Astrana Health, Inc. Q4 FY2020 Earnings Call

Greetings and welcome to the Apollo Medical Holdings Fourth Quarter and Year End 2020 Financial Results Conference Call. At this time all participants are in a listen-only mode. A brief question-and-answer session will follow the formal presentation. (Operator instructions were provided.) As a reminder, this conference is being recorded. It is now my pleasure to introduce your host, Investor Relations Representative.

Thank you, operator and hello, everyone. Thank you for joining us. The press release announcing Apollo Medical Holdings Inc. results for the fourth quarter and year ended December 31, 2020 is available at the investor section of the company's website at www.apollomed.net. To provide some additional background on these results, the company has made a supplemental deck available on its website. A replay of this broadcast will also be made available on ApolloMed website after the conclusion of this call. Before we get started, I would like to remind everyone that this conference call and any accompanying information discussed herein contains certain forward-looking statements within the meaning of the Safe Harbor provisions of the Private Securities Litigation Reform Act of 1995. These forward-looking statements can be identified by terms such as anticipate, believe, expect, future, plan, outlook and will and include among other things statements regarding the company's guidance for the year ending December 31, 2021. Continued growth, acquisition strategy, ability to deliver sustainable long-term value, ability to respond to the changing environment, operational focus, strategic growth plans and merger integration efforts, as well as the impact of the 2020 novel coronavirus COVID-19 pandemic on the company's business operations and financial results. Although the company believes that the expectations reflected in its forward-looking statements are reasonable as of today, those statements are subject to risks and uncertainties that could cause the actual results to differ dramatically from those projected. There can be no assurance that those expectations will prove to be correct. Information about the risks associated with investing in ApolloMed is included in filings with the Securities and Exchange Commission, which we encourage you to review before making an investment decision. The company does not assume any obligation to update any forward-looking statements as a result of new information, future events, changes in market conditions or otherwise, except as required by law. Regarding the disclaimer language, I would also like to refer you to Slide 2 of the conference call presentation for further information. For those of you following along with the accompanying PowerPoint presentation, there is an overview of the company on Slide 3. On today's call, the company's Executive Chairman and Co-CEO Dr. Kenneth Sim will provide an overview of 2020 annual highlights, as well as those for the fourth quarter. The company's Chief Operating Officer and Chief Technology Officer Brandon Sim will then discuss the latest operational developments, and Chief Financial Officer Eric Chin will follow with a review of ApolloMed’s results for full year 2020. Brandon will conclude the remarks with the discussion of the company's outlook as well as its long-term growth strategy before opening the floor for questions. With that, I'll turn the call over to ApolloMed’s Executive Chairman and Co-CEO, Dr. Kenneth Sim. Please go ahead, Dr. Sim.

Thank you. Good afternoon to all of you. And thank you for joining us to discuss ApolloMed’s fourth quarter and year end 2020 results, particularly as this is the company's first earnings call. With the help of everyone within our organization, we continue to do everything that we can to make sure our members are receiving the highest quality, the most cost-efficient care they have come to associate with ApolloMed. This is our first earnings call. We wanted to take a moment to answer the question: What does ApolloMed do and how are we different from other healthcare providers? I will turn it over to Brandon to go over the answer. And I will return to discuss highlights for the 2020 fourth quarter and the year. Brandon?

Thank you, Dr. Sim. To summarize, ApolloMed is a physician-centric, technology-powered, risk-bearing healthcare management and delivery company focused on operating an integrated value-based care model. That's quite a mouthful, so I'll break it down a little. Physician-centric: this means that we believe that doctors are the quarterbacks of the healthcare system. They're the ones that hold the power to advocate for you, the patient, as best as they can. And by providing them with the tools and technologies that make their jobs easier, we're able to help our contracts with decisions, provide higher quality care and better patient experiences in a more cost-effective manner. Keep in mind, our business does not rely wholly on a staff model, the way that some other healthcare organizations do, such as Kaiser Permanente or One Medical. The majority of our physicians are independent and responsible for operating their own practices. But they're often exclusively contracted to work with ApolloMed through our affiliated IPAs or Independent Practice Associations. In that way, we serve as a platform for our over 7,000 providers. Technology-powered: healthcare and its delivery, as we all know, is fundamentally broken. And it's our driving mission here at ApolloMed to solve this problem. We believe that a key way to address very tough problems surrounding access-to-care, cost-of-care, inefficiency and waste in the healthcare system and a whole host of other problems is through the smart and domain-adapted use of technology. Technology is what allows us to manage care effectively, perform value-based care that puts patient outcomes first, and scale our platform nationwide. And as our technology platform improves and learns through our machine learning and artificial intelligence methods paired with our clinical expertise, its quality and impact will only accelerate, furthering our mission to fix healthcare for all. Finally, the risk-bearing part of the model: with our risk-bearing model ApolloMed takes on the risk of the patient through our consolidated IPAs, which means that we're allocated a certain amount of dollars per patient from various healthcare payers and charged with meeting that patient's healthcare needs. This model enables us to incentivize our contract physicians to deliver the best care in the most cost-efficient manner possible. Doctors want to work with us and be a part of our platform, because we've aligned their financial incentives with patient outcomes and because we provide them actionable suggestions for improving patient care. In addition, those that surpass certain measures for quality even have the opportunity to partake in the savings we generate or earn additional financial bonuses. So not only do we provide our doctors with the technologies and tools to ease their administrative burden and help them deliver better care, but we also offer the benefit of additional financial incentives if they do well by their patients. Caring for patients is a doctor's passion, and we really want to help them do that to the best of their ability. I’m proud to point out that we have a proven track record of managing this risk profitably over large populations. Thanks for sitting with me as I introduce ApolloMed. Now I'll turn it back over to Dr. Sim to discuss ApolloMed’s results.

Thank you, Brandon. We had a milestone year in 2020, which is particularly notable given the circumstances we were all operating under. We repeat all of our previously provided guidance matrix, even those that we raised when we announced our third quarter results, as well as analysts' estimates for the year. For 2020, the company achieved total revenues of $687.2 million, which is a 23% increase from $560.6 million in 2019. A net income attributable to ApolloMed of $37.9 million, which is a 168% increase from $14.1 million in the prior year. These are noteworthy numbers for the company and were a result of three items. Firstly, Next Gen ACO's phenomenal achievement in the 2019 performance year, for which we recognized a $19.8 million positive impact from a shared savings settlement to the top line in Q3 of 2020. Secondary contributions from IPA acquisitions we made in 2019. And thirdly, from organic growth. We reported EBITDA of $203.5 million in 2020 compared to $46.8 million in the prior year. An adjusted EBITDA of $126.5 million, which is a 70% increase from $74.5 million in 2019. I would like to place greater emphasis on the adjusted EBITDA figures, as these numbers back out the impact of excluded assets, which primarily included two line items: one, real estate assets that generate some rents; and two, a small health plan called Brand New Day that was sold in early 2020. Adjusted EBITDA also backs out the impact of equity method investments, recently acquired IPAs that we are continuing to integrate into our organization and provider bonus payments. On the bottom line, we benefited from a trend of decreased utilization across our organization due to the pandemic, particularly in the first half of the year, which resulted in $25.1 million in savings from medical claims and expenses. And we're also beginning to see some of the benefits of our proprietary technologies and platform as total operating expenses increased 15% a year, while we grew our top line by 23%. As our results demonstrate, our business model has proven to be very resilient in the phase of the pandemic. For full year 2020, over 81% of ApolloMed’s revenue was capitated and as such was not affected by COVID-19 or the lower demand for services by patients. Further, the sub-capitated providers do not expect an increase in expenses; they're not heavily exposed to payor surface income that is affecting other healthcare companies and there have been minimal disruptions as many of our providers have moved to telehealth for appointments. I'm proud of our team's ability to adapt, as we quickly transitioned our workforce to work from home while remaining 100% operational and not materially affected in any way. We believe that the shift from volume to value-based care will continue and our resilience throughout 2020 is a testament to the stability of the capitated model and the viability of a pure-play value-based care model, which is essentially what ApolloMed operates. Finally, I would like to thank our committed and highly engaged team members. We believe we have developed a highly scalable model for the cost-efficient management and delivery of high-quality healthcare that are well positioned to meet our goal of nearly doubling our lives under management to approximately 2 million in 2021. In that regard, we recently announced the promotion of our Chief Technology Officer and Interim Co-Chief Operating Officer, Brandon Sim, to Chief Operating Officer. Brandon will continue in his role as Chief Technology Officer as well, but given his leadership in strategy and operations, as well as his impressive work in developing the company's technology platform, we're proud to promote him to the COO role. We’re excited for his continued leadership. Last week, we also announced the appointment of Dr. Jeremy Jackson to the newly created role of Chief of Staff. Jeremy will work closely with the executive team and play a key role on special projects for ApolloMed’s technology platform, business development, strategy, and operations. Having first-hand experience as a practicing physician and as a consultant to various companies within the healthcare space, Jeremy is no stranger to the challenges facing today's healthcare providers. I am confident his contributions will be extremely valuable as we work to prioritize and execute on our growth initiatives. With that, I will turn it over to Brandon for an update on our operations and developments in our proprietary technology solutions. Brandon.

Thank you, Dr. Sim. We recently announced that our wholly-owned subsidiary APACO, which has participated in CMS’s Next Generation ACO model since 2017, generated $37.3 million in gross savings for the 2019 performance year. This resulted in $19.8 million in shared savings from CMS. APACO was among the top performing Next Gen ACOs in the country out of 37 in both gross savings amount and gross savings percentage. This phenomenal performance had a notable positive impact on our financial results for 2020, contributing $19.8 million to our top line and $13.3 million to our bottom line. Keep in mind, our Next Gen ACO only serves approximately 29,000 members out of over 1.1 million members we manage. We participated again in the Next Gen ACO model in 2020, but will not be seeing results for that performance here for several months to come. And we continue to participate in this model in 2021. Many of you are aware that CMS is exploring different direct contracting models as a shift toward value-based care continues. We are participating in the application process for the new DCE or Direct Contracting Entity global model and are optimistic about our prospects given our Next Gen ACO's phenomenal performance. We also announced in late January of 2021 a strategic alliance and investment in New York-based CAIPAMSO whereby we will own 30% of the post-closing total interest in CAIPAMSO on a fully diluted basis. With this partnership ApolloMed will be bringing its proprietary technologies to benefit CAIPA’s physicians. The strategic alliance will provide ApolloMed with a low-risk entry foothold in the State of New York with the possibility of expanding the relationship down the line. CAIPAMSO provides management, consulting, administrative and other support services to professional healthcare service providers, including CAIPA, a leading IPA serving the Greater New York City area. With over 1,000 private practice providers covering over 70 specialties, CAIPA's provider network provides medical services and care to approximately 500,000 patients. CAIPA has consistently been one of the top performing provider networks in the region, both in quality and value-based performance, and we felt that their values and philosophy closely mirror those of ApolloMed. For those reasons, we are extremely excited to partner with them now and going forward and we expect the transaction to close by the end of the second quarter of 2021. Moving to developments in our technology platform, as Dr. Sim mentioned, one of the keys to successful outcomes is our proprietary technology platform. The U.S. healthcare system is fraught with inefficiencies and redundancies creating expensive and potentially ineffective patient care. It's filled with lack of price transparency, it’s filled with missed opportunities — troves of data that can be used to help patients through preventive or proactive care. And I could go on; the U.S. is not a leader in the way I'd like us to be in healthcare cost per capita. We're on a mission to fix that here. Since I joined the company in 2019, ApolloMed has invested heavily in developing a fully integrated, proprietary software platform which will enable us to not only scale our managed care model efficiently, but also increase physician and patient satisfaction as we improve our ability to deliver high-quality patient care. Our solutions address three key pain points in healthcare delivery and managed care: one, revenue cycle management; two, care management; and three, population health including quality and risk management. What really sets us apart from the technologies of other health care companies is our team of expert technologists and our approach to development. We're combining our deep understanding of value-based healthcare from a clinical perspective with the latest software engineering, machine learning and artificial intelligence methods. The true partnership between our engineers and scientists, as well as our healthcare providers across the spectrum, ranging from billers and coders to nurses, PCPs, specialists and hospitals and more. Our investment in combining domain-specific expertise with algorithmic expertise has already paid dividends. We've created automated rules-driven technology solutions that process medical insurance claims in an automated fashion. As of a recent month, over 80% of the claims received for IPAs are processed in a fully automated fashion, meaning that doctors are paid faster and more accurately, while lowering our operating costs. We've also created a care management tool that seamlessly integrates across the managed care ecosystem. We have a provider-facing platform as well that not only eases the revenue cycle management process for providers, but also helps them improve on quality and focus on patient outcomes. These proprietary tools are key to lowering clinical and financial costs, as well as supporting profitability of our value-based care systems as we scale our patient and provider base nationwide. The solutions have already saved ApolloMed millions of dollars in annual operating expenses, and the benefits of our technology platform will only become more and more obvious in future quarters as our operating margins improve and as the platform learns and grows. We are committed to continuing to develop these technologies going forward as we intend to maintain our leadership position in the space and ensure the scalability required to support our rapid growth. I'd like to also add that our proprietary technology platform presents a long-term opportunity as well with the potential to be licensed in a software-as-a-service or SaaS model. At this time, we are focused on providing value to our existing MSO clients and partners, and continuing to invest in building the best platform possible to ensure scalability and patient outcomes. I look forward to providing feature updates on our platform as we progress. With that, I'd like to turn it over to Eric to review our financial results.

Thank you, Brandon. And thank you all for joining us today. As I run through the results for the full year of 2020, you'll see that we delivered strong year-over-year growth and that our model has proven stable and predictable over the course of a pandemic. As a reminder, we do have a supplement available on our website www.apollomed.net/eventspresentation, which may be helpful as I take you through the numbers. Let's walk through our results for the full year of 2020. We reported record total revenue of $687.2 million, a 23% increase from $560.6 million in 2019. As Dr. Sim mentioned earlier, this was primarily driven by three things. One, a shared savings settlement of $19.8 million earned from ApolloMed's participation in an aspiration-based risk sharing model through its Next Gen ACO. Two, the acquisitions of Alpha Care IPA and Accountable HealthCare IPA in 2019, which contributed an additional $52.4 million and $29.0 million in capitation revenue respectively. And three, organic revenue growth. Capitation revenue of $557.3 million represented 81% of our total revenue, no change from 2019. In terms of membership, we ended the 2020 year with over 1.1 million managed lives, an increase of 15% compared to 980,000 lives a year ago. Taking a closer look at our membership, 558,000 or approximately half of our members were fully capitated through our consolidated IPAs. Total operating expenses were $606.7 million in 2020, an increase of 15% from $528.2 million, and that was primarily due to a full year's worth of operating expenses coming from Alpha Care IPA and Accountable HealthCare IPA, which we acquired in June 2019 and September 2019, respectively. Alpha Care IPA and Accountable IPA had increases in costs of $52.2 million and $28.0 million respectively. Net income attributable to ApolloMed was $37.9 million, also a record for the company, and that was an increase of 168% from $14.1 million in 2019. Our earnings per share on a diluted basis were $1.01 per share compared to $0.39 per share in 2019. Adjusted EBITDA, which excludes the impact of equity method investments and recently acquired IPAs' other income and provider bonus payments, was $126.5 million compared to $74.5 million in 2019, a 70% increase year-over-year driven by the significant increase in net income. Turning over to the balance sheet, we are well positioned with the capital resources needed to execute on our growth initiatives. We ended the fourth quarter with $193.5 million in cash and cash equivalents, a notable increase from the $103.2 million we had at year end 2019. Our working capital remains steady at $223.6 million, unchanged from the end of 2019. Total stockholders’ equity increased to $330.9 million at December 31, 2020 from $192.3 million at December 31, 2019. Moving further down the balance sheet, total net debt at the end of the fourth quarter was $245.7 million. We are safely in compliance with our debt covenants, with consolidated total net leverage ratio of 1.64 times compared to the maximum permitted 3.50 times and a consolidated interest coverage ratio of 13.91 times compared to the minimum permitted 3.25 times. I'd now like to turn it back over to Brandon for a discussion of our growth strategy and outlook for the remainder of 2021. Brandon.

Thanks, Eric. When it comes to our growth strategy, we have laid out our plans for geographic and membership expansion over the course of this year and beyond. We currently manage over 1.1 million lives and we plan to grow this number to approximately 2 million in 2021, both within the State of California where most of our managed lives reside as well as in other geographies and primarily through an M&A strategy supported by organic growth in our existing markets. The CAIPAMSO strategic alliance and investment was a small first step forward in this expansion plan. We have a robust M&A pipeline and continue to seek like-minded physicians to join our managed care and population health platform. We believe that the continued shift towards value-based care nationwide, as well as the demonstrable quality we've produced in terms of clinical and financial outcomes, provide a very strong tailwind for expansion efforts. All this brings me to guidance for 2021, which is listed on Slide 11 of our supplement. We are providing the following guidance ranges for the year ending December 31, 2021. We anticipate revenues of between $690 million to $710 million, net income of $50 million to $60 million, net income attributable to ApolloMed of $35 million to $45 million, EBITDA of $95 million to $105 million and adjusted EBITDA of $115 million to $125 million. Keep in mind that our 2020 net income and EBITDA included approximately $99.6 million of gain on the sale of a small health plan called Brand New Day, which was sold in early 2020, which ultimately benefited our affiliated IPA, Allied Pacific IPA, and had no effect on net income and adjusted EBITDA attributable to ApolloMed shareholders. Our 2020 net income and EBITDA also included $25.1 million in savings for medical claims and expenses as a result of decreased utilization during the COVID-19 pandemic. We do not expect that to repeat this year. This explains the significant difference of the 2021 guidance versus our 2020 results. Additionally, our guidance does not take into account any potential acquisitions or other major business transactions we may complete over the course of 2021. We are committed to remaining open and transparent on any new material developments and we'll re-evaluate our guidance as appropriate as the year progresses. We believe that we are well positioned to capitalize on shifting industry dynamics and are committed to continuing to serve the members in our communities. In addition, we're also placing a stronger emphasis on our IR efforts and increasing awareness of our story. Not too many people are going out on the road anymore these days, but we have several conference presentations coming up, one of which is tomorrow at the Barclays Global Healthcare Conference. It is a virtual event, and we welcome all of you to listen in. With that, operator, let's open it up for Q&A.

Thank you. We will now be conducting a question-and-answer session. (Operator instructions were provided.) Our first question comes from Gene Mannheimer with Colliers. Please proceed with your question.

Thanks. Good afternoon, and congrats on a strong year and your inaugural earnings call as well.

Thank you, Gene.

Yes. Gene, good to hear from you. And to answer your question, this is one of those situations where COVID-19 has impacted our numbers due to a decrease in hospital utilization during the year that drove shared savings with our hospital risk pool partners. And that's driving the revenue increase for the fourth quarter there.

So should we assume that where the impact of COVID tapers off this year that we should not expect that type of risk pool settlement going forward?

Yes, great question, Gene. So the COVID-19 question is probably one of the biggest debates that we have here in terms of our modeling. And really, from a management perspective, the way that we've forecasted it and we're looking at it is looking at our internal data from last year throughout COVID-19. Barring any re-infection in 2021 and assuming that the government's vaccination plans go according to plan, we see the claims creeping up and we're forecasting the claims to be creeping up in early 2021 with it kind of getting back to close to pre-COVID levels in the middle of 2021, say June, July timeframe.

Okay. All right. That's helpful to understand. Thanks, Eric. And in terms of your EBITDA guidance for the current year, which is above our estimate, does that include or contemplate anything from the shared savings settlement that you would typically see in the second half? Is that included in this guidance or is it all organic?

Yes. So in our 2021 guidance, we have included something for ACO shared savings settlement based upon our internal analysis of the claims data that we received from CMS. So it's completely our own estimate, but we've modeled out an amount that is consistent with the prior year.

Okay. But it's unknown currently whether that would hit in the third quarter or the fourth quarter, right?

Correct. That all depends on the settlement process with CMS, which if we use the history tends to come in late September, early October. And so unfortunately, it kind of bridges that quarter cut-off there.

Right. Okay. That's great.

Quick point here Gene. While as Eric mentioned earlier, there are internal estimates of the shared savings included in the guidance, we want to emphasize that our guidance is conservative and does not factor in the impact of any acquisitions or other major business transactions that may or may not be completed over the course of 2021. So just to get a sense, just a level set on what is included and what isn't in the guidance that we provided so far.

Okay, good. Good to hear. So the guidance is really organic with the exception of the shared savings settlement, which is organic, but you're not anticipating acquisitions in your modeling here. How about on that note, regarding the type of investment as I understand that, at this point, with that relationship, you're not in the business of managing care or lives of that half million lives, but rather, you're taking an interest in just the administrative side? What does that do for you from a financial perspective in terms of revenue and EPS that it brings?

Yes, that's a great question, Gene. Just goes back to your earlier question really quickly. So what is included in the guidance is some of our internal estimates of shared savings as well as the claims impact due to the—hopefully—the recession of COVID in quarters three and four, as Eric mentioned, but not any acquisition. So just to be clear on that point. And then to answer your most recent question regarding the effect of CAIPAMSO on our financials, that deal has not yet closed. We anticipate that we close in Quarter 2 of this year as previously guided. Upon closing, as you mentioned correctly, it is a 30% fully diluted interest in the administrative services provided to CAIPA. We can model that similarly to the way we model our MSO lives currently, in our network medical management wholly-owned subsidiary. It will be similar to that in terms of impact on financials and is a management company that manages around 500,000 lives. If that helps, it will look similar to our NMM line of business. Whether that consummates to something greater is something that we are currently working on but are not at liberty to share. We'll definitely keep the investor community updated as we get more information.

One point there Gene: it will not have any impact to top-line management fee income. It will show up as investment income because it's a 30% minority investment.

I got you. Right, right. Okay, good to know that. And then last thing for me and I'll jump off here: you mentioned early on that you are applying to participate in CMS’s innovation model, I guess the Direct Contracting Entity? Can you discuss the timing for that, and what the impact of that might have on your business? Thank you.

Thank you, Gene. This is Brandon Sim. So the timing is such that we are applying for January of 2022. Currently, we are completing our current contract with CMS's Next Gen all-inclusive model, taking risk in Part A and Part B until the last day of December 2021. That will, we hope, be a smooth transition into the DCE model beginning January 1, 2022. The impact of that is two ways to look at it, Gene. The Geo model, which is a subset of the DCE, continues to be considered. With a new administration coming in and the new Director of CMS, after her review of the Geo model, if she agrees to continue with it, we are looking forward to hypothetically doubling or tripling our benchmark with CMS, because this Geo model allows us not only access to a broader claim base of patients, it allows us to actually go out and recruit members with a number of waivers—six or seven of them—giving us the ability to proactively contact patients to recruit them into the Geo model. If the Geo model is not approved, then we will just be in the regular global risk model, the professional model with CMS, and that would at least allow us to keep the 30,000-member benchmark as we had in prior years, but the growth potential might not be as tremendous. So that's kind of where we are at. Minimally, we'll continue with the 30,000-member benchmark, or we may have a great opportunity to double or triple membership if the Geo model, which is a subset of the DCE, prevails. So I hope I've answered the question, Gene.

Yes, very good color. Thanks, Dr. Sim. And I'll jump out and maybe catch up with you a bit later. Thank you.

Thank you, Gene. I look forward to talking to you soon.

Thank you. (Operator instructions were provided.) There are no further questions at this time. I'd like to turn the floor back over to management for any closing remarks you may have.

Hi, everyone. Thank you all for your time today. I want to close by extending a special thank you to our providers, support staff and all of our team members and employees. At ApolloMed, we realize that a lot of us continue to deal with the fallout of the COVID-19 pandemic even a year later. And as a healthcare company, we are doing all that we can to be part of the solution in bringing us out of this pandemic. We really appreciate everyone's support, and look forward to speaking to all of you on our next quarterly call. If anyone has any additional questions, please feel free to reach out to us or our investor relations firm at Equity Group. Thank you.

Thank you. Ladies and gentlemen, this concludes today's web conference. You may now disconnect your lines at this time. Thank you for your participation. And have a great day.