Elevated Mortality Impact
Q: Why is mortality elevated and affecting volume growth?
A: Mortality is higher than expected, contributing to a 50–100 basis point gap in volume growth. It's up this year compared to six months ago, and although we have hypotheses like an elevated flu season, we lack a quantifiable explanation. We believe this is temporary and not structural, expecting volumes to normalize over time.

Guidance Raise Breakdown
Q: How did you raise guidance by $95 million?
A: We increased revenue per treatment guidance from 3% to 4%, adding approximately $85 million. Improved labor costs contributed $30 million, while lower volume resulted in a $20 million headwind. This bridges to the $95 million increase before accounting for the $60 million in closure costs.

Revenue Per Treatment Growth
Q: Is the increase in RPT sustainable into 2025?
A: While the improvements are sustainable, we expect contributions to RPT growth to decline over time. Benefits from collections and contracting will annualize in 2025, but it's unlikely to see another 3.5%–4% growth next year.

Clinic Closures and Volume
Q: How are clinic closures affecting volume growth?
A: Clinic closures have reduced volume growth by 40–60 basis points, as we closed roughly 200 clinics to optimize capacity. Mid-sized and smaller operators have gained share, but we believe the trade-off improves our fixed expenses by $100–$150 million, offsetting the estimated $50 million loss of volume.

Leverage and Capital Allocation
Q: Do you plan to lever up for share repurchases?
A: We're maintaining a leverage range of 3x to 3.5x. As EBITDA grows, we'll need more debt capacity to stay within this range. Excess capacity may be used for capital-efficient growth or share repurchases, following our capital allocation philosophy.

Mortality Normalization Outlook
Q: When will elevated mortality normalize?
A: Predicting normalization is difficult, but we don't believe it's structural and expect a return to normal levels. We're working to understand the causes and consulting nephrologists, but no systemic trends have been identified.

Integrated Kidney Care Losses
Q: Will IKC meet the expected $50 million loss for the year?
A: Despite a year-to-date loss of $60 million, we still expect to meet the $50 million target due to revenue recognition in the back half of the year. The loss is expected to reduce significantly in Q4.

Commercial Mix and Exchanges
Q: How have exchanges impacted commercial mix?
A: Commercial mix remains around 11%, with exchanges contributing an increase of about 200 basis points to revenue compared to pre-COVID levels.

Future of Commercial Contracting
Q: Will commercial contracting remain a tailwind?
A: We don't foresee dramatic changes from 2024. While inflation considerations remain, dynamics with payers are consistent. We're focused on providing value with great clinical solutions at the best cost. Margin strength is likely to remain in 2025.

Collection Improvements Runway
Q: How much runway is left in collection improvements?
A: There's more to come in 2025 due to annualizing current improvements, but contributions to RPT growth will decline over time. The benefits have exceeded expectations since we started this effort.

Geographic Variations in Census
Q: Is lower census growth isolated to specific areas?
A: No, we're seeing lower census growth pretty much across the board.

International Business Margins
Q: How will international business margins evolve?
A: Margins may tick up but are unlikely to reach U.S. levels. Dynamics vary by country, affecting revenue and margins unpredictably due to factors like single-payer systems.