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Teladoc (NYSE:TDOC) Q4 2018 Earnings Conference CallFeb. 27, 2019 4:30 p.m. ET
Contents: Prepared Remarks Questions and Answers Call Participants Prepared Remarks:Operator
Welcome to Teladoc's fourth-quarter and fiscal-year 2018 earnings conference call and webcast. [Operator instructions] It is now my pleasure to turn the floor over to Valerie Hartel in Teladoc investor relations.
Valerie Hartel -- Investor Relations
Thank you, and good afternoon, everyone. Today, after the market closed, we issued a press release announcing our fourth-quarter and full-year 2018 financial results and filed our Form 10-K. The release and filing are available in the Investor Relations section of the teladochealth.com website. Joining me this afternoon to discuss our fourth-quarter and full-year 2018 results are Jason Gorevic, our chief executive officer; and Gabe Cappucci, our chief accounting officer and controller.
We will also provide our initial 2019 outlook. Our prepared remarks will be followed by Q&A. As a reminder, certain statements made during this call will be forward-looking statements, which are subject to risk, uncertainties and other factors that could cause actual results for Teladoc Health to differ materially from those expressed or implied by the forward-looking statements. For additional information, please refer to our cautionary statement in the earnings press release and our filings with the SEC available on our website.
On today's call, we will discuss certain non-GAAP financial measures that we believe are important in evaluating our performance. More details on these non-GAAP measures to the most comparable GAAP measures and a reconciliation of the two can be found in our press release posted on teladochealth.com. At this time, I would like to turn the call over to Jason.
Jason Gorevic -- Chief Executive Officer
Thanks, Valerie. It's great to have you on board at Teladoc, and thank you, everyone, for joining us this afternoon. 2018 marked another record year for Teladoc Health, as our solid performance in the first three quarters continued through the fourth quarter and has allowed us to enter 2019 with significant momentum. In the fourth quarter, we saw strong increases across all our key metrics, and we exceeded our expectations across the board.
For the fourth-quarter 2018, total revenue increased 59% to $122.7 million in the quarter and organic revenue grew at 33%. Total visits were strong at 861,000, representing an 86% increase. Excluding Advance Medical, we saw a 41% increase in visit volume. Our adjusted EBITDA increased over 146% to positive $5.8 million for the quarter.
And our net loss per basic and diluted share was $0.35 for the fourth-quarter 2018, compared to a loss of $0.76 for the fourth-quarter 2017. I'd like to highlight our exceptional performance in driving increased visit volume in 2018, which resulted in higher visit revenue, including strong execution against our performance-based contracts and boosting our annual utilization rate by approximately 250 basis points to 9.4% in 2018. The strength in visit volume results from three primary factors. One, virtual care is becoming mainstream.
The recent Accenture consumer survey on Digital Health is just the latest evidence that we are past the point of inevitability for virtual care, and it is rapidly becoming a main component of the healthcare delivery system. Two, our Surround Sound member engagement efforts continue to get more effective as we saw the yield on these investments improve again in 2018. Three, we are seeing the benefits of our diversification strategy in which we have dramatically broadened the scope of clinical services that we offer. Our clients are increasingly looking to Teladoc to solve a larger, more diverse portion of their healthcare needs.
And visits per user increased to a new high watermark in 2018, with more than 1.5 visits per active user in the U.S. Also contributing to our favorable fourth-quarter results was the sequential 6% increase in our subscription access fees. The more than $6 million increase during this period compares favorably to the same period in 2017. Looking at the full-year 2018, our revenue increased 79% to $418 million.
Our total visits grew 80% to $2.6 million. And as promised, we reported positive full-year adjusted EBITDA for the first time in 2018, ending the year at $13.4 million. And our adjusted net loss per basic and diluted share was a loss of $1.47 for the full year, compared to $1.93 loss for the full-year 2017. Results in 2018 were driven by successful execution of our key priorities, and I'd like to call attention to a few highlights from the year.
2018 was the best-selling season in the company's history, with wins coming across our diversified array of services and customer channels. We doubled our growth in the mid-market, doubled our population of members with access to more than one of our products and saw another year of exceptional win rates in the hospital and health systems market. Success across our health plan, employer and broker channels resulted in more than 3 million new members launching on January 1, with significant additional membership lined up to go live over the course of the year. We saw particularly good growth where we partner with health plans to engage their self-insured clients to use our virtual care services.
Our performance in international markets exceeded our expectations in 2018, and we've already closed meaningful cross-sell and expansion contracts in 2019, as we execute on the vision of selling our full suite of products around the world. With our Advance Medical integration ahead of schedule, our pace of global innovation and the services we offer clients has never been greater. Importantly, we've managed this successful integration while continuing to focus on execution and providing exceptionally high-quality care. And last but not least, I'm excited by the continued acceleration of consumer adoption of virtual care.
And Teladoc Health is at the forefront of that movement. We have firmly established ourselves as the industry leader, and in 2018, we were the provider with the most downloaded app in the telehealth category. Now for more details on our 2018 financial results, I'm going to hand the call to Gabe Cappucci, our Controller and Chief Accounting Officer. Gabe?
Gabe Cappucci -- Chief Accounting Officer and Controller
Thank you, Jason. I'm happy to join you on the call today to review Teladoc Health's fourth quarter in more detail as well as highlights on key full-year results. I want to echo Jason's sentiment regarding our two '18 performance and the significant progress we've made over the course of the year. Digging into the quarterly results, I'll start with revenue.
Total revenue of $122.7 million represents a 59% increase compared to a year ago. For the full year, total revenue increased 79% year over year to $417.9 million. On an organic basis, revenue increased by 33% for the fourth quarter of 2018 and 36% for the full year. Revenue from subscription fees of $102.7 million increased 57%, compared to a year ago and accounted for 84% of our total revenue in the quarter.
U.S. subscription access fee revenue of $78.3 million continues to represent about three quarters of total subscription revenue. International subscription revenue of $24.4 million accounts for the remaining 25%. Turning to membership.
We ended the year with 22.8 million U.S. paid members, up 16% compared to a year ago after adjusting for Aetna's 3.6 million lives that converted to a visit-fee-only arrangement in 2018. As a reminder, our definition of members includes just U.S. paid members that are associated with the PMPM or paid U.S.
membership. In addition, visit-fee access was available to 9.5 million individuals at year-end. On an average per member per month, or PMPM, for the fourth quarter, it reflected $1.16, compared to $0.95 in the fourth quarter of 2017, or $1.13 on a pro forma basis when adjusting for the impact from Advance Medical. As Jason mentioned, we had an excellent quarter with respect to visit volume with 861,000 visits, an increase of 86% compared to a year ago.
Visits from our U.S. paid membership came in at 607,000, which represents an annualized utilization rate of 10.8%, a 272 basis point increase over last year's fourth quarter. For the full-year 2018, we completed 2.6 million total visits, and our annual utilization rate is reflected at 9.4%, up from 6.9% in 2017. Taking a closer look at our visits from U.S.
paid members during the quarter, approximately 50% of them, or 302,000, were paid visits, and the other 305,000 were from our visits-included members. International visits totaled 205,000 in the quarter, and we completed 49,000 visits for individuals with visit-fee-only access. To wrap up my commentary on revenue, U.S. paid membership visits generated $15.8 million in the quarter, a 36% increase over the fourth quarter of 2017.
As a reminder, this line includes revenue from general medical visits as well as other specialty visits, primarily comprised of expert medical and commercial behavioral health services. Gross margins for the quarter were in line with our expectations at 67.4%, compared to the 70.6% in the fourth quarter of last year. The year-over-year decline in gross margins reflects a mix shift in revenue and the acquisition of Advance Medical. For the full year, our gross margin was 69.2%, compared to 73.6% for 2017.
In terms of gross margin dollars, we generated $82.7 million in the fourth quarter, compared to $54.4 million a year ago, representing a 52% increase. For the full year of 2018, total gross margin dollars increased to $289.2 million, which represents an increase of 68% from 2017. Operating expense in the quarter totaled $100.5 million, an increase of 27% from the $79 million in the fourth quarter of last year. Eliminating noncash charges, such as depreciation and amortization, stock compensation as well as one-time acquisition-related costs, adjusted operating expenses would have been $76.8 million or 63% of total revenue, compared to $52.1 million or 67% of fourth-quarter 2017 revenue.
Looking at the full year, adjusted operating expense as a percentage of revenue was 66% for 2018, down from the 79% in 2017. Adjusted EBITDA increased to $5.8 million for the quarter, which compares favorably to the $2.4 million from last year's fourth quarter, reflecting our ability to generate the aforementioned improved operating leverage. As Jason mentioned, we recorded positive full-year adjusted EBITDA for the first time, ending the year at $13.4 million. Concluding my rundown on the income statement, our net loss in the quarter was reduced to $24.9 million, compared to a loss of $44.4 million last year.
On a per share basis, our net loss was reduced to $0.35 for the fourth quarter of 2018, from $0.76 in the prior year. For the full-year 2018, our net loss was reduced to $97.1 million from $106.8 million in 2017. On a per share basis, our net loss was reduced to $1.47 from $1.93 in 2017. Turning to the balance sheet.
We ended the year with $478.5 million in cash, cash equivalents and short-term investments. Our total debt as of December 31, 2018, was $562.5 million, which consists of our two convertible note issuances, the $275 million 3% convertible note that mature at the end of 2022 and the $287.5 million, 1.38% notes that mature at the end of 2025. That concludes my review of the fourth-quarter and full-year 2018 results. I'll now turn the call back over to Jason to provide our initial 2019 outlook.
Jason?
Jason Gorevic -- Chief Executive Officer
Thanks, Gabe. For the full-year 2019, we expect total revenue between $535 million and $545 million; an EBITDA loss between $40 million and $50 million; adjusted EBITDA between positive $25 million and $35 million; total U.S. paid membership of approximately 27 million to 29 million members, and visit-fee-only access to be available to approximately 9.8 million individuals. Total visits, we expect to be between 3.6 million and 3.9 million.
Net loss per share based on 71.9 million weighted average shares outstanding is expected to range from a loss of $1.52 to $1.66 per share. And as we said before, we expect to be cash flow positive for the first time in 2019. Now I'll go through the first quarter 2019 expectations. We expect total revenue between $126 million and $129 million; an EBITDA loss between $14 million and $16 million; adjusted EBITDA between $0 and a positive $2 million for the quarter; total U.S.
paid membership of approximately 26 million to 26.5 million members, and visit-fee-only access to be available to approximately 9.8 million individuals; total visits between 950,000 and 150,000,000 visits; and a net loss per share based on $70.8 million weighted average shares outstanding is expected to range from a loss of $0.44 to a loss of $0.46 per share. Now let me provide you with some additional context on our current expectations for the year. First, let me talk a little about our first quarter as it relates to the diversification of our business and the impact of the flu season. As I mentioned, earlier, Teladoc Health has diversified our distribution channels, our customers and the services we offer.
As a result, we expect continued diversification of customer start dates throughout 2019. We see this trend continuing with health plan expansions, cross sale of new services, international growth and mid-market employer growth, none of which are constrained by calendar year starts. With respect to the flu season, we continue to witness a more moderate season this year versus the intense season we experienced a year ago. Both the CDC flu data and the Teladoc Health flu tracker show the flu having the greatest impact during the first eight weeks of the year.
While this flu season has been less intense than last year, it has more closely mirrored the 2017 visit pattern. As I noted, we are successfully lessening the impact that the flu has on our overall visit volume as we diversify the services we offer across a broad spectrum of conditions. Therefore, we are confident with our Q1 visit projections, which demonstrate a material sequential increase in visit volume, albeit less of an increase than we saw during last year's monstrous flu season. Second, as a reminder, the first quarter is typically our least profitable quarter of the year as we realize the expense of onboarding millions of new members in advance of associated visit revenue.
As with previous years, this impacts our adjusted EBITDA in the first quarter, resulting in a step down from the fourth quarter of 2018 to the first quarter of 2019. Third, we are making strategic investments over the course of the year to support our future growth. Our investments are focused on several important priorities that will yield benefits in the back half of 2019, in 2020 and beyond. We are preparing to take advantage of the opportunity in Medicare Advantage in the 2020 plan year.
We're investing ahead of the additional business we expect to on-board this year from large health plan clients. We're enhancing our platform to provide a seamless cross-border U.S., Canada telehealth service, which will be the first of its kind. And we are continuing to develop our virtual-first strategy that we believe is the model of the future. I'm excited about the strong interest we're seeing and sense of urgency in our discussions with existing and prospective clients to make virtual health services the front door to healthcare, given the ever-increasing cost of traditional healthcare models.
To wrap up our discussions, Teladoc Health had a very strong 2018, which exceeded our expectations. Heading into 2019, we see the pace of virtual care adoption increasing and Teladoc Health uniquely positioned to benefit from this trend. From supportive legislation and regulatory actions, to growing consumer preferences for telehealth services, to the volume of new businesses we are onboarding, to the RFP activity we're seeing across all channels globally, I couldn't be more confident or excited about the outlook for Teladoc Health in 2019 and beyond. I'd like to thank the Teladoc Health team around the world for their continued commitment to our mission and to living our values.
As I hear our patient stories, either directly or through you, I am humbled by the impact that we're having and incredibly energized by what is still to come. I look forward to sharing updates with you throughout the year. And with that, we'll open up the call for questions. Operator?
Questions and Answers:Operator
[Operator instructions] Your first question comes from the line of Lisa Gill with JP Morgan. Your line is open. Please go ahead.
Lisa Gill -- J.P. Morgan -- Analyst
Thanks very much. Jason, just to start with that last point where you talked about the strategic investment. Is there a way to quantify how much you're spending in 2019?
Jason Gorevic -- Chief Executive Officer
Yes. So we haven't given details on the magnitude of the investment in those strategic areas. What I'll say is that some of those are more long range, strategic initiatives like our virtual-first effort, where we see ourselves uniquely positioned to take advantage of that market trend and it requires some investment, both on the clinical side, the operational side and in technology. And others are more sort of immediate term and responsive to customer requirements and/or opportunities.
So for example, the seamless North American U.S., Canada virtual care product is an example of one where it was in response to client demand. Investing ahead of large clients and those sort of growth and launches, obviously, is client-specific. And then, we've talked a lot about Medicare Advantage as an opportunity that really takes off in January of 2020.
Lisa Gill -- J.P. Morgan -- Analyst
So I think what I'm trying to bridge is that if I look at your guidance on the adjusted EBITDA of $25 million to $35 million, and if we clearly look at, call the midpoint of that at $30 million versus The Street expectations at $42 million. When we think about that $12 million delta, is there a way to help bridge The Street expectations versus where we're coming out? One. I heard you talk about the flu season and we clearly have seen that less in 2019 than it was even in '18. So how much of an impact that has? And then, as we think about the strategic cost, are there other things that we should be thinking about when we think about really trying to bridge that EBITDA of what you're going to be able to produce in 2019 versus where The Street was?
Jason Gorevic -- Chief Executive Officer
Obviously, it's hard for me to comment specifically because I'm not running the analyst models. I'll say, certainly, the flu season has an impact on really first quarter revenue. It's not a huge impact, as we said, as a result of our diversification of our visit volume. And I think we gave strong guidance relative to visit growth in the first quarter.
But certainly, there's a little bit of headwind there. I think aside from that, we will continue to see, as we have messaged historically, a slight decline in our gross margin. It's going to continue to be -- actually, it's been slower than we had expected. I think we had signaled closer to $65 million, we came in more like $67.5 million for the quarter, which I think is reflective of the fact that we continue to move people to mobile, as opposed to our call center, which has been a positive trend for us.
But we do continue to see modest decline in our gross margin, in part because of the mixed shift toward visit volume and visit revenue, and in part because of the Advance Medical running at a lower gross margin than the historical Teladoc business. But having said all of that, we're still guiding to doubling of our gross margin -- sorry, our adjusted EBITDA margin next year, '19 versus '18.
Lisa Gill -- J.P. Morgan -- Analyst
And then, if we just think about some of the new relationships, whether it's things you talked about at our conference, the expansion of the relationship with United, the CVS relationship as well as the timing of TRICARE. Can you maybe just talk about each one of those, what your expectations are? What we'll see in United for 2019? Will we see a ramp in the new CVS relationship in '19, and then, lastly, TRICARE?
Jason Gorevic -- Chief Executive Officer
Yes, so I'll start with United. In January, I thought I'd be able to provide more details on this call. I feel great about our relationship with United and I'm extremely confident that we'll get to the finish line on this opportunity. It's just taken a little longer than I expected.
It's a large, complex agreement and those things rarely move as fast as you'd like them to, certainly as fast as I'd liked them to. So as a result, I can't really provide additional details at this point. But I remain extremely confident, and in fact, more confident than I was when I was at your conference, whatever it was, seven weeks ago. And I expect to be able to provide more information shortly, of course, subject to any confidentiality constraints relative to that agreement.
With respect to the TRICARE business, we launched that in December to a defined population in a relatively narrow geography. The point of the limited launch was to make sure that, operationally, everything was running perfectly before we rolled it out, generally available to the whole population. The relationship with Optum is fantastic. We've worked through the early, natural sort of onboarding process and building out the processes, the interfaces between the Optum nurse line and our technology and physician network.
And now, it's sort of back to the government to decide on the timing relative to the expansion and rollout of that more generally. And finally, you asked about CVS. We are continuing to see CVS expand. We expect another few states in the first quarter to launch and we continue to see that over the course of the year.
I'm not really at liberty to give a rollout plan because it's not my -- it's not in my control, it's up to CVS. But we do continue to see growth month-over-month in the volume that we're seeing through that channel.
Lisa Gill -- J.P. Morgan -- Analyst
OK. Great. Thank you.
Jason Gorevic -- Chief Executive Officer
Thanks, Lisa.
Operator
Your next question comes from the line of Sean Dodge with Jefferies. Your line is open. Please go ahead.
Sean Dodge -- Jefferies -- Analyst
Hi, good afternoon. Thanks for taking the questions. Jason, I guess, going back to the revenue guidance. Could you maybe help bridge for us the very positive comments you made around your success during the recent selling season and a revenue guide that implies organic growth near the lower end of the 20% to 30% range you guys have historically talked about.
Are there headwinds you're fighting in parts of the existing business other than the flu that we've discussed? Or is it just some of the recent wins that you've alluded to are a little bit bigger and expected to ramp more toward the back half of the year? I guess, anything you could add around the pace or the cadence of the guidance and the bridging would be helpful.
Jason Gorevic -- Chief Executive Officer
Yes, Sean, it's really the latter. So it's no question that the 2018 selling season was, in fact, our best ever. When we look at total bookings, which we define as the annual contract value of a deal or the aggregate of all of those deals, it's the biggest number we've ever put up. However, as I mentioned, there's more diversification in start dates, meaning we'll see new business starts and grow -- sorry, we'll see new business starts over the course of the year.
And also, we'll see some business that launches at the beginning of the year but expands over the course of the year into its full population later in the year. So while we might not get the full revenue impact of the tremendous selling season in 2019, the total magnitude of the new revenue as we exit '19 will be bigger than we've ever seen before. And as you can imagine, this will set us up very well going into 2020.
Sean Dodge -- Jefferies -- Analyst
OK. That's helpful. And then, maybe one on the virtual-first plan design. I know you've had one client, self-insured employer roll out an offering featuring some of those elements earlier this year.
Can you give us an update on, or maybe some sense of the activity that's been happening there around that concept? Are you talking to more clients about that? Are you seeing more testing being done? Anything you can add just to give us an idea of how much attention this is really starting to get from the payer community?
Jason Gorevic -- Chief Executive Officer
We're seeing a lot of interest from employers, health plans and the consultant community around virtual-first. And we're very active in leading that discussion. There's really no other place to turn for a comprehensive suite of virtual care products that enables that new plan design and turning virtual into the front door of the healthcare system. And we see everything from regional health plans to large nationals, everything from sort of midsize employers to very large employers.
And again, the consultant community is very excited about that. So I see that as gaining momentum over the course of this year and being part of a much larger population as we look into 2020.
Sean Dodge -- Jefferies -- Analyst
OK. Great. Thank you.
Jason Gorevic -- Chief Executive Officer
Thanks, Sean.
Operator
Your next question comes from the line of Ryan Daniels with William Blair. Your line is open. Please go ahead.
Ryan Daniels -- William Blair and Company -- Analyst
Yes, thanks for taking the question. I'm curious, if you think about your product offering, I know you recently launched something for lower back pain therapy and you pushed derma, you pushed behavioral. Are there any other key areas that you're hearing from either your health plan or your employer base that they want to add to the offering on a go-forward basis that we might see?
Jason Gorevic -- Chief Executive Officer
Yes, Ryan, I think we've talked previously about chronic care management and being able to provide more longitudinal care for those who are chronically ill. Naturally, going along with that is some of the remote monitoring capabilities. That's certainly an area that we pay close attention to. It's hard to find one that is -- that takes care of multiple chronic conditions as opposed to a single chronic condition.
But certainly, lower back pain is an example of that. It's not a diabetes or a hypertension-like condition but it does tend to be more of a chronic issue and frequently ends up in a surgical procedure. So from our clients, we've heard that that's a need and an opportunity, especially within certain verticals, in certain sort of SIC codes, if you will, among the employers. In addition to that, the virtual-first capability really goes hand-in-hand with that -- us acting more as a guide for the consumer through the healthcare system.
If the goal is to have the consumer come first to the virtual front door to be able to be guided to a virtual care solution or a more physical location and a traditional delivery system, then we need to make sure that we're available and capable of directing them appropriately. And so we continue to invest in those capabilities, and that is both technology and people to do that.
Ryan Daniels -- William Blair and Company -- Analyst
OK. And regarding the virtual-first strategy, obviously, a unique offering and competitive advantage given your platform and everything that you have. Can you talk a little bit more though about the pricing model for that? Meaning, is it someone who adopts at a higher PMPM and then you'll get both the visit fee when it's appropriate for a telehealth consultation? And do you get any type of referral fee for the physical, kind of keeping a patient in network, if you will, driving them to a high-quality facility or center of excellence versus them picking a random facility? Or is that just in the higher PMPM?
Jason Gorevic -- Chief Executive Officer
So I would say, all of those are in the discussion set right now. We're still early in the game in terms of white-boarding and strategizing with our clients. Some of them have asked us whether we would come in, in sort of an upside risk arrangement where there may be a base fee but the opportunity to really steer care, take care of people more efficiently through virtual means as well as use centers of excellence, top tier of network, top tier of the formulary, et cetera, can drive down the overall cost of care, and our clients see that as something where there may be a base fee and then a share of savings, so to speak. There are others who want more of a predictable higher PMPM-fixed arrangement.
And of course, as you mentioned, there is the opportunity for us to get higher-priced visits running through our system as we become the first stop for the consumer. So I think the answer is all of the above. And a little too soon to tell where the center of gravity is going to go.
Ryan Daniels -- William Blair and Company -- Analyst
OK. That's helpful. And then, my final question, I'll hop off. Just looking historically, I don't think the company has ever reported a sequential increase in EBITDA from Q4 to Q1.
So the fact that The Street had that modeled is probably just mismodeling versus reality, but I'm curious what specific line items you're going to see the biggest jump sequentially in the cost run. Is that really going to be more in advertising and marketing and the sales expense? Or more G&A oriented?
Jason Gorevic -- Chief Executive Officer
So I'll comment and then turn it to Gabe for the specific line items. But Ryan, you're exactly right. We frequently talk about the fact that the first quarter is when we're on-boarding the biggest population of new members, so we have expenses that are very concentrated in that on-boarding process, which includes our welcome kits to new members and things like that. Also, the first quarter is -- tends to be a visit-heavy quarter and so we had a little bit of gross margin compression as opposed to the second and third quarter, which are lower-visit volume and, therefore, higher gross margins.
And Gabe, maybe you can point Ryan to exactly which line in the income statement that shows up in.
Gabe Cappucci -- Chief Accounting Officer and Controller
Yes. Sure. And when you do look at the SG&A expenses, it's really going to be concentrated in the advertising and marketing line as you look to these onboarding activities. And as Jason mentioned, too, just some margin compression as we look at the higher visit volumes that we'll have in the first quarter.
Ryan Daniels -- William Blair and Company -- Analyst
OK. Perferct. Very helpful color. Thanks, guys.
Jason Gorevic -- Chief Executive Officer
Thanks, Ryan.
Operator
Your next question comes from the line of Richard Close with Canaccord Genuity. Your line is open. Please go ahead.
Richard Close -- Canaccord Genuity -- Analyst
Yes, thanks for the question. Just, Jason, I was wondering if you can maybe provide us an update on the international. You hit on it a little bit, but just where you -- where maybe you're seeing strength, the size of opportunities, pricing and profitability. You've had Advance Medical for a couple quarters here and just wanted to gauge what you're seeing out there and whether that's living up to your expectations?
Jason Gorevic -- Chief Executive Officer
Yes, absolutely, Richard. I would say it's ahead of schedule and at or above our expectations. So from an integration perspective, going very well. We have sold and rolled out multiple clients where they were traditional desk doctors, single-product clients outside the U.S., and we have rolled out the full suite of Advance Medical capabilities and products, essentially cross-selling the full set of capabilities from Advance Medical.
That is the most common growth area that we're seeing. We've seen that in 2018, and we already have some of those sales in early '19 that we've closed. In addition to that, we're seeing new opportunities, both new populations from existing clients as they frequently have multiple health insurance companies in multiple countries around the world, and expansion among those international players who provide services all around the world, like AXA, and Bupa, and Cigna International and Aetna International, for example. So very, very bullish on the growth outside the U.S.
We've also seen some regulatory changes in the Brazilian market that opens up that market to significant opportunity, and we think that that will accelerate the outlook for a very, very large and attractive market.
Richard Close -- Canaccord Genuity -- Analyst
And as a follow-up, just with respect to the guidance since we've hit on that a little bit. Have you guys changed in terms of maybe the way you're looking at, as the year plans out, in terms of taking maybe a more conservative stance, a haircut here on utilization increases or the per member, per month, just to bake in a little bit more conservatism?
Jason Gorevic -- Chief Executive Officer
Richard, we've always taken a fairly conservative view at this stage in the year. I mean, I will say, very similar to last year, we have better than 95% visibility into the revenue for the year. But we try really hard not to get out ahead of ourselves. I think I look back at where The Street was and where we were going into the JP Morgan conference in January, when we gave preliminary guidance and actually the relationship to where The Street was relative to where our guidance was last year, was almost exactly the same.
And we didn't actually design it that way. We just looked back at it to look as an analysis and it came out to almost exactly the same situation. Now we were very fortunate to have a really strong year and we beat the initial guidance that we set pretty handily by the time we got to the end of the year. So I would say we are very consistent and I take some comfort in that.
Richard Close -- Canaccord Genuity -- Analyst
Great. That's very helpful. Thank you.
Jason Gorevic -- Chief Executive Officer
Absolutely. Thanks, Richard.
Operator
Your next question comes from the line of Ana Gupte with SVB Leerink. Your line is open. Please go ahead.
Ana Gupte -- SVB Leerink -- Analyst
Hey, thanks. Good evening. Thanks for taking my question. So the first one was on the pricing environment.
Beyond the mix shifting to per visit fees, what is the competitive dynamic that you're observing and is that part of your guidance for 2019, either from traditional competitors or with employers coming up with more broader platform, digital door solutions? Is there any pressure on just the pure virtual care solution or anything on health plans as far as their desire to in-source, perhaps, virtual care given that they are buying docs and they could overlay some technology there.
Jason Gorevic -- Chief Executive Officer
No, Anna, thanks for the question. We haven't seen particular changes in the pricing environment. Specifically, to your question about health plans in-sourcing this. I haven't seen any of that.
So I can't think of a single example of that, in among our clients or among those who are not our clients. I can't think of anybody who has actually decided to bring it in-house. We are seeing some competitive takeaway opportunities. And obviously, we are excited by those opportunities.
Where we have had competitive takeaways, we have outperformed the metrics we set forward as where we thought we were going to drive higher utilization. And I would say the opportunity is there. What we are seeing is clients buying a broader array of services. So we doubled the number of clients -- or number of members who have more than one service from us, and we see that as a trend that's going to continue.
So I would say there is expansion much more than any sort of semblance of contraction.
Ana Gupte -- SVB Leerink -- Analyst
That's helpful to know that there health plans aren't in-sourcing. So is it fair to say then with the Medicare Advantage change, as they are contemplating the CMS rule but they will outsource to players like you. Where do their own docs fit into the value proposition that they would have on virtual care for seniors with assisted home care or whatever they're planning to do.
Jason Gorevic -- Chief Executive Officer
Yes, so we are seeing a lot of interest from the MA plans. Obviously, a lot of those are our clients already and serve those populations from their networks. But in many cases, their networks aren't necessarily virtually enabled. So we have a broad set of discussions with our health plan clients, depending on what their network structure is.
If they own providers then we're frequently going in with our license platform to help enable their providers to interact with their members virtually. But usually, that gets supplement -- even when they have that, it gets supplemented with our network of physicians. And of course, if they don't have their own network, then we bring our full set of capabilities to them and enable the virtual sort of continuum of care. As you might recall for the MA population, we launched a product with AARP several years ago that is specifically for the aging population and facilitates a caregiver and their aging parent to be on a virtual visit with a doctor together, and we see that as being very attractive for the MA population.
Ana Gupte -- SVB Leerink -- Analyst
If I could ask one final one. Just on the theme of doc's -- primary care doc's being taken out by health systems and the plans. Are you seeing any pressure on the supply chain, on your contracts as far as your contracts with the docs? And is there any intent at any point to maybe even bring your own salaried positions in-house?
Jason Gorevic -- Chief Executive Officer
Yes, we're not really seeing constraints on the supply side. We on boarded over 1000 doctors last year. So that was very, very successful, and we continue to see a lot of interest from the physician community. Obviously, a lot of that is because of the tremendous volume of visits that we bring them and their predictability of income.
To the second question, we are looking and I think we have talked about this as far back as our Investor Day in September, about sort of evolving the model of our physician network, such that we have a core group of physicians who may be employed, may be contacted physicians but are more -- sort of more regularly dedicated to serving Teladoc Health and our members. And at the core of that, those would be serving our clients who have a broader array of our services, are embracing virtual first, and are really looking for a much more involved relationship from the virtual provider. And then, sort of concentric circles moving out from that to those at the outside who will continue to be much more transactional available on demand for people with relatively simple general medical needs. And so I think that will continue to evolve as our product portfolio expands and as our role in the healthcare system continues to evolve.
Ana Gupte -- SVB Leerink -- Analyst
Super helpful. Thanks, Jason for the color.
Jason Gorevic -- Chief Executive Officer
Thanks, Ana.
Operator
Your next question comes from the line of Sean Weiland with Piper Jaffray. Your line is open. Please go ahead.
Sean Weiland -- Piper Jaffray -- Analyst
Hi, thanks. So on the growth and utilization that you saw this year, congrats to annualized above 10%. What are the points of leverage you have from here to continue to drive that utilization? And I don't recall you ever giving us that number of visits per active user. So I wanted to think about how that metric can trend over time?
Jason Gorevic -- Chief Executive Officer
Yes, I don't -- so thanks for catching that, Sean. So that's a number that I don't think we've given out for a couple of years and the last time I gave it out, I think we were closer to 1.3. So there is a significant improvement there and you've probably seen some of the slides that we have shared more recently about how much the visits per user increases the more products that they have access to. And so I think you're seeing the benefit of that as people have access to more of our clinical services, their visits per user increases.
So we're seeing growth in two dimensions. We also set a record last year. I won't give the number, but we set a record in terms of new registrations last year. So if you look at -- if you think about, we're growing on two dimensions, more people, and more visits per people.
And so that makes me comfortable that we can continue to expand our visit volume and continue to grow our visit volume at a really attractive trajectory. Where we have headwinds are sort of artificial headwinds. As we on-board large populations, they start at their early stage of the utilization curve. And obviously, there is a dampening effect on our overall utilization rate.
And so sometimes those artificial sort of dampening factors aren't taken into account. And so we try to show and I think we've recently showed a cohort analysis of visit growth for year over year sort of holding a group constant, a vintage, a client pool if you will. And you can see the growth over time there. So I feel confident that we're going to be able to continue to do that.
And the more that we move to this sort of virtual-centric model or a virtual front door, the more that facilitates the steepening of the curve.
Sean Weiland -- Piper Jaffray -- Analyst
OK. Just so we're clear, how do you define an active user?
Jason Gorevic -- Chief Executive Officer
A user who had at least one visit in the year. So when we talk about surpassing 1.5 visits in the -- per active user in the U.S. population, its per -- an active user is defined as somebody who had at least one visit in the year.
Sean Weiland -- Piper Jaffray -- Analyst
OK. And one more quick one, 2019 cash flow expectations?
Jason Gorevic -- Chief Executive Officer
Positive. We haven't given specific guidance beyond saying that we expect to be cash flow positive.
Sean Weiland -- Piper Jaffray -- Analyst
Got it. Thanks so much.
Jason Gorevic -- Chief Executive Officer
Thanks, Sean.
Operator
Your next question comes from the line of Stephanie Demko with Citi. Your line is open. Please go ahead.
Stephanie Demko -- Citi -- Analyst
Thank you for taking my question. Jason, the last time we spoke, I noticed there was a healthy uptick into that Teladoc marketing coming through my benefits emails. So I was just hoping you can give us an update on that, maybe how you're seeing this impact consumer awareness, traction. And any related metrics you have to measure effectiveness of this ad campaign like clip-throughs.
Jason Gorevic -- Chief Executive Officer
Yes, definitely, Stephanie. We targeted you specifically. No, no, no, I'm just kidding.
Stephanie Demko -- Citi -- Analyst
That would explain all the pop-ups. I get a ton of them on my phone.
Jason Gorevic -- Chief Executive Officer
The -- we definitely continue to own our Surround Sound engagement capabilities. And as I think I said in my prepared remarks, we saw 2018 again, the second year in a row where we have seen meaningful improvement in our yield per dollar spent on our Surround Sound. So we look at that as sort of what do we have to spend to drive a new visit. And more and more we're seeing that actually improve meaningful -- meaningfully year over year.
We also, as you might imagine, spend to drive registrations because it's much less expensive for us to market to a registered user than to a user who hasn't yet -- to a member who hasn't yet registered. And so that's part of what you see in your email and your pop-ups and things like that. And of course, if we get somebody to download the app then we have the most opportunity to market to them with things like geolocating and geofencing, airports and things like that as well as, of course, if we can get them to engage in something like our Kinsa thermometer promotion then we can pop reminders to them in their moment of need. So all of those things work together and we're seeing that we can -- the more data we get from our partners, the more targeted we can be in those communications efforts.
And therefore, the more effectively we can be. And so that's been true for a lot of our health plan partners where we've really turned from a vendor, sort of at arm's-length, to a partner working together to drive utilization.
Stephanie Demko -- Citi -- Analyst
Can you give us an update on that mix spend of ad versus direct call usage, given its a better marketing channel?
Jason Gorevic -- Chief Executive Officer
So I think, you're asking -- I just want to make sure I understand the metric you're looking for. But are you asking about the mechanism that somebody uses to request a visit, meaning are they coming through the app, through our web portal or through our call center?
Stephanie Demko -- Citi -- Analyst
Correct.
Jason Gorevic -- Chief Executive Officer
So actually, we saw that drop to an all-time low in the fourth quarter where we got down to 26% coming through our call center. That's a really phenomenal change. In fact, it's not so long ago that we -- that I would talk about that as being 60% coming through our call center and 40% coming through electronic means. And today, we're down to 26% of requests coming in through the call center.
We usually see that tick-up just a slight bit in the first quarter as we onboard new members. And so I don't think we'll see quite as good leverage in the first quarter as we saw in the fourth quarter. That's pretty typical. But then as we engage consumers and sort of train them on the most efficient ways to interact with us, it tends to continue to shift toward digital channels.
Stephanie Demko -- Citi -- Analyst
Good to hear. And then one last one out of me. Just given the investments you have and the fear they are dampening your EBITDA growth. Could you help us think about the out-year EBITDA ramp in a more normalized basis?
Jason Gorevic -- Chief Executive Officer
Yes, we continue to target long-term EBITDA margins in the low-to-mid-20s. We feel very comfortable with that. There's no change to that based on our view of 2019. And in fact, we think that the investments that we're making now, help us to be more confident in that in the out-years because they continue to move us to playing a much greater role in the healthcare system through that virtual first model.
And there are significantly better margins, the greater role we play as part of a sort of central part of the healthcare system as opposed to being on the fringes.
Stephanie Demko -- Citi -- Analyst
Thank you. Very helpful. Thanks for taking my question.
Jason Gorevic -- Chief Executive Officer
Thank you, Stephanie.
Operator
Your next question comes from the line of Charles Rhyee with Cowen. Your line is open. Please go ahead.
Charles Rhyee -- Cowen and Company -- Analyst
Thanks for taking the question. Just a couple of follow-ups from earlier. Jason, you talked about the 2018 selling season being the largest you had in reference to sort of the organic growth we're looking at this year, maybe at the lower end of your 20% to 30% range. On a full run-rate basis, where would you kind of shake out.
Would you be at the 30%? Kind of below it, above it? Maybe can you give us a sense of that when we fully ramp the '18 selling season?
Jason Gorevic -- Chief Executive Officer
So you're asking -- I'm trying to understand exactly how to quantify your question.
Charles Rhyee -- Cowen and Company -- Analyst
Yes, obviously, what I'm trying to get a sense is if we were at a full run rate on the new business that was won last year, what would really the organic growth look like versus, obviously, we're having a timing issue as things ramp up this year and going into next.
Jason Gorevic -- Chief Executive Officer
Yes, I don't have that off the top of my head and I think it would be sort of backing into fourth-quarter guidance, if you're asking about sort of where we exit the year. I think the best way I can answer you is I still feel comfortable with our guidance with what we signaled, historically, about 20% to 30% organic growth. And I feel good about that for 2020, based on what I know today about the business that we sold and will be on-boarding over the course of 2019. And the visibility we have into the pipeline today.
And obviously, it's early in the year but I still feel very good about that 20% to 30% looking into 2020 and beyond.
Charles Rhyee -- Cowen and Company -- Analyst
And then, I guess similar to that, can you give us a sense -- when we're thinking about the EBITDA ramp through the course of the year, should we -- is it best just to use maybe this last year in terms of sort of the relative ramp as we see it going up. Obviously, the point being -- or was there anything during the course -- given the timing of some more of these contracts you expected to ramp up might make the ramp a little bit different.
Gabe Cappucci -- Chief Accounting Officer and Controller
Yes, no, this is Gabe. Yes, that's right Charles. We'll see a ramp throughout the year. Obviously, the first quarter is going to be the lightest quarter of the year because of the some of the on-boarding activities that we've talked about.
But then as we move to bring on some of the additional clients and revenue that we've talked about, we'll see that sort of natural ramp of adjusted EBITDA throughout the subsequent quarters.
Charles Rhyee -- Cowen and Company -- Analyst
Great. And my last follow-up is, when you talk about MA, the MA pilot that is coming up. How much of that opportunity though was really driven by provider choice in terms of a telehealth platform, since they will be providing the service and then they submit claims to the health plan. Is the health plan opportunity limited, maybe more toward to their own physicians? You kind of alluded a little bit to that earlier.
Just wanted to get a little bit more kind of thoughts around how to break down the opportunity in MA.
Jason Gorevic -- Chief Executive Officer
Yes, I don't think that it's -- I think we will certainly see some benefit from our license platform, our hospital and health system market and the interest of the providers to be more active in providing virtual care. But by no means do I think that that is the limit to the opportunity. There's no question in my mind, and we are already having conversations with the health plans about rolling out a model that looks more like there are some modifications to it, but looks more like our commercial model that we sell into health plans, to provide as part of the benefits package for their commercial membership. We're seeing the same interest relative to the MA population.
Charles Rhyee -- Cowen and Company -- Analyst
So in that model, if I'm a senior and I have an existing physician that I'm using, that physician would help to know that, for example, I am a Humana member, and they would go through the Teladoc system to provide virtual care. Would that mean they could theoretically having to use multiple telehealth platforms to serve different members in different MA plans?
Jason Gorevic -- Chief Executive Officer
I'm saying that it's just as likely to be member driven as it is to be provider driven. So certainly, we'll have hospital systems who provide our platform for their physicians. We have that today and so in the event that the senior has a relationship with a physician who is using our platform. Then they'll be able to have a virtual visit on our platform, with their doctor.
But it's also very much consumer driven where the health plan provides tools and a network and a capability that is well beyond what has traditionally been available through a nurse line or something like that. But it is really enabling a virtual visit with a physician who is available to them 24/7. And we see that -- we already have MA populations who use us that way.
Charles Rhyee -- Cowen and Company -- Analyst
OK. Got it. That's helpful. Thank you.
Jason Gorevic -- Chief Executive Officer
Thanks, Charles.
Operator
Your next question comes from the line of Sandy Draper of SunTrust. Your line is open. Please go ahead.
Sandy Draper -- SunTrust Robinson Humphrey -- Analyst
Thanks very much. A lot of my questions have been asked. Maybe just a couple of quick ones I may have missed. Jason, do you guys give an organic access fee revenue growth number? And I guess sort of a follow-up, did you give a broader organic growth number in the quarter?
Jason Gorevic -- Chief Executive Officer
I think we did. We adjusted out -- we adjusted for Advance Medical, and we said that it was 1.16 versus 1.13 if you adjust for Advance Medical.
Sandy Draper -- SunTrust Robinson Humphrey -- Analyst
OK, great. That's helpful. And then in terms of Advance Medical, I know it's only what six months into it but your sort of thoughts about the progress and how much were you able to bring them in on the selling season? Or is '19 pretty much going to be for Advance Medical coming off of their own selling season, and it's really a 2020 and '21 story when you can start to bring that in?
Jason Gorevic -- Chief Executive Officer
Yes, we are actively selling and one of the nice things about the international markets is they're not January-centric and so we've already had some clients where we've up-sold their product suite into our existing relationships outside the U.S. We have sold some deals already at the beginning of this year for population expansion, where we're in a part of a large international insurer and they're rolling out to additional segments of the business. And we're seeing good growth in new markets that are expressing interest in virtual care. What we saw in the U.S.
probably five years ago, maybe a little bit more in terms of the regulatory changes to embrace virtual care, a lot of the other countries around the world are following suit. And so that's very, very positive and I think I mentioned the Brazil market where they are seeing regulatory change and opening up the doors to virtual care. And we -- Advance Medical was an early entrant into that market and already has a footprint. So we think that we're ideally situated to be able to take advantage of that regulatory change.
Sandy Draper -- SunTrust Robinson Humphrey -- Analyst
Thanks so much.
Operator
Your next question comes from the line of Matt Hewitt of Craig-Hallum Capital. Your line is open. Please go ahead.
Matt Hewitt -- Craig-Hallum Capital Group LLC -- Analyst
Good afternoon. Thank you. Just maybe two question for me. First on the product access count, you provided the tables with 40% are using two or more.
That has been an area of focus. Where do you see that metric trending maybe as we exit 2019?
Jason Gorevic -- Chief Executive Officer
Yes, so I'm going to resist the temptation to try to give a specific number on that. I think the opportunity Matt is two-fold. One is to increase that number, and two is to increase the average number of products per -- in a given population. So what I hope to be able to come back to you with this time next year.
[Audio gap] three or more than four products because that's where we're [Audio gap]
Matt Hewitt -- Craig-Hallum Capital Group LLC -- Analyst
Great. And one last one, regarding the guidance, given the rollout with TRICARE and the prolongated contracting with United. How are those factored into guidance? Or how did you kind of fit those in over the course of the year? Any help there I think would help us as we kind of look at the modeling.
Jason Gorevic -- Chief Executive Officer
Yes, that's -- it's a great question. Thanks, Matt. I would say we've been very conservative but have included expectations of expenses and revenue from those two channels using our again conservative but best guesses. We have not included any membership for either of those channels in the membership estimates or guidance that we've given.
We thought it wouldn't really be prudent to do that. So I would say -- yes, I think that gives you appropriate color on it.
Matt Hewitt -- Craig-Hallum Capital Group LLC -- Analyst
Great. Thank you.
Jason Gorevic -- Chief Executive Officer
Thanks, Matt.
Operator
Your next question comes from the line of Mike Ott of Oppenheimer. Please go ahead. Your line is open.
Mike Ott -- Oppenheimer -- Analyst
Good afternoon. Thanks for squeezing me in. Jason, to piggyback on Charles question and your selling season comments on hospital strength, I'm wondering if you could expand just a bit on that, specifically, competitive dynamics and what are hospitals looking for in a Telehealth solution.
Jason Gorevic -- Chief Executive Officer
Yes, we -- 2018 was an amazing year. [Audio Gap] In the hospital and health system market. I think that's attributed to a couple of things. One, we're very consultative in our selling approach with the hospitals and tailor our solution to their needs especially, around because there are a wide variety, like a half dozen different priorities the hospital that might have.
And given those different priorities, it could result in a slightly different configuration of the offering. So that's been very successful. In addition to that, our product is extremely customizable for them so it's all private labeled through them. It integrates easily into their EMR and their scheduling systems and it is very physician friendly.
And the third thing is, we offer all of our services, clinical services, operational services, engagement services abilities that they can decide to take advantage of or not take advantage of and modify that over time. The difference that's changed really over the last probably three years, it used to be a chief medical information officer or a head of a department or an innovation office that was driving the decision making for virtual care systems or telemedicine systems. Now there is generally a head of telemedicine at the hospital and that person is looking across the entire enterprise. And so more and more, we're talking to that role or that individual about what the goals are over the longer term and how we can bring a broader set of capabilities to bear for that population or that client.
And that's helping us to direct our prioritization for that market.
Mike Ott -- Oppenheimer -- Analyst
Great. Very helpful. If I could squeeze in one more on behavioral BetterHelp, just wondering if you could say that 2018 contribution was in line with your, I believe, $60 million goal. And then any 2019 targets or gross that you could share with us?
Jason Gorevic -- Chief Executive Officer
Yes, so it came in north of that $60 million number for '18. We are very pleased with the performance of BetterHelp. And I [Audio gap] direct-to-consumer BetterHelp business. We have some B2B BetterHelp business although relatively small and then of course, we have our commercial behavioral health.
All of that is growing and that's where we see the biggest bundling so when we talk about having multiple products and services in a given population, the most frequent thing when it gets bundled with general medical is behavioral health. So across we gave some commentary on the fact that diversification is helping our first quarter visit volume in the face of a little bit of a flu headwind relative to last year and behavioral health is a big part of that diversification as we see our visit volume in behavioral health growing pretty significantly.
Mike Ott -- Oppenheimer -- Analyst
Great. Thank you so much for all that color, Jason.
Jason Gorevic -- Chief Executive Officer
Thanks, Mike.
Operator
Your next question comes from the line of Jailendra Singh of Crédit Suisse. Please go ahead. Your line is open.
Jailendra Singh -- Credit Suisse -- Analyst
Thanks for squeezing me here and thanks for all the color on 2019 guidance. But let me just follow up a little bit more on revenue guidance. So if I exclude the incremental Advance Medical contribution from '18 to '19, say $30 million, $35 million, we get implied organic revenue growth in like low-20% range. Obviously, this is kind of low end of your long-term guidance.
And a kind of decent moderation from what you guys did in 2018. I understand flu headwind but with CVS rollout, 20%-plus increase in U.S. paid membership, pick up in visits and PMPM. I was just wondering why the organic growth is not better than what is implied in your guidance.
Can you help us to understand that?
Jason Gorevic -- Chief Executive Officer
I think it's consistent with what I said earlier about our philosophy around guidance at this time in the year. And again, as I said, we have about 95% visibility into our 2019 revenue. We take a view at this point in the year where we take a relatively conservative view toward our in-year revenue, and we have some large clients who -- that could roll out sooner and larger. And could roll out a little later and smaller.
And so we've had 14 public reporting quarters and we've met or exceeded our guidance in 13 of those. And our intention is to continue to take that philosophy.
Jailendra Singh -- Credit Suisse -- Analyst
OK. And I'm sorry if I missed this, but did you field the guys the -- your expectations for gross margin trends for 2019?
Jason Gorevic -- Chief Executive Officer
We didn't. We generally give sort of directional where it's going. And what we did is, we continue to see a glide path into the mid-60s. We've been fortunate to outperform our expectations over the last year really -- probably two years I guess as you look back.
And again, I think a big part of that is we've been the beneficiary of the shift to mobile as our engagement strategy has really pushed people to digital channels for engagement. And sort of a mix shift toward visit revenue and we've seen some lower gross margins in some of our acquired companies. So I think you put all that together, we feel very good about where we are coming out of 2018. We do think that we'll continue to see a modest decline into the mid-60s.
Jailendra Singh -- Credit Suisse -- Analyst
OK. And then my last question, I don't know if you can guys can talk about the impact of the Interstate Medical Licensure Compact, IMLC for the company. I believe 25 states are now part of it. Do you see this helping your margins or is there any way this can help your revenue as well.
Give us some flavor like what this might mean for your company.
Jason Gorevic -- Chief Executive Officer
Yes, I don't think it's really going to impact our revenue. It's certainly possible that it can increase the number of states that a physician -- in which a physician is licensed. And therefore, they'll be able to make themselves available to a broader set of our population. That can only be helpful relative to the supply side of the equation.
I don't think it's going to have
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