Evolent Health, Inc. (NYSE:EVH) Q3 2023 Earnings Call Transcript
Evolent Health, Inc. (NYSE:EVH) Q3 2023 Earnings Call Transcript November 4, 2023
Operator: Welcome to the Evolent Earnings Conference Call for the quarter ended September 30th, 2023. As a reminder, this conference call is being recorded. Your hosts for the call today from Evolent are Seth Blackley, chief executive officer; and John Johnson, chief financial officer. This call will be archived and available later this evening and for the next week via the webcast on the company's website, in the section entitled Investor Relations. I will now hand the call to Seth Frank, Evolent's vice president of investor relations. Please go ahead.
Seth Frank: Thank you, and good evening. This conference call will contain forward-looking statements under the U.S. federal laws. These statements are subject to risks and uncertainties that could cause actual results to differ materially from historical experience or present expectations. A description of some of the risks and uncertainties can be found in the company's reports that are filed with the Securities and Exchange Commission, including cautionary statements included in our current and periodic filings. For additional information on the company's results and outlook, please refer to our third-quarter press release issued earlier today. Finally, as a reminder, reconciliations of non-GAAP measures discussed during today's call to the most direct comparable GAAP measures are available in the summary presentation available in the Investor Relations section of our website or in the company's press release issued today and posted on the IR section of the company's website, ir.evolenthealth.com, and Form 8-K filed by the company with the SEC earlier today.
And with that, I'll turn the call over to Evolent's CEO, Seth Blackley.
Seth Blackley: Good evening, and thanks for joining us. Tonight, we're announcing another strong quarter of execution against our plan. We exceeded our guidance for profitability, continue to see strong business development and cash flow in the quarter, and are tracking toward our short- and medium-term targets. We believe we have the leading value-based specialty care platform in the market and continue to believe we are set up for continued success. Third-quarter revenue of $511 million represents 44.9% reported growth in the quarter compared to Q3 2022. Our specialty offerings, representing 87% of our total revenue, grew 80% versus the same quarter last year, with the NIA acquisition contributing approximately 24% of that 80% growth.
Adjusted EBITDA of $48.7 million exceeded our guidance, driven principally by strength in our maturing performance-based arrangements. Our profitability is also translating to cash flow with cash from operations in the quarter of $60.3 million. We averaged over $78 million product lives during Q3, and we believe that we're still in the early days of capturing the market opportunity ahead of us. This product life count is roughly flat with the second quarter of 2023 as we anticipated due to the offset of new lives added and impact of Medicaid redeterminations. Our shareholder value-creation plan remains the same of, one, strong organic growth; two, expanding profitability; and three, disciplined capital allocation. Let's review progress on each element of the plan before discussing the macro environment.
First, our growth algorithm is simple and powerful: find new customers, expand the number of products those customers use, and convert customers from our technology and services product to our performance suite. Today, we announced three new operating partnerships, bringing our total for the year to nine, ahead of our annual target of six to eight. First, we are announcing today that we plan to launch our cardiology performance suite with Florida Blue for their Medicare Advantage population in the first quarter of 2024, expanding on a successful partnership in oncology. We expect the cardiology expansion to contribute over $75 million of revenue on an annual basis. This type of expansion, which is a core part of our growth algorithm, is made possible by strong performance in our existing partnership, and we're excited to more comprehensively serve Florida Blue's Medicare members.
Within the performance suite, we also have opportunities to manage patients under our complex care area, formally known as Evolent Care Partners. When supporting patients under complex care, we take a similar approach to cardiology, oncology, or musculoskeletal care but deliver it through primary care physicians for the benefit of patients who are impacted by complex health conditions. Within complex care, we added two new operating partners for 2024. The first is a multi-specialty risk-bearing group in Texas, and the second is a medical group in the southeast. Finally, on the heels of our successful rollout of our technology and services for oncology specialty care solutions across Centene and WellCare's Medicare Advantage members nationally, we're happy to announce that Centene has added our cardiology technology and services solution to these Medicare members across the country, demonstrating the value of Evolent's solutions across multiple specialties.
Turning to our sales pipeline, we believe we are well set up heading into Q4 and 2024 across each element of the growth plan. We have large and interesting opportunities to expand the performance suite in the cardiology, oncology, and complex care. Performance suite growth opportunities are usually within existing accounts. Our technology and services suite opportunities are available for existing accounts as well as for new customers through RFPs. More importantly, some of these new customer opportunities are ones that we were not able to respond to prior to the NIA and IPG acquisitions. Today, we already serve many of the top health plans in the country, including 13 of the top 20 health plans in the country. Given the size of our installed base and that over one-third of our total addressable market is addressable from cross-selling opportunities, we continue to expect that the majority of new business going into 2024 will come from existing clients, and we continue to feel confident about exceeding our growth targets in the time ahead.
Turning to our second theme of expanding profitability, our diversified approach continues to expand our earnings growth. You'll recall that we typically generate about 75% of our earnings from our technology and services suite or our non-risk business at about 25% from our performance suite or our risk business. Our large technology and service suite business gives us a firm foundation of earnings to drive quarter-to-quarter profitability, with upside opportunities available from our performance suite. We believe our results this quarter continue to validate our margin expansion model where we continue to see strong results from the technology and services suite. In addition, our total adjusted EBITDA came in ahead of expectations because of our 2022 performance suite launches maturing slightly ahead of plan.
Our third investment theme is disciplined capital allocation, where our priority this year has been to generate cash and delever the business. John will go through more details here, but I'm pleased that since closing the NIA transaction in January, we have lowered our gross debt by $71.5 million, made up of a $37.5 million reduction to our revolver, a $23 million reduction from the 2024 note conversion, and another $10 million reduction in principal on our senior term loan. In addition, after September 30th, we repaid the remaining million dollars of our 2024 notes in cash. Finally, relative to the leverage targets we laid out earlier this year, we are on track for our annual cash generation objectives and are ahead of our targets for net leverage ratio.
Let's close with a macro view on our competitive position and focus on innovation where we believe Evolent is uniquely set up. As the U.S. continues to manage through challenges of higher interest rates and continued economic uncertainty, we believe the healthcare ecosystem, particularly the U.S. government as the largest single payer for care as well as state Medicaid programs, will be under even more pressure to identify opportunities for cost savings and look to slow the current course of medical inflation. Similarly, employers and, in turn, insurance companies are under increasing pressure to manage healthcare costs. As pressure mounts, levers like risk adjustment become less impactful, and the cost of devices and drugs accelerate. We believe that the industry is focusing more on managing specialty utilization.
Obviously, this is what Evolent does. We believe we are the market leader in reducing healthcare specialty costs while improving patient quality and reducing physician friction. We can do this work with a guaranteed savings approach to the performance suite or on a fee basis through our technology and services suite. Investors sometimes ask me what's the difference about Evolent versus its competitors. The legacy approach to managing specialty care through so-called utilization management is generally disliked, burdensome, and often adversarial and not clinically oriented. We've all experienced this in our personal lives as well. It's frustrating and only marginally effective. Given our provider-led heritage, even though we work for health plan customers, we have a deep understanding of physician needs and challenges when it comes to managing utilization.
Evolent's model is clinically driven, lower friction, and evidence-based. Evolent's genesis and historical provider heritage uniquely positions us to engineer solutions that engage physicians and patients in a better way, which I would describe as a clinical pathways model. Under a pathways model, we provide choices to providers, transparency, and clinical evidence in real time. This approach lowers friction with providers, and it allows for more holistic patient-centered thinking across the continuum of care. Let me give you a few examples of what I mean by this. First, as we integrate NIA into Evolent, we are using expertise in areas like imaging and genetics to support holistic cancer, orthopedic, and cardiology care in ways that the market has not historically seen.
We don't think about our quest for imaging or genetic tests in a silo. We think about it in the context of providing the best cancer, cardiac, or orthopedic care possible. Another example is Evolent's design of alternative payment models for specialists, which provide doctors with financial incentives to follow our pathways. And a third example is in the area of artificial intelligence, where we are investing heavily in technology to reduce administrative burdens on providers while also improving adherence to our pathways. Just last month, Evolent hosted an artificial intelligence summit with a broad array of senior health plan executives. During the summit, we provided a deep dive to both clients and prospects of our current AI enablement and the new capabilities we are bringing to the market in the time ahead.
There was strong consensus that increasing AI-based automation should help us with an even - create an even better lower-friction model of care. These improved services to clients are not just ideas on paper. They include functionality that is already live. As we have in other areas, we expect to aggressively innovate in AI and hope to take a leadership position in the value-based specialty care market. Now, John will provide a more detailed commentary on the financial results for the quarter and an updated guidance.
John Johnson: Thanks, Seth. Since our last call in August, we've had a calendar full of investor outreach, and it's been great to see many of you on the road and virtually. Before going through the numbers and our outlook, I'll hit on a couple of key themes from those conversations with the benefit of an additional quarter's worth of data. First, the impact of Medicaid redeterminations on our top and bottom lines has been a frequent question from investors. I'll start by reiterating that our exposure here is limited by the fact that 62% of our revenue comes from Medicare and commercial lines of business and only 38% from Medicaid. Our forecasts have called for a decline in our Medicaid membership of between 8% to 10% by the end of this year with an expected mid-teens gross decline when the process is complete sometime next year.
So, if our redetermination forecasts were to be for 20% instead of the mid-teens, that would represent a variance of only 2% in our year-over-year growth rate. Second, remember that we have regular dialog with our partners regarding the soundness of our capitation rates and have specific contractual provisions that enable us to update our rates as disease prevalence changes. As of September 30th, we estimate that our Medicaid states were approximately 25% of the way through the redetermination process. Recall that most of our Medicaid revenue comes from states pursuing a linear rather than frontloaded process and are generally deploying resources to assist members in retaining coverage. As an example, according to the latest data from the Kaiser Family Foundation, our states reported an average of 7% disenrollment rate versus a 10% rate nationally.
Looking at our own numbers, which, recall, typically exclude the pediatric population, our Medicaid membership declined approximately 4% on a gross basis, which was in line with our forecasts. If the linear trend continues, this would put us at the favorable end of our 8% to 10% expectation for this year and in line with our total forecast for the end of the process next summer. We estimate redeterminations represented a revenue headwind of about $7 million in the quarter, again, consistent with our forecasts. This consistency is one contributor to our upward revised revenue guide for the year, which is in the top half of the original range we gave in February. The incremental data also gives us additional confidence in our $300 million run rate target for adjusted EBITDA exiting 2024.
We also closely watched the impact of Medicaid redeterminations on our bottom line since members who are leaving the Medicaid program are thought to be lower cost than those who stay. Recall that when we set our guidance for this year, we incorporated an estimate for this shift based on the underlying medical expense trends that we saw in the population. This is also playing out as expected with modest increases in authorization rates at our Medicaid partners during Q3 that are in line with our overall forecasts. In total, we expect this to be a headwind to EBITDA of less than $5 million for the back half of this year, unchanged from our initial forecast. Second, we continue to hear investor interest in the underlying progression of profit maturation in our specialty performance suite contracts.
In the first three years after the acquisition of New Century Health, we launched over $400 million in annual performance suite revenue across multiple partners that we're managing today. This cohort has been live for more than 24 months and year to date is performing in our target mature margin range of 12% to 18%. This is a function of execution on our clinical model, skilled underwriting, and an overall utilization and acuity environment that is tracking with our expectations, as Seth addressed. As a reminder, our approach for new performance suite launches is to remain actuarially conservative until we have enough data to make a change to our assumptions. So, three to five quarters after we go live with a client for performance suite, we typically have enough actual performance data to shift from estimated medical expenses to actual claims expense.
And our financials will typically show a proportional increase in profitability as initial reserves are released to bring the cumulative contract period in line with actual experience. As an example, our year-to-date adjusted EBITDA includes about $25 million from prior-year claims development, net of refunds to customers for outperformance, which is principally driven by this dynamic as it applied to the launch of several hundred million dollars' worth of performance suite contracts in 2022. It is important to understand that this is not an unexpected or excess benefit but is a natural part of our business as we grow and is incorporated into our annual and multiyear outlooks. So far, in 2023, we launched another several hundred million dollars' worth of new contracts with this traditional conservatism.
All else equal, we would naturally anticipate a similar release of initial actuarial conservatism for these contracts during 2024. The third area of inquiry focuses on potential increases in medical expenses due to increased medical utilization. Our largest category, oncology, represents about 65% of our specialty performance suite revenue. At this stage, the prevalence and disease acuity of that population has tracked consistently with overall trends in oncology for this year. We have not seen a spike or a decline across the population for this year. The balance of our specialty performance suite or 35% is in cardiology, where we have seen modest increases in outpatient activity, consistent with broader industry trends and all in line with our forecasts.
While we continue to watch this space closely, these trends had minimal impact to our results in Q3. Finally, we get frequent questions regarding our balance sheet, cash flow, and capital allocation priorities. Recall that we set a target for this year of adding $120 million or more in available cash before paying interest, dividends, or prepaying debt, earn-outs, and acquisition costs. Through September 30th, we are 80% of the way to that goal with strong cash performance in the third quarter and consistent with our expectations. We have ample cash flow coverage to pay our interest expense. In terms of ongoing balance sheet management, we look to optimize three items for our business: cash interest, overall leverage ratio, and common equity dilution.
Since the close of the NIA transaction on January 20th of this year, we've lowered our gross debt by approximately $71.5 million by proactively paying down debt and retiring our 2024 convertible notes, which we completed in October. As a result, our net leverage ratio at the end of the quarter was 2.5 times, ahead of our target to be below three times by the end of this year. In addition, after the quarter-end, to prudently manage against dilution, we elected to pay the remainder of our earn-out obligation for the IPG acquisition in cash, avoiding the issuance of equity at current market prices. Now, let's go through the numbers before turning to our outlook. Revenue in the quarter was $511 million, an increase of 44.9% versus the same period in the prior year and $42 million versus Q2.
Sequentially, exceptionally strong growth in our Medicare line of business was partially offset by expected declines in our Medicaid revenue. In Medicaid, the decline included about $7 million related to redeterminations, as I mentioned, and about $7 million in customer refunds from reconciliations. These refunds were associated with some of the prior-year developments we experienced in the quarter for a modest net EBITDA benefit. We had an estimated $41.7 million unique members during the third quarter of 2023 and a total of $78.1 million product members for an average of 1.9 products per unique member. These membership numbers as a whole are approximately flat to Q2, representing new business growth, offset by the impact of Medicaid redeterminations.
At the product level, our performance suite membership stepped up to $3.9 million during the third quarter compared to $2.5 million in the same quarter last year and a little less than 100,000 higher than Q2. As anticipated, we saw an uptick in performance suite and specialty tech and services PMPMs this quarter as a function of new business rolling on. Average PMPM fee for the performance suite was $27.63 versus $27.02 a year ago and up over $3 on average from Q2, as anticipated due to the aforementioned addition of Humana MA lives in the quarter. As a reminder, fluctuations in average PMPM results from sales mix, depending on where growth is coming from along Medicare, commercial, and Medicaid lines of business, with MA typically associated with a larger PMPM due to the prevalence and acuity of illness in that population.
Average product membership in our specialty technology and services suite was $72.4 million members during the third quarter compared to $14.9 million in the same period last year, prior to the acquisition of NIA. Average PMPM fees were $0.37 in the third quarter of '23 versus $0.29 in the third quarter of '22 and $0.35 in the prior quarter. Product members for administrative services were $1.8 million compared to $2.1 million in the same period of the prior year and flat to Q2. Average PMPM fee was $12.50 versus $16.41 in the third quarter of 2022. Total quarterly cases associated with advanced care planning and surgical management totaled 15,000 for the third quarter, and average revenue per case totaled approximately 2,500, both in line with seasonal expectations.
As a reminder, these metrics reflect billed cases only and do not include cases for our performance suite populations. We continue to see some of these services increasingly deployed as part of our performance suite. Our adjusted EBITDA result was $48.7 million versus $28.1 million in the third quarter of '22, reflecting organic growth, maturation of our performance suite contracts, and the addition of NIA. Adjusted EBITDA margin was 9.5%, a year-over-year margin expansion of 150 basis points due to performance suite maturation, a higher mix of tech and services from NIA, as well as organic growth of tech and services solutions year on year. Turning to the balance sheet, we finished the quarter with $184.5 million of cash and cash equivalents, including approximately $12.2 million in cash held in regulated accounts related to the wind-down of Passport.
Excluding the cash held for Passport, we had $172.3 million of available cash, an increase of $41.8 million versus the end of the second quarter, a strong performance. Given the strong cash quarter, we reduced long-term debt by approximately $10 million through a principal payment on our senior secured variable-rate facility. Cash deployed for capitalized software development in the quarter was $4.3 million. Finally, in October, we closed out all remaining obligations under the 2024 notes. Let me close with a quick housekeeping item on filings you'll see today and tomorrow. Shortly after filing our form 10-Q, we will be filing a Form 8-K with NIA's audited 2022 financials and associated pro forma financial statements along with a prospectus supplement to register the shares that were issued as part of the NIA acquisition in January.
For clarity, this process does not pertain to any other shares. Turning to guidance, given our continued strong performance, we are increasing our full-year outlook for revenue and adjusted EBITDA as follows. We expect revenues to be between $1.945 billion and $1.965 billion, and we expect adjusted EBITDA to be between $192 million and $200 million. The associated quarterly guidance for Q4 is for revenues between $537 million and $557 million and adjusted EBITDA between $45 million and $53 million. We now expect capitalized software development to be between $25 million and $30 million as we have allocated certain engineering resources to non-capitalized product development work. And with that, let's go ahead and open it up for Q&A.
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