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spk14: Good day, and welcome to the Centene fourth quarter and full year 2023 earnings results conference call. All participants will be in listen-only mode. Should you need assistance, please signal a conference specialist by pressing the star key followed by zero. After today's presentation, there will be an opportunity to ask questions. To ask a question, you may press star then one on your telephone keypad. To withdraw your question, please press star then two. Please note today's event is being recorded. I would now like to turn the conference over to Jen Gilligan, Head of Investor Relations. Please go ahead, ma'am.
spk09: Thank you, Rocco, and good morning, everyone. Thank you for joining us on our fourth quarter and full year earnings results conference call. Sarah London, Chief Executive Officer, Andrew Asher, Executive Vice President and Chief Financial Officer of Centene will host this morning's conference call, which also can be accessed through our website at centene.com. Ken Fasola, Centene's President, will also be available as a participant during Q&A. Any remarks that Centene may make about future expectations, plans, and prospects constitute forward-looking statements for the purpose of the Safe Harbor Provision under the Private Securities Litigation Reform Act of 1995. Actual results may differ materially from those indicated by those forward-looking statements as a result of various important factors, including those discussed in Centene's most recent Form 10-K, filed on February 21, 2023, and other public SEC filings. Our Form 10-K for 2023 will be filed in coming weeks. Centene anticipates that subsequent events and developments may cause its estimates to change. While the company may elect to update these forward-looking statements at some point in the future, we specifically disclaim any obligation to do so. We'll also refer to certain non-GAAP measures. A reconciliation of these measures with the most directly comparable GAAP measures can be found in our fourth quarter 2023 press release, which is available on the company's website under the investor section. The company is unable to provide a reconciliation of certain 2024 measures to the corresponding gap measures without unreasonable effort due to the difficulty of predicting the timing and amounts of various items within a reasonable range. With that, I would like to turn the call over to our CEO, Sarah London.
spk10: Sarah? Thanks, Jen, and good morning, everyone. Today we reported a strong finish to a very productive 2023. Fourth quarter results include adjusted earnings per share of 45 cents generating full year 2023 adjusted EPS of $6.68. The quarterly and full year EPS results were slightly ahead of internal expectations and provide the organization with positive momentum as we head into 2024. We've been planning for and talking about 2024 for a while, and now that we're here, we're focused on positioning each of our lines of business for long-term growth while continuing the important work to fortify our platform as we prepare for 2025 and beyond. Specifically, we are working through the tail of the redeterminations process, positioning Centene to resume organic enrollment growth in Medicaid and to pursue new program opportunities from a position of strength. We are solidifying our Medicare Advantage footprint thanks to an annual enrollment period that largely hit the mark with respect to our target membership, including sales, retention, and disenrollments. and we are capturing a powerful growth opportunity in Marketplace, demonstrated by the increased revenue guidance we issued this morning. We recognize that amid these opportunities, we still have valuable bottom line work to do, and we are approaching that work with the same focus and disciplined execution that has defined the first two years of this management team's tenure. In fact, the CEN team wasted no time setting the tone for 2024, by successfully delivering what we believe to be the largest ever PBM platform migration and improving our pharmacy cost structure on behalf of our customers and members. We have processed more than 40 million scripts so far through ESI and are pleased with the way this massive undertaking has rolled out. There is always a period of issue management after a change of this magnitude, and the teams have worked tirelessly and collaboratively to prioritize member access to care during this transition. We will continue to closely monitor end-to-end processing and customer service as we move through the year. Additionally, in January, Centene closed the divestiture of Circle Health, the last of our international assets, and the company can now focus solely on our domestic core businesses. Circle marks the 10th divestiture since we began the portfolio review process in late 2021, and we are pleased to have purposefully streamlined our enterprise while keeping the portfolio of divestitures net accretive to earnings and generating cash for deployment. In the broader context of value creation, our SG&A initiatives remain on track to exceed our original savings goals, and we continue to identify opportunities to drive operating efficiency through modernization and process improvement. Annual enrollment periods for both Marketplace and Medicare also contribute to our confidence in Centene's 2024 positioning. continued pricing discipline in Marketplace, and the deliberate actions we took to align our 2024 Medicare bids with our strategic focus on lower income and complex members yielded the intended results on both fronts. Marketplace growth was more robust than anticipated, fueled by better than anticipated overall market growth, as individual commercial offerings continue to gain traction with an expanding consumer set. As such, we expect to deliver both growth and our planned margin expansion in Marketplace in 2024. Together, these dynamics position us well to achieve our 2024 adjusted earnings per share guidance of greater than $6.70. With that, let's click deeper into each of our core business lines. Within Medicaid, we have delivered important proof points around the power of incumbency while navigating the unprecedented dynamics of redeterminations. In December, we were awarded the Arizona LTSS contract that will expand our footprint in serving complex populations in that state. That same month, we added approximately 90,000 members to our care and coverage through the successful go-live of Medicaid expansion in North Carolina. And in early January, we successfully re-procured our New Hampshire contract, earning the top score in the Granite State among competitors. Our uniquely local footprint fosters important and trusted relationships with the communities and state partners we serve, and continues to differentiate us as we retain and grow our largest business. Turning to redeterminations, the process continues to track largely in line with our expectations. As of year end, we were approximately 80% of the way through the projected member transitions, and consistent with our modeling, we ended 2023 right around 14.4 million Medicaid members. Our health plan presidents, along with our Medicaid actuarial teams, continue to work in concert with our state partners to monitor the risk pool impact of membership changes and calibrate rates to match acuity in the near term. To that end, we received some, but not all, of the outstanding 2023 retrospective rate adjustments we mentioned during our December investor day before year end, and we still feel good about our 2024 Medicaid guidance as we sit here in early February. While Medicare has been a hot topic for the industry of late, we are pleased that the annual enrollment period played out largely as expected for Centene. And our 2024 financial projections for Medicare remain unchanged from investor day. Duals or decent members have grown as a percentage of our Medicare enrollment as thoughtful benefit design changes allowed us to invest in and effectively refocus our book on members to whom we have the strongest ability to provide long-term value. We expect DSNIP members to represent more than 35% of our Medicare Advantage membership by year end, an important step relative to our strategic plan. As an organization, we remain laser focused on advancing our Medicare quality agenda. We made progress on a number of initiatives in 2023 that create positive momentum as we continue to execute in 2024. This includes expanding our member outreach capacity, which ultimately allows us to conduct over 1.1 million preventive service outreach calls, reach 80% more members, and schedule 62 more appointments year over year. At the same time, we invested in digital data and provider connectivity, successfully deploying direct EMR connectivity to over 640,000 provider practices. And finally, we continue to drive core administrative and customer experience performance with service levels remaining in the high 90s through Q4. All of these efforts are important contributors to our long-term STARS performance goals. In 2024, as planned, we will continue to invest in this space with an obvious focus on Medicare Advantage STARS ratings, but with an approach that will drive benefit across lines of business. With respect to Medicare utilization, as you heard from us in December, our 2024 bids incorporate a level of elevated medical trend related to non-inpatient services. To date, based on our full year and fourth quarter claims experience, we continue to view our pricing posture as adequate to support our 2024 Medicare outlook. Preliminary Medicare advantage rates for 2025 were released last week. Bearing in mind the continued expectation for the multi-year phase-in of the risk adjustment model change that was finalized in 2023, we view the preliminary rates as insufficient with respect to general medical cost trend expectations. Drew will provide some additional thoughts on the preliminary rate in a moment. As this audience is well aware, we will receive final Medicare Advantage rates for 2025 in early April, and at the time of our first quarter call, we will have a better directional sense for bid strategy related to next year. Finally, Marketplace. As you've heard from us with increasing enthusiasm in recent months, Marketplace presents Centene with a unique opportunity for simultaneous revenue growth and margin expansion in 2024. Overall market growth was stronger than expected during this open enrollment period, and we successfully captured our target market share of the expanded pie, netting to stronger than expected OEP results for the company. Within our 4.3 million member footprint as of January, our market share increased to roughly 26%, up from 23% previously, serving as another proof point of our leadership in the space. This strong enrollment result is driving the $2.5 billion increase to our full year 2024 premium and service revenue guidance. Membership mix continues to skew slightly younger, consistent with the year-over-year trend we saw last year, and distribution across metal tiers is consistent with our expectation, with silver plans representing the majority of our enrollment. One driver of overall marketplace growth has been members impacted by Medicaid redeterminations. On that front, we continue to track towards the top half of our previously provided guidance range of 200 to 300,000 redetermined lives captured by Ambetter. Ultimately, the individual commercial market represents a strategic opportunity for Centene, and we are excited to enable the expanding reach of these offerings as the demands of the market evolve. While the dynamic businesses Centene operates in continue to ebb and flow, the strength and diversification of our government-sponsored healthcare platform creates resiliency. We see tremendous opportunity for our core products, both near and long-term. We will continue to execute against these opportunities to improve health outcomes for our members, generate profitable growth, and drive shareholder return. Before I turn it over to Drew, I want to take just a moment to thank the entire CENT team for how you showed up in 2023 on behalf of our members and our partners. I am honored to work alongside you in 2024 as we make this company stronger every day and transform the health of the communities we serve one person at a time. With that, I will hand the call over to Drew for more details around our financial performance and 2024 outlook.
spk15: Thank you, Sarah. Today, we reported fourth quarter 2023 results, including $35.3 billion in premium and service revenue and adjusted diluted earnings per share of 45 cents in the quarter. For the full year, we reported $6.68 of adjusted EPS, growth of over 15% compared to 2022, including a 5.5% beat to our original 2023 guidance. And that's on the heels of growing adjusted EPS 12% in 2022 compared to 2021. Our Q4 consolidated HBR was 89.5%, while our full year consolidated HBR was 87.7%, both in the range of our expectations. Medicaid at 90.0% for the full year was slightly higher than our expectations. As of Q3, we were 89.9% year-to-date, and we posted 90.6% in the fourth quarter. As we mentioned at our investor day in December, there were some open Medicaid retro rate adjustments. At year-end, had we received those adjustments, our full year 2023 Medicaid HBR would have been about 10 basis points better. All things considered, Over nine months into redeterminations, our original forecast for membership, acuity, and rates were very close. As you can see in the membership tables, we were at 14.47 million Medicaid members at year end, consistent with the 14.4 million we were forecasting as shared in the investor day appendix. That reflects an approximate 1.9 million Medicaid member reduction since 3-31-23, due to redeterminations as expected. To reiterate what we laid out at Investor Day, our 2024 guidance reflects a low point of 13.2 million Medicaid members at 331.24 and year-end 2024 membership of approximately 13.6 million. That all ties to our 2024 midpoint of 80.5 billion of Medicaid premium revenue. No changes to our 2024 view of Medicaid revenue, membership, or HBR. Medicare full-year HBR was 87.1%, which includes the $250 million premium deficiency reserve recorded in the fourth quarter that we first discussed with you back in April of 2023. On Medicare trend, we continue to see steady but elevated levels of outpatient trend consistent with what we began to see in Q2 and consistent with our forecast. We also saw a pickup of COVID costs in December, as we mentioned in early January, though not alarming compared to prior COVID cycles. We thought about the current level of trend when we booked the 2024 PDR and continue to believe our forecasts are consistent with delivering our 2024 Medicare segment guidance elements outlined at Investor Day. To help you with some math, the $250 million premium deficiency reserve lifted the fourth quarter Medicare segment HBR by approximately 475 basis points and the full year Medicare HBR by approximately 110 basis points. The commercial HBR at 79.8% for the full year continues to be strong. Simultaneously in Q4, we were also capturing growth from both redeterminations and the special enrollment period, and we were up to 3.9 million Marketplace members as of year end. That is the source of the strong premium growth in the fourth quarter. And as you heard from Sarah, we couldn't be more pleased with the growth that continued into January 2024, up to approximately 4.3 million members. This continued growth and HBR performance in 2023 sets us up very well to achieve our 2024 marketplace goals. Moving to other P&L and balance sheet items, our adjusted SG&A expense ratio is 9.7% in the fourth quarter, compared to 9.3% last year, consistent with our updated mix of business, along with Medicare distribution costs. Cash flow provided by operations was $8.1 billion for the full year, representing 2.2 times adjusted net earnings. This was primarily driven by net earnings, an increase in risk adjustment payable for marketplace, and the timing of pass-through payments. Our unregulated and unrestricted cash on hand at year end was approximately $200 million. During the fourth quarter, we repurchased 397,000 shares of our common stock for $27 million. For the full year, 2023, we repurchased 22.9 million shares for $1.58 billion, a little over our goal of $1.5 billion. Our debt to adjusted EBITDA was 2.9 times a year end. Our medical claims liability totaled $18.0 billion at year end and represents 54 days in claims payable compared to 53 in Q3 of 2023 and 54 in Q4 of 2022. Looking back at 2023, it was a very good year of execution. We beat original adjusted EPS by 5.5%. We bought back 4% of the company shares for a cumulative total of over 10% since Q1 of 2022. We continue to execute on divestitures. We completed five divestitures in 2023, closed the divestiture of Circle in January of 2024, and received approximately $850 million in net proceeds in January. In total, we have completed 10 divestitures and are close to wrapping up that successful phase of value creation. On January 1st, 2024, as Sarah mentioned, we successfully executed on our PBM conversion. RFPing and moving PBMs has become one of our core competencies. And as a result of that, we've improved our pharmacy cost structure on behalf of our members and customers. And we doubled Marketplace membership since year end 2022 and fortified Ambetter's number one position. 2023, pretty good year. We've provided detailed 2024 financial guidance elements at our December investor day. Since then, we've gained some additional clarity around the AEP and OEP results in Medicare and Marketplace. Medicare enrollment is tracking right in line with our expectations relative to both volume and product mix. I give the Medicare team credit for precision in sales, disenrollment, and membership product mix forecast, as well as execution in a challenging year. While Medicare Advantage is only a $16 billion revenue stream for us, It represents a meaningful margin expansion opportunity as we improve STARS over the next few years and begin to have that reflected in revenue in 2026 and beyond. To reinforce Sarah's comments on the 2025 advance notice, we're in the process of preparing our feedback with questions so far around the adequacy of fee-for-service trend and a new method for normalization that further reduced the rate. For us, the rate change as it sits today is approximately minus 1.3% before risk coding trend. And the new risk model introduced last year, and that's being phased in, still has a disproportionate negative effect on partial and full duals, the most vulnerable populations in Medicare. Our marketplace chassis continues to be well positioned for both growth and margin. Marketplace growth is running ahead of our previous expectations, allowing us to raise our full year 2024 consolidated premium and service revenue guidance by $2.5 billion, which takes our guidance to a midpoint of $136 billion. Appetite for Marketplace products continues to be strong as these offerings successfully provide both healthcare access and affordability for millions of beneficiaries. At this very early point in the year, we are reiterating our 2024 adjusted EPS guidance of greater than $6.70. As we turn the page from 2023, we can quickly reflect back on our second strong year of execution from this management team and positive progression of the company. I couldn't be more excited to drive success with this team and provide affordable access to healthcare. for our members in 2024 and beyond. Thank you for your interest in Centene. Rocco, you can open the line up, please.
spk14: Thank you. If you'd like to ask a question, please press star then one on your telephone keypad. If you're using a speakerphone, we ask that you please pick up your handset before pressing the keys. To withdraw your question, please press star then two. Today's first question comes from Steven Baxter at Wells Fargo. Please go ahead.
spk01: Yeah, hi, thanks for the question. I was hoping you could expand a little bit on the Medicare outlook embedded in your guidance. You know, it's certainly concerned that cost in the fourth quarter could be coming in higher than expected, and you certainly reported an MLR that was a bit above consensus, even X the PDR. That would seem to suggest, too, I think most that your Medicare assumptions for 2024 would be pressured, but you're saying that's not the case. So hoping you can expand on why that wouldn't be and maybe some of the underlying trend assumptions that you factored into your guidance here. Thank you.
spk10: Sure, Steven. Good morning, and thanks for the question. Yeah, we still feel comfortable with how we've accounted for trend in the 2024 bids, and as you heard earlier, no change to 2024 Medicare guidance elements. But let me talk a little bit about what we saw throughout 2023 and underlying trends. Let's talk macro first, and then we can talk Q4. From an inpatient utilization standpoint, that was pretty consistent throughout 2023, very little variation quarter over quarter. Where we did see a step up, as we pointed to multiple times throughout the back half of the year, was in Q2 in outpatient. And underneath that, the drivers were fairly consistent through the last three quarters of the year. So orthopedics with DME on either side of that cardiac and cardiovascular as a subclinical category. So those were pretty consistent full year. What was incremental in Q4, obviously the biggest item was taking a $250 million PDR. We also saw COVID step up between Q3 and Q4 and then sequentially month over month in the quarter. We also saw in Medicare only ILI step up late in Q4. Both of those have come back down as we're seeing in January run out data. We saw some RSV vaccine utilization in Q4, partly a function of our continued efforts to get seniors in for their preventive services visits. You heard me talk about that in my prepared remarks. That was also part of intentional investments we made in quality in Q4 as we prepared and positioned for 2024, which, as you know, is that critical third year in our cycle and our effort to get to 85% of members in three and a half stars by October of 2025. So those are really the elements of both full year 23 and then in Q4. And again, still feel comfortable with how we've accounted for overall trend in the 24 bids and no change to 24 guidance for Medicare.
spk14: Thank you. And our next question today comes from Josh Raskin with Nefron Research. Please go ahead.
spk06: Yeah, hi, thanks. I was wondering if you could give us some color on the Medicare Advantage membership losses coming into the year. I'm looking specifically at geographic mix relative to expectations, meaning, you know, did you lose the members where you expected? And then also, you know, were the balance of new sales and sort of gross losses consistent with expectations, retention, you know, was that in line? Just any color there would be helpful.
spk10: Yeah, thanks, Josh. We were, as Drew said, very pleased with the way the Medicare team executed in AEP and precision across all of the dimensions that you talked about, again, largely in line with expectations. We took an intentional refocus in the 24-bid strategy to try to align to those lower-income, more complex members, as well as to the duals in the DSNP population, and successful in terms of what we're seeing relative to the concentration of duals coming out of AEP. So pretty pleased with where we intentionally focused, what the impact looked like. And again, that was really a function of the team going PVP by PVP and building up a strategy where we could invest in those members that we wanted to retain and in those members that we feel like we're going to provide the greatest long-term value to. Ken, I don't know if you want to talk a little bit about some of the calibration we did on distribution as part of that effort overall.
spk03: Yeah, it's a really important add to Sarah and Drew's comments. You know, if you recall in prior quarters, we talked about the prior penetration with tele-digital brokers, and we made a conscious effort both in terms of owned assets and discipline with preferred partners. that moved the mix to a balance that we're really, really comfortable with. And our owned assets perform historically far better with respect both to retention and overall quality. And we're seeing that now in preferred partners. I think the distribution system has responded to obvious opportunities to improve quality, persistency, and product mix, as Sarah said. is directly in line with what we were targeting. So the level of precision is both impressive, important, and directionally where we're going to go.
spk14: Thank you. And our next question today comes from Kevin Fishback with B of A. Please go ahead.
spk17: Great, thanks. Just want to see, you raised the revenue guidance by $2.5 billion, but it didn't change the EPS guidance. Is there anything that you would highlight there as an offset on the EPS line, or is that just conservatism? And then just to make sure I understand the PDR, you're saying that the rate's not sufficient to cover. Friend, does your PDR reflect the current rate update, or does it assume something better? And if the rate update were to be reaffirmed, then the PDR might change. Thanks.
spk10: Yeah, thanks, Kevin. Great question. So on the marketplace front, it's really just acknowledging that we're very early in the year. And then I think you point out a really important point relative to the mechanics of the PDR and how that positioned us with the ability to look at full year trend in 23. So let Drew talk a little bit more about those mechanics.
spk15: Yeah. So the PDR that we booked in the fourth quarter, that's for the 2024 calendar year. And so you, you evaluate in Medicare, you evaluate it on an annual basis. Uh, and so 25 really doesn't come into play there because we still have the opportunity to adapt our bids accordingly. And obviously we don't have a final rate notice yet. We just have the advanced notice that, um, you know, we've got some work to do on, um, on the PDR. Think back to even Steven's question. we sort of get another bite at the apple of evaluating forward trend because we set the PDR and the accounting rules are such you're setting the PDR based upon your forward view of how you think 24 to play out. So that was, you know, any trend considerations that we had were embedded in that PDR we booked in the fourth quarter.
spk13: Thank you. And our next question today comes from Justin Lake at Wolf Research.
spk14: Please go ahead.
spk00: Thanks. Good morning. Drew, appreciate all the color on Medicare Advantage rates. You mentioned that your rate is minus 1.3%. Given trends in the mid-2s and you didn't really have much star impact year over year, it sounds like the combination of the V28 model and the fee-for-service normalization is somewhere in the negative 3.5% range. So first, is that math right? And then second, if so, can you compare the negative 3.5% that you're seeing for 2025, at least in the advance notice, versus how big a negative that was in 2024, so we can understand the year-over-year kind of impact. And then, if you can, break up the impact between V28 and the fee-for-service normalization on both a 2025 and a year-over-year basis. It would be incredibly helpful to kind of understand what's going on there. Appreciate it.
spk15: Yeah, let me try to parse that out. The line item of HCC model changes, which includes the risk score normalization that you pointed out, was about a point in our evaluation of the advance notice is about a point worse than last year. And part of that is the normalization change in calculation and going to like a regression model versus the omission of a base period. So that's probably as deep as we want to go on an earnings call. But if you foot up all of the elements, it's about a 1.3% on an absolute basis, current as we stand today, impact on rates. Now, that's before risk score trend. Obviously, that would push it into the positive zone. And, you know, we're going to push on some of the mechanics, and then we will, you know, we're in the position of not trying to grow Medicare Advantage. We're trying to ultimately recover margin back half of the decade. And so we'll just adjust the bids accordingly. And the products may be a little bit less attractive for seniors, from an industry standpoint, if we don't make a lot of progress on the final rates.
spk14: Thank you. And our next question today comes from AJ Rice at UBS. Please go ahead.
spk02: Thanks. Hi, everyone. Just want to pivot over to Medicaid for a minute. Obviously, you mentioned the retro adjustments. You didn't get marginal headwind, I guess, up. You've also talked about some states being proactive and giving you acuity adjustments ahead of time, and then you've got your normal rate cycle with the states. I wonder if there's any updated thoughts on where you land for 24 in terms of your Medicaid margin. And I think you had talked about the fact that coming out of redeterminations, you saw a potential for improvement in Medicaid margins going into 25. Just wondered if there was any updated thoughts on any of that.
spk10: Yeah, thanks, AJ. Let me talk a little bit about the dynamic we saw in Q4 and then how we feel as we sit here in early February. So full year HBR for Medicaid in 23 was really a function of Q4. And what we saw in Q4 was some of that timing dynamic that we've called out since the beginning of redeterminations as a dynamic that we were fully expecting to be managing through. The timing of matching rate with acuity as the risk pool shifts. So Q4 was a heavy member roll-off quarter, as we talked about. And later in the quarter, we saw some acuity pressure in the portfolio ahead of those 1-1 rates that had been designed to address that acuity clicking in. We also had some of those retro rates also designed to address the acuity coming in late in the year. And like we said, we got some of those before year-end, but not all, so continue to work on those. That's really what drove that lingering pressure in Q4. And as we sit here today, we've got really solid visibility into the rate for our 2024 member months, 63% of the book we've got visibility for. We've got those one-man rates now in place, and they are, in general, coming in toward the higher end of that composite range that Drew mentioned at investor day of 2% to 2.5%. And then we're still working on that handful of 2023 retro rates that would then come in in 24. You take that all together, acknowledge it's still early in the year, that's what makes us feel good about our 90.1 midpoint for the 24 Medicaid HBR. And then to your point, as any of those timing dislocations shake out in 24 and we continue to calibrate and match those up, then as we move into kind of the roll-off of redeterminations in 25 and beyond, that becomes a tailwind for the book overall.
spk14: Thank you. And our next question today comes from Scott Fidel with Stevens. Please go ahead.
spk05: Hi, thanks. Good morning. Just wanted to pivot back to Medicare. And just interested if you can sort of talk through for us just on the inpatient side. It doesn't seem like you saw anything unusual in the fourth quarter, but do want to confirm whether or not you did see any type of mix shift towards more short stay inpatient visits. and reduction in observation visits as mentioned by a large peer in Medicare. And then just sort of sticking on this potential theme, would love just your, you know, feedback and sort of thoughts around the implementation of the two-minute rule for MA and how you're factoring that into your 2024 outlook. Thanks.
spk15: Yeah, thanks, Scott. As Sarah said, the high-level inpatient was pretty steady throughout 2023. And you go a couple clicks below that, we looked at case mix, admits per thousand, alts per thousand. We didn't see a Q4 uptick in inpatient. If you look at observation days, we saw no meaningful shift in observation days. You know, we all know the two midnight rule doesn't start till 1-1-24, but we've been on top of that, you know, preparing for that, thinking through that as we formulated our forecast for 2024, and we think we've got that captured. And obviously, the industry, we can still do medical necessity on that. But yes, we'll be observing that two midnight rule beginning in January.
spk13: Thank you.
spk14: And our next question today comes from Lance Wilkes with Bernstein. Please go ahead.
spk16: Great. Could you talk a little bit about the pipeline and some of the upcoming bids with respect to Medicaid? or some of the upcoming RFP awards. And then more broadly, Sarah, if you could talk a little bit to, as you've gone through some of the recent wins and as you're looking at satisfaction scores within states, what are areas of strength that are helping you with either retention or new wins? And are there particular areas of opportunity, and what are some of the plans to address some of those areas? Thanks.
spk10: Yeah, thanks, Lance, for the question. So as you pointed out, we've had some great positive momentum of late with New Hampshire, Arizona, North Carolina expansion, as well as Oklahoma. And that makes us feel good as we roll into what's an active RFP season. We obviously have Florida in flight and really proud of the Sunshine team and the work they're doing. as well as Georgia and then Texas for later this year in 2025 go live. So we continue to track that. We continue to have, I believe, the best BD team in the business, incredibly strong local teams that are being really thoughtful and incrementally forward-looking in terms of, as we said, Investor Day, making sure that we're competing on promises kept, not just promises made. And so that, I think, goes to the second part of your question, which is really what are we seeing in the market in terms of the investments we've made over the last two years around customer satisfaction and that local community partnership? And we're really starting to see improvement in terms of partner satisfaction, provider relationships, as well as quality. So if you look at our Medicaid quality scores year over year, you're seeing really nice improvement there. Those have been things at the top of our list in terms of focus over the last two years, and I think starting to see those bear fruit. Those are really important drivers as states think about who they want as partners relative to the managed Medicaid business. I would say the other major theme that we continue to hear and we continue to be focused on pretty organically, frankly, is health equity. And so the emergence of the 1115 waivers and thinking about how to put dollars into things like housing, food, jobs, child care that ultimately drive pretty significant health care outcomes. And that's something that states are increasingly interested in partnering over. Again, something that Centene has been naturally focused on as a byproduct of being local in our approach and having the strength of those longstanding incumbent relationships. So I think really good improvement in the places that we've focused and really good core strength in the areas that are going to matter going forward.
spk14: Thank you. And our next question today comes from Cal Stemmick with JP Morgan. Please go ahead.
spk18: Yeah, thanks for the question. I wanted to ask two in the marketplace. So first, can you talk about the demographic trends of the incremental membership you got? So any insight on the acuity and metal mix of the extra members you added compared to what you initially anticipated? And then on ICRA and the Indiana pilot, how many members did you enroll in that product? And what are some of the key milestones you're looking to evaluate the pilots move through this year? Thanks.
spk10: Thanks, Cal, for the question. So as you heard, the demographics for the population that came in during OEP for us were pretty consistent with our expectations. And the distribution of tiers between silver, gold, and bronze, also pretty consistent. We still have the majority of our members in that silver tier. So the demographics have not shifted materially. One of the things that I think is interesting, this may just be the data geek in me, but if you look at what we're seeing, not just in our book, but overall in the market, There's some interesting small shifts in the demographics overall that I think tell us a lot about what's actually driving the underlying growth above and beyond just what we know in terms of affordability and awareness from the enhanced APTCs and the additional marketing dollars going into navigators and the broker channels. So we're seeing year over year over year age coming down slightly, which I think supports our view that We're seeing a younger pool, we're seeing a healthier pool, and we're seeing some of those gig workers coming into the market. We're seeing the distribution in gender between male and female shift a little bit, so more men coming into the marketplace, which we see as a signal of digging deeper into that uninsured population because women tend to move sooner out of that population. And then we're also seeing the gold tier as an industry tick up a little bit, which we see as supporting our view that there's small group migration coming into the market. Obviously, we've got anecdotal evidence around that. But that's true in our book. That's true in the overall industry. And again, I think very consistent with what we think is driving sort of 31% overall market growth. But pleased as well with the fact that within that growth, we were able to grow our market share within Footprint. And then relative to ICRA, obviously, that's still very much a nascent market. The Indiana pilot is very new. I'm happy to say that we sold our first customer in January, so a good early proof point. But the goal there for us is really to test and learn and gather data. And we're pretty confident that we're going to be incrementally smarter about how that market is evolving as we go throughout the year.
spk13: Thank you.
spk14: And our next question today comes from Gary Taylor at TD Callen. Please go ahead.
spk11: Hi, good morning. One clarification, one question. I just want to clarify, Drew, on the negative 1.3% 25 advance notice for Centene. Does that exclude STARS or basically assumes for Centene no different STARS impact than the negative 15 basis points that CMS sized? for the industry. And then my question is, I just wanted to see if you could just balance these very diverse views on MA. Your MA MLR first nine months was down 110 basis points year over year. Fourth quarter was up 310, excluding the entire PDR. And you only boosted the PDR by 50 million or 30 basis points on 24. You said your MA outlook looks unchanged. So there's two camps this quarter. There's Centene and United saying the sharp fourth quarter MA MLR spike means nothing for 24. And then there's Humana who said the sharp spike in the quarter is the new baseline heading into 24. So it's been a while since I've seen such divergent views across the industry that all had sort of the same cost acceleration. So can you just explain again why you're landing where you're landing on 2024 MA?
spk15: All right, so let me take the first one first. So of the minus 1.3%, our star rating change is minus 0.5. So absent that, we'd be at minus 0.8. So it's a little bit heavier than the industry as a whole, which I believe CMS was at minus 0.2. So hopefully that helps with the math there. On Medicare, you know, Sarah said, Look, we're looking hard at our outpatient trend, which we're not happy with, but it's steady at that elevated level relative to May-June timeframe, and that's sort of what we built into the forecast. So that would be a change year over year. Inpatient, we talked about that. I mean, no uptick, as we said earlier. Maybe one of the elements that may be a little bit unique with us is that As we see the year developing, and there's a dial we have on quality spend and initiatives, and there's a lot of quality initiatives that we're going to do regardless of what our aggregate EPS result is, but we really stepped that up in Q4, and that triggered a heavier level of office visits, which is a good thing, getting our members in to see their physicians. It triggered RSV vaccines, which is a good thing, and we saw that coming through in December. And as Sarah mentioned, we did have ILI. The only area of the business where ILI, influenza-like illness, was heavier year over year was in Medicare. And obviously, that's transitory. It's already come down in January. So those are the other elements that you should think about when evaluating Q4. But we feel good about our forecast. We had another buy at the apple on the PDR, Gary. If we thought trend was going to be 50 million higher, Then the 250 next year, the PDR would have been $300 million, and we were reported $6.61 or something like that. So I feel good about our forecast. We've got work to do in Medicare to improve the macro, but we're ready to tackle 2024. Thank you.
spk14: And our next question comes from George Hill with Deutsche Bank.
spk07: Good morning, guys. I actually want to ask Gary's question kind of a slightly different way and kind of focusing on what seems to be kind of two different narratives as it relates to the utilization trend. I guess more broadly, and one is kind of the, it's like there's the seasonal utilization of this that has come through that now needs to be, that now we're returning to a baseline trend that is normal X the seasonality or the bolus. And there's another narrative that is trend is running below baseline, call it on or adjusted basis because of the impact of COVID. And now we have a kind of a three-year heightened utilization trend to get back to baseline. Sarah, I guess I'd ask you if you kind of have a preferred utilization narrative that you guys are seeing. Like, are we kind of working through this short-term backlog as it relates to utilization that should normalize? Or are we running below a longer-term trend that we need to return back to likely verbal to your basis?
spk10: Yeah, I mean, I certainly prefer our narrative, and I think about it really specific to Centene. So I appreciate the need to try to harmonize what different companies are seeing, but we remain focused on what we're seeing in our population. The idea that we saw some of this trend in Q2, that we accounted for it in our 2024 bids. We feel sufficiently confident We had a second bite at the apple at the end of the year with the benefit of the full year's visibility of utilization, the assumptions that we've made in 2024, how we feel about our ability to apply clinical initiatives, leverage our value-based relationships, and manage through the trend that we're seeing. That's really our focus, less so worrying about what others are saying.
spk14: Thank you. And our next question today comes from Dave Windley with Jefferies. Please go ahead.
spk04: Hi, thanks for taking my question. So I wanted to clarify and then ask the question. So Drew, you've mentioned, you've actually both mentioned second bite at the apple a couple of times. I wanted to make sure I understood that that was a second bite opportunity kind of up to the end of the year. Or does that mean if things develop in a way that causes you to have a different view of 2024 kind of currently that you could go back and revise your estimate for PDR. So wanted to clarify that. And then my question rotating over to SG&A is where are you related to headcount rationalization, real estate rationalization, other things kind of on the basic cost cutting value creation plan list to take out SG&A? Where do you stand in that evolution? Thank you.
spk15: Yes, so good questions around the PDR. And look, we don't love being in the PDR position, but we've got work to do on Medicare. But it did give us an opportunity to reevaluate a 24 forecast as we got into January and closed the December books. And what will happen mechanically throughout 2024 is that that PDR will largely be released in, forecasted to be released in Q4 because of sort of the mechanics of the seasonality of earnings in Medicare throughout the year. But every quarter, we reevaluate the sufficiency of that PDR relative to the 24 policy and calendar year. And if we have to tweak it, we will. But that would be within the confines of 2024. On SG&A, uh, still plenty of opportunity ahead. I mentioned, uh, an investor day that we've got at least a couple hundred basis points more in Medicare. We've got to go after, uh, over the next few years on real estate, largely through that, probably some tweaks here and there, but, uh, largely through, uh, for instance, the charges around real estate. Uh, we, you know, we're, we're through the bolus of that. And, uh, And then we've got our slate of initiatives that we continue to tackle and plenty of efficiency opportunities.
spk10: Yeah, I would echo that and just say that a lot of great execution in the first two years. We're going to realize that in 2024, but we haven't stopped. And you've heard us talk about building the pipeline for 2025 and beyond in terms of additional opportunities. Obviously, our long-term algorithm has 1% to 2% of margin expansion built in. And we do see additional opportunities to drive efficiency in the business as we standardize our workflows, the ability to then automate that with technology. So really pleased, not just with the execution thus far and the discipline to get us here, but really thinking about how we do work going forward. We do see opportunity for continued efficiency in the future.
spk14: Thank you. And our next question today comes from Sarah James at Cantor. Please go ahead.
spk08: Thank you. Could you remind us what the margin progression looks like on exchanges, like how many quarters it takes for you to get to run rate? And then just a mechanics clarification on the PDR. Are you guys booking that as the delta between where you view cost and target margin? Where, you know, it would roll over kind of flat at target margin from 24 to 25, or is it that you're booking it as the view of cost to break even? If you can give us the context of that. Thanks.
spk15: Yeah, on your second question, it's really neither of those. It's sort of the accounting principle on the marginal loss So it excludes things like marketing costs and certain investments. So think of it as the marginal loss that we're pulling into the year in which we set the bids. So certainly it's not booked anywhere near target margins. We've got a lot of work to do to go from essentially a minus 3.5% expected reported margin to in 2024 to you know that four to five percent pre-tax zone as we look at you know later later in the decade so uh stars will probably be two-thirds of that progression and like i said we still have sgna and clinical initiatives and it isn't interesting we're spending so much time on 12 of our revenue uh 16 billion important lever but we actually have some pretty other Good businesses like Marketplace that you just asked about. The margin progression we expect, you know, it's the sophomore year in which we pick up the benefit of the SEP, special enrollment period, members that come in for a couple of reasons. One is they're typically utilizing some degree of services and they get that out of the way and then become more normalized in the following calendar year. And then also the risk adjustment, the mechanics are punitive to some degree if you're only picking up a partial year. And then when you get a full calendar year, you have sort of the numerator and denominator sort of matching up. So we expect the benefit of last year's SEP members. If we continue to grow SEP, which that's not baked into our guidance yet, we're just at 4.3 million members. But if we continue to grow during 2024, that will be an expected tailwind for 2025.
spk10: And on that point, I would just note that we're seeing increase year over year in retention of SEP members, which means that we're poised to capture the benefit of that sophomore effect from that heavy growth we had in SEP last year. So that's a really nice trend that we've been watching and seeing that retention grow year over year.
spk14: Thank you. And our next question today comes from Nathan Rich at Goldman Sachs. Please go ahead.
spk12: So I'll ask one on the Medicaid business. I wanted to, you know, it sounds like the HBR so far as redeterminations have played out has been in line with expectations. The 24 guidance has that, you know, 50 basis point headwind effect. um, that was, I think, put in place for any sort of timing mismatch, uh, as it relates to acuity. I just wanted to clarify if that's something that you're seeing currently. And so, you know, reiterating your expectations for 24, um, you feel like, uh, what you've seen play out so far, you know, requires that 50 basis points or if the timing between the, the rate updates, um, and, uh, you know, the cost you're seeing in the underlying book, um, if, that timing has actually been, you know, matched up better than you had anticipated?
spk10: I would say at a high level, we're pretty pleased just given the complexity of the portfolio and all the state-by-state dynamics with the degree to which acuity and rate have matched up relative to timing. Obviously not perfect. We talk about what we saw in Q4, but across the entire portfolio feeling pretty good about that which is again part of why we're still confident in that 90.1 midpoint but maybe Drew you can talk a little bit about sort of risk corridors and other dynamics that you know we're tracking relative to that 50 basis points buffer.
spk15: Yeah so you also have to remember we've got PBM savings rolling into that we targeted that at 20 basis points so that's sort of a nice lever that we factored into sort of getting down to the 90.1 And then as we think about a question from earlier, 25, 2026, we would expect to get back into the high 89s on a same mix basis. From a risk corridor standpoint, while it's imperfect in terms of a buffer, depending on where you have sort of trend or rate pressure, We're still at about $1.8 billion in payback for the 2023 year. So we're still in a pretty heavy payback position for our Medicaid risk corridors and minimum MLRs. It's not across every state, but it's spread across a number of states. And that is something else to think through as we think about the future and rate action and matching acuity with rates.
spk14: Thank you. And ladies and gentlemen, this concludes our question and answer session. I'd like to turn the conference back over to the management team for any closing comments.
spk10: Great. Thanks, Rocco. Thanks, everyone, for your time and interest this morning. We look forward to providing updates as we move deeper into 2024.
spk14: Thank you. This concludes today's conference call. We thank you all for attending today's presentation. You may now disconnect your lines and have a wonderful day.
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