P3 Health Partners Inc. Q1 FY2023 Earnings Call

Good afternoon, everyone, and welcome to the P3 Health Partners First Quarter Results Conference Call. Currently, all participants are in a listen-only mode. Later, we will conduct a question-and-answer session and instructions will follow at that time. As a reminder, this conference call is being recorded. I will now turn the call over to Karen Blomquist, Vice President, Investor Relations of P3. Please go ahead.

Thank you, operator, and thank you for joining us today. Before we proceed with the call, I would like to remind everyone that certain statements made during this call are forward-looking statements under the US Federal Securities laws, including statements regarding our financial outlook and long-term targets. These forward-looking statements are only predictions and are based solely on our current expectations and projections about future events and financial trends that we believe may affect our business financial condition and results of operations. These statements are subject to risks and uncertainties that could cause actual results to differ materially from historical experience or present expectations. Additional information concerning factors that could cause actual results to differ from statements made on this call is contained in our periodic reports filed with the SEC. The forward-looking statements made during this call speak only as of the date hereof and the company undertakes no obligation to update or revise the forward-looking statements. We will refer to certain non-GAAP financial measures on this call. These non-GAAP financial measures are in addition to and not a substitute or superior to measures of financial performance prepared in accordance with GAAP. There are a number of limitations related to the use of these non-GAAP financial measures. For example, other companies may calculate similarly titled non-GAAP financial measures differently. Refer to the appendix of our earnings release for a reconciliation of these non-GAAP financial measures to the most directly comparable GAAP measures. Information presented on this call is contained in the press release we issued today and in our SEC filings, which may be accessed from our Investors page of the P3 Health Partners website. I will now turn the call over to Dr. Abdou, CEO and Co-Founder of P3.

Good afternoon, everyone. I would like to kick us off today by saying how proud I am of our team and its performance and achievement over the last period. As you have heard me saying before, we've committed to our investors that we would deliver on a number of very impressive profitability metrics to validate the model and we believe we have delivered. Our results will show that we have great momentum in our business model and we are feeling very confident and optimistic about how we are tracking in the second quarter and toward our 2023 overall performance. Today, we're updating our full-year 2023 adjusted EBITDA guidance to an improved range of a loss of $55 million to $35 million. This updated guidance from the prior range of a loss of $60 million to $40 million reflects our confidence in the performance of the business and all profitability data that we are sharing today will validate that. As I've shared with you in the past, 2023 is an inflection year in P3 Health Partners' lives. We have a significant number of persistent lives that we've never had before. For the first time, 83% of our lives that we are serving today are persistent. And we believe that metric is important as a first step to more clearly demonstrating the future profitability and trajectory of our model. The overall population funding has improved by 9.2%, up from $8.89 PMPM in last year’s first quarter to $963 PMPM this quarter. Our medical margin for the quarter was $39 million. The medical margin percentage was 13.1%, which is consistent with our guidance and other public peers, and we view this as a validating data point for the P3 model. Our network contribution was $17 million. It is important to note that once we tip that point where network contribution exceeds operating expense, the pendulum will swing to our profitability and we're quickly approaching that key threshold. The distance to reach that point is about $62 per member per month. And just to give you context, we improved our funding by over $70 PMPM. If we do that again, it will help us cross that bridge. We improved our medical costs by over $30 PMPM. If we continue to do that again, we will cross into profitability. So, it's important for us to see the levers that we're pulling. It's all improving about the health of our population, improving the funding and improving the medical cost ratio. Our adjusted EBITDA showed very strong improvement with a loss of $19.1 million compared to a loss of $4.1 million in the prior quarter. Included in the Q1 2023 adjusted EBITDA is approximately $3 million in costs that we do not expect on a going-forward basis. Adjusted EBITDA PMPM was a loss of $62 PMPM, an improvement of $71 PMPM compared to a loss of $133 PMPM in the fourth quarter of 2022. In our newer markets, we have scaled up quickly. We are feeling optimistic and confident about what we're seeing. Oregon, for example, is quickly moving toward profitability and had a very insignificant loss in the first quarter. California has a positive adjusted EBITDA. Across all of the markets we serve, we noticed an extreme increase in demand and a robust pipeline of growth opportunities, and we're very confident about our growth for the rest of this year and in 2024. In Arizona, our performance is strong. Our focus on quality has made us the leader in the market we serve. That focus on quality is clear, and I'll give you an example. We recently received full recognition from the CDC for our diabetic prevention and hemoglobin A1c program, which Dr. Bacchus will provide more color on later. With these very solid results, we are well on our way to realizing the $200 million in adjusted EBITDA in our material population and cohort, and we believe that is inherent in the P3 model. 2023 is a year where we have committed to deliver the data points to validate the P3 model, and our first quarter results are a reflection of that. When we think about where we are as an organization, I believe that we are with the right team, in the right space, in the right business model, and we are on the right track to achieve profitability. We have done extensive financial benchmarking analysis, comparing our results to our direct public peers, some of whom currently have $10 billion valuations. When they have a similar revenue level, we are spot on. I will leave you with this: our momentum is building, we're executing our plan and I expect to share more positive news in our second quarter results. I'd like now to turn the call over to Atul Kalaru, CFO.

Thank you, Sherif, and good afternoon, everyone. I'll start today by providing detail around what we achieved in the first quarter and how we are progressing towards meeting our full-year guidance and anticipated profitability in 2024. Top line results for the first quarter were strong, with capitated revenue of $299 million and total revenue of $302 million. The capitated revenue includes a higher mix of persistent lives on our platform, which in turn improves profitability. In the first quarter of 2023, we had strong improvements in both medical margin and network contribution in the quarter. Our medical margin, which represents the amounts earned from capitation revenue after medical claims are deducted, improved over the prior year period to $39 million or $126 on a PMPM basis. Network contribution, which we define as medical margin-less network expenses, improved by 114% over the year to $16.5 million. We believe that the trends in these two critical data points give a clear view of the progress we are making as we work towards reaching profitability in early 2024. Adjusted EBITDA loss was $19.1 million in the first quarter of 2023, a significant improvement compared to the loss of $40 million in the prior quarter. Included in the Q1 2023 adjusted EBITDA is approximately $3 million in costs that we don't expect on a go-forward basis. The Q1 2023 adjusted EBITDA is in line with our expectations for the quarter. As I mentioned on the last call, we anticipate the second and third quarters to show significant improvement, as we begin to see the benefits from operational efficiencies and receive midyear true-ups that will create a contour rather than a straight line spread of results. We expect the fourth quarter will be slightly softer than the second and third quarters, as we expect to see some seasonality as we move into the colder months and into cold and flu season. That said, Q4 should still see a meaningful improvement over Q1. Our net loss in the first quarter of 2023 improved by 14% compared to the same period in the prior year, in part due to the 300 basis point improvement in SG&A as a percentage of revenue. For the remainder of the year, we expect platform expenses to continue to taper as we exit the second quarter and get to a more normalized go-forward run rate unencumbered by these costs present in Q1. We started the second quarter of 2023 with a cash balance of $95 million. Although this is not reflected in the Q1 financials due to the timing of the transfer of funds from the capital raise we announced on March 31, which were received in the first week of April. For the remainder of the year, we expect our cash burn to be significantly lower than the prior year and we will end the year with more than adequate cash to operate until we reach positive cash flow. We are feeling really great about where we are from a liquidity perspective, even better now than we did on the last call. The capital raise put to rest our liquidity concerns and we are now myopically focused on operational excellence. As I sit here today in mid-May, I'm feeling really good about Q2 and 2023 guidance. I want to remind you of our guidance for 2023. We still expect 2023 revenue to be between $1.2 billion and $1.25 billion, and we are increasing the adjusted EBITDA guidance to now be a loss of $55 million to $35 million compared to the prior guidance of a loss of $60 million to $40 million. In addition, we are expecting our medical margin in 2023 to be in the range of $155 million to $175 million. Thank you all once again for your interest in the P3 story. And with that, I'll turn the call over to Dr. Bacchus, who will give you an example of how we are able to bend the cost curve at Q3.

Thanks, Atul. Good afternoon. As Sherif mentioned, we are winning in the markets that we serve from both the provider and patient perspective. From last year through the first quarter of this year, we have been better able to align stronger incentives for our providers to improve access to both their EMRs and patient visits, delivering better outcomes in quality of care, documentation, and utilization. As we discussed in previous calls, it takes providers approximately 24 to 36 months to fully encompass the care model on their persistent patients and become converts to the value that value-based care brings. This is precisely why we're seeing significant medical margin improvements company-wide. The provider engagement is paramount and I'm happy to report that we have more providers engaged with our teams in each market than anytime previously. But not only is the provider engagement important, patient engagement is equally important to engage patients to improve their care. By utilizing our care managers, care navigators, and others on the team, we have been able to significantly improve results on our high-risk, high-cost population or cohort from 2021 through 2022, reducing both hospital admissions and emergency department utilization by 19%. For our diabetic population, we have seen a 10% improvement in control of this condition, which is why we were recognized by the CDC as Sherif described earlier. Key technologies like our risk stratification tool and our Care Connect tool allow us to understand who is at risk and how to monitor them through their care journey. To push the point further, this high-risk, high-cost population saw a 71.5% improvement in their medical cost ratio, leading to savings of almost $13 million. Success, as we see it, is striving for meaningful relationships with both our providers and patients and enabling both of them via improved data, team support, or better care options. With that, I will turn the call back over to Sherif before we begin Q&A.

Thanks, Amir. Before we go into Q&A, I just wanted to remind you all that our commitment to our shareholders and investors that we will work hard on improving the funding continues to show results. We have improved that from $899 PMPM last year in the first quarter to $963 per member per month in the first quarter of 2023. That's about a 9.3% improvement. We have promised and committed to improving our medical margin. First quarter 2022 was $82 PMPM, and as we promised we increased the medical margin to $127 per member per month. That constitutes about 13.1% margin from our revenue. The medical cost ratio had improved from 91% in the first quarter of 2022 to 87% in the first quarter of 2023. We promised, we said it, we did it. And network contribution was $7.7 million in the first quarter last year, or $26 PMPM or 2.8%. This year, first quarter, as we promised, it's more than doubled to a $17 million network contribution positive, $53 per member per month. That is 5.5% of the revenue. That is why we have confidence in all the performance and the fundamentals of our operation and improvements in the health of our population. We increased our EBITDA guidance for this year as I mentioned earlier. With that, we're going to open for questions and answers. Operator?

Thank you. Today's first question comes from Brooks O'Neil with Lake Street Capital Markets. Please go ahead.

Good afternoon. I apologize. I'm juggling between a couple of calls, but I'm just curious what specifically is it in your opinion that gives you the confidence to raise the adjusted EBITDA guidance at this time?

Well, Brooks, this is Atul. Thanks for the question. Look, I think there's a combination of events and I think Sherif touched on them all. We feel good about where the revenue is coming in. We feel good about some of the cost reduction efforts that are in the hopper and are being worked on by the teams. And we feel really good about some of the reductions in operating expenses that have already come through and that are expected to come through. So, I think all of those things combined just compared to where we anticipate and where we initially set our guidance, we feel really good about where we are.

Great. And then could you just say obviously there's a lot of buzz in the industry about the importance of value-based care in the transition to value-based care? As you have taken steps to slow your enrollment growth this year to improve the performance of the various cohorts. I'm curious if you see in the marketplace growing or shrinking interest from payers and then how you'd characterize the interest in providers working with P3 to deliver value-based care to members.

Brooks, this is Sherif. Thank you very much. Great question. So, definitely growing intense, significant demand in our business and in our services and our engagement from both the payers and providers. So that's why that gives us the confidence. We have a clear line of sight to our growth within this year and next year. And we're grateful that we have on our platform almost 150,000 lives that we will convert from either shared savings or fee-for-service into our full-risk model over time. So we're seeing increased demand, exponentially increased demand from payers and providers.

Brooks, I would also add, this is Amir. From providers, yes, providers are getting more interested in value-based care primarily because the whole trend is headed that way. So because of that they're looking for teams of people that can enable them to be successful. And we do it in a way that's very easy for them to align with what we do to drive better performance. They don't have to sell their practice. They don't have to do the things that money people ask them to do. So because of that, the enablement and driving more value-based care into these fee-for-service practices is very, very strong.

Makes sense to me. Let me just ask one more question and then I'll jump back in the queue. Obviously, it's a little bit old news now at the end of COVID, but how would you characterize the impact of going from an environment that was strongly influenced, let's say, by COVID a year ago to an environment in which it seems like we put COVID in the rearview mirror and life is returning to normal.

So I think COVID taught us a lot about how we practice medicine from telemedicine and things like that. It's created us to be a little bit more nimble in how we improve or drive the access that we need to drive. And all those things have worked. And I think whether you're an independent fee-for-service practitioner or a large group, everybody has had to adjust. Yes, it's good to see that COVID is really now very much on a downturn. I mean, we still are seeing some cases, but very, very small. Also, understanding that the government recognizes that as well with the potential reduction as of May 11 regarding the surcharge due to hospitals, which will be stopping. So, all of those things create more value for not only companies like ours that allow physicians to continue those face-to-face visits that most patients, especially our senior patients, prefer. So with COVID going down, it's a good thing for everyone. But again, it has taught us to be more prudent in how we manage patients with any potential disease that may be similar in the future.

Thank you very much for taking my questions and I’m excited about all the progress you’re making.

Thanks, Brooks.

Thank you. And our next question today comes from Ryan Daniels of William Blair. Please go ahead.

Yes, guys. Thanks for taking the questions. Congrats on the strong start to the year and the EBITDA guidance uptick. A couple of housekeeping upfront and then some broader ones. First off, do you just have the number of lives on the platform at the end of the period for our models?

Yes. The at-risk lives, we have 13,400 at that full risk on the platform.

Okay. Perfect. And then you discussed the $3 million in cost that appeared in the first quarter that won't be in subsequent quarters. Was that due to any one-time cost during the period, or is that just a reflection of some of the operating expense reductions you put in place really started to hit their stride in the second quarter and then carrying into the back half of the year?

Yes, it's a good call out. It's really the latter. I mean these are expenses that are in the number. They're impacting the first quarter's EBITDA, but we know that just based on either contractual changes or decisions that we've made, they're just not going to repeat. I would also characterize $3 million as a potentially conservative number. I think we intend to really continue working on operating expenses. We've been talking and I feel really good about saying it again. We talked about high single-digit platform expenses for the company going forward. And so we certainly expect to see that shape up over the next couple of quarters.

Okay. Perfect. And then maybe one deeper dive into the numbers here. The medical margin performance is really notable and pretty impressive. I'm curious if you could double-click on that a little bit more and give us some color on what's driving that. I don't know if it's ramping effectively in new markets, some of the clinical programs you mentioned, just maturity of the patient base. Just what's driving that? Is that a remarkable improvement? And if that continues, obviously, it bodes very well for the path to profitability. So I want to get some more color there.

Sure, Ryan. It's actually a combination of a lot of those factors that you just described. Our whole model is geared towards getting in front of our providers and our care model from an education standpoint, so how they can improve in documentation, understand how to improve their charting, and at the same time improve quality to drive the revenue number. In addition to that, we also have a lot of work with our care managers, navigator teams, etc., working directly with them on those high-cost and high-risk patients. Therefore, we're able to drop that medical cost expenditure, especially on that top 10%. So those things together, obviously lift the revenue and at the same time drive down the overall medical expenditure. As we continue to work with our practices and educate them, and as I said earlier, it takes a little while for providers to really get in the groove, about 24 to 36 months. But once they do, you really start to see it turn. And the persistent number of lives are, therefore, very important. The longer you have a patient with you, the more you can improve on their overall care. So, as you said, all these factors work together to drive the overall results.

And then maybe just one more quick one, if I could. Just giving you the opportunity to hit on the Medicare Advantage rate notice and changes to the rate risk adjustment. A lot of providers have talked about that. It seems like it's not a material impact to the space. But just given the markets you're in and the analysis you've done, any thoughts on how that could potentially impact the organization in 2024 if at all? Thanks.

Yeah. Look, I think as you can imagine, this is an area where our analysts spend a lot of time reviewing and analyzing. And I think it's also important to stress, it is going to affect different companies in different ways. For our business, for our particular company, there are two components to it. There's an HCC component and there's a rebasing component; they largely offset one another. So, as Sherif mentioned, I believe on the last call, our position remains the same: we do not expect any material impact on the business.

Okay, perfect. Thanks so much and congrats on the strong performance and progress. Appreciate it.

Thank you.

And our next question today comes from Josh Raskin of Nephron Research. Please go ahead.

Hi, thanks. Good afternoon. The number of affiliate providers was flat from 4Q. And I'm just curious if there was some growth in there and then maybe some terminations and sort of if so, what causes determinations. And then more broadly if you could just talk about provider relations and growth and market development and how you feel about that pipeline?

Yeah. So great. Josh, thank you very much. So you're right. We've added a significant number of providers and we have said goodbye to some of them. Part of the improvement that Amir and Atul mentioned in the numbers, including the medical margin and the maturation of the population, is either moving the population to the same provider and increasing our concentration with the relationship with existing providers or letting the provider and the patient bring new population in. So we have experienced a significant increase in our providers, but we have like we said last time and the time before, our purposeful and responsible growth led us to terminate some of the nonproductive relationships and non-profitable populations and providers.

So is that typically a January 1 effect? Because I think about that juxtaposed with the 3,400 MA ads, which typically you would expect more in January, but maybe you lost some patients as well and that's why you still think you can grow 15% to 20% this year. Is there some seasonality to that process?

Yes. Definitely with the annual enrollment that takes effect January 1, and recently last year Medicare started having open enrollment, which is basically for the following 90 days after January, and you can change plans if you so desire. So we are putting a lot of effort, Josh, into realigning our plan partner with our provider partners where we can increase and enhance the membership without having to go add new providers. So basically, Dr. Smith that I have only Humana lives with them, I have Humana, United, Centene, Aetna, and Cigna with them. So that is a lot of our growth is with the same providers. So we're feeling very bullish about our growth this year and next year.

That's helpful. And then just the last one for me. The capitated revenue, the PMPM you mentioned in your prepared remarks too, was up a little bit more, or a lot more than we were expecting. Is that coding and effectiveness? Is that the persistence of membership, or is there some mix issue or something like that as well?

So it's all of the above and mostly the compliance and integrity of our coding process. And for the first time, as I mentioned, we have almost 82,000 to 83,000 lives that are persisting from last year to this year. We've never had that many or 82% of our lives were persistent. So mainly that persistence and the hard work that our team did last year.

Our next question comes from Gary Taylor at Cowen. Please go ahead.

Hi, good afternoon. I had two questions. The first one just a little bit of a knit I think, but the $5 million PDR charge in the quarter I know that's excluded from EBITDA, but that's related I guess to a specific contract? Is there any more detail on that?

I'm sorry, could you repeat the question, Gary? I didn't quite hear you.

The $5 million premium deficiency charge this quarter is excluded from EBITDA. Is that related to a specific contract, or is there any additional information on that?

No, it's not related to any specific contract. What we do is consider this as a GAAP requirement; it's a non-cash item as you can imagine. This reflects an estimate of unknown claims exceeding premiums. We are reviewing this based on our general policy for that calculation. We expect it to reverse when we become profitable. So this is a temporary situation. I think that's the way I consider it, and I anticipate it to reverse by the end of the year or very early next year.

Okay. My second question is, can you elaborate a little on your expectation of sequential improvement in EBITDA loss over the next couple of quarters before a slight decline in the fourth quarter? This outlook seems different from the seasonality trends observed in the last three years, where the EBITDA loss and MLR have typically increased throughout the year. I would like to understand this expectation better.

If you consider our operating expenses from the ground up, we anticipate much more consistency and predictability compared to the previous year. Last year's issues with the audit and various consulting fees made things more complicated. However, we expect a smoother flow in the upcoming quarters. Regarding revenue expectations, particularly with mid-year and final sweeps, we account for them effectively on a cash basis. We anticipate seeing some advantages from this in the second and third quarters. When I refer to the contour, that's what I'm indicating.

Okay. Thank you.

Ladies and gentlemen, this concludes our question-and-answer session. I'd like to turn the conference back over to Dr. Sherif Abdou for closing remarks.

Great. Thank you very much, Rocco. So as I mentioned, we're very confident in our results. We're excited to share those results with you. Our growth remains robust. And as I mentioned to Josh, our membership remains on our platform or just moved from full risk into an upside, which we turned into more positive as part of our purposeful and smart growth. Finally, I want to tell you that we're very committed to our vision of transforming healthcare and very committed to our mission. More importantly, we want to continue to do well while we're doing good. With that, I thank you all very much, and talk to you next quarter.

Thank you. This concludes today's conference call. We thank you all for attending today's presentation. You may now disconnect your lines and have a wonderful day.