Fresenius Medical Care - Q2 2023

Transcript

Operator (participant)

Ladies and gentlemen, thank you for standing by. My name is Emma, your Chorus Call operator. Welcome, and thank you for joining the Fresenius Medical Care report on the second quarter 2023 earnings results. Throughout today's recorded presentation, all participants will be in a listen-only mode. The presentation will be followed by a question-and-answer session, and if you would like to ask a question, you may do so by pressing star followed by 1 on your telephone keypad. If you need operator assistance, please press star followed by 0. I would now like to turn the conference over to Dominik, Head of Investor Relations. Please go ahead, sir.

Dominik Heger (Head of Investor Relations)

Thank you, Emma. As mentioned by Emma, we would like to welcome you to our earnings call for the second quarter 2023 from a cold and rainy Bad Homburg. We appreciate you joining us today to discuss the performance for the second quarter. I will, as always, start out the call by mentioning our cautionary language that is in our safe harbor statement, as well as in our presentation and in all the materials that we have distributed earlier today. For further details concerning risks and uncertainties, please refer to these documents as well as to our SEC filings. We will try to keep the presentation short and leave time for questions. As always, we would like to limit the number of questions again to two in order to give everyone the chance to ask questions.

Should there be further questions and time left, we can go a second round. It would be great if you could make this work again. Unfortunately, we are limited to 60 minutes for the call. With us today is Helen Giza, our CEO and Chair of the Management Board, and until the first of October, also our acting CFO. With that, Helen, the floor is yours.

Helen Giza (CEO and CFO)

Thank you, Dominik. Welcome, everyone. Thank you for joining our presentation today and for your continued interest in Fresenius Medical Care. I'll begin my prepared remarks on slide 4. Earlier this year, we laid out our strategic plan to unlock value as the leading kidney care company. We are actively executing against this plan, and today I am very pleased to be able to highlight several meaningful proof points that demonstrate tangible progress to date. At the beginning of the year, our new operating model was implemented, and last quarter we rolled out the corresponding new financial reporting. This leaves the simplification of our governance structure as the 1 outstanding structural element, and our extraordinary general meeting in July was an important step towards completing this aspect of the plan.

Following the 99.88% approval by voting shareholders in support of our change in legal form, all necessary administrative, compliance, and regulatory steps are moving forward, the entire process is still expected to be completed by the end of the year. At the same time, we continue to advance our operational efficiency and turnaround plans. Our FME25 transformation program is well on track to deliver EUR 250 million-EUR 300 million in sustainable savings by the end of the year, in the second quarter, we realized an additional EUR 75 million in sustained savings. This is positively impacted by the 53 net clinic closures in the U.S. that we have completed in the last three quarters, we plan to close up to 100 clinics as part of this program.

It's very encouraging to see the execution against our strategic turnaround plans has resulted in visible productivity improvements, most notably in Care Delivery. This contributed, contributed to achieving a second quarter margin of 10.4%, which is promising, as it is already at the bottom end of our 2025 target margin band for the segment. Our strategic plan also includes a careful reassessment of our portfolio assets and R&D efforts as we focus on sustainable, profitable growth assets and seek to divest non-core assets and dilutive assets. In the previous quarter, we decided to discontinue the development program for a PD cycler, and more recently, we announced the strategic divestments of clinics in sub-Saharan Africa and Hungary. These exits demonstrate progress against our portfolio optimization strategy.

It is also important to us that we have found reputable and well-established partners to ensure the continuity of care to the patients who had entrusted us with their care. As a reminder, portfolio optimization effects are excluded from our 2025 target margin band since the timing of the execution is dependent to a large degree on various external factors. This played out different to our expectations, for example, in the second quarter. Since our Capital Markets Day, we have received many requests to size the impact of our divestitures. Therefore, I would like to give you at least of an idea of how it could impact our revenues should we execute on everything under review through the end of 2025. In this case, we could see a negative impact from the overall portfolio optimization on 2025 revenues of up to EUR 1.5 billion.

Under the same assumptions, we expect a positive impact on margins. As you heard me say before, the resulting cash proceeds will be used towards deleveraging in line with our disciplined financial policy. I am also proud of the fact that as we execute against our strategic plan, we are simultaneously driving a winning culture focused on accountability, along with an ongoing commitment to sustainability. We remain a mission-focused company with our patients front and center in everything we do. Turning to slide 5. To that extent, we are continuously monitoring our clinical performance to enhance care. An important KPI in this regard is our Global Quality Index. The quality index considers dialysis effectiveness, vascular access, and anemia management. Through the second quarter, we continue to see sequential stability at a high level. I will move to slide 7 to review our second quarter business performance.

In the second quarter, we saw an acceleration in organic revenue growth, driven by both operating segments. This includes sequentially stable treatment volumes in Care Delivery U.S. I'm encouraged to see proof of strong underlying trends beginning to translate into improved financial performance. The execution progress I have mentioned in the beginning is also clearly visible when looking at the second quarter. First, the execution against our strategic turnaround plans has resulted in visible productivity improvements in Care Delivery. Secondly, our performance in the second quarter was also supported by savings resulting from our FME25 transformation program. Thirdly, we continue to execute on our portfolio optimization strategy with the announced divestment of 2 international markets and are actively working on divestment of other dilutive and non-core assets.

Given our stronger than planned earnings development through the first six months, we are narrowing our full year 2023 operating income guidance range, which I will speak to later on. Turning to slide 8. In the second quarter, we delivered revenue growth of 6% at constant currency. We continue to deliver accelerated organic growth with positive contributions from both segments. This development is driven by favorable pricing in both segments, by positive volume development in Care Enablement, and growth in the value-based care business within Care Delivery. During the second quarter, operating income on a guided basis improved by 44%. This results in a group margin of 8.3%. Earnings development in the second quarter was bolstered by reduced personnel expense, resulting from improved productivity, as well as from improved business performance supported by FME25 savings.

Although we have seen a degree of stabilization, our business still faces the expected inflationary pressures. That particularly impacts our Care Enablement segment. On slide 9. This slide shows the contributions to the operating income development by operating segment compared to the prior year second quarter. Starting from the left, you can see how we get to the starting point of our guidance basis. From the contributions of the two operating segments, Care Delivery represents 88% and Care Enablement 12%. The EUR 44 million special items in the quarter relates to EUR 25 million in FME25 costs, and the remaining EUR 19 million relate to charges associated with our legacy portfolio optimization, the Humacyte investment remeasurements, and costs associated with the conversion of legal form. On slide 10.

Revenue growth for Care Delivery was driven by organic growth, which was supported by a positive impact from our value-based care book of business in the U.S., reimbursement rate increases in both the U.S. and international markets, and a favorable payer mix in the U.S. In Care Delivery U.S., same store treatment growth was virtually stable on a sequential basis and at the midpoint of our volume assumption of -1 to +1 for the year. This reflects mortality trends effectively at pre-pandemic levels and still muted new starts as we move through the annualization of COVID-19 related excess mortality in the late stage CKD and ESRD populations. Earnings were positively impacted by lower personnel expenses resulting from improved productivity, with a meaningful contribution coming from the continued optimization of our clinic network. Savings from FME25 and business growth contributed in a meaningful way.

In Care Delivery International, organic growth was supported by the effects of hyperinflation in various markets. As I highlighted earlier, we also executed on our portfolio optimization strategy with international market exits in sub-Saharan Africa and Hungary and continue to progress further divestment decisions. Next, on slide 11. On this slide, we show how these trends have translated into financial performance. Care Delivery revenue increased by 6% on a constant currency basis, driven by a 6% organic development for the reasons I just outlined on the previous slide. In addition to positive business growth and FME25 savings development, Care Delivery also experienced a net positive labor and inflation development in the quarter. The tailwind is mainly driven by a low prior year comparable in the second quarter and by improved productivity.

While we experienced a labor tailwind in the first half of the year, we will face a different prior year comparable in the second half. Overall, while the market is stabilizing, we are still monitoring and managing key hotspot markets and implementing measures as needed. Therefore, for the full year, we still expect a labor cost headwind in line with our guidance assumptions. Turning to slide 12. Care Enablement revenue was supported by higher sales of machines for chronic treatment, critical care products and home hemodialysis products, as well as increased average sales prices, driven by the first impact of our targeted pricing measures. On the earnings side, second quarter business growth is muted by the negative currency transaction effects. The inflationary pressures are developing as expected.

In the 2Q, Care Enablement saw a positive benefit from FME25 savings, driven by organizational as well as manufacturing and supply chain initiatives. Next, on slide 13. Here we look again at how these trends have translated into financial performance in this operating segment. Care Enablement revenue increased by 6% on a constant currency and organic basis. This was driven by the reasons I outlined on our previous slide. On our guided basis, operating income for Care Enablement increased to EUR 19 million. The improved operating income was driven by FME25 savings as well as positive business growth, which already includes the negative currency transaction effects I mentioned earlier. Operating income was partially offset by inflation, which, as assumed in our guidance, continues to be the biggest headwind for this business. Year-over-year, the margin has improved as planned.

As laid out at our Capital Markets Day, the measures we are taking in Care Enablement to get into the 2025 target margin band will take time. Turning to slide 14. In the second quarter, we experienced a strong cash flow development compared to the prior year period. The increase in net cash provided by operating activities was driven by seasonality in invoicing and improved cash collection, as well as a weaker prior year comparable due to CMS's recoupment of advanced payments previously received under the Medicare Accelerated and Advance Payment Program in 2020, in the second quarter of 2022. Supported by our disciplined capital allocation policy, the quarter delivered strong free cash flow conversion. Our leverage ratio of 3.4 times remained in our target corridor of 3 to 3.5 times.

As it is still at the upper end of this self-imposed range, deleveraging remains our top capital allocation priority, with any proceeds from divestments to be used for deleveraging. I'd like to finish with our update to the outlook on slide 16. For 2023, we continue to expect revenue to grow at low to mid-single % rates. For our earnings outlook, we initially guided for a flat to high single-digit operating income decline for 2023. Based on our stronger than assumed earnings development in the 1st quarter and again in the 2nd quarter, we are confident to narrow our operating income guidance range from a flat to high single-digit decline by around 600 basis points. We now expect operating income to remain flat or decline by up to a low single-digit % range.

It's important to me that we provide a realistic but careful guidance that we have a clear path to achieve. Operating income improved sequentially and year-over-year due to stronger than expected operational performance. We carefully need to take into consideration the many moving pieces, like labor headwinds, continued impact from inflation, and potential currency transaction impacts in the second half of the year, as well as a higher comparable in the prior year. Even after considering all these moving parts, I feel confident with our new, considerably narrowed operating income guidance range. Of course, we are fully confident in our path to unlock value as the leading kidney care company and to achieve an improved operating profit margin of 10%-14% in 2025. Concludes my prepared remarks. I'll now hand it back to Dominik.

Dominik Heger (Head of Investor Relations)

Thank you, Helen, for your presentation and the insights. Before I hand over for the Q&A, I would like to remind everyone to limit your question to two, please, so that everyone has a chance to ask questions. With that, I'll hand it back to Emma to open the Q&A, please.

Operator (participant)

Thank you. Ladies and gentlemen, at this time, we will begin the question and answer session. Anyone who wishes to ask a question may press star followed by one on their telephone keypad. If you wish to remove yourself from the question queue, please press star, then two. Anyone who has a question may press star followed by one at this time. One moment for the first question, please. First question is from the line of Victoria Lambert with Berenberg. Please go ahead.

Victoria Lambert (Analyst)

Taking my question. First one is just on geographies, as Medical Care now wants to stay in. You guys are out of Hungary, you're out of sub-Saharan Africa. What would you consider your core geographies, but the U.S., obviously? My second question is just on the outlook for the business, how we can expect margins to develop in H2, given the margin performance between Q1 and Q2 was pretty volatile. Would just like to get a steer on how we should think about that.

Helen Giza (CEO and CFO)

Hi, everyone. Sorry, Victoria, thank you for your questions. On your first one, regarding geography, rather than getting into specific countries and geographies for obvious reasons, I think I would just come back to how we are thinking about the countries in CDI. As I've outlined previously, I would put those into three buckets. There's, you know, kind of the core markets that we feel are reimbursement friendly, are profitable, and that we feel that we can continue to grow those markets. Then there's a middle bucket of markets where they are profitable, we feel that we can improve the performance with, you know, a bit more focused efforts and maybe run those out over time with a, with a tail as needed if we don't see a way to kind of improve the profitability over time.

There's a third bucket, which are either unprofitable, they're smaller in scale. We don't feel that we can do anything with them, and there is likely a better owner than us for those those markets. Clearly you can see, with Africa and Hungary, they would, you know, kind of falling into that, that third bucket, and we will continue to move those forward at pace. You probably all appreciate, we can only communicate once we have definitive signed agreements, so the timing of these is difficult to project. We know what we have in flight, and I think that's why we're trying to size it, but at the same time, kind of, you know, be very clear in, in, in the focus there.

Look, on your second question about the outlook for H2, I'm not going to give you margin guidance by, you know, by CE and CD. We've obviously guided for the total company. You know, there, there are swings in that margin, you know, obviously as you've got the year-over-year comps on the, on the respective quarters. You know, obviously, we, we have a full year guidance out there. As we, as we, I think advised at the Capital Markets Day, with CE, obviously that is a, a longer climb, but we, we do expect to be above our 2022 number, which was 1.9%.

Victoria Lambert (Analyst)

Great. Thank you.

Operator (participant)

Next question is from the line of Veronika Dubajova with Citi. Please go ahead.

Veronika Dubajova (Analyst)

Hi, good afternoon, and hello, Helen and Dominik. Thank you for taking my questions. I will keep it to two, please. First, I want to just go back to the guidance for the full year, Helen, appreciate your comments about conservatism, but just maybe to push you a little bit. I think historically, the seasonality in your business is the second half EBIT was always higher than the first half. Are there any reasons whatsoever for that not to be the case this year? Because obviously the guidance seems to imply that, and I'm just trying to understand why that would happen.

Then my second question is just to drill down a little bit, in particular on the North America Care Delivery growth rate. Clearly some very notable benefit from revenue per treatment, just if you can quantify to what extent that's mix versus underlying rate increases, and how durable you think that is into the back half of the year. Thank you.

Helen Giza (CEO and CFO)

Hi, Veronika. Thank you for your questions. look, on your first question on guidance, you know, there, there's a lot to unpack there. What I would say, yeah, yeah, clearly, you know, you've heard my language. I want to make sure that we are delivering this quarter, quarter by quarter here, which we have done, you know, sequentially now for the last 3 quarters. You know, if you take our 2023 half 1 guidance, and then you look at the, you know, kind of the implied guidance, you know, y-you're doing the math correctly, it would, on the surface, assume that we have a lower H2 in 2023 than we did in 2022.

What I can say is we are expecting our half two, on an EBIT level, to be higher than half one, but there are some moving parts in that. In 2022, half two, we did have some, I'm not going to call them one-timers, or, you know, special items, but we did have some operational improvements, or maybe operational one-timers, let me call it that, rather than special, special items. We had some, you know, NCP deconsolidation gains, and we did get an additional consent payment in half one. Half two, 2022. As we look at half two, 2023. We also have to take in the increase from the stock price on stock incentive compensation. We are taking that into account for our half two outlook.

In addition to that, as you can see, we do have, you know, kind of a, a nice beat in half 1, but we're also-- and we don't expect, you know, some of that not to continue, but we are watching. In particular, I would say the transaction effects that we are seeing in some of these, you know, maybe more volatile countries. Underlying operational performance, I'm very confident about, but when you start to see the comparable half 2 over half 2, 2022 to 2023, there are some nuances in there. You know, I, I feel, I feel really confident in our ability to continue to drive, you know, half 2 growth over half 1. Hopefully that helps unpack some of that. Once you strip those out, the underlying is, is indeed, quite favorable.

In terms of your second question on North America CD growth, really excited with that growth, and it's actually both rate and mix improvement. You know, obviously the, you know, the reimbursement rate is coming through. On mix, mainly driven by Medicare Advantage, which is now sitting at around 40%. Right at 40%, actually. You know, nice to see all of these metrics going in, in the right direction.

Veronika Dubajova (Analyst)

That's very clear. Thanks so much.

Operator (participant)

Next question is from the line of Richard Felton with Goldman Sachs. Please go ahead.

Richard Felton (Analyst)

Thanks. Good afternoon, Helen. Good afternoon, Dominik. Just to follow up on what you're seeing in terms of labor costs in the U market. In particular, I'd be interested to hear an update on your reliance on sort of contract labor and general levels of wage inflation in that market. I mean, it looks like from your numbers that H one was, was pretty good, but your comments into H two sound a little bit more cautious. An update on what you're seeing would be very helpful.

Then my second question, to follow up on Veronika's question on the payer mix, in US Care Delivery, is there any reason why that sort of, you know, tailwind on mix that you saw this quarter is just sort of a one quarter anomaly? Or are some of those shifts kind of, a little bit more durable, and maybe duration more than just one quarter? Thank you.

Helen Giza (CEO and CFO)

Yeah. Thanks, Richard. Look, labor has continued to be, you know, a lot of moving pieces. I feel, you know, the assumptions that we called at the start of the year are holding. You know, we, we do talk about labor stabilizing and the availability of labor, obviously, improving. You know, the, the reduced volume of temporary labor and the rates, like, really dropping to, you know, kind of back to normal levels. What we saw in Q1, we saw continuing in Q2, and, you know, very de minimis now, compared to what it was last year. I think the bigger driver on labor, you know, not just the fact that, you know, costs and wages are in line with expectations, is the terrific job the U.S. operations team are doing on driving productivity.

That obviously helps, you know, and, and that's what we're seeing, the beat on that we saw some in Q1 and even more so in Q2. I feel we got our arms around labor. When I talk about the caution going into half 2, you know, I don't need to remind any of us of the hot mess we were in last July when we did our, you know, profit warning and, you know, the kind of the, the labor costs spiraling out of control, our availability of labor and impacting our, our operations. The reality is that we see a lot of that labor cost showing up in half 2 of 2022. We have, you know, obviously an unfavorable comp for 2023.

The full year that we are calling, we, we feel, we feel okay about. I, I, or maybe we feel good about. I think the watch out that we have is the high like, what we're calling hotspots. For, you know, for the majority of the, you know, the country, we've got this well under control. As you can appreciate, in some, you know, some states, some metro areas and hotspots, we are seeing, you know, some of those areas still a little bit more, more difficult to fill. While we are seeing this labor improvement and labor productivity, we are expecting to have to invest, you know, a little bit in these hotspot areas.

Nothing outside our guidance range, if we, you know, we, we don't want to be foolish here and not invest to kind of continue to drive the growth in, in future periods. That's just a bit of the moving part, and that caution is just that we are very, very carefully managing, you know, kind of every clinic, every location, and accordingly. This isn't a throw the kitchen sink at it, like maybe we had done historically, but very, very targeted view on these areas. You know, we, you know, we're seeing wage inflation still around that, that 4%. You know, we do go into the holiday period here, so we do use a little bit more temporary labor just to cover, you know, regular, normal seasonality.

That will be, you know, a little bit of a tick-up in open positions as we go through that seasonality, but overall, yeah, I think we've got our arms around it quite well, and the team has done an incredible job here. On your second question on payer mix, in the US, no anomaly there. I mean, we are, I think we've got our arms around the mix and rates, and we're seeing that kind of pull through. We are confident for that to continue in half two as it did in half one.

Richard Felton (Analyst)

Great. Thank you very much.

Operator (participant)

Next question is from the line of Hassan Al-Wakeel with Barclays. Please go ahead.

Hassan Al-Wakeel (Analyst)

Hi, good afternoon, and thank you for taking my questions. I have two, please. Firstly, on rate. What is your take on the preliminary ESRD PPS for 2024, which looked to be more modest an increase than many expected. Do you expect the final rule to land here, and could this present a challenge at all to your 2025 margin targets? Do you still think the 2025 PPS rate should accelerate meaningfully from here? Secondly, could you update us on the portfolio side and your progress on divestitures? You highlighted the $1.5 billion of revenues that are addressable if you do all you set out to, which is helpful. Thank you. Could you help quantify the rough margin differential or indeed tailwind, all else being equal? Thank you.

Helen Giza (CEO and CFO)

Thanks, Hassan. Clearly, we're disappointed with the 1.6% proposed rate. We obviously don't know what that is going to look like in the final rate. I don't have that, don't have that crystal ball, unfortunately. Obviously, we continue to put our case forward for an improved rate, but we'll see where the final rate comes in. As I've said previously, we have forecast and guided for moderate rate increases, and I think that is consistent with how we have thought through the 2025 targets. But obviously, we will continue to advocate for a higher rate for the cost increases that we've experienced.

We have no reason to believe that the, the reimbursement model shouldn't hold true, clearly, we've seen a disappointing reaction to the current inflationary environment in that, in that rate. You know, clearly, it's not just an issue for us, it's for, for all service providers. Look, on the portfolio, we, we do listen. We do that, we do take note of the many questions we got about, about that. We thought it was helpful to try and size it. Obviously, you know, we're not trying to get an unpacked 2025 detailed guidance because, you know, we're trying to be moderate with how we roll that out, and that's why we're kind of focusing on the, on the margin bands.

As I said, if we execute everything, it could be up to $1.5 billion of, of lower revenue. You know, clearly, we are -- and if you go back to my Capital Markets Day slide, that was quite deliberate. If you go back to there, and you can kind of look at the things that are either lower growth or lower strategic value, you can assume that they're all in scope. You know, what we are seeing if we execute on everything, and there are some that we would lose absolute EBIT, but there are others that are loss making. Our current assumption is that it would be margin accretive, and it wouldn't take us out of the margin band.

Hassan Al-Wakeel (Analyst)

Thank you.

Operator (participant)

Next question is from the line of Oliver Metzger with ODDO BHF. Please go ahead.

Oliver Metzger (Analyst)

Yes. Good afternoon. Thanks a lot for taking my questions. The first one is, you specified value-based care contribution as a positive driver of Care Delivery. Is there any chance that you can quantify the positive contribution to a certain extent, at least, and also whether we should expect the same magnitude for the next quarters? Second question is, sorry for over your... again, on your guidance, and I've understood all your words, so I appreciate the narrowed guidance band. On the moving parts, I still have some misunderstanding, to be honest, and that's particularly on labor cost. Initially, you had your labor cost and your assumptions of EUR 140 million-EUR 180 million. In the first half, now you have a positive EUR 49 million.

You still stick to the guidance and understand also the phasing argument. If I look for the whole guidance and understand that the lower end is not realistic anymore, therefore you increase, you narrowed it. You stick to one, the most, or the, basically the most important point of your input costs, the labor cost, and to say, "Okay, that's will not change." Could you help me to understand what are the other moving parts, which at the end, drove your guidance update? Thank you.

Helen Giza (CEO and CFO)

Yeah. Thank you, Oliver, for your questions. We're not gonna disclose the, the relative contribution for the VBC part of the business. Obviously, you know, we don't go into the subsegments here. You know, what we, you know, it's w-what we're working through, and Dominik and I have been chatting about this, is how can we give, you know, more metrics and more KPIs into this business as it continues to grow, both across our ESRD population and CKD population. You know, you, you know, our kind of projections on the medical cost under management, and you know that margin. We do have now about 125,000 lives covered with the biggest number of patients from, from CKD.

Let us, we're taking that as a follow-up to try and work through how we can disclose some supplemental KPIs on that, and we'll come back in in Q3. On the guidance question, yep, you're right. Our labor cost assumption is still $140-$180 out of a headwind, and we are favorable through half 1. We obviously have some additional productivity, but we also know that, you know, we've got this additional phasing in the back half of the year, and our merit increases kick in in July, so that's also in in half 2.

You know, obviously, you know, as you can appreciate, you know, we're working through, you know, kind of the overall guidance with a lot of moving parts, positive and negative. I am encouraged by the positive that we've seen in half one, also trying to be, you know, kind of cautious about half two. Obviously, as I, as I mentioned in my answer to Veronika, we obviously have some other things to navigate in the guidance that we didn't see when we gave guidance. I mean, I think the incentive stock comp is a piece of that, as well as, you know, watching this exchange rate.

Even with those negative impacts, I hope you are encouraged, as I am, that we are still able to improve our guidance. You know, we'll see how some of this plays out in Q three. You know, I feel confident with what we're doing today, but obviously watching some of these moving parts and how they, how they play out.

Oliver Metzger (Analyst)

Okay, thank you. One quick follow-up on the value-based care. Is it the, the payment or the money you, you have got, has it more a one-time characteristic, or should we expect, let's say, homogeneous cash inflow over the next quarters, basically in line with the overall assumption?

Helen Giza (CEO and CFO)

Yeah, I am. I, I'm sure some of my team are listening to the call and they're smiling as you ask that question. I think this is one of the hardest things to forecast in terms of the, the phasing of the revenue, and even internally, we refer to it as the lumpiness of the VBC revenue. I mean, I think some of this depends on, you know, kind of when the contract is signed, the terms of the contract, then when we get the, you know, the profit sharing or the risk sharing coming out of these contracts.

While we're doing our best to forecast what we expect on a revenue line from VBC, it is playing out, you know, quite lumpy, even against our own forecasts. We have to find a way to... We're doing our best to forecast it the best we can, of course. I think we then just need to come back with some explanations around that. It's, yeah, it's definitely absolutely not a straight line, unfortunately.

Oliver Metzger (Analyst)

Okay, great. Thank you very much, Helen.

Operator (participant)

Next question is from the line of James Vane-Tempest with Jefferies International Limited. Please go ahead.

James Vane-Tempest (Analyst)

Hi, good afternoon. Thanks for taking my questions. 2, if I can, please. Firstly, just to follow up on the divestments, of up to EUR 1.5 billion. Just wondering, Helen, you've given some scope in terms of the different buckets and where they could possibly get to, I'm sort of wondering, looking at those in aggregate, you know, it's possibly around, you know, 7%, I think, of 2025 revenues. If this is just the international Care Delivery, sort of ex-U.S., it's potentially up to 40% of that business. I was just wondering, is that focusing in the right area where those divestments could be, or are they in other areas?

I think related to that, I guess there's a question on the potential margin impact, but if these are below group margin, I'm not asking for a point estimate, but just in terms of how to think about it potentially. You know, if those are, essentially break even, then that would add around 70 basis points to a margin, roughly, or around a 5% margin, it could be around 30 basis points. I was just wondering whether that's a good quantum to think about where those could be and what the impact could be to 2025 targets, which exclude those. My second question is, I'm just curious what it would take for you to raise the upper end of the EBIT guidance range to above zero, and what is the impact to EBIT growth from divestments closed or that could happen this year? Thank you.

Helen Giza (CEO and CFO)

Yeah. Thanks, James. I think I spent a little bit of time laying out the CDI buckets for Victoria because she asked specifically about geographies. Obviously there are other assets in play and in scope, so you should look broader than just CDI. Again, I would maybe have you go back to the Capital Markets Day chart, where you can kind of maybe see some of those assets and where they fit on the chart. In terms of the, you know, the margin impact, I mean, basically what we're seeing, you know, with, with everything overall, it's why I can kind of say it's been margin accretive. The net of all of it washes out pretty flat to a small kind of EBIT number.

Maybe that's the best way to think about it, because we will be focused on some non-core assets that do deliver our EBIT, also on other assets that are negative in EBIT. When you take it all into account, it's probably a very low single-digit EBIT % impact. Maybe that's the best way I can size it right now. It's hard to do that because I haven't given you the guidance, which is through 2024 and 2025, and I know, I know I know that, but I think that's the best way to think about it.

James Vane-Tempest (Analyst)

No, that's very helpful. That gives a lot more color. Thanks for that.

Helen Giza (CEO and CFO)

Okay. Your 3rd question actually was about question 3-- question 2, after 1B. What would it take to raise the upper part of the guidance? Look, I, I think. I'm, I'm very encouraged by what we're seeing with the labor productivity. I think how labor will develop in, you know, these, what are these hotspot markets and what we might need to invest if those-... don't need as much investment. I think that could play a positive role. If we continue to get, you know, productivity, here at, you know, at an accelerated rate, I think that is, that's something, we'd like to see, and the team are managing it well.

I think the biggest unknown for me as I look at, you know, all the assumptions going into half 2, and I think we have a really, really robust view on, on, on H2, is really this foreign exchange transaction, and this volatility in exchange rates. You know, obviously, we look at what we can hedge and what we can't, but there's difference in, you know, kind of invoice currency versus local currency. You know, we've got China, we've got the Ruble, we've got these hyperinflation countries. If that stabilizes and it's not as bad as maybe we are looking at right now, I think that could also drive a, drive an improvement in, you know, kind of in, in the guidance. I think overall, you know, everything is, is on track. It's going really well.

Our spend levels are under control. Our FME25 is, is delivering quite nicely. You know, I think we're just, and maybe that's the caution. You all know me by now, just delivering this quarter by quarter. Of course, if we see the signs that we have the confidence to change it, we will. I mean, also, I mean, I don't need to remind everybody that we're, we're coming off a very volatile prior year. You know, I just really trying to take this a quarter at a time, which I, I think you, you said this morning in your report. Thanks very much.

Operator (participant)

Next question is from the line of Lisa Clive with AB Bernstein. Please go ahead.

Lisa Clive (Senior Analyst)

Hi there. Just 2 questions. 1 on reimbursement increases ex-U.S. Could you just give us a sense of what proportion of those are sort of tied to inflation, you know, CPI, et cetera, and what proportion of those are kind of a bit sort of at the discretion of a health ministry to just sort of raise at a certain point in time? Second question is just around the Care Enablement margins over the long term. You know, for med tech sector, especially where your position, you have 40+% market share, you know, compared to other med tech sectors, you would think that you'd have a high teens, maybe margin even into the 20s. If we think really long term, is there any reason why this is sort of structurally not possible in dialysis? Is it around the reimbursement model? What would really need to happen in terms of transforming how that business operates? Is it a more active product cycle? Is it better price discipline? Just sort of high-level thoughts on that. Thanks.

Helen Giza (CEO and CFO)

Lisa, I, I, we'll try and pull it here as well as, as I'm talking, but the reimbursement ex-US is very much a mixed bag. What we have been seeing, you know, where we've got reimbursement year, increases in Europe, for example, we are seeing that that is tied to wage inflation, and obviously we'll get the reimbursement increase, but then we are, you know, kind of having to invest that back in the, in the labor, in, in, in the clinics. I don't have a, a number to hand. I'll have Dominik follow back up on that one. You know, it's, it's, it's nothing. You know, we're getting our fair share of the reimbursement rate increases, but they don't fall through straight to the bottom line.

I think it-- I think the message here is, it is, for the most part, needing to be reinvested in, in labor and wage inflation because of the countries we're operating in. There's nothing else that's remarkable, I would say, ex-U.S. on reimbursement. Obviously, you know, you, hopefully, you picked up my comments on CE, that we are, you know, one of our critical initiatives is pricing, and we are starting to see the first, the first benefits of those price increases across our products portfolio, kick in in Q2 as we thought. Maybe then leads into your second question, Lisa, on the, you know, the long-term view.

Obviously, sitting here with a, you know, a 2% margin, we've got a long way to go to get into our margin band, but I'm confident that we can get there by 2025 with the initiatives and projects that we have in place. Clearly, we are still battling, you know, headwinds there, so we have to work, you know, much harder. I, I don't think there's anything that would say we shouldn't be, you know, kind of at a, at a MedTech margin. As Katarzyna spoke to at our Capital Markets Day, we have a mixed bag within that portfolio, and there are some markets that are hugely profitable and are above that average margin. I think our focus is really, you know, kind of teasing out those that aren't there and then deciding what we need to do with that.

Obviously, as we're working through FME25, we're always taking a look at our structural overhead and seeing if there's anything, you know, more dramatic that we can do and do it faster. I think, you know, the message here is we need to deliver on what we've got in hand, and I'm confident the team will, and then continue to look at the individual components in the portfolio. If we have to make different decisions on those, we will in time.

Lisa Clive (Senior Analyst)

Thanks very much.

Operator (participant)

Next question is from the line of David Adlington with JPMorgan. Please go ahead.

David Adlington (Analyst)

Hey, guys, thanks for the questions. First one, I was quite interested to hear about you talking about muted new starts still. I just wondered what if you could give us some further color there in terms of what's happening and when we might see new starts start to accelerate again, why that was being muted? Then secondly, just on the labor side, again, the $45 million tailwind, I think in the 2Q you pulled out. Just wondered how much of that was because your agency costs had fallen, if you could quantify that at all. As we look into the 2H, do you have a similar sort of comp in terms of agency? Are we rebased or back to normal agency levels in terms of a comp for next year? Thanks.

Helen Giza (CEO and CFO)

Thanks, David. It was a little hard to hear you, but I think I got your questions. One around muted new starts and the second around the labor tailwind. No, look, there's nothing, the muted new starts, that's something that we've just been seeing, right? There's nothing new or unusual there. I think, you know, just this annualization of COVID, as we had discussed, really still working its way through the end-stage CKD population. Nothing new or alarming, just the timing of this, you know, being worked through. You know, we, we are encouraged by the fact that, you know, the overall mortality is on a pre-pandemic level now.

I think it's just this, you know, just the color we've been saying on, you know, we, we know we will return to growth, just the trajectory of that, and we're sitting, you know, literally right at zero right now, which, you know, overall is, is encouraging. On your second question on labor, yeah, look, there is. You know, when we put our guidance out there, we obviously had a forecast for, well, what we thought the temporary labor would be. You know, we obviously have, you know, kind of really reduced our contract labor in 2023. And obviously, there would have been contract labor in the, you know, the challenging Q2 from last year.

You know, we, and then on top of that, we've got the productivity, which is reducing that headwind. Look, I think for me, the Q3 labor number is going to be, you know, the key on, okay, is it where we thought it was gonna be, or is it continuing to drive improvement? Of course, we've got this weird annualization quarter-over-quarter with all that was happening on labor and the merit increase that kicks in in Q3. Hopefully that helps explain. We haven't been talking about labor productivity for a while, so it's really, really nice to be talking about that.

David Adlington (Analyst)

Thank you.

Operator (participant)

Next question is from the line of Christoph Gretler with Credit Suisse. Please go ahead.

Christoph Gretler (Analyst)

Thank you, operator. Hi, Helen. Just, actually one question left, you know, and I think, you know, you mentioned that the transactional effect on the product business could be an element, you know, that holds you back, you know, on the margin, on the guidance upgrade. Could you actually discuss, you know, how meaningful that is, especially since, you know, FX moved so much, and I think your manufacturing footprint is pretty kind of, you know, in higher wage and higher cost countries like, you know, Germany, the US, and we have a lot of no inflation in this, sorry, a lot of devaluation in these emerging market currencies.

Helen Giza (CEO and CFO)

Yeah. Hi, Chris. Happy to do so. Look, to give you a sense of size, and maybe I haven't done this in any of the questions yet, or in my voice over, but, you know, to put it into perspective, the exchange impact was about half of our margin in CE in the quarter. You know, and it is that these countries with, you know, hyperinflation, whether that be, you know, Argentina and Turkey, but then seeing, you know, the kind of the, the Ruble, India, China. It's, you know, it's the main country. You know, those are the main country, sorry, currencies that drove it, in the countries and currencies, I guess, in, in the, in the quarter.

Obviously, we're taking a hard look at that, on what we can get under and, you know, both in contractual currency and hedging. I think that's also. I mean, we do hedge, of course, but, you know, the volatility here has had a, a more sizable impact than we were expecting. I think, you know, when I talk about the guidance, we're expecting, you know, some of that to continue. Whether it stabilizes or improves, I think will be, you know, kind of the key, the key driver. Again, we'll know more about that as we go through Q3.

Christoph Gretler (Analyst)

This manufacturing footprint optimization that, you know, you have now as part of the plan, FME25, does this not take into consideration in any respect this, you know, challenge, which I guess now is an ongoing challenge, not only...

Helen Giza (CEO and CFO)

Yeah.

Christoph Gretler (Analyst)

one time?

Helen Giza (CEO and CFO)

Yeah, of, of course, we are looking at the manufacturing footprint, but you have to remember, you know, that there is, we do have 44 manufacturing plants, and there is a reason that we have, you know, some of those manufacturing plants local. Obviously, you know, as we, you know, as we think through that footprint, and, you know, where we can consolidate, obviously where and the cost, does get taken into account. Then obviously, looking at the, the currencies we contract in as well.

Christoph Gretler (Analyst)

Thank you. I appreciate your comments.

Operator (participant)

Next question is from the line of Falko Friedrichs with Deutsche Bank. Please go ahead.

Falko Friedrichs (Analyst)

Thanks a lot. Two questions, please. The first one, going back to the same market treatment growth. Helen, what's your best guess when this could inflect then turn positive? Could this be in H2 this year, or is this rather something you would expect the next year? My second question, can you just very briefly update us on your home dialysis efforts and whether there's anything new to report on? Thank you.

Helen Giza (CEO and CFO)

Hi, Falko. Look, my best guess, well, I wish I had some crystal balls out here. Look, we're as flat to zero as we can be, right? At zero, you know, minus 0.1. My hope would be if we'd start to see this continued trend, it could go positive in, in Q3, of course. That my guess is as good as yours. I mean, I think the trend is going the right way. Let's hope that it does. You know, and that's why we've guided -1 to +1. You take the midpoint, you zero. You know, obviously, if you backed out the acute contract cancellations that we spoke about last quarter, we have the same impact this quarter that would have a slightly positive.

It's going, it's going the right, the right way. You know, on home, obviously, that's a key strategic initiative for us for a whole host of reasons. We continue to stay focused on that. We are still hovering around the, the 16% mark in Q2. You know, I think we were, if I get the numbers right, 15.7 in Q1 and 15.9 in Q2, so a slight improvement. Obviously, some of the, the labor stabilization and everything else is helping that, so we can drive trainings again. I think we're seeing our training volume up, which will in turn, you know, obviously translate into a higher, higher home percentage.

You know, we know that we've, we've really got to, you know, kind of turn this, turn the corner on this to get to our, our 25% goals.

Falko Friedrichs (Analyst)

Thank you, Helen.

Operator (participant)

Next question is from the line of Hugo Solvet with BNP Paribas Exane. Please go ahead.

Hugo Solvet (Equity Research Analyst)

Hi. Hello, thanks for taking my question. I have one on FME25. You're at about like EUR 60-61 million benefits in Q2. You're up to about the same level in Q1. Just wondering, how do you feel about timing, timing and phasing for Q3 and Q4 to reach that EUR 250-300 million by year-end? That would be my first question. Second on China. I remember you, you, you said it was an anomaly of strong growth in Q1. Just wondering, what you saw in the country in Q2? Thank you.

Helen Giza (CEO and CFO)

Yeah. Thanks, Hugo. Yeah, look, we're very, very encouraged with what we're seeing on FME25. We've had a good half one. We're on track, and obviously, we're still sticking to the, the guidance that we have out there for, for 2023, you know, full year. You know, no, no reason to change that at this point. We had 136 in the first half, 75 in Q2. That's, that's fully on track. In terms of China, you know, we had a really strong Q1, as you recall, stronger than we were expecting. We do see continued, you know, good, good, good growth there in, in China. I think, you know, what we have to kind of...

We, we expected Q1 to be a pull forward from what we would normally see as Q4. I think, you know, that's obviously, you know, what, what we're expecting. The Q1 was strong. We still had a strong April. It's, you know, obviously dipped off now as we kind of go into these next quarters, with that pull forward, and obviously, that's now reflected in the, you know, in, in, in our outlook for half two. Of course, we're, you know, really, really excited about that higher acute sales that does come with a higher margin compared to some of the other products.

Hugo Solvet (Equity Research Analyst)

Thank you.

Operator (participant)

In the interest of time, this concludes the Q&A session. I would like to hand back to Dominik.

Dominik Heger (Head of Investor Relations)

Thank you very much for your interest. We appreciate you joining after a long day with many reporting companies. Thank you for hanging in there with us and for your questions. While we are drowning in rain here, we'll wish you all a great summer, hope to hear, see, meet you after the summer break.

Helen Giza (CEO and CFO)

Yeah. Thank you. Thank you, everybody. Have a good summer. Take care.

Operator (participant)

Ladies and gentlemen, the conference is now concluded, and you may disconnect your telephone. Thank you very much for joining, and have a pleasant day. Goodbye.