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Executives

Edwin J. Detrick - Vice President, Investor Relations

David M. Cordani - President and Chief Executive Officer

Thomas A. McCarthy - Chief Financial Officer and Executive Vice President

Analysts

Matthew Borsch - Goldman Sachs Group Inc.

Christian Rigg - Susquehanna Financial Group

Justin Lake - JPMorgan

Scott J. Fidel - Deutsche Bank

Joshua R. Raskin - Barclays Capital

Ralph Giacobbe - Crédit Suisse AG

Christine Arnold - Cowen and Company, LLC

Kevin Fischbeck - Bank of America Merrill Lynch

Albert J. Rice - UBS

Ana Gupte - Leerink Swann & Company

Carl R. McDonald - Citigroup

Andrew Schenker - Morgan Stanley & Co.

David H. Windley - Jefferies LLC

Cigna Corporation (CI) Q4 2013 Results Earnings Call February 7, 2014 8:30 AM ET

Operator

Ladies and gentlemen, thank you for standing by for Cigna's Fourth Quarter 2013 Results Review. At this time all callers are in a listen-only mode. (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 conference over to Mr. Ted Detrick. Please go ahead, Mr. Detrick.

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 Tom McCarthy, Cigna's Chief Financial Officer.

In our remarks today, David and Tom will cover a number of topics, including Cigna's full year 2013 financial results as well as our financial outlook for 2014.

As noted in our earnings release, Cigna uses certain financial measures which are not determined in accordance with accounting principles generally accepted in the United States, otherwise known as GAAP, when describing our 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. 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 in our remarks today we will be making some forward-looking comments, including statements concerning our outlook for 2014 and future performance. These statements are subject to risk and uncertainties that could cause actual results to differ materially from our current expectations. A description of the risk and uncertainties is contained in the cautionary note in today's earnings release and in our most recent reports filed with the SEC.

Now before turning the call over to David I will cover one item pertaining to our financial results and disclosures. In the fourth quarter we recorded an after tax charge of $40 million or $0.15 per share for severance and other costs associated with a series of actions we are taking to improve our organizational efficiency. And we reported the charge as a special item. As described in today's earnings release special items are excluded from adjusted income from operations in today's discussions of our 2013 results.

As a reminder please note that when we discuss our earnings outlook for 2014 it will be on the basis of adjusted income from operations. And in addition our outlook for earnings per share for 2014 excludes the effects of any future capital deployment.

And with that I will turn it over to David.

David M. Cordani

Thanks, Ted. Good morning everyone and thank you for joining today's call. First I will discuss Cigna's full year performance and highlights for our 2013 results. Then I'll address how we continue to meet the needs of our customers and clients in ever changing marketplace. Next Tom will provide detail on the performance of the fourth quarter and full year for 2013 as well as provide the specifics for outlook for 2014. Then Tom and I will answer your questions before I leave you with just a few closing comments.

I'll begin with some highlights for the year. Our strong full year 2013 results has been outstanding track record of financial performance and marks Cigna's fourth consecutive year of competitively attractive financial results. All of our business segments contributed meaningfully to our results for the year with each segment delivering earnings and revenue growth.

For the full year 2013 consolidated revenue increased by 11% to $32.4 billion with each business segment delivering double-digit growth versus 2012. We reported adjusted income from operations for the full year of $1.93 billion or $6.79 per share, which represents a per share increase of 13% over 2012.

It's important to note that 2013 was a year of strategic accomplishments for Cigna as well. First our transaction to transfer our one-off reinsurance business, which improves our financial flexibility. Second is our further improvement of our PBM capabilities which enhances pharmacy offerings for our customers and clients while providing a platform and infrastructure to drive accelerated innovation and provides attractive financial benefits for both our customers and shareholders.

Third, we continue to deepen our global footprint with a meaningful progress in important growth markets including Turkey, India and China. And fourth, we advanced our capital health through strengthening the balance sheet and significant free cash flow from our businesses. Overall these result and accomplishments were driven by focused and effective execution of our strategy.

Turning to 2014 we expect Cigna will deliver competitively attractive earnings and revenue growth. Tom will elaborate further on our outlook in a few moments. But first I will address how we view the global environment we are operating in this year.

We anticipate that disruptive market forces, changing client and customer needs and a variety of headwinds will continue to create a challenging marketplace. Both developed and developing countries are confronting significant change in disruption, including an ageing population growing middle class, rising chronic disease levels and affordability pressures for all.

Our industry also continues to operate in an active legislative and regulatory environment, one that includes uncertainty around Medicare Advantage reimbursement levels, cost pressure resulting from reduction in hospital reimbursement levels due to government cuts, implementation challenges in public exchanges and changing reward structures for physicians in hospitals and globally health systems attempting to rebalance the public-private relationships as they seek to ensure sustainability of their social programs.

With these trends and uncertainties in mind across our segments and key markets we've built our capabilities to be able to adapt and deliver ongoing success. Cigna's businesses have the strategic direction, focus and core capabilities to anticipate, adapt and win in the global market. Our core strategy of Going Deep, Going Global and Going Individual continues to guide our company around the world. And by executing this strategy in our target markets and in new ones when we see opportunities, our capabilities are delivering differentiated values for our customers, clients and shareholders.

Our strategy enables us to improve individual health and productivity, engage with physicians to drive quality health outcomes and affordability and support our customers with products and services that provide them with much needed sense of security. To continue to succeed in these global markets there are three key areas that we continue to invest in, to ensure ongoing value creation. These areas are customer insights and engagement, consultative distribution and physician partnership models.

Insights give us deep knowledge that allows us to identify the right micro segments and match to distribution channels that best meet our customers' preferences. When combined with our consultative distribution capabilities analytical insights give Cigna the unique ability to bring our customers personalized solutions through their channel of choice.

These include selling through brokers and consulting channels for employers of nearly all sizes, in diverse geographies going through intermediaries, including affinity partners; going to individuals directly through telemarketing, Internet distribution and direct response marketing and selling through our new proprietary private exchange capability where we tailor benefit programs for the needs of employers, clients and brokers and provide greater choice and personalization for our customers.

In addition relative to the evolving private exchange market we've chosen to participate in those exchanges which most closely align with our target client needs. And we are staying close to evolving programs should they prove to deliver differentiated value.

Our third key area is care delivery and physician partnership capabilities. Here we are delivering superior health and productivity outcomes today in a local and personalized fashion and our innovation continues for tomorrow. In 2013 we increased the number of customers benefiting from our collaborative relationships with physicians by 50%, or an increase of 400,000 lives. We now have 86 collaborative accountable care initiatives up and running, which is up from 52 at the end of 2012.

Importantly we are seeing positive cost and quality outcomes for our customers. And additionally we continue to receive feedback from healthcare professionals that Cigna's approach to these initiatives is differentiated in the market. Our approach, which harnesses aligned incentives, specific actionable information and care extenders such as health coaches and case manager is highly leveragable in a rapidly changing marketplace.

In addition our global network of doctors and hospitals, coupled with our localized health management and coordination resources positions us to offer innovative solutions in our targeted markets around the world.

Now looking ahead we recognize that change is constant and change will continue at an accelerated pace. At Cigna we've demonstrated our ability to effectively anticipate and adapt to change. And we will continue to grow by retaining, expanding and adding new customer and client relationships.

More specifically in 2014 we expect to grow our U.S. and global healthcare businesses as well as our global supplemental business. When coupled with the continued strengthen of our Disability and Life business this will more than offset the market disruption and repositioning pressure of our U.S. Seniors business.

And finally our ongoing strong capital positioning affords us significant deployment opportunities to further build customer and shareholder value. Based on our focused strategy, diversified capabilities and differentiated portfolio of businesses we expect to continue to deliver competitively attractive and sustainable long term EPS growth of 10% to 13% on average all while continuing to invest back in our company.

Now to briefly summarize before turning it over to Tom; Cigna's strong financial performance in 2013 marks the fourth consecutive year of earnings and revenue growth for our company and provides a good foundation as we step into 2014. We have significantly advanced our capital health through a strengthened balance sheet and free cash flow.

We recognize that global markets will continue to be disrupted. In this environment of ongoing change we will successfully execute our focused strategy and leverage our differentiated capabilities and customer insights and engagement, consultative selling and physician partnership, all with the objective of delivering differentiated value for our customers and clients.

With that I'll turn the call over to Tom.

Thomas A. McCarthy

Thanks, David. Good morning, everyone. In my remarks today I will review Cigna's 2013 results and provide our outlook for 2014.

We had a strong year in 2013 with earnings and revenue both growing by 11% over 2012 and earnings per share growing 13%. These results represent a fourth consecutive year of strong revenue, earnings and EPS growth while also continuing to make significant strategic investments in capabilities across all our businesses.

Some other key highlights regarding our 2013 results include strong revenue and earnings growth in each of our business segments, despite a disruptive market environment, most notably in Medicare Advantage; enhancement of our pharmacy business through our arrangement with Catamaran; the strengthening of our balance sheet through the successful exit for the Run-off Reinsurance business and pension fund de-risking plan and continued strong free cash flow generation with $1 billion returned to shareholders through share repurchase.

While there was some pressure in our fourth quarter results the strength of our overall 2013 performance provides us with a solid foundation for growth in 2014.

Now moving to operating results. Our full year consolidated revenues grew 11% to $32.4 billion, driven by contributions from each of our segments and growth in our targeted markets. 2013 earnings were $1.93 billion, which represents growth of 11% over 2012.

Regarding the segments I will first comment on our Global Healthcare segment. Overall our Global Healthcare results for 2013 were solid. 2013 premium and fees grew 9% to $23 billion. Full year earnings were approximately $1.6 billion, representing growth of 6% driven by strong revenue growth in specialty contributions, operating expense efficiency and attractive medical costs in our commercial business partially offset by revenue and medical cost pressure in our seniors business.

Turning to medical cost. Our customer and physician engagement capabilities continue to deliver differentiated value for our clients and customers. Our medical trend outlook has improved throughout the year and we delivered competitively attractive results. For our total U.S. commercial book of business full year medical cost trend was below 5% for 2013.

Since nearly 85% of our U.S. commercial customers are in ASO funding arrangements they directly benefit from these favorable medical cost results. Regarding medical care ratios, in our U.S. commercial guaranteed trust business our full year 2013 medical care ratio or MCR was 81.5% on a reported basis or 82.3% excluding prior year reserve development.

We are pleased with results of our commercial risk businesses, which continue to reflect strong pricing, disciplined underwriting and continued effective medical management and physician engagement. Our fourth quarter 2013 guaranteed cost of MCR was higher than prior year. Some of this increase was anticipated due to the impact of business mix and broker fee changes continuing into the fourth quarter and some from large claim activity and modestly increased utilization in the quarter. While on the high end of our expectations this result is within the normal range of variability we expect for this business.

In our seniors business our full year 2013 MCR for Medicare Advantage was 84.8% on a reported basis or 85.2% excluding prior year reserve development. This is higher than we had expected. The elevated Medicare Advantage MCR for full year 2013 reflects revenue pressure driven by government reimbursement levels as well as higher medical costs.

The claim pressure in the fourth quarter of Medicare Advantage MCR is a continuation of what began earlier in 2013. This pressure is not improving as we had expected. While we continue to focus on opportunities to improve medical costs for our seniors business we expect to see pressure in 2014 and have reflected this impact in our 2014 outlook.

Moving to operating expenses, for 2013 our total global healthcare operating expense ratio, excluding special items was 21.7% which is a 90 basis point improvement over 2012 expense ratio. We accomplished this result while continuing to fund strategic investments. Overall we had a solid year in our global healthcare business.

Now I'll discuss the results of our global supplemental benefits business which continues to deliver attractive growth and profitability. Premiums and fees in 2013 grew 27% over 2012, driven by contributions from our recent acquisitions, most notably Great American Supplemental Benefits and our Turkey joint ventures as well as strong customer retention and new business growth.

2013 earnings in our global supplemental benefits business were $183 million, representing a 24% increase over 2012 and reflected attractive profitability while we continue to fund strategic investments for future growth. Fourth quarter results include some modest claim increases in our [Korea] operations due to seasonality and additional funding to enhance distribution capabilities.

For Group Disability and Life, full year results were strong. Group premium and fees increased 10% over 2012 results. 2013 earnings in our Group business were $311 million, an increase of 11% over 2012 primarily driven by lower disability loss ratio and higher net investment income.

For our corporate and another operations results totaled to an after-tax loss of $134 million for full year 2013. Overall our 2013 results reflect revenue and earnings growth from each of our business segments as well as significant free cash flow as a result of the continued effective execution of our strategy.

Turning to our investment portfolio, for 2013 we recognized net realized investment gains of $141 million after tax, coupled with a strong net investment income results. Overall we continue to be pleased with the quality and diversification of our investment portfolio.

Now I will discuss our outlook for 2014. While 2014 will be a disruptive and challenging environment we expect to continue to deliver differentiated value for our customers and clients and as a result strong financial performance, including revenue and earnings growth for our shareholders. This is based on effectively executing our focused strategy, leveraging our differentiated global capabilities and capitalizing on the multiple sources of growth in our diversified portfolio of businesses.

For full year 2014 we expect consolidated revenues to grow in the range of 4% to 7% over 2013. We expect full year 2014 consolidated adjusted income from operations to be in the range of $1.9 billion to $2 billion or $6.80 to $7.20 per share. Consistent with prior practices our outlook excludes any contribution from additional capital deployment as well as any prior year claim development.

Before reviewing more specifics for the year I'll comment briefly on the organizationally efficiency plan we implemented during the fourth quarter. As Ted mentioned we reported a special item charge of $40 million after tax related to the actions we are taking across our global operations, including actions to implement our pharmacy strategy. We estimate that these actions will yield annual after tax savings of approximately $45 billion going forward with the expected savings of $30 million after tax in 2014. The impact of these actions has been factored into our 2014 guidance.

I'll now discuss the components of our 2014 outlook, starting with global healthcare. We expect full year global healthcare earnings in a range of approximately $1.58 billion to $1.64 billion compared to our 2013 result of $1.57 billion. Excluding 2013 prior-year claim development of $77 million after tax this represents growth of 5% to 9% in 2014. This outlook reflects continued benefits from organic revenue growth, specialty contributions and operating expense efficiencies partially offset by continued pressure in Medicare Advantage. This also includes our updated view of the annual enrollment trade results for both Medicare and the public exchange business.

I'll now summarize some of the key accomplishments reflected in our global healthcare earnings outlook for 2014, starting with our customer base. Regarding global medical customers we expect 2014 customer growth of 1% to 2% after adjusting for the impact of the limited benefit business exit due to ACA legislation. Relative to Medicare Advantage, after taking into consideration the impact of market exits we expect modest growth overall during the course of 2014 with essentially flat customer growth in January.

Turning to medical costs, our 2014 outlook assumes some increase in medical utilization versus current levels and this increase has been reflected in our pricing. For our total U.S commercial book of business we expect full year medical cost trend to be in the range of 5% to 6%. For our U.S. commercial guaranteed cost book of business we expect the 2014 medical care ratio to be in the range of 80% to 81%. This range is lower than our 2013 results and reflects strong medical cost management and ACA legislation impacts.

For our seniors business our Medicare Advantage and CR for 2014 is expected to be in the range of 84% to 85%. This range reflects expected revenue and medical cost pressure in 2014.

Regarding operating expenses, our 2014 global healthcare operating expense ratio is expected to be in the range of 22.5% to 23.5%. This range includes approximately 130 basis points due to impact of the industry fee and taxes. Overall we expect full year 2014 global healthcare earnings to be approximately $1.58 billion to $1.64 billion which we believe is a competitively attractive result.

Now moving to the other components of our outlook, for our Global Supplemental Benefits business we expect continued strong top line growth and expect earnings in the range of $195 million to $215 million. This represents earnings growth of 7% to 17% when compared to 2013 and is consistent with our long term growth expectations.

Regarding the Group Disability and Life business we expect full year 2014 earnings in a range of $305 million to $325 million, compared with a strong 2013 result of $311 million. Regarding our remaining operations, that is other operations and corporate we expect a loss of a $175 million for 2014.

So all-in, for full year 2014 we expect consolidated adjusted income from operations of $1.9 billion to $2 billion or $6.80 to $7.20 per share. This excludes the impact of any future capital deployment for prior year claim developments. Overall this result represents a competitively attractive outlook and a disrupted market environment and underscores the benefit of our diverse and differentiated portfolio of businesses.

Before moving on I would note that we believe our 2014 earnings outlook will follow a different quarterly pattern this year for a number of reasons. These include absence of $48 million of after tax -- of prior year claim development in the first quarter of 2013 which translates to $0.17 on an earnings per share basis, the impact of sequestration and ACA related factors, start-up cost for business expansion and the timing of some expenses. As a result we expect first quarter earnings in 2014 will be lower than the prior year's first quarter.

Now moving to our 2014 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 a strong return on capital in each of our business segments. Our capital deployment strategies and priorities have not changed. These priorities are providing the capital necessary to support the growth of our ongoing operations, pursuing M&A activity with a focus on acquiring capabilities and scale to further growth in our targeted areas of focus and after considering these first two items we would return capital to shareholders, primarily through share repurchase.

Regarding free-cash flow during 2013 we repurchased 13.6 million in stock for approximately $1 billion and we ended the year with parent company cash of approximately $760 million. For full year 2014 we expect subsidiary dividends of $1.6 billion driven by a strong performance in each of our business segments. After considering all sources and uses of parent company cash and setting aside $250 million to meet liquidity means our outlook implies we would have approximately $1.8 billion available for capital deployment in 2014.

During the period from January 1st to February 6th we repurchase 2.6 million shares of Cigna's common stock for $225 million. This amount is included as part of the $1.8 billion available for capital deployment.

Overall our financial position and 2014 capital outlook remains strong. The strong margins and high returns on capital from each of our businesses coupled with the strength of our balance sheet means that we will continue to generate significant free cash flow to deploy for the benefit of shareholders.

During our third quarter call we also discussed the progress we have made in improving our financial flexibility regarding the funding of our pension plan. Based on 2013 contributions, the equity's market strong performance and an increase in interest rates during the course of the year the funded status of the pension plans has continued to improve. As of December 31, 2013 the unfunded liability of our pension plans has improved $1 billion over year end 2012 and the pretax unfunded liability is now approximately $600 million.

As a result we expect to contribute $100 million pretax to the pension plans in 2014 which is a significant reduction from prior years. This increases the free capital available for deployment in 2014 and has been contemplated in the capital outlook I guided earlier.

Now to recap our full year 2013 consolidated results reflected the strength of our diversified portfolio of global businesses and the continued track record of effective execution of our focused strategy. Our 2013 performance provides a solid foundation for 2014, highlighted by differentiated capabilities that create value for our customers and clients, competitively attractive growth in revenue and earnings, continued targeted strategic investments to enable sustained growth into the future and continued strong free-cash flow.

While we expect a continued disrupted market environment we are confident in our ability to achieve our full year 2014 earnings outlook. And with that we'll 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 Matthew Borsch with Goldman Sachs.

Matthew Borsch - Goldman Sachs Group Inc.

Yes and just hoping you can give us some more elaboration on the trend pressures on both the commercial and Medicare Advantage side, maybe just starting with which one is more concerning to you, it sounds like Medicare advantage because that's what you expect will persist to some degree into 2014, but correct me if I am wrong?

David M. Cordani

Matthew good morning it's David let me start with the -- I call it the framing of Medicare and then ask Tom to give you a little bit more insights on the commercial because there are two very different dimensions. First with the Medicare loss ratio into context, as you recall we entered the year with expectations that our medical care ratio for Medicare Advantage would go up as we price for and position the book for adoption of ACA.

In addition to that last quarter we talked about the revenue pressure that continued to mount for the Medicare Advantage portfolio, like the sequestration, risk adjusted et cetera and we started to see the impact of a bit of an uptick in medical cost. That carried on through the fourth quarter and from our assessment it's most notably seen in facility-based cost, as you know that's in-patient and out-patient based cost.

We see that manifesting itself a bit differently in our models. So we operate three different models in our portfolio; the integrated care delivery model, where we have either owned or tightly aligned delivery system; the highly engaged physician models; and then the less engaged physician models. While the impact of this facility elevation is taking place in many geographies, the impact driving the variance is different. So higher variance in the less engaged models, a lower variance in the integrated models if you will.

We have projected forward now that the impact of those medical cost pressures will carry into 2014. There is a variety of actions we can talk about later that we're implementing to address but we've taken the step forward and said until we see otherwise the impact of those medical cost pressures will continue into '14. We factored that into our outlook and still with the diversified portfolio we have were still able to grow earnings.

I'll ask Tom to comment now about the guaranteed cost in the commercial loss ratio, that's a different dimension. Tom?

Thomas A. McCarthy

Yeah Matt again on the commercial MCF if you step back the fundamentals of our commercial results for the year were very strong. Over the course of the year we continued to improve the outlook for the GCNCR, basically reflecting the very good overall medical trend in managed we've had for the year and we ended up with very strong medical cost trend for the total year.

In the fourth quarter we did see some increased variability, with both the large claims and some increased utilization. So we did end up on the high expectations of our -- high range of the expectations for the quarter but as you said more in-line with what we might expect for the performance on that business. And I would point we've previously commented there is potential for some uptick in results and utilization there, so not quite a surprise.

So in addition to the fact that we have a relatively small guaranteed cost block, this variability we see as more in-line with expectations versus the experience we saw in Medicare.

Matthew Borsch - Goldman Sachs Group Inc.

Just one clarification there, when you talk about facility based cost on the Medicare side do you mean more utilization or unit cost?

David M. Cordani

Matt it's David, it's less utilization, so the way we think about it, it's a combination of mix and services, causing an increase in either cost for admit or cost per episode of care. So it's manifesting itself more in terms of the, I will call it billing aspect as opposed to the utilization aspect.

Matthew Borsch - Goldman Sachs Group Inc.

Or the acuity, is that a fair word to use?

David M. Cordani

I am going to say Mathew, yes but so acuities I think if our clinicians would hear they would say the acuities and diagnosis spiking up, and I have to say we don't have the data to say that. The costs per episode of care are going up, and we see the impact of that in many geographies. But we don't see the one-for-one in terms of the acuity or the, I'll call it, severity of illness changing one-for-one with that.

Matthew Borsch - Goldman Sachs Group Inc.

Got it thank you.

Operator

Thank you, Mr. Borsch. The next question comes from Chris Rigg with Susquehanna Financial Group.

Christian Rigg - Susquehanna Financial Group

Good morning. Thanks for taking my question. Just wanted to come to the corporate and other expenses. If I look at the guidance for the full year and you implied -- what you had implied for the fourth quarter, it looks like those costs for the full year came in meaningfully below what you were looking for, particularly in the fourth quarter. Can you help us understand what might have changed relative to what you were looking for in 3Q? Thanks.

Thomas A. McCarthy

Chris, it's Tom I would say corporate results actually ran favorably through the whole year in 2013 including some tax items and really what's reflected in the outlook for 2014 is return to a more normal year.

Christian Rigg - Susquehanna Financial Group

Okay. So is it fair to say it was about $23.5 million to $29.5 million delta relative to what you are guiding for in 3Q?

Thomas A. McCarthy

I think we gave a range in 3Q. So it was a little better in the quarter but not -- that sounds a little high to me but somewhere in that range.

Christian Rigg - Susquehanna Financial Group

Okay. Thanks.

Operator

Thank you Mr. Rigg. The next question comes from Justin Lake with JPMorgan.

Justin Lake - JPMorgan

Thanks good morning. First I just want to go back to the Medicare Advantage cost, specifically because I know your book is pretty heavily capitated, so I am somewhat surprised with the magnitude of the MLR increase year-over-year. Can you walk us through that in terms of how much the actual core MLR had to be changing in order to have this flow through given your capitation agreement?

And then also as you kind of look out to 2014, given the MLR you've guided to in Medicare Advantage of 84% to 85% plus the tax, the typical SG&A, can you give us an idea where the MA margin kind of will sit under that MLR?

David M. Cordani

Justin, it's David. Let me start. First you used the term capitation. So I am going to use a different term, right. We have aligned physician relationships with our more shared risk relationships. So capitation tends to be a risk transfer as opposed to shared risk. But stepping back and following your logic, to my prior comment, what we've seen is the facility cost pressure is in multiple geographies, the performance or variance that we are experiencing is different.

So to your point in the less engaged or less aligned reimbursement models we're seeing more variability or more of a financial impact. In the most aligned models we're seeing less variability and less impact. So you are seeing the impact of your term capitation, I'll use risk alignment. Additionally as we looked into 2014 from a growth standpoint our net either new business adds or new business beliefs were stronger in the integrated markets or the highly aligned physician markets as opposed to the less integrated or less physician aligned. So we see that variability playing through but the macro point here is that the facility-based cost structure is in multiple geographies.

As it relates to 2014 the headline is this in our outlook and projection will create margin pressure or a decrement to Medicare Advantage margin 2014 relative to 2013. And even with that taken into as a whole of the diversification of our business we are able to grow earnings in 2014.

Justin Lake - JPMorgan

I guess what I was trying to get to on the margin question, David is just understanding what do you think the core margin of this business is longer-term and where does that sit in 2014 versus that kind of longer-term target, obviously with the thinking that 2015 is also going to have some pressure. So kind of the baseline where you are probably going to pass most of the cost over to the beneficiary at this point or get more efficient or do you feel like margins have further to potentially fall given the potential -- the rate pressures that we are looking through '15?

Thomas A. McCarthy

Well, Justin it's Tom again. In the long term we continue to see this business as kind of a mid-single-digit pretax margin performer. Obviously the pressure we talked about in '14 will be below that and as you pointed out kind of a flattish loss ratio doesn't get us to our target margins given the introduction of the industry fee in 2014. So I don't think we are prepared to quantify exactly where we would end up in 2014 but it will be below our long-term expectation for the business.

Justin Lake - JPMorgan

Okay, great, thanks.

Operator

Thank you, Mr. Lake. The next question comes from Scott Fidel with Deutsche Bank.

Scott J. Fidel - Deutsche Bank

Thanks. I was hoping if you could give us an update on some of the metrics around the exchange business so far, the public exchange in terms of how much enrollment have you seen so far and some of the indicators on the risk mix. And then just more broadly whether you expect the exchange business to be profitable or unprofitable in 2014?

David M. Cordani

Good morning, Scott, it's David. So as for the public exchange as you recall we've been open but highly focused, meaning open to the marketplace but highly focused. So to remind you we are in five states and a limited number of specific markets within those states. At a macro level our experience to date has been in-line with lot of the headlines that you have seen and we've seen with the lower all-in overall addition or adoption rate therefore lower covered lives and with an older base.

To put in context about half of the business we put on for January 1 came through the exchange and the half of the business came through off-exchange. As it relates to the makeup of the business think about the majority of our on-exchange business being in the silver plan. Think about a little variability in terms of the mix versus our assumption in terms of a little older mix relative to population.

Those who've bought on-exchange about 75% of them were subsidy eligible. And then finally to your last piece of your question we assume for this portfolio of business that this will not be a profit driver or a money maker for us in 2014 at this point.

Scott J. Fidel - Deutsche Bank

Okay. Thanks for those details. And then just a follow-up question just on group insurance and global supplemental benefits. Do you just have an outlook for revenue growth for each of those segments for us?

Thomas A. McCarthy

Well I don't think we've -- it's Tom, Scott. I don't think we provide the specific details of revenue growth by segment. But just overall in the commentary that we're expecting continued growth in-line with what we've seen lately in both of those businesses.

Scott J. Fidel - Deutsche Bank

Okay. Maybe, Tom to put it another way, do you think about top line growth in those businesses sort of in a similar trajectory as margins or earnings growth, or is there something on the margin side any of those that we should be considering relative to top line growth?

Thomas A. McCarthy

Probably fair in relation to global sup and group, I'll remind you 2013 was a pretty strong margin year. So the revenue might grow a little faster than the after tax profit in group, that's fair.

Scott J. Fidel - Deutsche Bank

Okay thank you.

Operator

Thank you Mr. Fidel. The next question comes from Josh Raskin with Barclays.

Joshua R. Raskin - Barclays Capital

Hi, thanks and good morning. Wanting to ask actually on the private exchanges, if you guys had any data or information around your experience, I know David you said, you are participating in several of them. So I am curious do you have any update data on how many lives you have single lives in '13 moved into exchanges in '14 and then may be how many you've gotten out of the private exchanges you are participating in, in 2014? And what's the mix of ASO and risk profile?

David M. Cordani

Good morning Josh, it's David. Just a moment of backdrop, as we said before, we view the private exchange environment is in the early stages of innovation and these markets have the potential for creating sustainable models on a go-forward basis. To-date we've focused on -- our energies on a number of the exchanges and those that most closely aligned with the needs of our current and target clients.

Also as you may have recently seen we announced and launched our own proprietary exchange when we made that public announcement this week. Specific to your question I mean as we anticipated 2014 has a small impact for Cigna from an exchange standpoint both inflows and outflows.

You can net them together and see if there is a diminished impact, think of tens of thousands of customers, not hundreds of thousands of customers with some new business adds and some losses in terms of the exchange netting to a small number that is not a needle mover for our membership, and slightly biased to the ASO but not limited only to ASO in terms of the movement in terms of how we're playing.

Joshua R. Raskin - Barclays Capital

Okay got you. And then just to clarify, I think you said Medicare Advantage membership you were expecting growth this year. It looks like just from the CMS data and I know it's never complete for the January month but it looks like you guys were down about 5,000 lives, did you say first quarter would be flat or the full year would be flat, I am trying to….

Thomas A. McCarthy

Josh you put the puzzle pieces together correctly, this is Tom. First of the year flattish, down 5,000 lives. Full year we expect to grow modestly.

Joshua R. Raskin - Barclays Capital

Okay, perfect.

Operator

Thank you Mr. Raskin. The next question comes from Ralph Giacobbe with Crédit Suisse.

Ralph Giacobbe - Crédit Suisse AG

Thanks good morning wanted to go back to MA, is it something you sense in the population that you attracted that's sort of driving the higher MLRs we haven't really seen a pop up to this point with peers and I guess how would you get a better handle on it?

And then along those lines how should we think about the higher trend in the context of your 2014 bids? And any sense at this point you talked about moderate growth there has been others in the industry that are going to grow significantly in terms of enrollment, any shot of churn as it relates to some of your existing -- if you can give that gross versus term expectation that would be helpful. Thanks.

David M. Cordani

Ralph, good morning, it's David. Just I'll give you a little color on the multiple questions you have there. First as we noted before we saw impact beginning to manifest itself in 2013, tied to facility-based costs and from our point of view the pressure that's being put back on the hospital systems as it relates to reimbursement pressure from the government we see making its way through the system and most notably in Medicare.

As I noted before not utilization but mix of reimbursement for the services, either per episode or kind of mix of acuity in terms of the billing as it relates to services. On a go-forward basis there is a number of actions that we're focused on driving in terms of our business to position us for 2015.

Having said that we've taken a more cautious view of our outlook for the Medicare business and factored that into our outlook for 2014. As it relates to the gross, the gross net lives think about our gross for 2014 overall, Tom just summarized it, over the year we'll grow somewhat in Medicare Advantage, a bunch of moving parts there. We'll have organic growth in the first quarter of the year, offset by some strategic market exits. We've also entered two new markets in 2014.

As we look at the make-up of our net losses and net gains, our growth profile is stronger in the integrated care delivery markets as well as those markets that have the most mature physician engagement model and some other markets that have less mature physician engagement models or less engaged physicians, we took a little bit more cautious approach relative to our product positioning in an effort to protect the margin sustainability, hence we lost some lives there.

So net, there is not a single churn answer. It varies by market, I will ask Tom to expand on that.

Thomas A. McCarthy

One other thing on that, Ralph so again to the point of how we are feeling about the health of the business, given the modest growth, obviously there isn't much turnover in lives in our portfolio, so we think we have a pretty good handle on that impact, our outlook is about 10% of our customers will be new to us. And that after you figure out [inaudible] in and out of lives and that compares to about 12% last year, so very consistent with our long term results.

Ralph Giacobbe - Crédit Suisse AG

Okay that's helpful. And then just one more quick one you've done a lot over the last 12 months to disrupt the balance sheet, with that being in pension. Just want to get an update your interest level in M&A at this point, any specific areas you'd like to bulk up or expand into and maybe even any thoughts on dividend at this point? Thank you.

David M. Cordani

Ralph I'll comment on M&A and I'll ask Tom to talk to us about the overall capital deployment priorities. As it relates to M&A, no major change in posture for us. We continue to view that we are strategically and financially attractive. There are three major categories of M&A opportunity that continue to be attractive for us. First, further expansion of our global footprint in global portfolio capabilities.

Second, U.S. seniors and/or duals capability that enable us to serve the growing duals population, and third our retail-based capabilities that allow us to better deliver more personalized solution distribution service capabilities, et cetera. So that kind of portfolio of priorities has not changed for us and if you look back over the last several years you can see we've been disciplined in terms of staying in those categories.

I'll ask Tom to elaborate a little bit more to the capital deployment priorities because as he referenced in his prepared remarks we will have a significant amount of free cash flow and capital to deploy in 2014.

Thomas A. McCarthy

Well and as we reiterated in the prepared remarks, so our first priority in capital deployment of course is to invest to support organic growth. Now the margin profile of our business tends to generate significant capital in excess of what's needed to finance internal growth. So that does give us the opportunity to deploy capital elsewhere.

As we've said many times we like to deploy capital strategically, that would be our preference through M&A or business expansions. Then if we don't find the right opportunities to do that we do return capital to shareholders. We're still using share repurchase as our primary vehicle for returning capital to shareholders. We do regularly revisit dividend policy, but at this point there is no change in that.

Ralph Giacobbe - Crédit Suisse AG

Okay. Thank you.

Operator

Thank you, Mr. Giacobbe. The next question comes from Christine Arnold with Cowen.

Christine Arnold - Cowen and Company, LLC

Good morning. As I look to my model, it seems like something at other MLR were elevated, I am kind of calculating in back of the envelope and haven't had much time with it. But it looks like the stop loss and experienced weighted-loss ratios were up about five percentage points year-over-year and also up pretty significantly. What's going on there?

Thomas A. McCarthy

Christine, it's Tom. So first a couple of things. Just stepping back, that global MCR does have a lot of moving pieces to it. So the characteristics of the business is the loss ratio versus expense ratio that we have across the broad portfolio are very diverse and even with the experience rate we have different business types that have different MCR levels.

So the movement around in the global result has a number of impacts in it. I would point to you though the headline result here really is the variability in our GC MCR in the commercial business. On the stop loss side we also did have a small change in reserving methodology, that produced some reserve strengthening in stop loss, but overall no material change to the overall for that business.

Christine Arnold - Cowen and Company, LLC

So was the international loss ratio up within -- I am trying to figure out there's lot of stuff going on here and I guess just to lay on the table expect the question on trends rising, because it's not, relative to this model, it's not just guaranteed cost and Medicare Advantage. There is other stuff that's significantly happening on the loss ratios.

Thomas A. McCarthy

Again Christine I take you to the bottom line, the bottom line margins really, the variability there is explained by what we talked about and the additional variability within -- the loss, the MCR really is more of a function of business mix. And again different lines of business have different loss ratios even though they have the same bottom line margin contribution.

David M. Cordani

Christine, the only add is that you referenced to a number of various lines of business in there.

Christine Arnold - Cowen and Company, LLC

Right.

David M. Cordani

So consequentially you could have some puts and takes within the various experience-rated different funding types. The loss ratio as reported in that aggregate loss ratio will move but the margin profile does not. And the headline that Tom is delivering is the important one which is the underlying margin profile of the discrete businesses is strong and intact in carrying into the new year. I also would flag it otherwise, also it's the reason while we caution not to overly analyze that aggregate parts because there is so many moving parts in it.

Christine Arnold - Cowen and Company, LLC

One last question here. I am trying to get kind of a run rate for fourth quarter, was that prior period negative development perhaps related to prior quarters such that the fourth quarter maybe was better than it looked on a run-rate basis?

Thomas A. McCarthy

Well actually in the fourth quarter as I mentioned we did do a very small stop loss reserving methodology change. So there really was modest negative prior period development in the fourth quarter in commercial.

Christine Arnold - Cowen and Company, LLC

But only in that stop loss

Thomas A. McCarthy

Yes.

Christine Arnold - Cowen and Company, LLC

Okay, thanks.

Operator

Thank you, Ms. Arnold. The next question comes from Kevin Fischbeck with Bank of America, Merrill Lynch.

Kevin Fischbeck - Bank of America Merrill Lynch

Okay. Great, thanks. I want to go back to the [appetite] for M&A here I mean I guess I think I understand what you are saying, the higher costs or being caused by in Q4 and expectation in 2014. But I guess is there a good way to get on top of those costs and really adjust that if you are below your target margin for 2014. I mean how do you think about positioning yourselves and getting back to normal margin when the '15 rates are also going to be difficult?

David M. Cordani

Kevin, good morning, it's David. There is two different sets of actions that are currently being actively worked, and again as I referenced before, they are going to be different depending on the market type. So our integrated markets versus our highly activated physician markets versus our less activated physician markets.

But as you think about bucket number one it's to further accelerate our timeframe to move less activated physicians to more activated and get them into the shared risk model or on a more accelerated basis deal with call in from the network. So that's buffer number one. And in those markets over the near-term I would say more comprehensively use traditional medical management and cost tools which you typically don't use in the more activated physician market. So that's bucket of actions number one,

Bucket of action number two around the facility side, several different actions. One is to seek for outright reimbursement activity to adjust to reimbursement levels contractually with the facilities. Absent your ability to do that seek to use the activated physicians to guide their patients to higher value facilities and lever free standing surgery centers where appropriate where the value is best.

And then finally if you are not able to get to the desired outcome as we are looking towards on the 2015 environment be willing to remove an underperforming facility from the network still obviously delivering network adequacy.

So all those actions are being worked. We believe you take in the -- an informed view of the earnings for 2014 into our outlook when stepping down our outlook here and our margin expectations but you hit the nail on the head on getting as much visibility into it as possible as we go into the second quarter for the bid cycle. And we believe we'll make some good traction in these actions.

Kevin Fischbeck - Bank of America Merrill Lynch

And does this dynamic with the clear out performance of the targeted provider alignment change your view at all about your ability to enter new markets over the next couple of years, and continue in markets you get this year and above with you might add one to two per year after that, does it harder to do that if you really need to have the specific alignment or is there enough kind of out there to be able to continue to enter new markets in 2015 and beyond?

Thomas A. McCarthy

Kevin, you speak to a real important point. I am going to answer yes and no. So the difference here is if you enter a new market de novo with no activated physician relationships the time to go from that to a fully activated shared risk is probably too long given the reimbursement environment we operate in.

So it puts a premium on choosing those markets that are both attractive from a senior standpoint and very importantly we have well developed commercial relationships with physician groups in integrated care delivery systems. We are already moving through that activated physician environment. So the opportunity for us is given that we have 86 of them up and running, we have more than our fair share of opportunities in front of us in new market to choose from.

So that's where the opportunity is and we would expect to continue to open new markets building off of the successful the success with the commercial proposition. So it comprises the timeframe where you could go from no activation to fully activated and integrated. And those collaborators will help us accelerate that timeframe.

Kevin Fischbeck - Bank of America Merrill Lynch

Okay. And just last question here on the efficiency review, it sounds like a lot of it was actually the Catamaran thing, I just wonder if that was right and if PBM is not part of that, understand kind of what has spurred this review and then just an update on how Catamaran is going?

Thomas A. McCarthy

Kevin, it's Tom. So PBM is part of the restructuring but I wouldn't to say it's the majority of it or it was never close to all of it. The restructuring included a number of factors. First just some general process improvement and efficiency enhancement throughout the organization. As we mentioned the impact from PBM implementation. We also were able to consolidate some real-estate locations and we had some realignment costs in our overseas operations. So it was a number of things across the organization to better position ourselves to grow and give us success into the investing initiative.

David M. Cordani

Kevin the only add I would give you to that is we have now a track record over the last four plus years in terms of continuing to seek efficiency and effectiveness gains in part folding that back into our investment portfolio to continue to invest that into new markets, new capabilities. And in part taking to shore up the expense ratio on a run rate basis in terms of the improvement you've seen year-over-year.

And this is a continuation of that good progress the organization has driven.

Kevin Fischbeck - Bank of America Merrill Lynch

Okay. And expand a bit on how Catamaran is going?

Thomas A. McCarthy

So we also put the PBM in total just putting Catamaran back in the context the PDM sets off another very strong year for us delivering very good economic outcomes, very good clinical outcomes for the benefit of our customers. Again in terms of how it's going just to remind what we are seeking to do, we are seeking to further improve on the operating platform \to drive the level of flexibility that's necessary to innovate for the future, further improve the underlying cost of goods sold for the pharmacy business as well as administrative expenses.

We've set ourselves a target for 2015 of about $0.50 EPS accretion and 2014 as a transition year is progressing well.

Operator

Thank you Mr. Fischbeck. The next question comes from A. J. Rice with UBS.

Albert J. Rice - UBS

Hi, everybody just to think through conceptually how you're setting up the guidance when you released third quarter and came in ahead of expectation, I think your comment at that point was on the increased performance you expected revenue growth and earnings growth for 2014. Today obviously you gave us a formal guidance and admittedly none of the other major companies are even projecting any growth, but at the high-end you have about 6%, at the low end about flat year-to-year.

Has there been any change, I am trying to put in perspective the comments about what you saw on the fourth quarter? Have you changed -- any of these things changing your view about 2014 relative to where it was three months ago.

David M. Cordani

A.J. it's David. So I think macro, you have the right picture here. When we provided the comments after the third quarter we said we expect the organization to grow both revenue and earnings albeit at a lower rate than our historic run rate.

I mean as we look at 2014 our opinion of that is when you take that 2013 results that we're rather proud of, when you back out the prior year reserve development because we don’t project any we jump off of a base of about 1.85 and we've given the range of 1.9 to 2, I mean that's a base that we believe is attractive.

The only think that changed in a while is what we've spent the time on this morning, is that our assumption on a perspective basis is that the medical cost pressure in Medicare will continue into 2014. So that reduces our Medicare Advantage expectation. But with the breadth of our portfolio we're still able to harness the overall strength of the portfolio and still delivering attractive revenue result on an organic basis, still delivering attractive overall earnings result and to remind you we don’t project any reserve development in our outlook and we're not projecting any further capital deployment beyond what Tom referenced.

So all in we think it's an attractive result for 2014 off of a very strong 2013.

Albert J. Rice - UBS

Okay. And just may be a quick follow-up to that you mentioned in this morning that in January alone you bought $225 million worth of stock. I guess how should we think about that in the context of this. I mean is it all of about that fact that you've got this extra liquidity that going to be available to you or in anticipation of today's result I guess it's interesting to me that you were fairly aggressive in purchasing in January, even coming up on this?

Thomas A. McCarthy

A.J., it's Tom I mean our share repurchase program tends to follow periodic pattern of repurchase. There is really no this particular signaling and decisions we make there and obviously we don’t give any guidance to future repurchase activity.

Albert J. Rice - UBS

Okay, all right thanks.

Operator

Thank you, Mr. Rice. The next question comes from Ana Gupte with Leerink Partners.

Ana Gupte - Leerink Swann & Company

Yeah, hi, thanks, good morning. So was just trying to put the third quarter and the fourth quarter and your guidance in context with growth model, longer term. If I just looked at global healthcare it appears you have continued margin pressure. You were probably in the high single to low doubles even maybe on margins. You are guiding to mid-single, so I mean it's less of a growth story. '14 you have Catamaran, so the healthcare and global healthcare.

So just longer-term is that whole business line going to be a slow growth for you -- are you seeing more conversions of self-insured. And then on the global supplemental side you were growing at a much higher pace in 2013 and now you are guiding to 17% which maybe your longer term growth guidance but again that was kind of an outsized growth, it feels like that's slowing down as well?

So what gives you confidence about your growth model and the whole fit about Cigna being a longer-term kind of build story that's undervalued in the long-term and are you signing any deals, to enhance the supplemental growth?

David M. Cordani

Well, Ana, good morning it's David. I think you put about 16 questions in to that. So I am going to take the first part. You probably framed -- of the underlying earnings performance and the earnings trajectory and the drivers of that. So I will take that piece of it. And then I am going to ask Tom to take the global sup component of your question.

When you think about 2013 just to put it back in context, for 2013 we successfully executed and delivered 11 and 11 from the top line and the bottom-line and 13% for the EPS and we were able to increase our outlook each quarter and we feel great about the overall year acknowledging the fourth quarter pressure on Medicare Advantage.

Looking to 2014 in a marketplace that's going to have a series of headwinds, including MA for the marketplace, including us -- our assumption of no prior reserve development, we are running off the limited benefit business which previously we gave you context to say that's about $30 million of earnings or so and that's still in the right trajectory. As well as in 2013 we delivered a medical cost that was superior to the underlying assumption. So we had positive spread from our ratings.

Looking to 2014 we don't make those assumptions. So in 2014, you have tailwinds which include ongoing organic growth in a very challenging market and we have a track record of delivery of that. Two, ongoing expense leverage, which we have a track record of delivery. And three, contributions from further strengthening of our PBM.

Taken as a whole we will generate organic earnings growth and organic revenue growth that we see as competitively attractive in a disruptive environment. And we believe positions us with strength as the marketplace conditions change somewhat to be able to continue to grow both our U.S. healthcare business, our global healthcare business, our global sup business our disability business as-well-as the seniors business as we get repositioned.

As it relates to deal, I will comment very briefly relative to that and kick you back to Tom on the global sup question you specifically asked. You see in our past track record we've been targeted and opportunistic relative to acquisitions that make good strategic and financial sense.

We've been very consistent in terms of where we see the category of assets we are attracted to and we will be disciplined relative to that, but our underlying organic earnings growth rate is what will drive the organization and very importantly, a level of free cash flow production because of the profile of our businesses that's going to be very attractive, no matter how we seek to deploy it for shareholder value creation. I'll ask Tom to talk a little bit more about global sup.

Thomas A. McCarthy

Yeah, Ana stepping back on global sup, obviously 2013 was very strong year, right, 27% revenue growth and 24% earnings growth, both very strong metrics. The revenue growth split about 50-50 between acquisitions and organically. So kind of the run-rate revenue growth in '13, excluding the inorganic activity was in the range of the long term expectation we had in the mid-teens. And that's again what we would expect to normally see in global sup going forward.

Our earnings projection for '14 is a little bit wide of that but keep in mind '14 has some start-up activities going on in it that tend to contribute over the longer-term but well within the range of what we might expect in that business and we are very comfortable with our positioning in these fast growing markets overseas.

Ana Gupte - Leerink Swann & Company

And then self-insured, do you think that conversion continues?

David M. Cordani

No.

Ana Gupte - Leerink Swann & Company

That's huge versus your growth?

David M. Cordani

Ana what we've seen to-date as it relates to self-insured that's been a continuation for us. So when you look at where there is indication the bulk of the regional segment and we define the regional segment quite broadly, it's the larger segment of business that we run in our company today. Employers are 250 to 5,000 employees and large single site, single state piece of the business, the bulk of that is self-funded.

Interestingly when you go down to the select segment, our fastest growing segment 50 to 250 employees and we've seen systematically growth of penetration of the self-funded capabilities. So Ana thinking about on that trajectory wise a few years ago you would had less than 50% of the new sales being self-funded and more than 50% of the sales being risk of guarantee cost, a year and half ago it was approached the 50-50 most recently it's 70% or so is self-funded and but still a full 30% of it being guaranteed cost and we're able to offer successfully both of those alternatives.

So both parts are attractive but the self-funded continues to do well largely because it's a highly transparent funding mechanism that allows us to align our incentives and the employer's incentives, give a level of visibility with them monthly and quarterly to actively manage their care programs, their health improvement programs.

Operator

Thank you Ms. Gupte The next question comes from Carl McDonald with Citigroup.

Carl R. McDonald - Citigroup

Great, thanks. I am going to ask Christine's question in a different way. If I look in the healthcare segment, Medicare expenses went up about $90 million sequentially in the fourth quarter. 45 million of that was guaranteed cost but the PDP was down $30 million sequentially and Medicare advantage was basically flat.

So somewhere in the other products Medical expenses went up $75 million sequentially that seems like too big just to be a stop loss reserve .Adjustment so just wondering do you have any comment on that?

Thomas A. McCarthy

Yeah Carl it's Tom, again different perspectives on different things you are trying to triangulate. It sounded like you were going sequential quarter three to quarter four. While I haven't done the math to reconcile the 90 million that you point out, we do expect pretty much heavy fourth quarter now an uptick in medical claims due to the [weather] impact. And I suspect that's what's underlying the math that you're seeing although again I haven't done the math that way to figure it out.

Again the headline on the medical cost results in the fourth quarter in commercial is as we've talked about some variability due to large claims and an uptick in utilization.

Carl R. McDonald - Citigroup

And there's definitely an increase in the guaranteed cost it just seems like there is $75 million missing somewhere else that hasn’t been explained. Second question is just on the Medicare loss ratio, it's increased to 150 basis points in each of the last two quarters. So what's get you comfortable that we are going to see that stabilize in 2014 rather than continue that acceleration?

Thomas A. McCarthy

Carl, it's Tom again. A good deal of that Medicare MCR increased also related to revenue pressure both as sequestration worked in over the year, risk adjusters adjusted over the course of the year. So those things we would expect to normalize out and the issue we're focused on is making sure we can get the medical costs under control.

Carl R. McDonald - Citigroup

Okay. Thank you.

Operator

Thanks you, Mr. McDonald. The next question comes from Andy Schenker with Morgan Stanley.

Andrew Schenker - Morgan Stanley & Co.

Hi thanks. Just a quick one here. I was thinking about your cost trend guidance for the year of 5% to 6%, only about a 50 basis point increase at the mid-point versus I guess when you started 2013 you were actually thinking in the region of 6% to 7%. So may be any color about how trends developed this year and your expectations for next year? And then any more detail on what's really driving that 50 basis points I think you said utilization I know have ACA related costs and then may be anything around in-patient versus out-patient, any of the other drivers, thanks?

David M. Cordani

Andy, it's David and just at a macro level and as Tom noted in his prepared remarks 2013 coming in favorable to 5% with that back in context we have several years in a row of competitively very attractive medical cost stream and as Tom noted with 85% of our book of business being self-funded those clients and employees benefit directly from that

As it relates to looking forward for 2014 what we're projecting somewhat of an uptick to that trend. So will go below five to five to six, so to the mid-point of little greater than the 50 basis points you made reference to. But the major headline in there is we've been still making some assumptions that some of the utilization pattern will uptick slightly.

There is no major category changes that are sea changes in there, little percentage but no major category sea changes in there for the commercial population.

Andrew Schenker - Morgan Stanley & Co.

Okay. So the most increase you're expecting is all utilization driven, anything related to ACA driving that at all or…?

David M. Cordani

Not, especially to call out.

Andrew Schenker - Morgan Stanley & Co.

Okay. Thank you.

Operator

Thank you, Mr. Schenker. The final question comes from Dave Windley with Jefferies.

David H. Windley - Jefferies LLC

Hi, thanks for taking my questions. On your -- I wondered David if there were any callouts or proof points that you could highlight on your ACO strategy and is that a critical, enough of a critical mass to have a major impact on your cost sharing performance across the business.

David M. Cordani

Sure, David. To context and come back to some of the prepared remarks. Well again the collaborative accountable care as we call them are still in the early stages of development. We are really pleased in terms of the amount of growth we have seen in those. So 50% growth year-over-year in number of customers that are experiencing it of about 400,000 lives going from a base of 800,000 to about 1.2 million, both seniors as well as commercial. Growth in collaboratives going from low 50s to mid-80s in terms of number of collaboratives. To the core of your question proof points, we are able to see now in some of the more mature collaboratives a meaningful improvement in both clinical quality engagement and cost.

So then it comes down to the ability to move trend is you really see trend move for employers that are higher utilizers of those collaboratives. So we have high concentration coming through to the benefit of some of those collaboratives. And with at a density of 80 plus collaboratives we have the ability in some markets to offer a network constellation that will have just the collaboratives or an incented collaborative model where the employer can make the decision to more aggressively steer their employees in that direction.

So headline is meaningful growth, still early but meaningful growth in terms of lives, physicians, collaboratives. Two, the exciting news is the proof points we would say off of an open access high performance clinical model, another step function in cost improvement and clinical quality because of the customer-physician engagement and that's really what that matters. And then driving now in a density where some employers could really benefit from using just collaboratives or highly intensive collaboratives that's the next stage what we are driving towards right now.

David H. Windley - Jefferies LLC

So a question kind of off the main topics here. The disability business I think has been under pressure from the general economic cycle. Has that turned the corner, I think disability was called out as a better performer?

David M. Cordani

Well I think you're right. Disability did perform really well in 2013. And as you pointed it's been operating in a very challenging environment over the last few years given the low interest rate and high unemployment. And we are, all are hoping both of those are normalizing and within that time frame through our focus on health and productivity produced great results that allowed us to mitigate a great deal of the environmental pressure and the fundamentals of our productivity in the world return to [work tools] in that business are very strong.

So as you say going into 2014 the background is improving market conditions and investment results. We are expecting to have another strong year.

David H. Windley - Jefferies LLC

Okay. Thank you.

Operator

Thank you, Mr. Windley. I will now turn the call back to David Cordani for closing remarks.

David M. Cordani

Thanks. So to wrap up I just want to emphasize a few key points from our discussion this morning. Cigna's full year results were strong and include earnings and revenue growth from each of our business segments, continuing our track record of strong financial result for the fourth consecutive year.

Our outstanding performances, made possible by the passion and focus of our 35,000 colleagues who are deployed around the world. And our Go Deep, Go Global, Go Individual strategy has enabled us to grow over the long-term in the midst of environment that continues to undergo considerable change and disruption. By leveraging our flexible and transferable capabilities across the globe which include our ability to have a deep understanding of our customers, use of complicated distribution and physician capabilities, we will continue to compete and win in the global markets for the benefit of our customers, clients and shareholders.

And based on this we are confident in achieving our full year outlook for 2014. And we remain committed to our long-term EPS growth outlook of 10% to 13%. We want to thank you for joining us this morning and your continued interest in Cigna. And we look forward to continue our dialog with you as the year unfolds.

Operator

Ladies and gentlemen, this concludes Cigna's Fourth 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 1-800-925-5415 or 1-402-530-8074. No passcode is required. Thank you for participating. We will now disconnect.

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