Teladoc Health Inc (TDOC) 2019 Q3 法說會逐字稿

Welcome to Teladoc's Third Quarter 2019 Earnings Conference Call and Webcast.

(Operator Instructions)

It is now my pleasure to turn the floor over to Adam Vandervoort, Chief Legal Officer.

You may begin.

Thank you.

Good afternoon.

Today, after the market closed, we issued a press release announcing our third quarter 2019 financial results.

This press release is available in the Investor Relations section of the teladochealth.com website.

On this call to discuss the results are Jason Gorevic, our Chief Executive Officer; and Mala Murthy, our Chief Financial Officer.

During this call, we will provide our fourth quarter and full year outlook, and our prepared remarks will be followed by a question-and-answer session.

Please note that we will be discussing certain non-GAAP financial measures that we believe are important in evaluating Teladoc Health's performance.

Details on the relationship between these non-GAAP measures to the most comparable GAAP measures and reconciliations thereof can be found in the press release that is 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 for Teladoc Health to 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.

I now turn the call over to Jason.

Thanks, Adam, and thank you, everyone, for joining us this afternoon.

After the market closed today, Teladoc Health reported another strong quarter.

I'm very pleased with our results across the full breadth of our business, delivering at the high end of our expectations, showing progress on several of our strategic initiatives and making strides on our path to profitability.

With positive momentum coming out of the third quarter and good visibility into the fourth quarter, we're raising our revenue and visit guidance for the full year 2019.

While Mala will delve into the specifics of the quarter shortly, I wanted to spend a few minutes highlighting the strong execution that underscores the quarter's momentum and serves as a foundation for long-term growth.

In the third quarter, we saw the greatest population expansion in the company's history as more than 17 million people gained access to Teladoc.

This significant increase was driven by our entrenched distribution footprint across channels, in particular, the accelerated momentum in health plans.

The largest population onboarded was UnitedHealthcare's 15 million commercial members.

This marks the first and only fully integrated virtual care offering within the UHD experience, as highlighted by their recent press release.

The initial launch went very smoothly.

Full engagement efforts are progressing on schedule, and we're pleased with the early results.

I'm extremely proud of our team and appreciative of the collaboration from the United team members who, together, brought this deeply integrated solution and seamless consumer experience to life.

On the visits front, we continue to see the acceleration of growth across our total book of business globally, with visits up 45% in the quarter.

Digging into the favorable growth, we continue to see accelerating adoption across all our clinical specialties.

In fact, we're seeing the strongest visit growth amongst our largest populations with multiple clinical specialties, which experienced a 59% increase in visit volume over the same quarter last year.

As we continue to realize the benefits from our sustained data-driven member engagement capabilities, combined with the breadth of our clinical services, we're uniquely equipped to take advantage of the growing macro consumer adoption tailwinds.

Mental health continues to be an area where we're seeing accelerated adoption.

In Q3, we were pleased to celebrate our BetterHelp channel, passing the 50 million message milestone, and continued strong utilization growth within our U.S. distribution channels.

Internationally, we launched the U.K. market's first and only virtual mental health service for navigating complex conditions with AIG Life, followed by this month's announcement of the expansion of our Great-West Life partnership to include the mental health navigator service in Canada.

On the heels of World Mental Health Day, however, it's clear to me that we need to do more.

The multinational study we released earlier this month reveals the intense need for greater access to mental health care, which pervades across borders and is growing at an alarming rate, as younger people are demonstrating poorer mental health than previous generations.

This study found that 61% of 18- to 25-year olds report that mental health symptoms have affected their job performance compared to 38% of all age groups.

This is truly a global challenge, and Teladoc Health's holistic portfolio of mental health offerings is optimally designed to meet the escalating demand.

Our portfolio spans services for those with needs ranging from texting or having a video visit with a therapist for conditions such as anxiety and depression, to psychiatric treatment and medication management, to those needing a full expert review and navigation of the health care system to get them back on their feet.

The level of conversation amongst buyers and consumers alike has never been higher or with a greater sense of urgency, and I remain confident we will continue to see strong growth for the foreseeable future.

Continuing on the topic of clinical specialty innovation.

In the third quarter, we launched Teladoc Medical Experts in the U.S. market, onboarding more than 100,000 employees from UPS and Nationwide Insurance.

Leveraging the best-of-breed insights and capabilities from our Advanced Medical and Best Doctors acquisitions into one single experience, the Teladoc Medical Expert service creates a virtual Center of Excellence for individuals grappling with the challenges of complex physical and mental conditions.

With this unique service, a doctor works with individuals right from the start to get timely answers regarding accurate diagnoses and treatment plans regardless of their geographic location.

The Teladoc physicians are also equipped to help people navigate seamlessly across both the virtual and in-person health care landscape based on their individual needs and preferences, leveraging Teladoc Health's proprietary analytics-driven physician database to make smart referrals into preferred health plan and Center of Excellence networks.

Turning to the selling season.

We see continued strong momentum, both in terms of net new clients and expansion of existing relationships.

As we close the year and enter 2020, our deal flow, RFPs and pipeline all remain strong across the full breadth of our diversified distribution channels.

One highlight this quarter is our momentum in the U.K. Our relationship with AIG Life is a great example of successfully leveraging our comprehensive integrated portfolio to realize 3 of our core growth pillars: driving new innovation across the market, selling our integrated suite of services and expanding the population.

Foundational to AIG expansion was Teladoc Health's successful registration with the Care Quality Commission, the independent regulator of health and social care in England.

I'm proud of our team in the U.K. for earning this important stamp of approval as it paves the way for accelerated growth in this key European market.

Turning to Medicare Advantage.

Client interest continues to grow with both existing and new health plan partners.

We're seeing early evidence of success with several wins, including an agreement with one of our largest and most significant Blues partners for their full Medicare Advantage population as well as with 5 other plans.

The pipeline of additional opportunities remains robust and are optimistic about the revenue impact that this initiative will have over the next 18 to 24 months.

And with that, I'll turn the call over to Mala for a review of the third quarter financial results.

Thank you, Jason, and good afternoon, everyone.

It's good to be here today to talk about our third quarter results, which reflects the momentum you're seeing across numerous facets of our business and is a continuation of our track record of delivering strong performance and results.

As I go through the discussion of the quarter, it bears reminding that this is the first quarter this year where our growth versus prior year is entirely organic but for the small impact of the M�decinDirect acquisition to our financials.

Total revenue increased 24% to $138 million for the third quarter as compared to a year ago.

As we continue to see a stronger U.S. dollar relative to last year against most major currencies in which we operate, our FX-adjusted revenue growth was approximately 80 basis points above our reported revenue growth.

Now as you know, FX rates tend to fluctuate over time, and we could see FX rates go in the other direction in future quarters.

Let's look at some details of this performance.

I will start with the U.S. paid membership and individuals with visit-fee-only access.

As Jason noted in his remarks, U.S. paid membership grew this quarter to 35 million members, up 55% compared to a year ago, as we further scaled our member base by onboarding new clients and expanding existing clients on our platform.

Membership growth in the quarter included the continued onboarding of a large health plan as well as approximately 1/3 of 15 million members in the commercial population of UnitedHealthcare.

As a reminder, the U.S. paid membership does not include individuals with visit-fee-only access.

Our U.S. paid membership has expanded sequentially in 14 of the last 15 quarters and reflects our entrenched distribution across several channels.

Individuals with visit-fee-only access increased to 19 million at the end of the quarter, up from approximately 10 million from the previous quarter and reflecting approximately 2/3 of the 15 million members in the commercial population of UnitedHealthcare.

Turning to visits.

We had an excellent quarter with respect to visit volume with 928,000 visits, an increase of 45% compared to a year ago.

Our press release highlights the details of visit volume during the quarter.

Visit volume from paid members in the U.S. grew 42% to 622,000, which represents an annualized utilization rate of 8%, a 17 basis point increase over last year's third quarter.

The utilization rate in the quarter expanded even with the substantial increase in the population of U.S. paid members versus last year.

Our leadership in the area of mental health drove visit growth of over 50% in the quarter.

The final point I'd like to highlight is that the growth in visits from new registrations is accelerating sequentially and year-over-year as we engage with members and drive adoption.

Driving our overall revenue growth in the quarter of 24% was revenue from global subscription access fees of $119.1 million, which accounted for 86% of our total revenue in the quarter and increased 23% compared to a year ago.

Additionally, U.S. subscription access fee revenue of $92.1 million continues to represent about 3/4 of global subscription revenue while international subscription revenue of $27 million accounts for the balance.

We saw the PMPM this quarter decrease, as expected, to $0.98 from $1.08 a year ago and from $1.06 last quarter.

As we've previously indicated, we typically experience a dampening effect on PMPM when we onboard large new health plan member populations.

Visit fee revenue for the quarter increased to $18.8 million, representing growth of 31% compared to the prior year and constituted the remaining 14% of global revenue.

U.S. paid membership visits generated $14.1 million in the quarter, a 25% increase over the third quarter of 2018.

This line includes revenue from general medical visits as well as other specialty visits primarily comprised of expert medical and commercial behavioral health services.

Visit-fee-only access revenue of $4.3 million comprised the remainder of visit fee revenue and grew 72% in the quarter.

Gross margin percentage for the quarter was in line with our expectations at 69% and consistent when compared to the 69.2% in the third quarter of last year.

The year-over-year consistency in gross margin percentage reflects strength in our diverse product portfolio as well as our disciplined, predictable pricing approach as we continue to gain new clients and members.

In terms of gross margin dollars, we generated $95.2 million in the third quarter compared to $76.8 million a year ago, representing a 24% increase and in line with the aforementioned revenue increase.

Turning to expenses.

Operating expense in the quarter totaled $115.1 million, an increase of 24% from the $92.6 million in third quarter of last year.

And noncash charges such as depreciation and amortization, stock compensation, as well as onetime acquisition-related costs are eliminated.

Adjusted operating expenses are $86.1 million or 62% of total revenue compared to $70.5 million or 64% of third quarter 2018 revenue.

The leverage in our adjusted operating expense includes year-over-year increases in advertising and marketing investments to support the onboarding of some of our recently added member populations as well as engagement and acquisition activities.

Concluding my commentary of the income statement.

Our net loss in the quarter was $20.3 million compared to a loss of $23.3 million last year.

The lower net loss included a onetime noncash tax benefit of approximately $8.1 million or $0.11 per share, reflecting planning associated with our global tax strategy.

On a per-share basis, our net loss was $0.28 for the third quarter of 2019 compared to $0.34 in the prior year.

Moving to the adjusted EBITDA and EBITDA.

Adjusted EBITDA increased to a positive $9 million for the quarter, which compares favorably to the adjusted EBITDA of $6.3 million from last year's third quarter, reflecting our revenue growth, gross margin performance and ability to generate improved operating leverage.

EBITDA was a loss of $10.3 million for the third quarter of 2019 as compared to a loss of $6 million for the same period last year.

Turning to the balance sheet.

We ended the quarter with $490.9 million in cash, cash equivalents and short-term investments.

Sequentially, our cash balances have improved by roughly $18 million, which is largely reflective of our year-to-date positive cash flows from operations of over $10 million and reinforces our confidence to deliver positive cash flow for the full year.

Our total debt as of September 30, 2019, was $562.5 million, which consists of our 2 convertible note issuances: the $275 million 3% convertible note that matures at the end of 2022 and the $287.5 million 1 3/8 percentage note that matures during 2025.

In terms of our expectations for the full year and the fourth quarter, here is the guidance for the full year 2019.

We are increasing revenue guidance to be between $546 million and $550 million.

The increase in guidance is a reflection of our strong performance throughout the year, both on subscription and visit revenue as well as better visibility into the ramp of recently onboarded member population.

We are tightening the guidance for EBITDA and adjusted EBITDA as follows: an EBITDA loss between $45 million and $41 million, adjusted EBITDA between positive $28 million and positive $32 million.

We expect total U.S. paid membership of approximately 35 million members and visit-fee-only access to be available to approximately 19 million individuals.

We expect total visits between 3.9 million and 4.1 million visits.

Net loss per share to be between a negative $1.49 to negative $1.43 per share based on 71.9 million weighted average shares outstanding.

And as we've said before, we expect to continue to be operating cash flow positive and have achieved that as of September 30, 2019.

For the fourth quarter of 2019, we expect total revenue to be between $149 million to $153 million, an EBITDA loss to be between negative $9 million to negative $5 million, adjusted EBITDA to be between positive $11.5 million to positive $15.5 million, total U.S. paid membership to be approximately 35 million and visit-fee-only access to be available to approximately 19 million individuals.

We expect total visits to be between 1 million and 1.2 million and net loss per share to be between negative $0.37 and negative $0.31 per share based on 72.5 million weighted average shares outstanding.

In concluding my remarks, I am pleased with our financial results, and I'm confident in our future ability to deliver consistent revenue growth performance as we scale while we continue to strategically invest in the business to enable our longer-term success.

One final point which relates to our Investor Relations team here at Teladoc Health.

I'd like to welcome our new Vice President of Investor Relations, Patrick Feeley.

Patrick has a highly successful track record as an equity research analyst focused on health care services, with stints at various banks, most recently at Barclays.

He will start his role at Teladoc Health on November 4. I know I speak for the entire Teladoc Health team when I say we are very pleased to have Patrick join the company, and I look forward to his leadership and contributions to our growth.

With that, let me turn the call back to Jason for his closing remarks.

Thanks, Mala.

I'm pleased with our momentum across the full breadth of our business, and I'm deeply appreciative of the hard work and commitment from our team members who underpin our success.

I'm also pleased with how we have evolved our leadership team structure to support the growth, scale and diversification of our business going forward.

With this new structure in place, Peter McClennen has decided to transition out of the company at the turn of the year.

Having joined Teladoc Health as the CEO of Best Doctors, over the past 2.5 years, Peter has played a pivotal role in shaping the integration of our offerings, teams and go-to-market strategies.

I'd like to thank Peter personally and on behalf of the entire Teladoc Health team for his contributions to the business and his passion for the mission.

I often speak about our many strategic differentiators: scale of global distribution, membership engagement, clinical quality and our network effect.

We see these come to life as our clients increasingly embrace the growing strategic and economic value that Teladoc Health's unique offering can provide.

It's gratifying to know that consumers also know the difference, ranking Teladoc highest in overall satisfaction as well as first in customer service, according to the first-ever J.D. Power Telehealth Satisfaction study, which was released earlier this week.

Looking to the fourth quarter and the full year.

We remain confident in our ability to deliver on our improved expectations as we lean on the broad-based strength of the business.

We're also turning our attention to specific plans for the coming year.

We look forward to meeting with you at our 2020 Investor Day, which we are planning to host in March.

As always, thank you all for your continued interest in the Teladoc Health story.

And with that, we'll open the call for questions.

Operator?

(Operator Instructions) Your first question comes from Lisa Gill with JPMorgan.

Jason, you know I have to ask this question, and I know you talked a little bit about the selling season saying that both deal and RFPs were strong, but can you just give us a little more color around 2 things?

One, you talked about expanding relationships.

Can you just give us any numbers around where people are expanding?

What they're adding to the relationship?

Is it that it's health plans, and they're adding more lives?

Is it employer/customers that are adding more clinical services across the platform, I guess, for either of the customer base?

And then as you think about that RFP activity as being strong, how do we think about that year-over-year as we go into 2020?

No surprise, Lisa.

I'd be disappointed if you didn't ask.

Yes, so there's no question the selling season has been incredibly strong, and it's been -- that has been the case across multiple of our selling channels.

In particular, we've had a great year in the health plan space.

International growth has been good.

Our hospital and health system client base continues to grow at a very rapid rate.

And I think I can give you a little bit more insight.

As we look at RFP volume, it's probably up about 25% year-to-date over last year.

Our bookings are up probably 30% over last year.

Deal size is up, so both in terms of average deal size as well as median deal size, which, of course, the median takes out the outliers on the large side.

And very importantly, and I think you -- this is part of your question, our multiproduct growth has been a strong contributor to our bookings.

So when I talk about multiproduct, that means we're selling multiple products into a new client or we're selling additional products into an existing client.

And multiproduct bookings have represented about half of our bookings year-to-date worldwide.

So I think that's really a testament to the breadth of our product portfolio and our strategy of increasing our clinical services to become a holistic virtual care solution for our clients.

Yes.

And as we think about the multiproduct booking that you just talked about, about half of them this year.

Just kind of to put that in perspective versus last year, I mean, we're -- as Mala said, this is the first quarter where virtually everything is organic.

So you've had the product offering out there, and now this is kind of the second year of having that full product offering.

How do we compare that year-over-year as far as what people are buying into?

Yes.

It's up significantly relative to last year as a percentage of our bookings.

So as I said, it's about half of our bookings this year are multiproduct sales, and that's up significantly as a proportion of our bookings at this time last year.

Okay.

Great.

And then just my last question, and I know it's early to think about 2020, but when we were together in September, you talked about your confidence in the longer-term revenue growth of this company being between 20% and 30%.

Is that still a number that you feel confident based on what you've seen to date for new business wins as well as expansion going into 2020?

Absolutely.

I still feel very good about 20% to 30% for the foreseeable future as our top line growth.

Mala, I don't know if there's anything you want to add to that.

I'd say, I'd echo that.

I'd also remind you, the base is getting bigger every year.

We feel pretty confident about the initiatives we have in place.

You've seen the unprecedented membership expansion that we had this year.

Obviously, we will work to activate that, and that will have an impact on not just 2020 but our growth beyond that.

So I would say, Lisa, we have all of the right initiatives and the right plans to invest to drive that growth.

Your next question comes from Jamie Stockton with Wells Fargo.

I guess, maybe the first one, just on the sales and marketing spend.

I think maybe Mala mentioned that you guys obviously onboarded a lot of lives at United and you had another big, I think, health plan that you onboarded during the quarter, if I remember correctly from your comments last quarter.

Specifically with United, should we think about this big spend this quarter as being kind of the expense of getting those lives on board?

Or will there probably be another kind of round of incremental spending that hits in Q1, more kind of in line with the normal benefit cycle for those individuals?

Yes.

Jamie, great question.

I'd say it's both.

I'd say, we -- as you can see from our financial results, we did invest in marketing spend this quarter.

I'd say for a couple of reasons.

One is, as you noted, we have a huge membership expansion.

We did invest ahead of that so that we can put the right plans in place to activate those members.

And we continue to invest efficiently in driving customer acquisition, so I would say that's the second.

And the third I would say is we are leaning into the cold and flu season that is upon us.

I would say, though, you should expect to see additional marketing spend as we go into next year as we will continue to activate the new members.

Okay.

That's great.

And then maybe just one more.

It's got a lot of attention on the call last quarter, but from a timing standpoint, I think it might be more relevant now, the Aetna renewal.

Just any color on what's going on there or how that relationship sits would be great.

I would say no change to my comments from last quarter.

I feel very, very good about our relationship with Aetna and both sides of the house there, Aetna and CVS.

CVS continues to roll out to more states.

We're now at 39 states plus the District of Columbia with the CVS video visits rollout and very strong relationships with my expectation for continued product expansion with the Aetna population.

So I continue to expect Aetna to be a strong and great client for many years to come.

Your next question comes from Stephanie Demko with Citi.

Patrick, welcome to the team.

So when I think about the levers to accelerate your revenue, utilization is always my biggest question mark.

And with that in mind, I saw a very healthy jump in your advertising expense this quarter.

Could you tell me a bit more about the drivers and any advertising measures we could be seeing soon coming out of Teladoc?

Yes.

So thanks for the question, Stephanie.

I think advertising spend falls into 2 main buckets for us.

One is driving utilization, as you indicate.

And of course, as we onboard large populations, we spend to activate that population, drive utilization, drive first registrations and then utilization and visits.

That increases as we onboard large populations, and I think you see that reflected in the quarter.

The other part of it is in our direct-to-consumer business, where we're spending against customer acquisition.

We continue to get more efficient on both of those.

So we are relentless about measuring the yield that we get out of the spend on both of those channels.

And we continue to see improvement in the yield that we get out of those.

So reducing our customer acquisition costs on the direct-to-consumer side, increasing our yield of visits per dollar spent on the utilization side.

Yes.

And Stephanie, let me add a little bit of color.

Jason talked about the direct-to-consumer.

We are always looking at our channel mix.

We are looking at where we spend our marketing spend across the different channels in different times of the year because, as you probably know, different channels costs differently.

So we are continuously sort of tweaking, changing and managing our channel mix.

And then the second thing I would say is to the point that Jason talked about activating the members, we do measure and have metrics internally, where we are looking at our cost of acquisitions, cost for visits, et cetera.

So we are measuring through the year on how we are doing against those.

And is there any way to quantify kind of how you are looking in the direct-to-consumer market?

If there are advertising channels you've exited or would not use going forward given the ROI?

Yes.

Stephanie, we're constantly rebalancing the mix, depending on the campaigns that we have in the market, the yield that we get out of each one of the channels.

So it may ebb and flow among various channels.

Sometimes, we light up new channels, and we find that they're particularly productive for us.

And we certainly have some of those.

But those are all pretty closely guarded components of how we manage the business.

All right.

And one quick modeling one.

When you guys bought Advanced Medical, there was a lot of signaling that the gross margins would be coming down in a pretty meaningful manner.

We haven't really seen that as much.

Is there anything to call out that you've been able to improve upon that model?

Yes.

We're consistently working, and we have been since the acquisition, on improving the gross margins of the Advanced Medical business.

We've seen progress on that, and we still see significant opportunity.

And I think you see that very well in the strong gross margins that we've been able to post this quarter and the past several quarters.

So the gross margin continues to fluctuate a little bit with seasonality.

You should continue to expect that, but we're proud of what we've done so far, and we still see significant opportunity going forward.

Is it safe to say that this is no longer a 65% margin mix that we were originally guided to?

Well, I think we're not saying that we're never going to get to the mid-60s, which is where we sort of guided over the longer term.

We're just moderating the glide path to that.

Your next question comes from Richard Close with Canaccord Genuity.

International-related questions here.

So on the paid visits revenue internationally, it declined 30%.

I'm just curious what happened there.

Was that just the FX maybe you were talking about?

And then, I guess, bigger picture, how do you see the global opportunity developing?

You obviously highlighted some things here with AIG.

I know last year on the third quarter call, I think you talked about AXA, Global Care.

I'm just curious how the international or global opportunity is playing out.

Yes.

So Richard, let me address the first question.

As you can see from the numbers, you're right, it is declining 30%.

It is literally the result of one particular client in Canada, where the case rate has gone down, and we are working very actively with the client to solve it.

It's off of a very small base.

So as you can tell, it is not really overly impacting our overall growth.

And then, Jason, the second question?

Yes.

I'm really excited, Richard, about the global opportunity.

I think AIG is the perfect example of what we're likely to see across our international markets, where we bring the full breadth of our clinical capabilities in order to increase the set of services we bring, the revenue and the population that we serve.

And we're running that play in multiple markets.

I think AIG is the first of what I expect to be many to come.

Your next question comes from Matthew Gillmor with Baird.

I wanted to hit on the revenue guidance for 2019.

It looks like 3Q came in about $1 million or $2 million above Street, and you raised the full year '19 revenue by more like $5 million to $6 million.

So I wanted to understand sort of what drove that increase and how that carries into 2020.

Was that sort of membership with new or existing clients or something else?

Yes.

So the way to think about that is I'd characterize it in sort of 3 different ways.

The first is, as you saw, we essentially delivered at the high end of our guidance for Q3, and so we are reflecting the flow-through of that to the full year.

And then the second thing I would say is, as Jason referenced in his remarks, we are seeing great momentum across many facets of the business.

And he particularly highlighted mental health.

We are calling it mental health.

We have called it behavioral health in the past on past calls.

So we are reflecting the momentum of that part of the business.

And then I would say more broadly, we are seeing -- as you can see from our momentum, we are seeing really strong momentum on visits.

So we are essentially factoring all of those into the guidance take-up this time.

And Matt, I guess, I would just add that the third quarter results reflected some mid-quarter adds.

We were pretty public about the launch of United on September 1. So we only got 1 month of that in the third quarter, but obviously, we get a full 3 months of it in the fourth.

So the run rate coming out of September is bigger than the average over the quarter.

Yes.

Got it.

That's helpful.

And then, Jason, I did want to get an update on Medicare Advantage.

It sounds like the momentum there is really good.

Can you share with us how that market's developed?

Are they contracting in a similar way to the traditional business?

And how are Medicare Advantage plans, these initial ones that are using telehealth looking to use it for their members?

Yes.

Very similar structure to our commercial membership.

We're seeing PMPMs plus visit fees.

We've already rolled out some MA populations over the course of this year as we've expanded with some of our large clients.

And as I pointed out, we have 6 already under contract and a robust pipeline still to come.

So I would expect that market to develop.

As I've always said, I expect that to be sort of a 3-year development for that to fully flow through the entire MA population.

Health plans never uniformly move en masse the first year that something is available.

And to be honest, we're still seeing some of the MA plans who are processing the new rules and figuring out exactly how they're going to put it into their plans.

So we're actively engaged with our clients and prospects around how to do that.

In some cases, we're sort of educating them on the rules because we can be specialists in that part of the rule.

Your next question comes from Sam Weiland (sic) [Sean Weiland] with Piper Jaffray.

It's Sean.

I think your -- the growth in members is probably masking an underlying growth trend in utilization, and I was wondering if you could speak to that and help us understand what the true growth of utilization is maybe in terms of the members that were paid members of last year this time.

What does that growth in utilization look like?

Yes.

So the way I would think about it, Sean, is we talked about us being at an 8% utilization rate for the quarter.

If we were to "normalize it," if you will, for the extra population that we added on, it's -- think of it about 50 basis points higher approximately for the quarter.

So that 50 basis points, that's not an annualized 50 basis points?

That's for the quarter?

No.

Sorry.

It's -- think of it on an annualized basis to be 50 basis points higher...

Within the quarter?

Within the quarter.

Within the quarter.

Okay.

Got it.

That's helpful.

And then in terms of your guidance, a bump up on revenue, tightening the range on EBITDA.

What is this trying to communicate to us in terms of the incremental profitability of these new adds?

Yes, that's a great question.

So here's what I would say.

First of all, just for context and a reminder, if you look at the midpoint of our EBITDA of the range that we have given, it's more than doubling the adjusted EBITDA from last year.

It's also -- in Q4, we are calling on a delivery for the fourth quarter that is roughly about equal to what we have delivered from an adjusted EBITDA through Q3.

We feel very confident that we are able to -- that we see a clear line of sight to delivering that.

And it is based on all of the same levers that we talked about in Q3, either revenue growth, the gross margin delivery that we expect in Q4.

Now I will remind you the gross margin in Q4 is typically more muted from a seasonal perspective relative to the other quarters, and then the operating leverage that we hope to drive in Q4.

So I would not say that we are trying to communicate anything different from what we have said before and from what our levers are to drive EBITDA -- adjusted EBITDA year-to-date.

Your next question comes from David Windley with Jefferies.

That's perfect.

Because I had a follow-up question to Sam's question.

He doesn't seem like a Sam to me.

The question -- Sean's question obviously -- the question that I have is around utilization.

And if the -- if you could share with us the range of utilization from your, obviously, very low for the most recently onboarded, I'm presuming, to what kind of levels are you achieving?

And what is characteristic of the highest achievement?

I think there was some mention in the prepared remarks about multiproduct clients, obviously, ones that have been on your platform for longer, but kind of interested in the profile of those.

And then as you've talked about advertising, what type of -- how important is it and what type of initiatives are you taking on to drive utilization towards those highest levels?

Sure.

Thanks, David.

We've talked about multiple times the fact that we have clients up in the 80% to 100% utilization range.

In fact, our own employee population is north of that.

Those tend to be employers where we have very close relationships and we can do direct communications, and we work hand-in-hand with the employer to promote the services.

It also tends to be where we have a broad scope of our products and services in the population, those multiproduct implementations.

I can give you a couple of stats that sort of help to set the tone around why we feel confident about the continued growth of utilization.

First, I would say, 50% of our -- of the growth in visits year-over-year are coming from new registrations.

So that's very, very strong for us because it keeps the flywheel moving, right?

We continue to add more people into the mix.

And having said that, about 60% of our total visits come from -- at least in the general medical population, come from existing users.

So we're adding more people in and we get repeat utilization.

And so we're seeing increased visits per user.

And then lastly, as you think about those new products and services that we bring to market, they frequently are stickier or create more visits per user.

So in our mental health population, almost 80% of our mental health visits are from repeat users, meaning it's not their first visit, but rather it's a second or third or fourth or fifth visit in the cycle of their treatment.

And so you put all that together, we feel really good about the underlying model.

And then layering on top of it is our surround sound engagement model where we have a very, very strong data underpinning.

We apply data science against it to target where we're going to communicate in digital channels, in worksite channels in partnership with our clients in the home and increasingly, on a more generalized basis.

Because now with over 50 million people who have access to the Teladoc platform, those more generalized lower-cost channels can be really effective for us.

I appreciate that.

And my follow-up question is around trends in PMPM versus visit-fee-only.

You mentioned in MA, in the answer on MA that you're seeing similar pursuit from the health plans with PMPM plus fee.

And the UNH was 1/3 PMPM of the total 15 million, I believe.

I guess I'm curious what your dialogue with health plans sounds like in terms of the interest in pursuing -- continuing to pursue PMPM models that I believe also helped to fund and contribute to your ability to grow that utilization.

Yes.

So that's exactly right.

Your last phrase is exactly the right lever.

We've proven our ability to drive higher utilization levels, and that is in the best interest of our clients.

And they come to us, and we model out what we can drive for them and what we can save for them.

And they get a very, very strong ROI on a total spend, which includes both the visit fee and the subscription fee.

We only have a handful of very, very large clients in that bucket of visit-fee-only.

And so I would call those the exception, not the rule and really not a trend.

So it's interesting.

I was looking back at what our PMPM and membership was 4 years ago, the first quarter after we went public.

And we had 12.6 million members and a $0.45 PMPM.

So people have been asking whether the PMPM is sustainable and can continue to grow over time since we went public, and we've more than doubled it while we've gotten to the point of being now more than 50 million people who have access to the platform.

So sorry, if I could turn that question around, and then I'll drop off.

I promise.

But to -- maybe to come at it the other way, what's the logic behind United not putting all 15 million members in PMPM?

Yes.

So I'm not going to comment on the specific negotiations and discussions with an individual client or put words in their mouth.

That would put me over my skis.

So with due respect, I'm probably going to pass on that.

Your next question comes from Ryan Daniels with William Blair.

This is Nick speaking out in for Ryan.

I guess on this new product offering with the mental health combination, I was wondering why only limit that to the 100,000 members, I think it was?

And then who exactly is receiving that benefit? .

Yes.

So you're talking about Teladoc Medical Experts.

Thanks for the question.

Yes.

So we just sold it to our first 100,000 employee client -- or 2 clients with 100,000 employees.

That was UPS and Nationwide Insurance.

This is really an enhanced combination of the expert medical services that were offered by Best Doctors, the expert medical services that were offered by Advanced Medical and the mental health Navigator that we stood up sort of at the -- roughly at the same time that we were doing the Best Doctors acquisition and putting them all together into a physician-led expert medical service that's really holistic and spans across medical and mental health and also spans across virtual care and physical -- the physical delivery system.

We're really excited about the prospects here.

We think this is not only going to be a very attractive product for clients but also make a big impact on the health of our members.

And we see this as just the beginning of a big trend.

And was this something that they came to you looking for?

Or is that something that you offered to them, kind of like on your own side?

It was a little bit of a combination of both.

Nationwide was an existing client, and we transitioned them on to this product and -- or we added it in really.

And UPS was going to market looking for a solution kind of like this, and we were able to meet their needs by pulling together all of our -- several of our assets into a single solution.

We were already moving down this path anyway.

So it was sort of a convergence of those.

Got you.

And then kind of shifting gears a little bit, I've seen quite a bit of data regarding flu season and how it's supposed to be a pretty bad one here.

I was wondering if that's reflected at all in your guidance.

And then if not, like, would that represent an upside, I guess, to where we're guiding it?

Yes.

So right now, the early indications that we are seeing, we are obviously monitoring it all the time.

It's very, very early for us to take a call on how much worse or not it is relative to last year.

So at this point in time, we have not made those specific assumptions of it being much worse than last year.

It's too early to tell.

Your next question comes from Daniel Grosslight with SVB Leerink.

I just got a couple for you on the mental health side of the equation.

So I think last quarter, you noted that you expect to see around 50% growth year-over-year on the mental health side, so about $90 million of mental health revenue for this year.

Wondering how you're tracking to that $90 million guide.

And then you also noted that mental health RFPs were up around 200% year-over-year last quarter.

Can you comment on the win rates you're seeing on those RFPs and what we can expect for growth rates in 2020?

So let me address the first part, and then I'll turn it over to Jason.

We -- what we specifically said is that we expect the mental health business to grow over 50%, north of 50% this year.

And so far, we feel pretty good about the momentum that we are seeing coming out of the business.

I've talked about it, Jason talked about it, et cetera.

Jason?

Yes.

On the RFP side, we don't generally release win rates within any part of our business.

Mental health falls into, in many cases, the multi-specialty or multiproduct RFPs.

We're -- it's only -- it's rare that we're seeing just mental health RFP isolated.

More often, we're seeing a multiproduct RFP that includes mental health, and we tend to have a very good win rate in those RFPs because of the breadth of our product portfolio.

Got it.

And just in terms of growth rate, obviously, you're working off of a bigger base now.

But how should we think about growth rate in that segment of the business, both DTC and the B2B side of it?

So we won't comment on specific growth rates for parts of the business, specific parts of the business.

I think that is something based on the color we provided and the comments we've made.

That is just something that you will have to sort of just factor in and reflect in your model.

Next question comes from Matt Hewitt with Craig-Hallum Capital.

This is Lucas Baranowski on for Matt Hewitt.

I guess my first one here, you've talked in the past about how your first go-live date in Canada was scheduled for Q3, and it sounds like that occurred.

So maybe you could just tell us what kind of traction you're seeing in Canada generally.

Yes.

Great receptivity in Canada to our new telemedicine offering there, which, of course, is in addition to our expert medical services, which were there already, and our mental health Navigator.

So that's another example of us continuing to expand the product portfolio.

Receptivity has been really good.

We launched with a client, the Johnson Group, as our first client.

And we're already seeing additional interest, and we're seeing good traction with that client.

Okay.

That's great to hear.

And then, I guess, just with some of the noise around potential competition, I guess, we were just wondering what levers could you pull to maintain your margin profile if competition comes in and decides to compete on price?

Well, I think there are a few things.

One is we have unmatched scale, right?

And so scale gives us a competitive advantage with respect to cost and enables us to protect our margins.

Two is the nature of our broad product portfolio enables us to not compete on a single product, but rather to compete as a full holistic virtual care solution.

And that is really a different offering.

It's incredibly difficult to replicate the entire breadth of our product portfolio.

And as a result, we're in talking about an entirely different strategy than anyone else can in the market or a new entrant into the market.

And the other thing I would also add is, we are really the only one who activates and drives membership engagement, and that really helps the returns for our clients.

And all of that allows us to not only drive to further scale, but also from a pricing perspective as we talk about extending relationships.

So it's all of the things that Jason talked about in his closing remarks on what are our strategic differentiators.

Your next question comes from Charles Rhyee with Cowen.

Just wanted to -- Jason, if I could just jump back to some of the earlier comments when we were talking about activating and engaging, obviously, the United population is coming on.

Are you guys able to bring all your engagement tools to bear when trying to reach out to this population?

And is there any differences between how you can activate these members, whether they're between -- is there any difference if they're a visit-only member versus a U.S. paid member?

So I won't get into the details of all of the tools that we're going to use, but what I will say is it's extraordinarily collaborative with the UHC team.

Our marketing teams have been working together for months in launch planning, communication, collaboration using joint capabilities between the 2 organizations.

And so I feel really good about both the collaboration between the 2 organizations and the yield that we're going to get out of that -- those efforts.

Okay.

And maybe just on the visit-fee-only model, if we think about the modeling.

For visit-fee-only visits, when we think about the way we should model it, should we think about sort of the revenue per visit similar to more like the Aetna contract or at least the numbers that we were kind of told a few years back regarding that?

Or how should we think about that as we build out our models?

Yes.

So we have always said that our visit-fee-only population is not just Aetna.

It is a mix of customers.

And we obviously have been fairly public with the pricing we have with Aetna, but we have more than Aetna in our visit-fee-only population.

So what I would say to you is just think about that broader mix, look at our results from a visit revenue perspective and a visit count and growth that we have for VFO.

And you will be able to come to, from a modeling perspective, more of a weighted mix.

Okay.

Okay.

I think I understand what you're saying here.

If I could just squeeze one more in here about CVS.

You talked about how that's ramping up, and we're now in 39 states.

Can you talk about how this ramp-up works as well, since I would imagine you don't really reach this population directly?

Is this really more incumbent on CVS to drive members that access their app or the website to the virtual service?

And can you remind us how that's captured maybe in your visit numbers?

Or is it separate?

So the answer to the first part of the question is yes, this is a private-labeled service where we power it with our technology.

We provide the clinical services.

Although the agreement, as we've discussed before, does provide for the opportunity for their providers also to provide the clinical services, again using our technology.

But they are responsible for the marketing and engagement of their customers.

And then with the second part of the question, we capture any visits that are on our platform in our visit volume.

Would that be in the U.S. paid member volume?

Or is that in visit-fee-only volume.

No.

The -- by definition, there is not a membership and so it's in visit-fee-only.

It's in the visit-fee-only.

Your next question comes from Allen Lutz with Bank of America.

The 4Q EBITDA range is pretty wide.

Can you talk about what gets you to both the top and bottom end of that range?

So the way I would think about it is as follows.

You are -- look at the revenue growth rates, and I'd look at it both sequentially from Q3 and I would also look at it from a year-over-year perspective for Q4.

So that's number one.

The second thing I would say is we have definitely always in Q4, lower gross margins typically because of the greater mix of visits and visit revenue.

But again, like I said, we are very early in the flu season.

At this point in time, I would stay with the midpoint.

But depending on that, that could change, whether you're at the bottom end or the top end, so that's the second thing.

And then the last thing I would say is we are definitely going to drive more leverage in the fourth quarter from an OpEx and a spending perspective.

We will -- typically, as we have talked about marketing spend in Q3, we are pretty judicious about when we buy, how much we spend from a marketing perspective.

So I do expect to drive leverage on that.

So I would say those are typically the factors that will drive us to either the bottom end or the top end of the range.

But I -- at this point in time, I wouldn't say there is any other extraneous set of factors other than those.

That's helpful.

And then on BetterHelp, is revenue growing faster than advertising?

Or are you viewing this as more of a land grab and you're willing to spend up to get an incremental member?

So we haven't broken out either the revenue or the advertising spend for BetterHelp or our DTC channel.

What we have said and what we continue to find is that our customer acquisition costs continue to come down, so we're getting leverage out of that.

Our pricing continues to be strong.

And our lifetime value of a member continues to increase.

So you can sort of derive the answer from those factors.

And we feel good about the direction all of those are heading.

And I would also say the data we track shows our membership churn is also improving.

So it's all of those different factors that essentially will allow us to get to a greater lifetime value and the ROI.

(Operator Instructions) Your next question comes from George Hill with Deutsche Bank.

Jason, I have a question, I guess, it's a little bit about the competitive environment and how you talked about this holistic virtual care solution.

We're seeing a lot of plan sponsors, particularly on the employer side, start to bring in what I would call like these niche -- they're not perfect telemedicine comps, but niche companies that do like an integrated tech stack and services around things like back pain, musculoskeletal, obesity, diabetes.

And I guess, just how do you think about whether those things, I guess, compete for wallet share with Teladoc or whether they're complementary opportunities for Teladoc.

Or is that like share of wallet that you guys try to take in the future?

And I'm just kind of -- I guess how you're seeing that edge of the market evolve?

Yes.

It's interesting.

We're seeing, quite frankly, quite a bit of vendor fatigue among especially employer clients who have one of each of the things that you just described and they're uncoordinated.

And they have to deal with each one of those vendors, and so they prefer to come to us for a holistic solution.

So you talked about musculoskeletal, we have a partnership with Telespine, which gets delivered through our interface in a seamless experience.

We also bring the expert medical services around musculoskeletal so that we can do treatment decision support before someone has back surgery or something like that.

Our partnership with Vida, where we're going to bring a seamless program to market through our interface, is really resonating with our clients and prospects because it has the promise of being a virtual multi-specialty practice, combined with a virtual Center of Excellence, all wrapped into one and kind of obviates the need for all of those individual point solutions.

So we're going to continue to focus on that holistic solution.

And we've been pretty methodical about building out all the various components of that or partnering or acquiring for them where we see that it's appropriate.

Your next question comes from Glen Santangelo from Guggenheim.

Jason, I just want to follow up on some of the comments you made earlier with respect to PMPM pricing.

I appreciate the fact that the company has done a great job over the last 4 years sort of growing that number, but I just kind of want to tie that back to some comments you've made more recently that the company's goal remains to be to sort of grow that PMPM pricing by $0.05 to $0.10 a year.

And I'm trying to reconcile that with some of the comments you made with respect to having a strong health plan pipeline.

And I appreciate the dilutive impact of bringing on those big populations.

And so given the comments you made about your pipeline, like how should we think about that number on a go-forward basis, at least in the near term?

And then Mala, I'm not sure kind of what's implied in the 4Q number and how we should maybe think about 2020 in that regard.

Yes.

So what I would guide you to is we have always said that when we onboard large populations, there will be a temporary dampening impact on the PMPM.

What I would expect is -- you should actually remember that we launched United only in the last month of the quarter.

So if you think about the PMPM in Q4, you will continue to see a depression in the -- a dampening in the PMPM for Q4.

But what you should also see is, over time, you will see the PMPM reassert and grow.

And the thing I would say, why?

Because, again, we are, today, a diverse set of businesses and channels, right, all the way from the health plans that you've talked about, where, yes, the PMPM is one thing for a health plan.

But when we sell through the broker channel, for example, the PMPM that we have there is multiples of what you see in the health plan.

That's a channel for us.

So I would say, think of us as a diverse portfolio of channels with different PMPMs.

And what you are seeing us deliver and demonstrate because of that diversity of channels is a growth in PMPM, absent the temporary impact of the -- when we onboard large populations.

The one other thing I will tell you is if we were to, again, normalize for our -- the expansion that we had in the quarter, our PMPM would really be at about 107.

So you will see -- so that's the point I'm making about the dampening, and then you should see it growing back.

Okay.

That's helpful.

Maybe if I could just follow up one question on the selling season.

I think you touched on this a little bit, but it sounds like with the RFP volume up 25%, Jason, are you seeing any increased interest in one of the revenue models, whether it be PMPM or shared services or visit-fee-only?

Are you seeing more interest in one way or another?

And does the company have a strong preference one way or another?

Can you -- do you prefer PMPM because you can increase the membership engagement?

What's the company's preference?

And what are you seeing from the customers at this point in time.

Yes.

The RFP volume or content is pretty consistent with what we've seen historically.

We're not seeing any major shifts in that.

And what we've always said is that we have enough data, enough experience and the sort of underlying analytics to be successful regardless of what the economic model is.

And we know how to price the business according to the expenditure and the costs that we're going to lay out in order to deliver it.

So we have target gross margins that we work to and we're able to dial in, regardless of what the economic model is.

There are no further questions at this time.

I'll turn the call back to the presenters for any closing remarks.

Thanks very much.

Appreciate it.

We're excited about what was another great quarter, and thank you for joining us.

This concludes today's conference call.

You may now disconnect.