Q4 2023 CareMax Inc Earnings Call

Participants

Roger Ou; Senior Vice President of Finance and Investor Relations; CareMax Inc

Carlos De Solo; President, Chief Executive Officer, Director; CareMax Inc

Kevin Wirges; Chief Financial Officer, Executive Vice President, Treasurer; CareMax Inc

Presentation

Operator

Good morning, and welcome to CarMax's fourth quarter 2023 earnings call. Please note, this call is being recorded.
I would now like to turn the conference call over to Roger Ou, Senior Vice President of Investor Relations. Please go ahead.

Roger Ou

Good morning, and welcome to Caremark. Because Fourth Quarter 2023 earnings call. I'm Roger Ou, Senior Vice President of Investor Relations and I'm joined today by Carlos De Soto, our Chief Executive Officer; and Kevin Wirges, our Chief Financial Officer.
During the call, we will be discussing certain forward-looking information. These forward-looking statements are based on assumptions and assessments made by care mattress management in light of their experience and assessment of historical trends, current conditions, expected future developments and other factors we believe to be appropriate.
Any forward-looking statements made during this call are made as of today, and Jamba's undertakes no duty to update or revise such statements, whether as a result of new information, future events or otherwise. Important factors that could cause actual results, developments and business decisions to differ materially from the forward-looking statements are described in the company's filings with the SEC, including the section entitled risk factors in today's remarks by management, and we will be discussing certain non-GAAP financial metrics. A reconciliation of these non-GAAP financial metrics to the most comparable GAAP measures can be found in this morning's earnings press release.
Now I'd like to turn the call over to Carlos.

Carlos De Solo

Good morning, everyone, and thank you for joining our call today. I will begin by talking about our near term strategy to preserve our earnings, power and liquidity. Given recent trends in the sector, I will then be discussing the steps we've taken to begin rightsizing our business for the current environment. Afterward, Kevin will discuss our Q4 financials.
Over the course of 2023, we have navigated challenges, including some related to our rapid growth over the past couple of years and others affecting our industry overall. We met our membership targets with 111,500 Medicare Advantage members at the year end and we met our guidance on full year revenue.
However, full year adjusted EBITDA was unfavorably impacted by prior year developments, INCREASED flex card utilization and higher than expected medical utilization. Additionally, as we noted last quarter, some of the unfavorability had to do with claims payment patterns which develop differently from prior years.
In light of these headwinds, we have worked with our lenders to receive and limited waivers on certain financial covenants contained in our credit facility. In the short term, the cumulative effects of our prior year developments and rising medical expense ratios have lengthened the time in which health plans normally pay us. In the fourth quarter, we drew the remaining $60 million of our delayed draw term loans to continue funding our operations, all while implementing cost saving initiatives across the organization. These actions and others that we are undertaking may help bridge us to our expected MSSP payment later this year.
In the interim, we aim to drive more structural changes operationally financially and strategically that are designed to protect and maximize the long-term value of CareMax's. As I'll discuss, these may include strategic options to monetize the value of certain assets and right size the capital structure of the company.
As noted on our third quarter call, we have undergone a comprehensive operational review of the Company. We have begun implementing large-scale changes with three main goals in mind. First, optimizing our cost structure to give our key stakeholders confidence in our near term liquidity. This includes cost reductions. We've already taken that amount to approximately $20 million of annualized cash savings.
Second, emphasizing performance and profitability in our existing book of business over growth. And third, exploring strategic options across our lines of business to maximize the value of certain assets. These actions are designed to help position TMX for long-term success as the US health care system continues its shift towards accountable care.
In the past several months, we have streamlined our workforce, including centralizing functions under key operational leaders. Overall, we estimate our net payroll reductions are contributing $15 million of annual run rate savings.
We have also acted on opportunities to consolidate our center footprint in South Florida by tucking smaller sites into larger ones, allowing us to maintain service levels for patients while lowering operating costs. Since Q3, we have been able to complete six of these consolidations resulting in fewer but more efficiently run centers.
We believe our center rightsizing efforts today currently translate to approximately $5 million in annualized cash savings. Furthermore, we continue to work on optimizations in multiple functional areas, including transportation, shared services, IT and facilities, which may contribute additional savings this year.
From a clinical perspective, I am pleased to report that across all CareMax centers, we achieved an aggregate five star quality rating for the third consecutive year, showcasing our commitment to the highest quality of care for our patients.
In addition, we feel confident in the ability of our care processes to drive year-over-year improvement in our centers at medical expense ratio. While 2023 medical expenses grew at a rapid rate due to increased medical and benefit card utilization, we believe our care management initiatives and changes in payers benefit designs may contribute to a deceleration in medical expense growth in 2024 compared to 2023. As a reminder, our consolidated MER may remain elevated due to new MSO Medicare plans converting to full risk.
As discussed on our prior call, we have taken what we believe to be a prudent approach toward adding new contracts in our MSO. We ended 2023 with over 75,000 MA members and are focused on helping our affiliate providers optimize and value-based care savings in their existing panels.
We plan on taking increased risk in most of our MA contracts in 2024, including certain contracts moving to full risk. Full-risk lives now represent about 35% of our MSO MA population up from 15% in 2023. Based on our current projections, we believe our MSO has the ability to achieve similar or better and a medical margins compared to 2023.
In our government ACOs medical expenditures continued to develop favorably compared to national and regional trends, which we believe reflects our team's success in managing the underlying expense trends for the MSSPACO reach populations. We are optimistic that the investments we've made may lead to a similar or better savings rate in 2024.
Now let me give some highlights on the embedded value we believe we have built in our denovo and M2 assets. Our denovo centers are now serving over 6,000 Medicare patients under capitated at risk and fee for service contracts and are also seeing Medicaid and commercial patients.
We believe we have established a critical mass of operations in dense underserved communities within New York City and Memphis, Tennessee, and we have done so while keeping the Novo losses within our guided budgets in both 2022 and 2023.
We believe our work the past two years has laid the foundation for the denovo centers to achieve attractive margins and maturity. Nonetheless, the reallocation of resources toward clinical performance at our core centers and MSO entails delaying breaking even at the denovos compared to our original plan in recent months, we have had conversations with growth-minded parties that see strategic value in our denovos.
While early, we believe these discussions may potentially enable us to monetize the platform we have built in new markets, mitigate the impact of de novo losses or realize other financial benefits with these centers in RMS.
So we believe we have accomplished our key one year goals, converting traditional fee for service contracts into value-based care agreements with a glide path to full risk, incorporate our tech enabled workflows to manage complex populations at scale and foster physician engagement in a way that maximizes their potential earnings and improves patient outcomes with over 170,000 senior lives across MSSP, ACO reach and Medicare Advantage we estimate our MSO is now accountable for over $2 billion of annual health expenditures.
In 2023, we believe we have approximately doubled shared savings under our government ACOs compared to 2021. And we believe our operating plan can further drive the savings percentage rate to high single digits or better in our MA book care mix has successfully contracted with most of the leading regional health plans in their respective markets, introducing new opportunities for our affiliated providers to participate in savings we continue to deepen these partnerships and explore new ones with payers aligned with our measured approach towards taking risk.
In summary, given the recent industry trends, we expect 2024 and to be a transition year toward more balanced levels of reimbursements and expenditures and continuation of the process begun. Last year, we plan to work toward further optimizing our business for things we can control to help preserve liquidity and position our business to achieve our longer term goals. Kevin will now take you through our financial results.

Kevin Wirges

Thanks, Carlos, and good morning. As discussed on our third quarter call since 2021, we have grown rapidly in membership consolidated helped by contracts from acquisitions and added a significant number of new contracts.
Our fourth quarter results reflect additional prior year development or PYD, primarily related to updated data arising from these integrations. We have established a regular cadence of service fund reporting with most payers and continue to refine our data flows to mitigate these types of impacts in the future.
In the fourth quarter, revenues and adjusted EBITDA were negatively impacted by a combination of prior year developments, increased medical and flex card utilization and a provision for adverse deviation, which we treat as an explicit reserve separate from PYB.
As a reminder, we did not add back prior-year developments or reserves to adjusted EBITDA, but disclosed them to provide color on the in-year performance of our business. Additionally, Q4 GAAP net income was impacted by $369 million of non-cash goodwill impairment.
In the fourth quarter. Adjusted EBITDA was impacted in part by approximately $21 million of net unfavorable PYD over half was related to updated historical data from two MSO Medicare plans. While the remainder was due to final sweep accruals related to our membership in our centers. We also booked $15 million of reserves for adverse deviation that are intended to absorb potential future unexpected changes in revenues for external provider costs.
For the full year 2023 adjusted EBITDA was negative $63 million including unfavorable impacts of $42 million of total PYD and the $15 million of reserves for adverse deviation. This also includes $23 million of de novo losses, which were slightly favorable to our guidance of approximately $25 million in losses.
Reported 2023 revenue was $751 million, including $45 million of headwinds from PYD and $5 million from reserves, putting us toward the lower end of our latest guidance range.
Total medical expense ratio in 2023 was 91.5% and includes approximately 780 basis points from PYD and reserves. And this all members which have higher MBR than our standard members, it 450 basis points of impact. In addition, we estimate year-over-year increases in benefit card expenses drove about 400 basis points of unfavorability in NAR.
Finally, NAR was further impacted by Medicaid redeterminations, which have caused the average Medicaid acuity normalized faster than expected for higher pre-COVID levels. To share some recent trends within our center population, we saw elevated hospitalizations in December continue into January, which is typically the height of the flu season in South Florida.
However, inpatient admissions had shorter average lengths of stay in January in detail, also moderated month-over-month. While early, we are cautiously optimistic. The seasonal peak is behind us and continue to ramp our clinical programs and better manage avoidable admissions.
Looking back, our challenges in 2023 have been more about the things we had less control over, namely the timeliness adequacy and accuracy of data from newer health plan contracts, Medicaid redeterminations and flex card utilization.
In particular, we believe the impact of Flex card exceeded $30 million of medical expenses in 2023, nearly tripling from 2022. While these benefits are likely to stay in some form, would you not expect them to increase at the rate of growth in the past two years. And we have developed plans designed to mitigate duplicative costs at our centers and work closely review our service funds for potentially improper flex card expense.
More generally, these developments have reaffirmed to us. The importance have strong relationships and our business with our legacy health plans. We have a good history of alignment and a common view towards the long-term benefits of our high-touch model with our new payer partners. We couldn't be more excited to embark on that same journey with any partner.
Our efforts are most successful when our payers equip us with the right data tools and access and share in the upfront investments needed to manage it along those lines. We expect some of the structural changes Carlos mentioned may entail refocusing resources on payers, most aligned with our strategy.
We have done a significant amount of analysis to understand the unit economics of each health plan contract. As you might imagine, some are more favorable than others. We plan to thoughtfully consider actions for the cost to manage a plan outweighs the financial benefits for the company.
Because the outcome of these processes is uncertain, we believe it is premature to give precise guidance for 2024. In aggregate, our plan is designed to put CarMax on better footing in 2025, which we think will mark a favorable inflection point in revenue and adjusted EBITDA to believe headwinds in 2024 regional benchmarks for our markets will abate or even flip to tailwinds next year. And we believe 2024 star ratings for our core plans tie net improvement compared to 2023 which should favorably impact revenues in 2025.
Carlos mentioned we drew the remaining $60 million of DDTL in Q4 and ended the year with approximately $66 million of cash. Looking ahead, we are in active strategic discussions to maximize the value of certain assets, which may help generate further liquidity to bridge the company to the MSSD payment later this year and to 2025.
In closing, the management team, Carlos and I are deeply appreciative of our team members for their steadfast support and shared vision toward Accountable Care, we are committed to taking the actions we believe necessary to reposition Fairfax for future success. We look forward to connecting with you and updating you and our future development.

Operator

Thank you. This concludes today's conference call. We thank you for joining, and you may now disconnect.