Good day and thank you for standing by. Welcome to the InnovAge Fourth Quarter 2022 Earnings Conference Call. [Operator Instructions] Please be advised that today's conference is being recorded. I would now like to hand the conference over to your speaker today, Ryan Kubota, Director, Investor Relations. Please go ahead..

Thank you, operator. Good afternoon and thank you all for joining InnovAge's fiscal 2022 fourth earnings call. With me today is Patrick Blair, President and CEO; and Barbara Gutierrez, CFO. Dr. Rich Feifer, Chief Medical Officer, will also be joining the Q&A portion of the call.

Today, after the market closed, we issued a press release containing detailed information on our quarterly and annual results. You may access the release on our company website, innovage.com.

For those listening to the rebroadcast of this presentation, we remind you that the remarks made herein are as of today, Tuesday, September 13, 2022, and have not been updated subsequent to the initial earnings call. During this call, we will refer to certain non-GAAP measures.

A reconciliation of these measures with the most directly comparable GAAP measures can be found in our fiscal fourth quarter 2022 press release, which is posted on the Investor Relations section of our website.

We will also be making forward-looking statements, including statements related to our remediation measures, including scaling our capabilities as a provider, expanding our payer capabilities and strengthening our enterprise functions, future growth prospects, the status of current and future regulatory actions and other expectations.

Listeners are cautioned that all of our forward-looking statements involve certain assumptions and are inherently subject to risks and uncertainties that can cause our actual results to differ materially from our current expectations.

We advise listeners to review the risk factors discussed in our Form 10-K annual report for fiscal year 2022 and our subsequent reports filed with the SEC. After the completion of our prepared remarks, we will open the call for questions. I will now turn the call over to our President and CEO, Patrick Blair.

Patrick?.

Filling critical personnel gaps in each of the centers. We've reduced the number of critical open positions by approximately 60%. Physicians, nurses and home care workers continue to be the most challenging areas, but we're making steady headway.

We've also increased our overall FTE headcount by approximately 150 over the last six months to approximately 2000, including 1,300 clinicians. Standardizing the process of our interdisciplinary care teams who plan, coordinate and deliver care. We've implemented new processes and tools for these mission critical care teams across all 18 centers.

Our focus now is continuous performance monitoring and training. Improving the timeliness of scheduling and coordinating care with external providers outside the centers. Approximately 95% of participants are being scheduled within the target timeframes and backlogs have been largely eliminated.

We're now optimizing staffing, productivity measures and tools. Improving the efficiency and reliability of transportation for our participants. Driver open positions have been reduced by approximately 90%. Additionally, transportation is running at on time percentage of approximately 80%.

We are also in the process of implementing new scheduling and routing tools, which we believe will improve efficiency in a meaningful way. Standardizing our wheelchair program across the enterprise.

We've secured local and network contracts across all centers, and we are finalizing a few national partnerships with the goal to further improve quality and reduce costs in this area. Reducing documentation outside of the EMR.

We've completed training and proficiency examinations on how best to utilize EMR for care documentation across all targeted centers. Improving our telephonic response times and strengthening our home care network and reliability.

It's taking us longer to achieve our targeted results for these two initiatives due to the reliance on technology enhancements and the inherent challenges of the homecare workforce shortage. In the near-term, we've made solid progress through improved processes resulting in increased productivity.

Within homecare, these open positions are included in our critical hiring initiative discussed earlier. We're pleased with our progress and in the coming months we'll be focused on ensuring we have the structure in place to sustain and continuously improve in all of these areas.

Now turning to the quarter, we reported revenue of $172.9 million, which represents a sequential decline of 2.5% compared to last quarter. We ended the quarter serving approximately 6,650 participants.

For the fourth quarter we reported center level contribution margin of $23.6 million and a corresponding center level contribution margin ratio of 13.6% which represents a decrease of 2.2% sequentially when compared to the third quarter fiscal year 2022 center level contribution margin of $28 million.

To be clear, we're working through a unique transitional period as we return to a sense of normalcy, in the heights of COVID, while also navigating the odds. We're focused on getting participants back into the centers consistent with pre-COVID levels. And we're making long-term investments to fundamentally transform our ability to execute at scale.

Starting with revenue, net census overall is down approximately 2% sequentially, driven by a decline of approximately 6% in sanctioned markets. The sanctions in Colorado have heavily impacted the overall picture, as it represents approximately 47% of our total census.

We have invested resources to improve our overall enrollment in non-sanctioned markets to help offset these dynamics. These investments are bearing fruit, as we have seen gross enrollment increases of 34% in non-sanctioned markets, resulting in net census growth of approximately 3% in these markets over the same period.

As you know, most of our rates are contractually determined in factory and healthcare inflation. Our Medicare rates in fiscal year 2022 were approximately $3,900 PMPM, which represents an increase of 4.5% versus fiscal year 2021. Regarding Medicaid rates, we recently received updated rates for Colorado, Virginia, and Pennsylvania.

Barb will provide more detail in a few minutes. We appreciate that our Medicaid rates are set with some discretion by state agencies and believe the process is intended to address the cost pressures we’ve experienced, caring for our frail participants.

Center level costs were up sequentially impacted center level contribution margin, due to increasing headcount and higher wages for some roles.

We also made staffing investments to address a unique period where participants are returning to our centers, causing stress on our organization to provide care and fully reopen centers, while also covering the needs of many participants who are uncomfortable returning in person.

We have invested meaningfully in our centers as noted earlier, the belief strongly and the ROI of this approach. Both in terms of long-term compliance and reduced provider costs, including inpatient, post-acute stays, and long-term care borne from optimal center staffing. Separately, we also continue to observe elevated external provider cost.

On a sequential basis, overall, external provider costs were lower by approximately $4.5 million due to lower census and a decrease of $90 PMPM, but remain above historical levels. As we dug further into the data, we've learned a lot more about our cost that we knew quarter ago.

As with most healthcare cost trends, the drivers are multifaceted and include lower average daily attendance in our centers due to COVID, prolonged staff vacancies, turnover and productivity loss during audit periods, and fewer new participants entering the risk pool and the deconditioning of participants post-COVID.

Let me spend a couple of minutes on each. Average daily attendance. PACE is a center based model for good reason. Our ability to engage daily with our participants in proactively managed early warning signals is impaired with participants do not come into the center.

While COVID subsided in the fourth fiscal quarter, participant fear and concerns on returning to the center did not. This had a negative impact on our external provider costs. We can't quantify the precision, but believe it was a factor.

To address this we quickly actually dedicated initiative focused on increasing daily attendance, which in the last three months is improved by approximately 50% from when we began a focused effort in May. We believe getting participants back in the centers will improve our ability to manage these cost. Staffing turnover and loss productivity.

A critical factor in optimizing care efficiency, including the total cost of care is the focused attention of our frontline caregivers. Two continuing factors have created challenges. The first involves caregiver staffing turnover and vacancies. This is a challenge all provider organizations are facing.

The second involves the significant time and energy devoted to audit remediation, which we estimate is occupying approximately 15% of our caregivers' time, and approximately 30% of center focused leadership time, thus requiring incremental temporary staffing to compensate.

As we stabilize our staffing in emerge from the audits, we expect these temporary costs to gradually reduce. Risk pool and deconditioning. Enrolling new participants is critical to maintain a balanced risk pool.

Because we have been unable to enroll younger, healthier community based participants, we have not been able to offset the cost of longer tenure participants. To better understand these dynamics, we engaged a third-party to review the specific impact of COVID on our business.

Among their findings, the percentage of our participants in the first two years of their InnovAge tenure decreased from 46% pre-COVID to 41%, when comparing participants from first quarter 2022 with fourth quarter 2019, which skewed our risk pool toward longer tenure frailer participants.

Further, we have also confirmed after a COVID diagnosis, our participants often experienced higher cost over pre-COVID levels. The analysis referenced earlier indicated that participant expense was approximately 88% higher on average in the calendar year post COVID diagnosis.

This is consistent with emerging medical literature that people are more susceptible to a range of other conditions post COVID. In many cases, this deconditioning of our participants has led to higher rates of long-term care placement.

Like other risk bearing government program payers, the capabilities to improve quality and lower medical costs trends are a core part of the operating model, and a key reason why government payers are increasingly working with private companies.

As I referenced in the last call, these capabilities exist within the InnovAge today, but their effectiveness is mixed. We weren't prepared to handle such a multifaceted set of trend drivers at once.

Since we've gotten our arms around the drivers, we've developed a set of initiatives that we call Clinical Value Initiatives, or CVIs to mitigate the cost trends in key service categories like inpatient, assisted living and SNF.

For example, we've begun to action initiatives to reduce unnecessary readmissions within 30 days, ensure care is delivered in the most appropriate side of care, and that our risk scores reflect the acuity of the populations we serve.

Additionally, the largely untapped advantage that PACE organizations have over traditional managed care organizations is that we're also delivering the care and approximately 1/3 of the total cost of care occurs within our four walls.

While we admittedly need to start with the basics, we believe at maturity, we can generate a meaningful reduction in annual medical cost. Taken together, the results of the fourth quarter reflect continuous investment in the business.

Remember, we're making material investments in the centers because we firmly believe in the power of the center based PACE model to keep participants out of higher cost settings. It may cost more to operate our PACE centers going forward than it has in the past.

But we're building capabilities that will enable us to better manage external provider costs, which we believe will allow us to maintain an attractive long term margin profile. And with that, I'll turn it over to Barb to review the quarter in detail. .

A low single digit Medicare Part C increase partially as a result of sequestration fully resuming in July; a mid-single digit Medicare Part D increase; and for Medicaid, a mid-single digit rate increase inclusive of 10% in Colorado, which includes go-forward funding effective July 1 that offsets the increase in assisted living facility rates that went into effect in January; 5% in Virginia; 3% in Pennsylvania, effective January; no rate increase in fiscal year 2023 in New Mexico; and as previously disclosed, a mid-single digit rate decrease in California effective January 1, 2022.

Next, and external provider cost perspective. We expect external provider costs to remain elevated compared to historical levels, in part due to the post COVID acuity effect on our participants, although tapering in the near-term relative to the second half of fiscal year 2022.

For our cost of care, we expect cost pressures to also remain elevated as we continue to work through audit remediation and add to our workforce. However, we do anticipate that these costs will begin to moderate as our New Mexico and San Bernardino centers receive corrective action plans from their respective audits without enrollment sanction.

Regarding corporate G&A, we are continuing to evaluate the organization to optimize the business and refine our payer capability roadmap. As Patrick indicated earlier, we are focused on eight key provider operational excellence initiatives and building up our payer capabilities.

Going forward, we want to ensure that we have the structure in place to sustain and continuously improve the ongoing effectiveness of these initiatives. Regarding sales and marketing, we continue to make prudent decisions as we balance staff retention with our need and desire to grow, only after our remediation efforts are complete.

With new leadership in place, we are making investments in our sales and marketing capabilities, while closely managing our cost structure and will utilize our sales teams in non-sanctioned markets for participant outreach, and voluntary disenrollment mitigation in the near-term.

We believe the recent financial results reflect a transitory period for the business, influenced by several factors, including our participant profile, audit remediation efforts, and labor market dynamics. As Patrick stated, some of the costs reflected in our quarterly results will be temporary, while some will be permanent.

We believe that all the investments we are making into the core of our business, coupled with the development of our payer capabilities, will help us to effectively manage total cost of care while simultaneously working to ensure we have a highly compliant and effective care delivery model for the future.

I will now turn the call back to Patrick for his concluding thoughts.

Patrick?.

Thank you, Barb.

My ongoing commitment to all stakeholders continues to be doing everything in our power to proactively strengthen our operations organization wide, in order to earn the right to be released from sanctions, to avoid future issues, and to be a sustainably high performing PACE provider, able to serve participants for years to come even in more locations across the country.

While I'm pleased with our strategic and operational progress over the last three months, I'm correspondingly disappointed with the quarter financially, but remain resolute. I'm confident that we're on the right path, are working hard on it across the organization, and are making bona fide progress on all the important fronts.

I'm particularly pleased with our great team, including our new center based and enterprise leaders. As with all significant transformations, solid outcomes are always preceded by a compelling strategy, laser focus, effective execution, and a team with the right attitude and perseverance. It may take time.

But thanks to the efforts and support of our internal team and partners, my conviction that we will succeed grows every day. Operator, with that, we can now open the line for Q&A..

Thank you. [Operator Instructions] And our first question comes from the line of Jason Cassorla from Citi..

Just on the census front, I mean the breakdown of the -- excuse me 6% decline in sanctioned markets versus the 3% call it net growth in non-sanctioned markets if I heard that right, was definitely helpful. And you highlighted investing in resources in those non-sanctioned markets to grow census.

So maybe in that context, can you just delve a little bit deeper into the investments in those non-sanctioned markets? And if those investments can be made in sanctioned markets, once those are lifted? As well as what kind of capacity you have in those non-sanctioned centers that to continue to grow at that level? And then if we should think about that 2% level of sequential decline in a steady state environment until the audits are remedied, or any color around forward census trends that we should consider will be helpful?.

Thank you, Jason. Great question to get us started. I'll start with some of the investments we've made in our non-sanctioned markets to help drive growth, while we're under sanctions in a couple of our key buckets. The first I'd point to is we've been very selective in adding a few sales leaders to the organization.

We added a new Chief Sales and Marketing Officer that comes with a long track record of driving growth in senior programs.

And he's done a great job of really sizing up the sales organization, and making changes where appropriate, as well as building a much stronger accountability model as it relates to making sure we're out in the market, and we're doing everything we can to make seniors in the community aware of PACE.

We've also made a number of investments in our CRM system, which just again, helps with accountability helps with throughput and the acceleration of sales activity from building awareness all the way through to enrollment.

And I'm also really excited about the work that our sales team is doing now with our clinical leaders to make sure that we are very focused on making sure that every individual that joins InnovAge is a good fit for the program. So a lot of great work and a lot of great investment in that area.

I think these are investments that we've also started to make and apply to other markets. So while we're still under sanctioned in Colorado and Sacramento, we still begin to roll out these changes.

And ensure that once the sanctions are lifted, we're really committed to us faster ramp up back to historical levels of productivity than we've seen in the past. So there's a very focused effort to get to ramming speed, so to speak, for our sanctioned markets once they're released from concession. So let me ask Barb to comment as well..

Yes. Hi, Jason, it's Barb. So a couple of things, if I make sure I caught all your questions. But if I didn't, please let me know. So I think one of your questions was around the disenrollment rate. And maybe just reading between the lines does that that differ between the sanctioned and non-sanctioned locations? And it doesn't.

So that 2% on average -- 2% per month on average, is just pretty typical across all of our all of our centers, regardless if they're on sanction or not. And then I think your second part of your question was a little bit about capacity in our centers.

And so, generally speaking, we have said for -- since we went public that we do have capacity in our existing centers. So part of our growth strategy is around that organic growth. And we do have capacity in our existing centers.

It kind of ranges depending on the center and the size, but generally, we've got about 50% capacity across the enterprise in order to grow. So we do have a lot of organic growth capacity,.

And then just really quickly, on a follow-up there, just the 2% level of sequential decline in aggregate, is that a fair way to think about the steady state kind of declines as until we kind of get on the other side of these sanctions at this point? Or are there other nuances that we should be thinking about, just as we think about the go forward?.

Yes, I think it’s in that range, it's in that range to a little bit more neutral. So I think to really bifurcate what's going on, right, is that we have natural disenrollment in every center, and in about half of our business, we're not enrolling new participants, but we are growing in the other half of our business.

So, I think, Patrick, referred to those low single digit kind of increases net-net. So it's kind of in that range going forward..

And then just as my follow-up here, just on your balance sheet, and cash position. Maybe just a star, it looks like CapEx spending in the fourth quarter almost doubled compared to what you've done in the previous nine months leading up to the fourth quarter.

So maybe just to start, where was that CapEx allocated? It was generally just related to the audit remediation activities, or was it for other areas? And then, just as a follow up, obviously, your remediation is a top of mind, but you're hanging out right now with over $180 million in cash, only about $86 million of debt on the balance sheet.

Are there ways you can leverage that cash position for investments or otherwise? Or will you kind of be taking more of a wait and see approach perhaps until the audits are completely remedied at this point? Just any color on spending priorities just given your pretty hefty cash position and the audit remediation considerations? Anything there would be helpful.

Thanks..

Yes, sure. So one thing on the de novo is, just to clarify, I use the wrong preposition. So the 2.7 should have been through the fourth quarter, not in the fourth quarter. So that 2.7 million related to de novo, the senior related to most primarily in Tampa and Orlando. So that's where the investments are being made.

In terms of the cash position, yes, you're right. We're fortunate we have a fair bit of cash on the balance sheet. We are always looking to optimize how we invest that. And we definitely are looking at ways how to optimize that investment. But I think in terms of what we do long-term, it is a little bit more of that wait and see.

We're really, really trying to be focused on investing in the business and stabilizing the business so we can turn around and grow. And so it is a little bit more of that wait and see in terms of the cash approach..

Our next question comes from Sarah James from Barclays..

So it sounds like you guys are having a lot of productive conversations with regulators at the state and federal level.

And I'm wondering if they're giving you have a sense of what went on? How much of it was really across the industry in COVID versus what was company specific?.

Thank you, Sarah. This is Patrick. Our conversations with our regulators, most CMS in the states are very focused on InnovAge, and very focused on the work we're doing and the work we're collaborating on to address the deficiencies identified in the audit.

The notion of what's happening in the broader industry related PACE and impact of COVID or anything related to similar deficiencies is just not a conversation that we're focused on.

We've really stayed focused on our own work with regulators, and are really pleased -- as you said, really pleased with the progress that our teams are making, and can't say enough about the collaboration that we're getting from our regulators..

And then it sounds like you guys are making a number of changes that are going to have a long-term impact. There's some on the staffing and wage side. That could be a longer term headwind, but then it sounds like there's a lot of efficiency and cost of care initiatives that can be a tailwind.

How do you think about your long-term margin evolving?.

Maybe I'll start, and hand over to Barb. Well, I think we still hold a lot of confidence that we can achieve a very attractive margin profile for the company going forward. As we discussed before, our center level costs are a smaller percentage of our total cost than our external provider cost.

And so the notion is, yes, it may require more investment in our centers than we've made in the past. But we feel very confident that there's a significant opportunity for us to get an ROI from those investments by doing a much better job on managing our external provider costs.

And so we feel very confident that that's a formula that we can execute on. And we're already starting to see some wonderful progress on the part of our teams.

Barb, anything you'd like to add?.

No, I think just to sum up, Patrick. I think Sarah that we did have some -- we've had some headwinds in FY '22 really related to some COVID expense, expense related to labor market challenges, no different than the broader industry.

And so we're really focused on these other initiatives, the payer initiatives and the operational initiatives to turn the tide here and to be accretive to our overall margin profile going forward. So a little early to tell. We've really been in the assessment phase and the planning phase, if you will, and we're moving into the execution phase.

So little early to tell about will quantify how much of that, will have an impact on our margin, but we're [indiscernible] margin..

Great. And last question is just on the contract labor you guys talked about.

Could you give us an idea of what percent of your clinical staff is contract labor now versus pre-COVID? And is there any way to size the dollar impact from that?.

I'll make some just real high level estimation. So I think that we don't think that it's any higher now than I think it was previously. I mean, I think it's just proportional to the overall labor market. I think as a percent, it's probably about under 10% of our overall force.

So I think it's just one -- it's one component, obviously, it's a more expensive component. And we've obviously used that to backfill in places for critical roles..

Our next question of line of Jamie Perse from Goldman Sachs..

I was hoping we could start with Sacramento and some of your comments there. First, the five months of being on target with performance.

What specifically are you tracking there and maybe incremental color you can give on what the metrics you're tracking and how the key ones are faring versus your targets?.

Sure. Thank you, Jamie. I would start with my opening remarks that we are using a set of measures that we jointly developed with CMS and our state partners.

The sorts of things that you would see in those measures are things related to ensuring service orders are scheduled and provided timely, that participant or caregiver requests are identified and appropriately documented. There's measures related to care plan timeliness, and completion.

There's measures related to the frequency of our assessments, consistent with our care plan development with our members. And then things related to just the responsiveness of our interdisciplinary team overall.

So it's a variety of measures that we jointly developed with our regulatory partners that really have formed the foundation for understanding our progress in a common language between InnovAge and our partners.

And as you mentioned, in Sacramento in particular, we've had some very strong and consistent performance over the last several months, and that progress has been acknowledged by our regulatory partners.

And we're in close conversations to determine what are the next steps necessary to enter the validation phase, which is the final phase before sanctions can be released. But the timing of that, as we've said many times, still resides with the regulators..

One other quick one, just on the comments related to higher costs associated with longer tenured patients on the platform. My sense is that the revenue associated with those patients is also higher.

So can you talk to what the margin profile or patient contribution profiles of patient looks the first couple years on the platform versus as they are more tenured on the platform? Any color on that would be great..

Yes. Hey, Jamie. It’s Barb. So just to jump on it. So, really, this is really nothing different than analyze over time. And that is as the participants age in the program, they become more frail for services and often are in a different higher cost setting. So, that's really what we're referring to.

I think without putting any numbers to it, I think you get the concept that those higher cost settings, obviously, are -- erode our margin on those because of that. Now, to your point about, do we get more revenue related to that? To some degree. On the Medicare aspect, their risk scores are increasing.

So to some degree, we get more revenue, but on the Medicaid aspect, which really pays for those alpha SNF costs, that's not necessarily risk adjusted. And in fact, it's not risk adjusted. So we get some revenue to some degree, but not commensurate with necessarily the needs of that population..

Our last question comes from the line of Madeline Mollman from William Blair. .

I just have two things. One is, we're curious about the impact of inflation on your costs, particularly related to fuel and transportation. And I know that you said the 2023 rate is pretty much set.

But going forward with inflation remains elevated, is there any room for you to negotiate rates or to work with CMS to take inflation into account?.

Yes, this is an important part of our discussions with our state partners, actually throughout the year. And certainly as we're in the midst of a rate setting cycle is to ensure that the discretion that states have to address the cost that we're experiencing, inflationary costs as you refer to, is a critical part of all those conversation.

It's something we pushed very hard for. I think, Colorado was probably a good example of very successful discussions with our partners on what's driving our cost. But with that, let me ask Barb to punctuate. .

Yes. And I think in addition to what Patrick just said, some of the things that the states have actually done, certain states, we've received those ARPA funds. And in fact, that is meant to help us cover those inflationary costs, whether it's wage rates, or whatever it might be, the states have some discretion on how they allocate those funds.

But we have received ARPA funds from both -- from a number of states, Colorado in particular that Patrick was just referring to really folded that into our rates effective July. So I think that's one of the ways we cover it..

I might just add one closing thought on that is that it's important to recognize there can be some lag between when we're experiencing those costs and reporting those costs and when they're actually recognized in our rates. So sometimes we will have a tight matching between our inflation and the state's rates. So just wanted to add that as well..

One other quick question.

I know you said that you voluntarily sort of paused progress on your centers in Florida, but I was curious if you are -- when you decide to continue pursuing de novos, will you try to regain approval in states such as Indiana, California and Kentucky that you previously had planned to? Or are you going to pursue new states?.

Well, I’d like to separate those into different buckets. California being an existing state, I would just reinforce, there are several markets in California that are very attractive to us. And we've made inroads and progress in a handful of markets.

And when we're in a position to be released from sanctions, we'll certainly be pushing to move quickly on opportunities that may exist. Still work to do, but we'll certainly -- California is a priority that they're looking to accomplish with long term care type services, and we're going to be a great partner to them.

Kentucky and Indiana are also a bit different, though Kentucky is a market where we've actually already invested in the center there. And we're beginning to see, think through what are our options, and what is the timing in Kentucky but still a very attractive center for us.

And then Indiana is another market that’s certainly attractive, but we've not made final decisions about how to proceed in Indiana. And we're working through that as we speak now. But very much interested in de novo expansion when the time is right, and when we feel confident we have the support of our regulatory partners..

Now I'd like to turn the call back over to Patrick Blair for any closing remarks..

Well, thank you very much, operator. And before we close, I just wanted to take a minute to just reinforce how much we've accomplished as an organization over the last seven to nine months. I'm just extraordinarily proud of our team and their unwavering commitment to the company that continues today.

I believe our future is very bright and the path forward is clear. It's our commitment to continue to bring clarity during this transitional period to all of our stakeholders as we have relevant updates to share. And with that I'll close and thank everyone for their continued interest in InnovAge. Have a good evening..

And this concludes today's conference call. Thank you for participating. You may now disconnect. Everyone, have a great day..