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Progyny, Inc. (PGNY -1.37%)
Q4 2019 Earnings Call
Mar 05, 2020, 4:45 p.m. ET


  • Prepared Remarks
  • Questions and Answers
  • Call Participants

Prepared Remarks:


Good afternoon, and welcome to the Progyny, Inc. fourth-quarter 2019 earnings conference call. [Operator instructions] Please note, this event is being recorded. I would now like to turn the conference over to James Hart, vice president of investor relations.

Please go ahead.James HartThank you, Chad, and good afternoon, everyone. Welcome to our fourth-quarter conference call. With me today are David Schlanger, CEO of Progyny, and Pete Anevski, president, CFO, and COO. We will begin with some prepared remarks before we open the call for your questions.

Before we begin, I'd like to remind you that today's call contains forward-looking statements, including statements about revenue, net income, cash flow, our ability to sustain profitability, our business strategy, our ability to acquire new clients and maintain existing clients, market opportunities and size, business performance, our industry outlook, financial outlook, plans and objectives for future operations and other non-historical statements as further described in our press release. These forward-looking statements are subject to certain risks, uncertainties and assumptions, including those related to Progyny's growth, market opportunities and general economic and business conditions. We have based these forward-looking statements largely on our current expectations and projections about future events and financial trends that we believe may affect our business, financial condition and results of operations. Although we believe these expectations are reasonable, we undertake no obligation to revise any statement to reflect changes that occur after this call.

Descriptions of these and other risks that could cause actual results to differ materially from these forward-looking statements are discussed in our reports filed with the SEC, including our press release that was issued this afternoon. During the call, we will also refer to non-GAAP financial measures such as adjusted EBITDA. Reconciliations with the most comparable GAAP measures are also available in the press release, which is available at investors.progyny.com. I'd now like to turn the call over to David.

David Schlanger -- Chief Executive Officer

Thank you, Jamie, and thank you, everyone, for joining us this afternoon. I'm pleased to report that we had a strong fourth quarter, concluding what was a record year for Progyny in 2019. In addition to completing our IPO, we achieved our highest revenue, gross margin and adjusted EBITDA ever, and our selling season yielded the greatest number of new clients and covered lives in our history. In a few minutes, Pete will take you through the numbers in more detail, but here are some of the highlights.

Revenue grew 123% in the fourth quarter to $65.1 million, which was in line with our guidance. For the year, revenue grew 118% to $229.7 million, making 2019 the third consecutive year where we have more than doubled our revenue. In 2019, our gross margin increased 140 basis points to 19.8%, reflecting the improving economies of scale that we are achieving, while we are delivering a superior level of service to our clients. Our adjusted EBITDA of $3.9 million in the fourth quarter was also in line with our guidance and an eightfold increase from the year-ago quarter.

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For the full year, our adjusted EBITDA of $18.3 million, reflects a thirteen-fold increase from 2018 and the assisted reproductive technology, or ART, cycles that we manage in the fourth quarter increased 85% from the year-ago period. Overall, we are very pleased with our results for 2019 and believe we are well positioned for the future. The guidance we've issued today for 2020 targets revenue growth of between 72% to 81% for the full year as well as the continued expansion of our margins. It is important to note that this guidance is based on our historic utilization patterns and what we are seeing as of today and doesn't reflect any potential impacts of the coronavirus.

This is, obviously, a fluid situation and will require ongoing monitoring. But as of now, clinics have reported to us that they aren't seeing impacts on their appointment volume, and our overall member activity continues to be consistent with our normal expectations.So we are pleased with how 2020 has begun. Start to any year is particularly important to us because our model is somewhat unusual and that we don't grow ratably throughout the year. Instead, we experienced a step function increase on each January 1, which is when most of our newest clients go live with their programs.

We are a service business, which means we carefully plan and prepare for our growth so that our existing customers don't experience any diminution in the quality of their service, while our new customers experience a seamless onboarding. We identified the incremental resources that we need and hire and train those resources well in advance of the new calendar year. Our patient care advocates, which we refer to as our PCAs, are a good example of this approach. PCAs are the dedicated first point of contact for our members and are integral to our concierge member experience.

Even though PCA has come to Progyny with extensive industry backgrounds, often as fertility nurses or clinical workers, new PCAs undergo an extensive month-long training curriculum overseen by our in-house clinical staff. I'm very pleased to report that we have successfully launched 53 of the 57 new clients that we sold during the 2019 selling season, and the remaining four are expected to launch beginning in Q2. We participated in over 300 open enrollment events with our clients, educating members on their new benefits and answering their questions ahead of their go-live date or a new plan year. We added these new clients, while continuing to maintain or even improve our service levels.

For example, over the first eight weeks of the year, we improved our overall PCA call response time, while also increasing our NPS score as compared to the same eight-week period from 2019. We believe that our ability to achieve such high-quality financial and operational results over a sustained period of time demonstrates not only our strengths as a company, but also our competitive differentiation. For the benefit of those of you joining us today who are somewhat newer to Progyny, I'll spend a few moments describing our strengths and areas of differentiation. First, we are a leader in a large, growing and under-penetrated market.

The market for fertility benefit solutions is large because infertility is a common health condition, recognized by the World Health Organization and the American Medical Association as a disease. Infertility affects one in eight couples, which means it's more prevalent than other common conditions, such as diabetes or asthma. Based on the most recent data published by the CDC, the market for assisted reproductive technology in the United States is at least $6.7 billion. However, we believe the actual market may be more than twice as large because approximately half the people who require treatment don't get it because they can't afford it.

The demand for fertility treatment in the U.S. is growing at a double-digit rate, driven not only by its prevalence, but also by certain societal trends. Couples are waiting longer than ever to have children. Even though the biological clock is real and women's egg quality and quantity decline with age.

There is also growth in nontraditional path to parenthood, such as LGBTQ couples and single parents by choice, who need fertility services in order to have their families. Progyny offers to self-insured employers a fully carved-out fertility benefit solution for their employees and their spouses or partners. There are approximately 8,000 large self-insured employers in the U.S., representing 69 million covered lives, and we are in the very early stages of addressing this market. Our clients in covered lives today reflect just a 2% to 3% penetration rate.

And so we believe there's substantial room for us to continue to grow within just our core market of these 8,000 employers. We also see opportunities to expand into other types of clients, such as governmental employees, unions, universities, small fully insured groups, which would provide us with additional room to grow beyond the 8,000 self-insured employers. Beyond participating in a large and growing market, Progyny is unique in that we have been consistently generating clinical outcomes that far exceed national averages. These outcomes have been essential in driving our growth.

The pregnancy rate for our members is higher and our miscarriage rate is lower than national averages. As a result, we have a 26% higher live birth rate than the average results reported by all the fertility clinics in the country. We also have a much higher rate of single embryo transfers in the national average, which helps drive a 78% reduction in our rate of multiple births. Multiple births are the leading cause of preterm births and preterm birth drives higher NICU and maternity costs.

We've been able to produce these materially better results in part because, unlike the traditional health plan model, which is focused on limiting the utilization of services, our program design was built to create better outcomes and deliver value for members, doctors and clients. For members, we provide an extraordinarily high level of support and guidance. Our members are educated about their treatment options and are given the emotional support they need when making decisions about the best course of care. Our core belief is that an educated and supported patient makes better treatment decisions.

Our benefit plan provides comprehensive access to the latest technologies and procedures. When fertility specialists have all the necessary tools available and a supported patient that also has coverage for a full treatment event without mandated treatment protocols or dollar-based limitations, that doctor is empowered to provide the best course of treatment, given the unique needs of that patient and doesn't have to make compromises in care. We also engage in extensive data analysis and sharing with our network doctors to optimize their performance. For our employer clients, our better outcomes mean they spend less to provide fertility coverage to their workforce, with a higher live birth rate, employees are getting pregnant with fewer treatment cycles.

This means employers fund fewer rounds of treatment, with less multiple births and employers spend significantly less on the high cost of preterm births. In the short term, this includes cost for C-section and NICU expenses. In the longer term, this includes the ongoing care cost with the chronic health conditions that preterm babies often suffer from. The unique benefits of our solution are reflected in our expanding base of diversified clients.

Leading brands around the world are choosing to work with Progyny because of better outcomes we generate, superior member experience we provide to their employees, the overall savings we create for them. Increasingly, employers are recognizing that their health benefits plan needs to cover infertility to be competitive. Because infertility is a common medical condition, given how expensive infertility is to treat, without coverage, many of those affected by it, won't be able to pursue treatment. And so employees are demanding coverage.

Millennial employees, who are making up an increasingly larger percentage of the workforce, frequently cite the availability of fertility coverage as a primary reason they want to work for or stay with a company. In addition, from the employer's perspective, providing fertility coverage is the right thing to do because fertility treatments are uniquely experienced by women and failing to provide coverage makes a statement to the female workforce that somehow they matter less. Providing fertility coverage on the other hand, makes a positive cultural statement that an employer values their female employees and diversity in general. Currently, we work with 132 of the world's best companies, representing a broad cross-section of 25 different industries.

Though our earliest cohort of customers came primarily from the tech sector, the substantial majority of the clients added in our most recent selling season came from other areas of the economy, including media, manufacturing, food and beverage, pharmaceutical, consumer packaged goods, energy, retail and financial services. This increasing diversity in a customer base not only demonstrates that infertility is a human health issue, it is a universal health issue, but that providing coverage is relevant to every employer in every industry. 2019 was the fourth straight year where we added more clients and more covered lives than we did in the prior year. This highlights the growing willingness by employers either to begin to provide coverage or to expand their existing coverage.

In all cases where the client had been providing some coverage prior to Progyny, they were working with their carrier. And while the carrier remains our principal competition, we have established several distinct sustainable competitive advantages. The first element of our competitive moat is that we have focused exclusively on optimizing fertility benefit solutions for five years and have developed a substantial amount of insight and expertise. During this time, we have also made significant investments in our platform and systems, and we believe it would take either a new entrant or an existing competitor, even one with substantial resources, a considerable amount of time to catch up to where we are today.

However, in that time, Progyny will continue to develop and move forward. Next, we are the only organization that is collecting and tracking comprehensive treatment data and clinical outcomes in real time. This lets us uniquely demonstrate our value to clients by showing the tangible ways in which they're spending on fertility with Progyny is more cost-efficient than their alternatives as well as a direct impact it is having on their workforce through the birth of healthy babies. As I mentioned earlier, we also utilize our clinical data to help optimize our network physicians' performance.

We do this through the creation of quarterly clinic specific scorecards that we share our physicians and that helping us ensure adherence to best practices and outcomes. This process facilitates a collaborative relationship with the doctors in our network. We monitor the approximately 800 doctors in our network using this data, ensuring that our members are receiving the best care, but the doctors also benefit from this data considerably. Our clinic scorecards include hundreds of data points and compare each practices performance the Progyny network as a whole.

This insight allows physicians to identify ways to improve their practices. This collaborative relationship, another one of our unique advantages, is one of the reasons why the prestigious practices, the ones that patients really want to be able to see are in our network, even if many of them won't work with the traditional carriers. In fact, about 30% of the doctors in our network either won't work with commercial carriers or only work with just one other carrier. Additionally, in building our network, we have benefited from our leadership position and extensive client relationships.

In order to attract the best doctors to join your network, you need to be able to provide them with patient volume. But in order to have patient volume by effectively selling new employer clients, you need to be able to provide access to the best doctors. Without a comprehensive network, a start-up competitor can't support a client who has employees located across the country and who expects to provide equal access to care for all of those employees as well as providing employees multiple choices in selecting their provider. Another advantage we have is that we are integrating with more than two dozen carriers, including all the national carriers.

This allows our benefits to be provided on a pre-tax basis. We've built these relationships and integration solutions over the last four years. Through these integrations, we are able to deploy our solution as part of the company's overall health plan. This means the expenses of member incurs for fertility services as they relate to copays, deductibles and annual out-of-pocket maximums aren't treated any differently than if that member went to the doctor for any other health issue.

The VC-backed start-ups competing in this space are not integrated with the carriers. Without carrier integrations, the fertility benefits provided by these VC-backed start-ups are not part of the health plan and the program essentially becomes a post-tax reimbursement plan. The employee is going to pay income tax on the amount of the reimbursement. This is, obviously, a very different type of benefit and one that unfortunately puts the calculator back into the hands of the employee when treatment decisions are being made.

We believe the combination of all of these strengths, our large, growing and underpenetrated market, our differentiated model that drives superior outcomes, our expanding base of diversified clients and our sustainable competitive differentiators has driven our past performance and will continue to fuel our growth in the future. As we look ahead to 2020, our selling season for our 2021 clients is at its very earliest stages. At this time of year, HR managers are focused on ensuring that the benefits they just launched on January 1 are fully optimized, and they won't be making decisions about new programs for a few months. Typically, we've seen most new clients make decisions on new benefit programs at the end of the summer or the early fall.

Over the next few months, we are scheduled to participate in industry events, healthcare forums and workshops as well as in meetings with potential new clients, introducing ourselves, building awareness and surfacing the importance of providing coverage for infertility. We'll provide you with updates on the selling season on future calls. Now I'll turn the call over to Pete to walk you through the financials in greater detail.

Pete Anevski -- President, Chief Financial Officer, and Chief Operating Officer

Thanks, David. I'll begin by walking you through the drivers for our fourth quarter and full-year results and then share our expectations for the first quarter and full-year 2020. Revenue of $65.1 million in the fourth quarter increased 123% as compared to the $29.2 million in the fourth quarter last year and was in line with our guidance. For the full year, revenue of $229.7 million increased 118% from 2018.

Looking at the components of revenue. Fertility benefits revenue increased 93% from $27.8 million in the fourth quarter last year to $53.5 million in the current period. Over the full year, fertility benefits revenue increased 90% to $189.6 million. The growth in fertility benefits revenue in both periods was driven by the higher number of clients in covered lives.

Pharmacy benefits revenue increased from $1.4 million in the fourth quarter last year to $11.6 million in the current period. Over the full year, pharmacy revenue increased more than seven times from the prior year to $40.1 million. Our growth in pharmacy revenue in both periods was driven by the higher number of clients in covered lives. That growth outpaced fertility benefits revenue due to the fact that the first time Progyny Rx was available for the full selling season was 2018.

Our revenue in both the quarter and year 2019 benefited from having Rx available for the entire 2018 selling season, as Rx was sold into significantly more accounts, both new and existing. As of the end of the fourth quarter, we had 87 clients, representing 1.5 million covered lives. This compares to 33 clients and 720,000 members as of the end of Q4 last year. Turning to our utilization rates.

There were 3,782 ART cycles performed in the quarter, which is 85% higher than the cycles performed a year ago. Our reporting of ART cycles reflects IVF treatments, frozen embryo transfers and egg freezing and is consistent with the CDC reporting methodology. Our female utilization rate, which is the morality utilization rate metric because our revenue is driven principally from our female members was 0.44% this quarter compared to 0.45% a year ago. Utilization rates will vary from quarter to quarter due to a number of factors, which include the timing of when new clients go live, the time of the year and the demographic mix of the newest clients.

For the full year, our female utilization rate was 1.09%, which compared to 1.02% in 2018. Turning now to our margins. Gross profit of $11.8 million in the fourth quarter increased 117% from the $5.4 million reported a year ago. Our gross margin of 18.1% this quarter reflect a decrease of 50 basis points from the fourth quarter last year, due primarily to the timing of head count that was added to support the record number of new clients that launched on 01/01, which David described earlier.

For the full year, gross profit of $45.5 million, increased 134% from 2018. A gross margin of 19.8% for the full year reflected an increase of 140 basis points from the 18.4% gross margin in 2018, due primarily to achieving economies of scale as we continue to expand our business. Turning to our operating expenses. Sales and marketing was 5% of revenue this quarter, an improvement of 230 basis points over the prior year.

For the year, sales and marketing was 5.2% of revenue, an improvement of 170 basis points from 2018. The improvements in sales and marketing is due to the fact that our customer acquisition costs are primarily incurred in the first year and, to a lesser extent, the second year of going live with a new client. With our nearly 100% client retention rate, we benefit from this leverage in sales and marketing. G&A costs were 11.3% of revenue in the fourth quarter, an improvement of 230 basis points from the year ago quarter.

For the full year, G&A was 10.4% of revenue, an improvement of 480 basis points from 2018. The improvement in G&A reflect the leverage we realized as we build out our back office and support functions and apply these efficiencies over a larger base of revenue. With our improved margins, adjusted EBITDA increased substantially from $0.5 million in the fourth quarter last year to $3.9 million in the current quarter. For the year, adjusted EBITDA increased from $1.4 million in 2018 to $18.3 million in 2019.

While our adjusted EBITDA margin for 2019 was 8%, the adjusted EBITDA margins on our incremental revenue was 13.6% in 2019, demonstrating our ability to achieve kind of scale across our entire business. Net loss attributable to common stockholders was $4.4 million or $0.07 per share in the fourth quarter was compared to a net loss of $1.6 million or $0.31 per share in the prior year period. In 2019, net loss attributable to common stockholders was $8.6 million or $0.41 per share, which compared to a net loss of $5.5 million or $1 per share in 2018. The increased loss in both the quarter and the year was attributable to the noncash charges we previously disclosed that are associated with the valuation of the outstanding convertible preferred stock warrants, which were required to be remeasured each period.

As previously disclosed, those charges were $5.8 million in the fourth quarter and $18.2 million in 2019. According to our net earnings per share, as adjusted, was $0.01 in the quarter and $0.11 for the year and was consistent with our guidance. It's important to note that with the conversion of these warrants in the IPO in the fourth quarter, we will no longer incur any additional charges for this remeasurement. Turning now to our balance sheet and cash flow.

With the proceeds from the IPO, we closed the year with $80.4 million of cash and cash equivalents on the balance sheet. Cash used in operations was $5.5 million this quarter as compared to cash provided by operations of $4.1 million in the year ago period. Cash used in operations this quarter was primarily attributable to the payment of approximately $4.5 million for our annual D&O insurance for the first time as a public company in Q4. Additionally, the timing of payments to providers as well as the collection of our rebate receivable, which came in after year-end negatively impacted cash flow in the quarter.

We expect these timing items will favorably impact cash flow from operations in the first quarter of 2020. I'll close my remarks with our expectations for Q1 and the full-year 2020. For the full year, we expect revenue of between $395 million and $415 million, reflecting growth of between 72% and 81%. We expect full-year adjusted EBITDA of between $41.7 million to $45.3 million, reflecting the continued expansion of our margins.

We expect EPS to be between $0.30 and $0.34 on the basis of approximately 100 million shares. For the first quarter, we are projecting revenue of between $89 million and $94 million, reflecting growth of between 89% and 99% as well as adjusted EBITDA between $8.4 million to $9.3 million. We expect EPS of between $0.05 and $0.06 per share, again, on the basis of approximately 100 million shares. As David said earlier, these ranges are based on our historical utilization patterns and do not reflect any potential impact due to the coronavirus.

We haven't seen any impact, but we'll continue to monitor the situation and be prepared to give you any update on our next quarter's call. With that, we'd like to open up the call for your questions now. Operator?

Questions & Answers:


[Operator instructions] And the first question will be from Anne Samuel with JP Morgan.

Anne Samuel -- J.P. Morgan -- Analyst

Congrats on a nice quarter. I was hoping maybe you could speak to how utilization is kind of historically relative to the particular month of the year? And what level of visibility you have kind of based on that into the guidance at this stage?

Pete Anevski -- President, Chief Financial Officer, and Chief Operating Officer

If you looked at quarterly utilization year over year, those patterns generally trend pretty close, if you look across the business in terms of seasonal quarters. In terms of the patterns that we see and how they inform guidance, we not only use what we're seeing early in the year, so for the first, let's call it, eight weeks of 2020, but we also use historical utilization as it relates to our existing client base to inform our guidance not only for the upcoming quarter, but for the full year.

Anne Samuel -- J.P. Morgan -- Analyst

Great. And then with the lockup expiring soon, have you had any conversations or update from your larger shareholders around their plan?

David Schlanger -- Chief Executive Officer

Anne, it's David. Yes. Lockup expires on April 21. So the first trading day will be on the 22.

Our largest shareholders are Kleiner Perkins and TPG. And each firm has put in place a multiyear 10b5 plan that contemplates a thoughtful approach to reducing their large equity holdings. With respect to management, Pete and I are in discussions with our tax and financial advisors, and also anticipate putting a plan in place in the future. That's similar to our large holders, would also contemplate a thoughtful long-term approach through our concentrated equity holdings.

But like a typical executive plan, any plan that we would put in place would only contemplate selling a relatively small portion of our holdings in any given year. The other thing I'd add, Anne, is that we do have a bunch of other long-term shareholders that are smaller. And with respect to those shareholders, if market conditions allowed, we would contemplate doing the follow-on to help them get out in a more orderly fashion. But I think we all see the market has been a bit volatile.

So that was something that we'll monitor as time progresses.


The next question will be from Michael Cherny with Bank of America.

Michael Cherny -- Bank of America Merrill Lynch -- Analyst

Maybe to start, David. You mentioned about the guidance and not having any impact on coronavirus. I think in the time that Progyny has been around, clearly, there's been no instance where anything of similarity. But is there anything that your provider that your doctors have seen in the past in terms of how you'll see any fluctuation volatility if there is some type of impact? I'm thinking on a much smaller scale but any local dynamics of snowstorms or anything like that? And how long they could see some disruption in the event that things get a little haywire? I know it may not be the best corollary, but at least if there's any type of timing-related volatility and utilization that we have seen in the past, if there's any corollary we can look at here?

David Schlanger -- Chief Executive Officer

Well, so the first thing I would tell you, Mike, is that we've spoken to a number of the doctors in our network. And as of now, we're not seeing any strange patterns with respect to cancellations or changes in scheduled appointment volumes, etc. So they're seeing normal activity. And by the way, we're also seeing among our members' normal activity.

Obviously, if any particular geography has the local health authorities tell people to stay home, obviously, that could have a temporary impact with respect to people getting treatment in that geography. In the past, when there's been other issues like the SARS outbreak or something, when the acute issue has resolved itself, people continue to get treatment because, obviously, it was still the time for them to have a child and all their personal financial and professional issues were pointing to that being the right time to have a child. So again, we're not seeing anything now. The doctors aren't seeing anything now.

And again, people have a child when it's the right time for them. The other thing I would add is that most fertility clinics are not located in hospitals, they are private clinics. So when our members are receiving treatment, they don't have to go to a hospital where they may have concerns about other sick people being there.

Pete Anevski -- President, Chief Financial Officer, and Chief Operating Officer

Yes. Let me just add one more thing there, Mike. When we look back at when the SARS hit the U.S., I think it was 2012, 2013, middle of 2012 through early 2013, and you look at the CDC data in a number of cycles, oddly enough in those two years versus the two prior years, cycles actually grew in the U.S., didn't decline. So that's another indicator that something like that, I don't know that it's exactly similar to coronavirus, but something that widespread didn't have an impact relative to just overall cycles.

That's the only other thing that we could point you to just sort of, if you will, in terms of what's happening or may not be happening.

Michael Cherny -- Bank of America Merrill Lynch -- Analyst

I appreciate that. I know it's a very fluid situation. So the color is definitely helpful. And then shifting gears a little bit.

As you wrap up at the end of the year, you move forward into 2021's selling season, one of the things I know that you've discussed in the past is the viability and the strength of your sales force. Can you maybe talk about how the sales message continues to evolve as you have more and more customers, and particularly customers coming from such a wider degree of various different subsectors, how that changes or augments or expands the sales strategy and especially with some of the history of having Progyny Rx now for a more run rate period of time? I guess, just thinking about how the sales force goes to market? And what's evolved over the last couple of years, as your business has shot up growth rate pretty quickly?

David Schlanger -- Chief Executive Officer

Well, look, I think that given that a lot of our value is based upon the outcomes we generate and as we've had more and more companies more and more covered lives and members and companies from varying industries and geographies, it certainly reinforces the message and provides additional evidence that our value proposition really applies across again, all different types of industries, all different types of employers, all different types of geographies. So again, what we're seeing, the growth of our business just reinforces all those messages. But it's largely the same value message that we've been talking about and that you're certainly familiar with. So again, it's more validation for why our program is better, why it provides employers a more cost-effective solution, why employees continue to have a better experience.

And as we evolve as a company and have more experience, we've shown we can actually improve the employee experience. So again, just more reinforcing of many of the same messages. Now the other thing is, when you go out and sell large employers, they're always interested to know who else has the benefit and who else are you serving. And the more companies that you work with, the more "reference accounts" you have, so that they get more comfortable with the benefit.

They also are looking to remain competitive with each other and in their industry with respect to the robustness of their benefits. So again, there is this kind of network effect that we've talked about before, within an industry where you sell a few employers in those industries. Other employers in the same industry are looking to have similar benefits. And the last thing I would say is that the adoption of Progyny Rx continues to be strong.

And I think we've disclosed 75% of new customers take the benefit when they first sign up. We've had good success upselling those customers. And again, it's more validation of others doing what you may be considering doing as a potential buyer of our services.


The next question will be from Sarah James with Piper Sandler.

Sarah James -- Piper Sandler -- Analyst

And I apologize that there's a little overlap. I had some technical difficulties in the beginning of the Q&A. But 2020 guide is better than we expected. And I'm hoping to understand a little more of the assumptions going into revenue guidance.

So any change on utilization or client size there? And I know some of your customers we had talked about putting off the Rx decision, while they transition their core healthcare PBM contracts. So any details on follow through with those specific accounts, if you've had any traction in adding on the Rx benefit?

Pete Anevski -- President, Chief Financial Officer, and Chief Operating Officer

Yes. So I'll take the second question first. So as it relates to upsells in the RX benefit, yes, we did have a good upsell season, if you will, relative to RX. And we also had a favorable start day acceleration, if you will, with one of them.

And so one of the things that's contributing to the higher guidance for the full year is that one of our upsell clients that took Rx was originally planning to do it mid-year and ended up in the beginning of the year. And so that's favorable to us. The second piece that's contributing to the guidance is we are seeing slightly better utilization than we had planned, both from our new clients as well as our existing clients, it's real slight, but the math adds up to it has an impact relative to the full year, but it was favorable relative to what we had planned. The way we do these things is we use historical experience by industry, adjusting for known demographics at each new client and do our best guess in terms of expectations from new clients and generally speaking, they fall out within a range as an overall cohort for new clients, but sometimes slightly favorable, sometimes not.

So far, they're slightly favorable relative to what we planned when we rolled up all those new expected clients for the year.

Sarah James -- Piper Sandler -- Analyst

And to follow-on that, you talked about your 2020 book changing in mix with a lot of the sales coming from the nontraditional sectors, and I imagine it would continue even into '21. So how do you think about forecasting utilization under this mix shift dynamic? And would you anticipate utilization going up because of this mix shift?

Pete Anevski -- President, Chief Financial Officer, and Chief Operating Officer

So the important point about the comment around our expanding base of industries across our client base applies not only to this past sales year, but applies to the prior sales year for clients that went live in '19. I think that the point that we were trying to make is that the earliest years had the highest concentration of tech clients, and we continue to see expansion into other industries. It doesn't mean we're still not getting tech clients, we're getting them overall. Let me just make that point first.

The second point relative to engagement rates overall and what to expect is because the tech companies generally have a younger employee demographic with a larger household income, utilization rates tend to be higher with them than with other industries when you calculate it as a percentage of total overall covered members. So as a result, what we're seeing slight, but on a blended basis, slight drop in utilization rate year over year sometimes, but mix could impact that. But the differential that we expect or a slight increase. The differential that we expect for the 2020 year could be a slight increase, but the reality is that, the difference is so small, as we get bigger and bigger, more and more clients, more and more covered lives, it should just be pretty close to what it's been, plus or minus a couple of basis points each year based on actual utilization that happens.

So there won't be big fluctuations relative to our adding clients across industries. And as we grow bigger and bigger, it will just be more reflective of more similar to the overall base.


[Operator instructions] The next question comes from Ralph Giacobbe with Citi.

Ralph Giacobbe -- Citi -- Analyst

You mentioned and talked about your competitive advantages and particularly getting an early lead focused on fertility benefits. I guess, the question, how important is it at this point to expand service lines and sort of accelerate that? You've obviously done well on the pharmacy side. Just trying to get a sense of how important it is to sort of widen out, if you will, at this stage, it's still in early stage, but to sort of further out that lead that you have?

David Schlanger -- Chief Executive Officer

We think we can continue to grow at a very strong rate with our current solution. Nevertheless, we are, as we talked about previously, studying possible extensions to our service offering, particularly in adjacent areas and other areas of women's reproductive health. We think those opportunities will make both, I think, our benefits stickier and provide a better member experience, but also provide opportunities for additional revenues. So certainly, we're going to continue to look at those things and do what we think will be accretive to the business, but we can continue to grow, again, at high rates, given the solution we currently have in place.

Ralph Giacobbe -- Citi -- Analyst

OK. Fair enough. And then...

David Schlanger -- Chief Executive Officer

Yes. Remember, there are, as we talked about before, 8,000 potential employers were 2% to 3% penetrated. This solution saves them real dollars. It provides a better member experience.

There's all kinds of other benefits to the employers with respect to better employee productivity, less absenteeism, helps their diversity and inclusion programs. So there's a lot of reasons why employers bring us on and all those reasons continue to be very valid. And there's a lot of employers still out there that can benefit from all those things.

Ralph Giacobbe -- Citi -- Analyst

Yes. That makes sense. And then just a follow-up question. I wanted to ask about the gross profit margin in the quarter didn't show as much leverage on the short strong top line, and it was down and looked like it contracted a little bit year over year.

I think you mentioned in your prepared remarks, headcount add. So I just wanted to hopefully get you guys to just flesh out in terms of the adds and sort of the leverage sort of on that line as we think about, not just '20, but beyond?

Pete Anevski -- President, Chief Financial Officer, and Chief Operating Officer

Yes, I would encourage you to look at the full year and any quarter, in particular, the fourth quarter is going to have the most variability relative to timing of new hires, preparedness for the following year in terms of how many people we add, etc. So the full-year gross margin is more indicative of our ability and the improvement there is more indicative of our ability to improve gross margins overall, the fourth quarter and sort of the fourth-quarter results, the delta between the margin versus whether you compare prior year or any recent period is small in absolute dollars relative to the reality of what we achieved overall for the full year. I would also encourage you to look at the overall guidance for next year and our ability to expand, our belief that we could expand margins again based on that guidance, and embedded in there is expanding gross margins, again, across the business, including in gross profit. And so it is really nuanced within the quarter itself, not a lot to read into there.

So that's why we sort of put the comment in our prepared remarks around the impact of it because I know we look at the percentages and see a smaller percentage, but in absolute dollars, it's really small. It's the overall year that you should look at.


[Operator signoff]

Duration: 44 minutes

Call participants:

David Schlanger -- Chief Executive Officer

Pete Anevski -- President, Chief Financial Officer, and Chief Operating Officer

Anne Samuel -- J.P. Morgan -- Analyst

Michael Cherny -- Bank of America Merrill Lynch -- Analyst

Sarah James -- Piper Sandler -- Analyst

Ralph Giacobbe -- Citi -- Analyst

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