CareMax, Inc. (NASDAQ:CMAX) Q3 2023 Earnings Call Transcript

CareMax, Inc. (NASDAQ:CMAX) Q3 2023 Earnings Call Transcript November 11, 2023

Operator: Good morning, and welcome to the CareMax, Inc. Third Quarter 2023 Financial Results and Conference Call. [Operator Instructions] I would now like to turn today’s call over to Roger Ou, Senior Vice President of Investor Relations. Please go ahead sir.

Roger Ou: Good morning, and welcome to CareMax’s Third Quarter 2023 Earnings Call. I’m Roger Ou, Senior Vice President of Investor Relations, and I’m joined today by Carlos de Solo, our Chief Executive Officer; and Kevin Wirges, our Chief Financial Officer. During the call, we will be discussing certain forward-looking information. These forward-looking statements are based on assumptions and assessments made by CareMax’s management in light of their experience and assessment of historical trends, current conditions, expected future developments and other factors they believe to be appropriate. Any forward-looking statements made during this call are made as of today, and CareMax undertakes no duty to update or revise such statements whether as a result of new information, future events or otherwise.

Important factors that could cause actual results, developments and business decisions to differ materially from the forward-looking statements are described in the company’s filings with the SEC, including the section entitled “Risk Factors”. In today’s remarks by management, we will be discussing certain non-GAAP financial metrics. A reconciliation of these non-GAAP financial metrics to the most comparable GAAP measures can be found in this morning’s earnings press release. Now I’d like to turn the call over to Carlos.

Carlos de Solo: Thank you, Roger. Good morning, everyone, and thank you for joining our call. Today, I want to focus on a few key themes that reflect the value that we’re delivering today and are poised to deliver in the years ahead. First, I’ll provide an overview of our third quarter financial performance and our updated 2023 outlook. Second, I’ll outline the steps we are planning to take to accelerate our path to positive free cash flow, including a comprehensive business review. Third, I’ll share promising performance metrics in our national MSO that gives us confidence in taking increasing risk in our Medicare Advantage book of business. Additionally, we see indications of favorable MSSP and ACO REACH performance in 2023, supporting our expectation for meaningful cash generation toward the end of 2024.

Let’s begin with our quarterly results. Medicare Advantage membership grew by 4,500 in the third quarter to 107,000. Total revenue in the third quarter was $202 million, keeping us on track for our full year guidance of $750 million to $800 million. Adjusted EBITDA for the quarter was $2 million, impacted by $6 million in de novo pre-opening costs and post opening losses and $13 million in unfavorable prior period developments related to the first half of 2023. Although we remain encouraged by our underlying profitability excluding the impacts of PPD, we think the amount of prior year and prior quarter developments experienced year-to-date warrants updating our full year adjusted EBITDA guidance to a range of $15 million to $25 million. We believe our rapid growth in membership, payer relationships and geographies has resulted in greater near-term variability in our financial results.

If you recall, we added Medicare risk lines across Broward County, Orlando and Tampa in 2021, and as a result, conducted significant integration activities related to this membership throughout 2022 and 2023. Today, we operate our clinics along a single set of processes and are continuously working to improve our technology workflows. These efforts are designed to reduce the magnitude of prior period developments in the future, and we’re optimistic that performance patterns will normalize beyond this initial phase of our growth. From a medical management perspective, we believe our clinical efforts are helping to keep costs well controlled. The increase in outpatient surgical volumes observed last quarter has subsided and remained stable throughout Q3 and inpatient admissions also trended downward for another consecutive quarter.

We continue to leverage our specialty network to control a greater portion of external provider costs, driving high-quality preventative care for our dual heavy members. Over 50% of our specialist volume is now being handled in-house at CareMax, up from less than 30% a year ago, which we believe is contributing to higher quality of care and better outcomes for our members. In our government VBC business, we are pleased with the strong results achieved in the performance year 2022. Combined, our MSSP and ACO REACH entities generated over $50 million in earned savings, representing an approximately 5% gross savings rate. This is a record percentage of savings since our ACO’s initial participation in MSSP under prior ownership. To put things in perspective, our largest ACO with close to 100,000 beneficiaries has the highest percentage of dual eligible patients and the highest percentage of seniors aged 85 and above among the top 10 largest MSSP ACOs. We believe this gross savings rate validates the caliber of the provider network, infrastructure and team members that we have since onboarded to our organization.

We are further encouraged by year-to-date data points suggesting even greater shared savings in 2023, which Kevin will discuss later. Next, shifting to our second theme of accelerating our path towards sustainable positive free cash flow. In light of the changes in rates of reimbursement, utilization patterns and the capital markets environment, we have taken proactive steps to bolster our operational flexibility while maintaining our track record of clinical excellence. We conducted a comprehensive business review during the quarter that covered several critical areas, including an assessment of our cost structure, reprioritization of our medical management resources and refinement of our existing portfolio and upcoming pipeline of medical centers.

First, we have conducted a detailed examination of our cost structure, including optimizing staffing levels in both our corporate and center operations. We expect net savings from these actions to materialize more fully by Q1 of 2024. Second, we’ve reallocated resources to bolster our care management platform. This includes the expansion of our most successful care programs and increased oversight from our physician leadership team. With a more nimble clinical org structure, we’ve also become more agile at pivoting team members to evolving needs across our MSO and clinic populations targeting patients with the most complex conditions. For example, during the quarter, we successfully expanded a pilot of our higher utilizer program to match dedicated care coordinators with the most acute 10% of patients, overseeing their needs throughout their participation.

In that program, we achieved over 40% lower inpatient and ER utilization compared to an untreated control group. Another example, the disease-specific program, focuses on enhancing outcomes for patients that have a few specific chronic conditions, helping to drive lower Part A utilization. Third, we are evaluating our portfolio of medical centers for efficiencies, including opportunities to moderate the pace of our de novo development and consolidate existing sites. As of the end of October, we have opened five new clinics this year, including four along the Space Coast of Florida and one in the Bronx, which marks our seventh location in New York, at the same time, absorbed smaller, older sites into larger, newer ones nearby, generating synergies from higher capacity utilization per location.

Looking towards the remainder of this year and into 2024, we continue to maintain a pipeline of sites under development. However, we plan to carefully evaluate the timing of each of these sites on a case-by-case basis and aim to balance capital allocation in this area with our other clinical and data priorities. Fourth, in our MSO, we are turning our focus towards optimizing performance in our current Medicare Advantage contracts. While we continue to believe in the growth opportunities ahead, we are becoming more partial toward membership we believe to be immediately accretive to EBITDA, payers with a high degree of strategic alignment and contract terms that don’t encumber our near-term financial position. For these reasons, we are now targeting the low end of our previous year-end MA membership guidance range of 110,000 to 120,000 which we believe still positions us for EBITDA growth from our MSO MA contracts in 2024.

Moving on to the third theme of the day, we believe we are building positive momentum heading into 2024. Since closing the acquisition of our national MSO this time last year, we’ve embedded our leadership team across the footprint of our new markets. We are encouraged by the receptivity of our affiliate positions and strive to have aligned long-term relationships with PCPs across the network. To date, we have implemented our CareOptimize technology with 100% of these practices, providing 2-way data feeds for real-time insights. Furthermore, our quality team has now expanded coverage to 95% of the practices within our network, assisting providers and promptly addressing care gaps. As mentioned earlier, we believe our robust care management program serves as a differentiated advantage, offering extensive care coordination support to both our patients and PCPs. This type of comprehensive support equips our MSO positions with the resources needed to excel in our various value-based care models.

As we have discussed in the past, our negotiated Medicare Advantage contracts are designed to have a glide path toward increasing risk over time. A typical arrangement allows us to assume limited to no downside risk for the first 12 to 24 months while we implement our holistic care process. As a reminder, in many cases, we may have the ability to pull forward full risk if we believe doing so would be accretive to EBITDA. As we enter the second year of our initial cohort of 70,000 MSO MA members, we anticipate the investments made this year have the potential to drive year-over-year improvements in medical margin and EBITDA. This, in turn, will position us to unlock further value within our platform in the coming years as we move to full risk.

In closing, we are encouraged by the performance of multiple areas within our business and the focused direction of our organization. We have realigned the organization as we seek to improve the efficiency of our corporate and center operations. Our government ACOs are achieving robust results, and we are building strong partnerships across our MSO position network, providing a solid foundation for continued growth in 2024. With that, I’ll now turn things over to Kevin to provide more details on our financial performance in the third quarter.

Kevin Wirges: Thanks, Carlos, and good morning. As our third quarter results show, we are still in the early stages of executing our integrated value-based care strategy. Rapid growth in our Medicare Advantage book of business has created some near-term fluctuations. We are working closely with our health plan partners to ensure completeness and timeliness of data and over time, we expect these efforts to translate into more predictable financial outcomes. To reiterate Carlos’ comments, we are being responsive to these developments and to market factors by focusing on streamlining our operations and reducing our net use of cash. Now let me discuss the third quarter results, which include an $80 million goodwill impairment charge, primarily related to the change in our stock price during the quarter.

You may refer to our earnings release and presentation for a reconciliation of GAAP to non-GAAP metrics like adjusted EBITDA. I will first go over the performance in our Medicare and Medicaid risk lines of business, followed by progress we have made in our government VBC business. Like prior quarters, I will also discuss the impact of prior period development. Of note, substantially all of the PPD recognized in the third quarter relates to the first half of 2023 as we experienced immaterial prior year developments this quarter. Total revenues were $202 million, bringing year-to-date revenues to nearly $600 million. We believe this puts us on track to meet our previously raised full year guidance of $750 million to $800 million. Medicare risk revenues were $134 million and impacted by approximately $11 million of unfavorable prior period developments related to revenue accruals.

As Carlos noted, shortly after the business combination of CareMax and IMC in June 2021, we announced several acquisitions in Florida that drove over 50% growth in Medicare members in just six months. We have worked with our health plan partners over the past two years to integrate these members by consolidating contract terms, claims reporting and fund reconciliations. Those integration activities are now largely complete. We have consolidated our clinic operations into a single EMR and established standardized, more robust documentation processes which are designed to reduce the magnitude of PPDs in the future. Finally, it’s important to note that these acquired members were already in full risk growing contracts. We take a different approach to the newly contracted 70,000 Medicare Advantage MSO patients by introducing them into our ecosystem with a glide path to full risk over time.

In Medicaid, Q3 risk revenues were $24 million, down from $30 million in Q2, including $2 million of unfavorable prior period development from retroactive removals of Medicaid patients in historical periods. Membership declined by about 2,000 from June, slightly favorable compared to our projections. We continue to expect further attrition through year-end and normalization of Medicaid medical expense ratios toward pre-Covid levels. Reported external provider costs include approximately $9 million of unfavorable medical expense PPD related to the first half of 2023. We believe the PPD was primarily driven by higher fee-for-service claims expenses and by lower reinsurance recoveries than previously accrued. Among the developments were a couple of larger claims from earlier this year, which are also contributing to increased IBNR accruals in Q3.

We estimate the combination of risk revenue and external provider cost PPD, drove a roughly 1,200 basis point increase in medical expense ratio to 88% reported in Q3 or 83% reported year-to-date. As you can see on Page 13, we believe that excluding prior year developments, MSO member mix and the year-over-year increase in the 2023 benefit card utilization, underlying centers MER continued to perform within historical ranges. Keep in mind that for this year-to-date view, we only consider the prior year developments disclosed in the past couple of quarters since the prior period developments recognized in Q3 are reflected in the 2023 numbers. Flex card utilization in the third quarter saw a slight uptick compared to Q2. As discussed on our prior quarter call, we continue to work with our health plan partners to strike a balance between maintaining a competitive service offering at our centers and supporting our members with supplemental benefits that have not historically been managed through traditional utilization management or case management programs.

Based on our analysis of 2024 benefit plans, we primarily expect a combination of increased benefits at some plans and reduced benefits at others to result in external provider costs remaining at a consistent level in 2024 when compared to 2023. Now on to government VBC. Q3 government revenues were $28 million, bringing 9 month revenues to $60 million. As Carlos noted, strong performance in 2022 and favorable expenditure trends year-to-date drove increased optimism in our projected 2023 shared savings for MSSP and ACO REACH. So far in 2023, we believe the data suggests continued improvement in performance. Utilization metrics, including readmission rates and post-acute facility days are turning downwards, and overall expenditures for beneficiary are tracking favorably against benchmarks.

In addition, year-to-date enrollments of high-risk patients in nearly all of our care management programs are ahead of plan, giving us greater confidence in generating incremental savings in the back half of this year. For these reasons, our 2023 government VBC accruals now reflect an expectation of gross savings in the mid- to high single-digit percentage range from mid-single digit assumed previously. Related to this increase, we booked $8 million of favorable government revenue this quarter related to the first half of 2023, partially offsetting the Medicare and Medicaid risk PPD of $22 million. Please see Page 12 in our slides for a summary table. Let me provide an update on our MSO Medicare Advantage population numbering approximately 70,000.

In total, including full risk and partial risk members, we believe the MSO is performing at a slightly profitable medical margin year-to-date. 13 individual contracts representing about 1/3 of those lives are currently in upside-only arrangements, but will contractually begin to take some amount of downside risk in 2024, along with a higher share of upside risk. Based on information thus far from the health plans, we expect those contracts to be accretive to medical margin and adjusted EBITDA in 2024. More generally, we have been receiving financial reconciliation reports regularly from most health plans. We have greater visibility now into our MSO members’ risk characteristics compared to when we first gave 2023 guidance and believe we are in the right path towards giving more predictable guidance going forward.

Reported adjusted EBITDA for the quarter was $2 million, inclusive of $13 million of net unfavorable PPD and $6 million of de novo pre-opening costs and post-opening losses. As Carlos mentioned, we have conducted a comprehensive review of our operations in light of the recent PPDs, the higher cost environment and the integration of the MSO into our strategy. In particular, we’ve implemented cost measures, including delaying de novo investments and reprioritizing resources towards clinical management that we expect to result in cash savings in 2024 and improved medical performance among our full risk population. Absent further material PPD headwinds, we believe the third quarter adjusted EBITDA suggests the potential to approximately reach the lower end of our prior full year guidance of $25 million to $35 million.

Additionally, we would still expect Part D limits and patients hitting stop-loss deductibles to be seasonal tailwinds to medical margin in the fourth quarter. However, we are considerate of the potential risk around Medicare final sweeps, further unfavorable development and medical expenses, another COVID uptick or early flu, and uncertainty in year-end utilization of flex card benefits. For those reasons, we feel it is appropriate to lower our full year adjusted EBITDA range to $15 million to $25 million, including expected de novo pre-opening costs and post-opening losses of $25 million. Cash and equivalents were $32 million at the end of Q3. Cash used in operating activities was $19 million, narrowing from $22 million in Q2. Following the end of the quarter, we repaid the $35.5 million AR facility with proceeds from our 2022 MSSP payment.

Our $60 million of DDTL remains undrawn. We expect to draw up to fund operations through our next MSSP payment in Q4 2024, after which we expect to be sustainably free cash flow positive. Before going into Q&A, I would like to leave you with some comments on how we are thinking about 2024. First, with normalization in our Medicare risk revenue accruals and a recalibration of our completion factors, we expect lower risk of unfavorable prior period developments going forward. Second, we believe the data already suggests year-over-year growth in government VBC shared savings in 2023, which we see further opportunity to enhance in 2024. Third, we believe our MSO MA contracts will continue to contribute positive medical margin and EBITDA in 2024, and as our data capabilities improve, so does our ability to clinically manage this population.

And fourth, we are proactively rightsizing our cost structure for the new risk adjustment and benefit environment, running a more efficient business while maintaining our high standards of care for our patients. Operator, we will now take questions.

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Q&A Session

Operator: Thank you.[Operator Instructions] Our first question comes from Jailendra Singh with Truist Securities. Please go ahead.

Eduardo Ron: This is Eduardo on for Jailendra. Just to go back to the comment you made about your analysis of 2024 benefit plans and external provider costs being comparable in 2024 versus 2023. Can you just flesh that out a bit, is that around the benefit cards, or is that just regular utilization that you’re seeing? That would be helpful.

Kevin Wirges: Eduardo, it’s Kevin. Yes, we do take a look at all of the benefits, obviously, focused on the concentration of those plan benefit packages in which we have the majority of our patients. What we’re seeing is some of those plans are investing a little more in the benefit card, some of them were actually were retracting in certain plans in the benefit cards. But what we saw is the ones that were actually improving the benefits under those benefit cards are actually — have other historical co-payments that were, let’s say, 0 for like emergency room or ambulance now have co-pays on them, $75, $50, $150 or so. So we’ve gone through that list to understand how the benefits in totality would potentially look for 2024. Based on our assessment, that’s where we’re coming up with — similar to what we’re seeing in 2023 from an overall total cost standpoint.

Eduardo Ron: Got you. Okay. It looks like the impact of the benefit cards maybe worsened in Q3 versus what you guys had in the first half. Was that just, I guess, truing up some first half experience? Maybe just frame the benefit card impact in the quarter and make the expectation in Q4?

Kevin Wirges: Yes, it’s a good call out. So as we dive a little deeper and looking at explicitly what’s being included in benefit charges, there were certain health plans that are including OTC benefits in that card and card expenses. So we had to go back specifically for certain PBPs to understand what the impact of OTC was. We had to include OTC in the prior year and the current year to do that analysis. So I would say this is probably — the underlying assumptions haven’t changed too much. The impact was relatively consistent year-over-year. We just needed to include that OTC component when we did the year-over-year comparison.

Eduardo Ron: All right, and just the last one for me. The 4Q 2024 revenues, it’s still a pretty wide range, $150 million to $200 million, given that you’re less than two months away from the end of the quarter. What takes you from the low end on revenue to the high end?

Kevin Wirges: Yes, so there’s a couple of things. One, we talked about this before, obviously, PMPMs on the Medicare book of business tend to trend down throughout the year as your more acute patients expire and you’re bringing on newer patients. So the PMPMs tend to go down. Additionally, we do expect Medicaid premiums to trend a little further down from what we have in the run rate in the first three quarters of the year just due to the redetermination components. Then, we mentioned this in our prepared remarks, but we’re also cognizant of some potential on the Medicare final sweep. So we want to make sure that we have that cushion, if you will, in our guidance numbers.

Eduardo Ron: Thank you.

Operator: Our next question comes from Jessica Tassan with Piper Sandler. Please go ahead.

Jessica Tassan: Hi guys. Thanks for taking the question. So I guess I wanted to start with just what makes you all comfortable raising the accrual for 2023 MSSP and ACO REACH, just given the downward $2.2 million revision related to the final 2022 settlement in 2023?

Kevin Wirges: Yes. So Jessica, it’s Kevin. So we obviously work with our external actuaries, and we’re looking at trends that we’re currently seeing in our data. There’s a couple of data points. One, as we looked at historical trends for the past couple of years, historically, there’s been somewhat of an uptick that happens on those beneficiary costs from Q1 to Q2. We kind of saw the opposite actually happened in this year from Q1 to Q2. In addition to that, we talked about our care management programs being ahead of schedule from an enrollment standpoint for those high utilizers. And we’re tracking that very closely and seeing that the opportunities there that we anticipate to come to fruition are going to exist in the second half of the year over what we’ve experienced in the first half of the year. So it’s a combination of a multitude of things that give us confidence in that number.

Jessica Tassan: Got it. So can you maybe give us some color on kind of the maturity or the progression of savings rate in each program? So year 1 to year 2 to year 3, and then just the level of visibility that you get from CMS in year versus in the subsequent year to the performance year?

Kevin Wirges: I don’t know if we have the year-over-year-over-year improvement. What I would tell you is that this year, the 2022 payment year was one of the best that we’ve seen since the ACO has started under prior ownership. We have seen incremental improvement over the few years, I want to say going from 2% or so to 5% and now returning kind of ahead of that at this point. I’m sorry, Jessica, what was your second question?

Jessica Tassan: Just interested in the level of visibility that you get from CMS over the course of the year, specifically in MSSP and then in the subsequent year to the performance year. So how does your visibility kind of trend in 2022, for example, during the performance year, and then what are you learning over the course of 2023?

Kevin Wirges: Got it. Another good question. So the CMS data we get, similar to our health plan data, is lagged. So as we get visibility into that information, it’s really — obviously, we have visibility into our cohort of patients, our beneficiaries. It’s really the benchmarks that we’re really keeping an eye on. What I can say is that the third-party actuary who assists us with that is relatively accurate from those standpoint. Obviously, it changes and there is some fluctuations. You’re always going to have fluctuations when you’re dealing with the magnitude of data that we have coming in.

Jessica Tassan: Got it, and then my last question is just — as we think about 2024 kind of total Medicare Advantage membership, given some of your comments about being more — or just about being disciplined in terms of expansion. So should we think about total Medicare Advantage lives as being roughly flattish year-over-year with just the migration between partial and full risk? That’s it from me, thanks.