Ladies and gentlemen, thank you for standing by. I'm Haley, your Chorus Call operator. Welcome, and thank you for joining the Fresenius Medical Care earnings call on the fourth quarter and full year 2018 results. Throughout today's recorded presentation, all participants will be in a listen-only mode. The presentation will be followed by a question and answer session. If you would like to ask a question, you may press star followed by one on your touch-tone telephone. Please press the star key followed by zero for operator assistance. I would now like to turn the conference over to Dominik, Head of Investor Relations. Please go ahead, sir.
Thank you, Haley. We would like to welcome all of you to the Fresenius Medical Care earnings call for the fourth quarter and the full year. We appreciate you joining today. As always, I'm happy to start out the call by mentioning our cautionary language that is in our safe harbor statement, as well as in our presentation and in all the materials that we have distributed earlier today. For further details concerning risks and uncertainties, please refer to these documents as well as to our SEC filing. I know that it has been numerous planned news and many press releases on very different topics today. Plus, the news very early this morning about NxStage. Thank you for hanging in with us. Nevertheless, we have a little logistic time constraint today, and we will have to end the call at 4:30 P.M. sharp.
Therefore, it would be great if we could limit the number of questions again to two in order to give everyone the chance to ask questions. If there are further questions and we have time left, we are happy to go a second round. I hope this works for everyone. With us today is, of course, Rice Powell, our CEO and Chairman of the Management Board. Rice will give you some more color around the strategy and business development, go through some of the major topics of the quarter. Of course, also with us is Michael Brosnan, our Chief Financial Officer, who will give you an update on the financials and the outlook. I will now hand over to Rice. The floor is yours.
Thank you, Dominik, and a warm welcome from my side as well. Before we get into the specifics on 2018's performance, and we talk about 2019 and 2020 and guidance, it's been a while since we talked a little bit about our strategic value and the things that we bring to the marketplace strategically. So if you'll bear with me, I'll try to do this quickly, but I think it's been a while since we've discussed it and I'd like to cover it. We are going to continue to move away from selling single products and continue to move towards selling comprehensive, innovative solutions that help practitioners and patients and caregivers provide the best care possible.
Given our experience and the depth and the breadth of our 4,000 dialysis clinics around the world, I remain completely convinced that we are positioned to deliver the highest quality patient care and patient outcomes anywhere in the world. We're also creating an opportunity for us to be able to capture growth in the developing economies. It's something that we've talked about quite a bit. "Rice, you're too heavily invested in the U.S. You need to do more." We are doing more. We're now in 150 countries, as you know, with products, 50 countries providing service. There's a certain amount of risk that goes with those developing markets, but we think we can handle that risk, and it's the right move in order to continue to grow the entire portfolio and not be so dependent on one particular region or country.
I remain convinced that our care coordination assets and the opportunity it gives us to manage risk, predictively predict where patients are going to go. I'm not sure that's the right phrase, predictively predict, but I'll stick with it. It also gives us a way to drive value-based care, particularly in the U.S., which is something that is not going to go away. In fact, it's going to become a bigger part of the dialysis industry in the years to come. Now, looking at our home strategy, a couple of things I thought are very U.S.-specific would be of interest to you. If you look at the split of the total treatments in 2018, you see that 88% were in-center and 12% were home. That book, if you will, grew 4%.
Now focusing on the home treatments for 2018, we see that PD is 78% of those treatments, and it grew 8%. Home hemodialysis is 22% of that book, and yet it grew 14%. Combine those two, and you see a 9% growth in 2018. I think you understand why we're so excited about NxStage, our capabilities, and their capabilities combined. We continue to target 15% of our total treatments being in the home setting by 2022, and I'm optimistic that we can see better than 15% as we move through the next couple of years. In order to make this happen, we do have to make some investments. What is it that we're going to invest into if we're going to expand our home treatments? Patients and physicians and nurses need to be educated. We have home training clinics. We may need to refurbish some.
We may need to build some new ones. For every home treatment that we want to provide, we have to get the product there. The distribution infrastructure in the U.S. specifically has got to be maintained. It's got to expand, and we have to look at the most novel and creative ways to not drop product off at the corner and expect people to pick it up, but to take it into their homes and make it as safe and easy for them to use the product, store it in the right location, rotate the inventory. This is more than just a delivery per se.
Obviously, we need equipment, bags, solutions, tubings, et cetera, as we look at what we have to put in the home for these patients. We also believe that if we can do a better job of increasing early awareness to chronic kidney disease, we have more lead time to train patients, make sure they understand their options of in-center or home, and take advantage of trying to put these patients in the venue that they desire and that they're capable of functioning and thriving in. Moving to slide five, again, to talk a little bit about developing economies. I think China's a great example. Just for you to take a look. You can see healthcare expenditure and percent of GDP, and look at the size of the diabetic population.
We believe being an early mover is going to be key in China as well as some of the other developing markets. We're leveraging 15 years of experience in China in the product business. Very competitive, yes. But competition doesn't mean you're not learning things and learning how to get better. We're investing in our manufacturing capacities there, both for the home business and PD, as well as some of the HD things that we'll need as our clinic book of business grows. We'll continue to look at the opportunities, particularly in Asia, because it's the one place where we see care coordination opportunities in Australia. You'll see later in the presentation, that's working quite well.
Moving to slide six or slide seven, you can see as we normally have laid this out for you see clinic growth at 5%, patients at 4%, and treatments at 4%. I'm very proud. I'd like to say thank you to our employees at Fresenius Kidney Care, because we were able to maintain our five-diamond star status at 99.96% of our in-center and home hemodialysis programs. For those of you that know me, I would just simply round that up to 100%. I'm very proud of the work these people are doing. This is the U.S.-focused activity. I can assure you that if you look at our clinic activities in the other regions, they do very well. They just have not set up a program like this yet. Looking at slide eight at our quality outcomes.
I think the thing I'll point out today is if you drop down and look at days in the hospital per patient year, we're seeing progress in North America, 10.7 down to 10.2. EMEA, as well as Asia-Pacific. I'd say flat to slightly up in Latin America. Continuing to try to get our patients out of the hospital or keep them out of the hospital as best we can. Turning to slide nine for the full-year update. Q4 was a solid performance for us. We did achieve, and I'd say beat in some cases, our revised full-year guidance. That's a bitter pill because it's not the guidance that we wanted. The fact that we had to revise it and yet we were able to achieve it and exceed it a little bit, we take some comfort in that.
As we will talk about later in the presentation, our GEP II activities are ahead of schedule. You have seen that we are proposing a 10% dividend increase. I will talk a little more about that later. Obviously, the big news that came across my phone at 2:00 A.M. this morning, German time, was that we will be closing the NxStage book of business. We will close this transaction sometime in the next couple of days. We found out last night that it has been approved, so we have a little work to do. We will get that closed, and we will be communicating with you after that has taken place. If we can turn to slide 10, looking at the revised full-year guidance.
Quickly, I will just ask you to look at the reddish boxes on the right side of the page where you can see revenue on a comparable basis, growth in constant currency at 4%, a slight beat to the guidance we gave you, and the same for net income. You have had these figures for a while, so I will not read them to you, but we are pleased with that performance. Looking at the fourth quarter specifically, again, we see strong results there. The revenue, obviously in North America, was impacted by Sound and IFRS 15 implementation. We had some other income impacts that we have listed for you throughout the year with the divestiture of the ballot, FCPA. All in all, we think it is a good story, and we are pleased that we are able to deliver results slightly ahead of the revised guidance. Coming to slide 12.
I think the key thing here is, would you just take a moment and look at the trend lines. This was the first time that we had given you this slide back last quarter, and I am very pleased when you look at where we are, and I am not going to go through each of these, but the lines are going in the right direction. Everybody is making progress. Things look better. I would highlight for you the same-market treatment growth for the group at 3.2% in North America at 3%. Looking at slide 13 on the organic growth. Everybody contributed to this. They are the ins and outs in North America. I am not going to go through those again, but I am particularly pleased with what we saw in Asia-Pacific and Latin America in terms of their organic growth. Every region is contributing.
If we look at Q4 services on slide 14, I will direct my comments to the last two columns on the right. We have talked about North America and the special impacts there. EMEA, the growth was driven by same-market treatment growth and acquisitions, along with some organic growth. Asia-Pacific did very well. I would also point out, if you look at the care coordination in the quarter in Asia-Pacific, you can see where they are progressing as well. Turning to products, which I think was a concern for a number of people in the last quarter's call. Q4 products did very well. We are very pleased with what you have seen here. You can see on the dialysis product side, growth at 6% constant currency, organic growth at 7%.
I won't read these to you, but you can see every region did well, particularly North America, Asia-Pacific were doing quite strong. On the right, you can see the various product lines that they're in. In the sake of time and getting to your questions, I'm not going to walk you through each of those. They're there for your review. Turning to slide 16. Again, we will be proposing at the AGM on May 16th a 10% increase in our dividend, taking us from EUR 1.06 to EUR 1.17. I'm proud to say this is the 22nd consecutive dividend increase that we've proposed. The share buyback. We've made it clear to you we're looking to buy up to EUR 1 billion of shares. We'll do that over the next two years.
For those of you that had the opportunity to meet with Mike and I and Dominik back in September, I think I would just say to you, we were listening, we do continue to listen. What will we focus on in 2019? Looking at slide 17, we will continue to focus on resolving some of the identified operational issues that we talked about last quarter. We are going to invest around EUR 100 million in 2019 for cost optimization. I won't go into the details there. I'm sure you'll have questions, we'll be delighted to answer those for you in the Q&A. The key point here is this will be accretive to net income in 2020, obviously, you've seen that in our 2020 guidance that we've given you. We're doing a good job in GEP II. We can talk about that a little later.
Obviously, one of the largest things we'll be dealing with is the closure of NxStage and integrating them into Fresenius Medical Care. That's the conclusion of my prepared remarks. I hope you could understand me. It's February, yes, I have a cold from being on an airplane incessantly over the first two months of the year. Hopefully, you could understand me. With that, I'll turn it over to Mike.
Thanks, Rice. Hi, everybody. I'll keep things also moving, given our time constraint. I'm on chart 19, just a quick look at the full year of 2018. You see that the adjustments we've been making to get to comparable revenue all year long, I won't belabor that. In the blue section, it indicates what we believe we've achieved operationally, which is 4% constant currency growth, which exceeded our revised guidance from the fourth quarter. Turning to the next page 20. You see the two views of net income, which also I think you're all very familiar with the adjustments we've made, both to get to a comparable basis for earnings and then an adjusted or what I call the operational effects. We did land 2018 with 14% constant currency growth in comparable earnings and 4% constant currency growth on a fully adjusted operational basis.
Both of which exceeded the guidance that we provided in the fourth quarter. Taking a very quick look at Q4, you see the comparable figures adjusted in the same consistent way, 7% constant currency top-line growth on page 21. On page 22, you see 9% net income growth on a comparable basis and 4% on an adjusted basis with all the adjustments which we can review again if necessary as we go through the Q&A. Taking the time on the regional margin profile, I would just remind everybody that these numbers are on an as-reported basis. This is literally as you look at the face of the P&L and what you see in the statistical tables that we produce with the earnings release. For North America, you can see that income was down EUR 116 million to EUR 492 million on a constant currency basis.
The margin was 16.5%. The operating income includes lower compensation expense, margin benefit due to the adoption of IFRS 15, some non-recurring gains from fixed asset and investment sales in 2017, and additional impacts related to the gains from the divestitures of care coordination activities as we progress through the year. We also, in the fourth quarter, had about a EUR 12 million cost associated with the ballot initiative. On the dialysis business, the operating margins were at 18.5%. These margins declined as well due to the sales of some investments, a discontinuation of a non-IFRS accounting policy, increased accruals for potential settlements related to the GranuFlo matter in terms of states' actions on billing. You have the inclusion of the calcimimetics into the bundle, which affected the margins on the pharmacy or care coordination side of the business.
It affected the margins on the dialysis side of the business negatively. Excuse me. We had the offset in care coordination. On the revenue per treatment side, I would say that the revenue per treatment excluding calcimimetics was very consistent with the guidance that I had indicated for the full year being slightly down. On the cost per treatment side, similarly, the actuals excluding calcimimetics were consistent with the guidance that I gave several times being slightly up. On the care coordination side, as I mentioned a moment ago, you've got the shift of calcimimetics into the dialysis business that had a favorable effect on our pharmacy margins. Lower bad debt. We had the divestiture of the care coordination activities.
You also had the gain from the sale of Shiel in 2017's results. We did have an adjustment in the fourth quarter related to the ESCO revenue recognition. For Q4, in terms of the regional marginal profiles, just quickly going down the page, you can see that in EMEA, the margins decreased to 14.4%. This was driven by a charge that we took in the fourth quarter related to the intangible assets for Xenios, that was partly offset by the release of accruals. We also had the release of accruals in 2017 related to some favorable court settlements related to value-added taxes. That at least explains the higher margins that you see in 2017.
As we reported towards the back half of the year, we did see higher personnel costs in certain countries in the services side of the business in EMEA, and we had unfavorable foreign currency transaction effects. These were partly offset by an improvement in costs related to the management board change we had in the region, some decreased compensation expense, lower development costs related to V4, and the impact of one additional dialysis day in 2018. In Asia- Pacific, you can see that operating margins improved to 18.8%, and earnings improved about EUR 10 million. The increased margin was driven just by favorable impacts associated with business growth. Comp expense was down. This was partly offset by unfavorable foreign currency transaction effects, the headwind that we faced during 2018. A small reimbursement rate decrease in Japan, as well as an adjustment to our lease receivable in Korea.
Care coordination margins in the region increased from 19.8% to 21.8%, due broadly in association with the different care coordination businesses we have across the region. Latin America income declined, as you can see, to EUR 5 million, margins also showing a dramatic effect. Not surprisingly, this is largely associated with the hyperinflation effect that we talked about in Q3 relative to Argentina. For the full year, I had indicated that we expected something on the order of the same impact in Q4 that we saw in Q3, which would have been about EUR 17 million on an after-tax basis. It came in a little bit better than that. The total year effect is about EUR 32 million. Pretty much in line with what I had indicated. It is not on the page, corporate costs decreased by EUR 222 million.
This is obviously largely because we took a EUR 200 million charge for the FCPA in the fourth quarter of 2017. You did have a modest reduction in corporate costs in the fourth quarter from roughly EUR 89 million to EUR 67 million. This was broadly due to slightly more favorable results in our R&D organization, in our GMQ organization, and some favorability in corporate costs associated with variable comp. Turning to the next page, looking at cash flows. Cash flows, nice performance in the fourth quarter, 16.2% of revenues. This is essentially due to favorable development with regard to our day sales outstanding and trade receivables. We had a two-day improvement in the fourth quarter this year versus Q3, versus a one-day erosion in DSO Q4 in 2017.
You have a three-day improvement in DSO, and we had lower tax payments in the U.S. driven by the lower tax rate in the United States. Capital expenditures, when you look at the full year, essentially consistent with what our expectations were. Strong free cash flow both for the quarter at just under EUR 400 million and just over EUR 1 billion for full year 2018. Our ratings have not changed with regard to our credit, and we continue to delever as the year progressed, finishing the year at 1.8 times debt to EBITDA. Turning to the next page and touching on our Global Efficiency Program. You saw with our release this morning that we did report favorable results with regard to our expectations for 2018. We had anticipated about a 10% level of sustained savings coming out of 2018. We are reporting about 15% for the year.
We also took a look at our programs and are comfortable increasing the low end of the range from EUR 100 million to EUR 150 million. The range has narrowed and improved in that context in terms of what we expect over the course of 2019 and 2020. We'll just continue to manage through this program, trying to drive efficiencies through the programs that we've introduced as a part of GEP II. Turning to page 27, what we've tried to do here is, since we had given you preliminary indicative guidance in December, is benchmark what we're doing relative to our outlook for 2019 in the context of that preliminary indicative guidance. Keeping in mind that was early December. We have not closed the books.
You can see very broadly, if you take the midpoint of what we had indicated in December, we outperformed that a bit in the fourth quarter. We would say the adjusted basis for 2019 is EUR 16.026 billion. And when you look at the right-hand side of the page, the midpoint was EUR 1.357 billion. You see that we outperformed slightly, about 2%, for the fourth quarter of last year. You see that we have now adjusted our preliminary indicative guidance by the U.S. ballot initiative. This was done essentially because we have had, over the years, a number of matters that we treated differently between Fresenius Medical Care and the parent company, FSE. We decided to harmonize the framework as it relates to some of these differences.
We simply adopted the FSE framework with regard to how they treated the ballot initiatives in their base period and took the guidance down by 40%. That gives you an adjusted basis for 2019 of about EUR 1.341 billion, slightly lower than what we had indicated in terms of the midpoint for 20 in early December. Keep in mind that when you're looking at that and you're thinking about 2019, we also had not indicated that we would be doing a share buyback at that time. 2019 has obviously been influenced in terms of the cost associated with executing the share buyback. Turning to page 28 and taking a look at the outlook. We're indicating our outlook and our targets for 2019, revenue growth of 3%-7%. We have broadened the range a bit from what we traditionally do.
Historically, we've used a three-point range. We've broadened it to a four-point range to just put perhaps a bit more conservatism in light of our experience in 2018. Net income growth, we had said broadly flat in mid-December. We've now just essentially articulated a range for 2019 of -2% to +2% for 2019. On the right-hand side, again, you see the base against which it should be measured. 2020, self-explanatory, mid to high single digits both in terms of revenue and net income. The targets for 2019 and 2020 are in constant currency, and the base has been adjusted in order to make the business performance comparable. Thinking in terms of any FCPA-related charges, this does not include the implementation of IFRS 16, the leasing standard.
We adjusted the base for the contribution Sound made both to revenues and earnings in the first half of 2018. We have taken out the gains and losses associated with care coordination activities. Similar to the adjustment we made for the ballot initiative in 2018, we have also adopted the framework used by FSE in terms of one-time costs that are incurred. We've talked about the fact that we have a cost optimization program. We anticipate that will be a cost of about $100 million in 2019, and that one-time cost is outside the guidance that's indicated on this page. All of this is given that the NxStage acquisition had not closed by the time we gave guidance. The targets exclude the effect of NxStage, which, as Rice mentioned, will be coming back when we close and providing some additional information on that.
I think in the interest of taking your questions, that's the end of my prepared remarks, and I'll turn the call back to Dominik.
Thank you, Rice. Thank you, Mike, for the presentation. I'm happy to open the Q&A for more insights now. Haley, can you open the Q&A, please?
Thank you. Ladies and gentlemen, at this time, we'll begin the question and answer session. Anyone who wishes to ask a question may press star followed by one on their touch-tone telephone. If you wish to remove yourself from the question queue, you may press star followed by two. If you are using speaker equipment today, please lift the handset before making your selections. In the interest of time, please limit yourself to two questions only. Anyone who has a question may press star followed by one at this time. One moment for the first question. Line of Veronika Dubajova of Goldman Sachs, please go ahead.
Good afternoon, Rice, Mike, Dominik. Thank you for taking my questions. I will limit it to two. My first one is, I was hoping you could comment a bit on the mixed development that you saw in the North America dialysis business in the fourth quarter. Clearly, this was a negative surprise for you in Q3. I am wondering to what extent you saw a stabilization or improvement in that trend. Since we are on that topic, maybe, Mike, you can communicate also your expectations for revenues per treatment for the U.S. for 2019. My second question is on same-store growth or frankly, market growth in the U.S. Your large competitor last week made some cautious comments about slowing growth in the U.S.
I would love to get your thoughts on whether that's something you are seeing and thinking about, and how we should be thinking about the tailwinds and headwinds to volume growth in the U.S. going forward. Thank you.
Hey, Veronika, it's Rice. I tell you what, I think I'll let Michael handle the first question, and then I'll take number 2. Okay, that's fine. You good? Veronika, yep. In terms of mix development, we said that relative to the commercial mix as we discussed it in Q3, that we saw this as a three to four quarter effort to get this back on track to where we felt it would be appropriate. We typically don't comment on small basis point changes. What we can say in the fourth quarter is we did see things moving in the right direction on mix. We did see some improvement. As we expected, it would be slow and build momentum as we go through the year.
Small dips. Yeah.
Yeah. Then relative to guidance on revenue per treatment for 2019, I would say, again, I would do this excluding calcimimetics. I think that makes sense from the way we handled 2018. I would say that broadly, revenue per treatment will be flat to maybe slightly down in 2019. I would anticipate your question, Veronika, with regard to cost per treatment at the same time, to save you the trouble of getting back in the queue. I'd say consistent with what I had indicated in 2017, I would see cost per treatment as flat to slightly up. You do see some compression there, which not surprisingly is why we're undertaking GEP II and the cost optimization program, amongst other things.
Veronika, it's Rice. I was made aware that Kent seemed to indicate he thought there'd be a slowing. We're not actually seeing that, and I want to give you a reference that I think will be helpful for you to make up your own mind. There was an article that just published on Friday the 15th of February by Keith McCullough, and it was in the Journal of the American Society of Nephrology. What it really shows is incident rate and prevalence rate, and this is a graph that goes from 1980 all the way to 2030. If we focus ourselves from 2015 out to 2030, essentially what he's saying is, and I'm just going to give you the snippet, his words, not mine.
A recent study indicates that population changes in age and race distribution, obesity and diabetes prevalence, and ESRD survival are going to result in an 11%-18% increase in the crude incident rate from 2015 to 2030. Where we clearly understand that you may get a quarter where things look like they've slowed down, if you look at this on the long-term and you look at the long-term trends, we just don't believe it's sustainable that you're going to see the slowdown. We think it's going to completely continue to go the other way. We're in a little bit different place. In all fairness, this article came out, I think, the day after they had done their call. Timing's everything. That would be my take on this, Veronika.
That was very clear. Thank you both.
The next question is from the line of Patrick Wood of Bank of America. Please go ahead.
Perfect. Thank you very much. I have two, please. The first will be on the home side. Obviously you guys are expecting a large penetration increase in that as a proportion of your pace over time. I'm just curious, long-term, where you see the reimbursement structure for that business heading, mostly because it seems reasonably generous at the moment relative to the costs of providing care within the home. That would be the first question. The second question, I hate to be boring and bring it up, but AB 290 in California. If you're uncomfortable commenting sort of directly on the bill, that's fair enough. Maybe you could give us some stats, maybe the proportion of your patients sat within California. It would be helpful just to get a little bit of color around that. That would be great. Thanks.
Sure, Patrick, it's Rice. I'll take both of those. On home penetration, yes, it's going to increase, no doubt. Where does reimbursement go? Yes, it's true that generally the costs are lower, and we've talked about that before because there's less labor. Here's what I would say. As we look at growing this book of business and giving patients more of a chance or a choice as to where they want to go, there is a lot of discussion and dialogue coming out of CMMI in D.C., basically saying, "We have to change the way we pay for this. We have to do things differently." I would actually talk to you about going the other way.
I'm not as worried about reimbursement cuts as much as I think if we can truly show a home population that has better outcomes, less hospital days, and we can show that that's meaningful, repeatable data, then I think there's an opportunity that we can have discussions about saving the government money. What do we do about differential reimbursement? Can we get more for training? Can we do more to continue to get this momentum to move forward, if you will? I am in no way negative on where we are. Now, will this happen in two years? Absolutely not. We need to bring a body of data, no different than we've built in the ESCO program and other things that we've done. If anybody's going to bring it forward, we're going to do it.
I think we have to be open to what I'm hearing coming out of CMMI, that they want to look at different ways for us being paid and how can we really try to create more opportunities for these patients to be better served. I think we'll all have to stay tuned on that. On AB 290, can't say we were surprised that that came about. I don't think I have anything new to say. I think we made a comment last year about what we thought the impact of that would be to us. I think the more important thing to know is that we are spending time in the legislature in California.
We're going to continue to educate them and make sure they understand the ins and outs of what this kind of bill would mean, and we're going to try to work to find a way to get our story across as well. I think it's a little early to say much more than that, Patrick.
Appreciate the answers. Thanks, guys.
The next question is from the line of Tom Jones of Berenberg. Please go ahead.
Oh, good afternoon. I had two questions. The first, probably one for Mike. I just wanted to circle back on your comments regarding your expectations for revenue per treatment in 2019. Clearly, we've got a much healthier Medicare rate increase this year. With you guiding to flat to slightly down, that would imply that you expect commercial revenue per treatment to be down. I was just wondering, is that all related to the year-on-year decline in mix that you're seeing, or do you actually expect some year-on-year declines in like-for-like pricing on the commercial side? If so, maybe some color on why that might be. The second question, maybe a slightly bigger picture one for Rice. You did mention it, but I often think it doesn't get the attention it deserves.
The half a day per patient improvement you saw in the U.S. in hospitalization, it doesn't sound like much to the casual observer, but across your 200,000+ patients, that's 100,000 days a year less in hospitals, the equivalent of 274 years for a single patient. That's a huge system-wide saving given that adult ESRD patients are the cheapest in hospitals. How much of that do you think you're currently capturing through ESCO programs, risk-sharing programs, that kind of thing? Where do you think that number could go, and what would you like to do, or how do you see that sort of trend developing for you to keep a bit more of the savings that you're clearly making for the system on those kind of improvements in hospitalization rates?
Go ahead, Mike.
I'll take the first one, yeah.
Yeah.
On revenue per treatment, it does reflect our best judgment in terms of both what the outcome might be with regard to mix, not in terms of the absolute value of mix, but just the relative value of contractual rates within the mix. Then I think importantly, we nailed down the national contracts in Q4 2017 and over the course of 2018. We know exactly where we stand on those. We do see some headwinds with regard to potentially the regional and state-level contracts that we need to negotiate bilaterally as we go through 2019. That's reflected in our guidance.
Some of what we normally get done in fourth quarter, Tom, is still, as Mike says, end of year, if you will. We're working through that. On your big picture, yeah, it's a nice drop. What I would say is, one quarter does not a trend make. I think what's interesting when you look at what we see in the ESCO population, keeping in mind that that's 40,000, 45,000 versus 180,000 or whatever patients in the Medicare, Medicaid book that aren't in the ESCOs. We're seeing a couple of dips down in the ESCO program. I'm convinced that we are going to be able to bend this curve, if you will, on the hospital days. Tom, I think for us to do it repeatedly quarter after quarter, it will take some time. I think your math holds.
What's going to be exciting to me is when we get to the place where we can grow the ESCO program, we convert it to the Patients Act, if you will. We get enough patients, enough critical mass on this, we're going to be able to start to make a real dent. I'm not jumping up and down on one quarter, but this is a 10-year love affair for me that we're on to try to get this to where we're going. When you see it in the general population, if you will, it does make me feel good, but it's got to be more than just a quarter. If you go back to last year, I think in one of the quarters, we dropped a little bit, and it didn't hold. It's a little early to say we've struck gold, but we're going to keep mining.
I'll leave it that way.
Sure. Just one quick follow-up thing, as you mentioned it, the Patients Act. Any change in the tone in Washington post the midterms, or are you still pretty positive on something potentially happening on that at some point, assuming it can get tacked onto a decent-sized carrier bill?
We're still optimistic, and we're still pushing hard. Sometimes the harder we push, some knucklehead in D.C. does something that just kind of confuses everybody and makes them go nuts. We've got to find a quiet moment, if there is such a thing, to keep pushing this. We're up to the task. We're going to keep pushing on it.
Lovely. That's very clear. Thanks very much.
The next question is from the line of Ed Ridley-Day of Redburn. Please go ahead.
Good afternoon. Thank you. First of all, just to follow up on the care coordination margin, and the adjustment you made in the fourth quarter, if you could quantify that, it'd be helpful, and understand we've slightly stalled on the ESCO program. How we should think about profitability for care coordination in North America for 2019? That'd be my first question. Just on EMEA, should we really be thinking about further incremental deterioration in personnel costs in 2019, or do you feel it may be stabilizing?
Okay, Mike.
Yeah, Ed, just broadly speaking, with regard to Q4, I would say that when I look at globally the margins in care coordination, in particular adjusting for the impact that our exchange rate has, because we had a gain associated with a number of care coordination activities. As you've seen, there's noise that comes through in Q3 and Q4 relative to the change in the exchange rate. When you adjust for that, and in particular, when you take out the first half of-
First half of 2017, the Sound business. First half, the Sound business, you get to about a 9% margin for care coordination on a global basis. That to kind of reflect back on where we were in the third quarter. Off an adjusted 2017 base, taking Sound out and taking out the noise associated with FX on that gain, you get to about 9%. In the fourth quarter, I think relative to the ESCOs, which I mentioned, I just took a little bit more of a conservative view with regard to what our expectations are, because the reconciliation of that program has been postponed by several months with the government.
It's Rice on the EMEA personnel cost. What we saw in the third quarter was we had been given increases in Hungary, kind of government mandated, if you will. We also had decided to take some, I'd say, more of a market approach in Romania to our nursing staff. We had given some raises there, then we also had some inflation to deal with in the U.K. What I would say is, when we look in general within EMEA, we look at labor inflation at somewhere around 3%. Two of these, in the Hungary and U.K., we sort of had to do. Romania, we thought it was the right thing to do. I think we've budgeted merit increases appropriately for 2019.
Not to say that if a country comes back and really dictates that we need to do something else, we'll have to follow that, but we'll try to find a way to manage that as best we can. I don't think we're seeing a trend that would convince me we can't manage this process.
Coming back to the third part of your first question, care coordination margins for 2019. I would say a high single to low double digits.
Thank you. That's very helpful.
Okay.
The next question is from the line of Hans Bostrom of Credit Suisse. Please go ahead.
Good afternoon. I had a question regarding your lease liabilities, please. Since your capitalized lease value of EUR 4.2 billion, quite high value, considering that your outstanding nominal lease commitments were EUR 4.5 billion last year. From that follows a couple of questions. What is the discount rate you've used to capitalize to these operating leases? Secondly, have you been including a lot of embedded leases in your liability calculation, or has there been a considerable increase in leases for facilities over the year? Thirdly, a question regarding your relatively mature lease portfolio, where nearly two-thirds of leases are due to come to their term in the next five years. Should we be concerned that rents on the facilities that you might have to renew are going to come at a much higher level given that relative maturity? Thank you.
Hans, hi. It's Mike. Well, let's see. The discount rates actually are driven by what's in the individual leases. It's all over the map because this is a global effort we've undertaken. I can't give you a specific rate. The change over the course of the year, particularly, I guess, if you're looking at 2018 versus 2019, the complexity of IFRS 16 goes far beyond what we used to do in the past, which is just accumulate lease payment schedules off book, if you will. We've been at this for quite some time. I don't think we've had any dramatic change in the extent to which we lease meaningful assets around the world. I wouldn't attribute any particular change in behavior over the course of 2018 or that we anticipate a significant change in behavior in 2019 on that.
The biggest part of this liability actually relates to the fact that there's a very vibrant leasing market, particularly in the U.S., so most of this comes from the fact that our clinics are mostly leased in the U.S. Those leases, I'd say, I'm going to look to my folks here, but I'd say 5 to 10 years as a ballpark for maturities. To your point, we've done our best to give everyone an estimate. By the way, this is on page 36 of the material we distributed. That's where those numbers are coming from. We've done our best to give you some indication as to what we anticipate the impact will be of IFRS 16. There are estimates involved in terms of what we think the renewal rates will be around the world.
There will be a little bit of volatility as we all get used to what the requirements of IFRS 16 are going to be as we go forward.
When do you think you might provide some form of pro forma data for 2018? Would you be able to give that on a quarterly basis?
No. I think what we'll do is we'll probably try to give you an estimate of what 2019 would look like if we continue to apply the old standard. Both of those have some complexity to them, but I think giving you some indication as to what the numbers would look like on a pro forma basis with the old standard as we progress through 2019 would be a better indicator than trying to go the other way and recreate an IFRS 16 database for 2018.
Okay. Thank you.
Question is from the line of Gunnar Römer of Deutsche Bank. Please go ahead.
Gunnar Römer, Deutsche Bank. Thanks for taking my question. Let me start with a couple of housekeeping questions for Mike, please. On the share buyback program, can you confirm that you will be canceling the shares and by when? Secondly, I was wondering whether you can give us some guidance on corporate costs, the financial result, and the tax rate in 2019 according to your model. Also more of a housekeeping question. On the NxStage closing, I see that you're very confident to close in the next couple of days. I was wondering whether and when you would update your guidance for 2019, including the effect of NxStage. Coming to the operations.
I figured there was a comment on higher-than-expected implicit price concessions in today's release, and I was wondering whether that also explains some of the outlook for flat to slightly down revenue per treatment in 2019. Any comments around these higher-than-expected implicit price concessions would be very helpful. Last but not least, thank you very much for the margin guidance on care coordination. Can you also help us understand where you would expect to see the revenues for the business based on the current business in 2019? Thank you.
Thank you.
Gunnar, we're going to take your first two. We're really trying to limit people to two because there's a whole bunch of other people in queue. Mike, go ahead.
Yeah, we'll buy the shares under the safe harbor for the EU, which essentially would require either cancellation or reservation for compensation programs. It's our intention to cancel the shares. We tend to do that once a year, just in terms of efficiency. I would imagine you'd see one cancellation at some point in time over the course of 2019 and one over the course of 2020. In terms of corporate costs, I would estimate probably looking at corporate costs, excluding any FCPA charges on the order of about, let's say, EUR 370 million-EUR 380 million. That is up from where we landed, obviously, in 2018. I would say that the increase is essentially split, and by FCPA charges, I mean anything associated with settling with the U.S. government.
It's roughly split between the investments we're making in global R&D, a little bit of manufacturing, and then the balance in what we call core corporate, which are the investments we've made in HR. We're bringing on a new global HR system, some corporate compliance and corporate legal that's now deployed on a worldwide basis.
Yeah, Gunnar, it's Rice on NxStage. At this point, we do anticipate we'll close in a couple of days, and then very soon thereafter, we'll give you guys an update on the impact of NxStage. I would like to be clear. The guidance we have given you for this year is the guidance. Then we'll give you the impact of NxStage, we're not going to reissue guidance. We just think that's not a good way to do this. We'll make it clear to you what the impacts are, we're going to stick to what we've already issued. We just think it's simpler, cleaner, easier way to go.
I'm going to give you a bonus round because someone else will ask. Tax rate between 24%-26% for 2019. I think some folks thought they heard you ask about interest. I'd say interest is going to be, let's say, in the EUR 230 million-EUR 240 million range for the year. Okay. I think we got most of them.
Yeah.
Any chance you can comment on the price concessions?
There's no change in the business model. Nothing significant that I'd attribute.
All right. Thank you.
In terms of a change. Yep.
The next question is from the line of David Adlington of JPMorgan. Please go ahead.
Morning, chairs. Afternoon, chairs. Thanks for taking the question. Firstly, just on phasing maybe for the year. I think you sort of point towards second half acceleration. Maybe just give us further color both on the top line and on the costs on that side. Secondly, just on another IFRS 16 question, I am afraid. I think you pointed towards a $50 million net income headwind for 2019. Just given the sort of timing issues, I think that is probably largely driven by, does that mean we get a tailwind in 2020? Thanks.
Okay. In terms of first half, second half, I would say just very broadly with the overall guidance we have given and with the cost optimization program and the GEP II expectations, that is why we expect year-over-year the first half will be a little bit weaker than the second half. We also have one less dialysis day in the first half, which we pick up in Q3 in 2019 in the U.S., which has an impact. Your second question on the lease liability. The effect you are seeing in terms of the $50 million is really twofold. Not to get too technical on the bookkeeping, but IFRS 16 requires the interest method of amortizing your lease liability.
In the early period of adoption, no matter what adoption method you chose, your interest expense will be higher in the earlier years because you are applying an interest rate against the full value of the discounted lease obligation. That is why you see a spike in the interest that exceeds the EBIT. The second reason is we did have a sale leaseback program in the U.S., where we were able to recognize revenue and earnings associated with the machines. The machines were sold to a third-party leasing organization and then leased back for the services business. That will no longer qualify under the IFRS 16 accounting, as it did under the prior U.S. GAAP and IFRS accounting. That is also reflected in the change in net income of $50 million.
Interest method on the lease liability and dropping the revenue and earnings recognition on the sale leaseback program in the U.S.
We take one last question from the next one.
The next question is the line of Oliver Metzger of Commerzbank. Please go ahead.
Hi. Thanks a lot for taking my questions. The first one is on Q4. The last quarter has been better than thought, which resulted also in the higher comparable base in 2018. I'm a little bit surprised that the business experienced such a high volatility, even though the upside that the provided range from early December was not big enough. This time, it worked out for you quite positive. Could you share with us how you prevent that, in particular, after the last autumn, this high fluctuations come to us as a surprise, even, or in particular, as your company is loved for being just so highly dependent. My second question is on the healthcare products in Europe. After some weaker or only slow-growing quarters, the business turned quite positive in the low single-digit territory.
Could you give us an outlook whether you see this recovery rather as a product-driven recovery or a more, let's say, market-related recovery?
On your first question, Oliver, I appreciate we were able to report some good news in the fourth quarter. We had said 2%-3%, we came in at 4%. We did end up having, in a number of the regions, a stronger performance. I would say, as we mentioned a couple of times, we did adjust variable compensation in the fourth quarter because the earnings had not turned out for the year as we had guided or hoped they would. Secondly, I think in particular, when you look at Asia, where we had seen some significant currency headwinds, that started to turn a bit in the fourth quarter into a tailwind.
I think those are probably the good operational performance in a number of regions, then supplemented with some variable comp and a currency tailwind in Asia for why things came in a little bit better, 1% over the high end of the range. The other way we frankly have compensated for that a bit, when you look at 2019, as I mentioned, we've gone from a three-point to a four-point range, 2019. Yeah. Oliver, when you look at healthcare products for EMEA, I would say that it's just a lot of hard work. I think we were able to catch a break in a couple of places where we earlier in the year had anticipated we'd be shipping products as part of tenders. Didn't come in the fourth quarter, it came.
I'd say generally on both your questions, when you have a management team that feels like they disappointed, and we obviously did, people get real serious about figuring out how to turn the corner as quickly as they can. I think we had some good news, as Mike said, but I just would not take away from the fact of just really good hard work and trying to do everything possible to begin to turn the corner, if you will. Now, that's not always successful, but it did go our way in the fourth quarter, and we're pleased that we were able to do that.
Okay. Almost perfect words to end the call. We did run out of time. Thank you for everyone for your great questions. I hope we did answer them as good as we could. Thank you and goodbye to all of you.
Thank you.
Yep. Take care.
Bye-bye now.
Bye.
Ladies and gentlemen, the conference is now concluded, and you may disconnect your telephone. Thank you for joining, and have a pleasant day. Goodbye.