Teladoc Health, Inc. (TDOC) Earnings Call Transcript & Summary

Thank you, Patrick. Well, thanks. Hopefully, you'll be clapping at the end of the day. We really, really appreciate your being here. We recognize that it's sort of interesting circumstances. We have a lot of people tuning in on the web via webcast. I want to just start by saying that we are going to take Q&A, sort of twice during the day: at the end of the morning session before lunch; and then again, at the end of the day. If you are tuning in via webcast, there is a little box, you can submit questions. We'll try to get to all the questions, although, we may not be able to get to all of them. The agenda is as follows: I'll kick it off, and my objective is really just to sort of set strategic context for all the rest of what you're going to hear over the course of the day. I know that you hear a lot from me over the course of the year. So the objective here is really for you to hear from the rest of the team as well as some special guests. David Sides, our COO, is going to go through the commercial side of the business as well as some of the operational efficiencies that we're driving to enable our commercial growth. Stephany Verstraete will come up and talk about member engagement and how we continue to drive accelerating visit volume, which is one of our key differentiators. You'll hear from Dan Trencher, who will talk about our product strategy, vision and direction. You're going to hear more about things like virtual or primary care, specialty care and product line expansion. Lew Levy, our Chief Medical Officer, will come up. He'll talk about clinical quality, clinical service expansion, and he will also go into a little bit more depth about our role relative to the evolving situation around the coronavirus. We're going to hear over the course of the day from 2 special guests. David Sides will come up with Chuck Divita from Florida Blue, who's the CFO and Chief Commercial Officer there. And then later in the afternoon, you're going to hear from Judd Hollander, who leads Virtual Care and Innovation for Jefferson down in Philadelphia. TJU Hospital System is a client of both InTouch and of Teladoc Health. And so you'll get to hear sort of a full scope view of how they see the virtual health care landscape evolving. Before that, you'll get to hear from Joe DeVivo, who's the CEO of InTouch Health. It's sort of our coming out party, if you will. And over the course of lunch, we're going to ask you to go through a couple of innovation centers that we have set up. So you can see up close and personal the InTouch Health technology and how that gets used. And then finally, what you really all came for is to hear from Mala talk about our financial outlook, some of the levers that we have, and we'll give a little bit of guidance into what we see long-term outlook looking like and why we feel so confident in that. So again, we'll have 2 Q&A sessions. In addition, giving you the opportunity to ask some questions of our guests. So I'd ask you to please hold questions during the presentations. So with that, I want to start with the investment highlights, and I'm not going to read through all of these. You've seen most of these before. What I hope is, over the course of the day, we're going to bring these to light for you. And to give you confidence in not only the short term, but really, the long-term investment thesis, and what gives us such great confidence in continuing that growth trajectory and driving bottom line profitability. I want to start with our values. And the reason I want to start with our values is because we include these in every single meeting that we have, every town hall meeting we have with the Teladoc Health team, includes a highlight on our values. And we have a lot of the Teladoc Health team members in the room. And as we go through, each one of the executive team members sort of holds a couple of these near and dear to their hearts. For me, it's always been we keep our promises, which hopefully, is reflected in us meeting or exceeding our financial guidance consistently, historically and into the future. And as we talk about our role in the emerging coronavirus situation, it is really grounded in being passionate about taking care of people. So I want to pause just a moment because it seems to be on everybody's mind, it's in the news, and talk just a little bit about the context for that. We've been very active from really early January with the CDC and with the WHO in understanding how that situation is evolving. As many of you know, we are a global company. We have about 50 employees and about 100 doctors we work with in China. And so from the beginning of this outbreak, we've been involved in making sure that we were a source of information for those affected, for our clients who are worried about how this is going to progress and, very importantly, for members and providers. Keeping both of them informed, getting the right care and safe. And so that continues. We are in literally daily contact with the CDC. As Lew will talk about later, we have a member of our team at the CDC today for a significant meeting. And virtual care has the opportunity to play a unique role when it comes to outbreaks like this. We take that very seriously. We've been proactive about reaching out to our clients, both on the employer, the health plan, the international insurance side as well as provider organizations in helping them stand up the capabilities to be able to treat situations remotely if and when that evolves. Now I say if and when, because I am very clear about we don't know how this is going to play out, right? There are many, many scenarios. We really don't know how this is going to play out. And as a result, we are not going to give any guidance or insight into what impact that could have on our business, because we don't want to prognosticate about what scenario that -- what that's going to look like, and what scenario plays out. If and when it does, we do believe it will have a material impact on the business, and we will play a more significant role. We'll certainly inform the investor community as best we can. But at this point, we are not going to. So if you came here hoping for that, please, I apologize, but we'll be disappointing you. What I do want to say is that we take that role very seriously. And you'll hear more about the medicine behind it and our practices from Lew. I mentioned that we're a global company. About 20% of our business comes from outside the U.S. We're at about 2,400 employees now. When we close the InTouch Health acquisition -- and again, everything we talk about today will be without InTouch Health, what we've said consistently is when we close the transaction, we'll update our guidance and financials to reflect that. What I will say is, when we close, we expect that we'll be right around 3,000 employees globally. We are very much a different company than we were when we went public. And so when we talk about the size of our network, the scale of our network, we have very deliberately and aggressively expanded the scope of our clinical services, and expanded our distribution and the markets that we serve since we went public back in 2015. So we're coming up now on our 5-year anniversary, and the progress that we've made strategically is really staggering. So the team and I reflect back on this. We look back on this occasionally, and we wonder why it's -- the pace feels so rapid. And we look back and we say, wow, look at all that we've done in order to execute on the strategy that we set out then. Because remember, we said, we're going to be the destination for consumers whatever their clinical condition is, and at every front door to the health care system. And we've been aggressive and assertive about delivering on that. And that wasn't just organic development and building new things ourselves, it wasn't just partnerships, it wasn't just M&A; it was a combination of all of those things. And so hopefully, with each one of those announcements and each one of those footsteps forward, you've seen us continue to expand the scope of our offering. And that's part of what gives me comfort in the long-term opportunity in front of us and our unique ability to capitalize on that. And our unique ability to capitalize on that is founded in truly differentiated and unique assets and capabilities. So you've heard me say many, many times before, our competitive differentiation is not a single thing, right? It is not a molecule, it is not a single algorithm, it is not a single piece of IP; it's a complex system of leading capabilities and assets. And so over the course of the day, you'll hear various members of my team talk about different capabilities and assets that make up this wheel, right? And it's important to understand that we have very, very clear and deliberate strategies to continue to extend our lead in each one of these areas. And we think each one of these is critical to delivering on the full promise of virtual care. And so now as we add InTouch Health into the Teladoc Health family, it continues to expand our ability to cover the full spectrum of clinical acuity and in all of the care settings, right? So if you think outside of the hospital systems, when we did the Best Doctors acquisition, and then again, with the Advance Medical acquisition, it extended our ability to treat the more complex cases, the higher acuity situations outside of the hospital. Well, now with the InTouch Health acquisition, it does the same thing for us within the 4 walls of the health system and among facilities from one to another. And again, we'll paint that picture for you just after -- sort of at lunch and then just after lunch when we go through an overview of the InTouch Health business. And all of that puts us uniquely positioned in terms of the competitive landscape. So what you see is, there are companies out there who occupy a single position in sort of one of the quadrants of the overall health care landscape, ranging from acute to chronic or complex on the clinical spectrum, ranging from delivering clinical services, which we do every day with our global network of providers, to being an enabler where we provide the software and the technology for our health system partners and providers to do that themselves. And in some cases, it's a combination of the two where it's not an either/or, but it's an and, right? And we are uniquely positioned at the center of those 2 axis to be able to meet the full needs of the health care system. And that's part of what makes us unique and a leader in each one of the customer channels that we serve. And you'll hear David talk more about that as he goes through sort of the overview of each one of those customer channels, and why we win in each one of those channels. And so we unveiled this slide in January, and I think it's important just to spend a minute on this, and then you're going to hear Dan Trencher come back again in a couple of hours and talk about how this comes to life and really what it means. But again, just as we're uniquely positioned at the center of that access, we are -- we have a unique set of capabilities, assets. And as the only one who covers the full spectrum of clinical services, we have the opportunity to serve a much, much broader role in the health care system, one that covers primary care, right, in its sort of broader sense, not urgent care but primary care, multi-specialty care, where we bring in multiple specialists, and what I would call a virtual center of excellence, right? So when I talk about a virtual center of excellence, I talk about center of excellence is designed to do 3 things, really: one, diagnose, get to the right diagnosis; two, recommend the best treatment for that diagnosis; and three, actually execute on the treatment. Now we can do one and two virtually without seeing the patient in person, and we do that every day. And so then what makes this all come to life is the integration with the health care system, right? So it's not just about delivering it remotely, but it's also about being able to integrate with the health care system and refer into the most effective and most efficient part of the physical health care system for that treatment, for further diagnostic testing and to get -- to take advantage of all the data about the best place to get care for that specific individual. And so again, Dan will go deeper into this topic, but it's really important about understanding where we're going and what our role in the health care system will be. And so then as you think about how all of that comes together, what you'll hear from the team over the course of the day is about the underlying assets and capabilities, and how those support our growth strategies around expanding our footprint and our distribution, continuing to innovate and expand the role we play in terms of clinical services and accelerating that consumer adoption curve. And all of that supports an extremely compelling financial model that is characterized by recurring revenue, high visibility and continued high growth on the top line and leverage on the bottom line. And so then if you think about what that growth looks like, there are essentially 4 levers, and each one of them compounds on the previous one. So we have continued growth in our membership or the populations we serve, and we deliver more and more products into those populations, thus increasing the revenue that we get per person, with increasing utilization and visit volume over time and new payment models that are unlocked by the role that we play in the health care system, right? And so if you think about each one of those as another lever that compounds the ones underlying, that's what gives us tremendous confidence in the continued growth trajectory on our truly multibillion-dollar journey. So I was reflecting back -- as I was raising our Series F, which was the last round before we went public, I was sitting in the very nice offices of a Silicon Valley VC, and the VC sitting across the table, said, "I don't understand why you're not growing faster, and I don't really see the path to $1 billion." And I looked at her and I said, "I appreciate that. We're in our second year of triple-digit growth, and I'm quite certain in that $1 billion journey." And so now, it's nice and sort of gratifying to be able to reflect and say, okay, I get it. I understand the question then, and $1 billion is in sight. And because of everything I just went through, I think this is a multibillion-dollar journey, not $1 billion that we're sort of grabbing for. And so I've gotten a lot of questions over the last sort of 18 months about help me understand how big this could be. What does this look like at maturity? And I think it's important to follow up that sort of big claim about a multibillion-dollar journey with trying to paint a picture of what could this look like at maturity. And there is no better way I know of -- we've been racking our brains to be perfectly honest about, how do we paint that picture. And so I don't think there is any better way to bring this to life than to reflect on our own company, right? Our own population are, what I would call, power users, right? We, as a company, sort of epitomize what this -- what the opportunity is for virtual care. So I'm going to walk through a case study of our own employees and our own utilization, and the impact that virtual care is having on our population. Okay. So just to ground you, think about us as having about 1,500 employees here in the U.S., and they have dependents that bring us to about 4,300 people total. The rest of this stuff is actually pretty typical, right? So our age, sex is almost identical to the population of the workforce. Maybe we skew a little bit more female than male, and we're less than a year younger than the average sort of commercial insured population, right? So there is nothing here that would say much, much healthier, much lower cost or anything like that. And in fact, for those of you who cover health care a lot, you know that health care employees actually use the health care system a lot more and tend to have higher costs than the average. We do offer a whole array of our services, and really importantly, top-right corner, all of them are free to our population, right? So we believe very strongly in the value of what we do. And so we take on the cost, which is what we recommend to all of our clients, of course. Okay. So first of all, 80% have registered for their Teladoc account. This is really good, and I don't know what's happening for the last 20%. I can't really explain that. It's a little bit of a point of frustration for me, but we're going to work on that. The point that I would really highlight here is 307% utilization of general medical services, right? So that's pretty strong. And you'll see on the next slide how the -- what the impact of that is. 82% of mental health utilization with an average of about 4.4 visits per active user. This makes me really proud because as I've -- you've heard me say many, many times, mental health is a terribly underutilized service due to stigma, due to access issues. And this, to me, is a proof point behind how our service really breaks down those barriers to getting care. And we've had a significant increase over the last year. This is all 2019 data. So we had a significant increase last year in Expert Medical Services. Remember, we're sort of growing in, and we had finally fully integrated all of the best doctors' capabilities, and people and Advance Medical. And at the bottom there, 25% of our cases for Expert Medical Services are for musculoskeletal issues. So what's the impact? 35% fewer visits to doctors' offices, urgent care centers, emergency rooms for things that are appropriate for Teladoc general medical services. 18% fewer encounters for musculoskeletal issues. Just like I said about behavioral health and mental health, 40% of the people who got care said they wouldn't have otherwise gotten care. And then the punch line at the end, when we go to our carrier, right, our health plan, and we say, "How do our cost compare to comparable companies, age, sex, geography adjusted?" Our health care costs are 28% lower than the norm. All of these things, the first 3 resulted in a better life for our team members, and the last one is the payoff from a financial perspective when you get to maturity. And so then you can understand and extrapolate what would that mean, right? What does that mean when this really becomes the default way of getting care. And we continue to expand the population that we serve, and why I'm so confident that, that growth curve continues on our visit volume. And it's what gives me great confidence in the outlook that we provided for 2020, and, as you'll hear over the course of the day, beyond 2020, right? So we're not only pleased with our outlook for this year and very confident in it, but we also do a lot of scenario testing. And just like all of you do, what's the downside risk, right? And the truth is, we've done scenario testing against economic conditions. We've done scenario testing against political variables. We've done scenario testing on global health situations. And in all of those, our confidence for 2020 and beyond stays extremely high. So we think not only do we have a great outlook from a financial perspective for 2020, but we also think it's incredibly resilient and durable. And so with that, I'd ask you to sort of take that strategic context over the course of the day as you hear from my colleagues. And I want to invite up David Sides, who's going to come talk about how we execute on that growth strategy. David?

Thank you, Jason. Good morning. This is my first Investor Day. I'm David Sides, and I thought I'd just give you a little bit of my background. So 25 years making electronic medical records. So it used to be that -- it's hard to believe you had to actually find the medical record to treat a patient, and it was paper. And so until you found the paper, there was no treatment. And so that's mainly been solved. And I think the next evolution is really where we're focused at Teladoc on transforming health care to be, you don't need paper, you don't even need to be in the same room, you just need the tools to be able to treat people and get better access to care that way. So I'm really excited to be here, and I'll walk you through some of the key themes. I also do all of our commercial and operations. So I'll talk to commercial first. We'll talk about some macro trends and strategies, and how we're integrated in the global leader. We feel like we have a real right to win. What are the levers that we use to capture new opportunities? How do we get white space? How big does that opportunity look in our client base? What are the ways that we can go to market and continue our growth? So this isn't just a 1-year strategy, but a multiyear strategy for how we see growth continuing. And then what are the assets that we have, and how are we working on operational excellence just to stick -- to sustain that growth? So if we get all the growth levers pulled, and we're growing really quickly, how do we know that we'll be sure to be able to handle that growth at 10x current scale? So taking Jason's kind of strategic growth pillar, I'm going to talk through our footprint and distribution, and I'll talk to the assets and capabilities, second. But first, let me talk about our multichannel distribution. So we go to market a lot of different ways, and we're the leader in all of the channels that we address the market in. So if you look at health plans, we have 50 of the U.S. health plans in that channel. Global insurers, we have 70 global insurers around the world. We have 40% in the employer channel of the Fortune 500. Our clients, 4,000 hospitals and health systems with the combination of InTouch. And direct-to-consumer, we think we're the leading platform for health direct to the consumer, and I'll walk you through some stats on that later as well. So as the global leader, we're well positioned, and we have a long way to go. So just in our current client base, there's is a significant opportunity. So we have 56 million members in the U.S. Just at our current clients, there are another 73 million members that could use our services. And then you look at the rest of the market opportunity, and it's massive, and it's even better outside of the U.S., where we're in over 125 countries in 40 languages, but our penetration is barely there. So a lot of work to do here and the white space is one of our key focuses on how we continue to grow as we add products and clients at the same time. So our strategy is aligned with the macro trends, and I'll talk through these over the next series of slides, but one of the trends is integration. So clients are looking for one supplier for all their needs. Our strategy is an integrated commercial model, and we have capabilities that we think are market-leading enterprise telehealth platform and services that we offer. Another trend is government reimbursement, and we'll talk about that. That's on a good trend. We help work with governments when they're thinking through ways to control health care cost. How can I deliver better quality? What kinds of things could they do? And then we bring our capabilities up with our commercial team that's focused on government and helping government to get more efficient. And then the rise of consumerism and demand for virtual care, we provide a convenient solution, and we have our marketing Surround Sound that addresses that and gets people to the solution they need at the time they need it. So on this slide, we're talking about client integration. So one of the large employers, it's a given now that they're looking for telehealth. Over 50% think it has a very significant impact on their employers. But on the right side, they've got, many of them, greater than 20 programs focused on that. So that's a lot of fragmentation to manage as an employer when they could instead come to us and we'll take care of this in the lower part, you could have all of your programs from Teladoc. And to make it much more holistic for your members, for your employees, right? One way to get into the system and access all of the capabilities rather than having to try to go to different apps and different providers to try to get that health care need met. So I'm going to walk through kind of the evolution of our commercial model. We'll go around the wheel. There is a -- market maturity is happening. So telehealth is here now in most countries. You hear virtual care and RFPs, it's at the C-suite level, and our average deal size are increasing as you get to the C-suite level. So people are looking for not just one point solution now, but I'd like to get all of these solutions together at once. We have a disciplined strategy for how we approach the market. So we land and expand, and then we work on best practices for how do we take a client who has maybe our general med, adding dermatology, behavioral health to address the whole person, all of their needs at once. It makes us stickier. And in the next slide, kind of gives you an idea of the compounding of utilization. So once you use one service, you're more likely to use the second, third or fourth service. And then also for us, in the multiproduct, our pipeline is at all-time high. And over half of all of our new deals include multiple products. So this is a real shift for us, and it's one that really -- it's the trend, it's driving, and we're there with the capabilities and strategies to address. We're a global company. We offer things at scale. In 2019, about $108 million of revenue was from outside the U.S. We launched in Canada with the same platform we have in the U.S. with the Johnston Group. You can travel from Canada to the U.S. and get health care in the U.S. So that's the kind of thing that really differentiates us when you talk to people who are moving between countries or large employers who have people in many different regions, only we can kind of bring that capability. And we have another client in the U.K., AIG, where we bring the full virtual care, every offering from Teladoc and they're extremely excited about that, and they have really good retention of members using that as a strategy. Now we have multichannel model so that diversifies our revenue base. When Jason talked about the way we've modeled things, when you're into the market in 5 different ways, any one of them can go better or worse. And on the whole, the portfolio theory works out while we're still having good growth. So we go to market all different ways, just to be sure we're getting to the members who are looking for health care at the time, and we can address that. And if you look at it from -- compared to the IPO, 50% of 2019 subscription revenue is outside of what the company originally did with B2B U.S. growth health -- group health business. So that's really kind of showing the diversification and the expansion that we've driven into the market over the years. So what does this look like from an acquisition perspective when we go to market and go to market through all these channels? So we've invested about $1 billion in acquisitions. This middle piece is kind of the flywheel of every one of our acquired companies is actively selling all of our products into their client base. When we acquire a new company, we sell all products into that new client base. So we both get new clients and get new products and then send that through all channels, both directions. So it kind of creates this flywheel in the middle of growth every direction. We create new organic offerings. Like nutrition this year, we're selling that into every one of the acquired and legacy Teladoc clients. And so the flywheel's spinning, and we're integrating this execution and integrated model across all of our clients. So what's it look like for our 5 largest clients? You'll see the average number of products has gone up from 3.6 to 4.8. The revenue has gone up 40%. Visits are up 40%. Paid memberships up by over 100% and subscription revenue is up 35%. So multiple levers to capture value and get to the white space in these channels and opportunities. Second trend, favorable government reimbursement. The state Medicaid programs that are reimbursing for in-patient's home is more than quadrupled in the last few years. There is Medicare Advantage expansion. And this Medicaid, we think, is a really good market for us. So it's a high barrier to entry. It's very difficult to enter state-by-state. It's highly regulated. We've done the work to be in most states around the U.S., and it's a competitive advantage for us that we can now offer to others. I'll spend just a minute on the CMS rule for Medicare Advantage network adequacy. They've added additional physician specialties that can meet the network adequacy rule in 2021. So in addition to our dermatology, behavioral health, general med, we've added in cardiology, neurology and otolaryngology, ENT. So we'll offer all of those services to our clients to help with that piece, and we see that as a further expansion of our offering, our services and also the stickiness that we can bring when you can bring that many specialties to a base of members and clients. So another growth lever for us and a good tailwind as we enter 2021. And let me just give a quick client story to illustrate that. So we've been successfully applying our land-and-expand strategy here. We started the partnership in 2017. We added additional ACA members in 2019, launched Medicaid in 4 states. Both of us trying to see how do you communicate. There is a lot of regulation just in sending an email, you would think would be straightforward, but it has to be approved by the state regulator. A lot of complexity here. That went well, expanded it to 9 additional states, and now we're doing a national rollout. So clearly, the integration piece wins, right, especially when you're dealing with this kind of complexity of Medicaid. And once you -- once we deliver with our clients, it expands, and then we have that capability to deliver to even more clients. So an emerging trend of consumer habits are changing. People are looking for health care in different places. You see people go into the CVS Health hub, who's a client of ours, or Rite Aid to get health care when they can't access it in other places. And then they're going -- on the right side, going to the web. So our direct-to-consumer offering, BetterHelp, which is for mental health, gives you a view of how many monthly web visits we have compared to what we look at as other web-enabled health companies. And we're -- we think we're the leader there in that piece. So I'll give you some more details on BetterHelp. As you saw on the prior slide, we're well positioned to capture this trend of the consumers looking for health care, looking for mental health. How do I get that? We meet them at that need. Here are some of the stats. Stephany will talk more about how do we do that, what are the marketing campaigns, and how do we approach that market. But if you look at this overall, the BetterHelp revenue was greater than $100 million in 2018. We expect it to grow over 50% this year. So really good statistics on how we're both driving new members and doing a really good job. The team is doing a great job on retaining those numbers for multiple visits. And if you are a BetterHelp user, remember, you'll see improved outcomes. So after 3 visits, 75% of people with anxiety or depression report an improvement in their anxiety or depression on the DSM-IV scale after 4 visits. So really, meeting people -- there's a huge demand for this service, but meeting people where they have the need, wherever that happens to be, and it's a very large and growing business for us. So another way to look at our commercial work going forward is what is our sales productivity. So we added about 3% to the reps count, so not many, but our productivity is up 50% (sic) [ 20% ], while our retention is 90%, and that 90% retention gives us high visibility into our 2020 revenue. We're seeing bookings up about 30%. And as I've mentioned, a lot of multiproduct bookings. Over half of our bookings are -- include multiple products. So now I'll transition into talking about kind of our assets and capabilities. What kind of operating things are we doing? And how are we driving efficiencies on the OpEx line? And so we're making a lot of operational enhancements. So we're investing in a marketing showcase kind of -- to Jason's earlier point of our evolution, it's happening so quickly, it's hard for clients to keep up with what are all the capabilities that Teladoc brings to market. And so we're going to make those really visual and physical for them by setting up a really nice client experience center in our Dallas office. So you can see where is virtual care now, and where is it headed. Bring our clients in every 1 or 2 years to be sure they understand what our full breadth of capabilities are, what the white space looks like for them and where they could move things forward and get better outcomes for their clients. We've been automating using robotic process automation in a lot of our call center interactions, how we credential our physicians to be sure we're as efficient as possible. We've started to work on applying AI to that same thing to be sure we're auditing 100% of every call and visit. So we catch everything that happens in that piece. And then on the scale side, we're implementing a Follow the Sun model, where things roll over between places so that we get the maximum kind of efficiency and one company experience across the enterprise. Something that people are talking about a lot with the current outbreak is capacity. So we've increased our provider capacity 28% in the past year. We've increased our Medicaid providers thirtyfold. So my point here really is to say, we're doing a good job, and we are really raising the network up to meet the demand and have processes in place to be sure that, that continues as the growth continues on the commercial side. So we can meet the demand of people, and where they are at that time for whatever specialty they happen to need. And at the same time, we're -- that investment in technology has gotten us operating leverage. So our call center productivity for the last 4 quarters, gives you an idea of how much we're improving our call handle time through automation. And then we're also shifting people from the call center into the app or to the web to be sure that we're as efficiently handling them as possible. So they don't even have to pick up the phone, a good improvement there as well. And that brings me back to the summary, which is we're the global leader. We have an integrated offering. Our clients are looking for an integrated offering. None of them have the entire integrated offering. So they all need to buy more. That was my joke, but -- so we have a lot of things to sell. There -- we think we're meeting the trend of buying a single solution and one supplier to meet all of your needs. We have a lot of levers to get to those opportunities, including growing new products organically, new offerings or acquiring those new products and offerings. And we have the assets and capabilities to continue to be best-in-class, sustainable, operational growth as the commercial growth continues. So with that, I'll turn it over to Stephany.

Right. Good morning, everyone. So as David said, I'm Stephany Verstraete. I am the Chief Marketing Officer at Teladoc Health. By way of background, I've spent the majority of my career in consumer behavior change businesses that are high growth, transformative, and I've been with Teladoc Health now about 4 years. So as I prepared for this morning's talk, I was reflecting on our first Investor Day, which was about 2.5 years ago. And I was thinking about what I talked about then was the parallel that we're seeing between the adoption curve of virtual care and that of online dating, right? Now so for context, I spent 6 years at Match.com. And while I was there, we went -- the company went from 50,000 subscribers to 5 million subscribers on what was clearly a path to mainstream adoption. If we fast forward today, what I'm really excited about is a lot of those parallels still hold true. So I thought I would touch on 3 things: the first is, right, how we see the adoption rate accelerating; secondly, how we're uniquely positioned to really capture on this demand with our deep, scalable Surround Sound capabilities that you've heard us talk about before; and thirdly, talk about how this unmatched base of activated users is creating the flywheel dynamic that you heard Jason talk about. So let's start with how we see adoption accelerating, right? The macro consumer behavior trends today are really propelling that mainstream majority towards a point of inflection, right? The tip of the spear is general medical and behavioral health or mental health. As we overcome those universal barriers of awareness, I didn't know this existed in resolution confidence, we're actually starting to see people actively seeking out virtual care as the front door for their access point, right? Natural at this point in time as well is that price starts to come into the equation. So we see a rise of the importance of insurance coverage as a driver of increased adoption or a barrier to it, right? The chart in the middle, the bar chart, shows really the momentum we have around growing our activated base, right? So what you see there is how consistently year-over-year, we've accelerated the growth of that activated base. And if we look, for example, at the top bar, which is 2019, we actually grew our activated base 55% year-over-year, which outpaces the new membership growth. Similarly, on the direct-to-consumer front, we're seeing that become a primary front door for access to mental health care, right? When we look at the trends that we saw coming out of the global mental health survey that we fielded last year, this growth is really only scratching the surface of the demand that is out there when you look at how underreported the need is amongst employees, especially the younger and the next-generation that are rising, right? They're citing that this is negatively impacting their performance at work. David talked a little bit about some of the key metrics and growth metrics that we're seeing on the BetterHelp business. I think what's -- this build -- this chart builds on that, and what we're excited to see is really that acceleration over the past 12 months. A key to BetterHelp's success in capturing a disproportionate amount of the demand is really that team's maniacal focus on testing and learning, right, across all aspects of the business, whether that's the member experience or our customer acquisition channels. The charts that you see here really show that evolution and diversification of the traffic mix. And that diversification strengthens our overall growth trajectory and yields marketing efficiencies over time. Foundational to our success at really being able to activate this demand is our Surround Sound engagement engine, right? That is a unique combination of capabilities, data and analytics, and the scale, experience and expertise that really wraps together and brings that to life, right? These equip us with the ability to activate any demographic or any population across any front door with any coverage, right, under any economic model. So whether that's our core user, who today is coming in across a number of our front doors for -- right, she's our multi-specialty power user, she's a lot of the Teladoc Health employees that Jason was talking about earlier. It also equips us to really be able to activate the emerging Medicaid population who hasn't a highly complex engagement profile because of the regulations, because of the language barriers, because of the socioeconomic realities that make this a hard population to reach. When we think about the power users of the future, right, our brand trust and our core capabilities really position us well to be able to meet the needs and activate the incoming Medicare population. And last but not least, right, Gen Z, right? Our digital natives who fully expect to be able to seamlessly navigate the physical or the virtual front door on their terms. All right. So everything that I've talked about so far really plays at the top of this funnel, right? How are we moving people through the awareness resolution confidence barrier and getting them to this point of activation. Now let's look at the value and the momentum that this activated base generates, and this is the point where we talk about that flywheel dynamic. So what do we mean by that? Once a person comes and activates, right, so they register, maybe they give us medical history, right, there are a number of engagement touch points with which they've been -- we can then reach them and build that relationship. This is true across BetterHelp, it's true across Teladoc. And it's all this breadth and growing breadth of possible engagements that drive accelerated visit growth, right, utilization within our populations and lead to marketing efficiencies over time. So I'm going to spend a minute here, and let's take an example, right? Let's say that the first visit is a mental health session, right? Next could be a follow-up session to that. Under the quality experience, it could be that you get a birthday e-mail in your inbox that reminds you to update your medical history. That allows us to build a relationship, drive awareness of additional services or additional contact that we could have with you. When we get to the top, right, people still need reminders in that moment of need. And it's really our data and analytics that enable us to take all of the data points from this individual's journey as well as the 10 million visits that we've delivered over time to be able to proactively or responsibly, right, reach that person in the moment of need. Moving to trust and word of mouth. This is absolutely critical, especially as we think about more complex -- the complex care situations. And lastly, let's talk a little bit about the additional specialties, right? And the importance of having multiple needs met in one single experience, right? We've talked about the importance of this for a long time, about the fact that you have to meet multiple clinical needs in one single experience in order to drive utilization. So we weren't surprised last year when we heard users in the J.D. Power study cite, limited services is one of the primary barriers to increased usage, right? Jason talked about -- we're seeing this in our own populations, right? Jason talked about this, briefly touched on it at the J.P. Morgan conference earlier this year, but this is a very large client for us. And you can really clearly see how it highlights the impact on utilization and growth trajectory over time, right, by adding mental health and dermatology. Now if I was to put this in the flywheel context, what we're doing is, we're giving more people more reasons to have the first visit and more reasons to come back and use the service. So we go from a use case to what's the impact that we see across our full sponsored population. The chart on the left shows you the growth that we're seeing in a given year from users who have activated in the prior years, right? And we see very, very strong growth trajectory. This really speaks to the point that, Jason, you actually made just in the last call around the importance of capturing registrations during a peak period like flu season, for example, right? And how those registrations fuel growth over the years to come -- visit growth over the years to come. We also see that this dynamic is fueling growth of both first and repeat visits, right? And over time, what we're seeing is that repeat visit growth actually slightly outpacing and increasingly outpacing our new visit growth. What's driving that? If we look at the value that an activated user generates over time from a visit volume perspective, we looked at it on a 3-year basis, right? Interestingly, almost half of the visit value that will be generated over that 3-year period of time comes -- or 46%, comes in year 2 and 3, right? The importance, the lasting impact of building that activated user base to generate year 2 and year 3 value is evidenced here. It's also evidenced, the value of it also applies to marketing efficiencies. So on the chart on the right, what you can see is that we -- the advertising cost to activate that second and third and so on visit is substantially less, 85% less than the cost to generate that first visit. BetterHelp also has a similar flywheel dynamic that's based on the same engagement principles, right? Use of the service, quality of the experience and word of mouth is absolutely critical for this brand. What's really exciting is to see that the accelerating growth is not solely coming from putting more people at the top of -- into the top of the funnel, right? Each member is getting more value out of the experience. It's becoming stickier. And more -- a greater percentage of our revenue is coming from members who have been using the service for 3 months or more. So I think, in summary, right, I would say, we're excited about the rate of acceleration of adoption. We're confident in our ability to -- our capabilities and assets to really activate and capture that demand. And thirdly, we expect that the momentum that this flywheel dynamic that we're building -- sorry, we're -- we expect that, that flywheel dynamic is only going to continue to grow. So thank you. And I think next, we have -- I turn it over to Dan Trencher.

Thanks, Stephany. So again, I'm Dan Trencher. I lead Product and Strategy for Teladoc. So I've been with the company a little over 8 years. So I'm going to pick up on a theme that you've heard around illustrating the evolution of the industry and really evolution of Teladoc, and how we've driven that change within the industry through our new innovations that we brought to market. Secondly, one of the key dimensions to that innovation is around broadening the scope of services that are available through virtual, through a full spectrum of primary and specialty care. And then third, that's led to our strategy to bring full-stack solutions to our different markets and customer segments. And that really is resonating in the market, and obviously, generating growth but also opening new doors to new innovations and opportunities to expand. So a little bit of taking a step back and thinking about the history. It's amazing when you think back, Teladoc's more than 15 years old. And certainly, when we launched, and up until 5 or 6 years ago, we were really a one-product company, what is effectively remote urgent care, and that's sort of where the company was built off of. But we continue to expand step-by-step-by-step. So adding mental health care services, as you've heard about BetterHelp in our B2B mental health services as well. Virtual center of excellence, which I'll dive into a little bit more here, but it's all about bringing access to the world's specialists and world's expertise into the palm of the hands of our members and clients. Global is really interesting because it has been important, but just over the last couple of months, with what we've seen with COVID, you've really seen the power of what global solutions can bring, both for populations sort of stationed all around the world, but even for our employers who have global populations, and really are looking for solutions quickly to provide coverage and access to care for those populations around the world. Virtual First, we've talked with you all about a fair amount over the last year or 2. This is really a strategy and a model that our clients are adopting more and more for making virtual care the first point of entry for many of their consumers, many of their members to access care. And building off of that, is virtual primary care, something we're very excited about. So a true expansion of what we're providing in terms of clinical services around primary care. We've been providing acute episodic care, which is obviously a component of primary care, but now expanding into prevention, screenings, chronic condition support. And again, I'll talk a little bit more about that in a couple of minutes. One thing we recognize, though, is as this has -- as we've driven this evolution, and we're getting into these new spaces of care, it really is driving a new -- a real shift in the role of virtual care for our members and clients, right? So it's not just about sick care and acute care and a one-off visit between a patient and a doctor, right? It's about longitudinal relationships between a patient and doctor virtually, prevention, screening, having a full virtual care team. So you can think about bringing not just the doctor, but a nurse, or a nutritionist program, or a mental health services, altogether into one integrated team. Also having services in a model that's much more integrated with the rest of the community health care system, so it's not a silo, right, it's really tied in via referrals, via sharing of clinical information. And finally, a broad set and really pretty much any site of -- any place can be a site of care, so not just remote and in the home or in the office, but, as we're going to talk more and more about, different types of facilities and different types of points of care, all woven together into a single experience. Jason spent some time on this slide, so I won't beat it to death, but what I will point out, though, and emphasize is we're uniquely positioned in providing really various models of care underneath this. So we have our own networks, our proprietary physician networks, who are delivering care. We enable our clients, our clients who have hospitals and providers to provide care for their patient populations. And we're able to make referrals, in other way, guide our patients and our members to the right care for them at the right point, whether it's a virtual care access point or a community access point, all through a wide range, really the full spectrum of types of clinical care. And so I'm going to walk through each one of these circles. So I'll give a little more detail there. Where I'll start with is around primary care. So one of the challenges in our health care system here and really our health care environment here is fewer and fewer Americans, and this is certainly potentially true globally, are accessing primary care and really having a primary care physician relationship. It's starting at the younger generations. I don't how many millennials are out here. So you can -- you'd probably know enough to know accessing care differently, so we've got a couple in the front row here, okay. And so more than half or almost half of patients or the population of that age group does not have a primary care physician. And you can see it's still pretty substantial chunks at older ages as well. And to put the scale in perspective, there are about 250 million adults in the U.S., and as it shows here, a little over 1/4 do not have primary care physician relationship, so that's like 65 million people. And there are many reasons for this. It's changing expectations about convenience. We all have different expectations around convenience and connectivity. And it's changing behavior in that consumers are more and more skipping primary care, sort of traditional primary care offices but also services and then catching things on the back end when there's an acute acerbation, when risk factors have gotten out of control, and that ultimately leads to greater health care complications and expenses. So our job is to create solutions and provide solutions that consumers are going to adopt that are also going to help change this dynamic. So that's where our virtual primary care, VPC, solution comes into play. And it is really important, we say this as we're building this product every day, our goal is to not just create a video encounter with a doctor multiple times but to really reimagine how primary care is delivered. So it starts with having a wider range of data available to the physician, so biometric data. It could be worksite screening, it could be lab testing in a clinic or at a draw center, EHR data, all these other inputs that inform the visit and the relationship between the patient and his virtual primary care physician. And I'll emphasize that doctor could be one of our network doctors, so working for Teladoc, it can also be a model we're enabling our provider clients to manage their patient populations better and extend their primary care reach further out into their communities. It'll take the form of virtual checkups and creation of a virtual care plan, just like a traditional care plan that you may have that you work with your own primary care physician on. And then what's really key is the ability to, in a smart way, access additional services and clinical capabilities really tailored to that individual patient. So it could be referrals into preferred community care partners, it's obviously services that we can offer and mental health services, nutrition, Expert Medical Services and the ability to order labs and imaging and other sorts of things like that. So really, we see this as a full suite of primary care sort of services all within a bundled model. The next stop on the wheel is around specialty care. And we're really proud of the work we've done around expanding access to mental health services, so I'll stop there for a minute, whether it's our mental health care telehealth service where 1/3 of the patients who use the service have reported they would not have sought health -- mental health services prior -- or otherwise, I mean. And that's really important because that's one of the chief goals in mental health care delivered virtually. It's not as much about it's a cheaper visit, it's much more about engaging more people to help -- get the help that they need, which, obviously, has benefits in terms of productivity from a workplace perspective, but also, obviously, improves people's lives and also lowers costs long-term around chronic conditions. Our mental health Navigator service, so this is often for patients who have an existing diagnosis, a more serious diagnosis, and could be out in disability even. And we see massive savings from enabling patients to get the access and care that they need, in this case, seeing a psychiatrist, I think this is the Canadian statistic, 100 days plus faster than they could otherwise, right? And that generates huge savings for the disability carrier, for an employer and, obviously, benefits to the patient as well. And then finally, BetterHelp is same sort of dynamic, where almost 3/4 of the patients who use the service through us, this came through a study that we did in partnership with UC Berkeley, and UC San Francisco Hospital, see massive improvement within 3 months. And this is all great. We love the statistics, we love the dollars and cents, but it's really more about helping people, right? And so the individual stories. The video I'm going to play for you in a second is one of our BetterHelp members. There -- it's not an actress. There's no prompting, there's no scripting, but it's an authentic story about how she has been helped by the service. Things to think about and look for is the importance of having sort of a wide choice in terms of how services can be accessed. With BetterHelp, you can do video, you can do phone, you can do text chat. And just one thing, just as you're listening, we, of course, for privacy reasons, bleeped out or just ex-ed out the name of the therapist, the name of the patient, so it'll kind of skip a little bit on the audio. So let me play that. [Presentation]

Great. So I hope everybody can get the -- sort of the feeling of authenticity and sort of the power of getting -- enabling patients to get the care that they need. But specialty care is not just mental health. So as you all know, we launched a nutrition program at the beginning of January, a national network of registered dietitians, which is a great foundation for building our programs around chronic condition support. As well, last year, we launched a pediatric telehealth solution. So it's a specific version of our platform that we partnered with Cincinnati Children's on, but is becoming very popular amongst other pediatric sort of clients and facilities. It really tailors the software and the flows for the needs of pediatric scenarios, so pediatric dosing, obviously, privacy and different ways to manage the review of symptoms and other pediatric-specific data. So that's getting a lot of attention, and we're pretty proud of that as well. Last stop on the wheel is around virtual center of excellence. For those of you who are less familiar with those programs, centers of excellence are our programs that have been out in the -- sort of the health insurance market for a while. Fundamentally, a good example is bariatrics or liver transplant, generally, a program around a particular often-rare condition where you need to -- where the feeling is if you go to the right, very specific specialist hospital in one area of the country, you'll get the best outcome. It, obviously, has limitations, right? Limitation around geography, literally, does the patient had to fly there; limitations around the types of centers that you can access. So we can meet a lot of the same goals virtually, right? And it's through multiple different methods. So one is Teladoc Medical Experts. So this is our expert medical opinion service where, as Jason alluded, you can get that expertise right in the palm of your hand. Smart referrals, so once we're able to arrive at the right diagnosis for the patient, we can still refer into a traditional community center of excellence for care. And then finally, as we've developed our partnership here with InTouch over time, that's exactly what InTouch does every day, right? So extending the reach of neurologists and neonatal intensive care providers directly into the facilities when and where they're needed the most. And this is -- as we started marketing and as we've increasingly marketed this full package of services, it is resonating in the market. So this is just an example of a Fortune 100 employer who started with buying general medical from us back in 2015, had a great experience, great utilization, that was building; added Expert Medical Services, that worked out well; added dermatology; and then just last year, added mental health services. And so we've got great examples of clients who've done this and gone on that journey, and increasingly, new clients are buying the full boat to start with. And that really qualifies us with our clients to be able to talk about new solutions and bring new solutions to market. So we've talked about many of these. These are all opportunities we're evaluating. And so new clinical services, such as virtual primary care, and as David alluded to, some of the new specialties that MA is going to allow to count towards network adequacy, so building out cardiology networks, ENT and neurology for a broader set of use cases. New payment models, so expansions of reimbursement within Medicare fee-for-service and potentially Medicaid fee-for-service as well, as well as value-based arrangements. You can imagine hospitals and health system packaging solutions of ours with them and then gaining adoption from a health plan perspective, leveraging those relationships. And then finally, new care settings, right? So playing more in post-acute, leveraging the -- our partnerships on the retail clinic side, all these are part of the models that we're evaluating and are excited, that make us really excited about the future. So I'll wrap up and just, again, point out, we're really proud of the work we've done to help people, but also to drive innovation and expansion of the market and see no reason that we're not going to continue to do that in the future. So very excited. So with that, I'm going to hand it over to Dr. Lew Levy.

Thanks, Dan. I'm Lew Levy. I'm the Chief Medical Officer at Teladoc Health. My own clinical background is practicing general medicine in the Boston area for the past 32 years. So I guess that makes me slightly older than the average Teladoc Health employee, unless I started when I was 7 years old. And for, actually, 20 years of that time, I served as a full-time primary care doctor and also teaching over at Harvard Medical School as well as in the internal medicine residency program at the Brigham and Women's Hospital. And Jason referenced earlier that various members of the leadership team kind of see it as their role to champion certain values within the organization. And certainly, in terms of my own values, it would really be the value of unsurpassed clinical quality, the value of taking care of people and the value of succeeding together as a team. So as we kind of go through the content here, I hope that those values get communicated as well. Some key takeaways is that we do have industry-leading clinical quality and capabilities. Our global presence and really, the scale with which we are currently operating on across a really broad array of levels of acuity really gives us the power to unlock important insights from our data and analytics, and that we have a very strong clinical leadership team across the spectrum of acuity, which really gives us a true competitive advantage. We often like to start a lot of meetings at Teladoc Health with patient vignettes. And I just wanted to share with you a story about a young women who recently came to Teladoc Health because of some really significant difficulties that she was experiencing with back pain. And this, I hope, will also bring to life what we've been referencing a couple of times today around this notion of a virtual center of excellence, that place where one could go to, to really get the very top in terms of diagnostic accuracy as well as charting out that right treatment course. Abby came to us. She had been seen by multiple, multiple specialists for quite a bit of time, and she was matched with Dr. Jones as part of our Expert Medical Services. It was found that she actually had seen over 10 different specialists for her condition, and she was diagnosed with scoliosis and was told that she really needed to take it easy for the next 4 to 6 months. Being the dad of 2 dancers in my own family, I can tell you that telling a young women to not dance for 6 months is really, really difficult news to swallow. So obviously, they really were looking for another opinion here. They came to us. We brought together all of this clinical information, and importantly, we also brought together all of the imaging, and that really made the difference in this case. It was sent out to a top physical medicine and rehabilitation doctor who heads up a spine center at Harvard and in the Boston area as well as a top pediatric orthopedic surgeon from Wisconsin. And these individuals reviewed all of these films and found, lo and behold, there was a very small tumor that had been missed on the outside and that seemed to be pressing really right at the area of her back that it would make sense with her current symptomatology. They recommended that she should go forward and have a small surgical procedure to remove this benign tumor. She was referred to a local pediatric orthopedic surgeon who is skillful in this procedure. That small tumor was removed, and today, she's back dancing and doing her cheerleading, and it really is a quite successful story. But it's not a unique story. We find that through this program, about 40% of the time, we're able to change the diagnosis, and over 60% of the time, we're able to make very substantive treatment recommendations. Many of our cases also involve pathology review. And we find through the pathology review, which is inherent in this program as well, about 18% of the time, that pathology on the outside is incorrect. And through this very in-depth review, we're able to correct that pathologic review and we're also able, obviously, then to correct the diagnosis and put people on the correct treatment course. So I hope that this kind of helps bring to life a little bit about what we mean by COE, the ability to assess, diagnose, lay out the treatment course, even if it's not a typical COE program where they're actually coming to us for the bariatric surgery or the liver transplant. What makes a clinical quality program? Well, it's really a lot of facets to put together a clinical quality program that performs well at scale. Three aspects of this program that I'd like to highlight for you today are our clinical leadership team, I'd like to also talk about data and analytics and AI and the importance that that plays out as well as a lot of our industry leadership and partnerships that we've established over time. Two members of the clinical leadership team that I'd like to highlight, one is Dr. Jason Tibbels, who currently serves as our Chief Quality Officer. For many of you who have followed Teladoc Health fairly carefully over the years, I'm sure you're well aware of the friction that existed between Teladoc Health and the Texas Medical Board. Dr. Tibbels was actually in the center of that. He was one of these doctors that was seen as really practicing on this platform that really needs to get out of Texas as quickly as possible. And so there was quite a bit of friction there in the early days, and I think that all know that the punch line to the story was that, ultimately, the viewpoint of Teladoc Health, that what we were doing was something that was actually helping to provide access to great care to individuals, is something that should not be pushed out of town. And I just wanted to give a little bit of the punch line to this story with Dr. Tibbels is that last year, the Texas Medical Board reached out to Dr. Tibbels to ask him to become a member of the Texas Medical Board where he currently serves. So I think that, that really does exemplify how virtual care, telemedicine has moved from being a fringe offering to something that's very much in the mainstream of medicine today. I'd also like to highlight Dr. Bridget McCabe. She serves as our Executive Medical Director for our Patient Safety Organization. There are only about 50 to 60 patient safety organizations in the whole country. These are sponsored from the government. And this is the first Patient Safety Organization in virtual care. And she serves as our director. Her own background is public health as well as pediatrics, and she has been absolutely wonderful in terms of all of that has been going on with coronavirus, and we'll be talking a little bit more about that. All of these members are part of our global medical team. So we have medical directors in countries around the world, including China. And as part of our ability to respond to events, such as coronavirus, it really is tight coordination of this global medical team. So again, that core value of the importance of teamwork. Well, Stephany has a lot better slides than I do, but I think that, that whole notion of the flywheel effect that we can have in terms of our data and analytics, it's not just fueling our ability to communicate, reach members, engage members, activate members, it is also the substance of how we can power up a lot of our clinical programs. So last year alone, we did over 4.1 million visits, and we're a learning organization. So as we do more and more visits, this becomes a huge competitive differentiator because we're now able to harness that data, and through analytics and AI, we're able to get really meaningful insights. One very exciting pilot that we've recently kicked off through our Patient Safety Organization is a call recording pilot where we can start looking at sentiment and other features of the voice interaction between patient and physician, get meaningful insights and really find out what are the drivers of both clinical quality as well as member satisfaction. So we're very excited about that as well. We are also able to provide to all of our frontline clinicians normative data so that they can see how they stack up in terms of antibiotic prescribing, steroid prescribing, member satisfaction, and all of these tactics really help to drive superior clinical care throughout our platform. Lots of questions around coronavirus. Actually, I gave a webinar to our clients yesterday, we had over 1,000 people on the call. It's an area of enormous interest, and it's an area that we've been very much involved, as Jason mentioned, with the CDC from the beginning. Why is there so much interest in virtual care and Teladoc Health and coronavirus? I think it's really 3 very important aspects. One, if one can get these individuals who may have been exposed to coronavirus to get care virtually, what you're doing there is you're really controlling the spread of this disease. So we can do all of that upfront triage. We can make the determinations as to how likely is it that the individual actually was exposed to coronavirus, and is it most appropriate for that individual to seek care at home or should that person really go into the hospital. Judd Hollander will be speaking a little bit later on about the experience at Jefferson, but it's very important that Jefferson and the emergency room and all emergency rooms are not overwhelmed by individuals that could really seek care at home. Secondly, we're very concerned about our health care workers. So by keeping people at home, you're not exposing all of our health care workers to coronavirus. Third, there is also this very important concern around a shortage on personal protective equipment, masks, gowns, gloves. And if you keep people at home, you, obviously, are not exhausting those supplies. But this also exemplifies the power of our global platform. Within minutes of hearing about coronavirus, we had teams on the ground in China in our office in Shanghai, communicating directly with all of our global medical directors. So there was a very easy flow of medical information, and all of our clinical practice guidelines were then quickly disseminated to all of the thousands of doctors that are frontline providers on the Teladoc Health platform. So that easy dissemination of information and getting the word out there so that anybody who's seeking care in any of our offices around the world is getting absolutely the right care. And that's why we are continuing to communicate regularly with the CDC and the WHO. And as Jason referenced, today, the CDC is holding a very special session on the role of telehealth in coronavirus, and Dr. Bridget McCabe is at that meeting today. Because of our scale, because of our commitment to clinical leadership, we have really won the right to have a seat at the table in a lot of important venues. We are currently participating in 2 large government grants around virtual care, and one is specifically around antibiotic prescribing, and the other one is around clinical follow-up care. One grant is with the University of Southern California, the other one with Harvard Medical School. And we're very proud of these research endeavors. We're also increasingly becoming a bit of a learning lab. So the next generation of physicians that are interested in virtual care are increasingly coming to Teladoc Health to learn how can virtual care be delivered. There's also an organization, the American College of Continuing Medical Education (sic) [ American Association of Continuing Medical Education ], which grants continuing medical education credits to practicing physicians, which is a requirement of all treating physicians in the U.S. And Teladoc Health has the unique distinction of being able to grant continuing medical education to our providers through this organization, which is really another testament to the quality of the services that we offer. So in summary, we do strongly believe that we have industry-leading clinical quality and capabilities. We have a global presence and scale that really fuels our ability to get actionable insights from the data. And finally, this clinical leadership across a really wide spectrum of disease really is unmatched in the industry today. How important is all of this clinical quality in terms of our overall commercial success and some of the targets that David was talking about earlier? I think, probably, the best source of information on this one is really to hear from our clients themselves, and so we prepared a little bit of a short video that I'd like to leave you with. But thank you very much. [Presentation]

Great. So I'd like to invite Chuck Divita. He's the Executive Vice President for GuideWell. Let's see if I can get a slide here. Great. And if -- so he is the EVP of Commercial Markets, does all their commercial business. Before that, he was the CFO. And before that, Chief Accounting Officer.

Yes.

He's much more exciting than that as he's a Florida State fan and -- FSU fan. And last night, when we were talking about virtual care, he was watching on his phone. They hit it at the buzzer to beat Notre Dame. And so we were talking about here's how network adequacy works, and all of a sudden, yes, yes, right back to where the conversation was. Thanks for joining us, Chuck.

Thank you. I'm looking for the virtual fireplace, fireside chat.

We'll get one in the other room.

Okay. Good.

Tell us a little bit about GuideWell and what you're thinking about virtual health.

Okay. Great. Well, GuideWell is a company -- a holding company we created back in 2014 when we reorganized Florida Blue, which is the flagship, Blue Cross Blue Shield plan in Florida, the market leader. And so under GuideWell, we have Florida Blue, obviously, the predominant business, but we're also in a number of other businesses. We have the largest share of the MAT contract, the Medicare A and B. We're in 12 states, about 12 million beneficiaries that we administer that program for. We are in the clinical business, so we actually deliver care. We have about 50 sites in Florida where we do that. We are in the consumer engagement space. We also have minority investments in a number of other businesses like Availity; Prime Therapeutics, which is a PBM; and some other aspects. So really, all of that under a mutual holding company structure that's really mission based, et cetera. Maybe if I could, there's one other thing I wanted to mention to maybe provide some context to how we look at this virtual health space and, in particular, our relationship with Teladoc. We've identified 5 macro forces that are really driving the industry change and certainly change on us. And I think this virtual health space and with Teladoc really hit on almost every one of those macro forces as a strategy. The first one is affordability. We have a major affordability crisis in this country. Everyone in this room knows that. Whether it's at the federal level, state level, employers, individuals, families, it's a major issue. So everything we're doing is aimed at trying to positively impact the medical cost trend. Obviously, regulatory and political, we know that's a big factor; competition, and we touch more on that if you'd like; consumerism and what's happening in the provider space. A lot of changes in the provider space, many of which is not necessarily driving down costs, it's driving up costs. So when we look at virtual health, we're really looking at it through that lens and really looking at Teladoc, in particular, as a way that we can positively impact every one of those.

Great. You mentioned the providers. What are some of your thoughts on enabling providers, right, to be able to work on your network in a better way to reach their members?

Probably going to get myself in trouble a little bit on this one, but I think there are a lot of positive trends in the provider space from a health plan perspective and also some negative trends. A lot of consolidation has occurred over many years. And in most industries, consolidation would mean better cost to the consumer and sort of more efficiencies, and by and large, that has not happened in health care. It's meant more leverage, more clout and higher costs. Strategies like opening up freestanding emergency rooms and advertising that there's no waits, et cetera, which is not the right place for much of the care delivered. So those are some of the negative trends. Some of the positive trends are this resurgence and reinvestment in primary care, and your strategy's aimed right at that, too. We're leaning into that very heavily. But while it may be a small percentage of the dollars go to primary care, their -- actually, their decisions are impacting a huge portion of medical cost spend. So what we're doing in that space is we're developing strategic partnerships with providers that want to lean into the issues that I've talked about. And that's really how we're looking at Teladoc is not as a vendor, but as a strategic provider partner because, candidly, we're in the really early innings of the impact and potential that we have together.

Good. That's great. What do you -- how have you seen the early innings go? Any kind of concrete things that you thought through or value proposition that you've seen?

Yes. Well, this won't be surprising to you. But selling into health plans has a long cycle. Is that fair to say? And it's because it's of change. It's new. There's a lot of institutionalized kind of thinking. So -- and we approached it that way early on. We -- I think we started our relationship with Teladoc back in 2016, maybe even late 2015, and it was very much toe in the water. Let's run a pilot. Let's run a pilot with an ASO group, so we're not taking risk. Because people thought, oh, this is going to drive up utilization, which that never happened. Then we sort of expanded it and said, well, let's offer it as a buy-up opportunity, which, again, was still toe in the water and not really understanding the bigger picture. When I took this commercial role, I pretty quickly said this, "Guys, this is not around any of those issues. This is around accessing convenience right now. But over time, it's going to be about trust and impact." And we immediately decided to expand it to all of our commercial membership, as much as we could, there's some portion we couldn't. But about $2 million…

But we're going to win and expand there, too, Chuck don't worry.

I know. You will. But about 2 million members from a very small piece and we really got started in earnest, I think it was in September of last year and had really seen a significant ramp in the registrations and usage.

Great. What do you see -- kind of if you look out the next 3 to 5 years, how do you think things will continue to evolve in that marketplace? How are you going to really set yourself up for your big 5 trends.

Yes, I think first of all, we have an overarching virtual health strategy that we've developed, which is -- plays right into the things that you all have heard this morning. But it also factors in other aspects. The reality of it is a lot of the providers that are in the market, they have their own solutions, some of which is with Teladoc, some of which was others, some of which is homegrown. And so from a health plan perspective, we want to make sure that we can maximize the impact of this channel. And that's how we really see it. There's a role for bricks and mortar, there's a role for this, and how do we maximize the impact? So within that strategy, we're doing the normal things that you would think right now. But I can see that evolving over time to, one, impact more of the membership, and the visits and interactions that we're having through this channel are bigger and more lasting and more impactful, consistent with even like the virtual primary care because right now, the data we're seeing, it's very good. But it's like looking at things like did they go to Teladoc versus urgent care, or et cetera. What we need to get to, and that's how we're measuring it, which is actually pretty immature, ultimately, where I want to measure it is, okay, what is the impact of that visit on their overall total cost of care, on the quality, on the outcomes overall for that patient. And we get to that, then that's really going to maximize the value of the channel.

I think we've talked to them before, too, about kind of the rural -- I mean, Florida is a big state, so sometimes you actually have rural parts of Florida in the access. How do you see telehealth working in that part?

I think telehealth can play a major role, including with respect to specialists and things like that. Florida is very -- a lot of population around the coast, but in also a lot of rural markets. And I'll just give you one example where I think virtual health can play in there, and it's probably similar in other states. We have a market. I'm not going to name it. But we have a market within Florida, very important market, very thin on primary care, the primary care that is there are aging, retiring, very difficult to recruit new primary care to that market. And so it's been this sort of insular thinking for the marketplace for a long time. And so we have a couple of choices. We can see if we can hire doctors there or do something different. I can see a model where we expand the potential for primary care using virtual health in a more robust way. And in fact, that's one of the things that I want to talk to you all about. But I can see that being an important factor going forward because those trends in this market are not unique. That's the trend across the country with respect to primary care. So I see a big role for that.

Great. We have time for questions from the audience as well. Chuck's agreed to take some questions. There will be microphones going around. But -- and after that, we'll do the Q&A with the executive team. But if you have questions for Chuck, kind of what their strategy is, how he's thinking about it from a Florida perspective or even more broadly across GuideWell, we'd welcome them.

Yes, Lisa.

Lisa Gill, JP Morgan. Just going back to your comments about the primary care networks. How do you think about building out those primary care networks? Are you using some of your own doctors? Does your health plan own doctors, or are they all primarily Teladoc docs?

We do. We -- like I said, we have about 50 or so sites now, but those are through a few different ways. We have a couple of staff model HMOs, which is both insurance and provider. We have a joint venture with an organization where we built out 35 primary care plus some specialty centers throughout the state, and we also have our own provider assets. So what we're trying to do in Florida is I want to partner as much as possible. But in the event that we can't find the right partnerships that are going to align to what we're going after, then we're going to expand primary care ourselves.

And then just secondly, how do we think about new payment models? I mean we've been talking about value-based care for a long time. Health plans are looking at things in a different way. How do you think about the relationship, for example, with telehealth over time? Is this going to be more of a risk-based model? Some other type of model, do you think, will come to the market?

Yes, great question. We're leaning in very heavily to value-based care. And our CEO, Pat Geraghty, has really set a bold goal for us in that regard. And so I see both virtual health as a way to support that strategy for those organizations where we're moving to value-based care, and we can touch on that, if you'd like. But also, in and of itself, I think that the potential for virtual health to be a medical home to take on more of that kind of value equation is there as well. So I kind of see both of those channels, supporting the bricks-and-mortar in the market as well as having its own medical home.

There's questions over here.

I guess, Chuck, kind of 2 questions. One part, I know you lead the commercial markets. But from a Florida Blue perspective, can you talk about Florida Blue's mix of business, MA, whether or not you participate in the Medicaid and state commercial book? And then how far up the acuity scale do you see the organization going from wanting to owner provider perspective? You talked about owning specialty centers. Do you want to get as far as going like Western Pennsylvania, where you've got the UPMC versus Highmark battle and potentially own your own hospitals? Just kind of thinking about from the vertical integration perspective, how far do you want to integrate the stack?

Yes, I can definitively say, we will not be in the hospital business. That's a tough business and a unique one, although there were unique circumstances in Pennsylvania, as I'm sure you know, with respect to Highmark. And candidly, I think they've done a nice job integrating and creating a nice value prop there, as I've talked to those folks. We're about 75% commercial, and the rest, Medicare through Medicare Advantage med sup. We were in Medicaid for a while. We've exited Medicaid. We may reenter at some point, who knows. So it's predominantly a commercial book. We have a bold goal to grow Medicare Advantage. So over time, hopefully, we're going to see that change. In terms of the care delivery models, we're currently evaluating that. I would say we're already -- we've moved up in acuity a bit. For example, we have 3 sites in Orlando that are urgent care, but they're really almost ERs. They're not licenses ERs, but they're staffed with ER doctors, and they can do almost as -- like much of what an ER can do. So in those kinds of models, we're going to explore. We obviously have a lot of specialists in what we're doing. There's probably a limit, but I think the reality of it is we're going to have to go a little bit more higher and higher until we can figure out how we can move the needle on the cost of care. Because I'm just telling, it's a major issue, and there's really no end in sight without getting deeper in care delivery.

Matt Gillmor with Baird. I wanted to ask about -- this is probably related to Lisa's question a little bit. But with virtual primary care, how are you thinking about your ability to steer referrals to those efficient providers? And if you had any comments you could provide about how much money that would save a plan, or how much more competitive you could be with your premiums if you're able to execute on that.

Yes, our strategy on that is really to inform the member. And so we're working -- we have some capabilities now, but we're working on more and more to put in front of the member as well as the primary care physician our perspective based on evidence around quality and cost and so forth. And so I don't want to necessarily be in the business of, you need to go here or there. I'd much rather have the physician and the member make that decision, but make an informed decision because our research shows us that they're looking for us to help make those decisions because they don't really know where to go. So I think it's going to be evolved over time. For example, we've got a partnership with Embold Health. You may have heard of Embold Health. Us -- and we are working with Nexterra Energy, as an example, on ways to further inform their employees around the best places to go, and they're actually looking at designing benefits to sort of help feature that. So I think it's more -- it's softer and not harder in terms of steerage from my standpoint.

Can you talk a little bit about utilization of the platform of what you're seeing now, what you think a successful utilization would be? And are you leveraging everything that Teladoc brings to the table to access members directly? I need some water. Ever since I traveled to China, I just have this dry cough.

So our more earnest relationship with Teladoc is still very young. I would say it's only maybe 5 months old in terms of the significant moves that I mentioned. A key part of this to me is how far the health plan and/or the employer goes in promoting the access and the value prop. And we've gone pretty far in that. So I think that's good for both the health plan standpoint as well as Teladoc as part of the model. Early on, we were seeing, let's say, 3,000 registrations in the early months per month, and that's quadrupled through January, and the visits have done the same thing. So significant ramp-up. How far it goes, I don't really know. But we probably have at least a couple of million visits a year in the whole picture that probably are in the primary care urgent carer space. So I think there's a lot of upside. But it's hard for me to say how far that channel is going to go. But I will say that the trends are very positive. And I'm sorry, one more thing. We're using, I would say, basic products from Teladoc at this point with an eye towards others. We're looking at the behavioral right now. I think we've got a derm piece that kicked off, a pilot we're running. So I think there's a lot of upside inside of Florida Blue from that standpoint.

Jailendra Singh, Credit Suisse. Just a follow-up on that. What are the key metrics you're focused on in terms of how we evaluate ROI? Are you focused on utilization trends, like medical expense savings on your side? Just give me some flavor on that. And also, like, can you provide a little bit more color on how you pick those 2 million lives? Was it based on geography, or was it a specific population where you rolled out Teladoc Health?

Okay. Great. I would say it's fairly primitive how we're measuring ROI right now. And Teladoc can -- measures it in probably a more robust way, but conservative -- I was former CFO, so a little conservative. So we're really looking at things such -- on the ROI, such as if they went to a Teladoc visit, did they have another visit with a bricks-and-mortar within a certain period of time and if not, that was utilization that went to Teladoc versus going somewhere else. Very basic calculation from that regard, and that's a positive ROI in and of itself. I think being able to -- and I would think it's about 5% or 6% of those visits, and you all track this, the patient said they would have gone to the ER as an example. So that's -- the impact of what they're doing is more than what I'm describing, but just to be conservative internally. And I'm sorry, what's the second part of your question?

I was just going to ask to how did you pick those 2 million lives?

Okay. I'm sorry. Really, it was 2 million that I had direct decision-making authority over, and -- to be candid, and just said, so it's basically all of our fully insured book of business on the commercial side as well as all of our ASO business that's totally administered on our Florida platform and we said, let's make it available to all of that population.

Chuck, this is Glen Santangelo from Guggenheim. I just had a couple of unrelated questions. I'm kind of curious, in all your managed care experience, have you ever been a part of a discussion where you thought about maybe trying to build these capabilities internally, but ultimately, decided it was better to outsource? And kind of how do those conversations go internally? And when you ultimately decided to choose Teladoc as a partner, what were some of the most critical things that you guys looked at? Was it the range of services offered? Did pricing come up as part of that discussion? Like what was the thought process internally at your organization?

Yes, of course, within health plans, there's always a bias to build, just in everything. And so you have to always have to fight that. So I would say that's not unique to virtual health. Having said that, it was a pretty quick decision to say, okay, so let's say, if we built this, how do we scale that? And how would we operate that? How do we keep innovating and growing it. So pretty quickly, it's determined, that was probably not a great idea. So I'm not sure that everyone had legs, but I can't say that there aren't discussions like that happening inside of various companies. And you probably see that on the provider side as well. I think Teladoc's capability to both have access to physicians, but also support bricks-and-mortar strategies with the provider community, I think is a good way to sort of have your cake and eat it too, which is have an institutional solution I can have for all my members, but I can help fuel the other relationships I have in the market. So I think that was probably the answer to that question. In terms of decision-making, absolutely looking at capabilities, obviously, always looking at things such as cost and value prop. But more importantly, from my perspective, is how can this relationship grow? Is this a relationship that is innovative, open, easy to do business with? Do I buy into the long-term strategy of where the company is headed and where they see the market headed? And all those boxes were checked. That's kind of the way we look at it.

We have time for one more question.

Stephanie Demko, SVB Leerink. Just given some of the impressive uptake rate you've had in registrations, what have you found to be the most successful strategy to engage your patient base? And where have the misses has been?

Great question. I think a really concerted effort to inform our members, both through all of our channels, in our various channels as well as partnering with Teladoc in terms of their communication channels and their welcome kits and their onboarding of members. So I think it's a team effort. I think the -- I wouldn't say it's necessarily a miss, but like most things, there's inertia. And you kind of have to overcome that internally of an area saying, well, that's my space or -- so all of the human factor, I would say, is it. The other thing that I failed to mention that I thought was really important, and it will be more important over time is we're investing very heavily in our digital experience. And for example, we've got the Teladoc experience integrated in our mobile app. So we're promoting our app, we're promoting Teladoc, and I think all of those things are converging on higher levels of adoption.

Great. Well, please join me in thanking Chuck.

Thank you.

So that was awesome. Chuck, thank you. Chuck made the trip up from Florida. I'm going to ask the management team who presented in the morning to join us on stage. We'll do a Q&A on the morning session. We'll come back and do another one at the end of the day. So Mala doesn't get off the hook, you'll get her this afternoon. And so we have a few mics going around. Just a reminder, if you're tuning in on the webcast, there's a little box. You can submit questions through the webcast. Patrick is logged on, and we'll be able to relay any questions. We do have only so much time, so we'll try to get through as many as we can. I think I've stalled long enough for the microphones to go around. Do we have our first question?

Matt Hewitt from Craig-Hallum. Questions about coronavirus, twofold. Number one, and I realize it's early days, but is there anything over the recent past that you could use to kind of look at from an AI perspective, here's what happened from an adoption standpoint early on; and then if you look 3 months later, 6 months later, a year later, the utilization rates of those patients and how that translated into higher utilization? And then secondly, in your discussions with the CDC, a lot of that is information to help the doctors understand and disseminate information. What is the CDC telling you in how to prepare for what it looks like it's going to continue to blossom, helping the doctors actually treat and deal with the patients? I mean is the CDC telling you, you need to be prepared because a 14-day quarantine, we don't want the patients leaving the house, go after -- go and help the patients at their homes?

Yes. So I'll take the first part of the question and, Lew, you can take the second part. So I think the short answer is we don't have enough experience as a company at a large enough scale with a pandemic situation to be able to apply AI or machine learning to our own data on what the sort of longer-term impact looks like. When I think all the way back to 2009, when I started at Teladoc, that was swine flu, right, H1N1, and we had a pandemic program, where we were working with some of the drug distributors and some of our employer clients to get them antivirals that they were stockpiling for their population. That was doable on a very small scale, which is what we were at the time, right? We're a $4 million, $5 million a year company. And so the role that we played was much more limited. The role we can play now, obviously, is significantly greater, and we serve a significantly greater population. But I wouldn't say that we have enough data to extrapolate from a situation like that. We have a lot of data on flu situations. And as Stephany referenced, the benefit of getting someone to use for the first time and then getting them into that flywheel of repeat utilization. So we do have a lot of data on that, but I wouldn't say I would exactly match that to the current situation. Lew, do you want to take the second part of the question?

Sure. So I'd just like to reiterate what Jason said, we're really in the early stages here. So in our conversations with the CDC, they're basically talking about 3 potential models. One, that the coronavirus will be isolated in clusters across the country; another model that seems to suggest that it may be a much more widespread epidemic, but very mild. So currently, we know that over 80% of individuals who have coronavirus, it's nothing more than a somewhat trivial viral illness that people get over without any difficulty. The third scenario is really one of a more widespread disease that has significant morbidity and mortality associated with it. But all 3 scenarios are currently seen as being possible. And the CDC is very interested in Teladoc Health, just given our sheer scale around information flow. So we have done a number of enhancements to our platform to really know whenever we have a PUI, which is this person under investigation, they have both the epidemiologic background as well as the symptomatology to suggest that, in fact, they may have been exposed to coronavirus. So as we are finding PUIs and confirmed cases on the platform, we are communicating regularly with the CDC, so they're aware of what we are seeing.

George?

I have one for Stephany and David. And David, you said something in your presentation that jumped out at me. You guys have put together a few assets through acquisition over the last couple of years, and it sounds like the products are still being marketed under their individual brands. Is there -- okay, I see David shaking his head, so that's no. I was going to ask, is there like -- it sounded like BetterHelp was still being marketed at BetterHelp. I wanted to ask if there's a consolidated brand strategy, kind of where we are in that process. And yes, it sounds like you guys know exactly where I'm going, so why don't you take it from there?

Sure. So we do have a master brand strategy around Teladoc. So if you think about examples like Best Doctors, Advance Medical, right, those really will, in a thoughtful way, transition over time to the Teladoc brand from a consumer perspective. BetterHelp stays a stand-alone brand because it really fits that criteria around it is meeting a very specific consumer need and has a very strong loyal following around that brand. So really, we've established criteria that gives us sort of the ability to decide if it's not Teladoc, why would we make those exceptions, and BetterHelp clearly fits that.

I would only add that the -- internally, those 2 brands have gone away. It's just Teladoc Expert Medical Services, and it's actually the best of both companies. So we've totally redone that process to be even faster and higher quality.

Lisa?

I just really want to go back to the virtual primary care model. And so as we think about the virtual care primary care model, one, what's the relationship with the doctor? I mean is it one doctor? So for example, if I signed up today, would I have that same continuous relationship with the doctor? And secondly, as we think about these emerging models, and the reason I asked that last question around value-based care and where the models are going, how do you think about who owns that relationship? Is it ultimately going to be a payer who continues to take on risk, whether we think about Medicare Advantage? Is it going to be the provider who are also taking risk in certain markets? And then lastly, how important is it to have the electronic health record embedded into everything that you're doing today?

So I'll start, and then maybe, Dan and Lew, you can chime in. So I would think of it as a relationship with a care team, which likely includes a doctor and maybe multiple doctors as well as potentially a registered dietitian and a therapist and maybe a psychiatrist as well as other coaches around your overall care. So when Dan talks about reimagining primary care, the charge that I've given to the team is let's not just replicate and virtualize what exists today, let's really reimagine it. If you incorporated all the technology, broke down the geographic barriers and walls, and we're able to bring all the right resources and assets to bear for the consumer. And that's what the team is really charging hard on. I think that opens up a number of different payment mechanisms, right? For us collectively, us and the providers, to take on primary care capitation, to be in value-based care arrangements, to be in situations where we're being paid for intelligent referrals into the network that capitalizes on the kind of data that Chuck talked about, about understanding the efficiency and effectiveness of the network, and doing that very much hand-in-hand with local community, health care resources, with local health systems, with the capabilities that are in the market. And each one of those will be a little different for each of the payers we work with and the hospital systems that we work with. Dan, Lew, if you want to add anything.

The only thing I'd add is I think you hit a lot of the points around the different economic models. I'd add sort of value-based care is going to be critical for it. So you can imagine scenarios where addressing gaps in care and HEDIS measures that virtual primary care is a perfect platform and an environment to do that and also be able to capture the data and really be able to see that impact. And then to the question around -- there's going to be a heterogeneous sort of set of models because the health care delivery system is very heterogeneous. So different plans, Chuck's plan is in a very different place, probably, in their relationship with their local providers in their market than it might be in New York or in other places. And so that's why we're going to market with a set of strategies that sometimes is enabling a local provider, and then that might be in their own risk-based contract. Sometimes, it could be us offering a global -- or excuse me, a sort of a national, consistent model through our provider network, in which case, we might be taking more of the risk. So it really will be all of the above, probably. I don't know. Do you want to talk about sort of the clinical information and component of it?

Sure. So I think that Teladoc Health is in a very unique spot. We're in a unique spot because of the medical sophistication that we have in-house. And I think that we really are at a point where we can curate both the medical talent in terms of making sure that our virtual primary care offering has really wonderful doctors and clinical teams to interact with, but we're also in a unique spot in terms of curating technology. So not having technology there for technology's sake. But if, say, a person has a chronic cholesteatoma or a blockage in their ear and just need to be followed regularly, well, we can have Bluetooth-enabled otoscopes that are empowering either the primary care doctor or the ENT doctor to have regular checkups on the ear, without that individual actually going into a brick-and-mortar setting. We can also, through our data and analytics, have a very targeted program that we are really reaching out to segments of the population that we will know will develop really the best value from our clinical offering, and also technology in the sense of what we can prescribe. So in a typical primary care practice, your primary care doctor is not prescribing an app that might help you with your OCD or other kinds of problems. But we absolutely believe that we can coordinate a virtual care team. If there's a behavioral health intervention that needs to happen as well, that can all be knitted together, and we can deliver this type of solution, which really marries up the very best of clinical care with the very best of technology.

We have a question here.

[ Mark Banton ] from [ ReGroup ]. The $8 billion supplemental bills passed by the House yesterday, that contained $500 million for a temporary waiver, Medicare telemedicine restrictions. What aspects and what impact does that have to you, specifically on your operations, on your opportunities?

Yes. So we've been involved in the discussions in Washington, both with the CDC as well as on the hill. And we think there is good progress being made in trying to mobilize resources to address the situation. The part of the proposed emergency measures addresses telemedicine. It breaks down the -- some of the barriers around requiring rural situation and/or the site requirements for Medicare to reimburse for telemedicine. It maintains some things around having a prior relationship and a requirement around video. We think that all of this is positive in terms of reinforcing the role that virtual care can play. And so I think those are all really positive signals. We're going to avoid going down the path of trying to size what kind of an impact or anything like that. Again, because we just don't know what the scenarios -- what scenario is going to play out and what the volume is going to look like or anything like that. So it would be premature for us to do that.

We have a question from the Internet, if I can interject.

All right.

We have -- Dave Windley asks, going back to the Teladoc case study, the 28% lower cost, is that inclusive of the virtual care cost that we provided for free?

So that's the actual claims cost. So we asked our carrier, what -- tell us on a per member per month basis for comparable populations, what the per member per month health -- claims health care costs are. So it doesn't include the cost of the service that we provided, but that is a tiny fraction of that, right? That might be a couple of percentage points, if that, on the total cost of care. So perhaps you'd go from 28% to 26-ish on a net basis, but doesn't really even make a dent in that.

Here in front, Andrew.

Andrew Kaplan from Alex Brown. Do -- whether it's health systems or service providers look to you, is it that they look to your vision, or are they looking -- or are you looking for their feedback? Or how does that work? In other words, if you're working with Jefferson, they say that, "We're a large health system, we want you to do it this way." Or do they say, "Hey, you're the experts tell us how we can integrate this." How does it look that way? And how do you answer to all these other constituencies while keeping your costs in line of where you want to go?

So I won't answer for Jefferson, I'll let Jud do that. He'll come up this afternoon and talk about their process. What I will say is when we're talking to health systems, we have a very methodical process for walking a health system through what we call a readiness assessment, which is almost like a mini strategic consulting engagement at the very beginning of the process. Because they frequently come in with a bunch of ideas about what they want to do and frequently a scattered set of strategies. So what we try to do is help them understand what the capabilities and opportunities are, zero them in on the highest priority opportunities in the near term and then create a road map for the future. And that tends to create a much better engagement with the client about, let's do this first, let's get success, then let's build and expand sort of in terms of penetration into your system as well as the use cases and the role that virtual health can play. Where are we going, Andy?

Jailendra Singh, Credit Suisse. Going back to the case study you shared, Jason, about your own employees, pretty impressive figures there on activation, utilization and savings, et cetera. Can you highlight some like 1 or 2 key drivers, which actually drove those kind of numbers? And do you, like, face any hurdles or challenges in implementing those strategies for your employer clients?

Yes. So the great thing is that we actually live all the strategies that we propose and champion with our clients. We offer all of our services. So to Stephany's point about the more things you offer, the greater the engagement and the more reinforcing it is. We communicate with our employees about it. So I just got a note yesterday about my Teladoc benefits. And if you're experiencing end of winter eczema, we have this great dermatology program, just as a single example. And the cost-sharing is set up right. So all of those services are 0 cost to the consumer. And in spite of that, it's a tiny cost to the company of actually paying for those services, which is why we get such an incredibly high return on investment and impact on savings. And what we hear from our own team is that it makes a big impact on their lives. So this is -- as I've said over the years, this is one of those few win-win-wins in health care, where all the constituents are benefiting from a service.

Jason, I also think Chuck hit on it earlier, right? Michelle's team are fantastic partners with us. So we have right -- we follow the exact same model, and we have people that work with Michelle's team who are focused on it. And it really is that we talk a lot about the evangelism, both from the top and from the leadership. And I think we really see that being a big difference.

Yes. I mean, so Michelle is our Chief HR Officer. And we talk about the importance of mental health care in town hall meetings and things like that. So we hear from our employees that hearing from the leadership team empowers them to engage, and so that's why we get 80% utilization on mental health resources. Steph.

Stephanie Demko from SVB Leerink. I have a 2-parter on the virtual primary care solution. The first is you talked about a lot of data metrics that you plan on using? So how are you sourcing this data, and what cybersecurity precautions are you taking, given you're going to have all this? Then the second part is once you do have some of these real-time biometrics, have you considered having both inbound and outbound functionality similar to the Apple Heart Study?

Yes. So again, I'll start, and my experts can provide color. Two sets of data. There's data about the provider network and the efficiency of the provider network. And people like Chuck are expert on that, right? So they're understanding the performance of their provider network in terms of efficiency of delivery, effectiveness of outcomes, ultimate cost of care. And so, we're partnering with our health plan clients in understanding that and then using that data to be able to make intelligent referrals according to their rules. The other set of data is about the health of the member. And so I don't know if you guys want to sort of start to paint the picture of what that looks like.

Yes, we are, as I alluded to in my presentation, going to have a much broader set of inputs from -- to gather data about the patient. Certainly, work -- employers do work tech screenings all the time, as an example, but most of the time, the results don't go anywhere until they sort of sit on your desk, I'm sure many of you have had those. And so we are looking at models and then, actually, in our first launch, we'll be pulling in that data or enabling patients to upload that data. So our providers will have access to that screening data. It could be, you can imagine, from other community laboratory settings, certainly, devices the patient may have or using Apple Health or similar functionality that may be coming out on the Android platform. All of that will be sources of data that, at the patient's choice and discretion, will be available to us. But even when we can't get any of that, we'll be able to create some of that data, ordering labs, for instance, if somebody doesn't have any results. We don't want to create a gate or sort of a barrier to accessing virtual primary care. So we're going to have a pretty flexible model about where that data comes from. And certainly, when we operate in a model where we're enabling that local health system to deliver primary care, there, we'll be deeply tied in with their electronic health record system. So anything that system has on the patient will be available to the PCP.

I would just add the power of the PCP sort of predictably, having spent 20 years of my life doing it, but there's great data to support that. So if you fill out an HRA and it says, you should consider signing up for a smoking cessation program, that's valuable. But if you have a primary care doctor who's actually talking to you about your smoking and then making a referral, there's innumerable studies to show that there's much greater efficacy when your own doctor is making that kind of recommendation. And similarly, with nutrition and in other wellness initiatives, hearing it from your own primary care doctor and then making it easy to take that next action step, I think is also a lot of the power of the model. And we're also just obviously providing that very easy access to that kind of top-level talent.

Yes. I think just to maybe put a punctuation mark here, and then we'll take one more question, is one of the challenges with primary care is if you're lucky, the person goes for an annual checkup and then if they have a cold or the flu or the stomach virus or something like that. But that's not really longitudinal health care. That's episodic acute care and maybe an annual checkup, again, if you're lucky. The difference here is by making it -- by breaking down the geographic barriers and bringing health care to the consumer, you can increase the velocity and the frequency of the interaction and, therefore, the power of the data. And so to your point, that enables a much more 2-way communication that's at a much more frequent basis with significantly higher value, both to the consumer from an experience perspective and for their health. We have one more question.

Taylor Ogan, Snow Bull Capital. So mental health has clearly been a big growth driver for you. How do you -- what's in the pipeline for mental health, expanding that? Are you trying to go into universities, high schools? And then building off of Lisa's question, what do you -- how do you deal with people who want to see the same doctor for mental health consistently?

Yes. So I'll just clarify the latter half and then maybe Dan, Lew, David, you can chime in on road map for mental health. So our mental health is always a longitudinal relationship between a provider and a patient over multiple visits regardless of whether it's on a direct-to-consumer basis or on a B2B2C basis. It's always the same provider with that patient. And it may be multiple providers. So you may have a therapist who's having frequent interactions and a psychiatrist who's having less frequent, but still longitudinal relationship with the patient. Do you guys want to talk about road map?

I'll just add a couple. Certainly, where you were alluding to is actually -- is certainly part of the road map, so expanding to be able to take care of adolescents, as an example. The university market, college university market, is also an area of opportunity and growth for us and applying -- you can understand why I don't even need to explain it, why that's a great setting, particularly for our BetterHelp offering, which is really sort of the type of technology experience that, that age group is looking for. And globally. So we've continued to roll out programs globally. So in the U.K., other European countries are tied to our mental health Navigator offering. So lots of opportunity still in greenfield to go there. I don't know whether you guys want to add anything.

The only thing that I would like to add is that, increasingly, a number of our clients are looking to us to have creative solutions around substance abuse. So we recently did hire a new Vice President for our mental health program from Mass General Hospital. Dr. Kim Rosen, absolutely wonderful clinician and leader. And we are speaking to a number of organizations about how we might be able to creatively address a piece of this problem in terms of just the scourge of opioid addiction in the U.S. and globally. So that is another area of keen interest, along with the earlier comments around what types of digital tools can we increasingly prescribe. So as we think about formulary, we shouldn't just be thinking about medication. I think we should be thinking about really highly effective digital tools that can help individuals get better.

So I think that concludes our Q&A for the morning. Again, we'll be back in the afternoon for another Q&A session after Mala's section. I'm going to hand it to Patrick for the lunch instructions. And I think we have a little video closing the morning.

Do you have the clicker? Someone steal my clicker? Thanks. So in a few minutes, when we break for lunch, the InTouch team will have a demo set up for you guys in the 2 board rooms down the hall. If everyone can just take a look at the back of your name tags. You should see a number, hopefully. If you see the number 1, you'll be going to the Radio City ballroom -- boardroom. If you see number 2, you'll be going to the Rockefeller boardroom. If you have 3 or 4, you'll grab lunch first, then after about 15 or 20 minutes, we'll rotate you into those boardrooms. For those of you listening online, we'll have a video that will play over the webcast of the demonstration center. And before we break, we have a short client video here that will hopefully help drive home what all of you -- what we've shown here this morning. [Presentation]

Okay. So you guys can head out this door. Group 1, again, Radio City Boardroom; Group 2, Rockefeller Boardroom; Group 3 and 4, we'll rotate you in. If you don't have a number, you're stuck having lunch with me. And everyone, please be back at 1:00 for the afternoon session. [Break]

My name is Joe Devivo. I'm Chief Executive Officer of InTouch Health. We're going to do product demonstrations for everyone live. But being at home, we wanted you to be able to experience it well. So we'll introduce InTouch Health, and then we'll show you some really cool applications. So let's go to InTouch Health. InTouch Health is a high acuity telemedicine company in its origin. And at the core fabric, if you want to know InTouch, everything that we do is about maintaining the secret interaction between a physician and a patient. That's a trusting interaction. That is everything about InTouch. We obsess over that relationship and making sure technology melts away and that interaction always stays present. So to know health care is to understand that health care is really a patchwork of locations. We go to the doctor's office. We go to the urgent care clinic. We go to emergency rooms. We go to hospitals. Skilled nursing facilities, there's all these different places that are locations. And these locations are where we receive care; it's where we meet doctors. Now each of those health care locations have security. They have to ensure patient data is protected, and they're all not interoperable. If you know one thing about InTouch, InTouch is the platform that will virtualize health care from the inside of the health system out. Our company is focused on how do we allow that physician/patient interaction in a tremendously sophisticated environment to occur and occur every single time. And in order to make that work, InTouch built a network. Now network is a very generic term. But the network that we built is a set of data centers that are placed all around the world in a secure private cloud that allows a physician to authenticate into our cloud and go to any one of the locations that are credentialed to go give a consultation with a patient in a safe, highly reliable environment. We are almost a managed service provider for IT and for technology that melts away every time the physician and patient interact. To make that happen, it's very complicated. We need software to be able to allow those interactions, to manage the data, to see imaging, to schedule. We need the network to create that connection. And then we need devices and devices are very important because that, in a health care setting, is what they're actually looking at when they're interacting with a physician. And in order to give a physician the greatest amount of power, the greatest amount of information and control to understand that patient situation, some of the technology inside the devices are absolutely essential. So InTouch makes those devices. And all of that comes into an operating system, and we'll unpack that for you a little bit more. But what's so important is the ability to not just have the interaction within a certain ecosystem that they're comfortable with, but to allow any physician to launch anywhere in the world and that is what our Solo platform is, and I'll unpack Solo for you a little bit more in just a moment. The biggest challenge is to allow one physician through one application to get to anywhere that patient is, whether they're inside the health system or not, and each of those locations determine what type of technology and what type of device is necessary. InTouch has focused so much on the provider to allow them to have the simplicity to go from any environment, any location with tremendous ease. So for the physician, this is the Solo dashboard. From this one powerful software platform, the physician can launch to anywhere the patient is. This is the way that we focus on helping physicians put the patients first. If we make it easy for the physicians, the patients will just have the absolute best experience in their telehealth encounter. So let's now go through some demonstrations. We're going to show you an emergent use case, where it's a high acuity with a device that is in most of the emergency rooms throughout the United States. We'll show you a specialty clinic environment, and then we'll show you how we can allow that physician to interact in the home. So let's get started. Okay, so for this first demonstration, I'm going to need my solution architecture extraordinaire here at InTouch, Brian Kopacz, who is going to play the role of Dr. Kopacz, as you see on the screen, and walk us through the first emergent high-acuity case. Brian?

Thank you, Joe. One of the things I want to highlight here first is we talk about high acuity and I think in these use cases, knowing that we have the ability to solve many of them, one of the things we focus on here is speed and efficiency. It's paramount that we get the provider to connect to the patient as quickly as possible in these scenarios, and I want to show that, how quickly and how efficiently we can do that in our system. So looking at our Solo, the provider has been provisioned whatever devices that they have been entitled to be able to connect to. I'm going to connect to our Room 1 light. And in a matter of 2 clicks, you can see how quickly the connection is made between the provider and the patient. The initial view that we see is the widescreen panoramic view that the light has with its camera capabilities, but also, we have the ability to utilize some of the built-in functionality, being able to box and zoom in on the patient, being able to move the camera from left to right. We also can zoom in on areas that we would need to review, potentially, a pupil, to begin looking for any dilation or anything like that. So the camera is very capability with the zoom that we have to not only be able to zoom in on a patient, but also be able to zoom out and see the full view. I would like to pitch it back to Joe at this point to take a look more at the hardware and some of the functionality that we have there.

So on the device side, first of all, you see -- you know it's Dr. Kopacz here, so the patient has that identification. One of the core parts of our device technology, as we said, was maintaining that intimate relationship between the physician and the patient. There's nothing creepier than having a camera stare at you while someone's looking in a different direction. And so in order to maintain that intimate connection, when the physician's talking to the patient, the physician's facing the patient and has full peripheral view with one camera, but then a significant capability to zoom. But when they talk to the family member or another patient, they can -- the physician can actually articulate the device and have another intimate conversation. And to that extent, on the device also are peripheral ports to ultrasound, other types of devices can come into this device and stream a picture in picture into the doctor, so they can see wavelengths, they can see ultrasound and other types of items. And also, in an emergency room, it's very noisy. We have directional sound, so if a person who's speaking here next to someone else who's speaking at the same audible level, if you point to them, you'll hear them much louder as we see in many urgent care and also emergency rooms where it's noisy and boisterous. So for this next demo, we're going to talk about the specialty clinic use case and Brian, again, is going to do the physician site demonstration and then Chris Joslin and Scott Emrick, who are in our sales force, are going to help us on the patient side. So over to you, Brian.

Very good. Thank you very much, Joe. I think, again, one of the things to highlight here is scale, right, so the ability for me as a provider, a cardiologist perhaps who is servicing a large region, where I need to potentially service one or many clinics. So this platform enables me to be able to not only have scheduled or unscheduled and on-demand visits at a clinic, but also turn around and potentially be at a different clinic that same day. So when you think about cardiology, I have a follow-up visit with a patient and that patient is going to be Scott. And what I am going to do now is pivot over to Chris and Scott, and have them show you from the patient's side the process that they would to get into the waiting room.

I'm first going to illustrate that this device is not the same device you saw before. This is a lower-scaled, low-acuity device but the purpose is that Solo can enable the workflow through to accept the patient in and connect the provider or the specialist to a location that they're normally not accessible to. So we're going to beam in a provider, but I thought it would be of interest to understand that in this process, Scott is in his home community clinic and I'm his medical assistant. So we've taken the center of excellence and we've virtualized it so that Scott does not have to drive 2 hours to visit his cardiologist in a follow-up appointment. As the medical assistant, I've taken in all of Scott's vitals, I've placed them into the information for the provider, and then I will let the provider or the cardiologist know that Scott is ready to be seen. I verify Scott as the patient and I request the consultation from the provider. So now, Scott, we're ready to be seen by our cardiologist.

Excellent.

I as the provider am at the center of excellence and I have received a notification that Scott is ready to be seen. The provider then can review any information that they might have gathered on that patient, vitals or questionnaires or consents, but ultimately, after that review, the provider then can click connect to connect in to me with that patient. And this is kicking off not only the session for the provider but also, on the device, it is beginning to establish that connection as well. So looking at the video, you can see I as the provider and now we have Scott and Chris on the screen and similar to the use case that we showed in emergent, much of the same functionality exists with the VT as well, the ability to do things like boxed zoom, the ability to move the camera left/right and the ability really just to reset and bring that camera to its default position. So this concludes the use case showing a specialty follow-up clinic. I'm going to go ahead and end this session now and I would like to invite Joe back in just to kind of summarize what we're able to see today.

Thank you, Brian. Good job, Chris, Scott. Thanks. Okay. So what's important about this specialty clinic use case is it's truly leveraging a very valued specialist in a rural area, so the patients themselves get to stay home, get to go to a virtual clinic nearby which would be, say, some virtual center of excellence. That virtual clinic is not paying to have a full-time specialist on the staff, they're only paying for the time that that physician is present. And the physician at the hub can make an impact in many different regional hubs where one physician can, through Solo, manage going into one clinic and out of another clinic having a single cue and leveraging their expertise.

Finally, if we look at that same patient that we've been following, Scott, now Scott is at home where we've made Scott come into the clinic before and have his previous meeting, now we're actually going to schedule an appointment with Scott. So you could see on the screen that for this particular waiting room that I am scheduling a new visit. The difference is in this case, if you noticed, Scott is actually going to be initiating this session from the comfort of his couch using his own device. Now that we've scheduled this appointment with Scott, Scott has received a notification. It has a link in there that will allow Scott to start the intake process in order to get Scott into the waiting room ready to be seen by the professional. Hello, Scott. How are you this morning?

Good, Dr. Kopacz. How are you?

Very good. Very good. So thank you very much for allowing us to demonstrate today. We're now going to pivot back to Joe, so he can summarize all that we've shown.

So I hope you've enjoyed this brief introduction into InTouch Health. Later this afternoon, Jason Gorevic, myself, and some clients are going to discuss all the ways that InTouch Health and Teladoc come together to provide a whole new solution in health care.

We pride ourselves on quality box lunches, so we hope you had a good lunch. We pride ourselves on quality box lunches, so we hope you had a good lunch. We also really, really appreciate the Intouch health team running the demo and forgoing their quality box lunch to help bring that to light for you. And I was in at least one of the sessions. And it's nice to see the eyes light up of all of you as you get to see it and experience it, just like we've had the opportunity to do. And hopefully, that is the sort of on-ramp to this discussion, right? Because I think you can conceptualize it and you can hear me talk about the opportunity and why and why this is the right thing and why now, but until you really see it and until you see that sort of box zoom right in on the pupil and it comes to life for you and you understand how the doctor remotely, whether across town or across the country or around the world, can see what that looks like and deliver care into that remote location, it's hard to conceptualize. And so, again, thanks to the InTouch Health team. I'm going to go through just a little bit of an introduction. I'm going to keep this very brief. Because what I really want you to do is hear from Joe DeVivo, who has a lot to be proud of and has been a phenomenal partner through this process. So hopefully, this is really obvious. Why facility-based telemedicine? Well, first and foremost, both doctors and patients are in hospitals and in health systems, right? The majority of care is still delivered within those 4 walls. And we have this situation of underutilization of technology and specifically telemedicine technology, you have scarce resources who are very expensive, and you need to capitalize on those resources. The clinical use cases that are being virtualized is rapidly expanding. So telestroke, I would say, broke ground here, and there is this flood of additional clinical use cases. And all around, there are market tailwinds here. All of the same tailwinds that we've seen outside the walls of the hospital and health systems also exist within the hospital and health systems and from facility to facility. And so why InTouch? Well, hopefully, you got a taste of that. Very, very common culture focused on high-quality medicine, like you heard from Lew, you're going to hear the same thing from Joe. A very strong business model and financial profile. You're going to hear about recurring revenue, you're going to hear about growth and you're going to hear about strong gross margins as we get into the details of what the financials look like. And we feel very strongly in putting market leaders together. And each independently, each company who is a market leader. And together, that becomes exponentially stronger. Their market leadership is the product of many years of development and evolution. And so you're going to hear Joe talk about the evolution of their technology platform, the evolution of their use cases, the evolution of their business model. And from their founding, all the way through to today, they are the market leader. And so one of the things we went out and did is a lot of client interviews. We wanted to talk to their clients, some of them are common clients, but most of them aren't and we wanted to understand what they see. And the resounding continued refrain was that they love this company because they facilitate exactly what they want to do, get more efficient, deliver higher quality care and improve outcomes. And so you're going to see this over time, and you're going to hear Joe talk about their #1 class rating that goes along with Teladoc Health's #1 J.D. Power rating. Together, and I alluded to this at the beginning, and this sort of expands on it, and then you're going to hear about even more from Joe, this gives us the ability to cross across all the entire spectrum of clinical specialties and use cases and in all facilities and locations across the patient's journey. And I say facilities and locations because sometimes those are in facilities, brick-and-mortar facilities, and sometimes they're not, sometimes the care location is the home, right? Or the care location is a community center. Or the care location is a walk-in clinic, right. And other times, it's in a much bigger building with a lot more capital poured into it. But still, may not have the specialist there on site, right? And so this gives us the same experience for both the doctor and the patient, regardless of where they are in the health care system. And together, we partner with some of the world's leading organizations, right? So InTouch health has an incredible cadre of clients that they serve, both with the technology that they provide and the services that they provide, but also, in some cases, with the infrastructure that they manage and other technology companies look to them to ride on that infrastructure and ride on that network. And together, we serve employers and health plans and insurers and the opportunity abounds in all of the different channels that David talked about in his presentation as we serve all around the world. And then lastly, I just wanted to touch on, people have asked, well, what's the opportunity here? Like how big could this be? How big -- you make an acquisition, you spend capital on it, how big could it be? What's the opportunity? Just in the U.S., we see this as over a $10 billion opportunity. And again, this is a global opportunity, right? So InTouch Health historically has a small footprint outside the U.S. Obviously, you saw just before we went to the break, the AIG video and Teladoc Health has a larger footprint outside the U.S. and we see this as just a fraction of the global opportunity, right? And so I encourage you to pay close attention to the evolution of InTouch Health because what you saw there is the current state. And I think what you're going to hear from Joe is how they got there and where, together, we can go. So with that, I'll ask Joe DeVivo to come up and talk about InTouch Health.

Great. Thank you. Thank you, Jason.

Thanks, Joe.

It's such an honor to be here. Thank you for the Teladoc team for welcoming us so warmly into the family. You'll see pretty shortly why this makes so much sense if you haven't already. I'd like to introduce myself, though. So I've been in the medical device industry for 20, 25 years. I started working at U.S. Surgical just up the road and saw the dawn of minimally invasive surgery. Then I was fortunate enough to see the dawn of surgical robotics and working for Computer Motion. I've ran a global orthopedics business. And now I'm pleased to be at the dawn of virtual care. This is just the beginning, and it's very exciting. So what am I going to talk to you about today? I'm going to unpack our technology a little bit, so you can understand our software, our hardware, our solutions. I'm going to talk about what some of the benefits of us being together are. And then our financial model, the market opportunity, how do we go to market and how do we do business. To know InTouch is to know health care and the care locations. We all go to a doctor's office. We all go to an urgent care clinic. We go to the emergency room, hopefully not, anyone here, but we do. Hospitals, skilled nursing facilities, these are all locations. These are places, and these places weren't designed all the same. They have different processes. They have different IT infrastructures. They have different EMRs. They have different instances of an EMR. So the whole premise in telehealth is fractionalizing a physician and getting them to provide care in new locations. But when you don't have interoperability, it's a big, big challenge. I mean President Trump is going to speak next week at HIMSS on EMR interoperability. And if any of you were going to be at HIMSS, it was just canceled. But that's how important the topic of interoperability is in health care. Leave here knowing one thing about InTouch is that InTouch is the platform, which will help virtualize health care from the inside of the health system out. Health care is hard. Especially a lot of people in general industries would think, oh, we can create a product and then it's because we do it in this industry, it can transfer into health care. Health care is not easy. It's regulated. It's secure. It has consequences. We're managing patients. And so to sometimes provide a task or a value or a proposition, outside the health care system is easy, but inside is challenging. And so everything that we do is making that work. So we can have a secret interaction between a physician and patient. That's the essence. Let the technology melt away and ensure that, that continues. So this -- I saw Judd in here earlier. He'll be speaking in a bit from Thomas Jefferson. If you go to their neuroscience lobby, you'll see this image. And so they were gracious to let me show this. This is an image of Thomas Jefferson in Philadelphia, where their neuroscience department helps 38 different emergency rooms in their periphery, provide care. Well, why is that important? Well, about 1% of the time, a stroke patient will go to an emergency room. So what do you think the probability of a neurologist sitting in that emergency room, reading Time Magazine, waiting for that case is? Virtually 0. Now these patients, when they go to that emergency room, don't have a lot of time to be treated. And if you treat someone who doesn't have a stroke, they'll die. So it's a pretty important decision to make. So how do you improve this? There's 800,000 strokes throughout the United States, only 450,000 of them get to a health system. So what Thomas Jefferson does is take their expertise and launch it into 38 unaffiliated environments to provide immediate care to help patients who go into that facility. That is what InTouch does. Okay. So now to know InTouch, I have the luxury and the pleasure to introduce you to InTouch. So to know us is to know our culture and to know our founder, Dr. Yulun Wang. He's a surfer. He's the coolest guy you'll ever meet in your life. He's lived in the same house for 35 years. He started 2 businesses within a mile and a half of his home and his surfing spot. And he had a vision. And one thing about Dr. Wang is he's a visionary. He saw surgical robotics before anybody else. Has anyone heard of Intuitive Surgical? Okay. Well, 4 years before Intuitive Surgical was even incorporated, $65 billion company today, Yulun founded the first surgical robot company. And the heritage is, is surgical robotics and a medical company. So of course, in surgery, you have to be medical, regulated, et cetera. So in 2003, Intuitive Surgical acquired Computer Motion. And then from that platform, Yulun started InTouch Health. Well, what are the similarities? Well, right at that time, a procedure was done where they separated the console of the robot from the robotic arms and replaced 20 feet of cable with 4,000 miles of cable. Where on September 7, 2001, remember that date, 43 minutes, Professor Jacques Marescaux took the gallbladder out of a patient in France, sitting right here in New York City. And on September 11, 2001, they were on the Good Morning America's set just about to talk about that procedure when the towers came down. It's the most expensive, complex operation ever performed that no one's ever heard of. So that informed his journey because when you see the ZEUS robot, this is the old Computer Motion robot, what you see are 2 different things sitting here where there's a physician at a console, and there are robotic arms that sit over the patient. Well, what Yulun saw was there's 20 feet of cable between them. So what's happening, a surgeon is digitally transmuting their skills albeit 20 feet away. But the visionary in Yulun didn't just see the ability to scale and to provide accuracy in delicate operations, he saw the ability to create distance. And so the reason was -- Professor Marescaux here on the left and also Michel Gagner from New York City were able to do this operation, to digitally translate their capabilities all the way across the world. And that informed InTouch and InTouch started to create robots and people got interested. Some pretty sophisticated people got interested, as you see Yulun here on the right. And everyone loves robots, it always hits the press. And we are able to do things for people in some dangerous remote areas. And this is not our first outbreak. We -- the technology is being used to help not only transmute clinical expertise but to protect local caregivers. And even in some situations, where people might perceive it's not as sensitive, actually giving end-of-life consultations through a robot. And I think new protocols ensure that if a doctor sees something, they'll have someone in place. Some of these doctors wouldn't have even been there to diagnose if it wasn't for the robot because these are in remote locations. And now this is recent. So we're also a part of a solution in facilities. So we started off looking for a use case. We found telestroke in 2008, built an enormous market for ourselves in a great position. We then identified that our technology is fungible and can be used for multiple use cases. And then health systems since 2016 have said, "Hey, I get it. Let's -- but we need a platform that can be there for every use case." And this has been our evolution. We'll talk about class in a bit, but 2019 was about $80 million in revenue. About 70% of our revenue's recursive. So this is the last I'm going to talk about robots because we've pivoted to becoming a network and software company, and I'll show you how in some of the demos, you've seen that many use cases, and we're with all the blue-chip health systems. And this looks like a Teladoc slide doesn't it. Everything you see is up into the right, up into the right, well, we're there with you. We -- so -- and to know us, again, locations, users, where is the patient being seen and how many doctors are on our network. That's a pretty good metric. And then how many procedures or sessions, we call them sessions are occurring. So our session growth, our user growth, location growth and customers are growing. But as we penetrate a lot of customers, we see that even our growth rate of customers is less than our growth rate of all of our sessions and users because we're penetrating existing accounts, and we're driving new and new use cases. So it's very, very exciting. I need to show you this video because this will bring it to life. [Presentation]

It's a video, but you can applause. So the Mayo Clinic provides neonatology care to 10 major -- to 10 rural hospitals, who don't have a neonatologist on staff. And that's a simulation because we don't record sessions. And that simulation is a car crash victim, who delivered -- and this is not unusual, this is how they train their staff and how they identify this. Is that videoconferencing? What if you have a dropped call? What if something goes wrong? That's not an environment where something can go wrong. You need purpose-built technology that's focused on the entire experience, from the device to the network, to the software, to the facilities, to the integration, to the data, to the patient. That software that you saw there has a predetermined workflow, which requires them to step through the workflow to ensure that in those critical situations that they're identifying and they're a part of every step from a safety and security standpoint, that they have all those considerations. That is high-acuity telehealth, and I wanted to help bring that to life to you. So what does it require in order to do something like this, to have one facility provide consultations into another facility, that's completely unaffiliated? It's like me getting into each of your data systems in each one of your companies. How can I do that? I'd have to download 117 VPNs on my computer. I'd have to have 117 passwords that change every 30 days. Impossible. So in the beginning, when they stopped building the robot and said, you know what, this robot's cool, but I can't speak to it when it's inside one of these facilities. So the company totally pivoted to a networking company to figure out how do I link all of these facilities. So instead of traversing the VPN, we came up with a proprietary, secure protocol that allows our cloud to communicate directly to the device. So that physician who authenticates into InTouch once is 1 click away from any facility they're credentialed. We have user accounts. We know every doctor. We know where they're allowed to go, and we have a 24/7 monitoring where we receive about 100 phone calls a day from customers who are having issues. We place 300 phone calls a day to sites that are having issues that they don't know that are happening. Their network is down, we call them. They unplug the device, we call them. Something wrong with the software, we call them. Why? Has to work all the time. So I think you get the point now, right? So what we built was an operating system and an operating system that enabled that interoperability, that allowed you to operate within your ecosystem, but also operate in someone else's ecosystem, and it's very complex. So I'm not going to go through this. We'll be put here into you. So you can ask Jason questions about this for the rest of his life. So -- and that network is pretty proven. So to be able to have one password for 3,600 locations, 1,600 hospitals, who else has that? Nobody. And other companies have said, "You know what, you guys have built some architecture for yourself that, hey, could we leverage?" So we signed a pretty big deal with Intuitive. All 6,000 of their robots around the world will be connected through our environment. They will pull data out of the robot. They will push very important data to them. And if you follow Intuitive, it's their IRIS program. GE also, every MR that's installed today, there is InTouch software next to it. Why? Because they have to have a technician that not only installs it, but is there for the first 10 weeks. Any questions, any issues, they go through InTouch to get to that install. They do their training. It's called a virtual online trainer. You go on GE, Google it, you'll see their videos. It's built on the backs of the InTouch platform. Now GE is launching Mural, which is their ICU product, and it's all powered audio/visual through InTouch. So we're not the only ones who profess the power of our network. Our vision is to leverage every specialist in the health system to be the most productive. You lose 1 hour of physician time, you never get it back. Anyone ever hear of a power grid? Power grids operate because you can't store energy. If you can't store energy, it dissipates, you lose it. But if you redirect it to an area where it's needed, you capture that value. It's the same thing. Any organization that's high in labor is inefficient. Health care is 55% to 60% labor, incredibly inefficient. So we can help power not only improving access to care, but we can reduce cost of the care. I'm a firm believer that there are -- if there are 5 solutions to the global health care problem, I, unfortunately, cannot name all 5, but I can tell you there one of the 5 and that's virtual care. And that's now the collective product offering of Teladoc. So it takes software devices to create use cases. I think I pounded that in your head. I'll say it multiple times, but it's all this technology, and we make our own devices because there aren't devices that do what we do. But one of the profound things we did 4 years ago was we took the software out of our robots, and we started putting them on tablets and our phones and PCs. And now many of our enterprise hospital customers have hundreds of locations that are just buying software from us and paying for our network access, and that's how we pivoted from a hardware company to a complete digital engagement company. And talking about digital engagement, we think about all the use cases that can happen where you can deal with it remotely. I'm here to tell you that every single step or every procedure, every specialty will be impacted by digital care in the future. It's just a function of what is it and what's the use case. And let me explain to you what I mean. So you can go anywhere from primary care through follow-up when you enter in and through the health system. So today, all of those -- think of all the different specialties. You have nephrology, orthopedics. Well, you can do virtual care with orthopedics? Well, sure, you can. You have to follow the patient after, want to see their gate, you want to see workup. So the power of this is, today, the types of virtual use cases are the ones that you're hearing about quite readily; the ones that Teladoc provides, the ones that InTouch provides. But the road map is, like, if you look at banking, there's a digital journey in banking. You still have face-to-face interactions. They didn't put banking out of business. They just shifted the landscape of the branches and shifted what this overall footprint would be. But you now are delighting your consumers by empowering them or for those of you who flew here, you went online and booked your flights. Same thing is going to happen for health care. And the combination of InTouch and Teladoc is going to be a core part of the digital revolution of health care regardless of use case. Because just because it's a surgery and you're cutting them open, the workup beforehand, the follow-up after, there is no reason to have to log yourself into a doctor's office in order just to see your incision or to see your gate. You can do that at home and make it convenient and reduce the cost and reduce the trouble of health care, and so that is very software and power now. So the power that we give clinicians is extraordinary, and there is a ton of different ways, they give them images and data and that's a part of making this overall work. So now a little bit more about InTouch and the financial part. So we do have about 30% of our revenues are hardware. That network I talked to you about is about 27%. You see it's about 30% software. And we do provide neurology services, and that's about 7% of our revenue. How do we get paid? Simple. What did I talk about? Care locations' users. So we charge a monthly fee for care locations, can be anywhere from a robot to a piece of software. We charge a monthly fee for users. And depending upon how many modules they use is the more they pay per month. It's very simple. We've been #1 in the last 3 years. KLAS started looking at virtual care platforms, enterprise platforms. So this is not a category that Teladoc has been in, so it's not a win-lose thing. So for a virtual care platform, 2018, 2019, 2020, and then now J.D. Power, their first year out, just like KLAS' first year, we won. J.D. Power's first year, Teladoc won. We're the #1 company in our space. Teladoc is the #1 company in theirs. And this is, by far, the best virtual company on the planet and will be for a very, very long time. And it empowers that complete spectrum from home to home, every site, be a part of that digital journey in that interoperability because health care systems aren't ready for telehealth. In certain specialties, they need backup. They need support. And so the services Teladoc provides through the networking capabilities that InTouch provides creates a killer offering. So in conclusion, I hope I've communicated to you a little bit about our platform. I hope you understand how excited I am. Hopefully, you've seen a little bit about the organization, and I really appreciate your attention. Thank you. So -- oh, I get applause. You didn't get applause. Yes. So now I'd like to ask David Sides and Judd Hollander to come on up for another session. So David?

Thank you, Joe.

Can you take that?

Fantastic. So Joe didn't tell you that, that baby is not real. The first time I met him last summer, he showed that video and I was crying, by the end I was like, "Please, let the baby live!" Let me introduce Judd. Dr. Judd Hollander is the Associate Dean for Strategic Health Initiatives at Jefferson University and Professor and Vice Chair of Finance in the Department of Emergency Medicine. An ER doc by training. So if anything goes wrong, we're in good hands, between he and Dr. Roga. We're going to talk a little bit about his journey. We'll have time for questions at the end. And why don't we start just kind of a little bit with some of the things you've been doing with virtual care, maybe your Virtual First program and...

All right. So I'm going to do something different today. I have no slides. I'm going to ask you all to take out a pen or a computer and draw. So I could give you a little outline. That'll get you a little engaged, okay? Make a big circle, start at 6:00 o'clock. At 6:00 o'clock, it says baseline, okay? At 7:00 o'clock, it says little sick. At 9:00 o'clock, it says moderately sick. When the clock strikes 12:00 up above, it says emergency department. That's when people get sick enough to go in the emergency department. At 1:00 to 2:00 o'clock, it says acute care and from sort of 3:00 to 6:00 o'clock, it says post-acute care. Patients go around that. They start out at their baseline, whether they're a perfectly healthy 25-year-old that has a cold, and they get a little sick. If they don't get better, they may show up in the ER where 25% of people get admitted, okay? Most go through the acute care phase. Almost all of them get better because we do a pretty good job with them, and then they go back to their baseline, okay? So that's the way we think about things. What makes Jefferson unique is we had in partnership with InTouch a neuro stroke program going back to 2009, so really, really old program. And when I was hired in 2014, I was told to grow at an enterprise-wide telemedicine program. And my instructions were to go all in at once. And the interesting thing that we learned is we weren't smart enough to know where we would have gone if we picked and choose a pilot program here or a pilot program there because the things that worked are not the things that I would have rolled money on. In fact, I still find some of them hard to believe. So urology and ENT were two of our best surgical use cases. Within urology, one of the top 3 things was post-vasectomy care, right? If I was designing a program, I wouldn't say let's take people that just had surgery down there, and put it on a screen and send pictures back to the doctor, right? Just not going to be what I would have guessed, okay? We have been really successful with post-mastectomy care. Again, people would say, "Oh, well, women are going to want to show that on the screen," right? That sounds like not a good idea. On the other hand, the alternative is they're sitting there, half naked in a paper gown in a room when people are coming in and out, looking for a tape measure or a tongue depressor, and so now they can just see their doctor. So we learned, by kind of throwing mud at the walls and doing everything that, different things work. I'm going to give you an example of the way we think about it today, which we never thought about 2 weeks ago. And I'm going to take you through that whole scale of things, the programs we have built out around that circle to take care of our patients beginning at the baseline. And I'm going to just say, let's take a patient with a cold who came back from Italy last week, okay, for a timely example. And this, we are doing real world every day. Right now, unfortunately, timing is not good. I'm supposed to be on a phone call with the CDC that I'll join after this. So I won't be around after I get off the platform. But somebody has a cold, and they call in, and they can do one of 2 things. They could schedule a visit with their doctor. They could see their doctor. Their doctor now would screen them for coronavirus by questions and were they exposed. Or -- so that's the established doctor-patient relationship. And we break down use cases, I'll back up for a minute, into 2 broad categories. It's patient to provider, and then it can be an on-demand visit, which you've heard a lot about at direct-to-consumer and on-demand telemedicine today. Or it's provider to provider, okay? And provider to provider is kind of like what you just saw with the neonatal resuscitation. It's somebody who's smarter than somebody who doesn't have that level of expertise, getting walked through the procedure. So all of a sudden, they're -- somebody's at the bedside and somebody else has the expertise, and that works great. And I'll go back to the patient to provider and say, this performs on-demand and established visits. So either just calling an ER doc at Jefferson, I'm there 24/7/365, or one of my colleagues are, for on-demand. Or you might be seeing your ENT urologist, your surgeon, or your primary care doc because 2,500 people as of yesterday in our system were doing telemedicine visits, and we expect that to be 3,500 by March 16 so that everybody is coronavirus-enabled to do telemedicine. So back to the baseline. Fall off the baseline, little sick, need to be screened for a cold, coronavirus, the flu, whatever it is. You can either call your own doctor and do an established patient-to-provider a visit or you could call the JeffConnect on-demand app, which is a Teladoc white-labeled product that to the world looks like Jefferson, but it's powered by Teladoc. And since this is about Teladoc, what makes us use that is it's actually built for a health system. It's the only one that I know that was designed from the bottom-up built for me to use in the health system. So it works really well for my docs to use. And so patients log on, they download it from any one of the app stores or you can go on to jeffconnect.com or jeffconnect.org, register in 2 to 3 minutes, and then do your visit with a 3- to 4-minute wait after that. Our metric is nobody should ever wait more than 5 minutes. You are seen on that. We say, "Oops, you went to Italy, you probably should go to home quarantine or you should get testing," depending on where testing is available. We have network. We're now a local department of health, so they'll go to your house and do the testing if you're in Pennsylvania. If you're in New Jersey and you wanted testing, we have to use a different system for that, okay? Most of the patients we see with colds and sniffles, whether it be coronavirus or not, are fine. And they don't need to go anywhere, it's about symptom control. But if they get sicker or it's something that requires more testing, we take our JeffConnect app, and we, sort of working with Teladoc, have something called the virtual emergency department, where we could send them to get labs. Right now, we can send them to get coronavirus testing anywhere, automated system, or we can send them to get CAT scans or X-rays, if it's a different kind of patient and they need it. They go get it, it feeds back into the system. If they go into the emergency department, we have some technologies we use in the emergency department that are particularly relevant in coronavirus. We've been doing this for years. If you come into the emergency department, you are seen remotely. There is one provider off-site; can be at home. Most of the time, it's in a Jefferson facility, and that one provider covers 2 emergency departments. We don't have a triage nurse in most of those situations. So they come in, they see the doctor. The doctor does an exam via telemedicine, write orders on the patient and writes a note in the chart. Again, in this situation where I don't want people coughing and sneezing on me or even to walk in the room and shake their hands, this is perfect. It prevents that from happening, okay? Then they go into the acute care setting. If they're really sick and it's a neuro stroke program like for InTouch or any of the other use cases InTouch has, and you see they have tons of them, they can be seen by a remote physician with more expertise, if that's needed. At our shop in coronavirus territory now, we actually hand the patient an iPad, and they go in the room and there's paired iPads and nobody else needs to go in the room unless the patient's sick enough that somebody else needs to go into the room to do something. So we separate people out. We have used the JeffConnect app to do screening for coronavirus on our premises in the emergency department, and we have done it from home. Fortunately, in Pennsylvania, we don't yet have a positive, but we've done this screening in both of those situations. If you then need to be admitted to the hospital and go further into the acute care setting, we have the ability to screen you and take care of you, sometimes using InTouch technology, sometimes using other technologies, depending on the partnerships. So you could be seen remotely while you're in the ICU and continue to get your care. When you get better in the home, what makes this really unique is that we can then do established visits virtually with your own provider to prevent readmissions, which you will hear about is a big thing that CMS propagates in commercial payers. So we can reduce readmissions. One of the platforms Jefferson's been working on with InTouch is a tele-sepsis platform. And what you saw -- you heard about the neuro stroke program we have, and what you saw in the example that was shown on video, there is clinical decision support built in. It makes the assumption that ER docs are really busy. And when you get somebody really sick, you can't spend an hour in the room with that patient. Unfortunately, there's another 25 patients waiting to come back, and you don't know if they're sick or not sick yet. So being able to outsource the care, so someone else can watch that patient march through the clinical decision algorithm, maybe with a nurse, maybe with a resident, with somebody else, really gives us the ability to scale the amount of patients that we could care for and make sure they get great care along the line. So we've built that whole continuum and what excites me, and one of the reasons why David and others asked me to be here, is we've worked with InTouch, we know their capabilities. We've worked with Teladoc Health, we know their capabilities. And it now goes all around that circle. And using coronavirus as the example, we didn't have to make this up this week. This was all built out. I was -- "Judd, you're on the coronavirus task force, figure this out, how are we going to make this work?" And it doesn't take a long time to do it. One of the things that I always say is, if you don't have a baseline program when a disaster hits, you're not solving it. It's not in yourself. But fortunately, just talking to Teladoc a lot here today, they got a whole bunch of programs that could be rolled out that are useful for coronavirus. Some of it is pretty self-evident. You've heard about already. There are some other things coming down the pike that will extend past the typical Teladoc reach that should be out in the short period. But you need a baseline program to be able to take care of people. And so I picked the timely example, but I could do that with stroke patients, I could do that with appendicitis, I could run you through that wheel the same way with a million different conditions.

Great. You went down the coronavirus, why don't we keep on that. When we were in Philly a couple of weeks ago talking about this and I thought that Thomas Jefferson had really thought through like the different levels like Lew talked about. So it starts maybe regionally. It gets pandemic -- countrywide, pandemic. You guys have thought through bigger and bigger responses. Why don't you maybe talk about that a little bit?

Yes. So without getting into too much detail because I'm trying to get this published in a really high-profile place. There is 3 approaches that we're trying to deal with: one is, the first case I talked about, which is someone has exposure, someone has a cold, the worried well or the minimally sick, we discussed that already; the second one is they now show up somewhere, and so we have to take care of them. Somebody has to go in the room, but typically, people are going in and out of the room all day, and that's a really bad idea for coronavirus. So we limit it. Registration doesn't need to go in. Med students don't need to go in. Students don't need to go in. In fact, I don't even need to go in to see the patient if they're not really sick. If they're really sick, then we need to go in. So one person will go in, fully gowned and gloved or whatever the recommendations are at the time, and we call them [ pappers, ] but it's the whole respiratory setup. One person will be in there, and the video monitor will be inside and outside, and then we can take care of those people. Because if you need an infectious disease consultant, mostly I need their brain; mostly, I don't need them to listen to the lungs. So I can still get all the brain power I need, but I don't have to kill people off, taking care of patients. And then the third scenario is the -- what when all the providers go down, right? So you've heard, you've read, there are hospitals in California where one person had it and 115 people are furloughed. I was just at a conference, and Joe just mentioned HIMSS was canceled. That's a 40,000 to 50,000 person conference that just got canceled. This is going to happen more. But I was just at a conference with only 200 people. Woman I was meeting with is from Israel. She got back to Israel, they said that by definition, is an international conference. You're on quarantine for 14 days. So we are going to lose providers. They are going to be out. And the question is, how are you going to take care of patients when providers are out and telemedicine is obviously the answer. And the answer is to make sure enough providers are trained so they can take care of people, whether or not the provider can go to work. I do telemedicine from home all the time. It's fine. I VPN into my hospital's EMR. I do the documentation. I do what I need to do. The last thing we want is people going to the emergency department for testing because they'll walk past everybody else who is in the emergency department without coronavirus. Couple of people will get it, a whole bunch of people whether they get it or not will go out on quarantine and will shut down the health care system. So this virus is almost like telemedicine was built to deal with this. And it's companies like Teladoc Health that are out there already and are creative and quickly, on the fly, could add more solutions to more people to get out there that make a difference.

Well, and we talked about one way that involved those quarantined care providers is telehealth. So if you're going to be quarantined for 14 days, you're going to get tired to watching Netflix and be able to actually work again with people. It's a way to actually get capacity back in the system.

Yes. And we'll just swap. The person who's not quarantined will now go do in-person work and the person who is quarantined, if they were assigned to do in-person work, will go be home. At least, gives us a little excess capacity. We can't have everybody work from home because a lot of patients still need to be touched and examined, but it gives us an ability that other people may not have.

Great. Talk a little bit maybe about the benefits that you give to your own employees, kind of similar to Jason's story about what we do with our Teladoc employees, and how they can access the system.

Oh, so this is really cool. We have really tried to push out telemedicine in our whole region. But in our employee plan, January 2019, our very forward-thinking CEO, Steve Klasko, if you guys got nothing to do or you're quarantined and need Netflix, watch Klasko's TED Talk, it's great, very inspiring about the future of health care for real, said, let's try and drive people in the telemedicine who can benefit from telemedicine and let's try and reduce costs in our own insurance pool, we're self-insured, over $100 million that we pay a year. So we said since ER docs and all program staff are telemedicine program, if you call JeffConnect and you see an ER doc and they can't fix you via telemedicine, we'll wipe out your co-pay, if you go to the ER. We'll wipe out your co-pay, if you go to urgent care. And I think we even wipe out the co-pay if you get admitted to the hospital after you've done that. So if you're a patient and you don't call JeffConnect, and you're in our system, you're just wasting a lot of money. So literally overnight, adoption or utilization went up fourfold. And although, there is other things we've done in our employee pool, we've cut -- from what I hear, there's not my finances, we're reduced our employee spend on health care by 5% within 1 year. That's a pretty big number when you're talking about 35,000 employees.

Great. Love the stories. I want to be sure you get time to ask questions as well. Let me take questions from the audience, please.

Just on that white-label product that you're talking about, this decision for buy versus build in house, just can you talk through how you came to buy in Teladoc versus the provider choice?

Well, so this is really easy.

So the question was, why Teladoc -- just for the people...

Yes. Why Teladoc buy versus build. We're a health system. We got a big IT department. Teladoc is going to keep up with it. We can build a lot of stuff upfront, but us keeping up with day-to-day stuff. I'll give you an example that's really easy. If we totally built it ourselves, are we going to go in there and change the screening questions today and tomorrow and the next day for coronavirus, based on CDC recommendations? Do we have enough people in our system to keep up with that? My ask of Alan Roga and his team was, can you change that so it's centralized? So every -- I don't have to reeducate everybody who's doing a visit every day across my health system on what the questions are. Can you make it so when a patient registers, they answer the questions, and if it's positive, I see a pop-up on the screen, and I don't need to reeducate anybody? They get a pop up that says, "Hey, they screened positive for coronavirus." So that's just one example of something that in a health system, I don't have a -- I have a smart enough IT department to build something the first time. I don't have the capacity to rebuild it every day when everything else happens. So for us, it was really easy. And then why Teladoc? We did something that I think a lot of other people don't do. We didn't let vendors come to us and do a bright shiny story. We developed an 8-page list of specs that we wanted. And then we went through and had like a real RFP as to who meets the most specs, and then we made them get behind our firewall and test it. And we made them test it on phones, Samsungs, iPhones and different browsers, and said, okay, because everybody says it works everywhere. And you heard Joe from InTouch say, you can't have calls drop. Well nothing is more annoying when you're trying to get your early adopters or your docs to start using something and the patient disappears, right? If that happens, they're gone. They're never doing telemedicine, again, even though it's our enterprise-wide strategy. So we wanted somebody who could prove to us that their drop rate was exceedingly low. And they came in, and we did 10 calls behind our firewall, which is a bit of work just in the sales process. They worked better than anything else. And then the third part of the decision is, I need a doctor to build a platform. I don't need a tech person to build a platform because it needs to have a user interface that the doctors and patients want. And too often tech companies have somebody that has some medical background from 20 years ago that's doing something, but InTouch has a great partnership with us. We've helped design stuff and build with them. Teladoc, Alan Roga, David mentioned, he's a physician, so he knows what's there. They've worked with us. They've worked with other programs that have the physicians on the site, helping to build, and we're in close contact all the time. So I get to have input, but my input is to a doctor. And the beautiful thing about having Lew and Alan, it's to a doctor. They can understand what I'm saying. They can understand what my needs are, and they can relate to it. And when the tech team says, "Oh, that's an extra layer of code, we'll put that in a parking lot," that doesn't happen. So those combination of things are that what got us jazzed and still to this day, I get compliments from our crew on how things work.

Adam Noble from UBS. Just curious, what percent of your clinical staff is trained on InTouch, is trained on the telehealth platform today? And when you think about the number of user licenses that you have with the company, do you see ultimately, 100% of the clinical staff having a user license?Or it was full penetration, 20%, 50%, just any color around there would be helpful?

So I don't know that I should get into the terms of our deal. But our goal is to have every patient who comes to Jefferson, be able to do a telemedicine visit. That doesn't necessarily mean every provider can do it, because if you see rheumatologist A and they don't do it, then maybe rheumatologist B can do it. But our incentive program requires everybody to get trained on telemedicine who is seeing patients. And like I said, we have 3,500 people trained pre-coronavirus outbreak. We now have a mandatory educational program that everybody needs to complete who sees patients in the ambulatory setting by the 16th. So they will all be trained to do telemedicine. So I would say, it realistically won't be 100%, but we'll get into the 80% range in a 2-week period of time, pretty easily. The people that won't be are the hospitalists, okay? Our InTouch program now is largely neuro stroke. We're getting into the telesepsis. So we'll expand that out. Our Teladoc program is the established patient visits right now, so that's largely the backbone of our program.

So I get the value that InTouch is providing you, and I get the value that Teladoc is providing you. I'd like to hear about what you think the synergies are now that they're going to be under the same roof. Why is that better for you, the customer? And what are you going to be asking Jason to deliver on now that both assets are under one roof?

Do I get to say anything and Jason will deliver it because this is my chance?

I'm glad you didn't say David.

I'll put it in writing, so go ahead.

You get that anyway.

So we pretty much do. Well, I think it's just like medical records, okay? So I'm going to give you an analogy. When I got to Jefferson, this sounds like it's a joke. It's not a joke. For me to see a patient in the ER, I needed 11 different EMRs to access. I had one that I would write a note in, but if I wanted to order something, I had to use another medical record. Now I'm in an academic medical center, so there were residents around. So for 6 months, I never learned how to write an order. I was like, can you order this? And then one day I worked alone, and I'm like, "Oh, my god, I better figure this out." But then the results came back to the labs in a different system, EKGs in a different system, outpatient ambulatory clinics were a different system and I could go on and on. And then I would admit somebody upstairs, and the inpatient record would be different. And they're like, why didn't you look at the ambulatory record. And why didn't you find their old EKG from 2004. And I'm like, "Really? I can't remember my passwords for anything but the first one." And then if you don't use the password in the system for 30 days, it locks you out and you have to reset your password. So you could actually go to an ER shift and spend your first 4 hours just logging on to 11 different platforms. So people learn to ignore them, okay? That's the EMR background. I don't want to relive that with telemedicine, right? I want to be able to, I log on to one password. If I'm doing a direct-to-consumer visit, if I'm doing a scheduled visit, if I'm also taking telesepsis calls that day, I would like to be on one platform to do that. So over time, I walked you through that wheel because it gives you the perspective of all the things we're doing. And right now, they are not tied together, but yet the technologies from Teladoc Health can take care of everything around that wheel. So Jason swore just now, as you all heard it, that these would be fully integrated with single sign-on and we'd be able to do everything. And I will say the other thing on neuro stroke guys who have been using InTouch for more than a decade, there are just no dropped calls. That's not true with anything else. There's some lower level dropped calls with most other platforms. Some platforms have much higher rates of dropped calls, really a problem to go back and do it. The InTouch platform, their dropped call rate is effectively 0. I mean -- and so being able to integrate that technology across everything else. And the single sign-on that Joe talked about is just going to make life easier. I think it's a really good partnership to expand the portfolio of services that our enterprise will use.

Judd, you've already kind of touched on this in several small points. But to the degree to which you can some more, I guess, can you compare and contrast what came back in the RFP from Teladoc versus some of the other vendors who might have sold it? Just trying to get a sense for -- it sounds like Teladoc was far and away the best. But just would love to hear some more of the differentiating factors between Teladoc and the other vendors in the market?

So I'm going to be a little vague on that, okay? But then I'll speak more towards the positives of Teladoc than the negatives towards anybody else. The biggest thing is, for us, when we were rolling out direct-to-consumer and established patient visits, the Teladoc platform was built for health systems, not just for provider networks. They do both, right? Because they can handle all your services but if you're a provider network, and this is just Judd's opinion, I'm not speaking on behalf of Teladoc, you have 1,000 doctors out there. If I see you as my patient and I don't finish documentation, you don't want me to see the next patient because who cares, someone else will see the next patient. But if I'm the doctor taking care of my own patients, I don't want to make the next patient wait. I want to see them right away. I can do my documentation later. That's one example of different needs of a health system than a provider network. And so Alan's team and my team worked really closely to say, these are the things that need to happen, and there's a bunch of advisory boards that again have doctors' opinions feeding into doctors that are in the company to make sure it gets developed right because, honestly, if I just have a conversation with a tech guy, they may not understand what I'm saying. I need the doc sitting at the table on the side of the company to make sure we can grow it out. So the biggest thing was a willingness to develop a platform that was specific for us using our own physicians. And most of the other networks are using their own physicians and not letting the health system be as fluent with using theirs. It was the willingness to test behind the scenes. And it was the willingness to -- and at the time we were doing this, I think Teladoc was already public. So it's now not looking for an exit strategy. It's looking to grow a business. And it's not purely about customer acquisition, but it's about customer retention, and that's making people happy. And as there's many other companies that are not yet public, they're wrestling with how much do I build when and how much money do I spend before we get to be public. So I think the combination of those things as well as the line items on the spec sheet and what they committed to doing were the biggest advantages we saw.

Great. Well, thank you very much, Judd. That was fantastic. Let's give Judd a round of applause.

Thank you.

Thank you. Great job.

And now the moment you've all been waiting for, let me introduce Mala Murthy.

Thank you, David. Well, since I know Jason always keeps his promises, when Judd gave Jason the homework assignment, my blood pressure went right up. Anyway, good afternoon. I'm Mala Murthy. I'm the CFO of Teladoc Health. It's really great to see all of you. I hope the last 4 hours have given you a good sense for our values. Jason talked about that several hours ago. It gives -- it's taught you -- told you about our vision, our strategies and capabilities for growth and how we are actually executing on those strategies. So what I want to do is bring it all home and tell you what it means for us financially. So our vision and strategies for growth essentially translates into 3 themes: first, we have a demonstrated track record of delivering and exceeding our financial expectations; second, we have a compelling financial model, and I'll talk to you more about that and why that gives us confidence in the expectations that we set; and last, I actually want to look forward and talk to you a little bit about the progress we want to make in terms of our financial milestones. So let's start with our financial model. Nothing rocket sciencey about this. And I'll talk specific numbers in a bit. But if you think about the virtuous cycle financially, it all starts with revenue scale. The chart that Jason showed, we started with $77 million, not that many years ago, and we are at $700 million today at the midpoint of our guidance. And we intend to continue to grow from a revenue perspective. David, Stephany, Dan, Lew, they all talked about from their own vantage point, how they're going to grow that scale and support that scale. We have operating leverage. Why? We have attractive gross margins. I'll talk to you a little bit about that. And I'll talk to you a little bit about our efficiencies. Stephany talked about how we are getting smarter in our marketing mix. David talked about the call center productivity that we are getting. Those are examples of our increasing operating leverage. The revenue scale and the operating leverage are translating to increasing profitability and cash flow, which, over time, will give us access more efficiently to capital markets. And that, from a balance sheet perspective, will allow us to increasingly support both organic and inorganic investments, which, with the track record of integration that we have, will continue to fuel our revenue growth. So that's how we think about ourselves financially. We have a successful track record from a performance standpoint. And the numbers really speak for themselves. As Joe said, it's all going that way. If you look at it from a visit momentum, fueled by our membership expansion, that's translated to over 60% revenue growth since 2015. And we are increasingly profitable. 2018 was the year we turned adjusted EBITDA positive. 2019 is when we turned cash flow positive, both cash flow from operations and free cash flow, and we intend to continue to build on that. We had a strong 2019, capped off by a strong finish in Q4. We talked about it on our earnings call. I won't spend a lot of time on it. Suffice to say that we grew reported revenue 32%, organic revenue 24%. We more than doubled our adjusted EBITDA in 2019, relative to 2018, and expanded our EBITDA -- adjusted EBITDA margin. And the momentum we had in 2019, the membership momentum, the business momentum and the investments we have made, give us confidence in the guidance we have set for 2020, which to just quickly recap is 26% to 28% revenue growth, which will substantially be organic; once again, more than doubling our adjusted EBITDA in 2020 at the midpoint of our guidance of $60 million to $70 million; and adjusted EBITDA margin expansion again. So let's talk a little bit about our revenue. Jason talked about how our revenue is durable through cycles. Our revenue is actually also very predictable. Why? Even with the visit growth that we've had in the past few years, and you can see the strong visit revenue growth we have had on the top left at close to 60%, 80-plus percent of our revenue is subscription revenue, and it's highly predictable, because of the contracting nature of that revenue with our clients. Not only is that revenue durable and predictable, it's also increasingly diverse and it's sticky. Let me talk to you a little bit about that. First, we are global. In 2019, 20% of our revenue came from outside the U.S. We derive our revenue today from a variety of channels that, in 2019, all performed strongly, between 19% to 50-plus percent revenue growth. So David talked about the leadership position that we have in multiple channels, that is translating into strong revenue growth across all of these different channels. We are sticky. In 2019, more than 30% of our bookings was an expansion of existing relationships. And we have talked about how 50% of our global bookings are multiproduct, another testament to the increasing stickiness that we have with our clients. And last but not least, we have over 90% client retention rate, and that's not new. That has been so for several years. So Jason talked about how we intend to grow revenue and the compounding effect: more members using more of our products and services more frequently. Through it all, we have been growing PMPM. It's a question that we get from investors a lot. And you can see when we onboard large populations, yes, it does have a temporary depressing effect, you can see that on the chart on the left, but over time, we have been able to expand our PMPM. One of the reasons we have been able to do that is the chart on the right. It is because of the increasing products and services that we offer. If you look at 2019 and clients in the employer channel with who we added multiple products and looked at the average PMPM for those clients before and after the added multiple products, you can see the significant impact it had on increasing PMPM. Stephany talked at length about our activation flywheel and how that drives new and repeat visits. All of that culminates in what you see on the left, on the strong visit momentum that we have. Importantly, though, we are also expanding our revenue per visit through all of that. Once again, because of multiple products, as we have talked about on our earnings calls, it's not only gen med, it's behavioral health, it's derm, it's those multiple products that are increasingly showing up in our visit mix. And you can see how that is helping our utilization expand over time by on average more than 100 basis points every year. Let's now talk about gross profit and gross margin. So if you look at our gross profit growth since 2016, we have grown gross profit at about 60% compound annual growth rate, pretty close to our revenue growth over the same time. Why does that matter? What it says is we are growing our gross profit not just on the back of volume, but we are also protecting our gross margins in doing so. In fact, if you look on the right and look at our gross margins, pro forma-ed for all of the large acquisitions we have made over the last few years, you're actually seeing our gross margins expand. So our gross margins will be somewhat negatively affected by the increase in visit revenue mix. By the way, that's not a new phenomenon. That's been going on for a few years, but we've actually been able to protect our gross margins through that. Why is that? So let's talk a little bit about the levers and dynamics that are happening within our gross margins. So first, we are definitely seeing a pretty significant mix shift towards digital access, right? 78% of our visits are accessed digitally, and that's up quite significantly, as you can tell from the beginning of 2016. And that's definitely helping from a gross margin perspective. David talked about call center productivity. We have gotten that. In 2019 alone, the growth in our call center staff significantly under paced the growth in our call center volume. That's helping productivity. And we will continue to find new and different ways to drive that. We will continue to be judicious about pricing. We have been, we will be. And as we absorb the InTouch acquisition with the hospital and health system business growing, it will be in line with our overall gross margins. In fact, as the software component of that business grows, it will be accretive to our gross margins. But with all of that said, given all of the puts and takes, we do expect that over time, on average, annually, gross margin will compress anywhere between, say, 0 to 100 basis points. But to more than offset that and mitigate that, we will drive operating leverage. So this chart shows you how we have already been doing that quite sharply. The solid line is our OpEx to revenue on a GAAP basis, and the dotted line is the same thing on a non-GAAP basis. And I think the numbers, again, speak for themselves. You can see the different ingredients of our OpEx in the bars, and you can see how the growth of those has under paced our revenue growth, thereby driving that operating leverage. Now when we think about our operating leverage and how we will continue to drive that, it's really more subtle than that. We think about it in a few different ways. And I'll spend a little bit of time talking about that. So let's start with marketing efficiencies on the left. For us, it's about driving revenue yield and increasing revenue yield. We will continue to invest in marketing. We've always said that. But we do -- we have and we will continue to drive revenue yield. Stephany talked about how we are doing that. We invest upfront in driving new visits and then we spend a lot less on repeat visits. We are getting a lot smarter about what channels we use, what marketing channels we use and how we can become more efficient at that. So all of that helps us drive efficiencies in marketing spend, and we drive the revenue yield up. And you can actually see us doing that on the left most graph where, if you look at 2016 and 2019, and look at our revenue per dollar of spend in marketing across customer engagement and consumer acquisition, it's more -- it doubled. If you look at technology, G&A and legal spend as a percentage of revenue, '16 versus '19, 63% versus 41%. We've driven efficiencies in that. And last, on selling, incremental revenue per dollar of selling expense, once again, you can see we are getting more efficient on average annually by about 6% to 7%. So I hope all of this has given you a little bit more color on how we are driving our revenue and how we are increasingly becoming more efficient in driving profitability. Now let's look at our balance sheet. Our balance sheet is solid. We ended the year with $517 million in cash and marketable securities. We generated cash flow, as I said, both from a cash flow from operations and a free cash flow standpoint. And even after the acquisition of InTouch, we expect to have more than $350 million of cash as dry powder for making additional investments that we would like to. And as you all know, our convertible notes are nicely staggered. So this balance sheet flexibility that we have allows our financial strategy to support our business strategy. When Dan, Lew, Stephany, Joe and David talk about all of the various initiatives they have in the pipeline, those require investments, and we will use our balance sheet prudently and judiciously to make those investments, both organic, as this slide shows, aligned tightly with our strategic imperatives, whether it be expanding footprint and distribution, whether it be, as Dan talked about, and there's been a lot of interest in virtual primary care in this room, increasing our consumer adoption or importantly, investing in various assets and capabilities, whether it be artificial intelligence, Follow the Sun service model, things such as that. And then last but not least, we will use our balance sheet smartly for M&A. And we've talked about how, when we look at M&A, we look at really 4 things. We look at the strategic fit. We look at the cultural fit and how closely the targets are aligned with us in terms of values. We look at revenue growth and we look at gross margin and profitability. And we will continue to do that. Obviously, for both organic and inorganic, we look at returns. We spend a lot of time thinking about the return on capital. We also, as you will see from the slide, have a good track record of integrating our acquisitions. If you look at the large acquisitions we've made in the past few years, and we get asked this by several of you, and look at the visit volume for those acquisitions in the fourth quarter of the year that we acquired them versus the visit volume of those at the fourth quarter of 2019, once again, you can see the growth and the momentum. And that's a testament not just to be strength of the targets we acquired, but equally importantly, the fact that we invest in them even after we acquire them, and the fact that we have successfully been able to cross-sell those products into our legacy base. It's all of those things that drives this. As I look forward, I talked to you about, I want to look forward in terms of the progress we want to make financially, we will continue to drive 20% to 30% revenue growth. And it's the levers that we have talked about really since the morning. We will also drive adjusted EBITDA margin expansion in the range of 200 to 300 basis points, once again, by driving efficiencies that we've talked about. And this will be over the next 3 to 5 years. So in summary, what I want to leave you with is the following. Our track record is one where we meet and exceed our expectations and targets we set. We keep our promises. We have a compelling financial model that is about durable, predictable, diverse and sticky revenue and increasing operating leverage. We have a solid balance sheet that we will use prudently, judiciously. And over the next 3 to 5 years, we expect to continue to grow revenue in the 20% to 30% range, and expand our adjusted EBITDA margins by 200 to 300 basis points every year. So before I invite Jason and Joe to the stage for closing Q&A, thank you all for coming. I hope the day has given you a good sense for not just the breadth but the depth of what we do. Many people, when we talk to investors say, "Isn't it easy to just replicate you?" I hope what it has told you is, there is that magic secret sauce that -- it was the same question, by the way, I asked Jason when I interviewed, and now I know the answer a lot better. So I hope it's given you a much better rounding for the complexity of what we do and the breadth and depth of what we do. So with that, let me get Joe and Jason up on stage for a very short closing Q&A.

David, maybe you want to join us, too, in case there's anything that I want to throw at you. All right. So again, we have microphones going around the room. For those of you tuning in via webcast, you can submit your questions to the web. Lisa has the mic.

I do. Lisa Gill with JP Morgan. So Mala, I just want to talk about your expectation around improving EBITDA margins, the 200 to 300 basis points. It's a new metric that you're giving us. I believe you said that this is a 5-year annual goal. Is that correct? How do we think about the impact of the changing business mix? So as we think about bringing in InTouch, we think about different marketing plans, et cetera? That would be my first question. And then secondly, how do you think about that -- is that just on an organic basis? And Jason, how do you think about what you're missing at this point from the Teladoc platform?

That's like 4 questions. Go ahead.

Yes. So the way we've thought about that is, first of all, what I've put out there is organic. But we've talked about a lot of different scenarios of how our business can go in different directions, different directions in terms of new products that we'll take on. We've talked about alternate payment models and the impact that may have. What I would say, Lisa, is at the end of the day, we've always said this, we will price smartly and judiciously such that we protect our gross margins. And that we continue to drive operating leverage. And I'm very confident based on what we know today, and the different scenarios of our product strategy as well as the other elements of our business that on an organic basis, the 200 to 300 basis points adjusted EBITDA margin expansion is doable. In fact, we are very confident of that. And then the only last thing I would say is, when we fold in acquisitions, depending on the financial profile of the acquisitions, while there may be some impact on that adjusted EBITDA margin, our expectation is the synergies will start folding in, and that will help us from an adjusted EBITDA. I mean, it should to make sense of the return on capital for the acquisitions. So that's how I thought about it.

And I think the last sort of secret question was about M&A strategy. The -- so first and foremost, we're focused on closing the InTouch Health deal, executing on integration and realizing the promise that Joe and I talked about. At the same time, Drew would be bored if all he had to do was work on integration and so we are always opportunistic in looking at the market. As the only public virtual care company, as you've heard me say, we get to look at everything. We say no to almost everything we look at. We're very disciplined and selective in what we say yes to. When I think about the road map, M&A should ultimately support the strategic road map. When I think about the road map that we talked about earlier that Dan laid out, chronic care management continues to be an area of focus and opportunity for us. Remote patient monitoring very much lends to virtual primary care, chronic care management and takes advantage of the InTouch capabilities, both in the facility and reaching out of the facility. It's hard to find the right asset there, but that is an area of interest. You'll continue to see us expand geographically on an opportunistic basis, like we did this past summer in France, and we continue to see the international marketplace as very receptive and a lot of opportunity. All of those could take the form of build, buy or partnership. And we always try to assess all of those when we're looking at a strategic opportunity. Matt?

Matt Gillmor with Baird. This is probably for David or Jason. I was curious if you had any perspective with respect to the coronavirus and what that means from a sales perspective. I know it's really hard from a visit perspective. It did sound like from your comments that your customers are coming to you and sort of seeking advice with respect to how to deal with this. And I was curious if you had any thoughts about whether you'd see any benefit from the selling season and the pipeline.

Yes. David, you want to take that?

I think, overall, we've been working on how do we increase the speed that we can deploy our solutions with our clients. And so that preparation suits well now when clients are saying, "Can you stand something up for us right away?" And so we're talking with clients who need something -- we'll stand something up in days rather than weeks with them to say, here's how we can back you up or here's the tools we can provide for you to provide care through your health system. And so there's a lot of discussions around that. And we're being reasonable about that because we'd rather get more clients quickly and then say, look, if you start down this virtual journey with us, over time, we think you'll add in more products and solutions so we'll make this a reasonable ask in the beginning where it's very easy to deploy in a small use case, and then you can go to the larger use cases over time. So it's early days, but there clearly is a lot of interest in the market and we'll see where that goes. And we're just being kind of reasonable on the approach and trying to be responsive to the market.

Stephanie?

Stephanie Demko, SVB Leerink. This is probably a question that's for Jason and Joe. When I think of inpatient telehealth, telepsychiatry tends to be one of the biggest use cases. With that in mind and you have those DTC product, you do a lot with behavioral health, do you see it evolving more into a DTC telepsychiatry solution, too?

Yes. So I'll start and then you can jump in. So one of the things that I think, certainly, I didn't highlight and maybe neither of us highlighted is, the combination of the footprints of the 2 organizations provides a tremendous sort of network effect, being able to take advantage of our provider network to the InTouch clients as well as the extended physician population that has access to the technology through the InTouch provider network of clients. And so it almost has a multiplying effect of the total physician population that's on the collective platform. And we do see the opportunity really significantly to leverage that entire population and sort of cross-pollinate both in a direct-to-consumer or B2B2C manner as well as from facility to facility. Anything you want to add, Joe?

Sure. Today, behavioral health is actually our highest volume use case, but it's a different administration of behavioral health. It's someone comes into the emergency room and has demonstrated that they have some symptoms of being mentally disturbed. That emergency room is not allowed to discharge that patient without a behavioral health consult because they may hurt themselves or someone else. And so when you unpack the layers of services that are required and you start consolidating what both companies have been able to accomplish, there's a lot of other ways to create those services. So it becomes a very powerful collective package. And taking the physicians and then having them come through our infrastructure, because Judd gave us an assignment, right, you have to have that one portal, so we'll get on that, but that's what's going to leverage a significant amount of the power of the interaction.

So just to be clear, and I want to say this, I think Judd's still in the room.

No. He left.

He may have moved on with the CDC. So he's gone. I can say this. Our team set forth a set of integration principles and one of the absolute top principles was one interface for the physicians. So what Judd said up here and asked for, I know that we can deliver and I can promise because it's actually in our first 5 principles or guiding principles for the teams on what we're going to do with integration. Ravi?

Ravi Misra with Berenberg Capital Markets. Just want to, Mala, push you a little bit on the gross margin commentary that you were talking about. A lot of good work kind of moving that number up, yet, you're saying over the next few years there's pressure. And I guess I'm a little bit confused by the pulls and takes there in terms of, it seems like the pricing is going in the right direction, the efficiencies are going in the right direction. But what's driving that mix the other way?

Yes. So like I said, Ravi, there are a lot of positive things exactly like you said, but what I want to do is leave room. At the end of the day, what I want to look at is, we will grow or expand our adjusted EBITDA margins, as I said, in the 200 to 300 basis point range. Between revenue growth and that, I want us to have sufficient levers such that we can grow the business responsibly. There are -- in terms of how we go towards the various new products that we are going to introduce, we've talked about that, they will have different gross margin profiles and we have different channel mixes. So there is that as well. So I just -- again, remember, it's a range we are giving. There are years, as we have demonstrated where -- and quarters where we have expanded our gross margins or been dead flat relative to last year or the prior year. And there are some quarters where we have seen a compression in gross margins. Remember, we have always said that as we grow scale, we do expect our gross margins to sort of drift into the mid-60s, right? So that's not inconsistent with what we have said before. So I would say it gives us enough flexibility from a business model standpoint to make the right investments and sort of balance between the top line growth as well as the bottom line profit growth.

And so implied in that, Mala's right on every single thing there, not surprisingly. Our revenue from visits just grows so fast that we -- that has, by its nature, that component of revenue has lower gross margins. And so we're a little bit a victim of our own success when we massively expand our visit volume, which is what we've done over the last several years. It just has a slight compressing effect on the overall gross margin. And we think that's okay because, as Mala said, that gross profit dollars has grown at a 60% CAGR.

Yes.

Where's the next one?

Jailendra Singh from Credit Suisse. I have a question for you, Mala, on pricing. So I think in the past, you talked about $0.05 to $0.10 of annual PMPM increase long term. Is that all driven by multiproduct sales to your existing membership base? Just trying to understand what is the pricing trend on core basis. Like if you don't have any multiproduct sale, how is pricing trending? And my second question is what is the impact from these new MA lives? Is the pricing similar to your existing PMPM or is it better or worse? Any comments there?

So let me address both. The second question is pretty easy. So based on all of the lives that we have already put on, which as we said is over 1 million, it's very traditional PMPM pricing that we are seeing. So it's right in the ZIP code of what we already have on our books. On your first question, as you know, it's never one factor. Definitely, it is the multiproduct expansion. It's also channel mix, right? We have talked about how different channels that we go through have different PMPM. Some of them have manyfold the PMPM of some of our other channels. So it really depends on channel mix. And how that plays out in different years is different. So in 2019, for example, a lot of our growth, as we have talked about, is on the back of health plan. That will be different in different years. So there is that factor as well that impacts our PMPM.

Vivian?

Vivian Wohl with Federated Kaufmann. Joe, on the right side of your slide, you had retail monitoring so I thought maybe you could both comment on what the potential might be within the CVS relationship. And then also just generally comment on how mature the use case is for monitoring discharges to skilled nursing and maybe earlier discharge to the home?

Well, I'll leave the CVS use case for you.

Why don't you talk about Rite Aid and what you're doing with Rite Aid?

Sure. So what we're doing with Rite Aid is we have kiosks that are in multiple locations today where patients can go meet a physician, have their diagnostics taken. And it's a very efficient way for a patient to have those vitals taken versus sending hardware to the home. But within the platform, we're still trying to see how remote patient monitoring firms up. The platform that we have clearly can allow for the data capture, the data streaming and the interaction, but there's a lot of fragmentation in that market still. There's certain health systems want to have caregivers be there as a part of it, too. So we're kind of waiting for that model to firm up. But for us, we are location agnostic. And that's why we built the architecture. So wherever the marketplace goes, we'll have the technology to be there, whether it's in the home or pharmacy, an employer, to set up an easy workstation so it can all work. So that from a technology standpoint, we feel we have it covered. But the reimbursement models, the economic models all still have to firm up. Anything?

No. I think you nailed it. George?

George Hill from DB. Mala, just a quick follow-up on the margin question. Given the gross margin trajectory that you outlined, can you talk about which discretionary spending categories we'll see the most leverage in as you go from your mid-60s gross margin profile to the -- I guess what bridges the gap between that 250 basis points of EBITDA margin expansion per year?

Yes. So I talked about the 3 -- think of it as the 3 buckets from where we will drive operating leverage. And my expectation would be that we would continue to drive efficiencies really across all of them. How are we going to do that? So if you think about selling expense, we have already talked about our average deal size growing. So as we continue to make progress on that, that should help us drive selling efficiencies. We will never compromise on the sort of the investments we need to make, whether it be from selling or whether it be for marketing. But again, for marketing, it is about driving revenue yield, getting smarter about channel optimization and when and how we place our marketing bets. And then really on overhead, it is about just rationalizing overhead smartly. And so for example, we have done some streamlining of our offices. David led that effort earlier this year. Again, these are things that we will do surgically. We will never do something that's mass scale.

I think we have time for one last question. Sean?

Well then, I have to ask a softball question if it's the last one, don't I?

It would not be like you to ask a softball question.

Well then, I have a hard question, I have an easy question. The hard question I have is for Mala. The PMPM on these new health plan lives, you've given us great disclosure and said, well look, aside from those, the PMPM is growing, but that lets us back into, it's dramatically lower. And so what I want to understand is what's the deliverable that allows you -- to the customer there, to the health plan, that allows you to be profitable at those much lower rates? It seems like it's an entirely different line of business that perhaps from a disclosure standpoint should even be, not that we're looking for more operating metrics from you guys, but separated out.

Yes. So first of all, I have not disclosed and we have not disclosed that it's dramatically lower. So here's what I would say. When it comes to these health plan relationships, it's about 2 things. The first is, and this is why I talked about gross profit, right? So it's about the volume that we get from them versus the gross margin. So it's about thinking about gross profit. So that's one. The second, though, importantly is, this is where the land and expand really, really is meaningful because we land with a health plan customer, but then over time, as we sell in incremental products and services, that gives us a seat at the table to improve our gross margins. So it's both of those that are important when we think about the financials of, say, a health plan.

And we feel good about the profitability of those clients out of the gate.

Yes.

Still waiting for the softball.

Where's the softball?

Where's the softball?

Come on, lob it up there.

Okay. The softball question. Joe, I'm really interested in the network that you've built. And I guess my question for Jason is how do you flip the network that Joe has built, his data network, into other use cases beyond what was developed?

I think the data network gives us the opportunity to sit on top of a global technology platform that will enable us to deploy capabilities, both physical, virtual and sort of point-to-point outside of a facility with a single log on. So just like Joe talks about, being able to take one physician and put that physician into any one of the facilities where they're credentialed. We think that we have the ability to do that into any endpoint on a highly reliable, highly scalable global network. And as I said, you get the network effect of all of the providers who are providing care into the InTouch clients to add into that. So historically, we've had to go out and contract with physicians one at a time. This gives us the ability to go sort of one to many, one provider, one facility to all of the physicians who are enabled and credentialed through that facility. That's a very, very powerful and proprietary network effect. So thanks for the softball. I appreciate it. All right. That concludes our day. And so I know it was a lot, almost 5 hours of time that we've asked you for. And hopefully, we've made it valuable for you. I said at the beginning that you could applaud at the beginning, but what really would be a measure of our success was whether we got applause at the end of the day. I just want to thank my team. In case it's not evident, we really like what we do and we enjoy working together. And that's part of what makes it fun in addition to the really important mission that we have. Thank you, as I always finish, for your support. Your support enables us to continue to grow and continue on that journey. So thank you again.