ALHC - NASDAQ

Good day, and thank you for standing by. Welcome to Alignment Healthcare Third Quarter 2023 Earnings 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. [Operator Instructions] Please be advised that today's conference is being recorded. I would now like to hand the conference over to John Kao, Founder and CEO. Please go ahead.

Hello, and thank you for joining us on our third quarter earnings conference call. We are pleased to deliver strong results through the third quarter as we exceeded our outlook expectations across each of our four key performance indicators. For the third quarter of 2023, our total revenue of $456.7 million represented approximately 27% growth year-over-year. We ended the quarter with health plan membership of 115,600 members, growing approximately 18% year-over-year. Adjusted gross profit was $60.6 million, producing a consolidated MBR of 86.7%, while our MBR excluding ACO REACH was 85.7%. Lastly, our adjusted EBITDA was negative $8.4 million, ahead of our outlook range. Our third quarter's success continues to demonstrate that we are executing against our founding vision of delivering high-quality and low-cost outcomes through our member-first operating model. These include strong performance across three key value drivers; growth, utilization, and Stars. In terms of growth, our strong intra-year membership growth momentum is a tangible sign that our sales and retention improvements are yielding results. Following our third quarter outperformance, we are raising the midpoint of our membership guidance to reflect 20% membership growth for year-end 2023, while also increasing our revenue guidance to reflect 24.8% growth year-over-year. Further, as I'll share more during our call today, we are feeling confident about our AEP positioning and membership growth outlook for 2024. Regarding utilization, our MBR results in the quarter reflect continued progress at our clinical operations, improvements to our medical management model, and steady utilization performance. Our provider engagement at Care Anywhere teams, enabled by AVA, delivered 152 admissions per thousand in the third quarter despite absorbing higher than anticipated new membership growth. Lastly, turning to Stars, we are pleased to announce that 92% of our health plan members are in plans rated four stars or above for 2024. This significant achievement is a testament to the quality of our member experience delivered through the seamless relationship between our internal team and our external providers. Each of these achievements demonstrate the power of having a purpose-built MA platform which unites the best-in-class technology with integrated member experience and provider engagement. Expanding further upon our Stars results, our 4-star California HMO contract rating marks the seventh consecutive year in which our largest contracts achieved at least four out of five stars. Our strong result is particularly notable this year as the percentage of members in plans rated 4-star or [technical difficulty] fell from approximately 80% to 55% across our California markets. In 2025, many competing plans will now face declining stars payments and the phased-in effects of the new V28 risk model. Amidst this environment, we will continue to capitalize on our relative funding advantage and our high-quality low-cost operating model. Outside of California, our North Carolina and Nevada markets will have 4.5-star-rated contracts. As we continue to grow in our new states, we are driving continued improvements in star ratings by doubling down on our support with doctors across these regions to create a seamless experience for our providers. Turning to AEP, we are pleased with our results for the first two weeks of AEP, and we expect to grow January 1 membership at or above 20% year-over-year. For the 2024 plan year, we once again enhanced our portfolio of curated products supported by the strength of our stars and cost management capabilities. While many of our local competitors have declining or flat benefits, Alignment's low-cost position and commitment to quality and product innovation enabled us to fund increased benefit richness across all of our flagship plans for 2024. Specifically, we are excited to share that 95% of our non-S&P members have the same or lower maximum out-of-pocket costs and monthly premiums, with expanded dental allowances across many of our plans. We also curated our selection of products to address the distinct needs of seniors everywhere, whether it's a health-conscious member who values direct savings or someone in need of a more dedicated care regime. Further, the recent collaborations with leading household brands, like Instacart and Walgreens, exemplify our drive to integrate innovative solutions into the healthcare landscape. This is just a sample of how our pioneering and disciplined approach to product design leads us to be optimistic about 2024 membership growth. We look forward to providing you with a more fulsome update on our AEP results in early January. In conclusion, our year-to-date progress reinforces our confidence in achieving our 2023 guidance, our 20% growth target in 2024, and an adjusted EBITDA breakeven result next year. Now, I'll hand the call over to Thomas to cover the third quarter financials, as well as our outlook for the remainder of the year. Thomas?

Thanks, John. For the quarter ending September 2023, our health plan membership of 115,600 members increased approximately 18% compared to a year ago. The year-over-year improvement and outperformance against guidance were led by both sales and retention improvements as investments made earlier this year on our sales infrastructure, distribution, and member experience began to take hold. Our favorable membership growth, combined with sustained revenue PMPM performance drove our third quarter revenue to $456.7 million, representing approximately 27% growth year-over-year. Year-to-date revenue grew approximately 27% year-over-year, and grew approximately 22% excluding ACO REACH. Adjusted gross profit in the quarter was $60.6 million, reflecting an MBR of 86.7% or 85.7% excluding ACO REACH. As John mentioned, our results in the third quarter marked our second quarter in a row where inpatient admissions per thousand ran in the low-150 range. Continued strength in our performance was supported by strong member engagement with our clinical programs and stable underlying utilization trends. SG&A in the quarter was $83.1 million. Excluding equity-based compensation expense, SG&A was $71.3 million, an increase of approximately 19% year-over-year. SG&A excluding equity-based compensation expense as a percentage of revenue decreased year-over-year by approximately 100 basis points in the third quarter, and 180 basis points year-to-date. Taken together, our adjusted EBITDA of negative $8.4 million was better than our expectations heading into the quarter. Moving to the balance sheet, we remain solidly positioned, and entered the quarter with $515.6 million in cash and short-term investments. Our cash balance at the end of the quarter again included an early payout from CMS of approximately $146.3 million. We recorded the early payment as deferred premium revenue in Q3, and will recognize it as revenue in Q4. As a reminder, this does not have any impact on our income statement metrics. Cash and short-term investments excluding the early payment were approximately $369 million. Turning to our guidance, for the fourth quarter, we expect health plan membership to be between 117,600 and 118,600 members, revenue to be in the range of $422 million and $442 million, adjusted gross profit to be between $46 million and $54 million, and adjusted EBITDA to be in the range of a loss of $18 million to a loss of $10 million. For the full-year 2023, we expect revenue to be in the range of $1.78 billion and $1.8 billion, adjusted gross profit to be between $206 million and $214 million, and adjusted EBITDA to be in the range of a loss of $34 million to a loss of $26 million. On the back of strong third quarter performance, we are once again increasing our full-year 2023 membership guidance and raising our full-year revenue guidance. Our latest membership and revenue guidance reflect 20% and 24.8% growth at the midpoint, respectively, consistent with our long-term objective to reliably drive 20% annual growth. Meanwhile, our narrowed adjusted gross profit guidance range for the full-year implies an MBR of 88.3% at the midpoint, roughly unchanged from our prior outlook. Our latest guidance reflects MBR tailwinds from our strong year-to-date outperformance and utilization balanced by a higher mix of new members in the fourth quarter. As a reminder, our year-end membership outlook has increased by 4,100 members at the midpoint relative to our initial guidance, and new members typically start at higher MBRs as we ramp up our clinical engagement activities. Additionally, we are reinvesting some of the year-to-date favorability towards certain clinical and annual wellness visit activities in support of our 2024 objectives. Lastly, our adjusted EBITDA range of negative $34 million to negative $26 million now implies a 200 basis point year-over-year improvement in our implied SG&A outlook as a percentage of revenue. This includes incremental SG&A from the ramp up of resources to support our anticipated January 1st growth. As John mentioned, we are pleased that the strength of our product positioning is translating into solid performance during the first 2 weeks of AEP, and we expect to deliver January 1st membership growth at or above 20% year-over-year. To wrap things up, our year-to-date results continue to demonstrate the headway we are making towards our long-term growth and profitability targets, and we look forward to updating you on our AEP results in January. With that, let's open the call to questions. Operator?

Thank you, sir. [Operator Instructions] Please stand by while we compile the Q&A roster. And I show the first question comes from the line of John Ransom from Raymond James. Please go ahead.

Hey, good afternoon, everybody. Just thinking long-term, I know you've got some long-term margin goals that look a little bit more like a traditional MA. Where you sit now, what kind of revenue and/or membership do you think you need to get to get to those longer term margin goals?

Hey, John, this is Thomas here. The way we would think about that is a function of not just a certain level of membership or revenue, but additionally taking into consideration the pace of our new market expansion initiatives over time, just given the drag on profitability, both MBR and SG&A that a new market has. And so, for instance, I think if we were to focus on only driving market share gains in our existing geographies and not add a single incremental county or new state over time, I think we could likely reach that goal faster. I think given the value proposition of extending our care model and kind of capturing some of that growth opportunity outside of our existing geographies, means we will likely continue to add new markets looking out into maybe 2025 or 2026. And so, I'm not sure we're going to draw a line in the sand on a certain revenue or membership target, but I think that's how we sort of think about the main drivers as to the pace of that growth time.

Thank you.

Thank you. And I show our next question comes from the line of Scott Fidel from Stephens. Please go ahead.

Hi, thanks. Good evening and nice to be joining you all on the call tonight. Question, just appreciate the initial color and visibility into the growth in the AEP. And just be interested if you can break that down a little bit more in terms of what you're seeing in terms of growth from a traditional individual MA as compared to D-SNP and then maybe some observations on sort of how the growth is looking in the core California market as compared to your other markets. Thanks.

It's got happy to provide some color there. So, we're obviously a little over two weeks in now and I'd say what we're seeing so far is generally consistent with our expectations heading into AEP. So, we've shared in the past that we see a significant growth opportunity across our counties in California and that will likely continue to be the largest driver of our overall net membership growth looking out into 2024. Based on the first two weeks of results, I believe that will continue to be the case and you'll continue to see that be the largest driver looking ahead to next year. Outside of California, it's probably a little too early to provide too much commentary, but we're seeing some pretty solid progress across most markets, and we're excited about what that means for our 2024 setup. In terms of our product mix, as John mentioned in his section, we really try to take a balanced approach to design products for different populations across the acuity spectrum, across the income spectrum, different products tailored for different ethnicities. And the idea is that we really want to have a product offering that meets the needs of really every type of senior consumer. And so, I'd say what we've seen so far is a pretty balanced level of growth across our different types of products. To your point, we do have about 30% of our members today that are dually eligible, and we've enhanced some of our C-SNP products heading into 2024. I think we'll see some nice growth there. But we've also designed products on the other end of the spectrum, looking at products that are more cash rich or rebate products that tend to attract a younger or healthier senior. So, we're really seeing a nice traction across the board, and we'll continue to try to drive a balanced mix of growth across all products in the future.

Okay, thank you.

Thank you. And I show our next question comes from the line of Nathan Rich from Goldman Sachs. Please go ahead.

Hey, good afternoon. Thanks so much for taking the questions. John, I wonder if you could maybe provide a little bit more color on the relative funding advantage you called out, I guess, particularly in California and maybe where you invested in the business. And I guess as it relates to retention as well, what you're expecting for 2024 relative to 2023, I think you saw some improvement this year that helped. So, just be curious what your expectations are for next year. And then, just as a follow-up, how should we be thinking about MBR next year, just in light of the growth expectations that you have that should result in what seems to be some market share gains? Thank you.

Yes, sure. Hey, Nate, good to hear from you. With respect to the relative funding advantage, what I'm really talking about is the revenue PMPM associated with Stars. And obviously that's going to be something that impacts everyone in the sector on the Stars that we just were notified on in heading into 2025. But I think that combined with the V28 risk model changes and the two together, we think are material advantages to us. And so what I mean by that is getting the stars advantage is pretty significant. I think we're one of four health plans in California that have four stars or higher. And two of those other health plans are essentially vertically integrated health systems. And the third one is really interesting, got a four star rating, but only 20% of their membership actually resides in California. And the H number is actually outside of California. And so, the significance of that is that the way in which we work with our delivery system is a competitive advantage. And it's all about provider engagement and making our contracted provider network more successful. And whether that's in the form of IPAs, medical groups, or directly contracted providers. And so, that's starting to manifest itself through the Star ratings. And I think that's going to continue to be just a competitive advantage. On V28, we've said this before, we have not run the business at a very high RAF number. We've been very, very conservative, and compliant, and we'll continue to do so. And I would say others have been more aggressive. And I think the relative advantage we have with some of the headwinds on V28 are significantly to our favor. Those two, I would expect to be reflected in the upcoming, not only in the upcoming 2024 bids for 2025, but also we predicted a lot of this in the '23 bids for 2024. And it's starting to all manifest itself. Last thing I'd say is kind of the financial discipline we've exhibited to protect margin is going to start paying off. And I think that's one of the underlying reasons why I feel so confident that we're going to get to our margin profile and get to at least EBITDA break even next year. And those are the two big drivers. And our bid strategies were spot on and I'm feeling very, very comfortable with where we are two weeks in. And, we’ll share a lot more in January. That helped, Nate? Did I answer all of it? Or did I miss on or two?

That’s helpful. Maybe just a follow-up on just the MBR and how we should think about that next year, any color or early thoughts?

Yes. No, I think we are going to make -- well, two things. I think we are going to make incremental improvements on retention. I think we signaled earlier in the year that we had aberrations with some supplemental vendors. I think we addressed all of that; cleaned all of that. It’s already started showing. All of our member satisfaction metrics and retention metrics, I would expect us to have continued improvement in that. And in MBR, there is a lot of initiatives that we are undertaking. Both that are AVA-centric, meaning more refined stratification models, more consistent stratification consistency, higher degrees of engagement with our care anywhere, levels of engagement. I would say continued focus on the mitigation efforts associated with V28. So, our risk adjustment is going to -- we’re going to get that mitigation offsets operational workflows. So, all of that -- and I would say also this whole notion of just having more doctors talking to doctors. We have already proven I think again through stars and some of the shared risk NOI that we have got, we are working with these IPAs really well. Like, we are setting ourselves apart from everybody else that we are making it work and supporting IPAs that we don’t own. We contract with them. And the next logical step for us is to work closer with some of the doctors that want to work closer with us to have even higher degrees of performance management. And, those two things give me a lot of optimism for even improved MBR performance heading into 2024. Now, I would say we got to focus on the members that we have in 2023, and kind of the members that have been longer with us for a year. Obviously, we are going to continue working on the MBR of the newer members as well. But, overall, I feel very, very good about just every operational part of the company right now.

Great. Thanks very much for the color.

You got it.

Thank you. And, I show next question comes the line of Whit Mayo from Leerink Partners. Please go ahead. Whit, your line is open. If you have your phone on mute, please unmute your line.

Can you hear me now?

Yes.

Hey, Whit.

All right, headset problem. I had a question just on stars. And, I mean it’s kind of an exciting star season for everybody. Just looking at the new numbers I mean I think you guys may be tight on at least one of your contracts. And, I just want to hear kind of what you are happy with, not happy with? Any initiatives you have on your way to ensure that you retain the four-star designation whether focus on caps or anything specific you like to throw out?

Yes. Hey, Whit. It’s John. Yes - no, we are happy with what was just announced with the 24 stars. Again, I think the new methodology -- the two key methodology was tighter for everybody across the broad. And so, I am just very happy about that. For dates of service in 2023, I feel even better positioned than I did earlier in the year about dates of service in 2022. And a lot of the initiatives that we’ve taken on administration, on TEDUS and Part D, I feel very comfortable with. And then, caps obviously is something that we have had challenges with. And, it’s I think central to some of the initiatives we’re focused on in terms of provider operations and provider engagement. Not just IPA management, which I think we do a very good job of, and we support the IPAs but also working with some of the underlying doctors and making sure that their success and performance metrics continues to improve. And so, I feel good about the initiatives we're undertaking at CAPS, but I got to tell you, with what I have seen thus far in terms of all the other measures, and we're basically tracking numerators and denominators for every single measure on a daily basis so that we can ensure that gaps get closed on a daily basis. And I sit in on a lot of these conversations, so I see it live. I'm very comfortable we're going to be four stars or more, and really I'm pushing people to get higher. That's kind of the mode that we're in.

Okay, good. That's helpful. And second question, maybe just an update on broker strategy. I know you guys have really tried this year to tie up tighter with a number of brokers. I don't know, market like Texas or something kind of comes to mind. Just feedback, feeling better or worse after seeing other plan offerings that are out there, how do you feel about the progress you're making?

Yes, a lot of tailwinds. And again, it gets back to some of the just kind of comparative benefit advantages that we have that I think are a result of what I said earlier, tailwinds with respect to stars and tailwinds with respect to V28. It all manifests itself in your product strategy, and we have very strong products. If you have very strong products, and you have the operational sales control that I think we have in place now with respect to distribution, we're getting very, very good results from the broker community. And the quality of the brokers, the compliance of the brokers has been very good. We need five-star brokers. If you're not a five-star broker as measured by kind of CTMs and just general satisfaction, you're not going to work with us. It's really just implementing and enforcing that. So I'm very happy with that. I would also really shout out our sales leadership and sales operations teams have done a very good job this year. And it's just, it's at a level of just kind of organization and control and visibility and transparent, all of its very, very good. So, again, I'm very optimistic about that. And again, I like that shows in the first couple of weeks of AEP. And that momentum, as I keep asking every day is that momentum continuing? And people are saying, yes. So, we'll see what happens, but so far so good.

Okay. Thanks, guys.

Thank you. And I show our next question comes from the line of Jessica Tassan from Piper Sandler. Please go ahead.

Hi, guys. Thanks for taking the question. So, I wanted to ask just, we know alignment was kind of first on the debit card supplemental benefits. Can you just discuss any areas of innovation for 2024? And just what would you expect the member or how would you expect membership mixed shift as a result of that supplemental benefit innovation?

Yes. Hey, Jess, it's John. No, we're pretty excited about a couple of announcements that we've made. One is with Walgreens. We've got some co-branded plans and select markets with Walgreens. That is going exceedingly well. The brand name is helping us a lot. The brokers love it. And then, the other one I would call out is Instacart, which is very, very innovative. And we're looking to deepen relationships with them across more geographies. But kind of introducing Instacart as a primary grocery benefit is very innovative. And we have bulked up some of our resources and our member experience teams to ensure that we can navigate and help our members through that. And so far, the early indications are very positive. People love it. And once you kind of get the hang of using the app and navigating the app, they really love it. So, that's something that I think you're going to see more and more of this kind of retail technology convergence with benefits design. And I think when you kind of combine that with the degree of service that we provide them, which I'm super happy with, there's this kind of promise of convergence between health insurance or traditional MA health insurance with a senior lifestyle and kind of health, social determinants of health. You can see that convergence starting to, I think materialize.

And that's really helpful. I guess just one quick follow up there on the Instacart benefit. Do you have any more visibility into purchasing patterns or just better control over kind of discounting relative to a retail store? And then just to follow up would be on the community center in Southern California, just interested to know kind of what is the plan there? And is that a one-off or is that is the intention that those types of centers expand across markets? Thanks, guys. Appreciate it.

Thanks, Jess. Yes, first one, a little bit too early. It's but we will share that once we get through AEP and get you some metrics on Instacart. I think that's a good question. With respect to the Laguna Woods Retail Center that has been met with a huge amount of positive feedback from the community. And so, I think you're going to see us have more of these, I would call it mixed use centers that would not only necessarily be concierge centers, but also be clinical centers. And so, it's a little bit of a hub and spoke model, if you will. But in other cases, we're finding it to be positive that if you have the kind of the bulk of the engagement, particularly around that chronic patient at the home through our Care Anywhere models, that's still the most capital efficient, most effective way of serving the needs of these folks. But we're also finding having a physical presence that people can actually see a big sign that says alignment and they can go in and just get all of their questions answered. They can go in and have an annual wellness visit. It's going to -- it's not only going to be a kind of a branding advantage, but it's going to, I think, accelerate the degree of engagement that we get on the clinical side. And just before anybody goes too crazy, it's just like we're not going to be doing a whole bunch of bricks and mortar. We're not doing that. I think that's very expensive. But it's select markets. I think you can expect us to do that -- see us do that.

Got it. Thank you so much.

You got it.

Thank you. And I show our next question comes from the line of Adam Ron from Bank of America. Please go ahead.

Hey, thanks. I just wanted to ask a question about guidance update. And I know you mentioned that, like the implied MLR is pretty similar to what it was before, but it didn't go up a bit. Just want to clarify that, that's related to basically new membership, our performance and the higher MLR on those new members. And then, I have one quick follow up to that.

Yes. Hey, I'm Thomas here. Yes, I think that's exactly right. So, particularly coming out of the third quarter with the favorable utilization that we've been able to achieve year-to-date, we also invested a few million dollars and plan to invest a bit more ahead in the Q4 regarding some of our clinical engagement in annual wellness activities, which is really about setting us up for a successful 2024 and beyond. To your point, we also then added that we did raise our guidance for the full-year by 4,000 roughly members at the midpoint, which, as our year one members typically do have higher MBRs than our loyal or returning members. So, that's the second part of the driver. But I would think about it as favorable outperformance and utilization, essentially funding a lot of these investments that we're making to set us up for a successful 2024 and then the incremental growth on top of that.

It makes sense. And then, I guess following up on the discussion from last quarter, we're like national payers and MA had problems with utilization and you weren't really seeing it. But now that you have more claims data from like May and April and the time period from when payers are really worried about utilization, is there anything that you are seeing that's similar to that commentary or you're still really having a different experience from all the other public companies and if so, is it just like geography that would explain the difference or what else would you point to?

Yes, so from an outpatient standpoint similar to our comments last quarter we have not seen a considerable increase in 2023 relative to our 2022 experience. So, I think on a year-over-year basis our overall outpatient claims PMPM are up in the low single digits, again, within the realm expectations had into this year. I think our theory as to why that is twofold. So, I think, first of all, we saw a pretty considerable increase in our applications been in '22 relevant to 2021. And so, I think to a certain extent, for us based on the markets wherein or other factors, I think we saw some of that return maybe earlier than others. And that was captured as part of our run rate in '22 heading in 2023. I think additionally, while a lot of our focus with care anywhere is on those chronic complex members, who we have the opportunity to really improve things like unnecessary or affordable hospital admission improve their readmission rates and things of that nature. I do think there's obviously some benefit with our broader clinical model and provider engagement efforts that helps on the outpatient side as well. It seems to be less of the material driver where we generate the savings, but I think that's a tailwind for us relative as many of our competitors.

Awesome, thanks.

Thank you. And I show our last question comes from the line of John Ransom from Raymond Jain please go ahead.

Hey, there. Thanks for the follow up. There's been some industry trade chatter that your hospitals have dropping MA plans and it's getting harder to assemble that works. How is your go to network strategy to change or not change and why of some of that or do you think that's over one?

Yes, hey, John. It's John. I'll take that one. Yes. No, there's been a lot of public scrutiny around this topic where you've had health systems that have entered into global capital arrangements with different pairs exit the business, and they're just not taking a global capital anymore. And in the conversation that I've had with many of the help system's CEOs, they aren't concerned about the headwinds associates with Stars funding and V28 funding. And so, when you're taking global cap, and I've said this from the get go, you got essentially two insurance companies within one supply chain, and there's not enough money to go around right now. And so, that's why a lot of this sensors are getting out of it. And the other problem with the health systems have right now is access in capacity problems. Meaning a lot of the branded, you all consider A to your health systems are running out of space. There's so much demand because the brand is so strong. And so, what's interesting is a lot of them are approaching us with their solution if not to just take global cap, that's not what they want to do. Rather what they want to do is actually leverage AVA to anywhere and lower senior admissions into their hospitals, and in turn replaced those admissions with commercial admissions which are correctly just better funding. So, I think somatically that's going to be a trend you start seeing, and as a growth opportunity there. And I think one of the things that they've commented to us is some of the larger national folks, the long-term viability working with somebody's folks really challenging for them. And so, I would see that trend continuing across the board, kind of geography agnostic. I think it's a consistent theme that I'm seeing everywhere. I know that answer to your question, John.

Yes. Not what I was expecting. That's interesting. So, just to tack one more on ACO REACH, is that ever going to be any kind of material profit driver, do you think the government has made that program attractive enough -- down or it is just going to be one of this little -- one of this Medicare programs where the government saves money but nobody makes any money participating?

Well, it's hard to underwrite it. I mean we've been consistent with that also. We think it's probably a pretty good program for physicians, kind of has on onboarding and on-ramp to value-based care, but it's hard to underwrite when they reset the benchmark every year. It's just like -- I don't want to say it, it's kind of race to the bottom, which is why we have not deployed capital like some of the others. I seen that before. So, I do think it's important to have it as a part of our portfolio simply because we want to help doctors, and so a lot of the doctors that we have good relationships with do have a component of either an MSSP, or ACO REACH, or just kind of some form of issue program and DCU program. And from a workflow point of view, we don't want it to be different than the MA book, so we're helping them just provide better care and better economics. But for us, I'm not sure it's something that we would underwrite.

Thank you, sir. That's it from me.

You got it. Thanks.

Thank you. So, we have one more question in the queue. That question comes from Scott Fidel from Stephens. Please go ahead.

Thanks. And I guess since John started round two, well, I'll tack on there. And actually, wanted to get your view on one industry level, just dynamic that's where California has been a bit more of the tip of the spear recently, just in terms of the union dynamics where we saw Kaiser agree to that new contract and then the minimum wage bill that was approved for healthcare workers. And definitely interested in how you're factoring that into your thinking on upcoming unit costs and negotiations with assistants out in California. Not really, I guess, as much for '24 but even taking more for '25 and '26.

Hey, Scott, Thomas here. I guess there's two parts to how we might think about that. So, the first is, in terms of its direct impact on our clinical workforce. The impact is generally negligible, just given the level of nurses and doctors that we employ across the state. So, not something that we view as a major driver of our '25 and beyond outlook, I think in terms of your point on how that may eventually flow through to our conversations with hospitals. We typically are contracting with hospitals on a percentage of Medicare basis, typically it's 100% of Medicare. And so, the way it will work for us in general is, as those hospitals are getting pressure, we often see that, that leads to greater levels of Medicare rate increases, which flows through to our contract to your point, but it also flows through to our revenue benchmarks. So, I think in general, our contracting approach is pretty well insulated from some of those dynamics overtime.

Okay. Thank you.