Fresenius Medical Care - Q3 2023

Transcript

Operator (participant)

Ladies and gentlemen, thank you for standing by. I'm Andrea, your Chorus Call operator. Welcome, and thank you for joining the Fresenius Medical Care Q3 Results Conference Call. 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. If you would like to ask a question, you may press star followed by one on your touchtone telephone. Press the star key followed by zero for operator assistance. At this time, it's my pleasure to hand over to Dominik, Head of Investor Relations. Please go ahead, sir.

Dominik Heger (EVP and Head of Investor Relations, Strategic Development and Communication)

Okay. So unfortunately, we had some technical issues, but I've heard the introduction has happened. Thank you, Andrea, for the introduction. As already mentioned, we would like to welcome you to our earnings call for the Q3, 2023. We appreciate you joining us today to discuss the performance of the Q3. 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 yesterday evening. For further details concerning risks and uncertainties, please refer to these documents as well as to our SEC filings that have already happened.

As we have a hard stop at 4:30PM CET, we have prepared only a short presentation to leave time for questions regarding the quarterly earnings and for our new CFO to introduce himself. As always, we would like to limit the number of questions to two in order to give everyone the chance to ask. Should there be further questions and time left, we can go a second round. I'm aware that there is, with GLP-1, one dominant topic in healthcare research overall, which we fully understand, but we would appreciate if we could focus in this call on the quarterly business developments. With us today is, of course, Helen Giza, our CEO and Chair of the Management Board, and as just mentioned, for the first time, Martin Fischer, our CFO.

Having joined the company on October first and after quarter end, Martin will share a bit about his background and focus areas in his new role, but he will not answer questions today, but for sure in our call in February. Helen will provide an update on the business development, financial performance, and outlook, and will then be available for Q&A. With that, Helen, the floor is yours.

Helen Giza (CEO and Chair of the Management Board)

Thank you, Dominik. Welcome, everyone. Thank you for joining our presentation today and for your continued interest in Fresenius Medical Care. I'm very excited to talk to you today about the meaningful progress we made in the Q3 as we executed against our strategic plan. However, before I begin the presentation, I wanted to update you on two changes to our management board. As announced earlier this week, Craig Cordola will succeed Bill Valle as Care Delivery CEO as part of a planned transition following Bill's plan to retire by the end of the year. Craig has many years of proven track record of operational management experience and successfully driving profitable business growth in different companies in the US Healthcare Services Industry. He will be a very valuable member of our management board and will continue our turnaround and transformation while leading Care Delivery into its next chapter.

The second change is that our new CFO, Martin Fischer, started on the first of October. I would like to say how thrilled I am to be joined here today by Martin, and I'd like to hand over to Martin to introduce himself.

Martin Fischer (CFO)

Thank you, Helen. Good afternoon, good morning to everyone on the call. I'm honored to speak with you today as the new CFO, as I've just completed my first month in the company. I would like to share a bit about my background and why I'm so very excited to be part of Fresenius Medical Care. I spent most of my professional career with the technology company, Siemens, especially within its healthcare division. In my most recent role, I served as the Global Head of Finance for the diagnostic segment of Siemens Healthineers, based in Tarrytown, New York. Prior to that, I held a wide array of management roles, mostly in finance leadership, with some positions in corporate as well as operational areas.

I have extensive experience in the European and American healthcare markets and had the opportunity to be an active part of the IPO of Siemens Healthineers in 2018, and to shape the standalone organization of the newly listed company post-IPO. Joining Fresenius Medical Care was a very conscious and deliberate decision on my part. FME is a global player with a great company purpose, with a great legacy and an even brighter future. In my role, I will work with Helen and the team to drive forward the successful turnaround of the company. Particular attention will be paid to securing sustainable, profitable growth. A prerequisite for this is the continuous implementation of the FME25 transformation program and a stringent financial approach.

I will focus on driving performance with clearly defined value creation priorities, a targeted resource and capital allocation, and rigorous financial assessment of our investments and strategic choices. At least doubling the return on capital by 2025 is one of my priorities, as is a clear commitment to manage the leverage ratio. To me, transparent capital market communication is a key element of my approach. As a pragmatic and optimistic person, I highly value clarity, integrity, and reliability. It is very encouraging to see the company's turnaround measures already beginning to translate into improving financial performance. I'm optimistic about our ability to drive further improvement to 2025 and beyond. I look forward to speaking with you in the future, and with that, I will hand back to Helen.

Helen Giza (CEO and Chair of the Management Board)

Thank you, Martin. I'm really excited to have you on board and already see how great we are working together as a team. I will now begin my prepared remarks on slide 4. You are all familiar with our strategic plan to unlock value as the leading kidney care company, and I would like to highlight some of the accomplishments of the quarter. The simplification of our governance structure with the change of legal form is the only remaining structural element to finalize, and I'm pleased to report that we have cleared all relevant hurdles and expect the conversion to be completed by December first of this year. With this, we will have completed all of our major structural changes within less than one year. 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 Q3, we realized an additional EUR 97 million in sustained savings, bringing year-to-date savings to EUR 232 million. This is positively supported by the now 70 net clinic closures in the US. We have realized accelerated productivity improvements in care delivery, which have helped to meaningfully mitigate the originally anticipated labor headwind of EUR 100 million-EUR 180 million for the year. As we focus on sustainable, profitable growth and seek to divest non-core and dilutive assets, we have continued to execute against our portfolio optimization plan. We announced yesterday that we have entered into an agreement for the sale of National Cardiovascular Partners, or NCP.

This business comprises 21 facilities, providing outpatient cardiac catheterization and vascular laboratory services in the US. In line with our disciplined financial policy and well ahead of maturity, we were successful in refinancing a EUR 650 million euro bond expiring at the end of November without accessing the bond market. Rather, we used a mix of long-term bank financing at very attractive conditions, as well as cash and short-term debt. The term loans carry variable interest rates, which gives us more flexibility to reduce debt, and of course, upcoming extraordinary cash inflows will enable us to further delever. I am not only proud of the fact that we are executing with speed and success against our strategic plan, but also that we are driving an important cultural shift. For the third consecutive year, we were named one of Newsweek's Top 100 Most Loved Workplaces in the US

Turning to slide 5. While it's not a Q3 earnings topic, clearly the GLP-1 medication headlines need acknowledging. We think it's important to reinforce our assessment of the future population and volume development. As our Chief Medical Officer, Frank Maddux, outlined at our Capital Markets Day in April and confirmed again more recently in an expert call, we expect the GLP-1 drug class to have a balanced impact on the ESRD patient volumes in the long run. We treat a complex patient population with multiple comorbidities, and it's important to remember that roughly 46% of our dialysis patients crash into dialysis, meaning they have either not been diagnosed nor been receiving regular medical treatment for their kidney disease earlier. So when we talk about the potential impact of these new medications, we talk about the other 54% that are more likely to have access to these medications.

At a high level, when assessing the potential real-world impact of a drug, we consider three main features of the use of the medications: medical effectiveness, prescription rate, and patient adherence. Starting with medical effectiveness. Based on the limited information that is available to us today, GLP-1s help control type 2 diabetes and have proven benefits for cardiovascular health that are a potential significant positive effect on people with diabetes. More CKD patients are likely to survive earlier CKD stages and progress to ESRD. Additionally, we have also assumed that GLP-1s would have a positive impact on slowing the progression of kidney disease. Based on what we know today, we expect these two competing effects to balance each other with respect to population impact. Looking at the prescription rates, there are unknowns here. Currently, current pricing of GLP-1s is prohibitive to broad adoption in the short term.

As could availability or access, but we would assume these would normalize over time. The impact of known and developing side effects will impact prescribing choices as prescribers gain experience in managing patients on the drugs. SGLT2 inhibitors, for example, have been widely available for a decade, with proven medical effectiveness for both cardiovascular health and more recently, for slowing the progression of kidney disease. Yet only 8% of our patients have ever been prescribed an SGLT2 inhibitor in the pre-dialysis CKD stages, and less have consistently taken them. Finally, we have to consider expected patient adherence and compliance over long periods of time. We know that the adherence rates to medications that require permanent use has not been anywhere near 100%, and that will challenge the full effectiveness of this class of drugs in our patient population.

When assessing all of these factors and based on the limited information available today, we come to the conclusion that the effects would be rather balanced on our patient population development in the long run. Multiple independent experts in this field are of the opinion that it may take at least a decade before we could fully observe the effects and impacts from GLP-1 on our patient population. Moving to slide 6. Ensuring the highest quality of care for our patients is of the utmost importance. To that extent, we are continuously monitoring our clinical performance to enhance care. Our Global Quality Index is an important KPI in this regard. The quality index considers dialysis effectiveness, vascular access, and anemia management. Through the Q3, we continue to see sequential stability at a high level. I'll now move to slide 8 to review our Q3 business performance.

In the Q3, we continued to deliver solid organic revenue growth, both in care delivery and Care Enablement. This was supported by sequentially stable same-market treatment growth in the US. The successful execution of our turnaround plans continued to translate into improved financial performance. Most notably, this included productivity improvements in care delivery and higher pricing in Care Enablement. Savings from our FME25 transformation program also contributed meaningfully to the improved performance in the Q3, and we continue to execute on our portfolio optimization strategy. As I mentioned earlier, we have entered into an agreement to divest NCP in the US. Based on the earnings development for the first nine months of the year and solid business expectations for the remainder of the year, we are raising our full year 2023 operating income guidance, which I will speak to later on.

You will have seen on the 27th of October that CMS announced the final ESRD PPS rate for 2024. Final ruling increased from 1.6 to 2.0%. The market basket has not been adjusted to reflect the higher labor costs, nor the inflation forecasting error has been addressed. While the 2% increase are a little improvement, it is still disappointing. However, in our 2025 margin targets, we have only assumed a moderate increase, so this is in line with our assumptions. On a very positive note, last week, the CMS Star Ratings for clinics were published, and I'm delighted to report that we outpaced the industry for 3, 4, and most importantly, 5-star clinics. This shows our strong and clear commitment to deliver high-quality care to our patients. Turning to slide nine.

In the Q3, we delivered revenue growth of 7% at constant currency, and we continued to deliver organic growth with positive contributions from both segments. This development was driven by favorable pricing, including hyperinflation in care delivery, and in care enablement, it was supported by both volume and price. During the Q3, operating income on a guided basis improved by 20%. This results in another sequential improvement of our group margin to 8.7%. Earnings development in the Q3 was driven by business performance, supported by FME25 savings and reduced personnel expenses from accelerated productivity improvements. Although we have seen a degree of stabilization, our business still facing... Excuse me, our business still faces inflationary pressures that particularly impact care enablement.

In the Q3, we also had a negative impact from the absence of a non-recurring consent payment on certain pharmaceuticals and experienced a further increased transactional exchange rate headwind in Care Enablement. Next on slide 10. Starting from the left, you can see how we get to the starting point of our guidance basis. The EUR 107 million special items in the Q3 specifically comprise EUR 53 million in legacy portfolio optimization costs, primarily relating to the NCP divestiture. FME25 costs were EUR 49 million, which has us well below our planned run rate for this year. We will likely stay below the lower end of our planned FME25 one-time costs this year, but should see a shift into the next year.

EUR 6 million in costs were associated with the legal form conversion, and the Humacyte investment remeasurement contributed positively with EUR 1 million. Turning to slide 11. In Care Delivery in the Q3, organic revenue growth was supported by a positive impact from our US value-based care business InterWell Health, along with reimbursement rate increases and a favorable payer mix. In line with our commitment to drive sustainable, profitable growth, we continue to exit less profitable acute care contracts in the US, and the negative 60 basis point impact was particularly pronounced in the Q3. When adjusted for acute contract impact, same market treatment growth in the US improves from negative 0.4% to positive 0.2%, compared to positive growth of around 0.1% in the first half of this year.

In Care Delivery International, revenue growth was supported by the effects of hyperinflation in various markets, but was negatively impacted by exchange rate effects. Care Delivery earnings overall were positively impacted by business growth, lower personnel expenses resulting from the already mentioned improved productivity and FME25 savings. We had planned to show a bigger contribution to earnings from InterWell Health in the Q3, and while we are continuing to generate positive savings from CMS's CKCC programs within the late stage CKD and ESRD key segments, we realized lower than expected contributions from our CKCC models for the 2022 program year. This translated into a higher than assumed margin dilution in the quarter. As I highlighted earlier, we also continue to execute on our portfolio optimization strategy with the signing of the agreement to divest NCP in the Q3. Next on slide 12.

Care Delivery revenue increased by 6% on a constant currency basis, driven by a 7% organic development for the reasons I just outlined on the previous slide. Operating income development for Care Delivery faced a meaningful headwind from currency translation effects in the quarter. Although we realized positive business growth, this lagged our own expectations due to the already mentioned lower than anticipated contribution from Interwell Health on CKCC. FME25 savings were a strong tailwind in the quarter as we continue to drive clinical operational efficiencies with 17 additional net clinic closures in the US, bringing the total now to net 70 closures. Although initially expected to be a sizable headwind for the year, we were able to compensate the higher wages and other labor cost increases by the accelerated productivity efficiencies, which yielded strong savings. Turning to page 13.

Care Enablement revenue in the Q3 was impacted by negative exchange rate effects, but supported by higher sales of in-center disposables and machines, as well as home hemodialysis products. It also benefited from increased average sales prices, driven by our targeted pricing measures. The Q3 earnings were supported by increased volumes, pricing, as well as FME25 savings. These positive developments offset inflationary cost pressures, which developed broadly in line with expectations and a further increased transactional exchange rate headwind. Care Enablement continued to execute on the FME25 and turnaround measures. We have made progress with organizational as well as manufacturing and supply chain initiatives. Next on slide 14. In the Q3, Care Enablement revenue increased by 5% on a constant currency and organic basis. This was driven by the reasons I outlined on the previous slide.

On our guided basis, operating income for Care Enablement increased to EUR 22 million. The improved operating income was driven by positive business growth, which already includes meaningful currency transaction losses, as well as FME25 savings. Operating income was partially offset by inflation, which, as assumed in our guidance, continues to be a headwind for this business. We have also seen a smaller currency translation impact. Turning to slide 15, a clear focus for us is our cash flow management. In the Q3, we experienced a strong cash flow development compared to the prior year period. The increase in net cash provided by operating activities was the result of a change in working capital items. This was mainly driven by the weaker prior year comparable, resulting from the CMS's recoupment of advanced payments previously received under the Medicare Accelerated and Advanced Payment Program in 2020.

Supported by our disciplined capital allocation policy, free cash flow conversion accelerated in line with operating cash flow. Our leverage ratio of 3.4 times remained in our target corridor of 3-3.5 times. As it is still at the upper end of this self-imposed range, delivering remains a top priority for capital allocation, with any proceeds from divestments to be used for further de-levering. As I mentioned earlier, we were successful in refinancing the EUR 650 million euro bond expiring at the end of November. We used a mix of long-term bank financing at very attractive conditions, as well as cash and short-term debt. This better positions us for further de-levering. By diversifying away from the bond market, we support further balancing of our financing mix and utilize our ability to access various funding sources.

I'd like to finish with our update to the outlook on slide 17. For 2023, we continue to expect revenue to grow at a low to mid-single percentage rate, but are likely to land in the upper half of this range. For our earnings outlook, we previously guided for a flat to low single-digit operating income decline for 2023. Our assumptions around inflation and volume have broadly developed in line with expectations. FME25 savings are likely to be at the upper half of the EUR 250 million-EUR 300 million range. While labor costs developed as assumed, the accelerated labor productivity we are realizing provides a compensating tailwind, which has additionally helped offset the emerging transactional exchange rate headwind in care enablement.

Based on the resulting stronger than assumed earnings development in the first nine months and our solid outlook for the remainder of the year, we now expect operating income not to decline, but to grow at a low single-digit percentage rate. Already in the Q3, our group margin improved 100 basis points to 8.7%, and in Care Delivery, we are with a 10.3% margin already at the lower end of our target margin band. Year-over-year, the Care Enablement margin of 1.7%, while low, has improved. And as laid out at our Capital Markets Day, the complexity and scale of the initiatives in Care Enablement to get into the 8%-12% band result in a more back-end loaded improvement.

We are 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. This concludes my prepared remarks, and I'll now turn it back to Dominik.

Dominik Heger (EVP and Head of Investor Relations, Strategic Development and Communication)

Thank you, Helen. Thank you, Martin. Before we hand over for the Q&A, I would like to remind everyone to be fair and limit your questions to two and to focus on the quarterly development. And again, only Helen will be available for Q&A this quarter. And with that, I hand over to Andrea to open the Q&A, please.

Operator (participant)

Thank you. Ladies and gentlemen, we will now begin the question and answer session. Anyone who wishes to ask a question may press star, followed by one on their touchtone telephone. If you wish to remove yourself from the question queue, you may press star followed by two. If you're using speaker equipment today, please leave the handset before making your selections. In the interest of time, please limit yourself to two questions only. Anyone who has a question may press star, followed by one at this time. The first question comes from the line of Victoria Lambert with Berenberg. Please go ahead.

Victoria Lambert (Senior Analyst of European MedTech and Services)

Thanks for taking my questions. The first one is just on home treatments. Could you provide an update on how this is progressing? I think when we last spoke, it was at 16%. And then the second question is just on the labor market. How many open positions are you at, and where is wage growth trending? Thank you.

Helen Giza (CEO and Chair of the Management Board)

Hi, Victoria. Thank you for your questions. On home, it's still stable at around that 16%, that we saw last quarter. And then on your labor question, we have seen some improvement since last quarter, and we're sitting at around 4,300 open positions, which is improving. Clearly, where our focus is on labor is, you know, kind of on the hotspot areas that, you know, some metro areas are still experiencing. But obviously the, you know, the labor situation is much more stable, and controllable than it was a year ago or even quarters ago. So we feel good with the development that we have there.

Dominik Heger (EVP and Head of Investor Relations, Strategic Development and Communication)

We would take the next question then.

Operator (participant)

The next question comes from the line of Hassan Al-Wakil with Barclays. Please go ahead.

Hassan Al-Wakeel (Director and Head of European MedTech and Services Research)

Hi. Thank you for taking my questions. I have two, please. So first, sorry to start with GLP-1, but as it relates to operational performance, to what extent do you think you are already seeing some impact from GLP-1 or SGLT2 among diabetes patients? Or could we indeed see an impact sooner than in weight loss? You noted that only 8% of your patients have been prescribed SGLT2 and CKD. Do you know what the number is in GLP-1 for diabetes? And related to this, are you seeing any increased uptake in transplantation on the back of improved eligibility around GLP-1? And then second, you talked about margin dilution from CKCC models in the quarter.

Could you quantify the full year contribution and help us understand why this is different to ESCOs, given the challenging experience you've had in the past here, and to what extent this is a worthwhile business for you? Thank you.

Operator (participant)

Ladies and gentlemen, we have lost connection with the moderator's line. They are connected back.

Dominik Heger (EVP and Head of Investor Relations, Strategic Development and Communication)

Hassan, could you please repeat your questions because we were dropping off?

Hassan Al-Wakeel (Director and Head of European MedTech and Services Research)

Apologies. Yeah, so let me do that again. So firstly, I was saying, sorry to start with GLP-1, but as it relates to operational performance, to what extent do you think you are already seeing some impact from GLP-1 or SGLT2 among diabetes patients, or could we see an impact sooner than in weight loss? You noted that only 8% of your patients have been prescribed SGLT2 in CKD. Do you know what the number is for GLP-1 in diabetes? And related to this, are you seeing any increased uptake in transplantation on the back of improved eligibility with respect to GLP-1? And then secondly, you talked about the margin dilution from CKCC models in the quarter.

Could you quantify, the full year contribution and help us understand why this is, why this is different to ESCOs, given the challenging experience you've had in the past, and to what extent this is a worthwhile business for you? Thank you.

Dominik Heger (EVP and Head of Investor Relations, Strategic Development and Communication)

Thank you, Hassan, and sorry for making you repeat that.

Helen Giza (CEO and Chair of the Management Board)

Thanks, Hassan. Yeah, look, as far as we can tell, we're not seeing any impact or tiny impact on GLP-1 at this time, and nothing that we could quantify. You know, in terms of your SGLT2 question, yes, it's pretty small, as you say, at 8% in that CKD. I don't have that number to hand of what that could be in diabetes. I'd have to follow up with Frank on that question. But I do know with regard to the transplantation piece of your question, the rates are very, very stable at the normal, at the moment. So we're not seeing so any kind of really change there.

You know, in terms of the number of patients who have any exposure to weight loss, I think, yeah, we would see that as, as small, you know, maybe kind of a couple of kilograms, and the only improvement was a slightly lower blood pressure. So, in terms of the diabetes piece, I'll follow back up, but overall, so far, we're not seeing really any other impact. In terms of your margin dilution question on CKCC, what I would say, you know, it came in, and we had the three-quarter true-up for plan year two come in, in the Q3. While it was positive, it was lower than what we had anticipated, and, clearly, you know, I immediately asked the same question, of is this ESCOs all over again?

Because we've definitely, you know, kind of learned the hard way on some of these government programs. You know, we're definitely seeing less transparency and more variability in the government reporting in terms of their data and methodologies around trend adjustment factors and patient alignment, which is making it more difficult and challenging, actually, for us to be able to predict those results with the lumpiness that we're seeing. What I would say is, you know, we in the coalition of CKCC participants are, you know, very much providing that feedback to the government to improve the collaboration between CMS and participants to drive the intended results. You know, I think for us, we will continue to do that work and ensure that we are getting the expected results.

And if we're not or something changes, then clearly we would exit where and when or if it makes sense.

Hassan Al-Wakeel (Director and Head of European MedTech and Services Research)

Very helpful. Thank you.

Operator (participant)

The next question comes from the line of Lisa Clive with Bernstein. Please go ahead.

Lisa Clive (Senior Analyst of European MedTech and Services)

Hi there. Thanks for taking the questions. Helen, I'll ping you too, although it's a shame Frank isn't on, given the interest in GLP-1 today. But I just... Per your comments around SGLT2 and GLP-1, I mean, they're not very widely used today, but the SGLT2 are going generic in 2 years, so that will change quite quickly. What I really would love to know is, where we've seen sort of similar experiences historically. I mean, you know, in looking at the CKD population in the US, it's actually been remarkably stable over the last sort of 15+ years. Yet over that time, the ESRD population has grown, you know, 3%-4% per annum.

So, you know, I know that the ACE and ARB class adoption has really helped control hypertension and improve mortality. So, you know, I take your point that there could be a sort of tailwind of sorts from these drugs to some extent. But we just really love to understand what the sort of historic experience has been within the dialysis population. And then secondly, on that, one of the issues around this delay in progression, you know, you may well get these patients in the end, especially if the mortality goes down, but at what age? Because the, you know, the proportion of patients in the broader ESRD population, you know, 20 years ago, 2/3 of those patients were under 65. Now it's more like 57%.

So a lot of these patients may age into Medicare before they end up with ESKD. So just would love to get your thoughts on, you know, the delay in progression and how that could affect your economics longer term. Thanks.

Helen Giza (CEO and Chair of the Management Board)

Yeah, thanks, Lisa. I will try my best there, but and also follow up with Frank afterwards. So, you know, the RAS inhibitors have been available, you know, have only been used in about 50% of the eligible people, despite the low price and wide availability. As we think about, you know, you talk about this 15 years of ESRD population growth, I think we'd speak to that as, you know, where we've seen an improvement in mortality and the average life on dialysis has extended. Now, I think that is more flattening off in more recent years and kind of with COVID effect there in those years, too. But I think that the improvement in mortality and average life on dialysis has obviously been a benefit in that patient population growth.

You know, in terms of your, you know, kind of your question on delay and progression, I think really what's behind your question is, are we gonna see a change in, you know, kind of mix here? You know, as we think about, you know, kind of an extended funnel on CKD and the cardiovascular benefits, which may delay you know, kind of ultimately a larger pool coming into dialysis because they have the cardiovascular benefits. If they have that, we could potentially see an age shift where you have younger, healthier patients who could be you know, kind of working or on commercial insurance coming into the ESRD population. And of course, you know, what we see today is... Let me get my numbers right here.

The average commercial patient is on insurance for about 30 months, or less than, less than 30 months. Sorry, I should say that, less than 30 months. So, you know, we—if we get more commercial patients in, and then we have that 30 months before they go on to, on to Medicare, that's, you know, we could see that age shift, you know, happen in that population. But I think that's something only time is going to tell, on, on what happens to that, to that mix. I mean, you're absolutely right that, you know, the average age of new starts now is over 65, and we already see that phenomena.

So I think what we'd be looking at is to see what happens in this CKD population and the shift, particularly in stages 3-5, and then, you know, what happens in that, you know, the commercial plans where, you know, kind of where they're already on, you know, less than 30 months coverage. You know, and I think, obviously, you know, we, we obviously have significant growth in MA the last 2 years. That becomes more important as well, in the age above 65 in the future.

Lisa Clive (Senior Analyst of European MedTech and Services)

Okay, thanks. Sorry, just one quick follow-up. On the patients, obviously, the MSP period is 33 months, but my understanding is actually a lot of your patients drop off after sort of 18 months if they're on COBRA because it gets a lot more expensive at that point. Is that a fair statement?

Helen Giza (CEO and Chair of the Management Board)

Yes, I think that's fair. I think on average, it's more like 18-24 months.

Lisa Clive (Senior Analyst of European MedTech and Services)

Okay, that's helpful. Thank you.

Helen Giza (CEO and Chair of the Management Board)

Yeah.

Operator (participant)

The next question comes from the line of Richard Felton with Goldman Sachs. Please go ahead.

Richard Felton (Equity Research Analyst)

Hi, thanks for taking my question. My first one is on the guidance for EBIT growth. Given the first nine months has been very strong, the upgraded guidance implies quite a sharp deceleration in Q4. So my question is, is that all comps related, or is there anything else you're seeing in the momentum of your business that's keeping you a little bit more cautious on Q4? That's my first question. And my second one is on Care Enablement. So look, it's another quarter where the margin's quite a long way below your targets.

Can you maybe, you know, provide a bit of color on how much the margin was impacted by transactional effects in the quarter, and then maybe a bit of an update on what you're doing to drive better performance and, and better margin in that part of the business, within the new organizational framework? Thank you.

Helen Giza (CEO and Chair of the Management Board)

Thanks for your question, Richard. Yes, and I think the flavor of the day, from many of the analysts has been, we seem to be predicting a sharp decline in Q4. And I think, you know, the high-level answer, it is one of comps. There is nothing fundamentally happening or shifting in the business in Q4 from an operational perspective. But I do think it's probably worth unpacking that, for the wider audience as well. So Q4 year-over-year, over 2023 to 2022. In Q4 of last year, with our performance, we had some significant favorability from our bonus plans, if you will, or the compensation-related short-term bonus. That was around EUR 30 million last year, and obviously, we're on track this year.

We did have some NCP deconsolidation gains in Q4 of last year of around EUR 40 million. And then, you know, this year, we also have the foreign exchange impact in CE that we didn't have last year. So that perhaps answers your second question. That number was around EUR 22 million, or projected to be around EUR 22 million. So that's the the CE transaction piece.... As I think about, you know, kind of what we've seen in Q3 and what our implied guidance assumes for Q4, a couple of things there. And again, some of the more Q3 to Q4 improvements that we had saw in Q3 that maybe don't happen in Q4. We do have some favorable phasing in in corporate.

In the quarter, you saw a very low corporate number that is kind of timing and phasing that we are expecting to come back in Q4. As I mentioned, we had the CKCC true-up of three quarters included in Q3. That wouldn't be expected to repeat in Q4, and that's around EUR 25 million or so. We have, you know, ongoing exchange planned in CE. And then in Q4, we are expecting lower contribution from our equity investment in our JV. So I think it's, you know, none of this is operational. It's either phasing or, you know, kind of one times that we've already called out and spoke to as watching in our headwinds in the business.

Richard Felton (Equity Research Analyst)

Great, thank you.

Operator (participant)

The next question comes from the line of Veronika Dubajova with Citi. Please go ahead.

Veronika Dubajova (Managing Director and Senior Equity Analyst)

Hi, Helen and Dominik, and thank you for taking my questions. I will keep it to two, please. One, I just want to follow up on Rich's question on the Q4, EBIT. I mean, I appreciate the year-on-year comparison looks very difficult, but also looking just at the absolute level. I mean, normally, Q4 is the strongest quarter that you guys tend to have from an absolute EBIT perspective, and it, it's looking far from it this year, Helen. Is there something that's changed in the seasonality of the business or something that's been pulled forward into the other three quarters of the year? Trying to understand that. And then my second question is on same-market treatment growth, and obviously, I appreciate we're still annualizing the mortality impacts from COVID.

Just curious on how you're thinking about the Q4 and whether you think we're gonna be in positive territory, and whether you're still comfortable with an assumption that is greater than 1% for 2024. Thank you.

Helen Giza (CEO and Chair of the Management Board)

Yeah, thanks, Veronica. Look, there's nothing fundamental changing in Q4. I think, you know, we've got, you're right, it's always our strongest quarter. I think this really is one of, you know, phasing of expenses. I think, you know, as I mentioned earlier, the lower contribution from the equity investment and the ongoing, you know, kind of transaction effects that we're seeing in CE. You know, kind of the quarter was buoyed up a little bit on the, you know, the true-up of the CKCC, which came in with three quarters. So I'm not looking at that anything in Q4 with a level of concern that says there's something drastically bad or different happening in either seasonality or the underlying performance.

Look, I think some of this will depend on, you know, where in the guidance range you're expecting us to come in. But everything that we're doing, and we've done so far this year, continues in, you know, in Q4. On your question on same-market treatment, obviously, we are encouraged by the, you know, the continued sequential improvement into positive territory once you've adjusted for the acute contracts. You know, the, you know, the improvement Q3 over Q2 is, you know, is, is obviously encouraging. We have guided -1% to +1%, and we are, haven't said that we'd be more than 1%, in 2023. So, you know, we haven't put anything out there for 2024. So we're still, you know, working through our internal budgets on that.

So we feel very confident in our -1 to +1 and the trend that we have seen sequentially improving this year.

Veronika Dubajova (Managing Director and Senior Equity Analyst)

Apologies, I didn't mean to imply that you've guided for 2024 yet. I just think what you have said is you would have expect an improvement in 2024 versus 2023. So maybe let me rephrase the question, which is, do you expect an improvement versus the -1 to 1 that you've guided for, for 2024?

Helen Giza (CEO and Chair of the Management Board)

I would expect a continued improvement in that trend.

Veronika Dubajova (Managing Director and Senior Equity Analyst)

Okay. Understood. Thank you so much.

Operator (participant)

The next question comes from the line of Oliver Metzger with ODDO BHF. Please go ahead.

Oliver Metzger (Equity Analyst for Healthcare)

Good afternoon. Thanks a lot for taking my questions. The first one is more broader. So now with the final ESRD PPS rate, can you elaborate about your expectation? What does it mean for the US dialysis market? So the rate is clearly below inflation. So, do you really think that this is a rate where also some small operators might be forced to leave a field? And, the second question is on your value-based care approaches in general. So, also, Hasan mentioned you had similar problems with the ESCOs some years ago, and it looks, at least from the outside, that yeah, you get less money for bringing some extraordinary work. So, is there any very red line?

Are we talking only about some lower benefits, or would you describe it more as a general problem that potentially CMS-driven, value-based care looks nice on the paper, but eventually, it makes only sense to do value-based care with some commercial operators?

Helen Giza (CEO and Chair of the Management Board)

...Thanks, Oliver. Look, clearly our PPS final rate is disappointing, and, you know, we continue, you know, with the industry to engage with CMS on this calculation, and clearly they've acknowledged that there's a forecasting error in their calculation. Yeah, there's a lot of pressure here from, you know, from the service providers to get the right reimbursement increase in this higher cost environment. So we continue to, you know, kind of put the efforts in the right place there. And, you know, I think, you know, coming out of the final rate, we will still, you know, kind of be pushing for the right methodology on the calculation. So, you know, we're not giving up, and we continue to do the good work that we do there.

You know, what does that mean? I mean, obviously for us, you know, we're also, you know, kind of working hard on our operating leverage and our cost structure and everything else through this year, and beyond, and we have a scale where we can. What does it mean for smaller players in not just a lower reimbursement, but, you know, a higher cost of capital environment? I can't speculate on. Obviously for us, we're focused on our own turnaround and, being, you know, moderate in how we are forecasting it so that we can rightsize our org, you know, our organization accordingly. And as I said, that was within our guidance, you know, kind of our guidance assumption. You know, VBC, clearly, CKCC was a disappointment, but still positive.

And, you know, I think at the end of the day, we will continue to have those discussions and take a hard look at the government programs that we are participating in. We are extremely excited about the role we are playing in value-based care and our partnership with Interwell. I mean, I think, you know, our ability... You know, so CKCC, whether we had Interwell and value-based care or not, we'd have been hit with that, you know, under the old, you know, Fresenius Health Plan true-ups that we saw with the ESCOs. You know, what we are increasingly doing is turning the, the conversation and the discussion about our work with Interwell and how we are participating in value-based care arrangements with, you know, with the payers in Medicare Advantage and so on.

I mean, look, I think, you know, as we were talking about the, you know, the kind of the managing patients earlier in the CKD kind of funnel, that's really where this work with Interwell is really helpful in, you know, kind of supporting these patients in the CKD population, driving earlier detection and management of patients, which, you know, would begin, we feel, this management of these patients at an earlier age. So, you know, we, it kind of it's still early days, I would say, in the maturity of the environment for for VBC. We know that when we intervene in the management of the, this care, this patient population, that, you know, the, the medical loss ratios show us that we can save costs in care.

And I think for us, it's making sure that we, you know, getting the full benefit, we believe will improve with a, with a more stable and mature framework for VBC programs, and CKC is a, you know, a part of it, but not the whole, the whole ecosystem. And we are clearly the market leader in this, in this value-based care environment with the number of patients that we have on contracts, as well as our partnerships with, you know, with physicians. So, I think this is one where it's, you know, it's still a, an early environment, but one we're incredibly excited about, and they'll kind of see that we can participate in it.

Of course, the government programs, we continue to take a hard look at and, you know, we'll have to determine whether we stay in some, all, or none in the future.

Oliver Metzger (Equity Analyst for Healthcare)

One quick follow-up in this context. So, basically, there seems to be a, say, a disagreement about metrics or quality metrics, which have to be fulfilled. So is it just so difficult to define the right targets and to agree on the right targets? Because we are living in a digital world, and normally it's a yes or no, and it seems to be even some more room for discussions in these programs.

Helen Giza (CEO and Chair of the Management Board)

Yeah, look, we've come a long way. I mean, I know you might be all being a little kind of questioning this right now, but we've come a long way with the ESCO programs. What we entered into with the CKCC programs was a much better improved program. But what we are seeing, I mean, it's still, you know, not the full transparency, and you know, kind of the variability in the government reporting, as I said, that's making it a little bit more challenging for us. I think, you know, what is good is the ability to have the discussions and make sure that, you know, the kind of the intent of the plan is what's, you know, what's being delivered. So look, I think the...

Now we've got data, and now we've got reports, absolutely makes us equipped to continue to have the conversations with CMS. So it's not a, you know, it's not a closed door. And I think it's just more making sure that we are getting what we believe to be our fair share of our participation in the program and get paid for what we believe our data suggests. So, yeah, I think just more to come on this, but obviously, we had to, you know, we had to wait to get, kind of get this PY2 report in before we could even see what we were dealing with.

So I think that's a little bit of the challenge as well, is the visibility into what's happening, and what we, you know, when we get it. So, yeah, I think more to come and we'll continue to provide updates on our VBC book of business.

Oliver Metzger (Equity Analyst for Healthcare)

Okay, great. Thank you very much, Helen.

Dominik Heger (EVP and Head of Investor Relations, Strategic Development and Communication)

Okay, can take one last question.

Operator (participant)

The last question comes from the line of Graham Doyle with UBS. Please go ahead.

Graham Doyle (Executive Director and Head of European MedTech Equity Research)

Hi, guys. Thanks a lot for squeezing me in. Just a quick follow-up on the volume question from Veronika. Just one of the points you made, I think in the last call, was just around some working through some mortality in the sort of pre-ESRD funnel. Have you got any visibility on kind of what stage we're out on that? Have we got a few more quarters to go and then we're back to normal? That'd be good to get a sense of that. And then one bit of pricing, it would be great to get a sense of is in the negotiations, in terms of what we're thinking about for next year, even 18 months' time, are private payers being a bit more sensible about inflation than perhaps Medicare has been?

Helen Giza (CEO and Chair of the Management Board)

Yeah. Thanks, Graham. I don't think that there's anything that we can point to in terms of what is happening with that late stage CKD funnel and how that's translating into growth. I mean, as you can imagine, you know, growth is... continues to be, you know, a key area for us. But, you know, I think the key here is, you know, we're dealing with the annualization still of COVID, and we're exiting these, you know, acute contracts. But nothing else that I could point to at this point that says anything is changing. In terms of the private payers, as you know, these are more long-term contracts in nature, so they're generally locked up for a couple of years.

You know, with some of them or many of them, we have escalators in already. So we're not seeing, you know, kind of, you know, I mean, we want a higher price, they want a lower price. So it's always a, you know, a kind of a thoughtful, partnered negotiation. But we're not seeing, you know, kind of anything here on our big contracts that, you know, concerns us. But obviously, there are always ongoing discussions and negotiations.

You know, where we're seeing some of maybe, you know, plans want to change pricing, you know, obviously, our focus is on profitability, and we are, you know, kind of prepared to, you know, go out of contract or walk away from, you know, these smaller contracts where they don't make sense. But the larger payers, it very much is a partner discussion, I would say.

Graham Doyle (Executive Director and Head of European MedTech Equity Research)

Okay, great. Thanks a lot, guys. Appreciate it.

Helen Giza (CEO and Chair of the Management Board)

Yeah.

Dominik Heger (EVP and Head of Investor Relations, Strategic Development and Communication)

Okay. Thank you, everyone. I'm sorry that we run out of time, and I'm sorry for the technical issues we had, which obviously also did cost time. Apologies for that, but thank you for being patient with us and listening in. Thank you.

Helen Giza (CEO and Chair of the Management Board)

Yeah. Thank you, all. Take care. Bye-bye.

Operator (participant)

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