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[Foreign Language] Good morning, ladies and gentlemen. Thank you for standing by, and welcome to Dialogue Health Technologies web conference to discuss results for the fourth quarter of 2021. [Operator Instructions]
Listeners are reminded that portions of today's call may contain forward-looking statements that reflect current views with respect to future events. Any such statements are subject to risks and uncertainties that could cause actual results to differ materially from those projected in the forward-looking statements. For more information on Dialogue's risks and uncertainties related to these forward-looking statements, please refer to the company's MD&A and annual information form dated March 22, 2022, both of which are posted on SEDAR. [Foreign Language]
Our operating and financial results will be presented this morning by Cherif Habib, Co-Founder and Chief Executive Officer; and Navaid Mansuri, Chief Financial Officer. Cherif, you may begin your presentation.
[Foreign Language]
Good morning, everyone, and thank you for joining us today. Navaid and I are doing this quarterly call together in the same room for the first time, speaking to from our beautiful office in Old Montreal. It's really great to be back. Our journey as a public company started a year ago almost to the day. and as I reflect back on that year, I'm incredibly proud of what our team has accomplished. Aside from the IPO itself, we had a number of operational milestones that have set the foundation and pace for the years ahead. In January 2021, we launched our Integrated Health Platform, or IHP, by combining our Primary Care and Mental Health solutions with our newly built digital EAP. This laid the groundwork for the momentum we are seeing in our business currently. In May, we acquired e-Hub Health, which gave us the building blocks and credibility to add an iCBT solution to our existing services.
In December, we received a great vote of confidence from Sun Life as they acquired a 9% block of shares from a third party, bringing their total ownership in Dialogue to approximately 23%. The very next day, we announced that Canada Life would add iCBT to Consult+, sending a signal to the market that Dialogue's partnership with Canada's top insurance companies were both strong and growing. We also capped off the year with 1.85 million members or 900,000 more than in 2020 and saw less than 2,000 members churn in our mid-market and enterprise segments during all of 2021.
Subsequent to the year-end, we made 2 major announcements. The first was that Sun Life would begin offering the Dialogue EAP on its Lumino Health platform bundled with iCBT to effectively enhance its mental health coverage. The second was that we secured our largest EAP contract with Scotiabank, providing our services to the 38,000 employees in Canada. Both of these announcements clearly demonstrate that our innovative EAP service resonates with Canada's top organizations.
Now from a financial standpoint, we added more than $26 million of ARR, or Annual Recurring and Reoccurring Revenue, in 2021, and we grew our revenue by 90% year-over-year to $68 million. We also continued to progress on our profitability objectives. Our gross margin rose by more than 200 basis points to 42.3%, despite the lower margin profile of our legacy Optima business and recent inflationary pressures.
As I recap our accomplishments for the year and look towards 2022, I remain as excited today, if not more, as I've been at any time since we founded Dialogue almost 6 years ago. And speaking of my excitement, I want to take a moment to welcome Jennifer Buckley to our leadership team as our Senior Vice President, Commercial. Jennifer joined us a few weeks ago after 12 years at Workday, where she most recently held the role of Vice President of Sales and Country Manager for Canada. We look forward to learning from Jennifer and from her robust experience in leading go-to-market teams.
I now want to turn my attention to our Q4 highlights. We grew our ARR by 45% compared to the same period last year and added $9.6 million in new signings, representing a single quarter high-water mark for Dialogue. Our revenue increased 41% year-over-year, a very healthy growth rate that was almost entirely organic in nature. And our KPIs are all trending in the right direction as our customers adopt more of our services and increase their wellness spend.
I would now like to provide an update on M&A. Acquisitions remain key to our short- and long-term objectives. With a strong balance sheet at the end of Q4, we are in an enviable position to execute our plan. We aim to acquire companies that can enhance our operations and capabilities either by adding new customers, adding new services or allowing us to enter new markets. Ideally, we seek to find businesses that can check more than one of these boxes simultaneously. But more importantly, and I cannot repeat this enough, we will not collect assets just for the sake of flexing our balance sheet. Rather, we remain committed to a well-defined integration strategy.
First, we want to acquire a service that can be merged seamlessly in our IHP. Our ability to build a new service directly in our application was a major reason why we saw rapid traction with iCBT. Second, we want to strengthen our platform by moving upstream in the continuum of care. Historically, our focus has been on diagnosis and treatment, whether for physical or mental health. In the future, we want to add prevention to the mix. Having mentioned in prior calls, our interest in such things as fitness, mindfulness, better sleep and nutrition and many other aspects of general wellness. Third, we want to prioritize B2B business models that drive high percentage of recurring revenue.
In our discussion last November, we confirmed that several LOIs have been submitted. Since then, we have moved things along into due diligence on one of those targets and are hopeful that we can reach an agreement in the coming months. Of course, we are not standing still in the meantime, we continue to add opportunities to the top of our funnel, adhering always to the same rigorous and disciplined process that has been successful for us in the past. I'll now talk about some of our successes in Q4. As this was a record quarter for new ARR, there are many great wins to talk about and each one of them has its own particular story. But first, I'd like to discuss some trends that we see in the market and throughout our discussions with current and prospective customers. First, our IHP continues to make solid inroads with employers with one application, one point of entry and services that speak to each other, the simplicity and effectiveness of our offering is clear. Our customers see this immediately and often expand their initial scope of interest, asking to learn more about our holistic solution.
Our discussions with prospective clients frequently and naturally extend to additional services. As a case in point, 56% of new contract wins in Q4 were for 2 or more services, a fourth consecutive quarter over 50%. Second, we continue to see many customers switch to Dialogue from one, sometimes even two of their vendors as we disrupt the status quo. We continue to fare extremely well in head-to-head situations and love replacing a competitor's solutions as it validates our mission, our IHP strategy and the high quality of our offering. Third, customers are responding very well to our value proposition. We do not chase logos in exchange of low pricing. Rather, we have a premium positioning in the market, and as such, we emphasize the clear return on investment we provide for our customers. Our belief is that employers will get what they pay for, and we have successfully shown this over time. Ultimately, with Dialogue, they get best-in-class engagement and utilization rates as well as strong focus on driving positive outcomes for members.
Now let me tell you about some of our wins during the quarter. Following a request for proposal, a logistics company with more than 2,000 employees moved their EAP to Dialogue and added our primary care service to enhance their overall benefits. We were also extremely proud to win a competitive process against 2 other primary care service providers as we were selected by a global consulting firm with more than 10,000 employees. In another direct customer win and one where we again took away share from one of our EAP competitors, a North American agri food company chose our primary care service and EAP for their 14,000 employees.
On the expansion front, a high-growth enterprise software developer, who was previously a primary care only customer, added our EAP and Mental Health solution. The customer was so convinced by our approach to driving engagement and utilization and they left the competitors' EAP, choosing instead to partner with Dialogue. In a similar story, a financial services provider had already implemented our primary care service in January 2021. By November, we expanded our relationship and onboarded for nearly 3,000 employees to their full IHP offering, displacing once again a competitor's EAP.
We don't often talk about revenue synergies from our -- from Optima customer migrations, and so we'll provide a couple of examples this quarter. A company with more than 1,000 employees operating in the pharmaceutical industry moves from Optima to the Dialogue EAP, also adding primary care at the same time. This win came through a competitive process as the customer wanted to see what was available in the market. They ultimately favored our integrated approach rather than deal with 2 other separate suppliers. We also migrated a large farmers union to our Dialogue EAP, adding Primary Care and Mental Health at the same time, convincing a traditional farmers union to be moved to a fully virtual model demonstrates well the evolution of behaviors and the tailwind that Dialogue continues to benefit from.
And finally, on the partnership front, we added several large customers to Lumino Health and Consult+ platforms, including 2 well-known national employers, totaling more than 26,000 members. In many cases, customers that signed up for primary care services with our insurance partners also added other services directly through Dialogue. A labor union, representing more than 6,000 professionals, who was so impressed with our platform that they added a Mental Health service as a complement to Consult+. An energy company that was already getting primary care from our insurance partner went to tender for both EAP and Mental Health. The process lasted for a month and at the end of which, we won the privilege to offer both services directly through our IHP, displacing once again an existing EAP relationship.
In our last example, a large provincial college of nurses chose one of our partners to provide primary care service to its members and added Mental Health support through Dialogue. I personally love the story as it's quite the complement to have earned the trust of one of our most courageous frontline workers.
Our tax rate continues to improve, rising to 1.5 at the end of Q4 compared to 1.11 in Q3 and 1.07 in the fourth quarter of last year. In contrast to the steadier increases we had seen in previous quarters, the steep inflection in the tax rate was primarily due to the Canada Life's addition of iCBT. Another metric we track closely is the percentage of members with multiple services. Of note, we are measuring here direct customers only. On that basis, we now have 21% of members subscribed to 2 or more services compared to 14% in the same period last year. The percentage of customers that have taken our 3 services has tripled year-over-year to 9%. And of course, this higher percentage is on a larger direct member base. This demonstrates clearly the evolution of our customers as they increase their spend with us, taking on more services on our IHP. Our truly integrated offering is an important competitive advantage for us and a major reason why customers choose us and a tremendous driver of customer stickiness. I can never say that enough.
We recently heard a provider of mental health and wellness solutions mentioned on one of their business update calls that customers are showing a preference for vendor consolidation. We couldn't agree more. We would even add that customers are showing a preference for a single applications that truly integrate all the services on one platform. This is what Dialogue offers with the IHP, simplifying the experience, both on the front end for users and on the back end for administrators.
I'd like to spend a bit more time on our iCBT journey to provide perspective on what it means to have a truly integrated platform. Looking at the timeline of events, we acquired e-Hub Health in May 2021 to officially enter the iCBT market. In August, we launched our new service using e-Hub's clinically validated data delivered seamlessly on our IHP. This means members did not need a separate application, profile or log in to access this new service. By October, we enhanced our offer by adding 3 new self-care toolkits to address several other issues that can impact mental health. In November, we launched a second delivery model called iCBT Plus, which added weekly synchronous sessions with a coach on top of existing self-led therapy.
To put all of this in perspective, in a period of 6 months, we went from acquisition to full launch. We won our first customers, onboarded our first members, recognized our first dollars of iCBT revenue and signed 2 significant partnership agreements.
I will now let Navaid discuss our financial results in more detail. [Foreign Language]
[Foreign Language] Thank you for joining us today. Our strong performance in Q4 helped end a great year in which Dialogue continued to build awareness in the market and gain share. We had a record quarter of ARR growth, adding nearly $10 million in new signings. We ended 2021 with $85 million in Annual Recurring and Reoccurring Revenues, representing growth of 45% year-over-year and 13% sequentially. Both our direct channel and our partner relationships contributed to the gains as we benefited from our multi-pronged go-to-market strategy. Employers of all sizes continue to embrace our solutions in Q4, and we had many wins in nontraditional segments during the period, including a couple of meaningful trade unions.
Dialogue has come a long way since its early days as a primary care provider. In fact, last year, 59% of our new ARR was generated by services other than Primary Care, proof that our business model is diversifying and our IHP strategy is resonating with the market. Our Mental Health offering, including iCBT as well as our EAP, are providing us with new sources of growth for the future. Having multiple services also means that we have a diverse set of tools to attract prospective customers and introduce them to our IHP. Lastly, our pipeline of new potential business remains extremely strong even with record conversions in Q4. The interest for Dialogue's products and IHP remains high, and we are working hard to build further brand awareness and to ensure we remain -- we maintain our great momentum.
We ended the quarter with nearly 1.85 million members, up 98% year-over-year. Compared to Q3, we saw an increase of 5% or more than 82,000 new members. Of note, however, many customers that signed agreements with us in Q4 chose to launch our platform at the start of 2022 to account for budgetary requirements. As such, these wins were recognized in our ARR, but not counted in our members at the end of the quarter. We are flagging this exceptionally because we onboarded 100,000 such members in the first week of January alone. While this is a significant accomplishment for our customer success team, the shift in timing does imply a lower apparent growth rate in members on a sequential basis. When factoring the timing of these additions, members grew approximately 182,000 or 10% compared to Q3.
Last quarter, we introduced a new metric, which we call Member-Service Units, or MSUs. As a reminder, it is simply the product of our attach rate and the member count. This metric allows us to see the combined impact of our member growth and our cross-selling activity and can be compared side-by-side with member growth to better illustrate the traction of our platform. In Q4, MSUs grew by 178% year-over-year to $2.8 million. Since the launch of our IHP early last year, we have seen our customers increase their spend by offering more of our services as a benefit to their employees. We had an average dollar-based monthly Net Retention Rate of 102% in Q4, maintaining once again a level above 100%. As to member churn, it was below 2,000 in our direct mid-market and enterprise customer segments and 0 in the last 2 quarters.
For the fourth quarter, our revenue grew 41% year-over-year to $18.9 million, driven by our land-and-expand strategy and the addition of new services. It's worth noting that given that Q4 last year included the acquisition of Optima, our year-over-year growth was almost entirely organic with only a small contribution from our iCBT acquisition. On a more granular basis, Primary Care and Mental Health continued to experience strong growth in Q4 as revenue increased 61% year-over-year to $12.7 million and 10% compared to Q3. The EAP segment generated revenue of $5.2 million in the period, up 5% year-over-year. We view this service through 2 distinct lenses. The first is our rapidly growing modern and digital EAP. That portion of our business grew nearly 50% on a sequential basis. The second is our legacy Optima business, which relies on a distributed network of practitioners and offers a more traditional experience for members. That portion of the business will decline over time as we migrate customers to our virtual EAP.
Taking in consideration our recently announced customer wins and with migrations from Optima continuing at a good pace, we expect to see accelerating revenue growth for the innovative part of our segment -- of this segment. As well, gross margin should improve as we benefit from the more efficient and predictable digital model. And lastly, our OHS business in Germany progressed nicely in Q4 as revenue increased 68% year-over-year to $1.1 million and 14% compared to Q3.
Our gross margin for Q4 increased to 43.5% from 34.8% in the same period last year and from 42.6% in Q3. This performance represented the fifth consecutive quarterly margin expansion as we achieved efficiencies in our business, particularly due to the continued scaling of our EAP and Mental Health services. The migration of Optima customers to the Dialogue Virtual EAP also contributed to the improvement. We expect larger accounts to migrate in the back half of 2022. As with past quarters, the gross margin in our Primary Care segment remains well above 50%. As our virtual EAP and our iCBT service developed into a bigger piece of the overall pie, we should see a favorable mix impact on our margins. Before concluding on gross margin, I'd like to highlight that our Optima business fared well in Q4 as we saw a sequential increase in the gross margin with each passing month in the quarter. We are pleased with the general direction of the business and the adjustments that our team has made to deal with the cost pressures.
Operating expenses increased 37% year-over-year in Q4 to $13.9 million, decreasing slightly as a percentage of revenue to 73.4%. While operating leverage was only 20 basis points this quarter, meaningfully lower than in prior periods, it's important to note that we incurred a number of onetime year-end related -- year-end costs related to being a public company. Without these, operating leverage would have been approximately 130 basis points. While we are not adjusting our financial statements for these expenses, we do not expect them to recur in the future.
Additionally, we should also mention that our record quarter of ARR wins led to significantly higher sales commissions in Q4 that were paid out in the same period last year. Although this helps explain the lower operating leverage in the period, it's definitely a good problem to have. Lastly, our continued investments in our OHS business in Germany also negatively impacted our operating leverage as revenues fell short of expectations due to the impacts of COVID. That said, we are seeing momentum in our OHS business coming out of Q4.
Looking forward to 2022, while we are not providing guidance, we wanted to provide some insights into the trends we are seeing. Salary inflation, especially in tech roles, should come as a surprise to no one. The great resignation is causing the talent pool to shallow, leading companies like Dialogue to compete for scarce resources. We have also taken some decisions internally to invest in growth avenues that we feel we are now ready to pursue having reached the appropriate scale to do so. To offset the cost pressure, we have been implementing price adjustments and rolling out new pricing strategies with our customers. These will take effect throughout 2022. Additionally, we are doubling down on our work internally to drive process improvements across the organization.
Moving on to adjusted EBITDA. We recorded a loss of $5.7 million in Q4 or 30% of revenue compared to a loss of $5.2 million in the same period last year or 38% of revenue. We continue to pursue a disciplined growth strategy and are very focused on scaling profitably with a path to our first month of positive EBITDA in 2023. Before closing, I want to add a quick note on our cash balance, which stood at $104 million at the end of Q4. As Cherif mentioned, we remain well positioned to take advantage of M&A opportunities and look forward to complementing our strong organic growth with the addition of new services. Thank you again. We'll now open the floor for questions. [Foreign Language]
[Operator Instructions] The first question comes from the line of David Newman at Desjardins.
Congratulations. Great inflection in the top line here. It's remarkable, the traction that you're getting. So congratulations, great job. Just a few questions. One is kind of on the final comments, Navaid, that you made related to OpEx. Clearly, you've got the topline growth, but you have to invest back in the business. You've got the great resignation, as you point out. I know tech pressure on inflation and things like that, you got large account wins. And I think you're setting up as well a virtual call center for your major customers you just won.
So maybe just more -- not guidance, but just kind of the path forward that you see on the operating leverage and where -- what we should be thinking about almost by quarter as you leverage that topline growth into EBITDA.
Thanks, David. Thanks for the question. As you know, it's an area that we're extremely focused on. I talked about some of the pressures we faced in Q4. Some of them are nonrecurring, some of them are related to the excellent sales results that we had. But yes, I mean we are a tech business and investing in technologies is and will remain a priority for us, and we are seeing some cost pressures on that side. As an organization, we remain focused on our path to profitability in 2023, as I've mentioned. So going forward, we should continue to see operating leverage improve sequentially from one quarter to the next. And as some of the actions we've taken, I talked about pricing, like we're incurring the cost now, but the pricing will come into effect over the future quarters. So we'll see -- continued and marked and increasing improvement in operating leverage over the next several quarters as those flow through our revenues.
Okay. So since I'm limited to 2 questions, I'll make it a multipart. So the price increases, first of all, maybe just the timing of when -- are you going to cover the nut on the inflation and OpEx. And the second question is more a top line, is the ARR closing in on $90 million? I think to exit the year on a run rate basis, great ARR. I think you're up 45%, I think you said. So if we look out to this year, what would be sort of the -- all things being equal, where should that ARR go to? I know you're not going to give guidance, but kind of organically from what you've got, what you see in the pipeline, where could this end up? Two questions, but sorry.
So I'll address the -- in the order that you asked them. So on pricing, we have started communicating. So as you know, we have customers who are on long-term contracts. So as those contracts come up for renewal, we're communicating the price increases. We're providing them notice. We are definitely covering inflation, and in some cases, more than that, based on individual circumstances. Like we've talked about our pricing strategy and how we adjust pricing based on utilization. So all those get factored into price increases. So it's not one-size-fits-all approach, and our team is working very diligently on that. In terms of ARR, you're right. I mean, it's -- we don't necessarily provide guidance, but you saw our great results for Q4 -- for Q4 and for the full year 2021. And in terms of sort of the absolute dollar value growth, we'd be looking to achieve similar levels of growth in this year as well.
Congratulations and continue [ the success ].
The next question is from Chelsea Stellick of IA.
It sounds like 2022 is really setting up to be a good year. It sounds great. I'll limit myself to one question and then I'll join back in the queue. But -- so with the new customer wins and sort of as your member base grows, are you seeing any expansion in the utilization rates?
First of all, Chelsea, good to see you. It really depends on the program. So utilization rates are -- some of it we see on a -- there's a seasonality effect. So Q4 traditionally has been a high realization quarter, obviously, kind of the flu season and going into the winter. So that's something that we've seen in the past. So Q4 had a slightly high utilization. And then as we have more programs that are, for example, have a very low marginal cost like iCBT, the utilization discussion kind of becomes a little bit less important as it was because it's not driving up our costs. So to answer your question directly, in Q4, we did see some high realization due to seasonality, but nothing significant, nothing material.
And correct me if I'm wrong, average utilization is around 15%. So where were we in Q4?
We don't break out those numbers, but we were not far from that.
Yes. Our utilization, aside from the seasonality, is relatively stable.
The next question is from Doug Taylor at Canaccord Genuity.
You mentioned that your pipeline remains strong even after several pretty substantial reference customer wins, I would call them. Can you give us or expand a bit more on the complexion of the pipeline at this point, the number of additional customer opportunities of the same size as some of the ones you've revealed? Or is it across the board in all ranges of size of potential customers?
I would say to that, Doug, that we are really focusing more and more upmarket and enterprise. I mean you've seen some of our new customer announcement either in Q4 or subsequent to the quarter. A lot of big names, a lot of big logos. So as we scale and as we get to that size, obviously, we need bigger and bigger deals to move the needle, and our strategy has really been to target these large customers. We have a premium positioning, and I think in the enterprise segment, the discussion of value versus price is one that lands extremely well because these companies understand what you get is what you pay for. So I would say that our pipeline in the last 12 months has continued to grow, and in terms of composition, we're seeing more and more larger deals in there.
We typically target a 3x pipeline to assigning ARR target, whether you look at it quarterly or annually, and we're well above that. So we're very happy with where our pipeline stands today. And obviously, as you know, we've hired a superstar go-to-market leader in Jennifer Buckley. She started 2 weeks ago. So she's going to be driving that pipeline hard, and we're really looking forward to seeing the results of that.
Okay. And one follow-up for me. I think this one probably more appropriate for Navaid, but a very strong ARR build, as noted by yourselves and by some of my contemporaries here. If I'm not mistaken, there's still a reasonable size portion of that ARR, which is going to take a couple of quarters to begin contributing as you deploy. Can you update us on the progress on some of the outstanding go-lives and so we can help model the contributions from that ARR to kind of Q1, Q2 here?
Yes. Thanks, Doug, for the question. So of the $85 million that we reported at the end of Q4, all except one of those customers has been onboarded by now. Most of them are onboarded in January, a couple were in February. I would say, the most significant one is Sun Life. We announced the acquisition of -- sorry, the addition of our EAP to Sun Life, which was included in our $85 million number, and that will only get onboarded in Q2 -- lately in Q2.
The next question Endri Leno at National Bank Financial.
Good quarter. So 2-part question, I'll start for me. But first, Navaid, you mentioned when you're talking about the tech inflation labor that you are doing also -- you're investing into growth avenues that you have chosen to pursue at this point that you are of a certain size. So the first part of the question is, can you talk a bit more about those growth revenues that you're pursuing?
Yes. I mean as we talked about, I mean, investing in technology or launch new services, I mean we are a tech-enabled business, so we'll continue to invest in tech. But one example that I would also give you is that we announced our win with Scotiabank a few weeks ago. And for a customer like that, we are actually building out a tech-enabled call center functionality as well. So that requires some incremental investments on our part. So that's just one example. So when we -- as we're sort of winning new customers, investing in areas that we haven't historically invested in, and that's just one example of it.
That's great. The other part, and it still relates to growth. I mean if I see you guys, you primarily -- obviously, it's a B2B focus, but you've also won some unions, you mentioned Cherif and also Navaid, this last quarter. Any color you can give on the B2G kind of type of a contract? Are you pursuing that at all? What is the landscape out there?
Yes, sure. Endri, we look at B2G very opportunistically, right? So as you know, the B2G world is driven by RFPs. So every time an RFP comes out, we look at it and we make a determination whether it makes sense for us to compete for it or not. What we've seen recently is a lot of these RFPs are shorter term, which is something that we -- that is not interesting for us. We've also seen RFPs that had unit economics that were not consistent with our targets, and we just didn't feel like for the long-term health of the business, it made sense.
That being said, obviously, B2G is a big TAM, and it's a big opportunity, if the specifics of the RFP are right. So again, we look at them opportunistically. We hope to partner with the government. We hope to make our solution available to as many people as possible, but it also needs to make sense for us as a business to do so. So we look at them each individually and make a determination.
No, that's great color. And the second and last question for me is that you mentioned, Cherif, in the prepared remarks, on the M&A potential that you are looking at different geographies as well to potentially expand. If you can talk a bit about that, would that just sort of be a corollary to buying a new service? Or would that be a strategy to potentially get in a new market and then try to expand the services that you're offering?
I didn't hear the first part of your question. So you said, geography for M&A, and I didn't understand the...
If you are to go to a new geography with M&A, would that simply be a corollary to kind of growing the new services to doing the acquisition? Or would you still look to grow into that new market with the services you already have?
Yes. So the first priority is to add to the surface and the competitiveness of our IHP. That will always be the first priority. And if you look at our track record in M&A, every acquisition that we've made so far enhance our IHP. If with it, it comes with an interesting new market outside of Canada, that is fantastic, but the priority is always product-led and product focused. And as we've said many times, and I hope I am not being annoying to be repetitive here, again, we're not collecting a collection of assets. This is a true deep integration play, and we will never acquire something and not integrate it and let it run on its own. It has to be part of the IHP like we've done with iCBT and others.
And that's why perhaps, on an M&A side, we haven't announced as many good news as we would have liked because as we look at opportunities, we really look from a technology and service provision point of view, what is the integration potential. And it's more difficult when you're pursuing our strategy, but we truly, truly believe that is the right strategy for the long term, and it's going to help us grow better in -- the business for our clients.
Good quarter. Good year, guys. Congrats.
The next question comes from David Kwan at TD Securities.
Can you guys talk about some -- how you guys are staffing up on your EAP business just to meet existing as well as the new customer wins. How difficult is it to find and retain our talent as one of your key competitors talked about challenges and staffing appropriately in their EAP business, and how that's hurt their margins as they kind of align higher cost of contractors. I'm curious how you're seeing that from your perspective?
Yes, David. So we've obviously heard some of these comments on these calls, and we believe that what's happening is that some of our competitors are realizing the limits of a kind of contractor network, and they're trying to bring some of this in-house, which has been our strategy all along, right? So as you remember, since we started our digital EAP, we've never relied on an external network of providers. These have always been full time or highly engaged part-time employees of Dialogue, and because of that, we have a very good handle on the cost that it entails. And we're also able to serve a much bigger patient population with a lower number of providers. One, because of the staffing model, and two, because of our technology leverage.
And that means that -- and again, because they're virtual, it doesn't matter where they're sitting. So when we sign a huge bank like Scotia and they have hundreds of locations, offices, retail branches, it doesn't matter where our staff is located. So that kind of arbitrage has been extremely helpful. And as such, you've seen the sequential improvement in gross margin. We haven't seen the same pressures that our competitors have because we're built differently.
And just to add to that, David, I mean, on top of everything, as an example, it also allows us to offer much better service levels than our competitors. So for us, being able to see a mental health practitioner in 24 hours versus having to wait a minimum of a week, in some cases, 2 or 3 weeks, is something that we can offer with our competitors can't.
Sure. Maybe just sticking on the EAP business. You've obviously had some pretty good wins recently, including direct sales with Scotia and in the core back from last fall, in particular. Is adding any other services like Primary Care and Mental Health in the future just an issue with time? Like are they waiting, I guess, for their current contract to expire with their existing vendor? And then secondly, are any EAP customers that you're either talking with right now or existing customers. I guess, with your Scotiabank announcement, you're building up a call center service as well, are you finding additional interest that you can kind of leverage that building over the call center with other customers to help drive higher PMPM?
Yes. So the call center functionality we've built is something that we've -- this was a pull from the market. And again, we're trying to build a service that is -- that answers the needs of the clients and gives the best possible user experience. We strongly believe that in-person does not do that. So going to see somebody in a kind of a retail location, we believe this is a suboptimal experience. The pandemic has clearly shown that because even for our traditional EAP competitors, 100% of their volume during the pandemic, especially in some of the more serious waves were on virtual.
So I think the pandemic has shown everybody that virtual works, and the call center is another version of virtual, right? So whether you're speaking to somebody through an app or on the phone, what is important for us is that you don't have to actually get in the metro, get in the train to sit in the waiting room, which is just suboptimal for everybody. So that's why we believe in that. And for us, the call center is a premium add-on that a large customer can decide to add. It is an extra cost for us, and we pass that cost on for customers. Some decide that virtual only is more than sufficient and some like Scotia have decided to pay a little bit more to get the phone line, and that's also great.
And I guess on the other question just on like the wins with Scotia and dentalcorp and trying to cross-sell the Primary Care and Mental Health, in particular, you guys said. Is that an issue with timing and they are waiting for the contracts with their existing vendors to expire?
Obviously, I can't speak on behalf of the customers, but that is the reason we've built in IHP, and that is the whole point that we're trying to build and trying to educate the market. And as I mentioned in my remarks, we have a lot of older customers that were with us with years are adding new services, sometimes a new service every year. So with Scotia and others, of course, the hope for us is to get in with one service, deliver extremely well like we always do, get the high NPS, get the amazing customer satisfaction. Our customer success playbook is very robust and something that our customers really appreciate. And once we've demonstrated all of that, we've demonstrated the high utilization, we've demonstrated the health outcomes and ROI, then we're in a very, very good position. When this client decides to look at the market at what else is available for one of their other services, the relationship that we've built leads us to believe that they'll favor us and to consolidate more of their services in one place, which again is something that we've seen over the last 12 months.
The next question is from Scott Fletcher at CIBC.
I have a sort of a follow-up on David's question. Can you give us an overview or a reminder, I guess, on the staffing model for the Primary Care and Mental Health piece, just in terms of in-house versus contracted?
Yes. Our overwhelming preference is to have in-house colleagues that provide the health care services, right? So in any of our services, in any of the 12 kinds of professionals we employ, our overwhelming preference is to have full-time employed team members. Sometimes, we're not able to achieve that because, for example, physicians in Canada, as you know, are never employed by the institution for which they work. Even if you work for a large university teaching hospital, you're still an independent contractor and that's the model that we use for physicians. The difference, I would say, from other players on the market is that we are not an Uber-like model, which means that we're not matching a patient with a random physician every time they connect, we try as much as possible to favor continuity of care and to develop relationships between patients and providers.
And the only way to do that is to have highly engaged physicians that give us very predictable schedules. So we know that Dr. Mary is available every Tuesday and Thursday, from 2 to 6 p.m. So if you, Scott, come to the platform and you want to speak to Dr. Mary, we can book an appointment with her when she's working next as opposed to an Uber-like model, which is kind of playing roulette. So our overwhelming preference is to have our own employed full-time members. And when we can't, we do the next best thing, which is to have highly engaged part-time folks.
Okay. And a second question for me is I want to ask on the question on product development and the road map. So you gave a great rundown on M&A and what you're looking to maybe add there, but wondering if you could give us a sense on what the main priority is right now for -- on the internal side? And if there's anything that clients are pushing for that you don't currently offer that you plan on adding yourselves sort of...
Well, without getting into kind of the competitive part of the roadmap, what I would say is that the priority that we talked about quite a bit in the last few months is getting -- going upstream in the Continuum of Care. So again, instead of -- like now, somebody calls us because they're sick, right? So whether it's a physical illness or a mental illness, they calls because they're not feeling well. What we're trying to do is move upstream so that people use Dialogue to educate themselves and to live healthier lives so that they don't get to the sick part because obviously, there's only -- and thankfully, there's only a very small part of the user base that needs a diagnosis and prescription part, but a huge part of our user base that is trying to become healthy or healthier and this is where we want to focus on going forward.
The next question is from Adam Buckham at Scotiabank.
Congrats on the quarter. So my first question is on the margin profile. So obviously, pretty steady growth here over the last 2 quarters. Thinking about 2022, my understanding was a lot of the growth on a forward basis coming from the transition of EAP providers and to the new platform, right? And some of that was more chunkier, inclined towards the back half of the year. Is that sort of the expectation in terms of where the margin profile will end up on to 2022 year-end? Or how should we be thinking about that?
Yes. Thanks for the question. So yes, I mean, we have 2 different margin profiles. So we have our virtual businesses, as I talked about Primary Care as well is in excess of 50%. Our EAP and Mental Health on the virtual side are also scaling up to be around those levels as well. Obviously, our overall consolidated margin is diluted by our legacy Optima business. And as we migrate those customers, the margin gap will shrink. So yes, we have -- we've migrated a lot of the small customers in 2021. We'll be focusing on some -- on the larger customers over the next several quarters. And as those larger customers migrate, the impact on margin will be even stronger.
Okay. Great. And then maybe just a follow-up on that. So thinking about the sequential improvement, is it going to be sort of steady growth? Or is it back half weighted? How should we be thinking about it?
I would say, relatively steady growth, but a little bit weighted towards the back half of the year.
Okay. Great. So my second question, we've talked a lot about the Great Resignation and the competition for talent, right? And thinking about physicians and nurse practitioners. I'm just wondering what you guys are seeing in that market because we -- obviously, we're hearing every day about how there's all these stresses that are occurring in the medical channel and how people want to move on and they're just too stressed. Like is that not a benefit for your platform and that people get contracted hours. They don't have to worry about dealing with patients in-person. I'm just looking for color on what you guys are seeing in terms of competition for physicians and their practitioners.
Yes, good question. I mean I think when we talk about Great Resignation, we are more referring to the corporate side of the business or the non-healthcare side of the business. I mean this is where we've seen the most pressure the last couple of quarters both on the depth of the talent pool as well as compensation expectations. So this is really what we were referring to.
Now specifically to your question, it's never easy to build a provider network at the size and scale that Dialogue is -- has become. That being said, and I think I've mentioned this in previous calls, like we thought this would be the hardest part of building Dialogue when we started. And in reality -- again, it's not easy, but it's not the hardest part of building Dialogue. We have a very clear value proposition for these folks, and they can compare the culture and the benefits of working here versus the other alternatives and overwhelmingly, they're choosing Dialogue. So we've been very, very proud of that.
That being said, like we're very careful not to compete with the public health care system. We want to be a complement and being part of the solution and not to hollow out an already taxed and stressed public health care system. So we're very careful there to be an outline and a partner to the system versus a competitor.
And I'll add one more thing on that is, we've had a hypothesis that we're adding more capacity in the system by giving more flexibility to our health care providers and that hypothesis has been proven out over and over again because a physician, for example, that was only willing to work 3 hours a week 9 to 5 in the clinic is now saying, you know what, I don't mind after putting my kids to bed at 8 p.m., doing a couple of hours or logging on the Sunday to do a couple of hours. And this is capacity that was not there before. So we're really proud to be part of the solution.
Congrats on the quarter, guys.
The next question is from Doug Miehm at RBC Capital Markets.
My first question has to do with Germany. It's been a bit of a challenge over there, I gather. One of the reasons why numbers have come down a little bit. But my guess is, given that the world is opening up now that you do have a plan to get that going again, and we should see an acceleration in growth coming from Germany. Perhaps, you could expand on that a little.
Doug, I agree with your statement. It has been a difficult first 3 quarters in 2021 in Germany. Q4 was a good quarter, and we expect this momentum to continue. But yes, it has not been easy for us. COVID, as much as it didn't hurt our Canadian business was a strong headwind in Germany because obviously, when plants are closed, they're less interested in [indiscernible] health services and safety services. So -- but in Q4, I feel we've recovered nicely, and we expect that to continue into 2022.
Okay. Fantastic. Second question, probably a little bit more from Navaid. If you look at that 178% growth in Member-Service Units, can you compare and contrast that because it's a great number to revenue growth, though, that's coming in at, let's say, 40% to 45%. And why there is that differential over time?
Yes. Thanks, Doug. Good question. So 2 ways I would answer that question. One is the MSU number, the 178% is an end-of-period number. Whereas, the revenue growth is over a period of time. So that's one, but probably not the biggest, driver, right? I would say, the -- one of the bigger drivers of that gap is the MSU sort of measures, our effectiveness on being able to pass multiple services to our members, and not all services are pretty equal. So when you look at a PMPM of Primary Care or Mental Health solution or our stress management or EAP solution, it's very different than iCBT solution. So those are the 2 factors that were the numbers won't align, but we provide MSUs as an indicator of how many services our members are taking, but not all services are created equal.
Okay. Maybe I can sneak one more in. Cherif, just with respect to M&A, not specific to your company, but in the broader market that we've seen in the last several months, how would you characterize that relative to your own business model?
Yes. In previous calls, we've talked about a very, very big delta between private market multiples and public market multiples. And we've talked about the fact that our -- obviously, our own multiples and the multiples in the industry have contracted significantly over the past, call it, a year. Whereas, the private markets have not been stronger. That was true, I would say, until the end of Q4. Going into this year, what we're hearing from our investors and especially our early-stage investors that are more in the private markets is that there is a catching up that is happening and the valuations in the private markets are starting to follow public markets. Again, there's a huge, huge delta. We're not even close. But the trend is -- leads us to believe that it's just a delay and that eventually, the 2 curves will intersect.
That's good news for us because today -- and I've talked about this dynamic in the past when we're looking to acquire a private company, and they look at their alternative while there are tunes to raise at a very different valuation. So it makes it a little bit less competitive, but we're seeing those pressures kind of go away. And then some of the companies we're talking to that perhaps had stars in their eyes and their sights on very aggressive valuations for the next round are realizing that these rounds are getting a little bit more difficult to do and then perhaps, lower valuations and they're coming back to the table and having a discussion. So that's the dynamic that we're seeing, and I think the next few quarters will be beneficial to us from a valuation perspective.
Thanks, Doug. These are all the questions we have for today. Before passing it back to Cherif, I just want to let investors know for anyone that would like to meet with our team, we'll be hosting meetings at several conferences in the coming months, 3 of which will be in-person finally. The exact list of events is included in our press release issued this morning. You can also reach us at any time by e-mailing investors@dialogue.co. And it will be our pleasure to answer any questions you might have.
Cherif, the floor is yours again, to conclude today's call.
Awesome. Thanks, everyone, for your participation today. We really appreciate the engagement and the questions, even when they're tough, and we look forward to speaking to you again during our Q1 results on May 10. Have a great day, everyone. See you soon. Bye.
Bye-bye.