ones that I described, especially in the health plan space. We continue to do very well on the provider side and have done extremely well in that market. I would say, I feel better about where we are now than I did last year, although I'll refrain from giving you a number you can plug into your model.
Okay. I'll keep asking for the number, congratulations on the quarter.
Thanks, Lisa.
Your next question comes from the line of Ryan Daniels of William Blair. Please go ahead. Your line is open.
Yeah. Thanks, guys, for taking the question. Jason, one for you. You mentioned in your prepared comments you have about 15 months of data indicating that with more products, you see a more engaged workforce and more utilization of services. I'm curious, number 1, if you can talk about how you intend to leverage that for marketing purposes or sales purposes to expand that penetration. Number 2, any magnitude of how big of an impact it has as clients add multiple solutions?
Yeah. Thanks, Ryan. I would say this: it is very much a testament to the value of a comprehensive solution that delivers value sort of across the healthcare or along the entire healthcare spectrum. Ranging from acute episodic all the way to more complex and chronic conditions. What we see is With each additional product that we add into the mix, the engagement increases on a frequency of visit basis, as well as in terms of the breadth of the population that we serve and who engages with us. It's pretty unique to see that you get growth on both of those dimensions. You sort of expect to see one or the other. Both is really valuable to us.
In terms of how we're going to use that, we want to put that information in front of our clients so that they can see the value of a single multifunctional solution as opposed to a bunch of disjointed point solutions that they may go to get in the market. With respect to the magnitude, I think we're going to sort of hold at giving qualitative guidance on that. Again, I'd reinforce that the benefit is seen with each additional product that we deliver into a population. It continues to build with each additional product.
Okay, that's helpful color. In regards to the TRICARE, you indicated that as opposed to the April 1st kind of full launch, it's getting pushed back a little bit towards the end of the quarter, Q3 early on. Obviously, it didn't impact your guidance, so you must have modest VFO revenue in Q2 soon for that. One, can you confirm that? Number two, any discussion on why that is being modestly delayed?
Yeah. We were prepared for the launch. In fact, we got accolades from our partners on our readiness as well as the implementation process. The government just took a slightly more measured approach to their rollout plan. They rolled out the global nurse advice line. They just wanted to take a more step-by-step approach rather than a big bang, to rolling out the new components. The virtual care part is really a new component as opposed to a replacement of previous services. To answer a question maybe that's on your mind, but you didn't ask it has nothing to do with the VA, that we've heard of from other players in the market. It's simply just a more methodical approach to rolling out the service.
Mark, I don't know if you want to talk to the expectations with respect to revenue or impact with respect to revenue.
Well, Ryan, we came off a strong quarter, we're trending ahead of our expected numbers. We do take a little bit of a hit as we had a guaranteed amount of revenue to be generated from TRICARE from the date they commenced their contract with us or go live with us. Each month that gets delayed, obviously there's a shortfall in the projected revenue from that contract.
Okay. That's helpful. One quick one I'll hop off. Did you give a PMPM fee? I may have missed that, again, on a second line.
We did not. I don't believe we did in the prepared remarks. For Q1, it was $1.00, compared to $0.58 for Q1 of 2017, and on a pro forma basis, Q1 of 2017, would've been $0.79.
Great. Very helpful. Thanks, guys. Congrats on the.
Sure
strong start to the year.
Thanks, Ryan.
Your next question comes from the line of Charles Rhyee of Cowen. Please go ahead. Your line is open.
Yeah. Hey, thanks for the question. Hey, quick question about the visit fee only. Visits were 51,000. If I sort of annualize that number, it sounds like you're looking at maybe about a 2% utilization. Correct me if I'm wrong. That sounds like that's better than where Aetna was in the old model in terms of utilization. Is that the right way to think about it?
You're excluding the FEP lives, Charles, because from a visit fee only access perspective, those would've been excellent numbers had it just been for the 3.8 million Aetna fully insured members. You've got to add to that, a little over 5 million FEP members. Those really went live in February. Again, I think you, or most people know what the figures are with regard to expectations on the Aetna fully insured. We've spoken throughout the month of March, and now as April, we're trending at the levels we would expect to see to remain neutral or slightly above revenues that were generated in 2017 from this population.
When I was looking at the queue, where you kind of break out the visit fee only revenue, I think it was about three point something million. If I back into the 51,000, it kind of backs into sort of a per visit of $6, $9. Can you tell about the breakdown between FEP versus Aetna pricing?
Sure.
I saw figures of $140 and $150, $60, right?
That's correct. About $150 for those Aetna visits and in the area of $45 for those FEP visits. You could likely do the weighting and determine where it came out, but that's where you come out for the first quarter.
Okay. One last housekeeping. Stock comp for the year, do you have an estimate that's embedded in the guidance?
We do. Stock comp, I think that we provided a-
I think we gave around $32. Yeah, about $32 million.
Was for this year? Okay.
Correct.
Perfect. All right. Thanks, guys. Congrats on the quarter.
Thank you.
Thanks, Charles.
Your next question comes from the line of Sean Wieland of Piper Jaffray. Please go ahead. Your line is open.
Thanks. Thanks for all the transparency on the numbers. Just in follow-up to Charles's question, what are the strategies or the levers that you're employing to accelerate the visit fee-only visits? I know that they're tracking in line, but to drive utilization and to drive growth with those contracts, can you share with us anything that you're doing specifically to drive utilization there?
We've dramatically improved the set of strategies and communications with the Aetna team, regarding collaborative efforts to drive member awareness and engagement. We actually deployed a very talented executive to work with their team at Aetna, and we've seen much more sort of positive direction and movement from both the Aetna group as well as our own efforts to deploy the surround sound capability that Stephany's team delivers. That's been very positive. On the FEP side, we're doing quite a bit of work with the FEP team, both, A, to provide them with best practices and, B, potentially to provide them with additional consumer engagement services on a sort of retained basis where they pay us to provide those services for their population.
We're seeing very good movement on both of those, and I'm pleased with where the first quarter turned out, and I have pretty high expectations for the remainder of the year.
Can you share with us any insight into what's factored into your guidance relative to that utilization of visit fee onlys?
The visit fee only utilization expectation for 2018 will remain below 1%.
Per quarter?
For the year.
Okay. I'm sorry. Wasn't it just 2% annualized?
No, it wasn't. When you're looking at the figures for the lives that came in throughout the quarter, we ended the quarter with 9.5 million lives. We expect to have 18 million lives by the end of the year. You should expect to see approximately 1% utilization on that annualized number.
Okay, super. Thanks so much.
Sure.
Your next question comes from the line of Sean Dodge of Jefferies. Please go ahead. Your line is open.
Yeah, thanks. Maybe staying with utilization for a moment, and more specifically on the surround sound rollout. Do you guys have any updated data on the lift you're seeing in utilization, maybe six or 12 months after you implement a client?
What we generally see, and I think we've shown this in some of our investor presentations, is that first-year utilization gets off to a strong, but as you would expect from first year, not ultimately the sort of objective utilization. Where we start at about in an employer population in the 6% range, it usually steps up into the 8% range for year two and then up around 12%-14% for year three. We see the benefit of that over time. What we're also seeing is that first year is increasing because we're becoming more nimble about engaging the population out of the gate with our surround sound capabilities. That's been an improvement really over the last year, to where we're seeing benefit in the first year that a population is with us.
Got it. Okay, thanks. Jason, the benefits of cross-selling have come up a couple of times now. Do you have anything at your fingertips to give us a sense of the progress you all have been making in cross-selling over the last couple of quarters? Maybe how many clients you've cross-sold Best Doctors or behavioral health into, or something like change in average services used per client and how that's trended over the last few quarters?
We haven't given any specific numbers about penetration of the multiple products into our book. I would say that we're making good progress in bringing our clients up to speed on the value of the full continuum of services that we offer. The first quarter is always a slower quarter in terms of engaging clients for new services, even on a cross-sell basis, because they're just coming out of the open enrollment period, and getting through the implementation and introduction of new benefits. We would expect to see that continue to increase in velocity over the course of the year.
All right. Thank you again.
Yep.
Your next question comes from the line of Jamie Stockton of Wells Fargo. Please go ahead. Your line is open.
Thanks for taking my questions. I guess maybe the first one, Mark, the dollar PMPM that you're quoting, I assume that in the calculation there, it seems like you're setting the international aside and not including that in the numerator. Is that right?
That's correct. That's only U.S. paid membership, Jamie.
Okay, in the denominator, as far as the member number is concerned, are you including the international Best Doctors, or is the international Best Doctors?
Yeah, we're not. That's all excluded.
Okay. All right.
Yeah, there's no international members or figures included in that calculation.
Okay, that's great. My other question is around the advertising marketing spend. Came in a fair amount below what we had expected. It seems like you're seeing some really nice leverage on that line. Can you talk about, I think maybe in the last call or two, you've referenced that you're seeing more visits that people are requesting over the app. I assume that that's leading to better engagement levels without you having to put ads in people's news feeds and whatnot. Can you just talk about any metrics you might have around what kind of engagement you're able to drive without having to actually spend a lot of money to drive it? Because it seems like you're seeing some good leverage on that line.
I think over the past three quarters, we've been experiencing that faster trend away from the traditional means of entering Teladoc, which was through the call center for years. We had projected that there would be a slow and steady trend through the app and through the web, and that actually occurred at a faster pace. That helped us preserve our 70% margin. That also kept the price and the costs of customer acquisition down a bit as well because we've shifted to the digital format away from some of the print materials. We benefited from really two prongs. One is the service side, and the other one was really the CPI. That's going to continue.
The fact that we end up having some available dollars, we'll likely deploy those in areas where either we want to concentrate on clients where we believe we've got a greater opportunity to see increased utilization this year, or through some of our cross-selling and bringing additional services to clients that were traditionally Teladoc-only clients, and we're introducing them to the expert medical opinions and other services from Best Doctors.
Jamie, I would add that we've seen improvement in our registration rates over the course of the last year, which once a member has registered with us, we're able to use significantly less expensive means to remind them of our availability and drive utilization. There is a benefit to that.
Is there a lot of runway still there? Do you feel like you've maybe crossed really the 50%, or I don't know what the most relevant penetration would be?
No, we're still in the very early innings. There's a ton of runway with respect to driving registration.
Okay. Thank you.
Thanks, Jamie.
Your next question comes from the line of Stephanie Demko of Citi. Please go ahead. Your line is open.
Hey, guys. Thank you for taking my questions, and congrats on the quarter.
Thank you, Stephanie.
Could you give us an update on recent turnover in the chief revenue officer role, specifically how you're heading up the sales and product strategy and maybe any thoughts if you're planning on refreshing the role?
When we made the acquisition of Best Doctors, we were fortunate to bring on a great executive in Peter McClennen. We moved Peter into the role of President. We're very happy to be able to retain him as a member of the leadership team. To be honest, it would have been duplicative to have a chief revenue officer and the President. Peter really oversees the entire commercial part of the business. It was simply a function of putting the two organizations together and having two executives for one position.
Okay. Understood. One housekeeping item from me. Could you quantify the utilization uptick you saw from the flu season?
Stephanie, we likely saw somewhere between 5%-10% increase in our projected utilization as a result of the strength in January and February. Flu basically ended towards the end of February. We didn't see any incremental uplift in March. April has been coming in as projected, that's why we feel comfortable with our existing range of on the upwards to 2 million for this year.
All right. Very helpful. Thank you, guys.
Thank you.
Your next question comes from the line of Sandy Draper of SunTrust. Please go ahead. Your line is open.
Thanks so much. I would also echo the congratulations on a solid quarter and good start to the year. If I want to find one place that just in my funnel where things were a little bit light, Best Doctors revenue was up 4% year-over-year, maybe a tiny bit lower than I thought.
Mark, do you still generally view longer-term Best Doctors as a double-digit grower and maybe blending it all in, it's going to be tougher and tougher to get it? I'm just trying to get your sense of, how did it perform relative to your expectations, and how do you see Best Doctors playing out for the year? Thanks.
Yeah. Thanks, Sandy. We certainly do see Best Doctors, I know we set expectations at the beginning of the year that Best Doctors would generate growth upwards to 15% and hopefully by the run rate fourth quarter to 20%. The first quarter comparisons to 2017 were a bit strange because they disposed of a small business in Q1. There were also some clients that didn't return back into that business both subsequent or prior to and subsequent to the transaction. I think we have a steadier run rate. We saw far less attrition at the end of the year than we had projected. I think we'll still end this year with growth that exceeds 15%, and I think we'll bring the Best Doctors base business to grow in excess of 20% into 2019. Still very comfortable with where they are today.
Okay, great. Really helpful commentary. Appreciate it.
Your next question comes from the line of Donald Hooker of KeyBanc. Please go ahead. Your line is open.
Great. Good afternoon. A lot of questions, of course, have been asked already. Just maybe on a more detailed question around sort of free cash flow, thinking about that. Kind of a great quarter. There are a couple sort of working capital items that moved around. I don't typically think of working capital for you guys, but I guess thinking about now we're in our first full year of Best Doctors, is there anything to think about with respect to working capital there? How do you think about free cash flow for the rest of this remaining quarters of the year?
Sure. Don, it's Mark. I think we burnt a couple million dollars of cash in this quarter. Working capital requirements, as I noted in the past, would likely range somewhere between $10 million and $15 million. We started the year with an excess of $120 million in cash. We've told everybody we'll end the year with an excess of $100 million in cash. I think we've also told people that we would look to be free cash flow positive. We're going to aim for that over the next two years. We haven't committed to a certain timeframe yet. As you noted, we have pretty light working capital requirements, and from quarter to quarter, I'd expect us to be either neutral in cash needs or requiring just a couple million dollars.
Got you. With regards to the hospital health system business, obviously that's a high growth area for you guys. What are the typical contract terms these days? I know it's early, but have you had any renewal experiences, and how have they gone in terms of pricing?
Most of our contracts are multiyear contracts between two and five years. The fact is that I don't think we've had a renewal to date. Some of those will come up, I believe, in 2019.
Okay.
Those contracts range. There could be $50,000 contracts and others that are up to $500,000 and beyond based on the size of the system.
Okay, I figured that. Then in the behavioral health revenues, can you disclose that, and I'll cede the floor?
Yeah. Behavioral health continues to grow dramatically. I know we've set expectations for an excess of $50 million for this year. We're on a run rate to exceed $55 million. They're exceeding our expectations and highlighting the fact that there's still plenty of runway there.
Thank you.
You're welcome.
Your next question comes from the line of Richard Close of Canaccord Genuity. Please go ahead. Your line is open.
Great. Thank you. Jason, I was wondering if we could dive deeper into some of your remarks. You talked about committing resources organically and inorganically. I believe you mentioned internationally there. Are you suggesting you're looking outside the U.S. possibly for a platform? Then I'd welcome any perspective you guys have on the two mergers that were announced yesterday in the hospital space with American Well and Avizia and Reach Health and InTouch, and whether you need to do something on the hospital side.
Sure. Yeah. With respect to M&A and really sort of investment overall, what we've said pretty consistently is that we look for investment opportunity, either in build, buy, or partner with respect to continuing to expand the product portfolio, as well as continuing to expand the markets that we serve, and our footprint in attractive markets. That could include everything from new product capabilities that bring us new clinical services, all the way to existing players who are operating in markets where we're not as strong. I think that we've been pretty consistent about that, and we continue to follow that approach with respect to our strategy. On the two recently announced mergers. We're very familiar with Avizia. We have respect for the company, but we almost never run into them in competitive situations.
The majority of their business is really centered around hospital-based hardware, which isn't really aligned with our strategic focus. We don't think that it has a particularly material impact on the competitive landscape. Then with respect to InTouch, sort of the opposite. We're not really surprised by the announcement. InTouch has been trying for a while to move from a hardware-based business to more of a software orientation. They acquired Reach, which is a small software business that's been working for some time to find a substantial market for its product. Reach is another company that we really never see in competitive situations. We operate in pretty different space than InTouch. We don't think that either of them has a particular impact on our success in the hospital and health system market.
Obviously, we always continue to monitor the competitive landscape, and look at how we can continue to expand the value of our platform as a service offering, which is where we're going to stay focused, not really with a hardware orientation. Is that helpful, Rich?
Yeah. No, that is. I also had a question on CVS. I was looking at their website, I guess for MinuteClinic there, and I was looking to see if there was anything on telehealth. Can you give us an update in terms of the relationship with the CVS and expected launch there for you guys?
I'm not allowed to give a launch date. We're in active development with CVS of the product. We're really excited about the prospects for that product. We're working very collaboratively with the CVS team. The relationship is very strong. The vision is there. As I said earlier, I only see opportunity with respect to some of their future as they look to make the acquisition of Aetna.
Okay. Thank you.
Your next question comes from the line of Mohan Naidu of Oppenheimer. Please go ahead. Your line is open.
Thanks for taking my questions. Just had one question around the visits in Q1. The flu has been great for you guys in terms of number of visits, but I just want to understand, did you guys see strength in new members trying Teladoc versus visits from members who have used Teladoc before and coming back for flu? As a follow-up, just on the new members who tried you guys because of the flu, did you see a repeat use from those guys? Thank you.
Yeah. Thanks, Mo. We said on our last call that during the flu season, about 50% of our users were new users. That's a good trend and a slight step up from the year before. That was true for the full quarter. It's too soon to tell about repeat usage, but when we looked back at that for prior years, it wasn't different for members who used us for the flu than it was for other conditions. We would expect that to play out over the course of the year.
All right. Thank you very much, Jason. That's all I had.
Okay. Thanks, Mo.
Your next question comes from the line of Matt Hewitt of Craig-Hallum Capital. Please go ahead. Your line is open.
Good afternoon. Most of my questions have been answered. Maybe just one on the competitive landscape, and obviously, you just addressed a couple of the more recent news items. Given the deregulation that you've seen over the last few years, has there been anything from a competitive landscape that you've seen some new dynamics or some new opportunities creep up that maybe others are entering, or more importantly, I guess, from your standpoint, where you're seeing opportunities to expand maybe farther than you had before? Thank you.
Sure, Matt. Look, I think that the big change in the competitive landscape is the expansion of our platform to become a much more holistic virtual care solution. We still see, and in fact, ATA, the American Telemedicine Association conference is going on right now. As we look at the landscape there, we feel even more bullish about the prospects for the company, in contrast to the multitude of point solutions that are in the market. It's always a good thing to get a sort of competitive check at a large show like that, and it was really an affirmation of our strategy as we scan the landscape.
Great. Thank you.
Sure. Thanks.
Your next question comes from the line of Matthew Gillmor of Robert W. Baird. Please go ahead. Your line is open.
Hey, just had one question left as well. I was hoping to get an update on Medicare Advantage. I know there was some discussion on that last call, but it's been a couple more months here, and we're waiting, I guess, on this regulation to be published. Curious if you've had additional discussions with MA plans and if you have a better sense for how that model will be constructed in terms of PMPM fees or going towards visit only, given the success you've had.
Yeah. There's a lot of discussion going on. In fact, I just sat on a panel at a conference talking about connected care for seniors, with a number of other health plans who were engaged in the discussion and thinking about how to serve the MA population. I don't think there will be any material movement in terms of buying behavior until the regs are published by HHS. We're watching and waiting, and are ready to provide input and insight if requested, as we're fortunate to be in a situation where we have more data on the delivery of virtual care than anybody else in the market. We feel good about where it's likely to go. But, until the regs are published by CMS, we're in a little bit of a wait and see.
Got it. Thanks, Jason.
Yep, absolutely.
Your next question comes from the line of Glen Santangelo of Deutsche Bank. Please go ahead, your line is open.
Yeah, thanks for taking my question. Jason, I just want to follow up on the comments you made with respect to the selling season. Kind of sounded like you're kind of about where you want to be, but maybe could you just elaborate maybe a little bit on the tone of those conversations as they maybe relate to the different types of contracts you can sign and the different models? For example, are you expecting more visit fee only as we head into 2019 or less? What sort of trend changes should we expect?
I feel very good about where we are in the selling season. I like the size and volume of opportunities that we're seeing. Mostly, to be perfectly honest, I'm excited about the scope of the opportunities that we're seeing, and the opportunity for us to bring multiple products to bear for our clients. That's especially true in the health plan space, where they tend to be big bites. With respect to the fee structure, I think it's all over the board. The good news is that we have a lot of experience now and data that enables us to align our incentives with our clients. We're seeing all different types of discussions, all of which meet our sort of financial hurdles with respect to pricing.
Okay. Thank you.
Yep, absolutely.
Your next question comes from the line of Steven Wardell of Chardan Capital Markets. Please go ahead. Your line is open.
Hey, guys. Congrats on the quarter.
Thanks, Steve.
Can you tell us a little more about international? You cited some progress internationally. What would you say are your top countries, and how would go-to-market approaches, and contracts differ there?
We're strongest internationally in Canada, the U.K., and Australia, New Zealand. We have some other pockets where we have pockets of strength, like the Netherlands, for example. The go-to-market strategy in those markets is really in partnership with large financial services organizations, and insurance companies. We've been very successful, but really with historically somewhat limited product portfolio. It's been really focused on expert second opinion. In Canada, we've done more innovation into behavioral health, and specialty pharma. That has borne fruit for us. We're excited about what we're hearing from our clients in all those markets is interest in expanding the product portfolio to more closely match what we have in the U.S., which is the full continuum of services ranging from general medical all the way up to expert second opinion.
We are actively looking at how we approach that and how we deliver a more fulsome product portfolio.
Great. Thank you.
Our last question comes from the line of Richard Close of Canaccord Genuity. Please go ahead. Your line is open.
Great. Thanks for the follow-up. Mark, I'm just curious, you've outperformed in first quarter. The guidance for the second quarter is ahead of our expectations, I believe consensus as well. Can you walk us through the process of not raising the annual guidance?
Sure. We just finished the quarter. We haven't even had the opportunity to look at the month of April. We'll feel much more comfortable after we've closed out six months, potentially July also, so seven. When we speak to you again in August with the first six months results, that's when we'll assess the opportunity to increase the range. But we've got a nice range there now. If we're heading towards the higher end, we'll let you know. If we need to raise it, we'll let you know as well. As you know, it's common for us not to see much significant movement in Q2 and Q3, but if we've got visibility into what's looking like it's going to come together as a strong Q4, we'll obviously attend to the raise in August.
Okay. Thank you.
Sure.
This concludes today's conference call. You may now disconnect.