Teladoc Health, Inc. (NYSE:TDOC) 41st Annual J.P. Morgan Healthcare Conference January 9, 2023 12:00 PM ET
Jason Gorevic - CEO
Mala Murthy - CFO
Conference Call Participants
Lisa Gill - J.P. Morgan
Good morning. Are we good to go? Good morning. My name is Lisa Gill and I'm the healthcare services analyst with JPMorgan. It is with great pleasure this morning that we have with us Teladoc Health. Presenting for Teladoc Health, will be CEO, Jason Gorevic. And then for the Q&A session, CFO, Mala Murthy will join me here at the table.
With that, let me turn it over to Jason. Jason?
Thanks, Lisa, and thanks, everybody for joining us this morning. It's so nice to be back in sunny San Francisco. Really happy to be back in person after a bit of a hiatus. But as I think about the last three years, an awful lot has changed. When we were here three years ago, we were pre-pandemic. Telehealth was something that some people knew about, people had engaged. But I would say, legitimately, people didn't really appreciate the scope and the scale of what telehealth could do.
Virtual care now is expected to deliver on the full scope of consumers' healthcare needs. And at Teladoc Health, our mission is to empower all people everywhere to live their healthiest lives by transforming the healthcare experience. We do that through a comprehensive, broad and deep telehealth platform.
Our virtual care platform now serves over 80 million people and that platform enabled over 21 million visits just last year in 2022. Because of the fact that we deliver over a 0.5 billion digital health interactions through 30,000 providers on our platform and deliver unmatched consumer experience with over a 60 Net Promoter Score. Teladoc Health is the number one brand in virtual care. It's not just the number one brand among consumers. It is also among health plans, hospitals and health systems and both domestically and internationally.
Through the last three years, a lot has changed. What hasn't changed is the financial strength of Teladoc Health. You may have seen this morning, we issued an 8 K that narrowed our guidance to the high end of our previous range with that narrowed our guidance to the high end of our previous range with quarterly revenue -- new revised guidance, but between $633 million and $640 million. Meaning a full year revenue number of $2.403 billion to $2.41 billion.
We also reiterated our previously announced adjusted EBITDA guidance of 88 million to $98 million for the quarter and $240 million to $250 million for the year. That constitutes a 400 basis point improvement in margins over the last three years. So as we've gone through this transformation of what consumers expect and what Teladoc Health delivers, we've expanded our margin, created greater scale and consistently now delivered positive operating cash flows with a strong balance sheet of over $900 million on the balance sheet.
This is in stark contrast and I get asked a lot about the competitive landscape. This is in stark contrast to many of the small competitors out there whether they are public or private who lack the scale to be able to take advantage of this financial discipline and deliver strong financial results consistently.
When I think about the last selling season, you may have heard me say at the end of the third quarter, that the third quarter was a catch up quarter when we talk about bookings. Bookings in the first half of the year had been slower due to a lot of the macro environmental things that were going on and the fact that more and more we're selling a more complex bundle of services that legitimately elongates the sales cycle. The third quarter was a strong quarter and the fourth quarter came in just about exactly with our -- in line with our expectations. So we closed the year with bookings for the full year '22, very similar to bookings for the full year '21.
I want to highlight some of the ways that we grow and do it in the context of some of these new deals that we've put on the books over the course of ‘22. In some cases like with Centene, we're expanding the populations we serve with new products like our partnership around Primary360 and especially with respect to their exchange based virtual first health plans. So we piloted that program with them in ‘22 and we've significantly expanded it going into ‘23.
With some clients like some of our Blue Cross Blue Shield partners, we're going in with the entire suite of our chronic care solutions, delivering on the promise of whole person virtual care and doing it in a way that meaningfully moves the needle on the full cardiometabolic suite of services that we offer which delivers better clinical outcomes and lower costs for our partners and for their clients and members.
We do that both with health plans as well as with large employers. Southwest has been a client for almost a decade now, and they started with General Medical Services. And today, we've expanded to our entire suite of cardiometabolic chronic care solutions. That's a great example of our land and expand and how we continue to deliver more value for our clients.
I'll talk in a little bit about a new product that we're bringing to market for hospitals and health systems. Inpatient connected care, where we light up our hospital room and virtualize it so that a hospital can take better advantage of a scarce professional workforce. Because we all know that the hospitals are under pressure for the availability and the cost of clinical resources. And we're delivering care and technology assets both domestically as well as internationally. And Charite is a good example of that in Germany.
When we think about and I hear a lot about whole person care, there are a lot of companies out there talking about whole person care. When we think about whole person care, we really mean that you have to have the entire full credit answer. From a consumer's perspective, you have to have everything from primary care to acute care, everything from chronic condition management to specialty care, and you have to take care of both the mental and physical health of a consumer because they are intricately intertwined.
And the green bubbles here represent the capabilities that are necessary to do that at scale. If you can't engage a consumer population, you can't drive meaningful behavior change, and therefore, you can't drive better outcomes. If you don't have an integrated experience, then it's a disjointed set of capabilities and clinical programs, that's not whole person care. And so I can confidently say that we're the only one who has the set of capabilities, the integrated consumer experience and does it at significant scale.
And when we look at what are the proof points of that, the proof points are in what are our clients buying from us and what are our consumers using. When I look back at 2017, fewer than 10% of our population had access to more than one of our products. Today, over 50% of the population we serve. Remember, that's 80 million people. Over 50% of them have access to more than one of our products.
And when I look at chronic care programs, just in 2019, we're at 3% of people using more than one of our chronic condition management programs. And today, we're at about 28% of people engaging with more than one of our chronic care management programs. In a couple of slides, I'll show you what the impact of that is on clinical outcomes.
Now this has been a journey, right? I've been in this role for 13 years. And over the course of that time, our vision hasn't changed. The mission to deliver on whole person care hasn't changed. What has changed is the scope of our offering. And this has been a methodical march to be able to expand the scope of our capabilities, the clinical programs that we deliver, and therefore, the value and impact we have for the clients who buy from us, the partners who work with us and the consumers that we serve.
And you can see in '23 and beyond, we're continuing this march to be able to deliver more value and make a bigger impact on health outcomes and on cost of care. We want to partner with health plans and with employers to deliver better care. We also recognize that the health systems can't be ignored in this effort. And so we engage both on the health system and delivery side of the market as well as on the planned sponsor side such that we can bring a fully integrated set of capabilities that works with the entire health care system, not against it.
I want to highlight just three of these innovations that we've brought to market over the last -- probably nine months now. First, just last week, we announced the delivery of our unified one app, a single app that gives the consumer access to all of our clinical programs and all of their clinical data in a unified experience under one Teladoc Health brand and that brings together both mental and physical care, both chronic and acute and episodic as well as a longitudinal relationship where one exists with either a specialist for chronic care management or with a primary care physician under our Primary360 program.
We've been talking about whole person care for a couple of years now. This is where it all comes to life in a single experience for the consumer. And most importantly, it delivers better clinical outcomes because it's all together in one experience.
Last year, we launched Chronic Care Complete. Chronic Care Complete takes the legacy Livongo capabilities, devices, which sit on top of robust data science and deliver digital interactions with the consumer to change behavior and improve clinical outcomes. And we put that together with the Teladoc Health Virtual Care delivered by physicians. And so now when someone has an exacerbation or needs medications titrated, there's a physician there working with all of our digital assets to deliver a better experience, but most importantly, better clinical care that drives better outcomes.
And lastly, I mentioned our inpatient connected care. This enables a health system to take their nursing workforce and make them virtually enabled into every bed and every room in a hospital. Where hospitals are under pressure and health systems are under pressure for a more expensive and scarce workforce. This enables them to get better productivity and better leverage that workforce. The investments that we're making, and we've been talking about the fact that over the last couple of years, they've been heavy investment years. But those investments are necessary to be able to deliver whole person care in a comprehensive manner and do it at scale.
And so on the bottom, the bottom row here, you see all the capabilities. Technical capabilities, logistical capabilities, quality of care delivery capabilities that enable the delivery of the care at scale in a comprehensive manner. These things may not seem sexy, but they are absolutely required. They are a pre-requisite to be able to deliver whole person virtual care at scale.
And so on the top, the top row is what the consumer sees. It's what the consumer experience is. So when we talk about a stepped care model, it's the ability for the consumer to experience digital interactions when that's appropriate and sufficient and interact with a highly trained, highly specialized physician when that's really necessary. It enables us to leverage technology and also human resources to be able to make the biggest impact and deliver the most efficient and most appropriate care to the consumer.
Last year, we announced last mile integration, where we now are able to have pharmaceuticals delivered directly to the consumer's home. Of course, if you have a virtual care environment, you don't want to then have to have someone make a trip to the pharmacy, right? So we want to make sure we can deliver that to the home. We also have enabled now in-home lab testing for similar reasons, right? All of this should come to the consumer just like every part of everything else we do in our lives.
And this year, we're partnering with health plans to close gaps in care, using data better to be able to close gaps in care. And you'll see some of those results when I talk about our Primary360 and some of the clinical performance around our Primary360 product. And all of this is in service of delivering more value. If the features are only features, but they only really are meaningful if they move the needle on clinical outcomes, cost of care and consumer experience.
I mentioned the expansion of our multiproduct sales and our multiproduct utilization. So let's go one level deeper into what that means in terms of clinical outcomes. When someone has more than one and engages with more than one of our chronic condition management programs, they're checking their blood glucose more than twice as much, right? So we know that when we engage someone with multiple programs, they're going to be a more engaged and more active member of changing their behavior. They can only measure that if they're actually checking their devices.
And so we know that, that's a mechanism to be able to get people to live healthier lives and take a more active role for themselves. This is in stark contrast to single point solutions that are in the market. Similarly, the more programs someone has access to, the more engaged they are and the more they impact their hemoglobin A1C levels. And you can see how that makes a bigger impact, every additional program that they engage with.
And lastly, mental health is a critical component of helping someone manage their chronic conditions. So you can see that they achieved almost a 2% increase in weight loss when they engage with our mental health programs and a significantly larger impact on their A1C levels when they engage with our mental health programs. Delivering great health care isn't just about the physical, it has to incorporate the mental health components of it.
And so I said I'd go deeper. When we started talking a little more than a year ago about Primary360, we said it was going to take us a little bit of time and a little bit of experience and some scale to be able to really demonstrate what the results are. So here are some of those results. We're getting greater engagement from those who have been disenfranchised by the health care system. 65% of the people who engage with Primary360 say that they didn't have a primary care physician.
Once you engage people, you can then engage with them on better prevention. So 20% of the women who came to us were in need of a pap smear. They were overdue for their preventive screening and we were able to get them in and get that scheduled. And 31% were due for a colonoscopy. And we were able to get that scheduled and get them the preventive care that they need. Preventive care leads to earlier detection.
37% of the people who are being treated for diabetes under our Primary360 product are newly diagnosed diabetics. And 25% of those dealing with hypertension are newly diagnosed by Primary360. These are people who would have gone undetected. Remember, they didn't have a primary care physician and would have led to exacerbations, more cost to the system and worse outcomes. And the clinical impact is significant. 56% of those presenting with high blood pressure have lowered their blood pressure. And more than 50% have used more than one Teladoc Health Service. The benefit of multipronged holistic whole person care is real. And the consumers feel it with over 70 Net Promoter Score from our Primary360 program.
Finally, I want to turn to our BetterHelp direct-to-consumer mental health business. There's been a lot of questions and a lot of talk about BetterHelp. And I think it's because it's been so successful, right? We just announced as part of our 8-K this morning that BetterHelp did over $1 billion in revenue in 2022. That's staggering growth. Over 1 million people received therapy over the course of '22 from BetterHelp.
With nearly 50 million interactions with therapists and over 25,000 therapists on the platform. This is incredible scale and incredible impact. More than 50% of people in this country who are in need of mental health don't get it. And BetterHelp is a better modality, it's more accessible and it breaks down barriers to getting care that people need. And it's a business that benefits from scale.
More data, more innovation leads to better matching between a therapist and a consumer, which we know drives better outcomes and stickier relationships. And better engagement leads to better retention and there's a brand halo to this. BetterHelp is by far the leading consumer mental health brand in virtual therapy. But beyond all of that, it gets to what's really the impact. 88% -- we get all kinds of questions about, well, what's the conversion rate? How good is this? How efficient is this business?
88% of members who have a first therapy session stick with it after that first therapy session. Two-thirds of patients report clinically significant improvement in their anxiety or depression using the GAD-7 or the PHQ-9 as the measure, which are industry standard measurement tools for depression and anxiety, and we deliver a great consumer experience with NPS over 70. These are the hallmarks of a business that has grown, but has also leveraged data and scale and experience and innovation to continue to improve.
So as I wrap up, and I think I'm 1.5 minute over time, and we go into Q&A. I guess I just want to reiterate that there are a lot of virtual care companies out there who are narrower, who lack scale, who are nipping at the edges with single point solutions, but there's really only one virtual care leader that's operating at scale and delivering on the promise of whole person virtual care.
Q - Lisa Gill
Thank you for all the comments, Jason. So let's start with, obviously, you talked about where we're going to end 2022 and really shift the focus now to beyond '22. And I know you're not giving guidance for '23 at this point. We do have to wait for the fourth quarter for that. But how do we think about the underlying business and what's really changed post-pandemic? And how do we think about your business model going forward?
Yeah. Thanks, Lisa, and thanks again for having us. We really appreciate it. I think the biggest difference post-pandemic is consumer expectations, right? Consumers have gone from thinking about virtual care for limited episodic capabilities to really looking to longitudinal relationships, holistic relationships that are more than virtual urgent care, right, and that take care of them regardless of what they need, but also are integrated with the physical delivery system.
And as I look toward '23 and beyond, that's what we're seeing from buyers, right? Buyers -- we go out and do a lot of buyer research, right, among health plans, among large employers. And what we find is, whereas pre-pandemic the majority of buyers were looking for individual point solutions. We're now at the stage where it's 50-50. 50% of buyers say, I'm looking for best of breed individual points, and I'll do the integration of them. And the other 50% are saying, I'm tired of all that, right. I'm sick of doing the integration myself, and I realized that unintegrated point solutions don't deliver on the full capability. And so I think that's why 75% of our sales last year were multiproduct sales.
I appreciate the numbers around BetterHelp. And I think for those of you in the room that follow Teladoc, that's been really the pressure point for 2022. As we thought about the fourth quarter and where the numbers have come out, maybe just help people to understand how you're thinking about the BetterHelp business. Does it fit within Teladoc overall and longer term?
And then secondly, Mala I heard you talk about the [indiscernible] have more visibility into BetterHelp going forward. So what are some of the metrics that we'll see? Will you see this broken down specifically where we think about sales and margins, et cetera., on a go-forward basis?
Yeah. So if I think about the BetterHelp business, certainly, if I think about 4Q, we talked about the 8-K revenue today. We talked about it being about $1 billion in revenue for the full year. Listen, this is a business that has scaled very significantly. What is important as we think about this business also is that it has done so with strong margins. And we've talked as we have gone through the year about the pressures on ad spend, et cetera., in the marketplace. Certainly, there has been an explosion of capital going into overall digital health, but certainly in the metal health space.
And several of the companies who have operated in this space certainly have plowed a lot of capital into digital -- into ad spend. And listen, we've also seen some bad actors in the space who have taken advantage of the suspension and regulations to sort of aggressively promote controlled substances. That is not what we do. What we have always said is, the way we approach this business is in a way that we will drive sustainable revenue growth and at attractive margins, and we do so taking advantage of our scale or experience. And importantly, as Jason talked about, our high quality standards.
So if I think about this business going forward, certainly, it will -- the right way to think about it is balancing our revenue growth with profitability. And as you said, we will provide more transparency on a quarterly basis as we move forward. We are going to give you more color on the exact metrics that we will disclose when we talk about it in February.
And does it make sense, I mean just given the valuations of some of the other companies out there, would there be a value creation opportunity to not have BetterHelp as part of Teladoc or does it make sense for this to still be a component of Teladoc when we think about consumer?
Yeah. So we do the analysis all the time in all the parts of our business, right? It's part of being good stewards of capital. We get a lot of benefits from the synergies between the two parts of the business, the direct-to-consumer business and the B2B business. Just some examples. BetterHelp developed a very, very sophisticated matching algorithm for matching a consumer with a therapist. It's based on just years of and reams of data, and we did it using a machine learning algorithm or a set of capabilities to deliver this algorithm.
We apply that now against the B2B side of our business to deliver better mental health outcomes because of better matches. Similarly, because BetterHelp is a direct-to-consumer marketing engine in order to attract new clients, we've developed things like media mix optimization algorithms that we also apply against the B2B side of our business to be able to do better consumer engagement. And we've always said that part of our value proposition to B2B buyers is that we get greater engagement than any of our competitors.
And so there are significant benefits. Similarly, we have used some of our learnings out of the B2B side where we get more pressure from our health plans and employers to deliver on higher quality standards, and we've applied those against BetterHelp in a direct-to-consumer environment. So it may not be quite as evident but there are significant synergies from the combination of the two.
So we've been writing a weekly piece on flu. And I know that years ago, when your company was much smaller, so we made a big difference, right? It could be a big swing factor, it would introduce people to a tele-benefit during that period of time and maybe use it again. My understanding is not as big a deal these days. But was there a benefit in the fourth quarter ran flu?
Yeah. So if you think about visit revenue overall for our business, it's about 10% of our overall revenue, and flu is a subset of that. So if you think about the impact of flu on our 4Q, it's approximately $2 million. So again, if you think about it in the scheme of the overall revenue we have, compared to a few years ago, we are so diversified compared to what we were a year ago. So flu is a small portion of visit revenue, which in turn is only about 10% of our overall revenue.
Does it still introduce the idea of telehealth or did the pandemic do all that for us, Jason?
Yeah. I think we're past the point of awareness, right? We don't have to build awareness in telehealth anymore. And historically, pre-pandemic, the flu would help to do that. Now it's more about sort of expansion and educating consumers on the full scope of what they can get from virtual care, right? So the full scope of being able to take care of chronic conditions, being able to get longitudinal primary care, being able to get integrated mental health into those programs.
So I don't think it really has -- maybe it does a little bit around the edges to engage a consumer. They have a great experience. And so they're willing to come back for more. I do think once we bring more people on to our single unified app, that will expose them to the full breadth of our services. And so more in the top of the funnel, if you will, will have a downstream impact on all of those other services.
As we think about '23, it's been interesting, I think, for all of us in the room to watch what's happened with employment trends much stronger than anticipated. But as we think about the macro background and we think about especially a direct-to-consumer product like BetterHelp, how do we think about how that could fare because it wasn't around back in '08, '09.
You want to me to?
So if we think about the overall macro trends, the first thing I would say is parts of our business were a lot more subscale or not even developed in the '08 cycle, for example. So let's first start with that as a caveat. But if I think about the various dynamics playing out, Lisa, let's start with the BetterHelp part of the business, right? It's interesting.
There are a couple of different somewhat opposing dynamics at play. If you think about, say, inflation staying high or macro uncertainty generally impacting consumer sentiment, making them feel more uncertain, that certainly may have an impact on them availing themselves of BetterHelp because as we have talked about, it is an expensive product. It's one of the more expensive products that's not in a box that you can buy online as we say.
But opposing that, Jason talked about it in his remarks, if there is a recession and material job loss and people lose their employer sponsored coverage, they can absolutely avail themselves of BetterHelp, which is going to be less expensive than traditional brick-and-mortar. So you have a couple of opposing forces here. Somewhat similarly on the B2B side as well, Lisa, we have talked, as we have gone through this year about the macro uncertainty certainly playing on employers minds, benefits managers being distracted, right? They have a lot to sort through.
And therefore, even as we are confident about the value we deliver to them and the ROIs, it may be challenging for them to add on additional programs. That said though, given that their cost inflation and given especially the medical cost inflation that would be a perfect opportunity for us to be able to sell in the value we deliver and how we can help them in terms of cost savings.
Jason, you've talked in the past on chronic care. And I've talked about a pilot program that you had with Blue Cross Blue Shield in 2021. Maybe if you can just walk us through kind of where it is today. So many in this room and other places are talking about value-based care and what does value-based care actually really mean when we think about this? And what is the role that Teladoc can play as we think about that future?
Yeah. So we're leaning heavily into value-based care. I know it's probably an overused term, you're right. For us, value-based care really means being paid for either the clinical quality and clinical outcomes that we deliver or the cost impact that we have or both, right, sort of full stop. So in this case, this pilot we did with a Blue Cross Blue Shield plan said, here we're going to take a fixed per member per month or per subscriber per month fee for some of our chronic care programs. We want you to measure the cost of those populations that we serve and that we engage with, and we want to share in the savings that we generate.
And so the client did their own actuarial team, did the analysis. They measured the impact. We were significantly, significantly less expensive, meaning the -- we drove cost savings relative to the benchmark population that significantly exceeded their expectations. We were able to achieve a share of savings bonus. This was a small pilot, so it wasn't material in our overall financials. But I think the benefit there is that, number one, we were able to get this bonus. But more importantly, the Blue Cross Blue Shield plan accelerated their rollout of these programs because of the impact that we had on this population and the demonstrated value that we were bringing.
We see ourselves continuing down that path with multiple payers going forward. We see others who are more focused on clinical outcomes. And so we're willing to put our fees at risk for achieving real outcomes and movement of the needle in terms of someone's A1C or their blood pressure or weight loss. And so we want to be held accountable for delivering real value. And finally, we're in market now with a client where we have a Primary360 population. We get paid a specific per member per month fee and we share in the savings we generate or if there's a cost overage relative to a benchmark population. We share in that as well.
We have a ceiling on -- and it's a 50-50 split with us in the plan. So we are mutually motivated to drive better results. We have a cap on what our revenue can be in terms of a bonus. We have a floor in terms of the downside. So we know exactly what our exposure is. But we want to be holding hands with our partners to deliver better care and lower cost and do it in a way where our incentives are aligned.
When we think about the biggest opportunities going forward when we think about both value-based care. I think the example you just gave is some level of primary care capitation within Primary360. Is that a bigger opportunity? Is chronic care a bigger opportunity for you longer term? And as I think about the customer you're going to be most focused on in these areas, is this the self-funded employer or is this the managed care plan?
I think the answer is yes, right? So when we do, for example, kind of a primary care capitation with an upside, downside risk corridor, we want to bundle in our chronic care management programs because that's how we're going to have the biggest impact on cost and outcomes. So we're bringing all of those together. And I think the true answer is, where we are going to make the biggest impact is where we bring all of those capabilities together for a given population.
It's not to say we won't sell chronic care either diabetes as a stand-alone product or a full cardiometabolic suite without primary care and take some level of risk on that. But I think where we're going to have the biggest impact is when we bring all of those capabilities to bear. And we're seeing significant interest both from the plans as well as from large employers. And even in some cases, the large employers who are self-funded, pushing their health plans to do this and make our products and services available through the plan.
I think post pandemic, it's been a rough time for Teladoc. And I think that you guys have to stay focused on delivering on the numbers, getting people refocused on the areas, getting more visibility. We're all looking forward to that on BetterHelp. But Jason, we're sitting here together at 9:00 a.m. on Monday. A year from now, what do you hope that investors will better appreciate about Teladoc than they do today?
Yeah. I think my hope is maybe three things, they better understand the components of our business and appreciate how each one of those components contributes to the overall performance. Second, they really see us differentiating ourselves in terms of delivering on the promise of whole person care in a way that is broader and at a scale that nobody else really can match. And third is that we get appreciation for the financial performance of the business, which I believe is really differentiated in the sector.
Yeah. I don't -- I think sometimes when we talk to investors, they don't realize that you are cash flow positive.
Indeed. So if you think about the strength of our balance sheet, the fact that we have $900 million on our balance sheet, the fact that we are operating cash flow positive. And we will continue to make progress on that. These are absolutely -- it allows us to invest in our business. The innovation slide that Jason talked about, that is something that we are building and using the strength of our P&L and the strength of our balance sheet to help drive. So that is absolutely a differentiator for us.
Great. Well, we're out of time. Thank you so much for joining us, everyone, and thank you, Jason and Mala.