Fresenius Medical Care AG American Depositary Shares (Each representing 1/2 of an Ordinary Share)

Ladies and gentlemen, welcome to the report on the third quarter 2025 conference call. I am Sandra, the chorus call operator. I would like to remind you that all participants have been listed in only mode and the conference is being recorded. The presentation will be followed by a Q&A session. You can register for questions at any time by pressing star and 1 on your telephone. For operator assistance, please press star and 0. The conference must not be recorded for publication or broadcast. At this time, it's my pleasure to hand over to Dr. Dominic Hager. Please go ahead, sir.

Thank you, Sandra. Welcome, everyone, to our earnings call for the third quarter 2025. As always, I start out the call by mentioning our cautionary language that is in our safe harbor statement as well as in our presentation and in all the materials that we have distributed earlier today. For further details concerning risks and uncertainties, please refer to these documents and to our SEC filings. We will have roughly one hour for the call. In order to give everyone the chance to ask questions, we would limit the number of questions to two. Thank you for making this work, as always. Let me now welcome Helen Gieser, CEO and Chair of the Management Board, and Martin Fischer, our Chief Financial Officer. Helen, the floor is yours.

Thank you, Dominic. I'd also like to extend a warm welcome to everyone on the call. Thank you for taking the time to join us today and your continued interest in Fresenius Medical Care. As many of you know, the U.S. is in government shutdown since the 1st of October, and many healthcare policy decisions are open. like the questions of extended tax subsidies for the exchanges and whether they will expire by the end of this year, or the publication of final 2026 ESRD PPS rule. This requires us to remain flexible in planning and agile in running our business. We remain focused on what we can influence. In Q3, we made meaningful progress in advancing our FME Reignite strategy and positioning ourselves for sustained value creation. Our strong third quarter results reflect continued momentum and disciplined execution as we further accelerated top-line growth while delivering a clear step-up in earnings growth and profitability. And the step-up is in line with our full year planning. I will begin my prepared remarks on slide four. In the third quarter, we realized strong organic revenue growth of 10% with positive contributions from all three operating segments. In the U.S., same market treatment growth was slightly positive. This is in line with our assumption of flat to slightly positive growth for 2025. Operating income growth increased for a third consecutive quarter and accelerated to 28%. As a result, this drove a step change in profitability with our operating income margin expanding from 9.9% to 11.7%. The improvement in profitability was supported by continued momentum in our FME25 Plus program, which generated a further $47 million us already to 174 million euro of savings for 2025. As part of our new FME Reignite strategy and capital allocation framework, we announced an initial share buyback of 1 billion euro in line with our commitment to reignite value creation for shareholders. The share buyback program officially commenced in August with a first tranche of up to 600 million euro. Through 30th of September, 3.6 million shares had been repurchased for a total investment amount of 151 million euro. And until October 31st, we have repurchased in total 4.35 million shares for a total investment of 188 million euro. For full year 2025, we are very well on track to achieve our outlook for the year and therefore reiterate our guidance. Next on slide five, the American Society of Nephrology's Kidney Week takes place in Houston this week. Already last year, we saw a lot of interest in high volume HDF on our 5008X machine at the ASN. I do expect a high level of interest and engagement again this year, especially as we start the 5008X rollout, and with that, a new therapy becomes available in the United States. This will set a new standard of care. We submitted around a dozen of clinical abstracts that are specifically focused on high-volume HDF, from the risk reduction resulting from HDF therapy to the implementation of HDF in clinics to AI support for clinicians during implementation. Besides the scientific side of HDF, it's also great to see how the feedback is from the phrologists that visited one of our clinics that already run with HDF. And I want to share what they said. Being able to see the human experience of HVHDF firsthand was one of the most pivotal moments for me. And given our mission and the potential of the HVHDF therapy, we would love to explore having our clinics serve as index centers for the North American rollout of this modality. This shows that we are not only excited about the broad rollout in 26, but how well prepared we are in all dimensions and how well received it might be. Next on slide six, with the launch of the FME Reignite Strategy, we have committed to reignite growth and innovation across our organization. In care delivery, we are supporting overall volume growth by raising the bar on quality even higher, further enhancing clinical outcomes and patient safety. This is especially important to me because it directly reflects our purpose-driven, patient-centric approach where the patient is at the heart of everything we do. We are already seeing encouraging progress on our quality and safety initiatives, and I would like to share some examples from the U.S. market. Frequent adherence is a key focus as patients with chronic illnesses often struggle to adhere to their care plans. This frequently involves helping our patients to understand the importance of sticking to their treatment plan and working with them to remove barriers. Since the beginning of this year, controllable mistreatments have decreased due to improved alignment amongst physicians, patients, and clinicians. Many ESRD patients begin dialysis with a central venous catheter, which, while necessary, poses a high infection risk. Although our long-term goal is to transition patients to permanent access, bloodstream infection prevention remains even more critical during this period. Antimicrobial interventions reduce infection rates by 70% compared to conventional care. In August, we launched a program to further increase antimicrobial catheter treatments to eligible patients. Adoption to date has been strong, with 84% of eligible catheter patients now receiving bloodstream infection protection, and we are on track to achieving greater utilization. Protection against the flu is especially critical for our vulnerable patient population. And because flu strains change yearly, annual vaccination is necessary to maintain protection. Our U.S. clinic network has launched its annual vaccination campaign, and vaccination rates are 34% higher than where they were at this point in 2024. We already have more than 72% of our patients vaccinated. And like in previous years, we expect to come to 85% before the end of the year. These are just a few examples for reducing hospitalization and costs for the healthcare system, and at the same time, increasing the number of treatments while improving patient outcomes and reducing mortality over time. I'm extremely proud of the work we are doing and the results we are already achieving. It gives me great confidence and excitement for the path ahead. Turning to slide seven, this quarter we saw strong execution across all three of our operating segments. I will take you through some of the key highlights by segment. In care delivery, in line with our expectations, U.S. same-market treatment growth was slightly positive with 0.1%. This reflected the carryover effect from elevated mortality, which was driven by the severe flu season earlier in the year. and positively offset by improving admissions, as well as slight improvements in mistreatments. In our international markets, same market treatment growth increased to 1.2%. Third quarter care delivery performance benefited from favorable rate and mix development in the U.S., as well as accelerated contributions from phosphate binders in our pharma business. We further executed on our portfolio optimization plan, closing clinic divestitures in Brazil, Malaysia, and some other smaller markets. One highlight for me in care delivery, which I'm sure comes as no surprise, is the availability of high-volume HDF treatments in select U.S. clinics. We are progressing every day and are very encouraged by the initial feedback we have heard from our patients that have been receiving HDF treatments. The work we are doing is paying off, and I'm very proud of the team's focus and execution while never wavering on the highest quality of patient care. These patients report feeling significantly better with increased energy levels and improved sleep quality and reduced post-treatment recovery time. Clinic staff have highlighted the benefits of quieter, less stressful workflows, thanks to the enhanced automation of the machine, which supports more efficient and patient-focused care. The excitement is palpable. While we are not expecting this to be a major driver of operational performance this year, our learnings are rapid from the early rollout of select clinics, which is providing valuable insights, allowing us to further enhance and refine the clinic training and conversion process. This will set us up for a seamless, large-scale launch in 2026, which will be the start of the broad transition of our clinic network. Turning to value-based care. As expected, we continue to face a degree of earnings fluctuations. We are also facing delays to 2026 by CMS in providing reporting data for the CKCC program, which adds to these fluctuations as these cannot be planned. In value-based care, we realized a higher number of member months due to continued contracting growth, as well as a growing network of providers. and we are further enhancing our care models through increased use of artificial intelligence. As part of our Reignite strategy, we took an important step forward by increasing and strengthening our ownership stake in our value-based care asset into WellHealth. This reinforces our leadership position in renal value-based care, which is supported by the vertical integration benefits that our business model offers. With this step, we are better able to leverage the full scale and size that Fresenius Medical Care as a total company offers. This and the underlying progress we are already making in value-based care is positioning this business for long-term, more profitable growth. Care enablement delivered another strong quarter, supported by volume growth and positive price We continued to capture sustainable savings as part of FME25+, driven by disciplined execution of the next level of footprint optimization across both manufacturing and supply chain. And as a result, our care enablement margin further progressed compared to the prior year, despite being increasingly challenged by transactional exchange rate impacts. I will now hand over to Martin to take you through the financial performance in more detail.

Thank you, Helen, and welcome to everyone on the call, also from my side. I will pick up on slide nine. In the third quarter, we achieved organic revenue growth of 10%, with all three sections contributing to this strong performance. At constant currency, revenue increased by 8%. We continued to divest assets as part of our portfolio optimization plan. Divestitures negatively impacted revenue development by 60 basis points. Operating income, excluding special items, increased by 28% on a constant currency basis. This significant increase led to a clear step change in the group margin to 11.7%, well into the implied range of 11% to 12% for 2025. Special items negatively affected operating income by around €100 million. This comprises costs relating to FME25+. and our continued portfolio optimization, as well as effects from the re-measurement of our investment in Humasight. Next on slide 10. This slide breaks down the significant 180 basis points margin improvement. All three segments contributed to the positive margin development with an especially strong contribution from care delivery. Net corporate costs developed favorably by 19 million euro. This was primarily driven by virtual power purchase agreements with around 20 million euro, and corporate costs broadly stable otherwise. Foreign exchange rates developed unfavorably, with a negative 24 million euro translational impact. The average US dollar exchange rate in quarter three was 117, compared to 113 in the second quarter. I will now walk you through the financial developments in each segment, starting with care delivery on page 11. Care delivery realized organic revenue growth of 6%, supported by both care delivery U.S. and international. In the U.S., organic growth of 6% was driven by favorable rate and pale mix development, positive contributions from phosphate binders, as well as reduced implicit price concessions, which demonstrate our progress on active revenue cycle management. Internationally, we realized strong organic growth of 4%, including 1.2% same-market treatment growth. The continued execution of our portfolio optimization plan negatively impacted care delivery revenue development by 120 basis points. Care delivery significantly improved profitability in the third quarter. With a margin of 14.5%, it is at the upper end of our 2025 target margin band. While we still saw muted same-market treatment growth, The business growth was supported by positive rate and mix effect and additional higher contributions by phosphate binders in our pharma business. These factors compensated for the missing income from the consent agreement on pharmaceuticals, which we had in the third quarter of last year. The facing is different this year, and we do expect this to come in the fourth quarter, but at a lower level. Higher sustainable savings through FME25 Plus helped to partially compensate for higher labor costs, including elevated medical benefit costs. The unfavorable development of exchange rates also had a sizable negative impact on operating income. Let us move to slide 12 to review the development in value-based care. Value-based care further accelerated revenue growth, realizing 42 percent organic growth. This significant increase was driven by a high number of member months, mainly due to continued contracting growth. The higher growth in value-based care is also driven by gross revenue recognition instead of net revenue recognition of a major country. This change does not result in additional earnings growth. Operating income in value-based care amounted to a loss of €21 million, compared to a loss of €37 million in the prior year. This reflects the quarterly earnings fluctuations that are inherent to this business model. As mentioned by Helen, we are also facing delays to 2026 by CMS in providing reporting data for the CKCC program, leading to a delayed revenue recognition. Due to this shift, we assume a slightly more negative operating income contribution from the value-based care segment. I will provide an overview of the financial performance in our care enablement segment on slide 13. Care enablement realized strong revenue and organic growth of 5%. Revenue development was driven by solid volume growth and continued positive price momentum. Care enablement achieved a 38% increase in operating income. leading to a margin increase of 200 basis points to 7.6%, in line with our expected pricing for the year. Business growth was, as mentioned, driven by volumes and pricing, which was partially offset by higher-than-expected and increasing currency transaction losses. Further sustainable savings from the FME25 Plus program compensated for the expected inflationary cost increases. Moving to slide 14. Due to the cash flow disruptions from the changed healthcare cyber incident in 2024, it is more useful to assess cash flow development on a nine-month basis. We have realized strong cash flow development through the first nine months of the year, with operating cash flow increasing 8% year-to-date. In the third quarter, operating cash flow declined compared to an inflated prior year base that benefited from around 400 million euro in catch-up reimbursement following the change healthcare cyber incident. The negative year-over-year effect was partially offset by favorable working capital development in this quarter. Our disciplined use of cash reflects the priorities set out in our new capital allocation framework, which is designed to reignite value creation. We reduced our net debt and lease liabilities compared to the prior year period. As highlighted by Helen, our share buyback program is well underway. By the end of September, we repurchased 3.6 million shares, or 1.2% of our share capital, with an investment volume of €151 million. In addition, we invested €312 million in the third quarter to strengthen the ownership in our value-based care asset, Interwell Health. This is reflected in financing cash flow. In parallel, we ended the quarter with a further strength in net leverage ratio of 2.6 times, well within our target range of 2.5 to 3 times. I will now hand back to Helen to review our outlook.

Thank you, Martin. I will finish my prepared remarks on slide 16. The strong growth in our value-based care segment due to the type of revenue recognition of one contract results in stronger than expected revenue growth in this segment. Therefore, we expect to be at the very top end of our low single-digit percent revenue growth range for 2025. As explained, this growth in value-based care driven purely by contract-type related revenue recognition does not drive additional operating income growth. Looking at operating income growth for the group, we have shown continued progress through the first nine months with an expected acceleration in the third quarter. This brings us to 18% operating income growth in the first nine months. We are not only in our target range of high teens to high 20s percent operating income growth already, but also demonstrate with 11.7 percent a new and improved level of profitability, despite a challenging environment and very low same market treatment growth in the U.S. When I look at the big picture for 2025, we are confident in our continued improvement of our underlying business. With nine months under our belt, we would like to update you on our latest thinking for the operating income development for the year. The positive momentum in FME25 Plus will deliver around 40 million euro more, delivering around 220 million for the year, helping us to directly offset the increasing medical benefit costs. The acceleration in the third quarter of our pharma business contributions from phosphate binders is now estimated to be around 80 million Euro higher than the assumed 100 million. This is helping to offset the full year headwind from lower volumes in the US and the increased foreign exchange transaction headwinds. As always, the fourth quarter is our strongest quarter. We do expect further acceleration in earnings growth and margin expansion. With all that I just outlined above and our 18% operating income growth in the first nine months, we are not only already above the bottom end of the range, but we are confident in confirming our full operating income guidance range for 2025. As we approach year end, I know many of you will want further insights into our outlook and assumptions for 2026. To manage expectations here, we are currently in our planning process for 2026, and I'm sure you can all appreciate that there are several moving pieces. In addition to the normal headwinds and tailwinds we navigate any given year, we also need to see how MIPS evolves for phosphate binders and to what extent price erosion will impact our pharma business. What happens to extended ACA tax subsidies, the final CMS pricing for 26, as well as the potential impacts of new tariffs and pharmaceuticals pricing. we acknowledge the key KPI is next year's same-market treatment growth. Our Q4 volume data will clarify trends in mortality, referrals, and overall volume, shaping next year's outlook. Just like every year, we will share our 2026 outlook along with our full-year results in February. With that, I'll hand it back to Dominic to start the Q&A.

Thank you, Helen. Thank you, Martin, for the presentation and the updates. Before I hand over to the Q&A, I would like to remind everyone to limit the questions to two. If we have time over, we can go another round. With that, I hand it over to Sandra to open the Q&A, please.

Thank you. We will now begin the question and answer session. Anyone who wishes to ask a question may press star and one on the telephone. You will hear a tone to confirm that you have entered the queue. If you wish to remove yourself from the question queue, you may press star and two. Questions on the phone are requested to disable the loudspeaker mode while asking a question. In the interest of time, please limit yourself to one or maximum two questions. Anyone with a question may press star and one at this time. Our first question comes from Oliver Metzger from Odoo BHF. Please go ahead.

Okay, good afternoon. Thanks for taking my questions. First is on your guidance, on the margin guidance. So, in your slide, you show that the care delivery already stands at the top end of your expectations. And having said this, do you see the stronger progression in Q4 coming over relatively spoken from care enablement, or do you expect due to the timing of payments a step up in value-based care? Second question is on the treatment adherence. technically beneath mortality, it's definitely one of the areas where you're not where you want to be. Do you see, because COVID is already five to six years, or five years ago, and you see that, you commented that the patients who were, patients during COVID have a lower adherence than the patients who you recruited afterwards. So do you still this normalization form of, you know, over time patients just passing away due to normal mortality, or do you see that there's some other reasons why this level is elevated? Thank you. Thank you.

Sorry, we were on mute. Sorry, Oliver, and thank you for your question. Look, on your first question regarding guidance, we do expect to see continuous improvement in all segments, but we also see strong support from care delivery. On your second question, I'll make sure I unpack all those pieces in there. In terms of, you know, I think you started with treatment adherence and also kind of wrapped up in there reasons for mortality. There's no question our mortality levels are still elevated. But, you know, where we're focusing on things that we can control are seeing an improvement in missed treatments. Obviously, those areas that we can control, if we can make sure our patients continue to get their treatments, that obviously helps the treatment volume. And we are seeing those improvements in referrals. So obviously we work hard on those mistreatments because that has a double effect on improving the number of treatments, but also ultimately if the patients keep getting their treatments, it should help with mortality as well. And as you saw from one of my opening slides, we're also working on our catheter rates kind of coming down as well. So all of that should help mortality. Just tied up with our general strategy of the focus on patient quality and patient safety. In terms of your comment on, you know, the passing away, maybe, you know, reason code, I don't know that we can tease out that it's anything different. I mean, there was a time in COVID that, you know, that you could kind of get the COVID piece. And if you remember, we used to report that as excess mortality. Now we just class it all as, you know, the general mortality. And there's nothing in those trends or that data that is telling us it's anything new or different. It's just that it continues.

to stay it continues to be elevated okay thank you i was referring towards the patients who were already on dialysis during covert that they have a higher average number of missed treatments compared to the patients who came to dialysis afterwards

Yeah, that would have been the case because they were already, you know, kind of vulnerable. And those that were with us during COVID would have had more mistreatments than, you know, that we see in maybe new patients coming in. Sorry, I misunderstood that direct question on COVID.

Okay. Thank you very much.

Okay. The next question comes from Veronica from Citibank. Veronica, the line is yours.

Hi, guys, and hopefully you can hear me okay. Thank you for taking my questions. I have two, please. One, I just want to go back, Ellen, to your comment on phosphate binders. Apologies. There was a lot of numbers, and I probably misunderstood it, but I just want to confirm that you are now expecting $180 million of benefit from phosphate binders this year versus the $100 that was assumed in the guidance previously. And I guess just to play a little bit of devil's advocate, if I strip that one AC out of the care delivery margin trajectory, obviously I don't know exactly how much you've booked in the 30 quarters of the year versus the full year, but it doesn't seem like there is a huge amount of margin improvement underlying in the business. Tell me if I'm doing that math wrong. I did it very quickly on the fly, but I just kind of would love to understand what you're seeing margin-wise if you strip out the phosphate binders. And then my second question is just looking to 2026 and Medicare Advantage trends in particular, we are seeing some early signs of reduced enrollment. I'm curious how you're thinking about mix as we head into next year from a Medicare Advantage perspective and, you know, to what extent we should be thinking about this maybe no longer being a tailwind to the business into next year. Thank you guys so much.

Yeah, thanks, Veronica. I think I can tackle both of those. Sorry, I may have stumbled. As I was saying, the phosphate binders number, there was an 80, a 100, adding up to 180. So my apologies if everyone didn't catch that on the call. You're right. We are now seeing that full year number to be 180 versus the original guide of 100 through Q2 2018. We are seeing favorability in our pharma business, and Q3 was particularly strong with that uptake. The FKC side of the house or the piece that we see in the clinics is developing in line with expectations. we are seeing more favorable pharma and are now expecting that trend to continue that we saw in Q3 into Q4. Obviously, that's something that we are kind of trying to get our arms around for 2026 as well as we think about, you know, utilization and pricing for the binders while it's still under the Tdapa period. But it is in line with, you know, kind of with what we saw in Q3. Look, I would say on your broader question and why I thought it was important to bucket the moving parts, yeah, I mean, I can pick the favorability from binders. I can pick the favorability from FME25. But it shouldn't be lost that we are. While we do have this softer volume, we are having to overcome the loss margin from our original assumptions on volume, as well as the underlying transactional exchange that we are seeing. And the medical costs that are driving the labor costs higher in terms of increased utilization of our employee benefit claims as well as the volume of claims. So as you can appreciate, we're juggling a big business here. We're trying to keep balancing the pluses and minuses, but there are some underlying negatives that these positives are helping us offset that are all coming through in the year. In terms of your Medicare Advantage question, it's an interesting one because we also started to pick up headlines from the big payers that they were backing off some of the coverage of MA plans. What we have seen through Q3 and projecting into Q4 is actually no change in that MA mix and that book of business, and actually it continues to grow ever so slightly and is quite sticky. What we are seeing in the market is while some of the big payers might be backing off some plans, it is more of a consolidation of MA plans and the overall enrollment numbers are looking consistent. And that's actually come from the government as well. So, you know, we see quite a steady mix. as well as similar number on enrollment. But there is consolidation of the number of plans out there that payers are doing at a more local level. So right now our current assumption is that we wouldn't see a big impact in MA. Maybe just to kind of put a final point on the mix and things that we are watching, of course, the ACA exchange, whether that does conclude at the end of the year or whether there will be some deals on extending that. So that is the piece that we are watching closely on ACA. you know, where those patients may end up during the current open enrollment period, which started, I think, at the weekend. So we'll continue to navigate that. But overall, looking quite steady here on MA.

Okay. Thank you. The next question comes from Hassan from Barclays. Hassan, the line is yours.

Hi, thank you for taking my questions. A couple from me, please. Firstly, on EBIT guidance, range remains pretty wide as we move into Q4. What is driving the risks here to your mind, and why is the bottom end of the range not more likely? And what was the phosphate binder benefit in the third quarter, please? Secondly, on treatment growth, can you talk a bit about admissions and mistreatment as you've moved through the year and how you see Q4 growth given, you know, the flu impact was obviously quite meaningful in the first half at 60 basis points. Appreciate that you don't have the Q4 detail, but how do you consider the moving parts as you move into 2026 and the confidence around, you know, the 2% plus treatment growth that you've previously talked about? Thank you.

Thanks, Hassan. I'll tackle some of that, and maybe, Martin, you can take the first way, find a pieceway question. But let me unpack what I can and then pass you over to Martin. Yeah, look, the EBIT guidance, we always knew that the EBIT range is wide because of the implied margin. range bets there as well. As you heard from my commentary, and you can see in the numbers, we're already at the bottom end, and we've left the range wide open, which I think you all know me by now. That tells you that I do think that there are opportunities for that top end to also be in play, as you can appreciate. slightly bigger number on FME25, slightly less impact from exchange, those numbers can move the needle, you know, kind of around that range. So you know I don't shoot for the bottom end. We are still excited about the underlying growth and momentum we're seeing, and that's why I've left the range wide open. On treatment growth, you know I've been trying to put a lot more color on inflows and outflows rather than orienting around the net number because there's a lot happening there. Over the course of the year, we have seen improving admissions. If I look at it versus Q3 this year versus Q3 last year, they are improving, and nine months over nine months, is improving. Mortality is down, but still elevated. And, you know, mistreatments we are chipping away at and making improvements. I think the commentary you've seen from the industry is they have been higher, but we are really excited about the work that we've been investing in taking hold, so that mistreatment number is improving as well. along with all the patient safety and patient quality work we're doing. So, you know, we're excited about that. Missy, what else I didn't touch there? On your flu, obviously we did have a severe flu season in the first part of this year, and you're right. You remember that number correctly, 60 basis points impact. We will have to see how the flu season unfolds. you know, kind of develops, obviously, in, you know, Q4. You know, I'm excited about it. You could probably tell and encouraged by the high level of vaccinations. That's great. Despite the narrative maybe catching the headlines in the U.S., our patients are taking good care of themselves, and we are taking good care of them. So we'll see how that develops. But, you know, obviously that's a year over year depending on how we see how severe a flu season, if it is a severe flu season, is. going into next year, which, you know, the kind of the other question that you have on the 2%, we're still confident in that 2% once we see mortality normalized. And as we know, mortality is still elevated. And, of course, we're, you know, in slightly positive territory currently. So, you know, the funnel improving obviously helps. All the work we're doing on outflows obviously helps. And once that mortality level normalizes, we have no reason to believe we don't get back to the 2%. And obviously, we'll give our best stab on that once we kind of finalize our outlook for 2020. for 2026. And don't forget, I mean, I know it's, you know, we're kind of in the early stages of HDF, but our expectation as HDF continues to get traction over the course of 2026, that will also help with, you know, kind of mortality, mistreatments, et cetera. So, there's a lot in your question. Hopefully, I covered all my pieces. And Martin, do you want to just take that Q3 phosphate binder question?

Let's tackle the phosphate binder. As Helen outlined, we did see a pickup in the third quarter against the second quarter in our pharma business, whereas the clinic business assumptions are coming in broadly as expected. For the third quarter, the total effect of phosphate binders was a mid-double digit million amount, and to underpin the 180 that Helen mentioned, we are also assuming a similar dynamic on the farmer side in the fourth quarter, a similar amount in the fourth quarter as well. Perfect. Thank you.

Interesting. Thank you. The next question comes from Ugo from BNTP. Ugo, the line is yours.

Hi, guys. Thanks for taking my questions. A quick one on SME25, which you upsized. Can you maybe point to the reasons for that? Is that production move to Mexico that's finally kicking in or any other things? And second, on the rollout of HVHDF, can you maybe share the number of clinics? Sorry if I missed that. And compared to your plan presented at the Capital Market Day, given the early learnings that you have from the rollout, does it change anything in your plan from 2026 in terms of how fast you think you will be able to deploy that instrument.

Thank you. Do you want to take that FME25 question and I'll pick up with HDS?

Yes, sure. So as you saw in the third quarter, we had strong momentum and we are already after nine months almost at the full year original guide that we had for FME25+. And that momentum is continuing and as Helen outlined, we are pushing to further accelerate our efforts That is true for care enablement where this also helps us to offset some of the inflation and the extra transaction headwinds that we have, but it's also true for the global functions as well as for care delivery. So we are making good progress and we are leveraging the momentum, hence the upgrade of around 40 million that Helen articulated.

Thanks, Martin. And then, Hugo, on HDF, as you can all appreciate, we are in the early rollout. We are adding a very small number of clinics, and we're adding them as we go. In fact, we added two more just last week. That continues to gain momentum, and we are progressing every day with our, you know, kind of installations, training, learnings, getting patients ready not just on the new machine, but maybe more importantly on the HDF machine. So that will continue through the rest of the year. And yes, we're fully on track with what we shared for 2026 at our capital markets day. So exciting, exciting times for us.

Okay. Thank you. Next question comes from Graham from UBS. Graham, the line is yours.

Afternoon. Thanks a lot, guys. Just in terms of thinking about care delivery and sort of the moving parts for next year, it's just directionally, but just phosphate binders presumably just lapping it becomes a bit tougher. And it's been such a big driver of growth this year. Is it not reasonable to think that US volume growth becomes more important? And just if I look at the first nine months of this year, 2024 and 2023, there's not a huge difference. And obviously next year we've got the head-to-head of like HDF coming through, but then equally maybe some new drugs for IgA nephropathy. So when you look at it, just like how confident are you that you can generate volume growth, which in turn generates operating leverage, rather than phosphate binders and cost savings driving care delivery margins, just as we shift away from the cost piece driving growth and more so the actual top line?

Yeah, thanks, Graham. Great question. So obviously, as we're trying to help you guys think about phosphate binders, you can obviously see where we are seeing the benefit is in our pharma business. So that's less of an FKC topic, more of just the pharma volume, which we do supply those products both within our own clinics but also to outside customers. So that, while we're still in this period through 2026, will become a topic of what is the volume, what is the utilization of those drugs, and what is the pricing. So, you know, obviously we have to see how that plays out. Obviously, on your question on volume, while we've got these low volumes and numbers, you can obviously see that the impact on EBIT in itself is not the number that makes or breaks any given year. And as you know, in running this business, it is all about numbers. you know, kind of the balance and think about those moving parts for next year, the balance of underlying volume, kind of the reimbursement, operating leverage and utilization in our clinics. So we're kind of taking a hard look at that. And then the efficiencies that we drive and obviously managing labor. So as we all appreciate, volume is always helpful to drive that operating leverage. And, you know, I think the other thing here is that there are parts of our country and places that we operate that we are seeing growth, and we are, you know, really pleased with that progress. So we're kind of constantly amongst our 2,600 network of clinics looking at where we're seeing growth, where there's opportunity to further grow and expand. and obviously in other areas look to see if we need to, you know, sort of consolidate or exit some clinics. So, you know, we are preparing all those scenarios, but obviously under the assumption that volume is returning and the work that we are doing, which shouldn't be underestimated on the outflow side, that if we can reduce hospitalizations and we can reduce mistreatments, that obviously adds to the volume on the patients we already have. So, as you say, when you add in the benefit from HDF and, you know, for those that are on GLPs, we like that mortality benefit they get, too. I think that overall kind of is giving us some confidence that, you know, where we can see, you know, outside elevated mortality, the things we can control, we're starting to see some improvement on. So, you know, I think it's a combination of all the things that we do and what will make us operationally excellent, you know, balancing the volume, the price, the mix, the operating leverage, the clinic footprint, and the cost structure. So I think we understand all those moving parts, and more than ever, seeing the benefits of the work we've been doing this past couple of years on the turnaround and transformation.

Maybe just a quick one on the HDF benefit. Just based on what we saw in Convince, should we see kind of a benefit in the actual headline US treatment number next year, or should we think about it maybe more like phasing into the first half of, say, 27?

Look, I think the expectation is once patients are on it, the CONVINCE trial did show that after three months we got benefit. So as we ramp up for those patients that are on it, we should start to see improvement. Now, obviously, as it ramps up, I would say maybe this time next year we can start to say, hey, this is what benefit we're getting from those patients on COVID. on HDF, but we're going to need to kind of get that data behind us. Obviously, 26 being the ramp-up year, you won't feel or see the full effect, but we are, as you can appreciate, this is an opportunity for us to track patient zero, if you will, and really start to kind of see the data of those patients that are on HDF and, you know, what their performance is on that, you know, on this treatment. So 26, you know, maybe while, you know, not maybe while we're excited, you know, obviously it is ramping up over the years. So we will tease out the relevant KPIs as we go through next year and report on what seems to be, you know, kind of the right insights for you guys.

Okay. Thanks a lot, guys.

I really appreciate it.

Of course. Thanks, Graham.

Thank you. The next question comes from David from J.P. Morton. David, the floor is yours. Hey, guys.

Thanks, guys, for taking the questions. Maybe you're keeping best to quantify the impact on EBIT next year, well, actually the next three years, if the subsidies aren't extended. I just wondered if you were willing to do the same. And then secondly, just a bit of a specific one, but volumes in Q3, were they impacted negatively by a sales day mix, and does that become a tailwind in the fourth quarter?

Yeah, thanks, David. Let me tackle that second one first. Spain market treatment growth for us normalizes days. So our 0.1% is like-for-like. Where it would be impacted on mixed days is on the overall treatment numbers. So I would say market treatment growth is pure. So just wanted to dispel any confusion that the market might have picked up on that one. David, on 2026, as you can appreciate, we're still in, as I've mentioned, still in planning. I'm not prepared to put any number out there while we're still working through that and even reviewing it. We haven't reviewed it with our – finalized it with our management board, let alone supervisory board at this point. So I think you understand the levers. You understand our usual headwinds and tailwinds. You understand some of the moving parts that we're watching. I think that's all I can say at this point, and you'd be surprised if I said anything different because you know me. But thank you for asking.

Fair enough. I thought I'd try.

Thank you very much. You were the first to try. I'm surprised. I'm a 50% of the call.

Thank you. So the next question comes from Anna from Bank of America. Anna, the line is yours.

Hi. Thank you for taking the questions. Maybe as a follow-up to one of Graham's questions on the impact of the HVHDF rollout for next year, Do you think that could start to positively impact USA market treatment growth from a referral standpoint as soon as next year? Just any color on how you're thinking about that. And then as well on the care delivery growth of the 5.6%, those three components, the favorable rate mix, phosphate binders, and implicit price concessions decreasing. I think you've broken out the phosphate binders pretty clearly, but any other numbers you could give us around? those other two components and how you expect those to trend into Q4 would be super helpful. Thank you.

Yeah, thanks, Anna. Let me take the HDF question, and Martin can maybe unpack the CD question that you have. Look, on your referrals number, yes, I would suggest and think that that is – my pen just fell apart – that that would help us positively. I deliberately read the quote from one of our nephrologists, and we've had a number of nephrologists kind of coming through our clinics to see this. So, yes, we have seen significant interest and positive feedback, and we are being, as you can appreciate, quite deliberate in where we are launching HDF first. So that is, yeah, really exciting, and as you kind of, on the back of, you know, Graham's question, That mortality improvement and, you know, the kind of the increased treatment improvement, we should see as soon as we get patients moving on this, and that should ramp up over 26. So really, really exciting to see that, and I can't wait to hear how ASN goes this week for the team that's there. Martin, do you want to take that CD piece?

Sure do. And for the implicit price conversions as well as for the rate mix assumptions that we have for CTE, You saw this being a positive in quarter three. This is the work we do in revenue cycle management paying off and us increasing our revenue yield. So we are collecting more for the amounts that we invoice. This is an ongoing effort, and we are seeing the first benefits, and we do expect this to also be a positive in the coming quarters for us as well. And that does also impact then on the, let's say, underlying performance improvement and will be a positive tail for CTE.

Great, thank you.

Thank you. So we do not have any further questions. I would like to thank you all for listening and for asking questions and being interested, and hope to see many of you on the road in the next couple of weeks. Thank you.

Thanks, all.

Thank you.

Take care.

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