678197ce-8a30-4972-8bfa-93818e2a76f8_Telehealth-Premium-Analysis.pdf
Telehealth: Premium Analysis
Overview
Telehealth is the trend that shows the most evidence of overnight, digital transformation ushered forth from covid-19. According to a new report from S&P Global, telehealth patient volume has increased 3,000 to 4,000 percent during the early months of the Covid-19 outbreak.
In times of indiscriminate buying and indiscriminate selling, things can get noisy. As we continue to focus our efforts on breakouts that become buy and holds, we believe this is a trend that will outperform and are eying an entry despite a run-up in some names.
According to the report from S&P Global, providers that rarely employ remote care options have switched over to telehealth services. Facilities such as NYU Langone Health saw 7,000 video visits per day or about 100,000 video visits in April compared to 300 visits per month pre-pandemic.
According to American Telemed, three-quarters of U.S. hospitals are using digital technology to reach their patients via video, audio, chat, or email. Patient use of telehealth is up from 11% in 2019 to 46% this year, with 76% of consumers saying they are interested in using telehealth in the future.
These reports allow for enough evidence to track this trend but predictions may prove to be too low by year-end. You can read a rather optimistic write-up of various accounts as to this explosive trend here.
These two comments piqued my interest as we see that volume continued into May:
“In just the last three months, our healthcare providers completed over 605,000 virtual visits, including nearly 247,000 in just the month of May. What’s equally impressive is our projections for telehealth usage post-pandemic.
Mass General Brigham providers will go from approximately 1,500 virtual visits per month to 250,000.”
“In established virtual care leader, PSJH’s telehealth network was able to scale services from 70,000 telehealth visits in a year to 70,000 in one week to support the COVID-19 surge. Their clinicians leveraged telehealth technologies in many ways, including helping diagnose appendicitis in a young patient, working with a firsttrimester pregnant patient to guide her using a fetal heart rate monitor, providing a more calming experience for behavioral health patients, and staying engaged with frail and elderly patients.”
We see similar evidence of this in Veeva’s earnings call where management stated telemedicine is increasing rapidly from less than 1% of visits in February to 30% of visits in April. Teladoc and Livongo are guiding for over 70% growth during a year when companies like Google are expected to report a dip in revenue for the first time.
On July 25th, the current telehealth regulations are set to expire. Examples of this include increasing the services used by Medicare, paying for virtual care, and letting doctors treat patients across state lines. Also, recently on June 15th, thirty senators signed a June 15 letter asking for temporary telehealth provisions to be made permanent.
According to an analysis on Medicaid and CHIP Payment and Access Commission, 44 states and territories expanded telehealth services by changing Medicaid policies in response to the pandemic. Additional state-based policies now allow a patient’s home to qualify as an originating site.
In early June, a new bill was sent to Congress called the “Evaluating Disparities and Outcomes of Telehealth During the COVID-19 Emergency Act of 2020” that proposes a study of telehealth use for children’s health and mental health. The goal is to establish new policies for telehealth coverage including for Medicare and Medicaid Services.
As Livongo points out in their most recent earnings call, in-patient appointments are important and by no means will be permanently replaced. Yet, remote monitoring and virtual appointments are here to stay and the trajectory here will change if regulatory barriers are lowered permanently. If this is the case, then there’s nothing quite like having the right product when a new microtrend is ignited.
Essentially, we do not think these trends are in the rear-view mirror or a temporary pull forward situation, rather we believe we are in the beginning stages of a green field for cloud software in the sluggish and expensive health care industry. Driving down costs and increasing effectiveness can literally save lives.
We think one of the most bullish points is that the tech giants have eagerly wanted to move into this space and select companies with market caps with $7 billion to $15 billion market caps have instead taken the lead (LVGO and TDOC). We’ve included Veeva in this analysis as a more conservative choice as the company has shown consistent revenue growth and profit margins. Should we see a rotation to profitability, Veeva will be a top choice. As of now, I am asking Knox to prioritize Teladoc and Livongo as we think these momentum plays can become solid buy and hold companies.
Veeva
Veeva Systems is an industry-specific competitor to Salesforce but with more data management and regulatory compliance features than typical customer relationship management software (CRM). Biotech and pharmaceutical stocks can be volatile yet Veeva has navigated this well and has proven to be a stable way of investing in these industries. In Veeva’s S1 filing, there were 23,000 life sciences companies with revenues of $1.6 trillion. The market is now at $2 trillion and growing at 5%.
One major benefit to Veeva over the other two companies covered in this report is that Veeva is mature and has shown verifiable gains for many years and increasing cash flow to upwards of $400 million.
Subscription revenue retention rates are 120%. Revenue increased 38% year-over-year in the most recent quarter to $337 million with non-GAAP operating income increasing 39% year-over-year to $130 million. Non-GAAP net income increased 34% year-over-year to $105 million. The company’s forward growth for the upcoming quarter is at 27% to 28% with EPS between $0.63 and $0.64. The company has over $1 billion in cash and no debt as of April 30th, 2020.
Full-year FY 2021 revenue guidance is between $1.38 billion and $1.395 billion with EPS of $2.50 to $2.55. This forward guidance was reduced by $10 million on the top end and operating income was increased by $10 million due to reduced travel expenses.
The company has a goal of tripling this revenue to $3 billion by 2025.
Financials Takeaway: Veeva is a financially fit company with nearly 30% revenue growth and decent profit margins of 20%. Although in the current hypergrowth climate, this may be overlooked right now, there may come a time when profitability is more desirable than sheer top-line growth. When this time comes, Veeva is a solid company.
Product Overview:
Veeva spans three products: Veeva CRM, Veeva Vault and the Commercial Cloud, which includes event management on the Physicians World platform and patient analytics Crossix. Last year’s revenue primarily came from higher-margin subscription services at around 80% compared to lower-margin segments at 20%.
Veeva CRM is fairly straight-forward customer relationship management software that allows sales reps to collaborate across teams and engage more customers to drive business growth. The Commerical Cloud combines CRM with other offerings, such as data applications and warehouses for data management and new AI products to identify next-best actions.
Commercial cloud is expected to contribute about $580 million in revenue with total subscription revenue being $1.14 billion. Of the $580 million, Crossix adds $76 to $78 million. The headwinds to the Crossix business will be offset by the strength in CRM add-ons. Crossix was an acquisition recently made for $430 million in cash to strengthen Veeva.
Vault:
Veeva Vault is a CRM platform and applications suite built for life sciences. The value proposition Vault offers is to combine content applications and the associated data onto one platform for efficiency and compliance.
The name Vault is a nod towards security and regulatory oversight while allowing for horizontal application access. Vault revenue is expected to top $550 million for FY2021 and is growing in the 40% range and also now accounts for half of revenue. Veeva is looking to expand into cosmetics, consumer goods and chemical businesses. Management thinks the market could be at least $1 billion annually for Vault.
Veeva’s narrow industry-specific focus allows the company to move quickly, such as when the company accelerated the launch of SiteVaultFree for remote monitoring. AstraZeneca implemented Veeva’s remote monitoring to manage clinical trials for covid-19.
The clinical suite project is a unified platform for clinical trial management system (CTMS), electronic trial master file (eTMF) and studies. AstraZeneca is preparing to supply upwards of 1 billion doses of a covid-19 vaccine. Veeva stands to benefit from ongoing Covid-19 lockdowns due to the need for virtual monitoring of clinical data and the need for virtualized sales channels.
Veeva has had the luxury of being a first mover with a lack of direct competitors. Microsoft has a new health care and data solution that is more geared towards sharing health care data to find cures and improve patient health. This may not overlap as much with Veeva’s CRM which is more concerned with improving the sales process but there may be some overlap here with Veeva’s Vault product.
Conclusion:
Veeva stands out as a company with consistent growth and strong profitability. According to some analysts, Veeva should see more upside on profits than Salesforce. Although it’s reasonable to say that some of Veeva’s growth this year may not sustain after a vaccine, there is likely going to be some permanent effects of digitization across health care and life sciences.
Teladoc
Teladoc’s revenue grew 41% year-over-year to $180 million in Q1 2020. The global subscription access fee revenue increased 29% YoY to $137 million with the United States increasing 33% and global increasing 17%.
Net losses and EPS year-over-year were marginally the same with about $30 million in net losses or ($0.40) to ($0.43). Adjusted EBITDA was positive $10.7 million compared to $1.2 million in the year-ago quarter.
This was a miss on EPS as analysts expected ($0.36).
Visit fee only revenue saw phenomenal growth of 93% year-over-year to $43.7 million with the United States increasing 205% for visit fee only and 69% growth for paid visits. This is an area where Teladoc has a growth opportunity globally as the International visit fees grew only 5% YoY. Total United States Paid Membership saw growth of 60.8% and Visit Fee Only growth of 88.7%.
The company is guiding for revenue growth of $215 million to $225 million next quarter representing growth of 65% to 73%. Adjusted EBITDA in the range of $20 million to $24 million with EPS of $(0.28) to $(0.23).
Total revenue guidance for the year is between $800 million and $825 million with adjusted EBITDA in the range of positive $70 million-$80 million. Net loss per share in the range of $(1.27) and $(1.13).
The company has $508 million in cash and long-term debt of $447 million. In May, the company raised $850 million in convertible debt with proceeds partly used to exchange $228 million in existing 2022 notes for a combination of cash and shares of Teladoc health common stock.
Financials Takeaway:
Teladoc is guiding for accelerating revenue growth from 41% to 65%-73%. If Teladoc can deliver this (and maybe more) it will continue to be a top stock this year. What we see is a divergence between subscriber growth and reported revenue, which is a good thing as subscriber growth will drive ongoing revenue growth this year. Additionally, if Teladoc reports another strong quarter, I believe it will be differentiated from cloud software peers that may see 20% or so revenue growth this year (and have yet to report this due to Q1 having minimal exposure to the shutdowns).
Product Overview:
Teladoc Everyday Care offers nonemergency video calls with physicians for $59 with insurance or $75 without insurance. There are 43 million members using Teladoc’s service with 4 million appointments hosted last year.
Teladoc also offers products such as Advance Medical, which is a medical opinion program that gives expert medical opinions from 800 dedicated health care professionals and 450 medical doctors. As of now, 35 million people access the service. Bestdoctors is a second opinion service that Teladoc acquired for $440 million in June of 2017. Betterhelp is a direct to consumer mental health product. Healthiestyou makes health care as easy as possible with prescriptions and access to doctors with an emphasis on ease for people on-the-go.
Current Growth/Flywheel Dynamic:
Teladoc is a coronavirus growth story with impressive numbers.
The company may be going through some serious flywheel effects. It took the company until 2019 to cross 1 million visits per quarter and this doubled to 2 million in Q1 2020. New registrations increased 125%.
The company expects to add 6 to 7 million paid members in the second quarter to end the quarter with 49 million to 50 million U.S. paid members. Management guided for 8 to 9 million total visits, or growth of 90% to 115%. The company expects adjusted EBITDA of $70 to $80 million, up 130% at the midpoint.
As Piper Sandler analyst Sean Wieland put it, the growth with Teladoc is “unprecedented across membership, utilization and scope of services.” Stephanie David Demko of SVB Leerink stated Teladoc is a sleep-easy name in highly uncertain times.
A few risks/competitors …
Teladoc’s moat comes from being first-to-market and working across many disciplines in health care, such as behavioral health, dermatology and second opinion ancillary services. The “right place, right time” may be hard for competitors to catch up to.
Allen Lutz of Merrill Lynch pointed out that the pandemic “is driving substantial engagement and interest from payers.” He is referring to payers moving into the space with United Health’s potential acquisition of AbleTo for $470 million that could pose a threat to Teladoc.
In the private markets, Zocdoc is a competitor and has an all-star line-up of investors. The company pivoted in April from being an appointment booking startup to including virtual doctor visits. Therefore, this competitor is only two-months old. Zocdoc has a different pricing model with medical providers paying a $299 annual fee and then is charged for each initial visit.
One could argue that Microsoft Teams is also a competitor here although the singular focus Teladoc demonstrates will be hard to beat, as evidenced by the acquisition of InTouch Health.
Livongo
Livongo is a hypergrowth company with many triple-digit growth numbers. Notably, this was the case before covid-19 as the core product for diabetes has been growing rapidly. The pandemic may be delivering new opportunities for Livongo to expand into behavioral health and other new areas.
This quarter, Livongo reported outstanding revenue growth of 115% year-over-year in the Q1 2020 results to $68.8 million. Gross margins are at 73% with non-GAAP earnings of $0.03 per share and adjusted EBTIDA of $3.8 million.
Livongo for Diabetes members increased by 100% year-over-year to 328,000 with clients up 44% quarter-overquarter. Estimated Value of Agreements nearly doubled from last quarter to $89 million up from $48 million.
To put this growth in perspective, Livongo had 114,000 members for its diabetes program in March of 2018 and 164,000 members by March of 2019. By December, the number was 220,000 (pre-covid) – so doubled in 18 months. The company then grew to 328,000 in March of 2020. These are numbers to pay attention to.
Revenue guidance remains strong for next quarter at $73 million to $75 million. The annual revenue is expected in the range of $290 million to $303 million, representing growth of 70% to 78%. This is an upward revision from $280 million to $290 million.
Adjusted EBITDA for the year is expected to be between ($14) million to ($10) million. The company had cash and cash equivalents of $368 million with no debt.
Livongo has demonstrated strong revenue growth year-over-year from $30 million in annual revenue in FY 2017 to $68 million in FY 2018 and $170 million in FY 2019.
Financial summary:
Similar to Teladoc, Livongo is guiding for some serious growth of 70%+. This is during a time when budgets may be cut in other areas of tech as Q1 did not provide enough exposure for internal budget planning to shift.
I do believe that TDOC and LVGO have the ability to deliver these growth estimates this year and can continue being winners.
Product Overview:
Livongo helps people manage chronic diseases. The diabetes-management technology platform helps patients with diabetes check their blood sugar levels. This is done with a cell-connected blood glucose meter to check blood glucose and receive personalized feedback and recommended lifestyle changes.
At the time of the IPO, Livongo’s prospectus cited case studies that the diabetes program lowered HbA1c, a clinical metric that reflects blood glucose over the last three months. The company’s platform also reduces cost with savings of 21.9% for diabetic patients. Livongo began with diabetes as the condition is chronic, costly and requires close monitoring.
By year-end, 35% of Livongo’s customers used solutions other than Livongo for Diabetes. To address heightened behavioral health needs, Livongo for behavioral health powered by myStrength is now offering specific COVID-19 and social isolation modules to manage stress and anxiety to all people. These also include Livongo for Hypertension and Livongo for Prediabetes and Weight Management.
Areas for growth:
Livongo can expand existing partnerships with companies such as Amazon Alexa, Apple Health, Fitbit and more. These companies are in need of a more vertically integrated monitoring solution for their hardware as they’re more experienced in hardware and more broad applications for consumer tech.
As management stated in the call, “Remote monitoring is here to stay, and we expect it to become the standard of care for the most vulnerable and expensive populations” – I agree that any solutions that can lower health care costs for providers and improve the health of expensive/vulnerable populations should be in high demand even after a vaccine. The main issue with remote monitoring is user adoption and this may be on a new trajectory with covid-19. Insurance companies may also help to drive this trend of monitoring.
On that note, I am not one to make acquisition calls as it’s impossible to predict what goes on in private negotiations but the synergy between what Livongo offers and what Apple needs for the wearables segment is uncanny. Bezos with Amazon is more visionary than Tim Cook, so if Apple does not look at the company, then Amazon could see Livongo as a way to leap forward very quickly with remote monitoring solutions.
In March, Livongo made inroads with a CVS partnership as detailed here.
Livongo has a product that aggregates data across devices for personalized insights (although this is challenging in health care with HIPAA laws around prescriptions). These personalized insights turn into nudges for specific actions and behavior support that are continually improved through recommendation engines. The company has signed deals with Dexcom and Prognos Health to accelerate the Health Signals platform and AI engine.
What Livongo Health does that separates itself from a long line of healthcare solutions providers is aggregate copious amounts of patient data and use artificial intelligence to provide helpful tips for people with chronic illnesses in order to incite behavioral changes so they live longer, healthier lives.
Similar to Teladoc, the surge in demand has partly come from an easing of regulations and lower barriers from the coronavirus. For instance, with Livongo’s Behavior Health product, covid-19 modules make-up 3% of content but are driving 25% of member views.
Livongo is continually gaining more credibility with the Government Employee Health Association choosing them as a covered benefit for diabetes prevention for more than 2 million federal employees. The company is also on a new curated marketplace Health Transformation Alliance, or HTA and Welltok, for the consumer engagement platform that serves 7 million employees.
Kaiser Premanente has selected Livongo for Behavioral Health for their entire population. This is the largest behavioral health contract in the company’s history and will be roll out over the next five years.
The company states 147 million Americans are living with a chronic condition and 40% live with more than one chronic condition. The majority of health care spending goes towards chronic conditions with Livongo reporting this to be 90% or $3.7 trillion. With that said, Livongo believes their addressable market is $46 billion.
From what I can tell, Livongo’s retention rate is 94% as stated in the Q4 earnings report. Some cloud software investors draw a hard line at 100% with the pickiest drawing a line at 120%. My analysis tends to be more forgiving if the company meets other qualifications – such as guiding for forward revenue that is likely 200% higher than many cloud software companies this year (who have much higher retention rates).
Piper Sandler analysts estimate that the new contract (GEHA) could provide Livongo with 10,000 more customers this year, and said the company is positioned to pick up business from Medicare recipients.
Goldman Sachs analyst is positive of the quarter results. However, he cautions “Livongo does still primarily sell into the employer space, and the impacts of high unemployment/recessionary environment on its growth is a concern”.
KeyBanc analyst Donald Hooker raised his price target on the stock to $85 from $52. Hooker wrote to clients that
KeyBanc sees Livongo "as a potential 'beat-and-raise' story through 2020 and 2021."
I am also impressed with the company for the revenue growth prior to covid-19 between 2017 and 2019, plus the drive management had in bringing the company public when digital health companies were out of favor last July.
This was the first time in three years a digital health company went public. This decision shows Livongo is more of a leader than a follower, albeit a bit anecdotal, it doesn’t hurt to observe the behaviors of the management in these smaller companies and the risks they’re willing to take before there are tailwinds.































