Earnings Call Transcript
Teladoc Health, Inc. (TDOC)
Earnings Call Transcript - TDOC Q4 2020
Operator, Operator
Ladies and gentlemen, thank you for standing by, and welcome to the Teladoc Health Fourth Quarter 2020 Conference Call. Please be advised that today’s conference is being recorded. I would now like to hand the conference over to Mr. Patrick Feeley, Vice President of Investor Relations. Please go ahead.
Patrick Feeley, Vice President of Investor Relations
Thank you, and good afternoon. Today after the market closed, we issued a press release announcing our fourth quarter and full year 2020 financial results. This press release is available in the Investor Relations section of the teladochealth.com website. On this call to discuss the results are Jason Gorevic, our Chief Executive Officer; and Mala Murthy, our Chief Financial Officer. During this call, we will also provide our first quarter and full year 2021 outlook, and our prepared remarks will be followed by a question-and-answer session. Please note that we will be discussing certain non-GAAP financial measures that we believe are important in evaluating Teladoc Health’s performance. Details on the relationship between these non-GAAP measures to the most comparable GAAP measures and reconciliations thereof can be found in the press release that is posted on our website. Also, please note that certain statements made during this call will be forward-looking statements as defined by the Private Securities Litigation Reform Act of 1995. Such forward-looking statements are subject to risks, uncertainties and other factors that could cause the actual results for Teladoc Health to differ materially from those expressed or implied on this call. For additional information, please refer to our cautionary statement in our press release and our filings with the SEC, all of which are available on our website. I would now like to turn the call over to Jason.
Jason Gorevic, CEO
Thanks, Patrick, and thank you everyone for joining us this afternoon. 2020 was a transformational year for Teladoc Health and for the role of virtual care within the broader health care industry. We delivered needed health care to millions of consumers in the midst of the coronavirus pandemic and completed two significant acquisitions that together, under Teladoc Health, are defining a new category of whole person virtual care. Taken together, we dramatically accelerated our mission to empower all people everywhere to live their healthiest lives by transforming the health care experience. We delivered over $1 billion in revenue for the year, provided over 10.5 million virtual visits. And our license platform solution enabled an additional 3.9 million visits for our clients’ own clinicians pro forma for InTouch. We onboarded a record 15 million new paid members in 2020. And over the last 18 months, we’ve added 25 million paid members and 11 million members with VFO access, a remarkable result. During the fourth quarter, we saw broad-based strength across our business, driving revenue of $383 million, an increase of 145% over the prior year, and organic growth of 79%, excluding the additions of InTouch Health and Livongo. The strength across our channels, products and geographies, combined with a robust pipeline of new opportunities gives us tremendous confidence in the near-term and long-term outlook for the business. As we enter a new year, we have never been better positioned to meet the increasingly sophisticated expectations of consumers, clients and providers. We are heartened by the progress that has been made in the delivery of the coronavirus vaccines and expect some return to normalcy, coupled with strong continued demand for virtual care, well exceeding pre-pandemic levels. The strategic investments we made during 2020 to expand the breadth and depth of our capabilities, have uniquely positioned us to serve the growing client and consumer demand for virtual care, and have accelerated our path to realizing our vision of becoming consumers’ trusted destination for whole person health. The expansion of our capabilities in the hospital and health system market, including the acquisition of InTouch, positions us as the leader in that channel. Our enterprise solution enables the full suite of virtual care, regardless of the consumers’ needs across any location. Whether through one of our over 11,000 facility-based care locations or directly to the consumer’s home via a mobile device, our platform enables our clients to provide virtual care for a broad spectrum of use cases from high acuity, critical care in the ICU, to post-discharge follow-up and urgent care visits. We see growing demand as health systems around the globe look for an enterprise-wide secure integrated virtual care solution. During the fourth quarter, we continued to make strong progress in bringing our platform solution to international markets with multiple new deals, including a new contract supporting critical care programs for a large network of hospitals in Germany. Our expanded capabilities in the management of chronic disease have uniquely positioned us to deliver on the promise of whole person care. The combination with Livongo extends our leadership position and enhances our opportunity to redefine the future of virtual care, leveraging technology and data at unmatched scale to drive better outcomes and lower costs while delivering a better consumer experience. We have the capabilities to deliver and manage care virtually across the spectrum for consumers, ranging from wellness and prevention to coordination of care for people living with chronic conditions to high acuity for those dealing with critical illness. The combination is resonating in the marketplace, and we have signed multiple cross sales since closing the Livongo transaction. We highlighted the GuideWell and Tyson Foods deals on our last earnings call as well as a regional health plan cross-sell last month. We have now signed over a dozen new cross sales since the close of the transaction. And the pipeline of new opportunities has more than doubled in just the past three months. The early indicators give me tremendous confidence that we will deliver on the revenue synergies that we highlighted when we announced the transaction. Our industry-leading breadth and depth of capabilities come together to underpin our innovative virtual primary care offering, Teladoc Primary360. Primary360 is a differentiated whole person solution that leverages our capabilities to provide and coordinate care using a team-based approach and brings together health care providers across multiple specialties. Primary360 goes beyond just enabling virtual visits; rather, it’s a reimagining of the entire primary care experience, and it positions us to become the trusted health care destination for the consumer, regardless of what they need for both their mental and physical health. The results of our first virtual primary care pilot launched during the second quarter of last year have been highly encouraging. We’re seeing over 30% consumer engagement and incredibly high satisfaction with an NPS of over 90. Over 40% of hypertension and pre-hypertension diagnoses and over 25% of diabetes and pre-diabetes diagnoses made by our clinicians have been first-time diagnoses. This allows our clinicians and members to begin addressing the progression of disease and creates an opportunity for us to introduce the Livongo capabilities to those consumers early in their journey, which will ultimately drive better outcomes for consumers and lower the overall cost of care. Last month, we launched additional Primary360 pilots with multiple new partners, and the amount of interest from new potential clients has been incredibly strong. We have a pipeline of well over 100 opportunities, ranging from Fortune 1000 employers to large payers looking to partner on virtual first health plans. In fact, just last week, we signed another new partnership with a very large employer expected to launch later this year. We are making excellent progress on our integration efforts. Our commercial organization is now fully integrated, and our teams responsible for cross-selling have been collaborating for months. A few weeks ago, we virtually hosted our Annual Global Growth Summit, bringing together over 700 teammates across our commercial organization, including our new teammates from InTouch Health and Livongo. This annual summit is a great opportunity to not only equip our commercial teams with the tools they need to effectively communicate our leading value proposition in the marketplace, but to share best practices and learn from one another. The integration of our data platform and assets also continues to progress as we work to unlock the power of our combined data sets. We are now capturing 2 million blood glucose data points per week, and our clinicians are responding to over 100,000 patient messages via text and chat and providing over 30,000 visits on average every day. We are also making significant investments to integrate our products and services. For example, we see a tremendous opportunity for a new integrated behavioral health product that combines the capabilities of both Livongo and Teladoc. This innovative offering will pair the highly scalable, personalized self-directed digital care programs of Livongo’s MyStrength platform with access to the expertise and convenience of Teladoc’s virtual network of clinicians. With this integrated offering, we will create a new digital front door to behavioral health care, further breaking down barriers to mental health by allowing consumers to find the right care at the right time, increasing access and improving outcomes. We are already seeing tremendous excitement from clients globally for this next-generation behavioral health offering and expect to launch it more broadly in the market by the end of the year. Before I turn the call over to Mala to discuss our results and forward guidance in more detail, I want to talk briefly regarding our outlook for 2021. Following a transformative 2020 and with the significant momentum we have entering this year, we feel extremely confident in our outlook for 2021. For the full year, we expect revenue to be in the range of $1.95 billion to $2.0 billion, representing growth of 80% or approximately 40% to 43% pro forma for the acquisition of Livongo. This robust growth is the result of the broad-based momentum we continue to see across our business, including growth in utilization, a robust and growing pipeline of multi-product sales, including strong demand for our whole person chronic care programs, continued strength in the direct-to-consumer channel, increasing demand for our license platform in the health system market, growth in international markets and new member additions. With that, I’ll turn the call over to Mala for a review of the fourth quarter as well as detailed 2021 guidance.
Mala Murthy, CFO
Thank you, Jason, and good afternoon, everyone. Before I get into the details of the results, I would like to note that following the close of the Livongo transaction, we are streamlining some of our reported metrics. Our revenue disclosure will continue to be broken out between access fee revenue, visit fee revenue and other revenue. Each of those revenue buckets is further broken out into U.S. and international. Our visit volume metrics are aligned with our revenue disclosure, including both U.S. and international visit volumes, which is aligned with how we manage the business. We are also adding a new metric, Chronic Care Enrollment, which captures the total unique individuals enrolled in the Livongo suite of chronic care programs. This metric is based on a count of total unique members, so members utilizing multiple solutions are only counted once. Turning to fourth quarter results. Total revenue increased 145% to $383 million or 79% on an organic basis. U.S. access fee revenue for the quarter was $283 million, representing growth of 188% over the prior year’s quarter. Total international revenue of $34 million grew 16% versus the prior year. Visit fee revenue for the fourth quarter increased 80% year-over-year to $53 million, and comprised 14% of total revenue as compared to 19% of revenue in the prior year’s quarter. The decrease in visit fee revenue as a percent of total revenue is due to the acquisitions of Livongo and InTouch Health, both of which generate a significant majority of revenue from subscription access fees. Turning to membership and access. We ended the quarter with U.S. paid membership of 51.8 million members, an increase of 41% year-over-year. Individuals with visit fee-only access were 21.3 million at the end of the fourth quarter. Total chronic care enrollment, which includes individuals enrolled in one of our chronic care programs, was 596,000 members, an increase of more than 40,000 members sequentially. We provided 3 million visits in the quarter through our Teladoc network of clinicians, representing 139% growth versus the prior year. Platform-enabled sessions, which represent encounters facilitated by our licensed software platform and provided by our clients’ own clinician, was an additional 1.1 million in the quarter, more than four times the number of sessions in the same period last year pro forma for the acquisition of InTouch Health. As I mentioned earlier, we have streamlined our visit metrics to better align with how we manage the business, and our focus on driving utilization and delivering value for clients and members regardless of payment model. The annualized utilization rate for our paid members was 17.7% in the fourth quarter, an 825 basis-point increase over last year’s fourth quarter and a 120 basis-point increase sequentially. PMPM was $1.76 in the fourth quarter, up from $0.91 in the prior year’s fourth quarter with over half of the increase driven by the inclusion of Livongo in our consolidated results. Adjusted gross profit, which excludes depreciation and amortization of intangibles, increased to $260 million, an increase of 157% as compared to the prior year’s fourth quarter. Adjusted gross margin was 67.9% compared to 64.6% in the fourth quarter of 2019. Gross profit and adjusted gross profit include the benefit of $5.4 million in lower expenses on Livongo devices attributable to purchase accounting adjustments related to the merger. Adjusted EBITDA increased to $50.4 million in the quarter compared to $15.2 million in the fourth quarter of 2019. Fourth quarter adjusted EBITDA margin of 13.1% increased by 340 basis points year-over-year. Adjusted EBITDA includes a benefit of $5.4 million attributable to purchase accounting adjustments mentioned previously. Net loss in the quarter was $394 million compared to a net loss of $19 million in the fourth quarter of 2019. Fourth quarter net loss includes $57.6 million in transaction costs as well as $331.7 million of noncash accelerated stock-based compensation expense related to the merger with Livongo. On a per share basis, net loss was $3.07 for the fourth quarter compared to a loss of $0.26 in the fourth quarter of last year. Fourth quarter net loss per share includes $0.45 of transaction costs, as well as $2.59 of noncash accelerated stock-based compensation related to the merger with Livongo. Excluding all transaction-related costs and tax benefits, the per share loss in the fourth quarter would have been $0.27. We ended the quarter with $787 million in cash and short-term investments while our total recorded debt outstanding as of December 31st was $1.4 billion. Now turning to forward guidance. For the full year 2021, we expect revenue to be in the range of $1.95 billion to $2.0 billion, as Jason mentioned, representing growth of 78% to 83% over the prior year or 40% to 43% fully pro forma for the acquisition of Livongo. Our confidence in that strong revenue growth is underpinned by, first, continued growth in utilization, particularly among noninfectious disease-related visits such as hypertension, lower back pain, anxiety, and depression. During the fourth quarter, approximately 75% of our visit volume was related to noninfectious diseases, up from 50% in the fourth quarter of last year as our visit mix continues to diversify, a trend that has continued into the New Year. We’ve also seen tremendous growth in new registrations over the past year, with newly registered individuals growing at twice the rate of new member additions. Registered member growth creates opportunity for deeper engagement and is a leading indicator of forward utilization. Growth in specialty visits has been particularly strong, led by growth in behavioral health, which experienced visit growth of over 500% in 2020, as the growth in visits accelerated throughout the course of the year. All of that comes together to give us tremendous confidence in our visit volume outlook. And you can see that reflected in our strong visit volume guidance. We expect total visit volume to be between 12 million and 13 million visits this year, representing growth of 13% to 23%. Second, we have built a robust and growing pipeline of multiproduct sales, including strong demand for our whole person chronic care program. In 2020, two-thirds of Teladoc deals were multiproduct deals. And our experience shows that client retention, member engagement, and PMPM growth are all significantly stronger for clients that use more than one of our products. Next, in the direct-to-consumer channel, our BetterHelp brand has also continued to significantly outperform, delivering over $300 million of revenue in 2020. We expect another year of robust growth of at least 50% in 2021, as we continue to gain scale and expand our leadership position in that channel. Fourth, continued new member additions at both existing and new clients. We expect to grow paid membership to 52 million to 54 million members in 2021, which is net of the approximately 1.5 million COVID-related temporary members that have rolled off during the first quarter, as previously disclosed. We expect visit fee-only access to be available to an additional 22 million to 23 million individuals. We also see increasing demand for our hospital and health system platform solution, as these organizations look to invest in robust, secure and purpose-built telehealth capabilities. We expect organic growth in this channel at the high end of the 20% to 30% target range we provided last year upon the closing of the InTouch acquisition. And last but not least, accelerating growth in the international market, driven by increased penetration in existing geographies and expansion into new regions. We expect adjusted EBITDA in 2021 in the range of $255 million to $275 million, representing an increase of over 100% at the midpoint. And including an approximately $20 million benefit from lower expenses on Livongo devices attributable to purchase accounting adjustments related to the Livongo merger. The expected growth in adjusted EBITDA is driven by the contribution from a full year of Livongo as well as the overall strength across channels, partially offset by investments back into the business, including the integration of Livongo as well as new product development and enhancements to existing products. For the first quarter of 2021, we expect total revenue of $445 million to $455 million, representing growth of approximately 150% over the prior year’s quarter. We expect total paid membership in the range of 51 million to 52 million, which is net of the approximately 1.5 million temporary members discussed in prior quarters that have rolled off subsequent to year-end. We anticipate total visits during the first quarter of between 2.9 million and 3.1 million visits. We expect first quarter adjusted EBITDA to be in the range of $45 million to $48 million, including an approximate $7 million benefit from lower expenses on Livongo devices, attributable to purchase accounting adjustments related to the Livongo transaction. With that, I will turn the call back to Jason for closing remarks.
Jason Gorevic, CEO
Thanks, Mala. In closing, I want to thank the entire Teladoc team for their amazing commitment to serving our clients and members around the world during a challenging year. Over the past 12 months, we’ve seen a monumental change in consumer expectations for the way they access and experience health care as virtual care has firmly entered the mainstream. As a company, we’ve responded by significantly expanding our capabilities to meet the rising demands of clients and consumers around the world while extending our leadership position by delivering, enabling and empowering virtual care. As always, thank you all for your continued interest in Teladoc Health. And with that, we’ll open the call for questions.
Operator, Operator
First question comes from Lisa Gill with JP Morgan.
Lisa Gill, Analyst
Thanks very much. Congratulations on a great year, Jason. I just really want to understand just a couple of really quick things. You gave us so much information. Thank you to you, Mala. But, the first would just be around U.S. paid members, retention rates, competition in the marketplace. I know I usually ask about the selling season, but I know it’s a little early for that right now. But, just really want to understand how you’re thinking about the competitive market right now around what you saw on the retention side, because you clearly added a lot of new business. And then, secondly, you did talk about dozens of cross-sell, Livongo pieces of business in 2021 that are included in 2021. Is there any way to quantify that so we can start to think about reaching that $0.5 billion goal that you set when you made the transaction?
Jason Gorevic, CEO
Yes. Thanks, Lisa. Let me start with retention rates and the competitive landscape. And then, I’ll talk a little bit about the cross-selling situation. With respect to retention rates, they continue to be at high levels, consistent with historic levels, which have always been in sort of the low to mid-90s. We continue to see that. In fact, what we’re seeing is the pipeline is growing actually faster than we’ve seen in previous years. When I look at our membership opportunities, sort of the growth opportunities in our pipeline, the membership opportunity is up over 50% relative to the same time last year. That’s really indicative of the market and clients recognizing the value of the full solution that we have and the unique position that we occupy. I’ve had a number of large client discussions over the last several weeks as we start to move into this selling season and we start to talk about the opportunity of the full suite across all of our product portfolio, and it is truly differentiated. I was just talking to a regional blue plan who I believe we will take away from a competitor who has a much narrower set of products and can’t compete in the evolving landscape and sort of the new paradigm that we’ve created. With respect to the cross-selling what I think we said is over a dozen cross sales. Those will roll on over the course of 2021. I’d say we’ll have some impact on the back half of the year, but relatively small impact in the back half of this year. What we’re really looking at is the impact on 2022. We feel very good, in fact, better than we’ve ever felt before about the prospects for our revenue synergies. Just sort of characterizing the cross-sell opportunities, we look at the pipeline today versus the pipeline just sort of the middle of last quarter. Remember, we started commercial collaboration long before we closed the Livongo transaction. We’ve more than doubled the pipeline of cross-sell opportunities. I feel very, very good about it. We’ve taken a relatively conservative view of the contribution from the revenue synergies in 2021 and believe that those will materialize much more significantly in ‘22 and beyond.
Operator, Operator
Next question comes from Sandy Draper with Truist Securities.
Sandy Draper, Analyst
Thank you. I want to extend my congratulations on a very successful year. Jason, at a high level, we've discussed before your focus on higher visit fee growth compared to access fee growth. Before COVID, you effectively demonstrated the capability to enhance utilization and showcase the platform's value. Now, in a post-COVID environment, I'm curious about your long-term perspective. With the evolution of your model, do you believe that access fee growth will outpace membership growth? I'm interested in your thoughts on this growth dynamic, especially since things changed significantly with COVID. I would also appreciate Mala's input on driving new business and growth, specifically regarding visit volume versus access fees. Thank you.
Jason Gorevic, CEO
I appreciate the question. It's a complicated one. I believe visit volume will continue to grow at a faster rate than membership. However, with the significant increases in per member subscription fees from the Livongo business, we can expect revenue from subscription access fees to grow more quickly. There's a mix there. One factor that makes me optimistic about our continued visit volume growth is that this year, we saw visits increase by 140% year-over-year, even though infectious disease visits dropped by 17%. People are coming to us for a wider variety of reasons. Our mental health visits have skyrocketed, increasing over 500% through our B2B channel, and dermatology is seeing similar trends. Despite facing a historically low flu season due to social distancing and mask-wearing, we have factored this into our guidance for 2021 and are considering it as we look into the first half of 2022. I believe it won't be until the second half of 2022 that we see a return to a more typical cold and flu season. All of this is taken into account as we contemplate long-term growth.
Mala Murthy, CFO
Yes. And Sandy, it’s a great question. What I would add is if you think about the growth of both of those revenues, just to reinforce what I said in our prepared remarks in terms of why do we have confidence in the growth of both access fee revenue and visit revenue, it’s sort of a few different factors, right? One is on the access fee growth, to Jason’s point around, it is a much bigger base with the addition of Livongo and InTouch, most of those feet are access fee revenue, as we’ve talked about. And so, the growth there is going to be driven by our strong pipeline of multiproduct sales. We’ve talked about our growth in specialties, continued growth in our chronic condition programs, and then the growth in ATS and InTouch and our license platform solution, all of that is going to feed our access fee revenue growth. And then, to the point that Jason made around what’s driving visit revenue, it will really be the gains we continue to make in utilization. You saw from our results, we saw a very strong increase in utilization in the fourth quarter, over 800 points relative to fourth quarter of 2019, and sequentially, much over 100 points in relation to the third quarter. So, we will continue to drive growth and utilization, and that will obviously feed visit revenue growth. The growth in utilization is on the back of the significant increase in growth that we are seeing in noninfectious diseases. It was about 75% of our visit volume mix in the fourth quarter. So, we’re seeing strong growth there. We’ve talked about the growth that we are seeing in specialty, whether it be mental health, whether it be dermatology, so that is going to continue to drive the utilization. So, all of those factors are what is underpinning our confidence in both the access fee revenue growth as well as the visit revenue growth.
Operator, Operator
Next question comes from Sean Wieland with Piper Sandler.
Sean Wieland, Analyst
Hi. Thanks so much. And I guess, a follow-up to Sandy, just to go a little bit deeper. So clearly, membership growth is moderating in the outlook. And I’d just like to know, is that a factor of overall market penetration of virtual care, do you think that there’s opportunities longer-term to continue to grow membership? And then, related to that, you called out, Mala, new registrations. What percent of members today are registered members?
Jason Gorevic, CEO
Let me address the question regarding membership growth first. Last year, we added 15 million members, and in the past two years, we've seen a total increase of 25 million members. That's quite impressive. My confidence in continued membership growth comes from our growth pipeline, which is 50% larger than it was at this time last year. However, many of these opportunities are still early in the selling process. We had to restock the pipeline after a remarkable year. Therefore, we are taking a cautious approach to membership growth, considering the earlier stage of these opportunities, even though the potential for growth is significantly larger than last year. This provides me with strong confidence for the long term. Additionally, there is still room for growth with 65 million members within our existing clients, so I remain optimistic about ongoing membership growth. Our outlook is more about a multi-year view rather than focusing on quarterly results.
Mala Murthy, CFO
Yes. And to your second question, Sean, we, as you know, do not break out what you asked. We have given you a lot of information. As was pointed out earlier in the call, we don’t give you every piece of information. So, that’s not something we’ve broken out.
Jason Gorevic, CEO
We have talked, as you mentioned, about the increase in first-time registrants and how that contributes to our overall visit growth, not only in the year that they first register, but also that that enters the flywheel and we get them repeat utilization, especially among multiple products.
Mala Murthy, CFO
Yes. And it’s important that registrations, as we have talked about, are running well ahead of membership addition growth, right? So, that is also important as we continue to drive utilization in ‘21.
Operator, Operator
Next question comes from Stephanie Davis with SVB Leerink.
Stephanie Davis, Analyst
Hey guys, I hear everyone else, congrats on the quarter, congrats on the guide.
Jason Gorevic, CEO
Thank you, Stephanie.
Stephanie Davis, Analyst
Jason, you talked about a really strong international dynamic on your prepared remarks. I was hoping that you could talk a little bit more about maybe what pockets of geographies were you seeing the biggest strength and how the competitive dynamics differ in that market?
Jason Gorevic, CEO
Yes, absolutely. I’m really excited about our international products prospects. We’re just starting to really hit our stride and activate the international channels for the InTouch solutions, and we’re seeing tremendous interest in the international markets for the Livongo products. You know how large those opportunities are. With respect to the geographies, we’re seeing good growth in Europe, both on the continent as well as in the UK, where we continue to see the South American markets and especially Brazil as very exciting opportunities. The Brazilian market is characterized by a very tech-savvy population, and it’s a market where private health insurance is rather prevalent. Specifically in Europe, we launched with Telefónica and that continues to be a very, very strong relationship. We’re very bullish on the prospects for that relationship. And then, of course, we launched over the past year in the Nordic region. So, right now, those are probably our primary growth areas. We continue to have a strong and steady footprint in Canada and Australia and New Zealand. From my perspective, I’m very, very bullish there. I believe that unlocking some of those markets for the Livongo capabilities will be a game-changer in terms of the role of the international markets in our book of business.
Operator, Operator
Next question comes from Richard Close with Canaccord Genuity.
Richard Close, Analyst
So, I was going to drill down on membership, but that’s been hammered on here. But, can we talk a little bit about primary care, Jason? And how you’re thinking about that? Obviously, the comments on the pilots were positive. How do we think about the business model for primary care? What metrics you’re focused on there? And then, does it shift the revenue model more from an episodic type of payment to more recurring, or just overall, how does that model evolve?
Jason Gorevic, CEO
Yes, I appreciate the question, Richard. We’re really excited about the prospects for Primary360. We have a very large and diverse pipeline of opportunities for that model. It ranges from higher PMPMs to a wider variety of visit fees because a 30-minute introductory visit with a new primary care relationship is going to be worth more than an annual check-in or a symptomatic visit, for example. We’re also talking to several health plans about incorporating quality metrics and implementing more value-based reimbursement linked to our ability to improve the quality of care. This will start with small steps, such as documenting improvements in screening rates and appropriate preventive care, and progress towards more impactful outcomes-based measurements and ultimately, opportunities for us to enter into risk-sharing or shared savings arrangements with some of the payers. We’re already having those discussions but are very aware that we need to proceed carefully and ensure we have the right data to engage in those relationships with a clear understanding of where we can make the biggest impact. You’ll see an evolution of that model, but in all cases, it will result in significantly higher revenue per member for those we serve with our Primary360 product.
Operator, Operator
Next question comes from Sean Dodge with RBC Capital Markets.
Sean Dodge, Analyst
Maybe regarding the average PMPM, the sequential change was quite significant. Excluding the lift from the Livongo inclusion, can you provide insight into how much of that change was driven by multiproduct sales compared to pricing adjustments or true-ups related to the visits in the included contracts?
Mala Murthy, CFO
Yes. As you mentioned, there was a significant increase in the per member per month (PMPM) metric, rising to $1.76 this quarter from $1.18 sequentially and $0.91 previously. Much of this increase can be attributed to the addition of Livongo. However, even without Livongo's contribution, we observed a notable expansion in our PMPM this quarter. While I won’t detail the individual factors driving this growth, I can confirm that even when excluding the impact of Livongo for the two months of the quarter, we still experienced a meaningful increase in PMPM as we moved through the fourth quarter.
Operator, Operator
Next question comes from Daniel Grosslight with Citi.
Daniel Grosslight, Analyst
I wanted to focus a little bit on Medicare, both on MA and fee-for-service. I think in the third quarter, you mentioned you had around 2.5 million MA lives aboard. And CMS mentioned, I think, that around 21 million beneficiaries for the plan year 2021 will have access to some type of telehealth benefits. So curious, if you can give us an update on the MA progress you’ve made during this past AEP. And then, on the fee-for-service side, there’s been some noise out of the Inspector General’s office about auditing some telehealth visits. And I don’t know, it seems like the regulatory landscape in fee-for-service might be a little more uncertain. Curious to get your thought on that market in particular, which I suppose would go into your provider segment, and if the direct contracting within Medicare fee-for-service is going to have any impact on your strategy in that market?
Jason Gorevic, CEO
Yes. I’ll take the second one first, and then, Mala can speak a little bit to the progress we’re making in terms of our Medicare membership. I continue to think that Medicare fee-for-service is primarily an opportunity for us with respect to our hospital and health systems business, as hospital and health systems continue to lean in harder to providing virtual care for their membership and being reimbursed by CMS. We continue to be very active in terms of working with CMS and various state legislators for that matter on best practices when it comes to the regulatory environment. We’re very optimistic, actually. We think that the winds are all blowing in the right direction. It’s a rare bipartisan issue. We’re collaborative with respect to making sure that there are the right guardrails around it because we think that it’s important to have best practices proliferate with respect to not only payment models but also the best care being delivered to make sure that the consumers' needs as well as the payers’ needs, whether that’s the federal government or a private health plan are also looked after. We’re very active on those fronts. We’re actually applying quite a bit of technology to that to be able to do things, like use artificial intelligence to validate that a clinical visit took place and things like that. So, I feel very good about the direction that that’s heading. We continue to make progress in the Medicare Advantage market. I don’t know that we gave numbers updated with respect to our Medicare Advantage population. We’ll continue to keep you apprised of that as we go through the quarters.
Mala Murthy, CFO
Yes. And the only other thing I would add is, as we’ve talked about the 15 million member addition in 2020, we mentioned how we’ve seen nice growth in government, whether that includes Medicare Advantage or Medicaid. So, think of it more as we are seeing strong growth and membership addition across government.
Jason Gorevic, CEO
Maybe the last thing I’d just mention is, we’re also seeing private Medicare, meaning Medicare populations from within large employers who come through the health plans. It’s a part of the market that frequently isn’t talked about, but we’re seeing growth in some of those populations where the health plans are coming to us for those populations as well.
Operator, Operator
Next question comes from Charles Rhyee with Cowen.
Charles Rhyee, Analyst
Just to follow up a little bit on Primary360 as it relates to membership guidance. Is it right to think that Primary360 members of that growth is a conversion of existing U.S. paid membership numbers, or would that be incremental within the membership growth? And then, secondly, on the utilization number, which was quite strong. I know you don’t give this number, but in the past, but can you give a sense on how much of that utilization is from repeat users versus bringing in first-time users? Thanks.
Jason Gorevic, CEO
Yes. So, I’ll take the Primary360 membership and then Mala can talk a little bit about repeat utilization and registrations because I think really, it’s a question of new registrations. With respect to Primary360, the answer is actually both. In some cases, we’re going to existing clients to existing populations and making Primary360 available to them. We wouldn’t newly count those members, right? They’re already in our membership count. In other cases, there are new populations where we’re going to them and making our services available for the first time, and the product that we’re bringing to bear for them may be Primary360. It may also be Primary360 along with other products. So, you may get some into our Primary360, driving that revenue and then other members may have other versions of the product, either on a sort of as-needed basis or they may have our chronic condition management programs. You’ll see it show up in different ways. What you can be confident of is we’re only going to count a member once.
Mala Murthy, CFO
Yes. Charles, in response to your other question, we don’t provide a detailed breakdown, but here are a few key points. First, approximately half of our visit volume in the quarter came from first-time users, which is beneficial as it indicates potential for future utilization; once they try it, they are likely to return. This also contributes to our confidence in increasing utilization moving forward. Additionally, we're seeing new registrations significantly outpace membership additions, and the notable fact that about half of the volume is coming from first-time users is important. At JP Morgan in January, we discussed how the dynamics are supporting sustainable growth, including repeat visits which have shown strong growth over the past few years. I don’t want to elaborate too much, but remember that half of our visit volume in the fourth quarter came from first-time users.
Jason Gorevic, CEO
That’s true for the whole year. So, that trend was in the fourth quarter. That was true, and it was true for the whole year as well.
Operator, Operator
Next question comes from Jailendra Singh with Credit Suisse.
Jailendra Singh, Analyst
I just wanted to follow-up on BetterHelp, very strong trends there. Revenues in the $300 million range, expected to grow 50% in 2021. With that business now becoming a very sizable piece of your overall company, I was wondering if you are willing to talk about margins on that business, how does that compare with overall corporate margins and long-term profitability opportunity there? On a related part, with several employers now expanding telebehavioral and mental health services, do you see that having any impact on your BetterHelp DTC side of the growth prospects?
Jason Gorevic, CEO
So, let me answer about the market dynamics around BetterHelp and then Mala can talk to margins and performance. Yes, we really don’t. A couple of things, Jailendra. One, we’ve actually started taking BetterHelp into some B2B arrangements, in particular with respect to EAP plans, and that’s turned out to be a very fruitful market for us. The second thing I’d say is, most people who are turning to BetterHelp either don’t have adequate coverage or decide that they don’t want to use that coverage, especially for reasons of expenses, honestly. One of the value propositions to BetterHelp is that for a month’s worth of therapy, you can get therapy for a month, which would otherwise cost you in person about the same for a single visit or maybe a visit and a half, if you’re fortunate. The value proposition is very, very strong. And it has always been the case and continues to be the case that many of the people who turn to BetterHelp wouldn’t have otherwise gotten therapy. So, we continue to see that market be very, very underpenetrated; the opportunity is significant. We don’t see any slowing down of that in sight.
Mala Murthy, CFO
And from a margin standpoint, Jailendra, I am really pleased with the progression in margins that that aspect of our business has been making over the past few years. I obviously will not break out margins for any part of our business, but there has been really good progress in terms of margins. It’s on the back of a few things, right, just to give you a little bit of color on what’s driving the improvement in margins. We are seeing improvement in lifetime value. We are seeing improvement in retention and lower churn. We are definitely looking at constantly innovating when it comes to different channels. We do a lot of product improvements through the year. We test different pricing as we go through the year. There are a bunch of different levers that underpin the margin progression we are seeing. I have to say, if you think about revenue vis-à-vis the cost of acquisition, which we’re very keenly focused on, we’re seeing some very strong improvement in that. So overall, I’m pleased with the margin progression for BetterHelp.
Operator, Operator
Next question comes from Donald Hooker with KeyBanc.
Donald Hooker, Analyst
So, I wanted to revisit the PMPM metric that you gave, except Livongo. I guess, based on your comments model, it appears it was about $1.30 I think from your comments or somewhere in that neighborhood. That keeps marching up. Is there sort of a point in time where that sort of taps out? Just wanted to think ahead. That’s been kind of a driver for you over time? Is there sort of a full stack of your services where that sort of stops rising somewhere out in the future? Or maybe another way to ask the question, is there a particular client with a very, very high PMPM that you can sort of highlight?
Mala Murthy, CFO
When considering our PMPM and its progression, it really comes down to a couple of key factors. First, we have demonstrated through case studies that as we offer multiple products and services, we see a market increase in PMPM both before and after implementation. Expanding our suite of products and services has been a consistent focus for us over the years. Secondly, it's important to focus on products and services that are more longitudinal rather than episodic, as this fosters customer loyalty and leads to an increase in PMPM. Looking at the trajectory of our business and our plans for the future, I believe we have all the necessary elements in place to continue growing our PMPM.
Operator, Operator
And this does conclude the call for today. You may now disconnect.