DaVita (DVA) Q3 2026 Earnings Call Transcript

DATE

Thursday, Oct. 29, 2026

CALL PARTICIPANTS

• Group Vice President of Investor Relations - Nic Eliason
• Chief Executive Officer - Javier Rodriguez
• Chief Financial Officer - Joel Ackerman

TAKEAWAYS

• Adjusted Operating Income -- $561 million, reflecting outperformance in the Integrated Kidney Care segment and improved margins in Latin America.
• Adjusted EPS -- $3.82, driven by operational performance and the impact of share repurchases.
• Total Revenues -- $3.578 billion, representing growth from $3.42 billion in the prior year quarter.
• Full-Year Adjusted Operating Income Guidance -- $2.175 billion to $2.25 billion, narrowed from the previous range of $2.15 billion to $2.25 billion.
• Full-Year Adjusted EPS Guidance -- $14.30 to $15.20, raised from the prior range of $14.10 to $15.20.
• Integrated Kidney Care (IKC) Operating Income Guidance -- at least $65 million for 2026, an increase of at least $25 million over previous expectations due to higher shared savings rates.
• Share Repurchases -- 600,000 shares in the third quarter for $111 million, with an additional 500,000 shares repurchased after the quarter ended.
• U.S. Dialysis Treatment Volume -- 1.2% growth versus the third quarter of 2025, supported by patient census increases and improved mortality rates.
• Revenue Per Treatment -- $415.25, increasing 1.1% versus the prior year due to standard rate increases, partially offset by a lower commercial payor mix.
• Patient Care Costs Per Treatment -- $280.22, up 2.4% from the prior year as higher medical supply and labor expenses were partially offset by lower phosphate binder costs.
• Free Cash Flow -- $276 million for the quarter, with full-year guidance maintained at $1 billion to $1.25 billion.
• Technology Investment -- over $1 billion invested over the past few years, with current technology spend growing at more than 20% year over year.
• Integrated Kidney Care Patients -- 80,800 patients in risk-based arrangements, representing approximately $6.4 billion in annualized medical spend.
• International Adjusted Operating Income -- $46 million, a $20 million increase year over year primarily driven by performance in Latin America.
• Leverage Ratio -- 3.38x consolidated EBITDA, remaining flat compared to the previous quarter.
• Total Outpatient Dialysis Centers -- 3,269 centers globally as of Sept. 30, 2026, including 2,671 in the United States and 598 across 14 other countries.
• Fluid Management Improvements -- 10% improvement in treatments achieving optimal fluid removal, contributing to a nearly 5-pound reduction in average patient weight.
• Pilot Adoption Rate -- over 90% adoption for expanded HD dialyzers among clinically eligible patients in 150 centers.
• Medicare Fee-for-Service Impact -- 1.5% to 2% estimated net impact for 2027 from the ESRD final rule, which includes the permanent incorporation of phosphate binders into the dialysis bundle.
• Debt Expense -- $150 million for the quarter, with 80% of floating rate debt protected by 3-year interest rate caps.

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RISKS

• Ackerman warned that "the fourth quarter will have an approximately 1% headwind to treatment volume due to year-over-year day mix," referring to the calendar effect on scheduled treatments.
• Rodriguez stated that current IT investments in U.S. dialysis are higher than forecasted, noting it "represents a drag on our full year financial performance."
• Rodriguez noted that the 3.5% headline rate increase in the ESRD final rule "will be subject to downward quarterly adjustments after Q1" as reimbursement for certain drugs is recalculated based on updated volume and pricing.
• Ackerman reported that "medical supply costs and professional liability expenses were higher than anticipated in the quarter," though management expects these to revert to typical levels over time.

SUMMARY

DaVita Inc. (NYSE:DVA) reported third quarter financial results that led management to narrow its full-year 2026 adjusted operating income and earnings guidance. The company reported that outperformance in its Integrated Kidney Care segment and international markets helped offset increased technology investments and higher patient care costs. Management stated that its clinical strategy is focused on middle molecule toxin clearance and fluid management, which have contributed to long-term mortality improvements. While the company faces headwinds from a shifting payor mix and the expiration of certain tax credits, it confirmed that its technology modernization efforts are delivering tangible clinical and financial benefits across revenue operations and labor productivity.

• Management announced the national rollout of expanded HD dialyzers will begin next week, targeting the vast majority of eligible patients by November.
• CEO Rodriguez stated that the company expects a positive impact from lower mortality and higher volume growth to begin in the second half of 2028, supporting a goal of 2% or greater volume growth by 2029.
• The company expanded its upstream care reach through a partnership with Humana, which will include approximately 10,000 chronic kidney disease patients.
• Management estimated that a 1% change in Medicare reimbursement rates impacts annual results by approximately $30 million.
• CFO Ackerman noted that while technology spend is currently growing at over 20%, the company expects this growth to decelerate in future periods.
• Rodriguez stated that limited competition in the industry resulted from the difficulty of treating a vulnerable population with a high government insurance mix rather than internal operational factors.
• The company maintained its interest rate hedging strategy, with 80% of its floating rate debt covered by caps in a rising interest rate environment.

INDUSTRY GLOSSARY

• CKCC: Comprehensive Kidney Care Contracting, a Medicare fee-for-service demonstration project focused on value-based care.
• ESRD: End-Stage Renal Disease, the final stage of chronic kidney disease where the kidneys no longer function sufficiently for daily life.
• HD Dialyzer: A hemodialysis dialyzer, often referred to as an artificial kidney, used to filter waste and excess fluid from the blood.
• IKC: Integrated Kidney Care, DaVita's business unit focused on managing the total health and costs for patients with kidney disease.
• LDO: Large Dialysis Organization, a term used by CMS to categorize major providers like DaVita and Fresenius.
• Middle Molecules: Larger toxins that are often difficult to remove with standard dialysis but can be targeted with expanded hemodialysis technology.
• Phosphate Binders: Medications used by dialysis patients to prevent the body from absorbing phosphorus from food.
• TDAPA: Transitional Drug Add-on Payment Adjustment, a CMS payment mechanism for new and innovative renal drugs.

Full Conference Call Transcript

Operator: Good evening. My name is Michelle, and I will be your conference facilitator today. At this time, I would like to welcome everyone to the DaVita Third Quarter 2026 Earnings Call. [Operator Instructions] Mr. Eliason, you may begin your conference, sir.

Nic Eliason: Thank you, and welcome to our third quarter conference call. We appreciate your continued interest in our company. I'm Nic Eliason, Group Vice President of Investor Relations. And joining me today are Javier Rodriguez, our CEO; and Joel Ackerman, our CFO. Please note that during this call, we may make forward-looking statements within the meaning of the federal securities laws. All of these statements are subject to known and unknown risks and uncertainties that could cause the actual results to differ materially from those described in the forward-looking statements.

For further details concerning these risks and uncertainties, please refer to our third quarter earnings press release and our SEC filings, including our most recent annual report on Form 10-K, all subsequent quarterly reports on Form 10-Q and other subsequent filings that we make with the SEC. Our forward-looking statements are based on information currently available to us, and we do not intend and undertake no duty to update these statements, except as may be required by law. Additionally, we'd like to remind you that during this call, we will discuss some non-GAAP financial measures.

A reconciliation of these non-GAAP measures to the most comparable GAAP financial measures is included in our earnings press release furnished to the SEC and available on our website. I will now turn the call over to Javier Rodriguez.

Javier Rodriguez: Thank you, Nic. Good afternoon, everyone, and thank you for joining the call today. Once again, our teammates have delivered excellent care for our patients and solid results for our shareholders. We're seeing meaningful progress across our clinical strategy with investments in innovation translating into better patient outcomes and stronger business performance. Our maturing Integrated Kidney Care business is a prime example, as it continues to deliver clinical performance for our patients while starting to demonstrate its economic potential. In the same spirit, our rollout of expanded HD dialyzer marks an exciting new chapter in how we're advancing kidney care.

Today, I'll share more on these priorities, review our third quarter financial performance, provide our outlook for the remaining of the year and briefly discuss policy. But first, as always, let's begin with our clinical highlight. Today, I will highlight our advancements in fluid management. We're often asked about the clinical drivers behind our recent mortality improvements and fluid overload is one of those critical areas we target. Because kidney failure impairs the body's ability to shed fluid, managing fluid intake between treatment and safely removing excess fluid during dialysis requires constant vigilance for both patients and care teams.

Left unmanaged, excess fluid places strain on the cardiovascular and pulmonary systems, contributing to high blood pressure, heart failure and respiratory difficulties. By developing specialized clinical protocols, combined with dedicated teammate education and proprietary digital tools, we've uniquely empowered our care teams to manage fluid more precisely. Through these integrated efforts, we've seen a 10% improvement in treatments achieving optimal fluid removal, a 5% improvement in how patients manage weight gain between treatments and nearly 5-pound reduction in the average patient's weight. These advancements are critical drivers supporting our continued mortality improvement and enhancing our patients' daily quality of life.

While we're on the topic of clinical, I will transition now to an update on our efforts to deliver enhanced care for our patients through clearance of middle molecules. Last quarter, we highlighted recent clinical evidence for expanded HD dialyzers, including the potential for greater than 20% mortality improvement, along with our plans to deploy this technology broadly across our network. We have completed pilots in 150 centers for more than 10,000 patients to ensure a smooth and successful deployment at scale. Based on this experience, here's what we've learned. First, the feedback from patients and physicians was overwhelmingly positive. As background, approximately 75% of total patient census is clinically eligible for expanded HD.

This eligible pool excludes patients receiving dialysis at home or in acute care setting, pediatric patients and patients with acute kidney injury. Adoption amongst those clinically eligible patients in the pilot was greater than 90%, exceeding our expectations. And within that cohort, patients tell us they feel better after treatment and have more energy compared to their prior therapy. One goal with expanded HD is to enhance patients' quality of life, and it is exciting to hear early feedback to support this effort. Similarly, our physician partners have been overwhelmingly supportive. The buy-in from the medical community is critical to successful innovation, and nephrologists have responded to the clinical evidence and are actively engaged to transform the standard of care.

We deeply appreciate the collaboration of our physician partners in our continued efforts to innovate. Second, we are operationally ready. Our teammates, systems, supply chain are well prepared to successfully manage this transition. Over 95% of clinical teammates nationally are now trained on expanded HD to ensure a seamless continuity of care for our patients. As a reminder, the new expanded HD dialyzers are compatible with our existing dialysis machines. As a result, we will begin our national rollout next week and expect a swift network-wide transition, bringing expanded HD to the vast majority of eligible patients in November. Finally, from the financial perspective, we do not expect any material net impact on adjusted operating income for 2026 or 2027.

We anticipate the positive impact of lower mortality and higher volume growth to begin in the back half of 2028 and grow over time. Most importantly, this innovation means more patients living longer, representing a key milestone in our path back to 2% or greater volume growth by 2029. Transitioning to financial performance. Third quarter adjusted operating income was $561 million and adjusted earnings per share was $3.82. Joel will provide details on the moving pieces underlying those Q3 results. Taking a step back from the quarterly numbers to look at the full year, I want to highlight 2 trends shaping 2026 and our future performance. Starting with technology.

Over the past few years, we've invested more than $1 billion to modernize our technology platform and strengthen our capabilities across our business. These investments are delivering tangible clinical and financial benefits, contributing to improvements in mortality, revenue operations, labor productivity, IKC care management and pharmacy costs. I'm calling this out to highlight that our IT investments in U.S. dialysis is higher than we forecasted heading into the year. So it represents a drag on our full year financial performance. Going forward, we expect that growth in technology investments will decelerate. The second highlight is our results on Integrated Kidney Care, or IKC.

We are above plan in the third quarter, and we're on track to outperform our original IKC guidance for the year. We made meaningful progress delivering on the patient impact we began talking about in 2021, both upstream in chronic kidney disease and for our existing ESKD dialysis patients. Let me provide some color on the 2 operating levers, which contribute to IKC's financial performance. First is the medical spend under management. As we have noted in the past quarters, we have been disciplined as we seek opportunities to grow this business. We're making progress heading into the next year, including our recent announcement of Humana partnership, which will expand upstream care to approximately 10,000 chronic kidney disease patients.

Second is our savings rate, which reflects our ability to lower the total cost of care and has steadily improved year-over-year. This is particularly encouraging because it reflects continued gains in clinical performance as our care model matures. Our investment in technology are improving the ability of our care teams to identify where and when to intervene to help our patients be healthier. Our clinical interventions are driving reductions in avoidable hospital admissions and readmissions while achieving higher rates of planned optimal dialysis transitions. These results improve patient outcomes while generating substantial shared savings for CMS and our Medicare Advantage health plan partners. This gives us growing confidence in 2026 and the long-term economic of the IKC business.

We now expect IKC to deliver at least $65 million of adjusted operating income in 2026, an increase of at least $25 million over the prior guidance. This all leads to an update on our financial outlook for the remaining of the year. With one quarter remaining in the year, we are now narrowing our full year 2026 guidance ranges. We now expect adjusted operating income within a range of $2.175 billion to $2.25 billion and adjusted earnings per share within a range of $14.30 to $15.20. This reflects the increased guidance for IKC, offset by higher U.S. dialysis costs, particularly higher technology investments, as I previously noted.

Before I turn it over to Joel, I want to briefly comment on 2 recent policy updates. First, yesterday, CMS released the ESRD final rule. This confirms the permanent incorporation of phosphate binders into the dialysis bundle, which is a great outcome for patients and has been a successful cost saver for the government. Within the overall rate adjustment, there are more moving pieces than in prior years. The headline rate increase for large dialysis organizations is 3.5%, which is up 1.5% from the proposed rule. Unlike prior years, this will be subject to downward quarterly adjustments after Q1. And second, a few thoughts on the Kidney Care National Plan released by HHS last week.

We share the administration's goals around the earlier intervention, slowing disease progression, improving the transplant process, expanding patient choice and improving outcomes. We also appreciate the opportunity to work with the government to create a framework to encourage further competition within this complex ecosystem. Many elements of the plan will require policy development and potentially congressional action before translating into specific actions, and we look forward to working with HHS and the relevant agencies as that work progresses. I will now turn the call over to Joel to discuss our financial performance in more detail.

Joel Ackerman: Thank you, Javier. For the third quarter, adjusted operating income was $561 million. Adjusted earnings per share was $3.82, and free cash flow was $276 million. Today, I'll provide further details on the quarter's results and some thoughts on Q4 and full year guidance. Starting with U.S. dialysis. Adjusted operating income was in line with our expectations. I'll walk you through the trilogy, starting with volume. Overall treatment volume grew 1.2% over the third quarter of 2025 and treatments per normalized day increased approximately 65 basis points year-over-year. Patient census increases drove the year-over-year growth, primarily as a result of improving mortality. The census gain was offset in the quarter by an uptick in missed treatments.

As a reminder, the fourth quarter will have an approximately 1% headwind to treatment volume due to year-over-year day mix. Revenue per treatment was up approximately 1.1% versus the third quarter of last year and roughly flat sequentially. The year-over-year growth is the result of normal rate increases, offset by lower commercial mix and lower phosphate binder reimbursement as expected. Through 3 quarters of the year, the impact on our exchange census from the expiration of enhanced premium tax credits continues to play out as expected. Patient care cost per treatment were up 2.4% in Q3 compared to last year. Phosphate binder costs declined year-over-year as expected and partially offset the typical growth in labor expenses.

Medical supply costs and professional liability expenses were higher than anticipated in the quarter. We expect these costs to revert to typical levels over time. U.S. dialysis G&A costs were up less than 2% versus Q3 last year, excluding non-GAAP adjusted cyber expenses in 2025. Technology spend continued to grow at more than 20% year-over-year in the quarter, but the non-tech component of G&A was lower in the quarter compared to last year as a result of our ongoing cost control efforts and expense timing. Turning now to IKC. As Javier noted, the business is performing ahead of our expectations.

The outperformance this year is largely driven by a higher shared savings rate in our CKCC business, which is the Medicare fee-for-service demonstration project as well as the value-based care contracts we have with Medicare Advantage insurers. This is partially offset by higher operating expenses due to higher physician payouts from our shared savings and the launch of a new CKD program with Humana. We now expect this year's IKC adjusted operating income to be at least $65 million, representing a $45 million improvement over last year and a $25 million improvement over our prior guidance. Turning to international. Third quarter adjusted operating income was $46 million, a $20 million increase year-over-year.

This performance is largely the result of growth and improved performance in our Latin America businesses. These results exclude a charge related to our operations in China, which is not included in our adjusted operating income. The full year continues to track in line with our expectations for approximately $135 million of international adjusted operating income. Transitioning to capital allocation. We repurchased approximately 600,000 shares in Q3, and we've repurchased an additional 500,000 shares since the end of the quarter, including shares from Berkshire Hathaway. As a reminder, we repurchase shares from Berkshire each quarter as needed to bring their ownership back to 45% pursuant to our repurchase agreement.

We finished September with a leverage ratio of 3.38x consolidated EBITDA, about flat to last quarter. Debt expense in the quarter was $150 million. In light of rising interest rates, I will remind you that we maintain 3-year interest rate caps on approximately 80% of our floating rate debt. For full year 2026, as Javier noted, we are narrowing our guidance ranges for adjusted operating income and adjusted earnings per share. Our new range for adjusted OI is $2.175 billion to $2.25 billion, and our new range for EPS is $14.30 to $15.20. We still anticipate full year free cash flow between $1 billion and $1.25 billion. That concludes my prepared remarks for today.

Operator, please open the call for Q&A.

Operator: [Operator Instructions] Our first caller is A.J. Rice with UBS.

Albert Rice: I appreciate the comments on the ESRD rule that got finalized over the last 24 hours. I know the industry had sort of felt like the rate in the original proposal for phosphate binders seemed adequate, but the underlying rate for the treatments ex that was challenging. With the adjustments made, is there an ability to comment? One of the tricky things is how -- I know you guys had said the phosphate binder reimbursement would drop because ASPs were dropping in the relevant drugs. Can you just comment on whether the drop in what they've included was consistent with what you're thinking? And how adequate is the move up in the rest of the rate?

Joel Ackerman: Yes, A.J., thanks for the question. So as you noted, it's been 24 hours, and we're still unpacking the calculations. I'll start with the big picture, which is our estimate right now, and I'll emphasize that it's an estimate, is that the net impact for us for the full year '27 will be 1.5% to 2%. Just as a reminder, a 1% change in Medicare for us is worth about $30 million a year. This is an improvement over the prior rule by somewhere north of 50 bps. And the important thing to realize is the rule works differently now than it has in the past because of the change in the way that the TDAPA add-on payments are handled.

They're now recalculated every quarter rather than recalculated once a year. So the published number is really only the number for Q1, and you really have to break it into 2 components. There's everything other than the TDAPA component, which is fixed for the year. And if you look at what that is for the LDOs, it's 40 basis points, and that will be constant for the year. And then the TDAPA component, which for the LDOs is 3.1%, that only stands for the first quarter. And we expect that number to come down significantly in Q2 and stay down and potentially further decline over the course of the year.

So we've got that 40 basis points locked in, that 3.5% will come down significantly. And the net impact over the course of the year, we think, is 1.5% to 2% stronger in Q1, a little bit weaker over the rest of the year.

Albert Rice: Okay. Okay. And maybe my follow-up, interested about your comments on the IKC. It sounds like -- it sounds like you feel it's solidly profitable now. You can start to growing. Obviously, you've got the Humana transaction. It seems like to me there's probably a fair amount of business up for grabs if you wanted to lean into growth in that area. Can you maybe think -- talk about now that you feel like you're at a consistent level of profitability, how much you might think about adding to that business?

Javier Rodriguez: Sure. Let me take that one, A.J. It's Javier. We are in agreement with you. Our confidence in our capabilities in both in the clinical and actuarial has now reached a point that we want to pursue more business. But as we've emphasized, what you want is healthy contracts, you want your physician partners to be heavily involved. Our model of care is now scalable and you need integrated tech, which we now have. So we've got a lot of the pieces to the tool. And now it's about getting contracts and physicians that are aligned to make sure that we deliver on the care that both avoids hospitalizations and readmissions and brings down the cost.

Operator: Our next caller is Andrew Mok with Barclays.

Andrew Mok: Leaving the full year treatment guide alone implies treatments per normalized day would be up more than 1% in Q4 and an acceleration from the first 3 quarters. Is that the right way to think about the progression? And are you comfortable with that given the uptick in missed treatments you called out?

Joel Ackerman: Yes. So Andrew, first, your math is about right. It would involve an uptick in treatments per normalized day in Q4. I would expect that to come from 2 things. One is missed treatment rate reverting to a normal year-over-year pattern. What we saw in Q3 was missed treatment rates about 20 basis points higher than expected and higher than last year. And what we're assuming for Q4 is that it reverts to a normal pattern. We're assuming it will be consistent with Q4 of last year. So that's one thing. The second component driving it would be census.

Census growth was a little bit stronger in Q3 than we anticipated and that census growth over the course of the quarter drives higher treatment growth per normalized day in Q4 rather than Q3. So those 2 things together would drive the uptick in Q4.

Andrew Mok: Great. And can you update us on the ACA exchange headwind in the quarter and comment on where commercial mix is tracking relative to the about 10.7% I think you were expecting in the back half?

Joel Ackerman: Yes. Mix is down a little bit relative to the first half of the year, very much in line with our expectations. And we think we're on track for that $40 million year-over-year headwind for '26.

Andrew Mok: Great. And finally, if I could squeeze one more in. Wanted to follow up on your comments around HHS' Kidney Care Plan released last week. What were your initial impressions? And which elements of the plan do you think could translate into policy?

Javier Rodriguez: Yes. Thanks, Andrew. As we said in our opening comments, we have a lot of things that we like about the plan, and we are aligned totally, and we share the goals of the administration of fostering innovation, investing in early detection and prevention and increasing access to transplant. When the plan came out, I immediately reached out to the administration and told them we want to be right there at the table and want to be part of the solution. And on each one of those, of course, you can go into the subcomponents. As for the part that was a bit frustrating, it's how dialysis was portrayed in the rule.

The fact is, we offer world-class service, and we are great economic value. And this is confirmed as I travel the world and other countries really want our expertise to enter their countries. That said, there were some positive things around what they said within dialysis, which is - they want to solve for innovation in the bundle, which we, of course, want as well, and they want to reduce regulatory burden, which we would welcome. The part that's a little, let's say, not fleshed out enough and we need to solve for is the economic ecosystem. 90% of patients are covered by the government insurance with roughly 1% Medicare increase for the past decade.

And so there's an assumption in there that the cross subsidy by the private insurance in the 1 in 10 is accepted by the model. And so one of the main things that they want to do is attract new capital. And in order to attract new capital, we have to solve for this dynamic and one of the things that the government will have to pay more.

If I was going to continue a little -- while I got a little momentum because you hopefully can feel my passion on it, is that there's an underappreciation for the benefit of scale and expertise, that as I look at our body of work over the last couple of decades, we have developed and adhered to world-class protocols and best demonstrated practices. We have a dramatic reduction in mortality of roughly 25% if you measure it from the year 2000. When there's an emergency or a disaster response, we are there. When you look at sophisticated tech, we have it.

When you look at access to rural communities, 92% of patients in rural communities are within 10 miles of our centers. And by the way, you need a counterweight to big pharma and big insurance or else costs would go up a whole bunch. So in summary, I really took a little to heart that we are part of the solution, not the problem. We welcome more competition. But I want to be clear, the limited competition is not due to how we operate, but rather how hard it is to take care of this vulnerable population with high needs at 90% government mix.

And so you hopefully see the one part that got me going, but the rest of the plan, I'm totally behind.

Operator: [Operator Instructions] Our next caller is Pito Chickering with Deutsche Bank.

Pito Chickering: As we think about 2027, can you give us the known puts and takes as we think about modeling next year, including the treatment growth you're seeing with the acceleration of the census in the third quarter? And thoughts about revenue per treatment next year with what you learned about HICS, then the tailwinds from lower IT investments and any additional IKC tailwinds we should think about as you guys scale up?

Joel Ackerman: Sure. I'll take that one, Pito. It's early to give full guidance on 2027. That said, there's certainly a few things that we can help with. On the volume side, I would say we expect volume growth in 2027 to be higher than volume growth in 2026. On RPT, we expect a headwind from commercial mix, with ACA being the big component of that. And then on the cost side, I'd really call out pharmaceutical costs, which we think will come down in 2027, binders being the biggest component of that, but not the only component of it. You mentioned IT spend. IT spend will not come down next year. Our expectation is it will decelerate.

So the 20-plus percent growth that we've been absorbing for the last 3 or 4 years, we think we can get down from that, but I would expect it will continue to grow. So I'd say that's the known stuff for next year.

Pito Chickering: Okay. Great. And then on the HD dialyzer, I think you said that all the centers will be doing it by November, and expected to see sort of tailwinds mortality in the back half of '28. But I'm curious for the 10,000 patients that you've been treating, sort of, so far, have you seen any indication of lower missed treatments that could impact the near-term treatments? And how does this impact people on home hemo? Do they sort of come back in the center if people are having better results?

Javier Rodriguez: Thank you. And hopefully, you hear the excitement in our tone and our physicians and our patients and our caregivers. This is one of the most excitement I've ever seen in the community. And the short answer to your question is it's too soon to tell. This takes a while, as you can see from the studies in mortality, that it takes a while to have the impact on the inflammatory side. As it relates to people switching modalities, I doubt that, that will be the case. People make modalities on a lot of other matters. And if you look at PD as a modality, it already is quite good at clearing middle molecules as an example.

And so I think it will be just one other thing to consider, but I doubt that there will be shifts in modality selection.

Pito Chickering: Great. And the last question because I'm getting asked this a lot. I mean, again, it's back to 2027, I know that it's way too soon for, sort of, guidance here. But is there any commentary around just do you think that your standard growth rates for -- that you've been having the last few years in the business can continue next year with the headwinds, tailwinds plus the HICS on top of that? Is that the way you're thinking about it?

Joel Ackerman: I think you're right, Pito. It is too early to answer that question. Look, as we've said, we think we get a better volume tailwind next year than we've had this year. On U.S. dialysis margins, I think we called out the headwinds, tailwinds. A headwind on RPT, a tailwind on cost, how those shake out, we'll know more in February. And then I don't think we've really got much to say on either international or IKC yet.

Operator: Our next caller is Kevin Fischbeck with Bank of America.

Kevin Fischbeck: Can you talk a little bit about the benefit to volumes that you saw from Fresenius closing sites? I wasn't sure if there was supposed to be any kind of improvement in Q3 versus Q2 from that kind of normalizing. What did you see there?

Joel Ackerman: Yes. No, Kevin, that played out pretty much in Q1. So no change from Q2 to Q3 from that dynamic.

Kevin Fischbeck: Okay. And how do we think about the profitability? I know it's a 2028 and beyond issue, but of the improvement in mortality from the new dialyzer, I think there's some question about it's just kind of extending the life on dialysis and that's more of a Medicare as a percentage of revenue. Would that be as profitable? Should we be thinking about it as if it added 1% to treatment or that it add 1% to revenue and 1% to OI? Or is the growth algorithm different than that from improved mortality?

Joel Ackerman: Yes. So we're still waiting for better data on this. The natural thing would be to think that just the older patients or patients are adding on a year or 2 when you go from an average of 5 or 6 years to 6 or 7, and those are all Medicare patients. The early results are that is not the pure dynamic, that there are younger patients earlier in their journey whose lives are being extended. So it's not purely an addition of Medicare treatments. How that shakes out, whether it's the same mix of 10% or 11% commercial as we see overall or not, too early to tell.

But I don't think we're ready to conclude it's 100% additional Medicare treatments as a result of this improved mortality.

Kevin Fischbeck: Okay. And then last question here. Going back to that release from CMS a week or so ago, I can see like one of the things that they focused on was the AKF exposure. Can you just remind us where that is for you, how you're benefiting from that relationship?

Javier Rodriguez: Sure. Charitable premium assistance, for those of you that have not been keeping up, was discussed very heavily if you go back maybe 8 or so years. So we haven't discussed it for a while, so it's probably worth refreshing the topic. So it's basically a system that's been in place for many decades that enables patients, many who can no longer work full time due to kidney failure to maintain continuity of health coverage. One of the things that's not known is that the vast majority of patients receiving CPA use the grants to support government and supplemental coverage. And so that's probably not known. It's assumed that most of them use it for commercial.

But the significant majority of commercial patients actually don't use CPA. And for those that use it, most of them use it to retain coverage that they had before their kidney failure. So while there are many reasons to keep your private insurance, the most common is to retain it for family coverage and because there is a 3x more likely odds of getting a transplant if you have commercial insurance. So I think we can all agree that those are worthy reasons to keep your insurance. Again, just as a contextual thing, the grants are administered by the American Kidney Fund, otherwise referred to as AKF.

And they have been under some major heavy examination through investigations, inspections, rule-making and legislative scrutiny. And all have concluded that the grants benefit a vulnerable population and that the program follows the rules. And so now it's been sort of pointed out in the plan as something to look at. We, of course, welcome and we will transparently go through the process again. But one of the things that is interesting about the dynamic is that the irony that if that program is somehow or other diluted, it would actually make more patients be paid by the government. So that 1 in 10 commercial would go down.

And the other thing that would happen is that it would attract less capital. And so ironically, this would be contra their intent to bring more competition to the marketplace. That said, I think your question was around sizing it. And what I would just say is that in looking at it, and we disclosed the numbers roughly 8 years ago, the numbers have stayed completely flat. So that range still applies today.

Operator: Our next caller comes from Ryan Langston with TD Cowen.

Ryan Langston: On clinic capacity utilization, I think that's been kind of steady for a few years, but still kind of well below pre-COVID levels. So some of the initiatives you're working on like technology, RPT and rolling out HD kind of work themselves through. At some point, does pressing on this lever become more of a higher priority? And what types of things can you do to maybe increase that utilization?

Joel Ackerman: Yes. So look, we would absolutely like to get capacity utilization up. The best way to do it is to grow our census count. And that, we are doing that, as I mentioned before, our census count is up about 1%, a little bit more than 1% year-over-year, and we plan on continuing that. We do not have any plans right now to close clinics. That would be the other thing to do. So we'd like to get it up with more volume.

Ryan Langston: Got it. And then depreciation expense has been trending down sequentially for a few quarters here. Is this sort of a good run rate for us to kind of jump off of? Or might we expect that to come down a little bit in the fourth quarter?

Joel Ackerman: I think we're -- it's been coming down for many years now. I think we're getting to the point where we're probably not going to see a lot of continued decline. So I think we're in a reasonable spot where we are now.

Javier Rodriguez: Michelle, can we go to the next question?

Operator: Yes. Justin Lake with Wolfe Research.

Javier Rodriguez: Justin, we can't hear you.

William Westerfield: This is William Westerfield asking for Justin Lake. We just want to circle back to the final ESRD rates that came out last night and LDOs were up 3.5% with much of that coming from phosphate binders and DefenCath moving into the bundle. Could you just go through for us how you view that 3.1% increase in TDAPA payments across those 2 drugs? Like more specifically, how does the $12-plus binder number compared to your current binder rev per treatment for Medicare patients? And then for DefenCath, can you talk about how you will think about that reimbursement develop across 2027 and when you provide guidance for next year?

Joel Ackerman: Yes, Will, thanks for the question. So I treat the 2 very differently. Binders, very much in line with our expectation, not much growth -- not much of that 3.1% growth, we think, is from binders. We don't have full visibility on the baseline for 2026, but because it incorporates us as well as others. But we don't think that's really the big story in the 3.1% growth. We think it's largely about DefenCath. And the important thing to realize on that is because it's a post-TDAPA add-on payment, it will get recalculated every quarter based on updated volume and updated ASP.

And our current expectation is that number will drop significantly from Q1 to Q2 and stay low or continue to decline through the back half of 2027.

William Westerfield: Okay. And then on top of that, is there something that you're tracking to understand the utilization and how it might develop across the industry here in the second half and '27 that could help investors get ahead of the potential changes in quarterly reimbursement for '27? For instance, can we track script trends?

Joel Ackerman: I think the short answer is no. We don't have a lot of visibility into what's happening with the industry on that through the back half of 2026.

Operator: Thank you. And at this time, I'm showing no further questions. Speakers, I'll turn the call back over to you for any closing remarks.

Javier Rodriguez: Okay. Thank you, Michelle, and thank you all for joining the call. To wrap up, let me give some perspectives on our year so far. First, our business is resilient in the face of pressure both from RPT due to ACA declines and from treatment volumes growing below our historical norm. Second is investment in innovation. We have heavily invested to modernize our technology infrastructure, and we're also in a full swing on the rollout of new dialyzers that promise to deliver step change in care with longer and higher quality of life for our patients.

Putting all this together, we're delivering on our financial commitments with adjusted OI growth in the top half of our long-term guidance, and we're working hard to finish the year strongly. It's unusual to say at this time of year, but we won't talk until a little while. Have a great holiday season, and we'll speak soon. Be well.

Operator: Thank you. This concludes today's conference call. You may go ahead and disconnect at this time, and please have a good rest of your day. Thank you.

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