Oscar Health, Inc.

good afternoon my name is Lisa and I will be your conference operator today at this time I would like to welcome everyone to Oscar health 2023 first quarter earnings conference call if you would like to ask a question today please press star one on your telephone keypad I would now like to turn the conference over to Miss Cornelia Miller vice president of corporate development and investor relations please go ahead thank you and good evening everyone

Thank you for joining us for our first quarter 2023 earnings call, where we'll discuss our momentum early in the year and execution around our path to profitability. Mark Bertolini, Oscar's Chief Executive Officer, and Sid Sankaran, Oscar's Chief Financial Officer, will host this evening's call. And they're joined by Mario Schlosser, Oscar's Chief President of Technology. This call can also be accessed through our investor relations website at ir.highoscar.com. Full details of our results and additional management commentary are available in our earnings release, which can be found on our investor relations website. Any remarks that Oscar makes about the future constitute forward-looking statements within the meaning of safe harbor provisions 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 our annual report on Form 10-K for the annual or period ended December 31, 2022, filed with the SEC. And our other filings with the SEC, including our quarterly report on Form 10-Q for the quarterly period, ended March 31, 2023, to be filed with the SEC. Such forward-looking statements are based on current expectations as of today. OSCAR anticipates that subsequent events and developments may cause 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. The call will also refer to certain non-GAAP measures. A reconciliation of these measures to the most directly comparable GAAP measures can be found in the first quarter 2023 press release, which is available on the company's IR website. With that, I would like to turn the call over to our CEO, Mark Bertolini.

Thank you, Cornelia. Good evening, everyone. I would like to start by restating our company's mission and why I joined Oscar. I have spent my career advocating for increased consumerism, more digitization and virtualization, and higher levels of value-based care within the healthcare industry. I believe that Oscar is not only uniquely positioned to leverage these industry trends, but is the single platform that can drive this change. Between our innovative technology stack and our high MPS, the company has the right collection of assets to be a disruptor for years to come. We have the ability to move faster than our competitors given our size, culture, and modern infrastructure. I see a clear right to win for our company. I have spent my first five weeks at Oscar doing deep dives across the business and getting to know the people and to understand the culture. The energy and morale of the company is very high and the team is excited to deliver. My high level priorities for the business remain. One, achieve insurance company profitability in 2023. It is still early in the year, but I believe we are executing well against that goal as you will hear today. Two, target total company adjusted EBITDA profitability for 2024. To achieve total company profitability, we will need to continue to improve the performance and profitability in our insurance business and manage the whole cold spend in line with our profitability targets. Three, continue to enhance the value of our technology through the Plus Oscar business and bring more of our capabilities to market. Based on my current view, all three of the priorities I just shared are not only within reach, but we are well on our way to achieving them. As it relates to profitability, we have a lot of positive activities already in flight and have identified even more opportunities. I'll touch on this in greater detail in a moment. Turning to the numbers, as you saw from our results this quarter, the fundamentals of the business are sound and we are executing against our plan and profitability targets. We continue to serve more than 1 million members in Q1, and our industry-leading NPS increased to 50. Our medical loss ratio improved more than 100 basis points year over year to 76%, and utilization was in line with our plan. Our insurance company achieved profitability in the first quarter with a combined ratio of 95%, an improvement of 230 basis points year over year. Importantly, our total company adjusted EBITDA of $51 million reflects overall profitability for the quarter. While this is a function of seasonality, and we expect that our adjusted EBITDA results will trend downwards over the course of the year, it is still an important milestone for us. Next year, we are targeting for this metric to be profitable for the full calendar year. Sid will provide a more detailed review of our results in a few moments. Oscar is in a very different place than we were a year ago. A year ago, we were focused on absorbing our increased scale and ensuring that our operations could handle a sizable increase in growth. Today, we are focused on advancing the capabilities and technology to best serve our members and have been able to shift our attention to implementing a series of initiatives aimed at improving the efficiency of our operations. The results of the quarter show progress, but I still see more opportunities to accelerate. Regarding insurance company profitability, I see the biggest levers falling into core buckets that management previously laid out. One, addressing our total cost of care. Two, focusing on the administrative efficiency. And three, improving sculpting. The combination of these three objectives coupled with our opportunities to enhance the value of our technology position us well to achieve our goals. Starting with the total cost of care. We're seeing strong performance across several areas, including payment integrity, network optimization, and savings from vendor contracts. However, I see pockets of opportunities for improved financial performance in areas where we are underperforming against our potential. Specifically, there are many traditional scale processes for payers where I see opportunities to drive the bottom line. As an example, increased scale has driven material pharmacy savings and improvements in our processes with our PBM partner. While we've had great progress to date, I view these activities as merely the starting point to help reduce total cost of care over time. Moving to administrative cost efficiency. We have solidified the majority of our efficiency efforts at this point in the year. For example, We successfully executed our distribution optimization efforts during open enrollment and expect these savings to continue throughout the year. We are also achieving scale benefits in our cost structure. As another example, we recently negotiated a new multi-year agreement with a large risk adjustment vendor. allowing us to realize significant savings going forward. Our technology is also having an impact on our efficiency. Recently, we rolled out a series of interactive automation features that provide instant answers to members for common questions. This technology has reduced inbound volume by 5 to 10% across customer service channels, while retaining consistent satisfaction ratings. Finally, portfolio sculpting remains a key tool to help us improve profitability as we exit underperforming markets. The company has been disciplined in managing its portfolio and improving the sustainability of our margins over time. We're announcing today that we have decided to pause our participation in the California individual market for plan year 2024, as the plan has not met our internal targets. We intend to reshape our strategy and product offerings in preparation to reenter the market in the future. Turning now to PlusOscar. As you can see in our solid first quarter results, our technology is clearly having a positive impact on the business. While we are focused on profitability for the insurance company, we are continuing to build and develop Campaign Builder, which is PlusOscar's engagement and automation tool. I'm happy to report that we are officially live with our first Campaign Builder client that we announced last year. Since launch, our client has seen an approximately 60% engagement rate with English speakers and a 65% engagement rate with Spanish speakers, which shows the power of provider-led communication. We're also excited about signing another Campaign Builder customer, a large value-based primary care group that serves hundreds of thousands of patients across commercial, Medicare Advantage, and Medicaid segments. We will partner with this group to drive primary care utilization to owned and affiliated PCPs, close process gaps, and streamline operations. Campaign Builder is just one example of the technology tools that we expect to bring to market over the next several years. Given the market context, I also want to share some thoughts on AI. We believe that our proprietary technology stack is a sizable benefit for deploying large language models with great impact. In our many pilots and tests, large language models are good at explaining in natural language how a claim got paid, but only if the claim system produces coherent structured output. Large language models are good at extracting which specialty a member is looking for, but only if the system has good provider data. Large language models are good at translating provider contracts into a system configuration file, but only if your claim system is easily configurable. We are unique in having built a proprietary tech stack, including a modern data lake that will enable us to use large language models across every aspect of healthcare. We believe this can become a competitive advantage for us and our Plus Oscar offering. As we look to the future, we continue to see many tailwinds for the ACA. Specifically, growth due to the resumption of Medicaid redeterminations, the proposed new rule to expand marketplace coverage to DACA recipients, and the continued shift of employers in the market through individual coverage HRAs. OSCAR should benefit from the marketplace growth with our individual industry-leading NPS and consumer engagement. While the ACA is the most individualized market in insurance, I believe our innovative products and technology are highly applicable to other individualized markets as well. Medicare advantages is a space I know well. Based on my experience, I see opportunities to form interesting partnerships with like-minded provider groups to participate in this space. With that, I'd like to turn it over to Sid to provide additional insight on our first quarter results.

Thanks, Mark, and good evening, everyone. Our first quarter results show solid fundamentals across the business and that we're executing well against our plans. We ended the quarter with approximately 1 million members, which was consistent with our pricing strategy for a largely stable book. As we've previously mentioned, our pricing and portfolio strategy is focused on shifting our membership mix towards the average ACA population. This year, we have a higher proportion of renewing members than we've ever seen historically. We also have a more subsidized membership with a very modest shift from silver to bronze. Similar to trends we saw last year, we expect this updated mix will result in a higher morbidity population and therefore a lower risk transfer as a percent of premiums. We're pleased with this progress and I'll discuss the impact from this mix shift in greater detail in a few moments. As expected, our direct and assumed premiums grew modestly to $1.7 billion, driven by our high single-digit rate increase on average across the book. Our premiums before seeded reinsurance grew 8% year-over-year to $1.4 billion, driven by the same factor as well as a lower projected risk transfer.

Turning to medical costs,

our medical loss ratio improved more than 100 basis points year over year to 76.3%, driven by our disciplined pricing actions and total cost of care initiatives. Overall claims trends have been in line to slightly favorable with our expectations at this point in the year, accounting for the mix of our 2023 population. Within specific categories, We're seeing year-on-year decreases in inpatient and professional utilization, while outpatient is trending very modestly above last year. Partially offsetting this is a spike in pharmacy claims, but note it's early in the year. Given the morbidity of the population and our expected risk scores, as we stated, we expect less risk transfer this year. This will have an impact on the numerator denominator of our GAAP MLR, but not the overall underwriting dollars. With regards to seasonality, we expect the MLR will rise throughout the year, albeit less steeply given the risk transfer dynamics. Moving to administrative costs, our insurance company administrative expense ratio improved 120 basis points year-on-year to 18.6%, driven by the admin efficiency initiatives we've already successfully executed against, including distribution optimization and vendor savings.

We see Q1 as the highest quarter for our admin expense ratio this year.

Our combined ratio of 94.9 percent in the quarter improved by 230 basis points year-over-year and reflected insurance company profitability for the quarter. Based on our results to date, we believe we are on track to achieve our full-year insurance company adjusted EBITDA target of $20 million to $120 million. Our adjusted administrative expense ratio of 21.7 percent improved more than 200 basis points year-over-year due to the same factors that improved our insurance company expense ratio, as well as meaningfully higher net investment income. I am very pleased to report we achieved total company profitability in the first quarter, with adjusted EBITDA profitability of $51 million, an improvement of $88 million year-over-year and above our expectations. The key factors that drove the year-over-year improvement include the better operating performance of InsuranceCo, reduced quota share reinsurance fees, and increased investment income from higher interest rates. We expect Q1 represents the peak for adjusted EBITDA profitability this year, given our medical and administrative expense seasonality.

Shifting to the balance sheet,

We have $3.6 billion of cash and investments at the end of the quarter, including $260 million of cash and investments at the parent. As a reminder, the first quarter includes one-time items in parent cash, such as bonuses, that will not recur throughout the year. We also expect cash back to the parent from tax sharing payments that we expect to occur in the second half of 2023. Our subsidiaries had approximately $765 million of capital in surplus, including $230 million of excess capital. That excess capital positions us well to fund future growth and allows us additional opportunities to optimize our capital position over time. Based on the first quarter results, we are reaffirming all of our full year guidance including our MLR range of 82 to 84 percent and our adjusted EBITDA loss range of $75 million to $175 million. In closing, we are encouraged by our performance in the first quarter and remain confident in our ability to achieve insurance company profitability this year. We believe that sets us up well to execute against our plan for total company profitability next year and for further margin expansion in the years to come. We're excited to be the leading player in the ACA market, which has strong growth tailwinds, and we expect to expand our TAM with additional service areas next year. The combination of our disciplined pricing along with strong customer satisfaction and brand equates to value creation for Oscar in the years ahead. With that, let me turn the call over to Mark for final comments.

Thank you, Sid. I want to thank the Oscar employees for welcoming me and for the important work they do in serving our members. A mission like ours requires a special group of people motivated by driving real-world impact. Last month, we published our inaugural ESG report where we shared the progress we've been making towards advancing health equity. We're proud of the strategies and initiatives we've developed and continue to iterate to build a more sustainable and equitable future within our organization and our communities. In summary, we believe that we are off to a good start in 2023. The company is operating from a position of strength with profitability on the horizon. I am confident that we have the right roadmap in place to execute against our goals and the right mix of tools and experience to win in the market. I'm excited for the journey ahead and optimistic about our future. With that, let's turn it over to the operator for Q&A.

Thank you, sir. And everyone, if you would like to ask a question, once again, that is star one on your telephone keypad. Up first, we'll go to Stephen Baxter of Wealthy Fargo.

Yeah, hi, thanks. Appreciate the commentary on the portfolio sculpting and the actions you're taking in California. Mark, I was hoping you could talk a little bit about the importance of further membership growth and achieving the company's financial targets, including the admin efficiency you're targeting, I guess beyond California. At this stage, would you be expecting to grow membership in 2024, 2025? Any comments you have there would be great. Thanks.

Okay. Did you hear that okay? Are you going to repeat that?

Steve, could you restate the question for us, please? Sorry, it was a little cut off there.

Yeah, sorry about that. I think my connection is okay at the moment. So yeah, I appreciate the commentary on the portfolio scoped in and the actions you're taking in California. So I guess, Mark, could you talk a little bit about the importance of further membership growth and achieving the company's financial targets, including the admin efficiency that you highlighted? I guess beyond California, would you be expecting to return to membership growth in 2024 and 2025? Thanks.

Yeah, we expect to see our growth mirror that of the market or a little higher. And that's our goal with pricing discipline. So I'll make sure I'll say that over and over and over again. But we believe that we can grow better than the market. The market is predicted to grow in the 20s or low 20s, high 10s, high teens. And so we expect that we'll be able to put that growth into the marketplace for next year, 2024. And growth is important, but with disciplined pricing.

We'll go next to Josh Raskin, Nefron.

Hi, thanks. Good evening, guys. Could you just give us a rough size of the California book, either membership or revenues, and if MLR was expected to be, you know, at or above 100% this year? And then just related to the MLR, you know, down a little over 100 basis points in the first quarter, guidance sort of implies down, you know, a little more than 250, 250 basis points for the rest of the year. So just help me understand, was there some one-timers in 1Q or, I'm sorry, in the rest of the year, last year that would create that? And then just the last question, just what percentage of your revenues this year are with capitated providers or even in value-based care arrangements? Maybe where was that in 2022 and how is that playing into the strategy? Thanks.

Hey Josh, it's Sid. Thanks for the questions. I think you've got three there, so I'll try and tap them sequentially. First of all, just context on California. I think you referenced some of the history, but just important notes. In the early days of Oscar, it was probably about 25% of the portfolio. Today, it represents less than 5% of the portfolio. And certainly in the past couple of years, while we've been managing that portfolio and sculpting it, it's still underperformed our expectations somewhat with an MLR over 100%, as you've commented. So, you know, as we look at it, while California is an important state, the ACA will take a pause while we review the work required to reenter it in a more sustainable way. You know, with respect to your models, we expect to end 2023 with roughly 35,000 members in California and approximately $200 million in gross premium. So net-net, we'd expect the exit from California would have a very modest impact on the top line and would have modest accretion to adjusted EBITDA given its historical MLR performance. Moving to the second one, I think your second question, you know, I think your second question was really around year-on-year comparisons for the MLR. You know, really, I think what you're seeing, if you reflect on some of my comments, is the membership mix that we have, and in particular, the shift towards more renewing members, which as we alluded to, will change both the numerator-denominator of the MLR calculation And importantly, it will also flatten the kind of seasonality effect that you've seen historically. So of course, more detailed questions on that. We're happy to have the team sit down with you offline on that. I think your third question was just on capitation. We don't specifically disclose that. I think we've told you before that they've been roughly, you know, 40-ish percent of our provider contracts are on value-based care type arrangements. And I think we'd leave it at that, other than to say we continue to believe value-based care is a real opportunity, as Mark commented in his remarks.

Thank you.

We'll take the next question from Michael Haw, Morgan Stanley.

Hi, thank you. Just wanted to quickly confirm, are you expecting to grow at least high teens or low 20s membership growth next year? And that includes the Florida market exit? And then my second question is, this one's for Mark. As we look at Plush Oscar, and I understand in the past when you were acting as an advisor, part of your efforts were focused on Plush Oscar, but looking ahead now as CEO with the wealth of contacts in your Rolodex and Mario Laser focused on Plush Oscar, Curious how you envision the future pipeline developing near term. And I think you mentioned your prepared remarks, bringing more capabilities to market. Does that mean you're accelerating, modularizing more applications beyond Campaign Builder? And also, sorry, I know it's a five-part question, but did you announce the new Campaign Builder contract today? I wasn't sure if I heard that correctly. Thank you.

Yeah, so I think Michael and Sid here, I'll take the first one, then I'll hand it over to Mark to talk about Plus Oscar. You know, first off, just restating that was a California market exit that you referenced there. So California, which was, as I said, less than 5% of the overall book. You know, as we execute against the growth objectives that Mark highlighted there, TAB, we've proven that we can grow in these markets and we continue to target that growth and it's very realistic for 2024 inclusive. TAB, Of the California decision, but you should expect we're going to continue to show discipline in the 2024 pricing process around balancing growth and profitability. Because I think, as you see in the results this quarter, we feel very positive that the decisions that we've been making to drive the portfolio are really bearing fruit here and showing up in the financials. So we are pleased about that. Maybe with that, I'll turn it over to Mark to cover the plus Oscar thesis and how he sees that.

Sure. And to segue off of Sid's comments, it's important that we continue to generate internal generation of capital to support our investments in the business. And so we want to exercise pricing discipline. We do want to meet the market or exceed the market and growth. We believe because of the Plus Oscar platform that we have a competitive advantage now with an NPS score of 50 when the rest of the industry is averaging around zero. And so we actually, in our distribution model this last year, put that to test in a few markets to see whether or not we could maintain membership with such a high MPS score against the commission race in signing up ACA members. The platform is strong on the front end, very strong on the front end. And so that's why the campaign builder is taking off. And we did announce another client today. It's a large multi-specialty group practice that has Medicare, Medicaid, Medicare Advantage, Medicaid, and ACA in it. And so we will put that to the test as we implement that product. As far as the full platform being available, that is the work that Mario and I are now starting to work on in evaluating what we need to do to harden the platform. We have some new technology coming out on the back end that we are very confident in. But until we know that it works front to back, the whole platform won't be available, but we'll roll it out in pieces where we find it valuable for our clients.

Our next question is Kevin Fishbeck, Bank of America.

Hey, this is John Joy on for Kevin Fishbeck.

So, maybe sort of shifting topics a bit. How are you guys thinking about MLR, sorry, not MLR, Medicaid redeterminations and sort of what impact that could have to your membership? What does that risk pool look like with the new people getting on the exchanges? Do you think of a higher or like a lower MLR than the core? And kind of along the lines of the smaller groups. How is your CI plus OSCR going?

Sort of what traction are you seeing in the small group market?

Great. Thanks, John. And Sid, I'll take that. You know, I think as a reminder, we've mentioned before, we expect a relatively de minimis impact from Medicaid redetermination in our 2023 estimates. And we have said we do think these members will be higher acuity than our current population. You know, as of today, the majority of our states are now live, but still early in the Medicaid redetermination process. And we've been monitoring our book and haven't seen anything meaningful in the trends yet. But pulling up, I mean, we believe the ACA has many tailwinds to long-term growth, including Medicaid redeterminations over the next few years. And, you know, we have a, you know, a larger market with an appropriate risk pool, and Oscar will be very differentiated in delivering service to its members. So, you know, in the long run, we think that'll be a good thing. You know, with respect to your second question, I think a C plus I, you meant C plus O, you know, with respect to, you know, our small group joint venture. You know, I think similar to the theme you heard from us before, you know, we approach 2023 pricing with the balance of growth and profitability. You know, we continue to see balanced growth across our markets, Georgia and Arizona in particular. You know, but of course, you know, we're targeting profitable growth here. And, you know, we're going to continue to, you know, target good retention and have real investments in our member and broker experience.

One of the opportunities, Kevin, we're investigating is ICRA and the potential to grow the individual market through moving small group and middle market off of employer-sponsored and into ICRA coverage. And we're in the beginnings of that analysis. We see a lot of promise. When you look at the insured premium in the marketplace, insured premium is almost 70% individual when you look at Medicare, Medicaid, and ACA. There's more opportunity for us to grow that market over time. And so we will be taking a hard look at that this year and looking at a potential launch next year.

All right. Great. Thanks. See you guys tomorrow. Yep. See you tomorrow.

And we'll now hear from Nathan Rich, Goldman Sachs.

Hi. Good afternoon. Thanks for the questions. I guess when we think about getting to profitability for the total business by 2024, I guess, how are you thinking at a high level about the algorithm to do that between, you know, growth of the market and kind of leverage on that growth as you grow in line or above the market versus taking additional actions like exiting California? And are you considering any other reevaluations of the footprint as you think about the markets that you want to be in going forward? Thank you.

We will be growing the footprint beyond where it is today. So we're looking at new market entry opportunities. And that's what we talk about when we talk about sculpting the portfolio. Where should we be? Where we shouldn't be any longer? How do we change the portfolio to get the best return as possible? But I think underlying all of that is the scale that we now have should be brought to bear on the operating platform and our contracts with providers. We recently, as I mentioned, renegotiated our contract with our PBM partner with really good effect. That'll be something that we continue to do over time is to look for opportunities on the contracting side, look for opportunities on the operating side, because a lot of the operating opportunities at scale should be generating more internally generated capital for us. And that's what we are going to do to grow the bottom line for next year. And at the holdco level, we'll be paying attention to our spending. We'll try and keep it in line with growth unless we find real big opportunities in the Plus Oscar platform that we can use to gear up growth for the future.

The only thing I'd add to Mark's comments that Sid here is, really, we've given you guys some guidance in terms of what we think a target MLR for the year is of 82% to 84%. An important metric we look at is roughly 80% of the book for policy year 23, we expect to see within that range. And one of the largest markets that's outside that is California. And so You know, from that vantage point, I think, you know, we are very far along in terms of what we've done on portfolio sculpting. Because if I gave you that same number for last year, it's probably more like 60 to 65% of the book would have been in that target MLR range. So we feel very good about the progress. And, you know, we feel good about the strategy and execution, as Mark highlighted.

That's helpful. Thank you.

And everyone, a final reminder, it is star one. If you have a question today, we'll pause for just a moment. There appear to be no further questions. That does conclude our question and answer session.

It also does conclude today's conference. We would like to thank you all for your participation today. You may now disconnect.