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Q2 Earnings Takeaways

A number of earnings calls continue to highlight a favorable payer market; concerns over cash pay

Here’s a rundown of the calls and key strategic takeaways that caught my attention from a busy week of earnings. An odd theme across this quarter seemed to be a “beat-and-drop” dynamic, where companies consistently reported results ahead of expectations yet still saw their stock drop meaningfully.

Teladoc: What happened to BetterHelp’s cash-pay business in mid-May?

  • Teladoc’s stock dropped 25% after revising BetterHelp expectations downwards, noting that in mid-May BetterHelp’s cash pay demand fell off a cliff, after being on track through April. Teladoc noted that 70% to 80% of users now prefer its insurance offering, but it was unable to ramp up therapists quickly enough to meet demand from cash-pay users who see the insurance offering. A number of analysts’ questions sought to understand the drivers behind this supply / demand mismatch. One particular question seemed to touch on the key underlying challenge, asking whether economics for therapists are meaningfully better with cash pay than with insurance. Teladoc didn’t provide a clear answer there, or more generally, for why it couldn’t scale up therapists quickly enough to meet demand, but did indicate it will be focused on resolving this moving forward, so much so that it is deprioritizing OUS growth in the short term. That seems notable, as OUS has felt like a stronger component of Teladoc’s narrative recently. From a glass-half-full perspective, the BetterHelp insurance business is still on track, and demand appears to be there if it can address the supply-side issue now.

Humana: passes a major test for 2026; 2027 pullback causes unease

  • Humana's results came in ahead of analyst expectations, as it appears to have moved past the existential profitability questions related to its influx of new members in 2026. That said, it is still early in its journey to get back to 3%+ margins by 2028, as reflected in it sharing that it intends to exit low-margin plans totaling roughly 600k members in 2027. Humana expects to move ~40% of those members to other plans, which should help improve profitability on those retained members, particularly as Humana noted a majority of the plan exits will be in 3.5 Star plans. Humana also noted that its VBC plans are outperforming non-VBC plans without giving much in the way of specifics. It will be interesting to keep an eye on whether that is indicative of the same HMO v PPO dynamics the industry has been grappling with for years now. It’s worth contemplating Humana’s 2027 shift with the dynamic Alignment highlighted below around 2 or 3 plans potentially attempting to grab share in 2027. For those who remain skeptical that 2026 performance thus far has been more luck than skill, 2027 seems poised to put that to the test again as it aims to design benefits that retain members while prioritizing a shift towards profitability.

Centene: outperforms on margin recovery in ACA, stock briefly drops 10%

  • A week after Molina shared that its ACA book has death spiral-y vibes because of Silver metal level dynamics, Centene increased its ACA margin target to 4.5% to 5%, above its previous target of 3%, which seems more indicative of the broader market performance in ACA. In general, Centene is seeing positive HBRs across the board, and noted that Medicaid rate increases of 5% and trends in the 4% range provide a sense of optimism that the market has bottomed. Centene’s stock briefly dropped 10% after earnings, before rebounding. We’ll chat more below about an interesting comment in the analyst Q&A regarding Centene’s focus on investing in data infrastructure for AI. Centene’s ICHRA business has grown to 50,000 members, representing 2.5x growth, and is now offering ICHRA to a subset of Centene employees.

Alignment: outperforms in Q2, raises guidance, stock drops

  • Alignment continues to demonstrate strong performance in its business, beating expectations and raising guidance across all metrics. Its stock slid 17%+ on the earnings, apparently driven by Alignment is choosing to invest more dollars in the business in Q3, which will have a modest negative impact on both its MBRs and its SG&A ratio, as it invests in clinical operations and new market branding to prepare for new market growth in 2027 and beyond. Interestingly, Alignment noted that it expects two or three carriers to “come out of the woodwork” and aggressively compete for membership in 2027. This will be an interesting dynamic to keep an eye on — in a sense, I could imagine a scenario where Humana’s success in managing new membership in 2026 causes some other carriers to think to themselves, “why not us?”

Cigna: raises earnings outlook as specialty pharmacy continues driving growth; GLP-1s decelerate

  • Cigna noted that its specialty pharmacy business, including Accredo and its offerings supporting hospitals and health systems, is driving 22% earnings growth in its Specialty and Care Services business, highlighting the strategic value of access to 330+ limited-distribution medicines in a market with strong growth in patients on specialty medications. Cigna reported a deceleration in GLP-1 prescriptions in Q2, which had a modest negative impact on results for the pharmacy benefits segment, which is tracking below expectations now despite the adoption of specialty generics. It noted that this shift had little impact on its employer insurance book, as only 15% to 20% of its small group employers cover GLP-1s for weight management. There was some interesting Q&A discussion about how Cigna itself has discontinued GLP-1s for weight loss for its employees because of cost issues, which is similar to the decisions its clients are making.

Waystar highlights strong customer momentum; stock drops

  • Waystar beat Q2 estimates, raised guidance for the year, and so naturally its stock fell ~15% on earnings. Leaving aside how befuddled I am by that, its earnings call seemed to highlight some really strong momentum, noting that its platform RCM offering is resonating as it is both winning new $1+ million ACV bookings and expanding within existing customers. The Iodine acquisition appears to be paying dividends as it highlighted $6 million of bookings coming from Waystar clients purchasing Iodine capabilities. Waystar also called out the changing payer mix for health systems, noting that self-pay populations are growing and health systems need to invest in capabilities to protect reimbursement, highlighting a case study with Promedica where it identified $10 million in billable opportunities for patients presenting as self-pay.

    • For all the folks I see on social media talking about how great cash pay models are versus insurance coverage, I present this as Exhibit 1A of why I think the general sentiment about cash pay being cheaper than insurance is a complete mirage. Those cash pay prices are a relic of an environment where health systems think cash pay = no ability to pay, and as a very small % of revenue, price it as such. I have a strong hunch what would happen to those cash prices if the commercial market ever moved meaningfully to cash pay: health systems would seek commercial rates, much to the dismay of large swaths of X users.

Company Spotlight

Ilant Health Overview

Ilant Health’s CEO Elina Onishantsky joined me on Tuesday for a conversation about Ilant’s approach to building a value-based obesity care model, coming on the heels of its $15 million in Series A funding announced in June. Ilant is primarily working with employers today, in a model that resembles a center of excellence for obesity care. It seems like a timely conversation to be having as we’re seeing evidence that employers are beginning to move away from GLP-1 coverage over cost concerns, i.e. see Cigna’s Q2 earnings discussion above.

I thought the slide above was particularly interesting, articulating the point Elina made about the need for tailored offerings for different populations, which seems like a natural evolution in this market as it becomes more sophisticated in treating obesity. We’ll be keeping an eye on Ilant and other players in this market as it evolves.

Chart of the Week

UHG data highlights commercial cost drivers

UHG shared data on UHC fully insured commercial claims in 2024 and 2025, breaking down some of the key cost drivers of the 9% cost increase in the commercial market in 2025. Prescription costs are the largest driver, increasing 14% YoY, driven by specialty brand drugs (+13% utilization) and HOPD-administered drugs, i.e., infusion treatments (+21% utilization). Interestingly, branded non-specialty drugs, which include popular GLP-1s, were only up 6% from a utilization perspective in this period.

It’s also fascinating to compare this chart with what we’re hearing from Q2 earnings season; notably, that UHC is reporting 11%+ trend in 2026, while hospitals are reporting soft inpatient surgical volumes. If you plug those two numbers and solve for the rest, it implies some rather large increases across pharma/outpatient given the ~$1,000 overall increase.

Quote of the Week

Centene’s take on AI infrastructure

We’ve been listening intently for AI updates on earnings calls in Q2 season for a general vibe check on AI in the market. I discussed above how Waystar shared some interesting updates on how it is winning in the RCM market, but I thought this quote from Centene’s CEO, Sarah London, on its earnings call was the most interesting update in the market.

London expresses what appears to be a growing sentiment about AI implementation among corporate leaders, going back to Alex Karp’s viral CNBC interview in June, discussing how the AI labs have gone astray and lost the trust of executives. This WSJ piece the other day picked up on the theme, highlighting how corporations are prioritizing being “tokenomical,” a phrase that I am judging myself for typing.

Kitschy phrases about tokenomics aside, London’s assessment strikes me as a refreshingly honest and interesting counterpoint to a broader healthcare market narrative that is still largely touting the conceptual benefits of AI without actually describing how it is driving organizational transformation. I’d agree with London that getting the infrastructure right seems like a necessary prerequisite for long-term success here, and that doing so creates flexibility for an organization to quickly plug-and-play various initiatives across the application layer, whether those applications are internally or externally developed. There’s an interesting debate to be had over whether it’s the right move to prioritize this longer-term use case in a short-term environment where it seems states are increasingly questioning whether managed care is a better path than FFS. Does this quote highlight a long-term oriented partner thinking deeply about success? Or does it underscore the ineffectiveness of MCOs today, hampered by legacy platforms and tech debt? I can see the merits on both sides.

We picked up on this theme with Health Enterprise Partners’ Ezra Mehlman this week after he penned a guest post arguing that the infrastructure layer is actually where durable returns lie for healthcare investors. I’d imagine that this is an increasingly common conversation in the market over the coming months as large corporate initiatives are stymied by the legacy systems they’ve acquired in silos over the years.

Conversely, it’s also an interesting time to keep an eye on upstarts like Oscar and Devoted, who presumably have a much cleaner data infrastructure, which should theoretically enable them to move faster than the rest of the market here. This would be the moment that these models should really shine, right?

Other Top Headlines

  • Clinical AI startup Doctronic acquired Summer Health, a virtual pediatrics model. Doctronic, which has been in the news lately for its AI prescription renewal pilot in Utah, shared that this is the first of multiple new product expansions, both organic and inorganic, to be announced over the next year or two. It plans to launch a behavioral health program in the next quarter.

  • Akido shared an update on its AI platform, noting that it is in use across 100 clinics and 1 million patients in California, New York City, and Rhode Island. Akido got an early start on what has become a popular strategy over the last several years, acquiring stakes in a handful of provider groups (Chapparal Medical Group in CA and Rhode Island Primary Care Physicians Corp in Rhode Island) to deploy its AI platform within the practices. I’m reminded of the Thrive Holdings Long Humans thesis recently; while Akido started down this path way back in 2022. Akido is also deploying its software across a variety of other clinical use cases, including in a street medicine model in California and for Uber / Lyft driver healthcare needs in NYC. I am curious to keep an eye on whether we see Akido acquire more practices, and if not, how it continues to scale the platform.

  • Included Health acquired Firefly Health, in the latest signal of momentum in the alternative plan design market for employers. Firefly, which started as a virtual primary care model before adding an alternative plan design wrapper, will bolster Included’s clinical capabilities. Seems like a logical combination for the two companies as employer interest in the market picks up. If you’re pitching employers on managing the total cost of care, having a strong clinical component as a front door to a navigation offering strikes me as a needed feature these days. As always, I’d imagine the key question for employers remains how to drive employee adoption of the various perks they’re provided.

  • Dispatch Health announced it will focus solely on growth as a white-labeled platform for hospital-at-home moving forward, seemingly jettisoning its core historical model in favor of the Medically Home business it acquired last year. Hospital-at-home has seemingly lost a ton of momentum due to uncertainty in the payment model in the post-COVID era, but perhaps there are some glimmers of hope in Current Health’s post-Best Buy strategy, which focuses on complex patient populations.

  • Hippocratic AI is expanding its deployment at WellSpan systemwide, noting it is moving past “one-off pilots and into platform-wide deployment.” As part of the expanded relationship, Hippocratic will be deploying a team of clinical, technical, and deployment resources to work alongside WellSpan teams to help roll out these new tools. It seems one can infer quite a bit from those past couple of sentences summarizing the press release, both about the current state of the deployment and the opportunity the two organizations see. It seems that the transition to platform deployments in this market is happening very quickly, and that winning models will have a heavy human component.

  • The FTC filed a lawsuit against Hims & Hers, alleging misleading marketing practices and privacy violations. Hims responded, suggesting the claims are baseless. Given that much of the D2C healthcare industry seems to lean on Hims as a source of best practices, it will be worth keeping an eye on the ripple effects of this lawsuit.

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Funding Announcements

  • Function Health secured $450 million in revenue-based financing from General Catalyst’s Consumer Growth Fund. General Catalyst’s Consumer Growth Fund is a debt vehicle used to fund sales and marketing expenses, and in exchange GC gets a cut of future revenue generated. I will admit, I do not understand this move in the least. GC notes that this Consumer Growth Fund vehicle is for late-stage companies with clear CAC:LTV ratios that can use revenue-based financing to avoid dilution from losses associated with CAC. Ok, that part makes sense. Where I lose the plot is applying it to Function, particularly when the $450 million financing is 4.5x Function’s trailing revenue, which was reportedly $100 million in 2025. Couple that with the fact that Function has been on an acquisition spree recently to round out its product offering, and that those acquisitions appear to be lagging from a demand perspective — we’ve discussed in Slack how Ezra, the network of facilities offering whole-body MRIs, is growing slower than announced while it is still 2x the cost that was originally promised. Then add that we’re hearing about affordability challenges from public healthcare companies, and that this is a market that has historically been difficult to translate early-adopter momentum into mass-market appeal. Ask BetterHelp how it feels about the D2C cash pay business at the moment. The most plausible explanation I can come up with is that Function has gotten itself stuck on the hyperscaling rollercoaster ride at this point. After raising and acquiring companies at an astronomical valuation, it now needs to demonstrate that it can grow quickly on the heels of that, while hoping the CAC:LTV ratio holds steady so the model doesn’t implode. This capital will either help with scaling, or if it doesn’t, the outcome will be bad regardless, so why not double down on growth, I guess? I’ll be watching the forthcoming advertising/marketing campaigns from Function with curiosity here.

  • Healia Health, a model that helps dual-income families reduce their healthcare spend via one of their employers, raised $14 million. It’s an interesting model that appears to partner with an employer to offer HRAs to cover healthcare expenses in exchange fro that employee switching off their plan and onto their spouse’s plan at another employer. Logically, it makes sense that both the employee and the employer working with Healia would benefit from this move, although I’m not as sure that the spouse’s employer would appreciate it as much in this scenario. Either way, it seems to highlight the level of interest in concepts that help employers get creative in managing their healthcare spending at the moment; one way to do that is to pay people to switch to their spouse’s plan.

What I’m Reading

  • The Primary Ventures team mused on the role of the provider of the future in an AI-centric world, highlighting how AI could help panel sizes get up to 12,000 per PCP, and the various billing, regulatory, liability, and cost tensions inherent in that conversation. The future PCP, as argued here, is one who is playing a population health management role across tens of thousands of patients, overseeing AI that is doing most of the work. It is interesting to see them note that the math of AI care delivery is bullish for an FFS health system (more visits!), seemingly implying the answer that many now seem to be reaching: AI is having an inflationary impact by helping organizations bill more. Interestingly, one of the other luminaries I hear talk about this idea of a 20k - 30k PCP panel size, Vinod Khosla, has made the argument that risk-bearing providers should be best suited to benefit from this shift, using AI interactions to keep costs down. It will be worth keeping an eye on this dynamic and how incumbent orgs adopt these tools in FFS and VBC environments. Certainly, from the lens of a taxpayer, I’d prefer the latter.

  • The Cut, a New York magazine, featured a piece on the rise of concierge primary care models, examining it through the lens of providers who prefer working in DPC settings and the access issues it is causing for patients, both in theory and anecdotally in practice. It’s fascinating to read the Primary Ventures piece and then this piece in juxtaposition, and think about how two countervailing forces on the primary care supply side will work out. On the one hand, technology should, in theory, enable larger panel sizes, as Primary Ventures articulates. On the other hand, concierge clinics seem to be popping up everywhere in affluent neighborhoods, promising smaller panel sizes as a perk for both patients and providers. If a PCP’s options are increasingly to either manage 20,000 patients as an AI air traffic controller or to manage 200 patients in a concierge clinic, while likely getting paid more, I can’t fault doctors for choosing the concierge route. At the same time, it is interesting to note the critique of concierge organizations that seem bashful about the $20,000 annual prices they charge.

  • Something curious seems to be in the water at Kaiser’s VBC health system platform, Risant, at the moment. This week, its founding CEO, Jaewon Ryu, stepped down, with an interim CEO named while a national search is conducted. This comes the same week that Risant pushed out two articles on how it is succeeding in VBC: one an NEJM Catalyst interview with Ryu, one a Modern Healthcare interview with Cone Health’s CEO. The Modern Healthcare interview seems telling in that at one point, when asked about Cone’s VBC initiatives, the answer was essentially: it may seem like we’re just investing in growing acute care facilities, but that’s just so we can deliver on our ultimate goal of spreading VBC. Ah yes, the tried-and-true “I’m going to build hospitals as a Trojan horse for VBC" thesis at the center of every VBC platform. Keep in mind that Risant intended to acquire 5 to 6 health systems over several years; it is still at two after acquiring Geisinger and Cone in 2024.

  • Redesign Health released a survey of health system executives at Epic-based health systems, exploring how they think about working with startups while navigating Epic. It certainly seems like health systems expect Epic to win here, with 80% of executives expecting Epic to become a higher priority moving forward. Worth perusing if you’re a startup, investor, or executive thinking about how to play nice with Epic in the years ahead.

  • Morgan Health and EBRI released a survey of 984 employers, roughly 1/3 with 100+ employees and 2/3s with <100 employees, on the state of the ICHRA market. It’s worth noting the level of interest from employers in adopting ICHRA, with the biggest ask being that ICHRA plans look more like employer plans today in terms of benefits levels and coverage. While ICHRA may not be materializing as quickly as some of the venture investment in the market may have hoped, it still seems there is ample reason to be bullish about this market over the longer term.

  • Vizient published a good report looking at utilization demand trends over the next decade, highlighting slowing inpatient growth relative to ambulatory assets, as it expects outpatient volumes to grow 20% while inpatient discharges grow 7%. In particular, cancer outpatient volumes are expected to grow 20% versus 2% inpatient.

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