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Teladoc Inc (TDOC -1.93%)
Q1Â 2019 Earnings Call
April 30, 2019, 4:30 p.m. ET
Contents:
- Prepared Remarks
- Questions and Answers
- Call Participants
Prepared Remarks:
Operator
Welcome to Teladoc Health's First Quarter 2019 Earnings Conference Call and Webcast. (Operator Instructions) It is now my pleasure to turn the floor over to Valerie Haertel at Teladoc Health, Investor Relations.
Valerie Haertel -- Investor Relations
Thank you, and good afternoon, everyone. Today, after the market close, we issued a press release announcing our first quarter 2019 financial results. The press release is available in the Investor Relations section of the teladochealth.com website. Joining me this afternoon to discuss our results are Jason Gorevic, our Chief Executive Officer; and Gabe Cappucci, our Chief Accounting Officer and Controller. We will also provide our second quarter 2019 outlook and our prepared remarks will be followed by a Q&A session.
On today's call, we will discuss certain non-GAAP financial measures that we believe are important in evaluating our performance. More details on these non-GAAP measures to the most comparable GAAP measures and a reconciliation of the 2 can be found in our press release posted on our website. As a reminder, certain statements made during this call will be forward-looking statements, which are subject to risks, uncertainties and other factors that could cause actual results for Teladoc Health to differ materially from those expressed or implied by the forward-looking statements. For additional information, please refer to our cautionary statement in the earnings press release and our filings with the SEC available on our website.
At this time, I would like to turn the call over to Jason.
Thanks, Valerie. And thank you, everyone, for joining us this afternoon. I'm very pleased with our strong start to 2019 and extremely enthusiastic about our prospects for the remainder of the year.
We met or exceeded all our financial and operating expectations in the first quarter. In comparison to our Q1 2018, total revenue grew 43% to $128.6 million, including 23% organic growth when you exclude Advance Medical.
Visit volume of 1.06 million visits increased 75% or 29% excluding Advance Medical. U.S. paid membership grew to 26.7 million members, adding 3.9 million new members in the quarter versus 1.2 million new members in the first quarter of 2018, as we saw especially strong growth among new and existing health plan clients. And adjusted EBITDA came in within our expected range at $1.2 million.
Our robust first quarter growth underscores the increasing diversification of our business across products, channels and geographies and our enterprisewide commitment to operational excellence.
Let me spend a few minutes on our very strong visit volume. It's worth noting that this is the first quarter in which we crossed the million visits threshold, and I couldn't be proud of our team and our physicians who made this possible. The same primary factors I identified in our last call drove our first quarter volume. As we realized the benefits of our diversification strategy, the impact of our surround sound campaigns and tailwinds from mainstream adoption trends, all of which offset a weaker flu season. Compared to last year's epidemic flu levels, this season was marked by a slow start followed by a modest lift later in the quarter, resulting in overall flu visits declining by 32% year-over-year. Despite this headwind, we were able to deliver 29% organic visit growth.
As we significantly expand the breath of our clinical capabilities and continue to increase the effectiveness of our Surround Sound engagement efforts, our visit growth becomes even more predictable, resulting in a Q1 annualized utilization rate of 11%, which we were slightly ahead of last year. Among our clinical specialties, behavioral health continues to be a strong driver of growth with continued momentum in both our DTC and B2B channels. As a result of this strong adoption, we expect behavioral health total revenue growth to exceed 50% for the full year. Additionally, as we entered mental health awareness month in May, I'm particularly gratified by the fact that total behavioral health visit volume in the quarter increased by over 100% versus last year, a strong testament to the value of this much needed service.
Switching to our pipeline for 2019 and beyond. The U.S. health plan market continues to present one of the greatest potential areas for growth, in terms of population, visit volume and breadth of products and services. I recently had the opportunity to spend a few days with leaders from across the healthcare landscape, including the C suite of many large health plans and health systems. And I was incredibly encouraged by the intensity of focus on virtual care as a key component of product, medical delivery and consumer strategies. As traditional players wrestle with how to make virtual care at the front door to the healthcare system, it's becoming increasingly clear to me that Teladoc Health is uniquely positioned to equip them to achieve their goals. Due to the broad scope of our clinical services, our ability to address the widest array of consumer healthcare needs through a single intuitive interphase, and importantly, our proven ability to drive consumer adoption. Our growth of over 3 million paid members in Q1 2019 through the health plan channel is proof of our continued success. As we said in the past, strong growth in this channel can actually have a dampening effect on our average PMPM and overall utilization rates initially. We typically see utilization rates grow over time as we deploy our engagement strategies to these large populations. You'll see in our quarterly metrics that this is entirely due to mix and is a case of us being the victims of our own success. Gabe will further delve into these dynamics when he reviews our financials.
On the international front, we have continued to execute on our strategy, while positioning Teladoc as the only global virtual care solution, while maintaining focus where we see the greatest opportunity to capitalize on our first-mover advantage. In the first quarter, we took several steps to accelerate this leadership position. The European market is a good example of this, where we're seeing excellent organic growth and have successfully closed several cross sales in the first quarter. Additionally, we recently announced the acquisition of Paris-based MedecinDirect that expands our European footprint in a market where regulatory and reimbursement conditions are increasingly favorable to our virtual care. MedecinDirect has a well-established and highly complementary client base of leading insurance partners that can now benefit from access to a much broader spectrum of clinical services through Teladoc Health.
Finally, we announced the launch of Teladoc Telemedicine Services in Canada, a growth initiative we highlighted on the February call. This first of its kind offering provides Canadians with 24/7 access to convenient and high-quality medical care, regardless of their location, across Canada or the U.S. Market reception has been very positive, and our first client is scheduled to go-live in the third quarter of 2019.
In summary, our pipeline of new business opportunities across all our channels has never been stronger. We continue to see positive trends in the global regulatory environment leading to a processing picture for the 2019 selling season and beyond. Before I turn the call over to Gabe, I'd like to briefly cover the recently released CMS rule, since this has been a key topic as we head into the 2020 year for Medicare Advantage. CMS is very much behind the inclusion of telemedicine to increase accessibility to medical care and to lower costs. It's important to note that while the government has estimated savings from telemedicine in the ruling, it did not prescribe pricing for reimbursement. Pricing for services will be negotiated directly between virtual care providers, like us and the health plans. We are in active discussions with Medicare advantage plans spanning both existing and prospective clients, and we expect to have information on how we will be serving this important market in the back half of this year.
Now I'd like to turn the call over to Gabe to review our financials for the quarter and our second quarter guidance.
Gabe Cappucci -- Chief Accounting Officer and Controller
Thank you, Jason, and good afternoon, everyone. I'd like to Echo Jason's comments regarding our strong start to 2019, and I'll now review Teladoc Health's first quarter financial performance in more detail.
Let me start with the discussion of revenue. Total revenue increased 43% to $128.6 million for the first quarter as compared to a year ago. On an organic basis, revenue increased by 23% for the first quarter of 2019. Revenue from subscription access fees of $106 million increased 48% compared to a year ago, and accounted for 82% of our total revenue in the quarter.
Visit fee revenue for the quarter increased to $22.6 million representing growth of 26% compared to the prior year and constituted the remaining 18% of total revenue. U.S. subscription access fee revenue of $81 million continues to represent about 3 quarters of total subscription revenue, while international subscription revenue of $25 million accounts for the balance.
Turning to membership. We ended the quarter with USD 26.7 million U.S. paid members, up 28% to a year ago. As a reminder, our definition of members includes just U.S. paid members that are associated with a PMPM or paid U.S. membership and does not include visit fee access only. In addition, visit fee access reflected expansion within our current client base and was available to 10.2 million individuals at the end of the quarter. Even with the increase in health plan members as Jason discussed, we saw the first quarter 2019 PMPM increase to $1.03 from $1 a year ago or $1.02 on a pro forma basis when adjusting for the impact from Advance Medical. On a sequential quarterly basis, the PMPM was reduced from $1.16 as a result of the member mix impact from the new health plan members.
The broad membership of our health plan channel clients allows us to provide our services at our most competitive rates. It is important to keep in mind the opportunity that our health plan clients and other large populations provide as members utilize our services and experience our Surround Sound engagement, which drives visit volume increases over time. Further, as we deliver meaningful savings to our clients, we generally see our relationships expand enabling us to offer additional services, which also increases utilization.
As Jason mentioned, we had an excellent quarter with respect to visit volume with 1,063,000 visits, an increase of 75% compared to a year ago. When adjusting for the impact of advance medical, visit volume for the quarter increased by 29% as compared to the prior year. Visits from our U.S. paid membership increased to 718,000, which represents annualized utilization of 11%, a 10 basis point increase over last year's first quarter. Taking a closer look at our visits from U.S. paid members during the quarter, approximately 51% of them, or 365,000, were paid visits, and the other 353,000 were from our visits included members.
International visits totaled 282,000 in the quarter, and we completed 63,000 visits for individuals with visit-fee-only access.
To wrap up my commentary on revenue, U.S. paid membership visits generated $18.2 million in the quarter, a 28% increase over the first quarter of 2018. As a reminder, this line includes revenue from general medical visits as well as other specialty visits, primarily comprised of expert medical and commercial behavioral health services.
Gross margins for the quarter were in line with our expectations at 65.3% compared to the 70% in the first quarter of last year. The year-over-year decline in gross margin percentage reflects a mix shift in revenue and the midyear 2018 acquisition of Advance Medical. In terms of gross margin dollars, we generated $83.9 million in the first quarter compared to $62.8 million a year ago, representing a 34% increase.
Operating expense in the quarter totaled $106.8 million, an increase of 30% from the $81.9 million in the first quarter of last year. When noncash charges, such as depreciation and amortization, stock compensation as well as one-time acquisition-related costs are eliminated, adjusted operating expenses are $82.6 million or 64% of total revenue compared to $64.2 million or 72% of first quarter 2018 revenue. These adjustments better reflect our improved operating leverage, including synergies and members choosing digital communication through our app or the web.
EBITDA was a loss of $13.3 million for the first quarter of 2019 as compared to a loss of $10.8 million for the same period last year. Adjusted EBITDA increased to a positive $1.2 million for the quarter, which compares favorably to the adjusted EBITDA loss of $1.4 million from last year's first quarter, reflecting our aforementioned ability to generate improved operating leverage.
Concluding my commentary of the income statement, our net loss for the quarter was $30.2 million compared to a loss of $23.9 million last year. On a per share basis, our net loss was $0.43 for the first quarter of 2019 compared to $0.39 in the prior year.
Turning to the balance sheet. We ended the quarter with $479.7 million in cash, cash equivalents and short-term investments, an increase of approximately $1 million from the beginning of the year. Our total debt as of March 31, 2019, was $562.5 million, which consists of our 2 convertible note issuances, the $275 million 3% convertible notes that mature at the end of 2022 and the $287.5 million, 1.38% notes that mature during 2025. I will conclude my commentary with our expectations for the second quarter and the full year. For the second quarter of 2019, we expect total revenue to be between $128 million and $131 million, an EBITDA loss to be between $13 million and $15 million, adjusted EBITDA to be between positive $5 million to $7 million. Total U.S. paid membership to be approximately $27 million to $28 million and visit-fee-only access to be available to approximately $10 million individuals. We expect total visits to be between 775,000 and 875,000. And net loss per share to be between $0.42 and $0.44 per share, based on 72.4 million weighted average shares outstanding.
For the full year, 2019, we affirm our previous expectations of total revenue between $535 million and $545 million, an EBITDA loss between $40 million and $50 million, adjusted EBITDA between positive $25 million and $35 million, total U.S. paid membership of approximately 27 million to 29 million members and visit-fee-only access to be available to approximately 10 million individuals. We expect total visits between 3.6 million and 3.9 million. Net loss per share to be between $1.52 and $1.66 per share, based on 71.9 million weighted average shares outstanding.
And as we said before, we expect to be cash-flow-positive for the first time in 2019.
Let me now turn the call back to Jason for his closing remarks.
Jason Gorevic -- Chief Executive Officer
Thanks, Gabe. Before we open the call for questions, I wanted to provide a brief update on our CFO search. This remains a high priority, and we're seeing some great candidates, although our process is not yet concluded. I'm confident in Gabe and the finance team, which gives us the time we need to find the right step for our organization to drive us forward. I'll be sure to keep you updated as we have news to announce.
As I said at the beginning of the call, I'm very pleased with the quarter results. And I would like to thank the Teladoc team around the world for their continued commitment to our mission and to living our values. Our opportunities have never been greater as we execute on our strategic plan and deliver value for our clients and members.
I look forward to continuing to share updates with you throughout the year. And with that, we'll open the call for questions.
Questions and Answers:
Operator
(Operator Instructions) Your first question comes from Lisa Gill with JPMorgan. Your line is open.
Michael Roman Minchak -- JP Morgan Chase -- Analyst
It's actually Mike Minchak for Lisa. Maybe just to sort off, given that it's been a topic that's generated a lot of questions on our end, just wondering if you could talk a little bit about the NCQA accreditation? Can you talk about what that process entails? And what any feedback you might have gotten from NCQA regarding the recent extension?
Jason Gorevic -- Chief Executive Officer
Sure Mike. Thanks for the question. I'd start by saying we've got a good relationship with NCQA. We've been first certified and then accredited for years dating back to 2013. We are in the middle of this process. There's been much, I would say, ado about nothing with respect to the date moving by 2 weeks. That's just part of the process as they go through their review process. We're highly respectful of that process, and we expect I to be reaccredited.
Michael Roman Minchak -- JP Morgan Chase -- Analyst
Got it. And then just wondering if you could talk a little bit more about the selling season in the pipeline for new business. How does it compare this year relative to the same point in time last year? Are you seeing greater interest in sort of the comprehensive solution with customers looking to bring on more than one of your offerings? And then have you seen any interest from current or prospective customers in alternative models relative to the traditional subscription accessing model?
Jason Gorevic -- Chief Executive Officer
Yes. So the first question or the first part of that question is exactly what we're seeing. Similar are our fee volume to last year, but much more concentration, much higher concentration of comprehensive solutions sort of the fully integrated solution as the subject of the RFP as opposed to last year, which was much more characterized by 1 or 2 of our clinical services that were up for bid or as part of the RFP process. So we are seeing bigger opportunities that include a much broader array of our clinical capabilities. We are not really seeing much in the way of difference relative to financial models. Obviously, we are still early in the year, and so the RFPs don't generally dictate what the financial model looks like. It usually, gets deeper into the process before you start having those pricing and financial structuring discussions, but I don't see any significant move toward alternative payment structures.
Operator
Your next question is from Jamie Stockton with Wells Fargo. Your line is open.
Jamie Stockton -- Wells Fargo -- Analyst
Maybe just a quick more specific one on the Medicare Advantage opportunity. I think, Jason, in your comments you said you thought like we'd see some decisions more in the second half of the year. I guess maybe, one, do you think like they were really be confined maybe more to the third quarter when we see a lot of the decision making? And then the other question on the Medicare Advantage opportunity, I guess, I would throw out there is, if we think about the landscape plans, do you think that telehealth is a benefit that the majority will be folding in kind for the 2020 plan year? Or is this something that will kind of span over the next 2 or 3 years?
Jason Gorevic -- Chief Executive Officer
Maybe just a quick more specific one on the Medicare Advantage opportunity. I think, Jason, in your comments you said you thought like we'd see some decisions more in the second half of the year. I guess maybe, one, do you think like they were really be confined maybe more to the third quarter when we see a lot of the decision making? And then the other question on the Medicare Advantage opportunity, I guess, I would throw out there is, if we think about the landscape plans, do you think that telehealth is a benefit that the majority will be folding in kind for the 2020 plan year? Or is this something that will kind of span over the next 2 or 3 years?
Operator
Your next question is from Sean Wieland with Piper Jaffray. Your line is open.
Sean Wieland -- Piper Jaffray -- Analyst
Can you just update on some of the larger opportunities you have been working on TRICARE, United? What the expectation is for all out there?
Jason Gorevic -- Chief Executive Officer
Yes. I wish I could give you more information on TRICARE. We are as always at the mercy of the federal government with respect to their timing. We are delivering service for them, and operationally, delivering excellent results as well as great member experience. We are actively working to try to speed that along, but there's really only so much we can do. Our relationship with Optum obviously was the prime contractor there continues to be excellent. With respect to United, we continue to have a great relationship with United. As I said before, with a virtual care provider for several of United's populations. I'm very happy to report that we've reached agreement to expand to a much larger population. The rollout plans haven't been made public, so there is limited information I can provide at this time, but I'm extremely excited by this expansion of our relationship.
Operator
Your next question is from Ryan Daniels with William Blair. Your line is open.
Ryan Daniels -- William Blair -- Analyst
I have one on the benefits design front. I think one of your competitors in another health plan announced kind of a virtual first-type strategy where they are actually lowering planned premiums for membership within that. I'm curious if you're seeing any similar conversation, either in the pipeline or with your customers, where you can actually leverage your virtual first strategy to lower medical cost overall and get people at a right point of care and perhaps offer a little premium and attract members accordingly.
Jason Gorevic -- Chief Executive Officer
Yes, absolutely, Ryan, that's exactly what we're seeing. With the majority of our health plans, we are having some level of discussion around virtual first plan designs. And most of those plans are looking at it as a lever to reduce premium by, number one, resolving patient's issues for the first time in a more cost-effective setting by virtual setting; and number two, by using virtual care to better utilize all the rest of the tools in the health plan arsenal, including things like center of excellence programs in tiered network programs and most sort of optimal tiering of the formulary, in addition to getting people earlier into the care management, disease management programs, et cetera. So when we talk to large health plans, these are coming from the medical economics groups, which tend to be among the most conservative groups there are. They're looking at anywhere -- double-digit decreases in premiums that could result from these virtual centric plan designs.
Ryan Daniels -- William Blair -- Analyst
Okay. Sounds very helpful. And then pretty specific one on the income statement. It looks like you're seeing some really good leverage in the sales expense line certainly more than we thought. I think it was up under 18% year-over-year despite the strong revenue growth. Any color there behind kind of what's driving your leverage in that line, in particular?
Gabe Cappucci -- Chief Accounting Officer and Controller
Yes. This is Gabe. Just when you look at our sales expense, you're absolutely correct. As we deploy our troops, we've had lots of success in winning new clients and really working within the headcount that we have on board. So we track that very closely in terms of quotas and productivity and are really seeing the rewards with that as we continue to be very successful on the sales front.
Jason Gorevic -- Chief Executive Officer
I think, Ryan, we have seen larger clients coming on, so we tend to get greater productivity in terms of big bites and I can -- that can help to drive the efficiencies in that area.
Operator
Your next question is from Stephanie Demko with Citi. Your line is open.
Stephanie Damko -- Citi -- Analyst
Riding on the back of the Cincinnati Children's announcement, could you give us an update on the provider channel and any possible metrics if you can share, such as share pipeline or competitive win rates?
Jason Gorevic -- Chief Executive Officer
Yes, thanks, Stephanie. We're really excited about the Cincinnati Children's relationship, and we think that's going to be a breakthrough relative to pediatric care with obviously a marquee organization. The provider channel continues to grow incredibly quickly. It continues to be one of our fastest growing customer channels. We are continuing to see very, very strong win rates. We talked about that last year, and we continue to see this success in that. What we are also seeing is the expansion of our capabilities that we rolled out at (inaudible) this year, which enables the hospital to design specific workflows for different clinical used cases is really valuable and specifically we are seeing the hospitals come to us asking for a broader array of capabilities as they look to virtualize more of their clinical service lines. So we think that there is opportunity to continue to grow the hospitals with whom we work but also the scope of the products and services we sell into those hospital systems.
Stephanie Damko -- Citi -- Analyst
Got it. Very helpful. And then just one another one pivoting to behavioral health, just given strong growth you've talked about in that channel, what are your thoughts on buy versus build for expanding into further demographics beyond the more eccentric (ph) version right now?
Jason Gorevic -- Chief Executive Officer
Try not to go too deep into buy versus build on any given part of our business. I think, quite frankly, at this point, we are seeing very, very strong results in organic growth, both in the B2B and B2C channel, and so we feel very good about our set of capabilities. It's not to say we would never tuck-in a smaller asset that might deliver an additional capability that we thought we could leverage into those channels. But the organic growth, both in terms of membership, revenue as well as really importantly visit volume is very strong.
Stephanie Damko -- Citi -- Analyst
Perfect. It's safe to say that there has been little impact from the Youtube controversy?
Jason Gorevic -- Chief Executive Officer
Yes. I would say virtually none.
Operator
Your next question is from Sean Dodge with Jefferies. Your line is open.
Sean Wieland -- Piper Jaffray -- Analyst
Maybe on CVS. I realize that's another one that's a bit outside your control, but you're alive in 19 states. Now it looks like it's taking a bit longer than expected to make available in the remaining. Are there -- are there some regulatory or technical issues you've all encountered there? Anything else you can share about what's holding back the pace of that rollout so far?
Jason Gorevic -- Chief Executive Officer
Yes, Sean, you're exactly right. It's an area -- as I look at the quarter, it's the one area where I expect -- I'm a little disappointed. I expect it to get a couple of states rolling out in the first quarter, and we saw that spillover and not roll out in that quarter. Having said that, there are no technical issues. There are no regulatory issues that are standing in the way. It's simply a question of the cadence at which CVS decides to make that roll out happen. We continue to have a great relationship there. I have regular sea level conversations with them and -- both with CVS and with the Aetna relationship, we continue to see that become more strategic, more collaborative, and quite frankly, never stronger. So I think it's just an artifact of them sort of going through the machinations of their rollout.
Sean Wieland -- Piper Jaffray -- Analyst
Okay. That's helpful. And then on the MedecinDirect acquisition, is there anything you can share on annual revenue or EBITDA contributions from them?
Gabe Cappucci -- Chief Accounting Officer and Controller
Sean, it's very small. It's immaterial on both fronts. And so we're not going to give specific details, but I would call it very, very small. Essentially what we're buying there is a local market presence and relationships with -- about 30 insurance companies in France. To their credit, they really got out of head of the regulatory change in the French market, and they created these relationships and structures ahead of their being real reimbursement for those services. Now we're just seeing the regulatory change, which has opened up that market, and so we think that together we can be the beneficiary of all the groundwork that they have laid. So it's very, very small revenue now, but we're very excited about the opportunity there.
Operator
Your next question is from Richard Close with Canaccord Genuity Your line is open.
Richard Close -- Canaccord Genuity -- Analyst
Congratulations. So Jason you continue to sound pretty bullish here. And I think on the last call, you said something about feeling that the business trends you were provided confidence in the 20% to 30% organic growth target, both in '19 and 2020. Yes, obviously, we had some normalization this quarter to 23%. So just curious what your thoughts are about 2019 and 2020, whether you can reaffirm those targets?
Jason Gorevic -- Chief Executive Officer
Yes, absolutely, Richard, 100% behind that, I feel very good about where we're obviously we reaffirmed our guidance for this year. We're only, I think, 62 days after we gave our last quarterly report. So I think we still continue to take a fairly conservative view to our guidance, but I also feel, given what I know about the prospects for the back half of this year and what I'm looking at relative to pipeline and discussions we're having with prospects and clients, I feel very good about that 20% to 30% for 2020 as well.
Richard Close -- Canaccord Genuity -- Analyst
Okay. And then, I guess, a follow-up to Sean's question, TRICARE in United. Based on the guidance, I guess, for visit-fee-only membership that's staying around $10 million, it seems like you don't have any TRICARE really in the guidance for the remainder of the year. Is that correct?
Jason Gorevic -- Chief Executive Officer
That's correct.
Richard Close -- Canaccord Genuity -- Analyst
Okay. And then the same thing with the United population you just mentioned that's not in guidance?
Jason Gorevic -- Chief Executive Officer
That's correct. So well, let me just clarify. We do have for United our both revenue expectations and cost expectations. Those are built into our projections and our guidance. What we haven't included is any membership guidance because the roll out hasn't been communicated, and we have to be very respectful. These are United's clients. It's their rollout plan, and so we have to be sure that we're 100% in sync with them. We haven't included any membership in our guidance.
Richard Close -- Canaccord Genuity -- Analyst
So would it be fair to say that the revenue that's in your guidance is hair cut quite a bit from that population?
Jason Gorevic -- Chief Executive Officer
Yes, I would say, we've taken a very conservative view relative to our expectations there.
Operator
Your next question is from Anagha Gupte with SVB Leerink. Your line is open.
Ana Gupte -- SVB Leerink -- Analyst
Following up on that question, if you look at that 2020 impact of the Medicare Advantage potential revenue and United, the 22-ish million members growing for MA, United using its larger-than-expected contract, I'm not sure how much it is, but I'm assuming it's something to do with the commercial market that they have millions of members and even if you look at this, chasing a 2- to 3-year adoption story, with a typical commercial pricing, PMPM and per visit and even if the utilization is whatever 9%, 10% in the next 1 to 3 years, we can come up with something that is between those 2, like in the low-double digit percentage growth, at least, and you could assume more if it depends on the share gains. I mean, is that a fair way to think about it as we all start to have to model what the potential of these contracts is, and that ultimately what's going to drive your stock? 2020 is going to be what's going to move the needle now?
Jason Gorevic -- Chief Executive Officer
Yes. So we've always been very, very careful of that not getting over our skies. I think you're thinking about the opportunities in front of us the right way. We are careful not to quantify those until we're ready to quantify them and build them into our guidance. Obviously, we do the work internally, but you are exactly right relative to the macro trends, the specific opportunities with large clients as well as the regulatory changes. MA is a big catalyst. I fully expect Medicare fee-for-service to follow and suite over the next couple of years. So said another way, I've never felt better about the prospects for the business and the fact that virtual care has moved into the mainstream, and so we're starting to see the next wave of adoption, which makes me confident in sort of reaffirming my expectations around that 20% to 30% organic growth.
Ana Gupte -- SVB Leerink -- Analyst
Okay, helpful. Then the follow-up I have on that is, right now, you have -- yourself, you are the largest player at least in terms of the network strength, via Amwell, MDLive, Doctor on Demand. There's been more than just our franchise saying that health plans will be the catalyst for some of these big disruptive technologies to get adopted. We have Humana now with Doctor On Demand. It looks like, at least in the commercial market, Anthem has the strategic relationship with Amwell; Cigna and healthcare services with MDLive. You have it right now with CVS. I'm not sure if United is open architecture or not. Do you see each of you aligning with a particular large health plan as the way this goes, in terms of what the share gains look like for all of these large opportunities going forward?
Jason Gorevic -- Chief Executive Officer
I guess I'd characterize it first by saying, we have around 40 health plans as our clients. And so we are certainly not limited to even a few plans in terms of aligning. We see ourselves neutral quite frankly. And based on our current track record of success where we're seeing takeaway wins across multiple channels, not only health plans, and the fact that we continue to distance ourselves from the pack relative to the expanse of our clinical services, the engagement levels that we get, our global footprint and the scale of our business, I think we have the opportunity to continue to grow both with new clients, but with expansion within existing clients and by increasing the penetration relative to utilization and the scope of services that we offer. It's one of the things I've always liked about this business is that there are so many levers for growth, and as a leader, we're, I would say, uniquely positioned to be able to capitalize on those opportunities.
Ana Gupte -- SVB Leerink -- Analyst
Got it. So nonexclusive. Great. Thanks for the color.
Operator
Your next question is from Matthew Gillmor with Robert W. Baird. Your line is open.
Matthew Gillmor -- Robert Baird -- Analyst
I wanted to try a follow-up on United, and I appreciate if you can't really tell us much more than you've already said, but can you give us any sense in terms of the population type that will be covered. Is this commercial or government? And then any indication with respect to the pricing model, whether it's PMPM or visit fee?
Jason Gorevic -- Chief Executive Officer
I really can't Matt. I appreciate the question and why you're asking. I think more will become clear as we get closer to the launch date. Again, we want to be very respectful of United as our client and their communications time line and strategy. And so we have moved into the implementation phase of our relationship, and I'm really excited about that. And again, I think more will become clear as we get closer to the launch date.
Matthew Gillmor -- Robert Baird -- Analyst
Got it. Fair enough. And then following up with the discussion you had with Ryan on the virtual-first benefit design. I was curious if you're thinking has changed with respect to that contracting model you have with the physician network under virtual first? And is there any need to have a little bit more influence with respect to primary care doctors through employment? Or does the current contracting model still work for virtual-first offering?
Jason Gorevic -- Chief Executive Officer
Yes, it's a good question, Matt. We've been moving toward, what we call, sort of, a concentric circles model of the network, where at the core we will likely have physicians who are more closely aligned with the organization doing -- spending a larger concentration of their time, doing work for Teladoc, and our membership and becoming more highly trained on how to optimally become, what we call now, the virtual list. And you might recall that we launched a Fellowship program with Jefferson University Hospital, specifically focused on creating the virtual list of the future. And then as you move out from that core, we will continue to always have physicians who are much more transactional and episodically available for our members in the most efficient way to deliver that on a means that is very convenient and responsive for the consumers' needs.
Operator
Your next question is from Sandy Draper with SunTrust. Your line is open.
Sandy Draper -- SunTrust -- Analyst
Most of my questions have been asked, but maybe just one sort of follow-up on the international market, and I'm not sure how much the international market in Advance Medical are on toward the typical selling season, like we are here in U.S. But just sort of thoughts and how that's selling season is going and any differences they are seeing? Is it just being part of the larger organization, broader offerings, just sort of how things are going for them versus how it was a year ago. I guess it was maybe right before -- this has been right before you bought them?
Jason Gorevic -- Chief Executive Officer
Yes, Sure, Sandy. Very, very excited about our international opportunities and growth. As you call out, actually, their selling season is totally different than the U.S. There is no January-centric bolus of membership that comes on. It is smooth over the course of the year with no real concentration. What we're most excited about is the adoption of the full virtual suite of services by the international clients. I would actually say, in many cases, they are ahead of the U.S. clients with respect to embracing virtual care across the full continuum of services. And that's because, in many cases, their private health insurance companies who are looking to differentiate themselves when they sit on top of a nationalized healthcare system.
And we have many examples where we are being successful in cross-selling the full suite of capabilities that were to clients who were only availing themselves of 1 or 2 of our service lines. So we're both seeing new wins as well as expansion of populations and broadening of our solution set among clients. Clearly across the landscape, but I would say especially in the European market. And then lastly, we announced the launch of our Canadian telemedicine program. We have our first client lined up to go live in the third quarter. And again, just to reiterate, that's a unique program because it's cross-border between Canada and the U.S. for the Canadian population as they come south. They can still get a seamless experience. It's not 2 programs that sit side-by-side, rather it's one seamless program.
Operator
Your next question is from Donald Hooker with KeyBanc. Your line is open.
Donald Hooker -- KeyBanc -- Analyst
My question maybe more detailed question on the financial statements. I guess thinking about the gross margins obviously took a dip. I assume a big part of that, you talked about in the past, is Advance Medical. So is that -- is this quarter sort of a low watermark there for gross margins? Should that sort of start to walk up a little bit during the year and stabilize?
Gabe Cappucci -- Chief Accounting Officer and Controller
Yes. Don, this is Gabe. That's exactly correct. What we typically experience is in our first quarter and our fourth quarter of the year tend to be our lowest margin percent quarters as we have a higher concentration of visit activity. And then when you do look at the year-over-year comparison in gross margin percentage for the first quarter of 2018 versus 2019, it's exactly that. It's Advance Medical, which we acquired midyear last year.
Donald Hooker -- KeyBanc -- Analyst
Got you. And maybe just sort of a follow-up question on the Medicare Advantage opportunity for 2020 and beyond. What are you incurring? Can you maybe describe what you're doing to prepare for that? And anything specific? I mean, you're already lined up with 40 health plans you mentioned. Are there any specific services that you needed for that population? Are there any incremental expenses you're incurring now in preparation for that?
Jason Gorevic -- Chief Executive Officer
Yes, there are. I think we called out 4 different areas of investment on the last quarterly call and MA was one of them. And so specifically, we're focused on regulatory compliance, which there is a whole set of things that you have to do in order to make sure you're compliant with Medicare regs. Second is network construction and, there's a little bit of an overlap between network and regulatory because there are some requirements relative to the physicians. Third is in product and just making sure that we are sort of optimizing the product for the MA population. And fourth is optimizing our Surround Sound engagement strategies for that population because as we do with all populations when we go into a new customer channel or segment of the market we want to make sure that we are optimizing our communications to yield the most return for our investment on Surround Sound. And so we are doing some testing and some market research relative to that.
Operator
Your next question is from Jailendra Singh with Credit Suisse. Your line is open.
Jailendra Singh -- Credit Suisse -- Analyst
Can you help us understand the revenue and EBITDA ramp from first half to second half in 2019. If I look at your revenue and EBITDA, you guys reported in Q1 and include even the high end of the guidance for 2Q, it would still require some decent ramp in second half to get to the full year guidance. Just give some color like what you're assuming for second half ramp here?
Jason Gorevic -- Chief Executive Officer
Yes, so I'll give you the maybe sort of macro view, and we're obviously not going to give third quarter or fourth quarter guidance right now, but Gabe can sort of fill in a little bit color commentary. I would say, we are well aware of what the ramp looks like. If you look at the second quarter, that's always a lower visit volume, and therefore, a lower visit revenue quarter. And so you will see our subscription revenue increase as we continue to onboard new members and new clients. That continues into the third quarter, and we have pretty good line of sight into what that looks like and where that growth comes from. And then in the fourth quarter, of course, you get the double bump of the continued growth of the subscription revenue as well as the significant increase in fourth quarter visit volume, and therefore, visit revenue.
We have, again, I would say, very good line of sight. Last quarter, I think we said north of 95% visibility. I'm not going to get more granular than that and start giving our visibility in ones and twos, but we continue to have improved visibility into the revenue for the full year. And that's based on contracts that are already signed as well as late-stage pipeline deals that we see. I don't know, Gabe, if you want to add anything and maybe talk about the corresponding impact on EBITDA?
Gabe Cappucci -- Chief Accounting Officer and Controller
Yes, and that's exactly correct, Jason. I mean just as you see the P&L sort of ramping throughout the year, as we see access fees increasing, as we've been saying that we've been less centric on 1 1, and we will continue to see that growth throughout the year, we will have that phenomena. And then obviously in the fourth quarter, as visits will kick in, we'll also see increases in revenue associated with that. From an EBITDA standpoint, you will see similar dynamics and even more so from an adjusted EBITDA standpoint. At as we do anticipate that to sort of sequentially grow throughout the year as we are looking at 2019 right now.
Jailendra Singh -- Credit Suisse -- Analyst
Okay. And then one follow-up. Can you provide any update on the Aetna contract renewal? When do you expect a final update there?
Jason Gorevic -- Chief Executive Officer
I think I've learned my lesson not to handicap exactly when we're going to have large client sign contracts, but I would say that, number one, as I mentioned earlier, we've never had a stronger relationship with Aetna than we have now. It's more collaborative than it's ever been. It's more strategic than it's ever been. And we are seeing the results in our shared success together. I'm very confident in that relationship, and have great confidence if that's going to continue to be a strong relationship for several years going forward. I'll do myself the favor of not locking myself into a time line with respect to when it will have ink on paper for that, but I feel very good about it and really have no concerns there.
Operator
We have time for 2 more questions. Your next question is from Charles Rhyee with Cowen.
Charles Rhyee -- Cowen -- Analyst
Most of my questions have been asked, but just a couple of quick clarification, Jason. On the UNH (sic) UHN contract that you discussed earlier, you mentioned that you're not giving a membership number, but in that guidance, does that reflect the larger population being contemplated or that is contemplated in the new agreement?
Jason Gorevic -- Chief Executive Officer
Sorry, I'm not sure I understand. We have, as I said, what I would call, fairly conservative revenue expectations. We have, I would say, robust projections relative to what our costs are likely to be over the course of this year. Both of those are built into our guidance, but we didn't include any membership in our guidance relative to our membership.
Charles Rhyee -- Cowen -- Analyst
Okay. So in other words, when you first gave the guidance it was sort of what you'd expected originally, but since that time, we've seen an expansion in sort of the population size. That's not necessarily contemplated yet in the guidance. Is that fair?
Jason Gorevic -- Chief Executive Officer
No, I don't think I said that. No I don't think I said that. I said we are expanding to a much larger population than we have today. And it is what we contemplated and what we have been working on for quite some time.
Charles Rhyee -- Cowen -- Analyst
Okay. I'm sorry. Okay. I appreciate that. And then, I guess, just one more. Earlier you talked about the confidence in the NCQA certification. Is there anything specific about that? Because you've been through it a couple of times that you feel good about it at this point, in terms of what they are looking for specifically. If you -- maybe you can just remind us what are the sort of the key metrics they tend to look at when kind of doing it?
Jason Gorevic -- Chief Executive Officer
No. I know better than they speak for their process. They are the experts on their process and although obviously I may be aware of what's going on, I'm not a credential or so. I will try not to comment on the specific processes there. I'm -- I do feel good about what our credentialing processes are, and I'm aware enough of the process that we've been going through with NCQA, that my expectation is that we will receive our reaccreditation.
Operator
Our last question comes from Matt Hewitt with Craig-Hallum Capital. Your line is open.
Matthew Gregory Hewitt -- Craig-Hallum Capital Group -- Analyst
Maybe first and I realize you're still in the development stage here, but regarding the children's or the pediatric platform, maybe what are some of the nuances for developing that type of a platform versus one geared more toward adults? And once you've got that set, how quickly do you anticipate that being adopted by other pediatric facilities across the country?
Jason Gorevic -- Chief Executive Officer
Yes, the Cincinnati Children is a pretty unique and amazing organization. They take care of patients throughout all 50 states and in 89 countries around the world. So we are really excited about launching a pediatric virtual care platform with them. We think that, that will open up access for children not only across the country but around the world to have access to the really amazing specialists and care that's delivered by Cincinnati Children. So this is a great example of sort of the hub and spoke model, if you will, where the hub is just a tremendous organization with great expertise, and we can provide the platform that enables them to continue to make those capabilities available.
Matthew Gregory Hewitt -- Craig-Hallum Capital Group -- Analyst
As part of that platform, do you anticipate some of your other more specialized services like behavioral health and whatnot being included as part of that platform?
Jason Gorevic -- Chief Executive Officer
I think too soon to tell. That would -- certainly, my aspiration would be that we can help to bolster the clinical capabilities there, but we are still working on what the implementation plan looks like. And my guess with this as well as with most of our services is, we are just sort of scratching the surface in terms of what the opportunity is, and it will expand over time.
Operator
That concludes the Q&A portion of today's call. I'll now turn things back over to the presenters for any closing remarks.
Jason Gorevic -- Chief Executive Officer
I just want to thank everybody. I'm very, very excited about the results for the first quarter and even more excited about our prospects for the rest of '19 and beyond. So with that, I think we'll wrap up the call. Thank you.
Operator
This concludes today's conference call. You may now disconnect.
Duration: 63 minutes
Call participants:
Valerie Haertel -- Investor Relations
Gabe Cappucci -- Chief Accounting Officer and Controller
Jason Gorevic -- Chief Executive Officer
Michael Roman Minchak -- JP Morgan Chase -- Analyst
Jamie Stockton -- Wells Fargo -- Analyst
Sean Wieland -- Piper Jaffray -- Analyst
Ryan Daniels -- William Blair -- Analyst
Stephanie Damko -- Citi -- Analyst
Richard Close -- Canaccord Genuity -- Analyst
Ana Gupte -- SVB Leerink -- Analyst
Matthew Gillmor -- Robert Baird -- Analyst
Sandy Draper -- SunTrust -- Analyst
Donald Hooker -- KeyBanc -- Analyst
Jailendra Singh -- Credit Suisse -- Analyst
Charles Rhyee -- Cowen -- Analyst
Matthew Gregory Hewitt -- Craig-Hallum Capital Group -- Analyst
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