Teladoc Health, Inc. (NYSE:TDOC) 42nd Annual JPMorgan Healthcare Conference January 9, 2024 4:30 PM ET
Jason Gorevic – CEO
Conference Call Participants
Lisa Gill – JPMorgan
Good afternoon. My name is Lisa Gill, and I am the Head of Healthcare Services at JPMorgan. With me this afternoon, I have Teladoc Health. Presenting for Teladoc is CEO, Jason Gorevic. When Jason has done with his presentation, he’ll join me over here, and we’ll have a little fireside chat.
So with that, let me turn it over to Jason.
Thank you, Lisa. Thanks, everybody, for joining us today. Nice to be back in sort of sunny San Francisco. So Teladoc Health is truly the global leader in virtual care. Our mission is to transform how people get health care and to help them live their lives using technology and advanced capabilities of care delivery. We serve about 90 million people who have access to our platform primarily through large employers and health plans, but also on a direct-to-consumer basis.
I’ll get into the two segments of our business. The scale is a true differentiator. So not only do we have 90 million people have access, we’ll do about 20 million — over 20 million virtual visits a year. We’ll have about 0.5 billion health care interactions with our members over the course of a year. That gives us unmatched scale both in terms of leveraging our provider network.
We have over 40,000 clinicians on the platform. And also in terms of the data that we can harness and turn that into better insights, better engagement, better experience for the consumer. And that experience really bears itself out with Net Promoter Scores of over 60, unheard of across the health care industry, and that has helped us as we’ve recently been named by Newsweek as the number one most trusted brand in health care.
Our two segments that we operate in are our Integrated Care segment and our BetterHelp segment. I’ll click down into each one of those. Integrated Care represents about 56% of our revenue over the course of the last 12 months. It is our B2B2C business, where we sell to employers, health plans, hospital systems, both here in the U.S. and outside the U.S.
It breaks down into approximately 42% of our revenue coming from chronic care services. About 40% of our revenue coming from U.S. virtual care services and then about 18% of our revenue in Integrated Care comes from selling to hospitals and health systems, primarily here in the U.S. and then selling in the international markets on mostly a B2B2C basis similar to what we do in the U.S.
On the BetterHelp side of our business, we sell primarily virtual mental health care services on a direct-to-consumer basis with over $1 billion in revenue, that business has grown over the course of the last three years from about $100 million to $1 billion in revenue by far the largest virtual care provider in the mental health space, and really differentiates itself not only with the 30,000 clinicians who operate on the platform, but the depth of data that enables us to deliver better care, better matching of a consumer with a therapist, better consumer experience and higher quality.
On the Integrated Care side, we’re selling, what as I said, virtual care services. So think about that as virtual urgent care, virtual primary care services, virtual nutrition, virtual dermatological services, all bundled in together into a single experience that goes along with our chronic care services. So our chronic care services take care of things, mostly along the cardiometabolic continuum focused on things like diabetes, hypertension, prediabetes, weight management. And of course, we have our mental health services that span both of those and enable better outcomes for consumers who engage across the full spectrum of our whole person care bundled offerings.
The breadth of our clinical capabilities combined with the integrated consumer experience enable us to win in the virtual care market selling on a B2B basis.
As I go a little deeper into the Integrated Care segment, our products really align around this array of blue bubbles outside of the circle. If you think about where we started, we started on an acute episodic basis, delivering virtual urgent care for consumers at a scale that had really never been seen before. And it’s what enabled us to build a base of over 90 million members who have access to the platform.
Over the course of the next several years, we introduced additional services that were both episodic, but also more longitudinal in nature. More longitudinal services like mental health care, where someone has a relationship with a therapist and they’re interacting with that therapist multiple times over a course of care, things, but also more acute episodic things like dermatology services, where someone is frustrated with not being able to get a sick visit with a dermatologist for a matter of a couple of months, but is able to see virtually a dermatologist and submit images of whatever the lesion is or whatever is going on with them and get a response within a matter of 24 hours.
We then continued the expansion into chronic health care services. And now, as I said, that represents about 42% of our revenue. So if you think about our business, we have built an incredibly large base and we rely on a set of not just broad clinical services, but also depth of capabilities. That depth of capabilities enables us to distance ourselves from the pack for employers, about three quarters of whom are looking for a single partner to provide this breadth of services and to consumers where about four out of every five consumers say that they prefer to get their both physical and mental health care services from one virtual care provider as opposed to a series of point solutions that are disjointed and unintegrated.
We also rely on data science and machine learning and importantly, now generative AI in order to improve not only the clinical care that we deliver, but also the engagement with our populations. We get paid to engage the population, so that they use our platform because that’s how we deliver better outcomes and lower costs for our clients. So we’re using that set of data insights in order to better engage consumers to drive greater adoption and what we see is when we sell multiple products into a population, not only do consumers engage across those products, but they also drive better outcomes by doing so.
And then finally, our distribution platform is really unmatched. And then we’ll get into over the next couple of slides, what our land and expand strategy is and how we’ve taken advantage of that to continue to drive growth within our customer base and also leverage on the P&L.
So if we think about where that membership comes from and where our growth comes from? There are essentially two sides of the equation. One is just driving new members. So we do that by selling to new clients, new logos on the page, and also by expanding the populations that we serve within a given client. That frequently looks like an expansion of geography or new lines of business within a health plan and over the course of the last two years, we’ve added 14 million members to our platform to where we now serve 90 million members who have access to that platform.
We also, as I said, have a land and expand strategy. So we look to cross-sell that broad array of clinical services into our clients such that they can come through a single bundled offering to us in order to take advantage of a streamlined contracting process, a single set of data interchanges relative to eligibility and most importantly, a single clinical experience for the consumer.
And you’ll see how that plays out as we go into the next slides. The last dimension there is when we have access to a population, it’s our job to engage them and enroll them in our products and services and you’ll see, over time, we’ve used data and advanced analytics in order to consistently increase the engagement rates within those populations.
So let’s click down into what that penetration looks like across our population and among our different products and services and how that’s improved over time. So again, we have about 90 million members who have access to the platform. About 57% now have access to our mental health services in addition to our — what we would consider to be our more traditional general medical services. That’s up significantly from 2021, in fact, an 800 basis point increase in penetration, while remember, we’ve expanded that population by about 14 million over that same period of time.
Similarly, our chronic care services, we’ve expanded penetration from 12% to 14% while we’ve increased the population that we serve. And so remember what I said, about 42% of our integrated care revenue comes from chronic care, and yet we’re only 16% penetrated in our book of business. It provides not only a good growth engine, and we said in our third quarter call that year-over-year, we’ve driven a 13% increase in chronic care enrollment, but it also provides a tremendous amount of running room as we look forward into the years to come from a growth perspective.
And lastly, our newest product is our virtual primary care product called Primary 360. So that product really didn’t exist back in ’21 when we set the baseline for that. We now have about 2% penetration. It represented about $30 million in revenue in 2023. And we really see that as a growth engine for us going forward, not only in and of itself, but also as a catalyst where we sell the rest of our clinical services, along with our Primary 360 product in order to bring the full scope of whole-person care to the consumer.
As you can see here, this provides not only what has been a great growth engine for us over the past about 75% of our sales in 2023 came from existing clients, but also a tremendous amount of growth opportunity for us in the future.
You can see here, I mentioned we saw about 13% year-over-year growth in chronic care enrollment over the third quarter over last year. That’s really due to probably three primary things. One, as you saw from the last slide, we’ve just increased the penetration in our book of business. So we sold more chronic care services into more clients. The second thing is, more and more, we are bundling our chronic care solutions into a single bundle where we sell hypertension and diabetes management and weight management and diabetes prevention and mental health care services, all bundled together in a single offering for a client.
That really does two things. One, it addresses a significantly larger population within that client who can take advantage of our services. The other is it seamlessly provides for the consumer an entire array of services that they can benefit from, and therefore, drives greater engagement, but also better clinical outcomes. We sell that at a single price point that tends to be higher than a standalone service. We tend to see that about 30% of our members are accessing more than one of our chronic care services.
And then the other thing that it does is it significantly increases the population that we serve and engage. You’ll see later in the presentation how we’re not only taking advantage of the bundling, but we’re also using generative AI and advanced analytics in order to improve the engagement rates and enrollment rates in those products.
Here, I’ll give you two examples now of how our land and expand strategy plays out. These are real examples. We’ve blinded them for our clients. But this gives you a really good indication of how we start with probably a single product or maybe two products. We expand the scope of the products that we sell into a client and the populations we serve. This is a Blue Cross Blue Shield regional plan that we started back in 2021 with mostly just diabetes management and a little bit of digital mental health care. You can see back in ’21 that represented about $19 million of revenue for us.
As we look into ’24, this client has not only expanded the suite of chronic care solutions that they offer from us, but also has engaged with us for our virtual care services, general medical services, Primary 360 services as well as mental health care. And so this client, just over the course of ’21 to ’24 will go from $19 million to what we estimate will be about $63 million in revenue in 2024. Again, off of what was primarily a single condition chronic care customer back in ’21?
Moving from the health plan market into a midsized employer sort of typical midsized employer, this client started with us with General Medical Services back in 2020, about $90,000 a year. This year, we’ve now sold them not only a suite of chronic care solutions, but we’ve also essentially augmented our general medical services with Primary 360, which includes our general medical capabilities.
And so you can see the role that the different products play in expanding this client by about six times in revenue over the course of 20 to 24 million. These are pretty typical examples of clients where we come in, we prove ourselves, we demonstrate our value. And then in the case of the health plan, they actually kicked out a competitor and replaced that competitor with our general medical services and mental health services so that they could work with a single partner and an integrated experience.
I mentioned that we focus on improving our engagement rates. We focused on improved — we’ve always focused on consumer engagement. We’ve always viewed it as our responsibility, not only to provide the technology and the clinical services, but get people to use it, right? We are very — we’re acutely aware of the fact that if a client buys something from us, but nobody uses it, then it really provides no value. And so we see it as our responsibility to engage the population, get them to use it, get them to get the benefit from it and continually improve that engagement engine year-over-year.
So here’s an example on the left side of this slide of where we use generative AI to really do two things to improve the engagement capabilities that we have. So we have a set of a library of articles about various different conditions and health care sort of steps that you can take in order to improve your care. And we’ve used those for years in sending them out to consumers to try to get them to engage and enroll with our clinical programs.
Well, now we’ve taken generative AI to take a few versions of that and turn that into literally 100 versions of it based on micro segmentation of the population. We also use generative AI in our partnership with Microsoft specifically focused on open in order to generate next best actions to embed in the e-mail that is specific to that consumer, their actions, their clinical outcomes, and we’ve seen a very significant lift in the engagement rates and therefore, enrollment rates that we’re seeing.
And you see on the right side of this slide how that manifests itself year-over-year in improved enrollment rates within a population of recruitables. So that means we’re getting greater revenue out of the same population because we’re enrolling a larger set of the recruitable members.
We are seeing just like many people, the shift to value-based reimbursement, quite frankly, we welcome it. It’s still a relatively small part of our overall bookings. In 2023, about two thirds of our bookings were chronic care bookings and about 15% of those were — had our fees at risk for delivering clinical outcomes. We’re very confident in those, and we see attainment rates, meaning how much of the revenue do we actually attain in the high 90% range. And the reason for that is because of the clinical outcomes that you see on the bottom of this slide.
When you think about our overall book of business, we’re still in the low single digits in terms of fees at risk arrangements as a percentage of our overall revenue.
Our BetterHelp platform, if I turn to the BetterHelp side of the business is truly unmatched. And it’s unmatched because of a few things. One, the scale at which we operate, the fact that we’ve been doing this now since 2015 with incredible focus has built an unmatched brand in the market.
Our expertise has led to our ability to use really advanced machine learning capabilities to match a consumer with a therapist, which is the greatest determinant of them staying with the service. And as you see in the lower right corner of this slide, the improvement year-over-year of second year — sorry, second month persistence with the service has continuously improved over the last four years.
So people ask frequently about retention rates and duration and churn in this business because it is a direct-to-consumer business. And you can see how that’s improved year-over-year even as the business has grown to be in excess of $1 billion in revenue.
The advantages here are based on that scale that I talked about, having 30,000 clinicians on the platform is a real advantage. And so it’s not just an advantage to the consumer who knows that we can match them with a therapist who’s really going to resonate with them. But on the flip side of that, therapists really see value, right? There is unfortunately, systemic inefficiencies that leave a lot of therapists’ time unused, right? We’re talking about tremendous pent-up demand and excess supply that goes unused, and our two-sided marketplace really bridges the gap there and takes advantage of those unused slots in a therapist time.
And so we see tremendously high Net Promoter Scores on both the consumer side as well as on the therapist side. And that’s resulted in very strong delivery in terms of our overall financials. As we’ve said for the last probably 18 months, we’re focused on balanced growth across both top line as well as bottom line. And you’ve seen that borne out over the course of the first three quarters of 2023.
And especially, I’d point you to the free cash flow numbers, where over the course of the first three quarters, we threw off over $100 million of free cash flow. We’ve said we expect to deliver in excess of $175 million of free cash flow for the full year. And we will continue over the course of the next several years to grow our EBITDA dollars at a faster rate than our revenue growth in spite of delivering robust revenue growth.
And so hopefully, you’ve taken away these points, and I don’t have to reiterate them. I do — I will say, I think that we are probably still underappreciated with respect to our market advantage the financial performance that we’ve demonstrated as well as the bright outlook we have in terms of our growth potential going forward.
So with that, I will join Lisa at the table and open it up for questions.
Q – Lisa Gill
Great, right. Thank you so much for all the details. Jason. I think many of you know in the room that Jason and I now have known each other for 10 years. And you’ve really taken the company and has had an incredible journey, right? With 2020 really being kind of this pivotal year where prior to that, even I would have conversations of people don’t understand or know about virtual health care and then the pandemic hit.
As we sit here today and I look at your integrated services and the growth rate there is still kind of mid-single digit. What do you think it takes to really get and accelerate the growth? Or do you feel like when we look at a mid-single-digit growth rate, — and we look at utilization trends in primary care or low-single digits. So do you feel like you’re part of the way there already? Like how do I think about the integrated side?
Yeah. I mean, look, we have significant scale, right? And certainly, this was a business that was growing at 30% a year, and we were described as hyper growth. And the — if you look at the inflection in our growth and the giant step we took in ’20 and ’21, I think there’s just a lot of large numbers that says the growth rate is going to dampen on the top-line. I think we’ve also been pretty clear that we’re focused both on growing the top-line and on leveraging the P&L in order to drive better bottom line performance. And I would say differentiated free cash flow, right? This is a space that doesn’t have a lot of profitable companies and doesn’t have a lot of companies who are throwing off positive free cash flow.
And so we’re going to continue to do both of those right? We’re going to continue to drive growth. We’re not going to be a 30% grower. That’s not realistic. We’re going to continue to drive meaningful growth and at the same time to look to drive better performance on the bottom line and leverage the P&L.
Before I get into the selling season because you know I love to talk about that. When I think about the growth on the B2C side of the business, which has been very successful. But you did talk a little bit about the churn rate, the sustainability of saying on that platform. I think that there’s always that concern of what happens in an economic downturn never happened this year. But I know you’ve answered questions around student loans coming back next year, the competition in the marketplace. Can you maybe just spend a couple of minutes talking about BetterHelp and how you see that business evolving? You also talked about a B2B offering when you think about mental health.
And I think one of the things that we have found in our recent surveys is that more and more employers want to expand what they’re offering in the mental health area. So do you see an opportunity to maybe take some of that B2C and move it more to your B2B platform?
Yes. So BetterHelp is, again, this is a business that did $1 million in revenue in 2014, and it’s well over $1 billion now. We continue to see positive growth coming out of BetterHelp. I think you’ve seen a couple of years of tough comparables in BetterHelp. It grew astronomically in ’20 and ’21, ’22, we had an irrational and it turns out illegal competitor in the market. And that caused a weird cadence in terms of our ad spend. So that meant ‘23 had a weird set of comparables relative to the prior year. So I would look at full year growth of ’23 rather than sort of quarter by quarter. And I know a lot of investors get tripped up on that.
We continue to see a tremendous amount of opportunity in direct-to-consumer mental health care. I don’t think that’s running at a running room, so to speak. The — we put in the slide today that we shared, the ratio of gross profit to ad spend is about 1.5 to 1 right? So that’s a very healthy business and a business that runs at a strong gross margin comparable to the rest of our business. So the economic fundamentals of that are really strong and we manage it in a responsible way, right? We’re not spending to grow at all costs, we’re spending to grow profitably.
And I think that — so I think that’s — we are looking at opportunities to bring BetterHelp capabilities more and more into the B2B side of our business. We’re more and more selling BetterHelp directly to employers, organizations, associations and we see more opportunity to do that.
When we think about the selling season, one of the things that has come to our attention when we go out and survey employers is this point of sale or point-of-service fatigue, right? They’re tired of all these single point solutions. We’ve heard from different players that have 20-30 different types of solutions in our books of business. And so as I think about what you’re trying to bring together, can you talk about what you see as some of those opportunities, what you saw for the 2024 selling season as far as cross-selling goes, what people are looking for.
And one of the things that kind of stood out in your presentation today is that a lot of times when you bundle things, you have to bring the price down, right? And we didn’t really see that from your perspective.
Yeah. No, that’s right. So overall bookings last year were up about 10% year-over-year. About 75% of our bookings were multiproduct sales. Two thirds were chronic care sales. So I think there was a question in ’22 about whether we were running out of running room on Chronic Care. That’s the most profitable part of our business.
We delivered strong results in ’23. And I think if the bundling is an excellent point, so if you think about a bundle of services, our diabetes solution by itself, let’s say, we sell for about $65 to $70 per enrollee per month. When we go in and we sell a full bundle of services, we may — our price point will go up to, let’s say, $100 per enrollee per month, but they get access to the full suite of our chronic care solutions.
So actually, our revenue per member goes up the population that we engage increases, our gross margin goes down just a little bit because somebody will engage with multiple products. But the EBITDA margins actually go up because I only have to engage them once across multiple products. So we actually see it as a win-win.
Our clients like it because it’s a single contract, right? It’s an easy contracting path. It’s a single implementation. They’re not trying to integrate multiple point solutions themselves. And we like it because economically, we benefit from it. And the best thing is when somebody uses multiple of our solutions, they get better clinical outcomes.
I mean, obviously, a big area of focus in 2023 was GLP-1s. Last summer, you announced some new programs around weight management I think that, again, when we talk to employers. There is a big focus here of not just making sure that the right patient is getting a GLP-1 for weight loss, making sure that you can truly manage that patient and also do other wellness and management around that patient. So can you talk about what your success has been around some of these weight management programs going into 2024? And how you see that changing and evolving?
Yeah. So I think about 3 tiers to our weight management solutions. First is we have our historical weight management solutions that we’ve been selling for years and continue to sell both on a stand-alone and a bundled basis.
Second is what I would call a coach enhanced program, which has all of those solutions. There’s a coach engaged. And a lot of clients are looking for that either as a partner along with GLP-1s for people who have already been prescribed and are on GLP-1s or, quite frankly, as a precursor to someone going on GLP-1s because they’re really worried about the silver bullet approach, right? Somebody goes on GLP-1s, they don’t change anything else about their lifestyle. And then they’re hooked on it because otherwise, they’re going to get a yoyo effect. And that is a potential runaway cost.
So a lot of clients are turning — that’s probably where we’re seeing the most interest.
The third tier is where clients are saying, we really want you to engage clinically and be the sort of center of prescribing for GLP-1s and we want it to be a sort of a single point clinically. We’re only seeing that with a little bit of interest right now. I think the big thing, if I step back from it, though, is ’23, there’s just a lot of confusion and people trying to figure out what to do. So we didn’t see a ton of buying behavior in ’23.
We expect to see a lot more people employers, especially wrestle down their decisions about coverage and are they going to cover these medications? And under what conditions are they going to cover them, and then we believe that we’ll see more buying behavior over ’24 that will yield revenue for us in ’25.
Yeah, I would agree with that. I mean I think from our perspective, some of the survey work that we’ve done, I think a number of employers were quite honestly caught off guard in ’23, not realizing that some of their patients were even prescribe these products and then really trying to figure out what kind of program should we have around wheat management.
Diabetes is an easy one, right? We’ll cover it for diabetes. But when it comes to weight management, as you know, as a former executive in managed care, there’s only two states that require today, New York and California no surprise. So I think that there’s still a lot to be done there. So should I think of that as kind of more of a maybe 25-plus opportunity?
You put up a slide and said we’re very early on in value-based care, but we’ve also — you and I have talked about value-based care for 10 years and the growth in value-based care and the opportunity in value-based care. You talked a little bit about really driving towards outcomes and getting paid for that. But can you give us a little more color as to exactly how that works? And how many incremental opportunities do you see from that perspective?
Yeah. So we’re willing to put our fees at risk for delivering clinical outcomes, right? And the way that, that works is we know that we have a bigger impact on people with greater acuity of each of their conditions. We put together a matrix that says, here’s how much of an impact we’re going to have on all these different tiers of acuity, whether it’s A1C or blood pressure or weight or something like that, BMI. And then we hold ourselves to accountable for doing that, and we will put our fees at risk for that.
We have some clients where we’re willing to go put our ROI on the line for financial results, financial return on investment. It has to be a big enough population that we know that we’re not getting selection bias or something like that. But we’re certainly willing to do that. And then we have a couple of instances where we’re starting to put our toe in the water in terms of measuring total cost of care and putting our fees at risk relative to total cost of care. Mostly that — when we do that, we generally have upside and down downside risk-sharing corridors, where we share in that upside or downside with the client, but within a finite band.
So we’re not in the business of taking full capitation. We’re not able to impact the full cost of care to a degree where I would be willing to say I’m willing to not only put my fees on the line, but also become the insurance company. I’ve done that, and I don’t really want to go back to that. But we do feel very confident about our ability to impact cost of care, deliver positive ROI and make an impact on clinical results.
When we take a step back and we talk about the — of large numbers, especially around BetterHelp, we’ve seen that decelerating growth. But I mean, I do remember when it was $100 million of revenue and getting it to $1 billion is quite a feat. Is there a substantial level that you think it can grow at over time or a sustainable level? I mean, 19% is still really solid growth?
Yeah. We continue to see growth out of that business. I’ve had investors ask me, hey, is that run out of growing room? Is it going to shrink next year? I don’t think there’s any scenario where we believe that that’s the case. We continue to see growth out of that business. We’re going to manage it responsibly. And essentially, what you get to is — we have to improve — we continue to improve, and we do this every year. We innovate every year to improve retention rates, to improve lifetime value of a member, to bring down our — to improve our yield — revenue yield per dollar of customer acquisition spend and to optimize the mix of the channels that we’re using for consumer advertising. All of those things go into the mix in order to continue to not only grow the business, but continue to get strong financial performance on the bottom line.
You’ve had really nice retention when I think about the number of members, 90 million members on your platform. And over the years, there’s been a lot of focus by investors of well managed care or others disrupt this model. And many of them, whether they own their own physicians and maybe have a virtual option within that, we haven’t seen that. And can you maybe talk about where you are specifically with health plans and the opportunities that you see on a go-forward basis?
Yeah. I mean we serve — we serve health plans all across the spectrum, right? We serve regional Blue plans. We serve government programs oriented plans. We see large — we serve large nationals. So it’s not like we’re only right for a certain kind of help, we’re all across the board. We have seen great retention. We — every year, I can remember, we’ve seen greater than 90% retention rates. And we’re still early in that penetration, right? The lion’s share of that 90 million members comes from health plans just by definition, right? They’re the biggest aggregator in the market. And yet, we’re only 16% penetrated with respect to those chronic care programs.
Now you might say, well, a lot of those big managed care companies have their own chronic care programs I can point to at least one recently who has their own program and they just bought from us, mostly because their clients ask for us by name and so we really want to be able to get Teladoc programs, and we want to be able to get it through you along with all of our other services.
So we don’t see that even if a client — a health plan has their own offering, we don’t see that precluding our ability to be available for their clients and members. In fact, we’re seeing growth across — really across all of those types of clients.
We have less than a minute left. Jason, I know 2023 hasn’t been an easy year for the stock. As we look forward to 2024, what do you hope that investors will better appreciate about Teladoc that maybe they don’t today?
Yeah. Look, I think it’s taken investors a little while to get their heads around the fact that we mean it when we say we’re taking a balanced approach to top line and bottom line growth and to appreciate that the bottom line performance and the cash flow performance that we’ve seen an expansion of our margins that we’ve seen in ’23 is going to be durable into the future. And I think we’ll give guidance in February when we report our full year results. And I think as we give guidance in February, we will prove out the fact that, that’s going to be a multiyear continuous slide path as opposed to a one-year blip.
Great. Well, with that, thank you very much. I really appreciate it, and thanks, everyone.