Accolade Inc (ACCD) 2022 Q1 法說會逐字稿

Good day, and thank you for standing by. Welcome to the Accolade First Quarter 2022 Earnings Results Conference Call. (Operator Instructions)

Please be advised that today's conference is being recorded. (Operator Instructions) I would now like to hand the conference over to your speaker today, Todd Friedman. Please go ahead.

Thanks, operator. Welcome, everyone, to our fiscal first quarter earnings call. With me on the call today are our Chief Executive Officer, Rajeev Singh; and our Chief Financial Officer, Steve Barnes. Shantanu Nundy, our Chief Medical Officer, will join the question-and-answer portion of the call later.

Before I turn the call over to Rajeev, please note that we'll be discussing certain non-GAAP financial measures that we believe are important when evaluating Accolade's performance. Details on the relationship between these non-GAAP measures to the most comparable GAAP measures and the reconciliations thereof can be found in the press release that's posted on our website. Also, please note that certain statements made during this call will be forward-looking statements as defined by the Private Securities Litigation Reform Act of 1995. Such forward-looking statements are subject to risks, uncertainties and other factors that could cause the actual results to actually differ materially from those expressed or implied on this call. For additional information, please refer to our cautionary statement in our press release and our filings with the SEC, all of which are available on our website.

With that, I'd like to turn the call over to our CEO, Rajeev Singh.

Thanks, Todd. And thank you all for joining us. It's an exciting time to be here at Accolade. We're one month past the close of the PlushCare acquisition and are well underway with the work of integrating Accolade, Plus Care and 2nd.MD into a single business. Combine that with the excellent financial results to start the new fiscal year and the return of our first wave of employees to our offices, which we're very excited about as well as a sense of normalcy returning to the communities in which we live, and there is a strong feeling of optimism at Accolade today.

My reasons for optimism are grounded in a simple belief that we can deliver differentiated value for our customers. When I joined Accolade nearly 6 years ago, it was clear to me that the foundation of advocacy and navigation would be the cornerstone of a richer set of services that could one day bring value-based care to the employer health care market. Advocacy provides the foundational platform of broad engagement, longitudinal relationships and a rich data set that makes every incremental service that you add to it better. That evidence originally came in the form of partner relationships via our trusted supplier program and would eventually validate a bold acquisition strategy geared towards assembling the industry's richest set of tools for engagement, cost reduction and improving clinical outcomes.

Most importantly, our customers have been energized by these new capabilities and their potential for value. We're deep into these customer conversations and hard at work outlining for each how our enhanced solutions will do even more for their specific populations. Additionally, our integration and innovation teams are working feverishly to launch a fully integrated offering, one seamlessly combining advocacy primary care and expert medical opinion. Our mission is to create a health care experience that finally puts the consumers' needs first, and we cannot wait to show you how our vision for the future translates to an integrated offering.

For today, I'll spend time talking about our early progress, initial successes and high-level plans to change the industry. First, a quick review of the quarter. Revenue and adjusted EBITDA were both ahead of our guidance. Revenue of $59.5 million was 66% greater than last year, and adjusted EBITDA loss of $12.8 million reflects some of the investments we told you we plan to make an integration and the launch of a new enterprise primary care business. Steve will provide more color, including some high-level comparisons to account for the impact of our 2nd.MD acquisition.

From a business standpoint, I want to touch on a few key highlights from the quarter, including the integration of 2nd.MD and PlushCare, a positive start to the early selling season and the growing importance of behavioral health. I'll start with 2nd.MD. In just 3 months since we closed the acquisition, we have signed our first cross-sell customers with organizations like the City of Fort Worth and a Fortune 50 insurance company adding expert medical opinion to their existing advocacy services. These early cross-sell wins, more rapid than even we expected, along with 2nd.MD's continued new business success, validate our hypothesis of the transaction very clearly.

Additionally, as we announced when the transaction closed, expert medical opinion is now a core component of our total care offering. The value proposition, and more importantly, the measurable impact on employee well-being and health outcomes have immediately been apparent to our customers. Not only have we seen cross-selling success, but our first joint customer went live on July 1. We're optimistic about the pipeline of Expert Medical Opinion deals for the remainder of the year as well.

Most importantly, member NPS scores for Expert Medical Opinion remain at historically high levels, above 90%.

It's July. So we're in the prime summer months for the traditional health care selling season. For those of you who are new to our company, large employers tend to make big decisions related to their health care and benefit plans in the summer, in anticipation of fall open enrollment and a January 1 launch. As we've told you before, with our addition of new capabilities and expansion of our target customers to include businesses of all sizes, we are selling throughout the year. However, it's still an important time in the industry, and we've had a very positive set of success with both renewals and new business.

We signed deals in the first quarter in each of our customer segments, middle market, enterprise and strategic. In addition to some of the notable deals I mentioned for 2nd.MD, we also signed McKesson, a Fortune 50 pharmaceutical company for Total Health and Benefits, our premier offering. We also saw key expansions in the populations we're serving with Humana as well as notable customer wins via our new health plan partners who had established relationships with 2nd.MD prior to the acquisition.

One in particular was a Fortune 100 financial services firm, who is served by 2 national health plans. I note the multi-carrier dimension because while it is one customer selecting 2nd.MD, our ability to meet the needs of their full employee base relies on the strength of our relationships with multiple carriers.

One other note that I would call your attention to. One year ago, when we went public, we outlined the multiple flavors of advocacy offers we bring to market with the belief that customers who choose our lighter touch offerings might begin to upgrade to more fulsome solutions down the road. In fiscal Q1, we saw our first upgrades from total benefits and total care to total health with benefits. One of those was the Pepsi Cola National Brand Beverages Group, which is the second largest franchise bottler and distributor of PepsiCo covering the Mid-Atlantic.

Finally, we're continuing to see an increase in interest in mental and behavioral health. This past quarter, we signed more customers to our Mental Health Integrated Care solution with Ginger. Incrementally, we're incredibly excited about the embedded mental health capabilities in our new PlushCare primary care solutions. As COVID has exposed the incredible mental health crisis in the country, we believe our ability to provide a multifaceted behavioral health solution to customers, integrated with the most critical touch point primary care, is going to be very meaningful to our customers and their employees and their families.

And that's a good segue to transition to PlushCare. First, while it has been less than 30 days since the acquisition has closed, we've already had the current PlushCare solution as well as our expanded primary care strategy in front of a number of significant customers. Our field teams have all been trained on PlushCare, and all our new solutions. And we're actively executing on a cross-sell upsell strategy that is looking very positive.

When we announced the PlushCare acquisition, we talked about a parallel strategy of continuing to focus on the existing direct-to-consumer business while building out an expanded Accolade primary care strategy that leverages the core strengths of our navigation, advocacy and expert medical opinion offerings. The core PlushCare business has continued to perform very well. In fact, while traditional urgent telemedicine providers talked about a post-COVID return to lower growth levels, PlushCare has continued to grow subscriptions and business. We'll share more about that when we report our first combined quarter in October.

On the broader enterprise primary care model, that work continues, and we plan to roll out that strategy in the near future. One thing we haven't talked about previously is our plan to operate a fully featured solution for primary care on a stand-alone basis to customers in the quarters ahead. For many customers, especially those in the middle market, the existing PlushCare platform is a powerful primary care offering that our customers can begin using immediately. It's a testament to the combined execution of both the PlushCare and Accolade teams that we're able to move this quickly.

Next, I'd like to share a member story from a PlushCare position that I think is a good allegory for our broader primary care strategy. This story centers on a member who lives in a rural area far from a medical office, a problem for many of our customers' employees, by the way. Suffering from stable hypertension, she had reached out to PlushCare for help refilling 1 of her 3 blood pressure medications. The member was complaining about fatigue, but she didn't want to go to the hospital because of COVID.

A typical transaction-focused telemedicine provider might have simply refilled the medications. The PlushCare primary care physician built a relationship and convinced the patient to have a home blood testing kit sent to her. The testing kit revealed something serious and the requirement for more tests. Her glucose, liver and kidney levels were very elevated and her A1C was twice the normal level. The member thought her hypertension medication was out of balance. But in reality, she has undiagnosed advanced type 2 diabetes with chronic kidney disease, dyslipidemia and fatty liver.

At this point, you can see the incredible difference in the PlushCare approach compared to traditional urgent telemedicine. The PlushCare physician discussed a number of potential therapies, including medications and lifestyle changes. The PlushCare nursing staff guided the patient on glucometer use and self-monitoring for type 2 diabetes. The PlushCare off staff engaged with the patient, the pharmacy and the physician to ensure that the correct supplies were ordered and delivered to the patient.

The patient refused insulin, so constant monitoring, follow-up and testing was necessary. After 1 month, the patient has adopted new behaviors recommended to her by our PlushCare team, including installing a treadmill in her home and changing her diet. Her blood sugar levels dropped by half. Three months later, her A1C levels have dropped by half and her kidney and liver levels were back to normal levels. Her blood pressure had also dropped so the physician was able to discontinue 2 of her 3 medications. At the next follow-up, her levels have dropped even further to the point that she was no longer even considered prediabetic, and her blood pressure was in a normal range. This was a terrific example of a patient who had a clinical success despite having limited insurance coverage in a rural area with no close access to specialty care. And arguably she was successful because of the virtual care approach since access to a brick-and-mortar facility was a barrier.

Those barriers exist across the country. It could be related to location or socioeconomic factors or race. We have the opportunity to break those barriers and change the way care is delivered. When the PlushCare primary care doctor that delivered this care told this story, she talked about the difference that would have been made if the member had been engaged with Accolade before she knew she had this issue. This member with, her hypertension and multiple medications, would already be on Accolade's radar through our ongoing monitor of claims and likely actively engaged with the health system and nurse. When the member reached the PlushCare physician, the doctor would instantly have all of the patient's medical history, list of medications, critical insurance information and all the other benefits that the member's employer might be providing. An integrated medical expert opinion specialist might have been engaged sooner. And when it comes to the necessary supplies and follow-ups for this treatment and beyond to a comprehensive ongoing relationship, the physician and PlushCare care team would now have the extended capabilities has come with the Accolade Frontline care team.

As we look to what's next, this real life example clearly outlines our opportunity. A fully integrated data-driven approach to improving the well-being and overall health of our members is the goal and we now have a rich set of assets to achieve it. With that, I'd like to turn the call over to Steve to cover financials.

Thanks, Raj. First, I'll recap the results for the first quarter of fiscal 2022. Keep in mind that we closed the 2nd.MD acquisition on March 3, just a few days into our first fiscal quarter. Where appropriate, I'll provide color on the year-over-year comparison beyond the tables in the press release.

The PlushCare acquisition closed in June after the first quarter ended. So there's no PlushCare contribution or impact in any of these results.

We generated $59.5 million of revenue in the first fiscal quarter, representing 66% year-over-year growth on a GAAP basis over the prior year period. In our 10-Q, we provide pro forma results for the combined business that show 35% growth year-over-year. As we provide pro forma results for SEC requirements for the rest of this fiscal year, please keep in mind that we're selling our solutions both together and separately. So while the reported pro forma revenue growth and profitability numbers are intended to reflect the acquisitions as stand-alone, it may not always be a perfect representation of how we sell to customers and run the business overall.

As a quick example, we sell Expert Medical Opinion as part of Accolade Total Care, as an upsell and as a stand-alone solution. Some of that would be reported as 2nd.MD revenue for pro forma purposes and some will be recognized as Accolade revenue. The revenue outperformance relative to guidance was largely attributable to solid execution on multiple fronts. Both customer member counts and performance-related revenues exceeded the expectations built into our fiscal Q1 guidance, including the timing of achievement of a customer performance guarantee that pulled forward approximately $1 million of revenue into the first quarter, which also positively benefited adjusted EBITDA. Fiscal Q1 adjusted gross margin of 40.2% compared favorably to 38.3% in the prior year period. As stated on the Q4 call, we expect adjusted gross margin to remain relatively flat this year.

Adjusted operating expenses decreased slightly to 62% of revenues in Q1 of fiscal 2022 versus 65% of revenues in the prior year period. And adjusted EBITDA in the first quarter of fiscal 2022 was a loss of $12.8 million, which compares to $9.4 million in the prior year first fiscal quarter.

Turning to the balance sheet. Cash, cash equivalents and marketable securities at the end of the first fiscal quarter totaled $425.5 million. Note that during the quarter, we paid $236 million related to the 2nd.MD acquisition and received $245 million in proceeds after estimated expenses from our convertible notes offering. And after the quarter ended, we paid approximately $53 million related to the PlushCare acquisition. So on a pro forma basis, cash, cash equivalents and marketable securities were approximately $373 million heading into the second fiscal quarter.

Accounts receivable increased from the end of fiscal 2021 to $15.3 million at the end of fiscal Q1, representing about 24 days revenue outstanding for the quarter, consistent with our last update on the expectation that DSOs normalize in the 20 to 30 range. And the increase in AR over the prior quarter relates primarily to the acquisition of 2nd.MD.

Finally, we had approximately 58.8 million shares of common stock outstanding as of May 31, 2021. And note that this does not include any shares related to the Second MD earn-out or the acquisition of PlushCare. So for your models, you should include approximately 7.1 million shares issued for the PlushCare acquisition in June. Additionally, there are up to approximately 2.2 million shares related to the 2nd.MD earnout and up to 1.4 million shares related to the PlushCare earnout to be issued in calendar 2022.

And now turning to guidance. For the fiscal second quarter ending August 31, 2021, we expect revenue in the range of $69 million to $71 million, which includes PlushCare revenue from June 9 and adjusted EBITDA loss in the range of $22 million to $25 million. And for the fiscal year ending February 28, 2022, we expect revenue in the range of $300 million to $305 million, representing 78% growth over the prior year at the midpoint of the range.

Breaking this down further, we've said that we forecast the 4 Accolade business at approximately 25% growth and we expect 2nd.MD and PlushCare to grow faster than Accolade. If you assume a full year PlushCare contribution and combined PlushCare and 2nd.MD's calendar 2020 revenue with Accolade's $170 million in fiscal 2021 revenue, it would give you about 30% growth at the midpoint of the range.

Adjusted EBITDA loss for fiscal '22 is expected to be in the range of $49 million to $54 million, representing an adjusted EBITDA loss of approximately negative 17% of revenues at the midpoint. This is consistent with the color we provided last quarter and that the PlushCare close to expect approximately negative 20% adjusted EBITDA margins from PlushCare and incremental investment as we build our enterprise primary care business.

And now I'll turn it back over to Raj for his concluding remarks.

Thank you, Steve. Before we take any questions, a couple of quick announcements. Please keep an eye on your inbox for a couple of upcoming events. We heard good feedback following our deep dive session on Expert Medical Opinion, so we're planning the next session later this month, which will focus on data.

We're also getting ready to host our annual customer event again in September. Attendance will be limited to customers, but we do plan to webcast the keynote and host an analyst Q&A session. Please reach out to Todd for more info if you don't get an e-mail with those save the date details.

Operator, with that, I'd like to open the call for questions.

(Operator Instructions) Our first question comes from David Grossman with Stifel.

Raj, you gave some observations about the selling cycle and what you're seeing year-to-date. And now that you've completed these 2 deals, I know you mentioned integrated offering and going to market with that offering, but it's probably a little bit too early to comment on that. But now that you've closed these 2 deals, you are meeting with customers at a point in time when they're making decisions. What are their observations and questions about what this becomes and where their interest may lie going forward when you look at the integrated whole?

Yes. First of all, it's great to talk to you, David, and thank you for being here. I think it's a really important question you asked because our customers just like we are, look into the future. And in that look in the future, they're acknowledging that today, they're oftentimes confronted with a complex health care system and too many solutions to weave together on their own. Oftentimes, our buyers today are carving out solutions from their local health systems and from their plans and looking to weave together their own ecosystem of solutions. And unfortunately, too many times, that's very difficult for them to do, and they're seeing really low utilization rates.

They hired us to solve that problem when they bought our Advocacy services over the course of the years. What we've been able to do for the network of solutions that we've woven together that we have called our trusted supplier program is driving engagement not only for our own solutions, but for the partners that we brought to bear. And our customers see that metaphor. They see that metaphor as it relates to primary care. They see that metaphor as it relates to expert medical opinion. And they can see how that metaphor is multiplied when that solution is under the Accolade umbrella and going to be deeply embedded from a technology perspective, a process perspective and a clinical perspective. And so, David, so far, our meetings with our customers have been extraordinarily positive. They understand the hypothesis behind the acquisitions. They understand what the long-term value proposition should be. And I think what they're looking for is more from us on the vision of how that integration work and that's what we're giving them.

And then as you kind of take that back to a comment you made also in your prepared remarks about offering stand-alone solutions for both 2nd.MD and for PlushCare, is that targeted at specific market segments or specific problems you're trying to solve for the customer? Or is there more to it than that?

David, since we really got going here at Accolade, the mission has always been to meet the customer where they'd like to be met. Different customers are at different stages of their journey. And so 3 years or 4 years ago -- or 3 years ago, we announced the various flavors of our Advocacy offerings, meeting the customer at different price points with different engagement levels. We think the same story is true for Expert Medical Opinion, where every single HR buyer has that moment where one of their employees gives them a ring and says some family -- one of their family members have been diagnosed with cancer, what do I do? Second, our 2nd.MD or Expert Medical Opinion solution gives them the answer to that question. We think that same story is true around virtual primary care. Customers are looking for, particularly those who are wrestling with access and availability issues, are looking for answers to questions like that. And as opposed to trying to shoehorn them into a particular solution, we want to solve their problem. And that's been the nature of the way we think about approaching the market forever.

Our next question comes from Michael Cherny with Bank of America.

Congratulations on the nice quarter. I want to follow up a little bit on the selling season comments. Raj, I think you made a comment saying that some of the cross-sell came earlier than you expected. If you could characterize a little bit more about that cross-sell, is there any common traits that you're seeing between the customers and what's driving some of those -- that cross-sell capture at an earlier pace than you would have expected? Just trying to think through and also think back to the expert second opinion deal you did, where it seemed like you had a client there that was very excited about a potential cross-sell. I'm curious if you think about what we should be expecting and what's built into guidance as we move through the rest of the selling season and through fiscal '22.

Sure. Let me take the qualitative part of that answer, and I'll leave the guidance part of -- I'll leave the hard part of the question to Steve. I'll just answer the fun part, how's that? And the -- first of all, thanks for being here, Mike, and thanks for the kind words. The -- interestingly, if you look at the mix of cross-sell customers that we saw in the first quarter since we acquired 2nd.MD, we saw customers who were already in the process of evaluating 2nd.MD, who were Accolade customers who made a buying decision. Meaning they were in the process of evaluating 2nd.MD before the acquisition. We saw customers who began and closed the evaluation after the acquisition began.

And we saw customers who were looking at -- already on existing solutions and deciding to make a changeover since post the acquisition. So all 3 varieties of types of deals closed. And so I think the good news is customers fundamentally understand that second opinion utilization is critical. That if you can get utilization rates above 2%, above 3% that you can yield outsized value and extraordinary employee satisfaction. And that to the degree they're not seeing that in some of the other vendors that they're working with, that they have a lot of confidence that they can do so with Accolade and 2nd.MD combined.

And Mike, this is Steve. I'll speak to a bit about the guidance and what's factored in. As Raj mentioned, we're really, really excited about the early momentum with cross-selling that's occurring already. And we have, of course, factored some of that into guidance. But remember where we are in the selling season. This really will become a more significant factor into fiscal '23, particularly with respect to revenue because, as you know, most of our deals set up to be implemented during open enrollment and then launched on January 1. So you could think of the revenue impact from cross-selling as fairly minor. And at the $300 million to $305 million top line revenue guidance we're giving for the year really has a lot more to do with core organic growth from Accolade and then on its own, 2nd.MD, strong growth continuing there. And then PlushCare as well, both of which you'll recall, we signaled that those companies, we expect to grow in the 35% to 40% rate on their own, so to speak, as we're bringing together that integration and coming to market with Accolade maintaining that growth rate on a core organic basis at 25% or so, which pencils out to that guidance range.

Perfect. And then just one, hopefully, very quick follow-up. On the pull forward that you had on the at-risk revenue, the $1 million that you mentioned, can you just tell us, was that supposed to be part of the normal course of business that you would have recognized in 4Q? Just curious how pulled forward it was.

That's exactly right, the way you described it there, Mike. We expected it to occur later in the fiscal year. And we achieved that in the first fiscal quarter and so recorded it there. So we think it's important that you understand as you're analyzing those results. So very strong first quarter for all good reasons around member counts and PG performance on its own. And then you had that, call it, $1 million pulled forward from Q4 into Q1.

Our next question comes from Ricky Goldwasser with Morgan Stanley.

I have a couple of questions here. So first of all, just trying to understand the upside in the quarter. It sounds like, Steve, that $1 million is from the pull forward of the performance payments. As we think about the remaining upside, what is from core, in other words, from upside to your estimates on 2nd.MD performance in the quarter?

Great. Ricky, yes, a couple of things there. If you peel apart, and you'll see the 10-Q, which also either just got filed or will be filed imminently. We do pull apart the pro forma numbers for 2nd.MD and Accolade in the Q. So you'll get a chance to take a look there. You'll see the different components of it. And you'll see on a year-over-year organic basis, that 2nd.MD grew in the low 40s, 40%, about 42% year-over-year. So a very strong growth year. And you could assume that, that was -- we had guided towards a 35% to 40% range there. So strong growth from 2nd.MD.

And importantly, with Accolade, we're starting to see the negative effects of COVID wear off a bit in a very positive way, meaning employee counts came up strong for Accolade across our customer base, which is positive. And finally, with respect to PGs, as you know, we assume different elements of that around the savings, PGs and the operational PGs. And we've performed very well across all the different categories, customer satisfaction, engagement rates and cost savings to the extent cost savings are booked early in the year. As you know, about 80% of the cost savings revenues do get booked in the fourth quarter, but some of those do get booked during the year. And so it was a strong Q1 across each of those different categories.

Great. And then can you help us quantify the size of the investment that you're making to integrate the businesses? And as we think about those investments, should we think about them happening in fiscal year '22? Or should we model elevated level of investments spilling over to 2023?

Sure. I can help you with that quite a bit there. If you think about let's work backwards from the guidance that we just presented, and I'll bounce it off of what you had seen previously. So with the $300 million to $305 million top line guide and the EBITDA -- adjusted EBITDA loss guide of $49 million to $54 million, if you look at that step up from what we provided last quarter prior to the acquisition, what you would see there is a few different elements. One, we're investing significantly in the integration across the frontline care teams and the technologies that are supporting that so that we can create an incredible experience for the consumers who are the members, who are customers of the business.

And for our frontline care teams to bring together each of these complex elements. So where does that show up in our P&L? Shows up in the form of cost of revenues or gross margins, which has a lot to do with why we signaled expect roughly flat gross margins this year. Some of that investment is happening in the frontline care teams. You'll also see it in product and technology. So we'll continue to invest fairly significantly there. So that number ought to be in the low 20s as a percentage of revenue.

Another area we're investing in, Ricky, is across distribution. So if you look at the sales and marketing line this year, that number we expect to go up from what was in the high teens in fiscal '21 into the low 20s as a percentage of revenue this year. And that has everything to do with building out and expanding our go-to-market teams, the business development teams and the underlying marketing teams who are building that broader story that Raj spoke about in his prepared remarks and was just answering on a further question, which is piecing this all together in a way that would be a completely integrated connectivity between navigation, advocacy and the primary care and 2nd.MD Expert Medical Opinion elements.

So it really shows up across the P&L in those different ways, bringing the adjusted EBITDA loss into the 16% or 17% of revenue range this year. And we'll continue that investment while we chunk down towards breakeven over the next couple of years. So that's very intentional that we continue to capitalize on the growth opportunity in front of us while we also maintain that discipline towards breakeven over the next couple of years.

That's very helpful. And just my one last one. When I think about PlushCare and when I think about who are you competing with or who are you replacing, it seems that the platform is quite extensive. So should we think about PlushCare competing not just with primary care and behavioral health but also urgent care?

Ricky, I'll grab that one. It's great to chat with you. We fundamentally position our offering to our customers with the belief that the highest value we can provide is from a primary care and behavioral health perspective. And that, that solution, of course, is in a position where when delivered and when implemented on behalf of the customer, can also serve the needs of helping in urgent care situations. Oftentimes, one of the things we see is that urgent care is the lead-in event that leads to a primary care relationship. And so for our customers, I think the baseline positioning and the umbrella under which we're delivering the offering is certainly primary care, but we expect that it will lead to urgent care and emerging care situations where, we'll drive visits that way as well.

Our next question comes from Ryan Daniels with William Blair.

Congrats on the strong start to the year. Just wanted to have a follow-up question on the sales pipeline. I know, again, this is a heavy part of the year for you. And I'm curious if you're seeing more momentum towards the core products, given the return to work and maybe a need to reengage a workforce after being absent for a year. Or perhaps trying to keep a workforce engaged that's still working remotely to kind of drive cultural aspects for the organization, is that helping you with conversions or in conversations with clients?

Yes. Thanks for being here, Ryan, and thanks for the question. In fact, you really hit on some of the macro tailwinds that we think are a part of what's happening in corporate America today. First, employee engagement is fundamentally a challenge for companies who are wrestling not only with returns to work, but a variety of other issues that have their employees and their families distracted. Second, with return to work, there are a number of clinical and health care needs that are front and center to employees and their families. And figuring out where to find them in a system that, over the last 15 months, has gone through a shock is another tailwind and driver. And so on a macro basis, we think there are tailwinds that are driving what we continue to see is a growing pipeline and growing -- and a continued opportunity for the business.

Our next question comes from Jailendra Singh with Credit Suisse.

Congratulations on a strong quarter. I want to go back to selling season discussion. And thanks for highlighting and congrats on those contract wins. It seems selling season has been going really well for you guys. My questions are around, are you guys seeing any changes in the way employers are evaluating the alternatives on various offerings, given all the consolidation and changes over the past 12 months? Even insurers are aggressively expanding and pushing for their own or partner digital health solutions. And also like related to that, curious on your thoughts around if you're seeing employers looking for best-of-breed vendor approach or your coming cost employers having vendor fatigue and looking for more comprehensive solutions? Just give us a little flavor around that.

Yes. Thank you, Jailendra, for the question. And I'll try to wrap every element of that question up in one answer. And if I miss something, please follow up and we'll make sure and cover it all. As it relates to -- let's start with how are buyers approaching the selection process in 2021 and how has that evolved from 2020. I think the single largest area that we'd point to is that increasingly, we're seeing buyers come to the table with a value orientation and a clear understanding of what that value orientation is. Buyers understand that when you're seeing hundreds of solutions in the marketplace, that differentiating the pretenders from the real value drivers are going to be measured by value clinical outcomes, lowered costs and employee satisfaction. And that increasingly, there is a demand that contracting vehicles and measurement and success measures are all geared around those value drivers. So that's point one, I'd say. And that's certainly more profound in '21 than it was in '20, and we obviously believe that plays directly in our favor. And incidentally, on that point, the idea of being able to prove that value with documented savings and documented reports is obviously very important as well.

Part two of that -- of the question, I think, is our companies are increasingly looking to find their answers from a single place where they can drive a compelling health care experience with deep integration, particularly around core drivers around longitudinal relationships, navigation, primary care being 2 really good examples. And so we think we're -- that trend was manifested as a Wall Street Journal article a couple of quarters ago that talked about this. But that trend is manifesting across the industry. Particularly I'd say while it's absolutely true in strategic and enterprise accounts, Jailendra, middle-market accounts do not have the staff to really work through and understand the depth of all of the solutions that are on the market. And I think those are 2 -- I would say, are 2 things that are evolving as '21 -- as we hit the midpoint of the '21 year.

Yes, that kind of -- you actually covered my -- the follow-up question because I noticed in your earnings release that some commentary around your value-based model for the first time. So I just wanted to clarify that. I mean can you give some examples, be more specific like how these contracts might look like? And maybe to levels that do you currently have any value-based or risk-sharing contracts with employers?

Well, Jailendra, as you know, we take risk with our customers. About 1/3 of our fees are at risk on an ongoing basis today. And so in that regard, are we taking risks with any employers? Every one of our employment -- our employer agreements today has that element of taking risk in it. I think to the -- more to the point of your question around value-based arrangements, here's what we would point you to. We think the future is about extending that capability and tying it out to not just cost reduction but clinical value. And that, that is fundamentally going to be the future of the employer space. And so we'll give a little bit more detail about how we're thinking about contracting when we deliver the integrated offering, which will be a little bit later this year.

Okay. And then one quick question for Steve. Do you have cash flow outlook for fiscal '22?

We do. I think, Jailendra, for us, you can consider that adjusted EBITDA number to be a pretty good proxy for free cash flow. Maybe a bit higher than that this year to the tune of a few million dollars related to timing, but it's in that same ballpark.

Our next question comes from Jeff Garro with Piper Sandler.

Congrats on the quarter. You've spoken about -- very positively about your health plan partnerships. I'm curious about what's driving success with those channel partnerships. And the second part to the question is, over time, I would expect some efficiency, some leverage from using those sales channels. But are there still upfront investments to build those relationships that are part of the sales and marketing investments that you mentioned earlier?

Jeff, great to talk to you. Yes, there are some investments in building out new channel relationships with our carrier partners. We continue to be bullish on the opportunity to grow that channel. And we continue to see organic expansion within those channels that have already been solidified. Clearly, once the relationship is solidified, we have an opportunity to grow within their customer base. And yes, we absolutely believe that can be an efficient customer acquisition strategy. And optimally, you're seeing that in terms of even while Steve mentioned the increase in sales and marketing spend this year, we're still seeing really extraordinary customer acquisitions, LTV ratios in the business. So we're still very efficient from a sales and marketing perspective, and that's part of the reason why.

I think the reason for our success with those channels is fundamentally an offering strategy that meets the customer where they want to be met. And so we started with multiple forms of advocacy. That advocacy delivering core differentiation for carriers who might otherwise be unable to deliver that blend of technology, clinical capabilities and advocacy. In adding Expert Medical Opinion and virtual primary care, we've added 2 new solutions that are really core to what customers are looking for, and therefore, added new tools that our carrier partners can take to their customer base to differentiate themselves. So that the breadth and depth of our services, I think, is one of the things that really attracts partners to what we do.

All right. I found -- that helps. Great to hear the differentiation as well as continued focus on unit economics. Second question for me. Just thinking about the outlook and the contribution from 2nd.MD, maybe you could revisit the variable component of that business and how much seasonality you expect out of the business as we think about rolling forward the contribution in the first fiscal quarter throughout the rest of the year.

Sure. And Jeff, this is Steve. Great to talk to you again. So 2nd.MD, through their revenue model, has a couple of different ways that as part of Accolade that we go to market with that Expert Medical Opinion offering. Sometimes it's a PM, PM offering. Sometimes it's a case rate price. But it oftentimes has a performance guarantee associated with it. And as you will recall, the returns on an Expert Medical Opinion service through the Second MD offering is very substantial. It's something like $5,000 on average, and it can exceed $25,000 or $30,000 when a surgery is involved. So it's quite an attractive return for the paying customer.

The way that those PGs show up, though, is unlike Accolade where we're deferring a lot of that savings based revenue to the fourth quarter, 2nd.MD recognize -- we were able to recognize those typically as the year goes on because it's a different construct. So what you're going to see with Accolade over time, Jeff, is that fourth quarter, which today has a much more significant portion of a year's worth of revenue, it will start to flatten out a bit as we bring on board 2nd.MD for a full year. PlushCare, we just closed that transaction, as you know. As you see that in this year's fourth quarter and then next year, when you're looking at that on a year-over-year basis, you'll see the seasonality of the revenue recognition start to flatten out a bit. So it won't be as dramatic as it has been with Accolade.

Our next question comes from Richard Close with Canaccord Genuity.

Congratulations on the acquisition as well as the first quarter. Maybe just to hit on a couple of the questions that have already been answered or addressed but could add a little to it. With respect to talking with customers in the pipeline and the conversations around value and maybe some of the other companies that are looking at navigation, are customers or potential customers confused at all? Is there a lot of noise out there that you guys have to sort of educate the customer on? Just curious, thoughts on that, first of all.

Right. So thanks for the question, and I appreciate you being here. I think the best way to -- I think your question is really -- let me try to rephrase your question, make sure I'm capturing it. And then I'm going to come back to you with my view on it. The market is ripe with new entrants, innovation, and sometimes, that noise can be confusing. Is that noise confusing prospect buyers in the market and how are they responding to that confusion? Did I capture that well, Rich?

Correct. Correct.

Okay. Perfect. And so I think you're absolutely right. The macro or the meta issue that you're discussing, which is the plethora of solutions in the market is creating some confusion for buyers. And it's not just buyers, it's consultants and brokers and even carriers who are struggling under the weight having to keep up with the innovations in the market. We believe fundamentally that, that is part and parcel of why we're finding success in the market. It's not the only reason, but it is a part of the reason. Customers view us as a platform for weaving together their health care ecosystem. The example I'd give you today, McKesson that we mentioned on the call, obviously, a large pharmaceutical company. McKesson purchased both Accolade Total Health and Benefits and Expert Medical Opinion. You're seeing more and more companies look at the breadth of offerings from a single location where the offerings can be integrated, you know they're going to be utilized, and we know one person is responsible for all of that value. That confusion, we think -- confusion and noise in the market accrues to the value of platforms. We are, in our view, the right platform for our customers to weave all that value together.

Okay. That's helpful. And then maybe, Steve, if I could ask a question. I appreciate the flattening of the fourth quarter with 2nd.MD and now Plush being included. But if more customers are moving towards value, wouldn't you have that value coming in, like you said, predominantly in the fourth quarter as value becomes a greater mix?

Richard, I think I completely understand the question. It's early days yet for getting to the point where Raj, I think in answering Jailendra's question is, it's early days for us to move to a different type of contracting than we have today around value-based contracting and call it the next generation of that as we bring all of these capabilities together. So as we come back to you towards the latter part of this year with more visibility around how that looks, we'll give you some color about the expectations around the financial model. But I wouldn't expect that to have a material impact certainly in fiscal '22 being the current fiscal year.

Our next question comes from Stephanie Davis with SVB Leerink.

Congrats on the quarter. I want to dig in a little bit about this trajectory towards an integrated care offering. How should we think about the value of a physical footprint? And this is something that you either think you can supersede as an M&A opportunity? Or is it something that will need partnerships so you can sell for that last mile of care?

I say, well, let me take the -- Stephanie, it's great to talk with you. So Stephanie, first, great to talk to you. Thanks for the question. The last mile of care is extraordinarily important. Let me take the first part of that question, and then I'm going to ask Dr. Nundy to engage and talk a little bit about the power of collaboration in terms of our model.

For us, we do fundamentally believe that $3 trillion, $4 trillion ecosystem, the capacity to collaborate across the industry is imperative. We will be working directly with brick-and-mortar health care systems on the ground that are servicing our existing customers. We think importantly, Stephanie, and just -- and after this, I'll turn it over to Shantanu. Importantly, one of the things that's so powerful about our model is that we can deliver the concept of value-based care while running on the chassis of a fee-for-service health care system that doesn't require our customer to make radical change around the platform that they're currently running. And that's really important. We're not taking away choice. We're not forcing them to make radical changes to their existing infrastructure, which they fundamentally would struggle to implement. Instead, we can bring this really powerful concept to them and leverage everything that they're already using. Shantanu, do you want to jump in there and maybe speak to how we're thinking about that?

Yes, absolutely. And Stephanie, I think it's such an important question. I think from the clinical perspective, right, I think we think about the most -- the highest leverage point is the decision, the clinical decisions that people make in their lives, right? And that decision is really upstream of the service itself. And so when you think about that member story that we started with of the member with diabetes and the liver function issues, really where the system falls down the most for that person is what we call the interstitial space, right? It's like the space between visits where people have to go home and now make those decisions every day about their health and well-being. And so for us, that's where we thrive. That's what we've demonstrated over the past decade plus. And so we think that sets up a really nice way to collaborate with the ecosystem where it's really saying, hey, we're going to help people get to better decisions. We're going to be accountable for them. We're going to guide them through the 5,000 hours that they're not in a physical brick-and-mortar environment. But we absolutely see the need for that brick-and-mortar service. We just want to make sure that people are ultimately getting the right care that they need to get to the outcomes.

I guess a follow-up on that one, do you leave the kind of venue of care up to the client? Or is this something where you might want to steer them towards some of these more hybrid or risk on models that are starting to appear, just given their claims of improved ROI and cost savings?

Again, we'll tag team this one. I think, Stephanie, one of the things that we pride ourselves on is our capacity to get people to the right care by leveraging the tools that are in our tool bag as it relates to our intelligent provider matching capability that weaves together cost, quality and appropriateness care measures. Our Expert Medical Opinion capabilities, which allow us to ensure that we're on the right treatment decision support. I think the addition around areas that are focused on quality and cost and focused on measures like the measures that we're focused on with our customers are clearly going to be interesting to partner with us on behalf of our customers. Shantanu, would you add anything there?

Yes. No, I think I would add, I think part of -- I think what you're getting at with your questions on, I believe, is really that as brick-and-mortar sites move to value-based care, as employers have on-site clinics or they have particular brick-and-mortar or local assets that they develop partnerships with, how does that fold into our model? I think that's maybe part of your question. And I think...

You're reading my mind. That's exactly it.

Okay. Perfect. Perfect. Yes. And I think the short answer is absolutely. I mean, already, today, we have a number of customers that have on-site clinics. I think absolutely as the market continues to move towards more value-based providers, I think there's real opportunities to be able to provide differential value. Getting members to those environments, even those that are getting care at those local accountable care organizations, they're still missing a lot of the data that they need to really serve those members. And those numbers are still going to have other care needs that may or may not be best served by those local providers. And so we absolutely think that building on the capabilities that Raj talked about, that we're going to be able to construct those ecosystems to ultimately get to the outcomes that employers are looking to get to.

Our next question comes from David Larsen with BTIG.

Congratulations on a good quarter. Can you maybe talk a little bit about your long-term expectations for gross margin? I fully understand that there are investments going into integration this year for Plush and 2nd.MD. But as we think about like fiscal '23 and beyond, where would you expect gross margins to trend? What will get you there and over what time period?

Dave, this is Steve. Great to talk to you. You're right, absolutely taking gross margins up over time as part of our plan and expectation while we invest in that part of the business this year and into next year, roughly flattish this year. So think of that as mid-40s with a long-term target into the 50s, call it, the mid-50s over the longer term. I think what you're going to see though is this year and really into next year, similar types of gross margins in that mid-40s range to bring all of these capabilities together to create that fully integrated experience that drives the kinds of health outcomes and cost savings that we think are critical that are driving the growth in new customers and the very high retention rates we have with existing customers. Now over time, how will we take that from the mid-40s up into the 50s? It will be through a few different things. Very importantly, continuing to build out the technology platforms that create integrations that help our frontline care teams be more efficient. So it's leveraging the AI and machine learning engine to do something we call Next Best Action to help our frontline care teams know what would be the next best thing to recommend or where someone to direct -- where to direct a member elsewhere in the ecosystem. That all, as we automate that more, makes our teams more efficient. By the way, Raj alluded in his prepared remarks, we'll have a segment, an analyst segment on data coming up over the coming weeks that we'll go deeper into that.

And then secondly, as we cross-sell and upsell, there's leverage and operating leverage on the business overall, including on the gross margin line. As we are successful with transactions like Raj mentioned with McKesson and selling Total Health Benefits and Expert Medical Opinion, that combined offering, there's certainly leverage that we have on the frontline care teams that equates to improving gross margin at the margin, if you will. So there's opportunities there. Those are 2 big vectors where we think of driving gross margin improvement over time.

Great. That's very helpful. And then we've heard from a couple of health plans, like, first of all, there are very, very large health plans that are very much aware of Accolade. And we've heard a comment here and there like Accolade is doing such a good job. They're taking away some potentially like fully insured business from us. Because if the employer groups can purchase the self-insured product at a lower price point, then exactly, they can get all the benefits. Have you seen any large health plans sort of react to Accolade and try to bring in some of the services themselves? Have you seen any -- I don't know if backlash is the right way to describe it. But I mean, I'm assuming the answer is no, given how good your sales are. But have you seen large plans respond to your efforts here in any way that's been unexpected lately?

I appreciate the question. I think for us, and we talked about it a little bit earlier. We're finding increasingly that carriers understand -- and I'm going to actually flip your question and take it in a positive way. They're looking at the (inaudible) and acknowledging that we can add value to them with our differentiation. And so we acknowledge as well though, to be clear, that there are going to be moments where there's a level of competition, where we're going to exist in the market and compete where they've got their own advocacy solutions. But yet, when we win those opportunities, we have an opportunity to collaborate with them and serve the customer well. And so I think the short answer to your question is no. No longer answer, hopefully give you a little [color].

Our next question comes from Ryan MacDonald with Needham.

Congrats on a great quarter. Raj, you mentioned that behavioral health is continuing to have a strong impact on the selling season. And this is something we've heard similarly with the organizations that we've spoken with. But there's still this added layer of complexity there within the different behavioral health models of trying to navigate that. As you look at the evolution of Accolade and with your partnership with Ginger and the mental -- or the behavioral health component, that's included with PlushCare. Can you talk about how you're positioning those 2 as you start to integrate PlushCare more directly into your selling model?

Ryan, glad you're here. I'm going to hand that question over to our Chief Medical Officer. Shantanu?

Yes. It's such an important question because you're right. It's so top of mind, and we're seeing that come up over and over again from our customers, the concern about emotional health and mental health. I think the short answer is we don't think that there's a one-size approach, right? To your point, behavioral health covers a very broad gamut from depression anxiety to emotional health to substance abuse to more atypical psychiatric conditions. And so we think that over time, there's going to be -- it's going to require multiple types of services integrated together to ultimately meet the needs. Part of the challenge, as you know, is scale. I mean there's just -- there is a shortage nationally of therapists, shortage nationally of psychiatrists. And so really thinking about an approach that can meet our employers very, very broad needs while also maintaining high quality and outcomes is really what we're focused on.

Excellent. And as a follow-up for Steve. Steve, it's obviously very early days in the integration of both acquisitions. But just curious to get your thoughts on maybe some areas of upside surprise in terms of synergies that you might have discovered that maybe you didn't expect sort of pre-acquisition as we think about the businesses being integrated.

Sure. Ryan, I think the most positive upside we're seeing is on the go-to-market opportunity that really Raj spoke about earlier. We're seeing very strong reception from our customers and prospective customers around the integration of the offerings and the opportunity we have to not only optimize but to drive more and better utilization of the services, particularly the McKesson example, buying Expert Medical Opinion along with Total Health and Benefits is a great example, and we're seeing that across the business. And I think just on the ground, the way we're working together with the teams with Accolade and 2nd.MD has been really incredible, like-minded people with a common mission to improve health care -- massively improve health care has been really the backbone of the early success we've had there. And we're also seeing similar with PlushCare in the early days here. So it's mostly about top line and the TAM expansion opportunity and it's been extremely positive so far. That's right.

I'm not showing any further questions at this time. I would now like to turn the call back over to management for closing remarks.

Thank you, operator. Thank you all for being here. We really appreciate all your questions, and we look forward to updating you next quarter.

This concludes today's conference call. Thank you for participating. You may now disconnect.