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Cigna (NYSE:CI)

Q1 2013 Earnings Call

May 02, 2013 8:30 am ET

Executives

Edwin J. Detrick - Vice President of Investor Relations

David M. Cordani - Chief Executive Officer, President, Director and Member of Executive Committee

Ralph J. Nicoletti - Chief Financial Officer and Executive Vice President

Analysts

Scott J. Fidel - Deutsche Bank AG, Research Division

Justin Lake - JP Morgan Chase & Co, Research Division

Justin Lake - UBS Investment Bank, Research Division

Joshua R. Raskin - Barclays Capital, Research Division

Matthew Borsch - Goldman Sachs Group Inc., Research Division

Ralph Giacobbe - Crédit Suisse AG, Research Division

Christine Arnold - Cowen and Company, LLC, Research Division

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

Ana Gupte - Dowling & Partners Securities, LLC

Ana Gupte - Sanford C. Bernstein & Co., LLC., Research Division

Albert J. Rice - UBS Investment Bank, Research Division

David H. Windley - Jefferies & Company, Inc., Research Division

Peter Heinz Costa - Wells Fargo Securities, LLC, Research Division

Sarah James - Wedbush Securities Inc., Research Division

Christian Rigg - Susquehanna Financial Group, LLLP, Research Division

Operator

Ladies and gentlemen, thank you for standing by for Cigna's first quarter 2013 results review. [Operator Instructions] As a reminder, ladies and gentlemen, this conference, including the question-and-answer session, is being recorded. We'll begin by turning the call over to Mr. Ted Dietrich. Please go ahead, Mr. Dietrich.

Edwin J. Detrick

Good morning, everyone, and thank you for joining today's call. I am Ted Detrick, Vice President of Investor Relations. And with me this morning are David Cordani, our President and Chief Executive Officer; and Ralph Nicoletti, Cigna's Chief Financial Officer.

In our remarks today, David will begin by commenting on Cigna's first quarter 2013 results and how our broad portfolio of differentiated customer solutions provides us with many avenues for growth in 2013 and beyond. Next, Ralph will review the financial results for the first quarter and provide an update on Cigna's financial outlook for 2013. We will then open the lines for your questions. And following our question-and-answer session, David will provide some brief closing remarks before we end the call.

As was noted in our earnings release, Cigna uses certain financial measures which are not determined according to generally accepted accounting principles, or GAAP, when describing its financial results. Specifically, we use the term labeled adjusted income from operations and earnings per share on the same basis as the principal measures of performance for Cigna and our operating segments. And a reconciliation of these measures to the most directly comparable GAAP measure is contained in today's earnings release, which is posted in the Investor Relations section of cigna.com.

Now on our remarks today, we will be making some forward-looking comments. We would remind you that there are risk factors that could cause actual results to differ materially from our current expectations and these risk factors are discussed in today's earnings release.

Now before I turn the call over to David, I will cover a few items pertaining to our results and disclosures. Regarding our results, I would note that in the first quarter, we recorded 2 charges to shareholders net income, which we reported as special items. The first special item was an after-tax charge of $507 million or $1.75 per share related to our previously announced exit of the Run-off Reinsurance businesses, which was effective February 4, 2013. The second special item was an after-tax charge of $51 million or $0.18 per share related to a regulatory matter within our Disability business. I would remind you that the special items are excluded from adjusted income from operations in today's discussion of our first quarter 2013 results as well as our full year 2013 outlook.

And relative to our Run-off Reinsurance operations, our first quarter shareholders net income included an after-tax non-cash gain of $25 million or $0.09 per share related to the Guaranteed Minimum Income Benefits business, otherwise known as GMIB. As a reminder, the results of our GMIB business are excluded from adjusted income from operations and, therefore, also excluded in today's discussion of our first quarter results as well as our full year 2013 outlook.

Now regarding our disclosures, our GAAP cash flow statement explicitly discloses in cash flows from operating activities the amount paid in the quarter to Berkshire Hathaway in connection with our exit of the Run-off Reinsurance businesses. Adjusting for this one-time payment, which we view as a cost to dispose of the Run-off businesses, operating cash flows for our ongoing businesses were $670 million in the quarter, representing 1.3x our adjusted income from operations.

And also, please note that we when we discuss our full year 2013 outlook, it will be on a basis of adjusted income from operations which, again, excludes realized gains and losses on investment results as well as special items, and it also excludes the effects of future capital deployment.

And with that, I'll turn it over to David.

David M. Cordani

Thanks, Ted. And thank you, everyone, for joining us this morning. Today, I'll briefly touch on our first quarter performance. I'll address how Cigna's strategy continues to create value for our clients, customers and shareholders in a dynamic and disruptive environment. I'll also highlight how our global mix of businesses, differentiated capabilities and emphasis on our customers positioned Cigna to continue to grow going forward. And finally, I'll provide some brief comments on our expectations for the balance of 2013 and beyond. Following my remarks, Ralph will discuss our financial performance in a bit more detail, and then we'll take your questions.

We are pleased with our first quarter results, which demonstrate a strong start to the year for Cigna. Our performance was a direct result of continued effective execution of our strategy and the strength of our diverse portfolio of businesses. Our first quarter performance was driven by our commercial health care and global supplemental businesses.

In commercial health care, we continued growing in our target markets by achieving strong customer retention, expanding our existing customer relationships and adding new customers. And we posted another quarter of high quality medical outcomes and competitively attractive medical costs for the benefit of our customers and clients.

In the Global Supplemental Benefits business, we delivered a healthy increase in revenue and earnings, reflecting solid customer growth, effective cost management and contributions from recent acquisitions. Our Seniors business performed well, demonstrating the quality of our physician partnerships and the value we deliver to our customers. And the results in our Disability and Life business reflected challenging economic and interest rate environment we operate in.

Moving on to the specific financial results. Our first quarter consolidated revenues increased by 21% to $8.2 billion. We grew our global medical customer base by 277,000 people, or 2%, to more than 14.3 million medical customers worldwide. We reported adjusted income from operations of $497 million or $1.72 per share, which reflects a per share increase of 39% over the first quarter of 2012. And during the quarter, we further enhanced our financial flexibility through the exit of our Run-off Reinsurance business.

Our first quarter results are indicative of our leading employer, individual and senior solutions and capabilities, which drove 17% compounded annual revenue growth and 15% per share growth over the last 3 calendar years.

Looking ahead, companies and individuals alike will continue to demand health, well-being and security solutions that are of high quality and affordable. We will also see ongoing changes in the way customers access health care and wellness solutions, whether through evolving individual, employer and government-based channels or emerging changes in public and private exchange models.

At the same time, needs of customers will keep evolving as populations age, chronic diseases become more prevalent, middle classes continue to grow and customers become increasingly engaged and well-informed. Cigna's sustained strategic investments and continued expansion of our portfolio of employer, individual and senior solutions and capabilities positions us to continue to deliver differentiated value to our customers and clients in this dynamic global environment.

I'll now comment briefly on initiatives and investments we are driving for the benefit of our employer clients, individual customers and physician partners. From an employer standpoint, Cigna recently helped to convene, the first of its kind, Global Healthy Workplace Summit, where executives from nearly 30 countries participate in a dialogue of best practices for healthy productive workplaces. An example of shared learnings is that we are beginning to see best practices emerge globally as employees and countries, such as China and Indonesia, extend the healthy habits they learn in the workplace to the communities and homes.

Additionally, it is clear that employers continue to play a meaningful role in the health and productivity of their employees. From a solution standpoint, our consumer-driven health plans, which leverage choice and transparency, continue to grow and deliver attractive returns. Our clients have lowered their costs by an average of 13% in the first year by choosing CDHP while simultaneously improving the overall health profile of their employees. Cigna's customer base for these offerings increased by 26% in 2012.

For individuals, we further strengthened our individual market position and consumer engagement capabilities last quarter through initiatives such as launching new first-to-market products for dementia in Taiwan and new critical illness programs in Korea. In Turkey, we introduced new products to allow individuals to protect their own sense of security by helping them better save for health care and retirement needs. We also launched the myCigna app, which gives our customers instant access wherever they are to personalize health care information to help them find a doctor, view their account balances and deductibles and research drug prices at 60,000 pharmacies, just to name a few examples. We also continue to strengthen our partnership with physicians and health care professionals through our ongoing expansion of our Collaborative Accountable Care, or CAC, initiatives. We are now engaged in 58 CACs that cover 24 states, reflecting more than 10 new CAC relationships in the first quarter alone.

When taken together with HealthSpring's proven physician engagement strategies, these programs create a sustainable model to improve health, access to care, affordability and patient experience. We believe that this type of enhanced care coordination anchored by strong physician partnerships has, as demonstrated by HealthSpring, and will continue to yield superior results.

To further fuel our growth in the space, we continue to invest in our programs, which now support nearly 1 million Cigna customers across our commercial and Seniors business, and we are collaborating with more than 23,000 doctors.

In summary, we've invested wisely in a portfolio of capabilities that enables us to effectively anticipate our customers' and clients' evolving needs and successfully manage the enterprise in an evolving dynamic global marketplace.

Looking ahead for the balance of 2013, we will continue to build on our sustained track record of success, advancing our strategy to create differentiated value for our clients and customers as well as our shareholders. We are pleased with our first quarter results, and the strength of those results give me confidence that we will achieve our increased 2013 earnings outlook.

Turning to 2014, there is no doubt that the finalization of the CMS guidance for Medicare Advantage for 2014 introduces significant change that will cause customer, market and earnings disruptions. Having said that, our goal is to leverage our diversed, well-positioned portfolio of businesses to continue to drive competitively attractive revenue and earnings performance for 2014 and over the long-term. As you know, we continue to target earnings per share growth of 10% to 13% on average over the next 3 to 5 years.

Now to summarize before turning you over to Ralph, our first quarter results are strong and represent sustained success in executing a clear, focused strategy. At Cigna, we continue to succeed in a dynamic global environment, building on our strong track record of attractive financial results dating back to the introduction of our Go Deep, Go Global and Go Individual strategy in 2009. Our company remains grounded in customer centricity with a commitment to putting the customer at the center of all that we do. Our team of 35,000-strong across the globe continues to bring our differentiated value proposition to life each and every day for the benefit of our customers and clients. And lastly, the combination of our clear strategy, consistent execution and sustained investments positions us for continued competitively attractive results as we look to the future.

With that, I'll turn the call over to Ralph.

Ralph J. Nicoletti

Thanks, David. Good morning, everyone. Today, I will review Cigna's first quarter 2013 results and our increased outlook for 2013. We've had a very strong start to the year, demonstrating the strong fundamentals of our businesses as we continue to build upon our excellent track record. And I'd like to highlight several key accomplishments, specifically another quarter of strong top line and customer growth, quarterly earnings per share of $1.72, representing growth of 39% over first quarter 2012, and strengthening our financial flexibility through the successful exit of our Run-off Reinsurance businesses. The strength of our first quarter performance provides us with solid momentum for the balance of this year and confidence in our increased outlook.

First quarter consolidated revenues grew 21% to $8.2 billion, driven by growth in our targeted markets as well as an additional month of HealthSpring revenues. First quarter consolidated earnings were $497 million, representing 38% growth over first quarter 2012.

Regarding the segments, I'll first comment on our Global Health Care segment. Overall Global Health Care results were strong, particularly for our commercial business. First quarter premiums and fees for Global Health Care grew 20% to $5.8 billion, reflecting strong contributions from both our commercial and Seniors businesses. We ended first quarter 2013 with 14.3 million global medical customers, growing by 277,000 customers, or 2%, over year-end, with solid growth in commercial and Seniors.

First quarter earnings grew 44% to $427 million and were driven by revenue growth, primarily due to strong ASO customer growth and specialty penetration and an improved operating expense ratio.

Turning now to medical costs. We continue to improve the health outcomes for the benefit of our customers, driven by our effective engagement with physicians and delivering value-based solutions for our clients and customers. Our commercial medical trends are among the lowest in the industry and given that nearly 85% of our U.S. Commercial customers are in ASO funding arrangements, our clients directly benefit from these favorable medical cost results.

Regarding medical care ratios in our U.S. commercial guaranteed cost business, our first quarter 2013 medical care ratio, or MCR, was 77.6% on a reported basis or 80.3% excluding prior year reserve development.

In our Seniors business, our first quarter MCR for Medicare Advantage was 84.3% on a reported basis or 84.7% excluding prior year reserve development. The flu season resulted in elevated medical and pharmacy costs for our Seniors population and impacted our Medicare Advantage MCR by approximately 100 basis points. Across our commercial and Seniors risk books of business, our first quarter earnings included favorable prior year reserve development of $48 million after-tax compared to $41 million after-tax in the first quarter of 2012.

Moving to operating expenses. For the first quarter, the total Global Health Care operating expense ratio is 20.7%, which is a significant improvement over the first quarter 2012 expense ratio. This reflects leverage associated with our continued customer and revenue growth, realization of benefits of cost-saving initiatives and timing of investments and new capabilities in the quarter. We would not anticipate this operating expense favorability to carry through the full year as we expect our investment-related spending to ramp up over the first quarter levels over the remainder of the year. To recap, we have a strong start to 2013 in Global Health Care business on all key metrics.

Now I will discuss the results of our Global Supplemental Benefits business, which continues to deliver attractive growth and profitability. Premiums and fees grew 36% quarter-over-quarter, driven by strong customer retention and new customer growth as well as contributions from our recent acquisitions, most notably Great American Supplemental Benefits.

First quarter earnings in our Global Supplemental Benefits business were $55 million, representing a 28% increase over first quarter 2012 and reflects business growth, favorable operating expenses, product mix and favorable claims experience. Relative to operating expenses, it's important to highlight that we continue to invest in product, distribution and geographic expansion within this segment.

For Group Disability and Life, first quarter results reflect the impact of a challenging economic environment. First quarter earnings in our group business were $49 million, which were primarily impacted by unfavorable claims experienced in the Disability business. Results for our remaining operations, including Run-off Reinsurance, other operations and corporate, totaled to an after-tax loss of $34 million for the first quarter 2013 consistent with our expectations.

Turning to our investment portfolio. We are pleased with our results in the first quarter. We recognized net realized investment gains of $93 million after-tax, coupled with the strong net investment income result. These net realized investment gains were primarily related to disposition of investment assets associated with our exit of the Run-off Reinsurance business.

Overall, as a result of the continued effective execution of our strategy, our first quarter results reflect strong revenue and earnings contributions from our ongoing businesses as well as significant free cash flow.

Now I will discuss our outlook for 2013. We expect to continue to deliver strong financial performance based on focused execution, leveraging our diversified portfolio of businesses with multiple sources of growth and continued effective capital deployment. We continue to expect consolidated revenues to grow in the range of 8% to 12% over 2012. We have increased our outlook for the full year 2013 consolidated adjusted income from operations to be in the range of approximately $1.74 billion to $1.87 billion or $6 to $6.45 per share. This represents an increase of $0.15 per share over our previous expectations.

Consistent with prior practices, our outlook excludes any additional contribution from additional capital deployment and any additional prior year reserve development for the balance of the year.

I will now discuss the components of our 2013 outlook, starting with Global Health Care. We now expect full year Global Health Care earnings in the range of approximately $1.47 billion to $1.56 billion, an increase of $35 million. This increased outlook for Global Health Care primarily reflects the first quarter favorable prior year reserve development and continued effective execution. Additionally, I would note a variety of items that partially offset this favorability in our full year forecast, including the expected increase in strategic spending in the second half of the year as well as the impact of sequestration.

I will now summarize some of the key assumptions reflected in our Global Health Care earnings outlook for 2013, starting with our customer base. Regarding global medical customers, we continue to expect 2013 customer growth of approximately 1% to 2%. Relative to medical costs, for our total U.S. commercial book of business, we continue to expect full year medical cost trend to be in the range of 6% to 7%, which reflects an expectation for an increase in medical services utilization during 2013. We now expect the 2013 medical care ratio to be in the range of 82.5% to 83.5% for our U.S. commercial guaranteed cost book of business, which is 100 basis points lower than our previous expectations, driven by favorable reserve development in the first quarter. For our Seniors business, our Medicare Advantage MCR for 2013 continues to be in the range of 82% to 83%.

Regarding operating expenses, for 2013, we continue to expect our total Global Health Care operating expense ratio to improve by at least 50 basis points over 2012's full year ratio of 22.6%, recognizing that the balance of the year has an increased level of investments in growth initiatives and enhanced capabilities relative to the first quarter.

Now moving to other components of our outlook. For our Global Supplemental Benefits business, we continue to expect strong top line growth and earnings in the range of $160 million to $180 million. I would note that the first quarter earnings are elevated relative to the remainder of the year due to the timing of operating expenses related to ongoing investments in our growth initiatives and better-than-expected claims experience, which we expect to normalize over the balance of the year.

Regarding the Group Disability and Life business, we continue to expect full year 2013 earnings in the range of $270 million to $290 million. And regarding our remaining operations, that is, other operations and corporate, we continue to expect a loss of $160 million for 2013. So all in, for full year 2013, we have increased our outlook for consolidated adjusted income from operations to a range of approximately $1.74 billion to $1.87 billion or $6 to $6.45 per share. This represents an attractive outlook coming off a very strong 2012.

Now moving on to our 2013 capital management position and outlook. Overall, we continue to have good financial flexibility. Our subsidiaries remain well capitalized and are generating significant free cash flow to the parent, with strong return on capital on each of our ongoing businesses. We ended the quarter with parent company cash of approximately $620 million.

During the first quarter, we repurchased 1.6 million shares of Cigna common stock and we, subsequently, repurchased an additional 2.3 million shares through May 1. Year-to-date, we have repurchased 3.9 million shares of stock for approximately $250 million. Additionally, as of April 18, 2013, we completed the payment of the reinsurance premium to Berkshire Hathaway in connection with our transaction to exit the Run-off Reinsurance businesses. After considering all sources and uses of parent company cash, we now expect to have approximately $1 billion to $1.1 billion available for deployment during the balance of the year.

Overall, our capital position and updated outlook are strong and our capital deployment strategy and priorities are unchanged.

Now to recap, our first quarter 2013 consolidated results reflect the strength of our differentiated portfolio of global businesses and the continued track record of effective execution of our focused strategy with strong growth in our targeted customer segments. The fundamentals in our business remained strong as evidenced by our first quarter results, which reflected attractive growth in revenue, customers and earnings with the opportunity for excess cash deployment; the successful exit of our VADBe and GMIB businesses and the completion of payments to Berkshire Hathaway; and continued targeted strategic investments, which will enable sustained growth into the future.

Based on the strength of these results, we are confident in our ability to achieve our increased full year 2013 outlook. With that, I will turn it over to the operator for the Q&A portion of the call.

Question-and-Answer Session

Operator

[Operator Instructions] Our first question comes from Scott Fidel with Deutsche Bank.

Scott J. Fidel - Deutsche Bank AG, Research Division

First question, I just wanted to follow up on Medicare and see if you can give us your estimated all-in rate impact for 2014 from final rates, including the industry fee. And then, just talk about the effects of the risk adjustment model changes that you're expecting on HealthSpring and if you can flag any particular markets where you expect on to see more impact from that.

David M. Cordani

Scott, it's David. Just maybe a backdrop comment and then I'll address the rates, specifically because I think it comes into your risk adjustment point. First, as I noted on my prepared remarks, the 2014 rate adjustments, I've made no doubt about it, are disruptive and will be disruptive to the marketplace. Specific to our model broadly, we believe that the HealthSpring model continues to be a winning approach in the marketplace and it's positioned for ongoing success. Largely due to your ability to partner effectively with physicians and work around health engagement and care coordination on a go-forward basis, we think it's been proven as the only sustainable way to really improve health and lower health care costs and generate a level of affordability. So now to put that in context of the rate impact, in your question about risk adjusters and the like, for us, as you would imagine, the rate impact varies by market. You could think about the average of that being in the mid single-digits. That excludes the industry tax. So that's the rate impact excluding the industry tax, just so you know what the industry tax looks like. On a perspective basis, when you think about the capabilities we have, we have 2 large sets of capabilities. One, on average, a richer or more comprehensive benefit offering in our respective markets that we targeted because of the efficiency of our portfolio. So a little bit more latitude to work within those benefits and make adjustments and still have a competitively differentiated benefit. And then the physician partnership, to work with those physicians to get to the best efficiency and quality outcome for the benefit of their patients, our customers, as we work forward.

Scott J. Fidel - Deutsche Bank AG, Research Division

Okay. And David, just to confirm. So the variability that you're citing was sort of mid single-digit down vers, let's say, industry peers x the industry tax at maybe more like 3% or so, is that variability mostly off of the risk adjustment model impact?

David M. Cordani

Scott, it's -- time will tell, obviously, as the final rates converts to benefit offerings in the market. But I would say, again, my numbers are mid single-digit on average, and our view of the peer marketplace is in more of the 4% to 5%. So you might argue there's a point, a point plus of difference. I would not benchmark to your notion of a 2.5-point or 2-plus point difference. And you could argue that, that is largely the result of both geographic variability, and then, secondly, the efficiency of our program and effectiveness around the risk adjusters having a little bit larger bite out of it.

Scott J. Fidel - Deutsche Bank AG, Research Division

Got it. And then just my follow-up. I just wanted to shift gears and just ask about the outlook for ASO conversions in 2014, just hearing a lot of market feedback about increased interest in converting to ASO. And particularly, just in the Select Segment, what type of growth pipeline do you expect to see as a result of this since that's a particular area of the market where we're just hearing a lot of interest in ASO for 2014?

David M. Cordani

Scott, specifically to ASO or self-funded, as you know, the bulk of our corporation's U.S. business is in self-funded, think 80% to 85% of the business each day. As it relates to broad themes, we see a continuation of the broad theme from the last 3 or 4 years to just continued openness and a positive appetite for ASO. So we don't see it as a sea change by any stretch of the imagination. In the Select Segment, to your specific point, which we defined as employers with 51 to 250 employees, give or take, we've seen continued positive appetite there as well, so positive momentum, strong portfolio of capabilities and increase openness and receptivity in the market for that. If you look back to our growth results, our regional segment and our Select Segment results continued to be outstanding from a retention, business expansion and new business growth, and we would expect that to continue.

Operator

Our next question comes from Justin Lake with JPMorgan Chase.

Justin Lake - JP Morgan Chase & Co, Research Division

First question on 2014. In your prepared remarks, you talked about your confidence of being able to attract -- grow at attractive rates over the next several years. But specifically, you'd previously communicated confidence in the ability to grow earnings next year. I'm curious if you can give us an update on your thoughts there.

David M. Cordani

Sure, Justin. As you commented in my prepared remarks, we feel as though the positioning of our diverse businesses will enable us to deliver competitively superior both revenue and earnings growth in 2014 and beyond. We remain committed to our long-term EPS growth objective of 10% to 13% on average per year. And as you know, we've been able to deliver that over the prior years. Specific to 2014, given the disruption that the Medicare rate environment has introduced and our need to see how those rates convert to offerings in the market through the second quarter and then the offerings going into third quarter, we think it's early to comment relative to 2014 outlook. But I think the most important headline is we're confident that we're positioned to deliver competitively superior result in 2014.

Justin Lake - JP Morgan Chase & Co, Research Division

And so if Medicare Advantage is clearly the area of disruption, can you delineate what you're thinking in terms of membership growth versus margins?

David M. Cordani

Specific to MA, Justin?

Justin Lake - UBS Investment Bank, Research Division

Yes.

David M. Cordani

Yes. So I'll be careful in terms of my comments because the competitive realities will play out over the next several months. But let's just step back and use a little context here. As we've discussed in the past, whether you look at HealthSpring's history or Cigna's history, both organizations have been disciplined in terms of focus in geographies as well as discipline for sustainable growth. So within that environment, you should assume that there's a bias toward sustainability, so there is a bias toward a balance margin outcome. Having said that, in the disruptive environment we're going to be in, we think 2014 and, arguably, 2015 is going to present some meaningful both organic and inorganic growth opportunities and we remain open to the positive growth story because the HealthSpring platform is positively positioned to deliver, both today and in the future.

Justin Lake - JP Morgan Chase & Co, Research Division

Okay, great. If I could just ask my follow-up again on Medicare Advantage, more specifically around this new risk score model. The -- there has been discussions that in certain markets the rate decline is going to be much more significant than mid single-digits because of the risk score model. Can you talk about how that flows through to your capitated physician groups in terms of in the ability to cut benefit versus your taking the margin decline? And then, obviously, the capitated group getting a percentage of premium, how much of it does the capitated group take there? And how does that kind of affect their view on the Medicare Advantage business?

David M. Cordani

Justin, just a moment of backdrop then on the risk coding and then a little bit of direction how we -- how our model works there. First, just to put it in context, we should think about the risk coding as indicative of the level of both physician engagement with their patients and then active care coordination. So instead, otherwise, the more effective either a medical home, a care coordination or an accountable care organization would be, you'd have a more engaged, a more actively managed chronic population and the risk coding will be higher. And that's a dimension of success, right? You have a much more actively managed organization. To put that in context on what might transpire, take in diabetic, which is quite prevalent in the case of Seniors. In a fee-for-service model, the doctor's really not incented to do all the preventative care measures, to do all the care coordination, et cetera. So it tends to be more uneven. In a coordinated model like we have, you have active monitoring of the diabetic patients, blood sugar levels, proactive exams relative to retinal exams, LDL cholesterol, assessing kidney functionality. And as a result, you get to a much better quality of life for the individual, a better physician-patient outcome that works through and a better overall cost profile. So that's the backdrop. Specific to your question in the model we have, we have a partnership model with physicians bluntly to make sure that we get the right sustainable cost and the right sustainable value outcome in our respective markets. And the body of work we're going through right now, as you'd expect, is to ensure that our net benefit positioning and cost positioning for 2014, has a not only [ph] for 2014, but 2015 and '16. So that's an area where we're pleased with because we are working with our physician partners to get that outcome. We're not working against physicians in a contracting way, but we're working in a very transparent way. And that process is unfolding as we sit here today.

Operator

Our next question comes from Josh Raskin with Barclays.

Joshua R. Raskin - Barclays Capital, Research Division

Didn't hear a PBM discussion or update there. I think, you guys have been talking about first half. So 2 months to go, maybe any color there.

David M. Cordani

Sure, Josh. Maybe we're just waiting for your question on the PBM since there really is a lot of interest. As you know, as we've said in the past, that business continues to perform well. And when you talk about that, the service proposition, the clinical quality proposition, the medical trend outcomes, and it's delivering and, of course, the earnings for us. And as we've talked before, the scale addition presented by HealthSpring presented us an opportunity to evaluate a variety of alternatives. And just to make sure we have the right context, those alternatives are all focused on either maintaining or further enhancing our service proposition, maintaining or further enhancing our clinical quality outcomes, strengthening our positioning for ongoing innovation because the constant here is an environment of change and then further approving both affordability value for our clients and customers and earnings for ourselves. The specific update I gave you is our team is making very good progress and we're on track relative to our internal timelines to work through our body of work here.

Joshua R. Raskin - Barclays Capital, Research Division

And that timeline, as you've expressed earlier, was by midyear, right? Is that fair?

David M. Cordani

Correct.

Joshua R. Raskin - Barclays Capital, Research Division

Okay. All right, so no change there. And then just as I look at the guidance, obviously, you took the numbers up slightly less than what just the favorable development in the Health Care segment was. You bought back a little bit of stock and so there's probably some offset to that. And I'm curious, is it just around discretionary investment spending or is there any sort of quantification of other items that you guys are expecting to be headwinds? And I think you've said sequestration now was in guidance. But I thought that was previously in guidance, but just want to make sure I got that right.

Ralph J. Nicoletti

Josh, it's Ralph. Yes, to your point, we feel good about our outlook. It primarily reflects the benefit of the prior year development that we experienced in the quarter. We clearly had planned investments, behind capabilities and further growth in the balance of the year, which didn't come through in the first quarter as we expected, but we do see it coming through the balance of the year, so our guidance reflects that. And to your latter question on sequestration, as we went into the year and talked about our guidance, we did contemplate within the outlook range of that occurring. And our current guidance also contemplates the impact of sequestration as it flows through, starting in the second quarter.

Joshua R. Raskin - Barclays Capital, Research Division

Is there a way to size those investments? Are they higher than what you thought 3 months ago?

Ralph J. Nicoletti

No. I would say not higher than what we thought 3 months ago, if you step back on our operating expenses overall. It's important to point out, we've consistently improve our operating expense ratio while continuing to invest behind the business, behind growth. And as I noted in my remarks, we expect to improve our ratio by at least 50 basis points off of the 22.6% that we ended in 2012, so nothing unusual there. We're kind of marching through the plan that we had going into the year.

Operator

Our next question comes from Matt Borsch with Goldman Sachs.

Matthew Borsch - Goldman Sachs Group Inc., Research Division

So could you maybe talk about the outlook for '14? Not specifically, but if we think about outside of the Medicare Advantage business, should we think about 2014 being kind of a normal year given that you don't really have impact on your existing business from the commercial and Medicaid side of health reform or are there other angles that we should be thinking about ahead of that?

David M. Cordani

Matt, it's David. So relative to '14, again, most importantly, we believe that we'll continue to deliver competitively attractive both top line and bottom line results. I think, broadly, the way you frame it is a healthy way to frame it. When you think about our business portfolio and you look at the sustained success, for example, in our U.S. commercial business around the regional and the Select Segment, that's the same power that could be used to drive our results, our global individual business. The strength of our cash flow and improved financial flexibility that is built over the last 3 years and further enhanced by the successful exit of our Reinsurance business, all of those are positives. And you highlight the #1 disruptor or headwind. I think the way you're framing it is a very healthy way.

Matthew Borsch - Goldman Sachs Group Inc., Research Division

And maybe as my follow-up, if I could ask about your U.S. Disability business and just maybe frame the outlook there in light of the first quarter negative claims experience you had?

Ralph J. Nicoletti

Sure, Matt. It's Ralph. Again, overall, continue to be pleased with the Group segment in terms of the margins and returns in the difficult economic environment. We are on track to reach the guidance range. We did see some claims volatility in terms of size of claims in the first quarter, which we expect would more normalize over the period of a year. We're also expecting to continue to see operating improvements, which we've been doing over the last several years and that's actually been our outlook as well.

Operator

Our next question comes from Ralph Giacobbe with Credit Suisse.

Ralph Giacobbe - Crédit Suisse AG, Research Division

Just going back to MA, can you all give us a sense of what percentage of earnings MA represents at this point for the company?

Ralph J. Nicoletti

Ralph, it's about 15%.

Ralph Giacobbe - Crédit Suisse AG, Research Division

And then just in terms of follow-up, maybe talk a little bit about cost trends you saw in the quarter. It sounds like flu had more significant impact on your Seniors book, any impact on the commercial side? And may be if you could just talk generally about utilization, what you're seeing within specific categories and cost trend relative to that 6% to 7% that you mentioned for the quarter?

Ralph J. Nicoletti

Sure, Ralph. A few questions in there. First, let me start on the commercial side and then I'll come back on the Seniors side a little bit. Overall, as the quarter came in line with our expectation, certainly, on the commercial piece, a little bit more elevated in the Seniors side because of the flu impact in the first quarter but in line with our expectations, and our trend projection. It does reflect a slight uptick from the first quarter where we were more on the lower end of that range of 6% to 7% but we project a slight uptick as we move through the balance of the year. In terms of the kind of pieces there, I would say no real changes to the historical mix of the different utilization patterns within the trend. And then on the MA side, on the Medicare Advantage side, as I'd mentioned, we did give the impact from the flu in the first quarter, some of that was partially offset by prior year development that we did see in the quarter. And I think it's important to note that as we entered the year, we expected to move our loss ratios up a little bit to position ourselves with the new MLR guidelines in '14.

Ralph Giacobbe - Crédit Suisse AG, Research Division

Okay, great. And if I could just squeeze one more in. Just -- and maybe just an update on where you stand with what the exchanges, how much you think you'll participate at this point and sort of how your rate negotiations are going with providers and what rate you expect.

David M. Cordani

Ralph, it's David. I think your question really goes toward the 2014 public exchange environment. And as you know, we do not have an under 50 life employer block of business to protect and we don't have a material individual block of business. As such, we have a look at this market through a fresh lens. We've been running pilots in a finite number of markets over the last 3 years to learn and be prepared for this change. Looking to 2014, we have a bias to participate. We've done the work and continue to do the work to participate. That bias to participate is quite sharply focused on a limited number of markets. When we think about markets, we think about MSAs. Obviously, you're state-engaged, but we think about MSAs within the states because of localization. Finally, to the notion of your question, when we think about rates, we are also orienting our offerings against those markets where we both deem an attractive environment exist, and we have our most innovative Collaborative Accountable Care relationships because we think the better way to win on a more sustainable basis is, again, working with the physicians as opposed to against them in terms of pounding back and forth our rates. So limited number of markets, bias to action, highly focused work being done and in those MSAs, we'll be where our most sophisticated or innovative collaborative relationships are in place today.

Operator

[Operator Instructions] Our next question comes from Christine Arnold with Cowen.

Christine Arnold - Cowen and Company, LLC, Research Division

You said a bunch of times that you feel you have a lot of financial flexibility and I heard organic and inorganic Medicare Advantage opportunities, kind of hinting at potential for acquisitions and M&A. As you look at your portfolio, where do you see compelling opportunities from an M&A perspective, recognizing the probably smaller tuck-in acquisitions?

David M. Cordani

Christine, it's David. What I referenced before, you're correct, our financial flexibility is quite strong. Ralph noted it in his prepared remarks an excess of $1 billion -- $1 billion to $1.1 billion. Two, we meaningfully improved our financial flexibility post the Berkshire transaction, so you're correct from that standpoint. Two, we indicated that we believe that the CMS rate environment will create meaningful disruption in the marketplace in 2014 and '15. And that will create disruptive opportunity for growth both organically and inorganically. On the organic side, important to note, we are on track relative to our organic market expansion activities. That started in earnest as soon as we closed the HealthSpring transaction. And we've had good planning, good execution, et cetera, and that's on target. All we're indicating is that we have a go-to platform that we could integrate as you put acquisitions into, we have the financial flexibility and we have a model that has been proven successful in its ability to integrate. Beyond that, you should not read anything more into my comments.

Christine Arnold - Cowen and Company, LLC, Research Division

Okay. And then finally on exchanges, how are you viewing private exchanges for the large- and mid-sized employers? Do you see them gaining traction? Are you interested in participating? Or do you view them as kind of a threat to the shift to ASO that we've been seeing?

David M. Cordani

Christine, it's David again. So relative to private exchanges, first, let's have a little shared context here. There's a lot of early movement in the space, so we're early in the cycle. And within that, private exchanges are coming up to serve a variety of purposes. For example, having an improved retail purchasing experience for individual customers, we think that's a positive. For example, elevating the level of engagement in transparency-related purchases, we think that's a positive within -- as an individual level. There are some that are actually moving forward to share more economic burden or risk, with individual consumers potentially orienting against the defined contribution model. We think that could be a winning strategy so long as the individual is engaged and participative and understands what they're getting involved. And so point one is early in the cycle and a lot of different models unfolding. Second point is you should think about us as having a lot of experience dealing in an environment of choice. When you think about our larger case-size business, we're used to dealing in a choice environment, in the industry where we typically call it slice, where you have a B2B to C relationship and you're needing to market and present your offering for an individual of choice. We are participating and expect to continue to participate in some of the offerings that are in the market. And as we have been in the past, we'll be quite focused in terms of those offerings where we believe the designs are designed to be sustainable and where we could add value and win on a go-forward basis. So that's where we look at the markets today.

Christine Arnold - Cowen and Company, LLC, Research Division

Okay. Just a clarifying question on the last comment you made on individual. Are you able to compete in just MSAs or do you have to compete statewide? And what's the risk that you get in members in areas where you don't have the competitive cost structure?

David M. Cordani

So Christine, I think your question is now bouncing back to the public exchanges. And we -- first and foremost, we have demonstrated over the last, almost 4 years, that in our chosen Go Deep markets, we have a fully competitive cost structure. Our medical trends have been outstanding. Our client and customer retention rates have been very, very strong, so we feel good about that. Secondly, health care is local. health care is extraordinarily local. In the individual market, it will be even more localized. So we believe our ability to focus on key MSAs and key markets is going to be a winning strategy on a go-forward basis.

Operator

Our next question comes from Kevin Fischbeck with Bank of America Merrill Lynch.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

Just wanted to go back to the MA rate for a second. You guys have previously outlined a plan of entering 2 to 3 new markets per year. I just wanted to see what, if any, impact this MA rate had on those plans, either for 2014 or for out-years?

David M. Cordani

Kevin, it's David. You're correct. We had outlined as part of the acquisition both the opportunity and potential for entering new markets. I referenced earlier that body of work is on track. The team has done an extraordinarily good job in terms of both prioritizing markets. Good news is there is ample market opportunity then focusing on the markets where we think we have the biggest opportunity to go forward. There's no doubt, as I've said before in my prepared comments, that 2014 rate environment changes the profile across-the-board, whether you're looking at a new market entrée or existing market. Having said that, we believe our model of partnering with physicians presents an opportunity for sustainability and we're looking at this journey more than a 2014 environment, so we're on track relative to our activity there.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

Okay. And then just on the share repurchase side, I just think it's interesting, it looks like the average share price is about $64, which implies that you are buying your stock back after the final MA rate. And I don't know, obviously, it creates some headwinds to 2014, but I don't know if we should be taking that as a signal as far as your optimism in your outlook going forward hasn't changed a whole lot or whether the decision in share repurchases is more a reflection of other uses of cash available as far as maybe deals that look like they're in the short-term, so we shouldn't be reading too much into that. I don't know if you have a perspective or comment there.

Ralph J. Nicoletti

Kevin, it's Ralph. First, obviously, we feel very good about our position and our ability to grow the business over the long-term, I think, very important. And then as we look at our capital management priorities, they have essentially remained unchanged. And as we look at the window of time here in the short-term, we felt that deploying some of the excess capital to share repurchase was the best interest for the shareholders.

Operator

Our next question comes from Ana Gupte of Dowling & Partners.

Ana Gupte - Dowling & Partners Securities, LLC

My question is about your 2 portfolios in the Seniors business and the competitive disruption that you talked about specifically on Med Advantage and Medicare supplement. Are the segments that buy into each of these products distinct and separate based on either income level or age or other demographic characteristics or is this in fluidity across? And in light of the 2014 rated headwinds, is the disruption just likely to be limited to share shifting among MA players or would you see some reversion back to MedSup despite significantly higher monthly premium on that?

David M. Cordani

Ana, it's David. Relative to your first question in terms of -- I think you're looking at the demographic kind of economic profile and buying pattern profile difference in MA and MedSup. I'm going to make a macro statement, but averages are dangerous, and then try to sharpen it down. Macro average statement, the answer is yes. Then you got to cut down to local markets. And I think, as you know, what you'd see is that your MA penetration as dramatically higher and more mature in urban and suburban areas with a broader delivery system configuration. So you have 2 things. One, you have a little different demographic profile between your typical MA and your MedSup buyer. Two, you have a market bias, where MA is more vibrant in certain geographies, therefore, in other geographies, MedSup is, largely speaking, the only alternative for individuals to fill in against a fee-for-service offering. Fast forward that to your secondary question, the simple answer is, time will tell. And time will tell relative to the value propositions that are put on the table in the competitive landscape as it relates to benefit richness and the comprehensiveness of benefits. Now it's important to note, as you think about MA stepping back, broadly -- this is not a Cigna statement -- but broadly, MA participants, about 14 million seniors today, tend to be highly satisfied if you look at national satisfaction data, actually, extremely highly satisfied relative to their programs relative to alternatives. Secondly, MA participants, on average, have a bit lower income level than MA in totality. So you have a highly satisfied population and they're going to be looking at the level of disruption that's presented to them. So time will tell. The level of benefit offering and richness will be a meaningful determiner in terms of whether or not people view a shift to fee-for-service and buying a MedSup makes sense, but you have a highly satisfied population. And then finally, from a Cigna standpoint, we have deep blocks of business in key geographies where there are deep relationships with physicians and a lot of coordination with individuals. So we would expect to have less than average disruption because of that depth of relationship.

Ana Gupte - Sanford C. Bernstein & Co., LLC., Research Division

Well, I'll take that to mean based on the satisfaction, the income level, which is slightly lower in the market-specific preferences, that there's likely to be much less disruption than, say, the BBA compared to what we've seen in '14. And then a follow-up on that is no one's really talking about it too much, but there is discussion around the budget deal in Congress and the need to put in a long-term, fee fixed solution, maybe get rid of the sequester. And I think the Administration had a proposal around MedSup, or reducing the -- combining the -- deduct -- the Part A and B into combined deductible and putting a surcharge into MedSup. So let's just say -- firstly, are you having such discussions or any dialogue with D.C. on that? Secondly, let's just say this happens in the fall, then what are the ramifications of that?

David M. Cordani

Ana, I'm going to answer the first part of your question and I'm just not going to answer the second part of your question. On the first part of your question, we have been, we are and we will continue to be proactively engaged in D.C., on both sides of the aisle, relative to sustained program design, et cetera. We feel passionate around sustained evolution of programs, be they commercial, be they exchanges, be they Medicare, be they Duals, et cetera. It is an important part of what we think our responsibilities are. So we are and will be actively engaged in the dialogue, as you referenced, relative to the potential for an A, B combined deductible. Having said that, I don't think it's healthy to speculate what the possibility of outcomes are, given the inner workings of Washington. I'd leave that to your speculation and your debate in terms of the potential and the timing of that.

Operator

Our next question comes from A.J. Rice with UBS.

Albert J. Rice - UBS Investment Bank, Research Division

First question, I guess, relates to the comments about operating expense ratio improvement to 50 basis points. Obviously, if you can get that improvement through just leverage in the business or there can be specific initiatives that are designed to get that in, I would assume that you have investments that you're making, as others are talking about, in preparation for 2014, maybe not as much as some of the others. But can you just sort of comment on those 3 factors and how they plan to your objective to get to 50 basis points improvement?

David M. Cordani

A.J., it's David. I think you framed it nicely. First, if you look back over the last several years, we've committed to and we delivered consistent improvements to our expense ratio, and we're pleased with that. In addition to that, we've committed to and we've executed continued, highly focused strategic investments. So you're not seeing a big change in our strategic investment profile, for example, in advance of the public exchanges or otherwise. We continue to target investments within the organization. And obviously, to your point, as we successfully grow the franchise, there is revenue leverage opportunity that presents itself. And I'll end with a "for example". For example, last year, we talked to the investor community about a series of targeted investments we were incurring in the early portion of 2012 that would yield sub-finitive benefits to our expense ratio in the second half. Those were technology-related initiatives, vendor-specific, cutover-transpired, those were very targeted. Beyond that, you'd see ongoing efficiency exercises to help us get the productivity gains we need to be able to continue to reinvest going forward. And you should expect us to continue to generate that on a forward-looking basis as we invest back on ourselves.

Albert J. Rice - UBS Investment Bank, Research Division

Okay. And then my other question would be related to international and sort of open-ended. You -- in the prepared remarks, you mentioned a few areas of strong performance. But -- and I know in the press release you cited, particularly, South Korea. Can you comment on any areas that were particularly strong in the quarter and any areas that might be challenges worth, at least, highlighting?

David M. Cordani

It's David again. Well, the international operation when you think about our global footprint, there's a couple of portfolios of business there. One that both I and Ralph highlighted is the global Individual Supplemental business is performing extremely well. Within that portfolio -- I wouldn't highlight any one area -- I would reinforce the fact that within the delivery of those results, we're continuing to invest in product, we'll continue to invest in distribution channel, innovation. We'll continue to invest in new market entrées such as Turkey, which is up and running, as well as India. So that's one section of the portfolio. The second section of the portfolio, which is part of our Global Health Care business, really focus on the globally mobile population need. And that performed in line with our expectations in the first quarter, so I wouldn't highlight anything there.

Operator

Our next question comes from Dave Windley with Jefferies.

David H. Windley - Jefferies & Company, Inc., Research Division

So following on A.J.'s last one. In the earlier days of kind of evaluating ACA, Cigna talked about its ability to, say, import some of the distribution, innovation out, internationally, into the U.S. for individual market, say, Hix Distribution. And coming at that market, that exchange market, in a slightly differently way, is that still in the thinking? I haven't heard you talk about that.

David M. Cordani

Sure, David. It's David. Simple answer is yes. So when you think about our global individual supplemental business, that business is a direct individual distribution infrastructure, where we sell direct to individuals targeted offerings based on segmentations and needs based on life status. We deliver those products or solutions through a variety of distribution channels. Historically, telemarketing. Today, telemarketing, Internet, direct response TV, bancassurance or other affinity channel delivery. It's fueled by a large cadre of, I'll call them, marketing statisticians, product and distribution resources. We have been and continue to leverage those resources within the company. Lastly, the pilots I referenced earlier in a prior question, so we've run 3 years of pilots back here in the United States; manifested, round numbers, 200,000 individual primary lives. Those are driven -- aided by these distribution resources outside the United states as we're just trying to leverage those learnings and we think that gives us a nice advantage as we look to our target markets going forward.

David H. Windley - Jefferies & Company, Inc., Research Division

Okay. And then switching gears to your network development or physician partnering strategy, you've got your HealthSpring capabilities and then you have -- prior to HealthSpring, had already embarked on your a CAC strategy. I guess, I'm wondering how those have -- has, say, maybe melded together? And if you can provide us any metrics or any milestone or signpost as to how many markets you've expanded to beyond the HealthSpring markets, what your target is and over what timeframe.

David M. Cordani

Sure, Dave. So contextually, Cigna started on this path on or around 2008. We split up 8 collaboratives, different models, with the objective to learn. And by the way, you continue to learn as you go forward. Fast forward to today, we have just shy of 60 up and running. Span approximately 24 -- 23, 24 states touching 23,000 physicians. And between the HealthSpring Seniors lives and the commercial lives, we're approaching 1 million lives that are touched, so significant growth. The exciting part is you're seeing coming out of those collaboratives a lot of what HealthSpring was able to prove in the Seniors population. Higher level of engagement, higher level of clinical coordination, higher level of medication compliance for chronics, et cetera. As a result, higher satisfaction for both the patient or customer as well as the physician, and then improved cost. So we believe that there is a tremendous opportunity here as we go forward. Looking to the future, and I think we profiled this a little bit at our I Day, we have potentially a map of the country. And by MSAs, our objective is that, over the course of the next year, you're going to see another significant tranche of growth in the pipeline for new collaboratives. It is rather rich that are in front of us today.

David H. Windley - Jefferies & Company, Inc., Research Division

And embedded in that question, if I could, your approach has not included owning that primary care physician layer in any way. Is that -- does that continue to be your expectation or strategy?

David M. Cordani

Dave, I appreciate that. The -- to be clear we have some ownership physicians today. But our preferred approach, to your point, our preferred approach is to partner. And then in markets that are critical, where we don't believe we could have the right partnership opportunities, we are both willing and capable of owning. So that's the way to look at us.

Operator

Our next question comes from Peter Costa with Wells Fargo.

Peter Heinz Costa - Wells Fargo Securities, LLC, Research Division

Your fastest-growing business was actually Medicaid this quarter. And I believe that's held out from HealthSpring and then one of the targeted areas that they had. Do you expect to continue to focus on growing the Medicaid business going forward, particularly given your strong financial flexibility that you have right now?

David M. Cordani

Peter, it's David. Mathematically, I'm sure you're correct, but you're doing a percent change off of a de minimis base. If you go to another number, that is a large percentage change. Stepping back to the broader frame that you put forward, we've been really clear relative to Medicaid. Base Medicaid, if you will, is not an area, broadly from a national footprint, that we deem to be a strategic priority. In our focused Go Deep markets, where we believe we have an opportunity to differentiate value, is around the care coordination for the high-risk population. We can deem those as dual eligibles, high-risk population cohorts, et cetera, where the care coordination, care management physician partnership models work. So there is an initiative underway with early traction in Texas relative to that. But we need to look at all these as early generation initiatives, where we need to partner with the states to be able to deliver value as well as an early win in Illinois for us on a very targeted basis. But you should look at that as a small nucleus within our company and a highly focused nucleus today. However, an openness to grow in areas and in key Go Deep geographies where we can focus on the high-risk population.

Peter Heinz Costa - Wells Fargo Securities, LLC, Research Division

Great. And then just looking at your balance sheet for a moment, you still have a very large real estate portfolio. Was the reinsurance business relatively gone from your sort of forecasting here and in terms of going forward? Do think you'll be taking down that real estate assets based on the duration of those relative to the duration of the rest of your portfolio?

Ralph J. Nicoletti

Peter, it's Ralph. It's -- I guess, to your question, on a broader basis, we'll always look at our investment portfolio relative to our liabilities and ensure that we're matching our assets and liabilities and durations. So as the portfolio mix changes, we will make adjustments, not necessarily in any one asset class, but we'll take a look on a broader basis across all asset classes. But I think, over time, you could see the overall investment portfolio mix shift but it'll be in line with managing our overall liability.

David M. Cordani

Then Peter, it's David. I would just make an add to that. It's important to put, on Ralph's comments which are absolutely correct, in the context of a little bit of Cigna history here. We have a deep expertise in this area that is proving tremendous returns and tremendous sustainability to the returns. So you have a core competency there within our organization. To Ralph's point, there's fungibility, but we should think about that as a level of expertise that has delivered sustained results year in, year out, decade in, decade out in areas of headwinds and areas of tailwinds, which is why it's an important aspect as Ralph points to, we'll use within our portfolio.

Operator

Our next question comes from Sarah James with Wedbush.

Sarah James - Wedbush Securities Inc., Research Division

One of your peers recently talked to a slow multi-year ramp for the exchanges where year 1 might be more Medicaid and Medicaid-like than commercial for the industry as a whole. So how do you think about the pace of your growth opportunity in the public exchanges? And while on that topic, how prevalent would narrow network products be in your strategy? And how's that influencing where you ended up in the spectrum of pricing with providers?

David M. Cordani

Sarah, it's David. We're in for an environment, as we step into 2014, as a country of disruption in a variety of ways. And exchanges is one of those, just the nature of dealing with change. From a Cigna perspective, our message has been very clear. Again, as you know, we don't have a book of business that we need to protect here. We have new opportunities to focus on. We intend to act. We've taken discrete action within the company, we intend to be highly focused. And from a business standpoint, you should expect us to have kind of a controlled ramp as the level of market change unfolds. So we're in position to deliver on the promises for the new customers we'll be serving. Learn from that and innovate off the base of it. I'm not sure, to be blunt with you, whether or not it's going to be Medicaid biased or none. You could make an argument that there's a good value proposition there because the size and shape of the federal subsidies gets meaningful once you go below 250% of federal poverty level. But the buying behavior for somebody at 250% of federal poverty level is going to probably be a bit different than somebody at a 150% of federal poverty level. That's where the localization and the customer knowledge comes into play. As it relates to narrow networks, I think, the whole notion of transparency in choice is going to be mission-critical. We don't think about it as a narrow network for narrow network's sake. We think about it as, how do you get the highest value network configuration for the subsegment you're going after? And what's factored into our bias, Sarah, very importantly here is where are our Collaborative Accountable Care relationships? Think about it as a Cigna or the HealthSpring model, most mature. And how can you use those partnerships locked arm and arm with the physicians to get in the best value proposition for individuals. So yes, you could argue that the network will be a little bit more narrow, but it won't be traditional narrow network picking based on price. It'll be picked based upon collaboration and total cost outcome and total value.

Sarah James - Wedbush Securities Inc., Research Division

So we can think about maybe the markets that you do go into being built off of the areas where you do have this collaborative care model.

David M. Cordani

Absolutely correct.

Sarah James - Wedbush Securities Inc., Research Division

And then follow-up question is just on clarification on the one-time items in the quarter. Could you quantify any impact from sequestration delay and discuss what the $51 million regulatory matter was on the Disability book?

Ralph J. Nicoletti

Sarah, it's Ralph. First, on the sequestration impact, that isn't reflected in our special items, that's in our ongoing results. And as I mentioned previously, that was contemplated in our outlook range that we have and it remains there. So that's outside of special items. Regarding the $51 million after-tax special item, that is related to our Disability business and a regulatory review that we underwent regarding claims handling procedures, and we have reached an agreement in principle on handling long-term Disability practices. And as a result, we took a $51 million charge. That's really retrospective in terms of its -- of impact. And then going forward, prospectively, we expect that the effect of these claims processes and practices not to have an impact in our margins over time as the industry adopts the new procedures.

Sarah James - Wedbush Securities Inc., Research Division

Just to clarify. On sequestration, you had built in the fact that there was sequestration or that there was delay expected in the guidance? I'm just trying to understand if there was any difference in how the timing was.

Ralph J. Nicoletti

We factored -- Sarah, again, to be clear, we factored in our original guidance on our current guidance, a range of outcomes within sequestration within our outlook range. And what we're seeing is the result -- the actual sequestration coming in at the lower end of the range that we contemplated given the timing.

Operator

Our final question comes from Chris Rigg with Susquehanna.

Christian Rigg - Susquehanna Financial Group, LLLP, Research Division

Just wanted to come back to the cost trend, where -- you had net favorable development in the current quarter, where did the actual trend for 2012 shake out? And can you remind us how things progressed last year? And I guess, the heart of what I'm trying to get to is just how much of an acceleration you guys are actually expecting in utilization at this point over the latter 3 quarters of the year, relative to kind of where you are right now?

Ralph J. Nicoletti

Sure, Chris. It's Ralph. First, let me start with 2012. Largely, what we saw is -- and we saw in the prior year development, we finished closer to about 5% on the overall trend for the year. And the shape of that was largely somewhat favorable in the first quarter. We did see some escalation in the second quarter and that begin to moderate over the balance of the year. So there were some shape to it. As we move into this year and look at our first quarter and our trend projections, we've guided to 6% to 7%. We're on the lower end of that range in the first quarter and we're expecting a slight uptick from there overall as we move to the balance of the year. And that's why we're holding our projection to 6% to 7%.

Christian Rigg - Susquehanna Financial Group, LLLP, Research Division

Okay. And then just one last one on the PDP MLR in the quarter. I guess, all other things being equal, I would have thought by adding in HealthSpring for an additional month, that would exert a down -- or upward pressure on the ratio, but it actually came down. Is there anything notable there, whether it's regard to just a quarter or sort of benefit designs? Any color there would be helpful.

Ralph J. Nicoletti

Chris, I would just say nothing unusual there at all. It's just there was a seasonal pattern to PDP and we recorded a higher loss ratio in the early part of the year, and that's essentially what you're seeing.

Christian Rigg - Susquehanna Financial Group, LLLP, Research Division

Okay, I'll follow up off-line.

Operator

I will now turn the call back over to Mr. David Cordani for closing remarks.

David M. Cordani

Thank you. In closing, let me just emphasize a few highlights from our discussion today. We are pleased with our first quarter results, which demonstrated a strong start to the year for Cigna. Our performance was the direct result of the effective execution of our strategy and the strength of our diverse portfolio of businesses. Looking ahead, we believe companies and individuals alike will continue to demand health, well-being and sense of security solutions that are both high quality and affordable. And Cigna's sustained strategic investments and continued expansion of our portfolio of employer, individual and Senior solutions capabilities positions us to continue to serve our customers and clients in this dynamic global environment. And lastly, the strength of our first quarter results have positioned us to increase our 2013 earnings outlook. We thank you for joining us and your continued interest in Cigna, and look forward to our future discussions.

Operator

Ladies and gentlemen, this concludes Cigna's first quarter 2013 results review. Cigna Investor Relations will be available to respond to additional questions shortly. A recording of this conference will be available for 10 business days following this call. You may access the recorded conference by dialing 1 (800) 944-3380 or 1 (402) 220-3015. No passcode is required. Thank you for participating. We will now disconnect.

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