Earnings Call Transcript - ELV Q1 2020

Operator, Operator

Ladies and gentlemen, thank you for standing by and welcome to Anthem First Quarter Earnings Conference Call. At this time, all participants are in a listen-only mode. Later, we will conduct a question-and-answer session. As a reminder, this conference is being recorded. I would now like to turn the conference over to the company's management. Please, go ahead.

Chris Rigg, Vice President of Investor Relations

Good morning and welcome to Anthem's first quarter 2020 earnings call. This is Chris Rigg, Vice President of Investor Relations. And with us this morning are Gail Boudreaux, President and CEO; John Gallina, our CFO; Pete Haytaian, President of our Commercial & Specialty Business Division; and Felicia Norwood, President of our Government Business Division. During the call, we will reference certain non-GAAP measures. Reconciliations of these non-GAAP measures to the most directly comparable GAAP measures are available on our website at antheminc.com. We will also be making some forward-looking statements on this call. Listeners are cautioned that these statements are subject to certain risks and uncertainties, many of which are difficult to predict and generally beyond the control of Anthem. These risks and uncertainties can cause actual results to differ materially from our current expectations. We advise listeners to carefully review the risk factors discussed in today's press release and in our quarterly filings with the SEC. I will now turn the call over to Gail.

Gail Boudreaux, President and CEO

Good morning and thank you for joining us. Across the globe and right here at home we're facing a critical humanitarian crisis. All of us are impacted and our hearts go out to those struggling. I will focus my comments this morning on the impact of the COVID-19 global health crisis on our business along with the actions we've taken to provide support and relief. I will direct you to the earnings released for the financial results for the first quarter. Let me begin by saying how incredibly grateful I am to the men and women including many of Anthem's own clinical associates fighting in the frontlines of this healthcare crisis from small rural communities to the heart of New York City. I am also incredibly proud of the more than 77,000 Anthem associates who have been providing compassionate and tireless support for our customers, members, care providers and communities each day as we battle this pandemic together to ensure the safety and health of our associates and support the nationwide efforts to contain the virus. In March, we began transitioning our employees away from offices and now have nearly 99% working safely at home. In recognition of these unprecedented times, we are offering our associates up to 80 hours of additional paid leave providing online workouts, expanding mental health support and have increased our Anthem Cares Emergency Relief Fund to help associates manage through this crisis. Anthem has long served and met the unique needs of our local communities. Our commitment to improving lives and communities is core to our mission and we have approached our response to the COVID-19 pandemic with a local and personal lens. Anthem along with our association of 35 other independent and locally operated Blue Cross and Blue Shield companies have committed nearly $3 billion to ensure that more than 100 million Americans along with care providers and hospitals have access to the resources and support they need to help improve the health of America. Because of our strong blue brand and deep local roots we were well-positioned to work quickly and seamlessly with local, state and federal officials, local care providers, key customers and community partners from day one of the pandemic. And our associates are at the forefront of our comprehensive efforts. Our Anthem culture and values serve as our foundation for giving back in our local communities. Our deeply committed associates have been giving back in various ways such as online teaching, outreach via phone or mail to those isolated at home, making masks for non-healthcare industry workers, helping to provide personal care supplies and providing meal delivery to those homebound by the crisis across the country with partners like the American Red Cross, Boys & Girls Club, Feeding America and Americares. Anthem is on the forefront of delivering relief and support to those most impacted. We know there is great fear and uncertainty among consumers right now, particularly when it comes to safe and affordable access to care. We've removed barriers to care by waiving costs for treatment of COVID-19 including coverage for testing, treatment and inpatient hospital stays. We've waived prior authorizations for COVID-19 diagnostic tests and related covered services as well as ensured continuity of care by waiving early prescription refill limits on 30-day maintenance medications and encouraging the use of 90-day mail-order benefits if applicable. We've also expanded access to Telehealth and nurse lines for both medical and emotional health to meet the growing needs for 24 by 7 information, support and care. For our most vulnerable consumers in Medicare and Medicaid we've also reinforced our long-standing focus on social drivers of health to provide support with food, housing, transportation and more. From outreach to isolated seniors and families to donating meals and other needed personal care items, we are working to ensure our members' needs are being met, that they realize they are not alone in this fight against the virus. Our associates working with these populations are demonstrating their endless compassion and care during this time as well. We've seen examples of our team members personally delivering boxes of food and much-needed supplies safely to our members in dire need. Their commitment is inspiring but not surprising; this is how Anthem shows up every day to serve others. At the core of the crisis there's been tremendous focus on the need for testing and no bigger push for that testing than in the crisis epicenter of New York City. There we've partnered with the coalition of Asian American IPA to provide free mobile testing in the five boroughs across the city. We also established the Anthem Medical Associate Volunteer Program for associates with professional medical training and licensure, the volunteers at hospitals and other clinical settings in a variety of states including New York where the needs are so great. Our clinical associates are demonstrating Anthem's strong values and commitment to service as they stand fearlessly on the frontlines to deliver critical care. As Anthem's care provider partners continue their important work in local markets across the country we have simplified policies designed to help them deliver care to patients more quickly and effectively. Unless otherwise required under specific state and federal mandates, we have suspended prior authorization requirements for patient transfers and use of medical equipment critical to COVID-19 treatment. Additionally, Anthem is covering respiratory services for acute treatment of COVID-19 along with in-network and out-of-network coverage for COVID-19 laboratory testing. The actions we've taken are ensuring that healthcare providers are focused where they need to be with their patients. Partnerships are foundational to our work in Anthem. Today we're partnering with XPRIZE and other industry leaders to form a global pandemic alliance to combat COVID-19 and leverage learning to help prepare for future pandemics. Across the digital landscape, Anthem has been collaborating extensively with various state and federal partners as well as other private sector partners to innovate and help simplify the entire healthcare system experience through the use of technology. Anthem's digital-first capabilities are proactively addressing issues with COVID-19 to simplify healthcare for consumers. Our Sydney Care mobile app and the new Coronavirus assessment tool are helping people safely and conveniently assess their risk of having COVID-19, locate testing sites as may be needed and connect directly with a doctor via our virtual care solution. To date, we've seen more than 170,000 downloads of the app and witnessed a 250% surge in virtual care engagements via text and video. This crisis has made clear that Telehealth and virtual care will continue to be a key component of how and where care is delivered going forward. Our employer partners are certainly feeling the impacts of the crisis. Anthem is working closely with our customers to ensure not only the safety and well-being of their employees but to also provide affordable, flexible payment terms as they work through the financial implications of COVID-19. We recognize this action may add payment risk to our business. We also know it's the right thing to do. The economic impacts of the crisis may also drive an unprecedented shift in consumers from the employer market into our Medicaid and ACA segments. We are quickly reallocating resources as may be needed to meet these potential challenges. In the small group market, a segment especially vulnerable to disruption, we are proactively identifying groups at risk and providing more affordable product offerings. We're helping displaced members find coverage in the individual marketplace or in Medicaid. Anthem entered 2020 in a position of strength, ready to achieve our financial objectives and serve as a trusted partner in health. Our first quarter performance was in line with our expectations and while we know COVID-19 is likely to produce unforeseen challenges both short and long term, we also see tremendous opportunities to reimagine what's possible for our company and healthcare more broadly. While there is much uncertainty as you saw in our press release, we are maintaining our 2020 EPS guidance. We view this as the most reasonable posture given the multitude of offsetting factors across our diversified business. In a moment, John will discuss the financial scenarios underlying our guidance decision in greater detail.

John Gallina, CFO

Thank you Gail and good morning. My objective today is to share with you the actions that we've taken to enhance our liquidity and strengthen our already solid capital position as well as sharing some of the scenarios that form the basis of our outlook, but first I'll briefly review our first quarter results which were both strong and largely unaffected by the current crisis. This morning we reported first quarter GAAP earnings per share of $5.94 and adjusted earnings per share of $6.48. Medical membership totaled 42.1 million members as of the end of the quarter, an increase of 1.3 million lives year-over-year and 1.1 million lives sequentially, in part through the acquisitions of local Medicaid plans but also aided by our strong organic growth. Medical cost in the quarter were well controlled and slightly better than expectations. As anticipated, our individual business margin began to normalize to more sustainable levels where our Medicaid business was on track to achieve the midpoint of our 2% to 4% target margin range by year-end. Our MLR for the quarter was 84.2%, exceeding expectations. We had strong cash flow of 1.7 times earnings or 1.3 times earnings normalized for the health insurance fee while simultaneously seeing an increase of almost four days in the days and claims payable metric sequentially. Of note, IngenioRx is now a standalone reportable segment. In the quarter, operating gain in the segment was $349 million which includes approximately $75 million to $100 million that under prior segment reporting would have resided in the commercial and specialty business division. That said, IngenioRx's core performance is running slightly ahead of prior expectations. As the threat of COVID-19 began to accelerate in mid-March, we felt it was prudent to enhance our liquidity by drawing down a total of $600 million from our various credit facilities and an incremental $900 million through the commercial paper market. We are well positioned with total undrawn borrowing capacity of an additional $2.1 billion. Our total debt to capital at the end of the first quarter was 41.7%, slightly more than 150 basis points higher than if we had not taken these proactive steps in March to enhance liquidity. We will continue to closely monitor our capital position and evaluate ways to optimize our debt structure including access to capital markets. We also temporarily suspended our share repurchases beginning in the second half of March. It is clear that COVID-19 is having a profound impact on the global economy and there remains significant uncertainty around the shape and timing of an eventual recovery. We have spent considerable time evaluating various scenarios on how COVID-19 and rapidly rising unemployment will impact our financial results. Key factors we evaluated include the anticipated infection rate and hospitalization rate associated with members that contract the virus as well as estimating the number that need a ventilator or ECMO machine. The intensity and duration of the infection and the impacts on the healthcare system, unemployment rates, membership mix changes. Thus far, we have seen a slight uptick in Medicaid enrollment as a result of states temporarily suspending re-verification efforts and limited changes in our commercial business. As time goes on we expect a more significant shift of commercial group members into the Medicaid and ACA marketplace. Deferred non-emergent or elective procedures in the eventual timing of a rebound including assessing the capacity of the system and the ability to address pent-up demand. Extended payment terms and the likelihood of higher than normal bad debt expense, lower interest rates and overall capital market conditions. Higher interest expense with the increased borrowing to enhance liquidity and the impact of our decision to temporarily suspend share repurchases. Overall, we estimate that approximately 30% to 40% of our annual medical expense is related to deferrable elective procedures. As a result of deferrals we currently expect the second quarter MLR to be well below historical levels but expect an elevated MLR in the second half of the year as elective procedures return. We recognize many of you are requesting details on our expected business mix changes and the broader impact that COVID-19 on our business. Unfortunately, the rapidly changing environment prevents us today from sharing the level of specificity you would normally expect from us as a management team. We intend to regularly update the investment community as conditions evolve and visibility improves on key operating metrics. We are in uncharted territory and the future may look markedly different from what anyone expects. That said, we recognize our business is more diverse and resilient today than in past periods of economic disruption. In 2008, at the time of the Great Recession, commercial and individual customers comprised nearly 75% of our risk-based membership versus less than 30% today. We currently operate Medicaid plans in 23 states and DC and in most of our markets, we are first or second in terms of market share. This compares to operating in only 14 states in 2008. At the same time, our Medicare Advantage business is expanding and we expect strong growth for the foreseeable future. The diversity of our business today positions Anthem well to mitigate the challenges we see ahead. While the details and metrics underlying our EPS guidance will undoubtedly look different from previous expectations, based on our balanced business mix coupled with extensive modeling factoring various scenarios, we are maintaining our original full-year adjusted earnings per share guidance of greater than $22.30.

Operator, Operator

Thank you. We will go to the line of Stephen Valiquette with Barclays. Please go ahead.

Stephen Valiquette, Analyst

Great. Thanks. Good morning everyone. Let me commend you and everyone at Anthem on the work you're doing around the pandemic that you highlighted earlier and question is just around the medical reserves. I guess I'm curious if you're able to provide a little more color on the actuarial process around medical reserving for all the puts and takes related to COVID-19 and then did any extraordinary reserving impact that reported 1Q, ‘20 MLR at all? Wanted to confirm that one way or the other. Thanks.

John Gallina, CFO

Thank you, Steve. This is John. I want to clarify that our reserving philosophy remains consistent, prudent, and moderately conservative. Our reserves are based on the current understanding of claim developments. According to GAAP accounting, we cannot set aside reserves for claims that are expected to occur later in the year, which may involve accruals for pent-up demand and the use of elective or discretionary services. We’ve maintained a consistent and conservative perspective. The effect of COVID-19 on our first-quarter results and our reserve balances as of March 31 is quite minimal, as GAAP requires us to consider only what has been incurred up to the end of the reporting period. We do incorporate conservative factors to ensure that our reserves are justified, but COVID-19 has a limited influence on our March 31 reserve figures. Thank you.

Gail Boudreaux, President and CEO

Thank you for the question, Stephen. Again, appreciate your comments. We're really proud of the work that all of our associates in Anthem have done to help respond to this incredible humanitarian crisis and as John said, I just want to reiterate we've been very consistent in our reserving practices and process. Next question please.

Operator, Operator

We will go to the line of Ralph Giacobbe with Citi. Please go ahead.

Ralph Giacobbe, Analyst

Thanks. Good morning. Appreciate all the details. If the recovery is slower and costs do remain suppressed can you give us a sense of how close you are to MLR floors and potential for MLR rebates and then how that impacts or influences your thoughts around pricing into 2021 just given the timing of all this? Thanks.

John Gallina, CFO

Thank you, Ralph. Great questions. First of all, in terms of some of the MLR rebates, as you know, in our individual line of business we have earned above-target margins in both 2018 and 2019 and we expected a normalization of that to occur here in 2020. So obviously, regardless of the length or the recovery of the COVID-19 situation, I think individuals kind of have more rebates in any circumstance. In terms of some of the other lines of business, well clearly that does play a role in our modeling and in impacting really how the imbalance, inequities in the system might be handled by us throughout the year in terms of the forward view of trend. We will clearly price to the forward view of trend but we'll also have to understand the impacts on the providers, on the members, and on the customers here in 2020 and make decisions accordingly.

Gail Boudreaux, President and CEO

Thank you, Ralph. I want to build on John's comments because he covered the key points. We are closely monitoring the situation, and as you know, this is new information for us regarding how the coronavirus will affect us this year. Currently, we are still in the early stages of understanding the costs associated with treating our patients, including covering co-pays and deductibles. Fundamentally, we believe, as John mentioned, that we will consider this in our overall cost structure for our customers. Most of our business is currently one-to-one, and as the year progresses, we expect to have much clearer information to share. Thank you. Next question, please.

Operator, Operator

We'll go to the line of Matthew Borsch. Please go ahead.

Matthew Borsch, Analyst

Yes. Thank you. I'm just wondering could you just comment on how you think about the trade-off between the commercial and Medicaid membership and/or the Obamacare Exchange members in terms of well, revenues maybe more clear but in terms of the earnings mix and obviously that's going to be pretty different or I would assume for fully insured versus self-funded commercial members.

Gail Boudreaux, President and CEO

Thanks for the question, Matt. There are several aspects to consider. Our current priority is to support our customers as they navigate this crisis. Regarding our commercial membership, I'd like to break it down into individual components. It's still quite early in this process, and we anticipate some impact on our commercial enrollment due to the potential rise in unemployment. The initial stages have seen a limited effect because of furloughs. As John mentioned, our business is now much more diversified than it has been historically. In terms of membership distribution compared to the economic downturn in 2008, we have seen Medicaid expansion. We expect that around 40% to 50% of those members may enter the Medicaid market, which positions us well for diversification. Currently, all 14 of our markets include both Medicare and Medicaid, along with commercial and individual exchanges. Additionally, in 10 out of the 24 markets covered for Medicaid, we don't have a commercial presence, providing us an opportunity to impact those states as well. We estimate that about 40% to 50% may transition to the Medicaid pools while approximately 30% could move into individual exchanges where we also operate. Another opportunity arises as we collaborate with our commercial clients who are assessing the impact on their overall business. We offer various affordable options for them as they consider buy downs in different products, and we are noticing an increase in these opportunities. However, it's still early, and our primary focus is on ensuring the safety of their employees and helping them manage through this situation. That's our outlook on the enrollment breakdown moving forward, and we expect to gain more clarity in the coming months as we progress through this process. Thank you. Next question please.

Operator, Operator

We will go to line of Ricky Goldwasser with Morgan Stanley. Please go ahead.

Ricky Goldwasser, Analyst

Yes. Hi, good morning. In the prepared remarks you talked about IngenioRx and the outperformance that the core is performing ahead of your expectations. Can you just kind of like detail what the sources of the outperformance and what's looking better and also the trends in Ingenio as a result of COVID? Do you think that this is sustainable and how do you think that the business evolves throughout the year?

John Gallina, CFO

Thank you, Ricky for that question. I appreciate the opportunity to provide a little clarification on the IngenioRx first quarter results. As you know, they're a separate SEC reporting segment effective this quarter and of the operating gain earnings associated with Ingenio over $349 million. That probably differs from what some folks were thinking about the $4 billion of savings that we got from moving to the CBS contract, with at least 20% of that dropping to the bottom line and just very simplistic math would say that divided by four quarters that would be about $200 million per quarter. First of all, it's very important to note that we had transferred ASO PBM business that our commercial lock had been administering for the last few years into IngenioRx effective January 1 of this year and that added about $75 million to $100 million through the Ingenio performance, which obviously took away $75 million to $100 million from the commercial performance on a year-over-year basis. And then the rest of it was really just stronger performance. There was an impact from COVID-19. We did relax the refill too soon requirement in mid-March and we saw really a spike in scripts being filled during March that actually helped the Ingenio performance as well. So the $349 million is not run rate because as we look at the rest of the year we do expect that business mix to change with some of the impacts from the economy, Medicaid to grow and then the run rate of scripts is obviously different. We have seen a slight drop in new scripts here in April over historical patterns and so the $349 million you cannot just multiply by 4 but those are really the key factors and we're very, very happy with how Ingenio is performing and as you know this is a full year ahead of schedule that we're getting this $800 million dropping to the bottom line effective for the entirety of 2020. So very happy with the Ingenio performance. Thank you for the question.

Gail Boudreaux, President and CEO

Next question please.

A.J. Rice, Analyst

Hi everyone, I want to extend my best wishes to the entire Anthem team. In the prepared remarks, you mentioned telemedicine, Telehealth, and virtual care as changes that are likely to remain. As you observe the situation evolve, are there additional areas you think will experience long-term changes? How do you believe this crisis will influence healthcare delivery in the U.S. over the long term?

Gail Boudreaux, President and CEO

Thanks for the question A.J. and also thanks for your kind remarks. Now as we think about this again it is an unprecedented time. We did, our first focus was really to ensure that our consumers and members had access to care and we pivoted fairly quickly to virtual care. We've always had capabilities, but what we've seen is a real acceleration both through the use of our Sydney app online where people can go, check symptoms, understand where testing sites are, and we've seen a dramatic increase of people using those digital capabilities. In addition, our care providers have been able to go online and use virtual care. So it's not only just virtual console but it's also texting and communication. So as we think about this there has certainly been an increase. We do think that as we re-enter the economy obviously and restart it, we have to be incredibly thoughtful, understand what the testing is and the confidence in the economy. So I do think we're going to continue to see use of virtual care and it will continue to be an important part. It is something we started well before the pandemic but I think it also has accelerated the opportunity and people have become more comfortable with it. In addition, sort of physical health the other area that we think there’s significant opportunity is behavioral health and we've seen a big increase in the use of behavioral Telehealth. Again a capability we had; Beacon has always had this and we've expanded it as a result of the acquisition of Beacon Healthcare. One in three visits right now we're being used through virtual opportunity and we actually do see that continuing for behavioral and mental health support. So overall, I think that's one of the most interesting. The other opportunity I have is we've been working with our care providers trying to ensure that they are able to support their patients. We've seen our own teams through care more and aspire reaching out to those patients and ensuring one of our concerns is that they do get the appropriate care that they need. So our teams have been working with them both on the social supports. So I think that's another area that's really growing and as part of our Medicare Advantage plans today we do offer supplemental benefits that include many of those things. So as I think about this I think we're going to see much more virtual care. I think the social supports are going to continue to be really important behavioral health aspects not only because of loneliness which we've always known but also the use of virtual care is very important. So those are the areas that I think right now we're going to see an uptick and I think we'll see a continued one as people become much more confident in that usage. Next question please.

Operator, Operator

We will go to the line of Justin Lake with Wolf Research. Please go ahead.

Justin Lake, Analyst

Thanks. Good morning. Just a couple of quick numbers questions for me. First, can you give us an update on your Medicaid margin trajectory towards that 3% target by year end and then would appreciate any comments on your employer customers in terms of what you're seeing in April around premium collectability given what's going on in the economy? Thanks.

Gail Boudreaux, President and CEO

Great. Thanks, Justin. I'm going to ask Felicia maybe to comment on Medicaid and then I'll go to Pete Haytaian to talk a little bit more about the commercial marketplace. Felicia?

Felicia Norwood, President of Government Business Division

Good morning and thank you for the question, Justin. When you set aside COVID, our Medicaid business was on track to end the year around 3%, which is consistent with our original outlook. Our rate actions came in as expected during the quarter, and our out of period adjustments were actually negligible. So we really had a clean quarter with respect to Medicaid. When you think about our Medicaid business, over 50% of our Medicaid markets have rate actions that occur in the first half of the year. So we have very good visibility around that performance and if we look to the end of 2020 we may remain confident around ending the year at the midpoint of our target margin range of 2% to 4%.

Gail Boudreaux, President and CEO

Thanks, Felicia. Pete?

Pete Haytaian, President of Commercial & Specialty Business Division

Yes. Thanks, Justin. I hope you're well and the family is well. As Gail said, we recognized that this is obviously a really, really challenging time for our employers and for brokers and we're very focused on creating value for them. We've been in frequent communications with them on providing solutions as it relates to premium collections. This has been a topic of conversation. First, on March, March was really in line with normal months as you'd expect COVID-19 didn't really hit until the second or third week. So our premium collections as related to March were generally in line, and as it relates to April, we are seeing a slight uptick in the month for clients that are utilizing grace periods. In a typical month, the percentage of premiums for groups that are basically taking advantage of this is approximately 0.5% to 1% versus April we've seen it be around 3%. So a slight uptick but as Gail said we continue to work with our clients on options around affordability and certainly providing solutions around premium payments as a part of that.

Gail Boudreaux, President and CEO

Thanks, Pete. And just another piece of information, Justin, as you think about our overall premium, 70% of our total insured premiums is part of the government business and that has been collected in time, and we expect that to continue. Next question please.

Operator, Operator

We will go to the line of Lance Wilkes with Bernstein. Please go ahead.

Lance Wilkes, Analyst

First, I certainly appreciate everything you guys are doing during the crisis. My question is really related to a number of the actions you're taking and was interested in what you think the impacts are going to be from a cash flow and investment income standpoint given the acceleration of payables may be offset by slower claim submissions and then looking over on the receivable side, kind of a point of maybe some delays in premium collection. Also just had a quick clarification on your dental ASO business membership and maybe what occurred there as well. Thanks a lot.

John Gallina, CFO

Sure Lance. This is John. Thank you for the question. The investment income and interest expense it's probably going to be most instructive to view these on a combined basis. So let's just maybe started to beginning of the year and what has happened in the meantime is that the markets experienced a 150 basis point Fed rate cut that we did not anticipate and then we say what's the impact of that? Well, about 90% of our portfolio is in fixed maturities and they're all very high quality with the duration of over four. And which means that clearly any reinvested earnings are going to be down from what our original expectations would have been. The other 10% of our portfolio certainly has been subjected to a lot of volatility and subject to the same way that the overall markets have been subjected to a lot of volatility and it's sort of difficult to predict where that's going to end up by the end of the year at this point in time. On the debt side we do have some variable rate there. So we have a natural hedge against interest rates dropping and so we'll have a benefit on that side but maybe more importantly in order to optimize liquidity we've accessed more debt and we're carrying really higher levels of short-term cash than normal. And additionally, we do have some bonds that are going to mature in August and November under normal circumstances would have refinanced those later in the year but we're going to certainly be opportunistic in terms of timing associated with that and the impacts of carrying net debt. So all in, I would say that we're really looking at the net of investment income and interest expense to be a tailwind, I'm sorry a headwind against us for the rest of the year. So we had a slight tailwind with our first quarter actual results but for the rest of the year we think it will be a headwind and we've obviously taken all that into consideration as part of the $22.30 reaffirmation guidance.

Gail Boudreaux, President and CEO

And Lance, in terms of your question on the specialty dental that really is as a result of one large client that we knew we were going to lose. It came to us as the results of our acquisition of DeCare under contract roughly 10 years ago and that contract expired in 2019. So overall our specialty business when you take that out actually had a strong quarter but that was a known loss coming out of this contract expiration as part of an acquisition. Next question please.

Operator, Operator

We will come to the line of Gary Taylor with JPMorgan. Please go ahead.

Gary Taylor, Analyst

Hi good morning. I wanted to just ask a little bit for a little more detail on what you're doing with providers both hospitals health systems and your medical groups? I know you alluded to the $3 billion you've made available to providers. I think that's the broader Blue Cross system but just wanted a little more detail on is that just extending liquidity? I'd seen something from Blue Shield's those being done in conjunction with a bank taking the credit risk. I also know you made the $50 million donation to the foundation. So just wondering a little bit, what are you doing with these fee-for-service physician groups who are seeing really dramatic reductions in revenue and income in the near term?

Gail Boudreaux, President and CEO

Thank you for your question, Gary. You are correct; the $3 billion figure is part of the overall Blue Cross and Blue Shield system that we have been closely collaborating with. Our unique affiliation stems from our local roots, and we have been sharing best practices to effectively respond to the needs within our community. In terms of care providers, we've been working intensively with them and have taken several steps to support them during these challenging times. We have discussed co-pays and other related matters, but more importantly, we are focused on ensuring timely payments to our providers. Our primary goal is to support each of our provider groups in managing their receivables and reducing administrative burdens, including easing pre-authorization processes. We aim to facilitate their primary role of providing care to patients. Proactively, we have also concentrated on building strong partnerships within our communities. With respect to our fee-for-service providers in local markets, we've tailored our approach to meet the unique needs of each community. Our care provider teams are committed to working closely with them to reinforce our partnership, especially for those engaged in value-based care arrangements. We are dedicated to supporting their viability during this time and enhancing their capabilities for Telehealth and other essential services for their patients. Additionally, on the government side, particularly in Medicaid, we have been collaborating closely with our state partners to understand the critical providers and offer them the necessary resources and support across their patient bases. It is worth noting that prior to COVID-19, Anthem and the Blues across the system were recognized for having some of the lowest claims payable days in the industry, indicating our efficiency as payers. However, we have also been working to ensure that any outstanding receivables are addressed, allowing them to maintain separate cash flows. These are the primary areas of our focus, and throughout the system, we are committed to sharing best practices and finding ways to assist providers in their essential work of delivering patient care. Next question, please.

Operator, Operator

We'll go to the line of Sarah James with Piper Sandler. Please go ahead.

Unidentified Analyst, Analyst

Hey, this is Chris standing in for Sarah. I have a quick question about the commercial book and the pricing strategy for the June 1 renewals. Could you share some insights on the discussions you're having around that? Specifically, if there is a fall COVID-19 peak that leads to delayed surgeries in 2021, I'd appreciate any comments on pricing related to that cost assumption.

Gail Boudreaux, President and CEO

Sure. I'm going to ask Pete Haytaian. I think it's pretty consistent with the previous question as well, Pete maybe to give a little bit more color just to better our commercial business. Pete?

Pete Haytaian, President of Commercial & Specialty Business Division

Yes, sure Gail and I think it is consistent. Most of our book as Gail said renews on January 1 and this is such an unprecedented event, there are so many moving pieces and parts and so getting our arms around it, this is something that we're very focused on but things will evolve over the next few weeks and months. It will give us better visibility into rates and what we do with increases in the back half of the year and towards January 1. We feel like we still have time in that regard as it relates to the near-term rate increases, we don't have a lot of our book really renewing in the near term and since COVID wasn’t apparent at that time, it was not as greatly considered but as Gail said most of our book renewing in January 1 we have plenty of time once we see how medical costs and deferred electives occur in the back half of the year.

Gail Boudreaux, President and CEO

Thank you, Pete and also just I think to reiterate, we said this in the earlier commentary but I think it's part we always and we're going to keep saying consistent and disciplined pricing to our forward view of costs but we also recognize that this is a unique situation in terms of what's happening and we will work with our consumers and our customers to ensure that inequities that occur along the way that we are taking that into consideration as we understand the cost patterns of exactly what's happening. Next question please.

Operator, Operator

We will go to the line of Dave Windley with Jefferies. Please go ahead.

Unidentified Analyst, Analyst

Hi good morning. It's Dave for Windley. First question was just on, I was curious about the use of the $3.2 billion of PBM savings that's not going to shareholders. Is that something which is obviously in your control that you might use to support some of the EPS headwinds that you guys have disclosed and then just a quick second one, I'm wondering if you could provide an apples to apples commercial operating margin comparison to the commercial ASO pharmacies now out of that for the first quarter of this year?

John Gallina, CFO

Thank you, Dave for the question. So first of all, on the $3.2 billion that you're referencing which is the amount that's been provided back to members and consumers to help control healthcare costs associated with our better PBM deal. The way that we approach that is we really looked at each line of business and looked at it from a competitive marketplace, looked at it from a geographic marketplace where we were versus the competitors how close were we to MLR rebate MLR floors and went through and like a Medicare Advantage look that the benefit designs and how we could include our enhanced benefit designs and still ensure we achieve target margins. And we went through a very painstaking process, as I said with every line of business geography by geography by geography we end up going a little bit better than the 20% as you can tell by our first quarter operating results. But it's not a lever in and of itself that we could just pull and take a large chunk that down to the bottom line. We are in a very competitive environment and we are trying to deliver appropriate value to our members at the appropriate pricing. So we've always aspired to do a bit better but it's not just a short-term lever that we can pull. It's something that is part of a larger overall strategy in terms of price points, product designs and all the other types of things. And then the second part of your question associated with just year-over-year comparison. Really the most significant issue is to take the commercial operating gain that's shown in the press release and just go ahead and subtract $75 million to $100 million out of the operating gain from the first quarter of 2019 and then what you'll have is something that's much closer to an apples to apples comparison of how that commercial segment actually performed year-over-year.

Gail Boudreaux, President and CEO

Next question please.

Operator, Operator

We will go the line of Scott Fidel with Stephens. Please go ahead.

Scott Fidel, Analyst

Hi. Thanks. Good morning. I had a question just on how you're thinking about the exchange strategy in terms of the footprint in participation for next year. I know that you've taken a pretty disciplined approach towards market selection over the last couple of years but clearly just given the significant market shifts that will likely occur on how aggressively you're thinking about ramping that up and then maybe if you could just remind us at this point across your 14 Blue states just in terms of what your current footprint is on the exchange market?

Gail Boudreaux, President and CEO

Thank you for the question, Scott. I'll begin and then I may ask Pete to provide some additional insights. I appreciate your comments and agree with you. We have been actively involved in the individual market and state exchanges but have been careful in identifying the best opportunities for impact while maintaining balance. In 2020, we expanded our presence modestly across our 14 states, but as we've mentioned in previous calls, we weren't reshaping our approach. Our strategy is measured and balanced. We believe we have a solid foothold going into this and an opportunity to offer compelling products to our members in those 14 states within the individual exchange. With that, I will ask Pete to share his thoughts since his team has been deeply involved in our approach to the exchanges and our opportunities. Pete?

Pete Haytaian, President of Commercial & Specialty Business Division

Yes, sure. Thanks Gail and thanks Scott for the question. Yes, I am really proud of the team and the approach we've been very thoughtful over the last couple of years with regard to how we expand. We have been expanding our focal point in almost every instance is ensuring that we can partner with the right providers. We look very closely at value-based relationships. We look at where we can partner on critical clinical programs as well as programs like risk adjustment and then obviously where we can have the most viable and affordable product and choice for membership and that strategy's really played through over the last couple of years. We haven't fundamentally changed that and so as we think about what's happening with COVID and the potential recession we still are following those principles but as Gail said with respect to coverage we have pretty decent coverage across our 14 states. It certainly does vary and in some states we are very competitive across most of the counties in the state. In other states, we are much more targeted and I don't think we're going to fundamentally change that approach; if we can be competitive in many counties in the state we will be, but if we don't feel like we can we're going to be disciplined and not necessarily re-enter.

Gail Boudreaux, President and CEO

Next question please.

Operator, Operator

We'll go to the line of Kevin Fischbeck with Bank of America. Please go ahead.

Kevin Fischbeck, Analyst

Great. Thanks. I wanted to follow up on John's earlier comments regarding the belief that around 30% to 40% of your costs could be deferrable in some manner. I'm curious if that assessment is based on real-time data. Most providers we've spoken with have indicated that there will be a much larger drop in utilization than previously expected. I would like to understand how your historical perspective on costs is influenced by the current decline in utilization, which seems more significant than average. Additionally, I'd like to know, based on past instances of similar drops, what percentage of services tends to be cancelled versus rescheduled, and whether you anticipate that percentage changing this time.

John Gallina, CFO

Thank you, Kevin for the question. In terms of the 30% to 40% that was based more on a historical view and it may be closer to the higher end of the range in terms of what we're seeing right now and with real-time utilization but that's our historical view and we call it not emergent care and the things you can pick up the phone and schedule but it's been pretty consistent for us over the last couple of years when we've done the study and the analysis. In terms of the percent that gets deferred and the pent-up demand is comes back as increased utilization versus what gets canceled altogether. We've certainly looked into that and we've studied things like when there were snow days, or when there were hurricanes or natural disasters but those are all helpful; I don't know that they're really going to provide us the exact information we need from a modeling perspective because this is such an unprecedented time and it's just different. The scope and duration of the entire COVID-19 issue is going to be different than anything we've seen and so while we do expect a small amount to not come back it's really too early to provide an estimate or a percentage of what we think will be pent-up demand and the increased utilization in the future but we know that there will be increased utilization in the future once people are more comfortable going back to the hospital and to the doctor's offices as well which is another variable on that. So it's just one of many-many-many variables but it's a very important variable. Thank you for the question.

Gail Boudreaux, President and CEO

And I would also add that we also know and appreciate the patients are avoiding seeking some care in the interim and so that's an area with underlying medical conditions that we are concerned about and that could worsen. So we are closely trying to monitor and help those patients and make sure that they have the right access. So again as John shared this is unlike any of the historical models that we've had. We have certainly done a lot of modeling, but at this stage, I think it's really hard to give any point estimates about where this will end up and really appreciate your understanding of that. Next question please.

Operator, Operator

Charles Rhyee, your line is open.

Charles Rhyee, Analyst

Hi, can you hear me?

Gail Boudreaux, President and CEO

Yes. Please.

Charles Rhyee, Analyst

Thank you for taking my question. I'd like to clarify something from an earlier inquiry about virtual care. Gail, could you share what percentage of your ASO clients are currently using LiveHealth Online? Is it easy for clients to access Telehealth now, or would they have to plan for that next year? Secondly, John, we've discussed deferred costs, and it appears that investment income was higher than we anticipated. If we annualize the first quarter figures, it seems likely to exceed the annual guidance, even considering declining rates. Is there something we might be overlooking in the first quarter data? If we anticipate a normalization based on current interest rates, we also have less share repurchase and increased interest expenses. Are you suggesting that while we expect elective procedures to return, there will still be a considerable decline in the second quarter? Will there be a slight recovery in the third and fourth quarters, but ultimately, we still might be significantly down for the entire year? Or do you believe we could potentially stabilize near normal capacity by the fourth quarter? Thank you.

Gail Boudreaux, President and CEO

Thank you for your thorough question. I appreciate your patience as we address it. To start with your question about LiveHealth Online, we've seen a more than 39% increase in usage since 2019, which surpasses our expectations. Sydney Care, the app used by LiveHealth Online, has been made available to anyone wanting to utilize it and is not a subscription service. Users can download the app for Coronavirus symptom checking and testing, and it has seen strong engagement. LiveHealth Online represents a significant part of virtual care, and we're noticing increased usage not only in virtual consultations but also in communication around symptom checks and other related activities. This area continues to show strength with sustained growth; while we experienced an initial surge during the shelter-in-place orders, we are still seeing rising usage week over week. I anticipate that this trend will persist, and I expect continued growth throughout the year. With that, I'll turn it over to John to address your other questions.

John Gallina, CFO

Thank you, Charles. In relation to investment income and interest expense, this aligns with Lance's earlier question. We had a strong first quarter in that aspect, but considering the previously mentioned 150 basis points Fed rate cut and the significant volatility affecting 10% of our portfolio, we are accumulating cash to address liquidity challenges and ensuring we have sufficient cash and assets to meet all claims. We might access the debt markets earlier than usual on a net basis, which will be a headwind for the rest of the year. We haven't quantified that yet, but it's part of the $22.30 guidance. Regarding deferrable procedures at 30% to 40%, we anticipate that the medical loss ratio and earnings per share for the second quarter will be much better than historical figures. The comparable MLR for the second quarter is expected to be very low, and we believe pent-up demand will emerge. The main uncertainty is how long the COVID-19 situation will last before deferrable procedures can resume, and it's likely that some of these will extend into 2021. While 2020 might appear positive in isolation, over the next couple of years, individuals will seek care, which will have associated costs.

Gail Boudreaux, President and CEO

Thank you John. Next question please.

Operator, Operator

We will go to the line of George Hill with Deutsche Bank. Please go ahead.

George Hill, Analyst

Hello?

Operator, Operator

Mr. Hill your line is open.

George Hill, Analyst

Okay. Sorry. I don't know what happened there team. I guess just we would probably be in the beginning of the PBM and managed care selling season for 2021 right now and I guess I was focused on Ingenio with the market traction it had shown recently. I guess can you say whether or not you started to see the PBM selling season for 2021 start to move as normal with people working remotely and benefits consultants working remotely or you kind of expected selling season to be a push until the 2021 selling season starter? I guess any comments around the selling season as it relates to the virus would be helpful.

Gail Boudreaux, President and CEO

Sure. Thank you for the question. I think we are operating in an incredibly rapidly changing environment. I think it's still early to really understand the full implications. With that the way our sales cycle work a lot of activity for the beginning of next year really does occur now and we are seeing a slowdown in decisions. I mean, I think employers are particularly focused on ensuring the safety and health of their employees first and foremost and also trying to understand the implications to their own businesses. With that said we had a really strong pipeline and what we expect across many of these procurement opportunities, that they'll just, they'll move out further into next year. And so I think we still have really during opportunities but I do think we are going to see some deferred decisions just because of what's happening across this environment and the need for employers really to focus on their own business right now and the health and safety of their employees. With that said I think we've had a very compelling offering and still feel really strongly about the value proposition particularly the opportunities inside of our fee-based business and in the commercial business. Thank you. Next question.

Operator, Operator

We will go to the line of Josh Raskin with Nephron Research. Please go ahead.

Josh Raskin, Analyst

Hi, thanks. Good morning. Can you hear me, okay?

Gail Boudreaux, President and CEO

We can. Thanks Josh.

Josh Raskin, Analyst

Excellent. I wanted to follow up on the commercial membership and understand that March was 'normal' month from an enrollment perspective but sort of curious on early membership trends in April and do you get information on furloughs that where people actually maintain their benefits? Are you just getting benefit roles or are you actually getting employment roles? And then sort of the last part of that is just ancillary benefit cross-sell you guys have talked a lot about that trying to increase your ASO fee on a PMPM basis and do you think that sort of slows down the process; you sort of mentioned that the last question that employers are kind of just making sure everybody is okay first. So a couple of questions there just on commercial membership?

Gail Boudreaux, President and CEO

Sure. Thanks Josh. I'm going to have Pete Haytaian to answer your questions. Pete?

Pete Haytaian, President of Commercial & Specialty Business Division

Yes. Thanks. Josh. Yes, with respect to April it hasn't been fundamentally different than March. As Gail said in her commentary we are seeing furloughs accelerate. We obviously had the PPP, the federal relief and folks taking advantage of that. We've been working closely with our employers and brokers on affordable options. We've been working closely with them on creating relief around premium collections. So all that activity as it relates to April, we really haven't, we haven't seen an acceleration yet in disenrollment. We are beginning to see signs of that in the last couple of weeks of April. We did see in group change start to accelerate, so employees beginning to fall off the rolls but not to a very large number. More broadly we are expecting that to accelerate in the next month or so. And again our focal point has been creating solutions for employers and brokers, buy downs alternative to products, etc. As it relates to furloughs, yes we do get information from clients. We are very closely connected with our brokers and our employers. We've had multiple webinars. We've had multiple outreaches. We're staying close to them. They're actually asking us for a lot of advice around things like that. So for example, if they have, if they're furloughing employees and/or if they're reducing hours of employees, what kind of options exist for them? So I think that is part of the reason why you're not seeing as much activity in April out of the gate and then as it relates to our ancillary benefit strategy and our margin improvement in the ASO business, we had a really strong ‘19 in that regard. We had a strong first quarter in that regard. To Gail's point earlier with respect to RFPs slowing down that will inevitably affect us in 2020 as it relates to performing around the 5 to 1 to 3 to 1, but I think the other important part to point out around that is we're selling a lot of incremental value as it relates to going from 5 to 1 to 3 to 1 and it actually translates into affordability. So when you think about critical clinical programs and packaging of those programs, when you think of stop-loss, when you think of pharmacy and the integrated value proposition of pharmacy to the extent that we can sell through on that and have Anthem be a single source solution. I think we're enabling more affordability but that's with eyes wide open and the understanding that some of that may slow down in 2020. We are though once we get out of this we feel very good about continuing on our path to 3 to 1 and if not for COVID, Josh we would stick with what we had said and that is that we were on a path to definitely get to 4 to 1 in 2020. So we might see a slight slowdown in that but it'll pick up again.

Gail Boudreaux, President and CEO

Thanks Pete and Josh just a little bit more color on Pete's commentary and your specifics about how do we know what's happening as we do the deep analytics on our business, we are looking at SIC code obviously and just a little bit of color on that, our book does skew a little more towards large municipalities which are a little more stable as well as essential workers right now. So that's why you wouldn't see as much of that kind of furlough activity early on in our book of business. And we're going to take the last question please.

Operator, Operator

And that question comes from Steve Willoughby with Cleveland Research. Please go ahead.

Steve Willoughby, Analyst

Hi, good morning and thanks for taking my question. Just a quick follow up on a comment that John was discussing earlier as it relates to utilization coming back in the back half of the year, John in your prepared remarks you made a comment about assessing the healthcare systems capacity and I was just wondering if you could provide any more color or how you're thinking about that once we get any other side of this virus? How are you guys thinking in terms of the healthcare system being able to absorb capacity or utilization above normal? Thank you.

John Gallina, CFO

Thank you, Steve. That's an excellent question. If there are thousands of providers out there, there are likely thousands of answers to that inquiry. However, the number of surgeons, hospital beds, and access to appropriate care points is limited. It's challenging to provide an exact percentage or a highly specific model. By examining various facilities and the productivity and capacity data available from large public hospitals, we can make some assumptions about their capabilities. Considering the duration of the virus situation, I believe that once the pent-up demand is expressed, it will be difficult to address it all in a short timeframe. Instead, it will likely unfold over a longer period. This also assumes that patients are comfortable rescheduling their procedures and returning to hospitals and doctor's offices, which introduces another variable. So, while this is one of many important factors to consider, it is indeed significant. Thank you for your question.

Gail Boudreaux, President and CEO

Thank you John and thank you to everyone who joined us this morning. Despite the challenges facing this country with COVID-19, Anthem is well positioned to fulfill our promises to those we serve in this new era for healthcare. As we move through this pandemic, we'll continue to lead and lend our voices and perspectives across the healthcare system to support our members and customers as well as our care provider and other partners. The lives of those we serve will now change and in that spirit Anthem is also evolving to create a simpler more affordable and more effective healthcare experience in this new context. I'm confident we will emerge on the other side of this current pandemic even stronger and more nimble as the healthcare partner of choice demonstrating the strength of our brand where Blue Cross and Blue Shield currently serves nearly 1 in 3 people in the United States today. We hope you all stay safe and well and thank you again for joining us.

Operator, Operator

Thank you. And ladies and gentlemen this conference is available for replay starting at 10:30 A.M. Eastern time today through May 13 at midnight. You may access the replay system at any time by dialing 1-866-207-1041 and entering the access code 383663. International participants dial 1-402-970-0847. That does conclude our conference for today. Thank you for your participation and for using AT&T conferencing service. You may now disconnect.