UnitedHealth Group is the largest healthcare service provider in the U.S., managing over $250 billion in healthcare spend and serving over 165 million people. The Company has first-mover advantage at providing integrated service offerings aimed at bending the cost curve of providing access to care that improves the health outcomes for its members. Over the past five years or so, the Company has aggressively expanded beyond traditional health benefits by making several key acquisitions in large and adjacent healthcare verticals including pharmacy benefits, walk-in care clinics, specialized outpatient service providers, and physician practices. As much of the industry plays catch-up to United’s solutions, we expect United’s addressable market will continue to expand, along with the aging of the general U.S. population. The Company should be able to drive double-digit earnings growth, through a combination of competitively differentiated operating performance as well as capital deployment at attractive multiples.  

联合健康集团是美国最大的医疗服务提供商，管理着超过2500亿美元的医疗支出，服务超过1.65亿人。该公司在提供整合服务方面具有先发优势，旨在降低提供医疗服务的成本曲线，同时改善会员的健康结果。在过去五年左右的时间里，公司通过在大型和相邻的医疗领域进行多项关键收购，积极扩展了传统健康福利之外的业务，包括药房福利、步入式护理诊所、专业门诊服务提供商和医生诊所。随着行业的大部分公司努力赶上联合健康的解决方案，我们预计联合健康的可拓展市场将继续扩大，同时伴随着美国人口的普遍老龄化。公司应能够通过竞争差异化的运营表现以及以有吸引力的倍数进行资本部署的组合，推动两位数的收益增长。

After making several important acquisitions over the past 5 to 10 years, UnitedHealth Group segmented its business into two well-known subsidiaries: Optum and UnitedHealthcare. Like much of the healthcare benefits industry, the Company formerly had a heavy reliance on contracting with outside service providers for care. The Company’s health care benefits group now more exclusively relies on its internal Optum group to increasingly provide value-based care, rather than fee-based, while Optum offers its services to all comers often on a fee-basis. For example, Optum acquired urgent care facilities to help address all the patient issues that might require something more than a regular doctor visit yet are not serious enough for the emergency room (ER). By routing UnitedHealth plan members to Optum-owned urgent care clinics, those patients receive proper care while the health plan incurs substantially less cost than the ER visit. Many healthcare plans still do not cover this sort of outpatient “gap” in care and are at a disadvantage compared to UnitedHealthcare. Of course, while the Company’s plan designs often exclusively rely on Optum, Optum is still free to offer its services to outside healthcare plans, which helps the Company maximize the utilization of those Optum assets. For example, the Company has over 26 million people covered by its employer and individual plans; however, the entire Optum umbrella consists of nearly 100 million customers. Many of those outside plan customers come to Optum via the pharmacy benefit manager ([PBM] OptumRx) which the Company has scaled into one of the largest PBMs in the U.S. through acquisition and share gains.  

在过去五到十年里，通过进行多项重要收购，联合健康集团将其业务划分为两个知名子公司：Optum 和 UnitedHealthcare。与大多数医疗福利行业一样，公司过去高度依赖与外部服务提供商签约来提供医疗服务。目前，公司医疗福利部门更加依赖内部的 Optum 集团，逐步转向提供价值型（value-based）的护理服务，而非传统的按次付费模式；同时，Optum 也常以按次付费的方式向所有客户提供服务。例如，Optum 收购了多个急诊护理中心，以便解决那些可能需要比普通医生就诊更多但又不足以进入急诊室（ER）的患者健康问题。通过将联合健康计划会员引导至 Optum 自有的急诊护理诊所，这些患者能获得适当的治疗，而健康计划所承担的费用则远低于急诊室就诊费用。许多医疗保险计划仍未覆盖这种门诊“服务空白”——与 UnitedHealthcare 相比因此处于劣势。当然，尽管公司的计划设计通常专门依赖于 Optum，Optum 本身仍可自由向外部医疗保险计划提供服务，从而帮助公司最大化这些 Optum 资产的利用率。例如，公司在雇主和个人计划中覆盖了超过 2600 万人；而整个 Optum 体系下的客户总数将近 1 亿。许多外部计划客户通过药房福利管理（PBM OptumRx）转至 Optum，而公司正通过收购和市场份额拓展，已将其打造成美国最大的 PBM 之一。

UnitedHealth Group serves a couple of very large addressable markets that remain relatively underpenetrated. OptumHealth generated $40 billion in revenue during 2020 and has a nearly $1 trillion addressable market. The subsidiary employs (or is affiliated with) 53,000 physicians, more than double the number from 5 years ago, and the Company expects to add another 10,000 physicians during 2021. This aggressive consolidation of the highly fragmented physician market has helped drive out administrative and operational inefficiencies (costs) while maintaining or improving the health outcomes of patients. OptumRx is the Company’s PBM that pools together over $100 billion in purchasing power to lower the net cost of drugs for beneficiaries. After acquiring Catamaran in 2015, the Company insourced its pharmacy benefit from Medco Health (now part of Cigna) and turned the business into one of the top-3 scale buyer of pharmaceuticals. OptumRx is focused on faster growing segments such as specialty pharmacy and infusion services, and although margins are often lower than the rest of the business, our experience is that PBMs are not particularly capital intensive and generate high returns as a result.  

联合健康集团服务于几个相对未充分渗透的大型可拓展市场。OptumHealth在2020年创造了400亿美元的收入，拥有近1万亿美元的可拓展市场。该子公司雇用（或与之关联）了53,000名医生，是5年前的两倍多，公司预计在2021年再增加10,000名医生。这种对高度分散的医生市场的激进整合帮助消除了行政和运营上的低效（成本），同时维持或改善了患者的健康结果。OptumRx是公司的PBM，汇集了超过1000亿美元的购买力，以降低受益人的药物净成本。在2015年收购Catamaran后，公司将其药房福利从Medco Health（现为Cigna的一部分）内部化，并将业务转变为药品采购的前三大规模买家之一。OptumRx专注于增长更快的领域，如专业药房和输液服务，尽管利润率通常低于其他业务，但我们的经验是PBMs并不特别需要大量资本投入，因此能够产生高回报。

As for UnitedHealthcare, they handle roughly 20% of the U.S. Medicare Advantage plan population. With over 10,000 baby boomers aging into qualifying for the U.S. Medicare system every day, enrollment growth has compounded at over 10% for the past 5 years and should continue at similar rates through 2025. The Company achieves this market share and growth by consistently maintaining medical costs that are below traditional Medicare. The Company also serves about 26 million employer and individual members, one of the largest private payer books in the industry. Many of these members eventually find their way into the Company’s Medicare Advantage program, which enables the Company to have a much more detailed picture of member health status over time, allowing for more personalized, effective, and lower-cost care.  

至于UnitedHealthcare，他们处理了大约20%的美国Medicare Advantage计划人口。每天有超过10,000名婴儿潮一代进入符合美国Medicare系统资格的年龄段，过去5年注册增长率复合超过10%，并应在2025年之前以类似速度继续增长。公司通过持续保持低于传统Medicare的医疗成本来实现这一市场份额和增长。公司还服务大约2600万雇主和个人会员，是行业内最大的私人支付者之一。许多这些会员最终会加入公司的Medicare Advantage计划，这使公司能够随着时间的推移更详细地了解会员的健康状况，从而提供更个性化、有效且成本更低的护理。

The combined scale of the Company’s business segments along with supportive demographic trends in the U.S. should help the Company sustain double-digit earnings per share growth for the next several years. UnitedHealth Group should be able to supplement this growth through continued consolidation of the highly fragmented healthcare industry. The stock currently sports a below-market multiple, despite peer-leading profitability metrics and unrivaled scale, which made it an attractive addition to the portfolios during the quarter.  

公司业务部门的综合规模以及美国支持性的人口趋势应帮助公司在未来几年维持每股收益的两位数增长。联合健康集团应能够通过持续整合高度分散的医疗行业来补充这一增长。尽管拥有同行领先的盈利指标和无与伦比的规模，该股票目前的市盈率低于市场平均水平，这使其在本季度成为投资组合中一个有吸引力的补充。

“I, Pencil” has long been a favorite soliloquy on and celebration of free market economies for over 60 years. We reference it in our Letter as not only a compelling treatise on the mind-numbing complexities of making, well, a simple pencil but also a juxtaposition against the truly unfathomable complexities of our modern day, just-in-time global supply system. We hope by comparison we can convey our worries that Corporate America and Jane and Joe Consumer will continue to face uncharted waters of a mismatch between soaring consumptive demand and near-structural matériel and finished-goods shortages in everything! The manifest combination of COVID-related global shutdowns and the spun-off symptoms of labor shortages, raw material shortages, intermediate and finished goods shortages, double and triple ordering masking true demands, chain-reaction transportation gridlock, innumerable commodity, manufacturing, and labor inflation spikes has, as our greatest fear, both structural supply shortages and systemic (not transitory) inflation, that grinds well into 2023.  

《我，铅笔》长期以来一直是自由市场经济的一个受欢迎的独白和庆祝，超过60年。我们在信中提到它，不仅是作为制造一支简单铅笔令人麻木的复杂性的引人入胜的论述，也是与我们现代即时全球供应系统的真正难以想象的复杂性形成对比。我们希望通过比较，我们能表达我们的担忧，即美国企业和普通消费者将继续面临消费需求激增与几乎结构性的物资和成品短缺之间的不匹配的未知水域！与COVID相关的全球停工以及由此引发的劳动力短缺、原材料短缺、中间产品和成品短缺、双倍和三倍订购掩盖真实需求、连锁反应的运输拥堵、无数商品、制造和劳动力通胀飙升的明显结合，作为我们最大的恐惧，既有结构性的供应短缺，也有系统性的（非暂时的）通胀，这种情况将持续到2023年。

If compound interest is the 8th Wonder of the World, the Just-in-Time Inventories surely ranks a close 9th. When does the U.S. economy (and the global economy) get back to Normal? What is Normal? Is Normal post-COVID, 2019? 2018? Could 2021…2022…2023 be the New, New Normal? Yes, unfortunately, we think so.  

如果复利是世界第八大奇迹，那么即时库存无疑是紧随其后的第九大奇迹。美国经济（以及全球经济）何时能恢复正常？什么是正常？正常是COVID后的2019年吗？2018年吗？2021年…2022年…2023年会是新的、新的正常吗？是的，不幸的是，我们认为是这样。

Over the past few quarters, we cannot recall a single earnings conference call when the forecast or question of “getting back to normal” was not either prophesied or queried very early on in the call. Without fail, the forecasted or answered “Normal” continues to be “2019.” To be fair to corporate managers, this new, new operating environment circa-2021 is well beyond their collective career experiences. In essence, they are collectively flying by the seat of their pants. Charles Lindbergh they ain’t.  

在过去的几个季度中，我们不记得有哪一次盈利电话会议，在会议一开始时没有预测或询问“恢复正常”的问题。毫无例外，预测或回答的“正常”始终是“2019年”。公平地对待企业管理者来说，2021年左右的这种新的、新的运营环境远远超出了他们的集体职业经验。本质上，他们集体上是在凭感觉行事。他们不是查尔斯·林德伯格。

The psychological desire of investors and Corporate America to get back to a time pre-COVID is quite powerful. (Well, that goes for the lot of us too.) Once the pandemic began, the global economy suffered through unprecedented rolling shutdowns over the past 18 months, along with the concomitant collapse of the economic miracle of a just-in-time global supply chain – which we now realize was truly a modern economic miracle. Our evolving answer to the “getting-back-to-Normal” question is that today, 2021, is the New, New Normal. In all of its symphonic logistical elegance, 2019 was, in brutal hindsight, perfectly Abnormal. The year 2019 was Spinal Tap at 11 – 2019 was, indeed, perfectly unprecedented.  

投资者和美国企业对恢复到COVID前时代的心理渴望非常强烈。（嗯，这对我们所有人来说也是如此。）一旦大流行开始，全球经济在过去18个月中经历了前所未有的滚动停工，以及即时全球供应链这一经济奇迹的随之而来的崩溃——我们现在意识到这确实是一个现代经济奇迹。我们对“恢复正常”问题的不断演变的答案是，今天，2021年，是新的、新的正常。以其交响乐般的物流优雅，2019年在残酷的回顾中是完全异常的。2019年是《Spinal Tap》中的11——2019年确实是完全前所未有的。

We are all brutally aware of the collapse of global supply chains due to COVID shutdowns. Product orders in 2019 to be manufactured by early 2020 were never manufactured, completed, or shipped. Once global economies staggeringly reopened, backorders began to be filled, slowly at best. Then came a wave of unprecedented demand as trillions of fiscal stimulus checks flooded the market. All at once, global consumers who were locked down at home were denied the usual services (travel, vacations, restaurants, movies, and theater) decided en masse to cure their collective cabin fever by splurging on capital goods (cars, trucks, decking, pools, home repair). It didn’t take long to lay bare the shelves of capital goods – particularly home goods. (How goes that new kitchen you were promised would be completed back in February?) The modern global supply chain has never had to deal with collapsing supply, coupled with surging demand. Price increases across the commodity complex have exploded at rates of increase rarely seen by the current class of corporate managers. In addition, rolling factory reopening plans have been countlessly delayed due to spikes of the Delta COVID variant across the globe.  

我们都残酷地意识到由于COVID停工导致的全球供应链崩溃。2019年计划在2020年初制造的产品订单从未被制造、完成或发货。一旦全球经济艰难地重新开放，积压订单开始被缓慢地填补，最多也只是缓慢。然后，随着数万亿美元的财政刺激支票涌入市场，出现了前所未有的需求浪潮。突然间，被困在家中的全球消费者被拒绝了通常的服务（旅行、度假、餐厅、电影和剧院），他们集体决定通过挥霍资本货物（汽车、卡车、甲板、游泳池、房屋维修）来治愈他们的集体幽居病。没过多久，资本货物——尤其是家居用品的货架就被清空了。（你承诺在二月份完成的新厨房进展如何？）现代全球供应链从未不得不应对供应崩溃与需求激增的双重压力。大宗商品综合体的价格上涨以现任企业管理者很少见的速度爆炸式增长。此外，由于全球Delta COVID变种的激增，滚动工厂重新开放计划被无数次推迟。