Fresenius Medical Care AG & Co. KGaA (FMS) Q3 2023 Earnings Report, Transcript and Summary

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. [Operator Instructions]. At this time, it's my pleasure to hand over to Dominik, Head of Investor Relations. Please go ahead, sir.

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 third quarter 2023. We appreciate you joining us today to discuss the performance of the third 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 yesterday evening. For further details concerning risks and uncertainty, please refer to these documents as well as to our SEC filings that have already happened. As we have a hard stop at 4:30 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. [Operator Instructions]. I'm aware that there is, with GLP-1, one dominant topic in health care research overall, which we fully understand, but we would appreciate if we could focus in this call on the quarterly business development. 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 1 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. And with that, Helen, the floor is yours.

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 third quarter 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, will succeed as Care Delivery CEO as part of a planned transition following Bill's plans 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 U.S. health care 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 our new CFO, Martin Fischer, started on the 1st 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.

Thank you, Helen. Good afternoon and 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 side, especially within its health care division. In my most recent role, I served as the Global Head of Finance for the diagnostics segment of Siemens Health -- based in -- New York. Prior to that, I held the -- area 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 health care markets and has the opportunity to be an active part of the IPO of Siemens Health -- in 2018 and to shape the stand-alone 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 -- price of 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 special assessment of our investments and strategic treasures. 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 are highly value clarity, integrity and reliability. It is very encouraging to see the company's turnover measures already beginning to translate into improving financial performance. I'm optimistic about our ability to drive further improvements to 2025 and beyond. I look forward to speaking with you in the future. And with that, I will hand back to Helen.

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 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 1 of this year. With that, we will have completed all of our major structural changes within less than 1 year. We continue to advance our operational efficiency and turnaround plans. Our FME25 transformation program is well on track to deliver EUR 250 million to EUR 300 million in sustainable savings by the end of the year. In the third quarter, 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 -- in the U.S. We have realized accelerated productivity improvements in Care Delivery, which have helped to meaningfully mitigate the originally anticipated labor headwind of EUR 140 million to EUR 180 million for the year. As we focus on sustainable profitable growth and seek to divest noncore 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 -- laboratory services in the U.S. In line with our disciplined financial policy and well ahead of maturity, we were successful in refinancing a EUR 650 million bond expiring at the end of November without accessing the bond market. Rather, we use a mix of long-term bank financing at very attractive conditions as well as cash and short-term debt. The term loans carry -- 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 U.S. Turning to Slide 5. While it's not a third quarter earnings topic, clearly, the GLP-1 medication headlines -- 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 red 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 even 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 the drug, we consider three main features of the use of the medications: Medical effectiveness, prescription rates and patient adherence. Starting with medical effectiveness. Based on the limited information that is available to us today, GLP-1 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 early SKD status 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, calendar pricing of GLP-1 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 drug. 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 predialysis CKD stages unless have consistently taken them. Finally, we have to consider expected patient adherence and compliance over long periods of time. We know that the adherence rate 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 impact 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 third quarter, we continue to see sequential stability at a high level. I'll now move to Slide 8 to review our third quarter business performance. In the third quarter, we continue 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 U.S. The successful execution of our turnaround plans continue 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 third quarter. And we continue to execute our portfolio optimization strategy. And as I mentioned earlier, we have entered into an agreement to divest NCP in the U.S. Based on the earnings development for the first 9 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 a 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 9. In the third quarter, we delivered revenue growth of 7% at constant currency, and we continue to deliver organic growth with positive contribution 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 third quarter, operating income on a guided basis improved by 20%. This resulted in another sequential improvement of our group margin to 8.7%. Earnings development in the third quarter was driven by business performance supported by FME25 savings and reduced personnel expenses -- accelerated productivity improvements. Although we have seen a degree of stabilization, our business -- excuse me, our business still faces inflationary pressures that particularly impact Care Enablement. In the third quarter, we also had a negative impact from the absence of a nonrecurring percent payment on certain pharmaceuticals and experienced a further increased transactional exchange rate headwinds in Care Enablement. Next, on Slide 10. Starting from the left, you can see how we get at the starting point of our guidance basis. The EUR 107 million special items in the third quarter specifically comprised EUR 53 million in legacy portfolio optimization costs, primarily relating to the NCP -- costs. 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 onetime 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 human site investment remeasurement contributed positively with EUR 1 million. Turning to Slide 11. In Care Delivery, in the third quarter, organic revenue growth was supported by a positive impact from our U.S. value-based care business, InterWell Health, along with reimbursement rate increases and a favorable payer mix. In light of our commitment to drive sustainable profitable growth, we continue to exit less profitable acute care contracts in the U.S. And the negative 60 basis point impact was particularly pronounced in the third quarter. When adjusted for acute contract impact, same market treatment growth in the U.S. improved 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 effect 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 third quarter. And while we are continuing to generate positive savings from CMS' CKCC programs within the late-stage CKD and ESK 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 continued to execute on our portfolio optimization strategy with the signing of the agreement to divest NCP in the third quarter. 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. And 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 U.S., 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 third quarter 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 third quarter 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 third quarter 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 third quarter, we -- 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 recruitment 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 3.4x remained in our target corridor of 3 to 3.5x. As it is still at the upper end of this self-imposed range, delevering remains a top priority for capital allocation with any proceeds from divestments to be used for further delevering. As I mentioned earlier, we were successful in refinancing the EUR 650 million bond expiring at the end of November. We used the mix of long-term bank financing at very attractive conditions as well as cash and short-term debt. This better positions us for further delevering. And 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 an update to the outlook on Slide 17. For 2023, we continue to expect revenue to grow at a low to mid-single percentage weight, 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 installation and volume have broadly developed in line with expectations. FME25 savings are likely to be at the upper half of the EUR 250 million to 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 9 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 third quarter, our group margin improved 130 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% to 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% to 14% in 2025. This concludes my prepared remarks, and I'll now turn it back to Dominik.

Thank you, Helen. Thank you, Martin. [Operator Instructions]. And with that, I hand over to Andrea to open the Q&A, please.

[Operator Instructions]. The first question comes from the line of Victoria Lambert with Berenberg.

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 like 16%. And then second question is just on the labor market. How many open positions are you at? And where is wage growth trending?

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 improvements since last quarter, and we're sitting at around 4,300 open positions, which is improving. Clearly, where our focus is on labor is kind of on the hotspot areas that some metro areas are still experiencing. But obviously, 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.

We will take the next question then.

The next question comes from the line of Hassan Al-Wakeel with Barclays.

I have two. So firstly, 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-1s or SGLT2s amongst 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-1s for diabetes? And related to this, are you seeing any increased uptake in transplantation on the back of improved eligibility around GLP-1s? And then secondly, 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?

[Technical Difficulty]. They are connected back.

Hassan, could you please repeat your question because we were dropping off.

Apologies. Yes. 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-1s or SGLT2s amongst diabetes patients? Or could we see an impact sooner than in weight loss. You noted that only 8% of your patients have been prescribed SGLT2s and CKD. Do you know what the number is for GLP-1s in diabetes? And related to this, are you seeing any increased uptake in transplantation on the back of improved eligibility with respect to GLP-1s? 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 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, Hassan. I'm sorry for making you repeat that.

Thanks, Hassan. Yes, look, as far as we can tell, we're not seeing any impact or tiny impact on GLP-1s at this time and nothing that we could quantify. In terms of your SGLT2 question, yes, it's pretty small, as you say, at 8% at 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 transplantation piece of your question, the rates are very stable at the normal -- at the moment. So we're not seeing any kind of really change there. In terms of the number of patients who have any exposure to weight loss, I think we would see that as small, maybe kind of a couple of kilograms and the only improvement was with 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, it came in, and we had the 3 quarter true-up for plan year 2 come in, in the third quarter. While it was positive, it was lower than what we had anticipated. And clearly, it's immediately asked the same question of is this ESCOs goes all over again because we've definitely kind of learned the hard way on some of these government programs. 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 that -- those results with the lumpiness that we're seeing. What I would say is we, and the coalition of CKCC participants, are very much providing that feedback to the government to improve the collaboration between CMS and participants to drive the intended results. And 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.

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

Helen, I'll ping you, although if the same Frank isn't on for giving the interest in GLP-1 today. But I guess, per your comments around SGLT2s and GLP-1s, I mean, they're not very widely used today, but they -- SGLT2s 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, the -- and look at the CKD population in the U.S., it's actually been remarkably stable over the last sort of 15-plus years. Yes, over that time, the ESKD population has grown 3% to 4% per annum. So I know that the ACE and ARB class adoption have really helped control hypertension and improve mortality. And so I take your point that there could be a sort of tailwind of sorts from these drugs to some extent. But it would 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 may well get these patients in the end, especially if the mortality goes down, but at what age? Because the proportion of patients in the broader ESKD population, 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 the delay in progression and how that could affect your economics longer term?

Yes. Thanks, Lisa. I will try my best there, but I can also follow up with Frank afterwards. So the RAS inhibitors have been available for they've only been used in about 50% of the eligible people despite the low price and wide availability. As we think about the -- you talk about this 15 years of ESRD population growth. I think would speak to that as where we've seen an improvement in mortality and the average life on dialysis has extended. Now I think that is -- flattening off in recent years and kind of we have COVID effect there in those years, too. But I think the improvement in mortality in average life on dialysis has obviously been a benefit in that patient population growth. In terms of your kind of question on delay in progression, I think really what's behind your question is, are we going to see a change in kind of mix here as we think about kind of an extended funnel on CKD and the cardiovascular benefits, which may delay 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 kind of working or on commercial insurance coming into the ESRD population. And of course, what we see today is, I get my numbers right here, the average commercial patient is on insurance for about 30 months -- or less than 30 months, sorry, I should say that, less than 30 months. So if we get more commercial patients in and then we have that 30 months before they go on to Medicare, that -- we could see that age shift happen in that population. But I think that's something only time is going to tell on what happens to that mix. I mean, you're absolutely right that the average age of new starts now is over 65, and we already see that phenomena. So I think what we'll be looking at is to see what happens in the CKD population and the , particularly in stages 3 to 5. And then what happens in that the commercial plans were kind of whether already on less than 30 months coverage. I think obviously -- 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.

Okay. 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?

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

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

My first one is on the guidance, EBIT growth. Like given the first 9 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 then my second one is on Care Enablement. So look, it's another quarter where margin's quite a long way below your target. Can you maybe provide a bit of color on how much the margin was impacted by transactional FX in the quarter? And then maybe a bit of an update on what you're doing to drive better performance and better margin in that part of the business within the new organizational framework?

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 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 '23 to '22. In Q4 of last year, with our performance, we had some significant favorability from our bonus plans, if you will, 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 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 CE transaction piece. As I think about 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 improvement that we saw in Q3 that maybe don't happen in Q4. We do have some favorable phasing in corporate. In the quarter, we would -- 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 3 quarters included in Q3 that wouldn't be expected to repeat in Q4, and that's around EUR 25 million or so. We have ongoing exchange plans in CE. And then in Q4, we are expecting lower contribution from equity investments in our JV. So I think it's -- none of this is operational. It's either phasing or kind of onetime that we've already called out and spoke to as watching in our headwinds in the business.

The next question comes from the line of Veronika Dubajova with...

I will keep it to two, please. One, I just want to follow up on Richard's question on the fourth quarter is. I mean, I appreciate the year-on-year comparison looks very difficult. But also looking just at the absolute level. I mean normally, fourth quarter is the strongest quarter that you guys tend to have from an absolute EBIT perspective. And 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 3 quarters of the year? Just 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. But just curious on how you're thinking about the fourth quarter and whether you think we're going to be in positive territory? And whether you're still comfortable with an assumption that is greater than 1% for 2024?

Yes. Thanks, Veronika. Look, there's nothing fundamental changing in Q4. I think we've got -- you're right, it's always our strongest quarter. I think this really is one of phasing of expenses, I think, as I mentioned earlier, the lower contribution from the equity investment and the ongoing kind of transaction FX effects that we're seeing in CE kind of the quarter was buoyed up a little bit on the true-up of the CKCC which came in with 3 quarters. So I'm not looking at 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 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 Q4. On your question on same market treatment. Obviously, we are encouraged by the continued sequential improvement into positive territory once you've adjusted for the acute contract. The improvement in Q3 over Q2 is obviously encouraging. The -- we have guided minus 1% to plus 1%, and we are -- having said that we'd be more than 1% in '23. So we haven't put anything out there for '24. So we're still working through our internal budgets on that. So we feel very confident in our minus 1% to plus 1% and the trend that we have seen sequentially improving this year.

And apologies, I didn't mean to imply that you've guided for '24 yet. I just think what you have said is you would have expected an improvement in '24 versus '23. So maybe let me rephrase the question, which is do you expect an improvement versus the minus 1% to 1% that you've guided for, for '23 still in 2024?

I would -- I don't -- I would expect a continued improvement in that trend.

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

The first one is more broader. So now with the final -- or DPS rate, can you elaborate about your expectation? What does it mean for the U.S. dialysis market? So the rate is clearly below inflation. So do you really think that this is a rate where also some smaller operators might be forced to leave a field? And the second question is on your value-based care approaches in general. So also, Hassan mentioned, you had similar problems with the ESCO some years ago. And it looks, at least from the outside that, yes, 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?

Thanks, Oliver. Look, clearly, our PPS final rate is disappointing. And we continue with the industry to engage with CMS on this calculation. And clearly, they've acknowledged that there's a forecasting error in their calculation. There's a lot of pressure here from the service providers to get the right reimbursement increase in this higher cost environment. So we continue to kind of put the efforts in the right place there. And I think coming out of the final rate, we will still kind of be pushing for the right methodology on the calculation. So we're not giving up and we continue to do the good work that we do there. What does that mean? I mean, obviously, for us, we're also 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, and not just in lower reimbursement, but a higher cost of capital environment? I can't speculate on. Obviously, for us, we're focused on our own turnaround and being moderate in how we are forecasting it, so that we can rightsize our organization accordingly. And as I said, that was within our kind of our guidance assumption. CBC. Clearly, CKCC was a disappointment, but still positive. And 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 our ability -- so CKCC whether we had InterWell and value-based care or not, we'd have been hit with that under the old Fresenius health plan true-ups that we saw with the ESCOs. What we are increasingly doing is turning the conversation and the discussion about our work with InterWell and how we are participating in value-based care arrangements with the payers in Medicare Advantage and so on. I mean, look, I think as we were talking about the -- managing patients earlier in the CKD kind of funnel, that's really where this work with InterWell is really helpful in kind of supporting these patients in the CKD population driving earlier detection and management to patients, which would begin -- we feel the management of these patients at an earlier age. So we -- kind of it's still early days, I would say, in the maturity of the environment for VBC. We know that when we intervene in the management of this care of this patient population that the medical loss ratio show us that we can save cost in care. And I think for us, it's making sure that we -- getting the full benefit, we believe, will improve with a more stable -- of framework for VBC programs. And CKC is a part of it, but not the whole ecosystem. And we are clearly the market leader in this value-based care environment with the number of patients that we have on contracts as well as our partnerships with physicians. So I think this is one where it's still an early environment, but one we're incredibly excited about and they'll kind of see that we can participate in it. But of course, the government programs, we continue to take a hard look at, and we'll have to determine whether we stay in some all or none in the future.

One quick follow-up in this context. So basically, there seems to be, 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 a variety of targets? Because if you -- 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?

Yes. Look, I -- 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 to 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 not the full transparency and kind of the variability in the government reporting, as I said, that's making it a little bit more challenging for us. I think what is good is the ability to have the discussions and make sure that the kind of the intent of the plan is what's being delivered. So look, I think we -- 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 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 yes, I think just more to come on this, but obviously, we had to wait to get -- kind of get this 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 -- when we get it. So yes, I think more to come, and we'll continue to provide updates on our VBC book of business.

Okay. We can take one last question.

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

Just a quick follow-up on the volume question from Veronika. Just one of the points you made, I think, on 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 stays rather than that? Have we got a few more quarters to go and then we're back to normal? It'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?

Yes. 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, growth is -- continues to be a key area for us. But I think the key here is we're dealing with the annualization still of COVID and we're exiting these 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 generally locked up for a couple of years. And with some of them, or many of them, we have escalators in already. So we're not seeing kind of -- I mean, we want a higher price. They want a lower price. So it's always kind of a thoughtful partnered negotiation. But we're not kind of anything here on our big contracts that concerns us. But obviously, there are always ongoing discussions and negotiations. Where we're seeing some of maybe -- plans want to change pricing. Obviously, our focus is on profitability, and we are kind of prepared to go out of contract or walk away from these smaller contracts where they don't make sense. But the larger payers, it very much is a partner discussion, I would say.

Okay. So 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. So apologies for that. But thank you for being patient with us and listening in. Thank you.

Yes. Thank you all. Take care. Bye-bye.

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