医疗保健摘要2025年5月

Restricted - External U.S. Health Care Facilities & Managed CareNEUTRALU.S. Health Care Facilities & ManagedCareAndrew Mok, CFA+1 212 526 5496andrew.mok@barclays.comBCI, USTiffanyYuan+1 212 526 5568tiffany.yuan@barclays.comBCI, USMingchuan Song+1 212 526 9787mingchuan.song@barclays.comBCI, USThomas Walsh+1 212 526 5096thomas.walsh@barclays.comBCI, US Upcoming Events to Watch2025 Catalyst CalendarFIGURE 1. Near Term Catalysts to WatchTimingDescriptionWatch ItemNear-termHUM Stars Lawsuit RulingLegal path to HUM's starsrecoveryEarly JuneMA Bids DuePlan commentary on costtrend / benefitsJune 16Humana Investor DayStars recovery, path totarget MA marginsLate JuneESRD Proposed RuleChanges toreimbursement forphosphate bindersLate June / EarlyJulyACA Risk Adjustment Data2Q earnings impactBy July 4thTarget to PassReconcilliation BillThrough SenateMedicaid/SDP cutsJuly 29UNH 2Q EarningsNew 2025 guidance,Medicare trendcommentaryLate JulyPart D National BidsChanges to Part D demoprogramNote: FME covered by Hassan Al-WakeelSource: Barclays Research BaseBullNote$118,140$118,140$118,140Assumes ~ 25% of duals do not have a UNHaffiliatedplan and recorded inMedicare.$30,613$30,613$30,613Reported Medicare ex-PDP/Supp$148,754$148,754$148,754$58,242$58,242$58,242$206,996$206,996$206,9961.8%2.8%Base assumes 120 bps y/y margin degradation.0.5%1.0%Assumes 650 bps of margin degradation (about half of 1Q 100 bps MLRheadwind).1.5%2.5%Base assumes 250 bps y/y margin degradation.$3,094$3,094$5,117Base assumes incremental $2.5 bn EBIT headwind from 1Q guide.1.5%2.5%Upside margin just below target margins of 3-5%.$27,780$27,780$27,780Based on CMS enrollment file.0.0%0.5%Downside assumes 3%offtarget implied from CNC's 1Q.$0$139$2,261$3,094$5,2561.5%2.5%$8,181$8,181$8,181$82$123Downside assumes 3%offtarget implied from CNC's 1Q.1.0%1.5%$105,540$105,540$105,540$3,841$3,841$3,841Assumes incremental $700 mn Optum Health headwind from 1Q guide.3.6%3.6%$21.78$22.70$24.61Base implies EPS down 18% y/y.$22.87$25.02$29.54Base assumes flat MA margin.10%20%Research HighlightsAndrew Witty Steps Down and UNH Guidance Withdrawal•UNH Chairman Steve Hemsley, who presided over the company as CEO from 2006-2017 willreplace Andrew Witty. With the release, UNH withdrew its 2025 guidance, citing a furtheracceleration of Medicare Advantage trends, and endorsed a return to growth in 2026.Stressing UNH's 2025 EPS•Our base case 2025 EPS of $22.70 embeds 1.5% total MA margins, while our downside 2025EPS of $21.78 assumes incremental Part D pressure and 1.1% MA margins.•Questions around Optum Health's current deterioration remain front and center, but signs ofpressure emerged in late 2024. Notably, OH recorded a $1.4 bn non-recurring gain that ranthrough operating costs in 4Q24, which puts underlying operating earnings (ex-NII) closer to$4.3 bn EBIT and suggests a core operating decline of $737 mn y/y (-15%) likely attributableto v28. 3 FIGURE 3. UNH's Optum Health EBIT BridgeFIGURE 4. Summary of Notable Federal and Criminal InvestigationsType of InvestigationIssuePenaltyApproximateDeclineCriminal / Civil(DOJ)Medicare fraud; inflated expensereports, illegal physiciankickbacks$1.7 bn fines;Multiple executiveconvictions-50%Criminal / Civil(DOJ)Medicaid fraud; inflated expensereports$80 mn fines;Multiple executiveconvictions-67%Criminal / Civil(DOJ)Medicare fraud; falsified claimsto inflate revenue$900 mn civil settlement; noadmitted wrongdoing-74%Criminal / Civil(SEC,DOJ)Accounting fraud; overstatedrevenue by $2.7 bnCriminal executive charges, >$500mn civil penalties-99%Civil(CMS, DOJ)CMS complianceCMS Sanctions-5%Civil(SEC, DOJ)Multiple; billing, admissions, andlength of stay.Pending-50%Note: WCG was acquired by CNC. HLS was rebranded to EHC.Source: Barclays Research, Company Filings, NYT, WSJ, Bloomberg•When framed through this lens, we bridge to a reasonable Optum Health EBIT estimate of$5.6 bn in 2025, which is 42% below the company's initial guidance of $9.6 bn and 11% belowthe company's revised guidance of $6.3 bn.WSJ Reports UNH Under DOJ Criminal Investigation•On May 15th, the WSJ reported the DOJ is investigating UNH for possible criminal Medicarefraud. Looking at past investigations, initial headlines prompted strong negative reactionsand impaired the multiple for years.•On paper, a convicted felony would mandate exclusion from the Medicare program for fiveyears.However, we think it would bedifficultto exclude any national carrier from MedicareAdvantage, let alone UNH, which controls 29% of the total Medicare market.4 CMS Expands Medicare Advantage RADV Audits•We view the accelerated and expanded scope of audits as a negativeshiftin tone from theAdministration that looks determined to eliminate fraud, waste, and abuse.•Proportionally, expanding the sample to 550 implies total improper payments of $43 bn overten years, which we allocate to companies by market share below.FIGURE 5. Estimated Impact of Expanded Medicare RADV Audits$ mnUNHHUMCVSIndustry Ove