Elevance Health Inc. (NYSE:ELV) Q3 2023 Earnings Call Transcript

Elevance Health Inc. (NYSE:ELV) Q3 2023 Earnings Call Transcript October 18, 2023

Elevance Health Inc. beats earnings expectations. Reported EPS is $8.99, expectations were $8.45.

Operator: Ladies and gentlemen, thank you for standing by, and welcome to the Elevance Health Third Quarter Earnings Conference Call. At this time, all participants are in a listen-only mode. Later, we will conduct a question-and-answer session where participants are encouraged to present a single question. [Operator Instructions] These instructions will be repeated prior to the question-and-answer portion of this call. As a reminder, today’s conference is being recorded. I would now like to turn the conference over to the company’s management. Please go ahead.

Steve Tanal: Good morning, and welcome to Elevance Health’s third quarter 2023 earnings call. This is Steve Tanal, Vice President of Investor Relations. And with us this morning on the earnings call are Gail Boudreaux, President and CEO; John Gallina, our CFO; and Peter Haytaian, President of Carelon; Morgan Kendrick, President of our Commercial and Specialty Health Benefits business; and Felicia Norwood, President of our Government Health Benefits business. Gail will begin the call with a brief discussion of the quarter and recent progress against our strategic initiatives. John will then discuss our financial results and outlook in greater detail. After our prepared remarks, the team will be available for Q&A. During the call, we will reference certain non-GAAP measures.

Reconciliations of these non-GAAP measures to the most directly comparable GAAP measures are available on our website, elevancehealth.com. We will also be making some forward-looking statements on this call. Listeners are cautioned that these statements are subject to certain risks and uncertainties, many of which are difficult to predict and generally beyond the control of Elevance Health. These risks and uncertainties can cause actual results to differ materially from our current expectations. We advise listeners to carefully review the risk factors discussed in today’s press release and in our quarterly filings with the SEC. I will now turn the call over to Gail.

Gail Boudreaux: Thanks, Steve, and good morning, everyone. Today, we’re pleased to share that Elevance Health delivered another solid quarter of financial and operational performance, reflecting the strength and resilience of our diversified portfolio of businesses. Third quarter GAAP earnings per share was $5.45, including a charge we took during the quarter that I will discuss in detail in a moment. Adjusted earnings per share was $8.99 and reflecting growth of approximately 20% over the third quarter of 2022. Our results demonstrate our ability to execute on our enterprise strategy of delivering whole health solutions that are affordable, personalized and simple. Based on our strong year-to-date results and confidence in our outlook, we are increasing our guidance for adjusted earnings per share to be greater than $33 for 2023, which includes incremental investments planned for the fourth quarter that will accelerate our strategy and enhance the performance of our Medicare Advantage business.

It is the strength and resilience of our diverse businesses that provides comfort in our outlook, while the earnings power of our Health Benefits and Carelon division provides us the confidence to reiterate our commitment to our long-term target compound annual growth rate in adjusted earnings per share of 12% to 15%. Let me now turn to some highlights from our business segments. Starting with our Health Benefits division, which delivered robust third quarter results as we continue optimizing our diverse set of businesses, while responding to a dynamic and evolving business environment. In our Commercial Risk business, we are successfully executing on our goal to deliver operating margins in line with pre-pandemic norms. Retention has been consistent with our expectations, and we’re pleased with our progress, which we expect will extend well into 2024.

In the employer market, we’re delivering differentiated value where it matters for employers, affordability, experience and simplicity. Over the past three years, we’ve become the sole source medical benefits provider for 32 of our national clients, including nine additional customers who will be consolidating their coverage with us effective January 2024. For large employers, we continue to deliver differentiated value and are seeing employers move away from point solutions and slice offerings to selecting Elevance Health as their strategic partner for the integration of all of their medical benefits. Consistent with these results, our advocacy solutions business, which provides personalized guidance and support to help members both navigate the complex healthcare system and optimize their health and well-being will add 37 new clients in 2024 covering more than 550,000 members.

This includes two large employers who are returning to Elevance Health after previously testing third party advocacy vendors. In the individual market, we are seeing strong growth in plans that offer affordable and comprehensive coverage designed around the needs of consumers in our communities, including those transitioning from Medicaid to individual ACA coverage. Year-to-date, our individual membership has grown by 27%. Through the first half of this year, the latest period for which industry data is available, our individual ACA membership growth rate more than tripled that of our competitors in our 14 Blue states. Our government business also posted a strong quarter. In our Medicaid business, rates are actuarially appropriate, but we are absorbing a membership headwind related to the pace of Medicaid redeterminations, especially in states that have adopted accelerated time lines.

Nearly three-quarters of all Medicaid beneficiaries terminated in our markets to-date have less coverage for administrative reasons and 37% of the attrition from our own health plans has been driven by individuals under 18 years of age, many of whom may still be eligible for Medicaid benefits. We are doing all we can to ensure continuity of coverage for as many consumers as possible, working closely with our state partners to ensure individuals eligible for Medicaid retain coverage while also offering affordable ACA exchange plans in nearly all of our Blue counties. We are seeing encouraging signs in some of our Blue states where we offer Medicaid and commercial coverage. We have seen 30% or more of our Medicaid members who were terminated prior to the end of June, return or retain coverage with Elevance Health, albeit with gaps in coverage that can extend for several months.

We expect re-enrollment to accelerate in the coming quarters as we continue with our omni-channel approach to outreach and engagement, ensuring our members are aware of their options. Accordingly, we anticipate the rate of membership attrition associated with redeterminations will slow considerably in the coming quarters. In Medicare, we continue to offer high-quality plans that provide seniors access to comprehensive and coordinated care, and we are committed to doing so for the long-term. We’re disappointed, however, with our Stars performance for measurement year 2022, which is the basis for Star ratings that will impact the 2025 payment year and specifically, with our decline in consumer survey scores and the way in which CMS applied a new statistical methodology that resulted in significant increases to many star measure touchpoints.

To improve our performance in future periods, we have already commenced investments in four primary areas: service, product, network access and operations. For example, in July of this year, we built on the success of our innovative advocacy model in the employer market by adapting it for the unique needs of Medicare eligible consumers. This new program, My Health Advocate is a comprehensive, personalized and relationship-based customer service model that enables our members to effectively navigate the health care system, their benefits, and ultimately, to improve their overall health and well-being. Furthermore, we have enhanced our core and supplemental benefits to reduce member’s out-of-pocket costs for prescription medications, simplified our dental benefits and strengthened our grocery and over-the-counter benefits.

We’re also simplifying consumer and provider experiences through the automation and elimination of certain prior authorizations, accelerating our work with value-based care provider partners and improving clinical decision appeal rates. Collectively, these actions and the ongoing investments should enhance our performance in key star measures and ultimately increase member satisfaction with our plans. We are actively pursuing all our options and exploring actions to mitigate the direct financial impact on payment year 2025, including through contract diversification, operating efficiency, and capital deployment alternatives. We will provide updates on our action plans and progress in future engagements in advance of 2025. Moving to Carelon.

We are pleased with our momentum in the business as it continues to advance its strategy of integrated physical, behavioral, social and pharmacy services to deliver whole health affordably. Carelon Services delivered particularly strong growth in operating earnings, led by the expansion of our post-acute care management solutions. We also extended our service offerings in adjacent areas, including durable medical equipment and wound care, further enhancing our customer value proposition and differentiation. CarelonRx continues to make significant progress towards the near-term rollout of multiple new capabilities that will enhance the affordability and experience of pharmacy for our members and CarelonRx customers. One of these capabilities is EnsureRx an integrated benefit for commercial pharmacy members.

That compares the benefit cost for over 50 covered generic medications to our network of multiple cash discount cards then automatically applies the lowest cost at any pharmacy. The program launches early next year, and we will save our customers money while enhancing their experience EnsureRx will also capture claim data to ensure full safety checks and maintain the integrity of our data. We’re also pleased with the integration of BioPlus, which continues to track ahead of schedule, and we expect to begin migrating specialty scripts from our legacy pharmacy platform early next year. Finally, we remain on track to launch our advanced home delivery capability in the fourth quarter. Together, these businesses will allow us to deliver even better consumer experiences and enhance affordability while creating additional shareholder value over time.

Now I’d like to address the actions we took during the quarter to transform our cost structure and enhance our operating efficiency. With affordability of health care, a paramount concern for all of our customers and more uncertainty in the business environment heading into 2024, we took proactive and decisive action in the third quarter to increase our financial and operational flexibility and to ensure we will remain well-positioned to deliver on our commitments to all of our stakeholders. Specifically, we completed a strategic review of our operations, assets and the investments we’ve made over the years to identify opportunities to increase efficiency and enhance focus, all while driving greater impact from our programs at scale. This resulted in workforce and asset optimization that will make us more nimble, focused and efficient and allow us to concentrate our resources on the most promising programs while further optimizing our physical footprint.

The pace of technological innovation is rapid and accelerating, and we are committed to keeping pace. As we pivot away from some legacy projects including those tied to systems that are being replaced with cloud-based models, we are also scaling key digital programs for greater impact. One example is HealthOS, a key enabler of our strategy that is helping to change the way care providers deliver care, while reducing administrative burden. HealthOS is our digital platform for health that allows us to exchange data bi-directionally with providers in real time and essential to a number of our priorities, including our approach to value-based care. We are also in the early stages of rolling out new AI capabilities and large language models that are helping us personalize member experiences and automate administrative tasks.

We’re excited about the possibilities of the rapid technological innovation that is underway and are committed to continuous improvement, innovation and the ongoing optimization of our processes reengineering much of what we do while delivering more personalized experiences to our members along the way. Before I close – and are committed to continuous improvement, innovation and the ongoing optimization of our processes, reengineering much of what we do while delivering more personalized experiences to our members along the way. Before I close, I’d like to note that we remain confident in our ability to close the acquisition of Blue Cross and Blue Shield of Louisiana. We’re actively working with local regulators and stakeholders to address any remaining questions.

The deal offers tremendous value and opportunity for the people of Louisiana, including through the creation of a multibillion dollar foundation focused on improving their health and lives, and we look forward to the privilege of serving as their lifetime trusted health partner. As you will hear from John in just a moment, the balance of our diverse set of businesses, the momentum of our enterprise strategy and the decisive actions we have taken to enhance our operating efficiency, give us confidence in our ability to deliver strong growth in adjusted earnings per share in 2024. In closing, I want to thank all of our associates around the world for their dedication and hard work. In the third quarter, we were also pleased to be named one of America’s greatest workplaces by Newsweek and the number one best large workplace in health care by Fortune.

It is the work our associates do every day on behalf of the individuals we are privileged to serve that allows us to deliver strong operating results in service of our bold purpose to improve the health of humanity. Collectively, we are fueled by passion for having a positive impact on our communities, our members and the environment. With that, I’d like to turn the call over to John to provide more on our operating results and outlook. John?

John Gallina: Thank you, Gail, and good morning to everyone on the line. As Gail mentioned earlier, we reported strong third quarter results. Given outperformance against our initial expectations year-to-date, we have increased our outlook for adjusted earnings per share in 2023 to be greater than $33, reflecting growth consistent with our long-term compound annual target of 12% to 15%. Our outlook includes incremental investments we have planned for the fourth quarter to support growth in Medicare Advantage in 2024 and beyond. Based on our updated guidance, our five-year compound annual growth rate in earnings per share is expected to be 16%, which makes Elevance Health the only company in our sector to have exceeded 15% over that time frame.

We ended the third quarter with 47.3 million members, an increase of 42,000 members year-over-year driven by growth in BlueCard and ACA membership. During the quarter, medical membership declined by 664,000, driven by attrition in Medicaid due to eligibility redeterminations and a new entrant into one of our state programs in July, which resulted in a loss of approximately 140,000 Medicaid members. We are now three to four months into redeterminations of most of our states, and this enrollment in many appears to be front loaded with approximately three quarters of those terminated from Medicaid having lost coverage for administrative reasons. We are seeing many consumers return to Medicaid after being temporarily disenrolled, while others are experiencing gaps in coverage before transitioning on to ACA exchange plans.

Given the patterns we have observed to-date, we expect reenrollment in the Medicaid and transitions to ACA exchange plans to accelerate. Operating revenue in the third quarter was $42.5 billion, an increase of 7.2% over the prior year quarter. Growth was driven by rate increases to cover overall trend in our health benefits business, coupled with double-digit top line growth in CarelonRx driven by growth in pharmacy customers and the acquisition of BioPlus. The consolidated benefit expense ratio for the third quarter was 86.8% an improvement of 40 basis points compared to the third quarter of last year, driven by premium rate adjustments to cover medical cost trend and solid performance within our government business. Now I would like to spend a moment discussing the business optimization charge we announced as part of our results this morning.

As Gail mentioned earlier, we took decisive action during the quarter to position our company for long-term success by enhancing operating efficiency, refining the focus of our investments and optimizing our physical footprint. These actions will ensure we stay well positioned to provide affordable products while delivering on our commitments to all of our stakeholders. As a result of this strategic review, we incurred a business optimization charge of approximately $700 million, comprised of write-offs and write-downs of internally developed software and related assets, severance and leases associated with optimizing our physical footprint. These actions will result in gross annual run rate operating expense savings of approximately $750 million per year, a portion of which will be reinvested in growth opportunities, including Medicare Advantage and the accelerated rollout of certain digital capabilities.

We are committed to doing even better and we’ll continue to evaluate opportunities to enhance operating efficiency further. Elevance Health’s adjusted operating expense ratio in the third quarter was 11.1%, and a decrease of 30 basis points over the prior year quarter. However, the third quarter last year included additional out-of-period quality improvement expenses due to the accounting realignment we announced then. Excluding out-of-period quality improvement expenses in the third quarter of last year, our adjusted operating expense ratio would have been unchanged. Adjusted operating gain for the enterprise grew 12.6%, led by our Health Benefits business, which delivered double-digit growth as we continue to optimize premium rates and products while enhancing operating efficiency across the segment.

Operating margin for our Health Benefits improved by 30 basis points year-over-year consistent with our expectations. Carelon also delivered a strong quarter with growth in pharmacy growth in pharmacy customers and the acquisition of BioPlus propelling CarelonRx to 17.5% revenue growth. CarelonRx operating earnings included investments to support the build-out of our specialty pharmacy and advanced home delivery capabilities both of which will ramp up in the coming months. In addition, comparisons to the third quarter of 2022 have been negatively affected by the out-of-period fee-based revenue realized in the third quarter of last year. In Carelon Services, strong growth in operating earnings was driven by expansion of Carelon post-acute solutions and growth in our behavioral health business.

Turning to our balance sheet. We ended the third quarter with debt-to-capital ratio of 39.2%, in line our with our expectations and consistent with our target range. During the quarter, we repurchased approximately 1.1 million shares of common stock for $480 million. Year-to-date, we repurchased 3.8 million shares of common stock for 1.7 billion, pacing ahead of our full year outlook of approximately $2 billion. We will remain opportunistic with share repurchases, especially considering the share price and recent volatility in the market. As noted in our earnings release, we ended the quarter with $5.1 billion of board-approved share repurchase authorization remaining. We continue to maintain an appropriately prudent posture with respect to reserves.

Days and claims payable stood at 48.6 days at the end of the third quarter, an increase of 2.1 days sequentially and an increase of 0.9 days year-over-year. As a reminder, we continue to expect days in claims payable to be in the low 40s range over time and anticipate normalization towards this range in the coming quarters as cycle times shortened and COVID-related claims uncertainty recedes. Operating cash flow was approximately $2.6 billion or two times net income in the third quarter of 2023. Excluding the impact of the business optimization charge I discussed earlier, operating cash flow would have been 1.4 times net income. Given strong performance year-to-date, we are planning to make planning to make incremental investments in the fourth incremental investments in the fourth quarter in Medicare Advantage marketing and retention and in capabilities and services that we expect will enhance customer satisfaction, supporting our growth in 2024 and beyond.

While we are disappointed in the outcome of the recently released Star quality ratings, we remain committed to this important line of business for the long-term and are exploring all options to mitigate the financial impact on 2025. Turning to 2024. Although we are not planning to provide specific guidance on this call, I would like to review some of the tailwinds and headwinds that are known at this time, starting with our tailwinds. We continue to optimize our health benefits business, including by executing a multiyear margin recovery in our commercial risk-based margins to return to pre-pandemic levels and expect margin improvement will continue next year. We also anticipate improvement in Medicare earnings, driven in part by corrective actions taken in our 2024 Medicare Advantage bids to improve financial performance in Puerto Rico, where we experienced significant challenges this year.

We expect continued momentum in Carelon, including growth in Carelon services, driven by new product launches and opportunities for meaningful external growth across businesses and the ramp-up of BioPlus and the launch of Carelon Advanced Home delivery both of which to supplement ongoing momentum within Carelon Rx. We also expect to enhance operating efficiency as a result of the actions we took during the third quarter and we’ll continue to look for opportunities to drive efficiency as we transform our cost structure over the long term. And we expect today’s higher interest rate environment to drive growth in investment income. Our tailwinds will be partially offset by our headwinds, which all relate to the Medicaid business, where we anticipate membership attrition associated with ongoing eligibility redeterminations and the net loss of approximately 930,000 additional members associated with changes in our footprint.

While Medicaid rates remain actuarially sound, we’re also mindful of the risks associated with evolving risk pools. And we’ll continue to monitor and manage these dynamics closely. Beyond 2024, Medicaid offers attractive long-term growth opportunities, notably in specialized populations, and we anticipate a return to growth in 2025 and beyond. Most importantly, the balance and resilience of our diverse businesses provides confidence in our near-term outlook while the earnings power of our Health Benefits and Carelon Divisions, position us to deliver on our long-term growth commitments. At this point in time, we believe the current consensus estimate for adjusted earnings per share of approximately $37 in 2024 is appropriate. And we anticipate delivering another year of growth consistent with our long-term compound annual growth rate target next year.

We look forward to providing more specific guidance, on our fourth quarter earnings call. Finally, as many of you know, this will be my last earnings call as CFO of Elevance Health. It has been a pleasure to serve this organization for more than 29 years, including the past seven in my current role. I have been involved in 88 quarterly earnings calls since Anthem went public in 2001, including 30 of them as Chief Financial Officer. Every year has had its opportunities and challenges and 2024 is no different. We serve our members while furthering our mission and will continue to meet and exceed our shareholder commitments. The balance and resilience of our businesses has created numerous tailwinds and has allowed us to overcome various headwinds, and I’m confident we will continue to do so.

I feel fortunate to have been part of what I believe to be the best leadership team in the industry and to be leading the finance organization in an even stronger position than when I took over. I’ve enjoyed engaging with all of you over the years. I want to thank you for your support. I look forward to supporting Mark Kaye, as he assumes the role of CFO, ensuring a smooth transition before retiring, to spend more time with my family in the first quarter of next year. With that, operator, please open the line for questions.

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Q&A Session

Operator: [Operator Instructions] For our first question, we’ll go to the line of A.J. Rice from UBS. Please go ahead.

A.J. Rice: Hi everybody. Thanks and John, I wish you the best and the retirement. It’s been great working with you, and I really appreciate all the help over the years. I want to maybe just ask on the commercial at margin improvement story and what you’ve been doing there, is if you ex-out that the year this quarter, what was the underlying cost trend for you? Did you see any pockets of variance and utilization that are worth calling out? And you guys have said on the recorded or the message so far, several times that you have that there will be some additional benefits on the commercial margin improvement story into next year. Is there any way to size that that or talk about relative to how much gain you had this year from that repricing and the other things you’re doing to improve the margin on the commercial side?

John Gallina: Good morning, A.J. and thank you for the kind words at the beginning. In terms of answering your question specifically though, we’re certainly obviously very pleased with the performance of our health benefits businesses in the third quarter as well as year-to-date. As you know, we’ve increased margins quite significantly. And the health benefit segment margins, we guided to improve those 30 to 60 basis points year-over-year, and we’re very much on track to deliver that. From a line of business, in particular, we’re not providing specific margin information and specific detail on commercial versus Medicaid versus Medicare since we are operating this as a holistic health benefit segment. But we do expect continued improvement in the commercial margins into ’24 as we continue to work on our strategy of ensuring that the pricing truly reflects the underlying cost structure, as well as additional penetrations in the fee-based businesses what we used to call the 5 to 131 strategy.

So, we feel very good about where we’re heading and our trajectory into 2024. So thank you for the question.

Gail Boudreaux: Yes. Thanks for the question, A.J., and I’ll just reiterate John’s comments on commercial. I think the team has done a really nice job as we shared, this is a multiyear journey in terms of the commercial business, and we feel like we’re right on track. And as — the team has done a really nice job of balancing both membership retention, as well as getting our margins in line where we believe they need to be. So thanks for the question. And next question, please.

Operator: Next, we’ll go to the line of Nathan Rich from Goldman Sachs. Please go ahead.

Nathan Rich: Great. Good morning, and thanks for the question. And let me just echo my congratulations, John, on your retirement. I wanted to ask on the Medicare business. Could you talk about the goal for improving Star scores? Are you investing to kind of get back to the level that you are out with 65% of members in 4-star plans? And over what period are you thinking? And how should we think about the magnitude of the incremental investments planned for the fourth quarter as well as into next year. And any comment on the kind of how long it would take to reach the run rate of optimization savings, the $750 million that you talked about would be helpful as well. Thank you.

Gail Boudreaux: Thanks for the question, Nathan. Let me — I anticipate a number of questions around star. So perhaps I’ll just address that topic holistically. Improving stars for us is an enterprise priority. So I want to start with that. And we have a long-term commitment to the MA business and are committed to offering high-quality plans for seniors. But as I said in my opening comments, we’re extremely disappointed on the recent results of the Stars and the decline that we saw in the number of our members in 4-star plans for payment year ’25. Just a little background, I think, might help. We experienced some declines in the CAP survey scores, which were the most heavily weighted measures. And we were also impacted by that new CMS statistical methodology, which caused some significant increases in cut points.

As you think about our performance, we improved in about half of the star measures, but those were not enough to offset the impact of the heavily weighted measures and higher cut points, therefore, having three of our largest contracts suffered in our star ratings, which you’ve noted. As I shared, we have already started making those investments and earlier this year, we were specifically addressing areas around the heightened focus for CAHPS that drove the decline. One of the very specific examples is scaling the My Health Advocate model, which again I shared a little bit about that in my opening remarks. The model is unique and highly personalized customer service and it’s tailored specifically to help members with problems central to CAHPS improvement.

It’s a model that we’ve had in place in our commercial business and has been incredibly successful. Other areas that we saw in the data were about enhancing our core and supplemental benefits to reduce members out-of-pocket costs, which showed up in our start results, and also simplifying how those members use our over-the-counter benefits. We’ve gone on a journey around value-based care, as we’ve shared with you and we’re going to continue to accelerate that and embed some of those results as well into our contracting process. And we also made tech steps last year to improve the processes around clinical decision appeals, which was also an area around the higher cut points. In terms of financial impact, we expect a reduction in 2025 quality bonus revenue of approximately $500 million after offsets from our contracting provisions.

As John and I both shared, we’ve already aggressively begun to mitigate that headwind for 2025, and we do have a number of levels at our disposal, including contract diversification, operating expense efficiencies, capital deployment and looking at targeted network and product enhancements. Overall, we’re going to continue to work on that. Our timelines have already begun on this I feel we have a very, very good line of sight to the opportunities that we have. And again, because of the diversified business model that we’ve talked to you about, we feel that the earnings power of our combined businesses between health benefits and Carelon allow us to continue to feel comfortable about our adjusted earnings for share growth annually of 12% to 15% over the long-term.

So thanks again for the question. Appreciate the opportunity to holistically address what we’re doing about STARS. Next question, please.

Operator: Next, we’ll go to the line of Lisa Gill from JPMorgan. Please go ahead.

Unidentified Analyst: Yes, hi, good morning. This is [Kyle] on for Lisa. Just want to add my thanks to John. I’m wishing all the best. Switching to Medicaid, appreciate all the color on the redeterminations and the front-loaded disenrollment trends. Can you talk about how membership is trending relative to what you expected earlier this year and how acuity mix is trending? And then related on the commercial side, how membership growth is tracking it in the employer group and individual businesses? Are you guys getting the growth you anticipated? And is there anything to call out on the margin side? Is there anything about this year and the 2024? Thanks.

Gail Boudreaux: Thank you for the question, Kyle, and certainly appreciate all the commentary. First of all, on Medicaid, the Medicaid disenrollment, as we said, has been very much front-loaded. And in terms of how that compares to our expectations, our expectations were as it would have been more normalized over a 12 to 14 month process. What we are seeing is that there’s administrative churn and that a lot of people are losing Medicaid coverage temporarily and then they’re coming back on. We’re reenrolling folks 30, 60, 90 days after they were disenrolled and that was, that dynamic was not part of the original thought process but it’s certainly part of the reality. I’d like to say September 30th or December 31st for that matter is just going to be one point in time over a 12 month to 14 month process.