ALHC - NASDAQ

Good afternoon, and welcome to Alignment Healthcare’s First Quarter 2024 Earnings Conference Call and Webcast. [Operator Instructions] Please note that this event is being recorded. Leading today’s call are John Kao, Founder and CEO; and Thomas Freeman, Chief Financial Officer. Before we begin, we would like to remind you that certain statements made during this call will be forward-looking statements as defined by the Private Securities Litigation Reform Act. These forward-looking statements are subject to various risks and uncertainties and reflect our current expectations based on our beliefs, assumptions and information currently available to us. Descriptions of some of the factors that could cause actual results to differ materially from these forward-looking statements are discussed in more detail in our filings with the SEC, including the Risk Factors section of our annual report on Form 10-K for the fiscal year ended December 31, 2023. Although we believe our expectations are reasonable, we undertake no obligation to revise any statements to reflect changes that occur after this call. In addition, please note that the company will be discussing certain non-GAAP financial measures that they believe are important in evaluating performance. Details on the relationship between these non-GAAP measures to the most comparable GAAP measures and reconciliation of historical non-GAAP financial measures can be found in the press release that is posted on the company’s website and in our Form 10-Q for the fiscal quarter ended March 31, 2024. I would now like to hand the conference over to your speaker today, John Kao, Founder and CEO. You may begin.

Hello and thank you for joining us on our first quarter earnings conference call. For the first quarter 2024, our health plan membership of 165,100 members represented approximately 50% growth year-over-year. Total revenue of $629 million grew approximately 43% year-over-year and approximately 54%, excluding ACO REACH. Adjusted gross profit was $57 million, producing a consolidated MBR of 90.9% and an MBR, excluding Part D, of 88.3%. Meanwhile, our adjusted EBITDA of negative $12 million exceeded the high end of our first quarter outlook range and represents solid progress toward our full year adjusted EBITDA objective. Growth in the first quarter significantly outperformed expectations. This result continued to be driven by increased member retention, improved sales operations and competitive product offerings. Meanwhile, our ability to achieve our adjusted EBITDA outlook while scaling to support 4x the number of new members, demonstrates the power of our integrated data insights, clinical model, shared risk provider partnerships and operating platform. Central to our results is AVA’s visibility into emerging trends, which allows us to rapidly deploy our clinical teams to improve care outcomes and control our medical costs, even while achieving rapid growth. The combination of these differentiated capabilities led to a first quarter consolidated MBR of 90.9% reflecting only a modest year-over-year increase in our MBR despite growing membership 50% relative to 17% a year ago. This strong result is underscored by an MBR, excluding Part D, of 88.3% and a Part D MBR of 129%, both consistent with expectations and a further indication of our early success in managing our new members. Thomas will expand more on Part D seasonality in his remarks. Following the strong first quarter, we are raising our full year membership and revenue guidance, raising the low end of our adjusted gross profit guidance and narrowing our adjusted EBITDA range. Our updated guidance reflects expectations for continued membership growth momentum, a greater mix of new members, our confidence in our clinical model and improving operating leverage on adjusted SG&A. To manage our significant membership growth, our top priorities in the first quarter were providing our new members with exceptional onboarding experience and engaging with members who have the greatest chronic health needs. From a service delivery standpoint, our past investments in AVA consumer and in-sourcing member experience delivered exceptional results. These efforts resulted in an NPS of 69 at the end of 2023, a 30% reduction year-over-year in our first quarter new member voluntary disenrollment rate and a 4.9 stars Google rating across more than 4,000 reviews. All of this was accomplished while achieving over 50% membership growth. By improving member satisfaction and reducing disenrollment rates, we lower our member acquisition costs, raise our star measures, improve our net growth and increase the lifetime value of our membership. From a care management standpoint, the visibility created by our real-time utilization data allows us to quickly engage high-risk members to manage care and control costs market by market. We immediately began managing new members to experience an acute episode in January and successfully engage approximately 70% of new members post discharge. This resulted in 141 inpatient admissions per 1,000 for new members and 151 admissions per 1,000 overall. We expect to build upon the strength of these results throughout the year as we ramp up our care anywhere engagement. AVA stratification of at-risk member sees a significant jump 30 days after enrollment as our real-time data feeds analyze pharmacy data, lab values, admission, discharge, transfer information and other data sources. This presents us with the greatest cost improvement opportunity in the second, third and fourth quarters, as we raise our high-risk new member engagement levels. Once engaged, high-risk members typically see a 30% net improvement in institutional claims over the following 12 months. This, combined with our focus on improving outpatient quality outcomes which drives lower cost, gives us confidence in our continued MBR improvement throughout the year, consistent with our full year outlook. Looking ahead to 2025, we believe we are well positioned to grow health plan membership at or above 20% while expanding margins. As we plan for the current bid cycle, we believe we have distinct tailwinds that support our financial position and competitive advantages. First, there are over 1.2 million HMO members in our California markets who are in plans that will be rated below 4 stars in 2025, including approximately 700,000 who are in plans that are receiving 4-star or above payment today, but will be dropping below a 4-star payment next year. Meanwhile, roughly 95% of our California members are in plans that will have 4-star payment level in 2025. The difference between a 3.5-star and a 4-star plan is approximately 5% less per member revenue. While the difference between a 3-star and a 4-star plan is approximately 10% less member revenue, we expect this funding advantage to support our ability to offer attractive benefits while improving consolidated margins. Second, we believe the continued phase-in of the V28 risk model changes will further widen our relative advantage in risk adjustment. And third, following the announcement of the final Medicare Advantage rate notice, we expect a weighted average change in our effective growth rate of 5%, which is more than double the national average of 2.4%. These factors, combined with our differentiated operating platform and strong retention of new members, gives us confidence in our ability to deliver both growth and margin improvement in 2025. In conclusion, I’d like to thank each of our employees for being part of the team that is raising the standard for what it means to do Medicare Advantage right. Our unique degree of visibility, combined with our clinical and operational execution, is enabling us to navigate the dynamics facing the MA sector and gives us confidence in our 2024 outlook. Combined with tailwinds in 2025 on relative stars advantages, positioning into the continued risk model phase-in, clarity on benchmark changes in 2025 and increased scale, I believe we will achieve both strong growth and margin improvement in 2025. Taken together, we believe our operating model will continue to prove alignment is the optimal Medicare Advantage platform for today and for the future. Now I’ll turn the call over to Thomas to further discuss our financial results and outlook. Thomas?

Thanks, John. For the quarter ending March 2024, our health plan membership of 165,100 increased 50% year-over-year. This exceeded our expectation of 44% membership growth at the midpoint of our first quarter guidance as well as our year-end guidance range of 162,000 to 164,000 members. Our first quarter revenue of $629 million represented 43% growth year-over-year and 54% growth, excluding ACO REACH. The top line outperformance was primarily a function of higher health plan membership as our superior value propositions continue to resonate in the market. Adjusted gross profit in the quarter was $57 million, representing an MBR of 90.9%. The modest increase year-over-year was driven by significantly larger portion of new members, reflecting strong control over our medical costs even as we grew membership by 50% compared to 17% a year ago. First quarter performance was driven by favorable inpatient utilization relative to expectations with overall inpatient admissions per 1,000 of 151, declining 8% year-over-year. Our favorable utilization performance was partially offset by higher inpatient unit costs related to CMS’ increase in 2024 fee-for-service rates and greater supplemental benefit utilization. As John mentioned, our first quarter results reflect an MBR, excluding Part D, of 88.3% and a Part D MBR of 129%, both in line with expectations. As a reminder, Part D profitability improves over the course of the year as the health plans cost share declines meaningfully after the initial coverage phase. Consistent with normal seasonality, Part D increased our consolidated MBR by 260 basis points during the first quarter. Through the remaining 3 quarters of the year, we expect Part D to lower our consolidated MBR by 150 basis points. This results in a net change of roughly 400 basis points between the first quarter and the remainder of the year. We expect our Part C MBR to be only modestly higher for the rest of the year, meaning that Part D will be the primary driver of seasonality between the first quarter and the following 3 quarters. During the quarter, it’s worth noting that we were not materially impacted by the cybersecurity incident that disrupted a national claims clearinghouse. Importantly, we do not use those clearing house for pharmacy claims, prior authorization or provider claims payment functions. While we experienced a temporary dip in claims received in February due to the use of the impacted clearing house by a small number of our providers, we believe we are currently at normalized claims flow levels. SG&A in the quarter was $90.5 million. Our adjusted SG&A was $69 million, an increase of 37% year-over-year. Adjusted SG&A, as a percentage of revenue excluding ACO REACH, decreased by approximately 140 basis points year-over-year. We continue to expect even greater SG&A ratio improvement over the next 3 quarters, which I will share more on shortly. Lastly, our adjusted EBITDA was negative $12 million, ahead of expectations and putting us on track to achieve our full year adjusted EBITDA guidance. Moving to the balance sheet. We remain in a strong position with $302 million in cash and investments at the end of the quarter. Turning to our guidance. For the second quarter, we expect health plan membership to be between 167,000 and 169,000 members, revenue to be in the range of $625 million and $635 million, adjusted gross profit to be between $71 million and $77 million, and adjusted EBITDA to be in the range of $0 million to positive $6 million. For the full year 2024, we expect health plan membership to be between 170,000 and 172,000 members, revenue to be in the range of $2.495 billion and $2.525 billion, adjusted gross profit to be between $280 million and $310 million, and adjusted EBITDA to be in the range of a loss of $12 million to positive $12 million. The increase to our full year membership and revenue outlook follows strong first quarter membership outperformance and our expectation that our sales and member retention momentum will continue through the remainder of the year. Our revised membership guidance now reflects 43% membership growth at the midpoint for year-end 2024. Moving down the P&L. We are increasing the low end of our adjusted gross profit range and narrowing our adjusted EBITDA outlook. The following elements are captured within our updated adjusted gross profit outlook. First, while the increase in our year-end membership growth contributes incremental gross profit dollars, the new membership increases the MBR implied by our guidance as new members typically begin at a higher MBR. Second, we expect a continuation of higher inpatient unit costs related to CMSs increase in 2024 fee-for-service rates and greater supplemental benefit utilization, both offsetting the incremental gross profit from higher new member expectations. Third, we expect a moderate decline in inpatient admissions per 1,000 for the full year, partly due to member mix. The 13 admissions per 1,000 year-over-year decline we experienced in the first quarter from 164 to 151 places us well on pace to deliver on this objective. As mentioned earlier, we expect to see continued benefit from the ongoing engagement with new members and deployment of carrying our resources to those identified as high risk. Our differentiated engagement with both new members and providers is the core reason why alignment has not experienced the same degree of utilization headwinds that some others in the sector have experienced. Fourth, in addition to our normal course operations, we have identified new payment integrity programs that are currently being implemented. We expect these solutions to provide additional upside throughout the remainder of the year, particularly in the second half. And lastly, our Part D seasonality is expected to drive roughly 400 basis points of MBR improvement between the first quarter and the remainder of the year. This is consistent with our historical experience and normal course seasonality. Adjusted EBITDA guidance also highlights continued improvement in our operating leverage. We now expect our adjusted SG&A as a percentage of revenue, excluding ACO REACH, to be 11.8% at the midpoint, an improvement of 260 basis points year-over-year. Our operating leverage gains over the next 3 quarters are driven by a combination of factors, including first, continued fixed cost leverage relative to greater membership growth and productivity improvement measures, second, elimination of onetime expenses associated with the insourcing of member experience functions in 2023, most of which were incurred in the second half of last year and third, sales and marketing and year-over-year expense leverage, which is also concentrated in the second half. In conclusion, our strong growth has been well managed by our clinical and operational resources and is a testament to our differentiated Medicare Advantage platform. After our robust start to the year, we believe we are on pace to deliver against our full year outlook and are set up for both growth and margin improvement in 2025. With that, let’s open the call to questions. Operator?

Thank you. [Operator Instructions] Our first question comes from the line of Nathan Rich from Goldman Sachs.

Hi, good afternoon. Thanks for taking my questions. I wanted to, John, follow-up on your comments on – on 2025 and the company’s positioning. I guess, can you maybe talk about how you plan to use that cost advantage or kind of revenue advantage position in your planned bids and how you kind of see that flowing through to maybe what you’re planning for benefits relative to where you see the market going? And then one of the things I wanted to ask on more specifically was the changes to the Part D plan design that will go into effect in 2025. And you does that create any unique challenges as you think about how to price and position your plans for next year?

Hey, Nate, thanks for the question. We’re acutely aware of our competitive position in each of our markets. We’re right in the middle of bids right now. We’ve been studying IRA for the last couple of years so we know the nuances of that. We’re very comfortable with how Part D is going to be very important part of benefit design. I’m not going to comment on bid-related questions right now just due to the nature of the competitive dynamic. I would say though that we’ve always said 2025 is going to be very much a breakout year for us in the context of margin. And if you kind of look at just the growth that we’ve had this year and the strong performance in our ability to onboard the growth and then manage the growth from a medical management perspective, just getting to very basic levels of compliant risk adjustment on this new membership, you can do that math, it is very exciting for us. And then the continued improvement on margin on the vintage analysis of our existing members, just doubles – kind of double down on that margin perspective. So I think we are very, very encouraged by that. And for those of you who have been with us for the last couple of years is just very disciplined, and it’s all leading to a growth year and a margin year that we expect ‘25 to be very good.

And maybe if I could just ask a quick follow-up on that. The stronger growth this year, and it seems like you expect another year of strong growth in ‘25. Does that change the margin trajectory at all? And I guess, looking at how guidance was updated this quarter kind of post the strong membership gains, top line goes up about $100 million, but a relatively minimal impact to kind of gross margin and not much drop through to EBITDA. Do you feel like that dynamic changes at all, maybe as this year membership base matures? Or do you see the stronger growth kind of dampening the – potentially the margin over the next year or 2?

Yes, it’s a great question. I don’t – I mean I’m not saying we’re going to grow at 50% again next year for 2025. I do think we have good tailwinds in our favor. But really, I think margin expansion is going to be really important. And I think we can get the growth. If not 50% growth, we’re going to get the growth with the focus on the margin piece of it. And you just look at read and everything that’s publicly available. You look at the Stars ratings. There might be one or two competitors that do irrational things. They’ve done that in the past before. But that’s part – that’s okay. And we’ll have a very good 2025. I’m very, very confident of that.

Thanks very much for the questions.

Thank you. [Operator Instructions] Our next question comes from the line of Ryan Daniels from William Blair.

Yes. Congrats on the strong start to the year. Thanks for taking the question. Thomas, maybe one for you. Interesting data on the admits per 1,000 related to both new patients and then the overall book of business. Can you dive into that a little bit more? Is the new patient number lower because they are coming in younger and healthier despite the fact that they haven’t been in your clinical programs? Just any color there would be interesting. Is that a key cost driver?

Hey, Ryan, it’s John. I think Thomas is navigating some Wi-Fi issues right now. But the answer to the question is yes. And we’re pretty happy with that. And just let me comment on that. We’re not immune to certain utilization hotspots with some of the new members that we picked up. We have a couple of markets, not a lot of members, but we still have some members that had higher inpatient utilization, actually a couple of different markets. And we’re just all over it. We have visibility to it. We are addressing the care needs of these patients on a daily basis. And so we’re just managing it really aggressively. So it’s – I’m really happy with the performance on the admissions per 1,000. 151 for the whole book is a lot better than what we did a year ago even. And so these kind of continuous improvements that we’re making to AVA and to Care Anywhere are really starting to pay off. And I actually think there’s even more opportunity for us as we start maturing some other initiatives that we’ve got in the clinical.

Right. Perfect. Thank you for that. And then maybe another bigger picture question directed to you. We’ve seen some data recently talking about Medicare Advantage HMOs versus PPOs and the ability for providers with HMOs to better control cost and utilization and manage the patient. I know your exposure is mostly HMO lives versus some of your peers. Do you think that also is providing you with a unique advantage as it comes to your MLR stability or MBR stability versus what a lot of the other players are seeing as we enter 2024? Thanks.

Yes. I think that’s fair. I think that’s a fair statement. I think the way we design our provider contracts also, I think, is part of that answer. Kind of this notion of prior auth though is something that’s a bit of a misnomer in that a lot of our provider partners and a lot of what we do is auto auth. I think it’s making sure that we have the proper care navigation in the HMO to get people into the right providers in a kind of a timely fashion for access. That’s really important from a cap on a Stars perspective and kind of having – kind of a preferred network, if you will, in care navigating to the right, the highest quality provider, all those kind of dynamics, I think, are things that you get with the HMO. I think on the PPO, Ryan, the stratification model of identifying who the high-cost vulnerable PPO members and then caring for them with carrier, that principle still holds as well. And I think one of the things we’ve done a really better job on with the PPO is engaging those PPO members without a dedicated PCP and engaging them and making sure we get proper documentation on the coding side. That makes a big difference.

Thank you for all the color. Congrats again.

Thanks, Ryan.

Thank you. [Operator Instructions] Our next question comes from the line of John Ransom from Raymond James.

Hi, good evening. One issue for the industry is this thing about claims lag and what do you know when you know when you report a quarter, especially around outpatients. And I know you guys have your AVA technology and your Care Anywhere plan. But what – your ability to accrue your cost accurately, how has that changed? And what tools do you use that maybe some of your competitors when you stand here and say with confidence what the – kind of what the 1Q medical costs look like?

Hey, John, this is Thomas. I appreciate the question. So I think our ability to actually have the visibility that allows us to accrue for our performance in Q1 or any other quarter actually is very much underpinned by the visibility and control we have from a medical management standpoint. In other words, it’s not that we do things from a financial standpoint to create the visibility. It’s that we actually run our business day to day with things like admission discharge transfer data, i.e., heads in beds every single day, and then we use that information in order to actually track and accrue our financial reserves or medical expenses. And so more specifically, when I think about the broader spend outside of the inpatient setting, there is a lot of correlation between the different categories of spend. And so for instance, about 90% of our members go through the ER when they’re hospitalized. And conversely, on the way out of the hospital, about two-thirds of our discharges go to a skilled nursing facility or a home health facility. So there’s a high degree of correlation between how that inpatient KPI moves and how other categories of spin claims PMPM also move. And then beyond that, we do, of course, track off data on other things like outpatient hospital surgery or ASC metrics, skilled nursing, length of stay, home health per 1,000, etcetera. So I think our ability to have pretty good visibility to how the overall claims PMPM is running for the first quarter is quite strong. But it’s underpinned by us using that information day-to-day as opposed to the other way around.

Great. And then my second question, this is my favorite, like walking in the weeds Medicare Advantage question. But do you have any visibility on the 2Q midyear sweep? And what’s embedded in your guidance as we sit today?

Yes. So there’s two different sweeps we get in the second quarter. One is the final sweep from last year, which we typically receive at the end of May in our June payment file. And then we also get the midyear sweep on the 2024 membership, which typically comes at the end of June in the July payment file. So typically speaking, both of those two sweeps would be reflected in our 2Q financial results. We typically don’t accrue or expect anything on the financial sweep – the final sweep from the prior year. It depends upon the year. I would say, in COVID years, in particular, we saw outsized favorability associated with that sweep. But I think if you look at our results last year, which is probably more indicative of a normal year, we didn’t have near as much of a pickup last year. But nonetheless, if we do see any kind of positive favorability there, it would be, I think, in addition to what is currently guided. From a midyear sweep standpoint, very similarly, we typically see kind of a few basis points of pickup on the new members that allows us to actually have our full year new member RAF be consistent with what we got paid in January. And that’s really how we build our guidance over the course of the year on the new members, is whatever we get paid in January is whatever we expect to be paid for the full year. To the extent that, that comes in more favorable in the mid-year sweep, that could also be upside. We don’t like to kind of bank our guidance on that assumption because it’s out of our control. That midyear sweep comes from whatever was documented last year with the members prior health plan. So I think it puts us in a conservative position, but also at the same time, I think given what we’ve seen last year after COVID, that typically is not going to be a major driver of significant outperformance. It could be some modest upside.

Okay, thanks a lot.

Thank you. [Operator Instructions] Our next question comes from the line of Adam Ron from Bank of America.

Hey, guys. Thanks for taking the question. So you mentioned that this year was a growth year and that next year, potentially margin could be more important. But if I look at like even this year where you’re saying new members come in and they don’t have super high margins, you still are on track to, I think, increase EBITDA margins 200 basis points. So if next year, margins are more important, is there a reason why we shouldn’t see that kind of margin expansion again? Or are there one-time items like the ACO REACH kind of skewing that?

Hey, Adam, Thomas here. On the last part of that question, ACO REACH is not a significant driver of profitability improvement from ‘23 to 2024. I think we sized that in the kind of like $3 million to maybe $4 million or $5 million range in terms of dollars of improvement from ‘23 to 2024 guidance. So the vast majority of our improvement in 2024 is really coming from the Medicare Advantage business. And as we talked about, the vast majority of that is really coming from improved operating leverage through the adjusted SG&A line. And so I think to your broader question on 2025, while we’re not going to draw a line in the sand today on our 2025 margin goals for next year, I think what we were really trying to amplify in John’s remarks is that we think we have the ability to do both growth and margin improvement again next year also. And I think we’re in that position because of some of the tailwinds John described, where while we’re impacted by V28, I think we are less impacted by – relative to our local competitors. And then from a Stars standpoint, we very much have a funding advantage over the vast majority of our competitors for 2025. So I think that gives us a little more flexibility to achieve both next year and continue on the trajectory we set forth for 2024.

Makes sense. And then in your remarks, you mentioned a couple of things about a widening relative advantage in 2025 and how your competitors would see reimbursement headwinds. But one thing that was like sort of pushing in the other direction is the fact that the L.A., where your most few members are benchmarked, is expanding by 5%, which is very strong. So does that help your competitors overcome some of their reimbursement headwinds such that maybe they don’t actually have to cut benefits and they kind of close that relative advantage because they needed the reimbursement more? Like how are you thinking about that? Like – or is that a tailwind for you relative to your expectations?

So I think a couple of things. So in terms of the benchmarks in some of the markets, particularly Southern California, to your point, I think some of those markets have also seen higher inpatient and outpatient unit cost increases. And so a little bit of that, I think, is catch-up in 2025 relative to the 2024 rate updates with CMS. But I think from a competitive standpoint, we sort of look at it as one kind of pool of overall funding or reimbursement dollars for us and our competitors and each of us has our own pluses and minuses. So to the extent that we have 5% in a market and our competitor has 5% in a market, I agree that would be sort of a neutral factor. I don’t think it necessarily helps us. I don’t think it necessarily hurts us. But I think what creates that relative advantage are the other two factors, where, on average, there’s really only one of our major HMO competitive plans in our markets. That’s going to be 4 Stars. Everyone else is either 3, 3.5 or in some cases, 2.5. And so that extra 5% to 10% revenue PMPM funding advantage on Stars alone is, I think, a major advantage for 2025, even if some of the benchmarks in certain counties are going up by 5%.

If I could squeeze one more in. So Humana recently talked about the industry margin potentially settling out at around 3%. That’s like EBIT, not EBITDA. Do you have a view on that? Or has your view changed at all based on the new reimbursement environment? That would be my last question. Thank you.

Yes. I think our view of long-term margins is fundamentally unchanged in that the overall structure of the Medicare Advantage program is unchanged. So when we went public several years ago, we talked about a 6% to 7% adjusted EBITDA margin long-term, which I think is more like a 4% to 5% pretax margin. And when you think about what has changed in the more recent macro environment, you’re right. I think Stars has gotten tougher with the introduction of two key and the removal of some of the COVID kind of protection mechanisms that were put in place on Stars. V28 has been introduced. And then broadly speaking, across the board, utilization pressures have been seen in a variety of different categories of spend. And so while I think that’s put pressure on the industry at large in the short-term, I don’t think it changes the fundamental opportunity given that, at the end of the day, a number of plans have demonstrated the ability to run efficiently with SG&A at 10% or below. We’re starting to get pretty close to that, getting down below 12% in 2024. And from an MLR standpoint, the 85% MLR rule is unchanged. So I think just structurally, the opportunity is no different today than it was a year or a couple of years ago. I think the changes in macroeconomic factors, though, have put more pressure on the requirement to be a high-quality, low-cost player. And if you’re able to do that, I think you can still win in this current environment, and long-term, generate the same 4% to 5% pretax margins you could have or would have expected several years ago.

Just Adam, let me echo that. This is John. Let me echo that. It’s an opportunity for organizations that have the lowest cost structure or have a model to get to the lowest cost structure without compromising quality. And it gets measured by Stars because you get reimbursement that’s more, the better quality you are. But that’s why we’ve spent so much time and effort making sure that the care model and the belief that if you can manage the care, you’re in a position to control the cost. That’s the – from day 1, that’s been our philosophy. And I think there’s somewhat of a sea change that those that have just relied on risk adjustment to be successful are the ones experiencing tough margin compression right now. So it’s like a structural change intentional by CMS. And so those who have been in this business for 30 years or so have gone through four or five of these reimbursement blips. But the kind of the wave of aging of seniors and the political kind of power of MA, we just don’t see it slowing. In fact, we still see market share penetration going from 52% to 65% in the next 7 years. I mean, so I think it’s an opportunity. And I think it requires a structural change in terms of who will win and what will succeed going forward in MA. And I think we are really well positioned for that.

Awesome. Appreciate all the color.

Yes.

Thank you. [Operator Instructions] Our next question comes from the line of Whit Mayo from Leerink Partners.

Hey, good evening, or afternoon, guys. The new lives that you picked up in the first quarter, can you maybe quantify the – how much of those are agents versus switchers and if there were a lot of switchers, any themes on the switching, if you have any market intelligence on that?

Yes. Hey, Whit, this is Thomas here. So I’d say our OEP experience, which lasted through the April 1 eligible beneficiaries, was very similar to our AEP experience. And so what I mean by that is the majority of the membership or the new sales were planned switchers. But we see those planned switchers coming from a variety of our competitors across a broad swath of our markets. And so there is not really just kind of one or two or three competitors that were disproportionately taking share from. We are really, I think advantaged in most markets this year to take share from a variety of players, both in terms of the local or regional competitors and also many of the large national competitors. And I think in terms of our product mix, it’s also been pretty broadly distributed across the board. And sitting here today, we still have about 30% of our members that are enrolled in one of our sessions [ph] like our C-SNP products or are duly eligible, which is pretty consistent to where we ended at the end of last year.

Okay. And maybe this is a dumb question, but looking at the reserve roll forward in your Q, there was $5 million of favorable PYD, but there is a footnote below that references $870,000. I guess I wanted to – what’s the difference between the two and what the P&L impact was.

Yes, absolutely. So, we typically – on that footnote you are referring to, we try to look at the change in prior period reserves, excluding the – we think we put a 7% kind of margin factor on top of the reserves for adverse trends. And so think about that 7% as you added when – you kind of put your best estimate together for a given month, you add 7% to it. If your estimate on that month is perfect, that 7% will just release in the future. But at the same time, we are always adding new months with an additional 7% pad. And so it kind of becomes a wash from a P&L standpoint where you are constantly releasing it and adding it over time. So, we really like to focus on what the change in IBNR is excluding that 7%, and that’s the number that we report in our footnote. So, it was right, you are correct, just a little under $1 million for the first quarter, meaning that our year-end reserves for 2023, I think we are very strong and intact relative to the paid claims experience through the end of the first quarter.

Makes sense. Thanks guys.

Thank you. [Operator Instructions] Our next question comes from the line of Jess Tassan from Piper Sandler.

Hi guys. Thank you for taking my questions. I am curious to know just 2025 funding looks favorable in California. You guys obviously have momentum there from a brand perspective, strong provider network. Curious, just in any updated thoughts around the geographies where you intend to participate in ‘25 and beyond that, whether new market entries remains a significant factor in your growth.

Hey Jess, it’s John. No, we are going to – we are not going into states in 2025. The focus has been on the most efficient way to grow. And we just see so much momentum in our core markets. And even in the ex-California markets that we currently have, we are getting up above kind of that 5,000 member range. And what we have seen in the past is you get to 5,000, to get from 5,000 to 10,000 is just a lot faster. And then obviously, in California, we have got a lot of momentum. I would suspect that we are going to be more aggressive in 2026. And what I have said in the past is the goal, obviously, is to fund new market expansions from internally generated cash. And so I would expect us to be more aggressive in 2026 in terms of new states. I will say that the conversations that we have had with health systems and I would say, a large provider organizations has been very encouraging. And I think you will see more of those kinds of arrangements come together heading into 2026, which require us to have the deals pretty much done by the end of this year so that we can file four service area expansions in February of ‘25.

That’s helpful. And then I guess I am just curious kind of any thoughts on the potential for states’ Alignment initiatives for the dual population to kind of pressure future growth in your book, or just how are you thinking about contending with that in the future? Thanks.

Yes, it’s something that we have had to address over the last couple of years with the Alignment and the aligned programs in the CCI, care coordination programs in California. The rule that just came out, certainly, I think gives some of the Medicaid folks a little bit of an advantage. But what we are advocating for is chronic special needs programs and chronic special needs lookalike programs that in the most recent regs are certainly going to survive beyond kind of the 2030 timeframe. And kind of if you think about the kind of the reality of care quality, we think the quality of the products we have and the care model that we have to serve the seniors is better than any kind of forced kind of Medicaid solution. I just think it’s better quality. And I think people are actually voting with their feet with respect to some of the C-SNPs that we have. And that’s been – it’s been very successful for us.

Got it. Thank you.

Sure.

Thank you. [Operator Instructions] Our next question comes from the line of Andrew Mok from Barclays.

Hi. This is Tiffany on for Andrew. You called out higher inpatient unit costs and supplemental benefit utilization that you expect to continue into the year. Could you give a little bit more color on the expected cadence of those pressure points into the back half, and separately, just anything else to call out on calendar impact to MLR seasonality? Thanks.

Hey Tiffany. So, I think nothing specific from a supplemental benefit or inpatient unit cost standpoint over the course of the year. So, on the inpatient unit cost side, that obviously will impact any months or quarters where we have higher inpatient utilization overall. So, when you think about the next three quarters, we typically would expect inpatient utilization to be lower in the second quarter and third quarter and then have a bit of an uptick in Q4, specifically December around flu season. But generally speaking, I don’t think a lot of seasonality around those unit costs. And similarly, on the supplement benefit utilization side, we don’t anticipate much change there quarter-to-quarter over the next three remaining quarters of the year. I think from an overall seasonality standpoint, we would expect this year to be similar to other years where 2Q and 3Q tend to be lower on MLR and 4Q tends to be a modest uptick higher, though Q1 tends to be a high point for the year. When you think about, I think the improvement initiatives underway that we described in our prepared remarks, I think while our first quarter was very strong and I think it demonstrates our ability to manage really tremendous growth so far this year. There are some areas where we think we can do better, particularly over the back half of the year. So, from a clinical standpoint, getting from – how we say it internally is getting from good to great. And there are certain things that we do a very good job of today, but we think we can do an even better job on in the future, such as post discharge care navigation, SNF length stay management, SNF readmission rate, things that we are already pretty world-class on, but we still see areas of opportunity given the growth we have achieved where we think we can dial those levers a bit more in our favor over the back half of the year. I think similarly, on the payment integrity side, we started to see an uptick in our inpatient unit costs in the back half of last year. And I think as we have kind of looked under the hood on this, we do feel like there is an opportunity to use some third-parties to help us to ensure that we have accurate claim submissions from our different provider partners over the course of the year, particularly in the second half. So, I think those are some of the things that are going to be the biggest kind of drivers of that continuous improvement for us. But nonetheless, as John said earlier in his remarks, I think our first quarter really puts us in a strong position towards our overall full year guidance range.

Yes. And Tiffany, on the acute unit cost, I mean it’s clearly – the offset for that has to be improved kind of admission management, right, I mean and readmission management, and all the clinical quality drivers that we have spent so much time on. And I think last year, Thomas, we were 163 in the month of 80,000 admissions per 1,000 ran 151 [ph]. It’s going to require that kind of continued excellent clinical performance to offset some of those unit cost increases.

Alright. Perfect. Thank you.

Thank you. [Operator Instructions] Our next question comes from the line of John Ransom from Raymond James.

I knew I had another good question. I could remember that’s on the slide. I got some stem [ph] there. So, there has been a lot in the press about MA plans having more difficulty contracting downstream with hospitals pushing back. And then a lot of plans, you lay your risk off of some of these physician groups that are probably getting killed with V28. So, when you think about your provider contracting, how does that look now versus a year ago? And is there anything to call out there, good or bad?

Great question. [Technical Difficulty] about our shared risk contracting model. And we think it’s much more durable. We think that it comes in the form of either PCP capitation and/or professional capitation and then we share in the risk associated for the institutional costs. And so if we all work together and we cut these deals not only with the downstream providers, but also with the health systems, and we have aligning principles with hospital systems and IDNs. I think that’s going to be part of the future personally in terms of how the space shakes out. And so the shared risk model using the tools, using the data that we have access to, not just limited to the EHR data that’s in the providers, but having a holistic view of that patient through some of the tools that we have in AVA and our patient 360 longitudinal patient, exposing that information to the providers is what’s allowed us to take action with the providers to get the outcomes that we have. And it’s in a, I would call it, a capital-efficient model. At our old company, we had a lot of bricks and mortar, it’s very expensive. And so the whole thesis that we have is work with the community doctors that are independent and I don’t want consolidated per se, and/or health systems that have clinically integrated networks and give them the tools and create economics that are aligning. And the other thing I would say, John, is the health systems has approached us, and apologies for the long winded, but this is really important. They are approaching us going, particularly the top tier health systems, the top ones are overcapacity, meaning they are at 120% to 125% of what their physical capacity will allow. And so what they are asking us is, well, if we partnered, can you help us lower the admissions of seniors into our facilities. And that they are so confident that they have lower senior admissions, they can backfill those senior admissions with commercial admissions, which they are just getting paid more. So, they are getting 100% of Medicare, they are getting 200% Medicare. So, those kinds of, I think macro dynamics with respect to reimbursement, not only for the plan, but for the facilities and the doctors, all kind of are factored into where we see MA going forward. And I think you are going to see much tighter partnerships. And a lot of these folks are not happy with some of the, I will call it, kind of claims-editing protocols that certain MCOs are using with these health systems. And so they are kind of coming to us as an alternative. And that gets back to some of the questions that I think Jess asked with respect to how do we think about growing in new markets. And it’s going to be with provider partners in 2026 is the answer.

Do you think that’s the longest answer you have ever given in your career, John? I think it might be.

Not by a long shot.

And my other question, and this is kind of into the weeds. But 5 years ago, we made a lot out of these conveners. We see the headline that Optum is laying people off at Nova Health. Have we done all what we can do in terms of redirecting post-acute? I know Thomas mentioned this, but for every 100 post-acute discharges, are we doing the best we can still in terms of redirecting them to the home health versus SNF, or is there some wood to chop there, as you guys kind of alluded to?

You are talking about for the industry for us?

Well, for you guys. You guys – do you think you are at peak of in terms of…

I think there is a huge amount of opportunity for us to be better at that. And it’s very topical for us. We have – and I alluded to this, we have so much focus on inpatient acute admissions. And I think the opportunity for us to have post-discharge care navigation, SNF rounding, just all of those things that we know how to do, I think – and we do it, and we do it well, but I think we can do it even better, is the short answer.

Is it just hard to compete with the guys playing offense with dropping off the doughnuts and charming the discharge planners? Is it – what do you have to do to get on your front with some of these discharge planners, because you are kind of up against an industry that is pushing in the other direction?

I would say Alignment with the facility, Alignment and relationships with the facility, not at the discharge planner level, but at the CEO of the health system level. Those are the conversations that we are having now. And what’s consistent, John, is people like the care model. At the end of the day, in health services, most of the people we deal with, doctors and health systems, they actually care about optimizing care delivery and quality of care. That matters to them. And they see what we are doing. And to the extent that it is aligned with their economics, people want to work with us.

Yes. One thing I would add to that as well, John, is the bigger we get, the more it affords us the ability to have those conversations. And when you think about us today, we are starting to become more significant in many of our markets. And that’s, I think just given us better opportunities to engage across different sites of care and at different levels within those different institutions.

Yes. I mean I will shut up after this, but it’s just been surprising to me, going back through MedTech data, how stable to well the SNF industry has done when you have all these forces on paper pushing discharges into – literally cost of care, this one set the cost of the SNF, and yet those – their admissions are growing. That’s just been a big surprise to me that the industry is kind of still where we are in 2024. So anyway, that’s my editorial comment. Thank you very much.

You got it.