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UnitedHealth Group Inc. (NYSE:UNH)

Q1 2014 Earnings Conference Call

April 17, 2014 08:45 AM ET

Executives

Stephen Hemsley – President and CEO

Jack Larsen – CEO, UnitedHealthcare Medicare & Retirement

Gail Koziara Boudreaux – EVP; CEO, UnitedHealthcare

Daniel Schumacher – CFO

Jeff Alter – CEO, UnitedHealthcare's Employer & Individual business

Larry C. Renfro – CEO, Optum

John Rex – EVP and CFO, Optum

Austin Pittman – CEO, UnitedHealthcare Community & State

John Penshorn – SVP

Dirk McMahon – CEO, OptumRx

Dave Wichmann – EVP

Analysts

Matthew Borsch – Goldman Sachs Group Inc

Justin Lake – JP Morgan Chase & Co

Peter Heinz Costa – Wells Fargo Securities, LLC

Dave Windley – Jefferies LLC

Sarah James – Wedbush Securities Inc

Christine Arnold – Cowen and Company, LLC

A. J. Rice – UBS Investment Bank

Ralph Giacobbe – Crédit Suisse AG

Scott Fidel – Deutsche Bank

Christian Rigg – Susquehanna Financial Group, LLLP

Sheryl Skolnick – CRT Capital Group LLC

Josh Raskin – Barclays Capital

Operator

Good morning. I'll be your conference facilitator today. Welcome to the UnitedHealth Group First Quarter 2014 Earnings Conference Call. (Operator Instructions) As a reminder, this call is being recorded.

Here's some important introductory information.

This call contains forward-looking statements under U.S. Federal Securities laws. These statements are subject to risks and uncertainties that could cause actual result to differ materially from historical experience or present expectations. A description of some of the risks and uncertainties can be found in the reports that we file with the Securities and Exchange Commission, including the cautionary statements included in our current and periodic filings.

Information presented on this call is contained in the earnings release we issued this morning and in our Form 8-K dated April 17, 2014, which may be accessed from the Investors page of the company's website. (Operator Instructions) I would now like to turn the conference over to the President and Chief Executive Officer of UnitedHealth Group, Stephen Hemsley.

Stephen Hemsley

Good morning and thank you for joining us today. This morning we will review the first quarter results in the context of our full year objectives for 2014. Objectives that include continuing to diversify our services and product offering, continuing to develop and expand our capabilities and relationships and further strengthened and consistent fundamental execution and services to customers and consumers.

And we are working towards all these while new national healthcare policies begin to come into the place and new baselines for market behaviors and new market dynamics become realities. We plan to deliver revenues in a range of $128 billion to $129 billion for the year produce earnings in the range $5.40 to $5.60 per share and generate cash flows from operations between $7.8 billion and $8.2 billion.

UnitedHealth Group, UnitedHealthcare and Optum performed largely as we expected in the first quarter. We remained in our plans for 2014 and as usual continue to work through more challenges and benefits for the moment.

Longer term, we continue to more clearly see evidence for the growth opportunities for both UnitedHealthcare and Optum as we knew beyond the more negative immediate term impacts of the ACA and its implementation. This is was really the first quarter a full scale operation under the ACA.

Everything else in the past three years has been more of a preamble. The ACA's impacts on 2014 had been immediate and significant as we described at our Investor's conference. Nondeductible insurance taxes, ACA prescribed Medicare Advantage funding pull backs, commercial underwriting changes and various other provisions cumulatively reduced our per share, net earnings by nearly $0.30 for this quarter and sequestration cut an additional $0.05 in this quarter.

On a full year basis 2014 Medicare funding actions will cut roughly $0.45 per share beyond that. This makes a grand total of about $1.50 per share and externally driven year-over-year pressure fully consistent with our view at our Investors conference in December.

The ACA impacts every major line item of our consolidated results and distorts comparisons virtually all performance ratio. This will continue as the year's progresses, a new regulatory and tax baselines are established and settled in, but we think some very important early observations can be made about the ACA's first quarter introduction.

First consumers and benefits sponsors are showing by their actions the clear value they see in private sector, managed care products and services.

The capabilities of the private sector healthcare community are significant and have proven to be highly adaptable to serving the needs and demands of consumers in all stages and situations of life as well as government and private benefit sponsors and the broader health system.

And ultimately there should be advances access to care and the healthcare system as a whole will become more effective and efficient and consistent overtime. Early evidence of these is visible and will produce long-term growth opportunities for both UnitedHealthcare and Optum.

Let's review, how this played out in the first quarter for UnitedHealth Group starting with UnitedHealthcare, whose revenues grew $1 billion or 3.6% year-over-year to $29.3 billion led by membership growth in Medicaid. Over the past 12 months alone, UnitedHealthcare has implemented six new or renewed Medicaid contracts and grown to serve 395,000 new members.

In this past quarter, we grew by 255,000 people driven by the expanded eligibility offered in and about half the States, where we serve Medicaid beneficiaries as well as new membership in traditional categories.

We expect growth throughout the year and could well exceed the upper end of our outlook of $350,000 to $450,000 additional people served this year. The Congressional Budget Office forecasted 12 million people will obtain coverage through Medicaid by the end of 2016 and we will endeavor to gain market share serving the needs of these beneficiaries and their State's sponsors.

Nationally managed Medicaid, is also broadening to serve new patients with greater clinical needs like dual eligible. We believe our integrated and in the market clinical model gives us distinct advantages in serving these higher growth; more complex areas. Our model integrates behavioral, pharmaceutical, medical and social services with the focus on the 5% of the population that drives well over 50% of the total medical cost in the typical Medicaid program.

In Medicare, we began the year with growth of 360,000 across all Medicare product categories. As Part D sales were strong and Medicare Supplement also grew nicely. Participation in our Medicare Advantage program was essentially flat down 5,000 people sequentially and well within the range we expected, despite significant market exists and products network adjustments made in response to the 2014 Medicare Advantage rate cuts of more than 6%.

We continue to manage our Medicare Advantage products and cost structure with the local market level and we will stay focused on that task all this year and next; given the continued adverse funding climate for Medicare Advantage.

Commercial membership also began the year generally in line with our expectation with a sharp decrease in people served through fee-based relationship as well as some expected declined in risk-based business. As expect our individual policy business declined this quarter as we decrease by 90,000 with the advent of the ACA.

In the commercial market, we experienced a strong competitive period over early renewals for Legacy benefits, where many small group customers renewed early to avoid community rating and ACA price increases. These decisions were rational, driving healthier groups to renew early. While other groups took advantage of the community rating or that was the best course of action.

Over the last quarter, we have seen intensified pricing in several markets including small group in New York, a large market for us. We believe several carriers there including new entrants our pricing well below cost and what we would view as unsustainable pricing levels.

If this climate continues, we could see some further pressure on risk based membership beyond the ranges, we anticipated this year. And at Amil, we are beginning to see clear signs of response and recovery from surgeon utilization caused by aggressive access standards imposed nationally by the Regulatory Authorities in mid-2013.

We continued to project a 6% commercial medical cost trend plus or minus 50 basis points for 2014. First quarter usage benefited slightly from intense winter conditions across the mid-western and northeastern areas of the country.

Offsetting this item was the rapid launch of an effective and very expensive new hepatitis C therapy. The aggressive US pricing practices on this has been well publicized and continues to be quite controversial. We are working diligently to ensure this medication is applied under clinically appropriate standards.

Patients were treated across the Medicaid commercial and Medicare Part D categories that cost to more than $100 million to us in the quarter. The Federal Government will bear significant expense in the Part D program because the high cost of this treatment causes the patient to quickly move through the donut hole into the 80% CMS reinsurance quarter.

Meanwhile, State Medicaid Directors are at varying stages of concluding whether to include the medication on their approved state pharmacy list and if so, how to pay for it.

Stepping back from these first quarter trends are full year commercial care ratio will see pressure caused by a combination of the revenue impact from stronger than expected early renewal activity in December at pre-ACA rates.

The under pricing dynamic in New York at higher than expected utilization and cost related hepatitis. The size and diversity and United Health Group tends to mute the effect of the commercial variance on the consolidated care ratio, but we expect this ratio could lean toward the higher end of the 80.5% plus or minus 50 basis point range, we provided last December.

Before I turn to Optum, I want to recognize some of our colleagues with us today who have taken on new roles at UnitedHealth Group. All in keeping with our long standing philosophy of moving talented executives across the enterprise to broaden their experience and management depth.

Jack Larsen has moved from the Medicare business to head up our rapidly growing Optum Collaborative Care, which includes our Care Delivery businesses, a perfect transition given his background in Medicare and extensive M&A background.

Steve Nelson has shifted from his role leading our local market oriented Medicaid business to heading our Medicare and Retirement operation, where we are putting intense focus on market-by-market strategies around clinical care, network alignment and quality [stars].

And Austin Pittman takes over at our Community & State Medicaid business coming from his most recent assignment leading our overall UnitedHealthcare network and local commercial market leadership before that.

Turning now to Optum, it is becoming more evident the capabilities we have collectively built in our services, platform are increasingly recognized in the marketplace. Optum continues to grow and mature quarter-by-quarter. We continue to evolve to meet the needs of the market further integrate offerings, strengthen and grow relationships and align our efforts to the most valuable and sustainable opportunities to make the healthcare system perform better.

More participants recognized Optum is in position to help customers engage their toughest healthcare challenges. Our work assisting the healthcare.gov website in the last quarter of 2013 has led to new relationships, new pipelines of potential work and new contracts with the spectrum of customers for 2014. We expect further growth in government services this year continuing this first quarter's trend.

Our efforts to help our customers improve their end-to-end performance and their structural cost to move ahead with the launch of our Optum360 revenue management business with Dignity Health.

We are developing a pipeline of additional health systems and expect to add business to Optum360 as the year progresses. Optum is seeing positive market response to its broad business process outsourcing capabilities as well. Optum Health is aligned around five key growth areas; prevention, intervention, financial services, distribution and care delivery.

Broad capabilities meeting market needs, matched with an efficient, agile, customer focused organizational structure. The relationships we are building, leveraging these critical capabilities and they will be instrumental in Optum's future revenue and earnings growth as the consumer becomes a more significant buyer and decision-maker in healthcare.

OptumRx is working a strong prospect pipeline in pharmacy services. Our distinctive focus on managing total cost by synchronizing information and care process across the medical, lab and pharmaceutical continuum is driving significant interest. We are only able to generate this interest as a result of the meaningful investments; we have made in OptumRx over the past couple of years.

And similarly, we are making targeted investments in OptumHealth and OptumInsight to seek opportunities in areas such as consumer engagement, consumer distribution services, next generation analytics that combine administrative and clinical data at the scale 60 million people or more and next generation medical care review and compliance analytics.

We will also invest startup cost in the assimilation of each new Optum360 relationship. This quarter earnings bear $60 million of these investments, which will continue over the course of the year, but somewhat more waited in the first half. All of these resonate with one theme; new and sustained areas for growth by helping the system to perform better for everyone.

Turning to Optum performance for the quarter revenues grew 29% to $11.2 billion and earnings from operations grew 20% year-over-year to $650 million. Operating margins decline slightly due to the exceptional growth of the lower margin OptumRx business as well as the planned investment we just discussed.

OptumRx led this quarters reported results with revenues up 43.5%. Earnings from operations up 114.2% and operating margins expanding a full percentage point to 3.2%. We filled 140 million adjusted scripts this quarter up 38% year-over-year.

OptumInsight had strong growth in government and sponsored services in the quarter. At the same time, they slowdown and hospital clinical compliance services pressured revenues and operating earnings year-over-year and sequentially. As the Federal Government deliberated over medical necessity processes for Medicare, it's so called Two-Midnight Rule.

At the same time, our newly introduced compliance offering serving hospitals needs for clean medical necessity documentation for privately insured patients have seen accelerated growth in sales in and pipeline.

We expect OptumHealth and OptumInsight to increase in profitability as the year progresses accelerating into the second half. All in Optum delivered a strong first quarter with improved earnings and capital returns as compared to last year and remains on pace to produce $3.1 billion to $3.2 billion in operating earnings this year.

As well as roughly one-third of UnitedHealth Group's cash flow from operations. All, while investing in the future growth in its business. As a whole, we have a solid start to the year, against the increasing headwinds, we described at our investors conference.

UnitedHealth Group's first quarter revenues grew nearly $1.4 billion or 4.5% to $31.7 billion and net earnings were at $1.10 per share fully in line with our expectation. Cash flows from operations were strong at $1.4 billion up 34% year-over-year and a good start toward our full-year projection.

The biggest challenges in 2014 are the combination of nondeductible healthcare taxes and ACA mandated Medicare rate cuts. On top of sequestration and the government's continued systematic under funding of Medicare Advantage. Including the 2014 Medicare funding issue and other ACA provisions, these impacted our first quarter results by well more than $0.35 per share and will pressure our full year net earnings by about $1.50 per share.

We expect second quarter earnings per share will growth this past quarter's results, but as planned will come in below last year's reported second quarter, which benefited from strong reserve development. It did not bear some of the competitive commercial market pressures, UnitedHealthcare faces today and like this quarter, we will have substantial ACA effects.

Items we are watching including hepatitis C treatment cost, the full recovery State Medicaid fees, commercial risk-based membership, New York and the overall performance of our Medicare business. And we are always respectful of medical cost trend even though they are basically inline in the quarter.

As always, we will strive to deliver the best possible result in both the short and longer term. We expect our 2014 net earnings to land in the existing range of $5.40 to $5.60 per share and we mean that as a range. The items we discussed this morning, might serve temper ones thinking within that range.

Standing back from the number, UnitedHealth Group faces an expansive long-term growth opportunity. In the US alone, there is the opportunity to approach and serve the more than 700, the Fortune 1,000 companies not yet our customers. Today we serve, more than 85 million people leaving more than 230 million Americans, we do not touch.

There is a growing number of people in government sponsored programs, who are yet to benefit from Managed Care. There is significant upside potential in our PBM market share and there are multibillion dollar, multi-year opportunities that links services, technology and insight to fundamentally health-to-health system perform better for everyone.

Beyond the US, we see the same growing opportunities. As the challenges other national health system space around access, control, affordability and affected decision making are in fact the same ones, we have here in the US even as these systems differ. The level of a longer term success, we achieve will depend on two things.

First an adaptive and innovative approach to applying our three long standing core competencies of clinical care, organization and delivery. Health information analysis insight and advanced enabling technology. And second the effectiveness of our leaders in our organizational culture.

We serve in the sensitive social services arena in the early stage of important market changes and we believe success will come to those, who can build trust, serve with compassion and control costs; while driving higher quality outcomes.

We thank you for your time, this morning and look forward to your questions. So we will give you a second to get organized and we will pick up your question. Thank you.

Question-and-Answer Session

Operator

The floor is now open for questions at this time. (Operator Instructions). Our first question is from Matthew Borsch from Goldman Sachs. Your line is open.

Matthew Borsch – Goldman Sachs Group Inc

Yes, hi good morning. Could you talk about the outlook for Medicare Advantage for 2015? I realized we have to get through this year firs but, in light of the various changes that were made in finalization of the rate. I know one of your competitors has put out a point estimate for the all in rate impact and was wondering, if there was a range that you could offer on a similar basis?

Steve Hemsley

Yes, sure I think in terms of a range. First of all, we would comment that the final rate notice did mitigate some of the originally proposed cuts for 2015, but in fact when that results is that rates were once again taken down somewhere in the order of maybe slightly over 3% and that really comes on the heels of overall funding decline of over 6% in the prior year and that's against arising overall medical cost trend.

So we would bracket that around, let's say the 3.5% kind of range and honestly, if that is somewhat disappointing, we were hoping for and we are positive all in response and so we will be focused on working through and trying to mitigate that as we approach 2015, but I would bracket it in let's say 3% to 3.5% range.

Matthew Borsch – Goldman Sachs Group Inc

If I could just ask for one clarification on that? Is that inclusive of the because it's not a rate factor the impact of the increase in the industry fee, at least under the ACA provisions to-date?

Steve Hemsley

Yes, that is an all in kind of what we see funding deficiency to Medicare for 2015.

Matthew Borsch – Goldman Sachs Group Inc

Okay. Thank you.

Operator

Our next question is from Justin Lake from JP Morgan. Your line is open.

Justin Lake – JP Morgan Chase & Co

Thanks, good morning. Wanted to follow-up on the comments around 14 commercial MLR specifically, if those coming toward the higher-end of the range? Can you tell us whether, you think that would likely drive ETF to the lower end of what, being your full year guidance or if you think there are other businesses that could were to offset that and what they might and then just quickly on the MLR side.

You mentioned the $100 million of hep C cost in the quarter. Can you tell us what your original expectations were for hep C in Q1 and how you're currently expecting this cost to trend for the rest of the year, thanks?

Steve Hemsley

It was a little gobbled on that second one. Your second question is a $100 million related to what?

Justin Lake – JP Morgan Chase & Co

I'm sorry, $100 million of hep C cost, I think you mentioned up on them.

Steve Hemsley

I got it, okay.

Justin Lake – JP Morgan Chase & Co

For the quarter, how your expectations were for the end of the year for that versus $100 million and how you expect the trend for the rest of the year?

Steve Hemsley

I got it. Well, maybe the way to frame the care ratio and I will let Gail to drill and Dan Schumacher address this in more specifics but, we saw pressure in the first quarter. It is the first quarter those pressures are coming from a variety of sources. We will endeavor and try to mitigate against that over the course of the year, but we think it's appropriate to alert you to the fact that care ratio will feel pressure because of these factors.

And as you point out, we have a very diverse business not only within the UnitedHealthcare platform but in the Optum platform and we have a number of ways to fight back against those pressures and we are endeavoring to do that is early in the year and so we are staying largely within the ranges and kind of giving you a color around, where we see the pressure points.

And then in terms of hepatitis C, Gail, Dan?

Dan Schumacher

Sure, good morning. Justin. On hepatitis C as Steve mentioned. We saw $100 million of cost in the first quarter little more than that and that was across all of our benefits business. So Medicare, Medicaid and Commercial and I think what we are seeing in not in consistent with what folks are seeing across the industry, which is higher pent up demand, as there was more patients that were warehoused leading up to the launch hepatitis C vaccines.

And so we would expect that there would be some moderation and new patient volume as that initial pent up demand starts to wear off, but I would tell you that obviously these are 12 week and 24 week treatment regimen. So those folks that were introduced in the first quarter, will carry forward into the second.

In terms of its relation to our expectation. I won't say that's specifically other than to say that it's a multiple of what we had expected.

Justin Lake – JP Morgan Chase & Co

Thanks for the color.

Steve Hemsley

Next question, please?

Operator

Our next question is from Peter Costa from Wells Fargo. Your line is open.

Peter Heinz Costa – Wells Fargo Securities, LLC

Yes, I would like to understand a little bit more about what you expect to do about the rising cost of hep C going forward, as you mentioned moderating but you know when it becomes perhaps all [oral] towards to the end of the year. You would to expect to reaccelerate again and in particular for next year. So how you're going to price that into your businesses for next year, do you expect States to reimburse this year or carve it out?

So can you build on that a little bit and the other cost item, that you talked about was in New York, can you tell us? How you're going to respond in New York to the pricing pressure there?

Steve Hemsley

Sure, as you point out. How hep C is addressed really does vary across the businesses based upon the segment of business that we are in, so we will try to respond to several of those and maybe we will start out with Gail.

Gail Boudreaux

Sure, good morning. Let me first address the hep C, then we will talk about the issue in New York. I think as you mentioned first the hep C therapies as you know are very effective and one of the things that we are doing is working to ensure that appropriate clinical protocols and standards are in place, but as noted the price is exceptionally high and as Steve said in his opening comments that controversial and it's putting a lot of pressure on States, CMS and in terms of our day as well as our employer sponsor, so the cost has to be addressed.

As we think about actions. In the Medicaid space particularly. First and foremost, we are working with each of our states to ensure that we are aligned with their expectations on their PDL and how they want to handle that and also giving them ideas on risk mitigation from a cost perspective, what we are paying for the Medicaid it is the cost to the program that wasn't priced in.

So we are working with our States to figure out that funding gap. We do expect it as a cost of delivering service in that space and would expect that will be reimbursed but the timing is what is uncertain now because accelerated very quickly and as Dan said, in his opening remarks about this because warehousing and the rapid launch, this is something everyone's dealing with across the States right now.

In terms of the issue on New York. Let me open up a few comments, I'll just Jeff Alter, our CEO of our Commercial Business to comment. I think Steve highlighted in New York, we have a somewhat I think unique situation in the small group market in particular, where there are new entrants as well as existing competitors pricing below what we believe is the sustainable cost structure and pricing below, what we believe our cost.

We've always maintained pricing discipline. We're a market share leader in New York, we've had a long history of several decades of consistent performance in that market, but we do think that there is a market correction needed. We are going to stay very disciplined in our pricing but again because of the dynamic that's going on there. It's something that, Steve and we highlighted in our opening comments.

Jeff Alter

Hi, Peter. Good morning, it's Jeff Alter. Just add a little color to that. As most people are probably aware, we've served that market place successfully for couple of decades. We know that marketplace really well. We've got leading economics, we understand the pricing and we really believe at this point that market has got to come back to a more sustainable level.

We are comfortable with our pricing in that marketplace. It's just that others, I'm chosen to well below our pricing and that's going to create an issue in that market place. We will talk to the regulator about it. But in the short run, we are going to maintain our disciple like we have on that discipline that serve just well on that market place, but it will put pressure as we think about '14 as we pace into the other quarters in '14.

It will put some pressure on risk-based, our membership.

Steve Hemsley

Thank you. Next question.

Operator

Our next question is from Dave Windley from Jefferies. Your line is open.

Dave Windley – Jefferies LLC

Hi, thanks for taking the question. I wanted to shift over to Optum. Curious how you see, your margins progressing in Optum through the year. You mentioned ramping Optum360 making investments there. I know, you clearly need to see a pretty substantial ramp up over the course of the year to get to that margin guidance range. So interested in progression there please.

Steve Hemsley

We do expect that, Optum is performing exceptionally well and doing it while balancing investments and the assimilation of new business. So it's impressive performance John, Larry?

Larry Renfro

John, can start and then I'll [indiscernible].

John Rex

Yes, so just Dave to lead off, I'd say both overall Optum in the individual segment results were in line with the expectations. I think kind of part of what you're alluding to that Dave, is within OptumHealth and OptumInsight earnings were down year-over-year about 4%, 5% respectively here.

And what we are doing here is really investing for the future. I would say it's centerpiece of one Optum chapter two. It's all about investing for our future growth. Well I can, draw the parallels to OptumRx and what we did there over couple last few years investing several hundred million dollars into that business and you can now see the results as we are kicking off into 2014.

As we look at '14 for ourselves here in OptumInsight and OptumHealth. We'd be looking to invest over $200 million in those businesses this year. All about next generation clinical, administrative, data analytics, collaborative care. Our Optum360 business. We are consistent with kind of look we provided at Investor Day and back to your direct question on progression looking for 40-60 split in terms of earnings progression first half, second half. So get direct to that.

Larry Renfro

So Dave, it's Larry Renfro but let me make a couple of comments. As John said, Steve said we are investing obviously in future growth. This is all part of the one Optum plan that we put in place three years ago. Where we are continuing to balance growth, investments and cost management. I won't go back over what John was talking about in terms of the some of the examples, but I will mention the PBM because that is the perfect example of something we invested in for a couple of years and we are now starting to see the pay off of that.

I'd also tell you, that you could refer to healthcare.gov and the way that we've been working the Federal Government as well as the State as we are starting to partner that's part of one of our disciplines of larger and deeper relationship and we believe that's going to pan out, but the most important thing probably is that $60 million of expense in the first quarter was a planned expense.

We haven't [DDA] from our plan and we will reset at this point in time. I think you can look at both business segments and see that the revenues are up. I would tell you that OI or the OptumInsight backlog is up 18% to $7.2 billion and I can also tell you that OptumHealth and OptumInsight's pipeline is 58%.

So all this is planned, we are pretty comfortable where we are set with a solid start to the year and believe that will be strong for the rest of the year.

Dave Windley – Jefferies LLC

Thank you.

Operator

Your next question is from Sarah James from Wedbush. Your line is open.

Sarah James – Wedbush Securities Inc

Thank you. I wanted to follow-up here on [ZUBSOLV]. First if you could kind of frame it, so the $100 million is about 1,200 cases. Could you split that between the three segments then to follow-up on pricing? Is it currently priced into your commercial product for this year? How does factoring it into Part D work and then Gail said that, she expected [ZUBSOLV] to be reimbursed for Medicaid does that retracted to the drug launch or more going forward?

Steve Hemsley

I think we will respond kind of in more general terms. We are certainly not going to get into case specific across segments. So absent that, I think we can give you a response.

Dan Schumacher

Good morning, Sarah. Dan Schumacher again, with respect to the new patient volume that we're seeing. We are seeing the highest volume on a percentage basis in Medicaid lock as you would expect as well as in Medicare and then follow-up by commercial, but when you translate that through to the impact obviously Medicare is lower because of the reinsurance aspects of Part D.

So that gives you a sense of where the volume is coming from, with regard to the reimbursement. I'd ask Austin Pittman to provide some perspective.

Austin Pittman

Sure. Thanks Dan. So again as Gail mentioned, we are working diligently with all of our States first to get in alignment with their coverage decisions. Second on risk mitigations strategies, where we are covering again. We do expect it to that is a funding gap that will be solved certain issue of timing and we would expect that to be solved for the contract period.

Sarah James – Wedbush Securities Inc

Does that mean retroactive?

Austin Pittman

Yes.

Sarah James – Wedbush Securities Inc

Yes, okay. Thank you.

John Penshorn

Sarah, it's John Penshorn. Just I ought for caution on estimating number of people because as Steve mentioned the Federal Government is also covering some of this cost through their funding for the Part D program catastrophic coverage.

Sarah James – Wedbush Securities Inc

Got it. Thank you.

Steve Hemsley

Next question, please?

Operator

Our next question is from Christine Arnold from Cowen. Your line is open.

Christine Arnold – Cowen and Company, LLC

Hi, there. At your Investor Day you mentioned that you were targeting 10 or more really large customer relationships by 2016 within Optum and I hear you about the backlog and the pipeline. Could you talk about, where you see those large relationships progressing in and when we might see some of those?

Steve Hemsley

Sure. We will respond in general terms obviously it's sensitive in terms of these things are active in the market today. So we don't comment ever on specific clients or opportunities but in broader terms. Larry, do you want to?

Larry Renfro

Sure, I will start and I might ask Dirk and I might ask Andy and [Bill Miller] all three to comment on this. We obviously are talking a lot about what we are doing with Optum360 and that marketplace that is a growth market place for us. The pipeline as Steve said, we from competitive standpoint would not really want to talk about right now.

Especially what we are doing on the revenue cycle management side. So I will ask Bill in a second to talk about that. I would tell you on the PBM side. We continue to grow, we continue to see a large number of our RSP's that we are participating in and I ask Dirk to speak to that and on the government side.

Obviously what we were doing with the States, what we were doing with the Federal Government and some of the programs that we are involved in, our deals. But also, we are concentrating in the, what I call our collaborative care area that's our care delivery organization. We are going to beat that up bit, so I might ask Jack Larsen to start with that and just give a little feel for what we are doing there.

Jack Larsen

Thanks, Larry. Good morning, Christine. Jack Larsen. We would view the opportunity to investing our line with some of the better performing primary care physician oriented physician groups and other specialty groups around the country as really central to Optum taking on the mission of some of the toughest challenges of the healthcare system.

For example today, in our local care delivery organization. We shouldn't think about as our broadly speaking our physician groups. We serve in 19 markets today and we serve just a little over 1 million people as patients. I would expect this to continue to grow, through some of those larger more comprehensive relationships that your questions sort of pointing at as well as grow it organically and at the continued use of M&A which I think, we're pretty good at there.

Steve Hemsley

Well, maybe Andy you could talk about the government.

Unidentified Company Representative

Sure, hi Christine. Very quickly, we've been pleased to have the opportunity to serve both Federal and State Government. I think what they've seen is something that's [indiscernible] of the answer to your question is, they've hopefully seen the technology the general healthcare and the execution capability that an organization like Optum can provide.

I think that, we will build relationships both at the State level as well as take our technology out commercially in a bigger and bigger way really substantial relationship where we become a more embedded part of our clients.

Steve Hemsley

So maybe Dirk on the PBM?

Dirk McMahon

Yes on the PBM, hi Christine. Our pipeline's up a big year-over-year and this really on top of a nice strong sales showing last year. If you look at final [spinings], we've attended. We are certainly getting our ad backs with a big customers.

For example this year, I've already attended two final [spinings] where opportunities where in the 0.5 million member range. We are certainly getting our opportunities. We are excited about our pipeline, although I will tell you we are really still early in the season at lot [TBD].

Larry Renfro

Two more areas, I'll ask Mike [indiscernible] and this goes back to Steven's comment in his opening remark about the 700 organizations that we do not do business with today. Obviously on our consumer solution side, we are starting to really target. So Mike, maybe you might want to comment on those?

Unidentified Company Representative

Sure, this is Mike [indiscernible]. So from a employer perspective there's 700 of the Fortune 1,000 that Optum doesn't serve in any way today. We think there is a large opportunity out there for us to take a lot of our consumer solutions directly to those and wrap those services around them.

So we are in ramping up the sales force. We are in conversations, starting those conversations with the number of these large employers. We are also starting conversations with a number of associations and other places to try to get to consumers with product and services that we think will really empower them to take ownership at their healthcare in new ways.

Larry Renfro

So I'll end with [Bill Miller]. Bill, could you talk a little bit about our hospital market.

Unidentified Company Representative

Yes, so Christine. Thanks a lot. There's three things that I'll touch on and where these big relationships will continue to grow and foster and our three basic areas as we mentioned. Optum360 and we are in several negotiations with the next phase of clients, we obviously aren't going to expose those right now, but I'd also remind you that business platform is adding clients every day.

They may not be the big large multi-year arrangements and many of their if you look at our backlog going 18% to $7.2 billion that's a function of those tools that we have out in the marketplace of subsets of a full blown and the [NDL] being absorbed by many, many clients on a quarterly basis.

And those set the stage for large arrangements down the line and some of those are measured in the $10 million to $15 million arrangements over the course of three years to five years, but we will see other very large ones added over the year and then I think we are doing far more work on the ACO side helping hospitals, reengineer themselves to become ready for fee-for-value.

So we've had several large transactions in that space and we will continue to see those through the year and then finally, the other area emphasis for us both in our payer, provider. Andy touched on it in the government market is our continue ability to impact the market place from a BPO standpoint.

With our technology scale, with our state-of-the-art technology and ready to go technology along with our consulting services. We are finding acceptance in the marketplace whether it be amongst payers or providers to slide in the positions, where we are really managing large chunks of there, if you will core business so that they can focus on taking care of their members.

And with our backgrounds both on the payer and provider side. We end up being a pretty suitable partner in those really game changing decisions that governments, payers and providers are making and more consistent basis as margin pressures and talent pressures continue to mount the market place.

Christine Arnold – Cowen and Company, LLC

Great. Thank you.

Steve Hemsley

So I might complete that very comprehensive response, by saying if you listen Optum's challenges are out more around abundance. There are significant opportunities getting those relationships started right, recognizing. They're going to be substantially larger than the relationships we've had in the past that they're going to engage a broader spectrum of services and that they're much longer term.

We are trying to be thoughtful about these approaches in each of our businesses there as well as continuing to make sure that we are investing. So that we are delivering ever better value. So they're navigating in that those kind of waters right now which are really great waters to be in at the moment.

So next question.

Operator

Your next question is from A.J. Rice from UBS. Your line is open.

A. J. Rice – UBS Investment Bank

Thanks a lot everybody. I guess I was thinking, you hadn't really said much about your views about, with how the whole public exchange for share process played out and now that. We are done with the open enrollment. You got to think fairly quickly about what you're going to do with respect to 2015, give us any updated thoughts and assessments of how it played out and what your posture will be for next year?

Steve Hemsley

Sure. I'll have Gail and others to respond principally to that. We were involved from the Optum side, so we do have some perspectives from that. it is still very, very early in the life of the exchanges and second year in terms of how they will evolve, will be effectively somewhat by what I call, a lot of spontaneous change over the course of the first year implementation, which we understand that does require some consideration and calibration as we go, but Gail do you want to start?

Gail Boudreaux

Sure. Good morning. As you know, we had a very modest footprint in 2014 and as we've said and still believe, we do have buyers to increase that participation in 2015. There's a lot happening in that, we are in the process of doing our evaluation. Obviously, we are looking at how the markets and products are regulated. The networks that we would put in place, but there are some things that we did learn in the first part of the market for us that the size of the overall market is positive and that the configuration of products around sober, is also positive for the market and that there is now some experience and a desire to be, to keep the exchanges stable.

So we don't know much about second year pricing. We do enough first year pricing still again, at this stage just reiterate that our [bias] is to increase our participation to '15 and we will share more with you as those decisions are made over the coming months.

A. J. Rice – UBS Investment Bank

Okay and great thanks.

Steve Hemsley

You know, I'd also observe that while we will, if we engaged in readiness. You really don't have to commit until September I think. So we have time to see how this plays out a bit.

A. J. Rice – UBS Investment Bank

Okay.

Steve Hemsley

Next question, please.

Operator

Your next question is from Ralph Giacobbe from Crédit Suisse. Your line is open.

Ralph Giacobbe – Crédit Suisse AG

Thanks, good morning. Just wanted to go back to the comments on intensified pricing. I guess ones, where I make sure is it just in New York or you're seeing it. Your startup in other markets and then second did you say that, in New York it was coming from new entrants and existing competitors and then just the last piece. You're just trying to sort of tying in on how related it is to, the public exchanges plans, maybe pricing that would encourage dumping or is it or are you saying it's just sort of head-to-head off exchange sort of land grab. Thanks.

Steve Hemsley

I think that Gail and Jeff are perfectly prepared for this.

Gail Boudreaux

Good morning, Ralph. A couple of things because there is number of questions embedded in there. Let me start first with your questions around exchanges in early renewals. One of the first things, is that we've had a very successful early renewals of our small group customers in the fourth quarter that clearly is a big positive for us going forward.

In terms of the New York issue, I'm going to let Jeff specifically address it. We talked about it, but it is a unique to New York issue and yes it is both existing competitors well as new entrants, but there is some unique dynamics in that market.

You brought a question around what's happening in the competitiveness of the overall market. As Steve said in his opening comments, we have seen in the first quarter again after very successful early renewals of small groups and intensified pricing in some slack markets that is having an impact on our fully insured risk because we have stayed very disciplined in our pricing.

So that's really the dynamic that's going on it is select market. And there is dynamic of the early renewal that occurred that having impact on that. New York has some unique characteristics and we wanted to point that up because of those in your characteristics and I'll ask Jeff again to comment on that.

Jeff Alter

Good morning, Ralph. Yes actually, when you think of that New York market place it was probably one of the least affected by the ACA as it is been community rated. Some fairly stable from '13 going into '14 but there were some new entrants into that market place that in our opinion clearly are underpriced what the cost structure is in New York, not only our cost structure but certainly their cost structure.

And then over the last few years, we've had competitors that have left the New York market place that chose to reenter the market place in January '14 and we see those competitors also under priced for what the economics would call for it.

Steve Hemsley

So next question, please.

Operator

Our next question is from Scott Fidel from Deutsche Bank. Your line is open.

Scott Fidel – Deutsche Bank

Thanks, I know it's clearly very early here but just wanted to get your thoughts on expectations for the 2016 MA rates, just sort of thinking about some of the factors that benefited the 2015 rates at CMS, said that they may revisit for example freezing the move to the risk adjustment model, then also delaying their proposal one on the HRA proposals.

You know I there was hope and expectations at the 2016 MA rates, we can see the sky sort of clear there, but given some of those factors that I mentioned, just interested in your thoughts here on, 2016 MA rates?

Steve Hemsley

You know, I'm not sure that we offer kind of public perspective on future rate settings that we don't really have any control over. We are aware of the factors and many others that go into thinking in terms of rate setting. We are still digesting 2015 and I really am not going to comment about that rate setting process.

If you look back, our [batting] average on that would be pretty poor. So I don't think we are going to set into that, I would just speculate that there is been pretty steady funding pressure in terms of the Medicare Advantage program that it is been hit severely by the insurance taxes. It's been effected by the funding posture in various ways that CMS develops the rates each year and this is now been several years against a moderate but still rising overall cost trend.

So we will be very watchful and careful with respect to continuing to advocate for fair funding to the Medicare Advantage segment. It's a segment that serves 15 million seniors, it continues to grow. It continues to perform exceptionally well particularly in comparison to the fee-for-service program.

So we would be advocates of thinking that programs really should be more the future of Medicare and funded appropriately for that purpose and that it affects seniors. Our posture there hasn't really changed and it won't change in '16 and we will be hopeful that, to you know the funding perspectives take that into consideration going forward. Beyond that, I really can't really respond to your question.

Scott Fidel – Deutsche Bank

Okay, thanks.

Operator

Your next question is from Christian Rigg from Susquehanna. Your line is open.

Christian Rigg – Susquehanna Financial Group, LLLP

Good morning, thanks for taking my question. Just want to make sure, I understand the messaging on the Hep C sorry to come back to that, but you know Dan I know you said percentage wise you're seeing the most volume in the government segments. But in the press release, the only area where you're specifically highlighted is in the commercial side.

So is it fair to assume that, sort of the greatest area of surprise has occurred in commercial or there is been across the board. Thanks.

Dan Schumacher

Good morning, Chris. It's Dan. We've been surprised on the volume, the pent up demand across all three businesses and maybe I'll step through the Commercial Care ratio and how that goes into the consolidated and how you think about Medicare and Medicaid to put it into context around the pieces.

So from, as you look at the Commercial Care ratio it was higher this quarter than we had expected and there's really two pieces two it. One obviously Hep C and the other element is the early renewals. So we saw greater volume of early renewals and so customers choosing to stay with their existing plan typically healthier and younger and that led to less premium.

So those are two factors that were really influencing the commercial outcome and then when you blend that together with Medicare and Medicaid which had pressure from Hep C but overall are performing well in line with our expectations that meets the impact at a consolidated level. So hopefully that provides greater color on the implications inside each for the businesses.

Christian Rigg – Susquehanna Financial Group, LLLP

Understood. Thanks.

Steve Hemsley

And I wouldn't take any undue significance to the order. We just merely talked about commercial first and got it in there first, there was no intent there. Next question, please?

Operator

Our next question is from Sheryl Skolnick from CRT Capital Group. Your line is open.

Sheryl Skolnick – CRT Capital Group LLC

Good morning. I have to say to put this in context $0.35 worth of earnings pressure to come up with this decent quarter with hard work on a big organization and it's appreciated and I respect it very much. The question I have to get away from the important detail of Hep C and some of the other items is, to step back and perhaps take a look at the bigger picture of the company for a second.

I noticed that for example you spent $345 million, if my numbers are correct this quarter on acquisition. You're spending another $200 million on investments in the two Optum businesses Health and Insight in order to create platforms in structure and opportunity for further growth, but what I'm really I'm trying to get at it is, what else can you tell us or share with us about your thoughts on capital deployment.

Whether it be acquisitions or investment in the business or indeed dividend policy and share repurchase that we should be looking for as not so much offset but positioning the company for growth this year as well as in the out years.

Steve Hemsley

I offer a response that probably won't be very surprising and then ask Dave, if he has any comments. I would – our capital postures have been changed and in the broadest sense and they're all oriented towards balance of building for the future in continuing to grow and diversify and enterprise in a thoughtful and logical way and then making sure that we are returning capital to shareholders in a efficient as well as balanced way.

So we will continue to invest organically actually first and foremost and you can see those investments play out in our Optum business and there are also investments in the UnitedHealthcare business and I would also offer that a lot of our internal capital spending as you set in the financials are particularly related to technology in continuing to advance in a refine, a better and more modern health system that we can propagate across the country.

We continue to balance that with external growth and we continue to maintain a disciplined appetite to continue to grow and expand our business, where we see opportunities to either expand or position a market share that we are looking to pursue market position or secondly cultivate a capability and much of our investment is around bringing capabilities into [bear] and adding them to our portfolio.

Optum is a great example of this and our technology is its wealth. And then lastly to return capital by way of a balance between dividends which we have been advancing strongly and will continue to take an orientation to make sure that we are advancing them to a market pay out position and share buyback.

Those have served us well and they've been very consistently applied and it provides a nice balance in terms of being able to continue to advance, expand and diversify the business and capture that growth, which is really the sustaining longer term growth and opportunity as well as maintaining a discipline over capital efficiency and maintain appropriate and hopefully accretive capital returns and earning returns.

Dave Wichmann

Having that be, virtually impossible to say anything in addition to our shareholders. Dave Wichmann [indiscernible] for a couple of additional comments. First probably as you've seen in this quarter. We had a nice cash flow in the quarter particularly compared to last year and we are managing cash flows and our returns on invested capital very hard and in very disciplined way.

The increase in cash flows for this year to the $7.8 billion to $8.2 billion level be invested as Steve discussed. I think you've seen that, we had a very strong repurchase period in the first quarter here. Set 3 billion and 3.5 billion in shares repurchase through 2014 but clearly we are on track towards the upper end of that range at this stage.

In the spirit of continuing to return capital to shareholders. As you know, each of the last three years we've increased our dividend by 30% or more that is something that we are committed to reevaluate in periodically. We really look at the outlook of our business, the capital requirements of our business and then also what our peer benchmarks are I don't think it's news to anybody that we have some room to improve there.

On the M&A front, you notice there's a relatively modest investments but I think strategically important because they're aligned to, what we said at our investor day. They're really oriented more towards our Optum businesses where we see a stronger growth prospects turn these growth prospects and in that case.

We think, we've acquired the leading consumer digital health platform in the country, but in addition to that. We continue to extend our reach internationally with relatively modest but strategically important investments particularly in South America, where we think there's a wonderful opportunity long-term to grow.

So with that, I'll end. Thank you.

Steve Hemsley

Thank you for the question. Next question, please

Operator

Our next question is from Josh Raskin from Barclays. Your line is open.

Josh Raskin – Barclays Capital

Hi, thanks appreciate you guys taking the question here at the end. So I really just want to drill in to this commercial MLR ratio and make sure we are not overreacting to New York and a couple of things.

The good guys in the quarter to me would be the ACA fee. So it would be helpful if you could tell what the actual ACA fee was and maybe by segment that would be particularly helpful and then the impact of whether, it looks as though with your payables up four times as much as your premium sequentially. You're probably just assuming that utilization comes back and we will figure that out, when we get to see March, April claims.

And then on the bad side, hep C is $100 million of 36 basis points. Obviously not all of that is commercial and so I'm assuming maybe that's 10 basis points. So that certainly is not getting above your range and New York State I calculated you know about 7% your overall premium. So you know every 100 basis points there is seven bip.

So I'm struggling to figure out, what's going to drive you above the 80.5% plus or minus 50 basis point range in Commercial and really want to just make sure that New York is not bigger than sort of 7% impact or something that I'm calculating.

Well, we'll respond I think more in general terms and I agree there shouldn't be an overreaction and I would also agree that it is a portfolio of issues and pressures and we are kind of alerting you to that portfolio. So that is kind of context. Dan, do you want to respond?

Dan Schumacher

Sure. Good morning, Josh. It's Dan. You add a lot a pieces to that. First I want to clarify, you talked about the commercial loss ratio. The commercial loss ratio guidance is 79.2% plus or minus 50 basis point. The consolidated loss ratio guidance is 80.5% plus or minus 50 basis points.

And so as we look inside the Commercial business. We have two principal pressures, the bigger of which is the early renewal impact and having less premium. Good long-term thing, it impacts our premium in near term and then the second in the order of impact is, the Hepatitis C impact and when you put that together that gets muted on the Medicare and Medicaid side because they don't have those other dimensions we are talking about other than the Hep C.

And our consolidated basis, that might suggest that a loss ratio may lean towards the higher end of the range. That's about, also I think ACA fees. Our fees in the quarter, we're in the range of about $450 million on an expense basis and then obviously from a reimbursement standpoint, we have reimbursement in the commercial business, which is higher because it has insurer fees and the reinsurer's fees.

We have less in Medicaid because it's just the insurer's fee and then there isn't a mechanism in Medicare in premium to recover that. So hopefully that gives you some more context around the pieces.

Josh Raskin – Barclays Capital

Okay, so you didn't even mention as a pressure in commercial overall now. Is that because it's not big enough in terms of magnitude.

Dan Schumacher

That's more of an impact on the enrollment. So you look at a risk based enrollment and some of the pressure we are seeing there and potential forward, that's more a commentary on the enrollment and less on the loss ratio.

Joshua Raskin – Barclays Capital

Okay. So I guess I'm still struggling to understand the commercial ratios 79.2% plus or minus 50 basis point seeing impact of more than 50 basis points. Again I know hep C is small of the early renewals, I assume have to be a huge impact then much bigger than you guys were expecting.

Unidentified Company Representative

It's a very meaningful impact on the early renewal side, we saw more than two times the volume, we had expected.

Joshua Raskin – Barclays Capital, Research Division

Okay.

Steve Hemsley

But again, also a good thing in terms of it positions us and how it sustains that members and does it for a good period. So I think, while there is resulting pressure. The reality is, I think a very good business decision and a good outcome for us. Right.

Joshua Raskin – Barclays Capital, Research Division

Right and no impact from weather then because that wasn't mentioned.

Unidentified Company Representative

I would tell you, as we look at weather in the quarter. It was a very smallish impact. As you look which days were the heaviest in relation to what we see a normal patterns as you look at where our densities are from a population perspective. It wasn't particularly meaningful.

Joshua Raskin – Barclays Capital, Research Division

Okay. Thanks.

Steve Hemsley

But you've a very good list, Josh. You were listening very attentively and but I think we will conclude our Q&A session for this morning as always. There an opportunity for you to talk to John and Beth and so forth through the course of the day. I just might sum up by saying UnitedHealth Group, Optum and UnitedHealthcare are tracking to the plans, we shared with you.

As we told you in December. We fully expect the challenging conditions throughout 2014 and we are working through the headwinds of ACA implementations, the Medicare cuts, comparative market dynamics etc. we would have had an underlying growth rate of more than 20% absent the impact of ACA taxes in the regulatory provision.

We believe we have the right plans and plays to deliver on our commitments and we know the people of this company have the talent, the experience, the innovation and the drive and are determined to succeed. So we thank you again for joining us. We will see you next quarter and this concludes this morning's call. Thank you.

Operator

That concludes today's program. You may now disconnect at any time and have a wonderful day.

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