Andrew Mok

Andrew Mok asked about the drivers behind the implied free cash flow conversion of less than 80% for 2026, which is below recent history and sequentially lower. He also inquired about the expected impact of the new rebate-free model on working capital.

Answer

Brian Evanko, President and COO, attributed the expected $9 billion cash flow from operations (a $600 million decline from 2025) primarily to a lower contribution from the PBS business, including large client renewals and 2026 investments. David Cordani, Chairman and CEO, clarified that the rebate-free model would not impact the 2026 cash flow outlook, with working capital impacts to be reconciled closer to 2027-2028.

Andrew Mok highlighted that the operating cash flow and CapEx guidance implies less than 80% free cash flow conversion, which is below recent history, and asked about the drivers of this pressure and the expected impact of the new rebate-free model on working capital.

Answer

Ann Dennison explained that the 2026 cash flow guidance of $9 billion, a decline from $9.6 billion in 2025, primarily reflects a lower contribution from the PBS business due to large client renewals and 2026 investments. David Cordani added that the rebate-free model will not impact the 2026 cash flow outlook.

Andrew Mok questioned the profitability of Cigna's large Evernorth contracts, asking if some might operate at a near-term loss given the lower profitability mentioned, and how to think about the multi-year progression of profitability for these agreements.

Answer

David Cordani, Chairman and CEO, stated that Cigna does not comment on individual contract profitability but confirmed that very large relationships typically have lower earnings profiles. He emphasized that Cigna proactively engaged in these strategically important renewals. Brian Evanko, President and COO, clarified that Cigna does not consciously write business at a loss and that while these contracts run at a lower margin, they often deepen over time with expanded services.

Andrew Mok of Barclays asked for an update on Cigna's GLP-1 products and their dispensing economics, considering recent partnerships and a competitor's commentary on headwinds.

Answer

President and COO Brian Evanko stated that GLP-1 contributions to Evernorth are in line with 2025 expectations. He detailed a new program capping patient out-of-pocket costs at $200/month to encourage employer adoption. While market feedback is positive, he expects most clients to incorporate this new benefit at renewal. The overall economic impact from GLP-1s remains consistent with the company's full-year guidance.

Andrew Mok inquired about Evernorth's experience in the evolving Part D market under the IRA, asking about observed changes in manufacturer or member behavior and a potential pickup in specialty scripts previously covered by patient assistance programs.

Answer

President and COO Brian Evanko noted a structural shift toward more complex specialty medications. He reported that Evernorth's specialty script volumes grew in the mid-teens in Q1, with Medicare growth being 'considerably higher' than commercial. While the exact cause is unclear (IRA impact vs. manufacturer marketing), he confirmed the trend is a clear beneficiary for Evernorth's Specialty and Care Services business.

Andrew Mok of Barclays asked for clarification on why the pressure from higher specialty drug costs was impacting the stop-loss business but not appearing to affect the fully insured portion of the business.

Answer

CFO Brian Evanko explained that the total healthcare cost structure for 2024 was in line with expectations, but the mix of costs shifted disproportionately toward high-cost individual claimants, which specifically pressures stop-loss products. CEO David Cordani added an illustration: a moderation in lower-dollar inpatient events was offset by an acceleration in higher-dollar events like complex cardiac and oncology procedures, concentrating the financial impact on the stop-loss segment.

Andrew Mok requested more detail on the nature and magnitude of the planned strategic investments across the core PBM and specialty businesses that are expected to continue into 2025.

Answer

CFO Brian Evanko explained that these internal reinvestments are a core part of the capital deployment framework. He noted the company is tracking toward approximately $1.5 billion in discretionary CapEx for 2024, with the majority directed toward technology, including customer, provider, and broker-facing platforms, to strengthen capabilities in high-growth areas like specialty.

Andrew Mok asked for details on mistreatment and mortality trends during Q4 2025, any observed correlation between these metrics, and a breakdown of the expected ACA headwind cadence, including open enrollment performance and anticipated attrition rates.

Answer

Javier Rodriguez, CEO, noted no significant shift in mortality during Q4 2025, while mistreatments were up seasonally but consistent with Q4 2024, confirming a lagged correlation between mistreatment rates and mortality. Joel Ackerman, CFO and Treasurer, outlined the ACA headwind as approximately $40 million for 2026, $70 million for 2027, and $10 million for 2028, observing that open enrollment performed better than expected but awaiting payment data to assess true yield and patient resilience.

Andrew Mok from Barclays asked about the trends in missed treatments and mortality during the fourth quarter, exploring any causal links, and sought details on the expected impact and cadence of the ACA headwind, including open enrollment performance and attrition.

Answer

CFO Joel Ackerman reported no significant change in mortality during Q4, while missed treatments were up seasonally, similar to Q4 2024, noting a clinical correlation with mortality with a lag. Regarding the ACA headwind, he outlined an estimated $40 million impact this year, $70 million next, and $10 million the year after, observing that open enrollment performed better than forecasted. He emphasized patient sophistication in maintaining insurance but lacked specific data on premium assistance recipients.

Andrew Mok asked for clarification on DaVita's treatment volume trends following the recent cyber attack, questioning the revised outlook for elevated mistreatments. He also inquired about the financial contribution of phosphate binders and the reasons for lower-than-expected dispensing volumes.

Answer

CEO Javier J. Rodriguez stated the year was progressing as expected aside from the flu and the cyber incident. CFO Joel Ackerman explained that while patient admissions normalized post-attack, an unexpected spike in mistreatment rates in Q2 prompted a more conservative outlook for the rest of the year. Regarding binders, Ackerman noted the lower volume was due to patient adherence issues, not patient mix, and provided the contribution to revenue and cost per treatment.

Andrew Mok from Bank of America inquired about the breakdown of the 50-basis-point treatment growth revision between the flu and the cyber attack. He also asked how the costs from the cyber attack would be treated in earnings and sought more detail on the oral phosphate binder mix and its expected evolution. Finally, he asked about commercial mix and Q1 exchange plan growth.

Answer

CFO Joel Ackerman detailed the treatment growth revision, attributing slightly more than half to the flu's census impact and the rest split between Q1 mistreatments and cyber-related admission losses. He clarified that direct cyber costs will be non-GAAP items, while indirect costs are included in guidance. CEO Javier Rodriguez explained the phosphate binder favorability was due to a higher mix of iron-based binders, which they expect to remain stable. He also noted that commercial mix was flat in the low 11% range and open enrollment was healthy.

Andrew Mok from Barclays asked for clarification on the revenue per treatment math for phosphate binders, which seemed light. He also inquired about the acceleration in G&A costs and requested quantification of a settlement gain.

Answer

CFO Joel Ackerman explained the blended RPT impact from binders is lower than the per-patient Medicare amount because it doesn't apply to all payers and not all patients take the therapy. CEO Javier Rodriguez described G&A as part traditional cost and part investment in areas like IT and revenue operations that yield benefits elsewhere. Ackerman declined to quantify the settlement gain, calling it small and routine.

Andrew Mok asked about the hurricane impact on Q3 and Q4 treatment volumes, the implied acceleration in Q4 growth, the magnitude of 2025 headwinds and tailwinds, the financial impact of phosphate binders, drivers of G&A growth, and the ACA exchange mix.

Answer

CFO Joel Ackerman quantified the Q3 hurricane volume impact at 10 basis points and expects a lesser impact in Q4. For 2025, he suggested modeling headwinds and tailwinds as offsetting at the OI line. CEO Javier Rodriguez explained that the phosphate binder impact is currently unquantifiable due to unknown reimbursement, mix, and volume variables. Rodriguez also attributed higher G&A to investments in IT, wages, and reimbursement operations, and noted the company's QHP mix is around 3%, growing with the market.

Andrew Mok inquired about the larger-than-expected 2026 membership declines, particularly in Medicare, asking for details on what transpired during the Annual Election Period (AEP) and the components of commercial risk membership declines between ACA and employer groups.

Answer

Felicia Norwood, President of Government Health Benefits, Elevance Health, explained that Medicare enrollment during AEP was aligned with a focus on margin, with deliberate steps to reposition the business for sustainable value. While membership declined in the high teens percentage range, the mix of lost lives was consistent with strategy, primarily in PPO and HMO products in geographies where the company was disciplined. Mark Kaye, CFO, Elevance Health, added that employer group risk membership is expected to decline in the high single-digit percentage range due to a strong focus on margin discipline and deliberate pricing decisions, especially in lower-margin public sector business.

Andrew Mok inquired about the larger-than-expected 2026 membership declines, particularly in Medicare, asking for details on what prompted negative revisions during AEP and the components of commercial risk membership declines between ACA and employer groups.

Answer

Felicia Norwood, President of Government Health Benefits, stated that Medicare enrollment during AEP was aligned with a focus on margin, with deliberate steps to reposition the business. While membership declined in the high teens, the attrition was consistent with strategy, primarily in PPO and HMO products in non-strategic geographies. Mark Kaye, CFO, added that employer group risk membership is expected to decline in the high single-digit percentage range due to a strong focus on margin discipline and deliberate pricing decisions, especially in lower-margin public sector business. Gail Boudreaux, President and CEO, emphasized the disciplined approach.

Andrew Mok sought clarification on Elevance Health's Medicare operating margin comments for 2025 (slight increase), asking if it was a year-over-year improvement or a positive revision, and whether a path to target Medicare margins exists for 2026.

Answer

Mark Kaye, CFO, clarified expectations for Medicare margin stability with potential for slight improvement in 2025 (excluding a one-time settlement), driven by strong retention, disciplined cost management, and product positioning. He also noted weaker Medicaid performance and some favorability in ACA relative to initial expectations.

Andrew Mok inquired about the health benefits margins finishing at 1.4%, implying negative government margins, and sought clarification on whether the Medicare operating margin increase for 2025 was a year-over-year comment or a positive revision, and the path back to target Medicare margins.

Answer

Mark Kaye (CFO and EVP, Elevance Health) clarified that Medicaid performance was weaker than expected due to elevated cost trends and acuity shifts. ACA trends were somewhat favorable to expectations but still significantly above historical levels, with operating margins expected to be down high single-digits year-over-year. For Medicare, he stated expected margin stability with potential for slight improvement in 2025 (excluding a one-time settlement), supported by strong retention, cost management, and product positioning.

Andrew Mok asked for a breakdown of pressures in the ACA business between unit cost trends and risk pool shifts, and questioned why risk adjustment expectations remain unchanged despite higher morbidity.

Answer

CFO Mark Kaye explained that the pressure is approximately 70% from increased risk pool acuity due to membership shifts from Medicaid and 30% from higher utilization and aggressive provider coding. He stated that risk adjustment expectations are stable because the higher morbidity is a market-wide phenomenon, not specific to Elevance Health's member mix versus the market.

Andrew Mok noted that the Q1 MLR appeared better than implied by management's comments in March and asked for an explanation of what developed favorably late in the quarter and how it affects the trend outlook for the rest of the year.

Answer

Mark Kaye, CFO, clarified that the perceived outperformance was not due to a change in underlying trend. He explained that a larger-than-anticipated premium tax in a major Medicaid state had the dual effect of lowering the benefit expense ratio and increasing the operating expense ratio, with no material impact on operating earnings. This accounting adjustment was the primary driver of the variance compared to consensus estimates.

Andrew Mok from Barclays sought clarification on the 2025 Medicare Advantage membership growth outlook, asking for the actual growth from the Annual Enrollment Period (AEP) and how much of the full-year forecast it represents.

Answer

Felicia Norwood, President of Government Health Benefits, stated that AEP growth was strong and in line with expectations, driven by a significant group membership win from a long-standing commercial account. CEO Gail Boudreaux added clarity, stating they anticipate minimal additional growth for the remainder of the year, which gives them confidence in the 7% to 9% full-year guidance range.

An analyst from Barclays, on behalf of Andrew Mok, asked for confirmation on the magnitude of the Medicaid pressure in the quarter and questioned whether the Medicaid book is currently profitable.

Answer

CFO Mark Kaye confirmed the implied basis point pressure for 2024 was in the right ballpark. He stated that the Medicaid business is expected to be profitable for the full year, although it will be below its target margin range. He emphasized the importance of a long-term view, as single-quarter results can be affected by normal dynamics.

Andrew Mok asked about the year-over-year decline in HCA Healthcare's outpatient surgery, noting it was on a negative comp and moderated from the previous quarter, and if any specific payer categories were driving this volume pressure.

Answer

CFO Mike Marks clarified that overall outpatient revenue growth was higher than inpatient. For outpatient surgery specifically, same-facility cases were down about 50 basis points in Q4, with hospitals flat and ASCs down 1.5%. He attributed declines primarily to Medicaid and lower intensity cases like ENT, but noted good growth in net revenue and earnings for the outpatient surgery business overall. CEO Sam Hazen added that HCA continues to invest significantly in outpatient facility development, adding roughly 100 business units in the past year, with a strong capital pipeline and acquisition opportunities in the outpatient footprint, aiming for 18-20 outpatient facilities per hospital by the end of the decade.

Andrew Mok asked about the year-over-year decline in outpatient surgery on a negative comparable basis and its moderation from the previous quarter, seeking elaboration on the observed trends and any specific payer categories driving volume pressure.

Answer

CFO Mike Marks noted that overall outpatient revenue growth exceeded inpatient growth in Q4 2025. Outpatient surgery cases were down about 50 basis points year-over-year, with hospitals flat and ASCs down 1.5%. He indicated that payer mix remained solid, but declines were primarily driven by Medicaid, alongside a decrease in lower-intensity cases like ENT. CEO Sam Hazen highlighted significant investments in outpatient facilities (adding 100 units in 2025), a strong acquisition pipeline, and the strategic importance of outpatient growth for network resiliency and patient access.

Andrew Mok requested an update on underperforming regions outside the hurricane markets and the near-term addressability of those issues.

Answer

CEO Sam Hazen reported that one of the two previously challenged divisions has recovered, while the second is still working through issues, with confidence for recovery into 2026. He highlighted strong portfolio performance and effective management of core operations in Q3.

Andrew Mok from Barclays requested an update on underperforming regions outside the hurricane markets mentioned last quarter and the near-term addressability of those issues.

Answer

CEO Sam Hazen reported that one of the two previously challenged geographic divisions has recovered, while the second is still working through issues, with confidence for recovery into 2026. He highlighted strong portfolio performance in Q3, effectively managed core operations, and good volume mix.

Andrew Mok of Barclays requested the latest figures for ACA exchange revenue and admissions as a percentage of total, and asked for more detail on the performance of hurricane-impacted markets, including the remaining headwind in guidance.

Answer

CFO Mike Marks stated that exchanges represent about 8% of equivalent admissions and just over 10% of net revenues. Regarding hurricane markets, he noted the guidance was raised by $100 million due to better-than-expected recovery. CEO Sam Hazen added that the North Carolina market saw stronger-than-anticipated demand, though this was partially offset by a tighter labor market requiring more contract labor.

Andrew Mok requested clarification on HCA's hurricane commentary, questioning why the impact was considered neutral year-over-year when two markets were impaired in Q1 2025 but not in Q1 2024.

Answer

CFO Mike Marks reiterated that the company's full-year 2025 guidance assumed that the impacts from hurricanes would offset each other and not create a net tailwind. He explained that this assumption played out as expected in Q1, as the year-over-year earnings change in the two primary affected markets (North Carolina and West Florida) was effectively flat or neutral when combined.

Andrew Mok requested details on the performance of Mission Hospital, its impact on same-store volumes in the quarter, and the expected pace of recovery in 2025, including any explicit EBITDA assumptions for hurricanes in the guidance.

Answer

CFO Mike Marks explained that for 2025 guidance, the expected year-over-year EBITDA increase from the reopening of Largo Hospital is anticipated to be offset by a decline in the North Carolina division due to lingering hurricane effects. Therefore, no net tailwind from hurricanes is expected in 2025. He also noted hurricanes created a 20-40 basis point drag on total company volume in Q4.

Andrew Mok from Barclays pointed out the deceleration in inpatient revenue per admission growth in Q3 compared to the first half of the year and asked for the underlying drivers between acuity, mix, and rate.

Answer

CFO Mike Marks attributed the entire decline in the growth rate to state supplemental payment programs, which had a significantly lower year-over-year growth contribution in Q3 compared to the first half of 2024. He confirmed that underlying growth from acuity and strong payer mix remained robust during the quarter.

Andrew Mok inquired whether RadNet has a sufficient salesforce for DeepHealth following the iCAD acquisition or if more hiring is needed. He also asked for clarification on why EBITDA margins did not expand more significantly in the quarter despite strong Advanced Imaging volumes, seeking insights into cost factors or incremental margins.

Answer

President and CEO Howard Berger confirmed the need for more salespeople but highlighted that the iCAD acquisition brought a substantial salesforce, accelerating cross-selling and bundling opportunities. He explained that while capacity creation has been successful, it reaches limitations, and Q3 2024 was already a strong quarter. He indicated that future margin improvement is expected to be driven more by the Digital Health segment's clinical and operating tools, noting over 300 basis points of margin growth over the last four years, with AI and software poised to drive further expansion.

Andrew Mok inquired whether RadNet has an adequate DeepHealth salesforce following the iCAD acquisition or if more hiring is needed, and sought clarification on why EBITDA margins did not see better flow-through despite strong advanced imaging volumes in the quarter.

Answer

Howard Berger, President and CEO, confirmed that more hiring is needed for DeepHealth sales, but highlighted that the iCAD acquisition brought a substantial salesforce, accelerating cross-selling and bundling opportunities. Regarding EBITDA margins, he noted that last year's Q3 was already strong, and future margin improvement is expected to increasingly come from digital health implementation and AI-driven operating efficiencies, building on the 300+ basis points margin growth achieved over the last four years.

Andrew Mok from Barclays asked for clarification on the projected $4-5 million benefit from the 2026 Medicare physician fee schedule, noting it seemed lower than what the headline rate update would suggest, and requested details from the CPT code analysis.

Answer

Mark Stolper, EVP & CFO, explained that while the headline conversion factor is increasing, the net benefit to RadNet is mitigated by downward adjustments to the practice expense portion of RVUs for specific CPT codes and changes to geographic practice cost indices (GIPCs). He confirmed the company's exhaustive analysis supports the $4-5 million uplift estimate.

Andrew Mok from Barclays asked for clarification on the projected $4-5 million benefit from the 2026 Medicare physician fee schedule, questioning why it wasn't larger given the headline rate update.

Answer

Mark Stolper, EVP & CFO, explained that while the headline Medicare conversion factor is increasing, the net benefit to RadNet is moderated by specific CPT code adjustments, particularly to the practice expense portion of RVUs, and changes to geographic practice cost indices (GPCIs), which mitigate the overall uplift.

Andrew Mok of Barclays questioned the drivers of the revenue beat versus consensus despite headwinds, the implied margin expansion for the remainder of the year, and the significant Q1 increase in stock-based compensation.

Answer

CFO Mark Stolper attributed the strong underlying revenue to a bounce-back in March and April, while noting Q1 profitability is always seasonally challenged. CEO Howard Berger pointed to ramping de novo centers and advanced imaging growth as drivers for revenue and margin expansion. Regarding stock compensation, Mr. Stolper explained it was a Q1 anomaly due to vesting schedules and new grants, stating it will be 'significantly lower' for the rest of the year.

Andrew Mok from Barclays asked for more detail on labor inflation trends, whether RadNet has exposure to hospital-style physician subsidies, and the potential switching costs for customers moving to the DeepHealth PACS and RIS systems.

Answer

Dr. Howard Berger (Executive) and Mark Stolper (Executive) noted that labor pressures began post-COVID but RadNet has managed wage growth in the low single digits, below the industry average. Mark Stolper specified the 2025 guidance absorbs a $45 million wage increase and clarified that physician subsidies are a hospital-based issue not applicable to RadNet's outpatient model. Regarding switching costs, they explained that most existing PACS are old, on-premise systems, and the industry is entering a cycle where the superior technology of cloud-native solutions like DeepHealth makes the switch compelling for radiologists.

Andrew Mok asked about Humana's framework for new growth, specifically the level of growth the company is comfortable with before it impacts operational capacity, and if levers are already being pulled to manage this.

Answer

David Dintenfass, President of Enterprise Growth, explained Humana's growth approach focuses on lifetime value and NPV, appropriate pricing, margin stabilization, and customer experience. He noted that growth is dynamically managed to balance new member volume with operational capacity and retention, prioritizing a great member experience.

Andrew Mok asked about Humana's comfort level with new membership growth before it impacts operational capacity and if the company is already pulling levers to manage this growth.

Answer

David Dintenfass, President of Enterprise Growth, explained that Humana's focus is on maximizing customer lifetime value and NPV, prioritizing member retention and appropriate pricing. He noted that growth is managed dynamically, without a specific number, to ensure a great experience for all members, and that the company is committed to improving retention.

Andrew Mok of Barclays inquired about the potential implications for Humana's membership and margins following a competitor's announced pullback from the individual PPO market.

Answer

President and CEO James Rechtin stated that Humana sees 'bad benefit packages,' not 'bad membership,' and feels their products are well-positioned after two years of adjustments. George Renaudin, President of Insurance, elaborated that Humana has already made significant benefit reductions in 2024 and 2025, creating a value gap to peers, and feels its plans are now priced appropriately for long-term value, regardless of growth.

Andrew Mok asked for more detail on Humana's Part D experience relative to expectations, specifically regarding the pace of seniors entering the catastrophic phase and any observed changes in member or manufacturer behavior.

Answer

Chief Financial Officer Celeste Mellet stated that overall business trends, including pharmacy, are developing in line with expectations. She confirmed that guidance already contemplated low double-digit pharmacy trend growth and higher trends in areas like oncology, and that current performance is consistent with these projections.

Andrew Mok asked for the P&L split of the incremental Stars investments between MLR and OpEx, and for an update on mitigation efforts for the 2026 Stars headwind, such as the potential to crosswalk the group contract, in the event of an unfavorable lawsuit.

Answer

CFO Celeste Mellet stated that more color on the P&L location of the investments will be provided as the year progresses. CEO James Rechtin addressed the mitigation plan, confirming they are still assessing the group book crosswalk option and that a final decision is not required until late summer or early autumn.

Andrew Mok questioned the feasibility of Humana's 3% margin target for 2027, considering the planned investment spending and current Stars scores, and asked if a minimum Stars bonus level is required to hit that target.

Answer

CEO Jim Rechtin acknowledged that the 3% target is realistic but carries risk, stating that 'meaningful Stars progression' is necessary without specifying a number. CFO Susan Diamond added that factors like the rate environment, V28, and IRA will also be important, and that the current investments are expected to generate returns that support the margin recovery by 2027.

Andrew Mok inquired about the dynamics of facility closures or consolidations in the inpatient rehabilitation space, asking if the recent events were unique or indicative of a regular trend. He also asked about the implications for Encompass Health's business from broader changes in the Medicare landscape, such as a potential slowdown in Medicare Advantage growth or increased churn among national payers.

Answer

EVP and COO Pat Tuer clarified that the two satellite consolidations were unique, one-off events related to lease expirations, and no additional activity is anticipated. President and CEO Mark Tarr explained that if Medicare Advantage growth slows, the greater opportunity lies in fee-for-service Medicare, which pays a slightly higher rate and offers better conversion rates, a favorable dynamic for the company. He added that Encompass Health performs well across the payer spectrum, adapting to shifts between MA and fee-for-service.

Andrew Mok inquired whether the Q3 satellite closures and consolidations were unique events or a regular occurrence, given the focus on volumes. He also asked about the broader Medicare landscape changes, specifically a potential slowdown in Medicare Advantage growth or increased churn, and their implications for Encompass Health's business.

Answer

EVP and COO Pat Tuer clarified that the two satellite consolidations were unique, one-off events related to lease expirations, representing a very small percentage of the portfolio, with no additional activity anticipated. President and CEO Mark Tarr explained that a slowdown in Medicare Advantage growth would shift opportunity to fee-for-service Medicare, which pays slightly higher and has better conversion rates, a favorable dynamic for the company. He noted that Encompass Health performs well across the payer spectrum.

Andrew Mok of Barclays inquired about mature occupancy rates for single-bedroom facilities and the company's stance on potential CMS quality rating initiatives.

Answer

EVP & CFO Doug Coltharp stated that for all-private room hospitals, bed expansion is considered when occupancy exceeds 80%, with capacity running into the mid-to-high 90s. CEO Mark Tarr added that while CMS did not move forward with new quality initiatives in the final rule, Encompass Health is open to incorporating new quality measures if the industry agrees on the standards.

Andrew Mok from Barclays requested details on the drivers of the strong 3.9% growth in revenue per discharge and its expected trend, and also asked about the level of share repurchases contemplated in the new guidance.

Answer

CFO Douglas Coltharp attributed the strong revenue per discharge to low bad debt, a favorable payer mix shift toward higher-reimbursing Medicare, and positive quality metrics, but noted they do not assume the payer mix trend will sustain. Regarding buybacks, he did not provide a specific number but highlighted that Q1 repurchases exceeded the full year 2024 amount and that continued activity should be expected as declining leverage creates capacity.

Andrew Mok requested more detail on the specific drivers of rising group medical prescription drug costs. He also asked about the expected net benefit from provider taxes in 2025 and whether the 2024 benefit would recur.

Answer

CFO Douglas Coltharp identified GLP-1s, new cancer drugs, and a specific eye health medication as the main drivers of higher drug costs. Regarding provider taxes, he stated the 2024 benefit of $15.4 million included $5 million from prior periods that is not expected to repeat. He emphasized the item's unpredictability and noted it is not a point estimate in the 2025 guidance.

Andrew Mok asked whether the 7-8% growth in total FTEs would moderate or continue to track discharge growth, and also inquired about the underlying wage inflation and its future outlook.

Answer

CFO Douglas Coltharp stated that FTE growth is expected to remain highly correlated with discharge growth, as the company has stabilized its employees per occupied bed (EPOB) at approximately 3.4. He specified that underlying wage inflation (SW per FTE) was 3.5% in the quarter. He also noted that RN and therapist turnover rates were at very strong levels of 20.7% and 7.6%, respectively.

Andrew Mok questioned the shift in Centene's Medicaid profitability outlook from 'margin improvement across all business lines' to 'not expecting much improvement' for 2026, asking if this was framed in earnings dollars or margins. He also asked if there was a change in underlying performance, excluding idiosyncratic events in Florida.

Answer

CEO Sarah London clarified that the goal remains to drive back to more normalized Medicaid margins. She reinforced that Q3 HBR improvement reflected expected progress, aided by Florida's rate adjustment. The 2026 outlook of 'consistent profitability and margin' (relative to 2025's expected 93.7% HBR) is a prudent posture given better-than-expected 2025 trajectory and uncertainties, though she would be 'disappointed' if they don't exceed it. London highlighted momentum from 2025 levers (rate advocacy, clinical policy, network optimization, FWA) and upcoming 1/1/2026 changes (e.g., GLP-1 reversals, high-cost drug carve-outs).

Andrew Mok questioned the shift in Centene's 2026 Medicaid profitability outlook from 'improvement' to 'stability,' asking if this referred to earnings dollars or margins, and if underlying performance changed when excluding idiosyncratic events in Florida.

Answer

Sarah London, Chief Executive Officer, clarified that the 'consistent profitability' outlook for 2026 Medicaid is a prudent posture, given the better-than-expected 2025 trajectory. She emphasized that Centene is not 'taking its foot off the gas' on HBR improvement, citing ongoing efforts in rate advocacy, clinical policy design, network optimization, and fraud, waste, and abuse interventions. She noted that the Q3 HBR improvement reflected fundamental progress, aided by the Florida revenue adjustment, and that the goal remains to return Medicaid margins to normalized long-term levels.

Andrew Mok from Barclays requested clarification on the 2026 ACA outlook, pointing out the seemingly varied descriptions of 'return to profitability' and 'meaningful margin improvement,' and asked for a framework for the range of outcomes.

Answer

CEO Sarah London clarified that after operating slightly below breakeven in 2025, the company is pricing for a 'meaningful margin improvement' in 2026 with a focus on margin over membership. She explained that it is too early to provide a specific margin range, as visibility will improve after state rate certifications in August and the release of the competitive landscape file in September.

Andrew Mok of Barclays requested clarification on the 2026 ACA outlook, pointing out the difference between restoring 'profitability' and achieving 'meaningful margin improvement,' and asked for a framework for the range of potential outcomes.

Answer

CEO Sarah London reiterated that Centene is pricing for a return to profitability in 2026 with a focus on 'margin over membership.' While she described the expected improvement as 'meaningful,' she stated it is too early to provide a specific margin range. She noted that visibility will improve significantly after state rate certifications in August and the release of the market landscape file in September.

Andrew Mok asked for an explanation of how the Part D risk corridor works, questioning how the company can still target a 1% pretax margin if performance is poor enough to enter the corridor. He asked if it's applied at a level that allows for a blended 1% margin.

Answer

EVP and CFO Andrew Asher explained that the company is still on track for its 1% PDP pretax margin goal due to SG&A outperformance and the protective mechanism of the risk corridor. He detailed that the corridor creates a 50-50 cost split with CMS on losses exceeding 2.5% of the bid's pharmacy cost assumption, which is currently being triggered by high specialty drug utilization.

Andrew Mok sought clarification on how much better ACA effectuated enrollment was than expected and asked if the 20-30% membership decline assumption, should enhanced APTCs expire, contemplates member buy-downs.

Answer

CEO Sarah London clarified that enrollment is tracking slightly ahead due to a more muted impact from program integrity checks so far, but the company is maintaining its assumptions for a potential delayed impact. Regarding APTCs, she confirmed the 20-30% decline is a baseline scenario and that the company has run numerous mitigation scenarios, including member buy-downs and different product designs, and is prepared for various outcomes.

Andrew Mok questioned whether Medicaid HBR improvement is still considered a tailwind for 2025 after the Q3 setback and asked about visibility into the January 1st rate updates.

Answer

CEO Sarah London affirmed that Medicaid HBR improvement is 'definitely a tailwind for 2025.' She noted that initial 1/1 rates are coming in and a full update will be provided at the December Investor Day, reiterating confidence in growing adjusted EPS next year.

Andrew Mok asked about the recontracting efforts at Oak Street Health, seeking details on its current pre-tax operating losses, whether problematic external membership led to necessary benefit changes for the 2026 plan year, and the nature of contracting changes being made, including any shift of risk back to Medicare Advantage partners.

Answer

Brian Newman, CFO, stated that CVS Health does not share pre-tax losses for Oak Street Health but emphasized focus on its profitability, noting the goodwill impairment was driven by slowing clinic growth. Prem Shah, EVP, Chief Pharmacy Officer, and President, Pharmacy and Consumer Wellness, reiterated that value-based care remains critical, and Oak Street Health's Q3 performance was in line with adjusted expectations. He highlighted efforts to align with payers for sustainable terms, enhance the clinical model, and prudently slow clinic growth to focus on increasing membership.

Andrew Mok of Barclays asked for a reconciliation of the favorable Medicare results in the HCB segment with the unfavorable results at Oak Street, questioning the source of the pressure and the specific cost drivers.

Answer

CEO David Joyner and CFO Brian Newman clarified that the populations are different, with Oak Street serving a higher-acuity population and Aetna members being a minority of its patients. EVP & Group President, Prem Shah, attributed Oak Street's pressure to elevated medical costs and robust benefits, which are being addressed through enhanced leadership, technology, and a revised center expansion strategy.

Andrew Mok sought more detail on the 'early signs of pressure' observed at Oak Street Health, asking about the nature and timing of these trends and if any operational challenges had emerged.

Answer

Prem Shah, EVP and Chief Pharmacy Officer, responded that while the overall health care delivery business performed in line with expectations, Oak Street Health experienced some pressure from medical cost trends in the first quarter. He characterized the data as 'very immature' and noted the company will continue to monitor how claims develop, adding that this pressure was offset by favorability in other parts of the health care delivery business.

Andrew Mok asked for elaboration on the aggressive actions taken in the individual ACA business, including any changes to provider networks and the expected impact on margins embedded in the 2025 guidance.

Answer

CFO Tom Cowhey noted the individual exchange business was unacceptable, losing nearly $1 billion in 2024. Due to significant pricing actions, membership is expected to fall from 1.85 million to under 1 million in 2025, which should drive margin improvement but not a return to breakeven. Executive Steve Nelson added that the team is reviewing all components, including network design and risk adjustment capabilities, to improve performance and return the business to target margins over time.

Andrew Mok asked for an update on the expected pace of Medicare Advantage margin improvement and inquired about the reason for changing the target margin range from 4-5% to 3-5%.

Answer

An executive, likely CFO Tom Cowhey, explained the target margin change is primarily a mathematical result of the Inflation Reduction Act's changes to the Part D program, which increases the premium denominator. He noted that while margin improvement is expected in 2025 and 2026, the long-term pace is dependent on the rate environment. CEO J. Joyner added his focus is on accelerating performance through total cost of care management and asset integration.

Andrew Mok inquired about the change in Medicare Part D drug benefits for 2026, specifically the shift from copay to co-insurance for Tier III branded drugs, the company's experience with the 2025 copay structure, and the rationale behind the 2026 benefit modification.

Answer

Bobby Hunter, CEO of Government Programs, UnitedHealth Group, explained that the benefit planning takes a multi-year, metered approach, balancing variables like V28 dynamics and uncertainty around the demo program. He stated that the cautious approach led to modifications like co-insurance on Tier III drugs and deductibles, aligning with industry trends. He expressed confidence in 2026 Part D performance and noted no material concerns regarding 2025 MAPD or PDP selection mix or outlook.

Andrew Mok followed up on the Medicare Part D drug benefit for next year, noting the change from copay to co-insurance for Tier III branded drugs across most MAPD and standalone Part D plans. He asked about the experience with the copay structure in 2025 and the decision drivers for the 2026 change.

Answer

Bobby Hunter (CEO of Government Programs, UnitedHealth Group) explained that the company takes a multi-year, metered approach to benefit planning, balancing variables, especially given V28 dynamics. He cited uncertainty around the demo program persisting into 2026 as a factor for a cautious approach, pulling levers to ensure benefit design positioning. He feels aligned with the industry on co-insurance for Tier III and deductibles, expecting good performance in 2026. For 2025, he noted no concerns regarding selection mix or outlook for MAPD due to deductibles, and no material risk for PDP.

Requested a comparison of the relative margin profiles and paths to margin recovery for the three main Medicare Advantage patient populations: retail, group, and special needs plans (SNPs).

Answer

Robert Hunter stated that the group MA business continues to experience the most trend pressure but can be repriced annually. Retail and SNP populations are performing generally in line with each other. Growth is concentrated in the D-SNP and C-SNP space, which is accretive to the enterprise. For 2026, the company is making meaningful adjustments to the retail business, including exiting plans (predominantly PPO) that affect over 600,000 members to help drive margin progression.

Andrew Mok asked for the company's perspective on the risks and implications of potential pharmaceutical tariffs currently being considered by the administration.

Answer

Andrew Witty, an executive, acknowledged the situation is dynamic but stated the company feels 'better than pretty good' about its potential exposure. He cited multiple layers of protection, including pre-existing contractual price protections and legislation that limits manufacturers' ability to pass on price increases, concluding that UNH is well-positioned to handle potential tariffs.

Andrew Mok asked about the SG&A savings achieved this year, questioning the permanency of these cost changes and whether any components should be considered temporary as the company looks toward 2025.

Answer

CEO Andrew Witty emphasized that the company has been and will continue to be relentless and disciplined about cost management. He framed it as a necessary response to the CMS V28 rate cut, stating that to protect members, the company must sustainably reduce internal costs and eliminate external waste. He indicated that investors should expect this focus on cost reduction to be a key feature of the plan going forward.

Andrew Mok inquired about the timing of encouraging volume trends, specifically whether they were observed exiting Q3 or starting Q4, and the drivers behind payer mix improvement (employer-based vs. ACA). He also asked about the impact of tighter Medicaid eligibility in states like Indiana on Medicaid volume results.

Answer

Kevin Hammons, President and Interim CEO, stated that payer mix improvements began early in Q3 and are expected to continue into Q4, primarily driven by commercially insured business, with some improvement in exchange business. He noted that CHS has not experienced any significant impact from tighter Medicaid eligibility specifically in Indiana.

Andrew Mok inquired about the timing of encouraging volume trends (exiting Q3 or starting Q4), the category breakdown, and whether payer mix improvement was driven more by employer-based coverage or ACA. He also asked about the impact of tighter Medicaid eligibility in states like Indiana on Medicaid volume results.

Answer

Kevin Hammons, President and Interim CEO, confirmed that payer mix improvements began early in Q3 and continued throughout the quarter, with expectations for this trend to extend into Q4. He noted that Q4 2024 was strong due to a consumer confidence spike. The improvement was primarily in commercially insured business, with some contribution from exchange business, which remains a small component of overall net revenue. Mr. Hammons stated that Community Health Systems has not experienced any significant impact specifically in Indiana from tighter Medicaid eligibility.

Andrew Mok from Barclays sought to reconcile CHS's soft volumes with payers' reports of accelerating costs, asking about other potential drivers like regional or policy issues. He also asked about the potential impact from the expiration of enhanced ACA subsidies.

Answer

President & CFO Kevin Hammons suggested that in addition to consumer confidence, concerns within immigrant communities in states like Arizona and Texas could be contributing to volume softness. Regarding the ACA subsidies, he stated the impact is difficult to quantify and the company's focus is currently on legislative and lobbying efforts.

Andrew Mok asked why the company reiterated its guidance despite absorbing headwinds from divestitures, claims denials, and medical specialist fees, and whether this implied results would be in the lower half of the range. He also asked for details on which categories were driving the pressure in medical specialist fees.

Answer

CFO Kevin Hammons clarified that denial headwinds were already factored into the original guidance and that the impact of the latest divestiture was not material enough to warrant a change. He noted the 9% increase in medical specialist fees was within the guided 8-12% range, with anesthesiology being the primary driver. CEO Tim Hingtgen added that the company is mitigating these costs through its in-sourcing platform for hospital-based services, including anesthesia and, more recently, radiology.

Andrew Mok asked for the key drivers behind the forecasted $150 million to $200 million improvement in 2025 operating cash flow, given the lower EBITDA base. He also sought to confirm if the potential incremental $100 million-plus from DPPs would fully convert to operating cash flow and if that figure included any retroactive benefit from Tennessee.

Answer

Kevin Hammons, President and CFO, detailed the drivers of improved cash flow: the cash receipt in 2025 of the $40 million New Mexico DPP accrued in Q4 2024, the cessation of cash drag from the now-completed ERP implementation, and an expected tax refund of $70-75 million. He confirmed the potential DPP benefit would flow through to cash flow and clarified that the $100-125 million estimate does not include any retroactive amount for Tennessee, which would be additional.

Andrew Mok from Barclays questioned the timing and escalation of the claim denial headwind during the quarter, asked about the company's strategies to combat this issue, and inquired whether the denial activity was concentrated with specific payers.

Answer

President and CFO Kevin Hammons and CEO Tim Hingtgen explained that the denial activity accelerated throughout the quarter, representing a $10 million incremental headwind. They noted the issue is broad-based across payers. To combat this, Hammons highlighted the expansion of their centralized physician adviser program and enhanced appeals capabilities, which have successfully reversed about 25% of certain denied claims, though many remain in the adjudication process.

Andrew Mok asked about the drivers of ACA MCR pressure in the third quarter, specifically if there was a negative surprise in September data, and how confident Molina is that recent utilization and morbidity experience was captured in its 2026 Marketplace pricing.

Answer

CEO Joseph Zubretsky explained that the pressure was due to increased medical cost trend across all categories, particularly from special enrollment membership, with risk adjustment not being a factor. For 2026, Molina is reducing Marketplace exposure through 15-45% rate increases (averaging 30%) and a 20% reduction in county footprint, aiming for at least break-even margins. CFO Mark Keim added that Q3 MCR drivers included general trend pressure, SEP volumes, program integrity, and some prior-year development, emphasizing that 2026 pricing aims to minimize exposure.

Andrew Mok asked about the drivers of ACA MCR pressure in the quarter, specifically inquiring if there was a negative surprise in September weekly data and how confident Molina Healthcare is that recent utilization and morbidity experience was captured in its 2026 pricing.

Answer

CEO Joseph Zubretsky and CFO Mark Keim explained that the pressure was primarily due to increased medical cost trend across all categories, including higher special enrollment period (SEP) membership, with risk adjustment not being a significant factor. For 2026, Molina is reducing its Marketplace exposure, implementing rate increases averaging 30% (ranging 15-45%), and reducing its county footprint by 20%. The company expects to be less competitively priced (top 1-2 in 10% of markets vs. 50% in 2025), aiming for at least break-even, with pricing models targeting mid-single-digit margins. Q3 MCR was impacted by general trend pressure, SEP volumes, program integrity, membership attrition, and prior-year development on large dollar items and provider claims settlements, with pricing for 2026 reflecting the expiration of subsidies.

Andrew Mok from Barclays questioned Molina's confidence in achieving Medicaid margin improvement in the second half of 2025, given the inflationary trend environment and potential risk pool pressures. He also asked about the required premium increases for ACA plans in 2026 to reset margins.

Answer

CFO Mark Keim acknowledged that Medicaid trends are slightly outpacing known rate updates, leading to a higher guided MCR for the second half. CEO Joseph Zubretsky addressed the ACA question by stating that while specific rate filings are not disclosed, their 2026 pricing models incorporate a catch-up for 2025's underperformance, a significantly higher medical cost trend assumption (11%), and a conservative view on the acuity shift from subsidy expirations, all aimed at restoring mid-single-digit margins.

Andrew Mok sought clarification on the updated assumptions for higher rates and cost trends, asking which business segments they applied to and what specific factors were driving the changes.

Answer

CEO Joseph Zubretsky and CFO Mark Keim clarified that both the higher rate and cost trend assumptions were for the Medicaid business. They explained that while they have received higher-than-expected rate updates, they conservatively increased their cost trend outlook to match, resulting in no change to the full-year Medicaid MCR guidance of 89.9%. Keim noted seasonal illness ran about $10-15 million higher than normal but was anticipated in guidance.

Andrew Mok from Bank of America inquired about the specific components—rates, trend, and risk corridors—that caused the 2025 Medicaid MLR guidance to be higher than the target shared at Investor Day. He also asked for clarification on why risk corridors provided no material benefit in Q4 2024.

Answer

CEO Joe Zubretsky explained that the 2025 Medicaid MLR guidance of 89.9% is essentially flat with 2024, based on a 4.5% rate increase matching a 4.5% trend assumption. CFO Mark Keim added that the deviation from the Investor Day outlook was due to a 60 basis point higher jump-off point from Q4 results and a neutral impact from rates versus trend, which was previously expected to be a 20 basis point benefit. Regarding risk corridors, Zubretsky described them as an 'imperfect hedge,' noting the lack of benefit in Q4 was due to trend pressure occurring in states without remaining corridor protection.

Andrew Mok from Barclays asked for the drivers of the outperformance in the Marketplace segment and how this year's Special Enrollment Period (SEP) membership compares to prior years. He also inquired about the revenue recognition policy for off-cycle rate adjustments.

Answer

President and CEO Joe Zubretsky described the SEP membership growth as 'extraordinary,' noting it was driven by Medicaid redeterminations. He explained that this cohort had a younger, healthier demographic than typical SEP members, resulting in a lower MCR than historically seen. CFO Mark Keim clarified that for revenue recognition on off-cycle rates, the company requires documented evidence from the state and does not book revenue based on conversations alone.

Andrew Mok inquired about the necessity for value-based care recontracting and the evolving tone of discussions with payers. He also asked for a breakdown of the increase in EBITDA add-backs post-acquisition and the expected pace of realizing synergies.

Answer

President & CEO Brandon Sim emphasized Astrana's consistent, partnership-oriented approach with payers, which has resulted in friendly and smooth conversations even in a tough environment. He attributed the majority of the increased EBITDA add-backs to one-time transaction fees for the Prospect deal and reiterated the 12-18 month timeline for achieving $12-15M in synergies.

Andrew Mok inquired about the necessity for meaningful changes in value-based care recontracting and how the tone from payers has evolved recently. He also asked for a breakdown of the increase in EBITDA add-backs post-deal and the expected pace of realizing synergies.

Answer

President & CEO Brandon Sim emphasized that Astrana's consistent, partnership-oriented approach has fostered strong payer relationships, leading to smooth and friendly conversations despite industry pressures. He attributed the increase in EBITDA add-backs primarily to one-time transaction fees from the Prospect deal and reiterated the synergy target of $12-15 million over the next 12-18 months.

Andrew Mok inquired about the need for recontracting in the value-based care space and how the tone from payers has evolved recently. He also asked for details on the increase in EBITDA add-backs post-deal and the expected pace of synergies for the remainder of the year.

Answer

President & CEO Brandon Sim emphasized that Astrana's consistent, partnership-focused approach has resulted in strong, friendly payer relationships, avoiding the contentious recontracting seen elsewhere. He explained that the increase in EBITDA add-backs was driven by one-time transaction costs for the Prospect deal and reiterated that the company remains GAAP profitable. The synergy timeline remains $12-15 million over 12-18 months.

Andrew Mok of Barclays questioned the appropriate EBITDA run-rate for 2026, suggesting a baseline of $250 million after accounting for one-time items. He also asked about the timeline for the PDS spread rate to normalize to the $10-$10.50 range.

Answer

CEO Jeff Shaner advised against simply subtracting timing-related items, stating the business is fundamentally stronger and now operating north of a 10% EBITDA margin, though he cautioned against expecting a 15% margin. CFO Matt Buckhalter added that the PDS spread rate will continue to decline through Q3 and Q4, expecting to exit December at a normalized go-forward rate, but it will remain somewhat elevated for the rest of the year.

Andrew Mok asked for targets on moving communities out of the sub-70% occupancy band, clarification on the early-quarter softness in move-ins, and the drivers of strong operating cash flow and its impact on capital priorities.

Answer

EVP & CFO Dawn Kussow detailed plans for the sub-70% band, with 50 communities slated for disposition and 38 being addressed by SWAT teams. She attributed early Q2 softness to macro uncertainty but noted a strong rebound in May and June, with the economic benefit expected in Q3. Kussow and EVP & General Counsel Chad White explained that strong cash flow was driven by operational improvement and will be reinvested into the portfolio, particularly through 'first impressions' CapEx projects that are yielding good results.

Andrew Mok from Barclays asked for clarification on which occupancy initiatives were already contributing to results versus those that are new, the drivers behind the increased full-year RevPAR guidance, and the rationale for implementing a dynamic pricing strategy now.

Answer

EVP & CFO Dawn Kussow explained that initiatives like the 'SWAT teams' began in late 2024 and are now being expanded due to their proven success. The full-year RevPAR guidance was raised based on confidence that year-over-year growth will accelerate through the year, being stronger in Q4 than in Q1. She clarified that dynamic pricing is an ongoing tool, and the company is simply being more active in repricing both up and down to capitalize on specific market opportunities.

Andrew Mok asked for more detail on what drove the better-than-expected shared savings revenue in the quarter and how much of it flowed through to the Care Margin.

Answer

CEO Parth Mehrotra stated the outperformance was broad-based across all value-based contracts (Commercial, MA, MSSP, Medicaid) rather than from one specific program. He credited proactive risk management and operational execution over the past 24 months. He confirmed this performance translates directly to strong flow-through to Care Margin and EBITDA, consistent with prior quarters.

Andrew Mok from Barclays asked for more details on the M&A pipeline and the potential uses for the company's cash balance, which is approaching $500 million, if M&A opportunities are not pursued.

Answer

CEO Parth Mehrotra stated that the M&A pipeline is robust and the company is actively but disciplinedly reviewing opportunities including medical groups and risk entities. He emphasized that the strong balance sheet also provides a buffer against risks and supports medical groups. If the stock price deviates from intrinsic value, returning capital to shareholders is also an option.

Andrew Mok from Barclays questioned the increase in free cash flow conversion guidance from 80% to 90%, asking if it was due to broad outperformance or specifically better-than-accrued 2023 MSSP results, and if expectations for 2024 shared savings revenue had changed.

Answer

CEO Parth Mehrotra attributed the higher free cash flow conversion to broad-based outperformance across the fee-for-service and value-based care books, not just MSSP. He noted that while the company initially planned for flat shared savings in 2024 due to MA headwinds, performance has been better than anticipated, which is reflected in the updated guidance.

Andrew Mok expressed confusion about the weaker Medicaid volumes, asking for evidence that it's a payer issue rather than disenrollment, and requested clarification on the components of the operating cash flow guidance.

Answer

CEO Christopher Hunter reiterated that the company is observing different behaviors by payer and monitoring the situation, without providing specific evidence to isolate the cause. CFO Heather Dixon clarified that the operating cash flow guidance excludes non-recurring legal costs and that reported cash flow would need to be adjusted down for these items, which totaled roughly $80 million in the first half of the year.

Andrew Mok of Barclays questioned the cause of the year-over-year decline in specialty revenue for five consecutive quarters and asked when it might return to growth. He also asked if the Tennessee supplemental payments would be recognized in the acute inpatient revenue line.

Answer

Executive Heather Dixon attributed the specialty revenue decline primarily to the closure of four specialty facilities over the past 1.5 years as part of portfolio management. A secondary factor was a mix shift towards Medicaid within the specialty inpatient business. She confirmed that the Tennessee supplemental payments would indeed hit the acute inpatient revenue line.

Andrew Mok requested a disclosure of Acadia's total 2024 revenue exposure from state-directed supplemental payments. He also sought to reconcile the significant forecasted drop in revenue per patient day growth, questioning the interplay between conservatism on supplemental payments and other factors like core rates.

Answer

CFO Heather Dixon disclosed that gross supplemental payments for 2024 were less than $200 million before associated provider taxes, and she agreed that a net benefit of roughly two-thirds is a reasonable estimate. To explain the rate guidance, she cited three factors: supplemental payments providing less of a tailwind than in recent years, a deliberately conservative stance on policy uncertainty, and the normalization of the CTC service line's growth, which no longer provides the 100-basis-point rate tailwind it did in early 2024.

Andrew Mok asked if referral decisions are made at an organizational or individual level and challenged the view that the volume headwind is 'temporary,' given the sticky nature of referral patterns, seeking evidence of recovery.

Answer

CEO Christopher Hunter clarified that referral decisions are made by individuals. He provided anecdotal evidence of recovery, stating that direct engagement with concerned individuals has, in some cases, successfully improved the situation and restored referral patterns, describing it as a 'ground game' strategy.

Andrew Mok from Barclays requested a bridge for the decline in excess capital from Q1 to Q2, clarification on the minimum cash level held at the parent company, and an explanation for why the risk adjustment accrual isn't increasing more significantly year-over-year despite rising market acuity.

Answer

CFO Scott Blackley attributed the drop in excess capital primarily to the net loss recognized in Q2. He confirmed that parent cash levels are comfortably above internal targets. On risk adjustment, he explained that the current accrual rate is a good proxy for the full year as it now fully reflects the updated, higher market morbidity.

Andrew Mok from Barclays asked about the overall reimbursement environment for home and community-based services (HCBS), given that national Medicaid payers have cited it as a margin pressure point. He also questioned the drivers behind the negative same-store census volume in the quarter.

Answer

EVP & CFO Brian Poff acknowledged payer pressures but highlighted continued strong rate support from key states like Illinois and Texas, though he expects the pace of increases to moderate. President & COO Bradley Bickham and CFO Brian Poff clarified that the negative same-store census comparison was distorted by the prior-year inclusion of the disposed New York business, and that on a sequential basis, census actually increased.

An associate on behalf of Andrew Mok from Barclays asked for a breakdown of the 7.4% same-store revenue growth in Personal Care, especially given the decline in same-store census. They also inquired about how same-store gross margins compared after excluding recent M&A and divestiture activity.

Answer

W. Bickham, President and COO, attributed the strong revenue growth to better caregiver scheduling and improved service percentage, driven by new operational tools. He explained the census decline was a temporary effect of the Medicaid redetermination process. CFO Brian Poff added that on a same-store basis, the gross margin was 'fairly equal' to the prior year and slightly ahead of expectations.

Andrew Mok of Barclays asked for an outlook on wage inflation over the next 15 months, noting it appears elevated, and what would be required to lower unit cost inflation. He also inquired about the underlying trends and drivers of variability in the hospice length of stay and where it is expected to normalize.

Answer

President and COO Brad Bickham stated that wage inflation has not been as high as suggested in personal care, as rate increases have offset pressures, while skilled wage inflation is running around 3-4%. He also explained that hospice length of stay is now stabilizing to a more normalized level after volatility during the COVID-19 public health emergency, and the current levels are considered appropriate.

Andrew Mok of Barclays asked for an explanation of the year-over-year and sequential increases in 'other operating expenses' and 'professional fees.' He also requested commentary on working capital considerations for the remainder of the year.

Answer

CFO Dave Doherty explained that 'other operating expenses' can fluctuate due to items like provider taxes, while the increase in 'professional fees' was mainly tied to costs from facilities acquired in 2024. For working capital, he identified higher interest expense as the primary headwind for the rest of the year, following the expiration of interest rate swaps, but noted this is partially offset by ongoing improvements in revenue cycle management.

Andrew Mok of Barclays asked for details on the company's confidence regarding its low tariff exposure and questioned the significant increase in the cash payout to non-controlling interests (NCI) in the quarter.

Answer

CFO David Doherty attributed the confidence on tariffs to their partnership with GPO HealthTrust, which provides significant contract protection and visibility for 70% of their spend. Regarding the NCI payout, he explained it was a simple timing issue where year-end holiday schedules pushed some Q4 distributions into Q1, causing a temporary 'double up' that will normalize in subsequent quarters.

Andrew Mok questioned the lack of operating leverage in Q4, the drivers of high transaction costs and their expected abatement, and the reason for a large change in the deferred tax asset valuation allowance.

Answer

CFO David Doherty attributed the Q4 EBITDA pressure primarily to accounting for the corporate performance bonus, which was higher than in the prior year. He detailed that the elevated transaction costs were due to higher M&A volume, deal complexity, and costs related to the Board's strategic review, and expects these to abate significantly in 2025. Doherty explained the deferred tax asset change was a non-cash, technical accounting requirement with no impact on the company's cash tax position or use of NOLs.

Andrew Mok of Barclays sought clarification on the full-year free cash flow outlook, questioning if the prior target was still achievable given higher transaction costs. He also asked about the significant sequential decrease in G&A expenses.

Answer

Executive Chairman Wayne DeVeydt reiterated that the company is moving away from a static free cash flow metric because the dynamic nature of M&A deployment makes it less valuable. CFO David Doherty explained the sequential G&A decrease was due to a one-time $8 million stock-based compensation true-up in Q2, making the Q3 expense level in line with expectations when normalized.

Andrew Mok of Barclays asked for specific reasons why burden of illness assessments underperformed revenue expectations and sought clarification on the 6% first-half cost trend versus the prior full-year guidance of 5.3%.

Answer

CFO Jeff Schwaneke clarified the 6% trend was in line with expectations for the first half of the year. On risk adjustment, he explained the issue was not rejected codes but a need to better identify patient conditions, a gap that new clinical programs for diseases like heart failure and dementia are designed to close, with financial benefits expected in 2026.

Thomas, on behalf of Andrew Mok, asked for the latest 2024 national trend figure that CMS provided for the ACO REACH program.

Answer

CFO Jeffrey Schwaneke and CEO Steven Sell confirmed the latest published national trend for the ACO REACH reference population was 7.8%. They added a note of caution that this figure could be updated and potentially increase.

Andrew Mok followed up on the negative risk adjustment, asking whether it was a data or forecasting issue, the timeline for operational fixes, and how investors could gain confidence that the issue will not recur.

Answer

CFO Jeffrey Schwaneke characterized it as a forecasting issue where an overly optimistic forecast was created based on strong 2023 investment in the Burden of Illness program. To build confidence, he stated the current forecast is now tied to mid-year government data, incorporates a historical midyear-to-final lift analysis, and has been cross-referenced with the forecasts of their large payer partners to ensure a robust and well-supported estimate.

Andrew Mok of Barclays sought clarification on the calculation of the $14 million out-of-period risk adjustment benefit and asked if it should be excluded from forward-looking models. He also asked about the fully diluted share count.

Answer

CFO Jim Head explained that the $14 million sweep payment is a normal course of business, especially with high growth, and should not be backed out of the earnings base, though its magnitude is unpredictable. He noted it reflects a conservative stance on booking revenue for new members. Regarding the share count, Head suggested taking the detailed calculation offline to ensure accuracy.

Andrew Mok from Barclays requested clarification on Part D seasonality, noting that the MLR trend now seems to be increasing later in the year, contrary to initial expectations. He also asked for the reason behind the expected increase in Part D revenue PMPMs throughout the year.

Answer

CFO Robert Freeman clarified that while the Part D MBR could see an uptick in Q4, the overall second-half MBR is still expected to be lower than the first half. He explained the Part D revenue PMPM increase is driven by two factors: the timing of midyear revenue sweeps and the expected reversal of the company's risk corridor position from a contra-revenue payable to a positive revenue contributor later in the year.

Speaking for Andrew Mok, an analyst asked why Alignment assumes a flatter MLR slope from IRA changes compared to peers and whether it relates to their Part D benefit structure. A follow-up question concerned the drivers of higher Q4 G&A and the expected quarterly progression in 2025.

Answer

Executive Robert Freeman suggested the difference in MLR slope may be because peers have stand-alone Part D plans, which Alignment does not. He expressed confidence in their forecasting, expecting a similar MBR seasonality pattern to past years, just with a less steep slope. Regarding G&A, he attributed the Q4 increase to normal sales and marketing seasonality combined with higher commission costs from significant membership outperformance, while highlighting the 330 basis points of full-year operating leverage gained.

An analyst on behalf of Andrew Mok asked about the drivers behind the atypical G&A seasonality in the second half of the year and the durability of these savings into 2025.

Answer

Executive Robert Freeman attributed the favorable G&A trend to the absence of new market launch costs for 2025 and the lapsing of one-time expenses from 2023 related to insourcing member experience functions. He confirmed they expect continued SG&A leverage in 2025 as they progress toward their medium-term goal of 10% SG&A as a percentage of revenue.

Andrew Mok of Barclays questioned the startup losses at the Cedar Hill hospital, its accreditation status, and the impact on guidance. He also asked for clarification on the underlying EBITDA guidance changes, excluding discrete items, and the factors offsetting the soft behavioral quarter.

Answer

Executive VP & CFO Steve Filton explained the Cedar Hill losses were due to delays in Medicare certification, which he expects imminently. He noted that guidance includes a $25 million drag from the facility in the second half of the year. Filton confirmed the main drivers of the guidance revision were new DPP revenues, offset by the Cedar Hill drag and scaled-back behavioral projections due to lower-than-expected volumes.

Asked about the company's preparations for potential tariffs and whether there have been any changes in behavioral health referral patterns or relationships with JV partners, aside from weather impacts.

Answer

Approximately 75% of the company's supply chain is currently insulated from tariffs, and they are not yet seeing significant pressure. No structural changes in behavioral referral patterns have been observed; recent volume softness was attributed to weather, and they remain confident in their full-year volume target.

Andrew Mok of BofA Securities questioned the drivers behind the strong 2025 EBITDA guidance, which is higher than typical growth despite a forecast decline in state supplemental payments. He also asked about the unusually wide guidance range.

Answer

Executive Steve Filton attributed the strong underlying growth to a return to historical norms in volume and pricing, effective expense control, and the non-recurrence of significant 2024 malpractice expenses. Filton explained the wider guidance range is a measure of caution due to uncertainty in government reimbursement policies.

Andrew Mok inquired about the primary drivers for Universal Health Services' strong 2025 EBITDA guidance, which is higher than typical growth, and questioned the rationale for the unusually wide guidance range despite improved operational visibility.

Answer

Executive Steve Filton attributed the strong guidance to a return to historical norms in core EBITDA growth, driven by solid volumes, robust pricing, and effective expense controls. He noted the non-recurrence of significant 2024 malpractice expenses and benefits from lower interest costs and share repurchases. Filton explained the wider guidance range reflects conservatism due to potential uncertainty in government reimbursement policies.

Andrew Mok of Barclays asked for commentary on the acute care volume progression and its future outlook, and for clarification on higher corporate expenses.

Answer

Steve Filton stated that UHS expects acute care growth to return to pre-COVID levels, with revenue growth of 6-7% split between price and volume. He noted that unlike some peers, UHS doesn't anticipate a large incremental benefit from Two-Midnight rule changes. He attributed higher corporate expenses to a $5 million loss on debt extinguishment and $5 million in miscellaneous legal settlements, both considered nonrecurring.

Andrew Mok of Barclays questioned the deceleration in inpatient and adjusted admissions during the quarter and asked for the rationale behind the 50 basis point reduction in the full-year volume guidance.

Answer

Chairman & CEO Saum Sutaria clarified that the guidance adjustment was a simple reflection of the year-to-date math and not indicative of an underlying issue. He emphasized that the quarter was strong, with volumes reflecting the successful execution of their high-acuity service line strategy, and noted there was nothing unusual beyond normal seasonality.

Andrew Mok asked for perspective on how the total joints market in ambulatory surgery centers has evolved over the last five years and how much runway remains in terms of eligible population or penetration.

Answer

Saumya Sutaria, Chairman and CEO, stated there is still a lot of runway to move total joint procedures to lower-cost ASC settings. He cited barriers like hospital outpatient department (HOPD) strategies, physician comfort levels, and employed physician restrictions. He noted that the shift will be complete when clinical considerations are the only factor, and the industry is only about halfway through that process. Adequate outpatient reimbursement is also a key factor.

Andrew Mok asked about the specific drivers of higher acuity in the ASC segment, noting that the case mix disclosures do not make the source of high single-digit revenue growth obvious.

Answer

Dr. Saum Sutaria, Chairman and CEO, clarified that the high-acuity growth is driven by specific procedures within the broad 'Orthopedics' category, such as total joint replacements (hips, knees, shoulders). These cases have significantly higher revenue, and the strategy is to grow this high-acuity work, which boosts net revenue per case even with modest case volume growth.

Andrew Mok followed up on the Conifer topic, asking if there is an incremental enterprise EBITDA contribution from divestitures even if the service relationship is not expanded.

Answer

EVP and CFO Sun Park clarified that the incremental benefit referenced for 2025 comes from the "expanded opportunities" with divested hospitals. Chairman and CEO Dr. Saum Sutaria added that one large expansion will require investment to onboard, similar to a new customer, before reaching typical Conifer margin performance.

Andrew Mok of UBS requested a more detailed financial outlook and timeline for Contessa, specifically asking when revenue from new JVs would materialize and what the revised path to breakeven looks like.

Answer

Chief Strategy Officer Nick Muscato explained the timeline 'depends' on which Contessa business line grows fastest. Revenue will be driven by newly implemented JVs and significant growth in the palliative care business. However, since palliative deals are new, their earnings contribution is still being determined, meaning top-line growth won't directly translate to a proportional reduction in losses initially. He reiterated they are at the 'nexus' of maximum loss but was not ready to provide a specific breakeven timeline. Chairman and CEO Paul Kusserow added that securing a few more palliative deals could significantly address the losses.

Andrew Mok questioned how Amedisys expects to grow fee-for-service (FFS) home health volumes when overall FFS membership in the industry is declining, and asked for specific market share strategies.

Answer

President and CEO Chris Gerard explained that growth will be driven by two factors: a normalization of FFS utilization rates back to pre-pandemic levels and a targeted market-share-stealing strategy. He stated that even if the overall market is flat or slightly down in 2023, Amedisys plans to leverage its quality ratings and service offerings to win a disproportionate share of referrals in key markets.

Andrew Mok of UBS asked about the financial impact of higher fuel costs, the nature of the fuel supplement add-back in adjusted results, and the company's earnings sensitivity to mileage reimbursement rates.

Answer

EVP and CFO Scott Ginn explained that every one-cent change in mileage reimbursement has about a $1 million impact on earnings. He clarified that the fuel supplement add-back is a temporary measure reflecting higher-than-budgeted fuel prices, which is expected to decrease as prices normalize. The company also plans a permanent $0.02 increase to its standard reimbursement rate in the second half of the year.

Andrew Mok from UBS asked about the sustainability of the low 13.0 visits per episode (VPE) achieved in the quarter. He also inquired about the drivers behind the year-over-year decrease in corporate expenses and whether the Q1 level represents a good run rate.

Answer

CEO Chris Gerard confirmed that the 13.0 VPE is sustainable, attributing the Q1 result to a favorable patient mix and ongoing benefits from Medalogix. He expects VPE to stabilize between 13.0 and 13.25 for 2022. CFO Scott Ginn explained that while Q1 corporate G&A benefited from some favorable items like lower LTI, he expects the expense to increase from the Q1 level in subsequent quarters due to factors like increased spending at Contessa.