DaVita Inc.

Good evening. My name is Michelle and I will be your conference facilitator today. At this time, I would like to welcome everyone to the DaVita second quarter 2023 earnings call. Today's conference is being recorded. If you have any objections, you may disconnect at this time. All lines have been placed on mute to prevent any background noise. After the speaker's remarks, there will be a question and answer period. If you would like to ask a question during this time, simply press star and the number one on your telephone keypad. If you would like to withdraw your question, press star, then the number two. Mr. Eliason, you may begin your conference.

Thank you, and welcome to our second quarter conference call. We appreciate your continued interest in our company. I'm Nick Eliason, Group Vice President of Investor Relations, and joining me today are Javier Rodriguez, our CEO, and Joel Ackerman, our CFO. Please note that during this call, we may make forward-looking statements within the meaning of the federal securities laws. All of these statements are subject to known and unknown risks and uncertainties that could cause the actual results to differ materially from those described in the forward-looking statements. For further details concerning these risks and uncertainties, please refer to our second quarter earnings press release and our SEC filings, including our most recent annual report on Form 10-K, all subsequent quarterly reports on Form 10-Q, and other subsequent filings that we may make with the SEC. Our forward-looking statements are based on information currently available to us, and we do not intend and undertake no duty to update these statements except as may be required by law. Additionally, we'd like to remind you that during this call, we will discuss some non-GAAP financial measures. A reconciliation of these non-GAAP measures to the most comparable GAAP financial measures is included in our earnings press release, furnished to the SEC, and available on our website. I will now turn the call over to Javier Rodriguez.

Thank you, Nick, and thank you for joining our call today. I hope that everyone's having a safe and joyful summer. At DaVita, we've been focused on innovation and continuous improvement to provide the highest quality of care for our patients. Hand in hand with these efforts, we've been driving operational improvements across our organization. Our second quarter performance reflects strong traction across those initiatives, putting us on a path to deliver strong clinical outcomes and financial results for the year. Today, I will cover the second quarter results, offer some perspective on the industry landscape and drivers of long-term performance, and update our full year guidance. Before we get into the second quarter details, I would like to take a moment to celebrate a clinical and technological milestone. On our February call, we mentioned the rollout of our next generation clinical IT system, which we refer to as Center Without Walls, or CWOW. I'm happy to report that after five years of development, CWOW is now live in each of our approximately 2,700 clinics across the United States. This patient-centric, cloud-based system combines and replaces four legacy systems and is designed to provide seamless flow of information across each of our centers and all modalities. This includes real-time clinical dashboards, data sharing with our physicians and integrated kidney care platforms, and notifications such as critical lab alerts. For ease of use, it features wristbands for quick teammate login, improved ability to track and reschedule mistreatment, enhanced real-time documentation, and consolidated reporting for streamlined analysis. And while we're enthused about these immediate benefits, the most significant enhancement is the state-of-the-art data structure and platform upon which we can build further capabilities, including artificial intelligence, to advance the care delivery, in the years ahead. With this groundbreaking platform, our clinicians are able to access the right information at the right time in the right place. Transitioning to our financial performance, in the second quarter, we delivered adjusted operating income of $432 million and adjusted earnings per share of $2.08. These results were driven by improvements across our financial trilogy of treatment volume, revenue per treatment, and patient care costs. I'll touch on each of these in a bit more detail. On volume, we saw our second consecutive quarter of improvements in census and treatments per day. This is encouraging as it's a result of better macro environment and progress in our operating initiatives. We're trending near the top of our original volume range of down 3% to flat year-over-year And if these trends continue, we would anticipate delivering volume growth in 2024. Shifting to revenue and revenue per treatment. Revenue per treatment was particularly strong in the quarter. This was primarily driven by typical seasonal factors from patients meeting their copays and deductibles, along with normal expected rate increases and improvement in mix, including Medicare Advantage. Adding to the RPT increase, We have seen progress from investments we've been making in our revenue cycle capabilities. These investments resulted in higher cash collections and a decline in our DSO. I'm excited about the investments we've been making in this area, which represent a good example of how we are constantly improving operations. And finally, patient care costs improved as expected in the quarter. Although base wage increases remain well above historic pre-pandemic levels, other expenses including contract labor and pharmaceuticals continue to decline. This benefit was partially offset by elevated training costs. While staffing levels in our clinic are in a much better position compared to last year, we continue to experience above average turnover among facility teammates. As a result, we no longer expect an improvement in our training productivity during the back half of this year. Taking a step back from the most recent results, I would like to offer some reflections on the broader industry landscape and our effort to drive performance going forward. Beginning with the reimbursement rates. We're disappointed by CMS's proposed rule to update the ESRD prospective payment system for 2024. Specifically, the proposed rate increase falls short of expected cost inflation in 2024, and it fails to adjust for the acknowledged inflation forecast miss relative to actual wage and inflation increases over the past two years. The kidney care community will continue to advocate for for an adjustment mechanism to reconcile these forecast errors, similar to what exists today for skilled nursing facilities. In response to the persistent cost inflation, we are continuing our track record of innovation across all areas of our cost structure. Most recently, we consolidated portions of our facility footprint and reduced pharmaceutical costs through our conversion to Mercera for anemia management. These programs are proceeding in line with our expectations. Going forward, we will continue to drive cost efficiencies across the P&L. Through these efforts and continued improvement in our volume trends, we continue to target 3% to 7% long-term growth of our enterprise adjusted operating income. Looking forward to the remainder of the year, given our progress during the second quarter, we're revising our adjusted operating income range of $1.475 billion to $1.625 billion to a new range of $1.565 billion to $1.675 billion. We're also updating our adjusted earnings per share range of $6.20 to $7.30 to a new range of $7 to $7.80. Our performance relative to this guidance will continue to depend heavily on momentum in patient census trends, our ability to manage patient care costs within the broader labor environment, and sustained improvement in revenue cycle management. I'll now turn the call to Joel to discuss financial performance and outlook in more detail.

Thanks, Javier. I'll walk through a few factors driving our strong performance in the second quarter, starting with treatment volume. In the second quarter, U.S. dialysis treatments per day were up by approximately 0.3% sequentially. This is the result of continued census gains in the second quarter, driven by an increase in new to dialysis admits. Mortality remains higher than pre-COVID levels, but came in lower than Q1 and in line with our expectations for the quarter. Our mistreatment rate continues to be elevated relative to historic levels. Revenue per treatment was up $10.59 versus Q1. Approximately half of this increase was the result of seasonality, primarily due to higher patient responsibility amounts in the first quarter. Approximately $2 came from normal expected rate increases and continued increases in patient mix. An additional roughly $2 was the result of strong cash collections in Q2. As Javier said, we have been investing in improvements in our revenue cycle management systems and processes and are beginning to see the benefits of these efforts in both RPT and DSOs. We were anticipating these improvements, but they came earlier than forecasted. We expect these benefits to persist in the back half of the year and going forward. As a result, we now anticipate year-over-year RPT growth to be 2.5% to 3%. On a non-GAAP basis, patient care costs per treatment decreased 1.5% sequentially. While base wage increases remain high, we have successfully reduced most of the temporary compensation measures we relied on during 2022. At the end of Q2, contract labor has returned back to pre-pandemic levels. Operating income from our integrated kidney care business was approximately flat with Q1. The quarter benefited from positive prior period developments in our special needs plans and the timing of expenses that were delayed until later this year. For the full year, we now expect IKC adjusted operating income to be approximately flat to 2022 operating income loss of $125 million. Regarding our clinic footprint, in Q2 we closed or consolidated 16 centers in the U.S., bringing our year-to-date U.S. closures to 36. We continue to assess further facility consolidation and closures during the back half of the year. Regarding capital structure, we ended the quarter with a leverage ratio of approximately 3.7 times EBITDA and did not repurchase any shares during the second quarter. Our capital allocation strategy remains focused on capital efficient growth, a target leverage ratio of 3 to 3.5 times EBITDA, and the return of excess cash flow to investors through share buybacks. Given our increased guidance for the balance of the year, we have increased visibility towards bringing our leverage level back within our target range. That concludes my prepared remarks for today. Operator, please open the call for Q&A.

Thank you. At this time, if you would like to ask a question, you may simply press star and then the number one on your telephone keypad. If you would like to withdraw your question, you may press star, then the number two. Our first caller is Kevin Fishbeck with Bank of America. You may go ahead, sir.

Good afternoon. Actually, this is Joanna Gadzik filling in for Kevin. Thanks for taking the question here. So thanks for the call around revenue per treatment breakdown in terms of the drivers. They're clearly very strong performance and I appreciate the commentary. I expect, I guess, a faster growth for the year. So just looking into the pieces, because you said a better payer makes one of the drivers. Can you talk about specific commercial pricing and what kind of rate increases are you getting this year? And also, you know, any indications for how things are tracking into next year? Because I guess that's where maybe one area, because you also mentioned the Medicare rate out there being lower than cost inflation. So is the commercial pricing, I guess, tracking better?

Yeah, thank you for the question, Joanna. I'll start off, and Joel, you can supplement if I miss anything of importance. Private pay mix is holding up. It picked up 20 bps. And we continue to see that our private pay patients really value their insurance. As it relates to rate increases, just a reminder, most of our contracts are multi-year. So in any given year, we don't negotiate that many contracts. There's nothing really to call out on that. Our rate per treatment increases are in line with expectations. So is there another part to your question that I didn't answer?

No, this was, yeah, this was it. But I guess also related, if I can, a follow up to that topic in terms of the Marietta case. And I guess we spoke before and there's still, you know, bipartisan support for effects. So can you give us any update on that? And I guess on that topic, as it relates to pricing, commercial pricing issues. you know, are you seeing employers using this court decision to restrict networks or are they using it to maybe, you know, they bring it up in the price negotiations when it comes to pricing for self-employed?

Sure. Let me take a minute and let me lens up a little since some people are not tracking all of the Marietta. So it's probably best for me to divide it into what we know and what we don't know. So let me start with what we do know. As we look at our claims year-to-date, we have not seen much change compared to prior years, so there's not a lot of volume. But we have learned more about how employers change benefits and mislead members on how it's done, and so we don't want to accommodate this poor behavior. So what we have done is we've implemented a verification process at admissions, and if an employer eliminates a network dialysis benefit for its member, then we have the right to prevent that plan from having access to our centers. In addition, we continue to have very high interest, bipartisan interest, in making sure that policymakers protect our patients. So those are the things that we do know. What we don't know is how many employer groups are considering carving out dialysis from network in the future. And we also don't know if or when members of Congress will introduce the bill and how the CBO will score it. The last part of your question was, are payers using this in one way or another? And it has not come up in one negotiation because this is really more of a dynamic between the employer trying to decide what to do with the plan, not what the payer does with the provider. the provider and the payer both value network.

Does that help you, Joanna? Yeah, that makes sense. No, no, that totally makes sense, and I appreciate it. So in terms of what's going on in Congress and the score, is there any indication what we might hear about this, or that's not really something that we can predict from the outside?

Yeah, there's nothing we can predict from the outside. That's left to... policy makers, champions, and the dynamics of Washington, D.C.

Great. Thank you. And if I may, just on the guidance phase, it sounds like some improvement in the pricing rate and then, I guess, contract labor. Sounds like that's better. Is that the way to frame the guidance phase, the $7 million of the operating income or just the operating income guidance?

Yeah, Joanna. If I were to kind of give you the pieces of what drove 70 million of increased guidance that's middle of the range to middle of the range on OI, I'd say about half is the RPT, as you called it out. The other half is volume. We saw stronger admissions this quarter, and the nature of volume is it's cumulative. It'll never really kick in in any one quarter at in that big a way, but as it accumulates, you know, stronger in Q1, stronger in Q2, and we see it better in the back half of the year, for the full year, we think that'll contribute about half of the 70 million beat. Contract labor, it continues to improve, but it's now pretty much in line with what we were expecting. And as we said in the prepared remarks, it's really back down to pre-COVID levels and, and Hopefully it won't be much of a topic going forward.

Thank you. I appreciate it. Thanks for the call. Thank you. Once again, if you would like to ask a question, you may press star 1. Our next caller is Andrew Mock with UBS. Sir, you may go ahead.

Hi. Good afternoon. Appreciate all the color on the sequential RPT improvement, but just a couple of follow-ups there. First, is the seasonality component in line with historical seasonality, or is there something about the patient benefit design that's creating more acute seasonality this year? And can you go into a bit more detail on what's driving the better cash collections? Thanks.

Yeah, Andrew, thanks. So on the seasonality note, it's it was a little bit more than $5, which is per treatment, which is right in line with what we've seen historically. In terms of collections, look, we have invested in our processes and in our technology to get better information and to give better information to the health plans on everything from prior authorizations to other data required to claim submissions. And that's both the quality of the data and the timeliness of the data. And what we're seeing is we're getting paid quicker, and that's why you saw DSOs come down last quarter, and again this quarter. And we're also seeing we're collecting more, and that's what's driving the RPT increase. And I think the most important thing from our standpoint is this is not a one-time thing. These are fundamental changes that we've made that we think will persist.

Great. Appreciate the call. And then as a follow-up, the guidance, the OI guidance is up about 5%. I think your free cash flow is up about 10%. Can you help bridge the difference there or help us understand why the free cash conversion is better on the new guide? And I think I missed your comments on share repurchase, but we'd love to get your latest thoughts around there and the potential resumption of share repurchase. Thanks.

Sure. So the big difference between OI and free cash flow is the DSOs. As we see those DSOs come down, that'll add to the free cash flow for the year. In terms of share repurchases, we're on track with what we set out to do. Our leverage levels were above our target range. I think we were quite clear with everyone we wanted to get back down to 3.5 or below. We're making good progress on that. We're at 3.7 for the quarter, and we didn't buy back any shares. We don't expect to buy back any shares in Q3, but we feel like we've got better visibility now to get back to the 3.5 or below.

Great. Thank you. I'll hop back in the queue.

Thank you. Our next caller is Pito Chickering with Georgia Bank. Sir, you may go ahead.

Hey, Pito.

Pito, your line is open. We'll go to the next caller, Lisa Clive with Bernstein. You may go ahead.

Hi there. Apologies, Javier, if you touched on this in the opening remarks. I was a few minutes late. But just could you comment on the CMS rate increase and, you know, the fact that they made a mistake in the calculations and what the chances are of getting an improvement there? And also, just as we think about going into 2025, what would a fair rate increase look like? And perhaps what lower numbers should our expectation around that actually be?

Yeah, thanks for the question, Lisa. It's kind of funny. I've been here for a very long time, and not many questions used to come up about the rate increase with Medicare. And so we started to ask ourselves, why is this a new dynamic? And the reality is that the system is quite complicated, but it works relatively well in times where there's economic stability. And yet, when we're experiencing times of inflation or lack of stability, it's really showing that it doesn't work in many ways. So let me step back. If you were to spend time on trying to understand the methodology, you would really come to the conclusion that it is practically not possible to forecast because there's just too many things that are either proprietary or or use lag data or a benchmark that is not related to dialysis. It's a benchmark related to all healthcare costs. And it's all weighted and then discounted with some kind of productivity factor. And so the short answer is it's a big, complicated equation with some variables that we will not have visibility to. So that's the short answer. We can't forecast it. I can't believe anyone from the outside world can't. Secondly, what is an appropriate one and what we are advocating for is let's not have, let's call it winners or losers. We understand that forecasting is difficult, but let's have a reconciliation that is actually linked to actual costs and that if you get an increase and it exceeds what inflation, that there could be a decrease or vice versa. So that's what we're advocating for. As you know, it is very difficult in Washington, D.C. right now on trying to get funding, but we are trying to make our case.

And maybe just touching on MedPAC's role here, I mean, they're sort of, well, the economic advisor to Medicare, but they don't have any enforcement power. And I think there's Sometimes, some years, there's a big disconnect between the MedPAC recommendation and the rate, and then this year it was actually quite in line. I mean, from your perspective, do you guys even look at the MedPAC numbers? I think it seems like it should be a useful data point, but it often isn't.

Yeah, you know, the process from MedPAC is a bit opaque to us. We try to educate and highlight what is really happening with our cost structure and And, again, in periods of stability, it happened to be, give or take, within reason, acceptable. And now the gap is widening, and it's widening compounded year after year. So it's really starting to be significant.

Okay. And then last follow-up is, does this have, just given how the rate increase was, Does this change your decision on some clinic closures in any way? Because obviously that's always the worry that if the Medicare rates get too low, you just have clinics here and there where you're on all Medicare and it just doesn't financially make sense anymore.

Yeah, there's lots that go into the decision to close a clinic. In particular, you've got to really focus on patient care and making sure that our patients are being taken care of. But it is absolutely a consideration when you look at the economics. But sort of the first filter is continuity of care. The second is, is there a convenient place where that patient can be taken care of? And then after that, you get into economic factors such as reimbursement, leases, and other things. But we are aggressively looking at our footprint, and we continue to right-size to make sure that we are thoughtful about our resource allocation and capital allocation.

Great, thanks for that.

Thank you, Lisa.

Thank you. And once again, that is star one. If you would like to ask a question, our next caller is Pito Chickering with Deutsche Bank. Sir, you may go ahead.

Hey, can you guys hear me now?

Yes, yes, Pito.

All right, sorry about that. I'm not sure what happened there. Back to treatment growth here. pre-COVID, you know, like you were getting about 4,000 new patients a year, about two-thirds of those in the first half of the year from nephrologists dropping on and obviously the rest coming from hospitalizations dropping to you guys. I guess, how is that tracking this year at this point relative to sort of that 4,000 times two-thirds? Is that what you guys are seeing for new patients at this point?

Yeah, so, Peto, the The short answer is, if you're looking at admits, we are tracking pretty much to pre-COVID levels. The challenge is excess mortality, and that remains elevated, and that's the reason that we're not yet ready to say we're going to return to pre-COVID growth levels. That said, mortality has been coming down year after year since COVID started. It's down Q2 versus Q1. So if mortality continued to decline and return to pre-COVID levels, then the math you laid out of 4,000 new patients a year, we'd be back there.

Which is a perfect segue for the next question about mortality. You sort of talked about that. sort of coming down, I guess, is there any way you can give us sort of what is the rate of that decline and if it follows the path you've seen for the last three quarters, you know, is this sort of what glide path would that indicate?

Yeah, that's a, it's a tough piece of analysis to do because it hasn't necessarily been smooth quarter to quarter or year to year. So, Look, we're watching it carefully. We all know there's a minor surge going on, but I think minor is the operative word from what we've seen so far. So we're keeping a careful eye on it, but I don't think we can draw a trend line based on the history to say when we think mortality gets back to zero or excess mortality gets back to zero. Okay.

Okay. Is there somebody that can quantify for us what excess mortality was this quarter and when it was last quarter?

Yeah. Last quarter, it was roughly 900 lives. This quarter, it was between 500 and 600. Remember, we will sometimes update those over time. We get better views of excess mortality as time goes on. But somewhere... between 500 and 600 is our best estimate for Q2.

Okay, and I definitely understand sort of the complexity of coming up with those for a variety of different reasons. For Medicare Advantage, what percent of your MA patients are you currently taking risk for one way or another?

I'd have to do the math quickly in my head. Peter, I don't want to give you a bad number, so I'm going to, let's take that offline.

Okay. Next one here is, you know, on the managed care rate increase question that was asked earlier, I guess, are you seeing managed care do anything different in terms, not just in the rate increases, but potentially trying to steer patients? Like, have you seen any behavior changes for managed care in the last, you know, Just curious if they're trying to control costs within other parts of the business.

No, we haven't seen no changes at all.

Okay, got it. And then for the last one here, on the pace of consolidation for facilities, obviously you guys do the lowest hanging fruit first. But as you see success of capturing those patients within other centers, do you get more aggressive about consolidation than maybe you had originally planned for about a year from now? And when those patients are consolidated, do you see an increase of home treatments at that point?

Yeah, I think we want to be really careful about being, quote, unquote, aggressive. We want to be really thoughtful and balanced in all the tradeoffs that go into closing a center. We have to remember our patients are incredibly vulnerable, and one of the most important things is to be close to their home. And so 90 some odd percent of our patients are within 10 miles of their home. And that is one of the best things we can offer convenience. And, you know, we talk a lot about health equity issues and not being in the communities. We are in the communities. And so we take that pretty seriously. But as the economics constraints happen, if we are able to accommodate our patients, we are being very thoughtful on that. And we have other obligations like leases and other things. So there's a natural time to review a clinic to see if it's appropriate for closure.

Okay.

The second part to your question, I think, Vito?

Yeah, so, you know, Sulzer asks the same question in different ways, I guess. As if a patient is consolidated, do you see an increased utilization of home treatments? And then the second part of the question is, so what percent of treatments today are being done in the home?

No is the answer. We are not seeing any changes in whether a patient goes home or not. We continue to be very much an advocate of home. There's a lot of dynamics and education that go into that, and we want the right modality for the right patient, but we are huge home champions. And the mix on home is roughly around 15%. a little above that, like 15.2 or so, but it's been hanging around that 15%. COVID had a big impact on home that many patients felt more comfortable in that time of insecurity to go and be taken care of by professionals, but we're starting to see a slight pickup in patient choice to go home.

Okay, and then I think the last question for me here, can we get an update on Medtronic JV, I guess, you know, sort of how much of the drag is that on OI and just, you know, as you look at it today, kind of what's the pathway to that becoming operating income neutral? And just can you just, you know, refresh us and sort of why you saw that as a good opportunity for you guys? Thanks so much.

Sure. Just as a reminder, it doesn't hit our operating income. It's below the OI line, so it hits EPS. It's worth about $15 million pre-tax per quarter. That's on a non-GAAP basis. This quarter, we actually had some positive gain as a result of the transaction. And we think that number will decline over the next couple of years, and we anticipated getting to break even in two to three years. In terms of why we like this look, as Javier mentioned, we are really interested in figuring out ways to help our patients get home, and new technology can be part of that answer. We're looking for other ways to innovate beyond just the service and information capabilities that we can do. And we recognize Medtronic as a world-class leader in innovation on the medical device side, their history here combined with our knowledge would make for a great partnership, which is why we invested in Mozark.

Perfect. All right, and the last quickie for me, maybe I missed it. Did you guys quantify what the turnover was of nurses and technicians for this quarter and how that compares versus 2019? Thanks so much.

Thank you for that last question. We did not go into that level of detail. I think what we can say on labor, because we've gone into so much detail on labor is is in the overall category, it's playing out as expected. Some of the underlying components have shifted a bit. And so just to give a little more detail on that, base wages are above our normal averages. Our contract labor is back in line to normal. And we continue to have elevated training. And so that's how the levers are moving. But overall, the category is as expected.

Great. I'll stop there. Thank you guys very much. Thank you.

And at this time, I am showing no further questions, sir. We do have one more question. Andrew Monk from UBS, you may go ahead, sir.

Hi. Just wanted a couple follow-ups on the clinic closures. You closed down 16 clinics but opened 10 new dialysis clinics. I'm just trying to better understand what's driving the new clinics at this point, given I thought a lot of the clinic closures was a result of excess mortality. So what are you seeing in the market that's causing you to open new clinics? Are there any characteristics that you would call out about them, whether they're home dialysis programs or anything like that? Thanks.

Yeah. In general, you can imagine healthcare is local, and so there are areas where there are literally full clinics. There's sometimes relocations. Sometimes, as you called out, there might be just a home center that was needed. So there's a little of all, but as you can see, the number is materially smaller as we are very focused on making sure that capacity utilization is where it needs to be and that we're capital efficient.

Got it. And on the mortality, I think you gave us the absolute number in the quarter. Can you give us a sense of how the mortality rate in general is tracking, and how far off are you against pre-pandemic levels? Thanks.

The mortality level looks roughly a percentage or so higher than pre-pandemic. And as Joel talked about it, It's a bit cyclical and depending on the surge or if there is one or sort of the front end tends to have higher mortality the front end of the year or the back end in the year versus the middle of the year. But I think a good number is roughly 1% or give or take 2,000 patients.

Great. Thanks for all the callers.

Thank you. And at this time I'm showing no further questions.

Okay, well, thank you, Michelle, and thank you all for your questions. As you heard through our comments today, we've continued to drive operational efficiencies and make investments to fuel our performance now and to the future years as well. Some of those seeds that we planted are beginning to sprout, and some will take additional time and continued effort. We look forward to keeping you updated on our continued progress in the back half of the year. Thank you for joining the call, and be well.

Thank you. This concludes today's conference call. You may go ahead and disconnect at this time.