Alignment Healthcare, Inc. Q4 FY2021 Earnings Call

Good afternoon, and welcome to Alignment Healthcare's Fourth Quarter and Full Year 2021 Earnings Conference Call and Webcast. 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. Although we believe these expectations are reasonable, we undertake no obligation to revise any statements to reflect changes that occur after this call. 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 the prospectus for our initial public offering filed with the SEC on March 29, 2021, and in our Form 10-K for the year ended December 31, 2021. 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-K for the year ended December 31, 2021. Leading today's call are John Kao, Founder and CEO; and Thomas Freeman, Chief Financial Officer.

Hello, and welcome to our fourth quarter and full year 2021 earnings conference call. I appreciate you joining us today. I'm pleased to share that Alignment Healthcare had a successful 2021 financially and operationally, including a strong fourth quarter across our critical KPIs. We continue to distinguish our business by demonstrating the power of our proprietary AVA technology platform and our clinical model to deliver strong medical benefits ratio management while also achieving solid growth. That performance was driven by our team's steadfast commitment to change health care one person at a time and to always put the senior first. I thank our team for their tireless efforts toward making 2021 a success. For the fourth quarter, our health plan membership ended at 86,100, increasing 26% compared to last year. Total revenue of $298 million in the quarter grew 23% from last year, led by our health plan premium revenue growth of 28% year-over-year. Adjusted gross profit came in at $43 million in the quarter with a strong MBR performance of 85.7%, and adjusted EBITDA was a loss of $9 million. Our robust performance rounded out the year translated to total revenue of $1.168 billion in 2021, reflecting 22% total revenue growth and 28% health plan premium growth year-over-year. Our 2021 adjusted gross profit was $144 million, with an MBR of 87.6%. Lastly, our adjusted EBITDA was a loss of $33 million, ahead of expectations. As important as our strong financial performance was in 2021, even more important was our continued progress towards building the foundation to achieve our vision of changing health care for seniors across the country. We believe our data and technology-enabled care model produces the highest value for seniors and is the cornerstone of our ability to manage future growth. With that in mind, we successfully continued to invest in our AVA technology platform that allows us to scale our Care Anywhere clinical model. We launched our patient panel management module, which acts as a workflow enablement tool for our Care Anywhere teams. We improved our risk stratification and inpatient admission prediction module, which is now able to accurately predict the highest 10% of our members who will represent 50% of inpatient admissions over the next 30 days. We implemented our Medicare risk adjustment suite, which improves the timeliness and accuracy of our Medicare risk adjustment activities on revenue per member. And we finalized other AVA applications geared towards scaling our clinical best practices. These investments led to increased member engagement for Care Anywhere from 57% in 2020 to over 64% in 2021. Better medical management outcomes show 156 inpatient admissions per thousand in 2021, which is approximately 38% lower than fee-for-service benchmarks. A 14% readmission rate compared to CMS fee-for-service benchmarks at 19%, improved clinical outcomes as reflected in our 5 Star HEDIS scores and the Net Promoter Score of 64, which is significantly higher than the national Medicare Advantage NPS of 38 and includes an all-time high NPS score of 82 for our Care Anywhere program. All of this work is paying off in our MBR. While our 87.6% consolidated MBR for the year was quite strong, it is important to note that our year 2 and beyond markets are producing MBRs in the 86% range, while our year 1 markets in DCE markets are at 98% and 107%, respectively. We expect these MBRs in our newer markets to come down as we grow market share and deploy our provider engagement and Care Anywhere best practices, consistent with the vintage analysis we have previously shared. The strong 86% MBR of our year 2 and beyond markets is primarily driven by our successful California franchise, representing over 99% of this cohort and excluding our two 2021 California market launches. This performance consists of 16 diverse and unique counties that required us to leverage AVA to ensure a successful outcome. This 86% MBR is led by our at-risk membership performance where our more tenured at-risk members are even lower than our 86% in aggregate. As a reminder, we define our at-risk membership as our seniors where we take financial risk for at least a majority of the members' claims expenses through our aligned provider partnership relationships. Our effective MBR management has led our California business to approach adjusted EBITDA breakeven in 2021. We are also forecasting that we would be slightly adjusted EBITDA positive for 2022, even with the continued growth investments we're making in the state. These proof points are prerequisites to being able to successfully manage our future growth ambitions. We believe this performance validates our clinical operating model that gives us confidence that the model is scalable. We previously shared our AEP concluded with approximately 92,700 members as of January 2022, representing 16% year-over-year growth. We discussed where we thought we performed well and where we thought we could have done better, including being negatively impacted by competitive headwinds in Southern California. Though the level of competitive activity was abnormally aggressive in our four California counties this past AEP, it is part of the normal cadence of our business. With that in mind, our 2022 investments are focused on step 2 of generating replicability, which is continuously improving the reliability of our growth model. We believe that investing in a greater depth of market management infrastructure as well as our member experience will allow us to better leverage our geographic diversification, irrespective of competitive market dynamics. First, we are aggressively resourcing our market management and network development teams. This includes hiring additional community engagement representatives, local provider contracting team members, and dedicated sales resources who will support more consistency in our future market by market growth. Second, we see an opportunity to deliver even better quality by continuously improving our service delivery and focusing on member experience workflows. Based on the latest national CMS data from 2020, our voluntary disenrollment rate was approximately 37.5% better than the national average. Furthermore, our AEP voluntary disenrollment was minimally higher compared to the prior year despite some of the broader churn issues noted across the industry. We're proud of our current results. We're confident we can deliver even better service to our members. In summary, last year, we exceeded our financial goals, all while accelerating the differentiation of our key competitive advantage, our clinical model. I continue to believe the long-term benefits of the work we achieved in 2021 far outweigh the short-term membership headwinds we are now addressing. This year, we are continuing to invest in replicability and portability through market management resources and member experience workflows. When you combine that with our 2021 MBR and clinical outcomes as well as the strength of our balance sheet, it makes me quite optimistic about our commitment to our long-term 20% growth rate and the scalability of the model. Thank you for your continued interest in Alignment's journey. I look forward to updating you throughout the year. Now I'll turn the call over to Thomas to cover our financial results as well as the outlook for 2022.

Thanks, John, and thanks to everyone who has joined us on the call today. I want to reiterate John's sentiment that we are proud of our 2021 results and committed to building upon them in 2022. On the call today, I intend to touch on a few highlights from the year, review the fourth quarter results in more detail, and conclude with a discussion of our first quarter and initial full year 2022 outlook. For the year ending 2021, our health plan membership surpassed our initial expectations and ended at 86,100 members, representing an increase of 26% year-over-year. Over the course of the year, we added approximately 6,000 members from January 2021 to December 2021, which is in line with what we achieved the prior year as well. Our total revenue grew 22% to $1.168 billion, driven by our strong health plan premium revenue growth of 28%. Further, our adjusted gross profit of $144 million reflected in an MBR of 87.6% for the year, demonstrating the power of our clinical model and our AVA platform. As John mentioned, we're particularly proud of the strength of our California franchise where our MBR outcomes continue to showcase the differentiation of our core capabilities relative to the market. Lastly, our full year adjusted EBITDA was minus $33 million, materially exceeding our expectations for the year on the back of strong adjusted gross profit performance as well as continued discipline through the SG&A line. Our consolidated adjusted EBITDA loss for the year reflects our legacy markets continuing to build momentum towards consolidated profitability. Meanwhile, given the strength of our MBR outcomes over the last several years, we continue to believe in the importance of reinvesting this performance towards future growth. Our balanced approach targeting sustainable growth with an eye on long-term profitability is something that we will continue to balance moving forward. Turning to the fourth quarter results. Total revenue of $298 million in the quarter represents a 23% increase compared to a year ago. Our health plan premium revenue accounted for $284 million of total revenue and increased 28% year-over-year. Our adjusted gross profit in the quarter was $43 million, representing an MBR of 85.7%. We approached our fourth quarter guidance with a cautious view towards potential spikes in COVID-related utilization, but we're pleased to see overall fourth quarter inpatient utilization approximately 5% better than contemplated in guidance. This utilization outperformance, along with sustained revenue PMPM outperformance led to our adjusted gross profit outperformance in the quarter. Our MBR was below 86% for the second quarter in a row in the fourth quarter, showcasing the replicability of the foundation we are building. SG&A in the quarter was $78 million. Excluding equity-based compensation expense, our SG&A was $53 million, an increase of 7% year-over-year. This leads to adjusted EBITDA, which was a loss of $9 million in the fourth quarter, ahead of expectations. Our balance sheet remains an area of strength for Alignment where we ended the year with $312 million in net cash. We believe we are well capitalized to support our organic growth ambitions and meanwhile continuing to look for small but accretive opportunities to deploy capital towards M&A. Turning to our guidance. For the first quarter, we expect health plan membership to be between 93,700 and 93,900 members, revenue to be in the range of $330 million to $335 million; adjusted gross profit to be between $32 million and $35 million and adjusted EBITDA to be in the range of a loss of $17 million to a loss of $13 million. For full year 2022, we are forecasting health plan membership to be between 97,300 and 99,000 members, revenue to be in the range of $1.33 and $1.345 billion. Adjusted gross profit to be between $163 million and $173 million and adjusted EBITDA to be in the range of a loss of $47 million to a loss of $39 million. As part of our forecast, we are assuming continued growth of our health plan membership throughout 2022. Our net growth anticipated from January 2022 to December 2022 is comparable to our experience in prior years, and we believe that it is achievable given the continued investments we're making in our local market management and our member experience. Our revenue PMPM forecast is based on our latest internal data regarding our returning members documentation for payment year 2022 as well as our initial payment we received in January for our new members this year. We're pleased with the progress we're seeing on our returning member documentation, however, that is slightly offset by new member risk adjustment factor that is modestly lower than our expectations heading into the calendar year. Our revenue PMPM forecast also reflects the adverse impact of the return of sequestration, which is slated to begin in the second quarter this year. From a utilization perspective, our adjusted gross profit guidance reflects our recent experience in the first part of 2022. Omicron had less of an impact on inpatient utilization through the first half of January. However, it began to more significantly increase in the back half of January and the first part of February. Our COVID inpatient admissions per 1,000 peaked in January at a rate that was close to 2.5x the COVID admissions per 1,000 we experienced during the Delta wave last summer. As we've seen in prior waves, however, we did experience a partial offset from a reduction in noncore utilization. Importantly, the back half of February has stabilized at a more normalized rate of COVID and non-COVID inpatient utilization, and we're optimistic about the fact that another variant has come and passed without causing a significant deviation from our overall expectations. The anticipated seasonality of our adjusted gross profit line and MBR for the first quarter reflects our recent Omicron experience, and we feel we are well positioned to deliver on our overall 2022 adjusted gross profit objectives. Turning to our DCE venture. Our DCE membership stands at approximately 5,200 members to date, and we anticipate that membership to continue to remain roughly flat over the course of the year. As a reminder, our health plan membership of 92,700 as of January 2022 as well as our forward-looking health plan membership guidance excludes our DCE membership. Given the recently announced ACO reach model, we are actively working through our 2023 approach and evaluating some of the underlying model changes. Similar to our prior comments on the global and professional direct contracting or GPDC model, we will evaluate pursuing the ACO reach model as long as we believe it's a financially viable model for us that can lead to better outcomes for seniors in traditional Medicare. While we are seeing progress with respect to better outcomes for seniors in the GPDC model, we have remained cautious with respect to that program's long-term economic potential. We look forward to keeping everyone informed as we work through these new regulatory changes and their potential impact on our go-forward strategy. Lastly, as we said before, it is a strategic imperative of ours to drive growth of the business sustainably and responsibly. We believe our 2022 adjusted EBITDA guidance is reflective of this balanced view of growth versus profitability. As John mentioned, our California franchise is set to potentially break even on an adjusted EBITDA basis in 2022, which is a powerful testament to our gross margin engine. Our consolidated adjusted EBITDA loss, therefore, reflects the continued investments we're making to support our new 2021 and 2022 health plan markets, our 2023 and 2024 growth and market expansion initiatives, and our recent public company expenses that we expect to achieve operating leverage on over time. These underlying trends and components of our consolidated adjusted EBITDA guidance as well as the strength of our balance sheet, which provides us with significant strategic flexibility, give us confidence in our path towards our long-term growth and profitability targets. Wrapping up, our fourth quarter results were a strong end to an exciting and busy year. Looking forward, as John noted, I am confident we are well positioned to further build our foundation towards scalability and long-term profitability, and we look forward to updating you on our progress throughout the year.

John, you discussed this a little bit, but I want to go back to it. In regards to the slower-than-anticipated membership growth, can you again go into how much of that was related to greater churn in existing members versus more difficulty attracting new members given some of the competitive dynamics in the market?

Sure. Ryan, nice talking with you. Yes. Our churn was slightly above the previous year. And so that fundamentally was not our problem. And for AEP churn, I think for 2020, we were at about 5.5%, and we think we went up to something like 6.5%, something in that range. And so I don't think that was the big problem. I think the competitive nature in some of our markets was the main culprit. And specifically, we're talking about what we announced was 92,700 members for 1/1 compared to 96,000. So we're talking about a delta of 3,200 members. And candidly, that's not something that should have prevented us from hitting our numbers. It is just the truth of it. And so we've been very aggressive in looking at all the other markets that we have and being very aggressive about resourcing those markets with what I would call market management resources and specifically community representatives, building relationships with all the different senior centers and churches and whatnot in each local market as well as more provider contracting individuals that are telling the story of why it works to be part of Alignment. So we've just been very aggressive on that. And are we happy about being at 16%? Absolutely not. It’s pretty much driven all the competitive fires and the management team to make up for the shortfall, and we're aggressively attacking it. But we're going to get these kinds of competitive products every year somewhere. We always do. And we've always been able to overcome it in the past. In many respects, it's something that I would have rather happen to us now. We're talking about 3,000 members. And we're making all the changes needed to not let that happen again.

Okay. I appreciate that. That's very insightful. And then maybe a totally different topic, and I can address this to you again, but both of you can probably comment. Just in regards to direct contracting, margin is clearly lower there. Some providers have seen success, but you continue to take what I would characterize as a more conservative stance to your long-term participation and the outlook of the program. Can you talk maybe about what the main concerns are you have about D.C. and the economic impact that might keep you from moving forward more aggressively with that?

Ryan, this is Thomas here. Maybe I will start and then John can chime in. So I think in terms of what we've seen so far, I think we shared back when we first started in the second quarter of 2021, that our MBR in that program was just north of 110%. And so we actually have seen a lot of progress over the course of the year, and we're pleased with some of the not just financial but operational outcomes we're starting to achieve in terms of engaging the care in our population and applying a lot of those lessons learned and best practices from MA towards the seniors in the program. I think having said that, though, we clearly are not where we want to be long term. I think our overall MBR to get to EBITDA breakeven in the program is in the 95% range. I don't think we need to be necessarily at 85% to make it work from an EBITDA or net income perspective. But we recognize that we're not quite there yet just given our starting point in terms of both members and benchmark. And so we're kind of working through what the new program changes and what they might mean for us in the future, both from an economic perspective. And I know folks have asked about from a governance perspective, we might have to consider some changes there going forward as a possible participant in the ACO reach program. But I think we're sort of in the early days of thinking through what that means for us and how that might impact our 2023 strategy.

Yes. Ryan, it's a great question. It's John. I think we're looking at it from a strategic lens also. I mean I really think that the Medicare advantage TAM continues to go up. The market share continues to go up. And so I think our strategy with respect to focusing resources on that in MA is the right one. However, we are looking at, and I would say underpin and underscore early stages looking at really unlocking some of the capabilities that we've developed in AVA and the AVA Health technology platform. And it's been somewhat a result of providers asking us to help them with getting into value-based care, specifically in the context of the ACO reach program. And so we're exploring that from more of a fee-based perspective. And we've touched on it in the past. But if you think about us driving our strategy in MA with our products and our provider engagement and complementing what we're doing on the fee-for-service side with some of the technology. There seems to be some synergy there that we're exploring.

It's Michael Ha on for Ricky. So I just wanted to touch on the competitive M&A environment again. So when thinking about the landscape in 2022, I mean, arguably one of the most competitive benefit offering years in recent history. But as I look at your average benefit richness this year, just per our own analysis, it looks like you guys are still pretty competitive. So heading into next year, as you look to rebuild your membership growth, how do you view the balance of investment into benefit richness versus other contributing factors? And based on your comments, it sounds like you're primarily focusing on bolstering things like customer service, sales, and other member experience factors.

Yes. Michael, it's John. Your comments are correct. It's really both and I would say, and so let me be very specific. Number one is four components the way I look at it is in addition to benefit design. Number one is just the market management. And it's really just focused community representatives, resources that are just in the field, in each market, we are doubling down on that pretty much at every single market as we head into 2022. Historically, we've focused on provider engagement, making sure that we focus on quality, making sure we focus on making sure that the model is working. But I would say that we've under-resourced that part of it. So number one is market management, resourcing, and investment. Number two is what you alluded to, which is just improved service delivery. Our NPS scores are high. We're 5 stars in terms of our members liking our plan. But we've got 22 different supplemental types of benefits. We've got 10 vendors that support that. And there are a couple that we can improve on. So we're really doubling down and focusing on that, making sure that the experience and the service levels that we give to our members is just the best in the business. I just think service delivery is pretty much everything. So we got to get that to the next tier. The third pillar, I would say, is continuing to execute on our operational scalability. We've got a multiyear plan. We're about halfway through it in terms of just making sure that all of the workflows are automated, and we're getting a good PMPM scalability from those initiatives, but we got to continue doing that. That's what's going to fund a lot of the end market resources. And then lastly, is really just to continue making the broker experience more seamless for us and for them. We're making investments in AVA to make sure that there is a faster, more automated direct payments to the broker community. That's something that they've shared with us that they want a faster payment, more transparency. I think if we get those foundational layers in place, I think that, combined with just more specific market tactics, market by market, combined with the benefits and products that we're talking about, I think we're going to get just more consistent growth in terms of both market share increases and new market penetration in some of our newer markets.

You mentioned mergers and acquisitions. With your significant cash reserves, what criteria would you use for M&A? Looking at 2022, do you think it's more or less likely that you would make a move? Also, considering the limited number of transactions, how do you assess valuation per member gross profit or any other factors? What are your thoughts on this?

John, this is Thomas here. So I think we started sharing back really around the time of the IPO that we were considering some of this in addition to our organic growth strategies. We talked about it both in terms of some potential payer assets, things that were small enough to be manageable for us, but also probably small to where they might not be as meaningful for some of our larger competitors. And then also provider assets, either in new markets where they could serve as an entry strategy as a part of our expansion efforts or in some of our existing markets where we think it fits into our overall competitive framework. So with that in mind, I think we still remain offensive on kind of both of those types of areas. But I think what we've seen across the market over the last few months is obviously a change with respect to investors' sentiment around profitability. And we're being disciplined in making sure we protect our balance sheet, which is obviously clearly an asset of ours today. And we want to make sure that if we do anything, it does not impede our ability to get to EBITDA breakeven and support our organic growth efforts with the cash balance we have. But with that said, I think we have plenty of capital on the books today, and I think we could explore some smaller and of course, highly accretive opportunities. In terms of how we might value those to your other part of your question, I think it depends on the type of asset. I think per member valuations are interesting, but I'm not sure they always tell the whole story because not all businesses and members are made equal. We would look at revenue, gross profit, EBITDA, and kind of all of the above in addition to membership.

And then my second question is, and this is probably not answered little bit I'll take a shot. Let's look out to the future and you're double the size that you are today, 200,000 members. Do you think the geographic mix would look similar to today? Or do you think that a couple of big new states?

John, it's John. I think if we look out 2 to 3 years, I think you're going to have a couple of the new states that we're in, begin to take root and get to that 10-plus thousand member threshold we talk about and we've communicated we want to get to kind of operating breakeven in each market in 3 years when I get to 10,000 members in 5 years. That's been consistent with all the new markets that we've entered with a couple of exceptions where we've grown faster, specifically in our Sutter markets and our San Diego markets. I really think our model is going to be well received outside of California. I think the demand from the primary care community for alternatives is very high. I think we can be that solution. I think as we partner with those PCPs, we're going to be able to generate kind of those kinds of growth numbers. While we are still mindful of EBITDA, and we're still mindful of managing growth and protecting our balance sheet. If we get the performance I expect in the markets that we lost in '21 and '22, we'll probably do a couple in '23. I don't think we're going to do 4 or 5. I'd be surprised, I should say, again, just to make sure that we're minding cash flow.

Congrats on the quarter. I want to start with a couple on intra-year enrollment. You mentioned that will be part of the mix again in FY '22. Just curious on feedback so far from the spring OEP enrollment? And also your product mix now has expanded into more special needs plans. To what extent does that allow you to sign up more members outside of those formal open enrollment periods?

Yes. Jeff, Thomas here. So we're obviously about 2/3 of the way through OEP. I think it's going well so far. I think the way we thought about our full year guidance and how our full year enrollment may come together, looking at January to December is really in relation to our last couple of years' worth of experience where if you look back at 2020 or 2021, we added about 6,000 to 7,000 lives from January of those calendar years to December at the year-end before the impact of AEP. If you think about our guidance and kind of where we said we were at as of January 2022 and our range for year-end 2022, you'll see obviously a symmetry between what we're projecting this year and what we've been able to achieve in years past. Our goal is to really start to capitalize on a lot of the investments that John described in terms of our market management initiatives and some of these member experience initiatives that we hope will start to take through over the course of the year as well.

Excellent. And any comments on the special needs plans and whether those can be more of the mix this year?

Yes, I think so. We're actually launching those, as you noted, in more markets than we've ever had before, and that's certainly a part of our broader product roadmap as we think about 2023 as well. I'd say it's maybe a little bit too early to say how much of a material impact that will have on intra-year enrollment. But it is one of the drivers that we're certainly focused on, both in terms of our D-SNPs and as well as our C-SNPs. Yes, it makes a lot of sense. So typically, what we experience over the course of the year is an SG&A on a quarterly basis that builds from kind of first to fourth quarter, which is reflective of, to your point, the AEP portion of our expense, which is largely concentrated, obviously, in the back half of the year related to sales and marketing as well as some of our year 0 launches where we're starting to onboard and hire folks related to our upcoming new market launches that typically start around June, July, August and kind of run into the AEP period as well. As you think about the first quarter of 2022 relative to the back part of 2021, I think you're seeing a slowdown in some of that sales and marketing spend that we would anticipate to ramp back up later in the year. And I think there are also some other adjustments that happen throughout the year, such as our AIP or our overall incentive plans that tend to ramp up or ramp down throughout the year as well. So I think that's part of what you're seeing also in terms of Q4 versus Q1 seasonality.

Maybe Thomas, to start. I think the implied PMPM growth for '22 is about 2%. If I heard you correctly, I think you said that the new member RAF was maybe a little bit lower than what you had expected. And then you're expecting the return of sequestration. I didn't know if there was anything else that I might have missed just as we think about PMPM growth this year. Can you maybe talk about the ability to kind of manage those higher-cost members and just kind of overall level of confidence and visibility in the MLR outlook that you gave?

Yes, yes, absolutely. In terms of your first question on revenue PMPM sort of year-over-year, I think you're right that we have suggested that our new member risk adjustment scores are a little bit lighter than expectations. When I say a little bit, I mean to the tune of a few percent and nothing too significant, but modestly lower than what we would have expected coming to the year based on our prior experience by market, which varies by market. However, that is being offset by what we've seen on our returning members, where I think 2022 really looks to be a more normalized operating environment based on all of our operational activities in 2021. The other thing to keep in mind is every year as we go through our bid cycles and we're making benefit investments, those do have an impact on our overall revenue PMPM from year-to-year. Of course, that's offset by the benchmark trend. When you combine those four things, returning members, new members, benefit enhancements, as well as benchmark trends, all of that for us this year is rolling together to something like you said, I think, about 2%. In terms of the MBR outlook, I think we feel pretty good. What we experienced in Omicron over the last part of January and into the early part of February was a bit of an accelerated clip in COVID-related inpatient utilization compared to some of our experience with prior waves, just given that it's obviously a much more highly transmissible variant. But that being said, it's come down significantly. As of the end of February, it was at a much more normalized rate between both Covid and non-Covid consistent with our expectations. So I think we feel strong and confident in terms of our overall MBR outlook for the year and look forward to keeping you guys updated on it.

That's helpful. Any updated thoughts around the timeline to profitability for the overall company? I think the EBITDA guidance for '22 is generally consistent year-over-year. Maybe just what the path looks like from here? It sounds like you may be close to profitability in California. What would that mean for the overall business?

Yes, makes a lot of sense. We are looking at this kind of market-by-market inside and outside of California and also some of our newer ventures like DCE. We have seen a lot of progress in California over the last two years, and we're really pleased with where that is shaping up today. Those comments from John and I earlier include a lot of these growth investments we're making in market management infrastructure as an example. We are really seeing some strong performance there. Meanwhile, our consolidated EBITDA profile this year reflects a lot of those investments for the 2021 and 2022 new market launches. Examples include North Carolina, Nevada, and Arizona as well as some of our 2023 and 2024 growth and market expansion initiatives. To your question on our overall path to profitability, we are still envisioning that over the next several years, the strength of our legacy markets will continue to perform and be able to fund the investments we continue to make in the new markets. The open question and interrelated relationship is the pace of the new market investments. As John mentioned, we continue to plan to make new market investments over the next several years, given our confidence in some of our historical and more mature market performance. While we are comfortable today with a modest EBITDA loss, I don't think you're going to see us go crazy and chase growth at all costs or drive our EBITDA profile to a much more significant loss than what we've currently put out in guidance. We think we're on the right path over the next couple of years, and importantly, we have a strong enough balance sheet to get us there without the need for any type of financing.

I just want to go back, Thomas, to just spend a couple of minutes talking about your outlook for medical costs for 2022. As we think about COVID specifically, things like antivirals, thinking about the new testing initiatives, is there anything specific in your guidance for any of those? As I would expect that, that would be kind of outside the norm of what you explained before, where if we saw hospitalization, we saw less outpatient and they offset each other. So anything specific there that we need to think about for 2022?

Yes, I think you're spot on that there continues to be progress across the market. We view that as a positive. The way we think about that, I think we shared with some of you before, our average inpatient unit cost or case rate for an average COVID hospitalization is over 1.5x as expensive as a non-COVID hospitalization. Over the course of a year and what’s contemplated in our guidance is a mix of both COVID and non-COVID admits per 1,000 or inpatient utilization. The extent that there is additional expense related to, to your point, antiviral medications that can help prevent some of those downstream more costly expenses, net-net, that could be a positive for us. So something we're keeping an eye on. But at the time, I don't view that necessarily as a risk and potentially an opportunity, if anything.

And then just secondly, I appreciate your comments around moving towards profitability. When we think about long-term target margins for your business, how should we think about that longer term? Is the anticipation that it would be in line with some of the other MA peers in the 4% to 5% margin range?

Well you say 4% to 5%, that's pretax? Yes. I think that's probably in the right realm. I think we've said, starting back when we went public, our long-term adjusted EBITDA margin goal was 6% to 9%. We've talked about the kind of 6% to 7% range being sort of the pure health plan business and the opportunity to strive for 8% to 9% being related to some of our efforts both around vertical and horizontal integration. From a vertical standpoint is our ability to leverage some of our AVA capabilities, clinical model and some of our other subject matter expertise through provider relationships. Horizontally, I think over time, we would look to potentially in-source some of our things that are currently outsourced, such as our supplemental benefits, things like behavioral health, areas where we think there's an opportunity to either buy or build businesses to sell into our existing installed base of membership, which is becoming decent in size.

So at the midpoint, it looks like about 20 basis points gross margin expansion and 40 basis points EBITDA margin compression. So about a 60 basis point delta there which translating into $8 million. Is that how we should think about the incremental investment in growth spend built into '22? Is there any clinic investment in that amount? Are there any other headwinds factored in there?

I think that directionally sounds about right. No specific headwinds certainly contemplate. What you're probably seeing in terms of the SG&A line is sort of the run rate impact of the new markets we launched in 2022. What would have been "year 0" in 2021. You're getting kind of a full annualized impact to some of those investments in Arizona as an example. We are forecasting over the back half of the year related to some of our potential growth and market launches for 2023. What you’re seeing is the layering on of these additional market investments. Yes. I think our 20% goal remains organic. If we see opportunities for M&A, that would look to complement or add to that. But I think from just a 20% perspective, we remain focused on trying to achieve that organically year in, year out.

Most of my questions are answered. I just want to go back and make sure I understand what you said about the market management folks in the field. Are you referring to sales representatives, your own internal brokers, or what type of people are you talking about that are present in the markets more?

Gary, great question. Yes, I would say that traditionally, the people that we had in the markets were the provider engagement representatives. We’ve worked with many of the IPAs and medical groups, making sure different clinical operational gaps were closed on HEDIS and STARs as well as MRA gaps and ensuring that data was properly ingested to feed AVA. What we're doing is adding additional resources that we would call community reps. These individuals will work will seniors and senior centers and different types of organizations within each community to get much more activity on the sales side and work with brokers. We're also adding more providers into the network, both primary care and some specialists in each community. We have known that we wanted to do that. We've been mindful of long-term profitability, but we've gotten the growth by focusing on kind of the former. I think this is caused us to accelerate the investment in this area. We'd probably have done it anyways next year, but we're really accelerating it to this year. Just to get more consistency in the product growth. Hope that answers the question.

No, I don't think anything overly material or consequential. We feel pretty good about our approach to IBNR and our reserving methodologies. We've shared with many of you in the past that we have a pretty detailed oriented view in terms of how we track our inpatient utilization in terms of facility mix, in terms of high-cost cases that we anticipate would be above and beyond our average kind of average case rates and unit costs. We feel pretty good about the way we've approached it, and nothing too material in terms of the day-to-day just speed in which we process claims, I'd say.

This year, you are experiencing slightly slower growth, which typically indicates less leverage on general and administrative expenses. It appears that you are making additional investments. It seems that your perspective on margins remains largely unchanged. Can you explain how you are financing these investments? Are you prioritizing different aspects within general and administrative expenses? Are you adjusting your investments in benefits compared to other areas? How should we interpret the margin effects of your current strategies?

Kevin, this is Thomas here. I think it's sort of 2 things I'd say. One is you're right. We're looking to make improvements across the business in terms of our operating leverage, not just in terms of a lot of the fixed costs, which, of course, you'd expect us to get the fastest operating leverage on over time as we continue to grow. We're still working through a lot of areas and a lot of our more variable cost centers where we think those areas will obviously continue to grow with membership, but there is a way that we continue to be more efficient. You're seeing some of that improvement come through on both sides. I'd also say in terms of the membership kind of shortfall as of January, as John mentioned, being around 3,000 members short of our 20% growth target. As much as that is frustrating to us and something we're working to attack as we speak, overall, that 3,000 member doesn't have too much of an impact on our overall kind of leverage objectives and ability to achieve those year-over-year from '21 to '22. So that's obviously a minor headwind, but I wouldn't say it's causing us to completely rethink our SG&A for 2022.

Okay. That's helpful. And I guess maybe just the competitive marketplace. It feels like at least the larger disruptive companies have gone public, the market has kind of told them you need to be closer to profitability. You guys have always operated that way, but it seems like some of the other companies who have been more focused on growth over profits are now changing their strategy. Do you believe the same thing is happening in your local markets that there's reason to believe that the competitive backdrop will get less competitive? Or is that not necessarily the right way to think about the actual companies you're competing against?

Kevin, it's John. Yes, I think it's always going to be competitive. The legacy players are very good at this. You've got a lot of new entrants that have been very aggressive. I would say that the question at hand is sustainability of the degree of aggressiveness. I think it's something we've seen come and go. With some of the tailwinds that many of the plans experienced the last couple of years, they invested a lot of that into benefits. We’ve always said that you really can't get into this business without some form of kind of ability to manage risk effectively and kind of this clinical model. We think we're going to demonstrate consistency around that. That's why we've focused so much on the clinical model and investing in AVA and investing in Care Anywhere and differentiating ourselves from everyone else. At the end of the day, I just think we have the most efficient model to deliver value to the consumer. So, that's a long-winded answer, but we are not taking anything for granted, Kevin. I think this little blip we had last for AEP is having us look at everything.

Thanks for sneaking me in here. I'd like to kind of follow up on Kevin's question a little bit about the competitive nature and benefit design and the like. You guys are a high-touch plan, high benefit plan, always have high star ratings. In the context of people offering very rich benefits last year, is the fact that the rate update this year being higher, is that actually like a negative, meaning it allows other people to catch up to you guys? Or are there things incrementally that you can do that still differentiate yourselves on the benefit side? How should we think about that? Because I haven't been able to figure out if it's a good thing, bad thing, or neutral.

Kevin, this is Thomas here. I tend to agree with you that there's a certain bit of neutrality to it. What I mean by that is, first of all, while the advanced notes was positive, we are still waiting to see how it comes out for our specific counties here over the next month or two. With that in mind, to the extent that it is another solid benchmark year like it was in 2022, that gives all plans the same level of incremental flexibility regarding benefits. So you're right that may allow a competitor to invest in their own benefit offering to enhance it. But that same funding mechanism is what we have. If we're already ahead of them, we should be able to stay ahead. If it happens to be a modest benchmark increase here, the same thing. Ultimately, if the funding mechanism for incremental benefits is similar between us and a competitor, what would allow us to continue to win in the marketplace and maintain our product positioning that's ahead of many competitors really gets back to our ability to be high quality and low cost to begin with. I would never say a higher benchmark trend is a bad thing, and we certainly wouldn't say that. But I am not sure it would cause us to feel very different about our opportunity for growth in 2023, one way or the other.

Fair enough. That's actually really helpful. And just one quick follow-up. You discussed your improvement in member engagement from 57% in 2020 to 64% in 2021. Can you sort of quantify what that does in terms of MLR? Where do you think that can go, whether it's in 2022 or going forward? What is the incremental patient engagement? Have you quantified the benefit to you or to the member in any way?

Yes. I don't think I've quantified it in terms of the impact on MBR per se, but maybe I can give you some data points to help triangulate here. As you’ve heard us say before, our historical performance is kind of in that 160 to 165 inpatient admissions per 1,000 range. We shared with Mini back in January that we ran about 155, 156 for full year 2021. You’re seeing us continue to improve engagement rates, as you’re seeing us continue to improve. You've heard me talk about the recall rate. It’s the capture of our AVA inpatient risk prediction models and readmission models. I think all of that lends back to the inpatient utilization metric that we track almost on a daily basis. I think we’re seeing a lot of progress with it. Over the long term, we still think there are opportunities to continue to improve it. We want to get to 100% but that may be a bit aspirational, but that's probably the long-term goal. In the short term, you’ll hopefully continue to see us make drives on that metric, and you’ll see it come through in the form of improved readmission rates and hopefully lower MBR as well.

And at this time, this concludes today's conference call. Thank you for participating. You may now disconnect.