Humana Inc. (NYSE: HUM) Q2 2021 earnings call dated Jul. 28, 2021
Corporate Participants:
Amy Smith — Vice President of Investor Relations
Bruce D. Broussard — President and Chief Executive Officer
Susan M. Diamond — Chief Financial Officer
Analysts:
Justin Lake — Wolfe Research — Analyst
Kevin Fischbeck — Bank of America Securities — Analyst
Matt Borsch — BMO Capital — Analyst
A.J. Rice — Credit Suisse — Analyst
Ricky Goldwasser — Morgan Stanley — Analyst
Stephen Baxter — Wells Fargo Securities — Analyst
Josh Raskin — Nephron Healthcare Investment Research — Analyst
Lance Wilkes — Bernstein — Analyst
Ralph Giacobbe — Citi — Analyst
Scott Fidel — Stephens — Analyst
George Hill — Deutsche Bank — Analyst
David Windley — Jefferies LLC — Analyst
Rob Cottrell — Cleveland Research — Analyst
Presentation:
Operator
Ladies and gentlemen, thank you for standing by, and welcome to Humana Second Quarter 2021 Earnings Call. [Operator Instructions]
Now I would like to welcome Ms. Amy Smith, Vice President of Investor Relations. Ma’am, please go ahead.
Amy Smith — Vice President of Investor Relations
Thank you, and good morning. In a moment, Bruce Broussard, Humana’s President and Chief Executive Officer; and Susan Diamond, Chief Financial Officer, will discuss our second quarter 2021 results and our updated financial outlook for 2021. Following these prepared remarks, we will open up the lines for a question-and-answer session with industry analysts. Joe Ventura, our Chief Legal Officer, will also be joining Bruce and Susan for the Q&A session. We encourage the investing public and media to listen to both management’s prepared remarks and the related Q&A with analysts. This call is being recorded for replay purposes. That replay will be available on the Investor Relations page of Humana’s website, humana.com, later today.
Before we begin our discussion, I need to advise call participants of our cautionary statement. Certain of the matters discussed in this conference call are forward-looking and involve a number of risks and uncertainties. Actual results could differ materially. Investors are advised to read the detailed risk factors discussed in our latest Form 10-K, our other filings with the Securities and Exchange Commission and our second quarter 2021 earnings press release as they relate to forward-looking statements, and to note in particular, that these forward-looking statements could be impacted by risks related to the spread of and response to the COVID-19 pandemic. Our forward-looking statements should therefore be considered in light of these additional uncertainties and risks, along with other risks discussed in our SEC filings. We undertake no obligation to publicly address or update any forward-looking statements and future filings or communications regarding our business or results.
Today’s press release, our historical financial news releases and our filings with the SEC are also available on our Investor Relations site. Call participants should note that today’s discussion includes financial measures that are not in accordance with generally accepted accounting principles or GAAP. Management’s explanation for the use of these non-GAAP measures and reconciliations of GAAP to non-GAAP financial measures are included in today’s press release. Finally, any references to earnings per share or EPS made during this conference call refer to diluted earnings per common share.
With that, I’ll turn the call over to Bruce Broussard.
Bruce D. Broussard — President and Chief Executive Officer
Amy, thank you. Good morning, everyone, and thank you for joining us. Today we reported adjusted earnings per share of $6.89 for the second quarter of 2021, in line with our previous expectations. We continue to focus on delivering strong operating results while navigating a dynamic environment due to the ongoing COVID-19 pandemic, all while staying true to our commitment to delivering the highest quality healthcare experience for members and patients.
Well, we are maintaining our full year 2021 adjusted EPS guidance of approximately $21.25 to $21.75 at the midpoint, representing full year adjusted EPS growth of 16% above the 2020 baseline of $18.50 in excess of our long-term growth target, while acknowledging the continued uncertainty driven by COVID-19 hospitalization trends and the rate at which non-COVID cost normalized.
As Susan will describe in more detail, our full year adjusted EPS guidance now assumes a $600 million COVID-19-related headwinds that is expected to be largely offset by favorable operating items. In addition, this guidance assumes no COVID costs will run — non-COVID costs will run approximately 2.5% below baseline in the back half of the year, including an assumption of minimum COVID testing and treatment costs for the remaining of the year.
I’d like to reiterate that our core fundamentals are performing well, and 2021 is a year of COVID-19 transition with various pandemic-related financial impacts, including reduced Medicare Advantage revenue resulting from the significant temporary deferral of utilization in 2020 as well as the lingering near-term uncertainties regarding the pace and level of the return of utilization for the balance of the year. We also acknowledge that we are seeing increase in COVID utilization in recent weeks, which we will continue to watch closely.
While we continue to navigate this pandemic-related uncertainties in 2021, as Susan will lay out in detail, we expect 2022 to be a more normal year. The healthcare system has been open for several months, and we have seen vaccination rates in the seniors reach approximately 80% nationally. Accordingly, our members continue to engage in more routine interactions with their providers, which we anticipate will result in more normalized Medicare Advantage revenue next year as providers are able to ensure that our members are receiving appropriate care and that their conditions are being fully documented.
I would reiterate our remarks from the last quarter regarding our Medicare Advantage bids for 2022, which reflected the continued uncertainty associated with COVID-19 and our premium and claims assumption with a focus on maintaining benefit stability in 2023. While it is still too early to provide 2022 guidance, we believe our operating discipline in 2021 combined with the depth of our planning for 2022 Medicare Advantage AEP puts us in a strong position for financial growth in 2022.
I will now turn to an operational and strategic update. Importantly, our underlying core businesses continue to deliver strong results on solid fundamentals with individual Medicare Advantage membership growth outpacing the industry. As we highlighted at our recent Investor Day, this growth is balanced across various product lines, including HMO, PPO and Dual Special Need Plans or D-SNPs.
Our Medicaid business continues to perform well in 2021 and our South Carolina plan is now operational. We are diligently preparing for the Ohio contract go live date in early 2022 and are continuing to improve our operating model building off of our core Medicare Advantage capabilities. We also experienced slightly better than expected results in our home and provider businesses and increased mail order rates in our pharmacy business.
Finally, as announced last quarter, we’ve entered into an agreement to acquire the remaining 60% interest in Kindred at Home, and we expect the transaction to close mid-August, which we’ve included in our revised estimates for the year. Our strong operating performance this year is in part attributed to our strong partnerships with providers who are delivering high quality care to our members. We are currently seeing 87% of our provider partners and value-based arrangements and surplus.
Further, our relentless focus on consumer centricity has led to an all-time high net promoter scores for our retail organization, contributing to Medicare Advantage membership growth and resulted in an external recognition of Humana as an industry leader in customer satisfaction, including the announcement this morning that we received the highest ranking in mail order pharmacy customer satisfaction for the fourth year in a row in the J.D. Power 2021 U.S. Pharmacy Study.
On the public policy front, as policymakers explore changes to Medicare, including adding dental, vision and hearing as part of the Medicare benefit, we stand ready to both innovate for the more than 12 million of our members who already have these benefits, including 7 million dental and vision policies in our MA group as well as offer ideas of public private collaboration to leverage our deep capabilities in Medicare and specialty markets so that beneficiaries could quickly see benefits go from a proposed law to a tangible benefit.
Before turning the call over to our new Chief Financial Officer, Susan Diamond, I’d like to take a moment to speak about Susan’s experience at Humana over the last 15 years. She has served in various leadership roles across the company during her tenure, spending eight years as part of the Medicare and leadership team with various financial and operational in line of business responsibilities. She also spent two years on the finance team, leading enterprise planning and forecasting and overseeing the company’s line of business, CFOs and controllers. Most recently, she led our home business, growing it to the largest offering of its kind.
Her strong financial background and extensive knowledge of our business make her uniquely positioned to step into the CFO role. The board and I have great confidence in our abilities and the contribution she will make in the next chapter for Humana as we execute on our strategic plan and deliver shareholder value. In addition, during the strategic nature of the CFO role, Susan will continue to contribute in a meaningful way to our home health business.
With that, I’ll turn the call over to Susan.
Susan M. Diamond — Chief Financial Officer
Thank you, Bruce, and good morning, everyone. Today we reported adjusted EPS of $6.89 for the second quarter, in line with our previous expectations. Our underlying core business fundamentals remained strong, and we experienced a positive start to the year across our segments with the first quarter coming in modestly ahead of our previous expectations. Our results moderated back to expected levels in the second quarter, albeit with variation in the way specific underlying assumptions emerged, with COVID treatment costs coming in lower than expected, offset by non-inpatient utilization continuing to bounce back faster than originally anticipated. As I will describe in further detail in a moment, uncertainty remains for the balance of the year due to the pandemic, specifically as it respects COVID hospitalizations and the rate at which non-COVID costs normalized inclusive of both volume and unit costs.
Recognizing the majority of today’s call will focus on our emerging experience and our 2021 guidance, I want to quickly touch on operating performance across our segments before diving into that detail. Our Medicare Advantage growth remains on track and consistent with our previous expectations with individual MA growing solidly above the market at an expected 11.4% at the midpoint. Our Medicaid business results are exceeding our initial expectations given membership increases largely attributable to the extension of the public health emergency as well as higher than expected favorable prior period development.
In our Group and Specialty segment, consistent with our commentary on our last earnings call, medical membership declines are lower than we expected coming into the year. Our Specialty business results are exceeding expectations as utilization, particularly for dental services, has been slower to bounce back than initially expected. Finally, within we set our healthcare services operations, pharmacy continues to see increased mail order penetration as a result of customer experience improvements and additional marketing initiatives. The home business, CenterWell Senior Primary Care and Conviva are performing slightly ahead of expectations, and we remain on track to open 20 new clinics this year with Welsh Carson. In addition, as Bruce indicated in his remarks, we now expect the Kindred at Home acquisition to close in mid-August subject to customary state and federal regulatory approvals.
Before I go into more detail on our 2021 guide, I want to reiterate that the uncertainty we are seeing in 2021 relates solely to the difficulty estimating the impact of the pandemic and is not expected to carry forward into 2022. We remain comfortable with how we approach 2022 pricing, which I will expand on later in my remarks.
Turning to full year 2021 guidance. I would remind you, our adjusted EPS guidance represents growth at or above the top end of our long-term target of 11% to 15%. Our philosophy regarding 2021 guidance has been to provide transparency into the uncertainty caused by COVID-19 and the ability to deliver our targeted earnings growth with solid underlying core business performance and largely offsetting COVID-19-related headwinds and tailwinds. We have been consistent in and remain committed to this philosophy.
There is a reasonable path to achieving adjusted EPS within our initial guidance range. And accordingly, today we are maintaining our full year adjusted EPS guidance of $21.25 to $21.75, while acknowledging the continued uncertainty as it respects to COVID hospitalization trends as well as the pace at which non-COVID costs bounce back and at what level they ultimately normalize. Additionally, we expect our third quarter adjusted EPS to reflect a low-20s percentage of our full year adjusted EPS.
As Bruce indicated, given our experience to date, together with our current estimates for the back half of 2021, we have effectively recognized a $600 million COVID-related headwind for Medicare Advantage in our full year guide, offset by favorable operating items. These favorable items include, among others, higher than initially expected prior year development, the previously discussed better than expected specialty and Medicaid results and the expected contribution from Kindred at Home given the transaction is expected to close in the coming weeks.
Now let me provide an update on the underlying changes since our initial detailed guide in February, articulate key assumptions regarding utilization in the back half of 2021 and expand on the continued pandemic-related uncertainties I described. I will begin with Medicare Advantage revenue. As discussed last quarter, given our significant exposure to Medicare Advantage, we are disproportionately affected by COVID’s impact on Medicare Risk Adjustment or MRA. Recall, our risk-adjusted revenue for 2021 is determined by 2020 dates of service, medical utilization and resulting documentation, which as previously discussed, was materially depressed in 2020.
As we have indicated since the beginning of the year, the MRA headwind we are facing in 2021 is significant, and we have closely monitored it over the course of the year. Our April guide recognized we had $300 million of additional pressure from MRA relative to our initial expectations for the full year, which was offset by the net benefit of the extension of sequester relief. In July, we received the mid-year MRA payment, and it came in modestly lower than expected. We are however taking operational steps now to be able to recover some of the MRA revenue in the final payment for 2021. Accordingly, our MA premium estimates, net of capitation, remained largely in line with our initial expectations when factoring in the net sequestration benefit.
Now turning to benefit expense. At the beginning of the year, we indicated that we expected non-COVID costs for our Medicare business to run 3.6% to 5.5% below baseline. We define baseline and 2019 experience trended forward based on a normalized trend factor excluding the effects of COVID. In the first quarter, we acknowledged that non-inpatient costs were bouncing back faster than initially expected. However, that was offset by COVID utilization decelerating faster than expected. We also recognized, however, visibility into non-inpatient claims were significantly less than inpatient. And therefore, we acknowledged that there was more uncertainty around non-inpatient service categories in terms of exactly where we stood.
However, at that time, we could still tolerate overall utilization returning to baseline late in the year if the non-inpatient acceleration we were seeing was due to pent-up demand and leveled off in the second and third quarters. In the first and second quarters, non-COVID costs run approximately 7% and 3% below baseline respectively with the bounce back outpacing expectations in the second quarter. Non-inpatient utilization did not level off and instead continue to increase in the second quarter and was offset by lower than expected COVID costs and other business outperformance.
As the healthcare system has been open for several months and a high rate of the senior population has been vaccinated, our current guidance now assumes that non-COVID costs level off and run approximately 2.5% below baseline levels in the back half of the year. Consistent with our original forecast, our current guidance assumes minimal COVID testing and treatment costs in the back half of the year. That said, we do acknowledge that we are seeing increases in COVID admissions in recent weeks, although it is too early to determine if they will be offsetting declines in non-COVID utilization and we will continue to monitor this recent development.
Finally, as it respects to our 2021 guide, for our commercial business, we expect all-in utilization for COVID and non-COVID to continue to run above baseline as anticipated. In summary, I want to emphasize that 2021 is a COVID transition year. There is a reasonable path to deliver against our guidance expectations. However, if non-COVID utilization or COVID treatment costs increase beyond our expectations in the back half of the year, it will present a headwind to our guide absent offsetting tailwind.
I also want to reiterate that the $21.50 midpoint of our original guide continues to be the right jumping off point for 2022 adjusted EPS growth. Our members continue to engage in routine interactions with their providers, which we anticipate will result in more normalized Medicare Advantage revenue next year as providers are able to ensure that our members are receiving appropriate care and that their conditions are fully documented.
During the first half of 2021, provider interactions and documentation of clinical diagnoses that will impact 2022 revenue outpace those experienced in the first half of 2020 and are approximately 80% complete in line with the estimated completion rate for the same time period in 2019. Lastly, I would remind you that our Medicare Advantage bids for 2022 reflected the continued uncertainty associated with COVID-19 as it relates to our premium and baseline non-COVID claims trend assumptions with a focus on maintaining benefit stability into 2023.
Before we open up the line for questions, I’m excited to announce two finance leadership changes that will promote the growth and versatility of our finance leadership team. First, with the expected integration of Kindred at Home, our home business is growing significantly, and Amy has accepted the role of Vice President and CFO of Home Solutions. She will be a key member of the Home Solutions leadership team, responsible for the financial oversight and planning and forecasting for the segment. Lisa Stoner will succeed Amy, accepting the role of Vice President, Investor Relations. Lisa has worked with Amy over the last four years and is well known and respected by our investors. We are excited about the opportunity this affords both Amy and Lisa, and Lisa’s continuity in Investor Relations will allow for a seamless transition.
With that, we will open up the lines for your questions. In fairness to those waiting in the queue, we ask that you limit yourself to one question. Operator, please introduce the first caller.
Questions and Answers:
Operator
Thank you. Your first question is from the line of Justin Lake from Wolfe Research. Your line is now open.
Justin Lake — Wolfe Research — Analyst
Thanks. Good morning. Obviously, a lot to cover. I’ll try to keep it to one question here. I’m hoping you could give us a few numbers. One is the MRA. Can you tell us what the full year impact is of the negative MRA? And I think there’s a lot of confusion around two things. One, it sounds like the first half or the second quarter I should say was worse than expected and yet you still kind of came in line with from an MLR perspective. So you’re telling us the back half needs to be more optimistic. So what happened in the second quarter beyond that allowed you to make the MLR, but still had higher medical costs in the back half? And then I guess, around that, the $600 million specifically, can you flush that out in as much detail as you can? Because is that comparable to the old COVID estimate or is that a new COVID headwind that you’ve kind of thrown in there for the back half of the year for us to think about?
Susan M. Diamond — Chief Financial Officer
Sure. So I’ll take these one at a time. I’ll start with your last question around the $600 million. So just to clarify, the $600 million represents our full year estimate of the Medicare Advantage only net headwinds and tailwinds related to the COVID pandemic. And if you recall back to our initial guidance earlier this year, we provided a schedule that laid out the specific line items that were considered in that and a range of estimates at the time. So the $600 million represents our current view and what is contemplated in our guide related to those items on a net basis. So the net of all the various headwinds and tailwinds based on our current expectations.
As it respects the first half and second half, as we described in the call, what we continue to see throughout the first half of the year was COVID costs coming down faster than initially expected, but non-COVID, outpatient in particular, rebounding faster than expected, and that continued through the second quarter and we anticipate that that will extend some into the third quarter before it levels off.
In the first half of the year, the benefits we saw from COVID-related costs as well as some lower inpatient — non-COVID inpatient costs, we do not expect to continue at the same rate, because our expectation had always been that those costs on the COVID side would come down as a result of the rollout of vaccinations and that utilization would rebound to more normal levels, such that there is less positive upside that can offset those costs in the second half of the year, which is why we are now estimating a net 2.5% decline in non-COVID utilization in the back half of the year to meet our guide.
As it respects MRA, I think we provided the net detail in terms of what our current estimates are. I know we’ve provided the line item in the initial guide in terms of the beginning of the year. And what we’re saying is, on a net basis, net of capitation, there is about a $300 million additional headwind. And in the context of the overall guide, that is largely offset or fully offset by the net impact of the positive sequestration benefit.
Justin Lake — Wolfe Research — Analyst
Okay. And then just the quick follow-up on the $600 million, that was all really helpful. The $600 million, can you just tell us what that compares to specifically? Did you have like $400 million to $700 million COVID number growing into the original schedule? Is that the comparable now? And then have you said that that’s all eaten away in the first half of the year? So effectively that updated $600 million is comparable to the $400 million to $700 million and it’s completely gone effectively so you don’t have any — none of that’s assumed in the back half? Is that the way to read it?
Susan M. Diamond — Chief Financial Officer
Yeah. So just to be clear, so this is a — the $600 million and four year estimate, so inclusive of first half and back half. But I also want to clarify, it is not meant to be specific to the line item that’s labeled COVID testing and treatment on that initial schedule. That was one line item. When we referred to this $600 million, it is the net impact of all of the line items that were represented on the schedule.
And the other thing I would add as well in terms of your question about how did you offset that, there is a lower COVID and other inpatient costs, but also recall, we had other business outperformance that we mentioned in the discussion around the prior period development, commercial Medicaid that also offset some of that headwind we experienced in the first half of the year as well.
Justin Lake — Wolfe Research — Analyst
All right. Thank you.
Amy Smith — Vice President of Investor Relations
Thank you. Next question please.
Operator
Your next question is from the line of Kevin Fischbeck from Bank of America. Your line is now open.
Kevin Fischbeck — Bank of America Securities — Analyst
Great, thanks. Wanted to I guess follow-up on the assumption of trend in the back half of the year, I guess you’re saying core utilization 2.5% below. I guess, if you could maybe provide a little more color on that? How do you get there? Are some things above average, some things below average? If I understood what you were saying, I think you said when you include COVID cost, total trend is above average, I just want to make sure I heard that. But just a color on how you get to the minus 2.5% for the back half of the year? And why there isn’t more of an assumption of core back to normal by the end of the year?
Susan M. Diamond — Chief Financial Officer
Sure. So just to provide a little more detail. So as we mentioned, the second quarter ran about 3% below baseline for that non-COVID utilization. Our third and fourth quarter now on average are estimated to run 2.5% below baseline. And recall, that that’s inclusive of both utilization as well as unit cost. So as I mentioned, we do expect given that the country has been largely open, our population is largely vaccinated that we will see those non-COVID utilization start to normalize. And so we’ve allowed for some additional return to baseline relative to what we’ve experienced in the second quarter.
I would also say that as we see that utilization come back, we also see that the average cost per hospitalization will come down because lower severity cases are reintroduced. And so the combination of leveling off of utilization and continued reduction in the unit cost contribute to that 2.5% below baseline. I think you’ve suggested that overall utilization might be above baseline. I think you might be referring to my comments about commercial where we had planned to see in total COVID non-COVID to run slightly above baseline as we were beginning to see that at the end of 2020. But for our Medicare business, because we’re including limited COVID costs in our forecast in the back half of the year, it’s not contributing significantly. So that would not take it over baseline.
Kevin Fischbeck — Bank of America Securities — Analyst
Okay. But when you say below baseline, inpatient, outpatient, physician, drugs, I guess those four categories, are they all kind of there or some above some below?
Susan M. Diamond — Chief Financial Officer
Sure. We are seeing variation in some of the service categories, as you can imagine. One of the reasons we believe that some of the pent-up demand has been worked through the system is things like surgical procedures, colonoscopies and things like that, we did for a period of time see it go slightly above baseline, but other traditional normal course ER and observations and other activities continue below baseline.
Kevin Fischbeck — Bank of America Securities — Analyst
Yeah, thanks.
Amy Smith — Vice President of Investor Relations
Thank you. Next question please.
Operator
Your next question is from the line of Matthew Borsch from BMO Capital Markets. Your line is now open.
Matt Borsch — BMO Capital — Analyst
Yeah. Thank you. Maybe I could just continue on this theme. Trying to understand what the Medicaid baseline through the end of the year. Do you think that what is sort of thought of as deferred care or the healthcare that didn’t happen that would have happened I guess really over the last five quarters. Is a lot of that just not going to cut — that isn’t something that is going to flow through as pent-up demand? Sort of embedded in there is that assumption that — and the seniors I guess are going to still have some avoidance to the healthcare system even in the back half of this year. Just trying to understand that.
Susan M. Diamond — Chief Financial Officer
Yeah. I would say that our view would be given the pace at which the non-inpatient utilization in particular bounce back, which was faster than we anticipated that we are seeing — and a lot of that you’ll see they’re re-engaging with their physicians and specialists more than normal rate. And so I think we do believe that some of the pent-up demand as a result of the deferred care in 2020 has been reflected in our first half of the year results. And then again because of the length of time a country has largely been open that pent-up demand has worked through. And therefore, while we will — we are expecting a little bit more return to baseline relative to our second quarter performance that that will stabilize through the back half of the year.
Matt Borsch — BMO Capital — Analyst
Okay. Thank you.
Amy Smith — Vice President of Investor Relations
Okay. Thank you. Next question please.
Operator
Your next question is from the line of A.J. Rice from Credit Suisse. Your line is now open.
A.J. Rice — Credit Suisse — Analyst
Hi, everybody. Just to put a fine point on some of the discussion, and then two other data points. The 2.5% for the back half, I think in the beginning guidance you said that the utilization for the full year would be 3.6% to 5.5% deferred both relative to baseline. If we got an updated number, how much are you at the lower end of that? Are you even the overall range if you think about that original number?
And then I would also ask you about the operating expense, obviously you’ve updated that. Is that mainly related to Kindred? Are you expecting more investments in the back half of the year in other areas? And then if I could squeeze in one more, your comment about the offset of sequestration versus the MRA headwind this year. Does that in your mind reverse next year? So if we lose sequestration, you — the MRA catch up by having fully quoted all of the people from last year and this year offsets that? Is that the way to think about it?
Susan M. Diamond — Chief Financial Officer
Sure. So I’ll take this one at a time. So the first — to your question, based on our experience for first half of the year and our 2.5% expectation in the back half of the year, if you do all that math, it suggests that for the full year, our non-COVID utilization will end up at about 3.7% below baseline. So effectively the low end of the range we’ve giving you at the start of the year.
On opex, as you said, you’re exactly right. The reason for the change in the guide and the increase that is directly attributable to incorporating the Kindred performance into our guidance points. And so that is largely the reason for that increase. We do, however, I would say, in terms of our core business and even within Kindred anticipate some investment, like we would in normal course. Kindred, as you can imagine by integrating it, there are some investments we might want to make there as it respect to value-based operating model that we’ve described at Investor Day. And so that is contemplated in there as well.
On your second question on sequestration, we do expect that to reverse in 2022. That would have been contemplated in our bids and pricing. And our MRA assumptions, as we think about 2022, would not be impacted by that exclusively. They are independently calculating what we believe the risk adjustment will be based on the diagnosis to admissions that we would expect in a more normal environment.
A.J. Rice — Credit Suisse — Analyst
Okay, thanks.
Amy Smith — Vice President of Investor Relations
Thank you. Next question please.
Operator
Your next question is from the line of Ricky Goldwasser from Morgan Stanley. Your line is now open.
Ricky Goldwasser — Morgan Stanley — Analyst
Good morning. So one clarification on utilization and then another question. So just to clarify, Susan, basically what you’re saying is that the 2.5% below baseline really encompasses the fact that care is happening outside the four walls of the hospital, I think you mentioned lower ER visits. You’re also mentioning that you don’t expect 2022 risk adjusters to be impacted by this lower utilization. So is it that just you’re seeing a shift in work here is being provided, i.e. the telehealth primary care and that’s what’s impacting that below baseline the dollar number? And then my second question, if you can give us just some color and context around the announcement that we saw last week on the investment that you’re making with Anthem into a new PBM?
Susan M. Diamond — Chief Financial Officer
Okay. So to your first question on the 2.5%. So again, that is related to non-COVID utilization and all inclusive of inpatient and non-inpatient, again, both rate and volume. And so I wouldn’t say that we’re necessarily seeing shifts in the site of service or the site of care, but rather just as utilization returns to normal. There is some level of utilization that hasn’t — just hasn’t come back on an absolute basis. But really, we are seeing with the exception of some of those specific service categories I mentioned like surgical, other categories are largely still running below baseline across the board.
As far as MRA impact, as we said, what we are seeing in terms of the normal routine interactions with our providers, our interim assessment activity and other annual wellness programs, those are all trending exactly as we would expect to see in order to deliver against our 2022 revenue estimates contemplated in pricing. And so we feel really good about our trajectory there.
Should we see somewhat depressed utilization in the back half of the year, given the way risk adjustment works, generally speaking, we feel good that so long as there is not sort of a full shutdown like we saw in 2020, which is not what we anticipate currently, we feel confident that we should be on pace to deliver against what we need for MRA, again based on what we’re currently seeing.
I don’t know, Bruce, would you like to address the Anthem partnership?
Bruce D. Broussard — President and Chief Executive Officer
Sure. Similar to what we’ve done in the past in other more utility-oriented areas, I think Availity would be an example of that, where we’ve tried to find partners within the industry that can help build a longer term utility. And we look at the particular partnership with Anthem as the opportunity to update and really give a more both increased productivity and at the same time increased experience for members in the area of the PBM side. We for a number of years have been using SS&C as a vendor to help in the — with the existing technology. But now have been able to take it and really enhance it through this partnership with Anthem and SS&C.
Amy Smith — Vice President of Investor Relations
Thank you. Next question please.
Operator
Your next question is from the line of Stephen Baxter from Wells Fargo. Your line is now open.
Stephen Baxter — Wells Fargo Securities — Analyst
Hi. I was hoping that you could talk in a little bit greater detail about why the risk adjusted revenue ended up coming in below where you expected it for this year? I guess, you had a lot of visibility into certain inputs and not others, to the extent you could flush those out. I think it would will help give us a better sense of how comfortable we can be around next year’s assumptions? Thank you.
Susan M. Diamond — Chief Financial Officer
Sure. So as it respects, the $300 million that we referenced that we’ve contemplated in our April guide, so just for context, Stephen, our January payments in 2021 would reflect claims that were submitted through the September submission deadline. And then that requires us to estimate the submissions that will come in organically as well as a result of our activities around chart review and prospective programs for the remainder of the year.
At that time, we were not anticipating a significant surge that we saw across the country in the fourth quarter due to COVID and the resulting reduction in non-COVID utilization. What that led to you was lower what we refer to as organic diagnosis submission. So those are not related to the campaigns that we initiate, but rather organic submissions across the provider community based on the utilization that’s happening. And those ultimately proved to come in lower than we had anticipated. And generally speaking, I think we’ve mentioned before that those who were getting submissions are more difficult to estimate obviously then the initiatives that we are executing. So that is what’s reflected in our April guide at the time.
In terms of the mid-year adjustment, as we’ve said on previous calls, the adjustment there was solely related to new members or members who were only enrolled for a partial year in 2020 where we don’t have full visibility to their claims. And so while we made an estimate of what we thought the impact would be based on what we were seeing within our concurrent population, ultimately as that mid-year payment came in, it reflected a lower level of contribution for those new members than our estimates had originally anticipated.
I would say that going into 2022 because those impacts were directly related to the COVID pandemic and impact to utilization, I would not expect to see that continued uncertainty here into 2022, based on what we’re seeing so far this year.
Amy Smith — Vice President of Investor Relations
Thank you. Next question.
Operator
Your next question is from the line of Josh Raskin from Nephron Research. Your line is now open.
Josh Raskin — Nephron Healthcare Investment Research — Analyst
Good morning. So I understand we’re coming out of the second quarter with non-COVID utilization running 3% below baseline, but how do you see that continuing to run 2.5% baseline for the second half of the year if you’re also assuming that you’re not going to see any COVID — direct COVID costs for testing and treatment. I sort of think of those as related? And then with a rise in direct COVID costs, so if we did see this increase that you guys mentioned that you’re seeing in the last couple of weeks, if that did continue, would that end up being a net negative now because you’ve got all the direct cost, but you’re already assuming lower utilization?
Susan M. Diamond — Chief Financial Officer
Sure. So I would say that our view of non-COVID is not influenced by what the recent activity I think we’ve seen in COVID cases. That is not why we’re assuming that it runs below baseline. Our view is again just based on the trajectory we’ve seen that given the level of utilization increase we’ve seen that we were at a point where it will be in the plateau and level off and sort of just the new baseline for the back half of the year.
As it respects COVID, as we mentioned, it is very early. In terms of the increase we’ve seen, it’s literally just in the last couple of weeks. It is still a bit too early to determine whether or not we will see offsetting non-COVID utilization impacts like we have seen in all previous surges. I will say, just this last week, we just began to see some level of reduction in inpatient, non-COVID inpatient as the COVID cases increase. It’s simply just too early to really assess the duration that we might see in terms of an uptick and the offsetting utilization. But should we see offsetting utilization in the non-COVID space, in order for that not to present a headwind, it would be incremental to the 2.5% that we are currently forecasting.
Josh Raskin — Nephron Healthcare Investment Research — Analyst
Got it. Thanks.
Amy Smith — Vice President of Investor Relations
Next question please.
Operator
Your next question is from the line of Lance Wilkes from Bernstein. Your line is now open.
Lance Wilkes — Bernstein — Analyst
Yeah. My preliminary question is on the pricing environment. You called out a little bit of pricing environment in I think in group MA, can you talk a little bit about that pricing environment’s impacts and magnitude in ’21, outlook for ’22 and then in general for pricing both individual and group? How does this work towards your return to kind of target margins here? And then on the utilization, the one extra thing I’d just ask on that 2.5% below baseline is just if you’re getting any indications on impacts of Delta variant on utilization in any of your owned clinics? Thanks.
Susan M. Diamond — Chief Financial Officer
Sure. So taking it at a time. So first as it respect to pricing, you’re asking about the group MA, and I think as we’ve said before, the group MA space, particularly for larger group accounts continues to be highly competitive, and we would expect that to continue. And so the margins that we would see on those accounts to continue to be competitive and pressured. I think as we think about group MA, there are lot of other benefits to winning those large accounts in terms of the impact they can have in a local geography on the network and our ability to work with provider partnerships, etc. But we expect that to be continue to be competitive.
On the individual side, this is always a process we go through every year to understand sort of the rate environment, the competitive environment, other business performance. We always strive to maintain benefit stability knowing how important that is to our members as well as our sales and distribution channel. So that’s always our goal. And there’s always a number of puts and takes that we will consider, including the broader enterprise performance as it respect, first and foremost, delivering against our overall growth target of 11% to 15%. And after considering sort of strategic investments, other business performance and then understanding what’s required of our Medicare business and what we’re trying to achieve balancing both growth and margin in the long-term, all of those are taken into account. We remain committed to achieving long-term, our targeted individual margin of 4.5%, and that will vary each year based on those things that I mentioned. But we expect this to continue progress towards that goal.
On utilization, I would say, really it’s too early I think for us to really see anything specific at the clinic level. That information is not as real-time available to us as our health plan information is. So to date, I have not seen anything that would provide us any visibility. I will say there are some concentrations geographically, as you’ve seen probably in the press. Florida is a state that is seeing higher rates given we have a concentration of some of our clinics there. I imagine that they would see some, but we actually don’t have detailed information on that just yet.
Lance Wilkes — Bernstein — Analyst
Okay, thanks.
Amy Smith — Vice President of Investor Relations
Next question please.
Operator
Your next question is from the line of Ralph Giacobbe from Citi. Your line is now open.
Ralph Giacobbe — Citi — Analyst
Thanks. Good morning. I guess, going back to the 2.5%. If your assumption is that 2.5% below baseline, I think your original guidance was to run above baseline towards the end of the year. So why wouldn’t that represent upside or where is the offset there? And then can you give us how much COVID cost you’ve seen sort of through the first half against that $600 million full year estimate? Thanks.
Susan M. Diamond — Chief Financial Officer
Okay. As it respects to 2.5%, as you mentioned, I think in earlier calls, during the first quarter, we did mention that our original forecast did contemplate over the course of the second half of the year that we will begin to approach baseline and potentially for a short period of time see above baseline utilization related to pent-up demand. So we just projected that to occur later in the year.
Our view is that given the rate at which we’ve seen it bounce back more quickly that we have seen that in the first half of the year instead. And so at the time, I don’t think we’ve given specifics on sort of the monthly trajectory, but in general, our original forecast going into the year did anticipate a slower return to baseline and could tolerate it getting to baseline by the end of the year. But as I described in my remarks, because we saw the faster bounce back in non-inpatient and in the first half that was again largely offset by the reductions in COVID and inpatient, those trends will not continue at the same level. And therefore, we will need to see below baseline utilization on the non-COVID side in order to achieve that full year estimate of 3.75%.
And then could you repeat your second question, I’m sorry, about the COVID costs?
Ralph Giacobbe — Citi — Analyst
Yeah. Just trying to get a sense of what it ran in the first half of the year relative to the updated sort of $600 million? Are you fully through the $600 million at this point? Is that what you’re trying to imply and there is nothing baked in the back half? Just trying to get a sense of magnitude there.
Susan M. Diamond — Chief Financial Officer
No. So again, that $600 million is the full year estimate. It does, just to be clear, include the assumption that the non-COVID utilization will run 2.5% in the back half of the year. So that’s contemplated in that. But I don’t think we had intended to provide any quarterly detail of how that’s emerging. But that is a full year number. It would not represent just the first half of the year.
Bruce D. Broussard — President and Chief Executive Officer
Yeah. Just to highlight on the $600 million. That is if you were to go to the first quarter or the February earnings release for the four quarter, we’ve put together some lows and highs all the way from MRA, COVID testing, the depressed utilization and sequestration. And what the $600 million is, as if you were to take that and roll that forward now, all the ins and outs from that would be the net number of the $600 million. The operational aspects of our business, as Susan has talked about, is offset all of that $600 million. But included in that $600 million net number is an assumption that 2.5% of low baseline will be remaining for the remaining part of the year.
Ralph Giacobbe — Citi — Analyst
Okay. Thank you.
Amy Smith — Vice President of Investor Relations
Next question please.
Operator
Your next question is from the line of Scott Fidel from Stephens. Your line is now open.
Scott Fidel — Stephens — Analyst
Hi, thanks. Bruce, I think you just clarified part of the question that I was going to ask, which is just confirming that the net headwind and tailwind that had been zero in that 4Q ’20 slide deck, that’s now $600 million, right? And then also just on the MRA piece, in that same slide deck you had called that out at $700 million to $1 billion of expected headwind. I guess, given the update that you guys have given us around the $300 million incremental impact a couple of months ago, and then how things came out in the mid-year claims review, just interested if you have an updated estimate that we can compare now against that $700 million to $1 billion number? And that’s sort of, I guess, just putting this all together, just how this sort of nets out to for 2021? Putting all the pieces together, what that sort of implies and what you’re assuming for your MA pre-tax margin so we can think about sort of the earnings run rate now relative to the long-term target margin? Thanks.
Susan M. Diamond — Chief Financial Officer
So what I would say, we never at the time, as you mentioned, the schedule that we gave you which provided a range of $700 million to $1 billion, I don’t think at the time we ever said exactly where we were in that range in terms of our internal estimate. I think what we just wanted to clarify was that we have seen $300 million of net pressure incremental to that, which is again in terms of the schedule offset then by the sequestration.
And then can you repeat your second question? I’m sorry. I think it was ’21 — what was your ’21 question, I’m sorry?
Scott Fidel — Stephens — Analyst
Yeah. Susan, basically it’s just trying to take all these different pieces together and what they net out what sort of the underlying pre-tax MA margin assumption is for 2021 so we can think about that relative to the long-term target?
Susan M. Diamond — Chief Financial Officer
Yeah. So what I would say is, as you see in our guidance points, our MER target or our MER range hasn’t really changed. I mean, because of the offset and the nature of those offsets, there were many within the retail segment and Medicare in particular. So I would say, in general, there is not material movement in the individual MA margin because the headwind — net headwind is largely offset by other positivity. And as we mentioned, the positive prior period development, as an example as well as the sequestration would be attributable to the retail segment.
Scott Fidel — Stephens — Analyst
Okay. Got it.
Amy Smith — Vice President of Investor Relations
Thank you. Next question please.
Operator
Your next question is from the line of George Hill from Deutsche Bank. Your line is now open.
George Hill — Deutsche Bank — Analyst
Good morning, guys, and thanks for taking my question. And I’m going to try to put in two very quick ones. I guess, Bruce, as I think about the JV investment with Anthem, that’s much more of an infrastructure and back-end investment as opposed to more of a PBM JV, if I understand that right. And then just kind of net-net of everything, am I hearing things right that the 21.25% to 21.75% is the right jumping off point as we think about fiscal ’22 EPS, inclusive of all the moving pieces, basically that they’re all offsetting?
Bruce D. Broussard — President and Chief Executive Officer
Yeah. Your first question, you’re exactly right. It is an infrastructural investments. Again, it’s a utility for the industry and actually we would enjoy others to join that joint venture over a period of time. In regards to your second question, you’re exactly right. The midpoint is 21.50% and that is what we will base our ’22 growth off of.
George Hill — Deutsche Bank — Analyst
Okay. Thank you.
Amy Smith — Vice President of Investor Relations
Next question please.
Operator
Your last question is — I’m sorry. Your next question is from the line of Dave Windley from Jefferies. Your line is now open.
David Windley — Jefferies LLC — Analyst
Thanks for taking my question. You touched on this a little bit, but I want to try to bring a finer point to it. The 2.5% baseline in the second half, would you expect that — notwithstanding timeframe, but would you expect that to return to baseline or are you seeing some permanent shifts like ER utilization that would cause you to stay below baseline beyond 2021? And then what are you seeing in terms of member acuity as the bounce back utilization has come? Are you seeing higher acuity as patients represent for services? Thanks.
Susan M. Diamond — Chief Financial Officer
Sure. Great question. So the 2.5% represents an average for the back half of the year. I think it remains to be seen at what rate it ultimately settles in. It could come in more depressed in the third quarter and then get close to baseline. There’s obviously a range of scenarios that could emerge, some of which could be that by the end of the year, it gets closer to baseline. So I think that until we get to the plateau and see that sustain, I think it will be hard to assess the long-term, whether that’s a long-term new normal or not. So we’ll continue to watch that.
As for acuity, I would say, so far we are not seeing indicators that there is a higher acuity or there has been impacts from the deferred care in 2020. We are continuing to watch it, but so far we have not seen any sort of systemic indicators of that. And in fact, some of the things that we were able to initiate along with our provider partners to ensure members receive needed preventative care through telemedicine were quite helpful during the pandemic. And one data point as an example was that we saw higher medication adherence through the pandemic than we actually did pre-pandemic. So a nice indication that members were receiving the needed preventative care, receiving their medication and hopefully staying on top of their conditions. But so far we are watching it, we are not seeing any indications of higher acuity.
David Windley — Jefferies LLC — Analyst
Good. Thank you.
Amy Smith — Vice President of Investor Relations
Next question please.
Operator
Your next question is from the line of Rob Cottrell from Cleveland Research. Your line is now open.
Rob Cottrell — Cleveland Research — Analyst
Hi, good morning. Thank you. Wanted to revisit the operating cost guidance and how should we think about that for future years, observing the full year cost of Kindred? And also, any potential synergies that could offset that into 2022 and beyond? Thanks.
Susan M. Diamond — Chief Financial Officer
Sure. As I said, the current year guidance revision was a direct — is directly attributable to incorporating Kindred in the guide. To be quite honest, we’re going to need to do some work post closing and integration to revisit our forward, probably more in 2022, what our guidance points look like and whether they need to change. Obviously, within Kindred, they have direct cost of care. Those are all — all of their costs are included in that opex ratio. It’s not showing up anywhere else in the guide. So that’s something we’ll look at. So we’ll need to see whether there is anything we should break out separately specific to the Kindred business.
As it respect to synergies, the Kindred transaction was not really a traditional synergy play. We obviously don’t have a home health business to integrate into. The operations will be largely standalone. We are certainly looking at opportunities to see where we can create synergies based on the capabilities we have and they have, but I would not expect those to be significant. The real value is going to be on the new products and models that we intend to introduce, particularly the value-based model we shared during Investor Day. That will be the source of value creation as a result of that transaction.
Bruce D. Broussard — President and Chief Executive Officer
And just to re-emphasize, we don’t see net-net our operating cost going up as a result of the transaction outside of some investments we’re making in the short-term as a result of the integration. We continue to maintain a long-term orientation to continuing to increase our productivity, you’ve seen that over the last number of years and that has not changed and the investors shouldn’t walk away from that. This is a increase in costs. We continue to keep that as a discipline. I think what you do see is it’s just sort of taking one organization and that has a different margin, a different operating structure and bringing it into our operating structure. And as we bring the two together, we’ll have that same emphasis of continued improved productivity on the organization.
Amy Smith — Vice President of Investor Relations
And I think that was our last question. So Bruce, if you any closing comments.
Bruce D. Broussard — President and Chief Executive Officer
Yeah. And we really appreciate everyone’s support. We recognize that this quarter as a result of the transition year of COVID is a difficult one. We are very oriented to continuing to have the transparency between what is COVID and what’s operationally, and I hope you guys can discern between those two as we continue to have further questions on the operational performance.
That being said, I do want to leave the investors with the understanding that we continue to believe that the organization’s operational performance in ’21 has been very strong as a result of what you see and just some of the offsets, operational offsets of some of the headwinds from COVID. And then secondarily, as we see 2022, we did take a very conservative view into pricing and our planning for both AEP. And as we start to enter the AEP season, I think you guys will say that thoughtfulness and reflect some of the uncertainties that maybe continue into 2022. So as always, we appreciate your support and we also appreciate our teammates continuing to drive to both improve our operating performance and serve our customers in the best we can. So thank you.
Operator
[Operator Closing Remarks]