Morning. I will be your conference facilitator today. Welcome to UnitedHealth Group fourth quarter and full year 2012 earnings conference call. A question and answer session will follow UnitedHealth Group's prepared remarks. As a reminder, this call is being recorded. Here is some important introductory information. This call contains forward-looking statements under U.S. federal securities laws. These statements are subject to risks and uncertainties that could cause actual results to differ materially from historical experience or present expectations. A description of some of the risks and uncertainties can be found in the reports that we file with the Securities and Exchange Commission, including the cautionary statements included in our current and periodic filings. Information presented on this call is contained in the earnings release we issued this morning and in our Form 8-K, dated January 17th, 2013, which may be accessed from the investor's page of the company's website.
At this time, all participants have been placed in a listen-only mode, and the floor will be open for your questions following the presentation. I would now like to turn the conference over to President and Chief Executive Officer of UnitedHealth Group, Stephen Hemsley. Please go ahead.
Thank you. Good morning, and thank you for joining us. Today, we will review our strong 2012 growth and earnings performance, affirm our outlook for 2013, and discuss in broad terms how and why we see 2014 and beyond as a period of continued growth and opportunity. Full year 2012 revenues grew 9% to $110.6 billion, and net earnings were $5.28 per share. 2012 per share earnings increased 12% year-over-year, attributable to both broad-based growth and intense management of medical and operating costs. Both UnitedHealthcare and Optum exceeded their fourth-quarter revenue and earnings outlooks from our November investor conference. Cash flows from operations of $7.2 billion were again 1.3 times net income. Fourth-quarter cash flows were $1.7 billion, or 1.4 times net income for the quarter. And we ended the year with $1.1 billion in non-regulated cash.
We raised our dividend by 30% earlier this year and repurchased more than $3 billion of our shares. Before reviewing these results in more detail, I would like to discuss a couple of recent topics we believe have been prominent in the minds of investors. The first topic is exchanges. There is significant interest in the impact exchanges may have on the sector in total and on UnitedHealthcare specifically. We can share our thinking about exchanges only in broad terms at this point, recognizing, one, there are still many significant unknowns with respect to how exchanges will begin and actually work. And as you know, details in this sector count. So we are holding back on making specific decisions in many cases until greater clarity can be established.
Secondly, the way we think about exchange markets and how we may position ourselves state by state with respect to exchanges, we see to be proprietary competitive insights. To begin, we are advocates of efforts to expand coverage to as many Americans as possible, we would never have drawn the line at exchanges alone. If you want to expand coverage, use every channel possible, make it easy, convenient, ubiquitous. We advocate that exchanges be a level playing field and fairly regulated. The more complex exchanges become, the greater the potential for unintended market distortions, therefore the greater reluctance to use them. Healthcare at its core is local. Theoretically, there will be as many as 100 very local market exchanges, 50 for individual coverage and 50 for small group, and that's just the beginning. You can expect each will operate somewhat differently.
There is a great deal to evaluate before pursuing any of these exchange markets, similarly to what we do today for Medicare and Medicaid. The level of interest in exchanges will be driven by how we assess each local market, how the exchange and its rules are set up state by state, and our market position relative to others in a market as we see it today and as we evaluate it going forward. That equation will evolve and change over time as exchanges mature. Going in positions on exchanges will be just that. We are not tied to them in one direction or another. Broadly, we would expect to participate in a number of exchanges. We're not going to offer a precise number, but a broad range, perhaps from 10 to 25 or more, with absolutely no firm commitment to that range.
We will only participate in exchanges that we assess to be fair, commercially sustainable, and provide a reasonable return on the capital they will require. Like Medicaid, if we are in a situation or market dynamic that we do not see as sustainable, we will either not participate in the first instance or ultimately withdraw. Similarly, we will continually evaluate state-based exchanges that may not have been attractive when initially introduced. As they mature and evolve, if we see them as both fair and sustainable, we would look to participate. In a perfect world, we would participate in them all. Exchanges will create new market dynamics that could impact our existing businesses, depending on ultimate member migration patterns for each market, the pace of that migration, and its impact on our established membership.
We do not expect these impacts to be dramatic or necessarily negative to us Today, our individual and 2 to 50 member risk-based health benefit businesses contribute approximately 10% to our total earnings. Their margins are consistent with our overall commercial insurance results. The feedback we receive from this community is that they remain committed to offering health benefits to their employees. While these earnings are still meaningful, we are diversified to the point where we do not feel compelled to engage in any market where conditions leave us uncertain as to long-term viability. There has been speculation as to how exchanges will happen by September 30th, 2013 and what their impact on 2014 will be. The simple answer is we don't know.
The idea that robust exchanges, whether state-based or federal, will be enrolling large numbers of individuals or groups by September seems challenging, and our sense is the initial consumer and small business response may be modest. We are committed to being ready. We believe we have strong product offerings that are valuable to the market in terms of quality, access, affordability, innovative design, and service excellence. These characteristics and features are compelling in or out of an exchange channel. In the long term, we are expecting and preparing for an exchange category of coverage to become established as a new benefit category between Medicaid and the traditional commercial benefits markets.
We anticipate this category will have meaningful participation, that we will serve the majority of those markets, that it will be a rational product category with sustainable margins, our businesses and our earnings will grow as exchanges become more established. Moving to pricing and medical cost trends. There has been no shortage of commentary about the 2013 commercial pricing environment across the commercial benefits industry. The positioning of the ACA insurance fee and rate review and approval processes across states and against the backdrop of 2013 commercial medical cost trend outlooks. We can only comment on our experience, which has seen the commercial pricing environment strengthen from that in 2012 in general. We have nearly 70% of our 2013 business priced, the markets have been rational in our view, competitive, better than 2012 for us.
We have been very steady in our pricing disciplines year to year, consistently adhering to and aligning to our forward view of costs, we take measured membership losses in instances where we cannot get our price, as we did in commercial risk markets in 2012 and expect to again in 2013, as we discussed at our investor conference. We have a broad and diverse portfolio of innovative product offerings that align to buyer values, we are able to hit a broad range of price points. Accordingly, our membership losses have been relatively muted, particularly when considering the ongoing impact of funding diversions. We have included the ACA insurance tax and other ACA cost factors in our 2013 rate filings. We are working effectively with our state partners through the rate approval process. As always, some have been more challenging than others.
At the end of the day, we must price to our costs, if we conclude that a state's posture on commercial insurance pricing is not economically sustainable, we will have no choice but to withdraw from that market. We have not been put in that position to date. Our medical cost management capabilities have steadily strengthened year by year, our networks are very cost competitive. We have a market-leading spectrum of pay-for-performance arrangements now exceeding $20 billion in annual medical spend. Our 2012 all-in commercial medical cost trends were effectively managed to under 5.5%, we are constantly refining and intensifying our healthcare affordability efforts. We remain comfortable with our 2013 medical cost trend outlook range of 5%-6%.
We are confident in our pricing disciplines, the yields we are achieving, and our resulting 2013 commercial care ratio outlook, which remains unchanged at 82% ±50 basis points. Turning back to 2012. Both business platforms produced strong results well above our expectations as we entered 2012. UnitedHealthcare grew by nearly 2 million people in the U.S. and added 4.4 million in Brazil late in the year. Revenues grew by 8% year-over-year. 2012 operating earnings of $7.8 billion exceeded our most recent outlook, and our fourth quarter operating margin of 6.1% was stronger than we expected. We expect an ever-improving alignment of benefit designs, consumer engagement, clinical management, and care delivery relationships to deliver quality healthcare for consumers along with competitive cost performance in 2013 and beyond. Optum grew earnings from operations by 14% in 2012.
Optum's disciplined simplification and integration agenda is advancing at the same time its revenue growth is accelerating and expanding its margins. In the fourth quarter, all Optum segments grew both earnings and operating margins year-over-year, driven by business growth and the benefits of investments made in the first half of the year. 2013 begins, we remain optimistic. Both Optum and UnitedHealthcare are solidly on plan as we move into the year. Our businesses are executing well for customers, we continue to grow market share. The initial OptumRx customer transitions and new business installations across OptumRx and UnitedHealthcare have been virtually seamless, including our new Medicaid assignment in Kansas. UnitedHealthcare's preparations to serve TRICARE, which will begin in April of this year, are going well.
We have been awarded the opportunity to serve an estimated 20,000 people in the Florida State long-term care program beginning in August of 2013. UnitedHealthcare is also beginning on an exclusive basis to market to the Medicare beneficiaries residing in The Villages in Florida, the largest retirement community in the U.S. We continue to feel positive about our Medicare growth across all product categories. UnitedHealthcare is experiencing strong January medical membership growth in excess of 600,000 people, led by public and senior sector growth and positive results for our employer and individual. Strong fee-based commercial growth should more than offset the expected decline in risk-based products caused by the weak employment market and UnitedHealthcare pricing disciplines. We are also experiencing strong growth in Part D. UnitedHealthcare created a new affordable basic plan for consumers nationally and elevated its large 4 million member plan to an enhanced plan status.
The change to enhanced status changes the seasonal patterns of earning recognition, shifting more of the profits to later in the year with no impact on full-year profitability. For Optum, we expect 2013 to show strong growth, with operating earnings advancing in a range of approximately 35% to over 40% above 2012 levels, as we previously communicated. The Optum businesses are seasonal in their progression of earnings, we expect the first half and second half contributions to be proportionately similar to 2012, say 40% in the first half and 60% in the second. Our annual outlook for 2013 remains unchanged, with revenues forecasted in a range of $123 billion-$124 billion of net earnings, and net earnings in a range of $5.25-$5.50 per share. The rest of the 2013 financial coordinates we shared with you at our November 27th conference remain consistent as well.
Perhaps I can offer a few comments on consensus earnings estimates for 2013. In total for the year, we are in the same general zone as the Street, which is typically oriented at the top side of our $5.25-$5.50 per share range. We see quarterly progressions somewhat differently, with our progressions more oriented to the second half of the year due to such things as the dynamics of growing seasonality, the mechanics of the Part D program, and the like. We should mention again that last year's first quarter had more than $0.30 per share in prior year net reserve and rebate development, which we do not forecast. The takeaway is, on an annual basis, the upper end of our guidance is in the general zone with consensus.
The quarterly progressions we see for 2013 favor the back half of the year more than the current consensus numbers would suggest. Something on the order of a 3%-4% shift from the first half to the second half, with most of it coming from the first quarter. Our capital disciplines remain focused and consistent. 2012 was an unusually active year in terms of acquisitions and business development. We expect 2013 to be more moderate. We continue to forecast operating cash flows to range from $7.2 billion-$7.6 billion, with capital expenditures to stay within a range of $1.25 billion-$1.35 billion. As we have said, we will look to continue to advance and mature our dividend in 2013, a process our board will address in our mid-year session.
We expect to repurchase shares near the $3 billion end of the range provided at our investor conference. Despite the fact that we are only 16 days into 2013, there is an unusual level of focus on 2014 given the anticipated ACA changes. Our foregoing comments clearly indicate that we do not have any unique insights or precision around a 2014 performance outlook. As always, there are other potential factors impacting both the broad marketplace as well as our specific industry sectors that may influence 2014 performance aside from ACA-driven market changes.
What we can say is that based on our view of what is known at this point and for our overall mix of business, we do not view 2014 in a negative light relative to our expected 2013 earnings per share outlook, and that 2014, 2015, and beyond hold the potential to be periods of positive growth and opportunity for our businesses. Factors that play into that perspective include a belief that the federal administrations charged with ACA implementation are interested in smooth implementation and sustainable adoption, interests shared by critical policymakers and legislators. A meaningful number of ACA market changes have already been introduced to the market. Minimal MLR rules, benefit and coverage expansions, et cetera, with limited disruption. Administrative and regulatory guidance to date has been rational, predictable, and reasonably collaborative given the nature of the ACA legislation.
There is certainly a great deal more to work through and significant unknowns, but so far it has been manageable. In the end, the ACA expands an enormous national healthcare market that will be served by the private sector. As we have said from the beginning, the ACA will reshape some market rules, but will not change the basic nature of the market needs for high-quality healthcare at affordable costs and for a higher-performing overall healthcare system. The ACA will not determine who will respond to be the ultimate long-term winners or losers in serving those market needs. The ACA actually intensifies the demand for the core competencies we deliver to our businesses.
They are knowledge to optimize care resources and capability to manage both high-quality clinical care and costs, information to inform and align healthcare for optimal performance on both individual and overall system levels, and enabling technology to make it all work in modern and efficient ways. Over the last several years, we have shaped our enterprise as a uniquely adaptable construct of market-facing businesses that serve the critical markets that the ACA is expanding. Today, our businesses are performing at more consistent and higher quality levels than ever before. We have simplified our businesses to be well-focused and coordinated. We are more integrated and scaled with steadily increasing productivity. We've been driving market innovations at higher levels than at any time in our history. We have invested in brands and have steadily elevated our market visibility and reputation.
We have strong and deep leadership and have been investing in our people and our culture. We have maintained an appropriate balance in our capital stewardship, steadily returning more capital to investors while building, expanding, and diversifying our businesses for long-term growth. While working this change agenda, we have continued to execute consistently on the fundamentals. Since 2009, UnitedHealthcare has consistently taken market share, having grown to serve 4.5 million more people in the U.S. while positioning to serve another 4.5 million people in Brazil. Optum has been formed, aligned, re-baselined, and on its way to doubling its 2011 earnings over a four-year period, significantly increasing its relative contribution to our overall earnings. At the UnitedHealth Group level, our financial performance has been distinctive in a recessionary environment. Since 2009, revenues have increased $23.5 billion or 27%.
Operating earnings are up by nearly $3 billion or 46%. Net earnings have grown by more than $2 per share from a base of $3.24 per share at 18% compound growth rate. We have generated cumulative cash flows from operations of more than $20 billion over those past three years. We dedicated a portion of this amount to repurchase nearly 200 million shares at an average price of about $43.50 per share, reducing our weighted average shares outstanding by more than 11%. This is a different company than it was a decade ago, different than just three years ago, and it will be predictably different three or more years from now. We will remain disciplined in preparing for change and growth. We're established in our markets, growing market share, and producing strong and dependable results for shareholders.
We expect to continue to serve healthcare providers, governments, and consumers to grow and deliver positive results for investors this year, in 2014, and in the years to come. The takeaways this morning in our mind are strong 2012 performance across the board. 2012 commercial cost trends favor the forecast. 2013 commercial pricing competitive, but better than 2012 for us. We're focused on 2013 growth with our outlook in line with our previous guidance. We are working effectively with states, care providers, regulators, the broad group of participants in the healthcare market. We are preparing for 2014, including the introduction of exchanges in the market. Thank you for your time this morning. I hope we've been helpful in answering a few questions, but we'd like to hear your areas of interest today.
Could we ask the moderator to take this over, and we'll begin to respond to questions. Thank you.
The floor is now open for questions. At this time, if you have a question or comment, please press *1 on your touch-tone phone. If at any point your question is answered, you may remove yourself from the queue by pressing the # key. We ask those with questions to limit to one question per person so we can get to as many participants as possible. We request that you do not utilize a speakerphone or headset when asking a question. We'll go first to the side of Matthew Borsch with Goldman Sachs. Go ahead, your line's open.
Yes, thanks. My question's on the outlook for Medicare Advantage and just hearing your comments about the pragmatism of the implementation so far. When you look at all of the provisions that are impacting Medicare Advantage in 2014 and 2015 in the interests of, quote unquote, "parity" seemingly without regard to the supplemental coverage that you're providing for low and moderate income seniors, do you think those provisions, as it stands today, are manageable? Or do you think that they will need to be revised as you move through the next three years?
I would say, if you're basically saying that as it exists today, we would always have an appetite for things that would offer, let's say, more flexibility and more responsiveness in the marketplace for Medicare Advantage. We would also hold a view that Medicare in total would benefit from themes of what I might call modernization of the program, and we see those things most effectively in the private sector today. Our posture on Medicare Advantage is that we would be advocates of continued change and proactive change around themes of modernization. As it relates to the specifics of the regulations and the elements that are affecting rates and so forth, I think we would prefer things to be somewhat to otherwise, but I think that it is manageable as it exists today.
We think that if things that move further would really start to impact beneficiaries, affect quality of care, that there would be significant pushback if there were greater activities going forward, as you deal with elements like the fiscal cliff and things like that. I don't know if, Dan, you want to comment, or Jack?
Thank you. I think Steve said it right. The only thing that perhaps I might point out, Matt, we certainly always would have a fairly short list of things we perhaps might suggest modification, more modernization of anything. A lot of the provisions with healthcare reform are things that we are doing more broadly across our business. For example, a focus on payment for success and outcomes and the like that are embedded in Star Rating. Those are things that are really good and should be preserved. We might have a different point of view on the individual elements, of course, but I think the bigger things that are in play are things that will ultimately be good for Medicare Advantage and certainly Medicare broadly.
All right. Thank you.
Next question, please.
We'll go next to the side of Justin Lake with J.P. Morgan. Go ahead, your line's open.
Thanks. Good morning. Steve, it seemed like you were comfortable in saying that you see no real reason why you wouldn't be able to grow earnings in 2014. Am I hearing that correctly?
Yes. From this distance and given the opportunities in front of us, yes.
Great. Outside of the exchange uncertainty, which I think we all understand, can you walk us through your main business segments and let us know anything that you believe would take you off the typical growth path? I know you have a 13%-16% target. Matt just mentioned Medicare Advantage. Anything further you could tell us there? Medicaid, some of the other segments that might be different than what we typically see year-to-year.
I'm not sure I fully understand the question, if you're asking what gives us a sense of why 2014 could represent continued growth and opportunity is that if you look at across the expanse of our businesses over the last several years, as a lot of these elements have been formulating coming in the marketplace, we have been growing market share, growing in our commercial businesses, growing in Medicare. States have been responding in terms of Medicaid and expanding. The military business is coming online. Our Optum businesses are really establishing some very positive momentum as they mature. At the same time, their growth opportunities seem to be taking off because of the pressure in the healthcare system in total.
There is the opportunity to do this all over again in Brazil off a platform that is already market leading, that's a pretty good hand to be holding at the moment, particularly in a nation that's looking for positive change and higher performance out of its healthcare system and a population that continues to value high quality benefits, modernization and innovation that comes with those benefits, and costs. Costs matter, we are all over costs in terms of the focus of our clinical programs, strategies with our networks and so forth. I think that we are executionally trying to take this enterprise to a next level of performance. Those factors suggest to me that we have as good a chance as anyone of growing and performing in the marketplace.
Do you expect to grow EBIT next year, or are you talking about EPS?
I'm talking about growing earnings. I have no interest in giving guidance on 2014 at this distance. You asked me what themes, that's what we responded.
Great. Thanks.
Thanks, Jeff.
We'll go next to the side of Scott Fidel with Deutsche Bank. Go ahead, your line's open.
Thanks. Appreciated some of the comments on the exchanges. Just interested if you can give us some early thoughts on the three Rs now that those have come out. Whether you think they will be successful in helping to mitigate adverse selection in the exchanges.
Gail, Dan, you want to?
Morning, Scott. This is Dan Schumacher. I think the guidance that came out was generally in line with our expectations. With respect to risk adjustment, the only modest change is that when you start sharing, happens a little later than what I think people were generally thinking. We do think it is some level of protection in the new market.
Yeah.
The only thing I would add, this is Gail Boudreaux. In terms of these comments on exchanges overall, while the three Rs are important, the fundamental economics and structure of the exchange is equally important. As we think about that, the discipline of that analysis, I think, around the exchanges and where you participate is very important to us.
Okay. Then just a quick one, just sort of some of the one-timers that were in the market more for the fourth quarter. Just any insights on sort of the impact of Hurricane Sandy and on utilization in the New York metro area, and then sort of impact on the flu, if you saw any? Thanks.
Sure, Scott. This is Dan again. With respect to the flu, yes, we did see an elevated flu over what we would consider to be normal in the fourth quarter. As we look at that, it added about $50 million of incremental expense beyond what a typical flu is. We did have some moderation with respect to Storm Sandy as well. When we put all those things together, as well as look at our flu experience through the first three weeks of January, we feel comfortable with our trend outlook for 2013.
Okay. Thank you.
We'll go next to the side of Chris Rigg with Susquehanna Financial Group. Go ahead, your line is open.
Thanks. Good morning. I just wanted to come back to the fourth quarter medical cost side. It looks on a consolidated basis, MLR is up 80 basis points, but commercial's flat. I think this is the first quarter in a while where there's sort of been a deviation between trends on the government side versus the commercial side. Can you provide any color there? Was there anything in Medicare or Medicaid that's worth sort of highlighting?
Dan?
Chris, this is Dan again. No, I don't think there's anything to highlight underneath there. The fundamental change in the group loss ratio came down to the change in favorable development year-over-year. As we look at each of our businesses in the commercial and in government programs, we did have favorable development. However, it was stronger in the commercial business, and that's why you see that difference in the relative change.
Okay. I just want to try to slip one more in here. Earlier in the call, Stephen, you talked about fair in the exchanges. I guess, could you just help us understand what would be something unfair in an exchange? Just any kind of detail there would be helpful. I'll leave it at that.
Well, I'm not going to talk about unfair elements. I'll have Gail Boudreaux respond to this, but I think she was hitting on it before in terms of how they really work, kind of the state's posture, the federal posture with respect to making them viable, and what we said, sustainable markets. Gail?
Good morning. Steve hit sort of three things in his comments, one fair, commercially sustainable, and providing us a reasonable return. As we think about exchanges, just a couple of points I guess I'd like to start with. One is we see it as a market, not the market. There'll be robust markets inside and outside of the exchange, and we also expect the rollout to be more measured so that January of 2014 is just the beginning. In terms of your specific question, what makes it more attractive is flexibility. Flexibility around product design, clinical models, network configuration, as well as an ability to be priced essentially for the risk and earn a fair return. As we establish and look at exchanges and the viability of those are the kinds of factors that are important in assessing those marketplaces.
Thank you.
We'll go next to the side of Christine Arnold with Cowen and Company. Go ahead, your line's open.
Morning. Optum's a huge part of the growth story over the next couple of years, and it looks like each of your Optum divisions did a bit better than expected exiting the year. Can you talk about some of the major factors that are resulting in Optum divisions doing better than expected? Maybe what's going really well and ahead of expectations entering 2013?
I think leadership has a lot to do with it. Larry, do you want to?
Sure. I'd be happy to. Christine, it's Larry Renfro. If you go back to last year, I think we laid out a few goals. We talked about, number 1, that we were going to have a 15% ROIC by 2015. We were going to have our operating margin at 6% by 2015, and we would double earnings of 2011. As part of that three-year plan, we dubbed that internally as One Optum. We had four main areas of focus during the year with financial discipline, re-engineering, simplification, portfolio management, and growth with five main drivers. Business alignment, business integration as one, cost management, organic growth, PBM insourcing, and strengthening leadership. I can say that we solidly, from our standpoint, executed, and we did it in a simple fashion. We feel pretty good about 2013. We are pivoting to growth in 2013.
I guess it just comes down to execution, and again, Christine, we feel pretty good about where we're at today.
Steve, one follow-up. At your Investor Day, you guys said that you see financial services companies, pharmacy retailers, consumer product companies seeking to enter the health insurance market. How should we be thinking about that? We haven't seen new entrants in a while.
Yeah, I've seen elements of that. I don't know if I could really comment, because I don't know what enter the market really means. If they're looking to be a distribution channel, that may be fine. I think that this is an extraordinarily complex space, and sometimes the complexity of it is not as apparent to you until you actually get into it. It is also an extraordinarily locally oriented environment. It is quite a challenge to be effective broadly on a national scale in healthcare and still be really executing at the street level. It's a challenging environment. I think there are actually a lot of competitive barriers to entry, and we will see how other non-traditional participants may come into it.
I take your point that there has not really been a non-traditional participant under this marketplace that I can actually think of, at least in the time that I've been studying it.
Okay. Thanks.
We'll go next to the side of Joshua Raskin with Barclays. Go ahead, your line's open.
Hi, thanks. I just want to follow up on the comments you made around the pricing environment. It sounded like you characterized 2013 as a stronger environment. You guys haven't talked about a stronger pricing environment in a long time. I'm curious, what are the drivers of that? Is that there's less rebate experience that needs to get incorporated? Is it the industry fee or new cost for reform? I'm just curious what exactly stronger pricing environment means and any color as to what's driving that.
Sure. Gail?
Sure. Good morning. In terms of your question on a stronger pricing environment, I think first of all, we see it as a stronger pricing environment because we're achieving the yields that we set out, and we are able to feel good about our benefit cost ratio at 82% plus or minus 50 basis points. In terms of the overall environment, Steve said in his comments it's still competitive. There are a multitude of different drivers and states, and we've talked about that on these calls over the last several quarters. We think we've got a really strong mix of affordable products in the marketplace that gives us a very broad portfolio to offer to our competitors, and we see that as a driver giving people options in the marketplace. I think our cost structure helps us do that.
From that perspective, we've been able to achieve what we set out at Investor Day around the yields that we talked to you about.
Yes, just to follow up on that, Gail. I would look at the MLRs that you guys have reported, maybe even specifically in the commercial segment in the last year, and it certainly looks like you were achieving your pricing yields. Or is it more you saw extraordinary cost moderation that was not anticipated, and this year you think you're. I'm just trying to pair out. Are you actually seeing stronger yields relative to expectations? Is that kind of what we're seeing?
We're seeing our yields in line with the expectations that we outlined to you at Investor Day. There's also a mix component as you look from 2012 to 2013. We've put a significant amount of affordable products in the marketplace, and we're seeing strong uptake on those. We saw that in 2012, and that continues into 2013. Maybe I'll ask Jeff Walter, who leads our Commercial Business, to provide some comments as well.
Morning, Josh. I think with Steve's remarks, when we say we see the market, the pricing environment, we're talking predominantly about ourselves. We still believe the market hasn't changed over the long, we'll call it the last few quarters. It's competitive, it's rational. We measure, I guess, weakness versus strongness on our ability to grow and retain membership, and during this season, we've been able to perform better around growth and retention of existing accounts.
Okay.
It may be as much around execution as anything else. Maybe we are just executing better this year than we did last. We seem to be operating in a more rational way with respect to pricing dynamics, and we are getting the margins that we are targeting. I think it's no more complicated than that.
Okay. Thanks.
It is profoundly local. Jeff will school me on this regularly that when we talk about these things in generalities, they really come down to market-by-market dynamics.
Okay. Thank you.
We'll go next to the side of Ralph Jacoby with Credit Suisse. Go ahead, your line's open.
Thanks. Good morning. Just want to talk a little about the industry tax in 2014. Maybe if you could talk about sort of your initial conversations with employers and maybe even states for sort of pricing of the tax and in Medicare, maybe specifically, your plans to sort of offset that and if you think that will have any impact on sort of the attractiveness of your product versus fee for service Medicare.
Yeah. I mean, we're not interested in revealing kind of the inner workings of some of these conversations. Generally speaking, it is a cost, and we price to cost, and cost is something that is universally recognized in terms of the elements of these products and in the rate review process. I think the consensus here is that's pretty much the issue. It's basically a cost element. All the pieces of the ACA really represent elements of costs that as they're introduced, are introduced into the rate approval process and are being discussed, and we think discussed in rational ways in the settings that we're in, and regulators who are also trying to achieve their objectives in their respective markets. For us so far, those conversations continue to be constructive, professional, and we will see where they lead.
Okay. I know it's a small portion, but I'm assuming the industry tax, in terms of the timing, some of it's going to be in 2013. I'm assuming that's in the guidance range for 2013. Again, I know it's a small number, but any help in sort of helping us sort of figure out what that amount is, and/or what % of the tax that would represent to you?
Yeah. I think we're feathering it in as it goes through for the year. I don't know if we can actually quantify that for you in a venue like this today. Rest assured that we are basically, that is going in on a month-by-month basis, as that legislation basically is designed.
Okay. Thank you.
We'll go next to the side of Sheryl Skolnick with CRT Capital. Go ahead, your line's open.
Good morning, nice job against a lot of headwinds, and also the commentary on the call has been very helpful. I want to focus on something that Gail said at the investor day, and I think I heard reiterated today, $20 billion of your benefit expense now is pay-for-performance based, and that I think I heard you say that your goal was to get to $50 billion. I have two questions about that. It seems that that's a key to success across all of the product offerings, like many of your other activities, not just on the exchanges. I'm curious about what has to happen differently, either internally or externally, to get to that goal, the timing of that goal. Also, how can we quantify or think about the impact on your earnings performance if you get there? Or I should say when.
I think that is a great question. We have been at this, actually, we think much longer than others. We've been in the different names, but the bottom line is it's been the same fundamental theme. We have a lot of elements structurally already in place along these lines, kind of built into our processes. Gail, do you want to respond?
Sure. Good morning, Sheryl. Just to reiterate what you said, we are currently at $20 billion of spend in pay-for-performance as part of our accountable care platform, and I think we shared that at Investor Day, how we think about that, which is a broad spectrum of working with physicians as well as integrated delivery systems around a continuum to meet them where they are, whether that's moving from just straight fee for service in the primary care side to including incentives all the way up through accountable care through integrated pay-for-delivery full capitation. Our goal is to get to $50 billion by 2017, which is a pretty aggressive goal. We've made significant progress year in and year out. In terms of how we get there, I think it's a concerted effort across UnitedHealthcare as well as in partnership with Optum.
Optum is clearly helping to enable the delivery system with their tools and what they're doing in the marketplace. On the UnitedHealthcare side, we're working to really change the relationship that we have working with the delivery system. That's actually happening in each of our local markets. We're embedding it into the core components of what we do, and it's not only on the alignment of the network contracts, but it's also our clinical programs. We talked a little bit about our Healthier Lives model at the investor conference. That's an integral part of getting there and what has to change and how we work with the delivery system to manage care. Then on our benefit design and our consumer engagement tools.
I think about all of those four categories together and how we get there, because paying the delivery system differently without changing our internal product design and structure and our internal processes isn't going to get us there. We look at it in a comprehensive way. That's how we see it and how it translates for us, I think, is into the medical cost structure we can offer our clients, the cost of products we put in the marketplace. As you see in 2013, the strong growth we've got in the market. As I think about even 2013, the strong growth we're seeing across our commercial and Medicare book is indicative of the progress we've already made in some of those fronts.
Said differently, it enables you to price at a value of the entire package, not just the premium per month, but also the value you're getting and the benefit and the access to care that actually makes you well.
That enables you to gain market share while maintaining your discipline on margin?
Yes.
In part. Okay.
I think that's very articulately said. Thank you.
Okay. It also gets to the issue of reducing utilization. If I could ask a follow-up that's only somewhat related, I'll admit. There was a lot of worry and chatter going into the call this morning. What is United going to say about utilization and the utilization trends that you're seeing? You've addressed it obliquely, I think, in telling us that your cost trend was somewhat below the midpoint of the range or the 5.5%, rather, to be precise. Can you give us some commentary on what you're seeing in terms of utilization pattern? I'm also curious as to whether utilization patterns in the quarter before we go into reform on 2014 might change at all as perhaps benefits change and how you think about that.
Dan, you want to touch on that?
Sure. Sheryl, you faded out at the end. With respect to utilization, our view fundamentally hasn't changed. Which is to say that, yes, we did see an increase in utilization in 2012 over 2011, and as we've talked about the categories on past calls, outpatient is higher, physician's pretty stable, and inpatient has actually been more restrained. As we look at the full year now, this is the fourth year in a row across all of our benefits businesses we've been able to reduce our bed days per thousand. We're actually driving out utilization through our programs and through our focus. We're very pleased with that result. With respect to the fourth quarter, we saw a little bit better utilization than we thought as well as a little bit better unit cost.
It gives us comfort in our forward outlook as we look at our 2013 trend in the 5% to 6% range.
Thank you. Next question, please.
We'll go next to the side of Peter Costa with Wells Fargo Securities. Go ahead, your line's open.
Thanks for all your forward-looking commentary today. Back into the fourth quarter, looking at the performance of the commercial business versus the consolidated business, it's clear that there's something that happened in the Medicare and the Medicaid business that seems like it got a little worse beyond just the base business. I guess I'm curious, was there unfavorable TPD in the Medicare and the Medicaid business in this quarter?
Hi, Peter, this is Dan. We had favorable development in both commercial as well as our government programs in the fourth quarter.
The current business, did something deteriorate there in those two businesses?
No, when you look at the mix of development across the businesses year-over-year, it's that change that's driving that dynamic. From a fundamental standpoint, our performance continues to be strong in both Medicare and Medicaid, despite challenging headwinds with respect to both state and federal pricing.
Would Amil have had a favorable impact on the MLR this quarter?
It's negligible when you look at it two months on the quarter, it doesn't move it.
No, it would not.
All right. Just last, just as a follow-up to that, any commentary about Amil overall and what you think you'll spend there in Brazil over the course of this year for acquisitions and capital spend?
Well, we wouldn't even talk about that, whether it was in Brazil or the U.S. We can give you some sense of how things are settling out in Amil.
Yeah, Peter, it's David Wichmann. Thanks for the question. I'll try to give you some information. It's very early stage, as you well know. We did close the first part of the transaction at the very end of October. You probably heard that we're in market doing some open market purchases of the public stock to the extent that it was below the BRL 30.75 offer price that we had offered. We were successful at doing some of that during in the November timeframe. We're preparing for the tender right now for the remaining public shares, and we expect to complete that tender still in the first half of 2013. That is on track as we had laid out both in the call around Amil as well as in the investor conference. Just as a reminder, we'll be financing that with debt.
It's about $1.5 billion to $1.6 billion to complete that transaction. Just generally, Amil's results are good. They posted about $1 billion in revenues for the two months in 2012, was solidly ahead on both medical and dental enrollment for the quarter, which we are pleased with. As you'd expect, the earnings net of minority interest are very insignificant to the quarter, and that's what we expected given both what we expected from the business as well as the purchase accounting applications to that as well.
Thank you.
Next question, please.
We'll go next to the side of Sarah James with Wedbush. Go ahead, your line's open.
Thank you. To follow on the exchange comments, with your view now of the fundamentals and the three Rs, how are you thinking about the mix of small group versus individual markets that you may participate in for the 10 to 25 that you had mentioned earlier? I'm assuming that excludes private exchanges. Then for the larger states like California and New York, how likely are those to be broken up into MSAs as opposed to statewide exchanges? Last question on that topic is I appreciate the breakout of the 10% individual and small group exposure, I wanted to look at exchange exposure a different way. There's several reports suggesting employers of low-wage, low-skill employees like retail or restaurants are more likely to dump into the exchanges. What is the exposure across your commercial risk book to those types of employers of low-wage, low-skill workers?
I'll offer a couple of responses. A lot of those that you just mentioned in the latter part aren't covering benefits at all today. Those would be the ones that most of the marketplace look to be added to the exchanges. I would also offer that the gravitational pull of our whole enterprise is towards the small group side. We have never been large players in the individual marketplace. I don't know if you want to comment.
The only other thing I'd add to Steve's comment, this is Gail Boudreaux, is specifically to, is this just public or private exchanges? We will participate broadly in private exchanges. We already do. We see that as another distribution channel. We've been very effective over a number of years doing that, and our subsidiary, Optum, also has some significant opportunities in the private exchange marketplace. That's a nice growth opportunity for us going forward.
This is John Shanahan, Sarah. We did not count the private exchanges in those broad range totals that Steve offered as a starting point.
Got it. The part on whether or not you think larger states like California and New York might break up the exchanges into something smaller than statewide, is that something you're looking into?
Jeff?
Hi, Sarah. It's Jeff Allen. Good morning. It's tough to comment beyond what we know publicly. New York has already indicated that there'll be multiple geographic-based exchanges there, we at least know one state is thinking more than just a single exchange.
Great. Thank you.
Sure.
Next, please.
We'll go next to the side of Kevin Fischbeck with Bank of America. Go ahead, your line's open.
All right, great. Thank you. Just wanted to follow up on the exchange commentary. I guess two points here. First, in the context of provider rates that you're negotiating, I guess what percentage of contracts do you have signed yet, and what rates are you zeroing in on? You mentioned that this product serves the population between Medicaid and commercial. Are you seeing pricing skew towards one of those ranges? As far as the commentary with the states goes, I appreciate you looking for more clarity. Makes a lot of sense. Is there a sense for the timing around when that clarity may come into view? As far as the federal exchange, is there a sense that that will be a very uniform exchange, or will they allow for flexibility to account for state variances?
This is Gail Boudreaux. Let me address your multiple questions, hopefully in order. First, around the pricing issue. As we said a couple of times, the exchanges we see very much as a local market dynamic. From a pricing perspective, we see that going anywhere from commercial rates to something less. Our goal is to match our underlying economics to each of the exchanges. We're in the process of doing that. As you know, we already offer multiple products with multiple network constructs, and we've been doing that for a number of years. We've aligned our payment and our network construct to the product offerings in those markets. We're going to leverage that history. That's our experience in building networks broadly across the U.S. to match the markets.
As you think about it, remember that we have to acknowledge that our products inside the exchange will also be available outside of the exchange. That expertise will be important in building your overall network construct and offering in the exchange. In terms of your other two questions, I don't know that we have great visibility or speculation on the timing of when those regulations will come out. We're obviously working really closely with our states. We have a dedicated team in place that meets with each of our markets, and we're preparing our own business to be able to support what does come out. I don't have any great visibility into the timing of the other two questions at this stage.
Okay, great. Thanks.
That's 50 different timetables. Again, these are very local dynamics. We have maybe time for two more questions. Next, please.
We'll go next to the side of Ana Gupte with Sanford C. Bernstein. Go ahead, your line's open.
Yeah, thanks. Good morning. Wanted to get a perspective on your margin outlook for 2013 in the Medicare business. When you had the investor day, you had the rate for 2013. You had your own Star scores and what the margin expectations would be based on that. Since then, you've seen your enrollment and dis-enrollment data and your mix of business, possibly relative to your competition, and then one more quarter of utilization. Do you see it being flat year-over-year on an MLR basis? Is it likely to get worse or better?
Yeah. Well, we really don't provide margin insight with respect to Medicare other than in the most general themes. Jack, do you want to comment at that level?
Hi, Ana. Jack Larsen. As Steve said, we don't comment specifically on margin trends in Medicare. What I can tell you is that based on the enrollment season that we're just finishing up here effective January 1st, the mix of new members that we're seeing is very much in keeping with the mix that we had anticipated in terms of individuals already in Medicare versus new to Medicare. Really not seeing anything surprising or what we had anticipated. On that front, I'd say we feel very good about the guidance that we offered back in November.
In terms of the age cohorts, are you seeing more of the 65-67 type, the younger age mix enrolling directly into Medicare Advantage and any mix shift likely on the 75+?
Yeah. That has historically been the pattern. Jack?
Yeah. Exactly right.
Likely to get worse or better?
Yeah, well, we really don't provide margin insight with respect to Medicare other than in the most general themes. Jack, do you want to comment at that level?
Hi, Jack Larsen. As Steve said, we don't comment specifically on margin trends in Medicare. What I can tell you is that based on the.
Is it going to get worse or better?
Yeah, well, we really don't provide margin insight with respect to Medicare other than in the most general themes. Jack, do you want to comment at that level?
Hi, Jack Larsen. As Steve said, we don't comment specifically on margin trends in Medicare. What I can tell you is that based on the enrollment season that we're just finishing up here effective January 1st, the mix of new members that we're seeing is very much in keeping with the mix that we had anticipated in terms of individuals already in Medicare versus new to Medicare. Really not seeing anything surprising or what we had anticipated. On that front, I'd say we feel very good about the guidance that we offered back in November.
In terms of the age cohorts, are you seeing more of the 65-67 type, the younger age mix enrolling directly into Medicare Advantage, and any mix shift likely on the 75+?
Yeah. That has historically been the pattern, Jack?
Yeah, exactly right. I think we are very aware of the cohort mix, and as I said, we're seeing what we had anticipated with really nothing remarkable to offer.
On the Part D side with your new product, can you comment on your margin expectations relative to what you had even directionally in 2012? From a seasonality perspective, as you're guiding us to a quarterly progression, would there likely be any change?
Well, we don't comment on the margins with respect to that as well. We're very comfortable with where we put our bids. We have gotten nice market response. The switch to an enhanced plan to open up a new basic plan was a very good move, but it just moves the recognition of earnings under those programs to the back half of the year. That's the geography of when the earnings come in is really the biggest change in there. Other than that, we've had a very good Part D season and put forward our bids in what we think is a very rational fashion, and I think we will be very comfortable with that. On the downstream impact is that it should drive a script volume to OptumRx, and that will be a positive for us as well.
That's I think all we could comment on that.
Great. Thank you.
Thank you. Last question, please.
We'll go last to the side of David Windley with Jefferies. Go ahead, your line's open.
Thank you for squeezing me in. I'm focused on Optum. Your margins have had really nice improvements sequentially for the last few quarters, ended the year above where your guidance range is for next year. I was hoping you could comment on perhaps what other than maybe seasonality might be the reasons that that would be lower than where you ended the fourth quarter. Second, could you comment on any early, say, operational feedback on the internalization of the Medco business? Finally, give us a sense of how quickly you can get Optum services into the Amil market and customer base. Thank you.
That will be our last three questions then. Larry, maybe you want to start off?
David, what was the first question? I got the last two.
The margins at Optum, whether they're the fourth quarter or it's seasonally driven, et cetera.
I think in Steve's opening remarks, he talked about that we do have seasonality at Optum. Obviously the first quarter, second quarter, the first half of the year, I think we gave an estimate of that would be about 40% and 60% in the latter part of the year. That was the trend in 2012. We believe that will remain the trend in 2013. What we're trying to do, David, is balance investments and growth with financial discipline. We're comfortable with our plan. We're comfortable with the three-year plan and how this all fits, I think you're going to see that seasonality over the year. If I move into the second area, I'll ask Dirk to comment on this as well.
When it comes to the PBM insourcing, I think you know that was a very large undertaking over the past couple of years, I'm going to address that on two fronts. The first front will be the technology, the operating platforms, the infrastructure, and I can tell you that as we progressed through the year last year, we met our targets, we delivered on that, and Dirk will talk about the conversion that's gone seamless in the first quarter. The second part of the PBM, as we were getting into the commercial business, was our external sales. I just want to comment that we kept going with sales as well with, I think we mentioned at our investor day that we had made 50 deals at that point in time.
About half those deals come from the national account side, the UHC, and the other half are independent external sales. It probably represents about a million new members. Maybe, Dirk, you could comment on
Your thoughts?
Yes. On the commercial migration, we just completed our first migration wave with 400,000 consumers moved from the ESI/Medco platform to our platform, plus all commercial new business, and that's going pretty well. We're excited. Actually, right now, we've sort of shifted gears and are thinking about the next migration wave, which is in 4/1. The first wave sort of out of the blocks, looking forward to the more conversions. On the sales side, all I would add is that we saw in 2012, extremely strong RFPs, and we actually didn't have enough people to answer all the RFPs. We've staffed up in 2013 to be able to handle all that volume.
Dave, maybe Amil?
Sure. Thanks, David. If you don't mind, I'm just going to take it up a level because it's a very early stage right now. We've just begun our planning for the integration work that we're doing with Amil. As you might suspect, most of that planning is really around the growth opportunities that exist in Brazil and possibly more broadly in the South American markets. Areas of focus for us are really in operations and technology. We think we can add a lot to Amil's platform in that respect. Growth, which is, again, the opportunities that exist in Brazil and again, more broadly in South America. Clinical areas, I think that's reciprocal. They are very competent clinically, and we're very competent at managing managed care populations that are networked. A nice sharing there. Then really around infrastructure and compliance, as you might suspect as well.
Certainly, many of the growth opportunities we see are for Optum. As I said, we're just beginning to plan those activities now. Certainly, pharmacy is one of those that we are looking at carefully. Broadly, I'd just say we see great opportunity in Brazil and South America also for the benefits business and having just been there last week, just reaffirms the terrific platform that we acquired. We're looking forward to the opportunities of the future.
Thanks. Thank you for joining us today. To kind of sum up today's discussion, in 2012, UnitedHealth Group continued a steady growth trajectory, delivered consistently in terms of strong fundamental execution, innovation, adaptability. It is a changing marketplace, we think we have resources to respond and adapt. While it's still early in the new year, we're well-positioned to leverage our capabilities, expand our position in the marketplace from 2013, we are off to a strong start in January. We look positively to the future in terms of what we offer the marketplace, as well as what the demands of the Affordable Care Act, the Accountable Care Act will represent in terms of opportunities for 2014 and 2015. We thank you for your attention, we'll see you next quarter. Thank you.
This does conclude today's conference. You may disconnect at any time.