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Intrinsic Value is all-important and is the only logical way to evaluate the relative attractiveness of investments and businesses.
Intrinsic Value is all-important and is the only logical way to evaluate the relative attractiveness of investments and businesses.
Ladies and gentlemen, thank you for standing by, and welcome to the Teladoc First Quarter 2021 Earnings Conference Call. At this time, all participants are in a listen-only mode. After the speakers presentation there will be a question and answer session. [Operator Instructions].
Thank you. I'll now turn the conference over to Patrick Feeley, Vice President of Investor Relations. Please go ahead.
Thank you, and good afternoon. Today after the market closed, we issued a press release announcing our first quarter 2021 financial results. This press release and the accompanying slide presentation are available in the Investor Relations section of the teladochealth.com website.
On this call to discuss the results are Jason Gorevic, our Chief Executive Officer; and Mala Murthy, our Chief Financial Officer. During this call, we will also provide our second quarter and full year 2021 outlook, and our prepared remarks will be followed by a question-and-answer session.
Please note that we will be discussing certain non-GAAP financial measures that we believe are important in evaluating Teladoc Health’s performance. Details on the relationship between these non-GAAP measures to the most comparable GAAP measures and reconciliations thereof can be found in the press release that is posted on our website.
Also, please note that certain statements made during this call will be forward-looking statements as defined by the Private Securities Litigation Reform Act of 1995. Such forward-looking statements are subject to risks, uncertainties and other factors that could cause the actual results for Teladoc Health to differ materially from those expressed or implied on this call. For additional information, please refer to our cautionary statement in our press release and our filings with the SEC, all of which are available on our website.
I would now like to turn the call over to Jason.
Thanks, Patrick, and thank you everyone for joining us this afternoon. After the market close we reported another quarter as outperformance across key financial and operational metric, driven by broad-based momentum throughout the business.
The strength across our portfolio draw revenue of $454 million in the first quarter, an increased of 151% over the prior year, including organic revenue growth of 69% for legacy Teladoc.
As a result of the momentum demonstrated across our channels and geographies and a continued development of the pipeline of new and expanded opportunities, we are raising our full year revenue guidance by $20 million to $1.97 billion to $2.02 billion for the year.
Turning to utilization. Our network of clinician provide $3.2 million visits during the first quarter, representing more than 50% growth over the prior year's quarter, despite historically weak flu season.
We continue to see significant strength in non-infectious disease and specialty visits with mental health volumes, in particular, driving growth in both B2B and DTC channels. We're also finding that specialty growth is acting as a gateway into multi service usage.
Our members who engage with specialty care are significantly more likely to utilize one of our other services. For example, members who had a specialty visit had 40% more general medical visits per member than those who use general medical alone. This is particularly encouraging given client trends toward multi product sales, with over 40% of our members now having access to more than one product.
Membership in the Livongo chronic care suite of products grew 66% over the prior year, as we added 62,000 new chronic care members in the quarter. And our share of wallet continues to expand as we gain deeper penetration within clients.
As a result, we've seen year-over-year revenue expansion within all of our top 10 chronic care accounts in the first quarter. Particularly encouraging is that over 15% of chronic care members are now enrolled in more than one program, compared to less than 5% a year ago.
With over 40% of adults in the U.S. living with more than one chronic condition, the opportunity is significant. And we continue to execute on our whole-person care strategy to address the full spectrum of consumer health needs rather than just one particular disease.
Enrollment in chronic care programs as a percentage of recruitables remained strong throughout 2020 and into the first quarter. Enrollment rates are consistent with Livongo's performance in recent years across the various perks of business, which is a significant achievement given that we have been addressing meaningfully larger populations. And in some cases, population types there are newer to us, such as government employee benefit programs, medicare advantage populations, and people with hypertension.
The strong enrollment performance is a direct result of our investments in data science, which has consistently led to greater consumer engagement across populations. As our differentiated and comprehensive product portfolio continues to resonate in the marketplace, we're seeing significant traction in both expanding our offering within existing clients, as well as adding new clients.
Earlier this month, we signed an extensive agreement to expand our relationship with a regional Blue Cross Blue Shield plan on the East Coast to offer our comprehensive whole-person virtual care solution to its members.
Beginning early next year, we will provide members access to our suite of products, including our virtual care solutions, and a full suite of digital chronic care solutions across diabetes, hypertension, diabetes prevention, and mental health. This deal is notable, as it covers all of the plans commercial books of business and represent another significant competitive takeaway.
Moreover, it demonstrates the power of our broad and integrated suite of products and our proven ability to deliver industry leading utilization and member engagement, which ultimately drives clinical and financial ROI for our clients.
In addition to a large pipeline of new and expansion opportunities, we continue to see opportunities for competitive takeaways, particularly in the health plan channel, as these clients look for enterprise platforms that can leverage technology and data at scale to deliver actionable insights.
We're also seeing strong interest in our Primary 360 offering from health plans, employers and even hospitals and health systems. And our vision to reimagine the primary care experience is gaining traction in the market.
Our primary 360 pilots that launched earlier this year are progressing well, and delivering encouraging results for clients and consumers. And we've already signed several additional deals expected to launch later this year.
Our comprehensive virtual care solution also continues to gain momentum in the international marketplace. During the quarter, we signed a strategic partnership with Generali Hong Kong, a leading insurance carrier in the region to offer our virtual care solutions to its members across Asia.
In Australia, we recently announced the partnership with MetLife to offer access to a customized platform across our comprehensive virtual care service to MetLife members in the region.
In the hospital and health system market, our industry leading enterprise platform solution continues to see strong demand around the world. In addition to new and expanded enterprise deals domestically, we reached multiple new agreements this quarter with health systems in Europe and Asia, as our strategy to take the InTouch capabilities to the international arena continues to pay dividends.
Similarly, the pipeline of opportunities to bring the Livongo suite of chronic care products to the provider market continues to grow, particularly among hospitals that are increasingly bearing risks through ACOs and their own health plans. And we've now signed several deals to bring our chronic care solutions to the health system market.
Turning to an update on integration. We've made considerable progress across our key work streams. As we previously noted, our commercial organization has been fully integrated, with sales teams selling across the entire whole-person portfolio of products since early this year.
We've now closed several deals for our new integrated mental health product that combines the Teladoc therapists and psychiatrists with the Livongo digital mental health capabilities to deliver a market leading solution.
Earlier this month, we also enabled the first wave of members to access and register for Livongo programs from within the Teladoc app. This is an important first step toward creating a seamless member experience that will allow us to engage with members more effectively across programs.
Additionally, we recently enabled capabilities for clinicians to refer members into Livongo chronic care programs from within the Teladoc provider workflow, leveraging our combined data to deliver clinically relevant insights that aid in decision making, and get consumers the right care at the right time.
We're making significant investments to integrate and enhance our technology platform to capitalize on our robust data and behavioral science capabilities across the entire organization.
Data is a significant part of what underpins our ability to provide a highly personalized experience, and deliver longitudinal virtual care, it's fully integrated with our digital solutions.
The investments were making in data capabilities will enable us to drive greater consumer engagement, expand the breadth and depth of our product offerings, and consistently increase the value we provide to consumers, providers and clients.
Our ability to deliver data driven insights, combined with clinical expertise at scale, will further our vision of becoming consumers trusted destination for whole-person health. Finally, while we're on the topic of innovation and data science, I'd like to welcome Claus Jensen as our new Chief Innovation Officer.
With more than 20 years of experience leading digital transformation at enterprise healthcare and technology organizations, Claus has deep experience across product innovation, information systems, health informatics, and data products. I'm extremely pleased to have Claus join our team and look forward to his leadership and contributions to our growth.
And with that, I'll turn the call over to Mala for a review of the first quarter as well as detailed guidance.
Thank you, Jason, and good afternoon, everyone. During the first quarter, total revenue increased 151% to $454 million, or 69%, excluding acquired revenue. Total U.S. revenue for the quarter was $416 million, representing growth of 175% over the prior year quarter.
Total international revenue of $38 million increased 29% over the prior year. Access the revenue for the first quarter increased 183% year over year to $388 million and comprise 86% of total revenue, up from 76% in the prior year's quarter.
The increase in access fee revenue as a percent of total revenue is primarily due to the acquisition of Livongo and InTouch Health. Both of regenerates the majority of their revenue from subscription access fees. Visit fee revenue for the first quarter increased 24% year-over-year to $54 million, and comprise 12% of total revenue, as compared to 24% of revenue in last year's quarter.
Turning to membership and access, we ended the quarter with U.S. paid membership of 51.5 million members, an increase of 20% over the prior year quarter. Note, that as we discussed on last quarter earnings call, the approximately 1.5 million temporary members that were on-boarded during the pandemic rolls off during the first quarter and are now excluded from our membership count.
Individuals that visit fee only access was $22 million at the end of the first quarter. Total chronic care enrollment, which includes unique individuals enrolled in one or more of our chronic care program was 658,000 members as of the first quarter, a 66% increase over the 396,000 members of the prior year's first quarter, pro forma for the merger with Livongo.
Average PMPM was $2.24 in the first quarter, up from $0.87 in the prior year's first quarter, and $1.76 in the fourth quarter. Of the $0.48 sequential increase in PMPM, roughly half was driven by the contribution of an extra month of Livongo revenue in the first quarter.
We've provided 3.2 million visits clinicians representing 56% growth over the prior year's first quarter. Platform enable sessions, which represents encounters facilitated by our licensed revenue and provided by our client own clinicians was an additional 1.1 million in the quarter. The annualized utilization rate for our member was 19.6% in the first quarter, a 620 basis point increase for the prior year's first quarter and a 190 basis point increase sequentially over the fourth quarter.
Adjusted gross profit which excludes depreciation and amortization of intangible increased to $308 million, an increase of 184% as compared to the prior year's first quarter. Adjusted gross margin was 67.8% compared to 60% in the first quarter of 2020. The 780 basis point increase in adjusted gross margin is primarily attributable to higher gross margin profile facilitated as Livongo revenue.
Gross Profit and adjusted gross profit in the first quarter of 2021 include the benefit of approximately $7 million in lower expenses on Livongo devices attributable to purchase accounting adjustments related to the merger.
Adjusted EBITDA increased to $56.6 million in the quarter compared to $10.7 million in Q1 of 2020. Adjusted EBITDA in the first quarter includes the benefit of approximately $7 million attributable to purchase accounting adjustments mentioned previously.
The adjusted EBITDA outperformance in the first quarter was driven in part by strong access fee revenue growth and better operating expense performance as we continue to make progress against cost synergies, including integrating back office functions, streamlining processes, and consolidating vendors.
As discussed previously, we anticipate reinvesting cost synergies back into the growth of the business over the remainder of the year. Overall, we've continued to have a high degree of confidence in our ability to achieve our multi-year revenue and cost energy targets.
Net loss in the quarter was $199.6 million, compared to a net loss of $29.6 million in the first quarter of 2020. The larger net loss was primarily attributable to increase stock-based compensation, amortization of acquired intangibles, and income tax adjustments primarily related to the merger at Livongo.
On a per share basis, net loss was $1.31 for the first quarter, compared to a loss of $0.40 in the first quarter of last year. Net loss per share includes a deferred income tax valuation adjustment of $0.57. Amortization of acquired intangibles of $0.30 and stock-based compensation expense of $0.57.
We ended the quarter with $723 million in cash and short term investments. While our total reported debt outstanding as of March 31, was $1.4 billion. Now turning to forward guidance. For the full year 2021, we now expect revenue to be in the range of $1.97 billion to $2.02 billion, up $20 million from prior guidance driven by strong growth in per member per month fees, as well as higher expected utilization, particularly among specialty visits.
We expect adjusted EBITDA in 2021 in the range of $255 million to $275 million, including an approximately $20 million benefit from lower expenses on Livongo devices attributable to purchase accounting adjustments related to the Livongo merger.
As we previously discussed, we expect increased spending over the course of the year as we invest in the growth of the business, particularly in new product launches, and expansions into new markets, the integration of Livongo and the development of our integrated data platform. We now expect total visits in 2021, to be between 12.5 and 13.5 million visits, representing growth of 18% to 27% over the prior year.
For the second quarter of 2021, we expect revenues of $495 million to $505 million, representing growth of 105% to 210% over the prior quarter. We expect total paid membership in the range of 52 million to 53 million and anticipate total visits during the second quarter of between 3.2 million and 3.4 million visits.
We expect second quarter adjusted EBITDA to be in the range of $61 million to $64 million, including an approximately 6 million benefits from lower expenses on Livongo devices attributable to purchase accounting adjustments related to the Livongo merger.
With that, I will turn the call back to Jason for closing remarks.
Thanks Marla. Before I turn the call over to Q&A, I want to take a moment to acknowledge the hard work of our team members around the world. This week, we were very pleased to be recognized in Time Magazine's first ever compilation of the 100 most influential companies.
Our inclusion along other global leaders is a meaningful recognition of our 4500 colleagues, and a direct result of all that we do for our members and clients every day. As always, thank you for your continued interest in Teladoc Health.
And with that, we'll open the call for questions. Operator?
[Operator Instructions] And your first question comes from Lisa Gill with JP Morgan.
Good afternoon. Jason. Thank you for taking my question. I just really want to start with your most recent thoughts on competition. As we think about some of the comments that you talked about displacing others, with some of your business wins the idea of Whole Care, talking about both employers as well as health plans looking for someone that has a deep embedded enterprise platform. We get a lot of questions around how do we think about Amazon care. The fact that MDlive has been sold to Cigna. Doctors On Demand and Grand Rounds coming together. So can you just maybe just level the playing field for who are you seeing when you're out there winning these pieces of business? And how you think about how that competitive landscape has really shifted and changed over the last couple of years?
Sure. Thanks, Lisa. We focus on our competitive advantages. And our competitive advantages, as you mentioned, are around the broadest set of clinical solutions, ranging from acute episodic to specialty care, chronic care and complex care, as well as being across all of the customer channels, ranging from employers to health plans, to hospitals and health systems, and on a direct-to-consumer basis. More and more, and I think this is really characterized by the makeup of our pipeline. Clients are looking for comprehensive multi product solutions. They're not looking for point solutions that they have to integrate themselves to stitch together and get the benefit of that.
And I think the data that we talked about today, about multi product usage and specialty usage, in particular being a gateway and driving higher general medical visits. Is the consumer proof point behind that. There's really nobody in the market who comes close to the comprehensive solution for both acute episodic and chronic care, as well as the range of both digital and professional services, in terms of our clinicians, that we can bring to bear. And we see that in our pipeline, based on the fact that it's characterized by larger deals than we've ever seen before.
Multi product deals are sort of the preponderance of the pipeline. And we see it in the competitive takeaways that we have booked, as we mentioned on the call large East Coast blues plan, as well as other very large opportunities in the pipeline. With respect to the moves in the market that you've seen, you'll recall last summer when we announced the Livongo acquisition. We talked about the fact that the market had accelerated, and that we foresaw the strategic chessboard moving. And ours was a move to put the leaders together in the market to create an unmatched solution, and bringing together InTouch Livongo and Teladoc certainly does that.
And there's there is no comparable move that that we didn't foresee. In some cases, we've seen a success and increased interest, as some of those smaller competitors have gone to health plans. And for the most part, one health plan doesn't want to buy from another competing health plan. And then in other cases, the moves in the market have been somewhat antagonistic toward the health plans, in an effort to disintermediate them. So it's been our view to work with the health care system, not against it. And that's proven to be beneficial for us, as we align with our partners and bring them greater value. So, all of those moves are sort of within the realm of what we expected. And I'm not going to call out individual solutions that you mentioned, or competitors that you mentioned. But for the most part, many of them we almost never bumped into, and some of the new entrants, we're just not seeing gain traction.
Just as a quick follow up, because you did say the word pipeline several times in that conversation. I love to ask about that, as we think about the forward year. Is there anything that you can give us around the size of the pipeline versus previous years? Or quantified in any way as we think about going into this next year for 2022?
Yes, sure. So, I would say a few things. One, as you recall, two months ago, when we reported the fourth quarter and full year results, we talked about the fact that our pipeline of new members was about 50%, larger than at the same time last year. It has only grown since then. And it has also moved along in terms of the deal stage. So you'll also recall that we said that it was characterized by a larger sort of gross opportunity, but there were earlier stage deals, and we've seen those deals move along the pipeline, as we would have expected. Obviously, one of those materialized into a very significant sale for us. And we have others in very late stage.
The other thing is that, we are seeing more large multi product deals than we've ever seen before. And I'm very, very encouraged by faster than I would have expected opportunities arising for the Livongo suite of products into the hospital and health system channel. That's moving along faster than I would have expected. And then, maybe last, we've talked about our Primary 360 offering. That pipeline has also increased materially since just the two months ago. And we see large deals moving along there. So, when we look, and you'll recall that it's very unusual for us to raise guidance at this time in the year. We did it last year, but that was in the face of the massive wave that we saw of COVID hitting the states.
But we've really I don't think before that we've ever increased our guidance at this time in the year. And so, I think that the increase in our revenue guidance for this year is both based on the performance we're seeing today, as well as the expectations that we have going forward.
And your next question comes from Sean Wieland by Piper Sandler.
Thank you very much. So, I'm most interested in this whole-person care at the blues plan you mentioned. I know, you said it includes your whole book of business. But I'd really like to know beyond that, what role are you taking on to really coordinate the care especially across medical and behavioral. And are the economics on a contract like this any different than standard economics?
So, what we said is, it's for their entire commercial book of this blues plan. And that we're selling our full suite of telehealth and chronic care solutions. We will also bring to bear as we mentioned, the integration within a single app have the ability to -- for the consumer to get access to the full set of services, as well as the ability for our clinicians to refer across those solutions. So, we have now executed on the first wave of that integration, that'll continue to develop over the course of this year, and will launch this service for them early next year. And that resonates, and that was part of the thesis behind bringing together all of these assets under one roof. And it's a significant competitive advantage when we're going out to. In this case, displace a competitor.
With respect to the economics, there are certainly some economies that we get from selling all of our solutions, or a full suite into a single client. It's one data feed for multiple products. And, Sean, as we mentioned, we get benefit from higher utilization when people use our specialty products. So, we are able to bring it to bear at a more competitive price, because of the economies that we get out of it. And ultimately, we drive higher revenue per user because they're using multiple services.
And your next question comes from Sean Dodge with RBC Capital.
Thanks. Good afternoon. Jason, on the Primary 360 program, you mentioned the pipeline, they're increasing. Can you give us a sense of how quickly you think offerings like that virtual primary care could ramp it? Maybe what kind of adoption you think you can achieve over the next few years? And then, you've said before, the revenue opportunity per member there is much larger. Can you put any bookings around that? Any quantification? Maybe in some of the pilots, how much how much did virtual primary care -- Primary 360 enhanced revenue per member?
Yes. So, the pipeline is very strong. We've already closed deals among several Fortune 1000 to launch in the second half of this year. And we expect to roll out nationally over in the first quarter next year. We've always said, we don't expect it to be a material contributor to our revenue this year. And we've taken that into account, even as we've increased our guidance for this year. We do expect it to be a meaningful contributor next year, and to increase over time. When we talk about the revenue opportunity per member, it's still a mixed bag when we talk about what's in the pipeline. And what clients are looking for. Some of them are happy with a higher PMPM and higher visit fees that reflect the increased value that each one of those visits and the increased intensity of each one of those visits.
Others are looking for more sort of value-based arrangements, including leading up to more risk arrangements where we have the opportunity to really benefit from the savings that we generate. And we're going to migrate into those over time. That's not going to be the preponderance of arrangements in the short term. But I do think that that's where we're going to go. And I think we have a unique opportunity and capability to do that, because of our scale, relative to anyone else in the market.
The other thing I'd also add, Sean is, it's one of the reasons why as we think about PMPM over the sort of medium to long term, it is an opportunity for us to expand our PMPM, because by its very nature, if you think about Primary 360, it is multi product. So we will be looking to capture economics, both from the expansion of PMPM because of that and the incremental population.
And your next question comes from Ryan Daniels with William Blair.
Yes. Thanks for taking my question. Jason, wanted to follow up on the strength in the behavioral business. It sounds like from our channel checks that that's one area in particular, that not only has benefited, unfortunately, due to COVID with an increase in need for care, but also more insurers and employers wanting that. And then more of a sustained movement towards telehealth versus in-person visits. It is truly conversational, and maybe has less stigma et cetera. So I'm curious to just dive a little bit more into what you're seeing in that market both on the DTC and then the more emerging B2B market for the organization? Thanks.
Yes, Ryan. You're exactly right. mental health continues to be the fastest growing specialty in our portfolio. And we are seeing the need for that service continuing to increase. The attraction of our product continuing to increase. I mentioned, we're bringing together Livongo digital assets with our therapists and psychiatrists capabilities into a single offering. And that's clearly resonating in the market. We talked last year Ryan about growing our B2B mental health visits by over 500% in 2020, and we're on track to more than double that this year as well, even after that incredibly explosive growth in 2020.
So that should give you an idea of how much traction we're getting. The other thing that I think is meaningful is that we mentioned that over 40% of our members now have access to multiple specialties. And certainly mental health is the sort of leading second product, if you will, to general medical. On the direct-to-consumer side, we also continue to see just surging demand for that product. We also see the utilization continuing to shift toward more live interactions. What used to be many years ago, a service that was focused primarily on text based interactions has migrated to more live interactions between the therapist and the consumer. And our ability to continue to scale that I think is a credit to the team, to the therapists who work with us and to the scalability of the platform. It also enables us to continue to bring significant value to consumers at an attractive price point, both for the consumer and one that is economically advantageous for us.
And your next question comes from Stephanie Davis with SVB Leerink.
Hey, guys, congratulations on the quarter once again. And thank you for taking my question. It's been about six months since Livongo you've closed. So I was hoping we can get an update on the platform integration side? Where are you in the back end? And one, can we see an integrated front end to really bring the platforms together from a user experience standpoint?
Yes. Well, thank you, Stephanie. I appreciate your comments. We're very excited about the progress of integration. We mentioned the rapid progress on the commercial side. And I think the team has just done incredible work to bring that together, breaking up territories, and reallocating, and bringing to market a comprehensive and unified suite is hard work. And the team has done just a tremendous job. We mentioned that we have now launched the first wave of consumers who can access the Livongo capabilities and products through the Teladoc app. That's really just the first step. I would expect early next year to have a completely redesigned user experience that integrates all of those capabilities. And really sort of optimizes the experience for the consumer and optimizes the -- sort of funnel if you will, into those different products.
The provider integration is material because we believe that providers referring into those programs will be a significant source of consumer engagement, which of course drives -- directly drives revenue in those products. And then on the back end, you asked about the data platform. And the data integration is really critical. We just have an incredible treasure trove of data. And the more we can integrate that 12 million plus, 12.5 million plus visits that we'll do this year, and all of the data from those visits. With the more than 2 million blood glucose readings a week we get, for example, as well as from all the other products, it just makes everything much more powerful, much more personalized for the consumer, and much more able to move the needle on consumer behavior change, which results in better outcomes and more ROI for our clients.
So we are deep in that process. And I'm really excited that Claus Jensen is joining us. We spend some time today just talking about the vision for what that can be. And I think we're going to really get the benefit of bringing the teams together and his leadership as well.
I'd also add Stephanie. The good thing is, we have a very, very clear roadmap. And we have spent a fair amount of time as a leadership team prioritizing that roadmap. So that, the investments we put against that, as we've talked about, I expect 2021 to be an investment year. It is stacked and aligned against those very clear priorities in the R&D roadmap, whether it be in terms of data integration, as you ask, recognizing a unique member from a eligibility and in identity perspective. That requires deep integration. And I would say, we are well on our way to this.
And your next question comes from Daniel Grosslight with Citi.
Hey, guys. Thanks for taking my question. Just a couple of questions around better health specifically. I think last quarter, you mentioned that you had started to sell that into the EAP. So I was curious how that will work alongside your traditional B2B behavioral health platform? And then on the DTC side, we've heard that capture main pretty elevated in behavioral specifically, particularly for paid search, curious how that's impacting your marketing strategy this year? And if there's any changes to the previously mentioned 50% revenue growth in better health?
Yes. Actually, we continue to see revenue per dollar spent on customer acquisition increase in our DTC channel. That continues to get more efficient as we use as we sort of optimize the channels, as well, I think we are benefiting from the fact that the market acceptance of getting therapy virtually has increased substantially. And so, awareness of that as a service. And acceptance of that as a service also provides a tailwind that I believe helps, in addition to all of the tests and learn that we've gotten over the course of the last several years. So, we're not seeing a challenge relative to customer acquisition costs in that channel.
The EAP services actually are always alongside behavioral health services that are built into the benefit package. It's really not an or it's and for most large employers. And there are different buyers on the health plan side. So most of the large insurers also offer an EAP and sell them together. And some of them we're selling our commercial behavioral health B2B services into the same health plan, that's also bundling our better health capabilities into their EAP. Does EAP generally has limited number of visits? And so the recipe there is that we are there for the consumer to provide them with those visits. And then, if they exhaust that benefit, they have the option of rolling in on a direct-to-consumer basis. So that becomes an opportunity for us to continue the relationship with the consumer.
And coming back to your question on CAC, and as Jason mentioned, the efficiencies that we continue to see and that, we monitor, as we've said, a lot of metrics across our business, including our DTC. And we continue to see gains in terms of better attention. And that drives greater lifetime value. So they're sort of the underlying levers that drive the revenue growth are still strong.
And your next question comes from George Hill with Deutsche Bank.
Good afternoon, Jason and Mala, and thanks for taking the question, Jason, you kind of talked about a clear product roadmap, but the space continues to evolve pretty rapidly as it relates to partnerships and M&A. I guess, can you talk about the opportunities that you guys don't touch? And maybe how you think about moving up the value chain into higher dollar cost areas as it relates to your clients? Thank you.
Yes. Thanks, George. We will continue to expand the scope of our clinical portfolio. And you saw us earlier this year make some announcements around chronic kidney disease. I think you'll continue to see us develop along the cardiometabolic continuum, which of course to your point has higher dollar impact and therefore a higher economic opportunity for us to make an impact. And again, our focus is on whole-person care. And so, there are things that you can do remotely. There area things that you can't do remotely. I think you will see -- my guess is, we'll continue to see more of a trend toward at home diagnostics. And that provides us with opportunities to expand the scope of what we do, and the value we can deliver for the consumer. And then, the opportunity for us to bring our Livongo solutions as they increase in scope into both the hospital and health system channel, as well as internationally will continue to provide us with opportunities. So, I don't see an end to our continuing expansion. And as always, we'll look at that in terms of build, buy and partner.
And your next question comes from Jailendra Singh with Credit Suisse.
Yes. Thank you. I've actually, Jason, you talked about the faster than expected opportunities in the Livongo business within the hospital and health system market. These hospitals health systems, you have been successful in contracting these. Have those been existing clients in Livongo where they were available to employees of their health system or these organic contract wins. Just maybe help us understand a bit more about your differentiation there? What is resonating with these health system clients?
Yes. Most of them are cross-sells, where we're bringing the Livongo capabilities into our existing hospital and health system clients on the Teladoc and InTouch side. The big move and the big shift, Jailendra is moving from the HR department, which is where Livongo used to sell into the C suite. Because the C suite of the hospital or health system is focused on their at risk population either within their ACO or within their owned or captive health plan. So whether that means that they're in a direct contracting relationship, or they set up a health plan or they have a JV or an ACO relationship with a health plan, more and more of the hospitals are going at risk for populations and their ability to discharge one of their patients with the Livongo capabilities is a massive step up in terms of their capabilities and ability to avoid readmissions, avoid exacerbations and avoid higher cost members.
And your next question comes from Richard Close with Canaccord Genuity.
Great. Thanks for the question. Jason, a lot of time spent on the fourth quarter call on membership. And in your answer to Lisa's pipeline question ended with the raise guidance. However, the membership guidance didn't change. So, on these takeaway deals that you're referencing, does that provide upside 2021 potentially? Or should we think of it more as 2020 to start from business?
Yes. So thanks, Richard. It's a good question. I would say the membership increases, and the sales that we're closing over the course of this year will have a much bigger impact on 2022 than on 2021. And actually, I have great confidence in what 2022 looks like based on the current status of our pipeline, and our line of sight into significant deals. Where we're likely to see upside in 2021, is in increased Livongo chronic care enrollment. We've factored in essentially no flu season in the back half of this year. So if we were to see a more normal flu season in the back half of this year, that would be upside to our revenue numbers. And of course, on our DTC channel, that's performing incredibly well. And if that were to accelerate, it would also provide upside in 2001.
And your next question comes from Charles Rhyee with Cowen.
Yes. Thanks for taking the question. Jason, when your competitors today talked about opening their platform, particularly for third party developers to add additional capabilities. I think that working with Google Cloud as well. Can you talk about sort of how you think about the broader ecosystem going forward? And maybe some of the opportunities that presents for you guys in that kind of area, as you think about -- you talked about by build kind of decision making on investments? Can you talk about sort of that with the Teladoc platform? And can you remind us -- I don't know if you talked about sort of who you're using as a cloud partner, but maybe you can just remind us that as well? Thanks.
Sure. On the cloud side, we're multi platform. So, we don't work with only one cloud provider. Rather, we work across cloud providers to sort of take advantage of the best of all of them. And we think it's best to be able to be a little bit more diversified. And then, with respect to the platform, and my vision of what we want to own and partner and open. I see it as concentric circles where there are things that we really want to own and deeply integrate, because that's going to deliver on the vision of whole-person care, it's going to best impact outcomes from a clinical perspective, as well as a financial perspective for the consumer and the client. And it is integral to the consumer experience.
Then there's a set of things and what I think of as the next circle, that are areas where we need deep partnership, because it's really important to the consumer experience, but they're not assets that we want to own, for all kinds of reasons, either it's not part of our core competencies, or it's not a beneficial economic model. But we do think that there's opportunity for deep partnership in order to optimize the consumer experience. And then there are many things outside of that, where I believe we will open the opportunity for other curated, right? So I'm not going to. I don't intend to open the platform for integration to all comers. I think it's our responsibility, quite frankly, to curate that set of in the third ring, but also areas where we can bring value to the consumer as well as value to those third parties by providing access to that large population that we serve. And I think the fact that we have really an unmatched population and meaningfully larger scale than anyone else in the market makes us the ideal partner.
And your next question comes from Allen Lutz with Bank of America.
Thanks for taking the question. Mala, you said that you expect increased spending over the course of the year. Where specifically is that increased coming from? Is that from the Primary 360 rollout? Is that from better health? And then also, is that an absolute increase? Or as a percent of revenue?
Yes. It's a great question. We talked about the R&D roadmap, and the fact that, especially now with cloud coming in, even more so, we will want to invest against the clear roadmap we have. So I would say, the investments will be against that, whether it be an integrated data platform, whether it be the unified product experience that we intend to deliver. Definitely Primary 360, it's a big that for us. It is something that, as Jason talked about, it's a multi year round, and it will require investment. So that is definitely something. We will continue to invest in behavioral health, whether it be on the B2B side or on the DTC side. So that will continue to be an investment for us. So, that would be those are the kinds of areas that we are looking at from an investment perspective.
Going to our second question on percentage of revenue versus absolute. We look at I think about it really in both ways. At the end of the day, what I'm looking at is, what are the priorities we have? How do we stack them? And most importantly, what are the returns? What are the ROIs against those investments? And can I see the very clear payback for the investments we make? Definitely I -- it will have to be -- I do look at percentage of revenue. At the end of the day, we have margins to manage, and grow importantly, but I also look at what is the dollar investment and what priorities it's eating.
And your next question comes from Kevin Caliendo with UBS.
Hey, thanks for the question. This is Adam Noble on for Kevin. I just wanted to circle back a little bit to your comments around the PMPM in the quarter. I think you mentioned that of the 48% sequential jump versus 4Q, half of that came from the extra month of Livongo. So kind of $0.24 beyond that. And I'm curious if you could break that $0.24 down between the growth and behavioral business, the sequential growth just in the chronic care business itself, as well as the upsells and other dynamics?
Yes, Adam. We don't provide very specific breakout on the different components of our business and therefore the different components of PMPM. But what I will say more generally is, I do -- we have with the numbers that we have given out in our prepared remarks. You can see the sort of the buckets of drivers that drove the expansion and PMPM. And as we have talked about the overarching trends in the business, whether it be multi product, whether it be multi service usage, and I would say even with the addition of Livongo. Now, those are all key drivers of the continued expansion in PMPM that I do foresee.
Yes. Maybe I'll give you just a couple of stats, some of them we talked about in our prepared remarks, and some of them may be incremental. But we talked about the fact that now 15% of our chronic care members are using more than one product. That's more than tripled since a year ago. And we're now at the point where about a third of our chronic care clients are buying more than one product from us for about 18% of your ago, right? So when we talk about multi product sales, it's across, really our entire portfolio, both on the chronic care as well as a acute. And then maybe lastly, an important data point is what is our and this really gets to my point about the pipeline, but what's our revenue per client look like? And our revenue per chronic care client is up 33% versus a year ago, right? So when you combine all of those, you can understand how we're not only getting more revenue per client, but we're also getting more revenue per member. And all of that contributes to increasing PMPM.
And by the way, it also shows that there is significant runway to continue to expand, right? So the fact is as grown as the Sunset from 5% to 15%. But there's enormous runway ahead of us. Same thing if you think about the clients, that'd be a contracting. So the point is we've made progress, and there is significant room to continue that expansion.
And that is all the time we have for questions. Ladies and gentlemen, this concludes today's conference call. Thank you for participating. You may now disconnect.