Earnings Labs

Fresenius Medical Care AG & Co. KGaA (FMS)

Q4 2012 Earnings Call· Tue, Feb 26, 2013

$22.53

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Transcript

Oliver Maier

Management

Welcome back, everybody. Good morning, good afternoon, everybody in the audience, everybody joining us on the Internet. Joining us today is obviously, Rice Powell, the CEO of Fresenius Medical Care; and Mike Brosnan, the Chief Financial Officer. Before turning it over to Rice, I would like to remind you that we will be making forward-looking statements and our actual results may differ materially from these results. We, therefore, encourage you to review our materials provided today in the 20-F filing for these factors. So that's all from my end, Rice, the floor is yours, please.

Robert Maurice Rice Powell

Management

Thank you, Oliver. Good morning, good afternoon, everyone. Before I begin my prepared remarks, first let me say that it's a privilege for me to be here. Sixteen years with the company, I've done a lot of different things, predominantly in North America, and this is a chance for me to do a lot of new things in different parts of the world. I'm quite excited to do this. And it's not lost on me that I have some rather large shoes to fill, following Dr. Ben Lipps, but I will do the best I can in the time that I have. And also, before I get into the first slide, I would sincerely like to thank my colleagues on the management board and all the employees at Fresenius Medical Care for the dedication and hard work that they put in throughout 2012, years past and also years to come in the future. When you look at delivering shareholder value, we understand at FMC that it's important that we give you an outlook of how we are going to continue to do that. I do think it's important that you recognize we are the market leader in a growing market. The dialysis market is going to grow about 4% in constant currency, on a volume basis. Patient basis is about 6%, but think about the fact that in 2020, this will be a USD 100 billion market and when we finished in 2012 it was a $75 billion market. So plenty of room to grow and thrive in this particular space that we're in. And I think we all know what drives this and what the conditions are among our patients, that continues to see them grow at about 6%. Obviously, in health care, if you cannot provide the highest…

Michael Brosnan

Management

Good afternoon and good morning, to everybody. I will walk you through the numbers and the outlook for 2013. Rice did not speak specifically about the fourth quarter, so I'll just comment on that a bit now in terms of revenues. We did have very good growth at 14% constant currency, to get to $3.7 billion in revenues for the quarter. Organic revenues grew at 8%, with care growing at 19% constant currency, and products at 4%, also on a constant-currency basis for the quarter. International revenue growth was very good at 6% constant currency, and that is also equal to the organic growth. We did not have any appreciable acquisition effect in the International business for the fourth quarter year-over-year. Care grew at 8% and products grew at 5% in the quarter on a constant currency basis. Very solid growth numbers for International and, in particular, I'll point out it's an improvement in same-market growth compared to the third quarter, where, as was pointed out to us several times in the third quarter call, we had hit a bit of a low in the third quarter for the International business. But it's now back to what we're accustomed to in those markets. In North America, care revenues grew 22% but they were influenced by the out-of-period revenue, that we indicated would take place in our Q3 call. Without that revenue, the growth would have been 17% and the organic growth would have been 5% for the quarter. So obviously, the delta of 12% is a consequence of the Liberty acquisition and the impact on revenues in the fourth quarter. Same-store growth was 4%, so pricing was slightly positive in the fourth quarter in North America. On the product side of the business, the business declined by 3%. Rice commented…

Robert Maurice Rice Powell

Management

Thank you, Mike. Just a real quick summary slide, then we'll get into your questions. Please don't leave here doubting that we don't believe that we have future profitable growth in our scope. We believe we can do this. One thing I'd like to point out to you, it's very important to me. When I say to you we have 3,160 clinics, we have 258,000 patients, let's not forget the individuality of the treatment. We have a human being that we're treating, that's very ill and they need us to do a good job. And I want you ever think, as these numbers get larger, that we lose the impact that we have every time we touch a patient. We take great care in that and I'm happy to see these numbers get larger, but at the same time, don't, for one second, think that we don't look at each patient as an individual that needs to be treated and handled with utmost care, expecting the best outcome. I think, sometimes, that can get lost in the message. We talked about this as a market niche that's growing and why it's going to grow. I also want to talk about profitable growth and continuity among the management team. You have a management board that's been together for a number of years. We have people with tenure, at 20 years, 10 years, 15 years, so be comfortable that you have a group of people that have worked together for a long time. Many of you have asked me the question, is the strategy of the company going to change with Ben's retirement and Mike becoming CEO? And the answer to that is, no. But also understand, the strategy that Fresenius Medical Care has had for a number of years was a…

Oliver Maier

Management

Great. Thank you, Rice. Thank you, Mike, for the presentation. So same procedure as before, we're going to take questions from the audience first and then I'm going to move to the questions from the audio line. So Martin is going to be first.

Martin Brunninger - Nomura Securities Co. Ltd., Research Division

Management

Martin Brunninger from Nomura. Just to confirm your increased revenue per patient. Is that a matter of collection from Q3? And is right that you said you should get more market share of commercial patients to get back to the appropriate level, maybe kind of elaborate what you meant with that. And second on OMONTYS that you highlighted, what was your assumption for 2013 and conversion from Epo to OMONTYS and how does that impact your profits for 2013, before you issued your guidance?

Robert Maurice Rice Powell

Management

Mike, you want to take the first one and I'll take OMONTYS?

Michael Brosnan

Management

Sure, yes. Just to confirm, the -- what I said was that we're seeing our commercial patients grow, but they're growing at a rate that is less than our overall patient population and that's why I've commented about the mix declining a bit in the third quarter. So the intention would be to improve the rate of growth of the commercial patients. I think that covers your question.

Martin Brunninger - Nomura Securities Co. Ltd., Research Division

Management

And how do you intend to do that, to grow the commercial patients?

Michael Brosnan

Management

It's very similar to when we were challenged to get the same-market treatment growth back to levels that we felt were appropriate. It's very much something that needs to be integrated into a daily basis across the country, with regard to the folks at the clinic level and how we interface with the sources that traditionally provide commercial patients, in particular, hospitals.

Robert Maurice Rice Powell

Management

In the case of OMONTYS and the conversion, we were very conservative. We had no big assumptions about what would happen. I mean, we really went into this pilot trial not knowing what the outcome would be. So several people have indicated, what will happen now? We will simply continue on. We've been a customer of Amgen's for a number of years, as you know. But we really didn't have any "bet the farm" sort of outlook on OMONTYS at the time we did this. I'm happy to tell you that the pricing that we had on OMONTYS was for a pilot study. I think I said this at the JP Morgan conference, we really had not begun negotiating a commercial contract with them. We were waiting to get through the pilot to really see how things went. We just weren't interested in getting too for ahead of ourselves.

Michael Brosnan

Management

And, Martin, let me follow-up, too, because I was thinking about acute onset when I said hospitals. Obviously, the ongoing source of commercial patients is also focused on our physician relationships as well.

Martin Brunninger - Nomura Securities Co. Ltd., Research Division

Management

Does DaVita HealthCare Partners still -- does it have an effect in your view that you lose some commercial patients?

Robert Maurice Rice Powell

Management

I don't think that it does. Keep in mind that HealthCare Partners is in Florida, Nevada and California. We have good presence in those states. It's been our best intelligence, as we've looked at this, that we've not felt like that we were losing commercial patients there. I actually think the activity around commercial patients is really very local in the markets, and you really have to be out looking at what you're doing and having good data as to where those patients are going and working with your physician partners. This is not an elegant term, Martin, but I would say it is really fundamental blocking and tackling and being out in the community and seeing what's going on.

Holger Blum - Deutsche Bank AG, Research Division

Management

Holger Blum, Deutsche Bank. Just wanted to come back on the guidance range of $100 million on net income, which is relatively broad. I understand, $40 million, $50 million is sequestration, as a non-factor [ph] , left for this year. What are the other major variables explaining the $50 million, $60 million delta in potential outcome?

Michael Brosnan

Management

I think you can look at the right-hand side of the page, that's why I went through that so carefully, as I think that what will contribute to that is what happens with regards to some of those other factors. The ability to mitigate costs associated with things like the medical device tax, how we grow our pharmacy operations and how we attack the growth of commercials in the U.S., coupled with the fact of a relatively modest impact associated with the timing of closing acquisitions. I wouldn't add to that. I think that's a pretty comprehensive list.

Holger Blum - Deutsche Bank AG, Research Division

Management

Okay. And then if you look back and follow your adjustments for the earnings space in 2012, it implies that you had a net income decline of 2% or EPS decline of 3% against 10% top line growth in 2012 on a clean basis, or bid [ph] on paper with a Medicare increase and a few other items, that should of been a somewhat better year, I guess. So what are the major, let's say, items which were really causing the underlying decline, then, in earnings? Is this Liberty, for instance? Maybe you could say a word there, to what extent that might have been dilutive in the first year of consolidation. What are your expectations there for '13?

Michael Brosnan

Management

Yes, yes. Well I think -- and again, some folks may debate how you treat the renegotiation of the Venofer agreement, but we have indicated that we'd get about 40 basis points of accretion in margin, and when you look at the charts that Rice and I presented, we were showing a 16.9% margin, adjusted in 2012, over 16.5% in '11. So I think in terms of profitability, we felt we achieved our margin goals in a difficult environment.

Robert Maurice Rice Powell

Management

And -- no question. We were later getting where we wanted to get with Liberty but, again, we were dealing with the Federal Trade Commission on when we could integrate and do some of those things. So I would tell you over, we feel like it was a tough but a good year in that regard, enough said.

Holger Blum - Deutsche Bank AG, Research Division

Management

And just to bring about the adjustments you made, that we rather should know, if you look at '13, we base our numbers to a lower base, that we should look at reported EBIT, which would mean on reported EBIT, you would have been some margin contraction and even net income decline if I take the...

Michael Brosnan

Management

No, that's correct.

Holger Blum - Deutsche Bank AG, Research Division

Management

Correct basis, so I'm more...

Michael Brosnan

Management

A margin decline in '13, you mean. You're talking about '13?

Holger Blum - Deutsche Bank AG, Research Division

Management

In '12. If I say, I should look at EBIT of 2.2, would be versus 10, top line?

Michael Brosnan

Management

Yes, I'll answer both, I just want to make sure which year I was talking about. In 2012, on a reported basis, the margins are 16.1%. So the swing is absolutely the renegotiation of the Venofer contract and, to a lesser extent, the contribution, which is de minimis. That's an 80 basis point swing for the year. So if you look at '12, the way we've presented it in 2012, you get to the 16.9%. If you look at '12, simply on a reported basis, which is what I've suggested as a base for '13, you'd be at 16.1%, so you'd have contraction of about 40 basis points. The Venofer, the opportunity to renegotiate that deal, we felt was important to the business. When you look at 2012, it seemed like the appropriate point in time to take advantage of the fact, as Rice mentioned in the third quarter call, that we had the right to look at that contract again. That was negotiated in the deal, back when we closed it several years ago. So we acted on that in 2012 and if you -- no question, if you include that in the numbers, then there's a contraction of margins. But I think there's no mystery as to why the margins contracted, it's because we renegotiated that deal. We rebalanced the economics between the parties and, most importantly, there were volume commitments in the old deal and we restructured the arrangement which, I think, is much more appropriate given the current market, such that we're not going to be bound to multi-year fixed volume commitments as we go forward. So that's why we did it and it's an 80 basis point effect on the margins between the as adjusted and the as reported.

Holger Blum - Deutsche Bank AG, Research Division

Management

That's clear. But you, although, have, let's say, nonrecurring one-time benefits in the same magnitude. So you would have a real margin decline, all but Liberty is a higher margin business?

Michael Brosnan

Management

No, I don't view the other items as one-time benefits. First, the investment gain, we never reported as part of our operating earnings at all during the year, period. So we took no sleight of hand advantage with regard to the $140 million investment gain. And with regard to the other activities, we've had several years, in fact, 3, where we've had substantial spending on acquisitions, 2010, '11 and '12. And historically, we have always included all of the activities related to acquisitions in operating earnings, with one exception. That was the RCG acquisition, because it was -- it dwarfed everything else we had done for -- but assured the formation of the company. And the out-of-period revenues and, perhaps, my explanation was too long-winded before, because out-of-period revenues are not unusual in the U.S., given the way health care revenues are recorded. They're not unusual at all. We had, had out-of-period revenues at a much lower level in 2010, 2011. And the reason I highlighted it in 2012 was, it was about 2x the normalized level and it was happening at the end of the year. So I felt, in fairness, I had to give you an indication that something would be happening in the fourth quarter. So I don't view that as a one-time effect at all. What I have done in looking at 2013 is ask myself the question whether I see, after a 2- or 3-year period, whether I see those activities continuing into '13. So I've -- and I don't see it. So therefore, what I tried to do, in a very simple way, is ask myself the question, what do I think is a good base and a base that won't require me, every quarter in 2013, to remind everybody of all of the activities of 2012. So the conclusion we came to was the best thing to do is use the reported numbers. But it's not, in my view, taking a one-time activity, such as the Venofer charge, and trying to argue that the out-of-period revenues was a one-time activity, because it wasn't. It was a quarter affect of $14 a treatment, a full year standalone effect of $4 a treatment and a year-over-year effect to 2011 of $2 a treatment. So it's very -- it was very much in the normal course of business for 2011, 2012. I don't know if it helped saying in a different way. I'm happy to take another question on it. It's an important question.

Holger Blum - Deutsche Bank AG, Research Division

Management

We can discuss it off-line. I don't think it's conditional [ph] if you switch the base, looking at '12 -- both '12 and '13 growth rates, but I'll leave it.

Michael Brosnan

Management

And I take your point. I'm focusing more on the absolute numbers for '12 and '13. Absolutely appreciate that changes how you want to interpret the growth rates. And as we talked about this before this meeting, appreciating that having read a number of your reports over the course of the last several months, different people will have a different point of view of that. So the intention is, we never tell you what to do, God forbid. But we felt we owed you at least management's view on how to look at 2013. But I absolutely appreciate that you may have a different view with regard to how to measure the growth rates. I think what we were trying to do is give a solid base to '12 and give our absolute dollar numbers for '13. And how that finds its way into the biosphere, we'll read about it.

Oliver Maier

Management

I think there's one more from Marcus.

Marcus Wieprecht - MainFirst Bank AG, Research Division

Management

Yes, Marcus Wieprecht from MainFirst Bank. One question on your P&L line is famous income from equity method investees. Maybe you could remind us, please, what the metrics are behind that line. It's quite substantially down and I have in the back of my mind that's somehow related to the joint venture you have. But some refresher, for me at least, would be helpful.

Michael Brosnan

Management

Yes, happy to, Marcus. It is -- there are a number of factors in that line, but the principal one is the Vifor-Fresenius joint venture, pharma joint venture. We had accelerated some of the costs associated with getting the PA21 the drug filings in place, particularly in the U.S. So that's what largely drove the change, the reduction in equity income associated with that. It's picking up our share of the costs associated with accelerating the filings for the phosphate binder drug PA21.

Oliver Maier

Management

One more from the audience. That's Volker.

Volker Braun - Commerzbank AG, Research Division

Management

Two questions related to cash flow, if I may. First of all operating cash flow of more than $2 billion represents roughly 15% of sales, which is a record mark. What would you consider as sustainable level, is this a sustainable level? And with regards to your acquisition budget of $300 million, what does that mean for your plans regarding the expansion of de novo networks? Maybe a few words on that, but, in particular, in the International market?

Michael Brosnan

Management

15% is a very attractive number and I would -- I wish I could say we'll sustain that for the mid-term, but I'm not going to say that. The 15% was influenced by a lot of -- as I already said, a lot of work around the world relative to managing DSOs. Some of that was because the DSOs had climbed over the course of the last couple of years, as a result of the sovereign debt crisis, in particular. So we made substantial progress getting the DSOs back down to a reasonable level. We also had some legal settlements in 2012, which I'd commented on earlier in the year. The Baxter litigation had with it an escrow, and when the patents for the hemodialysis litigation were invalidated, most of that escrow came back to us. We also had a settlement with -- here in Germany with the tax authorities, that resulted in their finally fulfilling a refund that we were due. So the working capital elements, the improvement in working capital, contributed to that 15% of revenues. So I would still guide to a midterm expectation that we'll be probably greater than 10% of revenues in terms of operating cash flows. And relative to your question on de novos and, frankly, off the top of my head, I don't recall the International de novo number, we typically don't guide to it. You want to comment on it?

Robert Maurice Rice Powell

Management

Yes. So we did 65 de novos in '12, about 43 in the U.S., 22 in the International markets. I think we're pretty comfortable that, in any given year, we'll be somewhere between 60 to 100. And if you look at what I think we're counting on for CapEx spending next year, somewhere in the neighborhood around $700 million, is that right? We think that gives us ample room to be able to do that. We're not really interested in backing off of that number. If we are in the right place, it's the right time to put a de novo in, we'll certainly do that.

Oliver Maier

Management

Okay, now, I think it's time to open up the audio line so, Jerry [ph] , if you don't mind, I think we can start accepting questions from the outside.

Operator

Operator

[Operator Instructions] The first question is from Michael Jungling, Morgan Stanley.

Michael K. Jungling - Morgan Stanley, Research Division

Analyst

I have 3 questions. The first question is for Rice. I can see on Reuters, a headline that I think you mentioned to the press, that the CEO expects a slight reduction in reimbursement as a result of the U.S. Medicare rebasing. What do you mean by slight? And secondly, what gives you the confidence that it will only be a slight headwind for you in 2014. Question number 2 is on the U.S. cost per treatment, how you're thinking about cost inflation for renal drugs and also labor? And then the final question I have is in relation to Renal Advantage. I think in the Q3 you highlighted that you're a little bit behind integration activities and, as a result, there were some cost savings that you could make going forward or catch up. How much did you make good in the fourth quarter and how much of integration savings are left for 2013?

Robert Maurice Rice Powell

Management

Thank you, Michael. I guess I'll have to learn to be careful how I define slight when I speak with the press but, no. In all seriousness, the discussion that we had was simply that, as I said today, I hope people don't take the $4.9 billion number and really run with it. I think it will be vastly different than that. And the discussion that we had was, when asked, "Well do you think reimbursement would go up?" I said, "No, I do not." But I'm comfortable that CMS is looking at the co-morbid conditions and all of the inputs on the rebase. Everybody tends to focus just on utilization of Epo, but keep in mind, there have been price increases and they've agreed that they're going to look at that. So I do think there will be some reduction, if you will. I never defined slight and I don't think I could define slight today. I oould certainly tell you what I'd like it to be, but I don't think that's going to get you what you're looking for. So I'll have to tell you, it's still undefined at this point and we'll watch with great interest as this unfolds over time. Mike, you want to take the cost per treatment. I'll come back around here.

Michael Brosnan

Management

I have to apologize, I didn't hear the question. Could you repeat the question, Michael, your second question?

Michael K. Jungling - Morgan Stanley, Research Division

Analyst

Yes, sure. When we look at U.S. costs per treatment for 2013, how should we think about cost inflation for renal drugs and also labor?

Michael Brosnan

Management

I actually was not planning on guiding at that level for 2013 because of the number of factors that we indicated on the page. So I'm probably not going to give you a specific. I would -- other than to say, we typically do see some inflationary aspects to our cost per treatment year-over-year. So I certainly think that would be the case with regard to our labor costs. On the pharma side, it's not as clear as perhaps it's been for the last couple of years. Because from a utilization perspective, obviously, with Epogen having been at the forefront in 2011 and, to a lesser extent, in 2012, I don't think we know enough today to give you a firmer guidance on cost per treatment other than what I've indicated for operating margins overall for the company. I don't know if you have a different view, Rice?

Robert Maurice Rice Powell

Management

No, I would say this, that I don't know how we would peg the labor at the moment. As it relates to utilization, we feel like we've hit a fairly constant baseline in our utilization of our pharmaceuticals. There are some things that we are continuing to look at with our algorithms. There could be some additional movement there. But, Michael, at this point, were not far enough along to really do that, and obviously, there's things that we have to consider in terms of the clinical outcomes and how do you approach those things. So it's probably not in our best interest to say too much more than that, at the moment, but know that we are sensitive to it and looking at it. In the case of Renal Advantage, as I said when we announced the deal, this was a very different situation. When we came together with the acquisition of Renal Care Group, we had published synergies and we were very comfortable at the synergies that we were looking to take there. We didn't really see a big synergy opportunity, per se, with Liberty, Renal Advantage. But I will say that we've gotten a better pace. We've picked up our base on the integration. I feel much better what we got accomplished in the fourth quarter. But you know, Michael, we never really commented on dollar savings or what we think we would get out of there. But clearly, one of the things that we had not done, and this is what I commented on, that when we looked at the situation with payer mix and where we were with revenue per treatment, not having been able to look and talk to the Renal Advantage book of business if you will, for a couple of months, it really put us behind the 8-ball, and I think we're making progress there, so I think I'll answer it that way.

Michael K. Jungling - Morgan Stanley, Research Division

Analyst

Maybe some housekeeping questions, just on the financials. For 2013 guidance, and I excuse myself if I missed it, but could you give some guidance on how you see sort of net interest and also how you see the tax rate? And when it comes to acquisitive growth, what is the spillover from acquisitions in 2012 to 2013? If I also include the $300 million of additional acquisitions, the CapEx that you've earmarked? So 3 questions on the financials and then I'll be quiet.

Michael Brosnan

Management

Yes, your first question on net interest. I think that we'll probably have a relatively stable, maybe a slight uptick in terms of the actual cost, the actual interest expense, just anticipating that rates won't stay precisely where they are today. But no material change from the numbers that you see in our 2012 actuals. On the tax rate, I think we're probably in the 33% to 34% range, in terms of the effective tax rate. And I must have a hearing problem today, I missed the third question.

Robert Maurice Rice Powell

Management

Acquisition spillover.

Michael Brosnan

Management

Oh, acquisition spillover. Yes, just -- we did close the Liberty transaction in late February, so there's a couple of months on that, and that's about $60 million a month in revenue. So a relatively minor effect with regard to the spillover on Liberty. And the other acquisitions that we closed in fiscal '12 are relatively small. So I think you're probably looking at a revenue effect of -- on the order of $110 million to $130 million, and I'd apply our normal margins to that in terms of a spillover effect.

Operator

Operator

Next question is from Lisa Clive, Sanford and Bernstein. Lisa Bedell Clive - Sanford C. Bernstein & Co., LLC., Research Division: One question. You mentioned your pharmacy business and the fact that you plan on expanding that quite a lot, particularly as you move into integrated care. You recently announced a deal with DaVita. Could you just explain how that fits into the equation as well? And then a second question, on your use of OMONTYS. The letter that you published, I believe it was on the 13th of February or so, didn't actually mention any deaths in the patients who are trying OMONTYS, Can you confirm that, that was, in fact, the case? I know you did cite that there were some hypersensitivity issues, but just trying to get a bit of a better sense of your experience with the drug. And then just lastly on the potential for a claw back, what is your sense today in terms of the small independent clinics, in terms of their level of profitability. I had seen a presentation from MedPAC in December that indicated that actually it doesn't seem like their profitability has really shifted much from 2010, when I think Medicare itself calculated they were making a 0.1% profit margin, and I guess maybe you've alluded a little bit to that, the fact that you've seen deferrals of purchases on the equipment side. Could you maybe just talk about how you think their financial health is these days?

Robert Maurice Rice Powell

Management

Sure, Lisa. It's Rice. So with the deal with DaVita that we announced, I guess, back in December, it really doesn't impact our belief that the pharmacy is important and the tools and the advantages that having our patients on our pharmacy gives us. We think that's fundamental to Fresenius and we are in control of that and we'll continue to drive patient uptake, because we think we will get better outcomes, better compliance. We had to make a decision, in terms of how to best use our capital, did we build out? Should we go build out a logistics chain to deliver the drugs, literally, get product to the clinics or should we just make-buy versus decision? We talked to a number of the players in the market that do that, but we've had a long relationship with DaVita. We work well with them, in addition, to competing with them. And we felt that they had a very renal-patient specific outlook on this with their pharmacy and we were comfortable that they're doing the fulfillment and the literal shipping of the drug. We thought that made sense, we felt we would get the attention that we wanted in doing it that way. So think of it as a make-buy decision and we really were looking for somebody that would give us great service in the logistical aspects of delivering the pharmaceuticals, the oral drugs, to our patients. In the case of OMONTYS, I believe there were 5 deaths, in total. That's what I saw in the literature. I believe 2 of those were attributed to cardiovascular situations, and then there were 3 deaths that people believe are hypersensitivity-related. I believe, Lisa, that at least 1 of those was in one of our clinics. I can run that down for…

Robert Maurice Rice Powell

Management

Yes, Lisa, What I would say is, I think it's a great program that we have. I think one of the things that we haven't talked about of late is that, as we set that program up and we had nurses come into the U.S., they were -- they scored some of the highest scores possible in standardized testing that they take. Unfortunately, as the administration has changed and things have gone on in the U.S., it is bloody impossible to get people into the country with work visas and to be able to take advantage of that opportunity. And what we've seen is, other parts of the world now, particularly in Europe and other places, are beginning to utilize these nurses coming out of the Philippines, because they have an easier time getting them in the country, getting them work visas, et cetera. We've had constant, constant dialogue with the immigration authorities in trying to work through these issues and we've made some progress of late, but we do think it's an advantage that we have. But we've just not been able to see significant numbers of nurses coming in, like we had hoped, just based on the things that are going on in the U.S. today.

Oliver Maier

Management

Okay, Jerry [ph] , I think, due to the time constraints, we have time for one more question.

Operator

Operator

The last question will be from Veronika Dubajova, Goldman Sachs.

Veronika Dubajova - Goldman Sachs Group Inc., Research Division

Analyst

Veronica here from Goldman. I have 3 questions, hopefully a couple of them pretty straightforward. One, Mike, I appreciate you don't want to guide on cost per treatment but I wonder if you might help us think about revenue per treatment in North America in 2013, given a couple of the moving parts that you have there, that might be quite helpful. My second question is on the integrated care pilot. DaVita was out there when they reported with, what seemed like quite negative commentary on the pilot and their take on it was that it was fairly disadvantageous to the large [indiscernible] organizations. I wonder if you share that view or if maybe your view on that is not as stringent. And as you think about this program being rolled out, what are the key pieces of feedback that you're passing back to CMS, aside from simple questions like, what are the quality requirements, et cetera. And my last question, just hopefully housekeeping. Hemoglobin, the percentage of patients between '10 and '12, saw a slight drop in Q4. It was much bigger than what we've seen in Q1, Q2 and Q3. I'm just wondering if there's anything funny about the numbers or if you can comment on that?

Robert Maurice Rice Powell

Management

Mike, you want to take number one?

Michael Brosnan

Management

Yes, sure. Veronica, I think our revenue per treatment for 2012 was $355 for the year, and what I would say is that I'm going to use the phrase, like-for-like. What I would say is on the like-for-like basis, I'd expect a modest positive in the rate per treatment in the U.S. And by like-for-like is I have to adjust for sequestrations, so that's worth about probably $3 a treatment. So sequestration out of the equation, I think I'm looking at a slight positive in the U.S.

Veronika Dubajova - Goldman Sachs Group Inc., Research Division

Analyst

Okay, and Michael, if I could just jump in there, does that mean that including sequestration, there's a chance that, like-for-like, that you see revenue per treatment down year-on-year, on a reported basis?

Michael Brosnan

Management

If sequestration is not corrected, yes, I would say, based on what I've guided to the $14.6 billion in revenues and the operating earnings at $2.3 billion, then I could see that revenue per treatment could be down, yes.

Robert Maurice Rice Powell

Management

Veronica, it's Rice. On the integrated care, let me say it this way. No, I'm not as, perhaps, exercised about this as Kent is. I am still delighted and appreciate that Marilyn Tavener and her staff made a decision and they moved forward it. Is the architecture of this proposal, could it be better? Yes. But I believe that we remain positive. We think, by working collaboratively with CMS and trying to be proactive and positive, it will result in getting some of these answers taken care of and hopefully getting them done in such a way that it doesn't disadvantage us. I clearly understand where Kent and DaVita are coming from, but we're going to look at this as the glass is half full. And there are a lot of smart people involved with this and we'll figure out how to make this work for everybody because, at the end of the day, I just very firmly believe that integrated care is the right way to go. And then lastly, on the hemoglobins, in the fourth quarter, they are down a little bit. I would tell you that I'm not worried about that. I don't think there's anything going on there in a major way. Again, we do see movement from time to time on that. But if I'm incorrect, I will talk with my Chief Medical Officer, but I think I'm right on this one. I don't think there's anything substantive there, but happy to come back and let you know that if they have a different opinion.

Oliver Maier

Management

Great. Thank you so much, everybody, and I think this actually concludes our meeting actually, for today for Fresenius Medical Care. Thanks, everybody, actually for being here and looking forward to seeing you next time. Thank you.