Ladies and gentlemen, thank you for standing by. I'm Natalie your Chorus Call operator. Welcome and thank you for joining the Fresenius Medical Care Earnings Call on the Fourth Quarter and Full Year 2021. I would now like to turn the conference over to Dominik, Head of Investor Relations. Please go ahead..

Thank you, Natalie. As mentioned by Natalie, we would like to welcome you to our earnings call for the fourth quarter and full year 2021. We appreciate you joining today to discuss our recent performance and our outlook. Some of you might have already joined our press conference earlier today.

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 our materials that we have distributed earlier today. For further details concerning risks and uncertainties, please refer to these documents as well as to our SEC filings.

We would like to limit the call to 60 minutes because we had a long day already therefore we would like to restrict the number of questions in the Q&A again to two in order to give everyone the chance to ask questions. Should there be further questions and time left, we can go a second round. It will be great if you could make this work.

With us today is, of course, Rice Powell, our CEO and Chairman of the Management Board; and Helen Giza, our Chief Financial Officer and Chief Transformation Officer for FME25.

Rice will give you some more color around the strategy and business investments, Helen will provide to you the details update on the financial as well as on our target for 2022. And with that, I will hand it over to Rice. The floor is yours..

Thank you Dominik. Welcome everyone. Thank you for joining our presentation today and for continuous interest in our company. I would like to start with thanking our entire team at Fresenius Medical Care, our frontline workers in the clinics, production sides and distribution centers for their continued tireless work.

It was an extraordinary situation that we’ve encountered over the past two years. It is inspiring to see the amount of energy mobilized by our employees for our patients. I’ll begin my prepared remarks on Slide 3.

In 2021 we delivered our financial targets for the year despite a stronger-than-projected headwind from COVID-19 in the second half of the year as well as increasing macroeconomic inflationary pressures relating to both labor and raw materials. We all know that the pandemic and its impacts cannot be forecasted.

We expect these challenges will continue to be a significant headwind in 2022. We will have to work with our best assumptions as we have done previously. During the fourth quarter, COVID-19 related excess mortality continued to accumulate for at a lower level than the spike we saw in the third quarter.

We continue to execute on our strategic priorities and I look forward to sharing the progress we have made with you later today. Finally, we will propose a dividend of €1.35 at our Annual General Meeting in May. Turning to Slide 5. The impact of COVID-19 related excess mortality on our patient base has been an unprecedented development for us.

In the near term, this is a challenge for our business that we must manage. At the same time, the key underlying drivers of our core analysis business for the medium-to-long term remain solid and have not changed.

As the global population continues to age along with increasing incidence of hypertension and diabetes, we project more than 6 million people will require dialysis by 2030.

We continue to see solid new patient starts confirming that these drivers remain intact and indicates the potential for a strong rebound in growth once COVID-19 is once and for all behind us.

Turning to Slide 6, we continue to believe that our midterm strategy prioritizes patient needs and quality of care, aligned with the key drivers and developments for our industry and positions our business to deliver attractive, sustainable, profitable growth over the medium term and beyond.

We are executing on this strategy despite the challenges with the pandemic. Within the Renal Care Continuum, our goal is to extend our patient reach by treating patients holistically as they move through different stages of kidney disease and different treatment modalities.

In the past year, we have expanded our treatment of CKD patients and appointed a head of transplantation medicine. This is a newly created position within our global medical office. In critical care, we have recently expanded our portfolio by offering an innovative adsorber which can be operated with our acute equipment.

And with unify we have established a vehicle that allows us to extend into CKD therapy with regenerative medicine approaches. Turning to Slide 7, on this slide we highlight two key examples of how we are not only delivering on our strategic priorities, we're also leading the market in doing so.

As a leader in Value-based care, we are able to build in our experience from having supported 500,000 Value-based care program participants and manage risk for more than US$20 billion in medical expenses over the past seven years. We have also built the largest database of CKD patients in the industry.

Today, we manage care for approximately 80,000 CKD and ESRD patients in both private and public Value-based care arrangements. This includes approximately 24,000 ESRD and 28,000 CKD patients that are part of CMS’s Kidney Care Choice models that started this January.

In 2022, we expect to generate approximately US$1.1 billion in revenues, and manage more than US$6 billion in medical costs. We expect to realize an operating income margin of around 1% of medical costs under management on top of the operating income we generate from the related dialysis treatments that we perform.

We are also excited about the progress we have made and the growth potential we see for home dialysis. After achieving our 15% plus target for home dialysis treatments in the U.S. a year ahead of schedule, we have now set ourselves an aspirational target of 25% of treatments at home by 2025.

We manage this growth during challenging times and are encouraged by the potential for further growth, especially once the pandemic and labor shortage is behind us and we were able to put full force behind training the growing pool of patients that are interested in desire home dialysis.

Moving to Slide 8, our commitment to sustainability is integral in our strategy and is another area where we continue to demonstrate progress. We are consistently advancing our global sustainability activities with the goal to drive the integration of sustainability principles into business activities and assume even greater accountability.

In 2021, we reached further important milestones of our global sustainability program in areas such as patients and employees, environmental protection, combating bribery and corruption and respect for human rights.

We measured on a global level, how we are progressing, how satisfied our patients are with our services, and the level of engagement of our employees. Moving to Slide 9, combating climate change is a challenge for all of society and we are taking action to be a part of the solution.

The Management Board of Virginia's medical care set the goals for our company to become climate neutral in our operations by 2040 while we continue to grow. To achieve this ambition, we have developed a decarbonisation roadmap and set our targets in line with a 1.5 degrees centigrade science based scenario.

A major milestone will be achieving our midterm target to reduce our absolute scope 1, and scope 2 emissions by 50% by 2030. The Ultimate lever for carbon dioxide reduction here is the transition to renewable electricity. Our roadmap to climate neutrality will be a multi-year journey, and we are at the beginning.

We will continuously review opportunities to improve. We will assess options from investing in energy efficiency, and opportunities that come along with new technologies. We will continue to look at the entire lifecycle of our product portfolio. We will report on progress each year.

We will continuously review the relevant impact of scope 3 emissions, or inclusions in our targets at some point in our future. Our carbon management is part of our global sustainability agenda, and closely linked with our company's strategy for long term sustainable success. Moving to Slide 10.

Last year, we announced FME25 in the transformation of our operating model in order to better execute on our strategy 2025 while creating shareholder value, and establishing the basis for sustainable, profitable growth beyond 2025.

We have taken some important steps toward transitioning to our new operating model, with only two future global operating segments. Helen, in her capacity as Chief Transformation Officer will provide further details on how FME25 is advancing later in this presentation. Moving to slide 12.

During 2021, we delivered approximately 53 million life sustaining dialysis treatments to approximately 345,000 patients. The decrease in the number of patients and the number of treatments directly relates to the tragic impact COVID-19 has had on the lives of our patients.

The 2% clinic growth mainly relates to growth in North America, due to acquisitions and newly opened clinics initiated prior to the onset of the pandemic. Turning to Slide 13.

We continue to see stable anemia as w ell as bone and mineral metabolism control, demonstrating that our patients are receiving consistent, high quality dialysis care, even during this terrible pandemic that we continue to deal with. Looking to Slide 14.

This slide compares the development of COVID-19 infections worldwide to the number of cases we have seen across our Fresenius Medical Care patient population. In the most recent and very significant surge in January, we have seen very high numbers of COVID-19 cases matching the emergence and spread of the Omicron variant.

The Omicron variant is highly contagious, albeit with less severity than prior variants or the original virus itself. We know that vaccinated and boosted patients suffer less risk of severe or catastrophic results from COVID-19. We are continuing to advocate that all of our patients be vaccinated.

We have seen increases in vaccination rates since our third quarter results at the beginning of November. At the end of January, approximately 80% of our patients in the United States have been at least partially vaccinated, and 57% of all fully vaccinated patients have already received their booster.

On a global basis, approximately 81% of our patients have been at least partially vaccinated and 58% of all fully vaccinated patients have already received their booster. Turning to Slide 15. During the fourth quarter, COVID-19 related excess mortality among our patient population declined to around 1800 excess deaths.

Globally on a 12-month basis, excess deaths amounted to approximately 10,000. Pandemic to date 20,000 deaths have occurred approximately. And again, pandemic to date 20,000 deaths.

Given the four to six week lag time, from infection to passing away, as well as the delay in recording of deaths that occur outside our facilities are outside of our control. It is too early to have a concrete data plan on the development of excess mortality so far in 2022. We all know that the pandemic and its impacts are not predictable.

So we can only make assumptions. We currently assume for the full year 2022, we could see as many as 5000 to 6000 excess deaths globally. With the spiking cases related to the Omicron variant and the vulnerable nature of our patients, we expect excess mortality in the first quarter could be rather hot.

Turning the Slide 17, in the fourth quarter, we achieved 3% revenue growth in constant currency supported by positive growth in both healthcare services and products. Our net income excluding special items declined by 32% on a constant currency basis.

Cost related to FME25 will be treated as special item and during the fourth quarter we had €43 million and FME25 related costs pretax. Our fourth quarter net income included a negative net COVID-19 effect of €76 million. We continue to face macroeconomic inflationary pressure related to both labor and raw materials.

We see in labor cost development in the U.S. is unprecedented at this time. In my 25 years with Fresenius Medical Care, I never remember saying a market as hot, if you will or as turbulent as we see it today at this time. Turning on slide 18. For the full year 2021, we delivered revenue of €17.6 billion reflecting 2% growth in constant currency.

Our net income excluding special items declined by 23% on a constant currency basis.

We were able to achieve the lower end of our guidance range despite some unanticipated and substantial headwinds, including a significantly higher than expected impact from COVID-19, a higher than expected wage inflation and the negative effects from the fair value remeasurement of our investment in Humacyte that accounted for around €40 million for the full year 2021.

Please allow me one comment regarding 2022 so that you do not have to waste one of your two questions to ask me about it.

For the first six weeks of this year, the convergence of on-going and well documented worker, raw material and transportation shortages, with historically high absenteeism rates due to the Omicron variant presented significant challenges for FMC and the industry.

This impacted our ability to meet customer demand for dialysis concentrates, and had a knock on effect with our disposable supplies for certain geographies within the United States. We have worked with all providers in the United States to prioritize deliveries in order to build up inventories in provider clinics and within our own warehouses.

Patient Care remains a highest priority for us as we work to navigate this unprecedented and challenging situation. We applaud the collaboration among all kidney care providers in the United States, which ensured that patient care remain the highest priority as we work together to navigate this unprecedented and quite challenging situation.

Moving to Slide 19. At our upcoming annual general meeting in May, we will propose a dividend for 2021. The proposal targets to ensure continuity of our dividend payments despite the unprecedented but temporary effects of COVID-19. We believe that the fundamental drivers of our business and growth remain unchanged.

In the experience that we are seeing with COVID is temporary and is lasting. This underscores our commitment to delivering shareholder return. At this point I'd like to turn it over to Helen and she'll take you through the financials as well as our outlook for 2022..

Thank you, Rice. Hi, everyone and welcome to this day of Tuesdays as it's being called. I'll kick off with our fourth quarter revenue growth on slide 21. During the fourth quarter, we realized solid revenue growth of 6%.

Despite significant negative effects from COVID-19, we delivered 2% organic growth with positive contributions from our international market. Moving to Slide 22.

In the fourth quarter, also Healthcare Services delivered organic revenue growth of 2% despite negative COVID-19 impacts from all regions, and lower reimbursement for customer metrics in North America.

In Healthcare Services, the adverse impact and COVID-19 related excess mortality on organic growth amounted to approximately 290 basis points for the fourth quarter. Asia Pacific stood out as a strong regional contributor in the fourth quarter, delivering positive same market segment growth of around 3%.

Turning to slide 23, revenue for our products business increased by 3% in the fourth quarter, and delivered 1% organic growth overall. Growth was driven by higher sales of machines for chronic treatment, home haemodialysis products, and incentive disposable. This was somewhat offset by lower sales of products for acute care treatment.

Continuing with Slide 24. Here we show the operating margin development for the fourth quarter. The largest negative impact on margins relates to inflationary cost increases on the materials and supply chain side, as well as higher personnel expense, which already referred to this unprecedented situation in the United States. In the U.S.

we continue to have an increasing number of open positions that are taking time to sell. The fair value remeasurement on our investment in Humacyte was the second biggest negative driver of our margin, with an operating income effect of €77 million.

As we do not have significant influence in Humacyte, we account for the investment in financial instruments at fair value through the P&L and have to record any change in the fair value of the investment in our earnings. This was set up many years ago and we're not in a position to change this approach.

Excess mortality continued to accumulate, and strict PPE protocols remain in place with the emergence of the Omicron variants. COVID-19 related costs continue to have a negative effect despite a positive contribution of U.S. Federal released funding of €51 million for our joint ventures. We incurred €43 million in costs related to FME25 in the quarter.

And a favorable impact from equity method investees in the prior year was also a headwind in 2021. On the positive side, we've benefited from a low base with the absence of €195 million impairments in our Latin America business that we have in the prior year.

And margins were also positively driven by an improved payer mix due to the growth in Medicare Advantage, following the introduction of acuity back in 2021. Turning to slide 25, we also wanted to provide some color on the margin drivers for the full year 2021. I won't go into as much detail here.

But you can see that the largest negative impact on margins for the full year relates to inflationary cost increases and higher personnel expenses, followed by significantly higher COVID-19 net effects than initially anticipated now guidance.

If you recall, when we set out at the start of 2021, our outlook assumed the return to normal mortality levels in the second half, which did not materialize. Again, the re-measurement effect on investment in Humacytes of around €60 million, FME25 related costs of €63 million and higher bad debt expense with other net negative drivers in 2021.

The largest positive margin drivers in the full year with the absence of the prior year impairment in our Latin America business, as well as higher reimbursement driven by growth in MA. Moving on to slide 26. During the fourth quarter, we generated operating cash flows of €669 million, which equates to 14.4% of revenue.

The increase was mainly due to improve working capital, including contributions from FME25 cash and lock initiatives and U.S. federal relief funding. This development was partially offset by continued recoupment of the U.S. government's payments received in 2020 under the CARES Act, and lower tax payments related to COVID-19 relief in the prior year.

€510 million was recouped in 2021. And with the recruitment of funds driven by our lower EBITA, our net leverage ratio of 3.3 is still within our target range of 3 times to 3.5 times. I will now move to the outlook on slide 28.

Looking ahead to 2022, I will walk you through what we see as headwinds and tailwinds and our related assumptions that tie into our 2022 outlook.

In 2022, we're assuming that the effects of excess mortality accumulated in 2021 plus the further 5000 to 6000 excess deaths related to COVID-19 will have a negative impact of roughly €100 million compared to the level of 2021. We are projecting the excess mortality among dialysis patients or declined sizably against the overall level of 2021.

However, for the first quarter, we are assuming the biggest impact of excess mortality. As Rice already said, we cannot make projections but only assumptions in respect to the excess mortality for COVID-19.

As indicated, we continue to face staffing shortages, the need to employ temporary labor or provide overtime pay and manage through this unprecedented situation in the U.S. Healthcare market. We anticipate costs will be around €100 million above the average 3% wage inflation that we typically budget for.

Should we receive any further government support, we would apply this to ease at least some of the pressure on the labor market situation in excess of the labor cost assumption I just outlined.

As we did not have cost related to a ballot initiative in 2021, the potential ballot initiative in California could translate to a €20 million to €30 million headwind.

And additionally, the unfavorable macroeconomic inflationary environment and the experienced elevated costs in the supply chain are expected to impact us with around €50 million more than last year. While these headwinds are substantial, we also anticipate strong positive tailwinds, many of which are longer term in nature.

We'll discuss these tailwinds on Slide 29. We have seen a further improvement in our payer mix to start the year. We expect our Medicare Advantage mix to be in the mid 30% across our entire U.S. patient base during 2022 following the most recent open enrollment period.

And for Medicare Fee for service patients, we benefit from the 1.9% increase in the PPS rate. We are anticipating positive organic growth driven by further penetration of home treatments and the expansion of our Value-based care arrangements.

Within this category, we also assume that the fair value remeasurement of Humacyte will be volatile, but neutral on a full year basis in 2022. While we continue to use highly elevated volumes of PPE, we were able to mitigate top impact against last year. This is expected to provide a tailwind of around €50 million.

We already expect sustainable savings of €40 million to €70 million as we advance our FME25 program. Moving to slide 30. Based on these headwinds and tailwinds I just described, for 2022 we are expecting a return to growth and low to mid-single digit revenue and net income growth on a constant currency basis.

As a CFO, I would like to flag that we do expect the low point in our net income development to be in the first quarter. The first quarter is expected to provide only a mid-teens percentage share of the overall 2022 net income. This is driven by the following effect.

We assume the low point of operating leverage due to the highest impact from excess mortality and utilization effects from 2021 and further accumulation of excess mortality in Q1. We do assume to significantly improve the operating leverage throughout the year. We've seen high cost for managing an unprecedented labor situation in the U.S.

Healthcare services market, covering temporary labor, extra shifts, retention payments, as well as higher medical benefits. And an unprecedented supply chain costs in the first quarter they are expected to moderate in the second quarter and beyond. We're also expected to see cost inflation for materials and supplies.

As you can see, some of these effects will remain with us throughout the year, but we will be most pronounced without impact in the first quarter. And anticipating your modeling requirements for 2022, I'd like to share some other relevant assumptions.

We anticipate corporate costs in the range of €480 million to €500 million at constant rate around half of this relates to R&D including our global medical office, through our financial results, we expect a range of €270 million to €290 million at constant rate. And we assume a tax rate of 24% to 26%, excluding special items. Next on slide 31.

As we've mentioned, we have already begun to make some important steps with our FME25 program. In December of last year, we announced our new management board, which went into effect at the beginning of this year. The new leaner structure reflects our future globalized operating model.

And we have now also named the next level of leaders below the management board. In the fourth quarter, we progressed with the transformation of the finance organization, which was already in place.

And in line with our program plan, we have kicked off a number of our FME25 initiatives, which also includes identifying initiatives to improve gross margins, reviewing manufacturing footprints and supply chain opportunities, as well as the product portfolio and pipeline.

These include some of the more time consuming initiatives like the global optimization of our infrastructure, which includes areas like clinic network, or IT infrastructure, and other future global systems. Including the program and consulting tasks, we spent €63 million on FME25 in 2021.

The impact from these initiatives had a deminimus cost reduction in 2021, but expect to have an effect moving forward. We will make significant progress in the transformation to our new operating model in 2022, which will continue to be a very important transition year.

Of the planned €450 million to €500 million of onetime costs to sustainably reduce our cost base by €500 million by 2025, we expect onetime cost of approximately €175 million to €245 million in 2022. We also anticipate €40 million to €70 million in sustainable savings in 2022 as I outlined earlier.

By the end of 2023, we still anticipate having made 80% of our investments while realizing around 50% of our savings. And by 2023, we expect to implement the new operating model along with new external reporting that should provide greater transparency into our operating segments.

We are planning to report revenues and operating income for each of the new operating segments. We also plan to provide revenue split in U.S. and international revenues for each of those operating segments. And as we move along our transition journey throughout 2022, we will continue to update you on the progress and our plans.

Turning to slide 32, while certainly the COVID-19 and inflationary challenges continue into 2022, we are confident about the mid and long term drivers of our business. With the support of the FME25 program and the progress we are already making on our strategic priorities, we plan to deliver on our midterm targets for 2025.

That concludes my prepared remarks and I'll hand it back over to Dominik to begin the Q&A..

Thank you Helen. Thank you Rice for your presentation. I apologize that there seems to be some issue with the line, which we can’t hear very clear. But Natalie, hand back to you to open the Q&A..

Thank you. And the first question is from the line of Veronika Dubajova from Goldman Sachs. Please go ahead..

Good morning, Helen and Rice and Dominik, thank you so much for taking my questions. I will keep it to two. One just would love to get an update on where you see MA penetration. I think Helen; you might have mentioned something around mid-30s. I know you measure it differently than.

But as always, they've been talking about something in a low 40% range in terms of their Medicare population, if you can give us a comparable number that would be helpful.

And just related to that a quick update on how the MA rates are developing versus last year and if you're seeing any payer pressure or rate pressure in that segment, as it’s the quite an important driver of tailwind. It was positive make for you guys. And then second question, slightly controversial.

This is probably more for the reason I apologize for the bluntness of it. But obviously we had heard from your majority shareholder earlier today that they would be willing to dispose of their stake in your business.

And I'm just curious Rice, how you feel about that? And to what extent, changing ownership would impact on how you run the business and what might that mean for FMC?.

Thank you, Veronika. Thank you for giving me that question in particular. Now, go ahead Helen, why don’t you take the first one..

Hi, Veronika thank you for the easier of the two questions. Regarding MA penetration, we ended the year, right around that kind of low 30. We are expecting to be mid 30% through 2022. And obviously, we're just coming through the open enrollment.

You are right, we do measure it slightly different to our competitor, our 35%, or mid 30% is a as a percentage of our total population was I believe our competitive as it just as a percentage of our Medicare population. So I don't have the comparison of percentages. But we have been consistent with it being as a percentage of our total population.

Rice, hand over to you..

Rate pressures. I can speak to that. So at this point, not feeling a ton of pressure at the moment, it's always going to be there. But we are still working and dealing with the payers and having our conversations.

But I can tell you it's not knockdown drag out, I would say, as we as we've undergone the beginning of this year, it is it will evolve to the rest of the year, Veronika. Question two. So FSE, considering selling their stake in us, their choice, their money, doesn't hurt my feelings.

I mean, we are totally focused, not just me and Helen, but the entire organization, on getting past this damn pandemic, delivering and unlocking value through FME25. We're going to stay focused on our job and doing what we need to do.

Now we're not naive, if it comes to the point that something happens with that stake and whomever it may be, I'm sure I might have a hit list who I'd like it to be. But I'm not even going to lose five minutes worrying about that.

At this point, we're just going to continue to do what we need to do to take care of our patients to give, a good return, unlock value and run the business and then we'll see where this goes down the road Veronika..

Understand. Thank you, guys..

The next question is from the line of Tom Jones from Berenberg. Please go ahead..

Oh, good morning. Thank you for taking my two questions. I think I've got one for each of you. First one for Helen, on staffing and vacancies I think you mentioned that the Q3 that there was actually a little bit of a P&L tailwind in some respects in the fact that you had so many open vacancies.

So it would be useful just to get a flavor of where you sit on the open vacancy front and whether actually filling those vacancies creates a little bit more of a headwind in H1 than it might do in H2 once those employees have bedded in. And then the second question fairly, hopefully a fairly straightforward one for you Rice.

With the home growth that you're anticipating, I assume that's all coming on the HD side, rather than any sort of structural changes or faster growth on the PD side.

And then maybe as a sort of sub question to that, between now and 2025, how should we expect that to develop? Is it kind of a linear thing? Or do you expect, kind of slow start and a fast finish in terms of getting from where you are now, which is about 15% of the total in home to getting to that that 25% number?.

Thanks, Tom. I'll take the question on labor, and as you can appreciate a lot of moving parts on this. We continue to see a high level of open positions more than we would like to see.

We have consistently talked about seeing around 6000 open positions and that's kind of increasing as time goes on, really due to the shortage of labor in the available market. I think last year we were able to cover some of this increasing pressure on cost with the open positions.

I would go for 2022 is obviously to disable those positions as quickly as we can. But I would argue that there's a number of moving parts here. Clearly as we tried to fill them we don't know what the ramp up is going to be there on filling the positions. So we are covering that with some additional tasks which, hopefully are more temporary in nature.

In terms of overtime, contract labor, traveling nurses retention and so on. But then as you can appreciate and what we're all seeing and reading in real time, and what's happening in the in the labor market in the U.S., is the significant pressure on wage compression and, and higher wage.

And obviously for us, we want to fill these positions, we don't want to have any interruption in supply, and making sure that we can, get getting good, get the staff trained. We are focusing our efforts on, kind of all kinds of different ways to try and kind of attract people into the walls that we have open.

But as you can see from the headwind, we do expect a year-over-year increase there, not surprisingly, with all that were, that we're trying to manage. But our goal is to keep focused on the filling the positions, the team are doing a terrific job balancing, kind of the labor, the labor challenges that we have.

And as we've mentioned, quite unprecedented for anything that we've seen in quite a long time here, bringing with the shortage as well as the inflationary increase, above what we would have seen historically..

Do you think that's – sorry Rice..

No, go ahead, please..

Sorry. It’s a quick one, it’s for Helen.

Do you think that there's any potential for the sort of broader macro inflation pressures being felt at the consumer level, to actually start to have some positive effect for you in terms of kind of making your employees willing to work longer at pushing sort of semiretired people back into the workforce, because it feels like we're in the foothills of the consumer getting hammered on inflation or the corporate center have felt earlier? So I just wondered if ultimately, that kind of starts to balance, swing back the other way in your direction? Because I know that the nurse market can be somewhat fluid in terms of people dipping in and out of the workforce?.

Yes, that's a great question, Tom. And in as we've gone through the investor meetings over the past quarter, what I've spoken to, at length is no, is this a temporary exsurge of healthcare workers out of the market because of you know, people are just burnt out from COVID. We are seeing, I would say people retiring.

So maybe the opposite of what you're proposing. But I think it will depend from the younger generation and that market coming back in and selling those divisions do they end up, working longer because of to your point, the cost of living and inflationary increases.

But, it's too early to tell I think of whether this is transitionary in nature, and it will, the available pool of labor will increase again, but we've definitely seen a significant contraction in that available pool.

And it's across the board that we had seen early on this increase of people retiring, and just this general feeling of being burned out and exiting the market. Time will tell I guess Tom..

Hey, Tom. So let's talk about home, my favorite topic. So when we look at home growth, generally speaking, we are seeing home hemo grow at a faster clip than PD, PDs in the mid-single digit range. And HHD is growing much faster than that. We've been low on double digit, little higher depending on where we are within the pandemic, if you will.

We would obviously like to see this growth be ratable. But I would tell you, I think we're going to have a slow start. And then it will pick up as we accelerate in 23, 24.

And the real issue there is with our nurses that are in the transitional care units that are doing the training, if we have an in-center clinic around the corner, down the block, wherever it may be, where we've got a lot of staff out due to COVID, particularly Omicron.

If we need to borrow that person, we will certainly do that to be able to provide the treatment. And so that gives us a little bit of tension as we're trying to look at how we're going to do this. I would also say the other thing Tom think about. We all know that PD patients are not going to stay on PD forever.

They are going to hit a point three, four or five years, where that is not going to work for them, they're not going to get the clearance they need.

We need to do a better job and we are but we've got more we can do to have those home patients on PD, stay at home, change her access out, get a blood access for haemodialysis, and then stay with us via HHD on the next age equipment. And we're making progress there.

But that is another bit of growth that you see, because as you know, PD tends to be transitory nobody really stays on PD forever. So I think we will see back end acceleration but I -- we need to be training more and we need to do that.

And I think the sooner we get through this pandemic, the better off we're going to be inorder to try to get that growth to be ratable..

That's right. so thanks..

You bet. Thank you..

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

Hi, one question on home dialysis, and then one on the CKCC. As we think about you shifting to potentially a quarter of your patients on home dialysis, how will that affect your clinic infrastructure given this trend? How should we think about CapEx? Are you going to be consolidating clinics? It would just be helpful to think through that.

And then second on see CKCC. Can you remind us how you are accounting for the patients? Are you going to book the revenues right away? What about EBIT? Or will it take a while to get an idea of what the run rate will be for revenues and EBIT? Obviously, ESCO was a bit of a disaster from that perspective.

So just remind us of where you are on the accounting front there Helen, that would be great? Thanks..

Hey, Lisa, it's Rice. Hope you're well; I'll take your first question. So as we see this shift to 25%, at home, what does the clinic infrastructure look like? Look, here's the way we think about this is I believe, we lease our clinics, they're not brick and mortar per se, that are sitting on our balance sheet in the classic sense of the word.

So we have ability to move from certain locations as we need to, we can let those leases expire. And we can move in different places. I would say that we certainly will see some movement in our clinics. We will probably have some clinics that we're not going to need as we go through time.

But sitting here today, in the pandemic, until we bury this darn thing and get it out of our hair, we would not be looking at trying to do anything like that, even if we were at 25% today, because we're using those clinics as overflow. We're using them for COVID positive clinics trying to keep our separation, if you will.

So I think that we will move in that direction over time. But we certainly want to make sure that we're well past COVID and the issues that it’s created for us.

The other thing that I would say is they'll always be a need for clinics, we're always going to have patients that are going to want to be in center simply because they don't have the wherewithal or the capability or the desire that their physician is comfortable that they are going to be able to do their treatments at home.

We do have hemodialysis patients today that are at home, they love it. But at some point in the year, they don't want to be on vacation, and idealizing at home, they want to go into a center we try very hard to accommodate them. It is tight sometimes depending on utilization. Now that world's changed some given what's happened with the pandemic.

But we're going to also want to have extra utilization capabilities in our clinics for people, particularly as home grows. And they're going to decide, hey, I'm taking a month off. I'm going to be in Florida. I really don't want to go do this in the hotel or the condo, can I get in one of your clinics.

And we certainly want to be able to accommodate that..

Yes. And then Lisa, on your CKCC question. A little bit different to the ESCOs in that revenue recognition we’ll be delaying until we actually get the reports. So we are thinking that we would get the feedback on the results against the, the benchmarks, probably at the earliest in half to of 2022. And then with a lag event going into 2023.

Obviously, we've all learned a lot from ESCOs and both in reporting and analysis. But, as soon as we get those, get those reports, we will pull up the revenue rack that goes with that..

Great, Thanks. Rice, just one follow up.

I mean, should we just assume then that you'll just have lower utilization of your clinics, at least for the next two, three years?.

No, I think it's something you should be aware of. I don't want to speak exactly for my team in North America because they tell me I'm not going to get it right.

But I think that's something that we should consider and you should expect there'll be some of that, absolutely as we're trying to come out of the pandemic and moving forward in a post pandemic world. Yes..

Yes. And maybe the other thing I would add is, as we think about our clinic, infrastructure and our lease, renewals, we are restricting those to shorter timeframes now to allow us for maximum flexibility and reducing the exposure there too..

Okay, thanks for that..

Sure..

The next question is from the line of Oliver Metzger from Oddo BHF. Please go ahead..

Hi, good morning from my side. Two questions, the first Rice, you mentioned this 1% incremental margin for Value-based care programs. So, thanks for providing this number.

For being more specific, is this the targeted margin and therefore, the maximum potential or is it your estimated positive net contribution coming from these programs? Second question is on the tailwinds. You have described of around 250 million for 2022. So, there are different factors.

You have mentioned in particular PPS rate increase just to clarify the rates of increase of 1.9% -- disproportionately high nor it appears as a very positive offset. So I’m surprised to see this as a tailwind.

Is it fair to say that Medicare Advantage brings the biggest tailwind and from a home treatment or is it more subordinated to that?.

Yes, Oliver. I'll take one and I'll give Helen too. So it's an estimated figure for us. Not the targeted, it's our estimated as we look at as we look at that..

And I’ll take this..

Yes, go ahead..

Yes, so Oliver on the tailwinds if you see that there's a lot going into that business growth. But obviously, the any increase in reimbursement is an increase for us. It helps us offset some of the past scores.

So we do see that rates increase as a tailwind overall, but as you're probably say that the Medicare -- the Medicare Advantage mix, along with the BBC growth and home help drive that overall 250 million. So a lot of moving parts as you can appreciate there.

But ultimately all having even as we think about the return is driving the growth here, positive return on operating income. As Medicare Advantage would be the biggest driver there..

Okay, thank you..

The next question is from the line of Patrick Wood from Bank of America. Please go ahead..

Perfect. Thank you very much. I'll give it to one actually. Just curious, I think I know the answer anyway.

But do you think there is any implication from the DaVita Supreme Court case going on with the Marietta Memorial Hospital and what that could mean for you know, the MSP situation or just kidney care in general? Just curious if you think there's any implications for a ruling there?.

Hey Patrick. Well look, anytime something ends up in the United States Supreme Court, I tend to think there's probably implications somewhere along the way for the entire industry. So I think that in my mind, I am watching this with great interest to see where it ends up.

But obviously, we can't pass let's say this comment on this intelligently until we see what comes out of the Supreme Court, what rulings they have, and then we'll go from there. I know a lot of people think this is going to be settled very quickly. And I don't mean settled in a legal sense. But we're going to get to this very quickly.

I think there's a March date for this. I'm just going to sit and listen. And we'll see what comes out of it. And we'll go from there. But I think you can't just dismiss that this would have some implications for the industry potentially..

Totally understand. Thank you so much..

Sure..

The next question is from the line of Falko Friedrichs from Deutsche Bank. Please go ahead..

Thank you. I have two questions, please. And firstly, could you provide an overview of all the ballot initiatives in the U.S.

in 2022 that you are aware of and that could potentially pose headwinds if they were to go through? And then secondly, on your tax rate, and Helen, the indication you gave us for 2022 is a good amount above what you printed in 2021. So any specific reason why the tax rate should increase that much again? Thank you..

Go ahead. I'll come back. Yes..

Hi, Falko. Yes. So yes, we are guiding the 24% to 26% for the tax rate. You will have seen for 21 that we came in 22.4. We did have some unfavorable true ups for tax audits and some uncertain tax position.

So I would say that was a little bit more than usual, but I feel comfortable with the other 24 to 26 that were guiding here, excluding those adjustments in 2021..

I’ll pick out -- so ballot initiatives, the only one that's really on our radar screen, there could be a couple of other minor things that we will probably have our folks at the State of Government Affairs probably can tell me about, but the one we're watching is obviously California.

It’s a state it just continues to give when it comes to ballot initiatives. Where we are with this is they have to get signatures to be able to get on the ballot.

I think they've got to produce those signatures sometime in March in order to get or maybe the first of April to get certified to go on the ballot, which will then be in November for the state elections in California. So there's a ways out. Obviously, we've been through this before. And so we're watching it closely.

We have people on the ground, looking and watching and learning. Our outcomes have been good for this. It's not without spending money from time to time, but we're on this and we'll be paying attention to it. But that's the only one that I think warrants us having a conversation about it in earnings call at this point.

The others I'm not aware of that could be a couple of minor ones out there..

Okay, thanks a lot..

Sure..

The next question is from a line of David Adlington from JPMorgan. Please go ahead..

Thanks. Yes, just got on to your headwinds on the cost side. I think they're totally looking for, about 100 million wages and 50 million from other cost inflation.

That's only about 1% of your total cost base, though, I suppose the question is, that does seem a bit like and how confident are you that it could be 1.5% 2% more? And assuming that does come through, how likely do you think you are going to get additional government support something sort of pointing towards in the slides as potential government support? And just wondering where that was coming from?.

Yes so David, we're doing our best that kind of forecasting the assumptions that we're seeing them as we have them now. Of course, anything that we have on cost increases, we're always trying to offset with efficiencies and cost reductions.

But no, I think labor is probably the most unpredictable one at the stage where we are, trying to size it based on what we're seeing an incredible pressure in the marketplace. But obviously, trying to balance that the best we can. With regard with leave it's kind of a assembled, it seems to be a multi phased approach with the government.

We did receive around 100 million, at the end of last year for joint venture provider funding. We were able to apply about half of that to the cost in 21. And about half of it will roll into 22. Now it is JV, so the fall throughout the minority interest isn't as great.

We did apply for large provider funding, and there is still government, in our -- is still government funding available, but we do not have line of sight into how that will be allocated and how much when.

So, what we're doing right now is kind of excluding it from our guidance, because we just don't know what and then, balancing that against the on-going labor pressures. So that's why we've tried to keep it quite discreet in how we have laid it out in our assumptions.

And as you guys tend to see it as quickly as we do when it pops up onto the website that we've got, we've got funding. So you'll know when we know if there is more available, and then how we can apply it. But right now year-over-year, the fun, the relief is neutral, because we got some in 21 and already have some going into 22.

And the bigger question is on this provider funding, that we know we're waiting to still waiting to hear about it..

Yes. And David, the government has done what they said they would do. Their first priority was the rural providers, the smaller providers and many of our joint ventures were in that bucket, if you will, so that has come and gone exactly as Helen laid it out.

We're now looking at the wholly owned subsidiaries; it is a one massive application that we applied for. And as well as we do, if it starts to pop on their website, that they're beginning fund flow that we will know and we'll start looking at that. But that's where we are at this point waiting to see when that will happen. We're told it will.

And so we're waiting to see when that's going to come in..

And I guess a cheeky follow up on the -- situation because I just wondered if you could just clarify the source of the challenges there, and how that's going to impact both in terms of sales and costs, particularly the first quarter?.

Yes. So what I would say is, we really kind of walked right into the perfect storm here. Meaning that, we've had issue with distribution relative to drivers and the cost to drivers and physically finding people to do long haul and short haul drives.

I think what really exacerbated this was that with the Omicron variant and all of the schools being open. If you go back to Delta variant, remember many of the schools were shut down and they were doing virtual school. And so we felt pretty protected in our factories in our warehouses in addition to our clinics.

But with Omicron and the schools being open for the first time, we saw a much higher absenteeism simply because kids were getting infected, they were coming home, parents were getting it. And then you're in that what I call that, downward spiral of absenteeism that you have to deal with.

Fortunately, it's not as fatal or fatal for those that have gotten it, but you're still out 6, 7, 8, 9 days. And so that's created some havoc for us. It will have some knock on effect into first quarter; I'll let Helen speak to that. But clearly, we are still at a higher level gas is at a big time high. And this is pretty much U.S.

focus, and what we're dealing with. We expect we'll get well, over the course of first quarter going into second quarter. We're making progress as we go now. Kita that's going to be keeping people at work and not having reoccurrence of the Omicron variant knocking people out.

And then we just got to get caught up on production distribution and making that work. But I would tell you, I'm always amazed at how this industry can compete. And then how we all come together when there's an issue to make sure that we're helping one another and taking care of everybody getting their patients treated as Q1 impacts..

Yes. So clearly, we expect to have this, this bigger impact in Q1 as a result of all that we've been experiencing with Omicron. I wouldn't be surprised that we would see each of the 50 million headwinds that we've highlighted for inflation and supply chain impacts about a third of that to impact us adversely in the first quarter.

So disproportionately, as we've mentioned, kind of recovering from that over the course of the year..

The next question is from the line of James Vane-Tempest from Jefferies. Please go ahead..

Hi, thanks for taking my questions. And just a follow up to the industry dialysis supply headwinds question. Has this impacted the products business? I understand some of the industry logistics issues may have been more specific to FMC. So I was just wondering whether this has been any benefit to your competitors on supply.

And has it also caused any reversal in homecare if patients haven't been able to get their supplies and be going to the clinics? And then my second question is a 40 million to 70 million savings.

Can you help us bridge the gap to the 250 million also in 2023, that's when the half of the full benefit will be delivered? Can you give us a color of the type of projects which are expected to deliver these? Thank you..

Hey James, it’s Rice. I'll take the first one. So this is truly an industry wide issue. Other product manufacturers are having issues as well. It's just that, trucking, labor, all of those things are in play. And so it's been difficult for everyone.

I'm happy to say we have not had a situation where people couldn't get treated, they had to go into the ER to get their treatment, everybody has worked hard to prevent that. We have certainly been hand to mouth a couple of times that we've been able to avoid that, some folks are doing heroic things on this. And so we've been able to stay up with this.

No one likes being at this level of frenzy, if you will James, but we've been able to manage that. But as we had our own issues, and we looked at and reached out to other manufacturers to see could they take any slack, there was no slack for them to take either.

So part of what we've done is we have facilities in Mexico and Canada that used to produce concentrate, they don't any longer. We were able to get them up in running again. And they're now set helping to supply. So we've been able to kind of pull this up from our own bootstraps. But I'd say it's more of an industry wide situation.

And we will help any other manufacturer if we can if we have something that we can spare that someone would need..

And then James, your question on the ramp up of savings to 2023 if you can appreciate where we're moving at pace to 2022. The kind of headcount reductions we're targeting with some of that, obviously, is a slower start. And you kind of get engaged in consultation with the workers council and so on, and what we can and can't do without an agreement.

But I would say, the -- all the projects that we've identified are kind of initiated and underway.

And they span a whole host of initiatives from our optimization of our IT systems and an infrastructure, finance transformation in terms of moving to the new model and outsourcing for shared services, office space consolidation and manufacturing footprint and clinic optimization.

So of all aspects of our operating model I would say that there's initiative identified and moving. Some of this looks a little, maybe a little slower or smaller as you look at the 23. But some of that is just the ramp up due to people and initiatives and the time that some of these complex projects take.

But we still stand behind our kind of categorization of edge and expect those significant savings as you identified over the course of 23. So that it's not all, not all back ended, but feel really proud of what's being accomplished by the organization at large today..

That's great. Thank you. Just a very quick follow up if I can go to David's question. The labor cost increase beyond 3% and the €100 million.

I know you don't specifically break out the labor cost per se, but without get it to a double digit increase or make an extra kind of mid-single digits just to help us kind of qualify a relative amount or an absolute number, which you provided..

Yes, and as you can appreciate, there's a lot of moving parts, but I can probably tell you like that, the 3%, they know those increases translates to 4.5% to 5% net. But of course, that net is a lot of moving parts on open division, temporary labor over time traveling nurses, retention, sign on bonuses, wage compression.

So probably the most complicated piece we've had to size as we've gone through this guidance, discussion, but I would say between 4.5% and 5% net increases what you could put into your modeling for 2022. The other thing I would say, and it's something that we're very mindful of is that isn't all permanent.

A number of the initiatives that I pointed out were temporary. So obviously, there will be some permanent increase here on the inflationary cost, that is in the base, kind of wage line or salary line, which obviously, we will continue to work to offset in the months and years ahead.

But there's a temporary and permanent nature to that, which I think is important to contemplate as well. Hopefully, that gives you the color there..

That's great. Thanks very much..

The next question is from the line off from HSBC. Please go ahead..

Thanks for taking my question. Mine was just on the equipment to the picture, actually, where just heard from some competitors, how they're bringing together home dialysis with patients monitoring systems.

Do you have any initiatives on that front, or how do you see that going forward?.

Yes, Sergie its Rice. So I would tell you that how you connect that home patient to their lifeline via physician, nurse, supplies, all of those things is critically important. We have been out on the market for over a year, maybe 18 months now with our Kinexus system, which does exactly that.

It allows our patients to tap into chat rooms where they can talk to their home nurse; they can talk to the physician. They can have telehealth visits with either one of them. They can actually get a hold of their driver that's going to be delivering product to their home to be able to redirect them or change the delivery time if it's inconvenient.

So there is the competition out there. You bet. Why, is because this is going to be critical to making this work. And I think we're in a very good position with what we've been able to get accomplished there.

And just like on the consumer side of our lives, these systems are going to continue to change and evolve, get easier to use as we go through time. But it is really necessary to be a link for these patients to know that they can electronically get a hold of someone or something that they may need.

So it's real world and it's there and we're happy to compete. We feel like we've got a competitive product..

Okay, so thank you, everyone. We are out of time or eight minutes about time. I thank you for your interest and I’ll hand over to Rice for the closing remarks..

So thank you, Dominik. I just wanted to say a few words. It's been an interesting day for us, a lot going on today. With our press conference on top of our earnings call and spending time with you just want to make sure you all understand where our minds are. Our minds are on-going forward doing what we need to do.

We know that we need to do better on unlocking value generating better growth, more profitable growth and that is what we're going to be all about. We're not going to get overly concerned about all the noise that may be out there or what could be, might be, maybe who knows.

I've learned over time that that usually doesn't deliver great results if you're sitting there speculating. So we're going to do our job. We're going to continue to focus on where we need to focus and continue to go forward. We will see you well, we'll see many of you on the road show I think, and in conferences.

And we'll be back talking about earnings in early May, when we conclude in Q1. Thank you very much. We appreciate your time. You all stay safe and be well out there..

Thank you. Bye bye..

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