American Well Corp Q4 FY2022 Earnings Call

Good evening. My name is Savannah and I will be your conference operator for today. I would like to welcome everyone to the Amwell Q4 2022 Earnings Call. Thank you. I will now hand the call over to Sue Dooley, Head of Investor Relations of Amwell. You may begin.

Hello, everyone. Welcome to Amwell's conference call to discuss our fourth fiscal quarter and year-end of 2022. This is Sue Dooley of Amwell Investor Relations. Joining me today are Amwell's Chairman and CEO, Dr. Ido Schoenberg; and Bob Shepardson, our CFO. Earlier today, we distributed a press release detailing our announcement. This release is posted on our website at investors.amwell.com and is also available from normal news sources. This conference call is being webcast live on the IR page of our website, where a replay will be archived. Before we begin our prepared remarks, I'd like to take this opportunity to remind you that during the course of this call, we will make forward-looking statements regarding projected operating results and anticipated market opportunities. This forward-looking information is subject to the risks and uncertainties described in our filings with the SEC, and actual results or events may differ materially. Except as required by law, we undertake no obligation to update or revise these forward-looking statements. On this call, we'll refer to both GAAP and non-GAAP financial measures. A reconciliation of our GAAP to non-GAAP financial measures is provided in our posted earnings release. With that, I would like to turn the call over to Ido.

Thank you, Sue, and hello, everyone. I'm pleased to report that in Q4, we successfully capped off an important and strategic year for Amwell. On many levels, it was an incredible year. We rallied as a company and executed well, making meaningful progress in the transition to Converge, our software platform that we believe will enable and empower the future of hybrid care and which has already been embraced and implemented by some of the most demanding and innovative healthcare organizations. I would like to begin by reviewing a few highlights of the quarter. Then I'll take a moment to discuss the market for our solution and describe key priorities for 2023. After that, Bob will review some key metrics, our financial results, and our 2023 guidance. Then we'll be pleased to take your questions. To begin, here are some highlights. In Q4, we had another great quarter for client migrations, and Converge is scaling well. Specifically, visits on Converge continue to rise, growing from 16% of total visits for the quarter in Q3 to 28% of total visits in Q4. In fact, all of our key operating metrics are trending favorably, and we'll let Bob review that in a moment. Our solution is resonating across all segments of the market. We continue to strengthen our relationships with strategic clients. In one standout example of this from Q4, we formally extended our long-term strategic partnership with Elevance Health. We are proud to be an important part of their digital platform for health, which aims to attract, engage, and retain more clients while also achieving operational goals. We believe this validates the benefits of Amwell as the strategic partner that can empower and enable the future of care, and we look forward to the future of this important relationship to help advance innovation from a visionary strategic partner. While endorsement for clients like Elevance in the high end of the market lifts the visibility of Converge, our value proposition extends to clients of all sizes. For example, Northern Light Health, located in Maine, is leveraging Converge to drive some of their system-wide goals around access to care, provider experience, and internal efficiencies by consolidating technologies and streamlining workflows. Northern Light is a brand new client that has rapidly deployed the Converge integrated schedule visit experience across many practice areas, with more to come. Our Physician Champion reports an improved clinical delivery experience with quality and efficiency gains compared to previous telehealth alternatives. We continue to deliver powerful new solutions in partnership with our clients. For example, with Northwell, we extended their existing roster of robust automated care programs to include an AI-driven pregnancy program aimed at reducing mortality. The chatbot called Northwell Pregnancy Chat identifies potential urgent concerns, links to care teams for evaluation and analysis, and accelerates time to care for women during and after pregnancy. Northwell delivers 1% of babies in the United States, and so far, the chatbot has been used by over 1,600 patients with a satisfaction rate of over 95%. In one powerful example of the benefits of this solution, Northwell helped escalate life-saving care for preeclampsia for a pregnant woman who reported high blood pressure in the chat. This is a great example of our enabling partner model. We collaborate around meaningful products that provide value, deliver outcomes, and empower our clients to set new standards for care. We are pleased with the consistent positive feedback on Converge that is flowing in from our clients. We are executing well, and we have put many of the platform transition-related challenges behind us while building on our track record as the enabling partner for hybrid care. Turning the page to 2023, it is increasingly clear to me that we made the right decision to replatform our solution. Now I'd like to speak to the broader environment for a moment and how I see our own role in it. We just completed our annual sales meeting, which was filled with the energy of a new year, the promise of our Converge platform, and the many strong client and partner endorsements of our approach. A lot has changed in the past few years. Our teams are motivated by the certainty that digital-first care is rapidly becoming the main highway for a variety of care modalities offered by all types of providers and services, and our role in this evolution is a significant one. Yet across our industry, we are facing uncertain times. As we see it in Amwell, economic uncertainty creates both headwinds and tailwinds for us. We know hospital budgets are constrained, and yet the challenges facing providers and payers drive an urgent need to leverage technology to achieve their operational goals. In our sales approach, we're striving in every conversation to convey to prospects and clients that our solutions are the must-have engine to resolve their pain points today and deliver on their strategic aspirations for the long run. We understand that ROI and outcomes that materialize quickly are a must in today's environment, and at Amwell, demonstrating ROI is in our DNA. This approach resonates with health systems, which are prioritizing digital care to achieve important goals around staff burnout, retention, new sources of revenue, and streamlining workflows. We support and embrace patients with our automated programs, engaging them to improve outcomes. We enable models of care that allow our clients to differentiate their own approach to care. Every day, I speak with healthcare industry leaders who are struggling to unify fragmented technologies and define emerging digital care models. They require a partner to work closely with, to simplify the staff, a partner who can imply a clinical approach to the underlying software infrastructure and best practices to advance their goals. At Amwell, our differentiation is clear. We have the clinical experience to understand the challenges our clients face. Our platform is purpose-built and future-ready, founded on years of investing and understanding the needs of our clients. Our approach to the market sets us apart. We are a trusted partner. We enable and empower our clients and never compete with them to deliver new and exciting ways to provide care while achieving important operational goals. As we deliver on Converge and the market response, we are solidifying our role as a digital transformation partner supporting our clients in defining and accelerating their strategies and aspirations that differentiate their own offerings. Regardless of the environment, we have used this highly dynamic period in history to undertake our own transformation, one that we believe has earned us a leading role to deliver on the promise of our mission and our long-term model. I'd like to take a moment to share a couple of key priorities for the coming year. As we begin 2023, we are laser-focused on achieving progress toward our long-term financial model with the following three top priorities. First, a top priority remains migrating the balance of our clients onto Converge. We will strive to ensure the successful migration of our remaining provider clients onto Converge, and deployments for payer clients have already begun. Another important initiative for us in 2023 will be to ensure the success of our strategic clients. As we continue with these large and complex deployments, we will provide a shining example for clients and prospects of all sizes who look to us for partnership, enablement, and acceleration of their digital care delivery plans. Finally, our sights are set on pursuing the tremendous opportunity to win new clients across the payer and provider universe while expanding our footprint within our existing client base. Reflecting this, we are arming our teams with powerful new selling tools to enable the sales dialogue, and we are upskilling our teams to master the enterprise-level solution-based selling environment we are in. As we pursue these initiatives, we are further empowered by knowing the hard work of 2022 is behind us, and we have achieved a lot. We have completed the core elements of Converge. We have retained the lion's share of our clients. We have effectively migrated clients and grown our percent of visits on Converge. Our client list includes our industry's most far-reaching and innovative organizations, and experienced industry leaders have joined our company and hit the ground running, partnering effectively with our existing talented teams. We look to 2023, aiming to fulfill the promise of our vision of enabling the transformation in healthcare to true hybrid digital care. With that, I would like to turn the call over to Bob for a review of our financials, some key metrics, and our guidance for the year. Bob?

Thank you, Ido, and hello, everyone. I'll start with a review of our operating metrics and financial results for the fourth quarter and the year, then I'll discuss our outlook and guidance for 2023. I'm pleased to report that all of our key operating metrics are trending in a healthy direction. Active providers is an important metric of the sustained value our clients see in our platform. We ended the fourth quarter with over 107,000 active providers, representing growth of over 11% compared to a year ago. As a subset, active providers employed by our clients grew 12% versus last year. We anticipate that our number of active providers will continue to rise as we migrate and implement existing and new clients onto our Converge platform. Another important metric is our average annual contract value or ACV, which is a good indicator of the value we are delivering to our clients and the success of our land-and-expand strategy. Health plan ACV increased over 19% to $863,000 in 2022 compared to 2021. ACV for health systems saw a 13% increase to $401,000. This is in line with our expectations during this time of the Converge transition as clients focused on migrating to Converge. We expect ACV to continue to expand as we look to grow our footprint within existing clients and add new clients over time. Total visits were approximately 1.7 million in the fourth quarter, an increase of 10% compared to last year. Urgent care visits drove most of this increase in what was the first real flu season since the onset of the pandemic. This surge in on-demand urgent care visits resulted in scheduled visits being 63% of the total, down from a prior range of 70% to 75% over the last couple of years but still up significantly from approximately 30% pre-COVID. For the year, scheduled visits comprised 70% of total visits. We continue to make steady progress migrating our clients to the new platform, and we are proceeding according to plan. In Q4, successful migrations drove visits on Converge for the quarter to 28% of total, and that number has continued to increase during Q1. Now on to our financial results. In a transition year with many moving elements, we are pleased to have been able to achieve our revenue guidance and exceed our adjusted EBITDA guidance for 2022. Total revenue was $79.2 million for the quarter, which represents growth of 9% over Q4 of last year. Total revenue for the year grew 10% compared to last year to $277.2 million. Subscription revenue was $30.7 million in Q4, relatively flat compared to the year-ago quarter. For the year, subscription revenue grew 12% to $120.9 million. During the year, subscription revenue growth was positively impacted by the inclusion of a full year of revenue from our 2021 acquisitions of SilverCloud and Conversa and was challenged by the temporary impact on bookings we had expected, while we focused on completing the Converge build-out, successfully migrating our existing client base, plus strategic client deployments. The diversity of our revenue stream proved to be a real asset in 2022 as AMG and client-related implementation services delivered strong growth for the year, supporting our overall growth rate during this time. Moving to visits. In Q4, AMG visit revenue was 12% higher than last year at $35.1 million. Visit revenue was strong this quarter and, in fact, was just shy of Amwell Medical Group's all-time high of $36 million in the second quarter of 2020 at the peak of the pandemic, demonstrating the enduring value of this service to our clients. For the year, visit revenue grew 7% to $124.3 million. Now on to some detail on visits. AMG visits grew 23% for the quarter and 11% for the year, with average revenue per visit at $71 and $76, respectively. As I mentioned, the early onset of an unusually heavy flu season drove urgent care volumes higher and hence, revenue per visit lower for the quarter. As we have said previously, while our AMG business is an important differentiator in the market and critical to many of our clients, our primary focus going forward is to drive high-margin recurring revenue associated with sales of the Converge platform, plus a growing number of modules, automated care programs, and services like AMG. Our services and Carepoints revenue grew 18% to $13.5 million in the quarter and 14% for the year. This strength was driven substantially by professional services revenue we earned as we implemented strategic clients onto Converge. As we have discussed on prior calls, revenues of this type highlight the strategic long-term nature of our client relationships and the ROI they see in deploying our platform. Turning to profitability. Fourth quarter gross profit margin increased 250 basis points versus last year to 42.4%. For the year, gross profit margin increased 80 basis points to 42.1%. Gross margins may continue to fluctuate a bit from quarter-to-quarter depending on revenue mix. Contributing to the increase for the quarter were a higher proportion of urgent care visits at AMG and a higher margin mix of services and Carepoints revenue. Over the long run, it's our goal to drive a steady revenue mix shift towards high-margin recurring software revenue in pursuit of our long-term model. Turning to operating expenses. During the fourth quarter, our progress in developing Converge crossed a meaningful threshold in our overall project plan. As required by GAAP, we capitalized $10.2 million of development-related efforts in the quarter. Adjusting for these capitalized software development costs, R&D expense increased by $1.6 million in the quarter to $37.8 million. As we have discussed, we believe that Q4 '22 represented our peak R&D spend. Given our progress in delivering Converge, we expect that R&D spend will decline sequentially on an absolute basis over the course of 2023. Fourth quarter sales and marketing expense increased 9% compared to a year ago. This was driven by higher sales and marketing activity across the board as we prepared for our January commercial kickoff meeting and ramped our overall sales efforts, reflecting the completion of Converge. We made some changes in our sales teams to align our resources around solution selling, which are aimed at driving pipeline development, deal velocity, and deal size. G&A increased 9% sequentially, driven primarily by the recognition of deferred noncash compensation associated with the terms of our SilverCloud acquisition. Adjusted EBITDA for the quarter was negative $43.4 million, bringing the metric for the year to negative $175.3 million. As we discussed on our third quarter call, Q4 completed a full year of careful expense management around headcount, and we achieved synergies from the early integration of our recent acquisitions. As a result, we achieved better-than-anticipated adjusted EBITDA, both relative to our preliminary guidance for the year as well as versus our updated guidance last quarter. Transitioning to the balance sheet, we ended the quarter with $538.5 million of cash and marketable securities. We are fortunate to have a substantial cash position as it provides the resources to fund this temporary period of investing and the flexibility to pursue strategic opportunities that are aligned with our goals. Turning now to our 2023 outlook. 2022 ended with puts and takes for our business, which we carefully assessed in arriving at our guidance range. First, we experienced both continued impact from COVID and an early and severe flu season which may not recur this year. As a result, we took a conservative approach and are assuming normalized AMG visit activity of 1.45 million to 1.65 million visits. We also looked carefully at the spending environment, taking into account conversations with our clients. As Ido mentioned earlier, a challenging macro environment presents us with headwinds and tailwinds. On one hand, the heart of our value proposition and our partnering approach directly addresses the budgetary and operational challenges our clients and prospects are facing today. This is driving demand. On the other hand, these challenges may also impact expansion and deployment cycles for our solution that are difficult to predict at this time. Finally, we anticipate steadiness in our services and Carepoints revenue, which we believe will remain at approximately 10% of total revenue. Considering these factors, we expect revenue to be in the range of $275 million to $285 million for the year. Given sales cycle timing, we anticipate the majority of the bookings we generate this year will come in the second half of the year. So a portion of the bookings momentum we aim to generate this year will translate to revenue growth in 2024. Next, some color on subscription software revenue growth, which is a primary goal for us. As we emerge from this time of transition and continued migration, we are turning our attention to reaccelerating client bookings via expanded use of new modules on Converge. With Converge ready and reference clients building, we anticipate a return to strong software bookings momentum. Therefore, we believe software revenue will grow faster than our overall business in 2023. Now on to our guidance for our progress toward profitability. For the full year 2023, we expect our adjusted EBITDA to be in the range of negative $150 million to $160 million. Much of the expected improvement in adjusted EBITDA will come from the anticipated reduction in R&D spending layering in over the course of the year, as we have planned. Wrapping up our guidance, we are encouraged by our progress to date. All of our key metrics are trending favorably, and we have put much of the risk of our transition behind us. Our teams are executing in product and client migrations, and we have earned the validation that our anchor clients ascribed to our approach to the market. The clients we have implemented onto Converge report a very high level of patient and provider satisfaction and technical success, and they provide us valuable referenceability with our prospects. Our ROI case studies are fueling robust conversations with our substantial pipeline of upsells and new logos. Before I conclude my remarks, I would like to comment on our long-term model as we outlined a year ago. As we enter the next chapter of our transition, we remain confident in the components of our long-term model, which describes our path to cash flow breakeven and remains our goal. We believe our differentiated approach to enabling digital care delivery positions us well to deliver sustained revenue growth and expanding profitability over the long term. Thank you for listening. With that, I'd like to turn the call back to Ido for some closing remarks.

Thank you, Bob. Before we conclude our prepared remarks and take your questions, I want to take a moment to thank our teams. They dedicate their talents to developing and deploying our solution, extending our market reach, delivering thought leadership around our mission, and finally, contributing to our unique company culture. In closing, we have driven every day at Amwell to continue along this path to achieving our goals and pursuing our mission. Our solution is in high demand because it solves important problems for innovative healthcare organizations seeking to evolve to hybrid digital care. We begin 2023 on strong footing. While there remain broader environmental uncertainties in our world today, it's early days for digital-first healthcare. Our role is unique and differentiated, and the opportunity before us has never been brighter. With that, we are ready to conclude our formal remarks. Thank you for listening today. Operator, we are ready to open the line for questions. Thank you.

Our first question will come from Craig Hettenbach with Morgan Stanley. Craig, your line is open. We will now move on to our next question from Charles Rhyee with Cowen.

This is Lucas on for Charles. I wanted to dive into the 2023 revenue guide that implies growth that's a bit lower than we had expected. Obviously, it's well-documented the difficulty that health systems are dealing with right now. I kind of wanted to dive into the conversations you guys are having with your customers. Is there something slowing with the migration to Converge? Are customers linking things on their end? Is it more of customers pulling back, or are they just putting projects on hold for the second half? If you could give more color around that, that would be great.

Thank you, Lucas. I appreciate the chance to discuss this. As I noted in our earlier comments, we are executing very closely to our plan, or even exceeding it. Last year was a transformative period for us as we revamped our main offering. This involved significant risks, including potential customer turnover, the rollout of the new platform, and the transition of clients onto it, among other challenges. We faced some minor obstacles but ultimately completed the year with a product that is fully operational. Additionally, we successfully transitioned 28% of our engagement to the new platform, which is notably more efficient, user-friendly, and scalable, presenting substantial growth opportunities. Importantly, we managed to retain the majority of our customers and nearly all of our key strategic clients, which is a significant achievement. We also secured commitments from major clients like CVS and Elevance regarding the new platform, although we haven't disclosed all of them yet. Reflecting on the year, the results were better than we could have hoped for. At the start of last year, we finished our partnerships with a significant number of contractors who were instrumental in developing the core features of the platform we are now deploying, enhancing our efficiency. Given these changes, we anticipated that 2023 would be a quieter year since we can't promote a platform that isn't fully completed yet. Furthermore, two emerging trends and challenges came to light that may not have been as clear last year and could affect your expectations. The first is the macroeconomic environment, which is uncertain in 2023 and could influence sales cycles, deployment times, and the speed of expansion. While our solution is essential and our clients continuously affirm this, these factors might hinder our growth this year. Secondly, we observed interesting developments regarding flu and the pandemic in the last quarter of this year, which turned out to be favorable due to a strong flu season and resultant revenue, but this could easily shift again. It seemed wise to factor these challenges into our guidance to safeguard against potential downsides. Given these challenges, we also deemed it unwise to list the advantages we see at this time. We know our platform is scaling effectively and has been validated by many sophisticated organizations, and it is well-timed in a market that is poised for aggressive growth over the coming years. I realize this is a lengthy response to your brief question, but it explains why we arrived at the guidance we provided.

Okay. Yes, that's helpful. And then in terms of your profitability guide, it seems like OpEx is going to be in a similar range to our expectations and the Street's expectations. I wanted to hear if we should still think about adjusted EBITDA breakeven by year 2025 and if that expectation has changed at all?

Lucas, I'll take that. It's Bob. So just taking the opportunities to rewind the clock a little bit to about a year ago when we put out that guidance, there were three kind of core assumptions underlying that path to profitability framework. And all of them at the time had different degrees of risk. The first was continued strong demand for digital care enablement. As we sit here today, we believe that the market opportunity is only better than we thought a year ago. And large strategics are voting with their feet on that. The second key assumption underlying that model was that we would deliver Converge and migrate customers — begin to migrate customers over 2022 to get us on a path to where we can sunset the legacy platform and realize the efficiencies associated with that. The proof in the pudding there is from a standing start, we went to 28% of our visits this quarter or this past quarter on the new platform, and that's continued to trend higher. I think that's a check there, too. And then, the last key assumption there was that once we delivered the core components of Converge, R&D would normalize. And that's happening. You'll see that in the first quarter start to present, and it'll continue to get better as we were able, as Ido said, to sunset the contractors that had really been the backbone of a lot of that incremental spend on Converge. So all of that kind of provides the foundation for bookings and revenue acceleration and our margin improvements. And as we sit here today, visibility on all of that is much better than it was a year ago. But there are things we don't control, like the macro that Ido just went through, and that can influence the pace positively or negatively to when we get to that breakeven path. If there is a delay, we're certainly well-equipped to handle that. We've got the balance sheet to weather that. And also, now that we've got a commercial platform in the market, a lot of our spend could be considered discretionary. And we have a lot more levers to play with than we have over the last couple of years when so much of our spend has been driven by delivering Converge. So, in summary, we can get there. But if we're delayed, we don't see any change in the fundamentals.

This is Matt Shea on for Ryan MacDonald. I wanted to follow up on the '23 guidance and start with — start with the revenue. So we were a little bit surprised to see platform revenue decline sequentially in the fourth quarter. And then based on some of the building blocks for '23, it looks like it's going to come in lower than expectations in '23 as well. So just curious, was there a churn in the quarter that caused the sequential declines or the outlook for '23, or is this solely just a bookings timing consideration? And then maybe you could remind us what the bookings conversion cycle looks like for Converge bookings to revenue?

Thanks. I'll take that too. I think what you ended with was really the most important aspect of the answer to the question. Again, this is — 2022 was very much a transition year and with it comes challenges beyond the macro. We did see customer churn at the low end, especially at the low end where the switching costs are a lot less in the market. Beyond that limited amount of churn that we saw at the low end, customer expansions are by their nature with the replatforming delayed, and new prospects want to evaluate the new platform before they sign up for multiyear contracts. So that dynamic is very much evident and we've been living with that for a lot of the last couple of years at this point. We're now at a point where we have a commercial platform in the market. And that plus a lot of tools in the toolkit for our sales force, we think is going to allow us to really start to inflect on the bookings side, which is going to drive, obviously, revenue growth. To give you a sense for the time from booking to revenue, it really depends on how large the customer is and how complicated the implementation is, but a reasonable expectation there, taking into account scheduling on the customer side, our side, and then the work is probably 5 months to 6 months on average. So you can imagine with bookings building over the course of the year and then revenue starting to present from that more in the back half of the year and then driving really growth into 2024, that's the dynamic going on with what's perceived to be, I think muted guidance for the year on the top line.

Got it. That is very helpful. It seems that same-store growth will be a major focus, and you've mentioned some changes to the sales team to support that. Previously, you discussed a timeframe of 15 to 20 weeks for a customer to join Converge, recognize the value, and then potentially upsell additional modules. Have you seen some clients complete this process? If so, what does that look like for them? Which modules are they most interested in upselling? How do you anticipate this trend evolving moving forward?

Sure, Matt. So it's hard to compare Converge to our legacy platforms. Converge is so much bigger, can do so much more, and has so many modules that really cater to a very wide spectrum of needs. Of course, not all our clients need everything at once. It's very common that they focus on the pain points that are important to them today, but they take great comfort knowing that they can really expand in a very material way to many, many directions. Another trend that is very apparent is our success with very, very large customers. Those customers usually buy from the get-go many, many use cases, although the deployment is staged; they throttle up. It's not binary; they don't do everything at once just because of operational reasons. But they do have a healthy appetite, and the ACV in those clients is significantly higher than what we've seen before. When we think about it, we really want to make sure that we maintain our very large footprint in the U.S. healthcare that we had before. And that certainly seems to be the case, and they all look better and better every day and really establish a trusting, lifelong or at least very, very long relationship with those clients as we serve their needs as a partner as the need really evolves. Saying it another way, if you think about digital care delivery, it's really hard to overstate the proportion and the importance of that transformation in the proportion of business of our customers. So the net of it, it really depends on different clients. We see examples all over the spectrum. We believe it's a timing issue. Some of the larger organizations, especially payers, have the capability to deploy more and the need to differentiate faster and accomplish more. Others are a little bit more careful in that environment, but they all trend in the direction of good appetite. I'm pleased to also share that even in our smallest clients with simpler use cases, some of which we lost to transition, we see a trend of coming back as they discover the need to buy more modules that are more sophisticated. To give you more color on that, maybe to be more specific, when you look at payers, the enablement of digital-first navigation, we feel is very much in mind today. Obviously, it allows them to offer a phenomenal member experience as well as a very efficient way to route those members financially and clinically to the most appropriate physical, virtual, or automated intervention. The benefit of that is that all those modalities work in harmony around a single patient experience. When we think about health systems, as Bob mentioned earlier, we care very much about staff retention. These days, patient experience, improving efficiency, and the opportunity to diversify revenues by going beyond their catchment area and beginning to trade information and services with other segments, very often payers that they can serve. So that's another very important trend. The platform is very wide. There are many, many examples. The power of the platform is the fact that it's a single platform that serves the entire market. And really, our clients are coming up with new and innovative ways to leverage that, that trend is likely to greatly accelerate and expand going forward. To net it all, we believe that we are in the very early innings in the very early days of realizing the potential of the same-store growth with our existing customers.

Our next question will come from Craig Hettenbach with Morgan Stanley.

Can you hear me okay?

Yes, Craig, good to see you.

Craig, yes.

Great. Apologize for the audio issues before. Just wanted to follow up on the comments around ACV and the growth that you saw this year, particularly as you kind of play out this year and going forward, just how you're thinking about the momentum behind ACV in any particular modules that you would call out, whether it's an update on the behavioral health side or saying that you feel the most, where you're seeing the best customer response?

Well, just on the ACV side, Craig, I'll just take a little bit on ACV and then Ido can address maybe some of the specifics around modules and behavioral. But we did see, especially on the health plan side, very nice growth in ACV driven actually both by existing customers taking more, so same-store sales, and new logos. And so that's very much in line with our plan and what we expect going forward. On the health plan side — I'm sorry, on the health systems side, it's a little bit more complicated of a story, still a nice tick-up there, but there are a number of moving pieces on the health systems side. We had some benefit from consolidating a full year of revenue from SilverCloud and Conversa for their customers on the health systems side. We also, unfortunately, did see some churn at the low end, as we've said a number of times here, and Ido did mention that we're starting to see some come back, but that did impact positively because we lost some small inputs to the average ACV there. So puts and takes there, and obviously, some movement around upsells as well was helpful, but it netted out to a reasonably attractive growth on the ACV side for systems. And again, we expect with bookings and revenue growth on the health systems side, the bookings more this year driving revenue growth in the second half and into next year that also tick up. So, we expect growth on both. It's a key driver for revenue growth for us, along with new logo signings. And so I think that's really, I think, an explanatory around the movement this year. Ido, if you want to provide some color around where that growth is coming from, from a module perspective?

Absolutely. So essentially, there are many areas of unmet need for U.S. patients or really patients around the globe. Our unique approach is not to try to fix it with the service ourselves, but rather to enable the connectivity to the trusted sources of care and empower them to focus their time significantly more efficiently. You raised a really important therapeutic area, which is behavioral health, and unfortunately, we see a full-fledged crisis now in the United States that drives different types of demand, including a rise in out-of-pocket DTC payments for different modalities of care with mixed results. We have a clear vision on how this should play out, but essentially, the method is similar to any other therapeutic area that we enable, which is to take the — to leverage the trusted providers that we know are integrated into our normal main path of care and just allow them to be dramatically more effective. So a good example, case in point, is SilverCloud that we acquired last year. SilverCloud, as you may remember, was able in the U.K. to dramatically increase the ratio between the number of therapies and the number of patients that they can care for more than fourfold— more than 4x. And as a result, a dramatic decline in the cost per intervention. And we did that not by hiring an army of psychiatrists and psychologists, but rather empowering the existing therapists to be much more effective with their time by automating a lot of tasks. That's the Amwell way in many ways. We see very strong demand for behavioral health enablement and efficiency, and we definitely believe, as you rightly guessed, that this is going to be a very high-demand module as Converge is being deployed this year. There are many other examples beyond the plans we have out there.

And our next question will come from Jack Wallace of Guggenheim Securities.

Just want to ask the ACV question as it relates to the guide just a little bit differently. It sounds like you don't expect many new logos this year. Is this expansion in the client base here? Within that expansion, my sense is that this is mostly upsells versus, say, intensity of use or your clients using the core platform across whether it's more facilities or more settings. Is that the case?

Not at all. I'm not sure how you got this impression; we maybe weren't clear enough. We see extraordinary demand for Converge by both existing clients and new ones. The decision to migrate is not an obvious decision. It takes time and integration, training, and things of that nature. The fact that in these uncertain times, we see such strong adoption for the new platform is very encouraging. But CVS definitely was not alone as the new organization that understood the value of the Amwell, the new Amwell platform, and we definitely plan to see others. The guidance is focused on revenues, not on bookings. We definitely see that as a year of significant acceleration as it relates to bookings, the recognition of which is dependent on various factors, including the macro and the pace of our customers that we need to be careful in predicting. But I would love for all of you to be with us to hear what the Converge clients are saying these days in the level of enthusiasm and encouragement, and that's true not only for existing customers but definitely true also for new ones.

And our next question will come from Hanna Lee with Bank of America.

This is Hanna Lee on for Allen Lutz. I was just wondering if you can provide additional color on the composition of revenue growth for 2023. Is it primarily coming from subscriptions or visits?

We — Hanna, thanks. We provided guidance for visit — for the number of visits that we expect for AMG, for Amwell Medical Group. So you'll see that, that is fairly conservative relative to what we posted this past year, primarily because we don't want to aggressively assume that we again see COVID spikes as well as early and severe flu in 2023. So I think we've been conservative there. And then, on the — I guess, we would expect — I would give a little bit of guidance that we would expect our software line item, subscription revenue, would grow faster than the overall revenue growth that is assumed for the entire organization. So I think that gives you a sense as to, I guess, what's going to drive and what the components of it look like.

And our next question will come from Jailendra Singh with Truist Securities.

This is Jay on for Jailendra. I want to discuss CVS. It’s clearly a significant implementation, so could you elaborate on the contribution assumed in your guidance? Additionally, how has the rollout been so far, and what opportunities do you see for CVS in other areas?

Sure. As many participants know, we are careful not to discuss our customers in detail. We are an enablement platform that helps our customers achieve important business goals, and they typically share updates when they are ready. CVS has mentioned that we play a significant role in their large cost-saving initiatives for digital care enablement, and we are very appreciative of that. Our relationship with them is strong, and we are optimistic about future growth and expansion. More broadly, for many of our larger clients, our business model begins with a start-up recurring fee, and as we gain traction, increase usage, and access larger addressable audiences, our value and revenue grow as well. This business model has proven effective. The potential for CVS to expand within its existing large footprint and positively impact the broader ecosystem is significant. However, we cannot make any automatic assumptions. Our guidance is carefully crafted based on factors we have high visibility into; it reflects what we believe is very likely to occur. While we see considerable upside potential, we cannot precisely predict the timing and revenue recognition outcomes.

And our final question will come from the line of David Larsen with BTIG.

It's my understanding that Converge is a very comprehensive platform. It is a full digital-first solution. That's one of the reasons why CVS selected you to be one of their key vendors going forward. I agree with that strategy. Can you maybe talk about how many sort of different kinds of modules beyond sort of pure telehealth are now part of Converge? So like, is there like diabetes, cholesterol, and mental health? Are there maybe like 10 or 20 additional sort of digital health modules that have plugged into Converge? And then is there a higher price point depending on how many different modules your clients select? And just any color around sort of the incremental revenue contribution for those would be very helpful.

David, you're absolutely correct. There are really two things here to bear in mind. One is Converge is indeed a platform, and it's a very open platform. It's designed to really bring together the patients, providers, and other participants around the entire spectrum and types of care that are physical, virtual, and automated, but also across the entire care continuum in an integrated way; so it's quite a task. Obviously, we don't expect ourselves to offer all those services, nor do we think that's the right way to go at all. But rather, we are enabling the connectivity, the integration, the orchestration more than anything else. In that way, Amazon is much closer to Amwell than Epic, for example, in the way that we operate. Converge is very easily open to third-party, whether it's medical devices or different types of programs and so on. We don't count them anymore if they are in the hundreds of more of those packages, if you will. Many of them are made not by Amwell. They're made by the likes of Sword and TytoCare and the Cleveland Clinic and really many, many other entities that want to participate in the integrated experience. The integrated experience is extremely important for our buyers. CIOs today struggle with enormous fragmentation, and everybody else is suffering, including patients and providers by needing to log into multiple apps and services; these are often not connected, the source of errors and cost in customer acquisition and in other ways. As we grow, we definitely plan to include some anchor applications, some services like automated vehicle health, which we think are very, very important, or a second opinion through our JV with Cleveland Clinic is a great example and use case for the ecosystem. But we fully expect a really limitless amount of programs and services to be offered by others. We definitely plan to monetize the value of integration, both by the impact it has on risk bearers on the one hand — and that's the important part — but also by allowing access to different vendors and innovators that really dramatically reduce their entry point into the covered services in the audiences that our clients represent. I hope that's a little bit clear.

And that will conclude today's question-and-answer session. Ido Schoenberg, I turn the call back over to you.

Thank you very much, operator. Thank you very much, everyone. We really appreciate your support of Amwell and our journey to Converge. We look forward to talking to you again soon. Have a nice evening.

And this concludes today's conference. Folks, you may now disconnect.