InnovAge Holding Corp. (INNV) Earnings Call Transcript & Summary

All right. Good morning, everybody. We're going to go ahead and get started with our program this morning. For those of you in the room, thank you very much for attending. And for those attending virtually, thank you for taking the time today and for your interest in our company. We'll start off with a couple of housekeeping items really quick. For those on the virtual platform, you can submit Q&A directly through the system underneath the viewer, and you can do that any time during the presentation today. For live audience, you'll have the opportunity for Q&A at the conclusion of our prepared remarks. I'm going to jump to our cautionary language. During today's presentation, we will refer to certain non-GAAP measures. A reconciliation of those measures to the most directly comparable GAAP measures can be found in the appendix of this presentation. We'll also be making forward-looking statements. I'll pause here briefly for the forward-looking statements. And we will post today's presentation on the company's Investor Relations website, and we've also filed the presentation with the SEC. For those listening to the rebroadcast of this presentation, we remind you that the remarks made herein are as of today, Tuesday, February 27, 2024, and have not been updated subsequent to this presentation. And with that, we thank you once again, and welcome Patrick Blair to the stage. Patrick?

Thank you very much, Ryan. Good morning, everyone. Welcome to those of you who have joined us in New York City and to those who are joining by the live webcast. We really appreciate everyone taking the time to hear our story. We think we've got a great story to tell you today. This is the company's first Investor Day, and we're very excited to reintroduce the company to some of you and to introduce the company for the first time to many of you here in the room and joining us by the webcast. I think our goal today is to give you a better sense of what we do, the people that we serve, the unique model we use to deliver high-quality care at a lower cost. And I think more important than anything, deliver a great patient experience and the secondary goal of mine is to give you exposure to some of our talented leaders. We have a few with us here today. So let me start by reviewing the agenda. I'll get us kicked off by providing an overview of the company, why we believe we have a strong investment thesis, how we're different than other value-based care models and why now is a unique inflection point in the company's history, given the internal transformation over the last 2 years. I'm going to be followed by Rich Feifer -- Dr. Rich Feifer, our Chief Medical Officer. Rich is going to be pinch hitting for Chris Bent, our Chief Operating Officer, who is sick and couldn't fly today. And he'll cover the people that we serve in a little bit greater detail, our operational capabilities, our operating [ model ] capabilities, our operating model and our best-in-class technology. And then Rich will continue and go deeper into our clinical model and give you a sense of how we provide the care that we do that's so important. We're going to take a 15-minute break after that. And then we're going to start with Matt Huray, our Chief Strategy and Corporate Development Officer; and Rob Borella, our Chief Sales and Marketing Officer. And they're going to walk you through our multipronged growth strategy. The two of them are kind of brothers in arms as it were as it relates to our growth strategy. And then Ben Adams, our Chief Financial Officer, is going to review our financial performance and provide you with some details on some of the key economic drivers for the business, and then we're going to conclude with the Q&A. But before we get started, let me just spend a moment on my background and what attracted me to InnovAge. It's been just over 2 years since I joined the company, and I'm genuinely proud and excited to be here. This is a special day and sort of the history of the company with the first Investor Day. And I've spent the last 20-plus years leading -- with leading government-sponsored and commercial health plans like Amerigroup, who is now part of Elevance, and BAYADA, which is one of the nation's largest home health care providers. These experiences have given me many opportunities to work closely with all of the stakeholders that InnovAge has, including Federal and state officials, frail seniors, community-based organizations, providers and investors. And I'm here for the same reason that I think most people join companies like InnovAge and that's to have a transformational impact on people's lives and to live professionally and embrace the doctrine of doing well by doing good. I really think that's -- there's no better model in health care, I think that to do that. So let's jump into the slides. There are 5 key components to our investment thesis, and I believe these are the reasons to have confidence in the company and in its future. The first is our business is focused on a largely untapped and growing market aimed at helping seniors live independently. That is what we do is we help people stay in their homes and out of nursing homes. That is our business. And this is increasingly important as more nursing homes have closed. With fewer nursing home beds, the need for alternatives is growing quickly, and we find pace at the forefront of this opportunity. And regardless of which side of the aisle you're on politically, PACE is universally viewed as a proven model to deal with the challenges of helping people live independently. That's our focus, and that's our market. When you think of the market, it's important to note that we're talking about seniors who are now 75 to 80 years old. The group reflects the leading edge of the baby boomers who are some of the early movers into Medicare Advantage 10 to 15 years ago. Many of these individuals now require a very different level of care than they did when they joined Medicare Advantage. Second, no other value-based care model controls more of the health care premium dollar than PACE. We're at full risk for Medicare and Medicaid long-term care services and our premium can top $9,000 per participant per month. This puts us in a very unique and differentiated position to truly impact the cost of care and quality along the full continuum of care. To put a finer point on this, our direct employees deliver roughly 30% of the total cost of care and are also able to coordinate directly or indirectly, much of the remaining 70%. Third, we're the largest PACE program nationally by census, and we operate in 6 diverse states. And these states represent roughly 30% of the country's dual eligibles. We've created a repeatable and scalable platform of people, processes and technology that not only allow us to deliver high quality in each of our geographies, but we've also built a foundation of payer capabilities that enable us to better manage capitated risk and improve economic performance. You'll hear Rich talk about this notion that we sort of set the intersection of being both a provider of care and a payer of care. Fourth, most of the platform investments are behind us. And that has two implications. First, we see a path forward with very efficient growth and margin expansion as we fill the existing center capacity and drive the center level margin targets of 20-plus percent. And second, with a pipeline of new centers under development, this creates visibility to future top line growth and embedded earnings as those centers mature. And lastly, we've assembled a great management team, and you'll get exposure to some of them today and have a deep bench beyond the folks in this room that can grow and scale the business in a responsible and compliant way. So let's look at the company at the glance. For those of you that are unfamiliar with what we do, we coordinate and provide preventative care, primary care, acute care and long-term services and supports to an underserved senior with complex medical needs who without those services would be at risk of entering a nursing home. Care for our participants is delivered by an interdisciplinary team in our centers and through a contracted network of hospitals, specialists, ancillary providers, who we work with to improve quality, lower hospitalizations, reduce skilled nursing stays and keep people out of long-term care facilities. Rich is going to go into more detail on the team and how we operate. Today, we operate 19 centers in 6 states with 3 centers under development. We had approximately 2,100 employees serving nearly 7,000 participants as of December 1, 2023. And because of the larger risk-based premium we receive each month, a small number of participants can equate to more than $700 million in revenue. On the far right are the targets we set for ourselves this fiscal year, which ends June 30. We reaffirm these targets on our second quarter earnings call earlier this month. When you think of our value proposition, we really do believe we have a value proposition that resonates with each of our key stakeholders. For participants, they get to age safely in their homes and in the community and avoid a high-cost nursing facility. Government payers are able to rebalance long-term care to a community-based approach rather than toward nursing facilities, and they benefit from the fiscal predictability of a capitated program. For physicians, PACE is the ideal model of care, which most closely reflects the training they received. They have interprofessional team-based care. We have small panel sizes and increased time spent with patients. We have rewards for quality over quantity. There's an independence from the burdens of managed care and the robust internal resources that ensure that care plans are delivered as intended between visits with physicians, and families have much less stress and a meaningfully reduced burden on their time as a caregiver. By coordinating and personalizing the care for each patient, we drive improved quality, better outcomes and lower total cost of care. We're a center-based model for a good reason. Through regular center attendance, we have active line of sight into the health status of our participants, which helps us to catch potential issues early and before they revert to a costly ER visit or a subsequent hospitalization. We believe PACE represents the gold standard in community-based care and has an advantage over other traditional managed care models who are often forced to coordinate care at an arm's length. We're not only coordinating all the care, but we're also delivering approximately 1/3 of the care in our centers. And you can see that we're effective at reducing ER visits, hospital admissions and falls while achieving high levels participant satisfaction. But I think most importantly, we can forestall or avoid transitions to a permanent nursing facility. Moving to the market. I think we all know the stats so I won't repeat them. But government programs are massive, and they're growing. The U.S. is spending more than $1 trillion on Medicare and Medicaid. We know that the cost is unsustainable. And we know that patients are often dissatisfied with the care that they receive. We believe there's a large market opportunity for organizations like ours that can deliver a comprehensive win-win solution to these challenges. Looking at the left-hand of the slide, you can see there are nearly 13 million people who are duly eligible and the market size is greater than $500 billion. This is the intersection in which we operate. When you apply the PACE nursing home level of care eligibility requirement to the 13 million dual eligibles, we estimate there are more than 2 -- we estimate there are more than 2 million dual eligibles, representing a market greater than $235 billion with fewer than 75,000 individuals enrolled in PACE today. I'll touch on some of the possible reasons for this low penetration in a moment. On the right-hand side, you can see how PACE enrollment has grown since 2015 and the growth that is projected by 2028 as stakeholders begin to more thoroughly embrace paces of solution to high-cost nursing home care. Once stakeholders understand what we do and understand the size of the market that we're serving, the question we often get is why this amazing program isn't serving more seniors. Well, like most things in health care, there's often a lot of interrelated factors. On the left hand of the slide are a few historical barriers that we believe have impacted the growth of PACE. First, it wasn't until the PACE Innovation Act was signed into law by President Obama in 2015 that PACE programs could operate as a for-profit organization. Until this law passed, PACE was comprised primarily a small nonprofit organizations operating in a single or a limited number of geographies. And because of the requirement for a physical center, many of the smaller programs just haven't had the infrastructure and resources, including the capital and investment and staff to expand into new service areas. And at the same time, CMS and state governments, they've been busy. For the last 20 years, they've been focused on launching new programs that improve coverage for not thousands of Americans but for millions of Americans. I think Medicare Advantage, the health exchanges, Medicaid managed care. And this has likely crowded out the attention devoted to the PACE expansion. Moving to the right-hand side of the slide. Since 2016, we've seen an increase in the number of for-profit entrants with a capital commitment necessary to achieve national scale. The demographics are also working to the advantage of PACE. The front end of the baby boomers is now approaching the average age of a PACE participant, which is about 77. We believe this population will require a more intense coordinated, community-based geriatric model of care that fully integrates Medicare and Medicaid services like we do. Lastly, the COVID-19 pandemic has thrust pace into the spotlight. PACE programs across the country successfully met the needs of frail seniors and their caregivers when compared to nursing homes. Infection rates were lower. Fatalities were lower, and participants continue to get the services they needed. PACE's response during COVID-19 has put PACE on the radar of lawmakers and regulators, and we believe this will be a catalyst for continued growth. Now let's look at how an individual becomes eligible for PACE. I think this is a question that many seek to understand, and we'll refer to an individual by the name of Deborah in our example, starting on the left. Many PACE participants have had experience with commercial insurance, but have also been uninsured and many have cycled on and off Medicaid throughout their lives. In this case, we'll assume that Deborah became Medicare eligible when she turned 65 Let's also assume her savings is small and her income is limited to just her monthly social security check. After some time on Medicare, Deborah experiences the onset of diabetes, pulmonary disease and dementia, which leads to frequent hospitalizations and several post-acute skilled nursing days. While Medicare does cover these episodes, Deborah's share of cost exceeds her monthly income and she begins dipping into her savings to pay the bills. Ultimately, Deborah's health conditions and expenses deplete her assets and threaten her ability to live independently without support. Regrettably, but thankfully, Deborah's deteriorating financial situation has qualified her for Medicaid, which now becomes responsible for her Medicare cost sharing. This stabilizes our financial situation for a while, but multiple chronic diseases are taking a toll on her functionality and she's becoming increasingly challenged with activities of daily living, such as bathing and showering. Deborah's challenges eventually make her eligible for additional Medicaid services like personal attendant care in the home. Again, this addresses Deborah's needs for a time, but our independence is still at risk. And based on the pattern of her increasing needs, the State then performs a detailed assessment of her physical and social circumstances and determines that without more intensive long-term care, services and supports, Deborah is at risk for nursing home placement. But that would require disrupting her entire life, giving up her home and moving permanently into a nursing facility in another community potentially. It's at this point, that Deborah investigates her options and finds PACE. And Deborah story frankly reflects most of who we serve. And it's just a tremendous rewarding experience to be in a position to help someone avoid the disruption that's often required for someone that goes into a nursing facility. You can imagine that we get a lot of questions that attempt to draw comparisons between the Medicare Advantage programs and PACE. PACE and MA are similar and that both have programs that serve dual eligibles. They take a monthly capitated payment and they are responsible for the care that participants receive. While both programs can be characterized as integrated care, there are some significant differences. Medicare programs essentially cover physician, hospital and pharmacy care. Medicaid programs cover a long list of long-term services and supports. But the cost PACE participants meet the state's clinical requirements to receive nursing home care, which means they've been assessed in our risk of institutionalization, if they don't receive a more comprehensive care in the whole model, they're going to go into a nursing home. PACE benefits include all Medicare and Medicaid benefits in one integrated program. And it's the most robust set of services of any government-sponsored health care program. Now this page is a little busy, but it's worth a time to walk through it because it reveals some important takeaways. Let's get anchored on the [ axis ] and what the numbers in the 9 boxes mean and this data reflects a sample of our enrollment from the fall. The X and Y axis refer to Medicare and Medicaid health coverage that our participants had before joining InnovAge. So if you take the top left box, which shows 13%, this tells us that 13% of the people who enrolled had both a Medicare Advantage plan and a Medicaid long-term care plan before joining InnovAge. If we drop down to the center box, it says that 17% of the people joined from Medicare fee-for-service and Medicaid fee-for-service. Now that we're oriented, what does this tell us? Well, first, it tells us that 42% of participants are coming from an MA plan. See the boxes in the first column. Those all represent individuals that selected InnovAge from a Medicare Advantage plan. Second, it tells us that about 30% come to us from either a Medicare fee-for-service option or a Medicaid fee-for-service option. Third, it tells us that more than half our participants are coming to us with no Medicaid, and we're helping them enroll Medicaid as part of the PACE enrollment process illustrated by the boxes in the bottom row. The data tells us we're attracting participants from a variety of prior Medicare and Medicaid coverages and that we're offering something that's truly unique and different. The data also is telling us that PACE is a gateway to getting Medicaid for individuals who may have fallen through the cracks. In summary, our data suggests that PACE is an attractive option for people whose needs aren't being met in Medicare Advantage or managed care, managed long-term care or fee-for-service coverage. And we believe this number will continue to grow rapidly. This supports my comments on the earlier investment highlights slide that is if the Medicare Advantage population becomes more aged and frailer the traditional Medicare Advantage model of care may fall short for some seniors who need a more comprehensive integrated product. And lastly, each of these boxes individually represent a large and growing market opportunity. Now let's talk about the team. I'm really proud of the team that we've assembled here. The entire team is new to the company in the last 2-plus years. And we've been very deliberate ensuring that we have the right leaders in the big jobs. This is the team with a background and experiences necessary to run a company several times the size we are today. And every one of these leaders is getting their hands dirty in the field with all of our centers on a daily basis. It's a team with carrying hearts and a mindset for responsible growth. And this is just the executive leadership team. We're equally proud of the bench we've built 1, 2, 3 layers below this group. And on the next slide, you can see our leadership team is supported by a world -- leadership team is supported by a world-class Board of Directors. Just as we developed a purpose-built management team, we've also developed a purpose-built, high-performance Board. The Board composition is intentionally deep in specific areas to reflect InnovAge's business from payer to provider, government to public company expertise, we greatly value the guidance, leadership and partnership with our Board. There is very little this Board hasn't seen when it comes to InnovAge's business. Jim Carlson and Richard Zoretic were colleagues of mine at Amerigroup. Amerigroup, as many of you know, is a public company that grew dramatically in the early 2000s. It was purchased by Elevance in December 2012. Their insights and those of other board members with experience growing, high growth businesses in this sector have been very valuable to us and the leadership team. And I can't say enough about the Board's working relationship with management. We could not be better supported and represented by this Board. Now my last slide to close this out here. Starting on the left-hand of the slide, the last 2 years have been very important to us. We used the time to strengthen the foundation across every facet of the business. We have meaningfully upgraded talent across the organization and added 3 independent directors to the Board. We expanded our compliance program to help us deliver compliant care every day at every center. We closed critical people, process and technology gaps in our centers. We laid the foundation for new payer capabilities to help us manage medical costs. We invested in tools and technologies, notably a custom instance of the Epic EMR, which Rich will touch on, which we've rolled out across all of our centers. We strengthened our relationships with regulators at both the Federal and state level. And to be clear, we've been working through a unique transitional period for the last 2 years. So looking ahead, if we can just execute in the next 2 years, like we've executed in the last 2 years, we're confident that we can deliver on the long-term goals for the company. We've done a lot of hard work, and we made the down payment to ensure that we have an enrollment playbook to drive consistent growth with a focus on filling our existing centers, scalable technology, processes and operating model to support the scaling of the business. Best-in-class payer capabilities to address unnecessary utilization and emerging cost trends, a pipeline of de novo centers under development to create long-term embedded earnings. M&A execution, integration expertise to further supplement our organic growth plan and the center capacity to support higher marginal profitability as we grow. So with that, I think you've heard enough from me. So I'll hand it over to my colleague, Rich, who will share a little more about himself and our operating and clinical models.

Thank you, Patrick, and welcome, everyone. Let me introduce myself briefly. I'm Rich Feifer, I'm the Chief Medical Officer at InnovAge. I am an internal medicine physician with experience in geriatric medicine, population health and value-based payment models, having practiced in some of the earliest and most respected staff model HMOs. In my career, my NorthStar has been the quadruple [indiscernible] health care quality, patient experience, cost reduction and clinician well-being. And nowhere in health care, is that more important than in the care of frail seniors those that we serve. I joined InnovAge about 18 months ago because PACE is the solution to so much of what challenges the health care system today. And InnovAge is committed to driving the expansion of PACE nationally. PACE is the alternative to institutional care, which is what most patients and families don't want. PACE is the way highly coordinated geriatric medicine is meant to be delivered, and PACE is the most efficient way to deliver complex care for the frail of seniors. So I'm going to start off by talking about our operating platform. Then I'll describe what makes our care model so unique and valuable. And then I'll turn to our payer capabilities. InnovAge, as you heard, serves a more complex population than traditional value-based primary care providers and payment models. I'd like to make it real for you. Let's contrast a PACE participant to a typical Medicare Advantage plan member. So picture a TV ad. We just went through open enrollment, right? Let's picture a TV ad of traditional value-based Medicare program participant. Let's picture a young senior named Mary. She's coming back from a workout. She's in her workout gear. She's drinking a smoothie, right? And she's talking to her new girlfriend, asking if they made their appointments yet for their dental care, which they got with their 0 premium plan. She's active. She's vibrant. She is healthy overall. This is the profile on the left side of the screen. We know that all too well. Now let's move to the right side of the screen. Let's talk about Deborah. Deborah is the participant, the patient who Patrick described just a moment ago. Deborah has multiple medical conditions impacting her daily life. She needs help getting dressed. She needs help taking a bath. She comes to the center once a week, and she sits with a group of PACE friends. She socializes. She chats about the day's events. She participates in activities. One of them gets wheeled to the dental suite to have their dentures fitted right there on the spot. Another one gets up to walk around the center via the wonder loop to get some exercise and the third, just developed a new cough that morning is able to be triaged and seen in the clinic within an hour. Compared to Medicare Advantage, our participants are significantly more complex and the benefit from our higher touch model. As Patrick also mentioned, InnovAge is uniquely positioned at the intersection between being a provider and a payer, and the PACE model requires excellence in both. As a provider, we are a fully integrated care team, delivering care in the center and in the community and as a payer, we have to manage the total cost of care, including supportive housing. This combination of being a provider and taking full risk for Medicare and Medicaid services, this positions us in PACE as an excellence and an aligned partner with Federal and state programs, it's at this intersection that we can uniquely identify and drive value, reducing unnecessary utilization and waste that's all too common in the health care system. So let me tell you a little bit about our centers themselves, their purpose-built to address a broad range of physical and social needs within a single visit. Our centers are the nexus of holistic, coordinated program and the defining feature of PACE, they're part of what makes PACE special. They offer one-stop shop for physical care and social and community interaction. And this is very important for our population, which is at risk of isolation. Other competing primary care models, they outsource much more of their care. But for us, the center is the hub, we spend 30% of our capitated revenue. The remaining care provided outside the centers. The remaining 70% is discussed every single day from our IDT or disciplinary team meetings to ensure that the best experience is delivered to our participants and the outcomes are delivered at the lowest cost possible. So we have, as you heard before, 19 centers today in 6 states. Our average square feet is 28,000. The average capacity is 750 and our average center visits per participant per month is 4 visits. So put that all together, and the capacity at our existing centers and those in development is [ 16.300 ] or 2.4x our current census. To accelerate the transformation that Patrick described earlier, we've been investing a lot in our people, processes and tools to deliver a better experience for participants, employees and for our government partners. We've intentionally filled our center positions. We have a full complement of IDT members plus support services, scheduling, medical records, transportation. We've instilled in our center leadership and owner's mindset and a caregiver's heart. We've created dashboards to meaningfully track metrics weekly, so we can course correct and ensure goal achievement. And our center leadership model, it involves a triad, medical, nursing and operations working together that I'll describe in just a moment. We use our 5-pillar framework to drive accountability for results at all levels of the organization. Our triad leaders, they're accountable for the outcomes in the 5-pillar framework that's grounded in compliance with metrics across each pillar. This is the visual of our 5 pillars, people, service, quality, growth and financials. And we're intentional about starting with the people first and ending with financials. It's our phenomenal people. They are the ones who deliver the care and the services to our participants. And as Patrick said, this is truly a model where you can do well by doing good. When we execute consistently on the first 3, growth and financials follow. So as a team, we track key quality indicators on daily, weekly and monthly basis, so we can identify hotspots early, and course correct when we need to. We've adopted a continuous performance improvement mindset. And this is all grounded in trusting relationships and a growth mindset where we can bring our best game and challenge each other and align around best outcomes for those we serve. Our gold standard is the care that we want for -- is the care that we want for a family member, for our loved ones, and we work tirelessly to deliver that. I mentioned a moment ago, we used a triad leadership model to deliver strong operational and clinical performance that includes medical, nursing and operations. We fully implemented this model regionally at the center level as well as the national level where accountabilities defined by role. We've elevated top existing talent where we've had wonderful talent to elevate. And in other cases, we brought in wonderful people from the outside, so that we've staffed up all of our centers with great triads. Along with this new leadership model, we've clearly defined what success looks like along with corresponding KPIs. And the benefits are enhanced communication through regular touch points daily and weekly, better decision-making with a full complement of voice is heard at the table, improved participant care with each leader driving toward a shared balance scorecard and ultimately, cost savings by the team working together to solution for challenges. The triad model is in place throughout the organization, as you see here. It's built upon the principles of collaboration and shared accountability. The members of the Triad work to see issues through each other's eyes enabling challenging issues to be addressed through consensus. Solutions are identified quickly and implemented through influence, communication and joint decision-making. So the triad members, again, we have the Operations Lead, the Center Director who's responsible for the P&L of each center. The Medical Director responsible for overall medical care and the Nursing Director running the clinic, leading condition management and care coordination. All other enterprise functions throughout InnovAge. They exist in various ways to support the triads and to support the center bringing tools, technologies and processes to reduce the administrative burden on the centers. As you also heard from Patrick, we run our business on a single electronic health record. This is the key element of our operating model as we consolidated from 3 EHRs down to 1 in 2023. And so all of our existing centers are on the same version of Epic right now, which we custom built. This is the first ever pay specific instance of Epic. This slide reflects some key capabilities that Epic offers to us. And let me specifically call your attention to a few. This score capture is very important. I'll discuss later. Care Coordination, critical analytics, these are best-in-class. And we're also expanding the use of Epic's patient and family engagement capabilities through my chart as an additional way to stay connected with our participants. Why does this matter? It matters because having a best-in-class EHR is foundational to deliver population health to a group as needy as ours. So I'm going to turn it next to our clinical model. But after -- first, I want to turn to a video, excuse me, I want to turn to a video that's going to give some color to how we delivery care in our centers. And as you watch this video, bear in mind, these are not actors. These are actual InnovAge participants, doctors and caregivers that you'll be seeing. So please enjoy that. [Presentation]

It's hard not to be in touch by that. Isn't it? probably most of us have loved ones who have different needs, increasing needs as they're getting older and isn't that what we want for them. So I enjoy watching that every time. But let me turn next to our clinical model. I'll go a little bit deeper for you. So our population, as we heard earlier, is sicker with more severe disease and multiple comorbidities. They have -- this is not your typical Medicare Advantage population, right? They have more than 10 chronic conditions, 12 medications on average, experience impairments of more than 2 activities of daily living like getting dressed or preparing meals and things like that. And by definition, our participants meet State criteria for being in a nursing already. They could be in a nursing home right now. And that's why so many of our patients are participants. If they did not have access to PACE, they, in fact, would be in the nursing home or they move in so much sooner. And even though our age distribution extends across the spectrum, as you can see here, PACE participants are far more complex with greater needs for care and support. These are the reasons why our risk score is so different from traditional Medicare. Our risk score is 2.42 most recently compared to 1.08. And to serve the needs of this highly complex population, our patients, our participants are seen much more frequently than other care models an average of 4 center visits a month and an average of 10 or more touch points with different members of the care team, including in the home per month. And we employ a much more comprehensive care team than traditional primary care practice. When I was in a traditional primary care practice, it was a capitated practice, but it was in a community this primary care setting. That was many years ago. The practice had PCPs and nurses. And that's it. We referred people out and you need other forms of care and other support from the care team. But in PACE, that's in one site. It's an integrated model. That's why, as Patrick mentioned earlier, 30% of our health care spend is delivered by our integrated team rather than the 5% that's typical of a primary care practice. And this intense team-based care is by the 11-person IDT, the interdisciplinary care team that collaborates daily to support participant needs, tailoring care planning to each individual. And what makes our care plan different from other model -- our care plan different from other models of capitated senior care is this concierge practice model. Our team's responsibility is to tailor the care plan to each participant's unique needs rather than trying to apply generic guidelines or care pathways that are common elsewhere in the health care system. IDTs are also responsible for identifying and addressing social determinants of health without the constraints seen in other parts of the health care system. For example, if a participant has issues with nutrition that's impacting their health, food and security, we can really address that by whatever means we need to. So let me highlight some of the IDT roles in just a little bit more detail, the PCP and the RN naturally manage medical care. The home care coordinator ensures in-home nursing and personal care needs are met. The physical and occupational therapists, they optimize functional ability and work to reduce the risk of falls, which is very important in this population, and I'll come back to that. We have master's level social workers in all of our centers identifying and addressing the psychosocial determinants of health. And very importantly we have a driver as part of that IDT and part of that care team. The driver helps participants to and from vehicles on both ends, transports them to the Day Center and to all of their outside appointments. And when things might not be going right, it's sometimes a driver who first identifies the issue and brings it to the attention of the team. Elsewhere in health care, you might be fortunate enough to find these 11 roles when you need them in the care of frail seniors. But what makes PACE special is that they're all under one roof, working in a highly coordinated team. The InnovAge care model. It's unique and its comprehensive and I want to focus on our 100% patient engagement rate. Now I'm sure many of you have heard about other care models that talent engagement rates that are much lower than 100%. But here in PACE all of our patients, all of our participants are seen by their primary care provider at least twice yearly and often more than that. This is not our goal. It's our obligation, it's part of the PACE model. Nobody -- Nobody in PACE has lost to follow up. So our PCPs can achieve and support this level of engagement because they have exceptionally small panels, often less than 100 patients each, allowing them the time they need to ensure that each participant receives the attention they require. The average time our PCPs spend with a new participant in their first month of enrollment averages 7 hours. That ensures that all issues are addressed and that the care plan is comprehensive from the very first month. Our PCPs typically conduct 3 to 7 clinic visits a day with visits lasting as long as is required often longer than an hour. They develop very deep trusting relationships with patients and families and they have a 360-degree view of everything that can impact their well-being. In support of our providers, we've invested heavily in people and technology. We have an after-hours RN program that visits participant homes and can often avert ER visits and hospitalizations and we have a whole team of internal auditors essentially replicating a CMS survey each month in every center to help optimize compliance and quality. As mentioned earlier, many aspects of care delivered on-site, and they're integrated with the primary care team. Some of them you already heard about, as members of the PACE IDT like PT, OT, speech, recreation, nutrition and social services, but others are equally important and are areas of particular emphasis for InnovAge, including behavioral health and dental care. Also worth noting is the enterprise level of support we provide to our PCPs. We have a very robust population department -- population health department with quality improvement specialists and analysts. We have infection control expertise and a collaborative national practice model of sharing of best ideas and practices. Each InnovAge center is expected to both innovate as well as learn from others as part of our national team. We've standardized each phase of the participant journey to ensure continuity of care and that's from enrollment right through the end of life and this is particularly important. Our clinicians are involved during the enrollment process itself, ensuring that our participants will benefit from PACE, and that will set the stage for relevant and effective care planning from the very first month. Although the process is standardized, care plans are far from standard. To the contrary, the standard process allows us to create highly tailored and customized care plans for each of our participants. Every participant is comprehensively assessed and reassessed by the entire 11-member IDT at least every 6 months, sooner if there's a change of condition. If and when needed, our clinicians have great depth in palliative and end-of-life care. And this process helps us achieve our primary goal, which is keeping participants independent and out of the nursing home for as long as possible. We rigorously track, measure and act on clinical KPIs in every center, every month, benchmarking our centers against one another and setting improvement targets year-over-year. Our most important priorities and the respective national targets that we've adopted are listed here. Our inpatient target is 5.4%. Our skilled nursing facility target, 1.9%. Our assisted living and nursing facility targets are 33% and 10%, respectively. Our emergency room utilization target is 7%. And our quality composite score target is 4/5 measuring particularly important care processes like advanced directed completion and cognitive screening. And let me spotlight 2 metrics that are very important for this population, 2 risks that always come up. One is falls, the risk of falls and they're all too common among the frail seniors and can lead to dramatic worsening in functional status, independence and even life expectancy. Well, our fall rate is 16%, 16% lower than industry PACE averages. The second I want to highlight, the second item is influenza vaccination. Flu, as I'm sure you know, is one of the leading causes of avoidable hospitalizations and death in this population and our vaccination rate against flu is 78%. That's 44% higher than PACE industry averages. We're very proud and we continue to work to make all of these even better. As I mentioned earlier, we are also building a portfolio of payer capabilities side-by-side with all these clinical capabilities. Now traditionally, PACE programs haven't focused a whole lot on payer capabilities. But we are because we are a payer. And we realize that we have a responsibility to be best-in-class at both being a provider and a payer. So we're making great progress. We're meeting our targets for capability development and value capture. Let me highlight 4 of them here. The first is provider network management that's focused on developing a high-performing network and renegotiating contracts accordingly. This is especially important for our assisted living and nursing facility partners, where we share responsibility for quality and compliance and where care decisions made by the facility can significantly impact our costs, such as the decision to send a patient to the emergency room. We are also carefully scrutinizing and revising our contracts to ensure our payments reflect market-based unit cost pricing. The next is claims payment integrity. And that's about ensuring appropriate payments and eliminating over payments to other providers. We are automating our processes and implementing claims edits that are more common among health insurers. Third is resource management, and that's about ensuring optimal efficiency of care delivery and utilization of the most appropriate services, particularly related to the metrics on the last slide. An important point is the role played by our medical directors and our IDTs who have ultimate responsibility for both care quality and care efficiency. We let those closest to care delivery decide what's needed and what's not. Finally, risk payment accuracy, and that's about ensuring that our risk scores are fully accounting for the complexity and the underlying frailty of our population. Our systems and our talented coding team, they support providers in ensuring that important diagnoses are appropriately and accurately coded. And of note, unlike Medicare Advantage, risk scores in PACE are not subject to RADV audits. That's the Risk Adjustment Data Validation program that CMS recently instituted. And that compares a sample of claims to the medical record and extrapolates overpayments and demands repayments to the -- applied to the entire population. Again, that does not imply to PACE. So across all of our payer capabilities, we made great progress in a relatively short amount of time, just a couple of years, and this is an area of continued focus going forward. Well, those are the end of my slides. And I think we're going to take a few minutes break. How about 15 minutes? before we turn it back over to our next speakers, Rob and Matt. So please enjoy. [Break]

Good morning, and welcome to Part 2. My name is Matt Huray, and I lead our Strategy and Corporate Development efforts at InnovAge. Along with my colleague, Rob, we partner on all things growth. The foundations of growth remain anchored around continuing to responsibly increase census in our existing centers. I'll turn it over to Rob in a few slides who will spend some time walking through how we've created a stronger enrollment process and then I'll close out the section with de novos and M&A. In addition to Rob's efforts, we've been challenging ourselves to find partners in our existing markets that could create a base of programmatic referrals in the future and make a greater impact in our communities. These run the gamut from health plans who have enrolled patients for whom PACE would be a better fit, health systems and IDNs in our community who have a meaningful presence. And as an example, might have care managers or discharge planners who are looking to find patients a more comprehensive health care solution. Low-income senior housing providers who house a lot of folks for whom PACE would be a good fit and home care agencies who are seeing Medicare or Medicaid patients who need a more comprehensive health care solution. We all appreciate that health care is local, and so our approach and partner list is customized by each market. Supplementing our existing center growth, we've resumed new center development through our de novos over the last 9 months. We're pleased that Tampa is now open as of 1/1, and Orlando will be opening soon. In addition, we have two centers in California that are virtually ready to go. More broadly, we have a robust market prioritization analysis, which evaluates all characteristics to new market entry, and we are proactively pushing in our Tier 1 markets where the need is greatest. Lastly, regarding M&A. Our overarching thesis is that in addition to PACE being a highly fragmented landscape, the operational complexity is very high, as Rich just articulated. These factors, coupled with more challenging market dynamics, which I'll walk through in a few minutes for smaller independent players and hospital-owned PACE programs, we believe sets up a strong environment in the future for opportunistic M&A. Okay. As you can see from the map, the [indiscernible] Priority 1 remains responsible growth in existing markets. That should probably be a priority of 1, 2 and 3. Each market is unique, but we still have capacity in our more mature markets like Colorado and Virginia and significant runway in newer markets like California and Florida. And in terms of magnitude, we have the ability to increase our census by approximately 2.4x without any significant capital investments. So what does that mean in economic terms? We wanted to translate what employing slack capacity in our centers could need for InnovAge. Here, we show 90% pro forma utilization relative to our existing utilization. That represents the high watermark of our high-performing cohorts. So we certainly know it's possible. You can see from the incremental census, that translates to an uplift of approximately $845 million of incremental revenue in our existing footprint. Said differently, we can more than double our existing revenue base in a capital-light manner. It's easy math, but we hope it crystallizes why we remain laser-focused on existing center enrollment growth. And with that, I'll turn it over to my colleague, Rob, who will walk through some of the actions we've taken to prepare us to efficiently execute against our growth ambitions.

Thanks, Matt, and thanks to everyone who has joined us here in New York today as well as online. I'll start with a little bit about my background. I've got a successful history of leading sales and marketing organizations at high-growth entities with the majority of my past 20 years being focused in health care businesses. Giant Eagle retail stores organically grew from $3 billion to $10 billion during my tenure, including a $2 billion pharmacy and consumer wellness division. My experience supporting senior health care includes Brookdale Senior Living, the largest independent and assisted living operator in the country that had 1,100 communities in 47 states. More recently, I led sales and marketing operations at a technology-focused health care IT organization that outsourced Epic, Cerner and other major EMR operations and support for large acute care hospital networks around the country. So when I was at Brookdale, one of the questions that I would get frequently is who is your biggest competition out there? Is it Sunrise Assisted Living? Is it Erickson? Is it Five Star? The answer was none of the above. It was simply staying at home and aging in place. This is my PACE why. That's the real beauty of PACE. Everyone wins. The family gets a sense of security as their loved one gets 24/7 access to care without having to juggle their full time jobs while driving around the senior all over town to primary and specialty care appointments. And as you saw in the video, our transportation is not just a cab ride. Our drivers care about our participants and help them arrive at their destination safely and comfortably. Our seniors get the comprehensive care that they need with no referrals required. But that care is not left for the senior to navigate alone. It's closely coordinated by dedicated social workers across all disciplines and is inclusive of dental and other services like physical and occupational therapy as well as providing meals and socialization. As Rich noted and by evidence on the testimonials on the screen, our seniors are surrounded by ongoing and regular touch points with mission-driven caregivers who have the time to spend with those seniors all day long in our centers as well as receiving home care services as those seniors may need. All this while achieving the seniors objective of retaining their independence and aging in place. Best of all, the PACE model is entirely free of costs like monthly premiums or cost sharing for services to the vast majority of our participants who are duly eligible for both Medicare and Medicaid. Okay. Now let's talk a little bit about how our enrollment organization is set up. This is how we identify and educate prospective seniors who can qualify for PACE services. And it's an area in which we made a number of improvements in the past 2 years. On the personnel front, we historically had a mix of case managers, social workers and some traditional salespeople on our team. While keeping the focus on generating PACE awareness and providing comprehensive program information, we've augmented our team today with skilled and experienced health care outreach and enrollment representatives identified by a top external recruiting firm. These are team members who know adjacent health care spaces like home health and similar senior health care models and are skilled in articulating PACE differentiators and care options available to seniors. We also overhauled, enhanced and standardized our incentive and compensation program with the goals of building awareness, creating access and serving even more seniors with PACE. To invest in the ongoing development of our team skill set and deep knowledge of PACE benefits for seniors, we conduct monthly training sessions, focusing on everything from educating our referral partners about the benefits of PACE addressing common objections and concerns that we hear and optimizing CRM usage to efficiently reach seniors and the community organization supporting them. We have improved our data analytics for our outreach and enrollment teams measuring and broadly communicating our daily activity -- communicating our daily activities and successes. Today, we have a team of about 90 trained professionals across all of our centers who personally guide the journey to PACE enrollment for our seniors. Our internal team is supplemented by one of the top health care marketing agencies in the country and produces thousands of inbound inquiries each month via our online and off-line awareness-generating and educational channels. To more efficiently address the increased inquiries from seniors and their loved ones and to get them onboarded to services as soon as possible, we built a new inside sales call center team using a sophisticated telephony platform. The call center team takes the extra time to understand the seniors ADLs and health challenges and conducts a discovery session for potential qualification and also further educates them on the milestones toward the enrollment journey. Those digital inquiries are supplemented by a field-based community outreach team members who nurture trusted relationships with dozens of categories of referral partners across our enterprise, including health networks, community and faith-based organizations and support of government agencies. Those referral partners also include joint venture partnerships like one we have in Sacramento with Adventist Health and Eskaton senior housing. Matt is continually evaluating partnership opportunities as a way for us to strengthen the presence in each of the communities we serve and as we move into new markets. And the final step involves the field enrollment team personally shepherding our prospective participants through the required clinical and financial assessments that I'll detail on the next slides. All of these activities are completed with warmth and empathy to help get our seniors the health care services they need as quickly and as efficiently as possible. So similar to the evolution of our outreach and enrollment team makeup and skill set, we also diversified and expanded our referral partners and channels. On the marketing front, we generate inquiries via consumer messaging delivered in digital and traditional awareness vehicles. Of course, those digital channels have continued to grow in terms of both total inquiries and enrollments, but they are also the awareness tools that require the highest dollar investment. Therefore, we first maximize higher converting no to low-cost tactics like word-of-mouth referrals from friends and families of existing participants as well as internal fixed cost channels that our community outreach team cultivates. These low to no-cost channels represent approximately 70% of our enrollments. Now because of our high NPS and satisfaction scores, our existing participants can be some of the best advocates to other potential eligibles. We frequently conduct Bring-A-Friend days where existing participants can bring interested seniors to our centers for experiential tours. Simultaneously, our community outreach team is visiting with our referral partners daily. For example, they're conducting informational sessions at senior living communities, connecting with case workers at adult protective services and other government support agencies, and they conduct grassroots educational efforts with other community entities dedicated to serving the needs of seniors. Our newest channel is what we call Awareness Partners, that is composed of organizations who primary mission is to help seniors understand their health care options. We work collaboratively with these entities to ensure PACE is one of the possible solutions offered, and they can refer interested seniors to us. Now that we've talked about where those inquiries are coming from. Let's talk about the enrollment journey, particularly. PACE enrollment occurs on the first of each month and throughout the year. As we have shared on our earnings calls, the state and local governments play a critical part in our enrollment process, ensuring PACE will be a viable solution for a seniors individual needs. The time it takes to complete enrollment measured from the day of initial inquiry, averages just over 2 months with multiple parallel pass and simultaneous processes all geared at getting qualified seniors, the PACE services as soon as possible. Onboarding includes thorough clinical assessments by our enrollment, our nursing and our center triad teams, along with financial analysis, typically associated with approvals required to receive long-term care Medicaid. Once these preliminary qualifications are completed, our enrollment team submits detailed case histories to state health and financial support administrators and persistently follows through to secure the approvals required to enroll in PACE. So what has resulted from this strategy to raise awareness, educate and inform? With all 19 centers now able to accept enrollments, we anticipate gross enrollments to be up significantly from the last couple of years. Adding to the significant growth in our inquiries and opportunities pipeline, the efficient use of resources has reduced our participant acquisition cost and days to service by 17% and 19%, respectively. This all translates to a compound annual growth rate in the high teens. And as Matt mentioned, going forward, we'll continue to focus first on filling the existing capacity in our current centers in addition to positioning our de novo markets for strong future performance. Lastly, the area where we have made our most recent improvements is in our awareness and educational messaging in a new national advertising campaign we launched late last year called Healthy Independence. Healthy independence is an articulation of the InnovAge mission to empower seniors to live life on their terms, healthy and independent in their own homes and communities for as long as safely possible. Prelaunch, we conducted research with several hundred prospective seniors and caregivers and heard clearly that the PACE program's primary benefit was comprehensive and free-of-cost medical care that enables our participants to spend more quality time with their loved ones. 84% of those prospective participants and caregivers we surveyed told us that they would be prompted to take action and learn more about InnovAge. It's now been just over 90 days since launching that campaign across broadcast, digital, out-of-home and print channels and we have seen inquiries grow an additional 10% while our cost per inquiry has dropped 28% with the introduction of very targeted messaging and sophisticated delivery strategies. Simply put, we are reaching more potentially qualified seniors with fewer advertising dollars and educational messaging that resonates very well. So let's conclude my section by taking a look at the TV commercial that is running in the markets that we serve. [Presentation]

Thank you very much, and I'll turn the presentation back over to Matt.

Thank you, Rob. Okay. Turning to Slide 45. You'll see the extensive organizational experience that InnovAge has supplementing organic growth that Rob just walked through, through both de novos as well as tuck-in acquisitions. In the last decade, the company has opened approximately 7 new de novos and has acquired 7 centers in multiple acquisitions. Each market is unique that you can see from the top market dynamic grow. And so we've been intentional in creating state-specific market prioritization, which essentially stratifies and ranks each state based on a multitude of criteria for success. I'll spend a couple of minutes on that in a few slides. Regarding de novos broadly, they're generally more attractive from an ROI perspective, but take longer to stand up and get to maturity. On the M&A front, we evaluate both the stand-alone prospects of the business and critically, how our capabilities can increase quality and compliance? accelerate growth, and improved profitability based on the sophistication of our platform that Rich unpacked earlier. Essentially, we remain opportunistic on both fronts. As you can see on the wheel, we are intentional around new market evaluation and entrants. We have a formal growth group comprised of a cross-section of the Board to present new opportunities akin to an investment committee. And I raised that because some of the best deals are the ones you don't do. And we've held ourselves to the highest standard and will only commit our resources and capital when we're highly confident in its future success. So what are some of those factors? It starts with foundations in the state. How is PACE viewed within the current administration? What are the challenges they're facing with regard to underserved seniors in their market. How are the competitive forces as it relates to managed care. For example, the prominence of programs like D-SNPs is MLTSS mandatory in that State for duals. Taken together, we approximate what the potential size of the eligible market would be taking into account the factors above. And then we look at the rate environment, particularly on the Medicaid side to understand essentially the viability, both in the community relative to the risk mix as well as how we think about the calculation and Ben will walk through this in a few moments, relative to the unmanaged spend or what in PACE referred to as the [ AWOP ]. We do a comprehensive analysis of the provider community, both acute and ambulatory to ensure that we can stand up a high-performing network at appropriate costs relative to the Medicare fee schedule. And then we look at labor supply dynamics, prevalence of clinicians, relative labor cost environment to ensure that we can deliver a robust experience to our participants, both on day 1 and over time. We also look at the real estate market, both to understand the relative cost, which informs our build versus buy and importantly, what the optimal street corner is to place our centers. This is one area where we've meaningfully improved our game from a data and analytics perspective and have third-party technology to help us pick that right street corner. I touched on partnerships at the outset, but if there are prominent groups in the market where a partnership creates a 1 plus 1 equals 3 dynamic, we're proactive in evaluating whether it be a commercial relationship or partnership and going as far as a potential equity joint venture like the one Rob mentioned in Sacramento. And then everything around the wheel ultimately goes into a detailed 10-year model to help us understand the opportunities, the risks and how we define success as we move to execution. To help bring the de novo model into sharper focus, I want to highlight our Tampa projections in purple. You'll note important inflection points like the center level margin breakeven at 18 months approximately as well as EBITDA breakeven between years 2 and 3. Critically, these projections are informed by our actual experience. On the next page, I'll go through our San Bernardino market in detail. But if you look at other precedents like our recent center in Sacramento as well as Loveland, Colorado over the last decade, each of them track to this actual maturation curve. At maturity, we're expecting Tampa to deliver over $20 million in annual contribution margin based on the $12 million -- $12.5 million of CapEx that we put into the ground upfront. And note, this does not include the $3 million to $5 million in operating losses, but we've been challenging ourselves to be more agile on timing of hiring FTEs based on a 1 year forward projection. Importantly, the most important driver to overcome that initial fixed cost hurdle is responsible enrollment growth. And as an example, just speaking of agility and new ways of working in our new centers, we're contracting for on-site dental services in the first year until we can build that critical mass of census, at which point we can -- it makes sense from an ROI on day 1 perspective to bring in an FTE full time. So it's little trade-offs like that, that we're using to improve against our own internal expectations. The previous slide was more of an academic construct on the previous page with regard to Tampa and our expectations, but we wanted to bring it to life with a case study that crystallizes several of the critical factors for success. In a way, you can almost walk through our wheel on Page 46 to understand what drove our decision and why it's been successful to date in San Bernardino. Starting with the state market dynamics, California is a highly attractive market overall. San Bernardino, in particular, was our first entry into the state of California. And now we have 3 centers open with a potential path to 2 additional centers in Bakersfield and Downey. What made San Bernardino attractive. First and foremost, the overall number of eligibles, the density in select communities, which is ultimately how we selected the neighborhood to best serve the ZIP codes in a way that anchored around the most at need individuals. Further, if you look at the relationship between the dual eligibles and the PACE eligibles, it was a large multiple. And that, we believe, was a good indicator of future potential demand as dual eligibles became older, had acute episodes and become PACE eligible. California has been a great partner to PACE overall and the Medicaid rate supports it to be -- the Medicaid rates support the ability to be successful in the state. It's a balanced competitive landscape, both from a payer and a provider dynamic which ensures the right balance for us to get a solid network at competitive rates and attract participants from less coordinated and personalized plans. We believed given the robust market opportunity that the community would support a large center. And so the initial footprint was approximately a 1,000 census capacity. As you can see from the enrollment progress at the bottom table, that was certainly true. Within 6 years, we were close to capacity, and we made the investment in 2020 as we looked ahead to in essence double the size of that footprint. Subsequent to that, we've seen increased census by almost 50% since 2020 and all at an attractive center level contribution margin, which Ben will walk through on a center-by-center basis shortly. We have a dedicated team and a standardized approach, which supports a franchise model for new center openings. From the time we enter a market, we have clearly identified workflows and a very programmatic approach. We also have dedicated teams, which you can see in the orange arrows at the bottom and how they all work together over time in the 2 to 3 years that perceive a new market opening. If we go from left to right in column 1, we have over a decade of experience to leverage and history and precedents. It starts with a government relations team and lobbying effort to ensure that we meet the specific needs of the state and can address their unique pain points. The challenges that we've observed in Louisiana are markedly different than the state of Kentucky than some of the markets that we're seeing even within the state of California and we want to be very thoughtful and intentional to best solve the needs of that community, not just the state broadly. Column 2, I spoke to analytics earlier, but that helps us to identify and optimize where we put our center. In column 3, based on the need and the market opportunity, we determine the target size of the center. Rich touched on it, but it can run the gamut from 15,000 square feet to 45,000 square feet. We have standard renderings for each, and then we customize based on the existing structure or we'll build a new center or from scratch ourselves, if that best meets the needs of the community. We have a real estate team who runs point and also, we leverage the same regional construction firms for that standardization, but we've worked with them in the past, and we both know what a best-in-class center looks like. In column 4, as we begin to operationalize, we incorporate members from our business development ops team and begin hiring key center-level staff like the Center Director and the Medical Director, 2/3 of the Triad that Rich walked through. In Column 5, we customize the staffing ramp based on the size of the center and expected enrollment. We have standardized Gantt charts and road maps to get everybody ready for opening. And before the center opens, we move these employees around 2 existing centers that are more mature to see what [ great ] looks like and get sort of the ghost of Christmas future, which we think from an operational perspective, helps to ensure best practices in those new centers from day one. And once we open, we don't leave the centers defend for themselves. That BD ops team that I mentioned steps in to ensure we're delivering the standardized workflows that we've refined and improved upon meaningfully over the last 2 years which was referred to earlier as the InnovAge way. And then closing out the section, a minute on the landscape. We are the largest by center number census and number of centers, as Patrick articulated, at the outset. Note that there are a few other 4 profit scaled players that we've highlighted. But importantly, what we haven't highlighted are the approximate 275 centers, which are largely single market and often single-pay centers. I touched on in my opening remarks, we believe it's a unique market dynamic where it's more challenging to be a small business. Capital has become more expensive. Some pay centers that are owned by hospitals, those hospital systems are evaluating or reevaluating reverting to their core, which we believe could unlock assets. And all that to say we believe it's a constructive environment where we anticipate future opportunities to acquire and/or partner with a path to control to accelerate over time. We're in several discussions today, and we'll apply the same rigor and thresholds of success. I just spent the last few minutes walking through. And with that, I'll turn it over to Ben to walk through the financial update.

Good morning, everybody. It's great to see all of you here. My name is Ben Adams, and I'm the CFO of InnovAge. And before I begin my comments, I thought I'd share a little bit about my background. So I joined InnovAge as CFO in July of 2023. Before that, I've been the CFO of a company called Kepro, which is an Apax Partners portfolio company that provides technology-enabled services for priority populations, which allows them to remain in the communities of their choice. Kepro was sold to CNSI, which is a Carlyle portfolio company at the end of 2022. The combined business is now [Technical Difficulty] known as the central health. And then before joining Kepro, I was CFO of RxSense, which is a health care information technology company based up in Boston, Massachusetts. That's majority owned by Parthenon Capital. And then going back further before my time as a CFO, I was a health care investment banker for about 20 years, focusing mostly on managed care companies and other health care services companies and I ended up joining InnovAge really because of its mission to serve the frail elderly. That mission is very similar to the mission of a lot of the companies I've worked with in the past. So it's a great opportunity to be here. Okay. So before I really begin going into some of the details of the financial model, I wanted to provide some context for our financial results, some context of our business model economics in context for the guidance that I'll be discussing. So on this page, you'll see a bunch of themes that are going to be echoed throughout my comments. First, the company has identified and implemented a large number of business initiatives. We expect that these business initiatives are going to yield significant benefits both operationally in terms of patient care and financially over time. Secondly, we've implemented a number of clinical value initiatives and margin improvement efforts, and they're on track at this point to achieve their target savings. However, given the number of initiatives are underway and their complexity, the exact timing of when we will fully realize these benefits is a little bit uncertain. Third, I think you'll see in our financial results, a sequential improvement which, I think, speaks to the fact that our operational initiatives that we put in place are really beginning to bear fruit at this point. However, as I also mentioned during our second quarter earnings call, quarter-to-quarter performance can vary in the business. And then specifically, we think that we'll have a little bit of enrollment softness in the third quarter. But that being said, we're very confident with the guidance that we put out at the beginning of this fiscal year, and that we reaffirmed at the end of our second quarter. Lastly, you'll see a significant number of embedded earnings opportunities throughout my presentation. And these are things such as a return to responsible growth, the ability to leverage our fixed overhead costs utilizing our excess center capacity, realizing efficiencies from our technology investments and most importantly, from leveraging our ongoing commitment to providing absolutely high-quality participant care which we think is going to make InnovAge the PACE provider of choice. So a little bit about our financial performance. As you can see from these charts, it has rebounded steadily over the last several quarters. Our census is up about 7.5% from 6,300 at the end of the third quarter of fiscal year 2023 to about 6,780 at the end of the second quarter. And if you look at our revenue on a year-to-year basis, it's up 13% compared to the same period one year earlier. So while we've enjoyed some very steady increase in financial performance, as I said before, it's important to remember that quarter-to-quarter results can vary, but we remain very confident in our annual guidance. So just as we've seen our census increase, and just as we've seen our revenue increase, we've also seen an increase in our adjusted EBITDA over the same period. You can see this in this chart on the right-hand side that shows our trailing 12 months adjusted EBITDA number. That number has increased $19 million over the last 12 months from negative $4.5 million at the end of the second quarter of fiscal year 2023 to a positive $14.5 million at the end of the second quarter of fiscal year 2024. At the same time, you can see from the numbers just below the bars, that our 12-month average, 12-month trailing de novo start-up losses have increased by $2.9 million from $3.2 million at the end of the second quarter of fiscal 2023 to $6.1 million at the end of the second quarter of fiscal year 2024. This increase was really driven by the increase in de novo center activity that Matt described just a moment ago. So there are several factors that account for this improvement over the course of the last 12 months. First, following our release from sanctions towards the end of fiscal year 2023, we've been able to establish a responsible growth pattern again. And enrollment growth is allowing us to capture the higher marginal profitability associated with utilizing untapped center-level capacity. In addition, as we've grown, our mix has shifted and has brought our mix of participants back in line with the assumptions that are underlying the PACE rates in each of our states. Second, we are seeing success with our clinical value initiatives, which are designed to improve the quality of patient care, increase the company's operational efficiency and offset a portion of medical cost trend. Third, as the company grows, we've been able to leverage our base of fixed operating costs. The majority of our corporate overhead costs and a significant portion of our internal cost of care are fixed. This gives us a significant margin improvement opportunities as we grow. And I'll walk through this point in a little bit more detail in a couple of slides. Fourth, we've made significant improvements in our risk or capture capabilities through the use of technology, some operational improvements, the use of outside third-party consultants, we are much more accurately capturing the risk or characteristics of our participants, and this is allowing us to get appropriately paid for each one of our participants. And fifth, we're in the process of building a best-in-class data and analytics capability. As you've heard from Rich and others, we've partnered with Epic to build a PACE-specific instance of their EMR, which we've rolled out to all of our pre-existing facilities. We expect that we're going to roll out the Epic system to our newly acquired Crenshaw facility during this quarter. And we're only beginning to tap the potential of what is in store for us with Epic. But based on what we've seen so far, our expectations is that will make a significant impact on improving our efficiency going forward. So let me talk a little bit about what we think our margin opportunity is. So we get this question very frequently about what is the potential intermediate-term margin opportunity and what is the potential long-term margin opportunity of the company. The one thing I'd say is as we've introduced operational improvements to the company, we continue to learn a lot more about the potential earnings capability of the business. But there's still a bit of uncertainty around the intermediate and long-term margin targets. More specifically about when they'll be achieved. But that said, we think it'd be helpful to share with you what we're thinking at the moment and what we're seeing in the business. So based on the best information that we have available to us, we're targeting an 8% to 9% plus adjusted EBITDA margin in the intermediate term, which we define as the next 2 to 4 years. Over the longer-term, which is we define as greater than 4 years, we expect that the impact of de novo centers will be less material compared to the overall size of the company and at that point, we're targeting a 10%-plus adjusted EBITDA margin. So these target margins are based on several assumptions, which are frankly very similar to the drivers I just described in the prior slide, and these drivers have already yielded significant benefits to us in terms of our adjusted EBITDA. We also think these assumptions are reasonable based on what we know about the business today. First, we believe we can capture incremental margin as we enroll new members into our existing centers. Second, we believe that our program of clinical value initiatives will become more effective at offsetting a portion of our medical cost trends. Third, we believe we can capture incremental margin by leveraging our corporate incentive overhead fixed costs. Fourth, we believe our investments in Information Technology and Data Analytics will continue to increase the efficiency of our organization. It's important to remember when you think about our intermediate term adjusted EBITDA margin targets that they reflect a mix of mature and immature facilities, immature facilities being recently acquired facilities or de novo facilities. As Matt mentioned earlier, de novo centers typically breakeven in about 18 months and they reach maturity in about 5 years. As a result, our adjusted EBITDA margin in the near-term will be heavily impacted by the losses incurred during the de novo ramp-up period. So for fiscal year 2024, we've provided some specific guidance on our estimate for de novo losses for the year. In the intermediate term, where the company's performance falls within this 8% to 9% plus range is really going to depend in part on our mix of mature and immature facilities. So let me give you some of the building blocks of where this margin improvement is going to come from. So I stated a few minutes ago that there are a number of embedded growth opportunities in the business, and I'll break these down for you here. First, it's really important to remember, as you've heard before, that InnovAge is responsible for 100% of the cost of our participants care. And that includes everything from third-party provider costs, pharmacy costs, inpatient cost, assisted living and skilled nursing costs as well as the cost of care that we provide through our own facilities. So the first component here is external provider costs, which represent about 2/3 of our overall health care costs, they actually represented about 53.9% of revenue at the end of the second quarter. That was for the first 6 months of the year. So as I mentioned before, care provided by third-party includes all sorts of things, including inpatient costs, housing in the form of assisted living and skilled nursing facilities, outpatient care and pharmacy costs. We can mitigate the increases in these costs somewhat through our clinical value initiatives. But these costs are generally going to increase in proportion with the gross in our participant census as well as underlying medical cost trends. Internal cost of care, the next line down, which represents about 29.5% of our revenue for the first 6 months of the year and about 1/3 of our overall medical costs. So if you break that item down about 80% of those costs of our internal cost of care are variable. These are mostly salaries, wages, benefits and the like related to our employees and these costs are largely driven by census growth, by our center level target staffing ratios and by trends in wage rates. But also included in this line item is about 20% of our costs that are largely fixed, and they go to support the delivery of care in our actual centers. So these costs include things like administrator costs or facility occupancy expenses. So this latter category of cost, the 20% will increase modestly over time, but it will grow a lot more slowly than the rate of increase in our census. And so this provides us with a real margin opportunity within our own internal cost of care. As with our external provider costs, our internal costs can be impacted beneficially by our clinical value initiatives. And so that will be a modest offset to those increases. So if you take those 2 line items and get us down to the center level contribution margin, that will translate approximately into a 20% plus center level contribution margin target over time. So to put this target in context, if you look at our most recently ended quarter, we had a 17.8% center level contribution margin for the whole business. But if you look at our top 5 facilities on an individual basis, they had a center level contribution margin, which was in the 20% to 25% plus range. So we know from the performance of these centers that we can get there across the board and so a 20% center level contribution margin target company-wide seems very reasonable. Next, if we look at sales and marketing costs. Sales and marketing costs typically run about 3% of revenue. We know that as we grow those costs aren't going to grow quite as quickly as our overall growth in terms of census. So we'll get a very small amount of margin lift out of sales and marketing. General and administrative costs are we're really going to see a favorable impact. They represent a significant margin opportunity. And these are largely fixed costs -- that things -- for things like executive, finance, legal and IT costs. And these things typically don't scale in proportion to enrollment. Moreover, we've put a bunch of investments into Technology, such as Epic that you've heard about. And we're also in the process of beginning implementation for a new Oracle financial system for the company. You add these technology investments together with a bunch of operational improvements. And we believe that what we have in place in terms of corporate overhead can support a significantly larger business going forward. So if you take all this information together and all the margin opportunities I just described, we think we can achieve this 8% to 9% plus adjusted EBITDA margin in the intermediate term. Again, just to reiterate, this 8% to 9% plus margin target includes performance -- it includes both mature immature facilities in the mix. And so where we fall within that range in the intermediate term is going to depend in part on our mix of de novo and mature facilities. In the long-term, we think that the impact of de novo facilities will become less important in comparison to the overall size of the business. And it's because of that, that we have a long-term adjusted EBITDA margin target of 10-plus percent. We think this is a reasonable target based on the information that we have available to us today and what we're seeing in the business. So one other thing I want to talk about here, and Matt alluded to this just a moment ago, is what happens on the center level contribution margin basis. When you think about the levers I talked about just a moment ago that allow us to increase margins over time, there is also another opportunity we have just related to filling up our existing centers. So in part, this comes from the fact that we can leverage some fixed costs that are in our internal cost of care at the facility level basis. But the other thing is that our facilities, the larger ones with higher occupancy just perform better. They're more efficient. So you can look at this bubble chart on the left-hand side, and you can see that our highest occupancy centers have some of our very highest contribution margins, both in a percentage terms and in terms of the dollars overall contributed to the company. So as we fill up our centers over time, we expect you'll see our center level contribution margin go up from the 17.8% that we had in the first quarter -- second quarter of this year, up towards this target of 20% plus. And as Matt mentioned in his comments, the best thing about filling up excess center level capacity, there are no incremental capital costs associated with doing it. So the next slide here reiterates a point that I think, frankly, most of you probably already know. So as a PACE provider, we received 3 different payment streams from Medicare and Medicaid on a monthly basis. In total, these 3 payments are about $9,000 per month and they break down roughly as follows: $3,000 PMPM related to Medicare Part C, $1000 PMPM related to Medicare Part D and about $5,000 PMPM related to Medicare. And again, we consider a $9,000 PMPM payment, it seems large. But it's important to remember that this covers 100% of the cost of our participants. So I'm going to spend a minute here talking about the rate setting process for PACE and how it works in both the Medicaid side and on the Medicare side. On the Medicaid side, each State has a unique benefit structure for PACE and unique rate setting process for states. So while there are methodological similarities between the states, each state has a great deal of latitude to decide how it wants to implement PACE rates. Consequently, rates and rate increases tend to vary significantly by state, depending upon that state's unique characteristics. So in general, as Matt mentioned a moment ago, rates are based on a discount to the amount that otherwise would be paid by the state if the participant was not enrolled in the PACE program. This you here refer to as the [ AWOP ]. The amount of the discount applied by the State varies and individual states can also vary amount of discount from year to year. And the methodology for calculating AWOP is also different by State. And it could be based on anything from state Medicaid fee-for-service rates to managed care premium rates to MLTSS rates or another metric that the state decides to use. And also depending upon what a state elects to do our actual PACE cost experience may or not -- may or may not be included in the rate setting process. It's important to remember that state Medicaid rates, unlike Medicare rates are not risk adjusted to reflect the acuity level of individual members. If you flip over to the Medicare side, things get a little simpler and easier to understand. So CMS rates for PACE are based on county-specific data and then they're risk adjusted. The risk adjustment models are used by PACE organizations are different from those used by Medicare Advantage plans. In addition, CMS has different county benchmarks for PACE plans and Medicare Advantage plans. PACE plans, and again, as Richard mentioned before, do receive a frailty adjustment here, which makes them different from other types of CMS plans. And PACE organizations unlike MA plans are not subject to RADV audits. So when you take all this together, the PACE rate setting process is complicated. But we think that our position as one of the largest PACE providers in the country and one of the few PACE providers that operates in a whole series of states that this gives us a diversity in terms of our rate portfolio and will allow us to generally have a more stable rate profile than many of our competitors. So a little bit on liquidity and capital deployment strategies. We ended the second quarter of fiscal year 2024 with $51.4 million of cash and cash equivalents and $44.7 million of short-term investments. In addition, we had $96.9 million of undrawn availability under our revolving credit agreement. So taken together, we have $195.7 million of available liquidity and we think this cushion is sufficient to meet our operating needs, our short-term start-up losses associated with de novo facilities and other strategic initiatives and obligations. When we think about capital deployment going forward, it's important to remember that we just are completing a significant period of investment in new facilities. We now have 5 new or recently acquired facilities that are either under development or they're in the early days of their enrollment cycle. So while we're always going to be considering M&A opportunities and de novo opportunities, in the short-term, our focus is really going to be filling up these new facilities and taking advantage of the embedded growth opportunity that exists within our current facility base. And lastly, I wanted to talk a little bit about the guidance that we issued at the beginning of the year and that we reiterated at this end of the second quarter. So based on the latest available information, we think our ending census will be between 1,600 and 7,400 members. Our member months for the year will fall somewhere between 79,000 and 83,000. Our revenue will fall somewhere between $725 million and $775 million. Our adjusted EBITDA will fall somewhere between $12 million and $18 million and our de novo losses will be between $12 million to $10 million and $12 million. So with that, that concludes my prepared comments, and I think I'll invite my colleagues to come back up to the stage, and we'll open up for Q&A.

Maybe we start with anybody from the webcast and then we'll transition to the room.

So the question on the webcast is, why were the 2 centers with 70% to 80% occupancy have single CLCM margins? Any structural reasons that drive the underperformance on those margins?

I'll start. I think that's referring to the bubble chart that we had there. I don't recall the de-identified data, but I think the likely answer is that those could reflect a couple of smaller centers that I think the date is also fiscal year-to-date. So a couple of smaller centers could be rate issues. So it could be a question of we're getting our targeted rate there, but also likely a medical cost trend or mix in the population that could drive that. I think the key point is if you look at the 19 centers, they're all sort of following that regression line up to the top right. And so I think despite maybe some periods where you might find someone below that's at high capacity below that target margin. That's also at high capacity. It's likely tied to the fact they're a mall center. Maybe there's a period where we're not getting the rates that we're targeting and possibly just a small utilization impact on a small center could have an impact as well. Anybody else want to have a thought on that?

They're smaller centers that tend to be a little bit less efficient. It doesn't mean we don't have a great margin opportunity in them, but there are centers working on them.

Jason Cassorla from Citi. Just relative to the 8% to 9% adjusted EBITDA target, you had relatively favorable rate growth in the mid-single-digit range over the past few years. Census has grown well coming out of sanctions. I guess I'm just wondering how you're factoring census and rate growth as you build to that target over the next 2 to 4 years?

We've put together a model that looks at sort of the next 3 to 5 years. And we've assumed basically a continuation of some of the enrollment growth trends that we've seen in the first 6 months of the year. We've got some assumptions in there about favorable rate mix, not widely different from what we've been experiencing over last year. And again, you have to look back, there were some factors, especially related to Colorado that changed some of the -- gave us a little bit more of a rate [ boost ] the historical period. But it's essentially sort of a continuation of trends. We're really seeing the pickup when we build that model going forward. There are some of the drivers that I talked about in terms of leveraging fixed costs, the rollout of the CBI's efficiencies we're getting at the G&A level related to technology investments and so we feel pretty good about that sort of 8% to 9% plus intermediate term adjusted EBITDA margin target. But the other thing to really remember is that in that number of the de novo losses associated with all these new facilities, right? And so those facilities take anywhere from take about 18 months to breakeven. They get EBITDA positive in 24 months, approximately 3 years and 24 months to 36 months. And they hit the majority in 5 years. So those are going to be a drag just because if you think about our portfolio today, we got 5 of those versus a total portfolio. So we've got almost 1/4 in these immature facilities. So that's going to be one things that impacts the 8% to 9% going forward. But when we think about a point in the future when we're kind of through those de novo loss periods or we expect to be through those de novo loss periods, we've got the business operating as it should. That's how we kind of come to that 10% plus adjusted EBITDA margin target.

Great. Maybe just a follow-up. I know you've prioritized in-center growth. Maybe can you just discuss the profitability of a new member starting on day 1, how that grows over time? and then the drivers of that profitability kind of between your clinical value initiatives, the cost reduction and the higher risk score capture for that member as a tenure with you?

Well, I guess what I'd say is we have different groups of members, right? And so we've got -- when you think about someone on their PACE journey, they're obviously freshmen, sophomore junior seniors. The average tenure is, I think, about 3.7 years. And essentially, their profitability profile changes over time. It also changes depending upon their housing situation. We have members who are ESRD members that have a different profitability profile than somebody who comes in who's basically who doesn't have ESRD who's sort of a healthy freshman as I would think. So when you think about the business overall, we tend to look at the profitability over the life cycle of the member as opposed to -- and if you think about that in context of what our customer acquisition costs are versus looking at it in each individual period, at least that's the way I look at it. And so if you are going to take a look at the average tenure of a member and then you look at the average premium of about $9,000 a month. You can figure out how many months they're going to be here, you can sort of figure out what the revenue opportunity is. You can look at what we're doing on a center level contribution margin basis. And so that's sort of the marginal dollar contribution for someone over their life cycle, and then you can sort of impute what we -- CAC costs are. And then you can kind of look at the 2, and that's a reasonable way to look at the enrollees.

I'll just add to that. I think that's been used sort of the analogy of freshman, sophomore, junior or senior. I think there was a point in time where we had more sort of juniors and seniors in our book, and we were enrolling just due to the demand at the time, we were rolling people that were further along in sort of their frailty sort of spectrum. And we took on a lot of people that had started with us already in assisted living. That's always going to be a part of what we enroll, but we were seeing a disproportionate share of people coming to us already in assisted living, which led to increased housing costs. I think we're now starting to see our new member enrollments reflect a more appropriate distribution of people living in the one's own home versus assisted living versus other community alternatives. And so that, I think, is helping us with some of the profitability slope, if you will, as a result, because our mix is starting to look more appropriate as they come in.

Yes, that's an important point because if you think about our mix, PACE rates are really set up to sort of reflect a community REIT mix. Our mix got lot of alignment in the last couple of years. Now it's coming back in alignment. That's going to be a help to us.

Jared Haase from William Blair here. Maybe just a little bit on some of the payer capabilities that you sort of highlighted as kind of an investment priority. Is there any component of that that's kind of a build versus buy debate. I am wondering if there's an opportunity around things like risk adjustment or maybe you could acquire an asset to sort of improve or iterate on those in terms of your capabilities?

Yes. It's a great question. And because that's an area that my background is sort of strongest in. I've seen the good and the bad decisions about build versus buy when it comes to payer capabilities. I generally think we're capable of doing all of this pretty well on our own. To your point, I think risk adjustment strikes me as one area where trying to build sort of a best-in-class solution to ensure your premium per member per month reflects the risk of your population. I do think that's something that there's a lot of great companies out there. I think we're working with the best. And there's no doubt they've helped us identify opportunities. There's still opportunity to improve, but I think that's an area where we'll rely on third parties to really help us not only identify opportunity both prospective and retrospective, but they're also really terrific at this data submissions that you make to CMS and making sure the submissions are clean, they're free of errors that there's nothing missing. So they're very good technically. And so I think that's an area. We've also used some third parties to help us identify and spot concerning service trends that maybe didn't show up in our own analysis of our claims data or our own operating analysis. And we've used that to either create a [ CBI ], which Rich team builds an initiative around a particular trend or what we may find we've got sort of out of market reimbursement rates, and it may cause us to want to renegotiate. And so we've used some third parties to help us sort of spot opportunity. But I think the talent and the capabilities for most of this with the addition of Epic, it actually provides a really sound foundation to help us spot trends and then act on them quickly. I think we'll do most of it in-house and do it pretty effectively. But I think you did see on one of the slides, what we are trying to highlight is sort of our progression against what we think a best-in-class company is doing. So by no means are we performing at the level of a top tier managed care organization today. But we're 2 years in, and we're finding lots of opportunity, and we're executing on it, and it's flowing through to our P&L. And so I think we're doing a good job. And it's going to take more time to get the capabilities where I'd like to see them.

Patrick, can I add to that? Please. So as you know, risk adjustment, there are 2 main pieces there. One is the submission process. You mentioned that. Let's go back to documenting the right diagnosis at the point of care by providers. And that's largely around chronic condition recapture, diagnosis that had been made in the past that are, for whatever reason, they're chronic conditions and they're missing in the present year. And if they're not coded in an encounter in the present year, their loss and your HCC score is going to be lower. And so we previously before we moved over to our version of Epic, we had previsit reviews and post-visit audits, and we were chasing down our providers like so many other people who are concerned about risk adjustment do trying to chase down our providers trying to get diagnoses coded. Fast-forward. Now we have Epic. Right now, we are already using best practice alerts in Epic during patient encounters with their primary care provider. So during that encounter, an alert pops up before the encounter is closed out saying there was essentially a diagnosis last year that hasn't been coded this year, should it be? And it gives the provider a chance to do it at the point of care. That is a far better way to get to higher rates of chronic condition recapture. So we're already seeing some movement on that, still some more room to go, but that's the way to do it right. And so it's leveraging Epic, but it's doing internally at the point of care.

That's great. I appreciate all the color. Maybe the follow-up out there and take it a slightly different direction thinking about the go-to-market strategy and some of the data that you shared, it looks like you're experiencing lower patient acquisition costs, a more favorable sales cycle. I guess, #1, would you expect that trend to continue over the next couple of years, just kind of improving efficiency from a go-to-market perspective? And then if that is the case, would it actually maybe accelerated investments in sales and marketing, just when you think about the efficiency from sort of an LTV to CAC perspective in terms of member growth?

Yes, I get started, maybe going to hand it off to Rob for his thoughts. I think we still have more opportunity there again. We're probably a year into really trying to optimize the entire sales cycle enrollment cycle. And I think we've made great progress on it. But I think there's more opportunity for us to -- as we grow in scale, we're going to get leverage with the partners that we use, who we buy media with, who we use to generate inquiries. I think we're getting smarter at that. We use a portfolio of organizations. I think we're getting smarter at some are higher performing, lower cost than others. And so we can move business to them and get an immediate pickup just on where we sort of place our business. I think we're learning more about which channels, Rob mentioned some channels are sort of load and no cost and some channels, you're paying for every inquiry. And I think as we get smarter and smarter about it by market, by center, I think the next step for us is to be much more focused on sort of the power of the portfolio, where can we direct our resources in a much more effective way rather than we're sort of just running hard at every center as hard as we can. I think there's an opportunity to sort of redirect resources to continue to drive lower acquisition costs and greater LTVs. So I think that's probably one of the areas that jumps out to me is there's an opportunity. Rob, where do you see opportunities?

Yes. I would echo Patrick's comments, and I'd also think about the incremental investments that we're making in our CRM system. And so with that is going to come enablement, so I can look at campaign, individual efforts, buy market, investment dollars and return in terms of gross enrollments and get much more granular in terms of figuring out where is the best place to place our bets and continue to drive [Technical Difficulty] participants.

We're going to take one from the virtual folks. When looking at the mix of external versus internal cost of 1/3 to 2/3, is there any way to change this over time? Do you have any plans to bring more care into the centers?

Let Rich take that one. He thinks a lot about this.

Yes. We look at this all the time. In fact, our move just in the last couple of years to bring behavioral health in-house is an example where our participants were not getting the right care, so there was a quality issue, and cost of care was high and access was a problem. And so we have been hiring behavioral health providers, not just because it's the right thing to do clinically, but because there was a good business case. We're spending less on behavioral health now and getting better results. So we keep looking at that across all aspects of care for sure. And where there's enough concentration of care where there's a justifiable need to bring in staff, whether it's part-time or full-time clinicians, something we would always look at.

Rich, you want touch on end-of-life care?

That's another really good example. Our population, they stay with us. In many cases, until they die. That's our goal is that they're so satisfied with PACE that this is their final step along their health care journey. So I mentioned before, we have to be really good at palliative and end-of-life care. Some PACE organizations that use hospice, use outside hospice agencies to manage symptoms near the end of life. And in fact, in some of our markets, we were as well. And we looked at that and we realized that, that was creating lack of coordination, lack of that integrated care model that's led by our primary care team. And so it wasn't really the right model for us, and it was also costing an exceptional amount. And so there was a cost issue and a quality and a coordination issue. In response to that, we're actually adding additional nurses and providers who have primary care -- who have palliative care and end-of-life expertise and ensuring that we have coverage evenings, weekends and after hours so that the need for hospice is actually significantly reduced. We believe that this is a -- this is part of what high-quality geriatric medicine is, we should be doing it. It is in scope for us, and we shouldn't be using outside resources. So that's another really good example.

Medicare coding is still based on HCC V22. Have you analyzed the impact of the risk codes and risk adjustment revenue PMPM if V24 or V28 is implemented for PACE?

I don't think we've got an answer to that.

I don't think we have any answer to that.

We certainly understand the differences. But given that PACE. I mean, the exception, why PACE isn't on V28 is more related to what I would refer to as the sort of small population size of PACE and ensuring that any movement from one model to the next is sort of actuarially sound. And I think there's a real question of how does PACE sort of make that make that leap. So we're certainly aware of the differences. We clearly, let's say, benefit from the differences, but at the same time, relative to V28 but I don't think we've quantified it quite yet.

One area that we benefit, and we haven't quantified it, looking at that, is the inclusion of dementia in the new model that we're moving to. Dementia is actually not included in our current risk adjustment model, which is kind of hard for us to get our heads around because dementia is so common. About half of our population has dementia. So the ability to code that diagnosis and how that contribute to risk adjustment is going to be very important.

Any other questions in the room? or here we go with Jason.

Just maybe a follow-up. I wanted to ask about the JV opportunity that you highlighted in the slides, you have the JV with Adventist right now. Can you elaborate on that opportunity a bit more and just remind us how the economics kind of work and how that one plus one equals 3 in your view?

So specific to Sacramento, the economics work as any equity joint venture would. We own the majority, we consolidate. We have 2 minority partners in that. This preceded my time. The thesis was we have a senior housing that will be creating an opportunity and a living situation for folks that would likely be eligible for PACE. You have one of the most prominent systems in that market that could be both helpful from a cost of care, acute as well as specialist physician networks as well as when you think about folks that are using the ER as primary care when you have recidivism that's hurting quality scores. When you have those care managers or discharge planners that we had talked about that are just looking to find somebody a long-term health care solution. Those are all different facets of the value prop and ways in which PACE plus one of those partners in the community can be greater than the individual parts. Now depending on the market, there are also places I talked about both payer and provider, there are other archetypes that we think could be really compelling as well. And so we don't limit to one. We're expansive in that. And depending on the market, you might be thinking sort of the hit list is 1, 2 and 3 a bit differently, but we think that there's an additive element to each of those.

I might just add one thought to that. I mean not really hit on, if you think about what we do as a care provider, what a hospital does as a care provider? our patients are generally very challenging for hospitals to manage. There's a lot of readmissions. There's a lot of DRGs that the costs go through an outlier, sometimes the management oversight of the patient can create challenges for their quality programs with CMS. So clearly, they see the real opportunity to work with someone that can take direct responsibility for a participant in every aspect of their life. So they see a lot of value there. As Matt mentioned, some of the hospital systems also have health plans that serve a Medicare advantage population. And within that book of business for a hospital system and their health plan, there are certainly individuals who are part of their risk pool that are very high cost. And even if the health plan is performing well from a loss ratio perspective, there are still some individuals that are probably not getting the level of care that they need through an MA program. I highlighted some of those remarks in my presentation. And what we're hearing from hospitals that have those health plans, if they were to have a stake in a center, it puts them in a position to be able to think where is that Medicare Advantage life, where they are going to be optimally cared for. Is it in our MA plan or would it be in our PACE program? And you could create a pathway for that individual to get a much more much more robust comprehensive care model through PACE, and it would be in the hospital's interest, both from a quality perspective and patient experience perspective, but also economically to the Medicare Advantage plan. So we're starting to hear of that kind of interest as we think about working with health systems.

Given the sanctions were focused on certain services not being offered, post sanction, can you return to pre-sanctioned EBITDA margins? And if so, how do you get there given that more services will likely need to be offered in compliance with PACE?

Well, there were a lot of dimensions to the deficiencies identified in the audits that culminated enrollment restrictions. And I wouldn't say that it was a result of services not being offered. I think one of the things that we dealt with and other PACE programs dealt with and all providers deal with maybe the timeliness of services. And we also identified through that process that our model could benefit for a stronger resource complement. And so we've invested quite a bit in each of our centers to make sure that they're staffed to deal with the volume and complexity of our patients. And so naturally, if you focus on just one dimension of the cost structure, you think about margin compression because of the investment [ we make ] in the center. But I think to the good question that was raised around our payer capabilities, the belief is that if we can do a better job managing the care, managing our provider unit cost, managing our claims payment, managing our risk adjustment that we're going to be able to make those deep investments in each of our centers and ensure we have adequate staff to support all the needs of our population while still expanding margins. And so I think it's -- we're going to get to the margins in a slightly different way than maybe the company has achieved margins in recent years.

I have one left on the online, if there's no other questions in the room. The last one is what's the patient mix across fragility mix for the existing patients? I think they're asking, can you give me some more color on the frailty of your population overall?

I'll say a couple of things and then maybe Rich wants to say a few things. I mean when Rich talked about the risk score being about 2.4 compared to a standard 1.08 Medicare Advantage population. That gives you some idea of how complex our population is and how frail it is relative to a typical MA population. I think the second thing to keep in mind is that because every one of our participants has to meet a clinical eligibility requirement for nursing home level of care, they are, all of them are at a common denominator, a very frail and at risk of institutionalization. And then beyond that, I think there's again, using the freshman, sophomore, junior, senior, they sort of come to us at either very late in sort of their frailty experience or they can come to us very early in their frailty experience. And I think we've got a pretty good idea of sort of what that mix looks like. And I think as an organization, we're getting -- we're beginning to see would expect as an appropriate mix, whereas the sanctions, I think, really had the impact of seeing our risk pool shift in that mix a bit. Now we're kind of coming back into line as we add new enrollees who are earlier in the frailty journey. Anything to add, Rich?

Yes, I'd just say that it's a remarkably wide range, right? the freshman, they qualify for nursing on level of care based upon state criteria, but that could be based upon just a few ADLs where they need a little bit of help, a little bit of extra help, and they need the socialization. They need the medical care, but on the other extreme, we're talking about people who could be bed-bound unable to care for themselves and paraplegics -- think about extreme levels of care. It's a wide range.

Okay. If we don't have any other questions in the room, I think we'll just close by thanking all of you for your time, both those in the room and those via the webcast. I think all of material -- the 8-K has been posted. The materials are out there for people to review. I'm sure there'll be a transcript of this for future use. And we just really appreciate your support of the company and are excited about our future and hopefully, we've done a little bit in the way of building your confidence in the company and its future. So thank you very much.