Earnings Call: Q4 2020

Feb 24, 2021

Thank you for standing by, and welcome to the TelDoc Health 4th Quarter 2020 Conference Call. At this time, all participants are in a listen only mode. After the speakers' presentation, there will be a question and answer session. Please be advised that today's conference is being recorded. I'd now like to hand the conference over to Mr. Patrick Feeley, Vice President of Investor Relations. Please go ahead. Thank you, and good afternoon. Today, after the market closed, we issued a press release announcing our Q4 and full year 2020 financial results. This press release is available in the Investor Relations section of the teladochealth.com website. On this call to discuss the results are Jason Gorevic, our Chief Executive Officer and Mala Murthy, our Chief Financial Officer. During this call, we will also provide our Q1 and full year 2021 outlook, and our prepared remarks will be followed by a question and answer session. Please note that we will be discussing certain non GAAP financial measures that we believe are important in evaluating Teladoc Health's performance. Details on the relationship between these non GAAP measures to the most comparable GAAP measures and reconciliations thereof can be found in the press release that is posted on our website. Also, please note that certain statements made during this call will be forward looking statements as defined by the Private Securities Litigation Reform Act of 1995. Such forward looking statements are subject to risks, uncertainties and other factors that could cause the actual results for Teladoc Health to differ materially from those expressed or implied on this call. For additional information, please refer to our cautionary statement in our press release and our filings with the SEC, all of which are available on our website. I would now like to turn the call over to Jason. Thanks, Patrick, and thank you everyone for joining us this afternoon. 2020 was a transformational year for Teladoc Health and for the role of virtual care within the broader healthcare industry. We delivered needed healthcare to millions of consumers in the midst of the coronavirus pandemic and completed 2 significant acquisitions Together under Teladoc Health are defining a new category of whole person virtual care. Taken together, We dramatically accelerated our mission to empower all people everywhere to live their healthiest lives by transforming the healthcare experience. We delivered over $1,000,000,000 in revenue for the year, provided over 10,500,000 virtual visits And our license platform solution enabled an additional 3,900,000 visits for our clients' own clinicians pro form a for InTouch. We onboarded a record 15,000,000 new paid members in 2020. And over the last 18 months, we've added 20 5,000,000 paid members and 11,000,000 members with VFO access, a remarkable result. During the Q4, we saw broad based strength across our business, which drove revenue of $383,000,000 An increase of 145 percent over the prior year and organic growth of 79%, excluding the additions of InTouch Health and Livongo. The strength across our channels, products and geographies combined with a robust pipeline of new opportunities gives us tremendous confidence in the near term and long term outlook for the business. As we enter a new year, we've never been Better positioned to meet the increasingly sophisticated expectations of consumers, clients and providers. We are heartened by the progress that has been made in delivery of the coronavirus vaccines and expect some return to normalcy coupled with Strong continued demand for virtual care, well exceeding pre pandemic levels. The strategic investments we made during 2020 To expand the breadth and depth of our capabilities have uniquely positioned us to serve the growing client and consumer demand for virtual care and have accelerated our path to realizing our vision of becoming consumers' trusted destination for whole person health. The expansion of our capabilities in the hospital and health system market, including the acquisition of InTouch positions us as the leader in that channel. Our enterprise solution enables the full suite of virtual care regardless of the consumers' needs across Any location. Whether through one of our over 11,000 facility based care locations or directly to the consumer's home via a mobile device, Our platform enables our clients to provide virtual care for a broad spectrum of use cases from high acuity critical care in the ICU To post discharge follow-up and urgent care visits, we see growing demand as health systems around the globe look for an enterprise Our expanded capabilities in the management of chronic disease have uniquely positioned us to deliver on the promise of whole person care. The combination with Livongo extends our leadership position and enhances our opportunity to redefine the future of virtual care, Leveraging technology and data at unmatched scale to drive better outcomes and lower costs, while delivering a better consumer experience. We have the capabilities to deliver and manage care virtually across the spectrum for consumers ranging from wellness and prevention to coordination of care for people living with chronic conditions to high acuity for those dealing with critical illness. The combination is resonating in the marketplace And we have signed multiple cross sales since closing the Livongo transaction. We highlighted the GuideWell and Tyson Foods deal on our last earnings call, as well as a regional health plan cross sale last month. We have now signed over a dozen new cross sales since the close of the transaction And the pipeline of new opportunities has more than doubled in just the past 3 months. The early indicators give me tremendous confidence that we will deliver on the revenue synergies that we highlighted when we announced the transaction. Our industry leading breadth and depth of capabilities Comes together to underpin our innovative virtual primary care offering Teladoc Primary 360. Primary 360 is a full credit differentiated whole person solution that leverages our capabilities provide and coordinate care using a team based approach and brings together healthcare providers across multiple specialties. Primary 360 goes beyond just enabling virtual visits. Rather, it's a reimagining of the entire primary care experience And it positions us to become the trusted healthcare destination for the consumer regardless of what they need for both their mental and physical health. The results of our first virtual primary care pilot launched during the Q2 of last year have been highly encouraging. We're seeing over 30% consumer engagement and incredibly high satisfaction with an NPS of over 90. Over 40% of hypertension and pre hypertension diagnoses and over 25% of diabetes and prediabetes Diagnoses made by our clinicians have been first time diagnoses. This allows our clinicians and members to begin addressing the progression of disease and creates an opportunity for us to introduce the Livongo capabilities to those consumers early in their journey, which will ultimately drive better outcomes for consumers and lower the overall cost of care. Last month, we launched additional Primary 360 pilots with multiple new partners and the amount of Our new potential clients has been incredibly strong. We have a pipeline of well over 100 opportunities ranging from Fortune 1,000 Employers To large payers looking to partner on virtual first health plans. In fact, just last week, we signed another new partnership with a very large employer expected to launch later this year. We are making excellent progress on our integration efforts. Our commercial organization is now fully integrated and our teams responsible for cross selling have been 700 teammates across our commercial organization, including our new teammates from IntouchHealth and Livongo. This annual summit is a great opportunity to not only equip our commercial teams with the tools they need to effectively communicate our leading value proposition in the marketplace, but to share best practices and learn from one another. The integration of our data We are now capturing 2,000,000 blood glucose data points per week and our clinicians are responding to over 100,000 patient messages Via text and chat and providing over 30,000 visits on average every day. This innovative offering will pair the highly scalable personalized self directed digital care programs of Livongo's MyStrength With access to the expertise and convenience of Teladoc's virtual network of clinicians. With this integrated offering, we will create a new digital front door to behavioral healthcare, further breaking down barriers to mental health By allowing consumers to find the right care at the right time, increasing access and improving outcomes. We are already seeing tremendous excitement from clients globally for this next generation behavioral health offering and expect to launch it more broadly in the market by the end of the year. Before I turn the call over to Mala to discuss our results and forward guidance in more detail. I want to talk briefly regarding our outlook for 2021. Following a transformative 2020 and with the significant momentum we have entering this year, we feel Extremely confident in our outlook for 2021. For the full year, we expect revenue to be in the range of 1.95 43% pro form a for the acquisition of Livongo. This robust growth is the result of the broad based momentum We continue to see across our business, including growth in utilization, a robust and growing pipeline of multi product sales, including Strong demand for our whole person chronic care programs, continued strength in the direct to consumer channel, Increasing demand for our licensed platform in the health system market, growth in international markets and new member additions. With that, I'll turn the call over to Mala for a review of the Q4 as well as detailed 2021 guidance. Thank you, Jason, and good afternoon, everyone. Before I get into the details of the results, I would like to note that following the close of the Livongo transaction, we are streamlining some of our reported metrics. Our revenue disclosure will continue to be broken out between access fee revenue, visit fee revenue and other revenue. Each of those revenue buckets is further broken out into U. S. And International. Our visit volume metrics are aligned with our revenue disclosure, including both U. S. And international visit volumes, which is aligned with how we manage the business. We are also adding a new metric, chronic care enrollment, which captures the total unique individuals enrolled in the Livongo suite of chronic care programs. This metric is based on a count of total unique members. So members utilizing multiple solutions are only counted once. Turning to 4th quarter results. Total revenue increased 145 percent to $383,000,000 or 79% on an organic basis. U. S. Access fee revenue for the quarter was $283,000,000 representing growth of 188% over the prior year's quarter. Total international revenue of $34,000,000 grew 16% versus the prior year. Visit fee revenue for the 4th quarter increased 80% year over year to $53,000,000 and comprised 14% of total revenue as compared to 19% of revenue in the prior year's quarter. The decrease in visit fee revenue as a percent of total revenue is due to the acquisitions of Livongo and IntouchHealth, both of which We ended the quarter with U. S. Paid membership of 51,800,000 members, an increase of 41% year over year. Individuals with visit fee only access was 21,300,000 at the end of the Q4. Total chronic care enrollment, which includes individuals enrolled in one of our chronic care programs was 596,000 members, an increase of more than 40,000 members sequentially. We provided 3,000,000 visits in the quarter through our Teladoc network of clinicians, representing 139 And provided by our clients' own clinicians show was an additional $1,100,000 in the quarter, More than 4 times the number of sessions in the same period last year pro form a for the acquisition of InTouch Health. As I mentioned earlier, We have streamlined our visit metrics to better align with how we manage the business and our focus on driving utilization and delivering value for clients and members regardless of payment model. The annualized utilization rate for our paid members was 17 point 7% in the 4th quarter, an 8 25 basis point increase over the last year's 4th quarter and a 120 basis point increase sequentially. PMPM was 1 point $0.76 in the 4th quarter, up from $0.91 in the prior year's 4th quarter with over Half of the increase driven by the inclusion of Livongo in our consolidated results. Adjusted gross profit, which excludes depreciation and amortization of intangibles, increased to $260,000,000 an increase of 150 7% as compared to the prior year's 4th quarter. Adjusted gross margin was 67.9% compared to 64.6 percent in the Q4 of 2019. Gross profit and adjusted gross profit Include the benefit of $5,400,000 in lower expenses on Livongo devices attributable to adjusted EBITDA increased to $50,400,000 in the quarter compared to $15,200,000 in the Q4 of 2019. 4th quarter adjusted EBITDA margin of 13.1 percent increased by 3.40 basis points year over year. Adjusted EBITDA includes a benefit of $5,400,000 attributable to purchase accounting adjustments mentioned previously. Net loss in the quarter was $394,000,000 compared to a net loss of $19,000,000 in the Q4 of 2019. 4th quarter net loss includes $57,600,000 in transaction costs as well as $331,700,000 of non cash Accelerated stock based compensation expense related to the merger with Livongo. On a per share basis, Net loss was $3.07 for the 4th quarter compared to a loss of $0.26 in the Q4 of last year. 4th quarter net loss per share includes $0.45 of transaction costs as well as $2.59 of non cash accelerated stock based compensation related to the merger with Livongo. Excluding all transaction related costs and tax benefits, the per share loss In the Q4 would have been $0.27 We ended the quarter with $787,000,000 in cash and short term investments, while our total recorded debt outstanding as of December 31st was $1,400,000,000 Now turning to forward guidance. For the full year 2021, we expect revenue to be in the range of $1,950,000,000 to $2,000,000,000 as Jason mentioned, representing growth of 78% to 83% over the prior year or 40% to 43% fully pro form a for the acquisition of Livongo. Our confidence in that strong revenue growth is underpinned by: First, continued growth in utilization, particularly among non infectious disease related visits such as hypertension, Lower back pain, anxiety and depression. During the Q4, approximately 75% of our Volume was related to non infectious diseases, up from 50% in the Q4 of last year as our visit mix continues to diversify, a trend that has continued into the New Year. We've also seen tremendous growth in new registrations over the past year with newly registered individuals growing at twice the rate of new member additions. Registered member growth creates opportunity for deeper engagement and is a leading indicator of forward utilization. Growth in specialty visits has been particularly strong, led by growth in behavioral health, which experienced growth of over 500% in 2020 as the growth in visits accelerated throughout the course of the year. All of that comes together to give us tremendous confidence in our visit volume outlook. And you can see that reflected in our Strong visit volume guidance. We expect total visit volume to be between 12,000,000 13,000,000 visits this year, representing growth of 13% to 23%. 2nd, we have built growing pipeline of multi product sales, including strong demand for our whole person chronic care program. In 2020, 2 thirds of Teladoc's deals were multi product deals and our experience shows that client retention, member engagement And PMPM growth are all significantly stronger for clients that use more than one of our products. Next, in the direct to consumer channel, our BetterHelp brand has also continued to significantly Another year of robust growth of at least 50% in 2021 as we continue to gain scale and expand our leadership position in that channel. 4th, continued new member additions at both existing and new We expect to grow paid membership to 52,000,000 to 54,000,000 members in 2021, which is net of the approximately 1,500,000 COVID related temporary members that have rolled off during the Q1 as previously disclosed. We expect visit fee only access to be available to an additional 22,000,000 to 23,000,000 individuals. We also see increasing demand for our hospital and health system platform solution We expect organic growth in this channel at the high end of the 20% to 30% target range we provided last year upon the closing of the InTouch acquisition. And last but not least, accelerating growth in the international market driven by increased penetration in existing geographies and expansion into new regions. We expect adjusted EBITDA in 2021 in the range of $255,000,000 to $275,000,000 representing an Increase of over 100 percent of the midpoint and including an approximately $20,000,000 benefit from lower on Livongo devices attributable to purchase accounting adjustments related to the Livongo merger. The expected growth in adjusted EBITDA is driven by the contribution from a full year of Livongo as well as the overall strength across channels, partially offset by investments back into the business, including the integration of Livongo as well as new product development and enhancements to existing products. For the Q1 of 2021, we expect total revenue of $445,000,000 to $455,000,000 representing growth of approximately 150% over the prior year's quarter. We expect total paid membership in the range of $51,000,000 to $52,000,000 which is net of the approximately 1,500,000 temporary quarter of between $2,900,000 and $3,100,000 visits. We expect 1st quarter adjusted EBITDA to be in the range of $45,000,000 to $48,000,000 including an approximate $7,000,000 benefit from lower And with that, I will turn the Call back to Jason for closing remarks. Thanks, Mala. In closing, I want to thank the entire Teladoc team for their amazing commitment to serving our clients and members around the world during a challenging year. Over the past 12 months, We've seen a monumental change in consumer expectations for the way they access and experience healthcare as virtual has firmly entered the mainstream. As a company, we've responded by significantly expanding our capabilities To meet the rising demands of clients and consumers around the world, while extending our leadership position by delivering, enabling and Empowering Virtual Care. As always, thank you all for your continued interest in Teladoc Health. And with that, we'll open the call for questions. Operator? First question comes from Lisa Gill with JPMorgan. Thanks very much and congratulations on a great year, Jason. I just really want to understand just a couple of really quick things. You gave us so much information. The first would just be around U. S. Paid members retention rates, competition in the marketplace. I I usually ask about the selling season, but I know it's a little early for that right now. But just really want to understand how you're thinking about the competitive market right now around what you saw on the retention side because you clearly added a lot of new business. And then secondly, you did talk about dozens of cross sell Livongo Pieces of business in 2021 that are included in 2021. Is there any way to quantify that so we can start to think about reaching that half $1,000,000,000 goal that you set when you made the transaction? Yes. Thanks, Lisa. Let me start with retention rates And the competitive landscape. And then I'll talk a little bit about the cross selling situation. With respect to retention rates, they continue to be at high levels consistent with historic levels, which have always been in sort of the low to mid-90s. We We continue to see that. And in fact, what we're seeing is the pipeline is growing actually faster than we've To the same time last year. And I think that that's really indicative of the market and clients recognizing The value of the full solution that we have and the unique position that we occupy. And I've had a number of large client discussions over the last several weeks As we start to move into this selling season and we start to talk about the opportunity of the full credit answer sort of that full solution across All of our product portfolio and it is truly differentiated. So I was just talking to a regional blue plan I believe we will take away from a competitor who has a much narrower set of products And can't compete in the evolving landscape and sort of the new paradigm that we've created. With respect to the cross selling, what I think we said is over a dozen cross sales. Those will roll on over the course of 2021. And I would say we'll have Some impact on the back half of the year, but relatively small in the back half of this year. What we're really looking at is Impact on 2022 and we still feel very good, in fact better than we've ever felt before about About the prospects for our revenue synergies. Just sort of characterizing the Cross sell opportunities. We look at the pipeline today Versus the pipeline just sort of the middle of last quarter. And remember, we started commercial collaboration long before we Closed the Livongo transaction and we've more than doubled the pipeline of cross sell opportunities. So I feel very, very good about it. We've taken, I would say, a relatively conservative view of the contribution from the revenue synergies in 2021 And believe that those will materialize much more significantly in 2022 and beyond. Great. Thank you. Next question comes from Sandy Draper with Truist Securities. Thanks very much. I would also echo the congratulations on a very Jason, from a high level, one of the things I know we used to talk about is you are really Focused on the higher visit fee or higher visit growth than access fee growth because back this is pre COVID, You are really showing the power of your ability to drive utilization and show the value of the platform. Post COVID, I'm just wondering when you think longer term is really because you shift post COVID plus the diversity of the model. Is it really more about access fee growth and that will grow faster than membership? I'm just trying to think about how you think and maybe Mala chime in as well, Thinking about that growth dynamic, because it clearly decoupled with COVID, but would love to just get your thoughts on driving new business and the growth. Is it around the visit volume versus the access fee? Thanks. Yes. I appreciate the question and it is it's a complicated question, right? Because I think visit Volume will continue to grow at a more rapid rate than membership will. But I think what you're going to see with This significantly increased sort of per member subscription fees that we get with the Livongo business, You're going to see the revenue grow faster on the subscription access Right. So there's a little bit of a mix there. I think one of the things that I would look at and makes me really Bullish on the future of our continued visit volume growth is the fact that This year, we saw visits grow 140% year over year in spite of the fact that infectious disease visits decreased By 17%. So we have this situation where people are coming to us for a much broader array of reasons. We're seeing our mental health visits increase dramatically over 500% through our B2B channel, for example, Dermatology similarly and yet we're facing Historically low flu season because of social distancing and mask wearing. We've taken that into account In the guidance that we gave for 2021 and we're even contemplating it as we look into the first half of twenty twenty two And because I think it's really not until the back half of twenty twenty two that you're going to see us return to a more sort of normalized Flu, cold and flu season. So all of that's taken into consideration as we think about the long term growth. So hopefully that clarifies a little bit, right? Visit volume grows faster than membership and yet subscription access fees are To grow faster than visit fees. Yes. And Sandy, it's a great question. What I would add is, if you think about The growth of both of those revenues, just to reinforce, what I said in our prepared remarks in terms of Why do we have confidence in the growth of both access fee revenue and visit revenue? It's sort of a few different factors, right? One is on the access fee growth to Jason's point around it is a much bigger base with the addition of Livongo and Intouch. Most of those feed our access to revenue as we've talked about. And so the growth there is going to be driven by Our strong pipeline of multi product sales, we've talked about our growth in specialties, continued growth in our Chronic condition programs and then the growth in HHS and InTouch and our licensed platform solution, all of that is going to Feed our access fee revenue growth. And then to the point that Jason made around what's driving visits revenue, It will really be the gains we continue to make in utilization. You saw from our results, we saw a very Strong increase in utilization in the 4th quarter, over 800 points relative to Q4 of 2019 And sequentially, much over 100 points in relation to the with respect to the Q3. So We will continue to drive growth in utilization and that will obviously feed visit revenue growth. The growth in utilization is on the back of the significant increase and growth that we are seeing in non It was about 75% of our visit volume mix in the Q4. So we're seeing strong growth there. We talked about the growth that we are seeing in Specialty, whether it be mental health, whether it be derm, so that is going to continue to drive the utilization. So all of those factors is what is underpinning our confidence in both the access fee revenue growth as well as the visit revenue growth. Next question comes from Sean Wieland with Piper Sandler. Hi. Thanks so much. And I guess a follow-up to Sandy's just to go a little bit deeper. So clearly membership growth is Moderating in the outlook. And I'd just like to know, is that a factor of overall market penetration of virtual care? Do you think that there's opportunities longer term to continue to grow membership? And then related to that, you called out, What percent of members today are registered members? So let me speak first, Sean, to the question of membership growth, we added 15,000,000 members last year and 25,000,000 members in the last two years. That's a staggering number. And I think What gives me confidence in the continued membership growth is what I mentioned earlier, which is that If you look at our growth pipeline, the membership growth opportunity is actually 50% larger than it was at this time last year. It's just that the those are earlier in the selling process, right? So we've had to sort of refill the pipeline, if After just an explosive year last year. And so we take a relatively conservative view of the membership Growth given the earlier stage and yet the growth opportunity is 50% larger than it was at This time last year. So I think that gives me significant confidence over the longer term. We still have 65,000,000 members worth of white space within existing clients. So I feel very, very good about continued membership growth And we look at it over sort of a multi year, not a quarter by quarter Yes. And to your second question, Sean, we, as you know, do not break out What you asked, we've given you a lot of information. As was pointed out earlier in the call, We don't give you every piece of information. So that's not something we've broken out. We have talked as you mentioned about the increase in first time Sure. But also that that enters the flywheel and we get then repeat utilization, especially among multiple products. Yes. And it's important that registrations as we have talked about is running well ahead of membership edition growth, right? So That is also important as we continue to drive utilization in 2021. Next question comes from Stephanie Davis with SVB Leerink. Hey guys, everyone else congrats on the quarter, congrats on the guide. Thank you, Stephanie. Thank you, Stephanie. Thank you, Stephanie. A really strong international dynamic on your prepared remarks. I was hoping that you could talk a little bit more about really what pockets of geographies were you seeing the biggest strength and how the competitive dynamics differ Net market? Yes, absolutely. I'm really excited about our international products prospects and We're just starting to really hit our stride and activate the international channels for the InTouch solutions and We're seeing tremendous interest in the international markets for the Livongo products. So and You know how large those opportunities are. So with respect to the geographies, we're seeing Good growth in Europe, both on the continent as well as in the UK. We continue to see The South American markets and especially Brazil has very exciting opportunities. The Brazilian market is characterized By a very tech savvy population and it's a market where Private health insurance is rather prevalent. Specifically in Europe, we launched with Telefonica and that Continues to be a very, very strong relationship. We're very bullish on the prospects for that relationship. And then of course we launched over the past year in the Nordic region. So right now those are Probably our primary growth areas. We continue to have a strong and steady footprint in Canada And Australia, New Zealand. And so from my perspective, I'm very, very bullish there. I believe that unlocking some of those markets for the Livongo capabilities will be A game changer in terms of the role of the international markets in our book of business. Next question comes from Richard Close with Canaccord Genuity. Great. Thanks for the question. I assume you can hear me okay? Yes, perfect. Excellent. So I was going to drill down on membership, but that's been hammered on here. But can we talk a little bit About primary care, Jason, and how you're thinking about that. Obviously, the comments on the pilots were positive. How do we think about the business model for primary care? What metrics you're focused in on there? And then Does it shift the revenue model more from an episodic type of payment or to more Just overall, how does that model evolve? Yes, I appreciate the question, Richard. We're really excited about Prospects for Primary360, we have a very, very large and diverse pipeline Of opportunities for that model. And it ranges honestly from higher PMPMs plus A wider variety of visit fees because of course a 30 minute introductory visit with A new primary care relationship is going to be worth more than an annual check-in Or a symptomatic visit, for example. Having said that, we're also talking to a number of health plans about Putting in quality metrics and incorporating more value based reimbursement associated with our ability to move the needle on Quality of care, and I think that will start with small steps along the lines of Documented improvement in screening, rates of screening and appropriate preventative care And move toward more impactful outcomes based measurement and ultimately the opportunity for us To enter into risk sharing arrangements or share of savings arrangements with some of the payers. We're already having those discussions, But we're also very cognizant that we need to step carefully into that and make sure that we have the right data to be able to enter into those relationships With eyes wide open and know where we can make the biggest impact. So I think you'll see an evolution of that model. But in all of those cases, a significantly higher revenue per member for those who were serving with our primary 360 Product. Next question comes from Sean Dodge with RBC Capital Markets. Thanks. Good afternoon. Maybe on the average PMPM, the sequential change there was pretty significant even Mala, what you explained, excluding the lift from the Livongo inclusion there. If we set Livongo aside, can you give us a sense of how much that was driven by Multi product sales versus maybe something like repricing or true ups related to the visits included contracts? Yes. So what we have shared with you is, as you said, there was a Pretty significant increase in the PMPM as you saw, dollars 1.76 in the quarter compared to 1 $1.18 sequentially and $0.91 so a very significant increase. The way I would think about it is A lot of it was because of the addition of Livongo to be clear. But even absent the addition of Livongo, we did See an expansion, a nice expansion in our PMPM in the quarter. I don't want to break it out more Specifically on how much of it came from a rerating of our visits included contracts, which by the way we have rerated through the year As we went through the visit volumes through the year, we've talked about that and that definitely did happen. But there are a lot of so I don't want to specifically break out The individual drivers, but what I will say is even excluding the impact of Livongo for the 2 months of the quarter, We actually did see a nice expansion in PMPM as we went through the Q4. Next question comes from Daniel Rosyth with Citi. I want to focus a little bit on Medicare, both on MA and fee for service. I think in In the Q3, you mentioned you had around 2,500,000 MA lives aboard. And CMS mentioned, I So curious if you can give us an update on the MA progress you've made during this past AEP. And then on the C4 service side, there's been some noise out of the Inspector General's office about auditing some Telehealth visits and I don't know, it seems like the regulatory landscape in fee for service might be a little more uncertain. So curious to get your thought on that market in particular, Which I suppose would go into your provider segment. And if the direct contracting within Medicare Your fee for service is going to have any impact on your strategy in that market? Thanks. Yes, I'll take the second one first And then Mala can speak a little bit to the progress we're making in terms of our Medicare membership. I think I continue to think that Medicare fee for service is primarily an Opportunity for us with respect to our hospital and health systems business. As hospital and health systems continue to lean in harder To providing virtual care for their membership and being reimbursed by CMS. We continue to be very active in terms of working with CMS And various state legislators for that matter on best practices when it comes to the regulatory environment. And we're very optimistic actually. We think that the winds are all going in the right direction. It's a rare bipartisan issue And we're collaborative with respect to making sure that there are the right guardrails around it because we think that it's important to have Best practices proliferate with respect to not only payment models, but also the best care being delivered And to make sure that the consumers' needs as well as the payers' needs, whether that's the federal government Or a private health plan are also being looked after. So we're very active on those fronts. We're actually applying quite a bit of technology to that To be able to do things like use artificial intelligence to validate that a clinical visit took place and things like that. So I feel very good about the direction that that's heading. We continue to make Progress in the Medicare Advantage market, I don't know that we gave numbers updated with respect to our Medicare Advantage Population, we'll continue to keep you apprised of that as we go through the quarters. Yes. And the only other thing I would add is, As we've talked about the 15,000,000 member addition in 2020, we have talked about how we've seen nice Growth in government, whether that includes Medicare Advantage or Medicaid. So it's so think of it more as we are seeing Strong growth and membership addition across government. Maybe last thing I'd just mention is we're also seeing Private Medicare, meaning Medicare populations from within large employers who come through the It's a part of the market that frequently isn't talked about, but we're seeing growth in some of those Next question comes from Charles Rhyee with Cowen. Yes. Thanks for taking the question. Just to follow-up a little bit on Primary 360 as it relates to membership guidance. Is it Right to think that primary 360 members of that growth is a conversion of existing U. S. Paid membership members or Would that be incremental within the membership growth? And then secondly, on the utilization number, which was quite strong, I know you don't give this number, but in the past. But can you give a sense on how much of those user utilization is from repeat users versus bringing in First time users. Thanks. Yes. So I'll take the Primary 360 membership and then Mala can talk a little bit about Repeat utilization and registrations because I think really it's a question of new registrations. With respect to Primary 360, the answer is actually both. So in some cases, we're going to existing clients To existing populations and we're making Primary 360 available to them. And so we wouldn't newly Count those members, right? They're already in our membership count. In other cases, there are new populations where we're going to them And making our services available for the first time and the product that we're bringing to bear for them maybe Primary 3 60, it may also be Primary 360 and other products alongside of it. So you may get some into our Primary 360 driving that revenue and then other members may have other versions of the product either on a Sort of as needed basis and or they may have our chronic condition management program. So I think you'll see it Show up in different ways. What you can be confident though is we're only going to count a member once. Yes. And Charles, regarding your other Question, we as you said, we don't break it out, but I'll just give you a few facts. The first is, if you think about our visit volume in the quarter, About half of it actually came from first time users. And as you know, that's always Really helpful as you think about driving future utilization, right? They try it once and then they will repeat. So that is something that is also a factor that underpins our confidence in driving utilization as we move forward. So the fact that we And then the only other thing I would say is, when we were at JPMorgan in January, we did talk about How we are seeing the flywheel dynamics fueling durable growth and we did talk about repeat visits Showing very nice robust growth over the past few years. I don't want to say more than that, But I would sort of think about the half of our visit volume coming from first time users in the 4th quarter. And that's true for the whole year. So that was a trend that was in the 4th quarter. That was true and it was true for the whole year as well. Next question comes from Jialindra Singh with Credit Suisse. Thank you. Thanks for taking my questions. Just wanted to follow-up on Very strong trends there, revenues in $300,000,000 range, expected to grow 50% In 2021, with that business now becoming very sizable piece of your overall company, I was wondering if you are willing to talk about Margins on that business, how does that compare with overall corporate margins and long term profitability opportunity there? Part with several employers now expanding telebehavioral and mental health services, do you see that having any impact on your BetterHelp DTC side of the growth prospects? So let me answer about the market dynamics around BetterHelp and then Mala can talk To margins and performance. Yes, we really don't. I think a couple of things, Jalendra. 1, We've actually started taking BetterHelp into some B2B arrangements, in particular, With respect to EAP plans and that's turned out to be a very fruitful market for us. The second thing I would say is Most people who are returning to better health either don't have adequate coverage Or decide that they don't want to use that coverage, especially for reasons of expenses honestly. One of the value propositions of BetterHelp is that for a month's worth of therapy, You can get therapy for a month that would otherwise cost you in person about the same for a single visit Or maybe a visit and a half if you're fortunate. And so the value proposition is very, very strong. And it has always been the case and continues to be the case that many of the people who turn to BetterHelp wouldn't have otherwise And so we continue to see that market be very, very sort of underpenetrated, The opportunity very significant. And so we don't see any slowing down of that insight. And from a margin standpoint, Jalendra, I am really pleased with the progression in margins that That aspect of our business has been making over the past few years. I obviously will not break out margins for Any part of our business, but there has been really good progress in terms of margins. And it's really on the back of a few things, right? Just to give you a little Color on what's driving the improvement in margins. We are seeing improvement In lifetime value, we are seeing improvement in retention and lower churn. We are definitely Looking at constantly innovating when it comes to different channels, We do a lot of product improvements through the year. We test different pricings as we go through the year. So there are a bunch of different levers that underpin the margin progression we are seeing. And I have to say, If you think about revenue vis a vis the cost of acquisition, which is something that we are very, very keenly focused on, We're seeing some very strong improvement in that. So overall, I'm pleased with the margin progression for better health. Next question comes from Donald Hooker with KeyBanc. Great. Good afternoon. Thank you for the question. So, I wanted to revisit the PMPM metric that you gave, ex Livongo. I guess, Based on your comments, Mala, it appears it was about $1.30 I think from your comments or somewhere in that neighborhood. That keeps marching up. Is there sort of a point in time where that sort of taps out? Just wanted to think ahead, do you have some kind of a driver for you Over time, is there sort of a full stack of your services where that sort of stops rising somewhere out in the future? Or maybe another way to ask the question, is there a particular Client with a very, very high PMPM that you can sort of highlight. If you think about our PMPM and the way I think about how that progresses, It really is about a couple of things. One is, we have actually shown case studies where as we sell multiple products And services, we actually see a market increase pre post in PMPM, right? So I would say the first is it is about expanding our suite of products and services, which is what we have And then the second thing I would say is, it's also about expanding into products and services that are more longitudinal, Not episodic, because that drives stickiness, it drives expansion in PMPM. So the way I think about it is If I look at the progression of our business and where we what we have done and where we are headed, and as I think about the growth of the various Pieces of our business that underpin the 40% to 43% growth that we talked about, I actually feel And this does conclude the call for today. You may now disconnect.