Teladoc Health, Inc. (TDOC) Q3 2021 Earnings Report, Transcript and Summary

Good day, and thank you for standing by. Welcome to Teladoc's Third Quarter 2021 Earnings Conference Call. [Operator Instructions] Please be advised that today's conference is being recorded. [Operator Instructions] Thank you. I would now like to hand the conference over to your first speaker today, Mr. Patrick Feeley, Head of the Investor Relations. Sir, please go ahead.

Thank you, and good afternoon. Today, after the market close, we issued a press release announcing our third quarter 2021 financial results. This press release and the accompanying slide presentation are available in the Investor Relations section of the teladochealth.com website. On this call to discuss the results are Jason Gorevic, our Chief Executive Officer; and Mala Murthy, our Chief Financial Officer. During this call, we will also provide our fourth quarter and full year 2021 outlook, and our prepared remarks will be followed by a question-and-answer session. Please note that we'll be discussing certain non-GAAP financial measures that we believe are important in evaluating Teladoc Health's performance. Details on the relationship between these non-GAAP measures to the most comparable GAAP measures and reconciliations thereof can be found in the press release that is posted on our website. Also, please note that certain statements made during this call will be forward-looking statements as defined by the Private Securities Litigation Reform Act of 1995. Such forward-looking statements are subject to risks, uncertainties and other factors that could cause the actual results for Teladoc Health to differ materially from those expressed or implied on this call. For additional information, please refer to our cautionary statement in the press release and our filings with the SEC, all of which are available on our website. I would now like to turn the call over to Jason.

Good afternoon, and thank you for joining us. This afternoon, I'm pleased to report another strong quarter marked by solid financial performance, more care delivered and deeper member relationships. Today, I also want to highlight 2 areas where we've made meaningful high-impact progress toward our goal of transforming health care: one, becoming the consumer destination of choice for virtual care; and two, gaining significant commercial traction for our integrated whole-person primary care approach. Consumers and clients are demanding a single integrated virtual health care solution that seamlessly takes care of all of their health care needs, redefines the care experience and leverages data to improve care at scale. During the third quarter, we continued to demonstrate on our unique ability to meet those demands with a whole-person care approach that continues to fuel our sustained growth. Our broad portfolio of capabilities drove excellent financial results, producing revenue of $522 million in the third quarter, an increase of 81% over the prior year, including organic revenue growth of 32%, which excludes revenue from acquisitions completed over the past 12 months. With our third quarter results and increased visibility to Q4 revenue, we're updating our full year revenue guidance range to $2.015 billion to $2.025 billion, representing growth of 85% over the prior year. While these financial results quantify our ability to deliver on our promises and sustain the success of our work to transform health care. Validation came in a number of forms. And we're very proud that Teladoc Health has once again been named #1 in consumer satisfaction by J.D. Power. We've always viewed our outstanding consumer experience as a key differentiator for us, but also as one of the unique ways in which we expand our role in an individual's health care journey. For example, we find that the Net Promoter Score for someone's first visit is a strong leading indicator of future usage. And a positive initial experience creates stickier relationships with our members. The recognition by J.D. Power is proof positive that we're delivering on our promise to our members. And the strong utilization increases in spite of the waning pandemic are the results. Our global network of clinicians provided 3.9 million visits in the quarter, an increase of 37% over the third quarter of last year. Even as pandemic restrictions continue to ease and vaccination rates improve, consumers are increasingly relying on Teladoc Health's virtual care. We're now on track to provide more than 14 million visits for the year. As has been the case all year, the strength in utilization has been driven by growth in visits related to noninfectious diseases and specialty care as consumers are turning to us for a broader array of conditions. During the third quarter, more than 75% of member visits in the employer and health plan channel were related to noninfectious diseases versus approximately 50% in the pre-pandemic period. Growth in mental health visits, in particular, continue to outperform across the direct-to-consumer, employer and health plan populations. And B2B mental health visits remain on pace to double this year as compared to fiscal year 2020. While we continue to see lower than typical transmission of infectious diseases across the country due to social distancing and PPE usage, our infectious disease volumes have continued to increase throughout the year. The combination of building momentum in infectious diseases and continued strength in noninfectious disease and mental health volumes gives us great confidence in our outlook for 2021. We have also made substantial commercial progress with our Primary360 product, which represents a key pillar of our whole-person care strategy. Primary360 reimagines primary care by delivering a fully integrated virtual solution of mental and physical health, leveraging technology and data, bringing together a full care team for the consumer and connecting into the physical delivery system to get consumers the right care at the right time. Over the last few months, we've signed several new agreements for Primary360, including 2 notable health plan deals. First, as announced earlier in the quarter by CVS, we signed an agreement to bring Primary360 to Aetna's self-insured employers nationwide beginning next year. Earlier this month, we also expanded our relationship with Centene to partner on its new Ambetter virtual-first health plans on the health care exchanges, beginning with 4 states in 2022. Each of these agreements provides members with access to our virtual care team, including a virtual primary care physician of their choosing and care extenders, such as nurses, 0 co-pays for virtual visits, unlimited messaging, integration with our virtual specialties such as dermatology and mental health, and navigation to local in-network providers when needed. We expect these partnerships, along with deals signed across our suite of whole-person solutions with HCSC and other Blues plans over the past several months, to contribute meaningfully to growth over the next few years as we drive adoption of our whole-person virtual care solutions. Another key on-ramp to our full set of products and capabilities is Teladoc's integrated suite of chronic care solutions. The number of individuals enrolled in our suite of chronic care solutions grew 31% year-over-year to 725,000 at the end of the quarter. In the third quarter, we continued to drive growth in multi-program enrollment. 24% of our chronic care members are now enrolled in more than one program, up from 8% in the third quarter of last year. The growth in chronic care enrollment, combined with the greater number of individuals enrolled in multiple programs, such as members enrolled in both our diabetes and hypertension programs, resulted in a 45% year-over-year increase in the total number of chronic care programs in which our members are enrolled. Before I pass off the call to Mala, I want to provide some initial perspective on our expectations for 2022. As you know, it's not our typical practice to comment on forward outlook at this point in the year, but we believe the additional color is appropriate given our insights at this stage of the selling season and our outlook on consolidated revenue growth for next year. First, we are as confident as ever in our multiple levers for growth in 2022 and beyond. Our unique ability to deliver longitudinal whole-person care is a significant competitive advantage, and our leading position in all B2B and DTC channels enables us to fuel continued growth. Given our insights at this stage of the selling season, our preliminary outlook for consolidated revenue next year is approximately $2.6 billion. We plan to provide additional details around the building blocks to that outlook at our Investor Day in 3 weeks. Chronic care is just one of those levers for growth and is increasingly converging with others, for example, through the integration of our capabilities into new high-value products like Primary360 and myStrength Complete. So far this year, chronic care has grown in line with our initial expectations. However, as we work through the 2022 planning process, we expect to be more conservative about growth expectations for stand-alone chronic care. Our preliminary outlook assumes stand-alone chronic care revenue will grow approximately 25% to 35%. And we believe strongly that our chronic care capabilities will also continue to unlock growth across our integrated suite of products and solutions. Our whole-person care approach is clearly resonating with clients and consumers as their expectations for virtual health care delivery continue to move up the value chain and expand from transactional, episodic demand toward integrated longitudinal care. As the only virtual care provider capable of delivering the full credit answer at scale, the breadth and depth of our solutions uniquely positions us to meet the market's evolving expectations and demonstrates why our clients are turning to Teladoc Health to satisfy a wider set of consumer health care needs. We hope this insight provides helpful context, and we look forward to sharing more at our Investor Day on November 18, where we plan to provide an update on our progress toward creating the integrated virtual front door to whole-person care as well as detail on our long-term growth outlook. With that, I'll turn the call over to Mala for a review of the third quarter as well as detailed guidance.

Thank you, Jason, and good afternoon, everyone. During the third quarter, total revenue increased 81% to $522 million or 32% excluding acquired revenue. Total U.S. revenue for the quarter was $483 million, representing growth of 89% over the prior year's quarter. Total international revenue of $39 million increased 17% over the prior year. Access fee revenue for the third quarter increased 99% year-over-year to $452 million and represented 87% of total revenue, up from 78% in the prior year's quarter. The increase in access fee revenue as a percentage of total revenue is primarily due to the acquisition of Livongo and growth in direct-to-consumer mental health, which is sold on a subscription basis. Visit fee revenue for the third quarter of $60 million increased 18% year-over-year. Turning to membership and access. We ended the quarter with U.S. paid membership of 52.5 million members, an increase of 500,000 members sequentially over the prior quarter. Individuals with visit fee only access was 23.6 million at the end of the third quarter. Total unique members enrolled in one or more of our chronic care programs was 725,000 members as of the third quarter, a 31% increase over the 553,000 unique members as of the prior year's quarter, pro forma for the merger with Livongo and an increase of 16,000 members sequentially, which was in line with our expectations. Average revenue per member per month was $2.57 in the third quarter, up from $1.18 in the prior year's quarter and $2.47 in the second quarter of 2021. The primary driver of the sequential increase in revenue per member was growth in direct-to-consumer mental health revenue. Now turning to visits. During the third quarter, we provided 3.9 million visits through our network of clinicians, representing 37% growth over the prior year's quarter. We saw strong growth in both direct-to-consumer visits and visits through our enterprise relationships with health plans and employers on a year-over-year and a sequential basis. Platform-enabled sessions, which represents encounters facilitated by our licensed platform and provided by our clients' own clinicians, were an additional 1 million in the quarter. The annualized utilization rate for our members was 23.7% in the third quarter, a 720 basis point increase over the prior year's quarter and a 210 basis point increase sequentially. Adjusted gross profit, which excludes depreciation and amortization of intangibles, increased to $353 million. Adjusted gross margin was 67.6% compared to 63.7% in the third quarter of 2020. The 390 basis point improvement in adjusted gross margin is primarily attributable to the increased mix of subscription fee revenue versus the prior year. Gross profit and adjusted gross profit in the third quarter of 2021 include the benefit of approximately $5.7 million in lower expenses on Livongo devices attributable to purchase accounting adjustments related to the merger. Adjusted EBITDA was $67.4 million in the third quarter compared to $39.5 million in prior year's quarter. Adjusted EBITDA in the third quarter of 2021 includes a benefit of approximately $5.7 million attributable to purchase accounting adjustments mentioned previously. Better-than-expected adjusted EBITDA in the quarter was driven in part by a slower ramp in technology and development spending versus plan. We continue to make material investments in technology and data science to deliver on the full promise of whole-person care at scale, and we are anticipating a material ramp-up in investment in the fourth quarter and into next year. Net loss in the third quarter was $84 million compared to a net loss of $36 million in the same quarter last year. The wider net loss was primarily attributable to increased stock-based compensation and amortization of acquired intangibles. On a per share basis, net loss was $0.53 for the third quarter compared to a net loss of $0.43 in the prior year's quarter. Net loss per share includes stock-based compensation expense of $0.45, loss on extinguishment of debt of $0.01 and amortization of acquired intangibles of $0.28. We ended the quarter with $826 million in cash and short-term investments while our total recorded debt outstanding as of quarter end was $1.2 billion. Operating cash flow in the quarter was $77 million. Now turning to forward guidance. For the full year 2021, we now expect revenue to be in the range of $2.015 billion to $2.025 billion. We expect adjusted EBITDA in 2021 in the range of $260 million to $265 million. As discussed previously, we are reinvesting cost synergies back into the business to fuel long-term growth, including the rollout of new capabilities and new products such as myStrength Complete and Primary360, continued integration of Livongo, enhancements to our integrated data platform and expansions into new markets. We now expect total visits in 2021 to be between 14.5 million and 14.7 million visits, representing growth of 37% to 39% over the prior year. For the fourth quarter of 2021, we expect revenue of $536 million to $546 million, representing growth of 40% to 42% over the prior year's quarter. We expect total paid membership in the range of 52.5 million to 53.5 million and anticipate total visits during the fourth quarter of between 3.9 million and 4.1 million visits, which represents year-over-year growth of 32% to 39%. We expect fourth quarter adjusted EBITDA to be in the range of $69 million to $74 million. With that, I will turn the call back to Jason for closing remarks.

Thanks, Mala. Finally, I'd like to add that in the midst of all the third quarter efforts we just shared, Teladoc Health as a combined company earned certification as a Great Place to Work. As some of you may know, this premier organization evaluates a company's cultural health through both objective measures and employee surveys before conferring its designation, and we are excited to get this positive report card in the wake of fully integrating our teams. As always, thank you for your continued interest in Teladoc Health. We look forward to sharing more at our Investor Day on November 18. And with that, we'll open the call for questions. Operator?

[Operator Instructions] Our first question comes from the line of Lisa Gill from JPMorgan.

Jason, I just want to go back to your comments around whole-person and that it'll be meaningful over the next few years. So just to understand this a little bit better, can you help me around how to about virtual primary care versus traditional when we think about both revenue and profit. And when you say meaningful over the next several years, is that a meaningful driver in 2022?

Yes. So thanks, Lisa. I'm really excited about our whole-person suite of capabilities. And let me go sort of first with what we mean by whole-person and then lean into a deeper discussion of Primary360. So when we talk about a whole person, we mean the philosophy of taking care of the entire person, both their physical health and their mental health, their acute episodic needs as well as their chronic and complex needs as well as taking care of them on a preventive basis. Things like making sure that they're getting their screenings, making sure that they're eating properly and have the counsel of a registered dietitian in our nutrition programs and that they have both digital and human interactions. So a model that brings digital modules to them when that's appropriate as well as a full care team that's there for them. And we've proven our ability to do that and the appeal of that with the number of people who are now enrolled in multiple chronic care condition programs for us as well as our ability to sell mental and physical health together. And we continue to see very, very strong results in multiproduct sales into our clients. And so what we see is that, that whole-person approach really resonates with the market, both with clients at the purchasing level as well as with consumers at the utilization level. As I go deeper into Primary360, we're very excited to have announced relationships with CVS for their Aetna self-insured clients and virtual-first plan designs that we'll be rolling out in that market nationally as well as with Centene and their Ambetter programs on the exchanges, again, with a virtual-first plan design. The economics are greater than our traditional general medical programs or the combination of a general medical and mental health program because we're bringing the full credit answer, so to speak, to bear for the consumer that takes advantage of our entire suite of capabilities. When we talk about a meaningful impact, we expect to see substantial growth off of an admittedly small base in '22. And in '23 and beyond, we expect that to have a meaningful impact on our overall financials as a company. And maybe last before I hand it to Mala for any additional commentary. I'll just preview that we're going to do a deeper dive into our Primary360 product as well as the opportunity for us to enter into more value-based arrangements to capture a bigger part of the savings that we generate when we host our Investor Day in 3 weeks.

I was going to save that question for the Analyst Day, Jason. But Mala, if you want to comment at all from a value-based perspective. Just listening to everything that you just said and thinking about value-based programs that are out there, thinking about capitation, this all sounds like this is very well suited as we think about some of those new programs that are coming to the market. So Mala, if you can add any commentary around the financial impact, but I'm just curious, Jason, do you see Teladoc taking risk in this area? And maybe that's something you're going to talk about at the Analyst Day.

I do see us taking risk, and I think we'll step into that. And I'm thinking of a slide that we're going to show at our Investor Day that demonstrates the degrees of risk and the progress that we'll make going from first clinical measures, to then risk corridors, to ultimately full capitation. Of course, you have to draw a box around that to make sure that we're taking credit for the savings we're generating where we're generating it and we're not taking risk outside the scope of where we can have an impact. So I think you'll see a lot more depth on that at our Analyst Day.

Yes. And I would add to the point Jason just made. The fact that we have the data and the data science capabilities that we have and the integrated data that we are hard at work on, all of those types of capabilities, along with the scale of technology that we have, is what we will bring to bear as we go on the journey in expanding Primary360. The only other thing I wanted to say, Lisa, and again, we'll talk more about this and other sort of levers of growth on Investor Day. As we think about the opportunity for us to penetrate deeper into our member base and think about revenue per member expansion, we are excited about Primary360 as one of the many levers we have to expand our revenue per member. Again, I still go back to what Jason said, we expect this to be a multiyear journey with meaningful increase in the 3 to 4 years ahead.

Your next question comes from the line of Sean Wieland from Piper Sandler.

I wanted to ask about some of the changing privacy landscapes out there limiting an app's ability to track us all over the place. What impact do you think this will have in your DTC marketing strategy and marketing costs?

Sean, I don't think that, that will have an impact at all. One of the things that I'm really proud of relative to our DTC efforts is, number one, our focus on privacy and compliance. But number two, also our focus on diversifying the channels through which we acquire new members and attract new members. And I know that there are plenty of companies that are very focused on 1 or 2 channels. We've done an excellent job over the last several years of diversifying into multiple channels and always doing it in a way that focuses on sort of the member first. So I don't think it will have an impact at all, Sean.

Your next question comes from the line of Jailendra Singh from Credit Suisse.

Jason, I wanted to follow up on your 25% to 35% stand-alone chronic care revenue growth commentary for next year. I know it is difficult to parse out, but is that before any synergies you expect from Teladoc-Livongo combination? And you also mentioned that you are taking a conservative view there. Can you help us understand what is driving that? Are you taking a conservative view around enrollment and adoption of Livongo offering or is it more around expectations around multiproduct enrollment?

Yes. So I'll comment on the second part. When we talk about chronic care management and our outlook, we've done a lot of work to make sure that we're very focused on the discipline that we bring and have always brought to our management of the pipeline and our forecasting process. When we look at the chronic care, the pipeline, I'd sort of break it into the different customer channels. We've, I would say, been very successful in selling into the health plan channel over the course of this year, and our pipeline still looks strong with new opportunities. Many of those opportunities, either the existing sales that we've made or the ones in our pipeline are, the permission and the partnership with the health plan to go sell to their self-insured clients, that takes a couple of years to unlock the full value of it because you have to go through the renewal cycle and the selling cycle to those self-insured clients. And so we're trying to be very realistic about the sort of on-ramp of those clients in the health plan segment. With respect to the employer market, that's a market where our products are extremely attractive. And historically, we've been very successful of selling into the employer market directly when we sell directly to large employers. That's a market where the benefits managers have, I would say, paused over the course of this year more than we've seen it in the past, and it's really due to COVID and then being focused on the pandemic and return to work. As I talk to our employer sales team, they see that picking up substantially as we get to the end of the year and people are starting to get back to the office and the benefits managers are starting to think about more of a return to normal. And so they're optimistic as we look into next year's selling cycle. And then there are 2 channels that I would say are just moving a little more slowly than we had originally anticipated. And again, we want to be conservative in our outlook. The broker channel, we had high expectations, and we're just starting to see that pick up now. It took a while to educate the brokers. We have a large distributed broker network. And it took a little while to educate them on a product set that they really didn't have access to before. We're now starting to see that pick up substantially, and we're excited about next year's selling season for that. And then lastly, international. I think the international markets, we have to go through some, both regulatory hurdles in terms of local certifications and approvals but also localizing our products to various international markets. And we're doing that in a fairly methodical approach market by market. So I think we will see growth internationally, but we don't have really anything in our plan for next year on a substantial basis. Maybe the last thing I'll say is, that's been, I would say, positively offset by our growth in the hospital and health system market, where we've noted before that we've seen, especially risk-bearing hospitals really lean into the chronic care solutions. And that's going better than we had expected. So when you put all of that together and we take a, I would say, critical look at the pipeline and our forecast, that's where we landed on that 25% to 35% outlook. Again, that's a contributor to our overall outlook of approximately $2.6 billion in revenue next year.

The next question comes from the line of Stephanie Davis from SVB Leerink.

I was hoping you could give us a broader view on the new Primary360 offering and how it ties into the existing health system? Is this something where we could see it tie into your existing hospital solution or should we think of it as a stand-alone play that will compete with the traditional health system?

We see our role, and this has always been the case. We believe that we can transform the health care experience and transform how people get care by working with the health care system and the physical delivery system and integrating into it. I've been quoted many times as saying, I don't think health care is ripe for disruption. We actually don't use that word when we talk about what our role is. But rather, we think our role is to work with the physical delivery system to improve the care that's ultimately delivered. Now look, we have certain advantages over the physical delivery system. I mean, we have 2 billion data points in our data platform of chronic care measurements from our chronic care tools. We're delivering over 25,000 personalized health nudges every day. And that's because we have this depth of data. We're providing over 30,000 virtual visits on average every day. So when you put all of that together, we have this incredibly rich set of data. And so we believe that we can really transform the primary care experience and the health outcomes from primary care, but we also recognize that we can't do everything. There's care that has to be delivered in person. And that comes in a number of forms. We'll integrate with certain partners for the last-mile delivery, whether that's in-home lab testing or in-home care that can be done in the home, the needs of physical interaction or referring into the most efficient parts of the delivery system. And Stephanie, to your exact question, I think the places where that will happen most seamlessly is the providers who are using our technology platform because we can make a seamless handoff to them and really act like a concierge for the consumer. But we also recognize that we have to be responsive to our health plan partners and refer into the most efficient parts of their delivery network. So I'm not looking to compete with it. I really think that there's an opportunity for us to improve the overall performance of the health care system and work with the health care system.

And the other thing I would also add Stephanie is, we are beginning to open the door to conversations with health system leaders around creating virtual front doors within their markets. So it's health plans, as Jason talked about, it's also around health systems. You know the role that primary care plays within their ecosystem. And this is where our Primary360 product can also be relevant.

The next question comes from the line of Richard Close with Canaccord.

Jason, I was wondering if you could give us an update on MyStrength Complete that I think you rolled out here recently over the last quarter. So just an update there, didn't hear anything in your comments.

Yes. We're really excited about myStrength Complete. So Richard, you know this, but just to recap. myStrength Complete really brings together the mental health assets of Livongo and Teladoc to deliver a true stepped care model where we bring digital solutions that enable digital modules for the consumer around things like cognitive behavioral therapy and dialectical behavioral therapy and mindfulness and other skills, combined with the legacy Livongo coaches and the network of PhD psychologists and master's level social worker therapists and psychiatrists from Teladoc into really the full continuum of care on the mental health front. We're excited about how the pipeline is building. I think we mentioned that we had made several sales even before the product was launched in the market. The pipeline is showing continued momentum, up strong double digits in terms of a percentage quarter-over-quarter and contributing to our overall outlook as we look into next year. I think the other thing I would just say is, I expect myStrength Complete to really complement the rest of our other sort of physical health products. So we're very excited about it, seeing good momentum in the market. And it's also a product that we're just beginning the rollout of internationally. So I don't think that, that will be limited to the U.S.

The next question comes from the line of Ryan Daniels from William Blair.

Jason, this is something you're asked probably every 2 to 3 quarters, and I want to give you another shot at this. But I'm curious what you're seeing more broadly in the competitive environment, in particular, with some of the on-site health clinics starting to offer more telehealth solutions and a lot of coalescence around digital health care with entities like the patient navigation companies. They're integrating things like second opinion services and telehealth and trying to sell that through brokers directly to employers. So can you provide a little bit of a State of the Union, if you will, on what you're seeing in the competitive landscape because it sounds like your win rate and retention remains very strong.

Yes. Thanks, Ryan. Maybe I'll start with the last point you made and just confirm that. Our win rates are staying very similar to prior years. So as we look at sort of doing the pipeline review now and where our win rates are, we're staying very similar to where we were in prior years in spite of the fact that everyone knows there's been a lot of investment in the space. Second, our retention rates are extremely strong. And third, we're seeing really good multiproduct sales. So 70% of our bookings this year were multiproduct sales as compared to about 50% last year, which I think really gets to the reason that we're winning, right? We're winning because of the full suite of our products and services. And the truth is that the point solutions, I would say, are really struggling at this point. And if you look at our late-stage pipeline, it's nearly double versus the size of what it was last year. And I look at all the various players in the market, I wouldn't probably want to be an on-site, sort of worksite clinic provider at this point since a lot of companies are talking about going virtual. And so that has its limitations. Dissimilarly, when I look at the navigation companies, I would say, honestly, having been a health plan president, the administrative side of that is fairly low value. I really want to, and we have always focused on making a big clinical impact using our data and our clinical expertise to improve the health of consumers and really focus on the health care and not the administrative portion. As I said, I do think we will play a big role, especially with our Primary360, in helping to get the consumer to the best site of care based on who the most efficient provider is in their local geography. And we can do that in a way that is untethered because we don't have financial incentive to refer to any specific provider in the market, which is not the case for a lot of the sort of hybrid models that are out there. So I think we can be really pure to our mission of improving care and reducing the cost of care. And the last thing I'd say is, and there was a recent conference where the team that came back said that the big sentiment there was pretty anti-payer in the conference and a lot of the earlier-stage companies were very anti-payer. And we recognize the role of the payer in the market and we really want to partner with the payers and the employers to bring the best care to the consumer. It's always been our position in the market. And again, we think we're uniquely positioned to do that in partnership with the delivery system rather than antagonistically.

The next question comes from the line of Charles Rhyee from Cowen.

This is Gwen Shi on for Charles. When talking about your DTC mental health offering, even though we know that an average subscription might be, say, 3 or 4 months long. How often does someone come back and say they start a new subscription later on? So in other words, even if we're seeing higher customer acquisition costs, are you seeing a level of customer retention such that you don't necessarily have to spend the CAC each time to gain that same user back?

Yes. So I'll start. I'm incredibly proud of our DTC team and the progress they've made. First, they've done a tremendous job based on some of the comments I made earlier about diversification and optimization around our customer acquisition costs. And the team is constantly testing new more efficient models and then rolling out those models on the customer acquisition side. So our cost of customer acquisition has come down very consistently. Second, as we look at our revenue to customer acquisition cost ratio, that's improved substantially over time. And it's because of what I would say, the first thing I mentioned, of course, customer acquisition costs coming down, but also that the team has done a phenomenal job with lifetime value of a member and improving the LTV of a member. They do that obviously. There are 2 levers for that, of course. One is pricing optimization and continuing to test different models for that. But the other one is to roll out value-added services and retention strategies such that one example of those is that a consumer can go to a lower cost lighter version of the product on an interim basis, sort of as they're in a better place in their lives and not going to lean into as much active therapy over a period of time, but it keeps them engaged with the platform and getting some level of mental health care and support such that they can reignite a more intensive therapy period and of course, at a higher price at some later date. We've also rolled out things like groupinars and worksheets that a consumer can use in order to track their own progress and work on things between interactions. So your point is an excellent point, and I'm glad you asked it because in order to make a business like that continue to improve, you have to be pulling a lot of different levers. And I would say, we are very, very good at test, learn. And lastly, when you get to the kind of scale that we have, when you make small improvements, it can have a big impact.

Yes. And when we say this business is about execution, which it is, that is, the things that Jason talked about is what we mean, right? It is test and learn and scale it. And that is what we mean in terms of execution and is fueling both the growth that we are seeing as well as the margins that we are seeing in the business.

And we'll spend some time on our mental health programs, both B2B as well as direct-to-consumer at our Analyst Day on November 18.

The next question comes from the line of Sean Dodge from RBC Capital Markets.

Maybe staying on BetterHelp. Jason, earlier in the year, you had said that, that was expected to grow at least 50% this year. And it sounds like from the tone, and I think you even said it directly that DTC has continued to outperform. Can you give us a progress report or update on how much that business is contributing now or how much it has outperformed that kind of initial 50% growth expectation you have?

Yes. So Sean, give us 3 weeks and we will satisfy all the questions you ask and the curiosity you have around that. But the headline I would say is, we are very pleased with the growth of this business. And you're right, the growth expectations we had set out is what you just said. And I would just say at this point that we are very pleased with how this business has grown, again, as I said, on the revenue, from a revenue growth standpoint as well as from a margin standpoint. And we will talk to where the business is in terms of scale and also importantly, how we are thinking about the growth of this business in the future when we get to Investor Day.

The next question comes from the line of Daniel Grosslight from Citigroup.

I have a similar question to Ryan on the competitive dynamic, but specifically focused on the virtual-first primary care plans that have come out. It seems like every large MCO now has announced a virtual-first pilot in some regard. So I'd love to get your thoughts on just the competitive dynamic there with the third-party vendors. But in particular, I'd like to get your thoughts on the potential for managed care organizations to utilize their own provider networks, like what we're seeing with United and what they're doing with their Optum Virtual Care group rather than partnering with folks like you guys for your virtual network.

Yes. So I think there are relatively few health plans in the country who have the capability and the owned provider assets that United has with its own OptumCare-owned providers. And of course, they're rolling out that product in the markets where they own those substantial number of primary care providers. We believe a virtual-first health plan should be a national product and be available in all geographies. And we've got a great relationship with United and we have a number of new opportunities in the pipeline right now across United in multiple parts of their business. When it comes to other health plans, quite frankly, we see a benefit to some of the big plans making announcements about virtual-first plans because local plans, quite frankly, have to respond. And so we're seeing that as a catalyst for activity, RFP activity with our Primary360 product, new pipeline opportunities and a sense of urgency from multiple plans across the country in response to that. We think quite frankly, because of the breadth of our product portfolio and the scalability of our platform, we'll win more than our fair share of those opportunities. And as we've talked about, those tend to be compelling economics because we play a bigger role with the consumer.

The next question comes from the line of George Hill with Deutsche Bank.

I guess, Jason, just as you think about Primary360, I guess can you talk about how much of it you think as net new growth versus the ability to grow wallet share within existing clients? And then following on that trend, I know this is probably going to be one of those questions that preempts Analyst Day. But I'd love you to talk for a second about how big you think Teladoc can be inside of the beneficiary wallet share, particularly inside of that employer sponsor spend?

Yes. So thanks, George. You're right. Some of that we will cover at Investor Day, specifically around sort of the economic opportunity for the full stack of our products and services. When I think about Primary360, I think the answer is, it will be both a driver of net new growth as well as an expansion within existing clients. Obviously, when you talk about somebody like an Aetna, we've had a long-standing relationship with Aetna for many years and many products. This is an expansion of our role there. And quite frankly, a bigger economic opportunity for us due to that expansion of our role. But I also look at other health plans where we're seeing opportunities, both formal RFPs as well as deep strategic discussions about the role of Primary360 and virtual-first plan designs and their new relationships that we haven't had before. And then lastly, the opportunity that Mala mentioned about bringing Primary360 to wrap around a hospital is a significant opportunity. I can think of a conversation I had with the CEO of a large academic medical center that is multisite and multifaceted just 2 weeks ago. And the discussion was about how we can stand up a virtual primary care offering that is essentially the front door to their system and takes care of their patients in a branded way, and we do that almost white labeled for them. So I think we're going to see new opportunities for that product and that capability that's beyond what we can even imagine today.

Your next question comes from the line of Donald Hooker from KeyBanc.

I was curious about sort of maybe the platform-enabled solutions metric that you share. And I was sort of thinking about that metric in the context of kind of all that I hear about with regards to labor shortages and wage pressures with health systems. And I'm wondering if there's any emerging opportunity to kind of work with providers in that context and around that metric.

Yes. It's a good question. We did see a significant shift as offices closed and both consumers and providers all of a sudden embraced virtual care in a way that they hadn't previously. And I think that, that is a sustained opportunity going forward. I talk to CEOs even of tertiary or quaternary facilities who are saying that they expect anywhere from 25% to 50% of visits to be virtual over the long term. And that's something that nobody would have imagined previously. I also think it does have the opportunity to break down physical barriers and enable more mobility of the workforce, to your point about sort of the labor market. However, I'd just caution that there are state regulatory barriers to doing that. And many of the states have gone back to requiring in-state licensure in order to deliver the care. We, of course, have always operated in that environment. And so that's not really a barrier for us, but it is something that I've heard a number of hospital system CEOs lament because it limits the reach of their own workforce.

Yes. I would also add, on the positive, though, I think what is also increasingly clear as we come out to some extent on the other side of the pandemic is the platform we have is purpose-built. And that is differentiated from just having, like a Zoom experience, for example. So there is a difference in the platform we have, and that is increasingly helping the conversations that we are having with the C-suite of health systems.

You may recall that we announced a partnership with Microsoft to deeply integrate our provider platform into Microsoft Teams. And we're seeing that drive substantial growth in our pipeline. So we're excited about that, and we think that, that will have the desired effect.

Your next question comes from the line of Ravi Misra from Berenberg Capital Markets.

So just 2 for me, both on kind of chronic care. The first one, can you just tease out a little bit on the 25% to 35% chronic care growth how you think of that in terms of enrollment versus kind of pricing? And then secondly, it's been about almost 2 years since the Livongo Dexcom agreement was announced. Can we get a little bit more color on how that stands today and maybe how you're looking to go forward on that?

Yes. So with respect to the Livongo Dexcom partnership, we expanded that last year as we moved more into testing CGM and being able to apply our data science against the data flow that can come from CGM. We haven't published or publicized the results, but we have seen some good early indicators relative to that. I think CGM will be just another data source for us. Obviously, for certain populations, CGM is more effective than for others and more cost-effective than for others. And so this was really testing the impact of CGM on type 2 diabetics. And so I think you'll see us continue to test new models along that path. With respect to the makeup of the 25% to 35% growth, we haven't broken that out publicly. I don't think we're going to do that here. You will get a deeper dive into the market for chronic care programs as well as our expectations for chronic care at our Investor Day.

The next question comes from the line of David Larsen from BTIG.

The visit volume growth was very good in the quarter, up 37% year-over-year. Can you provide any color around how much of that came from BetterHelp visits, if any? And then also within your membership right now, what percentage do you think would be eligible for like a primary care, virtual primary care physician? Is it like 25%, do you think, like the national average?

Yes. So with respect to our growth and visit volume, we're really excited about it. And quite frankly, I think there were a lot of naysayers a year ago wondering if we could continue to grow our visit volume after the really astronomical growth that we saw last year. So we're very, very proud of it. We had growth both on direct-to-consumer and the B2B bases. So we don't break those out, but I will say that we saw substantial growth on both of those fronts. I think it's probably, you can see the data, our visit revenue was up 18% year-over-year. And of course, all visit revenue comes really from a B2B channel. So we're seeing strong growth on both of those fronts. I think the other things that are just sort of worth noting, repeat usage is really strong. We saw repeat usage up 25% year-over-year in the third quarter, which I think is a good indicator and sort of is supported by the J.D. Power findings of us as the highest consumer satisfaction. And I think the other thing that's really nice is, we're getting substantial increases in multiservice usage from consumers. So I think all of that, and of course, multiservice is really only available to our B2B clients at this point.

And we are also seeing nice growth, very strong growth in specialty visits, including mental health that we talked about in our prepared remarks. We are seeing growth. We have been seeing continued strong growth in noninfectious diseases. What I will also add is, in recent months, we have also started seeing a pickup in infectious disease visit volume. So all of that is fueling our visit volume growth.

Thank you. And this concludes our question-and-answer session. I will now turn the call back to Jason Gorevic. Please go ahead.

Thanks, everybody. Appreciate your attention and all your questions. We look forward to seeing everybody in 3 weeks on November 18 at our Investor and Analyst Day. Take care.

Thank you. Ladies and gentlemen, this concludes our conference call. Thank you for participating. You may now disconnect.