Teladoc Health, Inc. (TDOC) Q1 2017 Earnings Report, Transcript and Summary

Welcome to Teladoc's First Quarter 2017 Earnings Conference Call and Webcast. At this time, all participants have been placed in a listen-only mode and the floor will be opened to your questions following management's prepared remarks. [Operator Instructions]. It is now my pleasure to turn the floor over to Ms. Jisoo Suh, Director of Investor Relations, you may begin.

Thank you operator, and good afternoon everyone. We look forward to discussing our first quarter 2017 results with you today. Joining me for Teladoc’s conference call are Jason Gorevic, our President and Chief Executive Officer; Mark Hirschhorn, our Chief Operating Officer and Chief Financial Officer; and Adam Vandervoort, our Chief Legal Officer and Chief Corporate Secretary. Today, after the market closed, we issued a news release announcing our first quarter 2017 results and filed Form 10-Q. The release and filings are available in the Investor Relations section of teladoc.com. As a reminder Teledoc intends to avail itself of the Safe Harbor provisions of the Private Securities Litigation Reform Act of 1995. Certain statements made during this call will be forward looking statements within the meaning of that law. These forward-looking statements are subject to risks, uncertainties and other factors that could cause actual results to defer materially from those expressed or implied by the forward-looking statements. For additional information on the risks stating Teledoc, please refer to our filings with the SEC. We'll start today's call with brief prepared remarks, followed by Q&A. Today's call will also contain certain non-GAAP financial measures, which we believe are important in evaluating our performance. For more details on these measures, the most comparable GAAP measures and a reconciliation of the two, please refer to the press release posted on teladoc.com. I will now turn the call over to Jason.

Thanks, Jisoo and good afternoon, everyone. I'm excited to report that we carried strong momentum and excellent results into the first quarter of 2017. Teledoc continues to demonstrate consistently solid execution and benefit from the overall network effects surrounding our business and the virtual care industry in general. In the first quarter we met or exceeded our guidance across each of our key metrics, in which we recorded total revenue of around $43 million or growth of approximately 60%; adjusted EBITDA loss of $9 million, which improved from approximately $12 million in the same period last year; membership of $20.1 million lives or growth of 34% over prior year and over $2.6 million newly added lives since year end; and finally, business of approximately 385,000 or growth of 60%. This represents a quarterly annualized utilization rate of approximately 7.6% or 127 basis point increase year-over-year, reflecting the high impact of our member engagement strategies combined with a relatively short but severe cold and flu season in January and February. As I noted, Teladoc's record high utilization rates reflect our surround sound engagement strategy, deployed via traditional channels such as direct mail, including the delivery of new member welcome kits as well as via highly targeted and increasingly cost efficient email and digital campaigns. Turning to an update on our new client business. We observed seamless implementations during the first quarter from accounts such as Southern California, Edison, Marriott Vacations Worldwide and Yale University, among many other. As well as from health plan clients that we previously mentioned, including Fallon and UltiCare that went live during the period. Meanwhile, continued demand for our virtual care delivery solutions resulted in newly signed accounts such as Dullards, Bear and Paychex to name a few employer clients, as well as specific source in health plan space. These clients are all expected to go live later this year. Our behavioral health and dermatology products continue to resonate as existing clients like KPMG, Chesapeake Energy and Lowes added to their core general medical specialties. We also have significant interest in our specialty products from our health plan partners and have begun to rollout behavioral health and dermatology into their large books of business. I would also like to highlight our continued success in the provider market where our solutions now support more than 140 hospitals across the nation. We're incredibly proud to announce newly signed agreements with multi-care health system comprising seven hospitals in Washington, WellSpan Health system comprising 6 hospitals in Central Pennsylvania, as well as recently expanded relationship with the Mount Sinai Health system in New York. Our increasing client roaster reflects the flexibility of solutions we offer to the hospital market as well our compelling vision to help providers build healthier communities and improve patient outcomes. We're also pleased by contributions from our behavioral health offering, in which revenue more than doubled year-over-year, to reach approximately $5 million in that first quarter. We expect to maintain this trend throughout 2017. Before moving on, I'd like to take a moment to go over our previously announced appointment of Peter Nieves to new role of EVP and Chief Revenue Officer, reporting directly to me. It's always been a priority of mine and the Board to stay ahead of our growth curve by putting the people and organizational structure in place to take us to the next level. Pete is an accomplished commercial leader with extensive capabilities than align perfectly with Teladoc's strategic vision. He has deep understanding of the employer, payer and broker consultant landscape, and previously came from Optum, where he served as the executive VP of employer solutions, leading all aspects of the employer markets sales and account management strategy. And before that, lead global growth strategy for MRSA. He’s already hit the ground running by working to further integrate our overall sales operations frame work as we continue to scale, identifying ways to extend our leadership position, get greater leverage out of our sales and product and development efforts across all client segments and deliver on our broader financial objectives. Now, I'd like to offer a few timely insights from Teladoc's second annual client summit held last week at our Louisville headquarter. We hosted approximately 40 clients who are leaders in their respective industries, including 15 of the Fortune 1000. And together, comprise more than 700,000 of our members. We're encouraged by client such as TD Ameritrade who have been using Teladoc for several years and are achieving consistent step function growth in utilization levels to reach over 20% on an annualize basis. Incorporating Teladoc is a center piece of their total rewards programs across their distributed work force. We also have the chance to discuss our product and capability roadmap as Teladoc continues to expand our service offerings to achieve our goal of providing a broad and integrated virtual care platform for our members and clients. Specifically, our clients reinforce our vision by expressing the following feedback and broad themes. First a sincere interest in our newer specialty products with particular excitement regarding the opportunity to address the massive problem of untreated mental illness to our behavioral health products. Secondly, strong demands for the continued expansion of our clinical offerings to broaden the scope of services available to members and to provide solutions that help our clients address more complex and costly medical conditions. Third, an appreciation for our select integrations with other service providers who are important partners of our clients healthcare management strategies. For example, we were highly praised for our recently announced partnership with ACO-led. And finally, clients expressed eagerness and collaborating with us to find new, creative and targeted ways to engage their employees and drive higher utilization of the Teladoc platform. Now, I'd like to provide a quick update on the legal and regulatory front, where we continue to be cautiously encouraged by current legislative developments in Texas. As many of you know, a bill that makes it clear that telehealth will continue uninterrupted in Texas, has been making its way through the state legislature and could become law in the next few weeks. The passage of this bill into law would resolve our outstanding issues with the Texas Medical Board and would represent a significant victory for the people of Texas in securing their path to quality, affordable and accessible healthcare. As you can see, we have a lot of exiting things going on at right now at Teladoc. I'm very pleased with the results we delivered in the first quarter. And I believe that we're on track to reach our review end objectives where we continue to target the fourth quarter to achieve adjusted EBITDA breakeven. We continue to execute on our growth strategy of extending our industry leadership and success in cross-selling new and innovative solutions through existing members. Having just wrapped up our client summit is very evident that our clients and members realize and appreciate the value of our platform. Given the growing awareness and acceptance of telemedicine, I have never been more optimistic about the opportunity in front of us. With that, I’ll now turn over the call to Mark to review our first quarter results in greater detail.

Thanks, Jason and good afternoon, everyone. Let's start with revenue, where we reported $42.9 million, representing 60% growth over the prior period. Organic revenue growth was approximately 41% over the same period last year. Subscription access fees accounted for $34.3 million or 80% of our total revenue and grew over 65% year-over-year, reflecting overall membership expansion and contributions from HealthiestYou. As a remainder, our core small to mid-size employer client base is comprised of accounts principally sold through brokers who embrace bundled, visits included contracts with higher PEPM rates. Subscription access fees grew 13% sequentially, reflecting growth in covered lives since year-end. Our average per employee per month fee or PEPM across our business was $0.58 compared to $0.47 in the prior year period, reflecting the positive impact from the increased visits included subscription mix, I just noted. Visit fee revenue for the quarter grew almost 40% year-over-year to $8.6 million, 100% of that growth is organic. Turning to total visits, we completed approximately 385,000 visits in the quarter or growth of 60%. This equates to a quarterly annualized utilization rate of 7.6%, which is the highest we’ve ever recorded in the quarter and 127 basis points increase over the same period in 2016 and 56 basis point increase from Q4 of 2016. Gross margin in the quarter was 72%, up slightly from 71% a year ago. The slight year-over-year increase is attributable to the Company's revenue mix where subscription revenues accounted for 80% of our revenue in this quarter compared to 77% of our revenue in the prior year period. Total operating expenses in the first quarter were $43 million, which increased 34% over the prior year, primarily due to investments in marketing, sales and G&A in order to support our 60% revenue growth. We take an opportunistic approach to investing in our infrastructure. For example, our new Phoenix office was initially focused on sales and marketing. This past quarter, we completed the final stages of creating a secondary operation center by taking advantage of the space available to us. To be clear, this was not a capacity driven build out, rather we saw tremendous value to our clients and members by ensuring that we have a fully redundant operation site with disaster recovery options to maintain continuity of service under all circumstances. Operating expenses, as a percentage of revenue, declined year-over-year by over 1,900 basis points with leverage in G&A, technology and development, as well as legal expenses. Sequentially, operating expenses increased by approximately $5 million with much of that increase in absolute dollar terms attributable to member on-boarding activities and additional advertising and marketing expenses. As we stated in the past, the first calendar quarter is our heaviest period for marketing and advertising costs as our focus is engaging members from newly on boarded clients. Our adjusted EBITDA improved to a loss of $9.1 million compared to a loss of $11.9 million in the same period last year. We continue to make progress on our goal of being adjusted EBITDA breakeven in the fourth quarter of this year. Net loss in the quarter was $15.7 million compared to $15.3 million in the same period last year. Net loss per share was $0.30 compared to a net loss of $0.40 in the same period last year, reflecting our higher share count in the current period. Our weighted average common shares outstanding were 52.2 million shares in this period compared to 38.6 million shares in the same period last year, reflecting the issuance of 7.9 million shares from our follow-on offering this past January and 7 million shares issued for our acquisition last July. Turning to our balance sheet, we ended the quarter with over $175 million of cash and short-term investments, reflecting proceeds from our follow-on offerings. Our debt balance remained constant at $42.4 million. As Jason mentioned, our priority is to grow Teladoc’s ability to play across the continuum of virtual care services and deliver greater value to our members and clients. We believe our strength and capital position affords us tremendous flexibility to both invest organically in our businesses and opportunistically look outside the Company for value accretive assets to expand the benefits of our platform. Now, I would like to provide our outlook for the second quarter of 2017 in which we currently expect total revenue between $44 million and $45 million; an EBITDA loss between $10.5 million and $11.5 million; an adjusted EBITDA loss between $6 million and $7 million; total membership of approximately 20.5 million to 21 million members; total visits between 290,000 and 310,000 visits; and a net loss per share based on 54.5 million weighted average shares outstanding is expected to range from $0.26 to $0.28. For the full year 2017, we continue to expect total revenue between $180 million and $185 million; an EBITDA loss between $31 million and $34 million; adjusted EBITDA loss between $19.5 million and $22.5 million in which we target to achieve adjusted EBITDA breakeven in the fourth quarter of this year; total membership of approximately 21.5 million to 23 million members; total visits between 1.4 million and 1.45 million; and a net loss per share based on 54.2 million weighted average shares outstanding is expected to range from $0.85 to $0.91. And with that, Operator, please open the call for questions.

The floor is now open for questions [Operator Instructions]. Our first question comes from the line of Lisa Gill of J. P. Morgan. Your line is open.

Thanks it's actually [indiscernible] [Mike] [15.17] for Lisa this afternoon. So with regards to selling season for next year, I was just wondering if you could talk a little bit about the level of demand from perspective clients relative to prior years. And how that looks across the various vertical segments and anything new the clients that you’re looking for, for next year, that might be able to offer?

So I would say still little early to try to develop or articulate trends for this selling season into 2018. With that said, I would say for us health plan activity has been strong, large employer activity similar to previous years, small market, meaning that smaller and mid-sized significantly more activity. But just remind you that that occurs over the course of the year, it's not just January first centric. The hospital market has been ramping up significantly and we continued to see more demand coming out of that segment. Our specialty products, as I mentioned when I was talking about our client summit, are getting a lot of attention across the spectrum from employers, especially on the large employer market and from health plans as well. The only other thing I guess I would say that’s different this year is that we’re seeing more activity with employers and health plans and hospital systems who previously chose one of our competitors and are coming to us for our solution and our ability to drive utilization. That’s happening significantly more this year than it's happened in the past.

And then I think in the past you’ve pointed opportunities to add lives at existing customers, so for example -- I think you had a couple million lives there, but just a fraction of the total covered lives. Can you talk about the progress you’ve seen just broadly in expanding the number of lives within existing customers and what the incremental opportunity there could like every time?

Yes, we’ve continued to see that trend where we -- especially in the health plan market, we land and expand. That doesn’t really occur in the employer space. But I would say, at United -- Blue Shield of California, Primera all are good examples of where we were successfully doing that.

Your next question comes from Sean Wieland of Piper Jaffray. Your line is open.

So on the lift in utilization, can you maybe break that down a little bit in terms of which areas or markets did you see the most lift? Did you see any kind of cause and effect of something that you tried maybe new in the quarter that either worked or didn’t worked regarding utilization?

I would say our utilization lift occurred across our various market segments probably you see the impact from the employer segment and the health plan segment more than you would from the provider segment. But what I'd say to answer the second part of your question is that we have continued to refine our digital marketing efforts and especially our ability to do highly targeted digital marketing and that has yielded very strong results for us. We have, I'd say, if you look at this first quarter of '17 versus first quarter of '16, substantially more targeted digital this year than there was a year ago.

And that delivers the greatest lift you think?

Yes, there is no question. I mean, what we see always is when we layer on targeted digital with direct mail with our on boarding welcome kits, we get both reach and frequency and being able to do the digital in a very targeted manner enables us to do it cost effective way.

And then to slide a follow up been here, member on boarding cost you said about $5 million of the sequential increase is due to member on boarding cost. Since this was a period where you probably added more members than in any other period, may be take aways from the quarter and ideas on how you can lower those member on boarding cost without impacting utilization. What's the thought process there?

In fact we noted that the $5 million came about a result of both increased advertising, as well as member on boarding costs. So you should think of that amount, about half of that amount attributable to direct on boarding costs. As Jason noted and to add to what he said regarding the utilization, utilization for us really peaks in the fourth quarter the last three years, our utilization has peaked in the fourth quarter of each of those respective years. And the amounts that we invest in on boarding clearly, is tied to the initial on boarding. But coming into the end of year we’ve got obviously other campaigns that we may launch where we always end up seeing the impact in the utilization. So it's far less of a question of bringing down those on boarding costs today and much more focus on the actual throughput of those investments. We're looking at the initiatives that drive the highest utilization, so we have a number of initiatives that we would focus on for certain employers and health plans and others that again still being sensitive to the cost we realize will have a greater impact on throttling up utilization.

Your next question comes from Charles Rhyee of Cowen and Company. Your line is open.

It's actually James on for Charles. So my question is can you give us a sense of what percentage of your customer base subscribes to more and then one product offering. And also little of your cross selling activity has been in line with expectations, and how much cross selling is embedded in guidance?

With regard to the number of members that are actively now receiving more than their initial, we’re right below 5%. So the penetration today is I believe on target with what we expected at the beginning of the year, but we expect many additional clients to take on those ancillary offerings throughout 2017. With respect to our ramp, I think Jason had noted earlier over a dozen clients in our Louisville facility this past week in our annual client summit. The overwhelming feedback was that there was significant interest in behavioral and other products that we’ve recently launched. So we’d expect to see a lot of in-year revenue as well as extension of contracts to provide for those additional services throughout this year.

And I think James I would just add that the health plan segment for the first time is showing significant interest in implementing those additional specialty products. So materially all of the early adaptors of those products were employers and now we’re starting to see significant uptick from the health plans as well.

Also for the quarter you beat 1Q guidance, Q2 guidance looks pretty good. Can you speak to what we should in the back half, was something pulled forward and that’s why you reaffirmed full year guidance? Or is it just kind of a measure of conservatism?

It's really a measure of our comfort in our -- and the traction that we received at the beginning of the year and our ability to -- now feel very comfortable with our revenue ramp and of course the lowering of the EBITDA loss quarter-over-quarter. We’re very comfortable with what we’ve seen in the first -- really in the first fourth months of the year and we continued to march towards that Q4 objectives.

Your next question comes from the line of Sandy Draper of SunTrust. Your line is open.

First question, could you maybe just walk me through or help me understand, is the health systems are coming on, not maybe like I think it was Yale, you mentioned Jason. It sounds like they’re an actual customer for their employees. But as health system partner, have you guys finalized what revenue model looks like and how -- who is paying or is that still an evolutionary process?

Just to clarify, Yale University is actually for the employees of the Yale University, not Yale as the medical system. However, when we talk about others, we are in fact talking about the hospitals themselves. Now sometimes they are using them for their own employees, but when we talk about our hospital clients for the most part we’re talking about them licensing our platform, it's a platform as a service model. We have a license fee, a base license fee and then there is a transaction fee as well. It defers depending on whether they’re using our physicians and the Teladoc network or their own physicians, but there is a transaction fee regardless. Obviously, if they’re using ours then it's a significantly higher transaction fee. And from our perspective, we get great feedback from the hospital systems and one of the primary reasons that we win there is because our solution is very flexible. It integrates well with their workflow and it enables them to essentially pick and choose what they would like to do themselves and what they would like us to do on their behalf. So again, the revenue model is a licensing fee similar to other platform as a service models plus a per transaction fee.

And then just a quick follow up, I would assume Mark that revenue is essentially and probably growing faster, but immaterial to where current total numbers are. Is that accurate?

That’s correct.

One last follow up, and I don’t know if there is a way that you guys can track this. I assume you could. But when you look at the growth in utilization, one of the things that I am curious and always trying to understand is, how much is market -- how much is also either word of mouth or repeat users for customers R$ you had on to two, three, four years. Do you track and you’re willing to give us steps on how often it's repeat users that are building a base line and how often they’re there? And is that a good way to think about the stickiness is you got existing users that may be once a year, twice a year, maybe it's every other year keep coming back to use the technology? Thanks.

The numbers that we talked about are about 1.3 or 1.4 visits per user per year. So if you do a math on that, the unique users is about 70% of the total visit volume. Certainly that increases overtime word of mouth is very powerful and that’s why when we talk about utilization among cohorts of our clients, we talk about them as vintages. We see the utilization increase from the first year to the second year and even more from the second to the third and fourth year. So certainly there is a benefit that we get from the maturing of our book of business overtime. But still the majority of business has been -- of our clients have been with us less than three years. So we continue to get the benefit of that overtime and when you combine that with our improvement and our ability to target communications to people, I think those two work-together to help drive the improvement that we're seeing in our utilization rates.

Your next question comes from the line of Matthew Gillmor with Robert Baird. Your line is open.

Wanted to ask a couple of follow up from the utilization front, so Sean asked about some of the key drivers on the digital side and you also mentioned the flu season having an impact in there prepared remarks. Is there a way to tease out how much was driven by the flu season versus maybe the secular growth components from broader awareness?

I would say this about the flu season; although, with severe, it was short lived. So when we look at the flu season, usually we get significant December effect and it lasts well into March. This year we saw it pretty intensively in January and February, but really not in December and March. So while it was more intense while it hit; it probably didn’t have as significant of an overall impact because it was shorter and we didn’t really see any impact of it and in fact it dropped off in the very beginning of the March. So I would say a small portion of that came from the cold and flu season, but the majority of it was a result of the communications, difficult for me to tease out the exact numbers on that, but I would say directionally that should give you the insight you need.

And then Jason you mentioned some of the employers shifting away from the free model and moving towards the PEPM to drive utilization. Can you give us a flavor for what they’re saying and why they’re shifting back? And are you seeing any change in some of the competitor pricing behavior towards the PEPM model? Thanks.

We're pleased to see that the market is becoming more rational that our customers are understanding the value that we provide and the importance of driving utilization. And I would say from small accounts all the way to the largest accounts, we're seeing them realized it; you get what you paid for and if you're not paying anything, you're probably not getting anything. So we have seen the recognition and in fact we've seen clients come to us proactively. We’ve also seen some operational challenges among some of our other competitors in the market, which again is causing clients who may be made a different decision a couple of years go to come to us. With respect to pricing, we’re seeing I would say more rational behavior. There is I think as companies have to go out and raise capital, they probably realize that they have to show more rational economic model. And certainly, we’ve been the beneficiary of that. You can see our mix has been good, our PEPM pricing continues to be strong. And I think everything from the clients to the consultants really understood that all of this hinges on whether you can drive utilization.

Your next question comes from the line of Ryan Daniels of William Blair. Your line is open.

Jason, one for you, you mentioned that your client summit that your clients have more desire for you to help them work with more costly in complex medical conditions. I am curious if you can talk little bit more about what that might include? And then perhaps what operating model changes you might need to impart in order to manage more medically complex patients than what you’re doing today?

That was a strong theme that came through. We have historically played in the high frequency, low severity and of the cost continuum. And I think our clients recognize that it's hard to reach people who’re at the end of that spectrum where it's lower frequency, higher severity and therefore higher cost. And with a model like ours that has such higher member satisfaction, they are looking to us to see if we can help them to address that other end of the continuum. When you asked about capacities, I would say we have been on the path to building those capabilities. And if you look at our progression, it's a very methodical one. So we started acute episodic care with our, what you would probably call, virtual urgent care or general medical product; when we added behavioral health that took us into longitudinal care where we were managing a patient over a longer period of time, frequently somebody with multiple comorbidities. Our tobacco cessation program gave us the ability to bring in a nurse coach in addition to the treating physician. And then our dermatology program brings in a specialty network in addition to our behavioral health network. Finally, the addition of our labs enables us to send a patient for additional lab work and really creates more of an interaction with the member around their biometrics. So you put all of those together and it provides a lot of the building blocks for being able to healthcare for patients whether in a primary or secondary capacity overtime and with much more complex cases. So while I will reframe from giving you specific conditions and/or products that we’ll have in the market, I can tell you that we’re actively looking at that moving up the continuum of care.

And is that also a big impact on your utilization rates, meaning that while it’s not just the short-term balance of the cold to flu, the sinusitis you’re broadening; so therefore, the utilization rate is also going to naturally see upticks since more consumers access different types of solutions from Teladoc?

Certainly, increasing utilizations by offering a broader array of services is we’re in the middle of our strategy. And I think that manifests itself two ways, one is the more you offer to a consumer, the more part of their overall healthcare you can take care of. But also with our behavioral health, for example, people don’t just have visit, right; it’s a series of visits with the provider and so rather than 1.3 visits per person, you see significantly more in our behavioral health product.

The Texas legislation the way it written today if that bill becomes a law. Would it require any material changes in the way you operate or deliver services for members in that space?

No changes at all. It would be required the one change would be that we would be able to offer video in Texas where we don’t today.

And then last one, I believe Mark, but just for guidance. If I look at the implied visits and membership at the mid points in revenue, looks like may be a little bit larger jump in PEPM fees than normal. And I’m curious if that’s just the impact of some of the SMB customers coming in or more of the visit included coming on that’s going to push that up a little bit sequentially?

Ryan, you hit one of the two, so it’s the visits included small medium size businesses again are attracted to that product. And then also the increase from those high subscription rates from our direct-to-consumer behavioral product, which I think I've told you in the past, will exceed 15% of our 2017 revenue.

Your next question comes from the line of Mohan Naidu of Oppenheimer. Your line is open.

Jason, going back to the earlier question about the selling season is there an improvement in clients’ understanding of telehealth offering when you're going to the market right now. And I guess you don’t need to start from the beginning and convince them that they need to get telehealth versus just going in and competing with other vendors?

I would say that’s true in the large employer market, it's increasingly true in the health plan market, the small and mid size market still a lot of education and of course we sell through a broker distribution channel there, so frequently, we’re orienting the brokers and they are orienting their clients. And then in provider space, that’s still a lot of green field, that’s a lot of new customers who are -- they may have a Chief Strategy Officer, who is leading the charge or many cases now they’re starting to have a telehealth officer at the hospital system who is starting to create a strategy around it.

One question around the specialty so you stressed a lot on specialty this call today. Is there something interesting going on with large clients pulling, you talked about lot of interest from health plan clients. Why are they suddenly looking at specialty now? Are they are seeing more data come out of your employer clients that convinces them to look at it?

I would say it's a combination of things; one, it's just a cycle of -- we’ve now been in market for a little while; we’ve been talking to our clients, health plan and employers about it. And so there is just a natural maturation in progress that we’re making there. I would say, there is quite a bit of recognition of the challenge of metal health and especially untreated mental health and its impact on cost of medical care, as well as especially when there are co-morbid conditions. And then lastly, certainly, we have now proven ourselves and we have reference clients that we can talk to and bring to bear for our prospects. And so that certainly helps our ability to bring a prospect along to comfort and then ultimately going forward with implementation.

Your next question comes from the line of Richard Close of Canaccord Genuity. Your line is open.

Just want to dive in a little bit deeper on Ryan's question on the client summit and broadening the clinical service offering. Mark, I was wondering if you could just touch-base in whether you move into those high cost areas, low frequency. Does that change the margin profile of the business at all, how were you thinking of that as you ramp up some of those new offerings in future years?

We’ve spent a lot of time looking at the relative margin variance and offering those services, and we’ve modeled them out. And to the extent that we’ve guided people into that high 60s gross margin level, that’s consistent with where we feel the business is going to go over the next couple of years. We continue to generate 70%, 72% upwards of 75% margins on the core business, but we see the contribution of those additional services likely contributing to us getting into that high 60% range over the next couple of years.

Jason, you throughout TD Ameritrade there, I think you said 20% utilization, if I am not mistaken. And can you just -- if that’s the case -- that’s what their utilization rate. Can you just walk us through what they did or what you guys did with them to get 20%? And is that something we should think about long term for a majority of customers?

So TD Ameritrade has been a client for quite some time. They are enthusiastic supporters. We worked closely -- we work closely with them, designing communications to their employee base, their strong internal champions. And I would say they are a good example of a model client. Having said that, at roughly 20% utilization slightly above that, they are not unique. We have many clients in the 20% to even 50% utilization range. In fact I had a client at our client summit that is at 81% utilization. So unfortunately we can't get approval from every client to talk about them by name on a call like this. But when a client engages with us and really partners with us to drive awareness, drive utilization it is very, very effective. And we’re fortunate we had about 40 clients, almost 40 clients, at the summit we get a lot of best practice sharing among them which quite frankly is one of the most valuable parts of the summit. We learn from it and they learn from each other. We’re starting to work on how we create better community among our clients so that they can do that on an on-going basis, not just once a year at our client summit and do it much more broadly by using technology and some of our capabilities to create more of a peer to peer best practice sharing, because we think the network effect of our 7, 500 plus clients can be very powerful.

And my final question again on this utilization. As you think about different segments, employer, payers now you got providers; although, that is pretty new. Can you just give us a ballpark in terms of what average utilization rate is may be for employer versus the payer? How we should think about that?

Richard, without giving a range, you should expect the employers to continue to re-characterize them as having both the best opportunity to increase utilization but also experiencing the highest utilization among our members. And next is obviously as a result of their tenure with them, the payers and clearly those newer clients that are coming on the providers, we would expect to see them ramp up. Clearly, easy to see them double and triple over where they are today. But with regard to where would rank, it's clearly the employers that will see the highest utilization coming from them.

Your next question comes from the line of Steven Wardell with Chardan Capital Markets. Your line is open.

My first question is, do you expect provide visits that you get through provider customers to defer from visits that you get from employer customers. But you described employer customers as high frequency low acuity. What about visit traffic that comes to you from providers, do you think that will be substantially different?

I would say in some cases yes and in some cases no, and it very much is aligned with the strategy and the use cases that the providers are oriented toward. And let me give you the two ends for the spectrum. On one end of the spectrum, those that will be very similar to our existing or to more traditional book of business are those providers who are looking to use Teladoc as a way to improve their branding and prove their presence in the local market and create a funnel for members into their system. And therefore, they put a co-branded product into the local market on more of a direct to consumer basis. So think about that as very similar to our general medical product. On the other end of the spectrum, we're working with providers who see the Teladoc platform as a phenomenal opportunity to better engage with patients post acute post surgical do post discharge, plan at here ends and follow up. And of course those are very different yet post surgical patients and the follow up is based -- is more oriented toward how their recovery is going, checking their wounds, are they on their meds, or is their weight stable things like that. So it really ranges depending on the use case and the priorities of the hospital system. But the nice thing about our platform one of the reasons that we’re having such success is that it really stands that it's flexible enough that it expands all of those use cases seamlessly.

And would you say you have customers who are fee for service and other that are fee for value in the provider world, and do they behave differently? Would you expect more business from the fee for value customers, for example?

I think it really dictates what their primary strategy is. So if someone -- if a provider is a more fee for value oriented, if they are taking a risk in an ACO type of relationship then they are much -- more likely to focus on eliminating leakage outside of their system, managing their resource consumption and things like the discharge planning that I just described. If they’re fee for service, they are probably more oriented toward increasing their volume and using Teladoc as a way to increase their patient flow.

And you mentioned the way to engage with providers is through a software license with them. Does that mean if they stand up your software on their premises or are they recently part taking in your -- for instance, the software?

It's the latter. We’re not installing any software on their premises. It is entirely a cloud based solution that we provide for them.

Your last question is from Matt Hewitt of Craig-Hallum Capital Group. Your line is open.

Two for me, actually one, how does the cost for these vary targeted digital marketing campaigns defer from the more traditional process you’ve implied last couple of years?

It's really much more cost effective because we can take more of a rifle shot approach rather than a shotgun approach. And so being able to target those who are most likely to respond in a digital fashion is obviously digital communication is a lot less expensive than direct mail, for example. And it would not be cost effective if you couldn’t do it in a targeted manner. But we have very sophisticated mechanisms to be able to do that. And over the course of the last, I'd say 18 months we’ve really significantly improved our ability to do it to take advantage of the technology that is out there in the market and really become a state of the art targeted marketer.

And then one last one from me, obviously, it could be a while before we have the final version. But the house pass is the new health care bill, what if any impact could that version and I realized that there could be changes in the senate. But is there anything that we should be focused on or paying attention to that could impact your business positively or negatively? Thank you.

I would say -- I would eco what you said about the fact that there could be changes and we are unlikely to know what the final bill looks like. Having said that, I would say generally it's fairly neutral for us. There are a couple of puts and takes but I think eliminating the minimum benefit plan probably opens up opportunity for other kinds of products in the market into which Teladoc fits very nicely. At the same time, pulling back on some of the Medicaid membership, we don’t have not much of our business now is Medicaid. And so I don’t think you would see anything that looks like a contraction in our existing customer base. So I don’t think that would have a significant impact on us as I look at our book of business today. Again, I think the bigger thing I would look at is there is generally positive regulatory momentum relative to telehealth both in Washington and in the states. And we're much more likely to see benefit from that than we are to see any substantial impact from the new healthcare bill or whatever that ends up looking like.

Your last question is from Richard Close of Canaccord Genuity. Your line is open.

On utilization, have you guys ever given any type of guidance in terms of the basis point improvement you expect on an annual basis, or any longer term targets?

We haven’t guided towards any longer term targets. However, we have suggested that as in the past where we have seen the highest utilization come in over the last three years, coming in on the Q4. We would expect that ramp from Q1 to Q4 to be an increase of anywhere from 15% to 25%. As you could imagine, because of the seasonality and as you can read into the numbers, we expect slightly lower visits completed in Q2 and Q3 and really the bulk of our visits coming in close to the 400,000 number in Q4 of this year.

So I think that concludes all the questions we have. I want to thank everybody for participating in today's call. As a final note, we also wanted to remind our shareholder that we filed our definitive proxy form as well as additional soliciting materials with the SEC, summarizing the Board of Directors rationale for 2017 shareholder proposals. We look forward to having you join our virtual annual general meeting on May 25th. And I’d encourage you to reach out to Jisoo Suh with any follow up questions. And so with that, I think we’ll close the call and again, thanks everybody for joining today.

This concludes today's conference call. You may now disconnect.