(UNH)
(UNH)
David S. Wichmann - Chief Executive Officer
Andrew Witty - Chief Executive Officer, Optum
Dirk McMahon - Chief Executive Officer, UnitedHealthcare
John Rex - Vice President and Chief Financial Officer
Tim Noel - Chief Executive Officer, UnitedHealthcare Medicare & Retirement
Heather Cianfrocco - Chief Executive Officer, UnitedHealthcare Community & State
Brian Thompson - Chief Executive Officer, UnitedHealthcare Government Programs
John Prince - Chief Executive Officer, OptumRx
Wyatt W. Decker - Chief Executive Officer, OptumHealth
Jeff Putnam - Chief Financial Officer, UnitedHealthcare
Justin Lake - Wolfe Research - Analyst
A.J. Rice - Credit Suisse - Analyst
Scott Fidel - Stephens - Analyst
Peter Costa - Wells Fargo Securities - Analyst
Josh Raskin - Nephron Research - Analyst
Kevin Fischbeck - Bank of America - Analyst
Lance Wilkes - Bernstein - Analyst
Ricky Goldwasser - Morgan Stanley - Analyst
Stephen Tanal - Goldman Sachs - Analyst
Steven Valiquette - Barclays - Analyst
Michael Newshel - Evercore ISI - Analyst
Ralph Giacobbe - Citi - Analyst
Gary Taylor - JP Morgan - Analyst
Sarah James - Piper Sandler - Analyst
Operator
Good morning, and welcome to UnitedHealth Group Fourth Quarter and Full Year 2019 Earnings Conference Call. A question-and-answer session will follow UnitedHealth Group's prepared remarks. As a reminder, this call is being recorded.
Here are some important introductory information. This call contains forward-looking statements under US federal securities laws. These statements are subject to risks and uncertainties that could cause actual results to differ materially from historical experience or present expectations. A description of some of the risks and uncertainties can be found in the reports that we file with the Securities and Exchange Commission, including the cautionary statements included in our current and periodic filings.
This call will also reference non-GAAP amounts. A reconciliation of the non-GAAP to GAAP amounts is available on the financial reports and SEC filings section of the company's Investors page at www.unitedhealthgroup.com. Information presented on this call is contained in the earnings release we issued this morning and in our Form 8-K dated January 15, 2020, which may be accessed from the Investors page of the company's website.
I will now turn the conference over to the Chief Executive Officer of UnitedHealth Group, David Wichmann. Please go ahead.
David S. Wichmann - Chief Executive Officer
Good morning and thank you for joining us. Six weeks ago, we had the privilege of spending the day with many of you at our annual Investor Conference, providing an in-depth look at the accelerating opportunities we see to serve more people, more deeply and to grow strongly into 2020 and well beyond.
As we conclude 2019 and step into the New Year, the performance of our business strengthens our confidence in the themes, opportunities, and outlooks of that day, as evidenced by today's results. We remain highly focused on driving affordability, innovating with consumer and customer response to products and services, improving operating performance and advancing NPS.
Full year 2019 adjusted earnings per share were stronger than our Investor Conference outlook, growing 17% for the year to $15.11 per share. Full year revenues exceeded $242 billion, growing $16 billion over 2018 with notable gains in our Medicare, care delivery and pharmacy care services businesses. Full year cash flows were $18.5 billion dollars or 1.3 times net income.
We finished the year encouraged by continued performance improvement in Medicaid. Early market interest in our new innovative line of employer-sponsored benefit offerings and 2020 individual Medicare Advantage annual enrollment results, which were our strongest ever. Within our Medicare Advantage offerings, including dual eligible growth we expect to serve nearly 700,000 more people in 2020, the upper end of the range of performance offered at our Investor Conference.
Our fourth quarter medical and operating cost positions continued to improve meaningfully enterprise wide with ample opportunity for further progress on both of these fronts. And our NPS improved nicely in 2019 across our businesses, particularly with network care providers, enrollees in Medicare Advantage and dual special needs plans as well as patients served by our OptumCare and pharmacy care services businesses.
Improved cost and higher satisfaction propelled by meaningful innovation allow us to contribute more comprehensively to the development and deployment of the kind of next-generation health system needed in the US and globally. A more forward looking modern health system built around the people we serve seamlessly woven into their lives, simple, convenient, transparent and compassionate, a health system that is more affordable creates a better experience for both patients and physicians and improves health outcomes.
The health system we are helping to build will better meet the personalized needs of people, it leverages the next-generation data analytics, such as the individual health record to empower patients and their doctors with actionable Intelligence that drive next best actions to improve decision making in real time. We are committed to a future where every person has access to high quality, affordable health care that meets their unique healthcare needs and financial means. We are employing specific actions to help achieve this, driving better health outcomes and aiming ultimately to reduce the health care cost trend to general inflation levels even with an ageing more chronically ill population.
Notably the bipartisan repeal of the ACA taxes in December was a strong step towards improving affordability for Americans. It will greatly assist those who have been most affected by the cost of those taxes, especially seniors, small employers, and those who are individually insured. As we continue to do better for those we serve, we will grow helping improve the health system one person at a time, intensely focused on driving improved consumer and physician experiences.
Looking to the years ahead, our strengthening capabilities and diversified complementary businesses operating in a large growing healthcare market position us well to achieve our long term adjusted earnings per share growth rate objective of 13% to 16%, while we continue as always to invest in the future for sustainable market leading performance and advancing shareholder returns.
With that, let me turn it to UnitedHealth Group President and Optum's Chief Executive Officer, Andrew Witty to discuss Optum's results and momentum heading into the New Year.
Andrew Witty - Chief Executive Officer, Optum
Thank you, Dave. At Optum, we're encouraged on humbled by the expanding opportunities to grow and serve more people, more deeply. There's a distinct energy and eagerness across all businesses as we enter 2020.
In 2019, Optum revenues reached $113 billion, growing 12% year-over-year. Total operating earnings grew 14% to $9.4 billion. OptumHealth revenues reached $30.3 billion in 2019, up 26% led by OptumCare, our care delivery business. We're steadily expanding into new geographies and expanding the depth and breadth of services in existing regions to better provide patients with the highest quality convenient and affordable health services. One measure that help - that will illustrate how we are serving people more comprehensively is revenue per consumer served, which grew 26% in the quarter. This measure will continue strongly advancing as we further build out our integrated care delivery network.
Turning to OptumRx, revenues of $74.3 billion grew 7%, even with the previously discussed impact of a single large customer transition. The 2020 selling season for core pharmacy benefit services has now mostly concluded and it was our strongest ever. Through our other pharmacy care and specialty drug businesses, given our current positions we see significant opportunity to more fully serve patients pharmacy needs in their communities and drive better adherence and clinical outcome.
At OptumInsight, revenues of $10 billion grew 11% and the revenue backlog was up 14% to $19.3 billion. OptumInsight perhaps more than any of our other businesses has a dual role, it has both unmatched capabilities to help distinguish our other businesses and serves as a profitable growing externally facing business on its own.
I'd like to spend a few extra minutes this morning on how we view OptumInsight and why we are encouraged by its potential. I'll start with the foundations. First, deep data and advanced analytics are at the core supporting modern technologies and platforms to make the health system more interoperable, transparent and efficient. Second, research, consulting and large scale managed services enabled by data analytics and digital and operational innovations made the consumer experience simpler, smarter, and more compassionate. And third, clinical expertise combined with rich data and analytics drive measurably better patient care and outcomes reduce its friction while lowering the total cost of care.
We are connecting the health system to deliver better outcomes, lower costs and improved experience for patients and their clinicians. This includes developing the connective infrastructure that integrates clinical systems, revenue management platform, and administrative claims transactions to enable critical bidirectional data exchange. Our solutions are harmonizing and organizing billions of transactions, while applying considerable intelligence through our advanced technology, clinical ontology, and data analytics capabilities.
We want to ensure critical decision support information gets to the right people at the right time, with rigorous protocols to protect patient privacy, all while offering full transparency of health system performance on both quality and cost. Our Optum360 business helps health systems and hospitals improved revenue performance and patient experience. We deploy natural language processing for computer assisted coding and documentation and provide data interchange and information exchange solutions as well as patient access services. Optum360 now manages about $70 billion in annual billings for unaffiliated customers. More than 5 billion pages of clinical documents are processed annually by our natural language processing engines. These are used in a variety of other applications and customer basis to help inform clinical actions and create administrative efficiencies from the more than 80% of the clinical record that is essentially free text such as physician notes and discharge summary.
Payment integrity is among OptumInsight's strongest growing businesses. We provide compliance and cost containment solutions both prior to and following the payment of a claim. We offer a comprehensive portfolio of services for data mining and predictive modeling to help over 250 national, state and local health plans and others ensure appropriate payments for services, saving billions annually.
Within OptumInsight technology businesses, we apply advanced analytics and deep learning models to health care - to healthcare data covering nearly 240 million people to help optimize clinical outcomes and reduce the cost of care. Key offerings include population health, risk analytics and technology support.
And our research and consulting businesses provide thought leadership and expertise that reaches more than 200,000 leaders across the sector. Importantly, this business keeps us at the forefront of how health systems and providers are thinking about and approaching the future and drives deeper more integrated customer relationships across the broader Optum businesses.
As we turn into the new decade, we stand at potentially formative moment where the application of leading 21st century technology and machine powered analytical protocols will open up for the first time the opportunity to create ever more precise predictions of individual and system health status and risk. This will accelerate a much more focused set of interventions to improve outcomes. I have no doubt, this will be an increasingly critical element of our Optum wide goal of improving clinical outcomes, quality and affordability.
Now I'll turn the call over to Dirk McMahon, UnitedHealthcare's Chief Executive Officer.
Dirk McMahon - Chief Executive Officer, UnitedHealthcare
Thank you Andrew. UnitedHealthcare is deeply embedded in every aspect of the health system, from how to finance and pay for health care to engaging people and aligning incentives to promote healthier behaviors and better medicine to improve overall health at lower costs.
UnitedHealthcare revenues grew by more than $10 billion to $194 billion in 2019. Operating earnings increased by 13% or $1.2 billion to $10.3 billion, led by the strength in our Medicare and dual special needs businesses. As Dave noted, we're off to a strong start in Medicare Advantage this year. I'd like to quickly share how we are helping to build a better health system. First, improving affordability; second, engaging and serving people; third, advancing product innovation; and fourth, sorting through hands on data driven clinical care.
Let's start with affordability, because that is the gating factor for greater access to care and improving the consumer experience. One of our goals is to engage more deeply with the highest performing physicians and other clinicians to advance both quality and affordability. We know these high performing providers achieve considerably better health outcomes, while lowering the total cost of care. Our medical cost trend over the last five years has strongly outperformed the national average. We are committed to driving significantly lower rates of healthcare spending growth than the industry. We see billions of additional dollars in potential savings for consumers and customers from areas such as our site of service initiatives and more deeply embedding digital tools to reduce the administrative burden for physicians.
We are also using digital and physical strategies to engage consumers in new ways to simplify their experience, reduce their financial burden, and lower the total cost of care. For example, for the nearly 0.5 million people enrolled in our Motion program. We offer incentives for increased individual mobility. People can earn more than $1000 a year when they achieve defined walking frequency and intensity targets. People enrolled in Motion are achieving better health at a meaningfully lower costs, that is why we're expanding this program and extending product designs that reward stronger consumer engagement and align incentives with their doctor.
A third area is product innovation. We are seeing early signs of customer interest in our innovative new offerings and consumer centric products that better align to the unique needs and financial means of people, while engaging them in managing their health. Some examples are Harmony, a new collaboration with OptumCare providers unites high quality care and coverage, creating a more integrative and effective consumer experience with as much as 20% savings for our fully insured customers. All Savers offer small employers with highly flexible affordable health plans and reduces employee out-of-pocket costs, with low or no preventative and primary care coverage. NexusACO enables large employers to offer a single ACO - ACO based plan nationwide, incentivizing employees to choose high performing providers and driving better outcomes through care coordination.
Bind, provides first dollar coverage and allows people to add coverage on demand for planned procedures offered by high value providers following rigorous care pathways based on best known science, while costing approximately 15% less than comparable plans. And finally, our virtual first product is attractive to the digital first generation. This new product offers zero dollar copay, 24 by 7 virtual care support at a lower price than traditional products. These are some examples of our innovation focus and health benefits and you should expect more as we redouble our efforts to engage consumers in more impactful ways and accelerate our growth in this category.
Lastly, we are deploying relevant information at the point of care to improve the way care is received and managed. Point of care assist is a tool that puts real time patient information at the fingertips of doctors and their EMRs, providing a seamless clinical workflow experience. This improves adherence to clinical protocols, facilitates real time authorization approvals, and helps refer the patient to premium designated specialists. Utility of this tool is significant for all as doctors save time and money, consumers avoid cost surprises, and most importantly health outcomes are improved. As we look to 2020 and beyond, there is a $900 billion untapped managed care market opportunity and health benefits, much of it in government programs where we have grown strongly and we look to serve more people more deeply across the system.
Now, I'll turn it over to John Rex, CFO of UnitedHealth Group.
John Rex - Vice President and Chief Financial Officer
Thank you Dirk. This morning we reported full year revenues of $242 billion, up $15.9 billion or 7% year-over-year, driven by double digit revenue growth in Medicare and across Optum. Fourth quarter adjusted net earnings of $3.90 per share grew 19% and brought full year earnings to $15.11, growth of 17%. Cash flows from operations of $18.5 billion, grew 18% over 2018 to 1.3 times net income, better than anticipated, partly due to timing factors.
Our balance sheet and return metrics remain strong, with return on equity of almost 26%. We ended the year with a debt to capital ratio of around 40%, even with over $10 billion of deployment for business combinations and capex, $5.5 billion in share repurchases and a 20% dividend increase.
Medical reserves developed favorably in the fourth quarter by $270 million, including $150 million from 2019. Overall, medical costs were well managed, resulting in an 82.5% medical care ratio for full year 2019. We continue to be highly attentive to operating costs as part of our overall affordability agenda. In 2019, our operating cost ratio of 14.5% improved 50 basis points, reflecting 60 basis points of operating cost productivity and the deferral of the health insurance tax, partially offset by the effect of business mix changes and continued investments in innovation, service, and growth.
We enter 2020 with diversified growth momentum, balance sheet strength and financial flexibility. On earnings progression, we continue to expect 47% to 48% of full year earnings per share to be realized in the first half of the year. A point to keep in mind on the quarterly progression, 2019 first quarter has one fewer workday than 2018, resulting in a higher earnings level. This year the first quarter has a more normal mix, but then adds an extra day due to leap year. Taken together, the day count shifting has a year-over-year impact on the medical care ratio of about 80 basis points, this will result in the first quarter 2020 MCR running higher than the second quarter and earnings per share progressing accordingly, with just under 55% of the first half earnings expected to be realized in the second [Phonetic] quarter. These impacts of course were fully contemplated in the 2020 outlook we provided at the beginning of December.
For full year 2020, we continue to expect revenues to approach $262 billion and adjusted net earnings per share in a range of $16.25 to $16.55. Consistent with our prior practices, we will more formally address these and other expectations after the first quarter.
With that, I'll turn it back to Dave.
David S. Wichmann - Chief Executive Officer
Thank you, John. As you can tell, we are confident in the outlook for our diversified and growing enterprise for 2020 and beyond. Our businesses remain strong and well positioned for continued balanced growth by delivering even higher levels of societal value. We remain committed to our mission and an intense focus on serving one person at a time at increasing levels of value, more affordable, better outcomes, and improved experiences while generating strong returns for you, our shareholders.
Operator, let's open it up for questions. One per caller, please.
Operator
[Operator Instructions] We'll take our first question from Justin Lake with Wolfe Research. Please go ahead.
Justin Lake - Wolfe Research - Analyst
Thanks, good morning. Wanted to ask about the quarter in terms of medical cost, looks like it came in better than you expected versus the update at the Investor Day any color there specifically, if you can expand on what's - how you're seeing kind of Medicaid progress from a cost and risk pool rate perspective as you kind of come into 2020 that would be really helpful as well. Thanks.
David S. Wichmann - Chief Executive Officer
John Rex.
John Rex - Vice President and Chief Financial Officer
Hey Justin, good morning. Yeah, I think I'd point out a few things here. You're correct, we did come in just a little bit better than our guidance at the Investor Conference. And if you think that - first I'd call it broadly across the businesses as we continue to see the impact of the affordability initiatives that we've been very focused on, having traction and having impact. So broadly across that I think it's fair to say also that we certainly did see some continued improvement in our Medicaid businesses. It's a place that we've been, that we've been focused on for a while here and that was also contributor. But broadly, I'd say across our businesses as we saw those affordability initiatives having traction.
David S. Wichmann - Chief Executive Officer
Thank you, Justin. Next question please.
Operator
Our next question from A.J. Rice with Credit Suisse. Please go ahead.
A.J. Rice - Credit Suisse - Analyst
Yeah, it's just - it sounds like on the call today you are reaffirming your expectations around Medicare Advantage enrollment. Obviously CMS has come out with their January numbers, it looks like in terms of the percentage enrolled in January, you're little bit lighter than you were a year ago. I don't know if that's a fair comparison, but I wondered is there anything in the data that's - I don't know if you have looked at what they put out that is missing from your perspective. I know it shows you down in group MA and maybe you're going to pick up and group MA. But just flesh out a little further what group MA over the course of the year would anything to reassure us about your expectations around MA for this year?
David S. Wichmann - Chief Executive Officer
Thanks A.J. You know we're very pleased with our AEP results and I'd say is by far it's our strongest year ever in individual Medicare. We did reaffirm the guidance but near to the upper end of that guidance today. So we feel pretty strongly on - with respect to our overall performance.
Tim Noel, can you add some color on some of the other questions?
Tim Noel - Chief Executive Officer, UnitedHealthcare Medicare & Retirement
Yeah, good morning A.J. Thanks for the question. In first half, some of that CMS partial AEP reporting can be a little bit misleading. And Dave said you know first and foremost, want to reiterate the confidence in our full year enrollment growth that we shared at Investor Conference for MA. And just to revisit that briefly, we said 500 to 550,000 in Medicare Advantage growth in the M&R [Phonetic] business, which includes both group and individual MA. And we also said that it'd be up to 700,000 in MA growth including duals within our community and state business. So when AEP completes, we'll have grown by 370,000 in individual MA including the duals better in CMS, and that's up 140% over last year's AEP and is our strongest performance ever in the annual enrollment period. We expect this to drive full year results about 700,000 member growth in individual MA and that split on January net growth versus the rest of the year is roughly 50/50 and that's consistent with historical pacing and also full year supported by the momentum that we've seen in AEP.
With respect to Group, you're right Group MA contracted modestly in the CMS reporting. When January all settles out, we expect that to be down about 65, but that will strengthen to flat to down 25 as the year closes out. And finally, all told, really great start to the year, strong signal of confidence for the full year in our growth guidance shared at Investor Conference.
David S. Wichmann - Chief Executive Officer
Thank you A.J. Next question. Next question please.
Operator
We'll go next to Scott Fidel with Stephens. Please go ahead your line is open.
Scott Fidel - Stephens - Analyst
Thanks. Just sticking on the membership updates for 2020 and obviously you just gave some good detail on Medicare. Just interested if there is anything to call out in terms of either the commercial business or the Medicaid business, in terms of expectations on membership relative to the ranges that you had provided at Investor Day? Then also just specifically within that just interested in how you are sort of approaching the North Carolina Medicaid situation, just given the budget situation there in terms of what you're assuming for timing implementation of that and how many lives you have factored in around North Carolina? Thanks.
David S. Wichmann - Chief Executive Officer
Good question, Scott. Thank you. Dirk McMahon will start and then Heather Cianfrocco can discuss Medicaid.
Dirk McMahon - Chief Executive Officer, UnitedHealthcare
Yeah, on the - thanks, thanks for the question Scott. So we'll be down a little bit in enrollment for 01/01/20 [Phonetic] in both the fully insured and ASO areas. But as the - throughout the course of the year we expect to gain membership in both areas, as we previously guided in December. As we look at 2020, we're going to continue with the pricing discipline that I previously talked about as we balance enrollment growth with our margin expectations. We remain - we remain focused on delivering a unique value proposition for our customers and consumers.
Hard to tell you where I'm optimistic for next year, in fully insured, expect strength in individual products and their middle market. As I look at our ASO block, I look at our all favors and I look at our middle market as well. With that, turn over to Heather.
Heather Cianfrocco - Chief Executive Officer, UnitedHealthcare Community & State
Thanks. Yeah, so good question with respect to - start with membership and talk a little bit about North Carolina. So in our membership for this year, we do - we do expect growth in Medicaid this year. And that's coming from a couple of places. North Carolina is in our 2020 guidance right now. We've got some other things in there. We've got some increases from - to markets like our Washington win last year, Texas win, recent Texas win, we are going to see some Nebraska expansion and then we see another strong year of [Indecipherable] as Tim just talked about for 2020. We can - really well positioned there with new county expansion, service their expansion and our AEP is off to a really, really strong start, so really excited about that.
Pressure is obviously North Carolina. So it's in our 2020 membership outlook and our revenue outlook and we assume it right now to come in about mid-year. We're really honored, we were selected, we're ready for implementation and we're eager to start serving North Carolinians despite the budget situation there. There is strong support for the program and for managed care there. So we're continuing to monitor the implementation date. We'll keep you posted on that and you all watch that as well. In the meantime, we've got - we're excited about the opportunity. It's in our outlook and we look forward to hopefully getting that on track here as close to mid-year as possible.
David S. Wichmann - Chief Executive Officer
And just to add on to that a little bit. Scott, we won also in Kentucky, we were pleased to win. Obviously that's being rebid now, but we'll hopefully prevail in the end there as well. And it's a strong RFP season for Medicaid broadly and I see the business having come around to being positioned with its turnaround, just in time to compete ferociously for that business. So, we're pretty bullish about the opportunity that exists in Medicaid and I think we're well positioned to grow.
Thanks for the question Scott. Next question please.
Operator
And we'll go next to Peter Costa with Wells Fargo Securities, please go ahead.
Peter Costa - Wells Fargo Securities - Analyst
Good morning, everyone. Nice quarter. I'd like to take it up a little bit in terms of looking at sort of the longer-term picture for Medicare. Couple of changes in the Medicare program, I'm curious what you think of as being the biggest risks to you in terms of your business. And those are paying for social determinants of health, which is something new for this year, allowing ESRD patients to join next year and Medicare fee-for-service, direct contracting by providers is starting. Can you talk about those three items and if they are risks to you?
David S. Wichmann - Chief Executive Officer
Sure. We'd be happy to discuss all three of those, Tim?
Tim Noel - Chief Executive Officer, UnitedHealthcare Medicare & Retirement
Yeah thanks, Peter. So I think I'll take ESRD first, but also want to caution you know the long-term outlook, especially with respect to 2021, and really any year it's a little bit premature to get into some of the nuts and bolts of how we see the landscape shaping out. But on ESRD we're very supportive of the change that goes into effect on 2021 and encouraged by the opportunity to serve more people. We're not concerned with some of the unknown elements around the reimbursement in payment models. We'll learn those details very soon. We remain confident expecting that those models will be fair, adequate and importantly, we believe that these people will be better served in Medicare Advantage. Also important to keep in mind, we serve 40,000 Medicare Advantage enrollees with ESRD today. Adults develop the disease post enrollment and our focus that these members is both on prevention and also on treatment. So we're pleased to have the opportunity to expand our reach and impact with patients that have the disease at the timing of enrollment.
With respect to source of determinants, we continue to have a key focus of our business. Consistently referring folks inside of programs where appropriate and some of the additional flexibility to apply social determinants and plan design are elements that we're leveraging in some of our demonstration projects in 2020. We're excited to learn a little bit more about this, soon as the year progresses and look for more opportunities to do things in this area in 2021.
David S. Wichmann - Chief Executive Officer
[Speech Overlap] Pardon me.
Peter Costa - Wells Fargo Securities - Analyst
The last one was physician direct contracting. Fee-for-service Medicare.
Brian Thompson - Chief Executive Officer, UnitedHealthcare Government Programs
Hey Peter, Brian Thompson here. We're encouraged by that as well. I think similar to what we've done with the bundled payment program, it's a good opportunity to work on advancing traditional Medicare and we're encouraged by that thinking and creativity and look forward to participate.
David S. Wichmann - Chief Executive Officer
And I might add overall Peter that we're bullish obviously overall on the outlook for both Medicare Advantage, but also the dual special needs marketplace as well. They're both very large today and growing end markets. MA is clearly outperforming fee for service in terms of overall benefit coverages and the quality of outcomes and the returns that people are getting in terms of their overall satisfaction. And so no surprise that it is performing as well and it seems to be gaining some momentum. So we look forward to continuing to compete hopefully growing at these levels, if not higher going forward.
Next question please.
Operator
And we'll take our next question from Josh Raskin with Nephron Research. Please go ahead.
Josh Raskin - Nephron Research - Analyst
Thanks, good morning. Question around the sort of broad space that's growing around physician enablement and I'm curious it seems like there's been a lot of interest, a lot of new competitors that are kind of focused on that. I know Optum has been very early, do you think of Optum as sort of the market leader and it's just broad movement of physicians taking more risk, is this positive for UnitedHealth Group?
Andrew Witty - Chief Executive Officer, Optum
Josh, thanks so much for the questions, it is Andrew. Yeah, we absolutely see physicians very much as a central element of improving care delivery, quality, and cost. It is what really driving OptumCare, which is clearly the central part of OptumHealth. As we see physicians move toward taking more risk, we see improvements across the board in terms of resource allocation, prevention focus, ensuring clinical outcome is maximized. We're very encouraged by that trend. This year alone we'd expect about 150,000 more patients to go into our physician risk managed programs across OptumCare. We continue to see that trend accelerate. It's very much, something that we then anchor the build out of the rest of our OptumHealth portfolio around. So in a sense is that thoughtfulness around how can we then create services, insight, data analytics, which help the physician make the best possible judgment to manage that overall risk profile of the patient. You see that then reflected in the relentless growth of the revenue per patient served across OptumHealth that's really been driven by this shift.
And so you're absolutely right, very important element for us. And it essentially becomes the core around, which we then envision and build our Support Services, our interventions and our analytics to empower the physicians to make the best possible decision on behalf of the patient. Thank you.
David S. Wichmann - Chief Executive Officer
I just add to that just slightly Josh, that UnitedHealthcare is working on physician enablement as well. This is what the core of Dirk's commentary this morning was around point of care assist. This is why we built and deploy the IHR and this is why we focus essentially in our Investor Conference around the way in which we engage both the digital and physical rounds to AI enable people to be able to operate much more effectively and serve their patients.
So thanks for the question. Next question please.
Operator
And we'll go next to Kevin Fischbeck with Bank of America. Please go ahead.
Kevin Fischbeck - Bank of America - Analyst
Great, thanks. Just want to go back to Medicaid for a minute. Can you talk a little bit about, I think you mentioned that in Q4 maybe you saw some improvement on Medicaid, but can you talk about the expectation for the year? I guess in particular, I guess two things, one is the implication of redeterminations and the rate updates you will get relative to that, how are the rate updates going and do you - are you modeling additional re-determinations as the year goes on? And the second, just quickly going back North Carolina, if North Carolina got delayed into 2021 would that impact your EPS guidance or is it more of a revenue number at this point? Thanks.
David S. Wichmann - Chief Executive Officer
I say we're making progress on - across all dimensions of Medicaid right now on rate cost and quality. Heather, do you want to take those questions?
Heather Cianfrocco - Chief Executive Officer, UnitedHealthcare Community & State
Sure. So maybe I'll start with the Medicaid performance. So we were pleased with the Q4 results. And when I say that I really mean there it's marching along right within expectations, was what we really executed on our affordability agenda. We see strong partnerships with our states to address what was for a period of time due to redeterminations or other underfunding issues, just acuity related underfunding. So as we look into 2020 I feel good about the progress made through all of '19, in particularly in the second half of '19 with respect to rates and with respect to affordability. And so as we come into 2020, we've got a view into our Q1 rate renewals, they're right in line with our expectations. They are top above what they were at the same time in '19. We've got a - we've delivered on our clinical programs. We're seeing strong NPS, customer service scores and quality. So, I feel good about that, as I say that you still expect us to hit our target margin by the end of the year. So that just gives us renewed confidence in what was committed to you already. So expect our Medicaid business to continue to perform along that track and we'll be hard at work on it.
With respect to North Carolina, yeah I guess I'll just say again, we're monitoring it every day right now. I was going to say that we're continuing to push and it is a big component of our opportunity in 2020 from revenue and a membership perspective. But that being said, there is a lot of other growth opportunities that we're measuring to. We didn't have Kentucky in our guidance, but we also didn't - and that got pushed, but we also didn't have the [Indecipherable] bid that we just won. So we're going to be monitoring all those things. And right now we're going to kind of work for a mid-year or close there too implementation and we'll keep you posted.
David S. Wichmann - Chief Executive Officer
Kevin, Dave again. If I could just add, so if North Carolina where to get pushed to 2021, it would not affect our expectations for the year. Our guidance would stay the same, it is as it comes out of the chute it's a relatively modest margin product. Our market as is often the case so we wouldn't expect any material impact on our expectations for the year.
Thank you. Next question please.
Operator
And we'll go next to Lance Wilkes with Bernstein. Please go ahead.
Lance Wilkes - Bernstein - Analyst
Yeah, could you talk a little bit about PBM margin for the - for the quarter. Interested in, I mean the improvement there, how much of that is driven by just the mix shift from the transition of large client and how much is other initiatives like cross sales or sourcing initiatives?
David S. Wichmann - Chief Executive Officer
Prince?
John Prince - Chief Executive Officer, OptumRx
Hi Lance, John Prince. Thanks for the question. As you looked at the fourth quarter, the margin was elevated as expected. So when we gave our guidance at Investor Day, we were expecting the operating earnings margin around 6.3%, 6.4%. So it is exactly what we expected. Why it was elevated? It is exactly what you mentioned was the loss of the large client where we lost the revenue, but it didn't really impact our operating earnings. The second driver was the supply chain strength in terms of our - continuing to negotiate with pharma manufacturers as well as the supply chain to get value to pass on to our clients, and so that was the other key driver.
As we look to 2020 guidance, you should expect our operating margin to fall back to where we have guided at Investor Day with 5.1% to 5.2% so that should be your expectation. It was more of an anomaly what happened in Q4 as expected.
David S. Wichmann - Chief Executive Officer
Thank you, Lance. Next question please.
Operator
We will go next to Ricky Goldwasser with Morgan Stanley. Please go ahead.
Ricky Goldwasser - Morgan Stanley - Analyst
Yeah, hi, good morning. So, you reiterated guidance this morning for 2020. Just wanted to clarify if the guidance already includes any impact from retail and mid-year renewals and also the benefit from the Diplomat acquisition? And then - follow-up on the - on the dual growth, I mean obviously 15% to 20% is what - is the implied growth, which is strong and above market, but when we think about that. Can you just kind of like help us think through the Part D dynamics and how that would flow through the P&L, if it's going to have any impact on OptumRx throughout the year?
David S. Wichmann - Chief Executive Officer
We'll have John Rex start and then shift to Tim Wicks or John Prince.
John Rex - Vice President and Chief Financial Officer
Hey Ricky, John Rex here. So in terms of those elements, you mentioned I say both immaterial in the scope of our company. You're correct, when we guided to 2020 initially the repeal of the hit was - the health insurance tax have not yet occurred, but I would call that immaterial to us. Yes, there is some impact but not material in terms of modest headwind in the scheme of our company. Not, not something that we would, we would call out. Also in terms of the Diplomat, the pending Diplomat acquisition also I'd call that immaterial, really no impact, it will be neutral in terms of our 2020 outlook. John Prince?
John Prince - Chief Executive Officer, OptumRx
Thanks Ricky. John Prince. In terms of the other pieces on Part D component that is expected. So I think we're not changing our guidance for 2020. What we expect in terms of Part D and Diplomat is built into our guidance. And so, we're comfortable with our expectations.
David S. Wichmann - Chief Executive Officer
Great, thank you Ricky. Next question please.
Operator
We'll go next to Stephen Tanal with Goldman Sachs. Please go ahead.
Stephen Tanal - Goldman Sachs - Analyst
Good Morning guys, thanks for the question. I guess, at this stage, I was just wondering if you could kindly give us a sense of what - HIT repeal, how we should be start to be thinking about modeling that in whether you commit the sort of at least the non-tax deductibility of it going away kind of flowing to the bottom line or if it's still too early? And then maybe just could you comment on OptumHealth, just given the risk taking nature of what you guys are doing, I thought it'd be interesting to hear from you all how the flu impacted the economics of that business in Q4, again sort of revenue, earnings, margin. Thanks.
David S. Wichmann - Chief Executive Officer
Great. I'll touch on the HIT and then Wyatt Decker will comment on OptumHealth. So overall, the HIT, we are as I said in the prepared remarks, we are pleased as if this would weigh, obviously it's great for seniors, families of small businesses, and individual insurers as well on average for couple - senior couples it is $500 to $600 it pretty much carries out the same for a family of four that's sponsored by a small business. And so obviously this has a strong economic impact on these families and individuals. So it's terrific to see it get repealed.
The other thing about it is, it removes the excessive volatility. I'm sure you're fatigued with it as we are, it's in, it's out and but more importantly in all of that is, is that it affects the volatility of pricing in the marketplace as well. So, hopefully you will see that stabilize as we get through 2020 and into 2021 as well. This - we're not going to discuss 2021 and what our strategies may be with respect to how we handle this. Obviously it's important that the tax value gets back into the hands of people that's what it was intended to do and that's what we intend to accomplish overall. And as John already indicated, while it has a drag on earnings for 2020, we're not changing our outlook as a result of that, that is small item in the broad scheme of themes.
And Wyatt Decker to discuss flu at OptumHealth.
Wyatt W. Decker - Chief Executive Officer, OptumHealth
Stephen thank you for the question. At OptumHealth and OptumCare we follow the usual flu modeling and we have not seen a material impact deviating from that in Q4 and we do not anticipate significant impact in Q1. As you may know it's been a reasonably robust flu season, but it's mostly the b strain, which is not as severe. So we also have a fee for service MedExpress practice, which tends to offset any hit we might take on the risk side. Thank you.
David S. Wichmann - Chief Executive Officer
Thank you Wyatt. Just I want to clarify one thing that Ricky asked and I'm not so sure we answered it correctly. It is really about whether not Diplomat, the proposed transaction is in our numbers for 2021 and our 2020. And the answer to that's no. It would not be in there. We don't include transactions in our forecasts until they close. So that is not included in there and as soon as it does close, quarter following we'll update our forecast accordingly. This is one of the reasons why we talked about the impact of capital deployment on our growth rate and how it can advance during the year because of transactions. In this case it will be very, very modest, but nonetheless I just wanted to make sure we have that clarification.
Thank you. Next question please.
Operator
We'll go next to Steven Valiquette with Barclays. Please go ahead.
Steven Valiquette - Barclays - Analyst
Thanks, good morning everybody. Actually, not to beat the diplomat pharmacy acquisition topic to death, but I know it's not a huge acquisition for you financially, but despite that I do have to believe they were just almost immediately be a ton of operational synergies when folding that book of business into your existing PBM and specialty pharmacy operations, probably in reimbursement and also in pharmacy network contracts. So I guess I was hoping to hear more color around what you see is the biggest area of synergy at this stage? And then just conceptually could this deal move the needle for UNH overall in 2021, obviously you can make it a sound probably in 2020 not much, but could it move the needle for the company overall in 2021? Thanks.
David S. Wichmann - Chief Executive Officer
It'll be nicely accretive to us. Unfortunately it also comes with a great deal of integration costs, most of which will hit 2020 as well. Would you touch on that John?
John Prince - Chief Executive Officer, OptumRx
Sure Steven it's John Prince just maybe talk a little more why we're doing the deal, because I think that's really at the core of it, which is to better serve individuals that have complex diseases like oncology, immunology and specialized infusion therapy. When you look at the capabilities of Diplomat around specialty pharmacy and infusion it fits well with the strategy of OptumRx focused on these unique populations that need better volume, helping improve their drug costs, improving health outcomes and overall value of care and doing it in a compassionate way. So we think it is a good fit of our two businesses that come together to better serve the key needs in the market. And so as we've talked about before, strategically especially drug cost is a key focus for the future is polyclinics. I think that strategically fit very well. We're obviously still away from closing the transaction, we are actively doing our planning for that and we'll be ready to start that as we conclude the transaction in the first quarter.
Steven Valiquette - Barclays - Analyst
I appreciate the color. Thanks.
David S. Wichmann - Chief Executive Officer
Yeah, no problem. Next question please.
Operator
And we'll go next to Michael Newshel with Evercore ISI. Please go ahead.
Michael Newshel - Evercore ISI - Analyst
Thanks. Maybe just going back to the flu. I just wanted to confirm that those earlier comments also apply to the UnitedHealthcare side as well. You've seen high outpatient activity, but severity in hospitalizations just don't appear to be that high at least to published yet?
David S. Wichmann - Chief Executive Officer
Jeff Putnam?
Jeff Putnam - Chief Financial Officer, UnitedHealthcare
Yeah, thanks for the question. Yeah on the UnitedHealthcare side similar dynamics. The flu season as you see in the CDC data started early and we are having elevated incident levels on the outpatient side, but overall severity as was mentioned is lower there and in-patient admits have been close to normal. So very modest impact in the fourth quarter.
David S. Wichmann - Chief Executive Officer
Thank you, Michael. Next question please.
Operator
We'll go next to Ralph Giacobbe with Citi. Please go ahead.
Ralph Giacobbe - Citi - Analyst
Thanks, good morning. You rolling out certain initiatives and benefit design changes to your fully insured book around site of service initiatives and prior off along with preferred lab network, etc. and it sounded like that actually benefited some - to some degree in the fourth quarter. Can you give us maybe a little bit of a sense of what proportion of the ASO book has adopted these initiatives may be for 2020 and/or how we should think about sort of the uptake over time? Thanks.
David S. Wichmann - Chief Executive Officer
I don't think we'll talk about adoption rates in the large national accounts business, but Dirk you want to talk a little bit about your overall efforts around containing medical costs?
Dirk McMahon - Chief Executive Officer, UnitedHealthcare
Yeah. As we think about medical costs you mentioned very effectively site of service being rolled that out to a lot more codes in November, knees and procedures like that. We're also very focused on our network negotiations to try to drive unit costs lower in many areas. I look at our trend, two-thirds of unit costs, the network is at the start of that. We're doing a lot of work in terms of increasing consumer engagement providing them with effective decision tools to rally in our other apps portal to other digital property to drive the right movements. And also got to thank Optum, a lot of work with our clinical models driving savings as well as payment integrity, as Andrew mentioned in his remarks. So we really have a full forward press on affordability. We think that is a primary driver of our ability to price effectively in the market and actually provide access for consumers and employers and everyone. So a lot of work on the affordability front.
David S. Wichmann - Chief Executive Officer
Dirk and team at UnitedHealthcare doing a wonderful job on affordability broadly in medical cost obviously they're interested in getting health care to be much more affordable. And the collaboration between Optum UnitedHealthcare has never been stronger in that front. Optum has really stepped in as they do with all the third-party health plans as well. It's really assist in driving this broad based agenda across the company.
We have time for two more questions. Next question please.
Operator
And we will go next to Gary Taylor with JP Morgan. Please go ahead.
Gary Taylor - JP Morgan - Analyst
Great, does that mean to ask two questions? No.
David S. Wichmann - Chief Executive Officer
Pardon me.
Gary Taylor - JP Morgan - Analyst
I was going to say, great. Does that mean I get to ask two questions?
David S. Wichmann - Chief Executive Officer
You can, we'll answer the first one.
Gary Taylor - JP Morgan - Analyst
I will ask just my question. My one question is I do appreciate the earnings cadence commentary given the leap year, but thinking since reported MLR such an outsized impact on the near-term stock volatility, wondering if you'd be willing to give us first quarter MLR range. I mean there are a few other moving parts in the quarter besides leap year that was pretty high March seasonality with extra Monday, Tuesday and then obviously with dilutive impact of the HIT reinstatement?
David S. Wichmann - Chief Executive Officer
John Rex you, maybe just, I know that was pretty complex in terms of the quarterly progression and we expected that - John you just want to make sure that everybody understands that well.
John Rex - Vice President and Chief Financial Officer
Sure Gary. Good morning. Let me give you a little more color in terms of the impact that occurs as we go into that. I described kind of some of the impact with workdays content and how that flows. And just in terms of thinking about that. So when value different days with different medical costs, weekend versus weekdays, even versus different days of the week. In terms of what I was describing there, it actually comes out, it's a little - it's not two days, it is more than one day, it is 1.3 days of impact in terms of the workday content is where it fall then to when you flow into a leap year like that and that pattern, typically of course repeats. So that's kind of the element that flows into that.
Then if you consider the other elements we talked about at - when we talk to our full year MCR progression and year-over-year progression, we talked about the impact of the health insurance tax, the 140 basis points and that impact. And then we talked about mix impacts also that occur over the course of the year. So those are really kind of the core that are as we consider, as we consider where we'd expect the medical care ratio to be lining up here as we you look at the first half of the year. I hope that gives you a little extra color.
Gary Taylor - JP Morgan - Analyst
So you don't want to give us a 1Q range today?
John Rex - Vice President and Chief Financial Officer
Sorry. What's that, Gary?
Gary Taylor - JP Morgan - Analyst
You don't - you don't want to give us the first quarter - [Speech Overlap]
John Rex - Vice President and Chief Financial Officer
First quarter pick - I think I kind of just described it actually pretty, pretty hopefully fairly clearly there in terms of the roll forward and how you would approach that. So if you take the components of the math that I just gave you, I think that should get you to a first quarter pick.
David S. Wichmann - Chief Executive Officer
So there is no change to full year guidance. John tried to lay out for you our first half last half would be and then within the first half, what the proportions would be as well. So you should be able to get a pretty good sense of things from all of that recognizing often times things don't shoot quite that straight. So plus or minus would probably be a worthwhile range to put around whatever point estimate you come up with.
Thank you very much Gary. Next question please.
Operator
And we'll go next to Sarah James with Piper Sandler. Please go ahead.
Sarah James - Piper Sandler - Analyst
Thanks for squeezing me in. Now that there is some bipartisan support for spread pricing though. Can you talk about the exposure in '19 you said it was about 25% of the book so did that needle mover for '20, what is the mix look like in your commercial book of spread versus pass through. And does this bill impact the value proposition that you see for OptumRx at all? Thanks.
David S. Wichmann - Chief Executive Officer
John?
John Rex - Vice President and Chief Financial Officer
Sarah, thanks for the question. As you know, we are committed to driving to a strategy around negotiating with the clients of a transparent model where more and more of our services are coming from administrative fees and value-based arrangements. Our clients decide how they want to pay for our services. So when we bid on a deal and for our client, we give them an opportunity either to pay through administrative fee or with spread or traditional. So it's the client choice. So as you look at it, we don't have a preference about where we want to go up in business model. We're in different on how a client wanted to choose it.
In terms of the commercial market, the trend in the market hasn't changed in the last several years. So actually the client is not going to move one way or the other in terms of spread versus administrative fee. As you look at the Medicaid market, there has been a trend over the last three years where more and more of the state organizations and have been moving to administrative fees. So if you looked at our client base three years ago, majority would have been spread. If you look at it today, less than a quarter is in spread and actually we expect that to almost disappear as you look out to next year or two years. So from us when they actually impact our financials, I won't speculate about what will happen in Washington, but we're well positioned from a business standpoint.
David S. Wichmann - Chief Executive Officer
Great question, Sarah. Thank you so much.
I'll go ahead and close now. Thank you all for your questions. Sorry, we can't get to everyone today. As you heard this morning, we remain confident in our outlook for 2020 and beyond. Our diversified in complementary businesses are strong and well positioned for continued balanced growth by delivering even higher levels of societal value, while generating strong returns for you, our shareholders. Thank you and this concludes todays call.
Operator