Earnings Call Transcript
Teladoc Health, Inc. (TDOC)
Earnings Call Transcript - TDOC Q3 2023
Operator, Operator
Good afternoon. Thank you for attending the Teladoc Health Third Quarter Earnings Call. My name is Matt, and I'll be your moderator for today's call. All lines will be muted during the presentation portion of the call for an opportunity for questions and answers at the end. I'd now like to pass the conference over to our host, Patrick Feeley, Head of Investor Relations. Patrick, please go ahead.
Patrick Feeley, Head of Investor Relations
Thank you and good afternoon. Today, after the market closed, we issued a press release announcing our third quarter 2023 financial results. This press release and the accompanying slide presentation are available on the Investor Relations section of the teladochealth.com website. On this call to discuss the results are Jason Gorevic, Chief Executive Officer; and Mala Murthy, Chief Financial Officer. During this call, we will also discuss our fourth quarter and full year 2023 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 in 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
Thank you, Patrick, and thanks everyone for joining us. This afternoon, we are pleased to report a strong third quarter with results that met or exceeded our key financial and operating guidance. Our performance reflects the fundamental strength of our business and our continued success in making better health available to our more than 90 million members. In my prepared comments this afternoon, I want to focus on three key themes that reflect the value that we're delivering today and are poised to deliver in the years ahead. First, our third quarter results met or exceeded our key financial and operating guidance, strengthening a solid balance sheet that distinguishes us across our industry. Second, the demand for our products and services remained strong with the largest payers and partners globally viewing Teladoc Health's whole person care as the prescription for point solution fatigue and a disconnected healthcare system. And third, we are taking additional concrete steps to further accelerate our business on bottom line performance. This includes a comprehensive operational review of our business. I'll talk more about what that means in a moment. Let's begin with Q3 results. On the top line, our consolidated revenue grew 8% on a year-over-year basis in the third quarter to $660 million. As a result of our continued efforts to drive margin improvements this year, our consolidated adjusted EBITDA of $89 million exceeded the high end of our expectations. We were pleased to see revenue from our Integrated Care segment grow 9% year-over-year to $374 million. Compared to the second quarter, revenue grew 4% sequentially, driven in large part by higher enrollment in our Chronic Care programs where enrollment now exceeds 1.1 million active users, driven by a combination of strong leverage over the cost structure, improving efficiency, and a contribution from performance-based payments earned during the quarter. The Integrated Care segment delivered $63 million of adjusted EBITDA or a margin of 16.8%, which we believe demonstrates the leverage that's inherent in the Integrated Care business model. Turning to BetterHelp, we recorded $286 million of revenue in the quarter, up 8% year-over-year and within the guidance range provided last quarter. Third quarter margins for BetterHelp improved nearly 500 basis points over the prior year's third quarter, and we're on track to deliver material EBITDA growth again in the fourth quarter, which is typically BetterHelp's seasonally strongest quarter for margin. After scaling rapidly to surpass $1 billion of revenue last year, we have since taken a more balanced approach to growth and margin at BetterHelp. This means we'll continue to prioritize profitable growth that meets or exceeds our return requirements. Customer acquisition costs remain near the midpoint of our outlook range, combined with stable gross margin trends. That means we anticipate landing near the midpoint of our prior full year segment revenue and margin guidance for BetterHelp. The second theme I want to cover is client demand where the environment remains strong for our whole person care solution. In thinking about the selling season so far, I'd call out three key trends. First, while there are still over two months left to go in the year, we are pleased that year-to-date our bookings are tracking in line to moderately ahead of the same point last year. We're seeing strength across all key products and channels. Through the end of the third quarter, product care sales represent just over half of our total bookings in the US, up incrementally from the same point last year. Next, we've seen particular success in pulling through Chronic Care sales and enrollment via our whole person bundled solutions. We are increasingly selling access to multiple Chronic Care programs at a single bundled price point. For example, clients purchasing our diabetes plus bundle enable access to multiple Chronic Care programs, diabetes management, hypertension, and weight management. This has the benefit of removing friction by creating a simpler contracting path opening access to all programs from day one and driving better engagement and outcomes for our clients. It also meets the member where they are, with more than one quarter of Americans diagnosed with multiple chronic conditions. By delivering more value to the client, it enables us to unlock better economics. Over the past 12 months, more than two-thirds of our Chronic Care deals included our whole person bundled solutions. That's helped drive faster program adoption, resulting in total Chronic Care program enrollment growth of 13% year-over-year. Finally, not only are we seeing growth within our existing client base, but we're also seeing significant competitive takeaways. This is a direct result of other players struggling to deliver for their clients and in some cases fallout from unprofitable business models with weak balance sheets. During the third quarter, we added nearly four million lives to our virtual care programs in competitive takeaways. While our Q3 results and selling season validate the value that we're delivering for our clients and members, we also recognize that there is still even greater potential to unlock business performance. We have built a strong and durable foundation for efficient growth, increasing profitability, and generating cash flow. You've heard us talk about a more balanced approach to growth and margin. In 2023, we're demonstrating that we can drive material EBITDA and free cash flow growth despite a lower rate of top-line growth. We will continue to focus on improving bottom line performance and we're confident that we can continue to deliver significant EBITDA margin expansion, particularly within the Integrated Care segment. There are few things that give us a high level of confidence in our ability to deliver EBITDA and free cash flow growth well in excess of revenue growth over the next few years. First, we are exiting a period of elevated investment following the Livongo transaction. As many projects wrap up, like our Integrated app that launched this year, we expect moderating costs will allow us to drive material operating leverage over the cost structure as we grow our top line. Second, over the past 12 months, we have broadly sharpened our focus on improving efficiency across the organization. You've seen those efforts begin to bear fruit this year as EBITDA and free cash flow have consistently exceeded our own expectations, which leads me to three. We're disappointed with the valuation of the stock today, which we don't believe adequately reflects the value we are driving today and will continue to drive in the future. At the same time, we also know there are significant opportunities to add value through improved business performance. To that end, we recently kicked off a comprehensive operational review of the business. This review includes two broad components. First, we have undertaken a portfolio assessment to identify any opportunities to sharpen the focus across our portfolio of products and services and ensure our investments remain highly selective and prioritized in the direction of our integrated whole person care strategy. Second, we are pursuing a comprehensive review of our cost structure. Following our cost reduction efforts earlier this year, we are confident that we have the right operating structure in place to support the next phase of our growth. Meanwhile, we are actively working to identify opportunities to improve upon this operating efficiency. For example, as a part of that exercise, we have begun standing up centers of excellence that will leverage shared services across the business to enable a more efficient operating structure. We are committed to a thorough review and analysis and we are working with a third party to bring an independent perspective. In short, we are accelerating our efforts to ensure that our business is operating as efficiently as possible in order to drive profit growth at a level that is meaningfully higher than our revenue growth over the next few years. We will do this by fully tapping the operating leverage that is a market differentiator for Teladoc Health as the leader in digital health at scale. We will do this while ensuring that our business remains centered on our mission and that no efficiencies are taken at the expense of keeping our promises to our clients or caring for our members. We look forward to sharing more details on these efforts in the coming quarters. And with that, I'll turn the call over to Mala to review the third quarter and share our forward guidance.
Mala Murthy, CFO
Thank you, Jason, and good afternoon, everyone. Third quarter consolidated revenue of $660 million increased 8% year-over-year. Third quarter adjusted EBITDA was $88.8 million above the high end of our guidance range, representing a margin of 13.4%. Consolidated net loss per share in the third quarter was $0.35, compared to a net loss per share of $0.45 in the third quarter of 2022. Net loss per share in the third quarter includes amortization of acquired intangibles of $0.42 per share and stock-based compensation expense of $0.32 per share. Third quarter free cash flow was $68 million compared to $20 million in the third quarter of 2022. We ended the quarter with over $1 billion in cash and equivalents on the balance sheet. Turning to segment results, Integrated Care segment revenue increased 9% year-over-year to $374 million in the third quarter, growing 4% sequentially. The largest contributor to year-over-year Integrated Care revenue growth was Chronic Care, followed by Primary360. On a sequential basis, the primary contributor to Integrated Care segment growth was the ramp-up of enrollment in Chronic Care programs. During the quarter, we added 49,000 new enrollments in Chronic Care programs, bringing total year-to-date net enrollment growth to over 100,000. We ended the third quarter with Chronic Care enrollment of 1.12 million, an increase of 13% year-over-year and 5% sequentially. The biggest drivers of new Chronic Care enrollment year-to-date have been hypertension, which is now approaching 30% of total program enrollment, followed by our diabetes prevention and weight management programs, which have each crossed the 100,000 enrollment mark this year. Program enrollment growth has been bolstered by our success in selling our bundled chronic care management solutions. In total, the Integrated Care segment added over 4 million members during the third quarter, ending at 90.2 million. The significant membership growth during the quarter was primarily a result of a large competitive takeaway during the quarter. Average integrated care revenue per US member of $1.41 increased $0.01 over the prior year's quarter and was flat sequentially. Excluding the large new population added during the third quarter, revenue per member increased $0.04 sequentially. Third quarter Integrated Care adjusted EBITDA was $62.8 million, representing a 540 basis point margin expansion over the prior year's third quarter. That margin expansion was driven by higher gross margin due to an increased mix of subscription revenue, an increase in performance-based revenue earned during the quarter, and improved operating efficiency, particularly on the G&A line. The margin outperformance versus our third quarter guidance was primarily driven by lower expenses, again, most notably on the G&A line. Turning to BetterHelp, revenue increased 8% year-over-year to $286 million in the third quarter, a decline of 2% sequentially, in line with our guidance range. Average monthly users increased 5% over the prior year's quarter. Third quarter BetterHelp adjusted EBITDA was $26 million, resulting in a margin of 9.1%. This represents a 490 basis point increase over last year's third quarter, a reflection of the more stable advertising environment compared to the prior year as well as sustained gross margin improvement. Now turning to forward guidance. We expect full year revenue to be in the range of $2.6 billion to $2.625 billion, representing growth of approximately 8% to 9%. We now expect full year consolidated adjusted EBITDA to be in the range of $320 million to $330 million, representing year-over-year margin improvement of approximately 200 to 225 basis points. We now expect full year free cash flow of approximately $175 million, up from our prior expectation of $150 million. For the fourth quarter, we expect revenue to be in the range of $658 million to $683 million. Assumed in the fourth quarter revenue outlook is high single-digit percent year-over-year growth in our Integrated Care segment and low to mid-single-digit year-over-year growth in our BetterHelp segment. One thing I would remind you of, which we've discussed previously, is that the cadence of BetterHelp advertising spend in 2023 is more heavily weighted to the first half of the year than last year. This change in ad spend cadence results in quarterly year-over-year comparisons that favor the first half of 2023 to the detriment of the second half of the year. Therefore, we do not see the year-over-year growth rate expected in the fourth quarter as reflective of the underlying growth in the BetterHelp business. Fourth quarter consolidated adjusted EBITDA is expected to be in the range of $107 million to $117 million. The adjusted EBITDA outlook for the fourth quarter assumed Integrated Care segment margins between 11.5% and 12.5% and fourth quarter BetterHelp segment margins between 22% and 23%. As discussed throughout the year, our prior guidance assumed a modest deterioration in the cost of customer acquisitions at the low end of the range and an improvement at the high end of the range. Recent customer acquisition costs continue to trend within that initial outlook range, albeit in the lower half of the range. We believe trends are likely to persist in this range through year-end. And you see that reflected in the revision of the high end of our revenue guidance.
Jason Gorevic, CEO
Thanks, Mala. Before we go to questions, I do want to share some work that we are particularly proud of in the wake of so much tragedy in recent days. As you may have heard, BetterHelp is offering therapy to anyone impacted by the war in Israel and Gaza at no cost. The support applies to anyone affected by the war anywhere. As some of you know, BetterHelp frequently offers therapy at no cost to those in need through our social impact program. In the past 18 months, we have responded to the Maui fires, Hurricane Ian, the war in Ukraine, the Robb Elementary Uvalde Shooting, and Midwest flooding among other crises. While no one has all the right answers right now, I'm pleased that BetterHelp and Teladoc Health can make a positive contribution to healing at a time of such great suffering. With that, we'll open it up for questions.
Operator, Operator
The first question is from Lisa Gill with JPMorgan. Your line is now open.
Lisa Gill, Analyst
Thanks very much. Jason, I have just have to say that, that's a wonderful thing that you do. I know this is a really difficult time for a number of people. I really want to focus on a few things. I know I always ask about the selling season, but I want to focus on two areas, and that's really around Integrated Care. The margins we saw this quarter. How you're thinking about that business going forward? The significant wins that you said competitively, you had four million lives that shifted over to your Integrated offering. Can you maybe just talk to me about the competitiveness in the marketplace today, what you saw in the selling season? I'm sure you don't want to name who you took those four million lives from, but can you talk about were the single point solutions or the other parties that you feel are fairly competitive to you? Just how do we think about how you're positioned on a go-forward basis, especially on the integrated side of your business?
Jason Gorevic, CEO
Yes. No, thanks, Lisa. I appreciate that, and thanks for the comments on our work with BetterHelp. If I think about the competitive landscape, I think the incidence of us selling bundled solutions really speaks to the power of the breadth of our offering and how that is significantly differentiated from anyone else in the market. As we've talked about, the majority of our chronic care management programs make up the majority of our bookings, and the majority of our chronic care management solutions are sold as bundles of services. We're also seeing very significant wins where we sell additional products and services into existing clients. In many of those cases, we're replacing single-point solutions or more narrow solutions by adding our products into those clients. And so I would say that the dimensions of our competitive wins come into really three categories: One is where we replace a single-point solution with either a bundle of solutions or by selling additional products into an existing client. Two is where our clients have, sorry, our competitors have failed operationally and/or in terms of the value proposition for the clients, and our proven track record of success and value creation wins the day. And three is where we're replacing someone who, quite frankly, is faltering in this current economic environment because they have a business model that isn't sustainable. We're seeing them struggle either to raise capital or, quite frankly, to exist at all as a going concern. So we've seen all three of those. The biggest one this quarter that represented the largest competitive win was the latter, where we saw a competitor fail, and we were able to step in and replace them. I think that really speaks to the strength of our balance sheet and the strength of our financials. Mala and I have never spoken to so many CFOs at clients and prospects, who are really kicking the tires to make sure that the partners they engage with are going to be here, not just today but into the future and be able to grow with them. The second part of your question or maybe the first part of your question was about Integrated Care margins. Mala, do you want to speak to that?
Mala Murthy, CFO
Sure, I'll address that, Lisa. If I take a moment to reflect on our Integrated Care margin performance in the third quarter and compare it year-over-year, we have expanded by 500 basis points. When looking at it sequentially, we've seen a significant improvement of over 600 basis points in our Integrated Care margins. Several factors contributing to this stand out. Firstly, there is the growth in our chronic care segment. This has positively affected our gross margins, and we are leveraging that growth. Furthermore, during the third quarter, we experienced revenue growth that was balanced between chronic care and Primary360, which has also benefited the Integrated Care side. Our cost controls and efficiency programs implemented this year are yielding results. As Jason mentioned earlier, we will continue to explore further opportunities for cost efficiencies across our business. Additionally, we recognized around $4 million from performance guarantees, which contributed approximately 100 basis points to our margin expansion due to the outcomes we achieved. Therefore, the main drivers of our margin expansion are the revenue mix and the cost efficiency initiatives we are focusing on. We will maintain this focus moving forward.
Lisa Gill, Analyst
Thank you.
Operator, Operator
Thank you for your question. Next question is from the line of Ryan Daniels with William Blair. Your line is now open.
Ryan Daniels, Analyst
Hey, guys, thanks for taking the question. One for you on the chronic care book of business. I think you mentioned hypertension. It's about 30% and seeing strong growth in diabetes and weight management. So curious what your longer-term thoughts are on the impact potentially to that business either favorably or unfavorably from all the GLP-1 data that's coming to market.
Jason Gorevic, CEO
Yes. Thanks, Ryan. As we said earlier this year, we don't really anticipate any material financial impact from the new program that we launched and announced earlier in the year. We think that that will have an impact for us in the future, and we expect to participate in being able to take advantage of some of the benefits of GLP-1s for people who are living with diabetes as well as for people who engage with our diabetes prevention and weight management programs. So we see that as paying off for us in the future. We also see, quite frankly, that the market is very engaged in this, and our clients are looking to us for solutions, especially because of the cost of those medications. With respect to whether that's going to be a headwind. Yes, I would say probably the hype has gotten ahead of the reality with respect to the GLP-1s. I mean, I think I saw an analysis recently where some people said that the airlines were going to save on fuel costs when the country engages with GLP-1s and collectively loses weight. I think that gets to maybe a little bit of overhype at this point. We've seen the prevalence of diabetes continually increase year-over-year and is expected to increase by over 25% in the next 10 years. While I think that GLP-1s can have an impact on moderating that rate of growth, I really don't think, and I wish it weren't the case, but I don't think we're going to suddenly see a massive decline in the need for people to engage in more comprehensive solutions that include behavior change with respect to activity, with respect to nutrition, and with respect to mental health care. And so I think GLP-1s, and really, we view them as a tool to enhance those programs, but don't really see them as a headwind. I think we also, again, going back to my initial comments, you have to take it in the context of the cost of those medications and the need for our clients to engage in programs that help manage the overall cost of them.
Ryan Daniels, Analyst
Okay. That's super helpful. I'll hop back in the queue. Thanks so much.
Jason Gorevic, CEO
Thanks, Ryan.
Operator, Operator
Thank you for your question. The next question is from the line of Jailendra Singh with Truist. Your line is now open.
Jailendra Singh, Analyst
Thank you and thanks for taking my questions. I understand we need to wait for a detailed 2024 guidance until Q4 earnings call. But I was wondering if you could give any directional color or qualitative color on revenue and margin trends or any additional puts and takes we should keep in mind across those two segments as we think about 2024 next year?
Jason Gorevic, CEO
Yes. I have a few points to share before I hand it over to Mala for further details. You can expect our EBITDA to grow at a faster pace than our revenue over the next couple of years, which we anticipate will also apply to 2024. We mentioned that the selling season for Integrated Care is in line with or slightly ahead of last year at this time, with a few months remaining in this selling season. Our late-stage pipeline appears to be relatively stable compared to this year. Client retention in that segment remains strong, in the 90s, with no significant changes. Regarding BetterHelp, we are adopting a more balanced approach to revenue and margin growth than we have in the past, and the results from the fourth quarter should not be seen as reflective of the overall growth of that business. While we will hold off on providing 2024 guidance for now, we expect to do so in the first quarter of next year. Those are the key points to consider for your outlook. Mala, did I overlook anything?
Mala Murthy, CFO
I would like to provide some additional insights on BetterHelp specifically. As we look ahead to 2024, there are two key considerations to keep in mind. First, the quarterly comparisons will differ significantly this year compared to last year. For the first quarter, we expect results to be above the run rate, while the fourth quarter will likely be below the true run rate due to year-over-year comparisons in advertising spending and revenue growth. It’s important to note that we’ve indicated all year that the timing of our ad spend is shifting compared to last year. In 2022, more than half of our ad spend occurred in the latter half of the year, whereas this year, a majority is happening in the first half. The second consideration is that BetterHelp’s revenue has been slowing over the past two years, which can be attributed to a few factors. Firstly, the business has grown quickly and is now significantly larger, making it challenging to maintain the same high growth rates annually. Secondly, as Jason mentioned, we’re managing the business with a focus on both top-line revenue and bottom-line growth, as well as cash flow. This balanced strategy emphasizes return on investment and margin, which unsurprisingly will result in a lower growth rate for top-line revenue. Lastly, as the largest player in the direct-to-consumer virtual mental health space, we are also the leading advertiser in this area. Our scale allows us to generate strong returns on our advertising investments, providing us with a competitive edge. However, there is a limit to the amount of advertising expenditure and customer acquisition that can be achieved in a short timeframe. There’s a natural growth rate each year as the market increasingly shifts toward virtual services, which ultimately limits how rapidly the direct-to-consumer business can grow profitably year after year. This context illustrates the dynamics we're observing in the BetterHelp business.
Jailendra Singh, Analyst
Very helpful. Thank you.
Operator, Operator
Thank you for your question. The next question is from the line of Richard Close with Canaccord Genuity. Your line is now open.
Richard Close, Analyst
Thanks for the questions. Jason, could you provide more details on your investment strategy moving forward? You mentioned it briefly, but how significant is this shift compared to previous years? It seems like you're adopting a more cautious approach, so I’m interested in examples of what might take priority.
Jason Gorevic, CEO
Yes. A couple of thoughts there, Richard. I think first of all, it's important to put it in the context of where we've come from over the last couple of years. We're emerging from a significant investment cycle during which we've spent a lot of time and effort building and integrating post Livongo acquisition. And so now I think it makes sense for us to look across the organization for further ways to enhance business performance. Part of that is focusing our investments on the areas where not only are we going to get the greatest return, but also are closest to the center of the bull's eye of our strategy. I think that also, you'll see in the continued progress we're making on capitalized software. You've seen that this year. I think you'll see that again next year as we move into more focused investments and less quite frankly, foundational investments on big chunks that have helped to get us to this point but also put the platform in place for us to move forward. You've seen that with our Integrated app. You've seen that as we've migrated some of our internal ERP and financial systems. You see that as we put in place some of the capabilities that enable us to deliver on a true integrated experience for Primary360. And so we'll continue to focus on delivering that whole person care in a differentiated manner but also making sure that we're judicious in making sure that we're delivering the return on capital spend.
Richard Close, Analyst
Okay. Thank you.
Operator, Operator
Thank you for your question. The next question is from the line of Charles Rhyee with TD Cowen. Your line is now open.
Lucas Romanski, Analyst
Hi. This is Lucas on for Charles. I want to ask about the performance guarantees that you recognize from generating positive outcomes. I'm assuming this is related to value-based arrangements. What portion of you guys' Integrated Care segment is derived from these sorts of value-based arrangements or at least engagements that enable you to recognize performance payments? And then can you give us a little bit on how these are structured and how you can earn from them?
Mala Murthy, CFO
Yes. Thanks for the question. The way I would think of it is, on a run rate basis, the amount of performance-based revenue tied to clinical outcomes would be in the single-digit percentage of our total Integrated Care segment revenue. So just to give you some sort of dimensions on the size of that. The other thing I would say is we have a long history of performance against these clinical measures. We have a lot of data to support our analysis. We feel very comfortable in terms of our ability to perform against these outcome guarantees. As I just said, it's a relatively small percentage of our revenue today. And finally, we also believe that we take an appropriately conservative approach in recognizing performance-based revenue. So all of it to say this is work contracts that certainly we have been used to delivering against for some time supported by data. This is a relatively small percentage of our overall revenue book today.
Operator, Operator
Thank you for your question. The next question is from the line of George Hill with Deutsche Bank. Your line is now open.
George Hill, Analyst
Hey, good afternoon, guys. And Jason and Mala, thanks for taking the question. I guess, I would have a question on BetterHelp. And Mala, I recognize the guidance that you gave for Q4. My question is kind of now that we're about a month past the Q3 close, I guess I would just ask like is that business from a membership perspective basically tracking in line with expectations to where you guys have guided for the balance of the year? And then, Jason, one for you quickly would be because it sounds like the company wants to take a pretty broad approach to a cost-cutting program. I don't know if there's any way to kind of size order of magnitude in the way that you're thinking about what the opportunity looks like inside of the cost structure?
Jason Gorevic, CEO
Yes. So maybe I'll take that one first, George, and then Mala can talk about where we are. The short answer is a month into the quarter, we're right in line with where our guidance is. So I can take that for Mala. I think with respect to our comprehensive operational review, we're really looking across the portfolio to ensure that everything we do is aligned with our strategic focus and maximizing our profitable growth opportunities. I think these efforts are focused on operating efficiency, and we've stood up now centers of excellence for things like member operations, clinical operations, client operations, revenue cycle management, supply chain, and purchasing, all areas where we can leverage our scale and make sure that we're driving for greater efficiency and take advantage of the opportunity to drive cost out of the business such that we can operate more efficiently. I mentioned before, we are emerging from a significant period of investment. It makes sense for us to really look at a more right-sized organization based on the cost reduction efforts that we took earlier this year and make sure that all parts of the business are contributing to our profitable growth. I think that is really the fundamentals of it. We don't have anything to announce today regarding what the magnitude of the performance improvements that we expect. As we're in the middle of that assessment right now, I think you can expect us to give you more color on that in the quarters to come as we quantify the opportunities and then help you to tie those opportunities to what we described earlier, which is EBITDA growing at a faster rate than revenue over the next couple of years.
Mala Murthy, CFO
The one last thing I would add is we have talked about all of the operating expense initiatives and things we would look at. I would also say if I think about gross margin and the gross margin improvement, which has been a strong contributor to our margin expansion. Think about BetterHelp and the gross margins that we are seeing there. We are taking steps to and initiatives to improve therapist productivity, whether it be group therapy, more digital interactions. So it's, I would say, both across gross margin as well as operating expense.
George Hill, Analyst
Thank you.
Operator, Operator
Thank you for your question. The next question is from the line of Jessica Tassan with Piper Sandler. Your line is now open.
Jessica Tassan, Analyst
Thank you guys for taking the question. So I'm curious, as you think about the kind of new guidance that EBITDA and free cash flow should grow faster than revenue over the next couple of years. Did we still be thinking about those long-term revenue growth target, the mid-single digit to high single-digit for Integrated Care and low double to mid-teens for BetterHelp as being valid against that new guidance, or should we think about sort of a different revenue growth rate on a consolidated basis? Thanks.
Jason Gorevic, CEO
Yes, Jess. We haven't provided long-term guidance for the overall business or its segments. You can expect us to share our outlook for 2024 in the first quarter of '24. Our indication today about anticipating EBITDA to grow faster than revenue over the next couple of years is likely the most extended outlook we've provided in recent quarters. As we finalize the findings and results from our operational review, that will contribute to a more multiyear outlook. We will aim to offer a longer-term perspective when we are ready, but I don't want to confirm those numbers as I don't remember us giving a long-term view.
Jessica Tassan, Analyst
Got it. Thank you.
Operator, Operator
Thank you for your question. The next question is from the line of Daniel Grosslight with Citi. Your line is now open.
Daniel Grosslight, Analyst
Hi, guys. Thanks for taking the question. I just have a couple on Integrated Care margins and the outlook for the remainder of the year. So if I heard you correctly at the midpoint, you expect around 12% margin for Integrated Care, which would be around 477 basis points of degradation, a lot of 100 basis points for the performance fee. So still talking around 375 basis points of degradation sequentially. I'm curious what's driving that? And then I guess if I look at the full year, what's implied by that 4Q guidance, it's around 250 basis points of margin expansion versus when we started the year, I think you thought it would be kind of flat to up 50, and then you changed that 75 to 125 basis points. Now it's significantly outperforming there. So maybe if you could just put a finer point on that and the outperformance there? And what we should expect going forward in fiscal '24?
Mala Murthy, CFO
Thank you, Daniel, for your question. In terms of the guidance we provided for the fourth quarter regarding Integrated Care, there are several factors contributing to the decrease in margins. Firstly, the fourth quarter is typically the cold and flu season, which leads to gross margin compression as visit volumes increase. That's always a consideration. Additionally, we are investing ahead of member onboarding, with several new client starts on January 1. We are incurring expenses in anticipation of these launches. We are also expanding our number of W-2 physician hires, which adds some pressure on margins for the quarter. Lastly, the performance guarantees added about 100 basis points to the third quarter margins, which will affect things sequentially. Regarding your question about full-year margin performance and the observed expansion and strength, it primarily comes down to two main themes. First, we are experiencing robust growth in Chronic Care revenue, which has consistently surpassed our expectations since the beginning of the year. The second factor is the benefits from our cost efficiency programs, which we have realized over the year. These two elements have enabled us to exceed our margin projections throughout the year.
Daniel Grosslight, Analyst
Makes sense. And then maybe just a follow-up. I'll take a shot at fiscal '24 as well. It seems like if anything, you're going to get more margin expansion in '24 versus what you are going to achieve in '23, which is around 200, 230 basis points, right? You got that operating efficiencies that might roll through and some other less spend on the Integrated Care app. So I'm just curious, should we think about 200, 250 basis points of margin expansion going forward as kind of the floor for you guys?
Jason Gorevic, CEO
We're going to stop short of giving a magnitude of the margin expansion. But I think by definition, the fact that we expect EBITDA to grow faster than revenue, you can take away from that that we are targeting margin expansion again in '24, and we'll give you more insight into the magnitude of that as we get into '24 guidance.
Operator, Operator
Thank you for your question. The next question is from the line of Elizabeth Anderson with Evercore ISI.
Elizabeth Anderson, Analyst
Hi, guys. Thanks so much for taking the question. I had a question about how to think about pricing and sort of if we think about the average revenue per US Integrated Care member? And then on the BetterHelp side as well. Like obviously, you had a bunch of new integrated care members roll on. So I just wanted to understand, is that something we should think of as kind of ramping as those members sort of come and get geared up, and so that's something that we should think about maybe over the next couple of quarters? Has that ramped? Or is that not the right way to think about it? And then obviously, you had a nice inflection in BetterHelp therapy revenue per user per month as well. So just how to think about the cadence of that as we kind of move forward. Thank you.
Jason Gorevic, CEO
Yes. I would describe, Elizabeth, thanks for the question. I would describe the pricing environment as stable. With respect to the members that we just onboarded in Integrated Care, it's really more of a revenue per member than a pricing question because we have to activate those members to drive visit revenue. The subscription revenue stays stable over time, but visit revenue tends to ramp. That's not really a pricing question. It's more of an activation and engagement question. And then, of course, we always look for land and expand opportunities so that we can increase our revenue per member. So when I think about pricing, I think of it as an apples-to-apples basis for either a single product or a bundle of products from one year to the next, and we're seeing it pretty stable. With respect to BetterHelp, we're always experimenting with pricing across markets. But overall, pricing hasn't changed in a notable way. I think if you're looking at revenue divided by user count, any small change you're seeing period-to-period is primarily a reflection of mix, including the growth of the other line item, which is mostly a DTC sleep asset, that's small but growing faster. Importantly, when you're looking at revenue in a quarter versus membership, there's quite a bit of impact or there's impact within a quarter of the timing of when members come on and then start paying for the program and/or roll off of the program. So overall, I would say pricing has remained pretty stable in that market.
Operator, Operator
Thank you for your question. The next question is from the line of Sean Dodge with RBC Capital. Your line is now open.
Sean Dodge, Analyst
Thanks. Good afternoon. Jason, you kind of alluded to it a bit in earlier response, but just on BetterHelp, with the resumption of student loan payments on October 1st. Is there any updates you can provide on what you're seeing at least thus far into October? Any potential impact that's having on new adds or churn or any kind of discernible change in customer behavior? I mean just, I guess, in general, around BetterHelp?
Jason Gorevic, CEO
We haven't seen anything in the data that suggests that, that's had an impact. Churn has been stable. We haven't seen significant notable change, nor are we assuming any significant change in churn in our guidance. So I would say, no, we haven't seen really any impact of that.
Operator, Operator
Thank you for your question. That will conclude the conference call. Thank you for your participation. You may now disconnect your lines.