agilon health - Q4 2025

Transcript

Operator (participant)

Thank you for your patience, everyone. The agilon health fourth quarter 2025 earnings conference call will begin shortly. During the call, you can register to ask questions by pressing star followed by 1 on your telephone keypad. Thank you. Thank you for your patience, everyone. The agilon health fourth quarter 2025 earnings conference call will begin in 1 minute time. In the meantime, you can register to ask questions by pressing star followed by 1 on your telephone keypad. Thank you. Hello, and welcome to the agilon health fourth quarter 2025 earnings conference call. My name is Carla, and I will be coordinating your call today. During the presentation, you can register to ask questions by pressing star followed by 1 on your telephone keypad. If you change your mind, please press star followed by 2.

I will now hand you over to your host, Evan Smith, to begin. Please go ahead when you're ready.

Evan Smith (SVP of Investor Relations)

Thank you, operator. Good afternoon, welcome to the call. With me are Executive Chairman, Ron Williams, and our CFO, Jeff Schwaneke. Following our prepared remarks, we will conduct a Q&A session. Before we begin, I would like to remind you that our remarks and responses to questions may include forward-looking statements. Actual results may differ materially from those stated or implied by forward-looking statements due to risks and uncertainties associated with our business. These risks and uncertainties are discussed in our SEC filings. Please note that we assume no obligation to update any forward-looking statements. Additionally, certain financial measures we will discuss in this call are non-GAAP financial measures. We believe that providing these measures helps investors gain a better and more complete understanding of our financial results, it's consistent with how management views our financial results.

A reconciliation of these non-GAAP financial measures to the most comparable GAAP measures is available in the earnings press release and the Form 8-K filed with the SEC. With that, let me turn the call over to Ron.

Ron Williams (Executive Chairman)

Thank you, Evan, and thank you all for joining us today. 2025 was a year for building the foundation of sustainable performance through intense focus on operational discipline. While we are navigating a comprehensive transformation, our mission remains unchanged: empowering physicians to lead the transformation of healthcare through our Total Care Model. The fundamental resilience and effectiveness of our partnership model demonstrates a durable, long-term growth runway through trusted relationships with community-based physicians. These individuals are leaders in their communities and have an average 10-year-plus relationship with their patients, creating deep community ties that are difficult to replicate. While we are not satisfied with our financial performance in 2025, we made tangible progress in the areas that matter most for a durable turnaround, which Jeff will provide more detail on in a moment.

Our tangible progress includes the advancement of our clinical pathways and quality programs, our disciplined approach to payer relations, and our continued focus on data-driven performance. All are driving greater clarity and sustainability across agilon's scalable operating model to support long-term value-based care success for our Total Care Model. Our preparation for the future includes applying our continued discipline and focus across these critical areas as we navigate the potential of a lower-than-expected rate increase in 2027 following CMS's Advance Notice. We believe the Advance Notice does not sufficiently reflect the ongoing population-wide increase in cost and utilization due to growing chronic disease burden and aging the Medicare population. Our further review of the risk model revision and normalization outlined in the Advance Notice, we believe the potential impact will be generally in line with the national average.

However, we believe that our clinically focused program remains a critical part of the long-term answer. Continued advancement of our burden of illness and clinical pathway initiatives with our partners will help to mitigate the impact of the risk model changes as they did for V28. In addition, given the focus of our model is the assessment of conditions at the point of care with diagnosis tied to documentation from a visit, we believe we have minimal exposure to unlinked or audio-only coding. We believe our ability to differentiate on the management of medical costs and quality outcomes should continue to position us well with health plans and physicians, with the expectation that the rate and cost spread will ultimately normalize over time. Throughout the year, we advanced several key transformation priorities, which are embedded in our expectation for material improvement in year-over-year medical margin and adjusted EBITDA.

At the midpoint, we expect revenue of $5.5 billion, medical margin of $325 million, and adjusted EBITDA at breakeven. Our 2026 outlook reflects the expected positive impacts from the team's execution on payer contracting, clinical and quality programs, cost initiatives, as well as premium increases. We also anticipate benefiting from payer benefit design changes, including increases to deductibles and maximum out-of-pocket expenses, as well as reductions in supplemental benefits. While this is expected to benefit cost trend, we are assuming that net cost trends will remain elevated in 2026 at approximately 7%. Let me now reinforce key areas we believe are supporting a stronger foundation for execution in 2026 and forward. First, we enter 2026 with an enhanced financial data pipeline and strengthened actuarial and analytical capabilities, improving financial discipline, clinical visibility, and overall predictability.

We're increasingly able to identify variants earlier and intervene faster. As we have previously stated, we now have greater visibility into detailed revenue and claims information, with the ability to calculate member-level risk scores utilizing our enhanced data pipeline, a key difference versus prior years. In addition, we believe the pipeline, AI-assisted advances for high-risk member identification and diagnosis through our Burden of Illness program, as well as execution on clinical pathways, will deliver results over and above the final year of the V28 impact. Second, through a disciplined approach to better underwriting the risks we take by contracting, agilon intentionally prioritized economic sustainability over membership growth. This approach included a willingness to pause growth, walk away from unprofitable payer contracts, and restructuring arrangements with certain payers in specific markets, temporarily migrating to a care coordination fee model as opposed to full risk.

As a result, we expect to benefit from incremental percentage of premium and enhanced quality incentives for the value we deliver. A reduction in Part D exposure to less than 15% of our membership, as well as shorter average contract term lists, which we expect will help us better navigate changing market dynamics, including exposures to adverse policy, utilization, or payer behaviors. In addition, our disciplined and rigorous recontracting process led us to exit certain payer contracts in specific markets. These contracts did not meet our minimum threshold of profitability. We expect membership will be reduced to approximately 430,000 members in 2026, including approximately 25,000 members in no downside care coordination fee arrangements with upside performance-based fees. We believe care coordination fee arrangements provide a long-term, risk-adjusted growth opportunity to potentially move these members, when appropriate, to a full risk arrangement.

Third, we advanced clinical pathways, which are evidence-based, data-enabled care models designed to help our partners proactively identify, diagnose, and manage the care journey for patients with high-impact chronic conditions. We believe these pathways, including heart failure, dementia, and COPD, can materially affect utilization, quality, and total cost of care. We concluded the year with active heart failure programs adopted in over 90% of our network. Congestive heart failure, or CHF, is the most mature and scaled pathway, serving as the blueprint for other conditions, including early identification, expanded support for Guideline-Directed Medical Therapy, and appropriate end-of-life care guided by patient preference and goals. Palliative care is also a core extension of our Total Care Model. It's designed to proactively support patients with advanced illness, often those with late-stage heart failure, COPD, cancer, or significant multimorbidity.

While only representing a small subset of our population, we have increased the number of patients engaged with this program. Clinically, it improves quality of life and care coordination. Financially, it helps us reduce avoidable late-stage utilization, particularly inpatient admissions and emergency care. Most importantly, the patients and their families have a better experience and clearer goal of care discussions and more coordinated support. Fourth, are our quality initiatives. Our quality programs continue to mature with stronger measurement discipline and improved care gap closures. Quality isn't just a scorecard for us, it's a lever for patient outcomes, member experience, cost, and revenue. The strategy recognizes that primary care performance directly drives the majority of Star measures, making agilon's physician-centric model structurally advantaged and an area of increasing focus by payers.

Our value-based care model enables exceptional quality performance by providing the necessary tools and support to help our network deliver the highest quality care. To drive additional performance in 2025, we strengthened our data access and analytic capabilities to further enhance our ability to identify care gaps. We also expanded our capabilities for providers to close care gaps in areas such as diabetic eye exams. Our network consistently delivers quality performance for measures we can influence and control ahead of benchmarks at 4.2 stars on a composite basis across the platform, maximizing quality bonus revenue while reinforcing physician alignment. In 2026, we believe we have the opportunity to more than double the incentive contribution. We indicated last quarter, 2024 results were very strong in ACO REACH and an improvement over 2023 results.

ACO REACH continues to demonstrate the value creation agilon can deliver and is shaping the way we are transforming our MA business. CMS recently announced the LEAD program, Long-term Enhanced ACO Design, intended to launch after the Reach model concludes at the end of 2026. LEAD is designed as a 10-year voluntary model with a longer planning horizon, benchmarking enhancements, and an emphasis on better serving high-needs patients. We see LEAD as a positive signal. It reinforces CMS commitment to value-based care with a longer-term structure that can support sustained investment and consistent operating execution. We executed on initiatives to reduce operating costs and controls. We believe we made meaningful progress on forecasting, performance reporting, and market-level accountability in 2025. These are critical to improving decision speed and execution.

We executed on $35 million in operating cost reductions above what we communicated at the end of the third quarter. This will enable greater operating leverage from the platform and support our business objectives. In summary, we are executing with urgency. While cost trends are expected to remain elevated, we believe our transformation actions will support improved operating performance. We plan to build on the progress made last year with a continued emphasis on discipline, execution, collaboration, and measurable positive impact for patients. We expect 2026 to mark a strong improvement in medical margin and adjusted EBITDA, supported by renegotiating with health insurers to better reflect the reality of today's environment, care costs, and plan-initiated decisions. A heightened focus on investments in quality performance as health plans continue to increase the incentives available for top quintile performance.

Continued progress to improve patient outcomes and reduce total cost of care through proactive chronic disease management and ongoing development and expansion of clinical pathways. Strengthening provider engagement and reducing variability in performance across markets and practices, optimizing our cost structure. Lastly, we will continue to advance initiatives which we expect to support continued performance improvement in 2027. With that, I'll turn it over to Jeff to walk through the financial results.

Jeff Schwaneke (EVP and CFO)

Thank you, Ron, and good afternoon. As Ron stated, 2025 was a transformational year. We took significant actions focused on improving the profitability of the business, including a disciplined approach to contracting, improvements in our burden of illness program, enhancing our clinical and quality programs, meaningful cost reductions, and continuing to advance strategic initiatives related to our data visibility, clinical, and cost management programs. Through the execution and implementation of these initiatives, we expect to drive significant improvement in profitability in 2026, while continuing to invest in our platform and partners. As we discussed last quarter, this is supported by several underlying market and payer-related tailwinds, including the 2026 final rate notice by CMS, payer bids, which were focused on margin. Our actions we took in 2025 centered on execution and profitability. For today's discussion, I will cover 3 key areas.

First, I will walk through our fourth quarter and full year results and a bridge to our jumping-off point for 2026. Second, I will walk through our 2026 guidance, including key assumptions driving improved profitability. Finally, I will discuss the strength of our capital position in a more disciplined near-term growth outlook. Moving to our financial performance for the fourth quarter and full year 2025. Starting with membership, Medicare Advantage membership at the end of the quarter and fiscal year in 2025 was 511,000 members. Our ACO REACH membership for the quarter and fiscal year in 2025 was 114,000 members. As a reminder, membership continues to be affected by our decision to take a measured approach to growth, inclusive of previously announced market exits in a smaller 2025 class.

Total revenue for the fourth quarter was $1.57 billion and $5.93 billion for full year 2025, respectively. Revenue in both reflect the impact of lower than expected risk adjustment revenue and previously disclosed market and payer contract exits. With respect to medical costs, we continue to see favorable development from the first half of 2025, with the respective cost trend now sitting in the mid-5% range. For the third quarter of 2025, we experienced elevated costs, primarily attributed to inpatient stays, including a few large, discrete, multimillion-dollar claims totaling $6.5 million. Based on this, we increased our medical cost trend for the third quarter of 2025 to 7.2%, up from the low-6% range we previously recorded.

Given the elevated cost trend we experienced in the third quarter, along with minimal paid claims visibility at close of the fourth quarter, we took a prudent approach and recorded fourth quarter medical cost trends at 7.4%. This brings our full year 2025 cost trend to approximately 6.5%, which we believe provides a solid foundation heading into 2026. medical margin for the fourth quarter was negative $74 million and negative $57 million for the full year. Both the fourth quarter and full year results are reflective of the elevated cost trend assumptions just discussed, as well as the previously discussed risk adjustment impact. The full year results include negative $60 million from exited markets and negative $53 million from prior year development.

Adjusted EBITDA was negative $142 million, and negative $296 million for the fourth quarter and full year, respectively. The fourth quarter reflects the items I already highlighted, partially offset by lower geographic entry costs and the benefit from continued operating cost discipline. ACO REACH was in line with our expectations. Adjusted EBITDA for the fourth quarter was negative $6 million, and for the full year of 2025 was $41 million. As Ron mentioned previously, ACO REACH performance further supports our confidence in our approach, the Total Care Model, and value we bring to our partners and members. On the balance sheet, we ended the quarter with $285 million in cash and marketable securities and $91 million of off-balance sheet cash held by our ACO entities.

Year-end cash was ahead of our expectations by approximately $66 million, including $34 million in permanent improvement and $32 million related to expense timing. In tandem with our transformation initiatives, after the quarter, we extended our credit facility and term loan. Details were filed in an 8-K. Next, let me discuss our outlook for 2026. As I previously mentioned, we are optimistic about our ability to deliver significant growth and profitability in 2026, driven by our actions in 2025. We have provided our first quarter and full year 2026 guidance metrics in the press release and earnings presentation posted on our website for you today. We have also provided bridges in the earnings presentation that walk from our jumping-off point to the full year 2026 guidance.

For the full year 2026, we expect year-end membership on the agilon platform will be in a range of 525,000-540,000 members. This includes estimated Medicare Advantage membership of 430,000 and ACO model membership of approximately 103,000 at the midpoints. The estimated Medicare Advantage membership reflects the market exits we announced in 2025, a small amount of growth, as well as the impact of our discipline contracting. As we highlighted on our third quarter earnings call, our contracting efforts were focused on achieving positive adjusted EBITDA across all markets, which embeds our assumptions and medical cost trends, payer-specific bids, quality performance, and market-specific cost structure for 2026.

As a result of this disciplined, profitability-focused approach, we exited several payer-specific contracts for 2026, which reduced overall Medicare Advantage membership by 50,000 members. Additionally, Medicare Advantage membership includes approximately 25,000 members in a care coordination fee structure, with additional incentives tied to quality and cost performance. For the full year, we expect revenues in the range of approximately $5.41 billion-$5.58 billion. As highlighted in the slides we provided today, most of the year-over-year improvement is expected to be driven from known factors, including increased percentage of premium from our contracting efforts and payer bids, which were on average at or above the CMS benchmark rate. Combined, these are expected to create over $625 million in incremental value in medical margin in 2026.

As mentioned earlier, in addition to exiting structurally unprofitable arrangements, we also reduce exposure to Medicare Part D costs to below 15% of our membership. We prioritize care coordination fee structures with performance-based incentives, more than doubling the quality incentive opportunity from 2025 for the value we deliver to our members and payers. With respect to our burden of illness program, we are confident that the enhanced data pipeline, which now includes over 85% of our members, AI advances for high-risk member identification and diagnosis in our BOI program, and execution on clinical pathways, are expected to deliver results over and above the final year of V28 implementation. We expect a net 40 basis point improvement year-over-year at the midpoint. As a reminder, over the last two years, we have more than offset the impact of the V28 implementation.

Our enhanced data pipeline has shown a 99%+ correlation rate and is expected to improve the accuracy and forecasting of our risk-based revenue. With respect to cost trend, we are assuming a gross cost trend of 7.5% for 2026, as trends remain elevated, and net 7% when considering the 50 basis points estimated benefit from payer bids. As we have stated previously, 2026 payer bids across our markets on average, demonstrated payers bidding for improved profitability with benefit design changes, including increases in premiums, deductibles, and maximum out-of-pocket expenses, and a reduction in supplemental benefits. It's important to note that this 7.5% cost trend for 2026 comes on top of the higher cost baseline that we are now assuming for 2025, which we believe is an appropriate stance in this continued elevated cost environment.

We expect medical margin to be in the range of $300 million-$350 million in 2026. This reflects the positive impact from our disciplined contracting efforts, a slight benefit from our BOI program, and a more conservative cost trend assumption heading into 2026 due to the continuation of elevated medical expenses. We anticipate G&A expense of approximately $234 million, which is slightly lower than the full year 2025, and geo entry expenses of approximately $15 million. G&A expense for 2026 includes the benefit from the organizational realignment initiatives we implemented in the second half of 2025, which reduced operating expenses by $35 million, exceeding what we previously communicated. This was partially offset by employee merit and medical cost inflation and the reestablishment of incentive compensation expense, assuming a full target payout.

We continue to focus on additional initiatives to optimize our cost structure and drive additional operating leverage heading into 2027. adjusted EBITDA for the full year is expected to be in the range of -$15 million to +$15 million or break even at the midpoint. This includes the contribution from our ACO REACH programs, which is expected to be in the range of $20 million-$25 million. As a reminder, our ACO REACH outlook reflects announced changes to the ACO REACH program for the 2026 performance year, primarily related to a rebasing of the risk adjustment cap from 2022 to 2019. We are confident these factors will drive improved performance. We are continuing to actively manage the business to further enhance execution across all initiatives, laying the foundation to drive improved performance beyond 2026.

I will discuss our capital position, which will enable our teams to continue executing on our transformation and deliver our anticipated material year-over-year performance improvement. We expect to end 2026 with at least $125 million of cash on hand, including our ACO REACH entities. This is driven by our better-than-expected year-end cash position, combined with our current 2026 outlook. We have extended our credit facility with our existing lenders by two years and currently plan to pursue a reverse stock split as indicated in our proxy filing. We believe the extension reflects the strength of our operating performance outlook and continued lender confidence in our business. I would like to address the Advance Notice rate notice released by CMS.

To reiterate, we are disappointed and believe the proposal does not adequately address the high cost and utilization trends experienced over the last several years. As Ron mentioned, after further analysis of the details provided with the Advance Notice, we believe our BOI and clinical pathway initiatives will help mitigate the impact of the risk model revision and normalization factor outlined in the Advance Notice. In addition, our initial analysis of the sources of diagnosis indicates we should experience minimal impact, as the strength of our model is our primary care partners' physical interaction with their patients. This would set our expected baseline closer to the published Effective Growth Rate. We will continue to analyze and monitor this release, and remain hopeful that a more comprehensive and appropriate approach will be taken when final rates are released in April....

In summary, we recognize that we are operating in a dynamic macro environment, including industry headwinds and regulatory changes. We have executed on a significant business transformation plan. Combined with our physician-centric model and scale, we believe positions agilon health to deliver sustainable value for patients, partners, and shareholders. With that, operator, let's move to the Q&A portion of the call.

Operator (participant)

Thank you. We will now begin the question-and-answer session. If you would like to ask a question, please press star followed by 1 on your telephone keypad. If you change your mind, please press star followed by 2. When we bring to ask your question, please ensure your device is unmuted locally. We will make a quick pause here for the questions to be registered. Our first question comes from Jack Slevin with Jefferies.

Jack Slevin (VP and Equity Research Analyst)

Hey, good afternoon, guys. Thanks for taking the question. I just want to kick off on some of the trend discussion because I think I caught all of it, Jeff, but I wanna make sure we've got sort of the right understanding in terms of, you know, what's baked in for 2025. I guess I just want to clarify. It sounds like 3Q has stepped up. You sort of roughly matched that or maybe stepped that up slightly. Just a little color of clarification there, and then, you know, if there's anything you've seen in some of that true up in the third quarter on what might be driving that acceleration and cost trend, I would be interested just to hear if there's any color on that point, on that at this point. Thanks.

Jeff Schwaneke (EVP and CFO)

Yeah, sure, Jack. Thanks for the question. Yeah, you're right. So what we saw in the third quarter, in the prepared remarks, we commented on really higher inpatient stays, so we had a lot more inpatient volume. Specifically, we had several cases that were over $1 million, and if you aggregate those, it's roughly $6.5 million of cases that were over $1 million in the third quarter. So, you know, sitting at this point, we took the cost trend in Q3 from the low sixes to 7.2%. Listen, we recognize that we have limited claims visibility, paid claims visibility for the fourth quarter, but we felt it prudent, given that Q3 is kind of coming in so high, that we moved Q4 up to 7.4%.

What that did is it took the full year from the low to mid 5s to 6.5%. Right now, we have 2025 at 6.5% cost trend.

Jack Slevin (VP and Equity Research Analyst)

Got it. Okay. That's really helpful. I appreciate that color. Then maybe just to follow up on some-

Jeff Schwaneke (EVP and CFO)

Yep

Jack Slevin (VP and Equity Research Analyst)

... of the 27 commentary, it sort of acknowledging you all have a lot of wood to chop in 26, and I think you know, that seems to be clear in sort of the guidance that's laid out. Maybe just on 27 on the rate notice and then on the ACO front as well. I guess, you know, I'm on record saying I think value-based care players can get to roughly 5% on rev trend. It sounds like you guys maybe have a slightly different bridge there, but are landing in a similar zone. Considering that sort of environment, 7.5% cost trend, that seems, you know, possibly conservative for 26, but maybe, you know, unclear where that goes.

How do you think about what actions you might need to take in 27 on MA, whether it's further contract adjustments? Maybe just, I'll leave it open-ended there, but interested to get sort of what that landscape might look like. If I can squeeze in a loose second piece on the ACO front. You know, I heard the LEAD commentary. Would love to hear just sort of how you're approaching, you know, what to do in 27 on that front with the end of REACH. Thanks.

Jeff Schwaneke (EVP and CFO)

Yeah, yeah. I'll handle the 27 commentary that you talked about, then I'll send it to Ron for the ACO part. Really, Jack, it's the same actions we've been taking, right? It's contracting, it's our burden of illness program. You know, we'll see how the final rate notice shakes out, but it's the same levers that we've been, I would say, executing on this year. We will do more of that as we think about 27. I would say the two open components are, you know, what happens with payer bids. Obviously, we get a preview of what those bids look like before we enter into our contracting discussions. That will be an important piece. Then overall, what do cost trends do?

I think from our perspective, we believe that we can continue to improve margins, you know, beyond 2026 through all of these levers that we've talked about today, and that's what we're focused on. Ron, on the ACO?

Ron Williams (Executive Chairman)

Yeah. Look, Jack, I think the ACO new model is encouraging in the sense that it's a 10-year model, which provides for a longer period of time, gives you a basis to plan and perhaps to make investments to support the development of the model. Now, we have encouraged, from a policy point of view, further clarity, much greater, even if stretching out of the implementation of the program. I think that at this point, there's not a lot that we know, but the main thing that we know is that it represents a continuing opportunity, and I think that the work that we've done so far in the current model will position us very well in terms of however the program unfolds. We're looking forward to being actively involved.

As a matter of fact, I'll be in Washington next week. Mehmet Oz is gonna be in a meeting I'm at. We'll continue to advocate positions to make that program effective for patients, for physicians, and for us.

Jack Slevin (VP and Equity Research Analyst)

Got it. Really helpful. Appreciate it, guys.

Operator (participant)

Thank you. The next question comes from Jailendra Singh with Truist.

Jailendra Singh (Managing Director)

Thank you, and thanks for taking my questions. I want to follow up on that incremental, inpatient mid cost you just were talking about for Q3. Were those claims tied to some specific payers or geographies? Just trying to understand if your Q3 reserving of 7.4 versus 7.2 in Q3, kind of assumes, Q4 reserving of 7.4 versus 7.2 in Q3 assumes those inpatient stays continue at a similar level or get worse. Just trying to understand if cushion built in Q4 is enough.

Jeff Schwaneke (EVP and CFO)

Yeah. Thanks, Jailendra. I guess a couple things. Number 1, they weren't concentrated in specific markets, is what I would say. We did see utilization step up not across the board, but in several of our markets, specifically in inpatient stays. I would say September appears to be the highest of the quarter, it was more focused on the end of the quarter is where we saw that. I understand your point. You're saying, you know, could these just be random, acute events that don't reoccur? That's certainly possible.

Again, with limited claims visibility, as we closed out the year, we just felt it was prudent to provide a solid foundation from which to jump off into 2026. We went ahead and moved that cost trend up to 7.4%. Again, limited claims visibility for us, but we felt it necessary to provide a good stepping-off point.

Jailendra Singh (Managing Director)

Got it. My quick follow-up on your OpEx cost initiatives, which is now $35 million benefit in 2026. Do you guys see any additional opportunities in terms of streamlining cost and what areas that could come from?

Jeff Schwaneke (EVP and CFO)

Yeah, I think it's all the areas that generated the $35 million. Certainly we're not done looking, okay? Let's put it that way. I think there are further opportunities for cost reduction. Some of that's going to require automation and AI and technology. I think they'll be harder to achieve, but it doesn't mean it's not there. That's what we're focused on as we think about executing on 2026 and heading into 2027.

Jailendra Singh (Managing Director)

Got it. Thank you.

Operator (participant)

Thank you. The next question comes from Michael Ha with Baird.

Michael Ha (Senior Research Analyst)

Thank you. Wondering, is there any update you've received on the 25 fee-for-service trend within ACO REACH? Is it still 8.5%? Also just on trends more broadly across both REACH and MA, there's been some conversation about the MA rate notice, some saying that back half trends are actually less steep. If CMS were to include more back half 25 claims experience, it might actually drive the Effective Growth Rate slightly lower than the Advance Notice. It sounds like your own back half trends have actually stepped higher versus the front half, which would obviously go against that-

Jeff Schwaneke (EVP and CFO)

Yeah

Michael Ha (Senior Research Analyst)

... that thinking. I'm curious to hear your thoughts on this.

Jeff Schwaneke (EVP and CFO)

Right

Michael Ha (Senior Research Analyst)

ongoing conversation.

Jeff Schwaneke (EVP and CFO)

Yeah. Yeah, for sure. Thanks, Michael. I think the first half we've commented on is in the mid-fives for us. In the MA population, we certainly did see an acceleration of cost trends, at least for Q3. We'll have to see how Q4 plays out, but at least for Q3, we certainly saw that. The fee-for-service cost trend, the latest on that is 8.1%, it came down a little bit. What I would say is in the ACO program, it was also concentrated in the back half, we have a lot more current data there from the government, is what I would say. Those cost trends were back, you know, tilted toward the back half as well, but they've come down from 8.5% to 8.1%.

Michael Ha (Senior Research Analyst)

Got it. Thank you. One more on the rate notice. I'm curious, after you've, you know, reviewed it yourself, I'm just wondering if there's anything you view as most notable with potential for CMS to improve. Again, there's conversation about another area, about the treatment of skin subs and the risk model recalibration. By that I mean, right, they adjusted the Effective Growth Rates excluded, but it doesn't look like they did that for potentially for the coefficients aligned with those skin subs. Now we have this strange situation potentially where it's distorting the risk model recalibration and driving this rate headwind. I'm curious if that's an area you've been looking at, thinking about, and just broader thoughts on areas of improvement into the final rate notice. Thank you.

Jeff Schwaneke (EVP and CFO)

Certainly all of those items that you have mentioned, in addition to what is the final kind of cost trend, all of those items are top of mind for us. I guess what I would say is, you know, again, just broadly, ultimately we're looking for rates that, you know, account for the cost trends that we've seen over the last several years, you know, however that shakes out. That's ultimately what we're trying to achieve. I guess we'll have to see how all of these things that you mentioned play out. Hopefully, some of those get delayed or lengthened or, you know, spread over time, to balance, I would say, the cost trend dynamics that we're dealing with. Ultimately, we'll have to see how that shakes out.

Operator (participant)

Thank you. Just as a reminder to all of the participants, so for us to be able to go through all of the questions on today's call, we kindly ask all the participants to limit themselves to only one question. Our next question goes to Ryan Langston with TD Cowen.

Ryan Langston (Director and Senior Analyst of Healthcare Research)

Hi, thanks. A few of the larger public plans have highlighted expected margin recovery in group MA specifically. I think the last disclosure of your mix was around 17% or 18%, kind of midway through last year. I guess, where does that percentage sit now and in 2026? I guess, how is that potential recovery reflected in the guidance? Thanks.

Jeff Schwaneke (EVP and CFO)

Yeah, thanks, Ryan. You know, it's a little early to figure out kind of where the membership is going to play out, is what I would say, but I don't think that we're gonna have two different of a mix, heading into 2026. You know, obviously, we really don't get final membership until towards the end of the first quarter, we'll, you know, we'll kind of give an update at that point in time. Right, right now, there's nothing that says our mix is gonna be substantially different from that.

Ron Williams (Executive Chairman)

All right, thanks.

Operator (participant)

Thank you. The next question goes to Matthew with Needham & Company.

Matthew Wagner (Managing Director of Healthcare Investment Banking)

Hey, thanks for the thanks for the question. wanted to hit on quality. Nice to see the medical margin opportunities there. I think in 2025, you'd been targeting $25 million of opportunity tied to quality. How did you do on achieving that? Then for 2026, as we think about that opportunity doubling, could you maybe just give us a sense of what those increased incentives look like and pathway to achievement? Is that just greater Star improvement or any discrete strategies you're laying out to achieve that quality opportunity? Thanks.

Jeff Schwaneke (EVP and CFO)

You know, a couple of things. You know, the quality, obviously, the measures aren't done yet. You know, there's run-out that has to happen, but I think we're in the ballpark or getting close to what we thought we would achieve for 2025. That's the first thing. The second piece, which you mentioned, is, you know, there's an opportunity for us to there's doubling of the potential for us to earn. What I would say is broadly across our network in 2024, we were roughly at 4.2 stars. We made progress and improved that in 2025. Now, the verdict's not all the way out because we have the run-out that has to happen, but we're pretty confident that we will do better in 2025.

As we think about 2026, the opportunity is there. What we have included in our guide is similar performance to 2025. We haven't banked on that in the guide, but we're obviously shooting for a higher level of performance. We have programs that are centered, as you can imagine, around driving that performance.

Operator (participant)

Thank you. The next question comes from Stephen Baxter with Wells Fargo.

Stephen Baxter (Managing Director and Senior Equity Research Analyst of Healthcare Services)

Yeah, hi. Thanks. Just wanted to make sure that I'm fully tracking the comments on the Advance Notice that you gave and why you think that your view of it is more in line with the Effective Growth Rate. I think, you know, you're saying that you have, I guess, little to no exposure to unlinked chart review, which, you know, makes perfect sense given the model that you operate. In terms of the other risk model changes, including the normalization impact, that 330 basis points item in the CMS announcement, are you saying that you just don't have exposure to that, or you're saying that other things like coding trend and clinical efforts offset that?

Jeff Schwaneke (EVP and CFO)

Sure.

Stephen Baxter (Managing Director and Senior Equity Research Analyst of Healthcare Services)

I'm just trying to get to what an apples-to-apples comparison is for you guys.

Jeff Schwaneke (EVP and CFO)

Good, good clarification. I would say, yes, we are exposed to that, and generally, we've run the math, and we're very close to what is outlined in the rate notice. What we are saying is that we've shown the ability over the last several years to offset the implementation of V28, and recall V28 was roughly 3% to 3.5% per year. We feel pretty confident that we can do that again in 2027. You know, that was the comment that was made, is we have a way to offset that, generally, we're viewing it as the Effective Growth Rate is really the number.

Ron Williams (Executive Chairman)

Yeah, I would just add that what's been driving has really been the implementation of our clinical pathways, and particularly with our congestive heart failure, we ended the year with about 90% of the platform well implemented in that program. We think we're crossing over with a pretty good run rate, and we think there's still a lot more prevalence in the communities for us to help patients get diagnosed and get on the right kind of therapy to help better manage that condition. We also will be implementing additional clinical pathways, which we talked about, that we think could be important contributors over time.

I think that one of the things I would say also is that we recognize that we need to focus on 2027 in terms of taking a step up in order to address this. So we're not saying that what we're doing, we think is perfectly adequate. We think it's a really, really solid foundation, and we're gonna be doing more to make certain, as best we can, that we can get to where we need to.

Stephen Baxter (Managing Director and Senior Equity Research Analyst of Healthcare Services)

Got it. My actual more tangible question, just on the medical margin bridge that you guys gave us in the slides, the $127 million for the payer contract, and there's any rough sense you can give on how much of that is percent of premium changes versus, you know, having less Part D risk? I'd love to just get a better sense of, you know, what inning you feel like you're in on this percentage of premium effort, and whether you kind of characterize the success you're having as being, you know, relatively broad-based or maybe having more success with a subset of payers and maybe there's more opportunity in front of you. Thank you.

Jeff Schwaneke (EVP and CFO)

Yeah, I would say the majority of that is either percent of premium or relief from the payers Star, specific payer Star issues that they've had. That is contracted and done. That's, you know, those are, that's locked-in value, is what I would say, as we think about the 2026 P&L.

Operator (participant)

Thank you. The next question comes from George Hill with Deutsche Bank.

Speaker 13

Hi, this is Liz, on for George. I just have 1 question on the Special Needs Plans. Could you help frame the current exposure to the Special Needs Plans versus the traditional MA membership, and whether the mix shift towards a Special Needs Plans means a structurally higher margin opportunity over time?

Jeff Schwaneke (EVP and CFO)

If I just look at our Special Needs Plans, it's roughly 7%, roughly, for us, right around 7%. I don't think we have enough information right now with our membership to determine if there's been a big mix shift, more to come on that one.

Speaker 13

Thank you.

Operator (participant)

Thank you. The next question comes from Justin Lake with Wolfe Research.

Justin Lake (Analyst)

Thanks. Appreciate the time. Couple of follow-ups for you guys on stuff you've already talked about. First, on the membership exits, right, and some of the recontracting you've done there. Is it fair to think that you've kind of walked away from the contracts and the plans that you think are not good partners, and the kind of go-forward improvement here will be execution and hopefully, you know, rates that reflect cost trends? Or do you still feel like there's more to come on that side? Also, you know, were there any partners that stood out there? Is it concentrated in one or two plans that you walked away from, or are you seeing that more broad-based?

Jeff Schwaneke (EVP and CFO)

Yeah, Justin, I guess what I would say is it's probably payer and market specific. It's not specific to any one payer. I think, as you know, economics are different across payers and markets, I wouldn't single any payer out, to say they were specifically an issue, and so it's broad-based. Ultimately, as we think about it, going forward, I think these are members that we can ultimately get to a contract, you know, sometime in the future. Obviously, we're in challenging macroeconomic times, and we just couldn't get to a deal this year. It doesn't mean we can't get to a deal ever. It just means the economics and the risk wasn't right for us at this point in time.

That's the same lens that we'll have as we, you know, renew contracts, for 2027.

Ron Williams (Executive Chairman)

I think the point I would make, Justin, is that we've been pretty clear about the value that we create, that if we're not wanting to be paid for it, then we will not be delivering that value. We'll see what happens next year as they realize that what we were telling them was really an important contributor to their success. We're hopeful, but we're also firm about it has to be the right agreement for us and for our physician partners.

Justin Lake (Analyst)

Perfect. Just last follow-up on the on trend. It'll be, you know, I think this question's been out there for a while, CMS went on their, on their call and said, "You know, we think trend's 5.5%." ACO REACH is, you know, been pushing 8%-9% the last couple of years. Have you been able to... You know, you sit in a unique position, kind of playing in a significant way in both. Have you been able to sit down and kind of bridge that gap in terms of...

You know, I know skin substitutes is a big part of it, but beyond that, do you think there's 300 basis points of difference between ACO REACH and Medicare Advantage, or do you think there are a couple of pieces that, you know, the industry can kind of bring down to D.C. and sit down with CMS and say, "Here's what you're missing?

Jeff Schwaneke (EVP and CFO)

Yeah, I guess what I'd say, Justin, is I think the industry and we are aligned that there seems to be a disconnect between the ultimate rate at the bottom line that's getting paid, and the cost trends that everybody, including fee-for-service, has seen over the last several years. You know, I think there's no answer here that bridges that gap, is what I would say. I think that's why everybody's advocating for, you know, kind of a revisit of what the initial rate notice is.

Justin Lake (Analyst)

Got it. Thanks.

Jeff Schwaneke (EVP and CFO)

Yep.

Operator (participant)

The next question goes to Craig Jones with Bank of America.

Craig Jones (VP)

Hey, thanks for the question. I wanna follow up on the, on the chart review, comment you made. Do you say you're in line, as in, you'll be in line with the 1.5%, or you think it'll be, like, closer to 0%? As you think about how that's spread among your payer partners, is it, you know, a pretty tight cluster, or are some potentially gonna have, like, a 5% impact and some will have a 0% impact? Thank you.

Jeff Schwaneke (EVP and CFO)

Yeah, you know, I think what we're saying is the removal of selected diagnosis is minimal for us, just given our model. Because we're, you know, we're highly aligned with the primary care physician and, you know, really, we're seeing those members in the office. For us, there's not a lot of unlinked conditions, given how our model is designed and our proximity to the primary care physician. I'd say that's just broad across everywhere. The Part C risk model changes, that obviously would be different by market.

Craig Jones (VP)

Okay, got it. Thank you.

Operator (participant)

Thank you. Our last question goes to Daniel Grosslight, Citi.

Speaker 12

Hey, this is Luis on for Daniel. I just have a quick cleanup question. I know you're intentionally slowing down market growth this year, that still includes $15 million of new geography entry expenses. Can you remind us where exactly that is allocated to? Thanks.

Jeff Schwaneke (EVP and CFO)

Yeah, that's really, capital commitments from prior growth. There's some of that that drags into the following years, what I would say. There was a little bit of growth this year, and obviously there's some other groups that we're talking to, but, you know, not really getting into that right now.

Speaker 12

Understood. Thank you.

Jeff Schwaneke (EVP and CFO)

Yep, thanks.

Operator (participant)

That does conclude the Q&A portion of today's call, so I will hand it back over to you, Ron Williams, for any final comments.

Ron Williams (Executive Chairman)

Yes, thank you. I would like to close by really expressing a deep appreciation and a huge thank you to our physician partners whose commitment to quality care to their patients is really fundamental to our long-term success. I also want to thank all of the employees of agilon who have really been focused on this transformation that we've gone through this year, positioning us for the kind of success that we've outlined in our guidance. Thank you for joining the call. We appreciate your questions and the opportunity to engage with you. Have a good day.

Operator (participant)

Thank you, everyone. This does conclude today's call. Thank you for joining. You may now disconnect.