Oscar Health - Q2 2023

Transcript

Operator (participant)

Good afternoon. My name is Abby, and I will be your conference operator today. At this time, I would like to welcome everyone to Oscar Health's 2023 2Q earnings conference call. All lines have been placed on mute to prevent any background noise. After the speaker's remarks, there will be a question and answer session. If you would like to ask a question during this time, simply press Star followed by one on your telephone keypad. If you would like to withdraw your question, again, press star one on your telephone keypad. Please limit yourself to one question and one follow-up question. Thank you. I will now turn the conference over to Cornelia Miller, Vice President of Corporate Development and Investor Relations.

Cornelia Miller (VP of Corporate Development and Investor Relations)

Thank you, good evening, everyone. Thank you for joining us for our second quarter 2023 earnings call, where we'll discuss our strong first half results, disciplined execution, and path to profitability. Mark Bertolini, Oscar's Chief Executive Officer, and Sid Sankaran, Oscar's Chief Financial Officer, will host this evening's call. This call can be accessed through our investor relations website at ir.hioscar.com. Full details of our results and additional management commentary are available in our earnings release, which can be found on our investor relations website at ir.hioscar.com. Any remarks that Oscar makes about the future constitute forward-looking statements within the meaning of safe harbor provisions under the Private Securities Litigation Reform Act of 1995.

Actual results may differ materially from those indicated by those forward-looking statements as a result of various important factors, including those discussed in our quarterly report on Form 10-Q for the quarterly period ended March 31, 2023, filed with the SEC and other filings with the SEC, including our quarterly report on Form 10-Q for the quarterly period ended June 30, 2023, to be filed with the SEC. Such forward-looking statements are based on current expectations as of today. Oscar anticipates that subsequent events and developments may cause estimates to change. While the Company may elect to update these forward-looking statements at some point in the future, we specifically disclaim any obligation to do so. The call will also refer to certain non-GAAP measures.

A reconciliation of these measures to the most directly comparable GAAP measures can be found in the second quarter 2023 press release, which is available on the company's investor relations website at ir.hioscar.com. With that, I would like to turn the call over to our CEO, Mark Bertolini.

Mark Bertolini (CEO)

Thank you, Cornelia. Good evening, everyone. I have been at Oscar just over four months now and have spent my time continuing my deep dives across the business. I am feeling even more optimistic now than when I joined the company in April. I will discuss my key learnings in a few moments, but let me begin by providing an overview of our second quarter performance. We had a strong quarter, and our results demonstrate that we are executing on our path to profitability. All of our key metrics are performing in line or favorable to plan at this point in the year, and our NPS increased to a record high of 57 this quarter. Our medical loss ratio improved 230 basis points year-over-year to 79.9%, driven by our disciplined pricing strategy and total cost of care initiatives.

We reached total company profitability for the second consecutive quarter with an adjusted EBITDA of $36 million and with a first half adjusted EBITDA of $87 million, increasing our confidence in our total company adjusted EBITDA target for next year. We continue to view insurance company profitability this year and total company profitability next year as important milestones for us, and we are very encouraged by our results today. Sid will walk us through a more detailed review of our financial metrics later in this call. As we look to next year, we plan to maintain a disciplined pricing strategy that we believe appropriately targets both growth and margin expansion. Our growth strategy for 2024 focuses on leveraging the breadth of our deep provider partnerships to expand into more rural areas.

We are planning to increase our service area footprint in more than half of our current states, which would meaningfully increase our overall TAM next year. On the margin side, we have identified increased benefits from our total cost of care initiatives in areas including the PBM and fraud, waste, and abuse efforts. We expect to drive further administrative cost savings from our increased scale and overall efficiencies from our technology. Most importantly, though, we are expanding our innovative and affordable product offerings to continue providing an optimal member experience. For example, following the success of our diabetes plan, which targets members with a specific disease state, we are introducing our Breathe Easy plan for members suffering from COPD and other respiratory conditions.

Available in select markets in 2024, this plan will reward and incentivize members around specific COPD-related benefits, with the end goal of driving better clinical outcomes and lower costs of care. With accessibility being central to our mission, we have also developed an enhanced version of our Spanish-speaking features to better serve the 30% of our membership base who are Spanish speaking. Our consumer focused approach has resonated well with these members, and we currently enjoy an NPS of 80. As we strive to deliver a best-in-class member experience, we believe that these are the types of personalized offerings and consumer friendly features that can help us continually enhance our competitive advantage and industry leading NPS scores. Let me now turn to some of my key observations over the last 128 days.

I have met with leaders across the organization and have spent time digging deep into critical aspects of the business, including our 2024 pricing and market position, the areas of our operations where I see opportunities for greater efficiency, and our long-term strategic positioning. Overall, I have been impressed with what I have found. Over our 10 year history, we have invested in our infrastructure and operations. We have made great strides in right-sizing our operations for our scale, but I see opportunities for even more value creation in core functions. For example, we have strong processes in place for risk adjustment, but we can further enhance these capabilities and build even greater degree of efficiency and impact. There has already been material work underway that is yielding a positive result, and I plan to spend even more time in these areas going forward.

Our people are our most important asset. I have spent a fair amount of time assessing our team, getting a better understanding of our strengths, and seeing where we can build upon our existing expertise. As we look at the needs of the organization going forward, we are making some leadership changes and bringing in some key hires to enable us to better build and execute on our strategic priorities. First, as we have discussed, Sid Sankaran, our interim CFO, is leaving Oscar. We are very appreciative of his leadership. I look forward to continuing to work with him as a member of our board. As we look to fill the position, we conducted a very thorough external search. It became clear throughout the process that we already had the best person to take on that role internally.

We are thrilled to share that we are welcoming Scott Blackley back to the role of CFO, effective August 14th. Over the last 10 months, Scott has served as our Chief Transformation Officer, spending his time focused on aligning our overall revenues and costs, enhancing our operational efficiency, and building out our Campaign Builder product. Today, we are on track to hit our key targets, and we believe there is no better person for this next phase of Oscar than a seasoned leader who understands the nuances of our business. As part of this transition, I will be spending more time with our operations team, bringing my decades of experience as an operator to drive continued efficiency and momentum across key functions.

We are also bringing on two new hires to round out our leadership bench: an industry veteran to run our corporate strategy and institute our management processes, and a senior leader to lead and ensure we continue to expand our +Oscar business. I have had the privilege of working closely with both individuals during my Aetna days. They will be starting in the coming weeks, so you will hear more about them during our next earnings call. Let me spend a moment on how we are thinking about the future. I have been embedding critical processes that will enable our long-term strategic planning efforts. As part of this work, I have initiated a new management process, built a framework for our multi-year plan, reviewed our tech roadmap, and met with the board to kick off a cadence of meetings that will focus on succession, long-term strategy, and performance.

I plan to spend the rest of the year driving continued performance improvements, laying the groundwork for our multi-year strategy, and accelerating +Oscar to expand on our modular approach. With respect to +Oscar, we have been seeing positive results with our first Campaign Builder clients. We currently have 235,000 unique patients active in the tool and have been seeing high engagement rates. We expect to continue our momentum in the second half of 2023 and look forward to bringing more modular components like Campaign Builder to the market. Speaking of our technology, Mario has settled into his role as President of Technology and Chief Technology Officer, and among many other things, has focused on how we can integrate AI into our tech and product roadmaps.

As we have shared in the past, our proprietary tech stack allows us to be exceptionally nimble in our response to major technological paradigm shifts like AI. We have identified opportunities to further streamline administrative processes, enhance decision-making capabilities, and ultimately provide a more personalized experience for our approximately 1 million members. We have developed dozens of AI prototypes and have made progress on a number of use cases and features that we plan to continue rolling out in the coming months. One example is Campaign Builder AI Actions, which leverages large language models to intelligently monitor for signals and deliver relevant interventions that better serve our members' and patients' clinical needs. If you are interested in staying up to date on our latest AI insights and developments, please visit hioscar.com/ai.

As it relates to the long-term strategy, we are working through an initial set of strategic pillars that will guide us through the next few years. First, we want to drive sustainable profitability and expanding margins through market-leading and scalable operations. Second, we believe that member engagement is one of our key differentiators and want to continually invest in our member experience. Third, I believe we should look to diversify beyond our current offerings to leverage our member-centric approach to an increasingly more individualized market. Finally, we will continue to externalize our tech platform so that we can power others throughout the healthcare system. I believe these are the right strategic priorities for us over the next several years. We will share a more detailed long-term view of the company with you at an investor conference next year.

With that, I would like to turn the call over to Sid. Sid?

Sid Sankaran (Interim CFO and Director)

Thanks, Mark, and good evening, everyone. As Mark noted, our second quarter results show the business is performing in line to favorable with our expectations, and that we are executing well against our plan. We ended the quarter with just under 1 million members, which was consistent with our pricing and churn assumptions. On the volume side, membership has been slightly ahead of plan. While we have had limited SEP growth this year relative to prior periods, this has been largely offset by Medicaid redeterminations. At this point, Medicaid redeterminations have resumed in all of our states. Early data indicates that the emerging Medicaid redeterminations are healthier than expected and are not exhibiting any anti-selection patterns. I'd also note that we are now eligible to enroll new members in Florida again.

As I noted last quarter, our portfolio strategy purposefully and successfully shifted our member mix closer towards the market average. We now have a higher proportion of renewals than any time in our recent history, which has resulted in an older membership that looks very similar to the overall ACA population. Shifting our mix has been part of a deliberate strategy, which has resulted in a lower projected risk transfer as a % of premiums this year. Our direct and assumed policy premiums were $1.6 billion in the quarter, a modest 3% decrease year-over-year, driven by membership and partially offset by rate increases. Similar to trends we saw last quarter, our premiums before ceded reinsurance, which includes the impact of our lower risk transfer, grew 8% year-on-year to $1.5 billion.

Turning to medical costs, our medical loss ratio improved 230 basis points year-on-year to 79.9% due to our disciplined pricing actions and total cost of care initiatives. Our overall claims trends have been in line to slightly favorable relative to our pricing expectations for the first half of the year. We are pleased with this trend, and it includes our expected mix shift to members with higher risk scores, as previously noted. Within specific service categories, inpatient is performing in line with our pricing assumptions, outpatient and RX are slightly higher than expectations, and professionals materially below. Let me focus on risk adjustment for a moment. Historically, we've had a younger and healthier population than the market average and have therefore been a large payer into the risk adjustment program.

The final CMS report for last year's risk adjustment was favorable to our expectations, driven by outperformance and value capture initiatives, including a successful pilot application with AI. However, we strengthened our RADV accrual and IBNR, which largely offset the benefit. While we expected a lower risk transfer this year due to our updated member mix, the initial Wakely report for 2023 still came in favorable to our expectations. Given that we are only partway through the year, we have maintained an appropriately cautious approach to our risk adjustment reserve, which we will reevaluate in the coming quarters as we see more data. Switching to administrative costs, our InsureCo administrative expense ratio improved 280 basis points year-on-year to 16.7%, driven by distribution optimization, vendor efficiencies, and operating leverage.

Driven by the MLR and InsureCo admin ratio benefits, our combined ratio improved 500 basis points year-on-year to 96.7%. Our adjusted administrative expense ratio of 19.5% improved 420 basis points year-on-year due to the aforementioned improvements in the InsureCo admin ratio, lower Holdco expenses, and higher net investment income. Our strong operating results drove another consecutive quarter of total company profitability with an adjusted EBITDA of $36 million. Our first half 2023 adjusted EBITDA of $87 million is nearly $200 million higher than the same period last year. We are very pleased with our results to date and the momentum we've seen throughout the first half of the year.

Shifting to the balance sheet, we ended the second quarter with $3.8 billion of cash and investments, including $250 million of cash and investments at the parent. As a reminder, we expect second quarter cash will be a high watermark for both cash and investment income for the year, as a large working capital benefit from our RA payable wears off next quarter. We expect to pay out the 2022 risk adjustment in August, and our lower projected 2023 risk transfer will continue to build throughout the year. Our capital position remains very strong. Our subsidiaries had approximately $840 million of capital and surplus, including $290 million of excess capital, driven by solid operating performance through the first 6 months of the year.

We believe our excess capital positions us well to fund future growth and allows us additional opportunities to optimize our capital position over time. Based on our encouraging first half results, we are making a few updates to our 2023 guidance. We now expect our MLR will be towards the low end of the 82%-84% range. Our lower MLR and higher investment income is also projected to drive our insurance company adjusted EBITDA to the top end of the $20 million-$120 million profit range. Importantly, we anticipate our total company adjusted EBITDA loss will be at the high end of the range or towards a $75 million loss for the year. In summary, our first half results increase our confidence in achieving insurance company profitability this year and lay a great foundation for total company profitability next year.

We are very pleased with our progress to date and how we are positioned to execute in the back half of the year. As we look to the future, we believe our disciplined pricing approach, innovative offerings, and industry-leading NPS sets us up well to win for many years to come. Finally, I'd like to say that coming back to an operating role at Oscar has been a wonderful experience and a real privilege. The finance team is in great hands with Scott, and his contributions as Chief Transformation Officer have set us up well for success. As Mark also noted, I'm feeling incredibly optimistic about the company's future and believe we have the right plan, people, and strategy in place to execute on our goals. I look forward to continuing to work with Mark, Scott, and the rest of the management team from my seat on the board.

With that, let me turn the call over to Mark for final comments.

Mark Bertolini (CEO)

Thanks, Sid. In summary, we've had a strong first half of 2023. Our results show that our discipline, focus, and execution are delivering meaningful impact across our business. We are on track with all of our key metrics, and we expect to achieve insurance company profitability this year and total company adjusted EBITDA profitability in 2024. As we look to the remainder of 2023, we see more tailwinds than headwinds, which we believe positions us well for 2024. We believe that the individual market is the future, and that our experience, consumer-focused approach, technology, and capabilities will enable us to continue thriving amidst this dynamic environment. I would like to thank the Oscar employees for their continued dedication and focus.

They are the reason why we continue to be in a position to serve our members and make healthcare more affordable, convenient, and accessible for people across the country. With that, I'd like to turn the call over to our operator for the Q&A portion of the call.

Operator (participant)

At this time, I would like to remind everyone, in order to ask a question, press star, then the number one on your telephone keypad. We'll pause for just a moment to compile the question-and-answer roster. Your first question comes from the line of Stephen Baxter from Wells Fargo. Your line is open.

Stephen Baxter (Senior Equity Research Analyst)

Hi, thanks for the question. Just to make sure we have this right, you know, I heard the commentary on the risk adjustment. 2022 came in favorable, but you didn't take much of it through to MLR or EBITDA. If you could maybe help us with the impact on either line, just how it translated through the P&L, that would be great. Then just to confirm the approach on 2023, it sounds like the initial read you're getting from Wakely is favorable relative to your initial assumptions, but that hasn't yet been reflected in either your results this quarter or the revised full-year guidance that you provided because you're taking a bit of a wait-and-see approach on that. Could you just confirm those couple of things? Would be very helpful for us. Thank you.

Sid Sankaran (Interim CFO and Director)

Hey, Steve, it's Sid here. Thanks for the questions. First, on 2022, effectively on 2022, we did see favorability in our final RA submission. That was offset somewhat by an accrual that we put up for RADV, and I would articulate our position as being cautious around margin with respect to 2022 claims, so we did top up the IBNR somewhat. As you looked at 2023, while it's early, I would say the initial Wakely submission was more favorable than we'd anticipated at this point in the year. We did highlight that we do expect lower risk transfer in 2023. We did have some partial favorability flow through into the P&L this quarter, but I would say, relative to the initial Wakely report, it was a small amount of favorability.

You know, we'll follow our process over the course of the year, and as the data emerges and we get more confidence in the data, we'll revisit that accrual in the coming quarters.

Stephen Baxter (Senior Equity Research Analyst)

Okay. Thank you. I'll jump back in. Thank you.

Operator (participant)

Your next question comes from the line of Jonathan Yong from Credit Suisse. Your line is open.

Jonathan Yong (Research Analyst)

Hey, thanks for taking the question. Just want to go to Florida. Your enrollment cap was recently removed. How are you thinking about any benefit as members are redetermined in the back half of the year there and just in the markets generally? Separately, I believe there was a restriction on extracting capital from the Florida sub as part of the agreement. Just curious how this changes your approach to the market, given so much of the capital was in Florida. Thanks.

Sid Sankaran (Interim CFO and Director)

Well, I think, vis-à-vis new... It's, it's Sid here. Thank you, Jonathan. I think vis-à-vis new members, you know, we'll be eligible to enroll new members, and we expect that that will occur as kind of standard business as usual as we return to the exchange. Those members, you know, I think we previously talked about, you know, the profitability dynamics of SEP members, so nothing, nothing different there. Vis-à-vis our, our return to the Florida market, I would just call out probably one thing. You know, the, the terms of our agreement are effectively consistent with our agreement when we entered the state with respect to the regulators. We always have targeted having constructive and proactive relationships with our regulators. We expect that to continue, and, we're very grateful for, everyone's support as we've reentered Florida and are excited to, you know, yet again, have another successful open enrollment.

Jonathan Yong (Research Analyst)

Okay, great. I think you mentioned that you see some increased benefits on the PBM side. Just curious what else you see on the PBM side beyond the initial contracting that, that you conducted. Thanks.

Sid Sankaran (Interim CFO and Director)

Yeah, no, Sid here again, nothing much I would add to that. I think obviously we've had a successful renegotiation to our PBM contract. I think, you heard from Mark in, in prior calls that, that process will, you know, was reevaluated with respect to our contract in 2023, and that we would anticipate that that benefit will continue to accelerate in 2024. Nothing new to add there.

Mark Bertolini (CEO)

We'll continue, this is Mark. We'll continue to look at the MAC lists and pricing quarter to quarter as we talk with our, with our vendor.

Jonathan Yong (Research Analyst)

Okay, great. Thanks.

Operator (participant)

Your next question comes from the line of Michael Ha from Morgan Stanley. Your line is open.

Michael Ha (Senior Equity Research Analyst)

Hey, thank you. As we look to next year and your ability to hit enterprise profitability, just given your optimism around membership growth next year, if you do achieve very strong membership growth, I'm, I'm curious, is there a level of growth next year that you believe could potentially place some pressure on your ability to achieve profitability? Or do you believe you're in a strong enough position now with the economies of scale, where you can realize enough operating leverage regardless of the, the magnitude of growth next year? You also mentioned expanding your footprint in more than half of your space. As you think about the composition of that growth, does it matter where that growth ultimately comes from, newer or older existing markets in your ability to hit profitability? Thank you.

Sid Sankaran (Interim CFO and Director)

Hey, Michael, it's Sid here. I'd probably make two points, you know, in response to your question. First, usually the, you know, your first question. I think, you know, I think it's important to just remind ourselves that, you know, Oscar really has been an execution story. You know, to quote Mark, you know, we're very focused on increasing that internal capital gener-generation. As we grow and as evidenced really by our financial performance in the first half of the year, you see that on the MLR side, we've been pricing for margin expansion, and we have had a real strong focus on best-performing markets and staying disciplined. New membership and new membership growth is really positive operating leverage to our story. We don't really see growth as a constraint to achieving that proper profitability target.

You know, with respect to the second question, I think we've also commented about this. I think, you know, the vast bulk of our markets right now are really performing at target MLRs. We've highlighted that in the individual market with some of the exits that we've made, you know, we're very confident in our current market performance. As you know, pricing is just being released in early, but, you know, obviously, we're pricing, you know, in line or above trends. Based on the current portfolio of how the individual market is performing, and again, just looking at the, the financial performance through the first half of the year, you're starting to see that, you know, definitively in the P&L. You know, we, we feel good about, you know, both the expansion into new markets and how current markets are performing. No real flags there.

Michael Ha (Senior Equity Research Analyst)

Great. Thank you. If I could just ask one follow-up question about, I guess, the bridge to membership growth next year. If you were to bridge it, you know, which buckets would you deem as being the most significant to achieving at least 20% premium revenue growth next year? Could it be the Florida enrollment cap removal, toggling broker commissions back up, or your 2024 rate strategy? Just any color there would be great. Thank you.

Mark Bertolini (CEO)

We're, we're looking to diversify. This is Mark, Michael. We're looking to diversify our revenue across more markets. We have priced appropriately and conserved, and, and, and with margin in mind in certain markets where we believe we can accelerate our growth in other markets. Florida will grow, but it won't grow at the kind of rates that supported us in 2022, which, you know, allows us from an operating leverage standpoint, to be a much more efficient in this growth period than we were in 2022. We don't see the kind of ramp that you would expect with growth in the latter quarter of the year, and rolling into 2024.

Sid Sankaran (Interim CFO and Director)

Yeah, I would just highlight a couple of things. I think you heard in Mark's prepared remarks that our NPS was at an all-time high this quarter. I mean, we really do not see, you know, any of our other competitors bringing to bear the customer experience or innovation that Oscar does. So, we're very pleased with how NPS has landed so far and expect to continue to invest in the member experience.

Mark Bertolini (CEO)

We'll be using Campaign Builder as a tool in re-enrollment, and growth, in this fall enrollment as we begin to address directly to our, to our members on the opportunities they have here at Oscar.

Operator (participant)

Your next question comes from the line of Gary Taylor from Cowen. Your line is open.

Gary Taylor (Managing Director and Senior Equity Analyst)

Hi, good afternoon. Just had a couple of questions. One, followed your commentary on the 2022 and 2023 risk adjustment, payable, accrual, and the offset that you called out for RADV accrual in IBNR. Question was, why are the claims payable on the balance sheet down about $100 million sequentially, with including this IBNR boost? I mean, it just implies inventories are down pretty substantially sequentially.

Mark Bertolini (CEO)

We, as I said in the first quarter call, we have worked very hard at making sure that we are efficient in collecting our risk adjuster in- information, settlements with providers, and our excess reinsurance coverage. We can't do that with claims and backlogs, so we have worked the backlog down. While we haven't pulled all the way that through the triangles, we believe that it's a huge opportunity for us to be more efficient and get as much internally generated capital as we can.

Sid Sankaran (Interim CFO and Director)

Yeah, Gary, just adding, it's Sid here, adding a little bit more color to that. We did, in particular, this quarter, to Mark's point, as part of a deliberate operational strategy, have three effectively large settlements that we cleared out this quarter. One of the reasons you've seen, our DCP be so high is we have had a fair amount of bulk reserves up for those settlements. As those work down, you know, you should expect DCPs will come back a little bit more in line, which will probably be higher than the market, but hopefully, our trend line, you know, brings the DCPs down.

Mark Bertolini (CEO)

Sooner or later, you run out of claims.

Gary Taylor (Managing Director and Senior Equity Analyst)

Yeah. We should still expect that to come down, and there's no P&L impact to that. It's a cash flow dynamic.

Mark Bertolini (CEO)

That's right, because-

Gary Taylor (Managing Director and Senior Equity Analyst)

Got it. Then just one more for me, since, you know, AI is, is obviously very topical this year, and Mark, you discussed it a little bit. Can you give us a little more, maybe some examples on... You talked about AI interventions. Are you talking about, you know, clinical interventions or flags with clinicians and providers, or would these be more interventions with your beneficiaries? Like, what are, what are some examples you're talking about there?

Mario Schlosser (President of Technology and CTO)

Hey, Gary, can you hear me in this microphone here? Okay.

Gary Taylor (Managing Director and Senior Equity Analyst)

Yeah, I was gonna say, Mark or Mario.

Mario Schlosser (President of Technology and CTO)

Go ahead, answer the question. two examples that I love the most, and I really will invite people to go to the website. We made the decision to open source a bunch of our insights as we developed them and a bunch of our approaches to, to applying AI. Two examples I like the most, one of them is when we, when we get claims traces out of our claim system, our new system, which played a role also in making sure we can work this claims backlog down this much, we get these explanations of the claim system for how we pay the claim. This is very complicated to look at and difficult to parse and so on.

We have a language model now that can take those kind of system outputs and explain in much more natural language, much more intuitively, why a claim got paid or didn't get paid. That is now being used by the internal claims folks to just get a quicker insight as to what the system did in a particular situation. We're pushing this over time also towards providers and provide a web application that Oscar has towards members and so on. That's a very nifty example because it relies on the smart claim system that needs to be there to begin with, and then can, on top of that, can a language model can make an additional impact. The other one is also in the claim system. It's the configuration of provider contracts.

When we get a provider contract, it's a 100 page contract or so with a hospital system, very complicated, lots of text in there. Turns out we can put that into a language model. The model can then, in a very nice way, parse what's in there and kind of pre-fill for an internal contracting person, what the configuration of our system looks like. We built those configuration tools also over the past two or three years or so. Now, fueling them with these language models is very powerful. You know, Mark has articulated that we have big plans around +Oscar and modularization of that further and further.

This kind of single-threaded system that we built there is very powerful, and I think we're just excited about bringing that to more and more organizations on the outside of Oscar as well, and they can now also benefit from these AI developments we have there. hioscar.com/ai, again, is the place to go to. There's a Confluence page there or a Notion page there that we update all the time. You can look at, and see how that looks.

Gary Taylor (Managing Director and Senior Equity Analyst)

Okay, thanks. I'll take a look. It sounds like the nearest term opportunities are still heavily focused on the administrative side, I think as some others have, have talked about side-.

Mario Schlosser (President of Technology and CTO)

Yeah.

Gary Taylor (Managing Director and Senior Equity Analyst)

- understanding.

Mario Schlosser (President of Technology and CTO)

I should answer that part of your question as well. Yeah, we have a couple of clinical use cases that are in the virtual primary care practice, for example, around some summarizing lab results, but they all have a human in the loop. There's a lot of work happening right now around AI governance and clinical use cases. We tend to be at the forefront of helping do that. There was randomly seen here, spearheading that. On the operation side, there's so much more that can be done, that, I think clinical use cases are incredibly interesting for us. We can take a bit more time in rolling those out very thoughtfully.

Gary Taylor (Managing Director and Senior Equity Analyst)

Thank you.

Mark Bertolini (CEO)

Your next question comes from the line of Joshua Raskin from Nephron. Your line is open.

Joshua Raskin (Research Analyst)

Hi, thanks. Good evening. Just the SG&A, or I guess just the G&A expenses, when you take out stock comp in the quarter, it looks like they were up about, I don't know, $8 million-$9 million sequentially. I don't know if stock comp is in any of the other line items, so that may be messing it up. I'm just curious if actual dollars were up and kind of what's driving that?

Mark Bertolini (CEO)

Yeah, Josh, Mark, that is investments in the back end, things like fraud, waste, and abuse, and other services that we're paying for that we're getting in, in our underlying claims result.

Joshua Raskin (Research Analyst)

All right. That, is it, is it fair to say more than reinvesting some of the savings that you guys have found in terms of dollars, you know, down significantly year-over-year?

Mark Bertolini (CEO)

Yes.

Joshua Raskin (Research Analyst)

Okay. Then, Mark, you've made an interesting comment that, you know, over time, I know it's a longer-term question, you look to diversify beyond your current offerings, and then juxtapose that with the commentary you made around it's an individual market. Should we be thinking about, you know, larger offerings back into MA or other individual markets? I'm just curious, more color on that.

Mark Bertolini (CEO)

There are 35 million people in the individual or in the insured, remaining in the insured employer market, in individual and small group and middle market employers. We see, mixed with our benefit plan designs focused on comorbidities, in stabilizing that population, an opportunity to move more ably toward defined contribution, where employers are less fearful of the fact that the few cases, sick cases in their, in their employee population will blow up a defined contribution pool. If we can stabilize that part of the pool, then we're able to offer a more flexible benefit program to the remaining of the employers through ICHRA and defined contribution. That's one approach.

We believe that's one where we have no fixed view of that market because we're not in it in a very significant way, where our competitors will be slower to move, in, in approaching that marketplace. That's a place we think we can excel at, in large part, because of our platform and, and our ability to reach customers more effectively and create a great member experience. The other part is indeed Medicare Advantage. With the pressure on rates that will come from the federal government around risk adjustment, we believe we have nothing to lose.

Others do, we have an opportunity to power health systems by taking their -3% Medicare margins and turning them into something positive, let's call it 4% versus eight, where they can, for half their book of business, really flip the earnings profile of their Medicare business and have a huge advantage for their institutions. There's a lot of work that needs to be done there yet. We have to be able to fully externalize the platform, not just components. We need to have a system integration partner or partners, we're talking to a number of people that we will consider in that space, so that we can do the right level of business process reengineering and partnership with these big health systems to get into private label Medicare Advantage business.

Joshua Raskin (Research Analyst)

Okay, got you. That's gonna be narrow network, you know, MA, sort of the, the Oscar model, right? Which will be high customer experience.

Mark Bertolini (CEO)

Sure. Yeah.

Nathan Rich (Research Analyst)

Okay. All right. Perfect. Thank you.

Operator (participant)

Your next question comes from the line of Kevin Fischbeck from Bank of America. Your line is open.

Kevin Fischbeck (Director and Senior Equity Research Analyst)

Great, thanks. I wanted to go to the, you know, redetermination comment that you made earlier. I think you said that the risk pool is coming in a little bit better than you thought. I guess, what, what had you been planning for as far as the, the risk pool? Did you think it would be equal to or worse than your current risk pool?

Sid Sankaran (Interim CFO and Director)

Yeah, I think, Hey, Kevin, it's Sid here. Previously, we've said that we thought it would be slightly higher acuity. While it's still early and it hasn't been, you know, a material part of our portfolio as yet, it's coming a little bit better than we've expected, but it's still early, and we'll continue to watch it.

Kevin Fischbeck (Director and Senior Equity Research Analyst)

I guess when you think about the visibility into that, I guess because obviously it's relatively new membership, I mean, do you feel like, during past SEPs, when, when new members come on, that you have relatively real-time information into that acuity, or does it take, you know, a quarter or two before you can really get a sense for where that is?

Sid Sankaran (Interim CFO and Director)

Well, I think, Kevin, as you know, honestly, every time you get a new member, there's a lag in terms of, you know, risk scoring and, of course, you know, some of the key drivers of the, the book, like pharmacy. I think with respect to our data and systems, we have as good data and systems around this space as, as anybody in the industry, and so we feel we have a good line of sight into it.

Kevin Fischbeck (Director and Senior Equity Research Analyst)

So when you think about how you price next year, because obviously next year, the membership is gonna be coming in, more fully from redeterminations, at least from a member month perspective, but probably from a member as well. Did you also kind of assume that higher acuity into next year? So if it ends up staying this acuity, is that a tailwind, or is that something that's still TBD in your final bids?

Sid Sankaran (Interim CFO and Director)

Well, well, I think, you know, as you look to pricing, you always want to have discipline and caution. You know, until you've realized the experience, we wouldn't price it. I think we, we still take a cautious view around those Medicaid redeterminations. Obviously, again, from a pricing perspective, as the experience comes in, we can revisit that over time.

Kevin Fischbeck (Director and Senior Equity Research Analyst)

Just going back to another question about kind of that, that breakout of, of the membership growth that you think you guys can do next year. How fast do you think the market is going to grow next year between redeterminations and everything else? Like, what, what's the industry gonna be growing?

Mark Bertolini (CEO)

We have said before, high teens for membership and low twenties for premium.

Kevin Fischbeck (Director and Senior Equity Research Analyst)

Great. That's, that's what you think the overall individual, the exchange market will do?

Mark Bertolini (CEO)

Yes.

Kevin Fischbeck (Director and Senior Equity Research Analyst)

Okay. All right. Great. Thank you.

Operator (participant)

Your next question comes from the line of Nathan Rich from Goldman Sachs. Your line is open.

Nathan Rich (Research Analyst)

Thanks. Good afternoon, Mark and Sid. Maybe just building off the last question. You know, could you maybe help put in context the geographic expansion? I know you said increasing your footprint in half your states. What's that kind of doing to the TAM that you can go after, as we think about, you know, potential membership growth next year?

Sid Sankaran (Interim CFO and Director)

Yeah. Nathan, it's Sid. Why don't I take that? I think, you know, first off, in, in the broader market, we don't, we don't yet know where, you know, final pricing and, and size, will be in terms of our growth. You know, we think there's a material TAM increase from us. For us, the biggest driver we've talked about is rural service areas where we have deep provider relationships, and folks are excited to grow with us. You know, I think at the same time, another unique driver we have is innovative product offerings, which, which Mark has talked about. And those enable us to, to tackle different, you know, segments of the marketplace. You know, ideally, you know, for us, as we think about it, that's kind of double-digit, you know, TAM growth.

You know, obviously a lot will depends on, final pricing and where, where things land in different marketplaces.

Nathan Rich (Research Analyst)

Okay, great. That, that's helpful. Mark, you had mentioned bringing in new leadership for +Oscar. Any change in kind of priorities or opportunities for that, that business from your point of view?

Mark Bertolini (CEO)

I, the areas where we will focus with the new leadership is to accelerate our +Oscar development. Now that we are comfortable with our ability to deliver on profitability, although we won't lose that focus, we now wanna start hardening the platform in ways that we can get external to the market sooner, rather than we otherwise thought we could. We think bringing leadership on now, not from the standpoint of development and building out the platform, which Mario and his team have done very well so far and will continue to do. It's more about the commercialization and go-to-market side of +Oscar, and how do we address the market.

The component-driven approach, which, which components will come next, but also how do we season the market in a way where we can approach a full platform with other actors in the healthcare ecosystem. The other person coming on board is a person that will, will help us focus on long-term strategy and the cadence necessary to deliver on that strategy over time. I have a way of approaching strategy that we used at Aetna, a management process that supports it, and a reward mechanism that incents it. We're building that out as we speak, and, and this person coming on board will be the person that will help drive up that side of the business.

Nathan Rich (Research Analyst)

Great. Thanks very much.

Operator (participant)

There are no further questions at this time. This concludes today's conference call. You may now disconnect.