Centene Corporation (CNC) Earnings Call Transcript & Summary

Good morning, everyone. I'm Jennifer Gilligan, Senior Vice President of Finance and Investor Relations. Welcome to Centene's last regularly scheduled June Investor Day. Beginning in December, our plan is to anchor around a single Annual Investor Day. And in exchange, we look forward to finding alternative and engaging ways to give you exposure to our businesses and key leaders at different times throughout the year. Now for some housekeeping items. Our press release as well as today's slide presentation are available on the Investor Relations page of centene.com. Additionally, please mark your calendars for our second quarter 2022 earnings call scheduled for Tuesday, July 26. While we won't read this disclaimer page, please note that various remarks we make today regarding future expectations, plans and prospects constitute forward-looking statements under U.S. Securities Law. Actual results may differ materially from those indicated by these statements as a result of various and important factors and risks, including those discussed in the slide you see in front of you and the risk factors contained in our most recent Form 10-K and other SEC filings. Centene disclaims any obligation to update this forward-looking financial information in the future. Additionally, during this presentation, we will be discussing certain non-GAAP financial measures. For more information on these measures, refer to the appendix in today's slide presentation, which is available on our website. On Page 3 of our slide presentation, you will find our agenda for today. We will open with a strategic overview from our CEO, Sarah London. She will pass the floor to Brent Layton for an update on the core businesses. Following Brent, Jon Dinesman will provide some framing for the current health care and political landscape. Jim Murray will then offer an update on value creation, and Drew Asher will close out our prepared remarks with a discussion around our financial outlook. Finally, we will use the remainder of our time together for Q&A. Speaking of Q&A, I will now walk through the instructions. For today's Q&A session, questions can be submitted through the Ask a Question box on your screen. Your questions will only be visible to the Centene Investor Relations team. We will read aloud the question and the name and organization of the person submitting question. And with that, I will turn the floor over to Sarah.

Thank you, Jen. Good morning, everyone, and welcome Centene's June Investor Day. We're webcasting this morning from our St. Louis Headquarters, and what we hope will be our last virtual Investor Day for a while. Our goal is to be with you in person and in New York City when we meet again in December. To start us off today, I'd like to highlight 3 key themes you'll hear from the team throughout the morning. First, the business is performing well. We are driving strong results through focus, disciplined execution and the thoughtful pursuit of profitable growth. We plan to carry this operating momentum into the back half of the year and apply a similarly rigorous approach as we navigate redeterminations and the evolving regulatory landscape. In the meantime, I'm pleased to announce that we are again increasing our revenue and adjusted earnings guidance for full year 2022. Second, value creation is on track and operating at scale. As you'll hear this morning, we are making great progress on the 2022 milestones we laid out in December. The work we're doing today not only positions Centene to deliver on our financial commitments, but also to better serve our members, providers and communities now and in the future. And speaking of the future, the final theme I'd like to call out is Centene's long-term strategy. This leadership team continues to think critically about and lay groundwork for 2025 and beyond. Today, we will share some of the key inputs into the powerful and sustainable growth engine that will drive Centene's future success. But before we get there, I'd like toto briefly reflect on where we've been and how much this organization has accomplished over the last 12 months. Last June, Centene announced a significant shift in our enterprise strategy. After decades of focusing on growth, and after successfully reaching a critical level of scale and stability across our 3 lines of business, we locked in new multiyear coordinates. An adjusted net income margin north start of 3.3% and a 2024 adjusted earnings per share target of $7.50 to $7.75, the latter representing 48% adjusted EPS growth from 2021. Thus began our value creation journey and an explicit commitment from this management team to deliver differentiated value to our stakeholders. What we have found is that the value creation framework introduced a year ago has proven to be both durable and well balanced across its 3 areas of focus. With a robust pipeline of initiatives identified for SG&A savings, gross margin improvement and strategic capital management, the value creation team has now extended its wing span over every inch of Centene's business. And as I hope has become clear, we are making significant progress. You've heard about the great work our HR and real estate teams have done in recent months to evaluate our extensive portfolio of real estate assets and determine the footprint will require now that Centene is embracing a more flexible work culture and remote work opportunities. You've also heard updates on our PBM, RFP, which is now on the street, as we leverage our national scale to maximize quality and lower cost within pharmacy services. And we've shared multiple examples of our commitment to streamlining Centene's core operating model, whether by consolidating our call center footprint, organizing around centers of excellence to distribute best practices across our 30 health plan or integrating our major transactional systems into a single unified technology platform. Our relentless focus on the core business and value-creation milestones was perhaps most evident just a few weeks ago, when we announced definitive agreements to sell Magellan Rx and Panther for a combined $2.8 billion. While both are great businesses, they are not businesses Centene needs to own. The mantra for Centene's portfolio review has not changed. If it doesn't fit, it doesn't stay. You should expect to hear continued updates on this and other portfolio review work, including progress on the international portfolio, as we move through the rest of this year. An important part of what has made this all possible is the tremendous support we've received across the organization. Rather than interpreting value creation as a large-scale cost-cutting exercise, the Centene team has embraced the fact that this work is perfectly aligned to our mission. Better processes, simpler and more streamlined technology and investments that prioritize impact for our members and providers will make it easier for us to transform the health of the communities we serve. This mission-driven approach has made it intuitive for the organization to prioritize value and strike a strategic balance between margin and growth. In the core business, we've demonstrated meaningful progress year-to-date on our margin expansion plan for Marketplace, having successfully leveraged product and network innovation, along with our knowledge of hyper local competitive dynamics to position and better for profitable growth. We took this same approach with our recently submitted 2023 Medicare bids and are pleased with how thoughtfully the Medicare team approached a margin-focused mandate, while balancing high-quality competitive benefits for current and future members. We still have a lot of work to do, but I am proud of how much this organization has accomplished thus far. We remain committed to sharing transparent updates on our operational milestones and the financial benefits, as we progress along the value creation journey. At the same time, we fully recognize that today's value creation efforts are a means to an end. Everything we do over the next 3 years will create a strong, efficient and innovative platform for the next phase of Centene's growth and market leadership. So what does that next phase look like? As we guide the value creation program, this leadership team has also been mapping the future. To formalize our thinking, we launched an enterprise-wide long-term strategic planning process at the end of Q1. At our December Investor Day, we plan to share more about our vision for 2025 and beyond. But in the meantime, I'd like to share with you a few of the reasons we are enthusiastic about how this long-term story is shaping up. First and foremost, we believe we have the right starting point. Centene is the proven leader in Medicaid and Marketplace and has been one of the nation's fastest-growing Medicare Advantage plan sponsors. With responsibility for more than 26 million Americans and government programs, we have an unparalleled footprint. Our size, combined with stable, experienced and disciplined leadership at the state and national levels give Centene the right to win. As we map the market, we believe our footprint provides superior opportunities to add specialized populations, expand into new markets, and introduce new and adjacent product offerings across existing lines of business. Moreover, we are confident in our ability to execute on these growth opportunities, delivering value to shareholders over the long term. Second, we believe that our roots in Medicaid position Centene to be uniquely competitive in the future. Why? Because health care is only becoming more local, and local is what we do best. Centene is singular in our ability to serve the needs of our members and communities because our team members live and work in every community we serve. This gives us the ability to literally meet our members where they are, to understand and assist them in their health journeys, day in and day out. We know how they make choices, what they value and who they trust. And we understand the resources available in each community that we can activate in order to support them. This network of local insights and trusted relationships transcends Medicaid, and we believe will continue to serve as the foundation for high-quality, low-cost growth across an expanding network of distribution channels. Third, as part of this long-term planning work, we are broadening Centene's provider strategy, and we are excited about the opportunities we see in this space. Over the last 2 years, Centene has made substantial progress with our [ VBC ] footprint, but there is more we can do to leverage the trusted relationships our members have with their providers. And we intend to bring forward new models and supporting data to better align with high-performing provider partners across all 3 lines of business. A great blueprint for this is Community Medical Group or CMG in South Florida, which we've repeatedly pointed to as an example of an asset we intend to keep and grow. To better understand why, consider that many of the CMG clinics are co-located with Medicaid access centers, which allows for a physically integrated value-based approach to address not just member medical needs, but the underlying drivers of a member's whole health, including food and security, affordable housing, transportation and more. Our goal is to place the most impactful set of whole health tools and data directly into the hands of risk-bearing providers and aggressively assist them to improve health outcomes, while bending the health care cost curve. Another major piece of the work underway and one I'm particularly excited about is Centene's data strategy and road map for digital innovation. Centene is the trusted steward of an ever-growing data set describing the health journeys of 26 million Americans, and that data is the power to do many things. It will allow us to make richly informed decisions as we manage the business, design and deliver best-in-class processes and systems and, ultimately, enable an aggressive automation agenda to control long-term administrative costs. This data will also empower our members with the information and tools they need to take control of their health in addition to their health care and make everything easier. From choosing the right benefit plan to finding the best physician, from accessing convenient care through telehealth, to engaging with innovative, deeply personalized digital care management support. And finally, the data will allow us to take our local-first approach to the next level. By codifying our knowledge of local resources, we can design programs that build health equity in a community and create sustaining health outcomes through an integrated approach to social determinants and the drivers of health. Simply put, we intend to be the best at data because data is how we will digitize health care. Our members and their caregivers do more digitally every day. And they are looking to us and to the health care system overall. to catch up. We believe Centene is in a unique position to develop and deliver digital capabilities that work for the most complex members of our system. This road map is a critical piece of how Centene will advance our mission and improve health outcomes at the individual local community and national level. The final concept is perhaps the most important one as we think about Centene's long-term strategy. At our core, Centene is a company of market makers. We have a history of creating new opportunities from the ground up. Yes, in recent years, we became known for growing the top line through our large-scale M&A efforts. But remember, we built 23 of our 30 health plans by hand. We were among the first companies to roll up our sleeves in the health care exchange and one of the only payers to never leave. We were the first to take on sole-source Foster Care programs. And today, we're applying that local market know-how to grow Centene's Medicare Advantage footprint. As we look to opportunities in 2025 and beyond, not only do we have confidence in the fact that our current footprint in government-sponsored programs is a position of strength, but we believe it is the right platform, from which to look at adjacencies and shape the evolving market dynamics in our favor. We look forward to sharing more detail on our long-term vision in December. In the meantime, thank you for traveling with us on this journey. With that, I will turn it over to the team to cover the rest of today's agenda.

Thank you, Sarah, and good morning. You know Jennifer Gilligan starts each of these meetings reading as required, but not exactly exciting disclosure statements. I'm starting to feel like I got my own version in that language to remind you who we are. That's exciting. Centene is the largest Medicaid managed care organization, the #1 Marketplace carrier, and we see strong growth year-over-year in our Medicare Advantage product. Today, I'll focus on the performance and the success of our 3 largest lines of business. We are halfway through 2022, and it's shaping up to be a busy year. We have implemented a new Medicaid contract in Nevada, which has nearly doubled our membership in the state since year-end 2021. We have also won reprocurements in Louisiana, in Indiana and Missouri. In addition to successfully reprocuring our Medicaid contract in Missouri, we were also fortunate to be awarded the new sole-sourced specialty plan for children in Foster Care. We are incredibly proud of this win. Centene is the national leader in managed care for children in the child welfare system serving over 230,000 children and young adults in 19 states. This includes 5 sole source and specialty contracts in Texas, Florida, Washington, Illinois and now Missouri. We have demonstrated that sole source contracts for youth with child welfare involvement improves health care outcomes through decreasing preventable emergency department utilization and improving access to primary care and behavioral health intervision. As we exit the pandemic, we're already seeing an uptick in RFP activity, and we expect to see more populations brought into managed care. For example, in Oklahoma, Governor Stitt recently signed a law to introduce managed care for the TANF and CHIP populations. This statewide program will include a sole-source secondary bid to manage the health care needs of children involved in the child welfare programs. We're also responding to an RFI in Georgia, where the Medicaid agency is asking about MCOs and about their ability to serve more medically complex populations, and we expect to see an LTSS bid in Indiana later this summer. In addition to a busy RFP calendar, the end of the pandemic will eventually bring the end of the public health emergency. Jon Dinesman will talk to you about this time line in a few moments. But we continue to work with our state partners as they consider how to begin redeterminations. Our strategy is tailored specifically on each state based on our early discussions and with our regulators. Our execution plan is well thought out, and we remain nimble to adjust to the evolving guidance from our state partners. We are ready to implement our plan when the PHE ends. We will be able provide more information on the market dynamics once our state partners have finalized their redetermined process. In the meantime, we continue to share best practices to help them arrive at the best possible solution. We continue to believe that our exchange product, Ambetter, will be a valuable solution for many members transitioning off the Medicaid roles. Our Ambetter product covers 25 of our 29 Medicaid states, and we believe we're among the best position in the health care market to capture those transitioning coverage through redeterminations. Our Ambetter product is in 27 states this year, having entered 5 new states and 274 new counties. And we ended the first quarter with over 2 million members. We are pleased with our open enrollment performance and the performance of our product in general. Today, despite a marked increase in competition, we continue to build on market position, including share gains in several of our major markets. We will continue to take a responsible approach to pricing, while focusing on providing products that meet the needs of our membership. For the first time in 2022, we offered a core product and 3 new products. These products are our PCP gatekeeper model, tailored network and an online medical home. They have proven to be valuable for both member retention and new member attraction. While our core product remains the top choice for our members, we are pleased with the results of these new products. As we consider and submit our bids for 2023, we're exploring, we're expanding these products and increasing our geographic footprint makes the most sense. We look forward to sharing more about our growth and expansion with you in December. We are closely monitoring the situation in Washington in regards to the enhanced advance premium tax credits. These tax credits have grown the exchange market and make products more affordable. Again, Jon will give more detail on this shortly, but I do want to acknowledge that we do expect the extension or removal of these credits to impact the exchange more broadly. As we've told you previously, we believe the removal of the enhanced advanced premium tax credits could lead to a 10% to 15% market [ contraction ]. Over the past few weeks, I've had the opportunity to meet with many of our brokers and agents on behalf of Ambetter. What they have shared with me is their appreciation in selling Ambetter because they can count on the quality and consistency of the product. In general, 2022 continues to prove that nobody knows Marketplace members and their needs better than Ambetter. Our hyper local approach and knowledge serves us well. And while the competition grows, nobody will be a stronger competitor than Ambetter. Moving on to our Medicare product. WellCare entered 2022 in 3 new states, bringing us to Medicare Advantage membership in 36 states. Our annual enrollment growth was impressive, ending with more than 1.4 million members, with 200,000 net new members and 18% membership growth since the start of the year. As we have completed our bid process, we see significant opportunity in Medicare and believe we have a strong value proposition to offer members in 2023. As we look beyond 2023, we recognize the unique role and significant impact our organization has with dually eligible members. We have over 1.2 million dually eligible members in our Medicaid product. In addition, we serve approximately 350,000 [ D-SIP ] members across 32 states in our Medicare product. Our strength and experience in Medicaid complex care supports our positioning and continued focus on leadership in the D-SNP market. What I'll tell you more in December, we are significantly expanding our D-SNP footprint for 2023. We believe that regardless of the coordination model, efforts to align membership across Medicaid and Medicare are key. We'll continue to be strategic partners to states and CMS as they work to advance integration of care and social support delivery for these critical populations. Looking ahead to 2023, we anticipate low- to mid-single-digit growth, while increasing Medicare margins. As you've heard from Drew in the past, we are not where we want to be with our STAR scores, but no doubt, our focus is strong improvement and quality today is job 1. As Jim will explain to you later, we are focused on people, process and technology to improve our operations and overall member and provider experience. Additionally, we are focused on clinical initiatives, network expansion, value-based contracting where we have aggressive growth across all of our lines of business. Whether it's Medicaid, Medicare or exchange, Centene is truly committed to value-based contracting. Yes, I mean up and downside risk, assigning members to the highest quality providers and capitation. This is done in complete partnership with our providers to increase quality outcomes and overall member satisfaction. This year, we've seen an increase in members attached to capitation arrangements across all of our products. This includes launching our first up and downside risk contract for our Ambetter product, which we'll discuss more detail in December. Early indications show that providers in our value-based payment arrangements are performing better than those providers in nonvalue-based arrangements, and 80% are earning incentives. We anticipate the number of our membership in up and downside risk arrangements will continue to grow. We want to reward those providers who drive positive health care outcomes for our members. In conclusion. Our largest lines of business remain strong and growing. We are focused more and more on operations and basics. Value creation and optimization of our operations will better serve our members and providers, and it's creating a firm platform to build future growth and support better outcomes. With that, I'll turn it over to Jon.

Thank you, Brent, and good morning. At a time when the partisan divide is as great as it has ever been, among many, especially in Washington, I wanted to use my time today to reflect on where we have come from and provide you some clarity on where we might potentially be headed when it comes to health care policy in our country. The period of the Obama years, which included a Democratic majority in Congress, we're transformative with the implementation of the Affordable Care Act. During that time, there was considerable noise from the media, political pundits and elected officials with the loudest megaphone. The perception was that government-sponsored health care coverage was volatile. As it turned out, perceived volatility and reality were very different, and Centene grew during this period to become the largest Medicaid and Marketplace provider in the U.S. Then came the 2016 presidential election and the Republicans took power in Washington. And with that, the focus shifted to whether repeal and replace would happen. Those same pundits, elected officials and members of the media focused on the big changes that might occur. The reality is Medicaid became more politically popular than ever before. The ACA became more entrenched. And as we recently witnessed, the COVID-19 pandemic made the need for high-quality, comprehensive coverage more important than ever. During the 2020 election, a health care debate focused on the viability of single payer or a public option became the focal point. Once again, people wanted to focus on the sound bites and that health care, especially government-sponsored health care had an uncertain path. When in fact, our nation's health policy has been quite stable over the last decade. Transformational changes to health care policy really happen in Washington. What we have witnessed over the last 10 years is a continued focus on covering all Americans by utilizing the Medicaid and Marketplace chassis, which demonstrates the continued value of managed care and delivery of accessible, affordable health care. Over the past 5 years, we've seen bipartisan support in providing coverage to those who need it the most, at both the state and federal levels, emphasizing the value of Medicaid, Marketplace and the Medicare programs. For example, voters in conservative states passed Medicaid expansion via ballot initiatives in Idaho, Nebraska, Utah and Missouri. During the COVID pandemic, under both the Trump and Biden administrations, we've witnessed bipartisan support for special enrollment periods, public health emergency flexibilities related to Medicaid redeterminations and telehealth, the enhanced advanced premium tax credits, continued support for Medicare Advantage, and most recently, the Biden administration has taken efforts to address the family glitch, which we see as a significant step in making the Marketplace more affordable for working families. Although the reconciliation bill originally extended the enhanced advanced premium tax credits, it remains uncertain whether Congress will pass a reconciliation bill by its expiration date of September 30. And whether enhanced premium tax credits would be included in any slim-down bill. The policy continues to be a top health care priority, but whether anything passes before the November election is unknown at this time. Regarding the public health emergency, the Biden administration did not provide notice that the PHE will be eliminated on July 15. So we expect the PHE to be extended another quarter. An extension for the third quarter makes it more likely that the PHE will remain in effect until the end of the year, but we remain agile in working with our state governments and are prepared to support our members and mitigate care disruption when redeterminations resume. Moreover, with the winter months creating uncertainty in terms of a potential COVID spike and the upcoming November elections, we believe it is unlikely that the PHE would be eliminated in October. Even with the passing of ballot initiatives for Medicaid expansion in Idaho, Nebraska, Utah and Missouri, and North Carolina moving to Medicaid managed care, we believe that federal debates on the ACA and then repeal and replace and most recently, the COVID pandemic, slowed down state efforts to pursue service expansions like age, blind and disabled, long-term care services and support and those with intellectual and developmental disabilities. We expect state activity to continue to ramp up as they look to ways to achieve budget predictability and meet the additional coverage needs of their constituents. Unlike the debate in Washington, states do not look for a one-size-fits-all solution, but solutions that meet the unique needs of their particular state. This requires engagement with companies that understand government-sponsored health care. And more importantly, those with the flexibility and expertise to provide health care solutions focused on a local approach. We believe no company is better positioned than Centene to work with our partner states in achieving these objectives. In closing, as partisan politics continue to sharpen division between the 2 political parties, we anticipate that the November 2022 election will likely result in divided government or at best, a slim majority, which makes any meaningful change to health care policy, unlikely over the next 2 years. The debate on coverage, cost and quality will continue, but we expect that our nation's health care policy will remain stable when it comes to support for our core Medicaid, Marketplace and Medicare business. Thank you. And now let me pass the mic to Jim for an update on value creation.

Thank you, John. Good morning, everybody. It's really great to be here today providing an update on our value creation efforts. For me, personally, it's been a pretty fast-paced and fun 6 months getting to know as much about Centene as I possibly could. I appreciate everyone's support and collaboration as well as the culture that's developing. I especially want to thank Sarah, who I might say astutely recognized that chronological age, there's no relationship to the ability to get things done. To get started, I thought I'd share a slide that Sarah and Drew presented to all of you last December. This slide depicts the various levers we have to pull to enable the progression of adjusted earnings to the range of $7.50 to $7.75 per share in 2024. Drew will soon go into detail on our overall value creation progress, while I focus my remarks today on the box on the left related to administrative savings opportunities, which is you can see are targeted to be in the $700 million in annual savings range. Although improving our profitability by $700 million would obviously be very positive, I also want to restate the points that Sarah made earlier. Value creation initiatives that we'll discuss today enable us to, one, eliminate complexity and thus becoming easier to do business with; two, shift to a web-based service tools and automation thereby engaging members and providers where, how and when they want to be met; and finally, becoming more data-driven, which will improve product and capability development as well as day-to-day operations and will ultimately, as Brent said, enable us to use our data to improve the health of our members. Each of these foundational improvements supports the no-regret strategic imperatives that Sarah outlined earlier. Although our work will be challenging at times, remembering that we are on a journey and our strategic foundation will be very rewarding. As a result, we view our value creation work as an enabler to our long-term strategy. As you can see, we've categorized value creation opportunities by life cycle, including short, mid and long term. It likely goes without saying that the degree of difficulty aligns to these time frames. Short-term savings initiatives will generally be executed on during 2022 with run rate savings beginning in 2023. We estimate that short-term savings will approximate $300 million plus. A large portion of these savings will be related to our real estate portfolio rationalization, where we've made considerable progress on evaluating our existing footprint. Drew will review this with you in detail in a moment. We are also well into rationalizing our vendor and discretionary spend. Some meaningful progress has already begun, and I expect that enhanced oversight will continue to bear additional fruit there. Midterm savings generally reflect our leveraging of our scale through shifting transactional processing to shared services to improve both economics and execution. We estimate midterm savings will be approximately $400 million plus, and we will achieve full run rate savings in 2024. In addition to these hard dollar savings, as I said earlier, this work lays the foundation to achieve an even greater level of future savings by reducing complexity, creating standardization and enabling self-service. You've heard us previously referenced our work to standardize key functions, like utilization management, pharmacy and call centers. To date, we've already shifted the reporting structure for these resources into shared services organizations and have begun to standardize specific processes. We will continue to shift and standardize additional processes as we move closer to our model health plan office construct. In addition to standardizing and reducing complexity, shifting transactions to shared services allows our health plan teams to build upon our industry-leading community presence and relationships, including our efforts around social determinants of health and health equities that Sarah talked about earlier. Let me turn to the final bucket, long-term initiatives will certainly be more difficult requiring a longer run rate because to accomplish these, we have to combine both technological and cultural change. Today, we have over 5 major IT platforms and over 500 applications supporting those platforms. Maintaining these multiple platforms has resulted in excess nonvalue-added spend. By consolidating these platforms, we can focus more of our technology spend on innovation and growth spend. We intend to consolidate to one platform with fewer than 100 applications within the next 3 to 4 years, which as you can see on the slide, suggests that we're already thinking about savings beyond 2024. While the platform consolidation itself is estimated to save about $100 million plus annually, meaningful future savings opportunity will come from the simultaneous investments we are making in tools to leverage the use of data and promote self-service. We're in the process of developing targets for those as we speak. While our long-term initiatives will take us beyond 2025, rest assured, we are committed to delivering on the promised $700 million savings target by calendar year 2024. In addition to the ongoing work we are delivering to meet our 2024 targets, I'd be remiss if I did not speak to how we are maximizing quality and STARS performance, which Brent referred to earlier. We have organized our efforts around 4 key areas: people, where we are focused on improving service delivery, improve processes, enhance technology and data-driven reporting and improved partner management and support. Many of these efforts are already showing positive progress. And as a result, we are confident that our 2025 STARS performance will be improved and enable us to offer competitive benefit plans and premiums. In closing, we are proud of what we have accomplished to date and remain steadfast in our focus on driving value creation throughout the organization continually as there is still much work to do. Our team's goal is to enable the company to reduce complexity and become even closer to our members and providers to deliver a better overall experience and improved health outcomes. With that, I'll now turn it over to my new favorite CFO, Drew, who will provide more detail around our execution progress and the other 2 pillars contributing to our Value Creation Plan.

Thank you, Jim. We're glad you're here. Let me start with a 2022 financial update, including our current thoughts around redeterminations and a review of the 2022 milestones that we shared with you at our December Investor Day. Then we will spend most of our time on the Value Creation Plan. But let me remind you, even though I will be focusing on the math and the numbers for this presentation, the purpose of the Value Creation Plan isn't just financial. It is meant to fortify our platform for future growth. As Sarah and Jim covered, the Value Creation Plan will improve our operational execution on behalf of our members and our state and federal customers. It will make it easier for critical partners, like providers and brokers, to do business with us. It will enhance quality and improve the affordability of health care. It will focus us on our mission to improve the health of our communities one member at a time. In late April, we reported a strong start to the year for Q1. As a reminder, our Q1 HBRs were on track. We lifted our revenue forecast and raised our adjusted earnings per share guidance to a range of $5.40 to $5.55. Now as we sit here in June with 2 more months under our belt and an assumed 90-day extension of the PHE through mid-October, we are pleased to again raise our adjusted 2022 EPS guidance by $0.15 to a range of $5.55 to $5.70. A little over half of that is driven by improved performance in Q2 with the remainder driven by continued growth as redeterminations get pushed out another 90 days. We are also raising our 2022 total and premium and service revenue guidance by $2 billion, driven by continued Medicaid growth. Some, but not all of that Medicaid growth will be given back through redeterminations in future years. Given continued growth, our run rate estimate of future revenue reduction from redeterminations is a range of $7 billion to $7.5 billion, up from our previous estimate of $6 billion. This represents an assumption of a reduction of 1.7 million to 1.8 million of our Medicaid members from expected growth of 3 million members since the onset of the pandemic. This is about 58% compared to our prior estimate of 53%. As we continue to grow during the PHE, these numbers will also tick up. As you heard Brent reference, we are engaged with all 29 state Medicaid agencies regarding the process of redeterminations, the expected sloping and our ability to engage with affected members to promote continuity of coverage. In addition, we have analyzed past experiences of membership and mix shifts. We've looked at members and performance in the more likely to be redetermined cohorts. We've examined our data, including members with low utilization compared to a historical baseline and our COB data. We've looked at past times, we have needed rate increases for various mix drivers, and when we've successfully have been able to advocate. We've developed data-driven playbooks to be able to engage with our states as soon as the first couple of months of redeterminations commence and have lined this up against rate update calendars. And we've examined our positioning in risk corridor paybacks, which essentially provide a partial buffer for increases in medical cost. So while there is a risk with shifting membership mix, we believe redeterminations will be manageable. This is based upon our analysis, financial work and history of rate influence as well as the forecasted sloping of redeterminations providing additional time to engage with the states. And it certainly is nice to have a 29-state diversified Medicaid footprint across multiple populations. On the Q1 earnings call, I noted that it is our job to manage the Medicaid HBR in the [ 89s ] regardless of what's thrown at us, we still believe that. So with respect to next year, consistent with our comments at the December 2021 Investor Day, we still see the progression of adjusted EPS, taking us through the low 6s in 2023. This includes impacts from both redeterminations and the Value Creation Plan. Now back to 2022. Year-to-date, utilization continues to be in check, and our Medicaid HBR is tracking consistent with our expectation. As Brent mentioned, Medicare Advantage continues to grow. And as of May, we are up 18% year-to-date membership growth. In the commercial business, which is largely represented by Marketplace, is tracking well to the 500 basis point year-over-year, expected HBR improvement, leaning favorable given preliminary risk adjustment data received in the second quarter. Overall, with our updated guidance, we expect approximately 64% of our full year adjusted earnings in the first half of 2022. We look forward to sharing more details once we close the second quarter and report on July 26. Now let's talk about the Value Creation Plan. Starting with an update on the 2022 milestones that we laid out for you at the December Investor Day. As you heard from Jim Murray, we are well on our way with a number of the operating model improvements, such as call centers, utilization management, pharmacy platforms and processes and provider engagement tools. We filed the 2023 Medicare bids in early June and are in the process with Marketplace bids under the refined portfolio management approach and expected advancement of margins. We are finalizing real estate decisions, which I'll cover in more depth in a minute, and we issued the PBM, RFP in April to ensure we have plenty of time to assess the unique alternatives each party can bring to Centene. We were pleased to announce in early May definitive agreements to divest Magellan Rx and Panther, and we sold off some other minor assets and used proceeds to buy back $200 million of our common stock in May. We still expect that most of our 2022 buyback from operating cash will be later in the year when health plan dividends are available to our parent entity. On that topic, this morning, we announced a $3 billion increase to our share repurchase authority and a $1 billion of authority to repurchase our senior notes. This is in preparation for closing of the 2 divestitures and ramping up the free cash flow of the company going forward. While we're pleased with the pace of progress, there is a lot more to accomplish over the next 2 years. We look forward to rolling this slide forward and providing you an update in our December 2022 Investor Day. This slide should look familiar. This is the road map for the $2 of adjusted EPS, we expect to yield by 2024 from the Value Creation Plan. The first pillar is SG&A, and you heard Jim cover a number of the actions that are expected to drive this $700 million plus opportunity. I wanted to provide a little bit more insight into the real estate analysis. Coming off of 2 years where the company was largely working remote due to COVID, we learned a lot about the balance between in-person engagement and the productivity and employee satisfaction of remote work. Over the past 5 months, we surveyed all of our businesses and examined each of our over 300 domestic locations, and struck a balance of a physical footprint with a flexible workforce. We are committed to our local-based health plan model, and we'll be maintaining a strong local presence. But in many cases, we just don't need the same square footage that we needed prepandemic as we adapt to a more modern work structure. The result is an impressive reduction of about 65% of our domestic leased space and an evaluation of our owned buildings. We are going through the formal decommissioning process, which will continue throughout 2022, and we'll be seeking subleases in some cases or lease terminations and others. All in, our plan will reduce our domestic leased occupancy cost by a run rate of $180 million to $200 million in 2023, a big lever in the SG&A pillar. We are finalizing the plan over the next month. And to the extent any of this benefit is realized before 2023, we will outline that as we report the rest of the year. Because we have multiyear leases and with a modest assumption of sublet income, we expect to take a pretax charge this year in the Q2, Q3 time frame of $750 million to $800 million related to our leased real estate footprint. In addition, we expect to write-down the book value of our owned real estate in the zone of $750 million to $850 million as we look at our sunk costs and adjust the carrying value to represent market values as we sublease space in our owned buildings. These real estate-related write-downs will be presented outside of adjusted earnings in our results largely in Q2 and Q3 of 2022. To be clear, these write-downs do not interfere with ability to achieve the $0.50 capital pillar of the Value Creation Plan. The gross margin pillar of the Value Creation Plan includes margin expansion in Medicare Advantage. This year, thanks to outstanding growth in '21 and 2022, we currently have about $20 billion of Medicare Advantage revenue. Every 100 basis points of Medicare HBR improvement would yield $200 million of pretax margin. This is independent of margin expansion driven by SG&A improvement that is reflected in the SG&A pillar. The margin opportunity for Medicare is higher in 2023 and 2025 and beyond than in 2024 due to expected STAR rating fluctuations. We are maturing our execution around STAR measures today that we expect will bear fruit in 2025 and beyond. Similarly, our starting point for our Marketplace business, while much improved in 2022, is still not at our long-term pretax margin target. Every 100 basis points of Marketplace HBR improvement would yield approximately $130 million of pretax margin. This won't all be from pricing or benefit alterations, clinical initiatives, value-based contracting, member engagement above and beyond normal trend bending, will continue and contribute to the HBR improvements. And effective January 1, 2024, we expect the results of our PBM, RFP will be a major contributor to this middle pillar labeled gross margin. Finally, our third pillar, strategic use of capital, is expected to yield a run rate of at least $0.50 in adjusted EPS by August by 2024. The largest contributor -- in fact, the majority of the $0.50 is expected to be driven by share buyback with cash generated from operations over the next 2.5 years. The balance will be driven by: one, improved investment income as we better manage our portfolio in a raising -- rising rate environment; two, a reduction in interest expense as we delever a little in our continued pursuit of investment-grade ratings; and three, any net accretion from divestitures. On that topic, as Sarah mentioned, we were thrilled to find very good homes for 2 of our businesses, Magellan Rx and Panther. We expect to close Panther in Q3 and Magellan Rx by the end of 2022. As we announced, added together, the combined gross purchase price was $2.8 billion. We expect a net about $2.4 billion of cash after tax leakage and deal costs. This will be deployed for additional share repurchase and some debt pay down yielding a neutral to slightly accretive result to be counted toward the third pillar. Note that these business was -- these 2 businesses were accretive coming into Centene, and we're pleased to be able to preserve that accretion in our run rate. As a result of selling Panther at a meaningful gain, we expect to record an approximate $450 million pretax gain outside of adjusted earnings when the transaction closes. This will help to partially offset the real estate charges we covered earlier. Beyond the numbers, there is an operational benefit to simplification and zeroing in on the businesses we plan to invest in going forward. When you add the 3 pillars up to yield $2 of EPS, incremental to our original 2022 jump-off point of $5.40 of adjusted EPS, you get $7.40 per share. And we expect to have a higher revenue base in 2024 than when we started the Value Creation Plan, even after redeterminations to which we expect to yield an additional $0.10 to $0.35 per share. This results in the target 2024 adjusted EPS range of $7.50 to $7.75. While this is a couple of years out, it's important to rally around a targeted north star. And we took the midpoint of $7.62 and built that into our compensation programs as you can clearly see in our proxy. The team is focused and energized to deliver on not just the Value Creation Plan, but a strategy beyond 2024 that continues to enable us to seize the growth opportunities in managed care government programs. So for those of you who have jumped on the bus, we appreciate your support. For those of you who haven't, we still have a few seats. Thank you for your patience and interest, while we make Centene the best it can be. Let me now invite Sarah back up for closing remarks.

Thank you, Drew. Before we turn to Q&A, let me wrap up by underscoring a few points. First, our business is on track and performing well, fueled by focus and operating discipline. This momentum and stronger earnings in 2022 provide a solid foundation as we manage through redeterminations and other important market dynamics over the next few years. Second, we've made solid progress on our value creation program. There's clearly a lot of work ahead of us, but you should feel confident that this management team is committed to transparent execution. We told you what we're doing, and we're doing what we told you. That will not change. And finally, we are well underway in planning for our long-term strategy for 2025 and beyond. We believe we are positioned exactly where we need to be for growth. The health care landscape is evolving, and we are thinking ahead to ensure that we meet and exceed the needs of our members and providers today and in the future. Thank you. We'll begin Q&A in just a moment.

We're now pleased to take some questions. As a reminder, you can submit questions through the Ask a Question function on your screen. Let's start with something on redeterminations. This is a question from Justin Lake, multipart. Can you break down your redeterminations estimate in terms of how many members you added through year-end 2022 during PHE and how many you have -- you anticipate that you'll keep? That number you've given -- so a question is of those that you plan to keep, how much of that is from organic growths versus retention of members that came in via the PHE? And then does your estimate of retention now include Marketplace? If so, how many Marketplace kept? And if not, what is a reasonable estimate here of Marketplace retention?

All right. I think I'll take that one, and thank you, Justin, for allowing me to win the bet that redeterminations will be the first question asked. So let me step back and frame redeterminations as a whole, and then we'll get into -- you didn't specifically ask about sort of the MBR sort of examination and mix shift. But let me hit a number of topics relative to redeterminations, and hopefully, it will answer most, if not all, of your question. So first of all, as you heard in my script, we've had 3 million member growth since the onset of the pandemic, excluding some wins, such as North Carolina. We expect 1.7 million to 1.8 million of those members or that growth to be given back through redeterminations is about 58% at the midpoint of that growth, which represents $7 billion to $7.5 billion of revenue compared to the last time we got together, we earned about $6 billion, and there's been yet another extension of the PHE. And just remember, we just added $2 billion of revenue to our guidance, which was largely Medicaid in terms of revenue. So our estimates are based upon state by state really drilling down and discussing and doing our own research. We're not relying on the January Kaiser study or things that are published. We're relying on the discussions and the collaboration we have with each of our 29 states. As we think about HBR impact -- by the way, those numbers do not include any benefit we might get in the Marketplace business from the catcher's mitt. So we're talking just Medicaid right now. As we think about HBR impact, we have examined data by cohort. We've looked at a number of past experiences of mix shifts, which have happened for a number of reasons historically in our business. We focused on the zero utilizers as some of you have asked about. And just to give you some data on that, if we dissect CHIP, TANF and Medicaid expansion population separately and we look at the baseline in the 2018, 2019, you might say it's an unaffected baseline. CHIP is actually flat. The percentage of zero utilizers in our book over the last year flat to that baseline time period. Interestingly, Medicaid expansion is actually down. And that's going to be a cohort, which we think would have a higher proportion of Medicaid redeterminations. TANF is up a little bit. But overall, when we look at the data, not alarming. So we took another step, and we went to the 0% to 25% HBR cohort to take a look at that. And that is up slightly. But once again, when we run numbers around that and look at that slight increase and look at it -- in addition, in the context of the amount that we expect to be in the risk corridors and paybacks for this calendar year, not alarming whatsoever. We're going to be doing a lot of rate advocacy. We've got a data-driven approach. It's been successful over a long time period, and we've already enhanced our process in anticipation of redeterminations. We've already had discussions with state partners about potential acuity shifts. We're working with external actuaries. We developed a tool for each of our health plans to capture data in the first couple of months of redeterminations, so we can have those data-driven discussions with states. And it certainly helps that 88% of our membership in Medicaid is in states where based on our research, we think it will be at least 10 months of a duration of that slope line of redeterminations. So that should give us plenty of time to engage with states. And obviously, it helps to have a 29-state diversified footprint. So are we vigilant about redeterminations? Yes. Do we believe it will be manageable? Yes. Hopefully, that answers not only your question, Justin, but probably a couple of others in the queue.

I'm over here crossing the map. So Justin let us cover a lot of ground. That was excellent. We're going to stick with redeterminations for one more. This is a little bit more broad and sort of policy based around double coverage. This is a question from Calvin Sternick at JPMorgan. Can you talk about how states are going about the issue of figuring out how much overlap there is between Medicaid, commercial and marketplace? And how do you feel about your current visibility into that potential overlap in your own book? And then there's a bonus round, which is recognizing that all states are really dealing with this. Is there any chance for some sort of a standardization around how this gets done at a federal level?

Let me hit first on sort of the numbers. That's one of the reasons why we did that sort of zero utilizer analysis because the hypothesis out there is that there's a bunch of zero utilizers because they have duplicative coverage. And so I think the data indicated that it's not much. But -- how about, Kevin, on some of the policy elements?

Yes, I was just going to say that there is opportunity for standardization around outreach and identification of these new members. Some states are taking some very different approaches. We know that California, for example, has gotten an auto enrollment process. We've got some states, of course, are less aggressive. There are essentially 3 buckets of states with respect to outreach opportunities. But there's opportunity for standardization within those buckets. And we're working already collaboratively with those states in anticipation of how to standardize.

Perfect. Let's go on to Marketplace. This is a question from A.J. Rice. He's with Credit Suisse. With respect to the uncertainty around the enhanced subsidies on the Marketplace, will CMS allow you to offer 2 bids? One, assuming that subsidies are extended, and one assuming that they're not? And also for the 10% to 15% that could be at risk if the subsidies are not extended, how would their attrition impact the risk pool for Marketplace overall?

So our bid process, it's state by state, regulated state by state, yes, with CMS and [indiscernible] with the umbrella, but we are submitting bids based upon the law of the land. And we're thinking about that in our pricing decisions in terms of shifting risk pools as we look at 2023.

Yes, CMS does not -- is not allowing 2 bids per se. They recognize that every carrier is calculated 2 bids. They know that the state DOIs really can only handle one submission, understanding that if the [ ETCs ] are extended that the second bid, assuming that, would be filed.

Got it. We'll stick with Marketplace here. And this is a question from Gary Taylor, and he's with Cowen. Brent suggested that exchange enrollment could decline by 10% to 15% if enhanced subsidies expire. And this makes sense as a stand-alone dynamic. But with some Medicaid redetermination lives coming towards exchanges and the potential for family glitch enrollment, is it likely that overall ACA enrollment could be flat? And second part is the current 2023 low 6s EPS guidance materially sensitive to the extension of the enhanced APTCs.

I'll take maybe the EPS part of it. And once again, have Kevin opine. Kevin runs our Marketplace business. The low 6s, there's multiple ways to get to the low 6s, and I think we've said that a few times. And so yes, you've got potential opportunities, you have potential risks. And we weigh all of that as we look at all the methods that can get us through the low 6s. And while that is a toggle element, it's not one that would push us out of the low 6s. And quite frankly, we are assuming the law of the land as we forecast going forward.

Yes. I think you look at the loss of the tax credit, it's very seductive to think about this as being fairly linear and neutralizing. It's just a little bit more complicated than that, and it is for a couple of reasons. So first of all, if you look at the impact of the family glitch opportunity, and that is roughly 5.2 million members as it's been estimated by some think tanks and such. There's a couple of complications. So first of all, there's not an employer notification requirement. So there's no requirement by employers to actually notify employees of this new affordability option. Number 2 is the provision, the regulation, draft regulation is requiring the separate tests being made for both the individual and for the family. And that's just a complicating process that just makes this just a little bit more difficult and clunky for employees to actually go through the affordability calculation. So between awareness and then the clunkiness of the calculation, it's a little bit unclear what -- how much penetration of that 5 million people is going to result and how quickly that can be. The challenge of the tax credit loss is actually that this kind of thing cascades throughout the whole membership. And in the past, and you go back even to the Romney days, when there has been such things as Supreme Court challenges or repeal and replace or a policy or political changes, it just destabilizes the Marketplace because folks think that the coverage is either going to end, it won't, there will be some new complication or wrinkle that won't make them eligible. So it just has the risk of a destabilizing factor.

I would just add, I think to emphasize what Kevin said that this is one of the reasons why we've been hesitant to really size what we think the opportunity is around the catcher's mitt because not only are there macro plates shifting underneath, but there's this sort of cascading effect. So if you look at the law of the land today, we're running with an estimate of a couple few hundred thousand. But again, there are major shifting factors, assumptions around the family glitch, whether the PHE extends beyond the end of the year and then what happens with enhanced APTCs and what the market impacts are all of that plays into a shifting assumption. So -- and that's a number that we're going to have to give you more updates on as we get more clarity, but it's why the complexity of the environment is not to be understated.

Good level set. So now we'll do a few around the macro. This is a question from Dave Windley at Jefferies. How does the prospect of recession influence your expectations about, one, the eventuality of redeterminations; and two, the change in churn in your membership base?

Well, clearly, if you look at past recessions, and even -- I've looked at the '09-2010 time period a few days ago, that there has been a tick up in Medicaid. So that could be a softer landing for the redeterminations. We're not assuming that in our 1.7 million to 1.8 million members, but that could be an opportunity.

The one thing I would say is I think we've been talking about the fact that if we do move into a recessionary environment, this is probably the healthiest the state budgets have ever been going into that kind of environment. So that will obviously have an impact as well.

Great. So relative to 2023 targets, and thinking about the operating landscape for next year. This is, again, from Justin Lake at Wolfe. Does the 2023 EPS target assume the roll-off of APTCs and does the 10% to 15% market shrinkage apply to CNC as well given exposure to high-growth states like Florida and Texas?

Well, we haven't yet minted our 2023 budget in AOP, annual operating plan, but there are multiple forecasts that take us through the low 6s that have both APTCs in, APTCs out and the dozens and dozens of other assumptions as we are casting forward trend and growth and redetermination. So -- we are as confident as you can be this early on delivering our forecasted low 6s.

How about we do some Medicare Advantage? This next question is from Josh Raskin at Nephron. What are your views on Medicare Advantage in both '23 and '24? Are we entering a multiyear margin improvement period in that segment? Or will growth pause for 2023 and reaccelerate again in 2024?

Well, as you heard Brent cover, we expect to grow in '23 low to mid-single digits. And couple that with margin expansion, which we think is a pretty good combo. As I mentioned in my remarks, the margin opportunity is more so in '23 and 2025 and beyond in 2024 because we have dropping STAR ratings to contend with and think about sort of volume versus margin, a little bit more pressure in '24 in that isolated element. But we're optimistic about what we can do in '25 and beyond.

We're going to stick with Josh on this one, different topics. Again, from Josh at Nephron Research. It seems as though many new capability based and tech-enabled companies are at more attractive valuations. How does the opportunity for M&A impact your capital deployment plan and specifically, the acceleration of buybacks?

Yes, I can cover M&A. We, I think, have been very consistent that large-scale M&A is off the table, but we have not shut down the M&A pipeline. And as we look at the focus on the core business and where there are opportunities that are aligned to that, we think there are some interesting opportunities out there. It's really more of sort of a bolt-on, tuck-in and I think taking a more disciplined approach around accretion. When you think about the capability and technology companies, I agree we're getting to slightly more rational valuations, but I think our bias is still more to acquiring health plans. We're pretty good at acquiring health plans. And again, that's consistent with focus on the core business. As we think about those technology and innovation partners, I think our bias philosophically is to be the best partner and platform for those capabilities and to be the best integrator and disintegrator of both technology and innovation, not necessarily the owner of both.

Great. Thank you. This next question is from Mike Wiederhorn at Oppenheimer. What are you seeing with state budgets? And what are your comfort levels in light of the economy?

What we're seeing is stability. Right now, state governments, the budgets are stable. They're strong, and we see that continuing.

This next question comes from Nathan Rich at Goldman Sachs. With 2023 consensus EPS of $6.30, would guidance for 2023 EPS in the low 6s range capture that? What are the key moving pieces to the outlook next year, so headwinds and tailwinds? And how are you thinking about organic growth relative to the long-term guidance of $0.10 to $0.35 of EPS?

Well, hey, at least you guys are consistent with wanting next year's guidance already. And we've given low 6s. We actually made that declaration when consensus happened to be at $6.20, I will point out last December. So we don't have the exact range yet. We are formulating our game plan for next year. We're optimistic enough to be able to ratify low 6s as we sit here today. And we'll see how the next couple of quarters go and be glad to update you as soon as we publish internally and get approved by the Board our 2023 annual operating plan.

And then I would just add for long term, the strategic planning process that we're going through is really a buildup of what we know, the choices we want to make, and then that creates a view of a long-term growth algorithm. So you should expect to hear more about that December.

Sort of sticking with financials and thinking about the numbers and also some capital deployment, a question that we've gotten from a few places this morning through the platform is around investment-grade ratings. So maybe, Drew, you could talk to the intentions around investment grade and sort of what the debt paydown initiatives have in store for us relative to that?

Yes, we think -- and actually, if you look at spreads widening in this environment, we think it's important at our size and scale and with our diversification that we're an investment-grade company. We've got 1 out of the 3 rating agencies at investment grade. So we're working on that. We're committed to continuing to delever. We're -- I think we're only at 3.4x debt to EBITDA, and we're going to push that towards 3. But that won't chew up much of our capital as we grow EBITDA. So still committed absolutely to achieving investment grade. Next step would be 2 out of the 3. But we've also got the value creation plan to deliver on in the $0.50 of accretion in that third bucket, which will be driven by share repurchase, which we're committed to, as you saw this morning, and reducing debt saves interest expense. And then the rising rate environment on the asset side is a nice tailwind. We contemplated some of that in that $0.50, but -- it's going a little bit faster, I think, than we all predicted sitting here last year in terms of the Fed moving rates. And just sort of to think about the impact every 25 basis point move is about $0.025 for us given the asset side of our portfolio, net against our floating debt. So that's someone else's question I just answered.

But that's some good color, thank you. So this next one is really about utilization. I think at the core, this question comes from Dave Windley at Jefferies. Your 2Q update speaks to a favorable performance on exchange. 1Q MBR ran a little higher than consensus expectations, and that seemed to be Medicaid driven. Would you care to speak more specifically to Medicaid cost experience in 2Q and anything related to utilization?

Good question. Actually, Q1 was right on track, including our Medicaid HBR. So Medicare was actually as a whole was a little bit better, driven by PDP, thinking back to Q1. But what we're seeing so far in Q2, we've seen a slight uptick in COVID in May and June versus April, but we're not that concerned about that because it's still meaningfully down from the Omicron phase in Q1, and we powered through that pretty well. In non-COVID, we're seeing sort of movements in line with normal seasonality and pre-COVID movements, which is good. If you think about the resiliency of providers as each wave has progressed of COVID creates a more stable and sort of normal seasonality picture. So, so far, so good. We've only got 2 months out of the quarter under our belt and look forward to updating you. But Marketplace, given some updates on risk adjustment from 2021 and then looking at our current performance, we were able to increase guidance at this Investor Day.

Great. This next one we've touched on a little bit, but this is directly around risk pools. And this question comes from Kevin Fischbeck at Bank of America. The risk pool in the exchange is likely going to change dramatically in 2023 with subsidized members dropping off and Medicaid redeterminations adding. How are you thinking about the impact of the risk pool and your ability to appropriately price in 2023?

Well, the good news is, while we can't perfectly predict the future, we knew the toggle points, including enhanced APTCs. And we, once again, are pricing to the law of the land there. So we thought about all of those elements as well as maintaining competitiveness and wanting to advance margins. So we're balancing a lot of things. The good news is we've also ramped up, as you heard Brent talk to last quarter or last Investor Day. The execution around clinical initiatives in the Marketplace business, some of the things that we've been doing in Medicaid and even Medicare Advantage for a while, stepping up our game in Marketplace so that we could create sort of that trend bend in capacity as we think about balancing those things.

All right. We're back to Medicare. This is a question from Scott Fidel at Stephens. Given the 18-plus percent MA enrollment growth year-to-date, can you discuss expected pretax margins for MA in 2022? And then how much margin improvement in MA do you think you can achieve in 2023 as you focus on margin improvement for your MA bids?

Well, the answer on 2022 margins is not enough, but they weren't priced for margin. We're priced for stability in HBR from 2021 to 2022, and that is holding firm. So -- and that's what our guidance for '22 is predicated on. So thrilled to have the execution. Maybe I'll ask Brent to comment on sort of just the operational reasons why we're doing well in Medicare Advantage. And looking at next year, thinking that we can both expand margin as well as continuing to grow at least in the low to mid-single digits for 2023. Brent?

Well, for 2023, number one, like you said, it would be our bid process, how we approached it. At the same time, it always helps that CMS has fair rates from that standpoint. Our focus on clinical initiatives and really our acceleration and value-based. And I spoke a lot about that, whether it's caid or care, we're focused very strongly on value-based. And those together gives us great -- really great hope for 2023.

We're going to stick with Medicare for a moment here. This next one is from Matt Borsch, and he's sort of discussing the same dynamics around sort of headwinds to MA growth as we work towards margin expansion, and to improve STAR scores. And so I think this is maybe a good opportunity to talk a little bit more about what we're doing in STARS and some of those specific initiatives. And he comes from BMO Capital Markets.

And I'll let Jim speak to this because his team is working on it day in and day out. But maybe just to sort of frame 2 of the major actions that we took earlier this year to move the performance in STARS as we look at 2025. The first was to centralize the quality program. And so for a little bit of history, when Centene purchased WellCare, we more than tripled our MA membership, and we brought 2 independent quality departments together. One, Centene's, it was operating in a more decentralized fashion, and then WellCare's was operating in a more centralized fashion. So we brought those together and then started to push them into a decentralized model because that was Centene's strategy at the time. And the reality is you can't run a quality program at the enterprise scale that we have in a decentralized fashion. So one of the things that's been really great about the value creation program is the opportunity to bring that program back together at the enterprise level. It allows us to pool talent. It allows us to pool best practices, to bring systems together and then pool funding. So we're prioritizing the right investments for improvement. So that was a major structural change that we undertook right at the beginning of the year. And then the other thing that we did, I think, was really important to recognize how critical quality is for the entire organization was that we baked it into the short-term incentive goals for the entire organization, top to bottom, for 2022. So those are 2 early moves that we made, but there's a lot more behind that. So I'll let Jim weigh in.

Sure. Building on Sarah's remarks, the ability to watch all of what's happening day-to-day is critically important. So the oversight and the governance of our activities is really important for this improvement. Recalling the slide, some of the things that were mentioned on the slide is our attempts to try to get the members to understand their benefits better. Lots of things around welcome calls and getting to the members a lot faster to explain how they activate their benefits will have a positive impact going forward. We also learned from some member surveys, and what have you, that we needed to improve some of the material that we provided to them at the time of their enrollment. Other things that we've focused on are a lot of workflow changes in the appeals area as well as technology and appeals to try to improve the workflow so that we could identify things more timely because timeliness is obviously very important in appeals. We've implemented ADT feeds to get data a lot faster so that we can figure out where we were with HEDIS on a regular basis. Some of the -- some of my past -- I like to see things daily. And so we're trying to move towards that kind of a real-time environment. And then another thing that was really important was -- and Brent talked a lot about value-based. We've got a lot of providers that are moving into a value-based model. And helping them to get the [ reporting ] tools to show them what's happening so that they could help us to drive some of the results that will drive our STAR scores was critically important, and we're in the process of doing that. And we're also incentivizing them to get their focus and change their behavior. So lots of things going on. More to come, but we feel pretty good about the progress we've made so far.

Lot of good work going on there. And a great segue for our next question here that also comes from Dave Windley at Jefferies. CNC is partnering in its value-based approach. Sarah also emphasized health care being more local. The value-based provider platform companies are trying to apply a standardized model regionally, if not nationally. What's the best way for Centene to pursue value-based strategies with a hyper-local approach?

Maybe I can sort of frame it and then Brent should weigh in on this because this is bread and butter for his team. So as we think about our -- broadly our provider strategy, it is going to look different from others because our membership base is different. So we have almost 70% of our members in Medicaid, as you all know. And the largest provider for Medicaid are the federally qualified health centers, and you can't just go buy FQHCs. So we contract with more than 1,700 FQHC sites across the country. And we think of that as an example of a very stable network that we need to think about how to enable, not how to own. And so there's a lot of thinking there around sort of the local approach, but also a value-based model that fits in an FQHC and a predominantly Medicaid context. And then more broadly, as we think about sort of how we line up to providers, for us, it's going to be a market-by-market buildup as everything that we do is to get to that sort of national portfolio. And we fully expect that there will be some markets where we want to build or buy, CMD in South Florida is a great example of that, or others where we want to pursue innovative partnerships or enablement models. And so that longer-term provider strategy work is providing a framework, but we have a lot of really good data from what we're already doing today that we're fitting into that. And so that's where Brent, the expert.

So we're value based in Medicaid and a generic standardized way is very difficult. It's called being local and having relationships and look, we've been in the Medicaid assistance since 1984. We've been doing some version of capitation to a lesser amount before the pandemic before that, and that's having enough relationship and communication with our providers to be able to do that. Since the pandemic, conversations and then ultimately negotiations and then actually contracts have accelerated from that standpoint and we see just as Sarah was alluding to with federally qualified health centers. We're seeing it with health systems. We're seeing it with very large group practices and even some smaller group practices. The discussion has changed dramatically, but it really is about relationships. It is about being local and knowing the different parts of a community, and the type of risk pools they have, realizing that TANF and [indiscernible] is different, that [ LTSS ] different. All these things matter when you try to move toward value-based within Medicaid.

It's an important dynamic for us. Thank you, everyone. So we have time for one last question. And this question is going to come from Lance Wilkes at Bernstein. On the PBM recontracting, when does the existing contract end? How long would migration take? And could you begin to see benefits in 2023 if an existing vendor is selected as your future vendor?

Yes. So I can take a stab at some of this, and Drew should weigh in as well. So the current contract ends 12/31/23. And the goal is part of why we both released the RFP a little bit early was to give us time for what has turned out to be very robust interest and engagement and to then award that by the end of this year, so we have a full 12 months to do the migration, if that's what happens. And so certainly, there is always theoretically the possibility that we could stay with the current partner and potentially bring those savings in. But as we continue to say, and I think we are seeing play out, there's nothing like a good old-fashioned RFP. And we're seeing a lot of innovation and good thought around partnership, and that includes not just economics, but the level of transparency, the level of quality, operating excellence, making sure that we've got folks who are thinking about how to interact with our members and providers in the best possible way. And what are some of the different ways that we could partner that are different than we have in the past. And so overall, I think we're finding it to be a really productive process. We'll obviously continue to share updates. And I think it's also just a really good example of how the kind of discipline that we're taking to the value creation work today will set us up with the right partners for our long-term strategy.

I could not have said it better myself. So I think it's a great way to end. That is a huge opportunity in that middle bucket. And thank you for joining us today.

Yes. Thank you for all the questions. We look forward to seeing everybody in December, if not before.

Thanks, everyone, for joining us today, and for all of your thoughtful questions. If anyone has any additional follow-ups, please feel free to reach out.